Are the neuroendocrine markers usually stained?

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Posted on Sat, 24 May 2014 in Cancer
Question: Hello,

I recently lost my wife of 30 years to breast cancer. My question is the pathology report. She was diagnosed from the biopsy and lumpectomy with invasive ductal carcinoma. After chemo therapy, she had a lymph node and margin surgery. This pathology report from another lab revealed the previous reports were incorrect and she was now diagnosed with primary Poorly differentiated neuroendocrine carcinoma. I’ve read now that Neuroendocrine markers are usually not routinely stained. Of course I wish I could go back to the beginning a request a second opinion on the first two path reports..

My question is this, are the Neuroendocrine markers usually stained ? This was April of 2013.

Thank you,
doctor
Answered by Dr. Aarti Abraham 55 minutes later
Brief Answer:
EXPLAINED BELOW

Detailed Answer:
Hello Mr. XXXXXX
Thank you for trusting us with your health concern.
I fully empathize with you for your loss, a void that can never be filled.
To answer your query
Do I understand this correctly - First your wife underwent a lumpectomy and biopsy - followed by chemotherapy - further extensive surgery. thus the two reports. Now, I have a few questions which will help me to understand the situation better .
1. Why was the report sent to two different labs ?
2. What was the time gap between the two surgeries - the lumpectomy and then the second extensive margin surgery.
3. Can you upload both the pathology reports.
NOw for my answers -
No, neuroendocrine markers are not routinely stained on a biopsy. The diagnosis of Neuroendocrine Carcinoma Breast ( primary ) ( NECB ) in itself is rarity, it comprises < 1 % of all breast carcinomas, it is that rare.
TO establish that this is indeed primary from the breast and not secondary from other organs, it is vital that on biopsy, breast cancer elements should be seen.
In most NECB , there are nests of areas which show features of other more typical breast cancers, such as invasive ductal carcinoma , for example.
However, the features of the cells do not fit in with those of typical invasive ductal carcinoma.
I hope I am making sense.
At first glance, it appears to be invasive ductal carcinoma, but there are atypical features ( hyperchromatic nuclei, more mitotic figures, nesting instead of tubular pattern of cells etc ), which prompt the pathologist to look further ie. perform more extensive staining to rule out NECB in the sample.
I guess what has happened is this -
1. THe first report was inadequate. What seemed at first to be invasive ductal carcinoma, was not properly and thoroughly evaluated by the pathologist for NECB, which I admit, is a bad lapse of judgement.
2. The lumpectomy specimen was not adequate enough to diagnose NECB. WHen a wider margin specimen was obtained, areas suspicious of atypical looking invasive ductal carcinoma emerged - and then staining for NECB was done.
3. Simple - the earlier report was an error. Whether this was the case, can be corroborated by having a deeper look at the second report, wherein , ductal components should have been present in the NECB sample, if present, then the earlier report was not an error, just incompletely processed. I mean, step B was not performed after step A, due to inadequate evaluation and lack of suspicion. IF no ductal components are present in the second report too, then the first report was a sheer mistake.

I do not know how much of this makes sense to you, I have tried to separate the proverbial wheat from the chaff, and keep the subject matter as less technical / scientific as I can, but some amount of medical jargon is inevitable.
I would look forward to reviewing the two reports, if it is possible to upload them.
Take care.
WIsh you a good day.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
doctor
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Follow up: Dr. Aarti Abraham 1 hour later
Thank you,
Report, pathology:
Case #: S13-15354 Collected: 4/11/2013

FINAL PATHOLOGIC DIAGNOSIS:
____________________


A. Lymph node, right axillary, sentinel #1, biopsy:
- one lymph node positive for metastatic carcinoma (1/1),
1 cm maximum dimension with extracapsular extension

