ESMO SUMMIT LATIN AMERICA 2019 Breast Cancer Clinical Cases Enrique Soto Pérez de Celis MD, MSc Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán México City, Mexico
CONFLICT OF INTEREST DISCLOSURE Dr. Soto Pérez de Celis has no financial conflicts of interest to disclose
CASE 1 A young woman with triple negative breast cancer
CASE 1 A young woman with triple negative breast cancer 32 year old woman One aunt with breast cancer after age 50 No history of pregnancy No alcohol consumption First menstrual period at age 14, has never used oral contraception No other comorbidities
CASE 1 A young woman with triple negative breast cancer April 2018: self palpated a tumor on her left breast • Ultrasound: septated lesion in the left breast (29 x 11 x 21mm). BIRADS 4A. No • suspicious axillary lymph nodes detected Biopsy: infiltrating ductal carcinoma, high grade, ER-, PR-, HER2++, Ki67 60%. • HER2 FISH: HER2 neu/CEN 17:1.45 (not amplified) A clip was placed in the tumor and sequential neoadjuvant chemotherapy was • planned
CASE 1 Questions Is neoadjuvant chemotherapy indicated in all triple negative tumors, regardless of 1. size and lymph node status? What are the probabilities of this patient having a genetic predisposition mutation 2. for breast cancer? The patient wishes to become pregnant in the future but cannot afford 3. cryopreservation, what other options are available?
CASE 1 A young woman with triple negative breast cancer The patient received neoadjuvant chemotherapy • 4 cycles of dose dense AC 12 cycles of weekly paclitaxel LHRH analogues were used during chemotherapy • Breast conserving surgery with sentinel lymph node was performed after • completion of NACT Pathological review: ductal infiltrating carcinoma in the breast (10 x 6mm). ER-, PR- • , HER2-, Ki67 25%. Residual Cancer Burden (RCB) 1.909 (RCB-II)
CASE 1 Questions Is it necessary to repeat the determination of HR and HER2 status after 1. neoadjuvant treatment? Would you offer additional adjuvant treatment to this patient? 2. What type of long term complications can we expect after completing treatment, 3. and what type of follow up is needed? Are there ongoing clinical trials of immunotherapy in this scenario? 4.
CASE 2 A postmenopausal woman with recurrent stage IV HER2-positive breast cancer
CASE 2 A postmenopausal woman with recurrent stage IV HER2+ breast cancer 59 year old woman • Father with pancreatic cancer, two paternal aunts with breast cancer at age 40 • Two pregnancies • No alcohol consumption • First menstrual period at age 15, menopause at age 52 • No other comorbidities •
CASE 2 A postmenopausal woman with recurrent stage IV HER2+ breast cancer June 2015: self palpated a tumor on her right breast • Ultrasound: tumor in the right breast (24 x 20 x 27mm). Two suspicious axillary • lymph nodes detected. BIRADS 4A Biopsy: infiltrating ductal carcinoma, high grade, ER-, PR-, HER2+++, Ki67 10%. • FNA of the axillary lymph nodes positive for carcinoma Staging revealed no signs of metastatic disease •
CASE 2 A postmenopausal woman with recurrent stage IV HER2+ breast cancer Received neoadjuvant treatment with trastuzumab plus weekly paclitaxel followed • by four cycles of AC, without radiological response in breast/axilla She underwent BCS plus axillary lymph node dissection • Residual tumor 19 x 14 x 0.8 cm Two positive lymph nodes HR-, HER2+++ Trastuzumab was continued until completing a year (10/2016), radiotherapy was • provided to the breast and axilla
CASE 2 Questions What is the ideal neoadjuvant chemotherapy for HER2+ breast cancer? Should 1. pertuzumab be added in all cases? Should this patient be tested for genetic predisposition to breast cancer? Would it 2. alter management? Should the patient receive adjuvant therapy after initial treatment (with the benefit 3. of hindsight)?
