Case Study: Electrons

Olivia Rozsits

Fun Facts

Estimates for 2016

About 246,660 new cases of invasive breast cancer will be diagnosed

in women
About 40,450 women will die from breast cancer

About a 3% chance a womans death will be due to breast

cancer
Death rates from breast cancer have been declining since
1989
There are more than 2.8 million breast cancer survivors
in the U.S.

Patient History

44 year old caucasian female

From Hilliard
Nurse at OSUMC

treated with electrons to the

scalp for subcutaneous
metastatic lesions from
primary breast cancer
Treated at the Stefanie
Spielman Comprehensive Breast
Center

Past Medical History

2012: Stage IIIa (pT2N2a) G3 Invasive Ductal Carcinoma (ER/PR+, Her2-)

of the left breast

treated with bilateral mastectomy with immediate reconstruction

with adjuvant AC and taxol chemotherapy (until 4/2013)

post-mastectomy radiation to 5,000cGy in 25fx with a 1,200cGy boost

to the scar (end date: 7/2013)

Jan. 2015: diagnosed with biopsy proven metastatic osseous disease and
metastatic liver disease

12/2015: radiation treatment to the lower T spine and L spine for

palliation purposes of pain to the RLE: 30Gy in 10 fractions

Past Surgical History

10/2012: complete mastectomy

10/2012: lymphadenectomy
axillary deep

10/2012:breast
reconstruction

10/2013: total abdominal

hysterectomy

Social Family History

Married, 2 children
never smoked
occasional wine or beer
Mother is carrier of BRCA 2
Paternal aunt breast cancer at
age 56
cousin breast cancer at age 48
cousin ovarian cancer at age
58
paternal grandfather
colorectal cancer

Presenting Signs

headache and intractable N/V

pain localized to subcutaneous scalp tumors

Pale, anxious, and uncomfortable female patient who appears

ill. She has a slightly cushingoid appearance.

Common Presenting Signs

Breast CA:

Single, dominant, asymptomatic mass in the breast

Skin dimpling
Peau d orange
Nipple discharge
Pagets disease- a form of IDC or noninvasive carcinoma
Mammographic abnormality

Brain Mets:

Decreased coordination
Headache
Vomiting
Memory loss
fever

Personality changes
Seizures
Speech difficulties
Vision changes (diplopia)
Strange behaviors

Epidemiology

Most common cancer among women (besides skin)

2nd leading cause of cancer deaths in women

About of women diagnosed with IDC are age 55 and older

As age increases, the cumulative probability of

developing breast cancer increases

Risk Factors

Female > male

Increasing age
Family history of breast
cancer

Previous history of breast

cancer

Atypical hyperplasia

Previous chest radiation

Lack of breast feeding

Nulliparity

Early menarche

Late menopause

Increasing age at first

birth

Oral contraceptives

Postmenopausal hormone
replacement therapy

High alcohol consumption

Sedentary lifestyle

Genetic Factors and Hormone Receptors

BRCA1 & BRCA2: genes that help prevent cancer by making proteins
that prevent cells from growing abnormally
Breast cancers linked to these mutations occur more often in
younger women
ER+/PR+: estrogen-receptor and progesterone-receptor positive
Treat with tamoxifen, arimidex, aromasin, femara
Her-2: gene that controls growth, divide, and repair of cells
Treat with Herceptin (stops the growth of Her-2 cancer
cells)

Breast Anatomy

Extension
Superior: 2nd-3rd costal cartilage
Inferior: 6th-7th costal cartilage
Medial: edge of the sternum
Lateral: anterior axillary line
(Tail of Spence)

Lies over the pectoralis muscles

Attached to the chest wall via a layer

of connective tissue called Coopers
Ligament

Layers of the Skull

Lymph Nodes

Findings

Two large nodular tumor deposits on scalp: Right

parieto-occipital and left parietal area. Erythematous
tissue breaking through scalp

Right largest lesion: approx 1.5-2cm

Left largest lesion: approx 1.5cm

MRI Brain 2/9/16

MRI Brain 2/9/16

MRI Brain 2/9/16

MRI Brain with Contrast

MRI Brain with Contrast

MRI Findings

Interval increase in size and number of dural lesions compatible with progressive metastatic
disease

The left occipital lesion was present on the prior study and has increased in size, confirming
that it is likely neoplastic in nature

There are also several tiny new metastases throughout the bilateral frontal, parietal and
occipital scalp

No brain edema

No brain metastases are seen

Nuclear Bone Scan

Multiple foci of increased radiotracer
uptake throughout

Bilateral ribs

spine and pelvic bones

sternum

bilateral femurs

bilateral humerus

calvarium.