B. Lymph node, right axillary, sentinel #2, biopsy:
- two of three lymph nodes positive for metastatic carcinoma (2/3)

C. Breast, right, excision without wire-guided localization:
- tumor type: invasive ductal carcinoma
- Nottingham SBR histologic grade 3 (1-3):
- tubule score 3; nuclear score 3 ; mitosis score 3
- size of invasive carcinoma: 27 mm (gross measurement)
- tumor site: not specified
- tumor focality: single focus
- lymph-vascular invasion: identified, extensive
- dermal lymph-vascular invasion: N/A
- in situ component:
- negative for lobular carcinoma in situ (LCIS)
- negative for ductal carcinoma in situ (DCIS)
- extent of tumor:
N/A (skin, nipple, or muscle not sampled)
- margins:
- margins negative BUT CLOSE for invasive carcinoma
- closest margin, inferior, negative by 0.1 mm
- lymph node (summary of all specimens):
- lymph node sampling:
sentinel lymph node(s)
- sentinel lymph nodes examined: 4 (parts A and B)
- total number of lymph nodes examined: 4
- lymph nodes with macrometastases: 3
- lymph nodes with micrometastases: 0
- lymph nodes with isolated tumor cells: 0
- lymph nodes without tumor cells identified: 1
- size of largest metastatic deposit: 10 mm
- extranodal extension: identified
- size of extranodal component: 5 mm
- cold ischemia time: 29 min
- total time in fixative: 29 hr
- ER, PR, and Her2 summary:
- ER and PR studies performed on prior biopsy
- Her 2 studies (FISH) performed on prior biopsy
- pathologic TNM staging: pT2 pN1a (sn)

D. Breast, right, additional deep margin, excision:
- negative for residual carcinoma
- radial scar, sclerosing adenosis and calcifications
identified in association with benign ductal epithelium
____________________




Microscopic Description:
A. The sections consist of one lymph node positive for metastatic
carcinoma. The metastatic carcinoma measures 1 cm maximum
dimension and shows 5 mm of extracapsular extension.

B. The sections consist of three lymph nodes, two of which are
positive for metastatic carcinoma. The largest metastatic deposit
measure 1 cm maximum dimension. There is no evidence of
extracapsular extension.

C. The sections consist of a breast excision specimen. There is a
poorly differentiated invasive ductal carcinoma with marked nuclear
pleomorphism, no tubule formation and extensive mitotic activity
(27 mitotic figures per ten high power fields). There is
associated necrosis and extensive lymph-vascular space invasion.
There is no definite evidence of ductal carcinoma in situ. There
is no evidence of lobular carcinoma in situ. The invasive
carcinoma is located 0.1 mm from the closest, inferior margin, on
slide C9. This is present as lymph-vascular space invasion. The
invasive carcinoma is located 2 mm from the closest deep/posterior
margin, 6 mm from the closest anterior margin, 8 mm from the
closest medial margin, 15 mm from the closest superior margin and
it is not identified in sections with the lateral margin. There is
a radial scar and sclerosing adenosis with associated
calcifications in the section from the lateral margin. An
intraductal papilloma is identified on slide C2.

D. The sections consist of breast parenchyma and skeletal muscle
with no evidence of residual ductal carcinoma. There is a radial
scar, adenosis, sclerosing adenosis and calcifications identified
in association with benign ductal epithelium.

Clinical History:
Surgical Dx: Pre-Op Diagnosis Codes:
* FEMALE BREAST CANCER [174.9]
Surgical Procedure: Procedure(s):
BREAST LUMPECTOMY EXCISIONAL W SENTINEL LYMPH NODE BIOPSY
-Specimen Number: 1fresh
-Specimen Type: Fresh
-Specimen: Sentinel Node #1 Right Axilla
-Specimen Out of Body Time (Breast Only): 1053
-Room Number: 1
-OR Phone: 311301
-Specimen Number: 2
-Specimen Type: Fresh
-Specimen: Sentinel Node #2, Right Axilla
-Specimen Out of Body Time (Breast Only): 1103
-Specimen Number: 3
-Specimen Type: Fresh
-Specimen: Right Breast Lump-short stitch is superior, long is
lateral, double stitch is deep
-Specimen Out of Body Time (Breast Only): 1136
-Specimen Number: 4
-Specimen Type: fresh
-Specimen: Additional deep tissue where tumor was probably
close-suture is at closest point
-Specimen Out of Body Time (Breast Only): 1138





the second pathology report is a pdf, don't know how to get this to you yet.

