<THE RECTANGULAR STAMP: Russian Federal Agency for High-Tech Medical Aid / Federal State Institution "P. A. Gertsen Oncological Research Institute of Moscow" (Rosmedtehnologiy / FSI “P. A. Gertsen Oncological Research Institute of Moscow” / The 2-nd Botkinsky proezd, 3, Moscow-125284, Russia)>

Hospital discharge list with epicrisis No. XXX (external-beam radiotherapy)

Female patient: XXX, born XXX (age XXX years), residing at Moscow, XXX. Telephone (mobile): XXX.

Female patient was in the department of external-beam radiotherapy P. A. Gertsen Oncological Research Institute of Moscow in the period from 13 October 2010 to 26 October 2010.

Diagnosis: cancer of the left breast (stage IIIA, T1, N2, M0). Status after combined treatment, which was carried out on 2007 in Russian Scientific Center for Radiology and Nuclear Medicine (quadrantectomy of the left breast, which was carried out on December 14, 2007 + 4 courses of polychemotherapy according to scheme AC + postoperative radiotherapy with a total radiation dose of 50 Gy for a breast, 60 Gy for a tumor bed, 48 Gy for a subclavian area on the left side + with subsequent switch from Arimidex to Tamoxifen).

Since October 2008, there has been increased tumor marker CA 125. Status after laparoscopic bilateral adnexectomy with photodynamic therapy, which were carried out on April 23, 2009. Progression of tumor growth (metastasis in the inguinal lymph nodes on the left side + increased tumor marker CA 125), has been detected in July 2009. Status after inguinal lymph node dissection on the left side with photodynamic therapy, which were carried out on August 17, 2009 + 4 courses of polychemotherapy according to scheme: Taxotere + Farmorubicin + postoperative radiation therapy.

Progression of tumor growth has been detected in March 2010: a solitary metastasis to the left iliac crest. Status during therapy with administration of bisphosphonates (Zometa) + 8 courses of monochemotherapy (Xeloda). The steady state of the lesion solitary metastasis in the left iliac crest. The negative dynamics of the disease: increased tumor marker CA 125. Status after a course of radiation therapy on ¼ (upper) part of the pelvis on the left side, with a total radiation dose of 28 Gy (40 Gy-eq).

Concomitant diagnosis: hypertension (1st stage). Dishormonal cardiopathy. Atherosclerosis of aorta, atherosclerosis of coronary arteries,            atherosclerosis of cerebral vessels. Hyperlipidemia (stage IIB). Fibroadenomas of the right breast. Hysteromyoma. Endometrial hyperplasia. Focal changes in the thyroid gland. Euthyroidism. Exogenous-constitutive obesity (1st grade). Osteochondrosis of the cervicothoracicus and lumbosacral spine. Retrolisthesis of Th1. Disc protrusion L4-L5. Arachnoid cyst at the S2 level. Osteopenia. Right-sided gonarthrosis 2nd degree. Transverse platypodia. Chronic gastritis with hypoacidity of the gastric juice (Hp++). Hepatic steatosis. Pancreatic lipomatosis. Pulmonary emphysema. Diffuse pulmonary fibrosis. Initial cataract in both eyes.

Results of histological studies:

(№ 3328-46/07) Microscopy: infiltrative ductal carcinoma. Metastases in 3 lymph nodes with invasion into the surrounding cellular tissue.

(№ 85499-512 P on April 23, 2009) Microscopy: the ovaries - atresic bodies, small serous cysts, no tumor growth. The walls of the fallopian tubes are folded. In fragments of tissue peritoneal tumor was found.

(№ 19921-28 on August 17, 2009) Microscopy: in 7 of 10 lymph nodes are metastases of infiltrative ductal carcinoma with small foci of necrosis, with mostly complete replacement of the lymphoid tissue and growing into the lymph node capsule, with the beginning of invasion beyond the capsule in some lymph nodes, and with the presence of tumor emboli in the blood vessels of lymph nodes capsule and cellular tissue.

Results of immunohistochemical studies:

Reaction to estrogen receptors: 3 points. The reaction with the progesterone receptor: negative. Reaction with Нег2/new: negative.

Results of cytological study:

(№ 8259/09) [+ immunohistochemical phenotyping) of the punctate from the left inguinal lymph node: metastasis of breast cancer.

Results of histological study:

(Trepanbiopsiya tumor focus left iliac bone): metastases of an adenogenous cancer, probably breast cancer.

Results of immunohistochemical study:

Reaction with estrogen and progesterone receptors: negative. Reaction with Нег2/new: negative. Reaction with the tumor markers SK-5 - negative. Reaction with the tumor markers Ki-67 positive in 5%.

History:

In 2007, on the above diagnosis in Russian Scientific Center for Radiology and Nuclear Medicine was carried out combined treatment (quadrantectomy of the left breast, which was carried out on December 14, 2007 + 4 courses of polychemotherapy according to scheme AC + postoperative radiotherapy with a total radiation dose of 50 Gy for a breast, 60 Gy for a tumor bed, 48 Gy for a subclavian area on the left side + with subsequent switch from Arimidex to Tamoxifen).