Patient Positioning and Immobilization

Prone on prone sponge

Pillow under ankles

Q fix pad

Treatment Options

Surgery

Modified Radical Mastectomy: removal of entire breast and

dissection (level 1 & 2)
Radical Mastectomy: removal of entire breast, axillary nodes,
pectoralis major and minor

Hormone Therapy

Axillary node dissection

Lumpectomy
Total Mastectomy: includes entire removal of breast

Tamoxifen: first hormonal treatment of choice

Anastrozole: aromatase inhibitor; decreases bodys estrogen; given
postmenopausal

Chemotherapy

Doxorubicin, Paclitaxel, Cyclophosphamide, Methotrexate, 5-FU, AC &T

Radiation Treatment Options

Tangents for outer quadrant lesions with uninvolved

axillary nodes
Tangents+Supraclav for outer quadrant lesions with
positive lymph nodes
Tangents+Supraclav+IMC for inner quadrant lesions
May do posterior axillary boost for deep and large
axillary involvement
Dose

Tangents: 4500cGy-5000cGy with electron boost of 1500-2000cGy

Supraclav: 4500-5000cGy

Treatment Plan

0.5cm Bolus on each field

Daily imaging (MV,kV)

Left Temporal Scalp

3,000cGy (10fx, 300cGy/fx)

6meV
G285, Kick Table to 340
338MU
20x20 Electron Cone
102.3cm SSD

Right Occipital Scalp

3,000cGy (10fx, 300cGy/fx)

G50, kick table to 330
361MU
10x10 Electron Cone
104.2cm SSD

Left Parietal Scalp

3,000cGy (10fx, 300cGy/fx)

6mev
G319
310MU
20x20 Electron Cone
103.27cm SSD

Dose Volume Histogram: L Temp Lobe

L Temp Lobe

Dose Volume Histogram: R Occip Lobe

R Occip Lobe

Critical Structures

Lens of the eye 1,000cGy

Brain stem 4,500cGy

Optic chiasm 5,000cGy

Spinal cord 4,700cGy

Side Effects

Breast
Acute skin reaction
Sore throat (supraclav)
Edema
Fibrosis
Telangiectasia
Pneumonitis
Cardiac toxicity
Rib fracture
Secondary malignancies

Scalp:
Patchy hair loss
Erythema
dry/flaky skin
Skin irritation

Histopathology

Ductal Carcinoma in Situ (15-20%)

Lobular Carcinoma in Situ (2%)
Invasive Ductal Carcinoma (60-80%)
Tubular Carcinoma
Medullary Carcinoma
Lobular Invasive
Mucinous
Adenocystic
Papillary
Pagets Disease
Inflammatory

Staging T

Tx- primary tumor cannot be assessed

T0- no evidence of primary tumor

Tis- Carcinoma in Situ

T1- tumor 2cm or less in greatest dimension

T2- tumor >2cm but <5cm in greatest dimension

T3- tumor >5cm in greatest dimension

T4- tumor of any size but with direct invasion into the chest
wall or skin

Staging N:

Nx:
N0:
N1:

N2:

N3:

the single most important factor in determining prognosis

is the presence or absence of metastasis to regional lymph
nodes

lymph nodes cannot be assessed

no regional lymph node involvement
regional lymph node involvement
A: spread to 1-3 nodes under arm with at least one area at least 2mm
B: spread to IMC
C: include both a and b
spread to 4-9 nodes under arm, or enlarged IMC
A: 4-9 nodes involved under arm, at least one 2mm large
B: spread to one or more IMC nodes
A: spread to one axillary node and to IMC node or to nodes under
clavicle
B: one axillary node and enlarged IMC node or spread to 4 or more
axillary nodes with IMC as sentinel lymph node

Staging M

Mx: distant metastasis cannot be assessed

M0: no distant metastasis found

M1: cancer has spread to distant organs

Most common spread to: brain, lung, liver, bone

Disease Prognosis and Survival

Stage

5 year Survival Rate

93%

88%

IIA

81%

IIb

74%

IIIA

67%

IIIB

41%

IIIC

49%

IV

15%

Possible Metastatic Sites

Lung

Liver

Pleura

Ovaries

Bone

Adrenal Gland

Brain

Pituitary Gland

Eyes

References

Class Notes

Cancer.org

Breastcancer.org

U.S National Library of Medicine