Breast Cancer: October 2019 Multidisciplinary Molecular Tumor Boards

ASCO University
Oct 07, 2019 10:26 AM

Participant Instructions: Welcome to the Multidisiplinary Molecular Oncology Tumor Board Series! This educational initiative is a collaboration between the American Society of Clinical Oncology (ASCO), College of American Pathologists (CAP), and Association for Molecular Pathology (AMP).

A new case will be presented bi-monthly with discussions led by an expert pathologist and medical oncologist. This month’s topic is led by Drs. Jairam Krishnamurthy (Medical Oncologist from Nebraska Medicine) and Subodh Lele (Pathologist from Nebraska Medicine).

Do you have an interesting case in mind? Submit your hypothetical patient cases for consideration in an upcoming Multidisciplinary Molecular Tumor Board discussion forum.

Participants are encouraged to leave comments and post questions about the case in order to generate a wide discussion among the cancer care community. You can also receive email notifications when new comments are posted by clicking the “Follow this Conversation” option located at the bottom of this page.

When posting, please abide by the terms and conditions of this website.

Comments

16626

ASCO University
Re: Breast Cancer: October 2019 Multidisciplinary Molecular Tumor Boards
Oct 09, 2019 7:36 AM

Patient Case

Ms. Q is a 27 year old Caucasian female with no major past medical history. She noticed a lump in the left breast about 4 weeks back, which she feels is increasing in size. She denies any recent trauma, fever, chills or skin rash. She has regular menstrual periods and her last menstrual period was 2 weeks back. She denies unintentional weight loss, loss of appetite or bone pain. She is very active and continues to work out 4-5 times a week. She denies any other symptoms.

Her vital signs are normal. On physical exam, there is a 3 x 3 cm firm mobile mass palpable in the left breast upper outer quadrant with no nipple or skin changes. There is one mobile palpable lymph node in the left axilla. Right breast and right axilla are unremarkable. The remainder of the physical exam is unremarkable.

Mammogram of the right breast is unremarkable. Mammogram of the left breast shows a well circumscribed mass in the left breast upper outer quadrant and no other abnormalities. An ultrasound of the left breast and left axilla demonstrates a solid mass measuring 3.2 cm x 2.5 cm x 3.1 cm in the left breast at the 5 o’clock position with one abnormal looking enlarged lymph node in the left axilla.

Ultrasound guided biopsy of this left breast mass and the left axillary lymph node are both reported as invasive ductal carcinoma, grade 3/3, Ki-67 index of 90%, Estrogen receptor positive (2%, weak intensity), Progesterone receptor negative (0%) and Her-2/neu  was 2+ by IHC.

16631

ASCO University
Re: Breast Cancer: October 2019 Multidisciplinary Molecular Tumor Boards
Oct 09, 2019 7:37 AM

Discussion Questions

  1. What additional workup is needed?
  2. Are these pathology results sufficient to start treatment?
Siddharth Kunte, MBBS
Re: Breast Cancer: October 2019 Multidisciplinary Molecular Tumor Boards
Oct 09, 2019 3:13 PM

Need additional staging (CT scans) and ECHO. Additionally need FISH for the equivocal HER2 IHC

Daniel Morganstern, MD
Re: Breast Cancer: October 2019 Multidisciplinary Molecular Tumor Boards
Oct 09, 2019 4:20 PM

Needs definitive determination of her2 status by fish or cish

does not need body imaging if basic labs CBC and  chemistries are normal.  

Daphne B. Stewart, MD
Re: Breast Cancer: October 2019 Multidisciplinary Molecular Tumor Boards
Oct 11, 2019 10:48 PM

Given positive node she requires systemic staging to exclude metastasis: CT/bone scan or PET.

Needs FISH to confirm her2neu amplification.

16636

Nicole Kuhnly
Re: Breast Cancer: October 2019 Multidisciplinary Molecular Tumor Boards
Oct 09, 2019 3:16 PM

Agreed. In addition, I would request repeat ER testing due to 2% low staining. Following these staging and path results, I would want to include genetics for a full family hx and germline test to rule out BRCA/ATM/etc mutations given her young age. 

