TEACHING POINTS• Women may not have the usual symptoms of breast cancer, even in the presence of metastatic disease. This is why mammograms are so important.
• Once breast cancer has been diagnosed, the histology has little prognostic value compared with the adequate staging of the cancer, and a treatment plan is formulated based on the stage of the disease and the tumor expression.
• A positive receptor status indicates that the tumor will likely respond to hormonal therapy. Overexpression or amplification of the HER2 gene usually indicates a poorer prognosis because such tumors typically have a less favorable response to hormonal therapy.
• The increase or decrease in tumor markers, such as cancer antigen (CA) 27.29 and CA 15-3 can help track both the course of the
disease and the response of the disease to treatment.
• The more advanced the stage of the cancer, the more likely the patient will receive chemotherapy to prevent metastasis and reduce
the risk of recurrence. Radiation therapy is used to reduce the risk of local recurrence.
CASE
A 56-year-old white woman in good general health initially presented to the emergency department on July 4, 2000, with jaundice and intermittent abdominal pain that had also occurred on several previous occasions. Her symptoms were consistent with cholelithiasis, and as part of her workup, ultrasound of the right upper quadrant was ordered. Testing confirmed cholelithiasis and revealed suspicious liver lesions. Endoscopic retrograde cholangiopancreatography (ERCP) was ordered, the obstructive stone was removed, and the jaundice resolved.
Two weeks later, the patient underwent laparoscopic cholecystectomy and biopsies of the liver lesions. Liver pathology results confirmed adenocarcinoma. Except for episodic abdominal pain and transient jaundice, the patient was asymptomatic and denied weight loss, change in appetite, or early satiety. Her medical history included a prolapsed uterus for which she underwent a total hysterectomy in 1982 and a clogged breast duct in October 1995. She began menopause in 1998. Her family history was positive for breast cancer in a maternal first cousin. The patient denied using tobacco, alcohol, or illicit drugs.
In August 2000, exploratory laparoscopy of omental and mesenteric nodules determined that the nodules were benign. At this time, the diagnosis was determined to be adenocarcinoma of the liver consistent with either cholangiocarcinoma or metastatic disease of unknown origin. Cholangiocarcinoma was considered the likely diagnosis based on the pathology evaluation as well as the lack of evidence supporting another site as the primary source of the disease. Because of the grim prognosis associated with the diagnosis, the patient was advised to accept her condition and make end-of-life decisions.
An unexpected twist Fortunately, the woman began researching her disease online and located a specialist at a nearby institution. After evaluation, he initiated chemoembolization of the liver using 50 mg of cisplatin and 10 mg of mitomycin. As part of his workup, the specialist ordered new scans. On review of the CT, he noticed thickening of the right breast.
Further ultrasound evaluation showed a 1.9×2.9×2.4-cm lesion. Biopsy of the lesion revealed infiltrating ductal carcinoma; estrogen and progesterone receptors were negative, but HER2-receptor status was positive. Comparison of the resected tissue with the previously biopsied liver lesion confirmed metastatic breast cancer.