CASE DISCUSSION

National Cancer Institutions

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Female 62 yr

Chief complaint:
Palpable left breast mass 4 mo

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Female 62 yr

Present illness :

4 month มีคลําพบกอนเตานมขางซาย กอนโตขึ้นชาๆ ขนาดพอเดิม ไมมีเจ็บที่บริเวณกอน

ไมมี nipple discharge ไมมีคลํากอนไดที่รักแร ไมมีผื่นหรือแผลที่ผิวหนัง

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Past History

-U/D: HT รักษา รพ พญาไท

-Menarche 12-13 year
-Menopause 55 year
-no FH of CA breast, CA ovary
-no PARA
-no Hx OCP+HRT

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Physical examination

● ECOG 0-1
● Breast: palpable mass 4.5cm at L2,
hard, movable, no nipple discharge,no
skin lesion,normal NAC
● Lt axilla : Palpable LN 1 cm, movable

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10/65

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MMG+u/s breast (07/10/65): BIRADS5

-Irregular angulated border mass with internal calcifications L2 4.7x2.1x3.2 cm.

-A 1.6x0.8-cm. hypoechoic left axillary lymph node without fatty hilum
-Two well-circumscribed isoechoic lesions at R10; size 0.7x0.3x0.7 cm and
0.7x0.3x0.5 mm
- Multiple benign calcification scattering in the right breast and a few in the left
breast.

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WHAT NEXT?????

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● CNBx L2 +FNA Lt axilla LN under u/s guide
● สง tissue patho+IHC

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PATHO

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Diagnosis

Left CA breast cT2N1Mx HER2 overexpression

Plan????

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CT chest+upper abd (10/65)

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CT chest+upper abd (10/65)

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CT chest+upper abd (10/65)

- A 0.5-cm RLL nodule; due to hight risk category of patients, F/U is advised.
- Several enhancing masses at the left breast, and a 1.0-cm left axillary lymph node;
please correlate with mammographic results
- A few (0.2-0.5 cm) non-enhancing hypodense lesions at both hepatic lobes; too small
too characterized, but likely to be hepatic cysts, F/U is advised.
- A benign bone lesion at T12 vertebral body

Bone scan (11/65)

no bone metastasis

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Diagnosis
Left CA breast cT2N1M0 HER2 overexpression

Plan : Neoadjuvant systemic therapy

4AC+4TH --> Sx (BCT) --> H

● MUGA (10/65) 75.1%

● Consult breast intervention for u/s guide clip replacement Lt breast

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F/U after 4AC

● กอนยุบลง ทานได ไมมีคลําพบกอนเพิ่มเติม ไมมี

n/v

● ECOG 0-1
● Breast: mass 3cm at L2, hard, movable, no
nipple discharge
● LN negative

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F/U after 4AC-4TH (03/04/66)
● Breast: mass 2 cm at L2, hard, movable,
no nipple discharge, LN negative

IMP: Left CA breast cT2N1M0 HER2 overexpression

S/P 4AC+4TH (ycT1N0M0)

WHAT NEXT???

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MMG+u/s breast (04/66): BIRADS6

- smaller size of an ill-defined mass in UOQ of left breast with architectural distorsion.
- unchanged of a group of pleomorphic microcalcification in UOQ of left breast.
- unchanged regional round microcalcification in UOQ of left breast.
- significant smaller size of an ill-defined solid nodule with internal group of microcalcification at
L2 ( marker site )1.4 cm.
- an ill-defined solid nodule at L2 ( 3 cm. from nipple ) 1 cm.
- No suspicion axillary node is detected.

#CT chest+upper abd (04/66):

- No change of a 0.5-cm pulmonary nodule at posterior basal segment of RLL, follow up is
suggested.
- Significantly decreased size of left breast mass.
- No change of a few small non-enhancing liver lesions, likely heatic cysts.
- Unchanged sclerotic lesions at T12 and L2 bodies.

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Diagnosis

● Left CA breast cT2N1M0 HER2 overexpression

● S/P 4AC+4TH (cT1N0M0)
● S/P Lt mastectomy with SLNBx (Dual technique) Isosulfan blue
dye , ICG
○ Sentinel report negative 0/5

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Patho

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Summary : Female 62 yr
● Left CA breast cT2N1M0 HER2 overexpression
● S/P 4AC+4TH (ycT1N0M0)
● S/P Lt mastectomy with SLNBx (Dual technique) Isosulfan blue dye , ICG
○ Sentinel report negative 0/5
○ Residual invasive 3*2.2 cm

● Left CA breast ypT2N0M0 (HER2 overexpression)

● Adjuvant : TDM1 or Herceptin until 1 year

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