FCCT Blog Post #17

KCMC-FCCT Tumor Board

After a several month hiatus over the summer, the Minnesota-KCMC tumor board resumed in September with presentation of a complex metastatic breast cancer case.

A 56 year-old woman with a 4 year history of metastatic breast cancer with bone-predominant involvement had developed jaundice, melena, transfusion dependent anemia, thrombocytopenia and splenomegaly. Seventeen years ago, at the age of 39, she had undergone a right modified radical mastectomy and adjuvant chemotherapy for localized breast cancer. Pathology reports from that time were not available but she was treated with 5 years of adjuvant tamoxifen thru 2013. Four years ago, in 2020, she developed bone metastases. It is unclear if a biopsy was performed, but she was treated with palliative radiation to painful bone sites, six months of palliative single agent paclitaxel with excellent response, and was placed on anastrozole. Over the next several years, her disease was followed by imaging and CA 15-3. She was treated with capecitabine and at one point, another course of paclitaxel due to progression. Three months ago, she developed jaundice, melena and significant anemia and thrombocytopenia. Upper GI endoscopy identified a gastric ulcer. A CT scan showed liver lesions but also significant splenomegaly. A peripheral smear was reviewed at tumor board but did not show classic signs of hemolysis or a leucoerythroblastic blood smear suggestive of bone marrow involvement by breast cancer. A reticulocyte count was elevated as was the LDH. She has required red cell transfusions for the anemia. A consideration for immune hemolysis was given, but her hemoglobin has not responded to a course of prednisone.

Our discussion revolved around the fact that although breast cancer receptor status was unknown in this case, this is invariably a case of estrogen receptor positive metastatic breast cancer. Late recurrences of breast cancer (13 years after original diagnosis) most always indicate estrogen responsive disease rather than triple negative or Her2/neu driven disease. Indeed, the original pattern of recurrence (bone-only involvement) favors estrogen receptor positive disease. The current cause of her anemia, thrombocytopenia and splenomegaly were unclear. She obviously had an element of gastrointestinal bleeding confirmed by endoscopy but this would not explain the jaundice or splenomegaly. We discussed various ways that the cancer, itself, could cause this presentation: micro-metastatic disease to the liver could cause liver dysfunction and splenomegaly; bone marrow involvement from breast cancer could cause anemia and thrombocytopenia but classically would cause a leucoerythroblastic blood smear picture. Since she had been on a treatment-free holiday, we did not think the treatment, itself, was causing this picture. We also discussed non-breast cancer related causes of jaundice, high-reticulocyte count anemia, thrombocytopenia and splenomegaly. This included infectious causes such as hepatitis B, immune causes such as Evan’s Syndrome (immune thrombocytopenia and hemolytic anemia) and other malignancies such as lymphoma. Further investigation for hemolytic anemia and a bone marrow biopsy were suggested.

Randy Hurley MD, cTropMed

HealthPartners and Regions Hospital Cancer Care Centers

Global Health Faculty, University of Minnesota