Grandmother told she has BC and now they don't know what it is

Szucs

MEDICAL ONCOLOGY CONSULTATION

Reason for Referral: breast cancer

90 year old female

Patient initially presented to general surgery in 8/2018 with abnormal R breast lump.

Mammogram and ultrasound done 8/2018 confirmed 1.9cm oval mass in R breast, s/p biopsy

FINAL PATHOLOGIC DIAGNOSIS
BREAST, RIGHT, 2:00, 1.9 CM MASS (RADIOLOGY PERFORMED ULTRASOUND GUIDED
NEEDLE CORE BIOPSY):
- MODERATELY DIFFERENTIATED INVASIVE DUCTAL CARCINOMA.
- NOTTINGHAM COMBINED HISTOLOGIC GRADE 2 OUT OF 3:
- TUBULE FORMATION: 3 OUT OF 3.
- NUCLEAR PLEOMORPHISM: 2-3 OUT OF 3.
- MITOTIC COUNT: 1 OUT OF 3.
- COMBINED SCORE: 6-7 OUT OF 9.
- NO CARCINOMA IN SITU IDENTIFIED.
- INVASIVE TUMOR SIZE: AT LEAST 1.4 CM.
- LYMPHOVASCULAR INVASION: NOT IDENTIFIED.
- NECROSIS: FOCALLY IDENTIFIED.
- MICROCALCIFICATIONS: NOT IDENTIFIED.
- BREAST RECEPTOR MARKERS (ER, PR, AND HER2): PLEASE SEE THE ADDENDUM REPORT.

BREAST RECEPTOR MARKERS
Date Ordered: 8/17/2018

INTERPRETATION
BLOCK:
1
ESTROGEN RECEPTOR (ER):
Interpretation: Negative
0% immunoreactive cells present
Intensity of staining: Absent
Scoring performed in invasive carcinoma
No internal control is present; however, the external control tissue on the same slide is positive.
PROGESTERONE RECEPTOR (PR):
Interpretation: Negative
0% immunoreactive cells present
Intensity of staining: Absent
Scoring performed in invasive carcinoma
No internal control is present; however, the external control tissue on the same slide is positive.
HER2 IHC:
Negative (0, absent or incomplete, weak staining in <=10% of invasive tumor cells)

8/27/18: discussed at breast conference. Recs: proceed with needle loc and SLNbx

9/21-9/22/18: admitted for Afib

CXR - hazy R lung base opacities, aspiration and/or pneumonia

CT thorax no contrast - multiple lung nodules measuring up to 2.2 cm, mediastinal, hilar and supraclavicular LAD, pleural and pericardial effusions, R breast mass

10/3/18, s/p US-guided bx of R supraclavicular LN

FINAL PATHOLOGIC DIAGNOSIS
LYMPH NODE, ULTRASOUND-GUIDED (RADIOLOGY PERFORMED) FINE NEEDLE ASPIRATION, SUPRACLAVICULAR AREA, RIGHT:
- STATUS POST ULTRASOUND-GUIDED NEEDLE BIOPSY 1.9 CM MASS 2:00 RIGHT BREAST (BPMS18-17034)
- EXTENSIVELY NECROTIC TISSUE SHOWING FEATURES OF METASTATIC, POORLY DIFFERENTIATED CARCINOMA (SEE COMMENT)

COMMENT
The findings are consistent with metastatic tumor. The overall morphologic as well as a minimal histochemical staining profile of this lesion is not specific and the site of origin of this lesion is not apparent The findings do not appear to support metastatic breast cancer. The possibility that this represents metastatic breast cancer is not completely ruled out but is not favored. Differential diagnosis includes, but is not limited to lung, proximal gastrointestinal tract, gynecologic or pancreaticobiliary tract. Two (2) other pathologists have reviewed this case and concur with this interpretation

SUBJECTIVE/ROS:

Weight loss, gradually, about 30lbs over the past year

Progressive fatigue over the past month, but still remains relatively active

Occasional SOB and dry cough

Denies bone pain, headaches, dizziness

____________________________________________________________________________________________________________________________________________________________________

Gen: elderly, pleasant, NAD

HEENT: no palpable LAD

CVS: irregularly irregular

Lungs: decreased breath sounds at bases

Abd: soft, NT, ND, +palpable hard mass 2-3cm in LLQ along surface of skin

Ext: no edema

Breast: left breast --> palpable hard mass, 3-4cm at 4 o'clock

Labs:

