*For medical professionals only
Celebrities gathered to explore the difficult cases of HER2-positive advanced breast cancer
On April 23, 2024, the fifth issue of "Big Coffee Style Multidisciplinary Diagnosis and Treatment Interactive Column for Breast Cancer" will meet you as scheduled in the form of online live broadcast. The MDT team of Fudan University Cancer Hospital and the MDT team of Fujian Cancer Hospital were specially invited to share diagnosis and treatment plans and discuss treatment decisions based on difficult clinical cases of breast cancer, aiming to promote academic exchanges, deepen the concept of MDT diagnosis and treatment, and help improve the level of standardized and precise diagnosis and treatment of breast cancer.
At the beginning of the meeting, the chairman of the conference, Professor Shao Zhimin from Fudan University Cancer Hospital, first delivered an opening speech and introduced the participating teams.
Professor Shao Zhimin from Fudan University Cancer Hospital delivered a speech
Member of the MDT team of Fudan University Cancer Hospital
Member of the MDT team of Fujian Provincial Cancer Hospital
Case sharing of a patient with HER2-positive advanced breast cancer
The case sharing session was chaired by Professor Song Chuangui from Fujian Provincial Cancer Hospital, and Professor Wang Lili reported on a difficult case of HER2-positive advanced breast cancer with brain metastasis. This patient with multiple lymph nodes, liver, lungs and multiple bone metastases with multiple lymph nodes, liver, lungs and multiple bone metastases of the left breast was enrolled in an out-of-hospital clinical trial and received first-line treatment with THP. After being discharged, he was transferred to our hospital for enituzumab + pyrotinib + vinorelbine and brain radiotherapy, and the efficacy was evaluated as peripheral partial response (PR) and brain disease progression (PD) after 3 months. After discussion, the second radiotherapy to the brain was performed, and after the brain progression, trastuzumab (T-DXd) was treated for 3 times, and the efficacy was evaluated as cerebral PR, liver stability, and "pseudo-progression" of breast lesions, and then T-DXd was added to a sufficient dose of 270 mg for 2 times, and then increased to 300 mg for 4 times. Since then, the patient's breast lesions have been PD again, and T-DXd+tucatinib has been treated so far.
Professor Song Chuangui of Fujian Provincial Cancer Hospital presided over the meeting
Professor Wang Lili from Fujian Provincial Cancer Hospital shared her case
Case MDT discussion
In the case discussion session, Professor Li Junjie from Fudan University Cancer Hospital presided over two MDT teams to sort out the diagnosis and treatment strategies of the case, and discussed and analyzed the common problems in the diagnosis and treatment process.
MDT Expert Discussion Session
01
The best imaging detection method and target lesion determination in this patient with stage IV multiple metastases breast cancer
Professor Chen Ying from the Department of Imaging: PET-CT, ultrasound, breast magnetic resonance, etc. were performed at the initial diagnosis, and all lesions were evaluated. For tumors with large burden, primary breast tumors, liver lesions, and cranial lesions can be listed as initial target lesions for observation, and bone and <1cm lung lesions can be listed as non-target lesions.
Professor Xiao Qin, Radiologist: HER2-positive breast cancer is highly heterogeneous, and for the case of multiple metastases throughout the body, needle biopsy should be performed on all lesions clinically. In addition, due to the different enhancement methods of different metastatic sites and different metastatic lesions, imaging evaluation can also be performed according to the tumor signal distribution to locate the target lesions.
02
First-line treatment options for newly diagnosed stage IV HER2-positive breast cancer with high tumor burden
Professor Fan Lei of the Department of Breast Surgery and Professor Huang Weiwei of the Department of Medical Oncology: The results of the PHILA study show that the investigator-assessed progression-free survival (PFS) of the first-line treatment regimen of large and small molecule targeted combination + chemotherapy is more than 2 years, and the current evidence level is Category II. However, due to its short follow-up time, the control group was a non-first-line standard regimen of trastuzumab + pertuzumab + docetaxel (THP). Therefore, the first-line treatment option for HER2-positive breast cancer with a newly diagnosed stage IV tumor burden is still THP, while for trastuzumab-treated breast cancer patients with brain metastases, PHILA is preferred.
