Symptoms & Diagnosis – Breast Cancer IDC, Stage 4 Triple Positive

 

What were your first symptoms?

I noticed the lump in December of 2015. It appeared out of nowhere. It wasn’t sore or anything. It didn’t change or get bigger after I started watching it.

I really didn’t have any other symptoms that were apparent. I had decided to get back into shape in the Fall of 2015, and I had done that before and not had any issues. This time around, though, it was harder. It was weird for me.

I did notice a little heaviness in my chest, and now with hindsight, that might’ve been something that was a symptom of cancer.

 

How did you get diagnosed?

I had a mammogram in April of 2016. The radiologist saw that mammogram while I was still there and told me I needed to go see an oncologist.

I had saline implants, so instead of a needle biopsy, they went in surgically for a lumpectomy. It was a same-day surgery. The next week, I got the diagnosis of breast cancer.

They took out the lump and the margins were fairly clean. They said they had good therapies for triple positive and HER2, but then they wanted to check the lymph nodes. They did a PET scan. The day I went back to the oncologist to start my chemo while waiting on the full diagnosis and staging, I found out it was metastatic and I was stage 4.

That was a lot to take in that day, but the treatment was still the same. My oncologist said it was a lot of information for me to take in on one day and was willing to reschedule my treatment, but I didn’t want to. We were treating it aggressively. I was there and ready and wanted to get started.

 

How were you thinking and feeling after the diagnosis?

My original oncologist isn’t my oncologist now. His bedside manner isn’t the greatest. The day he gave me the diagnosis, he kept asking, “Do you have any questions?” We didn’t know what to ask. Finally, my husband asked about prognosis. He said I had 2-10 years depending on how well my body reacted to the treatment.

By the time I got home, I’m googling everything. I read that the next place it can go is to your brain, which the doctor didn’t even mention. I’m thinking, “Is it there too?” We hadn’t done any testing for that. My surgeon ordered an MRI for me, and at that point, it was clear, so that made me feel better.

“My husband and I just thought of it as a chapter and something we were going to get through. It took a while to realize that this would be the rest of my life. We’ve definitely started living our lives how we want to.

There’s always a reason to not go on vacation or something, but now we don’t let those things get in our way.

How did you tell your loved ones about the diagnosis?

My husband was there with me. He’s always there with me. I have four adult boy children. I told them all early that I had cancer and thought it was early stages. I had to call them all back and tell them it was metastatic, and they all dealt with it like they do with Google and research.

My parents had a hard time with it. One of my first thoughts was, “Am I gonna outlast my parents?” We told our closest family first, and then I had to tell work because I knew I was gonna start losing my hair.

The full article is linked below

Breast Cancer IDC Triple Positive A Patients Story

My MBC Timeline

As a metastatic breast cancer patient, I have had questions about other patients with a similar diagnosis. If you are reading my blog you may also have this terminal disease. Because of that, I am including a timeline of my own treatment. I will update my timeline as needed.

December 26, 2015 –  First Symptom 

I found a lump in my right breast while taking a shower. I was not overly concerned about it. I had often had calcification spots in both breasts for years.  This lump was larger than the others previously. It was not painful. It did not change in size or shape.

April 23, 2016 –  Mammogram results 

Results:  Noticed R breast mass increasing in size. Mammogram reportedly with concerning finding in R breast but no focal biopsy due to implants.

April 28, 2016 – First time hospitalized (same-day surgery)  –  Biopsy ( I have saline breast implants)

Results:  R breast mass excision on 4/28/16. Path with grade II IDC, 3.2cm with extensive grade III ductal carcinoma in situ. ER(70% positive), PR(10% positive), HER2 3+, Ki-67 of 27%. Margins were negative but close with closest margin 0.29mm. T2NxM0.

May 17, 2016 –  Sentinel node procedure and port placement upper left chest wall  

Results: metastatic carcinoma in 2/2 sentinel nodes one with focal extranodal extension. Looks like this was followed by possible axilla node dissection. With metastatic malignancy in 2/2 sentinel nodes one with focal extranodal extension. Also found in 3/6 excised nodes again with focal extranodal extension. Total of 5/8 nodes. There were isolated tumor cells in one lymph node.

May 13, 2016 –  First oncology appointment   Consultation with Dr. Mark Nuttall, Oncologist, Revere Healthcare

May 20, 2016 –  Echocardiogram  

Results :  Normal

May 24, 2016 –  CT Scan  

Results:  CT C/A/P on 5/24/16 with multiple metastatic lesions in the liver (largest 1.7cm), also with multiple small pulmonary nodules, mildly enlarged mediastinal lymph nodes, and lytic lesion at T8 concerning for met.

May 27, 2016 –  First Chemo Infusion  

Taxotere 75mg/m2, Carboplatin AUC 6, Herceptin 8mg/kg to load then 6 mg/kgq with Perjeta 840mg loading followed by 420mg X6 every 21 days

June 10, 2016 –  MRI (Brain)  

Results:    No evidence of metastatic disease

June 17, 2016 –  Second Chemo Infusion  

Taxotere 75mg/m2, Carboplatin AUC 6, Herceptin 8mg/kg to load then 6 mg/kgq with Perjeta 840mg loading followed by 420mg X6 every 21 days

 July 8, 2016 –  Third Chemo Infusion  

Taxotere 75mg/m2, Carboplatin AUC 6, Herceptin 8mg/kg to load then 6 mg/kgq with Perjeta 840mg loading followed by 420mg X6 every 21 days

July 29, 2016 –  Fourth Chemo Infusion  

Taxotere 75mg/m2, Carboplatin AUC 6, Herceptin 8mg/kg to load then 6 mg/kgq with Perjeta 840mg loading followed by 420mg X6 every 21 days

July 29, 2016 –  Echocardiogram  

Results:  Normal

August 8, 2016 –  CT Scan  

Results:  Comparison to June 26.

