A patient with newly diagnosed breast cancer found to have mosaic TP53 likely pathogenic variant

IF 232.4 1区 医学 Q1 ONCOLOGY
Hetal D. Mistry, MacKenzie R. Adams, Charu Taneja, Lauren J. Massingham, Elizabeth H. Dibble, Kara L. Leonard, Jesse Hart, Galina G. Lagos, Mary Anne Fenton
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She reported recent fatigue and intermittent diarrhea but had a negative colonoscopy and food allergy testing this year.</p>\n<p>Her family history was significant for a maternal grandmother with a question of uterine cancer, a maternal grandfather who died of renal cancer at age 62 years, a paternal grandmother who died of brain cancer at age 56 years, a paternal grandfather who died of brain cancer at age 80 years, and a history of premalignant changes in the esophagus in her father. She has never smoked tobacco and consumes zero to three drinks of alcohol weekly. She has been physically active in multiple sports, including biking and swimming, and played the cello.</p>\n<p>Mammography demonstrated extremely dense breast tissue with new calcifications in both breasts. Diagnostic mammography demonstrated indeterminate grouped calcifications spanning 19 mm in the right breast at 5 o'clock and 7 mm in the left breast 12 o'clock. 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引用次数: 0

Abstract

CASE OVERVIEW

A 36-year-old, nulligravid woman with a history of controlled eosinophilic esophagitis, asthma, and dense fibrocystic breasts was referred to the Breast Health Center after abnormal screening mammography. She reported recent fatigue and intermittent diarrhea but had a negative colonoscopy and food allergy testing this year.

Her family history was significant for a maternal grandmother with a question of uterine cancer, a maternal grandfather who died of renal cancer at age 62 years, a paternal grandmother who died of brain cancer at age 56 years, a paternal grandfather who died of brain cancer at age 80 years, and a history of premalignant changes in the esophagus in her father. She has never smoked tobacco and consumes zero to three drinks of alcohol weekly. She has been physically active in multiple sports, including biking and swimming, and played the cello.

Mammography demonstrated extremely dense breast tissue with new calcifications in both breasts. Diagnostic mammography demonstrated indeterminate grouped calcifications spanning 19 mm in the right breast at 5 o'clock and 7 mm in the left breast 12 o'clock. She subsequently underwent stereotactic needle biopsies of both areas, which revealed right breast ductal carcinoma in situ (DCIS), nuclear grade 3, with 90% estrogen receptor (ER) expression; and left ductal carcinoma, nuclear grade 3, with 95% ER expression, 40% progesterone receptor (PR) expression, negative human epidermal growth factor receptor 2 (HER-2) status, and a Ki-67 index of 40%. Within the left breast biopsy there was an absence of myoepithelial cells, raising concern that the findings reflected an unusual type of invasive carcinoma. She then underwent bilateral breast magnetic resonance imaging (MRI), which revealed the known areas of DCIS in the bilateral breasts and also revealed a 1.0-cm mass inferior to the left breast DCIS at 12 o'clock that was considered suspicious. On subsequent ultrasound, it corresponded to an 8-mm mass in the left breast at 10 o'clock. A biopsy of the mass demonstrated a spindle cell tumor, favoring malignant phyllodes tumor with pleomorphic liposarcomatous differentiation that was negative for ER, PR, and HER2 (triple-negative), with a Ki-67 index of 30%.

At her multidisciplinary consultation, she was referred for genetic evaluation having met National Comprehensive Cancer Network (NCCN) criteria based on her diagnosis of breast cancer when younger than 50 years.1 Given the concern for invasive left breast cancer and possible need for chemotherapy, she was also referred for fertility preservation.

She completed a comprehensive 76-gene germline genetic test, which revealed tumor protein p53 (TP53) likely pathogenic variant (LPV; c.716A>G; p.N239S). Pathogenic variants (PVs) and LPVs are DNA sequence changes that are associated with increased risk of disease. There is well established evidence that PVs are disease-causing, and LPVs are strongly suspected but have less definitive evidence. Both are considered positive results in genetic testing indicating a diagnostic result.

When TP53 PVs/LPVs are identified in a comprehensive germline panel, this raises concern for Li–Fraumeni syndrome (LFS). However, delineation of the origin of the TP53 PV/LPV is necessary because detection of the TP53 PV/LPV can occur through multiple mechanisms, including clonal hematopoiesis of indeterminate potential (CHIP), mosaicism, or a true germline finding.