03
The role of radiotherapy in the treatment of breast cancer patients with stable extracranial lesions and progressive intracranial lesions
Professor Lin Peicheng of Radiotherapy: For this case of breast cancer patients with multi-site HER2 expression, if their symptoms are not obvious, it is clinically recommended to treat them systematically before radiotherapy.
Professor Ma Jinli of the Department of Radiation Oncology: Regarding the stabilization of extracranial lesions and the emergence of new metastases/progression in the skull, the treatment plan is first based on the urgency of the patient's local treatment intervention. If symptoms are obvious, local intervention should be done, and if they are not, drug therapy can be changed before radiotherapy is sought.
Prof. Weiwei Huang: In this case, the THP regimen was only maintained for 4 months (3 cycles), and in clinical practice, the original regimen can be maintained and cranial radiotherapy can be continued, but it can also be replaced with a combination strategy of large and small molecule targeting. In view of the patient's preference, the latter was chosen in this protocol.
Prof. Lei Fan: The median first-line PFS of THP regimen is 18 months, and about 16% of patients can survive for more than 10 years. Therefore, the treatment of this patient is recommended to continue THP therapy with radiotherapy. For the selection of large and small molecule targeted combination chemotherapy regimens, the choice of vinorelbine may refer to the results of PHILA et al., that is, the control of asymptomatic brain metastases is excellent. Moreover, according to the research on the compatibility of initum and the reimbursement policy of medical insurance, vinorelbine is also preferred, but in the real world, most of the chemotherapy drugs for the combination of large and small molecules are capecitabine.
04
Consideration of radiotherapy strategy for two target brain lesions in second-line therapy
Professor Lin Peicheng and Professor Ma Jinli: There are 5~10 target <lesions in the brain, which are treated by stereotactic radiosurgery (SRS) and have good local control. > 10 target lesions, whole-brain radiotherapy is performed. The shorter the control time of the first brain radiotherapy, the shorter the control time of the target lesion in subsequent brain radiotherapy. If the brain lesion progresses again, whole-brain radiation therapy may be an option.
05
Reasons for T-DXd therapy rather than small molecule TKI therapy after the third progression of intracranial lesions
Prof. Huang Weiwei: Patients with symptomatic HER2-positive brain metastases are mainly treated with surgery for single cases and radiotherapy for multiple cases. If it is asymptomatic, it is treated with ADC and TKI drugs.
Prof. Lei Fan: The pooled analysis of the DB01, 02 and 03 studies showed that the median CNS-PFS of HER2-positive breast cancer with active brain metastases was as high as 18.5 months and 12.3 months for stable brain metastases treated with T-DXd. The median PFS of the TKI arm in the PERMINE study was 10.8 months, and the HER2CLIMB study also supports the rationale for the use of ADC-first followed by sequential TKIs in HER2-positive breast cancer with brain metastases. In addition, in the CSCO Guidelines for the Diagnosis and Treatment of Breast Cancer 2024, T-DXd replaced T-DM1 as the only ADC drug recommended for the second-line treatment of HER2-positive advanced breast cancer. Therefore, in this case, T-DXd is the best choice after brain metastasis is repeated.
06
Whether the progression of brain PR, liver stability, and breast lesions is "pseudoprogression"
Prof. Zhimin Shao: Breast pseudoprogression only exists in immunotherapy, and since increasing the dose of T-DXd therapy is effective for patients, it can be judged that the progression of breast lesions is not pseudo.
At the end of the meeting, Professor Shao Zhimin concluded that with the rapid development of anti-HER2 therapeutic drugs, the prognosis of patients with HER2-positive advanced breast cancer with brain metastases has gradually improved. In the future, for the treatment of patients with HER2-positive advanced breast cancer, the clinical practice should adhere to the principle of making full use of each line of therapeutic drugs, so as to maximize the survival of patients and help them maximize their benefits!
At the same time, the sixth phase will meet you on time at 19:00 on May 6, and the MDT team of the Affiliated Cancer Hospital of Fudan University will participate in the sixth phase with the MDT team of Shandong Cancer Hospital, so stay tuned!
Exciting information is waiting for you
* This article is only for the purpose of providing scientific information to medical professionals and does not represent the views of this platform