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Section 2
Case History: 44-year-old Woman Presenting with a Breast Mass and
Bilateral Pulmonary Nodules
Editor’s Note: On the accompanying audio program, Dr
Kevin Fox reviews a case of a 44-year-old woman who initially presented
with breast cancer and bilateral pulmonary metastases. To demonstrate
how practice patterns differ among physicians, Dr Patricia Madej,
a community-based oncologist, and Dr Linda Vahdat, from Colombia
University, commented on a number of aspects of this case.
In addition several excerpts are included from an interactive panel
discussion on a very similar case presented at the recent Lynn Sage
Breast Cancer Symposium. Finally, 20 oncologists in community practice
were surveyed on specific aspects of this case, and the results
from the survey, along with comments from the audio program, are
included below.
KEY DISCUSSION POINTS
• Overall perspective on women presenting with metastatic
disease
• Should tissue have been obtained from a pulmonary lesion?
• Local therapy of a 4 cm breast mass in metastatic disease
• Chemotherapy versus hormonal therapy
• Sequencing of endocrine therapy in premenopausal women
• Combining ovarian suppression with aromatase inhibitors
• Choice of chemotherapy in metastatic disease
• Altruism as a key component in trial participation
| Initial presentation: 44- year-old
asymptomatic premenopausal woman presents with 4 cm breast mass,
negative axilla.
Biopsy of lesion: Infiltrating ductal carcinoma. ER,
PR strongly positive, HER2-negative
Chest X-ray: Bilateral pulmonary nodules very suggestive
of metastases. Proximal location of lesions prohibits CT-guided
biopsy (a biopsy would require thoracotomy or thorocoscopy).
Relevant family history: Patient has two siblings
with a history of pulmonary emboli. Coagulation work-up is
negative.
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OVERALL PERSPECTIVE ON WOMEN PRESENTING WITH METASTATIC DISEASE
One of the reasons I presented this case is the rarity of this
clinical situation. We don’t see many patients presenting de
novo with metastatic disease 23-25. Our center sees about 500
new breast cancer patients a year, of which two or three present
with metastatic cancer — it’s quite uncommon. Her breast
mass at presentation was a little bigger than what we see on average,
but the patient did not indicate
she has been neglecting it. She has been an extremely compliant
patient. My observation after 17 years is that patients presenting
with metastatic disease with a clear history of negligence cross
all socioeconomic groups. There is a misguided notion that negligence
of breast lesions and the resulting untimely development of metastatic
breast cancer is a socioeconomic phenomenon.
—Kevin Fox , MD
This is not a common presentation, but we do see several
situations like this a year, of women presenting initially with
metastatic disease.
—Patricia Madej, MD
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