LIVER: Small enhancing or calcified 9 mm lesion in the dome of the liver has improved. I suspect this is a treated hepatic metastasis. There is a hypodensity in the inferior aspect of the right hepatic lobe which is slightly improved. There are other small ill-defined hypodense lesions in the superior aspect of the right hepatic lobe near the dome of the liver which are probably treated hepatic metastases. No intrahepatic biliary ductal dilatation. Portal and hepatic veins are patent. GALLBLADDER: Normal. SPLEEN: Normal. PANCREAS: Normal. ADRENAL GLANDS: Normal. KIDNEYS: Normal. RETROPERITONEUM: Normal. GASTROINTESTINAL: Stomach appears distended. Large and small bowel are within normal limits. There is no mesenteric adenopathy or mass. ABDOMINAL WALL: No evidence for abdominal wall mass or hernia. PELVIS: Status post hysterectomy. Bladder is normal. There is no free fluid. No definite pelvic adenopathy or mass. LUNGS: Lung bases demonstrate improved pulmonary nodules. There is no pleural effusion. BONES: No definite evidence for focal lytic or sclerotic lesion to suggest osseous metastatic disease. Impression: Abdomen: 1. Decrease in size and number of the hepatic lesions consistent with improved hepatic metastases. 2. Distention of the stomach without evidence for bowel obstruction. Pelvis: 1. No evidence for pelvic adenopathy or mass. 2. Status post hysterectomy.

August 25, 2016 –   5th Chemo Infusion Herceptin  

September 9, 2016 – 6th  Chemo Infusion Herceptin   

October 2, 2016 –  7th Chemo Infusion Herceptin    

November 11, 2016 – Echocardiogram   

Results:   Normal

November 2016 –  8th Chemo Infusion Herceptin    

December 2016 –  9th Chemo Infusion Herceptin and Lupron Shot   

January 2017 –    10th Chemo Infusion Herceptin   

February 2017 –  11th Chemo Infusion Herceptin  

March 2017 –  12th Chemo Infusion  Herceptin and Lupron Shot  

March 29, 2017 –  Pet Scan  

IMPRESSION: 1. Small, nodular foci of increased FDG uptake in the medial right breast and right buttock as described above. These are nonspecific findings and continued surveillance is recommended. 2. Other benign areas of FDG uptake, including hypermetabolic brown fat. 3. No other PET/CT evidence of metabolically active malignancy.

April 2017 –  13th  Chemo Infusion  Herceptin

May 2017 –  14th   Chemo Infusion  Herceptin 

June 2017 – 15th   Chemo Infusion  Herceptin and Lupron Shot

July 2017-  16th   Chemo Infusion  Herceptin

Aug 2017-   17th   Chemo Infusion  Herceptin

Sept 2017 –  18th  Chemo Infusion Herceptin and Lupron Shot

October 2017 –  19th Chemo Infusion Herceptin

November 2017 – 20th Chemo Infusion Herceptin

November 10, 2017–   MRI (Brain)

Results:  * 2 new enhancing lesions in the brain highly suspicious for metastatic disease. One is in the right cerebellar hemisphere. The other is in the upper medial aspect of the left frontal lobe.

December 2017 –  21st Chemo Infusion Herceptin

December 21st, 2017 –   Stereotactic Radiation Therapy

January 2018 – 22nd Chemo Infusion Herceptin

February 2018 – 23rd Chemo Infusion Herceptin

February – Unilateral salpingo-oophorectomy

 I no longer needed to have a Lupron shot

March 2018 – 24th  Chemo Infusion Herceptin

March 12, 2018 – MRI (Brain)

Results:  1. Right posterior superior cerebellar enhancing nodule measuring 5 x 6 mm.  2. Left periventricular parietal lobe enhancing nodule measuring 4 x 3 mm. 3. Findings are concerning for metastatic disease to the brain parenchyma.

 Chemo Infusion

April 2018 – 25th  Chemo Infusion Herceptin

May 2018 –  26th  Chemo Infusion Herceptin

June 2018 –  27th Chemo Infusion Herceptin

June 7, 2018- PET Scan

Results:
1. No FDG avid metastatic disease is appreciated in the neck,
chest, abdomen, or pelvis.
2. Previously seen area of left upper lobe FDG avidity is
resolved and no longer present.
3. Very small bilateral pulmonary nodules which are unchanged
since prior in which do not demonstrate FDG avidity.

June 11, 2018 – MRI (Brain)

Results:   1. Small enhancing lesions in the posterior medial aspect of the left frontal lobe and superior margin of the right cerebellar hemisphere are stable compared to the most recent prior examination and is improved compared to December 13, 2017.   2. There is a small 3 mm enhancing lesion at the medial aspect of the left occipital lobe, immediately adjacent to the midline suspicious for an additional metastatic lesion. There is no significant local mass effect associated with this enhancing lesion.

July 2018 – 28th  Chemo Infusion Herceptin

August 2018 – 29th Chemo Infusion Herceptin

August 12, 2018 – Stereotactic Radiation Therapy

August 12, 2018 – 30th Chemo Infusion Herceptin

September 2018 – 31st Chemo Infusion Herceptin

October 2018 – 32nd  Chemo Infusion Herceptin

November 2018 – 33rd Chemo Infusion Herceptin

December 2018 – 34th Chemo Infusion Herceptin

December 11, 2018 – PET Scan

Results:  No evidence of active metastatic disease

December 12, 2018 – MRI Brain

FINDINGS:
* Gray/White Matter: Normal appearance of the gray and white
matter. Within the superior aspect of the right posterior
cerebellum immediately inferior to the cerebellum tentorium is
an enhancing lesion measuring 5 x 6 mm. More superior within the
supratentorial brain at the left periventricular parietal white
matter a 4 x 3 mm enhancing nodules present. There is associated
vasogenic edema surrounding both of these nodules.
* Ventricles/Extra-axial space: Normal for age. No abnormal
extra-axial fluid collection.
* Calvarium/Skull base: Unremarkable. There is no dural mass or
* Enhancement: The 2 previously described nodules are the only
areas of abnormal enhancement.

