Kaiser Permanente Medical Center
1425 South Main Street
Walnut Creek, CA 94596
..
Subject:
Full Text of Report: Prelim MT. ZION
Dear Doctor Johnson,
.. Thank you for the opportunity of providing this consultation and second medical
oncology opinion on this 68-year-old patient who, in March of this year, was
found to have metastatic breast cancer after her original primary diagnosis of
stage IIB breast cancer made two years earlier.
..
Her history is well known to you, but briefly, she had been receiving
surveillance mammography on a yearly basis, but in the early part of 2002 she
noticed a walnut-sized lesion developing at the 12 o'clock position of her left
breast. Apparently a mammogram was negative, but ultrasound was positive and a
left breast core biopsy performed of a 3 x 4 cm mobile node revealed a
high-grade infiltrating ductal cancer whose biomarkers were estrogen receptor
and progesterone receptor negative, with 0% immunostaining, HER-2/neu negative
and with a DNA index of 1.6.
..
On 03/12/2002, she had a left breast sentinel node procedure along with a left
axillary dissection and left breast lumpectomy. A 2-cm high-grade invasive
ductal carcinoma with associated high-grade DCIS was excised, although with
positive margins. The sentinel node was positive, with pericapsular and
extracapsular invasion of the breast cancer and three additional axillary nodes
were all positive for the metastatic breast cancer. There was no
angiolymphatic invasion.
..
On 03/27/2004, surgical re-excision was performed to obtain clear margins.
..
The patient was started on a course of adjuvant chemotherapy in late April, and
this was planned to be four cycles of Adriamycin-Cytoxan followed by four
cycles of taxane. However, a CA15.3 marker performed on 05/05/2004 was noted
to be markedly elevated at 85, upper limit of normal being 31, and after two
cycles of Adriamycin-Cytoxan, there was no apparent improvement in this tumor
marker. Thus, the oncologist switched to Taxotere and six cycles of Taxotere
treatment were given to conclude the adjuvant chemotherapy in early December of
2002.
..
Radiation therapy to the chest, left axilla, and periclavicular fossae on the
left side was performed beginning on 07/08/2002.
..
The patient had other staging procedures at the time of diagnosis, including a
bone scan which was negative, normal chemistry except for the CA15.3 tumor
marker, normal brain MRI, bone scan that was repeated and showed only evidence
of what was considered degenerative change in the L5 vertebra.
..
A CT scan performed on 04/09/2004 which showed only a small liver cyst and a
small lung calcified granuloma, and a PET scan that was performed on 05/29/2004
that was suspicious for four focal hypermetabolic lesions persistent in the
left axilla and consistent with metastatic nodal involvement.
..
The PET scan was repeated on 12/18/2002 and showed reduced activity in the left
axillary metastasis. However, the appearance of the hypermetabolic region in
the apex of the left lung that was thought to be possibly postradiation changes
and a suspicious eleventh rib and L5 vertebral lesion. This second PET scan
was at the conclusion of the adjuvant chemotherapy and at a time when the
CA15.3 had normalized, I believe.
..
The patient noticed, within two months of going off adjuvant chemotherapy, that
she was developing a rash on her left breast. There were attempts to treat
this with antibiotics, and the rash waxed and waned. There was another attempt
to treat this with steroid pills. Again, the rash waxed and waned. By late
2003, she had almost 90% of her left breast involved in this rash, and in early
2004, began to notice lumps in the posterior portion of her left neck.
..
On 03/03/2004, she had a left neck FNA in the node at the posterior triangle
which showed metastatic breast cancer, and on 04/19/2004, she had a left breast
punch biopsy within the rash area of her left breast which showed metastatic
breast cancer with extensive dermal lymphatic involvement consistent with
inflammatory breast cancer. At this time, her CA15.3 was between 70 and 80 and
the patient was enrolled in a clinical protocol in which Taxol was administered
on a once-a-week times three basis with 1/4 weeks rest, and in association with
Avastin 10 mg/kg infused on the first and third weeks. On this protocol, the
patient's rash improved and CA15.3 has declined to near normal levels.
..
She is presently in the midst of her seventh cycle of this Taxol- Avastin
protocol and her last CA15.3 value of 10/07/2004 was 39. Her CT scan which had
been performed every couple of months this past year has showed marked decline
in the multiple posterior cervical, axillary and high supraclavicular lymph
nodes. Her last CT scan of 09/21/2004 shows no evidence of any lymph node
greater than 7 mm in diameter. She still has some persistent redness of the
left breast and claims that her activity level is about 75% of normal on the
present clinical therapy protocol.
..
The patient's risk factors for breast cancer include onset of menses at age 13.
She has had three pregnancies. First full-term pregnancy was at age 18. She
entered menopause in the late 40s, when she developed hot flashes and started
estrogen replacement therapy which she took for nearly two decades, and these
were discontinued at the time of her breast cancer diagnosis in 2002. She took
birth control pills in her 20s for five or six years.
..
She is a former smoker, less than one pack per day. She currently drinks one
to four alcoholic beverages per week. She does not use recreational drugs.
..
She is a non-Hispanic Caucasian and not of Ashkenazi Jewish descent.
..
She has no family history of breast cancer. She has a maternal grandfather who
was a smoker who died of lung cancer. She has a maternal aunt who died of
liver cancer. She has a sister and twin brothers, none of whom have developed
cancer. Mother and father died at an early age, each of heart attack and
pneumonia.
..
PAST MEDICAL HISTORY: ..
Hysterectomy. Other than that, she is on no current prescription medications
beyond those prescribed as part of her clinical protocol.
..
ALLERGIES: ..
She has no known allergies.
..
REVIEW OF SYSTEMS: ..
