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    Breast Cancer Clinical Case Presentation: ESMO Clinical Practice Guidelines

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    Nina
    1) The patient presented with HER2-positive metastatic breast cancer with a solitary supraclavicular lymph node metastasis. 2) She was treated with multiple lines of HER2-targeted therapy and chemotherapy, achieving good responses initially. 3) She later developed further metastases including a solitary brain metastasis, which was treated with surgery and radiosurgery. 4) Currently she is receiving dual anti-HER2 blockade with trastuzumab and pertuzumab, with an ongoing partial response.

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    Breast Cancer Clinical Case Presentation: ESMO Clinical Practice Guidelines

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    Nina
    48 views18 pages
    1) The patient presented with HER2-positive metastatic breast cancer with a solitary supraclavicular lymph node metastasis. 2) She was treated with multiple lines of HER2-targeted therapy and chemotherapy, achieving good responses initially. 3) She later developed further metastases including a solitary brain metastasis, which was treated with surgery and radiosurgery. 4) Currently she is receiving dual anti-HER2 blockade with trastuzumab and pertuzumab, with an ongoing partial response.

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    1) The patient presented with HER2-positive metastatic breast cancer with a solitary supraclavicular lymph node metastasis. 2) She was treated with multiple lines of HER2-targeted therapy and chemotherapy, achieving good responses initially. 3) She later developed further metastases including a solitary brain metastasis, which was treated with surgery and radiosurgery. 4) Currently she is receiving dual anti-HER2 blockade with trastuzumab and pertuzumab, with an ongoing partial response.

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    Download as pdf or txt
    48 views18 pages

    Breast Cancer Clinical Case Presentation: ESMO Clinical Practice Guidelines

    Uploaded by

    Nina
    1) The patient presented with HER2-positive metastatic breast cancer with a solitary supraclavicular lymph node metastasis. 2) She was treated with multiple lines of HER2-targeted therapy and chemotherapy, achieving good responses initially. 3) She later developed further metastases including a solitary brain metastasis, which was treated with surgery and radiosurgery. 4) Currently she is receiving dual anti-HER2 blockade with trastuzumab and pertuzumab, with an ongoing partial response.

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    of 18

    ESMO Clinical Practice Guidelines

    Breast Cancer
    Clinical Case Presentation
    F. Cardoso, MD
    Director, Breast Unit, Champalimaud Clinical Center, Lisbon, Portugal
    ESMO Board of Directors & NR Committee Chair
    ESO Breast Cancer Program Coordinator
    EORTC Board of Directors & Breast Group Chair
    Disclosures
    Consultant:
    Astellas/Medivation, AstraZeneca, Celgene, Daiichi-Sankyo,
    Eisai, GE Oncology, Genentech, GlaxoSmithKline (GSK)
    Merck-Sharp, Merus BV, Novartis, Pfizer, Pierre-Fabre
    Roche, Sanofi, Teva
     CS, a 39-year-old lady came to our Breast Unit on June 2012,
    with a recent diagnosis of breast cancer relapse.
     In Nov 2009, she had been diagnosed with T2N1M0 left ductal
    invasive breast cancer, grade 3, ER and PR negative, HER-2+.
     She was treated with breast conserving surgery and axillary
    dissection. Pathology: ductal invasive carcinoma, 23 mm, 4+LN,
    ER/PR neg and HER-2+.
     She was treated with 6 cycles of TAC, trastuzumab for 1 year
    (end: May 2011) and adjuvant RT. BRCA 1 & 2 negative.
     In May 2012, she noticed a left supraclavicular lump. Work-up
    was performed with US and a biopsy that confirmed a lymph
    node metastasis of a ER/PR neg and HER-2+ BC.
     She had no other symptoms and tumour markers were normal. A
    PET-CT was performed and confirmed as only site of metastases
    supraclavicular LNs.
    Q1: Do you regularly biopsy metastatic disease?

    1. Yes
    2. No
    3. Only when receptors are negative in the primary
    tumour
    4. Abstain
    BIOPSY OF METASTATIC LESION

    A biopsy (preferably providing histology) of a metastatic lesion should be


    performed, if easily accessible, to confirm diagnosis particularly when
    metastasis is diagnosed for the first time. (LoE: 1 B) (98%)

    Biological markers (especially HR and HER-2) should be reassessed at


    least once in the metastatic setting, if clinically feasible.
    (LoE: 1 B) (98%)

    Depending on the metastatic site (e.g. bone tissue), technical


    considerations need to be discussed with the pathologist.
    Q2: Do you regularly use PET-CT in the initial work-up
    of metastatic breast cancer?

