Patient description
- 57-year-old lady, 2 children (20 and 24 years), she works as a teacher for German and History
- Postmenopausal
- Family history:
- Aunt with breast cancer, age of 55 years
- Brother Colon cancer, age 55 years
Case history
Two years ago, she went to her GP for a regular check-up where a lump in her left breast was found. This led to referral for a mammography, which showed a 3 cm large lump, a biopsy was performed which revealed a HR pos, HER2 negative breast cancer, G2, Ki67: 35%. Her axillary lymph nodes without pathological findings.
Physical examination results
She is in good performance status. No limitation in her daily activity. She had a cT2 cN0 HR pos. HER2 neg. breast cancer.
Results of pathological tests and other investigations
At that stage, she received a CT scan of the chest, abdomen and pelvis and a bone scan with evidence of two 2 cm nodules, suspicious of lever metastasis.
BRCA testung was performed and did not reveal a germline BRCA 1/2 mutation
CA 15-3 was always within the normal ranges.
Treatment plan
She received CDK4/6i + AI for two years now, which was well tolerated. She recently complains about increasing back pain. There is no loss of sensibility or range of motion.
Expected outcome of the treatment plan
Inhibition of a tumor growths of the metastasis for as long as possible.
Actual outcome
Due to the elevation of CA15-3 and her back pain, she went to her oncologist. There, a CT scan was performed. This revealed one new lever metastasis with a regression in the other two and known metastasis within the lever. A bone metastasis was found in her lumbar spine.
