clinical case discussion - iweventos casos clinicos 28-06.pdfcase #3 43 yo premenopausal patient...
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Clinical Case Discussions
Rad Onc
Surgeon
Surgeon
Surgeon
Med Onc Med Onc
Med Onc
Med Onc
Med Onc
Pathologist
16:20 - 18:00
31 y.o-female, 5 months before her wedding
she noticed a nodule in the axillary extension
of the R breast.
PMHx: none
Fam Hx: no cancer
Case #1
Dec 1st, 2018
2.4cm nodule in the
axillary extension of
the right breast.
Microcalcifications.
Atypical LN in R axilla
Core Bx:
IC NOS, HG3, no LVI, no DCIS
ER 10%, Allred 5
PR 50%, Allred 7
Her2+++
Ki67 40%
FNA of R axillary LN: + malignant cells
Genetic panel (Invitae): VUS in
FANCM(NM_020937.2):c.853A>G(p.Lys285Glu).
No distant
metastasis
What would you expect as local treatment after neoadjuvant therapy?
1. Breast conserving surgery + mandatory ALND followed by XRT including axilla, supra clav. fossae, int. mammary LNs
2. Bilateral adenomastectomies + mandatory ALND followed by XRT including axilla, supra clav. fossae, int. mammary LNs
3. Bilateral adenomastectomies + ALND only if SLNBx+, followed by XRT to SCF and Int Mammary LNs
4. Breast conserving surgery + ALND only if SLNBx+, followed by XRT to breast, axilla, SCF and int mammary LNs
5. Some other option
Question #1 (please vote):
Surgeons:
• what do you plan regarding the breast and axilla? Will thischange if you have a complete clinical response (including MRI)?
Rad Onc:
• will your RT plan change depending on pathological response?
Study Treatment pCR em RH+ pCR em RH-
NeoSphere Pertuzumab/Trastuzumab 26% 63%
TRYPHAENA Pertuzumab/Trastuzumab 46/50% 65-84%
TRAIN2 Pertuzumab/Trastuzumab 51/55% 84-89%
KRISTINE Pertuzumab/Trastuzumab 46% 71%
31, IC G3, HR+, Her2+++, cT2 cN1 M0
Med Onc:
• Which neoadjuvant regimen and why?
• What if cN0? Would you still start with neoadjuvant
therapy?
• Fertility preservation: how many weeks can you wait?
• Retrieved 15 oocytes >> peritonitis (ascitis, pain) >> 3 weeks for
resolution
• She received TCHP (Taxotere+Carboplatin+Herceptin+Pertuzumab) x6
(and LHRH analog for ovarian function preservation)
• Breast nodule and LN no longer palpable
• Surgeons:
• Do you repeat a pre-op MRI or PET-CT? Does it change your surgical
plan?
31, IC G3, HR+, Her2+++, cT2 cN1 M0
April 29th, 2019Dec 1st, 2018
Complete
clinical
response
May 14th, 2019: bilateral skin/nipple sparing mastectomies (per patient)+ R LND
(surgeon felt that LNs were macroscopically suspicious)
31 yo, IC G3, HR+, Her2+++, cT2 cN1 M0
Neoadjuvant TCHP x6 with complete clinical
respose
Bilateral skin/nipple sparing mastectomies + R
LND (LNs were macroscopically suspicious)
Pathology Report:
no residual tumor (either invasive or in situ)
0/27 LN
RCB 0
Surgeons:
• What is your opinion regarding RT now? What is the risk of
lymphedema?
Rad Onc:
• What is your opinion regarding RT now?
Pathology:
• Can treatment change IHQ results in the residual tumor
(i.e Her2+ > Her2-)?
• Is reporting RCB the standard? How long does it take to fully
evaluate RCB?
