What are the next steps for a 52-year-old patient with a 12 mm spiculated breast mass, infiltrative cancer, hormone receptor-positive and HER2 (Human Epidermal growth factor Receptor 2) negative status?

Management of a 52-Year-Old Patient with Hormone Receptor-Positive, HER2-Negative Spiculated Breast Mass

For a 52-year-old patient with a 12 mm spiculated breast mass with infiltrative cancer that is hormone receptor-positive and HER2-negative, the next step should be a modified radical mastectomy followed by appropriate adjuvant systemic therapy based on final pathological staging.

Initial Diagnostic Workup

Before proceeding with definitive treatment, ensure the following diagnostic workup is complete:

• Confirm hormone receptor (ER/PR) status and HER2 status 1
• Complete staging evaluation including:
  • Bilateral diagnostic mammogram with ultrasound
  • CT scan of chest, abdomen, and pelvis
  • Bone scan
  • Complete blood count and liver function tests

Surgical Management

A spiculated mass with infiltrative features strongly suggests an invasive breast cancer. Given the presentation:

• Modified radical mastectomy is the recommended surgical approach 1, 2
• Sentinel lymph node biopsy or axillary lymph node dissection should be performed for nodal staging 2
• Breast conservation therapy may be considered in select cases, but the spiculated nature of the mass often indicates a more infiltrative process requiring more extensive surgery

Systemic Therapy

For hormone receptor-positive, HER2-negative breast cancer, systemic therapy options include:

Adjuvant Endocrine Therapy

• Aromatase inhibitors (such as letrozole) are the preferred option for postmenopausal women 3
• Consider ovarian suppression (e.g., goserelin) plus an aromatase inhibitor for premenopausal women 4
• Duration of therapy is typically 5-10 years based on risk assessment

Adjuvant Chemotherapy

Decision for chemotherapy should be based on:

• Tumor size (12mm is relatively small but infiltrative nature is concerning)
• Lymph node status
• Grade of tumor
• Ki-67 proliferation index (if available)
• Genomic assays (Oncotype DX, MammaPrint) to assess recurrence risk

Radiation Therapy

• Post-mastectomy radiation therapy should be considered if:
  • Tumor >5 cm
  • Positive lymph nodes (≥4)
  • Positive surgical margins 2

Follow-up Care

• Regular clinical examinations every 3-6 months for the first 3 years
• Annual mammography of the contralateral breast
• Bone density monitoring if on aromatase inhibitors
• Consider genetic counseling based on family history

Special Considerations

• The spiculated appearance of the mass is highly suggestive of malignancy, with infiltrating ductal carcinoma being the most common pathology 5
• Hormone receptor-positive status allows for endocrine therapy, which significantly improves survival outcomes 6, 7
• For patients with high-risk features, consider more aggressive adjuvant therapy including chemotherapy followed by endocrine therapy 1

Common Pitfalls to Avoid

1. Underestimating the significance of a spiculated mass, which has a high likelihood of malignancy
2. Delaying definitive surgical management
3. Failing to complete proper staging before definitive treatment
4. Not considering genomic testing for intermediate-risk patients to guide chemotherapy decisions
5. Overlooking the importance of long-term endocrine therapy adherence

The management approach outlined above prioritizes definitive local control with appropriate systemic therapy to reduce recurrence risk and improve overall survival in this hormone receptor-positive, HER2-negative breast cancer patient.