WBC'S AUTO 9.4 10/02/2018

HGB 11.0 10/02/2018

HCT AUTO 34.0 10/02/2018

PLT'S AUTO 295 10/02/2018

CREAT 0.80 09/22/2018

ALT 12 04/11/2014

AST 16 04/11/2014

CA 8.7 09/21/2018

ALB 3.3 09/22/2018

No results found for this basename: ca153

No results found for this basename: CA125

No results found for this basename: IRON, IBC, FESAT, FERRITIN

No results found for this basename: B12

No results found for this basename: Folate

No results found for this basename: HAV, HAVG, HAVIGM, HBSAG, HBVSAB, HBCAB, HCV, HCVPCR, HCVPCRQL, HCVPCRQN, HAVIGG, HCVPCRLOG, HAVAB, HBCIGM, HCVAB, HCVGENO

Imaging: reviewed

Pathology/Procedures:

EGD, 5/2017:

IMPRESSION:

Mild gastritis and duodenitis s/p biopsies

Unremarkable esophagus

Suspect dysphagia is oropharyngeal in nature.

FINAL PATHOLOGIC DIAGNOSIS
STOMACH, ANTRUM AND BODY, BIOPSY:
- GASTRIC OXYNTIC AND GLANDULAR MUCOSA WITH FOVEOLAR HYPERPLASIA AND MINIMAL
ACUTE INFLAMMATION; SEE COMMENT.
- NO HELICOBACTER, INTESTINAL METAPLASIA, OR DYSPLASIA SEEN.

ASSESSMENT:

90 year old female with hx smoking, hyperlipidemia, A.fib on pradaxa and aspirin, osteoporosis, osteoarthritis of bilateral knees

R breast mass --> moderately differentiated invasive ductal carcinoma, ER/PR/HER 2 negative

Pulmonary nodules, mediastinal/hilar/supraclavicular lymphadenopathy, pleural/pericardial effusion

S/p R supraclavicular LN FNA --> metastatic poorly differentiated carcinoma, extensively necrotic tissue, with minimal IHC staining profile, not supportive of breast cancer. Ddx includes lung, proximal GI, gynecologic or pancreaticobiliary

Explained to patient and daughter today that although we may be dealing with a diagnosis of triple negative breast cancer with visceral mets, this is not definitely supported on the recent R supraclavicular lymph node biopsy and limited IHC staining profile. There is a possibility that given her smoking history, she may have another primary malignancy such as lung cancer. This will guide management.

PLAN:

- CT neck/C/A/P to complete workup and evaluate for repeat biopsy for additional tissue

- bone scan to r/o bone mets

- genetics referral

- baseline labs, including tumor markers

RTC 2 weeks

WC3

It sounds like she has breast cancer, and another cancer that has metastasized but the origin of the metastatic cancer has not yet been determined. They are speculating possibly the metastatic cancer may be lung cancer due to her history of smoking.

In other words, they think she may have two different cancers at the same time. Another possibility is she only has breast cancer

Szucs

So she either has breast cancer that has spread, or breast cancer, and another cancer that has spread? I have never heard of anyone having two cancers at the same time.

pupmom

Why was she getting mammograms at 90 years old? And all the other tests seem absurd at her age. There is a piece of the puzzle missing here.

WC3

pupmom:

Not really. My 90 year old grandmother just had a CT for a lung nodule. If it's cancerous we will look in to how to maximize her QoL.

ksusan

Unfortunately, there's no reason a person couldn't have two kinds of cancer at the same time.

pupmom

Ok. My 93 year old old father was diagnosed with pancreatic cancer through ultrasound. It looked like it had metastasized, and my sister and I decided no treatment. I miss him very much, but no way could he have endured treatment. He was referred to hospice and died right after they arrived at his nursing home.

Szucs

Pupmon, what could the missing piece be? Which tests seem absurd?

She did not have a mammogram, even though it is stated above that she did. She felt a lump on her breast in August of this year. She saw her primary doctor who sent her to have an ultrasound a week later. That same day she had a biopsy.

From there, she is told she has breast cancer, a lumpectomy was scheduled. During her pre-op, something on the EKG wasn't right and they sent her to the ER. She had a chest CT which showed something going on in her lungs.The lumpectomy was cancelled, and last week she had the second biopsy which was something to do with the lymph nodes. Yesterday she saw an oncologist for the first time and that's where it stands.

pupmom

I thought she had a mammogram. Sorry if that was wrong. I just wonder how much invasive treatment a 90 year old can tolerate. Of course it is not my call, but I have been there with both my parents.