Tumor Board with Navigation Session #53

Transcription

1 Tumor Board with Navigation Session #53 Moderator: Tina Rizack, MD, MPH With Dennis R Holmes, MD, FACS Reshma Jagsi, MD Jessica Lapise, MS, CGC Gary Levine, MD William Sikov, MD Heather Coelho, RN, BSN, OCN, CBPN IC Case #1 42 year old female with an extensive family history of breast cancer PMH: negative G1P1 (10 yo old son) OCPs age and then 21 to 35 Family history; Paternal grandmother with bilateral breast cancer in 50s and ovarian cancer age 66 Paternal great aunt breast cancer in 50s, died in 60s Daughter with premenopausal breast cancer Paternal aunt with bilateral breast cancer (ILC) in 60s Had BSO due to mother/s history Known BRCA2 8765delAG Father died age 50: renal cell cancer 40s and lung cancer Paternal uncle age 70: melanoma age 49 BRCA2 mutation diagnosed 7/2011 with site specific testing done by ob/gyn 1

2 Case #1 BRCA management BSO 2012 Breast MRI 2012: negative Desires prophylactic mastectomy Mammogram pre op Breast MRI 2

3 Case #1 mammogram Biopsy ADH She undergoes a bilateral nipple sparing mastectomy with immediate reconstruction 3

4 Pathology Left breast: Grade 2 IDC measuring 0.4 cm ER 76 90% strong / PR neg <1% HER 2 neu 3+ DCIS and ADH Right breast: benign Left axillary FNA: negative Undergoes 12 weeks of chemotherapy with TH with 9 more months of herceptin Case #2 34 year old female Self palpated mass in left breast PMH: Idopathic lymphedema of LLE with intermittent swelling Exercise induced asthma Social: married, physician. GynHx: GO and desires fertility 4

5 Family hx: Paternal aunt with breast cancer in her 40s PGM died 50s unknown causes Maternal GM breast cancer in 70s Case #2 imaging 5

6 Ultrasound MRI Ultrasound guided biopsy IDC grade 3 no DCIS no LVI ER >90% strong/pr % strong HER2 2+ FISH negative, ratio1.22 Case #2 biopsy 6

7 Referred to REI Develops ovarian hyperstimulation syndrome Suffers a LLL PE started on anticoagulation BRCA negative Completes neoadjuvant therapy with TC What surgery would you recommend? Bilateral nipple spearing mastectomy with SLN biopsy Right breast benign Left 1.2 cm residual IDC with close margin <0.5 mm grade 2 +LVI Repeat HER2 is 3+ 7

8 Surgery Bilateral nipple sparing mastectomy Left sentinel lymph node biopsy Pathology: Right breast benign Left 1.2 cm IDC Grade 2 No LVI Negative margins DCIS 1.5 cm, grade 3 Posterior margin 0.5 mm Stage ypt1cn0 HER2 repeated according to new CAP guidelines 3+ Case #3 54 year old male with a right palpable breast mass PMH: clear cell renal cell cancer s/p right nephrectomy 2006 DMII HTN Removal of a skin cancer from his leg (SCC) asthma sleep apnea divericulitis s/p segmental colon resection Morbid obesity 450# PE: 4 5 cm mass above the nipple areolar complex at 12 clock Family History: Sister with uterine cancer in 40s, 7 other siblings with no cancer Father had brain tumor Patient with 3 daughters Puerto Rican decent 8

9 Genetics Consult BRCA 1 and 2 negative Insurance would not cover BART Mammogram 9

10 Ultrasound Surgery Mastectomy SLN biopsy pt1cn0 1.5 cm Grade 2 0/3 positive nodes DCIS grade 2 Negative margins No LVI Pt started on tamoxifen Tolerated well 10

11 Case #4 35 yo G2P2 currently lactating Pumps breast milk for 17 month old and self palpated a mass in her left breast PMH: kinked aorta and palpitations History of C. difficle in 2002 Jehovah s witness GynHx: menses 13, OCPs age and 23 28, 1 st child at 30, breast feed both for ~1.5 years Family history Maternal aunt with breast cancer in her 60s PE: 4 x4 cm mass in left breast Mammogram 11

12 Ultrasound MRI IDC grade 3 No LVI ER/PR/HER2 negative DCIS Biopsy FNA axillae Positive 12

13 Neoadjuvant Treatment Treated on CALGB 40603: standard arm Bilateral mastectomy and left axillary dissection with expanders Develops post op hematomas requiring removal of expanders and evacuation of clot Severe anemia Final pathology: ypt1an2a 1 mm focus of IDC in left breast Extensive LVI and tumor emboli DCIS grade 3, 1.5 cm Negative margins 4/8 positive nodes Largest 1 cm Extracapsular extension 13