Patients

TP Treatment Planning

02/14/2024 - 4:30 pm

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Subjective

07/16/2024: The patient is a 65-year-old woman who presents with a right breast mass. She is unaccompanied.

Initial complaint: In 2020, pt felt a large lump in the right breast that kept growing. First noticed in November 2020. She was found to have cancer, TNBC, and received chemo (carboplatin, Taxotere, Herceptin, and Perjeta). Biopsies in 2021 showed atypia. She was offered surgery but opted not to have it. She was started on Tamoxifen, then switched to anastrozole, but she stopped taking it in 2022. She did not have radiation. 
Since then, she was getting MMG q6 months. She has had no biopsies for now. She feels a lump in the right UO breast/axillary tail. It seems to be staying the same. She is doing alternative therapies. She was getting high dose Vitamin C 75 gm TIW, now 50gm BIW, taking fenbendazole, and getting RIFE treatments, which started about 6 weeks ago.
The patient states that although her port has been removed, she still has pain at the port site. She is concerned about the possibility of a port again.

LABS (GENETIC/GENOMIC): none available; had genetic testing, negative for mutation BRCA per pt.
  
PRIOR IMAGING: 2011 was the most recent normal MMG, according to reports, but there appears to be a large lag with the next available imaging from 2020.

BREAST PROCEDURES:

05/26/2021 - Right breast stereotactic biopsy. 10:00. 11Ga x multiple cores with and without calcs. Patient declined marker placement. Pathology: atypical ductal hyperplasia with focal calcifications. Changes consistent with tumor bed. Focal stromal sclerosis, chronic inflammation, and stromal histiocytes.

05/26/2021 - Right breast stereotactic biopsy. 12:00. 11Ga x multiple cores. Patient declined marker placement. Pathology: atypical lobular hyperplasia. Ectatic duct with inspissated secretions, periductal chronic inflammation, and adjacent foreign body giant cell reaction. Focal stromal calcifications.

11/09/2020 - Right breast stereotactic biopsy. 12:00 6cmFN. 9Ga x multiple cores with and without calcs; Top Hat marker. Pathology: ductal carcinoma in situ, high-grade, with central necrosis. Microcalcifications present. ER negative, PR negative.

11/09/2020 - Right ultrasound-guided biopsy. 10:00 4cmFN, 3.1 cm palpable mass. 14Ga x multiple cores; T3 Hydromark coil marker. Pathology: invasive ductal carcinoma with apocrine and micropapillary features, grade 2. Grade 3 DCIS present. ER-positive but weak, 15-20%, PR negative, HER2/neu positive (score 3+), Ki-67 10-15%.

11/09/2020 - Right ultrasound-guided biopsy. 10:00 4cmFN intramammary LN. 14Ga x multiple cores; T4 Hydromark butterfly marker. Pathology: benign intramammary lymph node. Adjacent high-grade DCIS, 1 mm.

11/09/2020 - Right ultrasound-guided biopsy. 10:00 3cmFN for 1.1 cm palpable mass. 14Ga x multiple cores; T1 Hydromark barrel marker. Pathology: invasive ductal carcinoma with apocrine and micropapillary features, grade 2. High-grade DCIS is present. ER weak, less than 1%, PR negative, HER2/neu positive (score 3+), Ki-67 10-15%.

GYNECOLOGIC HISTORY:

Menarche 13; FDLMP about 57 yo; menopause natural; G2P2, FFTB 34 years old; breastfeeding 6 months total; birth control use on and off for about 10 days, then DepoProvera about a year; HRT none; TAH-BSO n/a

CONSTITUTION:

Bra size: 34B
Height: 5'6"
Weight: 147# (lost about 10 pounds since dx with strict diet)
 
SOCIAL HISTORY:

Smoking/Vaping History: Never smoker/No vaping
Alcohol/Drug History: No alcohol use/No drug use
Diet: "home cooked paleo diet; No coffee, green tea 3-4 cups a day"
Root canals: 1996 left x 3 teeth, had removed in 2020
Occupation: "Pharmacist, nutritionist"

FAMILY HISTORY:

Breast cancer: none
Ovarian cancer: none
Other cancers: Bladder ca father 73 yo (smoker)
Ashkenazi heritage: none
Siblings: sisters: 3; brothers: 1
Children: daughters: 1; sons: 1

COVID-19 vax 2021; COVID-19 infection 2020

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Objective

07/16/2024: This is a visual exam only via televisit. The right breast is wider, and the left breast is longer. There is skin tenting at the site of the right upper outer breast lump near/at the axillary tail. There is also mild discoloration of the skin. The patient verifies that the skin moves over the lump.