CASE 2 A postmenopausal woman with recurrent stage IV HER2+ breast cancer 16 months after completing trastuzumab she had a recurrence on the skin of the • right breast. Biopsy showed IDC, HR-, HER2+++. Unresectable. PET/CT was negative for other metastatic sites Treatment with pertuzumab+docetaxel+trastuzumab was administered for 6 cycles • with partial response Mastectomy was performed in October 2018 with residual HER2+ disease. • Trastuzumab was restarted
CASE 2 A postmenopausal woman with recurrent stage IV HER2+ breast cancer
CASE 2 A postmenopausal woman with recurrent stage IV HER2+ breast cancer 16 months after completing trastuzumab she had a recurrence on the skin of the • right breast. Biopsy showed IDC, HR-, HER2+++. Unresectable. PET/CT was negative for other metastatic sites Treatment with pertuzumab+docetaxel+trastuzumab was administered for 6 cycles • with partial response Mastectomy was performed in October 2018 with residual HER2+ disease. • Trastuzumab was restarted
CASE 2 Questions Should trastuzumab be continued after a local recurrence is treated with “curative” 1. intent? Should the patient receive “adjuvant” therapy with TDM1 after rescue 2. mastectomy?
CASE 2 A postmenopausal woman with recurrent stage IV HER2+ breast cancer Two months after mastectomy a PET/CT showed FDG uptake in a right-sided • parasternal node, contralateral axillary lymph nodes, and the left breast Breast biopsy: DCI, HR-, HER2+++, Ki67%. Parasternal node and left axillary • nodes with metastatic disease Genetic testing was ordered, the result is pending •
CASE 2 A postmenopausal woman with recurrent stage IV HER2+ breast cancer
CASE 2 A postmenopausal woman with recurrent stage IV HER2+ breast cancer
CASE 2 A postmenopausal woman with recurrent stage IV HER2+ breast cancer Two months after mastectomy a PET/CT showed FDG uptake in a right-sided • parasternal node, contralateral axillary lymph nodes, and the left breast Breast biopsy: DCI, HR-, HER2+++, Ki67%. Parasternal node and left axillary • nodes with metastatic disease Genetic testing was ordered, the result is pending •
CASE 2 Questions What now? 1. TDM-1? a) Locoregional control? b) What other options could be utilized in the future? c) Would the finding of a mutation from the beginning have altered the course of the 2. disease?
CASE 3 An older adult with screening- detected hormone receptor positive disease
CASE 3 An older adult with screening-detected hormone receptor positive disease 75 year old female • No personal or family history of cancer • Three pregnancies • No alcohol consumption • First menstrual period at age 15, menopause age 45. Did not use hormone • replacement therapy Comorbidities: diabetes, hypothyroidism •
CASE 3 An older adult with screening-detected hormone receptor positive disease October 2018: screening mammogram with a 12mm nodule in the left breast. • BIRADS 5 Ultrasound: left breast nodule (12mm). No suspicious axillary lymph nodes • Biopsy: infiltrating ductal carcinoma, Grade 1, ER 90%, PR 60%, HER2+, Ki67 10% • The patient underwent BCS plus SLNB • Pathology: IDC 1.4cm, negative margins, ER 90%, PR 50%, 2/2 sentinel lymph nodes with metastatic carcinoma
CASE 3 An older adult with screening-detected hormone receptor positive disease
CASE 3 An older adult with screening-detected hormone receptor positive disease October 2018: screening mammogram with a 12mm nodule in the left breast. • BIRADS 5 Ultrasound: left breast nodule (12mm). No suspicious axillary lymph nodes • Biopsy: infiltrating ductal carcinoma, Grade 1, ER 90%, PR60%, HER2+, Ki67 10% • The patient underwent BCS plus SLNB • Pathology: IDC 1.4cm, negative margins, ER 90%, PR 50%, 2/2 sentinel lymph nodes with metastatic carcinoma
CASE 3 Questions Was this patient a good candidate for a screening mammogram? 1. Would primary endocrine therapy be an appropriate option for this patient? 2. Is this patient a candidate for a gene signature test? 3. Are gene signature tests cost-effective in developing countries? a) Can clinical models obviate the need for gene signature tests in some cases? b)
0.6% of low clinical risk women in MINDACT (190/3337)
CASE 3 An older adult with screening-detected hormone receptor positive disease The patient was started on adjuvant endocrine therapy with letrozole • Cytotoxic chemotherapy was omitted • She was also started on adjuvant conventional radiotherapy to the breast and axilla •
CASE 3 Questions Can this patient be considered “low clinical risk” without a complete axillary lymph 1. node dissection? Is the evidence enough to omit chemotherapy in this patient? a) How long would you continue adjuvant treatment with hormonal therapy? 2. What are the prospects for using targeted therapy for the adjuvant treatment of 3. HR+ disease (such as CDK 4/6 inhibitors)? Is conventional fractionation of radiotherapy the preferred approach? 4.
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