    1. Always
    2. No
    3. Only to confirm oligo-metastatic disease
    4. In selected cases
    5. Abstain
    IMAGING, TUMOR MARKERS &
    EVALUATION OF RESPONSE

    Minimal staging workup for MBC includes a history and physical


    examination, hematology and biochemistry tests, and imaging of chest,
    abdomen and bone (LoE: 2 C). (67%)

    Notes:
     Biochemistry tests including liver function tests, renal function,
    electrolytes, calcium, total proteins and albumin
     In many cases a chest X-ray, an abdominal ultrasound and a bone scan
    are sufficient (lot of discussion about the optimal imaging modality- LoE 2C)
     Consensus that a PET-scan should NOT be part of the minimal staging
    workup but should be reserved for specific situations
    Q3: Which of the following would be your preferred
    option for 1st line therapy outside a clinical trial? (please
    note that Pertuzumab was not yet available at that time)

    1. Trastuzumab + Vinorelbine
    2. Trastuzumab + Capecitabine
    3. Trastuzumab + Taxane
    4. Lapatinib + Capecitabine
    5. T-DM1
    6. CT alone
    Q4: What if pertuzumab was available? Would you
    choose for this particular patient Docetaxel +
    Trastuzumab + Pertuzumab?

    1. Yes
    2. No
    3. Abstain
     The patient was started on Trastuzumab + Vinorelbine in
    July 2012.
     PET-CT performed after 3 cycles showed a good PR
    and continued response after 6 cycles (only 1 small LN
    remained). Some hematological toxicity.
     Vinorelbine was stopped (Nov 2012) and trastuzumab
    monotherapy continued.
     In Feb 2013, PD with cutaneous lesions in the left
    breast. PET-CT showed 1 mediastinal LN. No other
    lesions. Tumour markers always normal.
     A cutaneous biopsy confirmed infiltration by ductal
    invasive carcinoma ER/PR negative and HER-2 positive.
    Q5: Which of the following would be your preferred
    option for 2nd line therapy outside a clinical trial?

    1. Trastuzumab + Capecitabine
    2. Trastuzumab + Taxane
    3. Lapatinib + Capecitabine
    4. Docetaxel + Trastuzumab + Pertuzumab
    5. T-DM1
    6. Trastuzumab + Lapatinib
    7. CT alone
     The patient was started on Trastuzumab + Capecitabine in
    Feb 2013.
     Evaluated clinically and with photographs, showing a good
    response.
     PET-CT performed after 7 cycles: still 1 small mediastinal LN
    and FGD captation in left breast; no other lesions.
     Trastuzumab + Capecitabine was maintained.
     Re-irradiation was performed to left breast + left
    supraclavicular (capecitabine stopped during RT and then
    continued).
     Good response (almost CR).
     After 15 cycles, reappearance of cutaneous lesions. Biopsy
    confirmed malignancy with the same biology.
    PET-CT did not show any lesion.
    Q6: Which of the following would be your preferred
    treatment option outside a clinical trial?

    1. Trastuzumab + Taxane
    2. Trastuzumab + liposomal anthracycline
    3. Docetaxel + Trastuzumab + Pertuzumab
    4. T-DM1
    5. Trastuzumab + Lapatinib
    6. CT alone
     The patient was started on Trastuzumab + Lapatinib in Jan 2014.

     Evaluated clinically and with photographs, showing good response.

     In August 2014, cutaneous PD and in left breast, confirmed by


    mammography/US.

     Proposed to the patient T-DM1 or Trastuzumab + metronomic CM.


    She decided for the latter.

     In the meantime, a MRI of the left braquial plexum was requested


    since the patient had developed important neurological pain in the
    left arm, after RT.

     It showed post-RT fibrosis but also 1 brain metastasis in the


    cerebellum, with 30 mm. The patient was asymptomatic and a
    neurologic exam was normal. The brain metastasis was confirmed
    to be a solitary one with a brain MRI.

     The patient had just started the metronomic CT, and trastuzumab
    continued.
    Q7: Which of the following would be your preferred
    local treatment option for solitary brain metastasis?

    1. Surgery alone
    2. Radiosurgery alone
    3. Surgery followed by radiosurgery
    4. Whole brain radiotherapy
    5. Surgery followed by whole brain radiotherapy
    6. Other
    Q8: And regarding systemic therapy, which of the
    following would be your preferred choice?

    1. Keep the same ongoing systemic therapy


    2. Change to i.v. chemotherapy + trastuzumab
    3. T-DM1
    4. Taxane + trastuzumab + pertuzumab
    5. Stop chemotherapy and continue trastuzumab
    alone
     Brain surgery followed by radiosurgery to the lesion bed, without
    complications in September 2014.
     Pathology of brain metastasis: ductal invasive carcinoma, ER/PR
    negative HER-2 positive.
     Systemic therapy was maintained without change (metronomic
    CM + trastuzumab).
     2 months later, progression of lesion in the breast and cutaneous
    lesions. No surgical indication. No new metastatic sites.
     Decided to start T-DM1. She received 6 cycles with the best
    response as SD, followed by PD of cutaneous lesions.
     She was started on wPaclitaxel + Trastuzumab + Pertuzumab in
    April 2015. After 4 cycles, paclitaxel was stopped and the 2
    antibodies continued, with good PR. She is still on treatment.

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