January 2019 – 35th Chemo Infusion Herceptin

February 2019 – 36th Chemo Infusion Herceptin

March 2019 – 37th Chemo Infusion Herceptin

 April 2019 – 38th Chemo Infusion Herceptin

April 22, 2019MRI (Brain)

Results:  Multiple enhancing brain lesions. One of the lesions has decreased in size. The other lesions are unchanged in size, but there has been an interval increase in vasogenic edema adjacent to a left periventricular lesion.

May 2019 – 39th Chemo Infusion Herceptin

June 2019 – 40th Chemo Infusion Herceptin

June 25, 2019CT Scan

Results:  NEAD  1. There is no evidence for metabolically active metastatic

disease.  2. Stable small pulmonary nodules.

July 23, 2019 – 41st Chemo Infusion Herceptin

August 9, 2019- MRI(Brain)

FINDINGS:  An enhancing intracranial mass in the left parasagittal frontoparietal region has slightly increased in size (series 900 B image 103)., measuring 6 mm in diameter on the current study and 5 mm in diameter on the most recent prior. This measured 4 mm in diameter in July 2018.

An enhancing mass in the parietal occipital region, in close proximity to the falx cerebri, has significantly increased in size in comparison to the most recent prior. It now measures 7 mm in diameter (series 9, image 50) and was previously 4 mm in maximal diameter on 4/22/2019. There is also significantly increased peritumoral edema in this region.

An enhancing lesion in the superior aspect of the right cerebellar hemisphere (series 9, image 40) has increased in size from the most recent prior. Now measures 10 mm in greatest diameter and was previously 8 mm in April 2019 and 6 mm July 2018.

There is no acute intracranial hemorrhage, extra-axial collection, or shift of midline structures. The basal cisterns are patent. There is local mass effect associated with the left parieto-occipital mass, resulting in mild local effacement of cerebral sulci and subtle effacement of atrium of the left lateral ventricle. Elsewhere, ventricular caliber is within normal limits.

There is no restricted diffusion to suggest acute or early subacute infarct.

The expected intracranial flow voids are present in the major dural venous sinuses are patent.

Orbits are unremarkable. Paranasal sinuses and mastoid air cells are clear.

IMPRESSION:

Progression of intracranial metastases. Most notably, the lesion in the parasagittal left parietal occipital region is now 10 mm in diameter and was previously 8 mm in April 2019 and 6 mm in July 2018. There is also markedly increased peritumoral edema with local mass effect in this region.

This report was generated using Nuance Voice Recognition software.

It may contain inadvertent errors.

Electronically Signed By: Ben Jacobs MD

Signature Date/Time: 8/9/2019 10:09 AM

August 13, 2019 – 42nd Chemo Infusion Herceptin

September 3, 2019- 43rd Chemo Infusion Herceptin –

September 6, 2019- Repeat Echocardiogram – results normal

September 24, 2019- 44th Chemo Infusion Herceptin –

October 15th, 2019- 45th Chemo Infusion Herceptin –

November 5th, 2019- 46th Chemo Infusion Herceptin –

November 12th, 2019- MRI with and without Contrast

Examination: MRI BRAIN W-O and W CONTRAST

Referring physician: THOMAS SKIDMORE

CLINICAL HISTORY: Brain metastases. Follow-up. History of breast cancer.

COMPARISONS: MRI brain dated 8/9/2019.

TECHNIQUE: Multiplanar, multisequence MR images of brain were obtained without and with use of intravenous contrast.

CONTRAST: 5mL of Gadavist, 65mL Vial Used

FINDINGS:

Again noted are at least 3 enhancing lesions within the brain consistent with known metastases. These appear to be increase in size when compared previously. For example, the enhancing lesion within the right cerebellar hemisphere best seen on image 8 of series 11 now measures 1.6 x 1.2 cm compared to previous measurement of 0.8 x 1.2 cm. There is worsening peritumoral edema involving the right cerebellar hemisphere. Lesion within the left parasagittal parietal occipital region of the brain best seen on image 14 of series 11 is also increased in size now measuring 1.2 x 1.5 cm compared to previous measurement of 0.6 x 0.7 cm. There is associated worsening peritumoral edema at this level as well as increased susceptibility artifact at this level to suggest some intratumoral hemorrhage. Lesion within the left parasagittal frontoparietal region is also slightly increased in size now measuring up to 9 mm compared to 7 mm on previous study. Susceptibility artifact within this lesion also suggests small amount of hemorrhage. No definite new lesions appreciated. There is similar mild narrowing of the atrium of the left lateral ventricle as well as effacement of the sulci at this level due to local mass effect. Remainder of the lateral ventricles, third ventricle and fourth ventricle are unremarkable. Preserved major intracranial vascular flow voids. Paranasal sinuses and mastoid air cells are well-aerated. Bilateral globes and retrobulbar soft tissues appear preserved.

IMPRESSION:

Interval increase in size of previously seen intraparenchymal metastases with increasing peritumoral edema as described above. The largest lesion which has had the greatest degree of increase in size is within the right cerebellar hemisphere which now measures 1.6 x 1.2 cm compared to 0.8 x 1.2 cm on previous study. No overt findings to suggest new intracranial metastases.

Electronically Signed By: Fred Dawson MD

Signature Date/Time: 11/12/2019 10:30 AM

November 26th, 2019- 47th Chemo Infusion Herceptin –

November 27th, 2019 – PET and CT

REASON FOR EXAM: BREAST CANCER

EXAM: PET/CT from the skull base through the midthighs.