MAMMOGRAMS/ULTRASOUNDS:

02/29/2024 - Bilateral diagnostic mammogram images and reports reviewed. The reports states: Tissue marker clips from previous biopsies are in the right breast. Magnification views of the right breast confirm increasing pleomorphic calcifications in the right breast at 10:00 5cmFN and 12:00 7cmFN. In the right axillary tail at 11:00 8cmFN is a new obscured irregular 1.1 cm mass. Total extent of disease measures 5.4 x 7.8 x 5.4 cm (AP by TV by CC). No suspicious areas of architectural distortion in the right breast. No suspicious masses, calcifications, or areas of architectural distortion in the left breast. BIRADS: 6 Known biopsy proven malignancy.

02/29/2024 - Right breast ultrasound images and reports reviewed. The report states: A 1.3 x 1.1 x 1.0 cm irregular hypoechoic mass with indistinct and angular margins, an echogenic rim, internal vascularity, and posterior acoustic enhancement corresponds to the new mammographic mass at 11:00 8cmFN. A survey of the right axilla confirms morphologically normal lymph nodes. BIRADS: 6 Known biopsy-proven malignancy.

12/28/2022 - Bilateral diagnostic mammogram and right breast ultrasound images and reports reviewed. The report states: mammogram shows that the breasts are heterogeneously dense, which may obscure small masses. The left breast is unremarkable. There are fine pleomorphic microcalcifications scattered within the upper outer quadrant of the right breast spanning a distance of approximately 8.4 x 4.9 x 2.2 cm, coming to within 3cmFN, increased from the previous exam, and encompassing the clumped non-masslike enhancement seen on 4/18/2022 MRI. There is no architectural distortion. There are biopsy clips in the upper outer quadrant at posterior depth associated with ill-defined nodules, unchanged from prior exams. Ultrasound targeted to the right upper outer quadrant was performed. There are two hypoechoic lesions containing biopsy clips. There is an ovoid lesion in the 10:00 position 6cmFN measuring 0.7 x 0.4 cm, and linear lesion in the 11:00 position 5cmFN measuring 0.9 x 0.3 cm, unchanged from 10/25/2021. There is no new suspicious mass. BIRADS: 6 - Known biopsy proven malignancy

10/25/2021 - Bilateral diagnostic mammogram and right breast ultrasound images and reports reviewed. The report states: mammogram shows that breasts are heterogeneously dense, which can limit the sensitivity of mammography. There is no mammographic evidence of malignancy or significant change on the left. There are multiple postprocedure clips which are seen in the upper outer right breast. There is a postprocedure clip in the right breast 12:00 position. A T1, T3, and T4 unremarkable are seen in the 10:00 position 8-9cmFN at the site of invasive ductal carcinoma/DCIS. There is no significant interval change in the distribution of calcifications in the right breast from the 9 through the 12:00 position. No new suspicious masses or architectural distortion. In the ultrasound of the right breast, there are postprocedure clips found in the right breast 10:00 position 3cmFN and right breast 10:00 position 4cmFN. The previously biopsied masses are no longer visualized sonographically. Post biopsy scarring is observed in the right breast 11:00 position 5cmFN at the site of stereotactic guided biopsy. No new suspicious solid masses or architectural distortion noted. BIRADS: 6 - Known biopsy proven malignancy

05/07/2021 - Diagnostic mammogram and targeted ultrasound of the right breast images and reports reviewed. The report states: mammogram shows that the breasts are heterogeneously dense, which can limit the sensitivity of mammography. Segmental pleomorphic calcifications are noted demonstrated in the right breast long the 9-12:00 axis measuring 7.4 cm AP, 8.0 cm medial-lateral, and 3.5 cm superior-inferior. A Securmark top hat biopsy marker is visualized at 12:00 6cmFN at site of high-grade DCIS. T1, T3, and T4 Hydromark clips surrounding hydrogel are visualized at 10:00 8-9cmFN, at sites of invasive ductal carcinoma/DCIS. Ultrasound of the right breast and axilla was performed. Two Hydromark clips are visualized at 10:00 4cmFN, and an additional Hydromark clip is visualized at 10:00 3cmFN. Previously biopsied masses are no longer visualized sonographically. There is postprocedural change/scarring in the right breast at 11:00 5cmFN at site of stereotactic biopsy. There is no associated vascularity. No suspicious right axillary lymph nodes. BIRADS: 6 Known biopsy-proven malignancy

