Question 1

Breast Cancer - Neoadjuvant Chemo Vs Immediate Surgery

Accepted Answer

Patient: A 49-year-old female patient with a newly diagnosed breast carcinoma (unilateral). The patient sought a second opinion from a mammologist.

Available data: medical report, including ultrasound and mammography study of both mammary glands, histological and immunohistochemistry tests of the breast tumor tissue, tumor board recommendations, bone scintigraphy.

Problem statement:

Treatment tactics taking into account the initial data (unilateral breast cancer cT2, cN0, G2, ER/PR positive, HER2 negative, Ki-67 40%, G2, absence of lymph node and bone metastases). The local doctors had different opinions: some suggested preoperative chemotherapy followed by tumor resection; others insisted on immediate surgery.

Selected format:

Written second opinion.

Outcome:

Our mammology expert provided an assessment within 3 working days. In view of the available data, he identified the tumor subtype as B-type luminal cancer. He was quite sure that surgery was indeed the right option. However, indications for chemo, whether neoadjuvant, or adjuvant, were only relative, taking into consideration the malignancy grade and absence of metastases. The expert recommended conducting a genomic test of the available punch biopsy samples, which could determine the degree of breast cancer recurrence risk with very high precision. This would help avoid unnecessary use of cytostatics. Should the risk turn out to be high, chemotherapy would indeed be necessary due to the unfavorable ratio between the tumor and breast volume. It was only after it that organ-sparing surgery with sentinel lymph node examination should be performed, followed by radiotherapy and 5-10 year hormone therapy. In the case of low risk, one could start with surgery. As to adjuvant therapy, the decision should depend on the post-operative TNM status of the tumor.

Medconsonline comment:

The benefit of this second opinion is that it features a completely custom-made treatment plan. The key point was to spare the patient the side effects of chemotherapy, which would have otherwise been a standard option, though not in fact necessary.

It should be noted that so far not all mammologists are sufficiently informed about the possibilities of genomic diagnostics proposed by our expert, although such tests are already available in many countries, including the patient’s country of residence.

Consulting expert

Oleg Gluz

Professor, Dr. med., Leading mammologist and gynecological oncologist at the Breast Center Niederrhein, Moenchengladbach

Question 2

Multifocal Breast Cancer Treatment Options

Accepted Answer

Patient: A 57-year-old female patient was diagnosed with a soft tissue mass in the parasternal region. Watchful waiting recommended. The mass did not change in size for some time. However, three years after the patient discovered a lump in the lower quadrant of the breast. Both lesions were biopsied and confirmed to be malignant. Taking into consideration the complexity of the case (two cancer foci), the patient’s family insisted on seeking a second mammology opinion.

Available data: medical report, including breast ultrasound report, histology and immunohistochemistry testing of the breast tumor tissues, chest CT (report and images) and PET/CT report.

Problem statement:

Determine further treatment tactics.

Selected format:

Written second opinion.

Outcome:

The expert based his recommendations on the fact that both foci, according to histopathology tests, had the same biology (positive status of hormone receptors and negative expression of HER2). He also took into consideration tumor size and slightly accelerated cell proliferation, as well as the absence of distant metastases. In his opinion, two therapy options were seen as possible:

neoadjuvant (preoperative) chemotherapy for tumor downstaging (reducing the volume and infiltration of cancer) and making the parasternal mass operable, or

an attempt to conduct hormone therapy with an aromatase inhibitor.

In the latter case, another biopsy of any of the two foci was recommended in 2-4 weeks to evaluate the proliferative activity status (changes in the expression of proliferation marker Ki-67). If it decreased, hormone therapy could be considered highly effective, and then it should continue 4-8 months, subsequently followed by surgery and radiation therapy on the chest wall. Should proliferation not slow down, the expert highly recommended neoadjuvant chemotherapy, in case the patient’s physical condition allows.

Medconsonline comment:

The patient highly appreciated the detailed treatment recommendations, giving favor to the first option. The therapy was effective, and eventually a successful operation was performed.

Consulting expert

Oleg Gluz

Professor, Dr. med., Leading mammologist and gynecological oncologist at the Breast Center Niederrhein, Moenchengladbach

Question 3

Osteoporosis as a Complication of Breast Cancer Hormone Therapy

Accepted Answer

Patient: A 76-year-old female with a past history of invasive lobular breast carcinoma surgery. The patient underwent a five-year aromatase blocker (Letrozole) therapy course aimed at preventing cancer recurrence, accompanied by bisphosphonate treatment to prevent osteoporosis. A side effect of therapy was hyperplastic periodontitis. The patient sought a second opinion from an endocrinologist.

Available data: medical report, histological and molecular genetic testing of the breast tumor, oncological conference conclusion, CT osteodensitometry, a dentist’s report.

Problem statement:

Current drug therapy adjustment to find the best combination of cancer control medications in view of the patient’s severe osteoporosis.

Selected format:

Written second opinion.

Outcome:

An endocrinology expert reviewed the provided lab tests, radiology scans, mammology and dental summaries. The statement said:

“Since Letrozole treatment reduces bone density, it should necessarily be accompanied by bisphosphonates. However, bisphosphonates or monoclonal antibodies (e.g., Denosumab) should not be taken in case of periodontitis. Therefore I would recommend a selective estrogen receptor modulator (SERM) Raloxifene, which inhibits bone erosion. It should be taken into consideration that Raloxifene increases the risk of thrombosis; therefore not only bone density controls but also thrombosis prevention measures should be taken in course of treatment”.

Medconsonline comment:

The aim of the consultation was to seek the best possible treatment plan in view of the patient’s comorbidities. Our endocrinology expert recommended a correct combination of drugs which, on the one hand, would reduce the risk of breast cancer recurrence and, on the other hand, would not aggravate the concomitant disease.

Consulting expert

Werner Scherbaum

Professor, Dr. Med., A world-class specialist in internal medicine, diabetes, thyroid, rheumatic diseases and cardiology

Useful links:

Breast cancer treatment without chemotherapy

Mammology