Case 25-2009 — A 36-Year-Old Woman with Hormone-Receptor–Positive Breast Cancer  

Oleh:

Burstein, Harold J. ; Souter, Irene ; D'Alessandro, Helen Anne ; Sgroi, Dennis C.

Jenis: Article from Journal - ilmiah internasional
Dalam koleksi: The New England Journal of Medicine (keterangan: ada di Proquest) vol. 361 no. 07 (Aug. 2009), page 699-708.
Topik: Hormone receptor; breast cancer

Ketersediaan

Perpustakaan FK Nomor Panggil: N08.K.2009.04 Non-tandon: 1 (dapat dipinjam: 0) Tandon: tidak ada

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Dr. Barbara L. Smith (Surgical Oncology): A 36-year-old woman was seen in the multidisciplinary breast cancer clinic of this hospital for management of hormone-receptor–positive breast cancer. Approximately 3 months earlier she noted a lump in her right breast. Her primary care provider palpated a mass, adjacent to the nipple, in the upper central quadrant of the right breast. Approximately 2 months after she first noted the lesion, digital mammography, performed at another hospital, showed heterogeneously dense breast parenchyma, with no discrete mass, architectural distortion, or suspicious microcalcifications. The same day, ultrasonography of the breast revealed a mass, 1.3 cm by 1.2 cm by 0.9 cm, of heterogeneous echogenicity and with irregular margins along the inferior and lateral borders, located at the 12 o'clock position, 5 cm from the nipple. The patient declined to have a biopsy performed later that day. Seventeen days later, a core biopsy was performed, guided by ultrasonography. Pathological examination of the tissue revealed invasive ductal carcinoma, grade 1, which was positive for estrogen-receptor (ER) protein and progesterone-receptor (PR) protein, and negative for human epidermal growth factor receptor type 2 (HER2) according to fluorescence in situ hybridization (FISH). Sixteen days after the biopsy, magnetic resonance imaging (MRI) of the breast, before and after the administration of gadolinium-labeled diethylene triamine pentaacetic acid, with three-dimensional rendering, showed a mass in the right upper inner quadrant, 12 mm by 13 mm, with some rim enhancement, located 6.3 cm from the nipple. The patient was referred to the cancer center at this hospital, where she met with surgical, medical, and radiation oncologists and a genetic counselor, and the pathological slides of the biopsy specimen were reviewed. The patient had no other medical problems. An excisional biopsy of two enlarged right axillary lymph nodes had been performed 6 years earlier; pathological examination reportedly revealed reactive lymph nodes. Arthroscopic repair of a torn medial meniscus of the left knee had been performed 8 years earlier. Menarche had occurred at age 14. She was nulliparous and in the past had taken oral contraceptives intermittently for a total of 10 years. She was a student, lived with a roommate, and was of western European ancestry. There was no family history of breast or ovarian cancer. She consumed fewer than five alcoholic beverages per week and did not smoke or use illicit drugs. Medications included multivitamins and glucosamine and chondroitin. She reported no allergies. On examination, the vital signs were normal. The height was 160 cm, the weight 61 kg, and the body-mass index (the weight in kilograms divided by the square of the height in meters) 24.0. The breasts were symmetric and soft. A nodule, 1 cm in diameter, was present at the 12 o'clock position in the right breast, 2 cm from the border of the areola. The nipples were normal, with no discharge or erosions. A well-healed surgical scar was present in the right axilla. Soft lymph nodes were palpable in both axillae, and the remainder of the examination was normal. Laboratory tests, including complete blood count, measurements of electrolytes, and tests of renal and liver function, were normal. A chest radiograph was normal. After discussion, the patient elected to proceed with testing for mutations in the BRCA1 and BRCA2 genes, and she expressed a desire for breast-conserving therapy. Eleven days later, excision of the lesion in the right breast was performed with preoperative lymphoscintigraphy, intraoperative lymphangiography, and sentinel-node biopsy that included excision of three right axillary lymph nodes. Intraoperative pathological examination of a frozen section of a lymph node showed no evidence of metastasis. Examination of the breast specimen disclosed a mass, 1.4 cm by 1.0 cm by 1.0 cm; permanent sections revealed invasive ductal carcinoma, grade 2 of 3, with ductal carcinoma in situ, solid and cribriform types, within and beyond the region of the mass. A focus of invasive carcinoma was present away from the mass. Ductal carcinoma in situ was present at the superior, medial, and inferior margins. There was no lymphatic or vascular invasion. Examination of the excised lymph nodes with immunohistochemical staining for cytokeratin revealed several small clusters of tumor cells ranging from less than 0.2 mm (isolated tumor cells) to 1.8 mm (micrometastases) in deeper tissue levels of one of three lymph nodes. Tumor cells stained for ER protein and PR protein and showed no overexpression of HER2. A sample of the tumor sent to the Netherlands for a MammaPrint 70-gene analysis (Agendia BV) was reported as "low risk." Testing with the use of Oncotype DX (Genomic Health) revealed a recurrence score of 16, interpreted as a 10% risk of distant recurrence at 10 years in patients with node-negative breast cancer. Testing for mutations in the BRCA1 and BRCA2 genes was negative. One month after the lumpectomy, reexcision of the breast lesion and dissection of the right axillary lymph node were performed. Pathological examination revealed one 0.3-cm focus of ductal carcinoma in situ, grade 1, on 1 of 10 slides of the breast, and clear margins. Of 13 lymph nodes sampled, none showed evidence of metastases. A management decision was made.

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