10/28/2020 - Bilateral diagnostic mammogram and bilateral ultrasound images and reports reviewed. The report states: mammography shows a 1.2 cm ovoid obscured mass in the upper outer quadrant of the right breast at 10:00 7-8cmFN, with adjacent irregular focal asymmetries and architectural distortion upper outer right breast just anterior and inferior to obscured mass. Pleomorphic and fine linear calcifications are also present in the upper outer quadrant of the right breast 10:00 extending from middle to posterior depth. Additional grouped pleomorphic and fine linear calcifications right breast 12:00 6cmFN. No significant changes noted in the left breast. Bilateral ultrasound performed and upper outer right breast indicates a 1.2 x 0.5 x 1.1 cm oval circumscribed hypoechoic mass at 10:00, 4cmFN, showing diminished fatty hilum and increased cortical vascular flow suggestive of a pathologic lymph node. Additionally, an adjacent 3.1 x 1.2 x 2.5 cm irregular hypoechoic mass with indistinct margins is noted, correlating with a palpable lump. Posterior to the nipple at 10:00, 3cmFN, another 1.1 x 0.8 x 1.0 cm irregular hypoechoic mass with indistinct margins is identified. Multiple anechoic retroareolar ducts observed. In the right axilla, a 0.8 cm lymph node with symmetrical cortical thickening but no cortical vascular flow is seen, along with other benign-appearing lymph nodes. The left breast ultrasound reveals no suspicious cystic or solid masses, with anechoic retroareolar ducts. An incidentally noted 0.8 cm benign-appearing intramammary lymph node is seen in the upper outer left breast at 2:00.

BREAST MRI:

04/19/2024 - Bilateral MRI with and without contrast images and reports reviewed. The report states: the breasts are heterogeneously dense, which may obscure small masses. There is minimal background parenchymal enhancement. There are no suspicious enhancing masses, architectural distortion or non-mass enhancement in the left breast. There are several scattered foci of enhancement in the left breast. No abnormal nipple retraction or nipple enhancement. No abnormal skin thickening or skin enhancement. There is no axillary or internal mammary lymphadenopathy identified. No nonbreast findings. 
New enhancing masses in the right upper quadrant, the largest is in the axillary tail corresponding with findings seen on mammogram and ultrasound 2/29/2024. Patchy nonmass enhancement in the superior right breast centered at 12:00 likely corresponds to developing calcifications seen mammographically. There is additional non-mass enhancement at 10-11:00 that is new compared to prior exam and may correspond with the developing calcifications seen mammographically labelled 10:00. The constellation of findings on prior mammogram, ultrasound, and MRI is highly concerning for progression of disease. BIRADS: 6 - Known biopsy-proven malignancy

04/18/2022 - Bilateral MRI with and without contrast images and reports reviewed. The report states: minimal background breast parenchymal enhancement. No suspicious masses, enhancement, or lymphadenopathy in the left breast. Clumped nonmass enhancement is seen in the upper outer right breast this measures 4.0 AP x 2.8 transverse by 3.4 CC. There is a peripherally enhancing mass in the right breast 10:00 position 6cmFN which measures 1.1 x 0.8 x 1.2 cm. No suspicious lymphadenopathy. Findings in the right breast are concerning for recurrence of tumor. BIRADS: 6 - Known biopsy proven malignancy

04/19/2021 - Bilateral MRI with and without contrast images and reports reviewed. The report states: Breasts are composed of heterogeneous fibroglandular tissue and fat with presence of background parenchymal enhancement. The right breast shows complete imaging response to therapy as evidenced by no residual enhancement at the site of biopsy proven malignancy in the right breast 9-12:00. No rapidly enhancing masses or suspicious pattern of enhancement are observed throughout. Right axillary lymph nodes are not enlarged. In the left breast, no rapidly enhancing masses or suspicious patterns are identified. No axillary or internal mammary adenopathy is present, chest walls and nipple areolar complexes are unremarkable. BIRADS: 6 - Known breast carcinoma.

11/19/2020 - Bilateral MRI with and without contrast with CAD images and reports reviewed. The report states: mild background enhancement of the breast parenchyma. In the right breast, known multifocal malignancy is detected as masslike and nonmasslike enhancement extending along the 9-12:00 axes, starting approximately 0.7cmFN. This enhancement occupies a tissue volume of approximately 7.6 cm anteroposterior, 3 cm medial-lateral, and 4.7 cm superior-inferior, with heterogeneous and typical malignancy contrast kinetics. The left breast shows no suspicious mass or distortion, with no concerning enhancement on kinetic evaluation. No abnormal nodes are identified in the axillary regions or retrosternal space. The impression indicates unilateral, unicentric, and multifocal malignancy in the right breast, with the known malignancy appearing as described. BIRADS: 6 -Known malignancy.

PET/CT: none available.

LABS: none available.

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Assessment

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Plan

I had a thorough discussion with the patient, lasting about - minutes, which included a review of her imaging via Screen Share, pathology, labs, family history, and past medical history.