Diagnostic CT examination was performed through the neck, chest,

abdomen, and pelvis.

COMPARISON: 6/24/2019

INDICATION/HISTORY: Breast cancer, subsequent treatment exam

TECHNIQUE: The patient was given 15.1 mCi of FDG at 0957 hours.

The patient’s blood glucose level at the time of injection was

79 mg/dL. A low-dose 3.75 mm axial CT examination with the

patient in end-tidal expiration was performed specifically for

attenuation correction and anatomic localization, followed by a

3-D emission scan performed at 1137 hours. A separate diagnostic

quality CT was then performed for formal interpretation, per the

referrer’s request.

IV Contrast: Yes

Oral Contrast: Yes

Medications: None.

FINDINGS: There is no hypermetabolic lymphadenopathy identified

within the neck or chest. No hypermetabolic lymphadenopathy

identified within the abdomen or pelvis. No solid organ or bony

hypermetabolic lesions.

CT Neck:

* Skull base, Orbits, and Visible Sinuses: There is enhancing

lesion in the right cerebellum which has been seen on prior MRIs

of the brain.

* Salivary Glands: Normal.

* Soft tissues: No pathologic adenopathy.

* Thyroid: Normal.

CT Thorax:

* Heart/mediastinum: Normal heart size. No pericardial

effusion. No lymphadenopathy.

* Lungs/pleura: There small pulmonary nodules in the upper

lobes which are unchanged unchanged. No pleural effusions.

* Chest Wall: Bilateral breast implants. Left subclavian

Port-A-Cath overlies the left chest wall.

CT Abdomen and Pelvis:

* Liver: There are benign calcifications in the liver. There

are no suspicious liver lesions. The portal vein is patent.

* Gallbladder: No calcified gallstones.

* Spleen, pancreas, adrenal glands: Unremarkable.

* Kidneys: Benign left renal cyst. Normal enhancement.

* Retroperitoneum/Mesentery: No free fluid or free air. No

lymphadenopathy.

* Stomach/small bowel: Unremarkable.

* Colon: Unremarkable.

* Abdominal Wall: No hernia.

* Genitourinary/pelvis: Prior hysterectomy. Mild urinary

bladder wall thickening. No free fluid.

* Bones: No suspicious bone lesions. There is a rightward

curvature of the midthoracic spine.

IMPRESSION:

1. There is an enhancing lesion in the right cerebellum

identified on CT images of the brain.

2. There is no hypermetabolic metastatic disease in the neck,

chest, abdomen, or pelvis.

3. There are tiny pulmonary nodules in the upper lobes which

are unchanged.

This report was electronically signed by David R. Cottam, MD on

11/27/2019 1:32 PM.

December 2nd, 2019- MRI with contrast Spectroscopy Infusion

Report EXAM: MRI of the brain with and without IV contrast. MR spectroscopy. COMPARISON: PET/CT scan 11/27/2019. 4/22/2019, 12/11/2018. INDICATION/HISTORY: Metastatic breast cancer. Metastatic disease to brain. TECHNIQUE: A variety of pulse sequences and imaging planes were utilized for optimum evaluation. IV CONTRAST: 5.7 mL Gadavist MEDICATIONS: None. FINDINGS: MR perfusion: On the MR perfusion sequence, there is decreased perfusion within and surrounding all 3 of the enhancing intracranial lesions. MR spectroscopy: On the single voxel spectroscopy, there is no significant change in the choline, creatine, and NAA. In the involved left side, there are elevated lipid/lactate peaks and

an elevated myoinositol peak. On the single voxel spectroscopy in the involved left-sided area, there is decreased choline, creatine, and NAA with a widened mild osteopenia and increased lipid/lactate peaks. Brain: Since the prior MRI studies, there has been a significant enlargement of the areas of edema surrounding the right cerebellar mass that is stable to mildly enlarged when compared to the prior study. The enhancing portion of this mass measures 1.7 x 1.1 cm in axial plane, enlarged. There is a left occipital lobe mass which is parafalcine on axial image 16 with a moderate amount of adjacent edema. The enhancing portion of this mass measures 1.5 x 1.2 cm in the axial plane, enlarged. Again noted is the left sided single gyrus mass seen on axial image 22 with an increase in amount of adjacent edema. This mass measures 8 x 6 mm, mildly enlarged. Each of these masses demonstrate hypointense T2 signal with blooming on the GRE sequence indicating hemorrhage or hemorrhagic lesions. All 3 of these lesions demonstrate a moderate amount of enhancement. No new masses identified. No infarct. Ventricles, Cisterns, and Sulci: Normal for age. Vascular flow voids: Normal flow voids. Bones: The calvarium and visible facial bones are unremarkable. Sinuses: Unremarkable paranasal sinuses. Small left-sided mastoid effusion. Soft Tissues: Unremarkable. IMPRESSION: 1. There are 3 enhancing lesions as described above in the right cerebellar hemisphere, left occipital lobe, and left single gyrus area. These lesions have enlarged since the prior study and all demonstrate increasing surrounding hyperintense T2/FLAIR signal. There is also hemorrhagic component of all 3 of these lesions at this time, which is new. On the MR perfusion and MR spectroscopy, there are no findings to indicate active macroscopic active tumor. Recommend correlation with history. This appearance of hemorrhagic change and increased surrounding edema can be seen with radiation treatment. Radiation necrosis and/or pseudoprogression are most likely the source of the enhancement at this time. Recommend continued MRI follow-up.

December 9th, 2019- Bilateral Explant surgery

December 17th, 2019- 48th Chemo Infusion Herceptin –

January 14th, 2020- 49th Chemo Infusion Herceptin –

January 21st, 2020- 50th Chemo Infusion Herceptin –

February 4th, 2020- 51st Chemo Infusion Herceptin –

February 11th, 2020- MRI with contrast 

There are multiple enhancing lesions, including

* A posterior right cerebellar lesion measuring 2.4 x 1.6 cm, previously 1.8 x 1.1 cm, adjacent to the dural margin.

