American College of Physicians: Internal Medicine — Doctors for Adults ®


The MKSAP Challenge

From the July-August ACP Observer, copyright © 2005 by the American College of Physicians.

Clinical scenario

A 40-year-old woman was treated for breast cancer five years ago by lumpectomy, breast irradiation and three months of chemotherapy. Her original cancer was negative for estrogen and progesterone receptors and unequivocally positive for HER2. Her periods stopped during chemotherapy but resumed four months later, and she remains premenopausal.

She is evaluated now because of pain in her back, a nagging cough and fatigue. Physical examination shows palpable skin nodules over the affected breast, axillary adenopathy and dullness to percussion, and decreased breath sounds in the base of the left lung. Her liver edge is palpable below the right costochondral border.

Liver function values are approximately twice normal; serum bilirubin is normal. Radiograph of the chest shows multiple pulmonary nodules and a left pleural effusion confirmed by CT, which also shows the liver nodules. Bone scan and MRI are consistent with bone metastases. Biopsy of one of the skin lesions is consistent with metastatic breast cancer; it is negative for estrogen and progesterone receptors, and positive for HER2.

What is the most appropriate treatment for this patient?

A. Hospice care and comfort measures
B. Combination endocrine therapy with tamoxifen and an aromatase inhibitor
C. High-dose chemotherapy with bone marrow stem cell support
D. Trastuzumab and taxane-based chemotherapy
E. Combination endocrine therapy with ovarian ablation and an aromatase inhibitor



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