Case Study Adjuvant Therapy Advances - Carol

Metastasis to Cervical Vertebra

Carol Rock was an informed and highly educated computer expert who was on assignment to the air force in Abilene, Texas. In the summer of 1988, at the age of 44, she developed a tender node in her right axilla. She saw her gynecologist, who confirmed the finding, gave her a prescription for an antibiotic, and told her to return in 3 days if there was no improvement. The node disappeared, but rapidly recurred within a week. She was referred for a mammogram on which a 2.5 cm mass was found in the tail of her right breast. She had an ultrasound-guided needle biopsy and the mass was diagnosed cancer.

Carol elected to have a quadrantectomy of the right breast with an axillary dissection. On August 10, 1988, the mass was removed. It measured 1.5 cm30.8 cm and eight axillary nodes were involved with metastases.  She was staged as having stage 2, T1N1 breast cancer, strongly positive for both ER and PR. Her surgeon was well trained, having recently completed a surgical oncology fellowship at Memorial Sloan Kettering in New York City. He had firsthand experience with what the finding of eight positive axillary nodes implied and, to his credit, guided her to the MDA program. At MDA, Carol received six courses of CAVe, underwent bilateral oophorectomy, completed 6 weeks of radiation therapy, and finished the therapeutic program with three courses of MCCFUD. When her assignment in Abilene was completed, Carol returned to her home base in El Paso. She did well, continued her computer work, and had follow-up examinations every 3 months. However, in June 1993, Carol was found to have a small stage 1, T1N0 cancer in her left breast. Again, she elected to have breast sparing surgery and was treated with lumpectomy and radiation therapy but received no adjuvant chemotherapy. This cancer was negative for both ER and PR.

In March 1996, Carol began to notice neck pain while driving her car. By June, this progressed to the point that it incapacitated her and she was referred to Dr. Howard Chang, a neurosurgeon in El Paso. Films showed almost complete destruction of the third cervical vertebra to the degree that her head was unstable. Dr. Chang felt that the only chance he had to prevent Carol from becoming severely paralyzed, or worse, was to remove the damaged bone and replace it with transplanted bone, which, hopefully, would regrow and give her cervical spine some structural integrity. In the interim, she would have to wear a cage-like device which rested on her shoulders and was attached to her skull with screws. She was told, “Life will be Hell for the next 6 months.” Carol had no other option. So she went for it, thus living up to her pseudonym of Rock. The surgery was a technical success but the bone in her third cervical vertebra was found to be infiltrated with breast cancer. Fortunately, staging failed to show any other sites that were suspicious for metastases.

Radiation therapy could not be given to the area of healing bone. However, chemotherapy could be justified. So 2 weeks postoperative, he took the precaution of treating her with a little-used adjuvant drug combination: Adriamycin/vinblastine by continuous infusion every 21 days X 8, followed by FUMEP 32.

Although, Carol has received a cumulative dose of Adriamycin that is more than 540 mg/m2, she has had no clinical evidence of myocardial injury. She remains in good health, teaching computer science at the University of Texas, Austin, 20 years after being treated for breast cancer that had metastasized to her third cervical vertebra. We’ll never know if this metastasis was from the original cancer or the second primary. But Blumenschein believes that she has passed the criteria necessary to be considered cured.