She elected to proceed with bilateral skin and nipple-sparing mastectomy with left axillary sentinel lymph node (SLN) biopsy (SLNB) and Magtrace injection (Endomag; A Hologic Company) into the right breast for delayed SLNB. Neurotization of flaps was performed with a nerve graft from the fourth and fifth intercostal nerves to the nipple–areolar complex and placement of prepectoral tissue expanders. She recovered well after surgery, and the final pathology revealed right breast DCIS, no residual left breast DCIS, and a malignant phyllodes tumor excised to negative margins. Left SLNB was negative, and axillary lymph node dissection was not required.

新诊断的乳腺癌患者发现嵌合TP53可能致病变异
病例概述:一名36岁无孕妇女,有嗜酸性粒细胞控制性食管炎、哮喘和致密纤维囊性乳房病史,经异常乳房x光检查后转介至乳腺健康中心。她最近报告了疲劳和间歇性腹泻,但今年结肠镜检查和食物过敏测试呈阴性。她的家族史对于有子宫癌问题的外祖母,62岁死于肾癌的外祖父,56岁死于脑癌的外祖母,80岁死于脑癌的外祖父,以及父亲有食道癌前病变的病史具有重要意义。她从不吸烟,每周喝0到3杯酒。她一直积极参加多种体育运动,包括骑自行车和游泳,并演奏大提琴。乳房x光检查显示双侧乳房组织异常致密并有新的钙化。诊断性乳房x光检查显示不确定的成组钙化,在右乳房5点钟位置有19mm宽的钙化,在左乳房12点钟位置有7mm宽的钙化。随后,她接受了两个区域的立体定向针活检,发现右乳导管原位癌(DCIS),核3级,雌激素受体(ER)表达90%;左导管癌,核3级,ER表达95%,孕激素受体(PR)表达40%,人表皮生长因子受体2 (HER-2)状态阴性,Ki-67指数40%。在左乳活检中,肌上皮细胞缺失,这引起了人们的关注,认为这是一种不寻常的浸润性癌。然后行双侧乳房磁共振成像(MRI),显示双侧乳房DCIS已知区域,并在左侧乳腺DCIS下方12点钟方向发现一个1.0 cm肿块,认为可疑。在随后的超声检查中,它对应于10点钟左乳房一个8毫米的肿块。肿块的活检显示为梭形细胞肿瘤,倾向于恶性叶状肿瘤,伴多形性脂肪肉瘤分化,ER、PR和HER2阴性(三阴性),Ki-67指数为30%。在她的多学科咨询中,她被转介进行基因评估,根据她在50岁以下诊断为乳腺癌,符合国家综合癌症网络(NCCN)的标准考虑到浸润性左乳腺癌和可能需要化疗,她也被转介为保留生育能力。她完成了全面的76个基因生殖系基因检测,发现肿瘤蛋白p53 (TP53)可能的致病变异(LPV; c.716A>;G; p.N239S)。致病性变异(pv)和lpv是与疾病风险增加相关的DNA序列变化。有充分的证据表明,pv是致病的,并且有强烈的怀疑,但没有明确的证据。两者都被认为是基因检测的阳性结果,表明诊断结果。当TP53 pv / lpv在一个全面的生殖系面板中被发现时,这引起了对Li-Fraumeni综合征(LFS)的关注。然而,描述TP53 PV/LPV的起源是必要的,因为TP53 PV/LPV的检测可以通过多种机制发生,包括克隆造血不确定电位(CHIP)、嵌合体或真正的种系发现。她选择继续进行双侧皮肤和乳头保留乳房切除术,左腋窝前哨淋巴结(SLN)活检(SLNB)和磁trace注射(Endomag; A Hologic公司)到右乳房治疗延迟性SLNB。皮瓣的神经化是通过从第四和第五肋间神经移植到乳头-乳晕复合体和放置乳头前组织扩张器进行的。术后恢复良好,最终病理显示右侧乳腺DCIS,左侧乳腺DCIS未残留,恶性叶状肿瘤切除至阴性边缘。左侧SLNB阴性,无需腋窝淋巴结清扫。
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来源期刊
CiteScore
873.20
自引率
0.10%
发文量
51
审稿时长
1 months
期刊介绍: CA: A Cancer Journal for Clinicians" has been published by the American Cancer Society since 1950, making it one of the oldest peer-reviewed journals in oncology. It maintains the highest impact factor among all ISI-ranked journals. The journal effectively reaches a broad and diverse audience of health professionals, offering a unique platform to disseminate information on cancer prevention, early detection, various treatment modalities, palliative care, advocacy matters, quality-of-life topics, and more. As the premier journal of the American Cancer Society, it publishes mission-driven content that significantly influences patient care.
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