CASE STUDY
CASE STUDY TWO The 48 year old patient had a right sided 22mm Grade 2, 2/4 nodes positive ER 0 HER2 negative (T2N1M0) breast cancer treated in 2010 with chemotherapy and four field radiotherapy. She re-presented in 2016 with calcifications on a mammogram in her contra-lateral left breast, which was a biopsy proven high grade DCIS and staging blood tests were normal. She proceeded to left stereo wire guided wide local excision which removed 62mm of high grade DCIS, however surgical margins were positive requiring a re-excision which was clear. The decision of the multi-disciplinary team was radiotherapy to the left breast over five weeks. She attended for CT planning and the radiographer noted a small pulmonary nodule in her right lung of uncertain significance. This was discussed with the oncologist and although clinical suspicion was low, a chest x-ray was organised which subsequently confirmed the presence of a lung lesion. A CT chest and abdomen was then requested which unfortunately showed multiple liver metastases as well as a pulmonary metastasis. The patient completed her course of radiotherapy as she only had a few fractions remaining then a palliative course of chemotherapy was due to commence. Whilst this was an early detection of the lung lesion,
sadly combined with her liver metastases this meant that her disease was now incurable. Her initial cancer in 2010 was high risk as she was triple negative (ER0/ PR0/HER2 0) and node positive which confers a higher chance of developing metastatic disease despite her previous chemotherapy.
Case study 2.
CASE STUDY THREE This 74 year old patient presented with a symptomatic lump in her left breast and underwent imaging and biopsy which confirmed the presence of DCIS. She underwent left wire guided local excision which demonstrated a 12mm Grade 2 apocrine carcinoma (T1N0M0) with high grade DCIS extending to the margins. She had a re-excision and a sentinel node biopsy performed which showed no residual disease and 0/5 nodes were negative, ER 0 and HER2 0. Her minimal staging results were negative and despite her multiple co-morbidities, including chronic obstructive airways disease and peripheral vascular disease, she continued to smoke. The multi-disciplinary meeting decision was for a three week course of radiotherapy to her left breast alone. She attended for CT planning and the radiographer
noted evidence of a right sided upper lung nodule on the CT scan. This was discussed with the oncologist and as she was a known smoker, she was referred for an urgent CT of her chest. This showed a cavitating, spiculated mass in the right upper lobe measuring 15 x 21mm with no lymphadenopathy. Her breast cancer radiotherapy was then cancelled as it was a low risk cancer and she was referred to the respiratory physicians to investigate further. She remains on routine follow-up for her breast cancer. A PET scan was organised which confirmed a spiculated lung lesion, but the patient was felt to be too unfit for CT
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guided biopsy due to her poor lung function. Therefore a radical course of stereotactic ablative radiotherapy (SABR) of five fractions was offered to the patient and she was counselled on the risks of this, including a worsening of her shortness of breath which can be fatal. Despite the risk, she was keen to proceed. It was important in this case to avoid radiotherapy to her breast, as this may have compromised the potentially curative treatment she received for her lung cancer. It emphasises the need to assess each patient on a case-by-case basis as had the guidelines for follow-up of the nodule been applied, the opportunity to treat her lung cancer in a radical way may have been missed.
Case study 3.
JUNE 2017
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