Locally Advanced Primary Small Cell Carcinoma of the Breast
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A 64-year-old female presented to urgent care with the complaint of a large left breast mass. She first noticed the mass on the outer upper quadrant of the left breast 4 months prior. Due to the COVID-19 pandemic, she did not seek immediate medical attention. Subsequently, over the next few months, the lesion grew into a painful fungating, red mass protruding out of the breast. Once she noticed a significant colorless, foul-smelling discharge from the left breast she decided to seek medical care. She has a 30 pack-year smoking history but quit smoking several years ago. Her family history is significant for lung cancer in 2 of her aunts. There was no other significant medical or surgical history. She was not taking any medications.

A clinical exam revealed an 11-cm left breast mass with serosanguinous drainage. The breast mass was fungating with a 2-cm ulcer on the lateral border and she had palpable left axillary lymphadenopathy. Her lungs were clear to auscultation, heart auscultation revealed normal rate and rhythm. She did not have cervical, inguinal, and right axillary lymphadenopathy. Her neurological exam was normal. She was referred to a general surgeon and underwent a left breast biopsy. The biopsy revealed a necrotic tumor consistent with small cell carcinoma. Immunohistochemistry analysis revealed uniform staining with SOX-10, cytokeratin (CK), and variable staining with CK 7, TTF-1 (thyroid transcription factor-1), and GATA 3. Immunohistochemical stains were weakly to moderately positive for CD56, synaptophysin, and neuron-specific enolase (NSE). Ki67 was greater than 70%. Estrogen receptor, progesterone receptor, and Her2/neu stains were all negative.

She was classified as stage 3 based on the American Joint Committee on Cancer TNM staging system. Her case was discussed in a multidisciplinary tumor conference, and given the large size of the tumor, localized disease, and axillary lymph node involvement, her treatment plan included 6 cycles of neoadjuvant chemotherapy, followed by surgery, and subsequent radiation treatments. She was initially treated using cisplatin and etoposide chemotherapy, but due to the development of hearing difficulty, cisplatin was switched to carboplatin after cycle 3. She had a dramatic reduction in the size of the tumor with neoadjuvant chemotherapy. She then underwent a modified radical mastectomy of the left breast with left axillary lymph node dissection. Pathology showed that she had 1 out of 14 lymph nodes that were positive for malignancy. Margins were clear and ductal carcinoma in situ was not seen. At the time of writing this article, she has completed her chemotherapy and surgical treatments and is currently undergoing RT. Given the lack of trials and established guidelines for the use of RT in this disease, clinical judgment was employed based upon the known utility of postmastectomy RT in patients with node-positive invasive ductal carcinoma of the breast, and in the treatment of limited-stage small-cell carcinoma of the lung. A plan was developed using mixed-energy photons to deliver 5,000 cGy to the chest wall, axilla, internal mammary nodes, and supraclavicular nodes, followed by a 1,000-cGy boost to the scar using electrons. Deep inspiration breath-hold technique was used to minimize the dose to the heart and ipsilateral lung. The case was reviewed and approved at radiation oncology chart rounds at a tertiary hospital prior to initiation of therapy. Genomic analysis of her breast tissue has not been done yet due to the absence of metastatic disease.