* A posterior medial left cerebral hemisphere lesion, adjacent to the falx cerebri, measuring 2.4 x 1.7 cm, previously 1.3 x 1.2 cm. This lesion appears to be centrally necrotic.

* A superior medial left cerebral hemisphere lesion measuring 1.0 x 0.8 cm, previously 0.9 x 0.7 cm

Altered T2 signal, consistent with edema or gliosis, radiating posteriorly and superiorly from the superior left cerebral lesion, described above. The posterior superior left cerebral sulci are effaced.

Altered T2 signal, consistent with edema or gliosis, into the medial left cerebral hemisphere lesion.

Altered T2 signal, consistent with edema or gliosis in the right cerebellar hemisphere and cerebellar vermis.

Edema has increased since the previous examination.

No hydrocephalus. The left mastoid air cells are partially opacified, as on the previous scan.

IMPRESSION: Interval enlargement of metastatic brain lesions, with increasing edema.

Electronically Signed By: Gregory Smith MD

Signature Date/Time: 2/11/2020 4:36 PM

**************** ADDENDUM ********************************

Addendum:

A more recent comparison study from an outside facility, December 2, 2019, is also reviewed.

Metastatic lesions have progressed relative to the November scan as well as the December scan.

Electronically Signed By: Gregory Smith MD

February 14th, 2020- Repeat Echocardiogram – results normal

February 20th, 2020-First Neuro Surgeon appointment

Dr. Riechman — recommended taking 2mg Dexamethason one time a day for the next three weeks. This should reduce the edema/water and then have a follow-up MRI and appointment with him.

MRI

Appointment Dr. Riechman follow up

February 25th 2020- 52nd Chemo Infusion Herceptin –

March 17th 2020- 53nd Chemo Infusion Herceptin –

· Liver metastases (197.7) (C78.7)
· Metastasis to the brain (198.3) (C79.31)
· Metastasis to lung (197.0) (C78.00)
· Metastasis to lymph nodes (196.9) (C77.9)
· Bone metastases (198.5) (C79.51)
–Stage IV ER positive, PR positive, HER-2 positive invasive breast cancer of the right side with lymph node, pulmonary, CNS and hepatic metastasis. Please see treatment history as above.
I am concerned of progressive disease and also necrosis radiation-induced. There is not a tremendous amount of edema which is surprising that there is been little change despite the improvement with the steroids. I have used bevacizumab in some cases with radiation necrosis but I do not think that is warranted in this case. I discussed and reviewed her last imaging, blood pressure, steroids and management. I sent a text to her neurosurgeon. I will continue to try to get a hold of him.
Plan
1. Proceed with trastuzumab today and every 3 weeks. She will continue with aromatase inhibitor as well.
Order repeat PET CT scan and will get this scheduled prior to her return to see me and before any surgery takes place to help in that decision-making. This will be coordinated with the patient for ideal timing and likely will need to be after she is heard from Dr. Reischman.
2. Increase amlodipine 5 mg once daily. May titrate every 1 to 2 weeks as needed up to a maximum of 10 mg/day.
3. She will follow-up with Dr. Reischman of neurosurgery with regards to her dexamethasone and surgical decision making. If resection of these lesions is feasible and thought to be beneficial both by Dr. Reischman and Sherry this is our best option I believe.
If she does not hear back soon she is to call me and we may taper her dosing given her good effect.
4. Quarterly denosumab. Continue with daily vitamin D and calcium.
5. Continue with Arimidex. If we have to switch to lapatinib and

April 7, 2020- 54th Chemo Infusion Herceptin –  

Today was my first Herceptin infusion during the coronavirus outbreak. We have been quarantined at our home for three weeks. We have been working from home.  Strange times.  Steve was not allowed to go to my appointment with me. I had a personal call to ask specific questions before going to the clinic.

April 13, 2020- Full body Pet Scan

Examination: PET/CT skull base to mid-thigh-FDG.
Referring Physician: Steven Wallentine
Comparison: November 27, 2019.
Indication: Malignant neoplasm of the upper outer quadrant of the right breast. Intracranial metastases. No new symptoms.
Technique: The patient was given 10.622 mCi of FDG at 1024. The blood glucose level at the time of injection was 100 mg/dl. A 3-D emission scan was performed followed by a 3.75 mm axial CT examination. CT was performed for attenuation correction.
Findings:
CT neck: No abnormal FDG activity is seen within the neck. No definite lymphadenopathy on the CT porton of the study.
CT Chest: No abnormal FDG activity seen within the chest. The implants have been removed. There is a Port-A-Cath overlying the left chest introduced via the left clavian vein with its tip in the superior vena cava. There appears to be a small subpectoral seroma, left-sided measuring up to 5.4 x 1.2 cm. There are a few tiny nodules in the right upper lobe, unchanged. There is a shallow dependent pericardial effusion.
CT abdomen and Pelvis:No abnormal FDG activity seen within the abdomen or pelvis. There is a calcified lesion in the right hepatic lobe, stable. The patient is status post hysterectomy.
Impression:
1. No abnormal FDG activity seen.
2. Findings consistent with removal of breast implants since the last PET CT exam. There is a small seroma at the left chest wall.
3. The tiny pulmonary nodules are unchanged.
Electronically Signed By: Dalton Wright MD
Signature Date/Time: 4/13/2020 5:51 PM