Positive for fatigue secondary to her chemotherapy, past and present.
..
She wears corrective lenses.
..
She claims that she may have early signs of glaucoma, but she is not taking any
medications for this.
..
She has had nosebleeds and voice changes which have been side effects from her
chemotherapy treatments.
..
She has had some asthma and wheezing, breathing problems and chronic cough
while she has been on the Avastin and Taxol therapy. This is unclear and is
being investigated. This has sometimes been associated with shortness of breath
but has not severely limited her activities.
..
She has no gastrointestinal complaints. She has no significant weight loss
problems. She has no neurologic complaints. She has had some loss in libido
but no other change in genitourinary or hormonal problems.
..
She has a poorly healed punch biopsy site in the left breast associated with
the erythema in her left breast.
..
She has had hair loss in the past and at present on her chemotherapy.
..
She has had some sleep difficulty.
..
PHYSICAL EXAMINATION:
The patient appears her stated age, with normal vitals, and is in no acute
distress. She weighs 140 pounds. Blood pressure of 141/82, peripheral pulse
71 and regular. Oral temperature 98.7 degrees. She is here in attendance with
her ex-husband, who has been very supportive of her through her disease
process. She is wearing a wig; beneath the wig, she has sporadic baldness with
generalized hair thinning. No evidence of scalp lesions. Her pupils are
equal, round, reactive to light and accommodation. EOMs intact. Oropharynx
clear.
..
Neck is without adenopathy or thyromegaly. She has vague sensation of fullness
in the left supraclavicular fossa, but I can palpate no discrete lymph nodes.
The chest shows generally clear lung fields and cardiac exam by auscultation.
..
The right breast is within normal limits to palpation and inspection with
normal nipple-areolar complex and no evidence of right axillary or right
periclavicular adenopathy.
..
The left breast, on the other hand, has somewhat distorted nipple-areolar
complex. She has a circumferential erythematous pattern with areas of peau
d'orange consistent with inflammatory breast cancer. She has areas of
induration in the lower quadrants of the breast, and there is in the six
o'clock position the punch biopsy which is incompletely healed.
..
She has no tenderness or open skin lesions in the left breast. I can feel no
adenopathy in the left axilla or the infraclavicular fossa on the left. She
has the radiation tattoos evident. Abdomen is benign, with no organomegaly,
fluids or masses palpable. Extremities show full joint range of motion, no
edema. Symmetric pulses and reflexes bilaterally.
..
I see no other significant skin changes in the extremities.
..
Neurologic exam: Mental status and cerebellar function, cranial nerves grossly
intact, as is peripheral motor and sensory function.
..
ASSESSMENT AND RECOMMENDATIONS:
It appears that at the time of 2002 when she was staged as having a 2-cm T2N1
with 4 involved nodes, or stage IIB breast cancer, she was placed on an
aggressive adjuvant chemotherapy regimen and this was modified due to the lack
of response in the tumor marker, and perhaps also to abnormalities detected on
the PET scan. By these markers, there was some evidence of improvement on the
Taxotere portion of this adjuvant chemotherapy regimen. The patient completed
radiation therapy and her primary surgical therapy was adequate in all
respects.
..
However, it was very ominous that within two months of finishing her adjuvant
chemotherapy, the left breast erythema which was ultimately diagnosed as
inflammatory breast cancer arose, and waxed and waned but did not fully
disappear, and by the early portion of this year, it was also manifest with
posterior cervical adenopathy and by CT scan evidence of involved lymph nodes
of the left neck, supraclavicular and axillary regions.
..
However, it seems that there has been response to her clinical protocol
consisting of the other taxane, paclitaxel, in combination with investigational
agent Avastin, and she has now had seven monthly cycles of this combination
therapy and has objective and clinical evidence of response, although with the
persistent erythema in the left breast and some residual peau d'orange, it
would be difficult to state that she has had a complete response, even with
near-normalization of her CA15.3 and lack of CT evidence of discrete residual
lymph nodes.
..
I have recommended to the patient and her ex-husband that she continue on this
regimen until there is objective evidence of progression beyond even a rising
tumor marker.
..
I have reinforced the notion that she has metastatic breast cancer with
inflammatory breast cancer in the left breast, and I do not see any role for
surgery, and I suspect that there would be no tolerance for additional
radiation therapy.
..
I indicated that whether she were to discontinue her current chemotherapy
protocol or continue it, sooner or later her disease will again progress, and
likely spread, and at that time, there would be other chemotherapy options open
to her, including capecitabine, another form of liposomal anthracycline known
as Doxil, or combinations in couplets involving such agents as Gemzar.
..
Her success with taxanes would indicate that capecitabene-Taxotere or
Gemzar-Taxotere combinations might be considered upon disease progression.
..
Given the total lack of hormonal responsiveness, there is no point to the use
of endocrine therapy, nor would she be a candidate for Herceptin, given the
HER-2/neu negativity. However, other small molecule kinase inhibitors as part
of a protocol would certainly be warranted if she were eligible for such
studies.
..
The only study presently at UCSF includes Avastin in combination with Tarceva,
and thus she would not be eligible given her present therapy with Avastin, but
this may change in several months' time, and one might inquire of my
co-investigator here at UCSF, Dr. Hope Rugo, for her possible eligibility into
newer UCSF protocols for metastatic breast cancer.
..
Thank you for the opportunity to participate in the care of this lovely but
unfortunate woman.
Sincerely,
PROFESSOR OF MEDICINE
MEDICAL ONCOLOGY
UCSF COMPREHENSIVE CANCER CENTER
CAROL FRANC BUCK BREAST CARE CENTER
.. Post Script
D: 10/18/2004 11:44 A
T: 10/25/2004 1:51 P waw CS#: 774274 ..