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撰文丨Lily
The latest data show that breast cancer accounts for 25% of all malignancies and has become the most common malignant tumor in women worldwide. Breast cancer is a highly heterogeneous tumor, which can be divided into four molecular types through the analysis of gene expression profile, among which Luminal breast cancer is divided into Luminal A and Luminal B, accounting for more than 60%, which is the most common breast cancer classification, and its treatment difficulties lie in endocrine therapy resistance and long-term recurrence.
Professor Zhao Liangying from Dongyang People's Hospital was specially invited by the medical community to share a case of Luminal type A early breast cancer, and let us analyze and discuss the key difficulties in its whole process management.
Basic information of the case
The patient is a 53-year-old female.
He was admitted to the doctor on May 15, 2016 because of "3 years after the discovery of a lump in the left breast", with no special past history, no family history, and the age of menopause was 51 years old.
Physical examination: the left nipple is depressed, the outer upper quadrant of the left breast can reach a lump of about 4x4cm, hard, unclear, non-tender, can be pushed, the right breast is not obvious lump, the left armpit can reach an enlarged lymph node with a diameter of about 2.5cm, which is hard and can be pushed, and the right armpit does not reach the enlarged lymph node.
INVESTIGATIONS:
Breast ultrasound: hypoechoic area of left breast, maximum diameter of about 4.0cm, cancer is considered first, multiple lymphadenopathy in the left armpit, metastatic is considered, and no obvious swollen lymph nodes are found in the right armpit.
MAMMOGRAPHY: CENTRAL LEFT BREAST MASS WITH CALCIFICATION, LEFT NIPPLE DEPRESSION, AREOLAR SKIN THICKENING, CONSIDERED MALIGNANCY, BI-RADS 5.
Chest CT: 1. There were no obvious abnormalities on non-contrast CT scan of both lungs and mediastinum. 2. Left breast lump with left axillary lymphadenopathy, the tumor may be large.
CT with full abdomen: no abnormalities.
Fig. 1.Chest CT showed a left breast mass with left axillary lymphadenopathy
needle biopsy:
"左乳肿块穿刺活检"浸润性癌;in:Air(2+80%),PR(1+50%),Cerb-2(-),E-Catherine(-),P63(-),K5/6(-),G-67(+约10%). 左腋窝淋巴结转移性癌.
临床诊断:左乳腺癌cT2N1M0(Luminal A型)
Treatment
- In May 2016, patients were scheduled to be given an anthracycline-containing (EC-T) neoadjuvant chemotherapy regimen, and on July 4, 2016, 3 cycles of EC chemotherapy were completed.
- In July 2016, the neoadjuvant 3-cycle post-cycle review:
Breast ultrasound: a glandular mess area with a range of about 36×22×9mm above the left nipple was visible, with irregular shape, and blood flow signal was visible in CDFI, RI: 0.63. There were several hypoechoic nodules in the left axilla, the largest one was 22×9 mm, with clear borders, irregular morphology, and uneven thickening of the cortex.
Whole body bone scan: no abnormalities.
Figure 2.CT findings of left breast mass before and after 3 cycles of neoadjuvant chemotherapy
- On July 28, 2016, considering that the patient had reached stable disease (SD) at this time, he underwent modified radical resection for left breast cancer.
Postoperative pathology: (left) Breast invasive ductal carcinoma grade II, tumor size 5×4×1cm, tumor infiltration into subpapillary breast tissue, tumor metastasis in 18/18 axillary lymph nodes, negative nipple, skin and basal margins. PT3N3aMX immunohistochemistry: ER (3+ about 60%), PR (2+ about 30%), CerbB-2 (weak 1+), E-Cadherin (3+), CD31 (-), D2-40 (+), Ki-67 (+ about 25%).
- Postoperative treatment
The patient received 4 postoperative treatments with docetaxel regimen and radiotherapy (radiotherapy 6MV X-ray DT 50Gy/25f) on November 28, 2016
ask
What should be the next step for patients with Luminal A breast cancer who have not achieved pCR with preoperative neoadjuvant chemotherapy?
A. Capecitabine assisted in fortification
B. Conventional sequential endocrine therapy
Outcome of the discussion:
The patient started oral aromatase inhibitor (AI) endocrine therapy in December 2016.
- In June 2018, re-examination showed disease progression (progression-free survival: 23 months)
MRI of hepatobiliary spleen with contrast: multiple intrahepatic metastases, multiple lymphadenopathy in the hilar region, hepatogastric space, and posterior peritoneum. Multiple thoracolumbar spine and pelvis constitute bone and bone metastases.
Whole-body bone scan: bilateral multiple ribs, abnormal bone metabolism in the middle and upper part of the left femur, and metastatic bone tumors are considered.
CT of the lungs, MRI of the head with contrast, biochemistry: no abnormalities.
Right liver puncture pathology: metastatic carcinoma, liver metastases consistent with invasive ductal carcinoma of the breast according to immunohistochemistry.
IHC:ER (3+90%)PR-CerbB-2(1+) E-Ca(3+) Ki-67 (120%+) Hepa-Gly-3(-)CK7 (+)
ask
For patients with diffuse liver metastases, bone metastases, advanced breast cancer patients who have progressed on adjuvant endocrine therapy for 18 months, and have primary endocrine resistance, how to choose the advanced first-line treatment regimen?
A. Chemotherapy
B. Endocrine therapy + targeted therapy
Outcome of the discussion:
Patients began weekly paclitaxel therapy (D1, D8, D15) on July 17, 2018, and zoledronic acid every 28 days reduced bone adverse events.
- September 2018, 3-cycle post-review:
MRI of hepatobiliary and spleen enhancement showed multiple metastases of the liver, multiple lymphadenopathy in the hilar region, hepatogastric space and posterior peritoneum, and the lesions in the old control film (2018.06.30) increased and increased. Multiple thoracolumbar metastases. Metastatic tumors in the left lower lung.
Figure 3.Abdominal MRI showing diffuse liver metastases
ask
The patient is ineffective in the advanced first-line purple shirt chemotherapy and the tumor progresses rapidly, how to choose the next treatment?
A. Change of chemotherapy regimen
B. Change to endocrine therapy + targeted therapy
- In March 2019, after the change of treatment regimen:
MRI of hepatobiliary and spleen with contrast: multiple metastases in the left lower lung and liver, multiple lymph node metastases in the hilar region, hepatogastric space and posterior peritoneum, and the metastases in the control old film (2018.09.13) were reduced. Thoracolumbar multiple metastases.
Figure 4.CT findings of the liver before and after treatment
What should be the next step in treatment? Do you know the answer?
Editor in charge: Sheep
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