April 28, 2020- 55th Chemo Infusion Herceptin –  

May 30, 2020, – 56th Chemo Infusion Herceptin –  

June 4, 2020

MRI OF THE BRAIN WITHOUT AND WITH CONTRAST
REFERRING PHYSICIAN: Steven Wallentine
AGE: 56 years
GENDER: Female
HISTORY: Breast cancer. Follow-up intracranial lesions.
TECHNIQUE: Multiplanar multisequence imaging of the brain was obtained without and with IV gadolinium contrast on a 1.5 Tesla magnet. Images were acquired in the sagittal, transverse, and coronal planes.
CONTRAST: 5 mls of Gadavist, 65 ml Vial Used
COMPARISON: Brain MRI 3/12/2020
FINDINGS:
An index enhancing mass in the right cerebellar hemisphere has increased in size and now measures 2.5 x 2.5 cm, previously 2.1 x 2.1 cm. A heterogeneously enhancing mass within the left parietal occipital region now measures 2.7 x 1.5 cm and previously measured 2.4 x 1.3 cm. A paramedian mass in the posterior left frontal lobe now measures 10 mm in diameter and is not significantly changed. There is redemonstrated. Tumoral edema throughout the left parieto-occipital lobe and in the right cerebellar hemisphere, with progressive mass effect on the fourth ventricle (series 8, image 9) and increasing cerebellar ectopia with the right cerebellar tonsil now extending 8 mm below the foramen magnum (series 3, image 15).
There is susceptibility artifact associated with the above described lesions, suggesting chronic microhemorrhage.
There is no restricted diffusion to suggest acute or early subacute infarct. No evidence of acute intracranial hemorrhage.
Orbits are unremarkable. Paranasal sinuses and the right mastoid air cells are clear. There is a trace left mastoid air cell effusion.
IMPRESSION:
Progression of multiple intracranial metastases and progressive peritumoral edema, most significantly in the right cerebellar hemisphere with increased effacement of the fourth ventricle and increased mass effect with displacement of the cerebellar tonsils now extending 8 mm below the foramen magnum.
Electronically Signed By: Ben Jacobs M
Signature Date/Time: 5/20/2020 4:13 PM

May 20, 2020

MRI OF THE BRAIN WITHOUT AND WITH CONTRAST
REFERRING PHYSICIAN: Steven Wallentine
AGE: 56 years
GENDER: Female
HISTORY: Breast cancer. Follow-up intracranial lesions.
TECHNIQUE: Multiplanar multisequence imaging of the brain was obtained without and with IV gadolinium contrast on a 1.5 Tesla magnet. Images were acquired in the sagittal, transverse, and coronal planes.
CONTRAST: 5 mls of Gadavist, 65 ml Vial Used
COMPARISON: Brain MRI 3/12/2020..
FINDINGS:
An index enhancing mass in the right cerebellar hemisphere has increased in size and now measures 2.5 x 2.5 cm, previously 2.1 x 2.1 cm. A heterogeneously enhancing mass within the left parietal occipital region now measures 2.7 x 1.5 cm and previously measured 2.4 x 1.3 cm. A paramedian mass in the posterior left frontal lobe now measures 10 mm in diameter and is not significantly changed. There is redemonstrated. Tumoral edema throughout the left parieto-occipital lobe and in the right cerebellar hemisphere, with progressive mass effect on the fourth ventricle (series 8, image 9) and increasing cerebellar ectopia with the right cerebellar tonsil now extending 8 mm below the foramen magnum (series 3, image 15).
There is susceptibility artifact associated with the above described lesions, suggesting chronic microhemorrhage.
There is no restricted diffusion to suggest acute or early subacute infarct. No evidence of acute intracranial hemorrhage.
Orbits are unremarkable. Paranasal sinuses and the right mastoid air cells are clear. There is a trace left mastoid air cell effusion.
IMPRESSION:
Progression of multiple intracranial metastases and progressive peritumoral edema, most significantly in the right cerebellar hemisphere with increased effacement of the fourth ventricle and increased mass effect with displacement of the cerebellar tonsils now extending 8 mm below the foramen magnum.
Electronically Signed By: Ben Jacobs MD

June 3, 2020

Surgery Dr. Howard Reichman
Right suboccipital craniotomy and complete removal of the right side

June 4, 2020 

CT Brain/Head w/o Contrast
CC Provider: WALLENTINE, STEVEN
Att/Ordering Provider: Howard Reichman
Referring Provider:
Admitting Provider: Howard Reichman
Consulting Provider:
Originator:
Location: Utah Valley Regional Medical Center
(Status: Final)
REASON FOR EXAM: Other (please specify)
Craniotomy Postop
EXAM: CT of the head without IV contrast.
COMPARISON: MRI brain, 5/20/2020
INDICATION/HISTORY: Postop craniotomy
TECHNIQUE: Thin section axial imaging was performed with
sagittal and coronal reformats according to protocol. All
patients (including pediatric patients) were imaged with dose
reduction techniques.
IV CONTRAST: None.
MEDICATIONS: None.
FINDINGS:
Postsurgical changes from right occipital craniotomy and right
cerebellar mass resection. There is expected postoperative trace
pneumocephalus and blood products within the resection bed.
Edema within the resection bed is also present. No acute
hemorrhage is identified. The previously noted mass lesions
within the left parietal-occipital lobe are redemonstrated with
adjacent vasogenic edema. This vasogenic edema is again noted to
exert mass effect and effacement on the posterior horn of the
left lateral ventricle. The basal cisterns are patent.
Gray-white matter differentiation is otherwise maintained.
Calvarium is otherwise unremarkable. Paranasal sinuses and
mastoid air cells are clear.
IMPRESSION:
1. Expected postoperative changes from right occipital
craniotomy and right cerebellar mass resection.
2. Redemonstrated mass lesions within the left
parietal-occipital lobe with associated adjacent vasogenic
edema.
This report was electronically signed by Jonathan Harrison, MD
on 6/4/2020 3:51 AM.

