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Sample
Case
The
following is an example of an MDExpert second opinion
 MDExpert
believes
that the best second opinion is one received at a major cancer center
where a physical examination and direct interaction with a physician
are part of the overall assessment. MDExpert uses information from
previous doctor visits and studies to augment care with written
opinions from leading academic experts in appropriate oncology specialties.
CASE:
51-year-old female with newly diagnosed infiltrating ductal carcinoma
and ductal carcinoma in situ of the right breast
HISTORY
OF PRESENT ILLNESS:
The
patient is a 51-year-old perimenopausal female, on estrogen replacement
therapy for 5 years, who noted a new lump at about 2:30 in her right breast early this year. Mammogram
showed a small solid nodule. Subsequent excisional biopsy in
3/01 showed a lesion composed of both ductal carcinoma in situ
with comedo necrosis, and small foci of invasive ductal carcinoma.
The size of either lesion was not specified. The invasive component
had a modified Bloom-Richardson score of 1, and both in situ and
invasive carcinoma were present at the surgical margin. Her oncologist’s
understanding, after reviewing the slides with the pathologist,
was that there was “a large focus of ductal carcinoma in situ
with multiple tiny foci of microinvasion.” The tumor was ER,
PR positive, and Ki67 was <10%. HER2 was negative. On DNA
analysis, both an aneuploid and tetraploid stemlines were identified.
To
better clarify the pathology, MDExpert sent the original slides
for a second opinion. The slides were interpreted as such: The
excision of the right breast nodule showed infiltrating ductal
carinoma of right breast, low grade/well differentiated by Bloom-Richardson
method, 4-mm in size, comprising 40% of tumor, and ductal carcinoma
in situ of right breast, solid type, high nuclear grade with comedo
necrosis and calcification, comprising 60% of tumor. The overall
tumor dimension was 1.2 cm, and it was negative for vascular lymphatic
space invasion. The excision margin was positive for infiltrating
ductal carcinoma. Tumor cells were positive for estrogen and
progesterone receptor proteins, and negative for over-expression
of HER-2/neu oncogen.
The
patient underwent re-excision of the biopsy site with sentinel
node biopsy on 3/15/01.
No residual carcinoma, in situ or invasive, was identified. Sentinel
node biopsy showed reactive hyperplasia, but no carcinoma. Immunohistochemical
staining with estrogen and progesterone on the sentinel node was
likewise negative.
Since
that time, the patient had radiation therapy to the right breast,
6243 cGy (4/01-5/01). She tolerated the treatment well. She
is now trying to decide whether or not to begin treatment with
Tamoxifen. She is not considering chemotherapy at this time.
PAST
MEDICAL HISTORY:
-
Gravida 1 Para 1. Pregnancy was at age 26.
- Estrace
since 1995 for perimenopausal symptoms; LMP 6 months ago, although
she still has spotting. Estrace stopped 2/01.
- Internal
Hemorrhoids
PAST
SURGICAL HISTORY:
- Oral
surgery 1973
- Appendectomy
1972
- Right
breast biopsy,1995, for calcifications seen on mammography;
benign
ALLERGIES:NKDA
MEDICATIONS:None
SOCIAL
HISTORY: The patient is married and lives with her husband and
24-year-old daughter. The patient does not usetobacco.
She uses occasional alcohol. She is a labor and delivery nurse.
FAMILY
HISTORY:
No family history of breast cancer. Mother died at age 34 of
a glioma, diagnosed at autopsy. The patient’s father is alive
and well at age 78. He has hypertension. Her grandmother had
acute leukemia.
REVIEW
OF SYSTEMS:
The patient is feeling very well. She was mildly fatigued with
the radiation. She is returning to work.
LABORATORY
STUDIES: (3/15/01)
- WBCs-
5.9, hemoglobin- 14.2 hematocrit- 41.3, platelets- 270
RADIOGRAPHIC/DIAGNOSTIC
STUDIES:
- Mammogram
and ultrasound 2/01- small solid nodule in the right breast,
right upper inner quadrant (by physician’s notes; no report
available).
PATHOLOGY
REPORTS:
- Right
Breast Biopsy 3/8/01- Invasive intraducatal carcinoma. Size:
indeterminate, tubule formation score 2, nuclear pleomorphism
score 2, mitotic count 40 X objective score 1, final score 5.
Modified Bloom-Richardson: grade 1. Intraductal component:
present with comedo necrosis. Nearest margin/distance: margins
focally involved. Microcalcifications: present. The sections
of tissue microscopically demonstrate intraductal carcinoma
with comedo necrosis and a small foci of invasive ductal cell
carcinoma. The intraductal component is associated with granular
intraluminal calcifications. The invasive component is quite
small but invades the adjacent adipose tissue.
- Therapeutic
Analysis of right breast biopsy 3/8/01-
ER
by IHC: 50% favorable
PR by IHC: 10% favorable
Her2 neu: 1+/ negative
Ki-67: <10%
DNA Index/ PLOIDY:
-
The
DNA histogram shows two stem lines. The indices are 1.74
(aneuploid) and 2.06 (tetraploid).
