2015-2016 y.y.
Anamnesis of the disease: sick since December 2014, when she first noted a short-term temperature rise to 37.2. In March 2015, she found a tumor formation in her right breast. Went to the doctor in May 2015.
Surgery: sectoral radical resection of the right breast. Tumor size 2,0 x 2,0 cm.
Histological conclusion No. 13413-419 - morphological picture of infiltrative ductal breast cancer with a predominance of the intraductal component G2, tumor size - 1,2cm. 11 lymph nodes were examined, there are metastasis of ductal breast cancer in 7 lymph nodes, 2nd degree of malignancy. Expression of antibodies to estrogen, progesterone was not detected. Ki67: 15-18%, Her2+++
Were provided ultrasound procedures of abdominal and small pelvis organs 15.06.2015, and radiography of the lungs, pathology was not detected.
20.08.2015 BRCA 1 and BRCA 2 genes were tested for mutations in the profile (hereditary cases of breast and/or ovarian cancer). Diagnosis: not detected.
Diagnosis: Cancer of the right breast pT1pN2M0 stage IIIA
Treatment:
Since 21.07.2015 till 22.09.2015 – 4 intravenously injections of AC (doxorubicin 101,4mg, cyclophosphamide 1014mg) were performed
Since 13.10.2015 – till 26.12.2015 – 12 injections of paclitaxel were performed. Everyweek till 12 weeks. Doze 80 mg/m2
21.10.2015 Started treatment with targeted drugs. First (loading) doze of trastuzumab was injected 528 mg.
Since 11.11.2015 till 23.06.2016 - 16 injections of trastuzumab was performed. Doze: 6mg per 1kg. Total 17 injections, every 21 day.
Since 17.11.2015 till 20.11.2015 in the radiological department, the first stage of the postsurgery course of remote gamma therapy was conducted on the regional lymph outflow routes (parasternal, cervical, supraclavicular, subclavian, axillary lymph nodes on the rightside) to total focal dose (TFD) = 20 Gy and right mammary gland TFD = 20 Gy
Since 11.12.2015 till 21.12.2015 in the radiological department, the second stage of the postsurgery course of remote gamma therapy was conducted on the regional lymph outflow routes TFD = 40 Gy and right mammary gland TFD = 46 Gy
20.01.2016 positron emission tomography of the whole body was performed. Diagnosis: the presence of foci of pathological metabolic activity in the breast tissue and the surgical scar is not determined. The center of metabolic activity is paraortal (possibly the center of activity of brown fat, since the substrate does not differentiate) The presence of enlarged lymph nodes is not detected. Signs of focal pneumonitis.
03.06.2016 - abdominal ultrasound procedure
01.06.2016 - spiral computed tomography of the pelvic bones, spine
02.02.2016 - spiral computed tomography of the chest.
Diagnosis: no osteo-destructive changes, no pathology
2018 year
in October 2018, the patient independently discovered an new formation in the right breast.
After that, the following medical examinations were performed:
16.10.2018 - breast puncture was performed. Cytologically - ductal carcinoma.
19.10.2018 - spiral computed tomography of the chest. (there are signs of limited pulmonary fibrosis on the right in S2)
16.10.2018 - abdominal ultrasound procedure. (cholesterol of the gallbladder wall)
16.10.2018 - Carcinoma antigen 15-3 – 4,4 units per ml.
24.10.2018 magnetic resonance imaging of the brain was performed. (asymmetry of the lateral ventricles of the brain. Diffuse and focal brain changes was not detected)
02.11.2018 positron emission tomography of the whole body was performed. Diagnosis: diffuse focal increase in the level of metabolic activity, within the threshold level. May correspond to relapse.
22.11.2018 Surgery was performed. Subcutaneous radical mastectomy on the right with simultaneous plastic endoprosthesis (Natrelle inspira tsf n-tsx340) and mesh implant.
26.11.2018 Histological examination №95967
Macro description: the mammary gland 13х12х3,0 cm, in the cut there is the seal area 7,0x4,0x2,8cm, gray color with foci of yellow and dark red color. Distance from the upper and lower edges of the resection ~1,0mm.
Micro description: invasive carcinoma in the mammary gland, non-specific type (1.5 cm) with peripheral intraductal carcinoma «in situ», nuclear grade 3 (3,0 cm)
structure formation - 2 points
nuclear polymorphism – 3 points
mitotic activity – 3 points
histological degree of malignancy by Eston&Ellis – G3, (2+3+3)-8
Histological evaluation of tumor response to chemotherapy drugs - II degree out of V by Miller-Payne - small regression of the tumor, reduction in the number of tumor cells, but in general, the cellularity of the tumor remains high, fibrosis, hyalinosis, moderate cell-nuclear polymorphism.
Background: fibrocystic breast disease
No signs of tumor growth were detected at the margins (resection edges)
27.11.2018 Immunocytochemical examination №95968
Macro description: immunohistochemical examination of the surgical material taken from the paraffin block
Micro description:
1. Immunohistochemical determination of oncoprotein Her2neu:
Tinting pattern - intensive membrane tinting.
Calculation: 3+
Overexpression score – positive.
2. Immunohistochemical determination of steroid hormone receptors with a rating on the scale Allred Score:
Extrogen receptors – weak positive (2+1=3)
Progesteron receptors – negative (0)
3. Immunohistochemical determination of the proliferative pool of a tumor by expression Ki67: 80%
Conclusion: invasive carcinoma in the mammary gland, non-specific type G3 (1.5 cm) with peripheral intraductal carcinoma «in situ», nuclear grade 3 (3,0 cm)
Histological evaluation of tumor response to chemotherapy drugs - II degree out of V by Miller-Payne
01.12.2018 Chemotherapy Treatment Required
