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Section 1
Case History:68-year-old Woman Presenting with a Breast Mass and
Bilateral Pulmonary Nodules
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Summary of Case
(PATIENT OF DEBU TRIPATHY, MD)
1997: Initial Diagnosis
•1.3 cm breast density on mammogram,ultrasound
Core biopsy:moderately differentiated infiltrating
ductal carcinoma
ER: weakly positive;PR:positive
HER2:3+(Hercept test)
•Chest X-ray:1.0 cm nodule in right upper lobe
1.5 cm nodule in left lingula
Thorocoscopic biopsy:
Adenocarcinoma consistent with the breast lesion
ER: negative; PR: strongly positive
•Bone scan,bloodwork:negative
•Other medical history:Prior myocardial infarction,
left leg thrombosis, congestive heart failure (controlled
on medical therapy)
Therapy implemented by Dr Tripathy: Arimidex 1 mg
po qd
Outcome: After three months, partial radiographic
response was observed in the pulmonary lesions, which has
continued for four years. Patient has mild bilateral arthalgias
in her hands.
Key Discussion Points:
•Interpretation of patient’s ER, PR and HER2
results
•Chemotherapy vs endocrine therapy vs trastuzumab for
this patient
•Endocrine therapy plus trastuzumab
•Trastuzumab with or without chemotherapy
•Choice of endocrine therapy
•Choice of aromatase inhibitor
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INTERPRETATION OF PATIENT'S ER, PR, AND HER2 RESULTS
This tumor was weakly ER-positive — moderate or 2+ staining
in only ten percent of cells — but we still consider that a
positive value. Her progesterone receptor staining was strongly
positive — 3+ in 80 percent of cells. What exactly does that
mean in terms of her likelihood of response to hormonal therapy?
Most of us believe that there is a continuum, and that tumors expressing
less estrogen receptor have a somewhat lower likelihood of response
to hormonal therapy. But hormonal therapy is still a reasonable
option in a patient like this.
She was also HER2-positive.In the trastuzumab pivotal trial, 30
to 40 percent of patients were ER-positive, so it’s not that
uncommon. We estimate that eight to 10 percent of breast cancer
patients are HER2-positive and ER-positive.
The lung nodule was estrogen receptor-negative and strongly positive
for PR. It is not uncommon to see subtle differences in pathology
between the primary tumor and the metastatic disease. Sometimes
this reflects a true biological difference, but sometimes it is
an artifact of how the assay was done.So, it isn’t too unusual
to have a weakly ER-positive primary and then ER-negative metastases.
You rarely see a huge discordance, for example a tumor going from
strongly positive to strongly negative.
—Debu Tripathy, MD
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