Case Review: De Novo Metastatic ER+ Breast Cancer

Komal Jhaveri, MD, FACP:Today we’ll be discussing a case of a 65-year-old woman who [is] postmenopausal and was evaluated by her gynecologist with a new lump that she felt in her right breast. She described that as a grape-size lump in her right breast that she just recently noticed. Very rightfully, she was evaluated with an ultrasound that confirmed that there was a mass, indeed, which was about 2.5 cm. And following the workup, she then had a core biopsy, which confirmed a high-grade infiltrating ductal carcinoma. She then underwent a lumpectomy and a dissection, which revealed a 2.3-cm tumor [that] was grade 3, driven by the estrogen and the progesterone hormones, and negative forHER2, and 4 of 12 lymph nodes were involved.

This woman went underwent a staging CT scan of the chest, abdomen, and pelvis, which did reveal suspicious lesions in the bone. She therefore underwent a biopsy from the bone that confirmed that this was, in fact, metastatic from her breast cancer and was also driven by estrogen and progesterone hormones and negative forHER2. So in summary, we’re talking about a woman who’s newly diagnosed with de novo metastatic breast cancer to the bone, and it’s driven by estrogen and negative forHER2.

So we’ve certainly made a lot of progress for our patients with metastatic disease. And while we [have] not been able to cure this disease, we definitely have made some meaningful improvements for these patients [from] the new systemic therapies that have been introduced for treatment of metastatic disease.

But there are a few factors that obviously play into the prognosis with these patients, and some of these factors are clinical factors: Did this patient have de novo metastatic disease, or was this a relapse that happened within a few months or a very short time after the initial therapy, [even though] the relapse happened years after the initial therapy? Also, important factors to keep in mind are the estrogen and hormone receptor positivity orHER2positivity, which might drive into the prognosis for these patients. So the prognosis could vary anytime from a few months to many, many years and could also be dependent on the sites that are involved.

Transcript edited for clarity.

A 65-Year-Old Woman With Metastatic ER+/PR+ Breast Cancer

December 2013

• A 65-year-old woman was examined by her gynecologist after discovering a right-sided lump in her upper inner breast; she reported feeling exhausted lately, requiring frequent rest
• PE showed a grape-sized right palpable mass at 3 o’clock
• Diagnostic ultrasound showed a spiculated and hypoechoic mass measuring 26 x 23 x 21 mm; imaging in the left breast was unremarkable
• Core biopsy showed high-grade infiltrating ductal carcinoma
  • Hormone receptor status: ER+/ PR+
  • HER2,IHC 1+
• She underwent lumpectomy and axillary lymph node dissection that revealed a 2.3-cm infiltrating ductal carcinoma, 4 of 12 nodes were positive for disease
• CT of the chest, abdomen, and pelvis showed that the disease had spread to her bones and biopsy confirmed metastatic disease
• ECOG 1
• She was started on ribociclib + fulvestrant