Heather NeumanIsabelle Bedrosian
E. Mamounas Reshma Jagsi
ALND should remain standard of care in ALL patients
who are node positive prior to neoadjuvante
chemotherapy until...• We have a minimally axillary staging approach that:
• Is highly accurate, ie low FNR• Established through porspective, multi-institutional studies
• Accounts for tumor burden/tumor biology
• The FNR has established acceptable long term oncologic safety (ie LRR)
• Does not impair decisions regarding adjuvante systemic therapy that may affect survival
• We have considered potential therapeutic role of
axillary surgery in chemoresistant disease
Conclusion• Complete ALND is NOT indicated for all patiets with
+ nodes prior to NAST
• LOW risk of “missing something”
• SLN mapping with dual dye
• Removal of the clipped node
• Removal of ≥ 2lymph nodes
• Consequences of “missing something” in the setting
of adjuvante radiation are likely low
• Can spare up to 50% of women a morbid,
oncologically unnecessary procedure
SLNB Alone is Appropriate in Pts with (+)
Axillary Nodes before NAC
If you Do the Following:
• Appropriaes candidate selection (T1-3, N1)
• Dual agente mapping (isotope + dye)
• identification and removal of > 2 (-) SLNs
• Clip placement in the positive node with localization
and retrieval of (-) clupped node
• Considerations of performing IHC in the SLN and
completing ALND even with N0i+ disease
Conclusions
• When a patient has had complete ALND and no
disease is remaining in the axilla, cartainly no
directed RT to levels I and II is indicated
• Whether treatment to the other regional nodal
basins can be omitted will ultimately have to
await a definitive aswer from the large ongoing
NRG trial
• In the meantime, eligible patients shoould be
encouraged to enroll on the trial
Question #2 (please vote)
Regarding adjuvant therapy, what would yo do?
1. Finish 1 year of Trastuzumab and Pertuzumab, start AI continue LHRH
analog
2. Finish 1 year of Trast/Pert, start Tamoxifen and discontinue LHRH
analog
3. Finish 1 year of Trast/Pert, start Tamoxifen and continue LHRH analog
4. Finish 1 year of Trastuzumab, start Tamoxifen and continue LHRH
analog
5. Finish 1 year of Trastuzumab, start Tamoxifen and discontinue LHRH
analog
31 yo, IC G3, HR+, Her2+++, cT2 cN1 M0 >> TCHPx6>> pCR
Med Onc:• Continue Trastuzumab to finish 1 year ?
• Continue Trastuzumab and Pertuzumab
to finish 1 year?
• What if it was RCB1-3?
• Continue aLHRH + start na AI? Comment
on estradiol
• Continue aLHRH + start Tam?
• Tam only?
KATHERINE
KRISTINE
NeoSphere
TRYPHAENA
FEC q3w x 3
Herceptin q3w cycles 5-17
FEC q3w x 3
Herceptin q3w cycles 5-17
Docetaxel q3w x 4 → FEC q3w x 3
Herceptin q3w cycles 5-17
FEC q3w x 3
Herceptin q3w cycles 5-21
S
U
R
G
E
R
Y
SURGERY
Trastuzumab
to complete
1 year
T-DM1
3.6 mg/kg IV Q3W
14 cycles
Trastuzumab
6 mg/kg IV Q3W
14 cycles
R
1:1
N = 1486
S
U
R
G
E
R
Y
Trastuzumab
Pertuzumab
T-DM1
Pertuzumab
12 cycles of adjuvante
HER2-therapy
Case #2
36 year old, no PMX
Patient felt a lump in R breast
US and MMG: 1.4cm nodule at JUQ, axillary LN suspicious
Fam Hx: 2 children, Hx of breast and ovarian cancer (mat aunt / grandmother)
3/18/2019: Core Bx: IC NOS, G3, no LVI,
ER-, PR-, Her2-, Ki67 25%
Lymphocyte Infiltration 20%
FNA axillary LN: + for malignant cells
36 yo, IC NOS, G3, TN, cT1c cN1 M0
PET-CT: no evidence of metastatic diseaseInvitae – negative for pathogenic mutations
How should this patient be treated?
1. Neoadjuvant therapy with anthracycline and taxane, carboplatin,
followed by BCS surgery and ALND > Capecitabine if RCB1-3, XRT per
clinical stage
2. Neoadjuvant therapy with anthracycline and taxane, followed by
BCS surgery and ALND only if SLN+ > Capecitabine if RCB1-3, XRT per
clinical stage
3. Neoadjuvant therapy with anthracycline and taxane, carboplatin,
followed by surgery (decision after genetic panel) and ALND >
Capecitabine if RCB1-3, XRT adapted depending on the RCB
4. Some other option
Question #1 (please vote)
Pathology:What is the value of reporting Lymphocyte Infiltration in
2019?
Surgeons:For TNBC, what is your threshold to indicate neoadjuvant
therapy rather than surgery upfront?
Surgeons in audience: raise hands those who clip +LNYoung women with significant fam hx but negative for
genetic testing, what do you recommend?
Med OncNeoadjuvant chemo:
Do we agree about Carbo/Paclitaxel >> ddAC for every
TNBC?
What if BRCA mutation?
What if BRCA mutation with HR+?
• Is a genetic predisposition panel always necessary, or
BRCA enough?
