ESMO SUMMIT LATIN AMERICA 2019€¦ · ESMO SUMMIT LATIN AMERICA 2019. Breast Cancer Clinical Cases. Enrique Soto Pérez de Celis MD, MSc. Instituto Nacional de Ciencias Médicas

ESMO SUMMIT LATIN AMERICA 2019

Breast Cancer Clinical Cases

Enrique Soto Pérez de Celis MD, MSc

Instituto Nacional de Ciencias Médicas y Nutrición Salvador ZubiránMéxico City, Mexico

CONFLICT OF INTEREST DISCLOSURE

Dr. Soto Pérez de Celis has no financial conflicts of interest to disclose

CASE 1A 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


• 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 1Questions

1. Is neoadjuvant chemotherapy indicated in all triple negative tumors, regardless of

size and lymph node status?

2. What are the probabilities of this patient having a genetic predisposition mutation

for breast cancer?

3. The patient wishes to become pregnant in the future but cannot afford

cryopreservation, what other options are available?


• 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 1Questions

1. Is it necessary to repeat the determination of HR and HER2 status after

neoadjuvant treatment?

2. Would you offer additional adjuvant treatment to this patient?

3. What type of long term complications can we expect after completing treatment,

and what type of follow up is needed?

4. Are there ongoing clinical trials of immunotherapy in this scenario?

CASE 2A postmenopausal woman with recurrent stage IV HER2-positive breast cancer

CASE 2A 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


• 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


• 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 2Questions

1. What is the ideal neoadjuvant chemotherapy for HER2+ breast cancer? Should

pertuzumab be added in all cases?

2. Should this patient be tested for genetic predisposition to breast cancer? Would it

alter management?

3. Should the patient receive adjuvant therapy after initial treatment (with the benefit

of hindsight)?


• 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



• 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 2Questions

1. Should trastuzumab be continued after a local recurrence is treated with “curative”

intent?

2. Should the patient receive “adjuvant” therapy with TDM1 after rescue

mastectomy?


• 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




• 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 2Questions

1. What now?

a) TDM-1?

b) Locoregional control?

c) What other options could be utilized in the future?

2. Would the finding of a mutation from the beginning have altered the course of the

disease?

CASE 3An 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


• 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



• 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 3Questions

1. Was this patient a good candidate for a screening mammogram?

2. Would primary endocrine therapy be an appropriate option for this patient?

3. Is this patient a candidate for a gene signature test?

a) Are gene signature tests cost-effective in developing countries?

b) Can clinical models obviate the need for gene signature tests in some cases?

0.6% of lowclinical riskwomen in MINDACT (190/3337)


• 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 3Questions

1. Can this patient be considered “low clinical risk” without a complete axillary lymph

node dissection?

a) Is the evidence enough to omit chemotherapy in this patient?

2. How long would you continue adjuvant treatment with hormonal therapy?

3. What are the prospects for using targeted therapy for the adjuvant treatment of

HR+ disease (such as CDK 4/6 inhibitors)?

4. Is conventional fractionation of radiotherapy the preferred approach?

THANK YOU

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ESMO SUMMIT LATIN AMERICA 2019€¦ · ESMO SUMMIT LATIN AMERICA 2019. Breast Cancer Clinical Cases. Enrique Soto Pérez de Celis MD, MSc. Instituto Nacional de Ciencias Médicas