She did a biopsy then within a few weeks a lumpectomy. With the diagnoses from the first two pathology reports, started 3 months of chemo. PET scans were accomplished and showed no other cancers. When that was over, went in for a margin improvement and lymph node removal. That pathologist from a different lab re-diagnosed it as, primary poorly differentiated neuroendocrine carcinoma. By this time, the cancer had grown and spread to her liver.
3rd path report, I don't know what this all means.
we switched from an hmo to a cancer clinic for chemo after intial surgery this is why the different labs.






female who noted a thickening in her right breast on self-examination approximately one and a half months ago. She presented for evaluation, at which time a bilateral mammogram and right breast ultrasound was performed revealing a vaguely delineated medium sized rounded structure in the right breast measuring 1.5 cm in size as well as a focus of pleomorphic calcifications in the left upper outer quadrant, findings interpreted as category 4, suspicious, bilateral breast biopsy is recommended. She proceeded to a left breast biopsy on March 19th, which revealed benign findings. However, on March 22nd she proceeded to a right breast biopsy revealing poorly differentiated invas ive ductal carcinoma, ER/PR negative, HER-2/neu negative. Subsequently , on Apr il 11th she underwent a right lumpectomy/lymph node evaluation revealing a 2.7 cm focus of poorly differentiated invasive ductal carcinoma, margins negative yet with a 0.1 mm inferior margin, with evidence of extensive lymphovascular invasion, three of four sentinel lymph nodes positive, largest metastatic focus measuring 1 cm in size, with evidence of extracapsular extension. She is scheduled to proceed to a right axillary lymph node dissection in the near future. She presents today seeking a medical oncology opinion and possibly a second breast surgical opinion. Of note, she denies any systemic symptoms of concern. Furthermore, with respect to right breast findings, she denies overlying skin change, nipple retraction/discharge, or regional lymphadenopathy.




Right breast biopsy/right lumpectomy/sentinel lymph node evaluation as outlined above.


IMPRESSION:
1. Poorly differentiated right breast invasive ductal carcinoma, pathologic stage T2N1Mx, ER/PR negative, HER-2/neu negative, status post right lumpectomy with close margin, and sentinel lymph node evaluation, three of four lymph nodes positive.
2. Personal/family history potentially concerning for an hereditary breast/ovarian cancer syndrome.

RECOMMENDATIONS: I reviewed medical record as it relates to her recently diagnosed right breast cancer. As outlined above, workup is consistent with T2N1 disease, poorly differentiated invasive ductal carcinoma, invasive focus measuring 2.7 cm in size with a close margin, three of four sentinel lymph nodes positive with evidence of extracapsular extension. Using the Adjuvant! Online Risk Assessment tool, her estimated risk for systemic recurrence with no systemic therapy is approximately 6%. Since her lesion exhibits a triple negative phenotype, there is no role for adjuvant antihormone therapy or adjuvant Herceptin. However, given her stage at presentation, she certainly is an appropriate candidate to proceed with adjuvant chemotherapy which can reduce her risk of systemic recurrence to approximately 38%. In this regard, we reviewed a typical adjuvant chemotherapy treatment schedule consisting of dose­ dense adjuvant Adriamycin/Cytoxan x 4 cycles followed by dose-dense Taxol x 4 cycles. We reviewed possible side effects related to such treatment including but not limited to cytopenias with resultant infection and/or anemia, nausea, vomiting, alopecia, fatigue, cardiotoxicity, neurotoxicity, postmenopausal
symptoms, musculoskeletal symptoms, and an approximately 0.25% incidence of experiencing a secondary leukemia. I provided Ms. XXXXXX with written information on the aforementioned chemotherape utic agents for her further review. We also discussed the recommendation to proceed with Neulasta support on day 2 to minimize the depth and duration of Neutropenic XXXXXXX and associated infectious risk.

As outlined above, she is scheduled to proceed to an axillary lymph node dissection in the near future. defer to her surgical team regarding the recommendation for a completion lymph node dissection and



whether a reexcision is also recommended to optimize her margin status. We reviewed that she does not approximate the eligibility criteria for the Z0011 trial given that she has three lymph nodes positive.

Following chemotherapy , she will proceed with adjuvant radiation therapy.

review.