- Sentinel
Lymph Node Biopsy and Lumpectomy 3/15/01-
A.Sentinel
lymph node, right axilla: reactive hyperplasia, negative
for malignancy. Addendum 3/22/01- the sentinel node stained
with cytokeratin does not demonstrate evidence of microscopic
metastatic disease. The positive and negative controls are
appropriate.
B.Additional right axillary lymph nodes: reactive hyperplasia,
negative for malignancy
C.Right
Breast Tissue, Lumpectomy:
-Status post-excisional biopsy for invasive and intraductal
carcinoma, no residual malignancy identifie
-Fibrocystic
changes
- Pathology
Review 7/17/01
Excision
of right breast nodule
- Infiltrating
ductal carcinoma of right breast, low grade/well-differentiated
by Bloom-Richardson method, 4-mm in size, comprising 40% of
tumor
- Ductal
carcinoma in situ of right breast, solid type, high nuclear
grade with comedo necrosis and calcification, comprising 60%
of tumor
- Overall
tumor dimension: 1.2 cm
- Negative
for vascular lymphatic space invasion
- Excision
margin positive for infiltrating ductal carcinoma
- Tumor
cells positive for estrogen and progesterone receptor proteins
and negative for over-expression of HER-2/neu oncogen
Right
breast re-excision and sentinel lymph node and axillary
lymph node dissection
- Focal
atypical ductal hyperplasia of right breast
- No
residual carcinoma identified
- Excision
margins clear of tumor
- Coagulative
necrosis, fat necrosis, and granulation of previous surgery
site
- Negative
for tumor metastasis in one sentinel lymph node and three
additional lymph nodes
MDExpert
Pathology Review
In
the initial excision of the right breast nodule (S01-1548),
there is an infiltrating ductal carcinoma with coexisting
ductal carcinoma in situ. In the areas of infiltrating ductal
carcinoma, the tumor cells form predominantly irregular
glands and less frequently cords and solid nests. The nuclei
are large, irregular, and hyperchromatic. Nucleoli are small.
Mitotic activity is low, less than one mitosis per 10 high
power fields. Tumor cells invade into the breast and adjacent
fat tissue with desmoplastic reaction, but no vascular lymphatic
space is seen. Based on the Bloom-Richardson method, the
overall tumor grade is low/well-differentiated with two
points for moderate tubular formation, two points for moderate
nuclear atypia, and one point for low mitotic activity.
The total point is 5 out 9.
Ductal
carcinoma in situ occurs not only in the nodule of invasive
ductal carcinoma and also the surrounding breast tissue
as solid dilated ducts with necrosis and calcification.
Tumor cells have large, irregular, pleomorphic nuclei, multiple
nucleoli, and rare mitotic figures. The overall nuclear
grade is high.
The
nodule of infiltrating ductal carcinoma measures 4 mm in
dimension. When the areas of ductal carcinoma in situ is
included, the linear extent of the entire lesion as measured
on slide A is 1.2 cm, about 40% being invasive and 60% in
situ carcinoma. The excision margin is involved by crushed
invasive tumor cells.
Immunohistochemical
stains reveal 50-60% of tumor cells positive for estrogen
receptor protein, 10-20% of tumor cells express progesterone
receptor protein, and negative Herceptest. The proliferative
fraction of cells are low, less than 10% by immunohistochemical
stain for Ki 67. DNA ploidy pattern by flow cytometry is
reported as aneuploid and tetraploid with peaks are 1.74
and 2.06, respectively.
In
the re-excision specimen (S01-1752), no residual in situ
or invasive ductal carcinoma is identified. There is a small
focus of atypical ductal hyperplasia in slide 3A close to
the deep margin (green ink). The sentinel lymph node and
three additional right axillary lymph nodes are free of
metastasis. Immunohistochemical stain for keratin on sentinel
lymph node shows no keratin-positive cells to further affirm
the lack of metastasis.
The
final diagnoses are summarized below:
Specimen
No. S01-1548, excision of right breast nodule
- Infiltrating
ductal carcinoma of right breast, low grade/well-differentiated
by Bloom-Richardson method, 4-mm in size, comprising 40% of
tumor
- Ductal
carcinoma in situ of right breast, solid type, high nuclear
grade with comedo necrosis and calcification, comprising 60%
of tumor
- Overall
tumor dimension: 1.2 cm
- Negative
for vascular lymphatic space invasion
- Excision
margin positive for infiltrating ductal carcinoma
- Tumor
cells positive for estrogen and progesterone receptor proteins
and negative for over-expression of HER-2/neu oncogen
- Specimen
No. S01-1752, right breast re-excision and sentinel lymph
node and axillary lymph node dissection
- Focal
atypical ductal hyperplasia of right breast
- No
residual carcinoma identified
- Excision
margins clear of tumor
- Coagulative
necrosis, fat necrosis, and granulation of previous surgery
site
- Negative
for tumor metastasis in one sentinel lymph node and three
additional lymph nodes
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