FDA approval and studies:
I explained that cryoablation is currently only FDA-approved for benign breast tumors, specifically fibroadenomas. Although cryoablation has been done for breast cancer since 2013, we do not yet have FDA approval, although it is anticipated in the future. That said, cryoablation has been shown to be a viable option for invasive breast cancers in women older than 60 that are less than 2 cm, estrogen receptor positive, and her2 negative. I let the patient know that several physicians like myself extrapolate this information of cryoablation for larger tumors, multifocal cancer, DCIS that is visible on ultrasound, lobular cancers, or cancers with biomarkers other than ER+her2- with good results. 
For IDC, ER+her2-, data is available for 5 years, which shows a recurrence rate of 3% with cryoablation. However, this may differ with larger or multifocal tumors, DCIS, or those with different biomarkers. This does not mean that the area cannot be treated; it simply means that we do not have as much experience. We can certainly extrapolate that there is no reason why cryoablation would not work in these instances with appropriate treatment.

Not a stand-alone treatment:
I explained that cryoablation is not considered a stand-alone treatment. Currently, it is considered an alternative to surgery on the breast. I explained that if the patient is recommended to have radiation treatment, endocrine therapy (anti-hormone), or chemotherapy, they will still be recommended to have those additional treatments with cryoablation.

I explained that in the 1990s, studies were done to show that a mastectomy (Mx) and a partial mastectomy (PMx) with radiation therapy (RT) are equivalent in effect when it comes to overall survival and disease-free survival. This means that whether the patient has a Mx or PMx combined with RT, their chances of having breast cancer again or dying of the disease are very similar. In effect, RT will sterilize the remaining tissue to give the same protection as a Mx. Since cryoablation is being used in place of PMx, I still would recommend radiation therapy after cryoablation, as I would with PMx.

Abscopal effect:
In our discussion about cryoablation, I included the idea of the abscopal effect seen in small animal studies, which in effect, allows the immune system to create a sort of self-vaccine. We then also see the shrinking of metastatic sites, even if only the primary cancer is treated in these animals. We have also seen this effect in men with prostate cancer who get cryoablation and radiation therapy. This has not been studied in breast cancer patients, although the information is promising and exciting. I further explained that when cryoablation is done, this procedure not only kills the cancer itself but also freezes the blood vessels to the cancer, which supply the nutrients and ability for the cancer to remove waste.

Procedure specifics:
Cryoablation procedure, alternatives including surgery, risks, benefits, and expected outcomes were discussed in detail. The patient understands that no liquid nitrogen actually goes into the breast itself. In reality, it is a matter of physics that the liquid nitrogen cools the probe, which in turn cools the tissue surrounding the probe.  I explained that in my hands, I use cryoablation to mimic what would be done in surgery. This means that I measure the treatment area on ultrasound throughout the procedure to make sure that we have at least 1 cm margins all the way around the tumor.
I also explained that after cryoablation, there is not a concentric decrease in the size of the treated tissue. There is a slow removal of the waste from the cryoablation zone and remodeling of the breast tissue at the same time. I explained that breast cells divide and grow at a rate of about every 60 to 90 days. This causes a slow replacement of the cryoablation zone and cryoablation tissue with her own breast tissue. At no time is there a divot or a defect in the breast. This means that she may not feel a definitive decrease in the size of the tumor from the outside in the first several months. The tumor area may feel softer or more pliable as it is slowly replaced with normal tissue. This entire process takes anywhere from 18 months to three or four years, depending on the tumor itself. Eventually, the lump will completely go away, and the tissue will feel like normal breast tissue.

Post-procedural considerations:
The patient had many questions about aftercare after cryoablation as well as follow-up. These questions were answered in full. She understands there are restrictions on taking supplements for two weeks after the procedure and that the breast will be significantly swollen and possibly bruised from the inflammatory response that occurs as a result of the procedure. We discussed the need for imaging at regular intervals as well as ultrasound-guided biopsy two months after the procedure to make sure that there has been a complete cancer kill. She can have this done in her hometown or with me. I am also happy to follow her future imaging, which will start in six months, although I explained that I am not a radiologist and cannot definitively read the images.  The images will need to be reviewed by a radiologist, as well.

- - - - - - - - - - 
I made sure that this patient understood that with - carcinoma that is larger than 2 cm in a young woman, she does not fit the criteria for a typical patient who is successful with cryoablation. The patient has declined surgery and would like to pursue cryoablation. With the currently identified extent of disease in her breast, she is a sub-optimal candidate for cryoablation. However, I believe that with appropriately targeted cryoablation of the breast, it is possible to encompass the entire area of the tumor with appropriate margins.

The patient's questions were solicited and thoroughly answered. She stated her complete understanding. She understands to reach out with any new concerns.

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