Irecommend proceeding to a PET scan to further stage her disease as well as a pretreatment echocardiogram. Furthermore, in order to facilitate chemotherapy administration, I recommend placement of a subcutaneous port.

Questions were addressed to her satisfaction. She is planning to proceed with further surgical
management as recommended . If she opts to proceed with medical oncology care under my management, Iasked that she notify my office at which time I will coordinate initiation of therapy.

Breast cancer
Date of Diagnosis : 03/22/2013
TNM staging: T2 Pathologic N, pN1a, M[Unknown], Location: right breast. Stage at diagnosis: unknown.

Histology: invasive ductal carcinoma. Histologic grade: 3. Lymphovascular invasion: extensive. ER/PR: ER status: negative, PR status: negative. HER-2/neu: Receptor status: FISH negative. Ki-67/MIB-1: LI: unknown.
Current status: no evidence of disease.

.
Collection Information
Collection Date and Time
9/23/2013 1923


Result Narrative


Collection Date and Time
9/23/2013 1923






Collected 09/23/13 19:23:00


PATHOLOGY REPORT

Accessioned 09/24/13 11:49:00




Completed
10101/13 11 = 24 = 1s


Clinical Information

Malignant neoplasm of breast (female), unspecified site; preliminary issued
9/30/13

A . AXILLARY CONTENTS:



Diagnosis

- Two out of nine lymph nodes are positive for metastatic carcinoma, up
to

1.4 cm in span with extranodal extension, (2/9).



Encounter Date:
09/12/2013


B. DESIGNATED RIGHT BREAST RE-EXCISION OF LUMPECTOMY MARGINS:

- Invasive, poorly differentiated neuroendocrine carcinoma, 0.35 cm in span, SEE COMMENT .
- Surgical margins are negative for neoplasm; however, the invasive carcinoma approaches within 0.5 mm of the orange-inked superior margin, 2 mm from the posterior black inked margin, and 3 mm from the inferior
green-
inked margin.
- Skin -- negat ive for tumor.
- Surgical cavity biopsy site -- status-post prior biopsy/lumpectomy at ------ hospi1:al.
- Fibrocystic disease.







,.,

Pathology Synoptic
Specimen type: Right breast re-excisio of lumpectomy, wire localization Specimen size: 5 .5 x 0.6 x 3. .5 grams
Laterality: Right
Tumor type present : Invasive neuro.endocrine carcinoma Tumor site: Unspecified
Invasive carcinoma
Histologic type: Neuroendocrine carcinoma Size of invasive component : 0.35 cm
Histologic Grade - Nottingham combined histologic score: 3 out of 3 (Tubules : 3, Nuclear Grade: 3, Mitotic Count : 3, Total Score : 9/9} Tumor focality: Single focus
Number of foci: Single focus Sizes of additional foci: N/A
Jn situ carcinoma (DCIS): N/A Calcification:
Within benign component: Not identified Within in situ component : N/A
Within invasive component : Not identified Lymphovascular invasion : Not identified in current case Nipple : N/A





r I
Encounter Date:
09/12/2013


09/23/13 19:23:00 09/24/13 11:49 :00 10/07/13 11:24:15

Skeletal muscle: Negative Surgical margins :
Invasive carcinoma : Negative
Distance from closest margin : Less than 0.5 mm from the orange-inked superior margin
DCIS : N/A
Distance from closes margin: N/A Lymph nodes
Lymph node sampling: Axillary lymph nodes in current specimen; prior sentinel lymph node and right axillary biopsies performed at -----
(CS13-
15354, ------ report, which reported an
additional
sentinel lymph node and three right axillary lymph nodes
.. Lymph node status is as folows :
ri Total number of positive metasta tic lymph nodes/total lymph nodes
examined: 2/9 in current specimen; Kaiser Pathology Report , 813-15354,
. orted an-additional sentinel lymph node ich was positive and two out of three right axillary lymph nodes which were positive (3/4)
• Number of sentinel lyrr.ph nodes examined : Solitary lymph node from Kaiser (CS13-15354)
Lymph nodes with macrometastases (>0.2 cm): 1 in current specimen; 3
LI
add 'l lymph nodes reported in prior ------ Pathology report (513-15354)
Lymph nodes with micrometastases (>0.2 mm and < or = 0.2 cm): 1
Lymph nodes with isolated tumor cells (< or = 0.2 mm and < or = 200):