June 30, 2020- 57th Chemo Infusion Herceptin –  

July 1, 2020

Examination: MRI BRAIN W-O and W CONTRAST
Referring Physician: THOMAS SKIDMORE
CLINICAL HISTORY: Breast cancer with brain metastases. Include imaging of the mandible/maxilla to exclude to rule out osteonecrosis. Yearly follow-up.
TECHNIQUE: Multiplanar T1 and T2-weighted MR imaging of the brain. Sagittal axial and coronal images. Axial diffusion. Axial and coronal postgadolinium T1. 3.0 Tesla magnet, Revere health imaging, Provo Utah.
COMPARISONS: May 20, 2020
FINDINGS:
No restricted diffusion.
Patient has extensive high T2 signal, peritumoral edema involving the left cerebral hemisphere, posterior frontal, parietal and occipital lobes. The peritumoral edema extends to the corpus callosum and crosses the midline. This represents an interval change. There is heterogeneous diminished signal in the medial left occipital lobe. This corresponds to diminished signal on gradient echo images and represents susceptibility artifact likely chronic microhemorrhage. There is no evidence for acute hemorrhage. There is shift of midline approximately 6.1 mm. There is effacement of adjacent sulci. The brain stem cisterns are still widely patent there is susceptibility artifact overlying involving the right cerebellar hemisphere
Postcontrast images were reviewed. There is enhancement at the paramedian left occipital. The left occipital horn is displaced anteriorly and face. The lesion measures 19.8 x 30.0 x 22.0 cm. There is a second focus of enhancement, in the left posterior frontal lobe near the midline measuring 10.3 x 8.5 x 7.3 millimeters. There is enhancement about the right occiput likely postsurgical. The 2 enhancing lesions within the brain also have diminished signal on gradient echo images. There appears to be narrowing of the TMJs with some flattening of the condyles. I find no destructive lesion. There is a small fluid collection overlying the craniotomy site.
No extra-axial fluid-collection or hemorrhage.
Basilar cisterns are patent.
Orbits are unremarkable.
Paranasal sinuses and mastoid air cells are clear.
I have compared this with the last exam of May 20, 2020. There has been marginal increase in size of the enhancing lesions. The lesion in the right cerebellum previously seen has been removed. There is susceptibility artifact. Expected findings at the craniotomy site. There is a small fluid collection with fairly diffuse enhancement I believe is likely postsurgical. There is some linear enhancement of the vessels about the operative site. Cannot with confidence identify residual tumor.. The peritumoral edema has increased marginally since the last exam. The shift midline is also worsened marginally. The lesion in the paramedian left occipital lobe showing modest increase from approximately 23 x 16.9 mm to 30 x 19.8 mm in the. The lesion in the posterior left frontal lobe has increased from approximately 9.9 x 8.4 to 10.3 x 8.5 mm. There is no new lesion.
IMPRESSION:
1. The peritumoral edema has progressed marginally since the last exam exam. The edema does not cross the midline near the splenium of the corpus callosum. There has been a mild increase in size of the paramedian posterior left frontal lobe lesion and the left parietal-occipital lesion as described above.
2. There has been a marginal increase shift of midline.
3. The patient has undergone resection of the right cerebellar enhancing mass. There are postsurgical changes as described. The inferior displacement of the cerebellar tonsil has resolved.
4. I find no evidence for destructive lesion involving the mandibles. There are degenerative changes at the temporomandibular joints.
Electronically Signed By: Dalton Wright MD
Signature Date/Time: 7/31/2020 5:54 PM