Subsequently, female patient was under the strict dynamic control in Russian Scientific Center for Radiology and Nuclear Medicine. Since October 2008, there was increased tumor marker CA 125, from 32 U/ml to 119 U/ml. At carrying out complex inspection of data on recurrence and progression of the disease has been not received.

April 23, 2009 was carried out laparoscopic bilateral adnexectomy with photodynamic therapy in FSI “P. A. Gertsen Oncological Research Institute of Moscow”. In July 2009 has been detected Increased tumor marker CA 125.

Complex study during which the increased inguinal lymph nodes are revealed and verified is conducted.

Status of the female patient was discussed on a consultation together with the Head of Department, Professor E.G. Novikova: considering results of inspection and data cytologic research, decided to conduct an inguinal lymphadenectomy with photodynamic therapy.

August 17, 2009 was carried out inguinal lymph node dissection + photodynamic therapy.

Status of the female patient was discussed on a consultation together with radiologists and chemotherapeutists: given the progression of the process, the presence of adverse prognostic factors in the morphological study, decided to conduct the system of drug treatment in the second stage of the postoperative period.

From 31 August 2009 to 9 November 2009 was conducted 4 courses of polychemotherapy according to scheme: Taxotere + Farmorubicin.

Further treatment plan was discussed at a consultation with department head EBRT, PhD Rakhmanin Ju.A. and chief of chemotherapeutic of Moscow, Professor Borisov V.I. (distance on the phone): given the progression of tumor on a background of hormone therapy in the primary treatment of breast cancer, the prognosis is generally poor. At present, according to a survey of data on progression is not, however, the risk of local recurrence in the groin area (including the invasion outside of the capsule and embolism) and a further generalization of the process is preserved. Taking into account the hematologic toxicity of cytostatic therapy, the lack of data on the progression of the process, as well as carry out the 4 courses of chemotherapy, and the need for "local control" of the tumor, it was decided to refrain from further medical treatment. Recommended to carry out postoperative radiotherapy for inguinal-iliac lymph nodes on the left side.

Radiation therapy to the ilio-inguinal-femoral lymph nodes on the left side conducted from 3 December 2009 to 30 December 2009, on a linear accelerator ELEKTA, SIEMENS, AXSESS, in conformal irradiation with 4-shaped fields with a single dose of 2.5 Gy, until a total dose of 12.5 Gy (referred to in connection with the damage to the unit a break and continued treatment with 21 December 2009 (including the upcoming Christmas holidays) under the same conditions as the incident with a single dose of 3 Gy, until a total dose of 36.5 Gy equivalent to 45 Gy with the break).

Subsequently, female patient was under the strict dynamic control. In March 2010, the newly observed increase in tumor markers CA-125 (from 19.1 U/ml and 44.6 U/ml) and CA-19-9 (to 15.2 U/ml).

Results of a comprehensive survey:

Positron emission tomography - a pathological lesion in the left iliac crest.

Scintigraphy: hyperfixation drug in the right wing of the ilium in the sacroiliac joint, in the front left iliac crest bone.

Computed tomography: consolidated fracture of the left ilium.

Female patient received consultation of chemotherapeutic, PhD Bulanov A.A.: recommended chemotherapy (Xeloda) in combination with bisphosphonates (Zometa).

At follow-up in May 2010 (after 2 courses monochemotherapy with administration Xeloda), levels of tumor marker CA-125 decreased from 44.6 U/ml to 29.5 U/ml, and the level of tumor marker CA-15-3 was 12/7 U/ml. The steady state of the lesion solitary metastasis in the left iliac crest.

On examination in September 2010 (after eight courses monochemotherapy with administration Xeloda) level of tumor marker CA-125 increased from 29.5 U/ml to 38.4 U/ml, and the level of tumor marker CA-15-3 increased from 12,7 U/ml to 14.5 U/ml (negative trend). The steady state of the lesion solitary metastasis in the left iliac crest.

Female patient received consultation of chemotherapeutic, PhD Bulanov A.A.: recommended irradiation of metastatic lesion solitary in the left iliac crest bone during a break in chemotherapy.

In this regard, the female patient was admitted to department of external beam radiotherapy.

Radiation therapy to the quarter of the pelvis to the left (top of the iliac crest on the left) was carried out in the period from 18 October 2010 to 26 October 2010 on a linear accelerator SIEMENS, in conformal irradiation with 3-shaped fields with a single dose of 4 Gy, until a total dose of 28 Gy (equivalent to 40 Gy with the break).

Female patient underwent treatment satisfactorily, without adverse radiation reactions.

Recommended:

1) Consultation with chemotherapeutic to decide on the further course of treatment.

2) Follow-up after 1 month.

3) Dynamic control.

Attending physician: Anikina E.G. <signed>

Head of department: Rakhmanin Ju.A. <signed>

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