1
II reported by
Size of largest metastatic deposit : Extranodal extension: Yes




Additional pathologic findings : Fiystlc disease
TNM Stage (AJCC 2010, 7th ed) : pr.[, pN-see comment Special Studies : ----- 'f}J
II Performed on this specimen : Yes ?/ ) -/--

Performed on another specimen : Estrogen Receptor: Negative Progesterone Receptor: Negative
Proliferation Rate (Ki-67): Hjgh
" HER-2/neu by fluorescence in situ
Block examined : Bll




(greater than 20%)
hybridization (FISH) : See below


Note : Block with tumor for possible additional studies: Bll, 812




The CEN-

RIGHT BREAST RE-EXCISION OF LUMPECTOMY MARGINS (Bll ): Invasive ductal
carcinoma, negative for amplification of HER-2/neu gene by FISH study . average score per tumor cell is 1.80 for HER-2/neu probe and 1.60 for
17 probe . The HER-2/neu to CEN-17 ratio is 1.13. Immunohistochemical
study for HER-2/neu oncoprotein is also negative (score 0).


HER-2/neu interpretation by ----- Cai, M.D ., Ph.D .
XC/jh
n



...
ti



Collected 09/23/13 19:23 :00

PATHOLOGY REPORT

Accessioned 09/24/13 11:49:00



Completed 10/07/13 11:24:15


10/2/13

COMMENT: This case was discussed in detail with ---- on Wednesday, October 2, 2013, at 10:21 a .m. As mentioned at that time, it
is
ti
important to review the prior pathology material to search for an in situ
ductal component to help determine whether or not this is a primary neuroendocrine carcinoma versus a metastatic lesion from another source .
I
II have had an opportunity to review the original ----- core needle biopsy only, which shows that this is the same neoplasm as the current material, • based on the tt .& g, stained slides. Idid not receive tfie Kaier lumpectomy , which would be of intereSE to search for'l:'i1"""situ component .
Therefore , it is recommended that the initial lumpectomy surgical
pathology
II glass slides, from ------ be reviewed.

The stage p'r 2 is taken from the ----- report, which reported an invasive carcinoma , 27 rrun in span.


"


Description: Received is a portion of adipose tissue that measures 7.0 x
5.0 x 2.0 cm. The specimen is dissected to reveal 9 lymph nodes that

in size from 0.1 to 2.0 cm. One lymph node is sectioned to reveal

grossly
positive cut surfaces .

SECTIONS:
Al . 4 nodes
A2. 3 nodes
A3-4. One node bisected
A5 . Representa tive section of grossly positive lymph node .

f l B. RIGHT BREAST RE-EXCISION OF LUMPECTOMY MARGINS
Received fresh labeled with the patient name (initials LGT) Additional documentation : None
Specimen contains: Needle localization wire
I

Orientation: Previously inked by surgeon
ti The margins are marked as follows: posterior black, superior
orange,
inferior green, lateral yellow, medial
II purple.

PATHOLOGY REPORT


Collected
" 09/23/13 19:23:00

Accessioned 09/24/13 11:49 :00

Completed
10/07/13 11:24:15







into

Specimen size and weight: 5 .5 cm from medial to lateral, 0.6 cm from superior to inferior, 3.0 cm from anterior to posterior, 22 .5 grams Skin : 5.4 x 1.6 cm . A well healed scar is noted that measur es 3.0 cm. Number of slices: Serially sectioned sagittally from medial to lateral

13 sections
Lesion focality : 1 biopsy cavity
Lesion site and size : Slices 5 through 12, 2.4 cm from medial to lateral,
1.8 cm from anterior to posterior, and 0.8 cm from superior to inferior. Dis ance from surgical margins: 0.2 cm from the posterior margin , 0.5 cm

from the superior margin, 0.6 cm from the inferior margin, 0.8 cm from

skin, 0.6 cm the lateral margin, and grossly free from the medial margin. Remaining tissue: Yellow lobulated adipose tissue with approximately 10% fibrous tissue . No definitive tumor is identifjed surrounding the

cavity .
Three possible lymph nodes are identified in slices 10 through 13 that
range in size from 0.3 o 0.4 cm.
Tissue submitted Entire biopsy cavity is submitted. Approximately 70%
of
the remainder of specimen is submitted .