July 14, 2020

MRI Brain w/ + w/o Contrast
CC Provider: WALLENTINE, STEVEN
Att/Ordering Provider: David Glassford
Referring Provider:
Admitting Provider: David Glassford
Consulting Provider:
Originator:
Location: Heber Valley Medical Center
(Status: )
REASON FOR EXAM: arthrodesis status
ADDENDUM:
Request was made by the provider to evaluate the mandible for
suspected osteoradionecrosis. On the extended field of view
acquisitions extending through the mandible, there is
preservation of normal T1 marrow signal within the mandibular
structures without evidence of marrow edema on the T1
acquisitions were on STIR acquisitions to suggest osteonecrosis.
There are no visualized subperiosteal fluid collections. No
definite evidence of abnormal enhancement on the fat-saturated
acquisitions. Small cyst associated with the left
temporomandibular joint-favor degenerative change.
IMPRESSION: No findings to suggest mandibular osteoradionecrosis
at this time. If there is further clinical concern, CT may
provide complementary information to evaluate subtle breakdown
in mandibular cortex.
This report was electronically signed by Christopher R Trimble,
MD on 7/14/2020 8:07 AM.
EXAM: MRI of the brain with and without IV contrast.
COMPARISON: CT of the head 6/4/2020, outside MRI of the brain
5/20/2020, MRI of the brain with spectroscopy 12/2/2019
INDICATION/HISTORY: Metastatic breast cancer. Follow-up.
TECHNIQUE: A variety of pulse sequences and imaging planes were
utilized for optimum evaluation.
IV CONTRAST: Given
FINDINGS:
* Infarct/Hemorrhage: No acute infarct or hemorrhage.
* Gray/White Matter:
* Mass within the posterior cingulate gyrus in the region of
the occipital lobe on the left is noted. There is some low level
enhancement, though this may be technical in nature given lack
of significant contrast within the cerebral vasculature on the
post gadolinium acquisitions. This measures approximately 1.6 x
1.3 cm AP by transverse by 1.7 cm craniocaudad. There is some
peripheral low T2 and FLAIR signal which demonstrates intrinsic
T1 hyperintensity and some susceptibility artifact favored
represent calcification and/or chronic hemorrhage. There is
moderate perilesional T2 FLAIR signal hyperintensity/edema
extending into the left parietal lobe. There is also elevated
T2/FLAIR signal within the left aspect of the splenium of the
corpus callosum. Lesions similar to the prior brain MRI from
5/20/2020.
* Additional lesion with mild enhancement is visualized within
the cortical/subcortical left cingulate gyrus slightly more
anteriorly and superiorly which measures 11 mm x 11 mm x 11 mm.
This also demonstrates moderate adjacent edema within the
adjacent periventricular white matter. Lesion is similar to the
prior brain MRI from 5/20/2020.
* Given the technical limitations of the postcontrast imaging
detailed above, no definite evidence of additional lesions are
identified.
* There are postoperative changes from right suboccipital
lateral craniectomy. Small fluid collection extending inferiorly
into the suboccipital soft tissues representing a
pseudomeningocele or a seroma. This measures 4 cm transverse by
4 cm craniocaudad by approximately 2.1 cm anterior posterior.
There is mild enhancement along the margins of this collection.
There is no evidence of significant residual enhancement along
the margins of the resection cavity within the lower right
cerebellar hemisphere.
* Small focus of encephalomalacia along the anterior and
superior right cerebellar hemisphere.
* Ventricles/Extra-axial space: There is no evidence of
hydrocephalus. No midline shift or mass effect. No extra-axial
fluid collection is identified.
* Calvarium/Skull base: Cerebellar tonsils are normal in
position. There is no evidence of abnormal suprasellar mass
effect.
* Sinuses/Mastoids: Mild mucosal thickening in the maxillary
sinuses. Small left mastoid effusion.
* Soft Tissues: Orbital contents grossly unremarkable.
* Enhancement: As above
IMPRESSION:
1. Postoperative changes from right suboccipital craniectomy
and excision of a mass within the lower right cerebellar
hemisphere. Given the technical limitations on the postcontrast
imaging as detailed above, no definite evidence of significant
residual enhancement along the margins of this resection cavity
to suggest residual tumor in this location. There is a fluid
collection in the right suboccipital region favored to represent
a seroma more likely than developing pseudomeningocele.
2. Grossly stable appearance of 2 enhancing lesions within the
left cerebral hemisphere as detailed above as compared to the
preoperative MRI from 5/20/2020.
This report was electronically signed by Christopher R Trimble,
MD on 7/10/2020 8:26 PM.
***** Final *****
Dictated by: TRIMBLE, MD, CHRISTOPHER R.
Dictated DT/TM: 07/10/2020 8:26 pm
Signed by: TRIMBLE, MD, CHRISTOPHER R.
Signed (Electronic Signature): 07/10/2020 8:26 pm
Transcribed by: CRT

August 11, 2020- 58th Chemo Infusion Herceptin – 

August 19, 2020, Surgical Radiation Therapy

Two tumors. Each tumor zapped one time (five different days(

MRI OF THE BRAIN WITHOUT AND WITH CONTRAST
REFERRING PHYSICIAN: DAVID GLASSFORD FNP
AGE: 56 years
GENDER: Female
HISTORY: Brain tumor, right-sided weakness, difficulty with speech, follow-up. Duration of symptoms 2 months. History of breast cancer.
TECHNIQUE: Multiplanar multisequence imaging of the brain was obtained without and with IV gadolinium contrast on a 1.5 Tesla magnet. Images were acquired in the sagittal, transverse, and coronal planes.
Technical quality: No or minimal limitations
CONTRAST: 5mls of Gadavist, 65mls Vial Used
COMPARISON: 7/31/2020.
FINDINGS:
Extra-axial spaces: Postsurgical changes in the right posterior fossa. No acute lesions identified.
Ventricular system: There is mass effect on the posterior body, atrium, and trigone of the left lateral ventricle is trapped temporal horn. This has progressed slightly. The ventricles are shifted to the right.
Basal cisterns: Normal.
Cerebral and Cerebellar Parenchyma:
Infarction: There is no evidence of acute cortical or lacunar infarction.
Hemorrhage: None.
Injury: There is no evidence of traumatic brain injury.
White matter: There is extensive vasogenic edema throughout the left hemisphere, surrounding the left parietal and occipital masses. There is mass effect, effacement of sulci, ventricular compression, and midline shift to the right. The edema extends across the midline into the right occipital lobe. This has progressed in the interval
Mass: There is an irregular intra-axial enhancing mass in the medial left occipital lobe. The lesion measures about 3.3 cm in maximum dimension and has enlarged slightly. There is an irregular lesion in the anterior superior medial left parietal lobe measuring 1.4 cm. This has minimally enlarged. No new masses are seen. There are postsurgical changes in the right cerebellum.
Congenital: There are no congential anomalies. No Chiari malformation.
Other: None.
Enhancement: Otherwise unremarkable
Brainstem: Normal.
Midline shift: Approximately 8 mm of midline shift to the right
Paranasal sinuses and mastoid air cells: Clear.
Orbits: Normal.
Calvarium: Postsurgical changes in the right occipital bone.
IMPRESSION:
There are 2 irregular enhancing intra-axial masses in the left parietal and occipital lobes as described. The masses have enlarged slightly when compared to the previous examination. There is a large amount of left hemisphere edema with effacement of sulci, ventricular compression with partially trapped left temporal horn, and 8 mm of midline shift to the right.
Left occipital lobe lesion 33 mm in maximum dimension, 3 mm on the prior.
Left parietal lobe lesion 14 mm in maximum dimension, 10 mm on the prior.
Midline shift: 8 mm on the current exam, 7 mm on the previous.
Postsurgical changes in the periphery of the right cerebellum with no findings strongly suggestive of tumor recurrence.
Electronically Signed By: Brent Layton MD
Signature Date/Time: 8/19/2020 12:51 PM

September 1, 2020- 59th Chemo Infusion Herceptin –  

September 22, 2020- 60th Chemo Infusion Herceptin –  

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Medication

Anastrozole 1 mg daily

Clonodine 0.1 mg 2x daily