16646

Aman Buzdar, MD
Re: Breast Cancer: October 2019 Multidisciplinary Molecular Tumor Boards
Oct 09, 2019 3:31 PM

<p>HER2 fby FISH</p>

16651

Maaz Kamal Alata, MD, MBBS
Re: Breast Cancer: October 2019 Multidisciplinary Molecular Tumor Boards
Oct 09, 2019 4:13 PM

1. FiSH for HER2
2. Routine labs CBC Diff , Renal and hepatic profiles , Ca level and ALP.
3. Baseline ECHO
4. Tumor Board meeting schedule

16661

Atilio S. Giangreco, MD
Re: Breast Cancer: October 2019 Multidisciplinary Molecular Tumor Boards
Oct 09, 2019 6:29 PM

I agree with all recommendations 

16666

dehebert
Re: Breast Cancer: October 2019 Multidisciplinary Molecular Tumor Boards
Oct 10, 2019 2:36 AM

Her2 FISH testing, genetic counselling and testing especially BRCA1/2. Imaging work -up because of G3 , Ki67 90%

16671

Sarabjeet Kaur Arneja
Re: Breast Cancer: October 2019 Multidisciplinary Molecular Tumor Boards
Oct 10, 2019 4:36 AM

1) Additional testing for Her2 Status by FISH or CISH

2) Imaging studies ( PET CT) for staging purposes

 

16681

Jose Zago Pulido, MD
Re: Breast Cancer: October 2019 Multidisciplinary Molecular Tumor Boards
Oct 12, 2019 10:56 PM

I agree with all recommendation (fish, genetic and CT scan)

16696

ASCO University
Re: Breast Cancer: October 2019 Multidisciplinary Molecular Tumor Boards
Oct 21, 2019 10:49 AM

Faculty Response

Dr. Krishnamurthy:

  1. This young patient has at least Stage II B invasive breast cancer. There is evidence that patients with stages 1 and 2 breast cancer have a <5% chance of finding distant disease, whereas that risk is nearly 15% in patients with stage III disease, irrespective of immunohistochemistry. Hence, in this patient, in the absence of any other symptoms, I would advise refraining from performing any staging scans like CT scans or bone scans. Since she is <50 years old and has invasive breast cancer, she should meet with a genetic counselor to discuss regarding high risk genetic mutation testing including BRCA 1 and BRCA 2 testing, since that would have implications for her (will need bilateral mastectomy and bilateral salpingo-oophorectomy if she has a deleterious mutation) and her family in terms of knowing about risk for other cancers.
  2. Her-2 testing involves testing for the protein expression of the Her-2 gene which is measured by Immunohistochemistry. A negative test on that is a 0 or 1+ and a positive one is a 3+. A 2+ result on Her-2 IHC is considered equivocal and needs to be confirmed by Fluorescence in situ hybridization, which actually looks for the gene amplification. Hence, we should wait for the Her-2 FISH results before deciding on how to treat.

Dr. Lele: 

  1. If initial mutation testing in BRCA1 or BRCA2 genes is negative, further testing to identify large changes in the genes or testing for genes other than BRCA may be indicated.
  2. A HER2 test by IHC is considered equivocal when the carcinoma cells reveal weak to moderate complete membrane staining in >10% of tumor cells. In such cases further testing by in-situ hybridization (ISH) should be performed. If the results of the initial dual-probe ISH assay are inconclusive (HER2/CEP17 ratio is >/= 2 but there are <4 average HER2 copy signals /cell or HER2/CEP17 ratio is <2 and there are >/= 4 average HER2 copy signals/cell) additional work up is required as per the ASCO-CAP 2018 guidelines. Repeat testing from another tissue block from the same tumor may be performed in certain cases.

16701

ASCO University
Re: Breast Cancer: October 2019 Multidisciplinary Molecular Tumor Boards
Oct 21, 2019 10:50 AM

Patient Case Update

  1. Her-2 FISH came back with a Her-2/CEP17 ratio of 2.8 with Her-2 copy number of 5.1.
  2. High risk genetic mutation testing showed a deleterious mutation in the BRCA 1 gene and no other mutations

16706

ASCO University
Re: Breast Cancer: October 2019 Multidisciplinary Molecular Tumor Boards
Oct 21, 2019 10:51 AM

Discussion Questions

  1. What is the interpretation of these Her-2 results?
  2. What are the treatment options?

16716

Felipe Batalini, MD
Re: Breast Cancer: October 2019 Multidisciplinary Molecular Tumor Boards
Oct 25, 2019 5:32 PM

1. Her tumor is HER2+ (amplified) because both the Her-/CEP17 is >2 and the Her-2 copy number is greater than 4.

2. In the setting of a deleterious BRCA1 mutation, the recommendation would favor bilateral mastectomies and bilateral salpingo-ophorectomy. In terms of treatment, clinical trial participation should always be discussed. For this patient, I would recommend neoadjuvant therapy because the response to the neoadjuvant regimen could guide treatment choice adjuvantly (favor T-DM1 in the absence of complete response [ref to the Katherine trial]).


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