SECTIONS:
rr Bl . Representative section of the margin
B2 . Representative section from slice 3
83. Representative section of slice 5, biopsy cavity to closest posterior
ti margin and inferior margin
84 . Representative section of slice 6, biopsy cavity to posterior, superior and inferior margins
85-6. Slice 7 bisected
87-8. Slice 8 bisected
89-10. Slice 9 bisected
Bll . Representative section of slice 10 including biopsy cavity and first
lymph node
812. Representative section of slice 11, including biopsy cavity and remainder of first node
" 813 . Representative section of slice 12, entire second node
814. Remainder of slice 12 including remaind er of biopsy cavity and representat ive section of third lymph node
B15. Representative sections of medial raargin and remainder of third node.

II SCM/SCM

Microscopic Description

11 A. DESIGNATED "AXILLARY CONTENTS": Two out of nine lymph nodes are positive for metastatic carcinoma, the largest of which is 1.4 cm on
slide


Encounter Date:
09/12/2013


AS, with extranodal extension (2/9). The deposit in slide A2 represents
a
metastasis up to 1 mm .


PATHOLOGY REPORT


Collected 09/23/13 19:23:00

Accessloned 09/24/13 11 :49:00

Completed 10/07/13 11:24 :15


B. RIGHT BREAST RE-EXCISION OF LOMPECTOMY MARGINS: A surgical cavity biopsy site is relatively empty and is lined by benign stratified
squamous
n
epithelia with mild hyperkeratosis. This is marginated by reactive
fibroblastic response, fibrocystic disease, and in slides Bll and B12, there is residual invasive, poorly differentiated carcinoma, 0.35 cm in
I span. The superior orange-inked surgical margin in slide B7 is within

<• 0.5


mm of the invasive carcinoma. Elsewhere, there is chronic inflammation, hemosiderin-laden macrophages , foreign body multinucleated giant cell reaction and macrophages . 'rhe overlying skin ls atrophic and not

involved .

u IMMUNOPEROXIDASE STAIN RSULTS: A battery of immunoperoxidase stains is performed on blocks Bll for the first battery and 812 for the second battery . The results show that the tumor is negative with smooth muscle myosin heavy chain, p63, Brst-2 , estrogen receplor, progesterone
receptor,
marrunaglobin, and keratin 7. The tumor has a very high proliferative rate of greater than 20% and with nearly 100% nuclear positivity.

Subsequent stains on block Bll show that the tumor is also negative with lymphoid markers CD20 and CD45, and negative with triple melanoma stains. The tumor is strongly positive with high molecular weight and low
II molecular
weight keratins, keratin AE1/AE3, and CAMS.2 respectively. Also, the tumor
is strongly positve with the neuroendocrine markers, synaptophysin and
II CDS6 . For this reason, a TTF-1 and Napsin A and villin were ordered.




Bll.

The final battery of immunoperox idase stains was performed with CK20 performed on block 812 and villin, Napsin-A, TTF-1 performed on block

The lesion in block 812 is strongly positive with cytokeratin 20 . The lesion in block Bll is negative with TTF-1 , Napsin-A , and villin .

Control
slides worked.

The results of the immunoperoxidase stains favor a poorly differentiated neuroendocrine carcjn .


,
•,,.•
.






Histology: invasive ductal carcinoma. Histologic grade: 3. Lymphovascular invasion: extensive. ER/PR: ER status: negative, PR status: negative. HER-2/neu: Receptor status: FISH negative. Ki-67/MIB-1: LI: unknown.
Current status: evidence of metastatic disease.
Metastasis: Visceral status: asymptomatic visceral disease, Location: liver.


