Breast cancer treatment and survival have been improving in recent years, including among women with stage IV disease. Some women are able live for over a decade after a distant metastasis is found. Below we summarize the case of one such UK woman with HER2/neu overexpressing (HER2+) disease.
The woman, whose name is not given but we will call "Jane," was 46 years old when she was first diagnosed and underwent a mastectomy of her right breast plus axillary node dissection in 1993. Pathology showed that she had multifocal breast cancer, with one 8 mm grade 1 tumor and two grade 3 tumors of 10 and 25 mm in size. No lymph node metastases were found (i.e., she was lymph node negative). Jane's estrogen receptor (ER) and progesterone receptor (PR) status was not determined, but she was treated with five years of tamoxifen (which is normally given for hormone receptor positive disease) after surgery.
In December 2002, after almost 10 years, Jane was diagnosed with breast cancer in her remaining breast. It is not clear whether this was a relapse of the original cancer or a new primary breast cancer. Jane underwent a mastectomy of her left breast, as well as axillary node dissection. Pathology showed that Jane had a grade 3 (ER+/PR-) invasive ductal tumor of 23 mm in size with vascular invasion (invasion of the cancer cells into the blood vessels). This time, Jane had two positive lymph nodes. After recovering from surgery, Jane underwent six cycles of FEC (5-fluorouracil (5-FU), epirubicin and cyclophosphamide) chemotherapy and chest wall radiotherapy. She was again treated with tamoxifen based on having a weakly ER+ tumor.
First distant recurrence
Less than two years later, in August 2004, Jane had back pain which turned out to be due to multiple spinal bone metastases, with some spinal cord compression. Jane received effective pain relief from palliative radiation treatment to the spine. She then was treated with six cycles of Taxotere chemotherapy in combination with Herceptin (indicating that she was HER positive). Jane was also switched from tamoxifen to the aromatase inhibitor Femara. She also underwent two years of treatment with zoledronic acid (a type of bisphosphonate). Jane was also placed on a regimen of three weekly infusions of Herceptin, to be continued indefinitely.
Second distant recurrence
Jane continued under the Femara, zoledronic acid and Herceptin regimen for two years with good response. However, she then started experiencing slight nausea and had abnormal liver function blood test results. This led to a CT scan in August 2006 which found a solitary 9 cm liver tumor, in addition to numerous bone metastases. There did not appear to be any other new site in addition to the liver. The liver metastasis was considered inoperable. Jane was treated with Taxotere again and was also continued on Herceptin. After six cycles of Taxotere, the tumor diameter was more than halved, which made it operable. In March 2007, the tumor was removed (using an extended right hepatectomy) and Jane recovered quickly.
Third distant recurrence
Jane did well, with few symptoms of disease, until November 2007, when she again developed pain in her upper spine. An MRI actually showed some improvement in the extent of bone metastasis compared to the 2004 MRI scan. However, since Jane was in pain, she was again treated with palliative radiotherapy, which was effective in relieving the pain. Jane continued to be treated with Herceptin and Femara.
Fourth distant recurrence
Jane again did well, with few symptoms of disease, until June 2008 when she experienced headaches, dizziness and vomiting. A CT scan showed a single 33 mm brain metastasis. The entire mass was successfully removed surgically. This was followed by whole brain radiation treatment and Jane once again made a good recovery. At this point, Jane started receiving whole body CT scans every six months to check for additional metastases.
Fifth distant recurrence
A CT scan followed by a PET CT in May 2010 found a new 2.3 cm tumor in Jane's right adrenal gland. The PET CT demonstrated that this was the only remarkable source of uptake. In fact, only mild residual activity was found in the bone metastases and the liver and brain were clear. The adrenal gland was surgically removed in June 2010. It turned out to be a metastasis of poorly differentiated ductal breast cancer with moderate ER and weak PR positivity.
As of the April 2011 date of authorship of this case study, Jane was symptomatically very well and enjoyed a good quality of life. Her metastatic bone disease was quiescent. She continued to be treated with the Herceptin and Femara combination she had been taking for more than six years.