Patient: Kavery Suryaprakash | Female | DOB: 05/02/1959 (age ~67)

REPORT INTERPRETATION

1. Whole Body PET-CT (FDG) - Key Findings

Primary Tumour - Left Breast

• Irregularly shaped, heterogeneously enhancing lesion in the upper outer quadrant (UOQ) of left breast
• Size: 2.5 x 2.2 x 2.2 cm
• SUVmax: 14.0 (highly metabolically active - strongly malignant)
• Skin infiltration present (T4b feature)
• Pectoralis muscle NOT involved

Lymph Node Involvement (Loco-regional Spread)

Thyroid

• Diffuse FDG uptake in both lobes, SUVmax 7.7 (left)
• CT shows diffuse hypoattenuation (low density)
• Reported as: ? Thyroiditis - requires TSH, Free T4, anti-TPO antibody workup

Important Negative Findings

• No brain lesions
• No mediastinal nodal disease
• No lung nodules or pleural effusion (ground-glass opacity in left upper lobe apicoposterior segment is incidental - likely inflammatory)
• No liver, spleen, adrenal or bone metastases
• No distant lymphadenopathy (right axillary nodes are subcentimetric and non-specific)

2. Staging (TNM - AJCC 8th Edition)

The supraclavicular nodal involvement classifies this as N3c. Previously considered Stage IV, ipsilateral supraclavicular-only nodal disease is now classified as Stage IIIC with curative intent per AJCC 8th edition - an important distinction for treatment planning.

3. Lab Report Interpretation

CBC

Renal Function

• Creatinine: 0.74 mg/dL (normal) - safe for platinum-based chemo if needed
• Urea: 29.5 mg/dL (normal)

Liver Function

• All parameters within normal range (Bilirubin 0.17, ALP 76.5, ALT 14.2, AST 24.7)
• Albumin: 4.0 g/dL (normal - good nutritional status)
• Normal LFT confirms no hepatic involvement and safe anthracycline/taxane metabolism

Glycemic Status

• HbA1c: 6.10% - Pre-diabetic range (5.7-6.4%)
• Fasting glucose: 96.8 mg/dL (normal)
• Blood sugar monitoring important during corticosteroid use with chemotherapy

Coagulation

• PT: 12.9 sec (normal), INR: 0.87 (normal) - safe for surgery/procedures

TREATMENT PLAN

Step 1: Essential Workup Before Starting Treatment

1. Biopsy with IHC (if not already done): ER, PR, HER2 (IHC/FISH), Ki-67
2. Thyroid function tests: TSH, Free T4, anti-TPO antibody (for the diffuse thyroid FDG uptake)
3. ECHO/MUGA scan: Baseline cardiac function (essential before anthracyclines/trastuzumab)
4. Bone scan or dedicated skeletal survey if bone symptoms arise
5. Tumor markers: CA 15-3, CEA

Step 2: Neoadjuvant Systemic Therapy (PRIMARY treatment - before surgery)

Based on receptor subtype:

• Typical duration: 16-24 weeks of NACT
• Response assessed by PET-CT or MRI mid-treatment

Dose-dense AC (ddAC) regimen:

• Doxorubicin 60 mg/m² + Cyclophosphamide 600 mg/m² q2 weekly x 4 cycles
• Followed by Paclitaxel 80 mg/m² weekly x 12

Step 3: Surgery

• Modified Radical Mastectomy (MRM) with level I-III axillary clearance is standard
• Breast-conserving surgery may be considered if good response to NACT, but with skin involvement and N3c disease, MRM is preferred
• Pathological staging of surgical specimen guides adjuvant decisions (ypTNM)

Step 4: Adjuvant/Post-Neoadjuvant Therapy

• If pCR achieved: Complete planned adjuvant therapy per subtype
• If residual disease (non-pCR):
  • HER2+: Switch to T-DM1 (trastuzumab emtansine) for 14 cycles
  • TNBC: Switch to Capecitabine for 8 cycles (CREATE-X trial)
  • HR+: Add abemaciclib (CDK4/6 inhibitor) per monarchE criteria

Step 5: Radiotherapy (Post-mastectomy)

• Post-mastectomy radiotherapy (PMRT) is MANDATORY in N3c disease
• Fields: chest wall, axilla (levels I-III), supraclavicular fossa, ± internal mammary chain
• Dose: typically 45-50 Gy in 25 fractions + boost if needed

Step 6: Endocrine Therapy (if HR+)

• Premenopausal equivalent (age 67 - likely post-menopausal):
  • Aromatase inhibitor (Letrozole or Anastrozole) for 5-10 years
  • Consider Abemaciclib if high-risk residual disease (monarchE criteria: N2+ or N1 with additional risk)

Step 7: Address Thyroid Finding

• Organize: TSH, FT4, anti-TPO Ab, anti-thyroglobulin Ab
• If autoimmune thyroiditis confirmed - monitor and supplement if hypothyroid
• This does not delay cancer treatment

Summary for Treating Team

Important disclaimer: This interpretation is for educational/informational purposes. Final treatment decisions must be made by the patient's oncologist and multidisciplinary team (MDT) based on complete clinical, pathological, and molecular data. The receptor subtype (HER2/ER/PR) from biopsy is the single most important factor guiding targeted therapy selection.