Rounds with the Investigators 2012 | Breast Cancer
QUESTION: A 77 y/o Afro-American woman with a markedly contracted right breast which on mammography did not demonstrate any finding typical of carcinoma but clinically resembled a carcinoma en cuirasses. Core biopsy showed it to be a Grade I, ER-positive, PR-positive lobular carcinoma.
DR NEIL LOVE: So she did not have a single palpable mass — the entire breast was firm. The skin was densely adherent. On the axillary exam, she had palpable lymph nodes, but not clear whether or not they were pathologic. She had typical findings, quote, for carcinoma on the mammogram. And the biopsy showed that she had an ER-positive, supposedly HER2-positive lobular cancer. An FNA of the lymph node was negative. So how would you be thinking that through, Beth?
DR BETH OVERMOYER: There’s a lot of things that are strange. The HER2 positivity in the setting of lobular cancer, yes, it happens. It’s just quite rare. So I would really make sure that that is true. And then the FNA being negative on the axillary lymph node is also a bit concerning.
However, what you’re describing is this neglected, slowly growing, hormone receptor-positive breast cancer. If that’s really true and if the HER2 really was negative, then this is a perfect patient for endocrine therapy. And this should melt away and her breast should autonecrose, and she may not even have anything surgically to remove. So my hope is that the HER2 is actually negative and that endocrine therapy alone would be fine.
If the HER2 is positive, let’s say, then I still would offer her endocrine therapy and trastuzumab. She wouldn’t have to come in any more than every 3 weeks, being homeless and schizophrenic, and it would be better than endocrine therapy alone, as it is said in the metastatic setting. So I would give her anastrozole and trastuzumab if she’s really HER2-positive or letrozole alone if she was just ER-positive.
DR LOVE: Yes. Actually, we checked this morning about the HER2, because I agree with you. I thought it was strange. And the physician said it was positive. But interestingly, the second picture at the bottom is after having gotten anastrozole for a year.
DR OVERMOYER: Alone?
DR LOVE: Alone, right. So your point about whether it really is HER2-positive is interesting. Because when we went back to the surgeon and said, “Are you sure this is HER2-positive? What did you think about anti-HER therapy?” and the answer was, “Oh. Do you think I should be thinking about that?” But obviously the person had a great response to endocrine therapy alone. Any comments, Chuck?
DR CHARLES GEYER: Well, he’s probably sure his report says her tumor is HER2-positive. I mean, did he send it back — and was he skeptical about the result? Or does he just say, “Nope. That’s what the report said,” because I mean, that’s an obvious —
DR BONNI GUERIN: It’s a red flag.
DR GEYER: — question. Because before you committed her to it, you would want to be certain was it amplified? What was really going on with it? Because I would have a hard time treating this with anastrozole by itself if I thought it was HER2-positive, just based on the data that’s been done in metastatic disease. It’s so unlikely to respond. Now in her, you would worry about her compliance with anything. I would worry about her staying on anastrozole enough to get this kind of a response. And so I would be thinking, “Do I do every 3-week trastuzumab/fulvestrant or something that I can at least make sure she’s getting therapy with?” But what was done was the right thing to do, so you can’t argue with that.