Clinical Case 1: High-Risk Early-Stage HR+ Breast Cancer


Stephanie Graff, MD, presents a clinical case of a patient who is diagnosed with HR+ early-stage breast cancer.


Stephanie Graff, MD, FACP: Hello, and welcome to this OncLive® My Treatment Approach Program titled “My Treatment Approach: Interpreting the Data for Early-Stage Hormone Receptor–Positive Breast Cancer.” I am Dr Stephanie Graff, the director of breast oncology at the Legorreta Cancer Center and Brown University Lifespan Cancer Institute in Providence, Rhode Island. I’m joined today by my colleague, Dr Rachel Layman. Rachel, would you like to introduce yourself?

Rachel Layman, MD: Yes, thank you. I’m Rachel Layman. I’m a professor of breast medical oncology at the MD Anderson Cancer Center in Houston, Texas.

Stephanie Graff, MD, FACP: Thank you for joining me. Today Dr Layman and I are going to be discussing recent advances in the treatment of early-stage hormone receptor–positive [HR+] breast cancer. We’re going to walk through 2 hypothetical patient cases and discuss how our treatment approach might be slightly different and illustrate how we incorporate the recent data into our practices. Let’s get started.

In clinical scenario 1, we have a 39-year-old premenopausal woman who presents to clinic with a palpable breast mass after diagnostic imaging and her gynecologist-initiated biopsy. She has an ECOG performance status of 0. Her past medical history is notable for obesity. She has a body mass index of 31. Past surgical history is notable for cesarean section [C-section], and gynecologic history, she’s a g2p2 [gravida 2, para 2]. She underwent menarche at age 11, had her first live birth at age 29, and had a second pregnancy delivered via C-section at age 33. Her husband has had a vasectomy, which is her current form of birth control.

For [her] family history, she does not know her dad or her paternal lineage. Her maternal grandmother had lung cancer at 74 and her maternal grandfather had bladder cancer at age 62. There’s no other family history of breast or ovarian cancer that she knows of. Social history, she’s married. She works as a middle school teacher, [rarely uses] alcohol, and is a never smoker; she’s mostly sedentary. She uses no regular medications and has no known drug allergies.

On physical exam, she does have a palpable mass in the left breast in the upper outer quadrant that measures about 1.5 cm. It’s freely mobile in the 2 o’clock position and there are no skin changes and no appreciable axillary abnormality. You’re seeing her post biopsy so there’s some slight biopsy change. On mammogram and ultrasound, she has heterogeneously dense breast tissue, BIRADS C, with asymmetry in the upper outer quadrant corresponding with a marker at the side of the palpable breast mass. The ultrasound shows a hypoechoic mass in the 2 o’clock position of the left breast that again corresponds with where you’re feeling it that measures 1.5 by 1.87 cm.

They’re not able to adequately assess for lymph nodes on ultrasound, and a breast MRI is ordered after the biopsy, which shows a 1.8 by 1.9 by 1.3 cm mass with an associated hematoma and peritumoral stranding. The axillary lymph nodes are prominent, but they’re the upper limits of normal and have a normal high-limit cortex, so radiology favors that they’re likely reactive. The core needle biopsy from the ultrasound-guided biopsy that’s performed shows a grade 2 invasive ductal carcinoma, ER [estrogen receptor] 90%, PR [progesterone receptor] 70% per 2, 2+ by IHC [immunohistochemistry]. Chromatin insight to hybridization is negative, and she has a Ki-67 [score] of 40%.

The decision is made to move the upfront surgery and the patient opts for a lumpectomy and sentinel lymph node biopsy. At that time, she has an invasive ductal carcinoma grade 2 with lymphovascular invasion identified. She has associated intermediate-grade DCIS [ductal carcinoma in situ] within the specimen and the invasive component measures 1.9 cm. Margins are negative by more than 2 mm on the invasive and the insight to disease. Three sentinel lymph nodes are identified and removed and all 3 are involved by macro metastatic disease with the largest focus measuring 1.3 cm and no evidence of extranodal extension.

She then moves on to have a multidisciplinary tumor board discussion given her very young age and 3 out of 3 positive sentinel lymph nodes, and the decision is made for her to have an axillary lymph node dissection, and an additional 14 lymph nodes are removed at the time of her axillary lymph node dissection and 2 additional nodes are found to be positive for a total of 5 positive lymph nodes. So, her AJCC [the American Joint Committee on Cancer] anatomic staging is a T1CN2M0 invasive ductal carcinoma. She does have systemic staging studies performed with no evidence of distant metastatic disease.

Transcript edited for clarity.

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