DIAGNOSIS/TREATMENT HISTORY:
1. Poorly differentiated right breast invasive ductal carcinoma, pathologic stage T2N1MO, ER/PR negative, HER-2/neu negative.
a. Right lumpectomy with close margin and sentinel lymph node evaluation, 3 of 4 lymph nodes positive, April 11, 2013.
b. Status post four cycles of dose dense adjuvant Adriamycin and Cytoxan.
c. Status post two cycles of dose dense adjuvant Taxol thereafter transitioning to Taxotere due to Taxol related side effects, status post one cycle of Taxotere.
d. Right breast reexcision, further lymph node dissection performed 10/07/2013 revealed a residual focus of invasive carcinoma however, immunostains are consistent with poorly differentiated neuroendocrine carcinoma, measuring 0.35 cm, margins negative, with 2 of 9 lymph nodes positive for metastatic disease, largest focus measuring 1.4 cm. Upon re-review of her lumpectomy specimen, a small intraductal component is identified, supporting that this is a primary breast neuroendocrine carcinoma.





2. Diagnosed with metastatic disease consisting of liver metastases . Final pathology
review/summary of breast cancer pathology supports a diagnosis of primary breast neuroendocrine carcinoma.

HPI: ---- to clinic today to review interval radiology results and coordinate ongoing care. Since her visit on the 18th, she denies any new symptoms of concern.

LABORATORY: CBC reveals a white count of 12.7, hemoglobin 13.1, platelet cont 356. Chemistry profile is pending.

RADIOGRAPHIC STUDIES :
PET scan performed 10/19/2013 reveals interval development of enumerable hepatic metastases measuring up to 2 cm in size with an SUV up to 8.4. Note is made of progression of right antral mammary lymph node size consistent with nodal metastasis.

IMPRESSION:
1. Right breast cancer as outlined above.
2. Personal/family history potentially concerning for an hereditary breast/ovarian cancer syndrome, BRCA testing denied, investigation in process.
3. Tobaccoism.
4. Hypodense photopenic focus thought to be site of prior stroke identified on staging PET scan has resolved per brain MRI performed 05/04/2013.
5. Residualfatigue, gradually improving.
6. Intolerance to Taxol/Taxotere, completing 3 of 4 planned cycles of treatment.

RECOMMENDATIONS: Unfortunately, followup PET scan reveals enumerable hepatic metastases, consistent with stage IV disease. We once again discussed that upon further pathology review, her case is most consistent with primary breast neuroendocrine carcinoma, unfortunately now with hepatic metastases, consistent with stage IV disease. Thus, we changed the focus of our discussion from treatment with curative intent to treatment with palliative intent. Given the histology of high grade neuroendocrine
carcinoma, preferred therapy consists of cisplatin/etoposide, both drugs administered on day 1, etoposide also administered on days 2-3, cycles repeated at 3 to 4 week intervals. I recommend repeating staging studies after two cycles of therapy to document response and guide recommendations for ongoing management. We discussed that while her disease is not curable it is treatable, likely with median survival in the range of 6-12 months, contingent upon disease natural history and response to therapy. We once again reviewed that primary breast neuroendocrine carcinoma is a very rare entity, thus treatment recommendations and outcomes are extrapolated from other sites of neuroendocrine carcinoma such as lung and gastrointestinal tract. We previously discussed possible side effects related to
cisplatin/etoposide. Questions were addressed to her satisfaction, and she is comfortable in proceeding with treatment as outlined above. She will return to clinic on October 30th to proceed with her first cycle of treatment. Iwill plan to reevaluate three weeks thereafter prior to proceeding to her second cycle of therapy. Iwill provide her with appropriate support medications including Zofran, Compazine and Ativan. In the interim I asked that she contact me if she experiences any unexplained systemic symptoms or adverse side effects related to treatment.



Time in consultation: 70 minutes, 100% of which was spent face to face with the patient taking an interval history, reviewing laboratory/pathology/radiographi c data, discussing/coordinating care as outlined above. Patient evaluated 3:15 p.m.- 4:25 p.m.





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doctor
Answered by Dr. Aarti Abraham 11 hours later
Brief Answer:
AS BELOW

Detailed Answer:
It is very clear that the lumpectomy tissue was not properly evaluated in the first place, the Oncology people were more thorough , as is to be expected.
Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar
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Answered by
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Dr. Aarti Abraham

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