After 12 weeks of Carbo AUC 1.5/Paclitaxel 80 mg/m2
Complete
readiologic
response in breast
and axilla
MedOnc:Patient asks if she can be operated now and only receive ddAC
if RCB1-3
Case #3
43 yo premenopausal patient
• June 2018, patient noticed a lump in her left breast, with progressive
enlargement. Also, she noticed a palpable ipsilateral axillary lymph node.
• Clinical Staging cT2cN1
• October/2018: Left breast biopsy revealed an Invasive Ductal Carcinoma • Grade II, ER+ 100%, PR +100%, HER2 negative, Ki67 + 10%
• Pathology Review confirmed these results
• Fine needle aspiration of axillary LN: + for malignant cells
• Initial PET CT revealed a suspicious nodule in her liver
• Liver biopsy confirmed metastatic lesion
• Pathology result: Infiltrating carcinoma in the liver from breast origin : RE+, Mamoglobin +,
GATA-3 +, HER2 negative
How would you treat this patient?
1. LHRHa + AI + Fulvestrant
2. LHRHa + AI or Tam + any CDK4/6i
3. LHRHa + AI or Tam + Ribociclib necessarily (based on MONALEESA 7)
4. Chemotherapy until response in liver, then LHRHa+ HT
5. Some other option
Question #1 (please vote)
Clinical Staging cT2cN1M1 (oligometastatic)GH II IDC ER+ 100% PR +100% HER2 negative Ki67 + 10%
Med Oncs: What would you do now?
• Recommend hormone therapy? Which one? Combination?
• Recommend CDKi plus endocrine therapy. Which CDKi and
which HT?
• Recommend cytotoxic chemotherapy?
Premenopausal patient, 43 years old
Clinical Staging cT2cN1M1GH II IDC ER+ 100% PR +100% HER2 negative Ki67 + 10%
Single liver met (biopsy proven)
Med Oncs:
• Would you request any invasive procedure (liver, breast, axilla)?
Surgeons:
• Would you perform clipping of the tumor in the breast and/or theaxilla?
• Would you proceed differently if this were a Her2+ MBC?
Premenopausal patient, 43 years old
GH II IDC ER+ 100% PR +100% HER2 negative Ki67 + 10%Single liver met (biopsy proven)
• Patient was started on goserelin q28 days, letrozole and
palbociclib, with excellent tolerability and minor impact
on her quality of life.
• No dose reductions were necessary
Premenopausal patient, 43 years old
before
after
1. Continue systemic therapy only.
2. Proceed with BCS + ALND + XRT + follow liver lesion
3. Proceed with BCS + ALND + XRT with curative intent +
SBRT to liver lesion + “adjuvant chemo” with curative
intent
4. Some other option
What now?
Question #2 (please vote)
Patient underwent BCS + ALND and SBRT to single liver lesion:
Path: Residual IC NOS with signs of partial response
Grade I
Size: 1.5x1.0cm
ALND: 5/26 +LN, largest 2.8mm, no extracapsular
extension, signs of tumor regression in 2LN
Case #4
61-year-old female is referred after undergoing breast surgery for a cancer:
Screening MMG with a 2.6cm nodule in RUQ, with microcalcifications
PMHx: HTN, obesity, took HRT for 5 years (51-56)
Fam Hx: no cancer, 3 daughters
Physical Exam: palpable nodule in RUQ R breast, no palpable LN,
Core Bx: IC NOS, Grade 2, with high grade DCIS 20%, no LVI,
ER 90% Allred 8, PR 20% Allred 6, HER-2 negative, Ki67 20%
BCS + SNLBx: IC NOS, 2.5cm, high grade DCIS in <20%, negative margins, no LVI
1/3 SL with micrometastasis (1.7mm), with extracapsular extension of
0.7 mm
pT2 pN1(mi) M0, HR+, HER2 neg
Mammaprint: low risk (brace for tomorrow)
61, BCS + SLBx: IC NOS, 2.5cm, high grade DCIS in <20%, negative margins, no LVI, 1/3 SL+ for
micrometastasis, with extracapsular extension; pT2 pN1(mi) M0, HR+, Her2-, Ki67 25%
Mammaprint: low risk
• Surgeons: implications of micromets and
extracapsular extension in the axilla?
• RadOnc: When is hypofractionation indicated in
2019? Contraindications? Does intrinsic subtype or
risk group change XRT plan in 2019?
• MedOnc/Pathology:
• Do we agree that she needs NO chemo and NO
other signature?
• HT for a total of 5 years? 7 years? 10 years?
• Do you use CTS5 to decide duration? BCI?
Prosigna?