Integrative Tumor Board: Metastatic Breast Cancer

Abstract

History of present illness In December 2000, a routine mammogram showed a large zone of calcification involving the right breast. A sonogram revealed a solid oval mass measuring 0.8 × 1.0 × 0.6 cm in the retroareolar portion of the right breast. A biopsy of this area showed ductal carcinoma in situ (DCIS) with comedo necrosis, nuclear grade 2/3, lymphatic invasion absent. In February 2001, the patient underwent right simple mastectomy with sentinel lymph node biopsy. Pathology revealed extensive DCIS and focal invasive, moderately differentiated ductal carcinoma. The tumor size measured 1.0 cm, and resection margins were free of tumor involvement. Sentinel lymph node was negative for malignancy. Tumor was estrogen and progesterone receptor positive and Her-2/neu negative by fluorescence in situ hybridization (FISH) assay. The patient did not receive adjuvant chemotherapy, but following surgery, she was started on tamoxifen 20 mg daily. The patient continued to have regular menstrual cycles while on tamoxifen. The patient did well until October 2005, when she began to experience postprandial abdominal pain and nausea. In addition, she noted right hip pain and lower back pain. Extensive workup and restaging studies were performed. A computed tomography (CT) scan of the thorax, abdomen, and pelvis revealed small right axillary lymph nodes, mildly prominent lymph nodes in the anterior mediastinum, bibasilar effusions, an 11-mm lesion in the dome of the liver, ascites, multiple thickened loops of small bowel with mild dilation, gallstones, and findings suspicious for an omental cake formation. A bone scan showed diffuse sclerotic metastases involving the spine, ribs, calvarium, pelvis, and left proximal femur. Magnetic resonance imaging (MRI) viously in the reference range. In November 2005, the patient underwent bilateral thoracentesis. Cell block showed malignant metastatic adenocarcinoma, estrogen receptor positive, progesterone receptor negative, Her-2/neu negative by FISH assay. Tamoxifen was discontinued, and the patient was started on Zometa, as well as chemotherapy with Taxol and Avastin every other week. The patient received 2 cycles of chemotherapy with her local oncologist in New York. In December 2005, the patient presented to the Block Center for Integrative Cancer Care for a consultation on integrative cancer treatment. Beginning in January 2006, the patient commuted for treatment from her home in New York. She continued to receive weekly Taxol (day 8 given by local oncologist), Avastin every 2 weeks, and monthly Zometa. The protocol is based on the E2100 protocol. Her baseline serum tumor markers were as follows: CA 15-3 = 1334; CA 27,29 = 1708. In February 2006, tumor markers improved; CA 15-3 = 1035; CA 27,29 = 1081. In March 2006, a repeat staging CT scan of the thorax, abdomen, and pelvis showed a significant decrease in pleural effusions and no significant change in skeletal metastases or abdomen/pelvic findings. In April 2006, serum tumor markers continued to improve: CA 15-3 = 616; CA 27,29 = 712. At this time, the patient developed significant postprandial right upper quadrant abdominal pain. A HIDA scan revealed nonvisualization of the gallbladder, suggesting occlusion of the cystic duct. Avastin was discontinued temporarily because of potential cholecystectomy and increased risk of surgical bleeding. In May 2006, Taxol was placed on hold because of an upcoming cholecystectomy. In late May, the patient