D.C.I. SOS
67 year old presents to discuss adjuvant treatmetn for DCIS detected on recent mammogram. ER/PR negative on the biopsy. Lumpectomy shows 3 cm, G3 DCIS comedo type , no invasive disease. all margins were 2mm or greater.
What is the next best step?
Radiation
Radiation after lumpectomy for DCIS reduces ipsilateral breast events by 50-70%. No OS benefit. No Chemoprevention for ER/PR negatie tumors.
82 year old with 1.5 cm mass. biopsy shows ER/PR+ HER2 negative IDC. HX of prior stroke and atrial fibrillation. Lumpectomy is performed wtih negative margins.
What is the best next step?
Endocrine thearpy alone
CALGB 9343 study supports omitting radiation therapy for women over 70 with small (<2cm), node negative ER+ tumor (T1N0M0)
62 year old woman presents with back pain. She has hx of ER/PR+ HER2- breast cancer 10 years ago s/p lumpectomy, aduvant radiation and 5 years of tamoxifen. Imaging shows bone metastatic disease. Biopsy confirmes ER/PR +, HER- grade 2 invasive ductal carcinoma. Blood work is unremarkable.
What is the most appropriate next step?
What is:
Endocrine thearpy with CDK 4/6 inhibitor. Plus Zometa q 12 weeks
MONALEESA-2 Trial: Ribo/AI
MONARCH 3 Trial: Abema/AI
40 year old with new mass in RT breast. Presented wtih bloody breast discharge. Mammogram negative. Ultrasound shows subcentimeter mass below the nipple. Biopsy shows papilloma with ductal hyperplasia
What is the best next step?
What is surgical excision
This is an intraductal papilloma which is benign papillary tumor originating from teh lactiferous ducts. May present with bloody discharge. Mostly benign but the ductal hyperplasia is a high risk feature which warrnet excision.
45 year old referred for lobular carcioma in situ and atypicla lobular hyperplasia. excisional biopsy shows classic LCIS with a positive margin.
What is the best next step?
Chemoprevention with tamoxifen 5 years
56 year old with PMH of prolonged QT who is post menopausal women presents after lumpectomy of 4.5 cm ER/PR+, HER2 negative mass with 1/3 positive nodes (pT2N1). Oncotype shows 12.
In addition to endocrine therapy what do you recommend?
Abemaciclib 2 years
monarchE trial: high risk disease included
4+ nodes
1-3 nodes with tumor 5+ cm or grade 3
66 year old is in the ED after PCP noted ANC of 500. She has ER/PR + HER2- breast cancer metastatic to bone. She is on palbociclib 125 mg for 21 days each cycle and letrozole. She is currently day 22 of cycle. No symptoms noted.
What do you do?
Hold treatment 1 week and reevaluate
neutropenia is common with CDK 4/6i but neutropenic fever is rare! just hold 1 week and if ANC is more than 1000 then continue same dose.
56 year old with metastatic breast cancer (PD-1 netative) previously treated with single agent paclitaxel and single agent carboplatin. Germline testing is negative. She is progressing.
Best next treatment?
Sacituzumab govitecan
ASCENT trial phase 3 approved sacituzumab after progression on 2 prior lines of therapy. PFS 5.6 months vs 1.7 months in control single agent chemo arm.
68 year old with left breast calcifications on mammogram. Lumpectomy shows 6mm intermediate grade hormone receptor positive ductal carcinoma in situ. she has severe CAD, T2DM, COPD and generally poor health. She only wants to do adjuvant therapy that will improve her overal survival.
What do you recommend?
observation
DCIS chemoprevention with endocrine thearpy reduces new breast events but doesn't impact OS per 3375 patient meta-analysis. Adjuvant radiation reduces in breast recurrence but doesn't change OS
64 year old women found to have 1.1 cm mass on mammogram/unltrasound. biopsy shows grade 2 invasive ductal carcinoma and intermediate grade in situ carcinoma. Invasive portion is ER+/PR-/HER2-.
Mastecomy is performed finding 1.2 cm IDC with less than 0.5mm posterior margin. sentinel node is negative. Oncotype 8.
What is best management of the close margin?
Nothing!
negative margins (no ink on tumor) minimizes the risk of recurrence. wider margins do not improve risk.
70 year old with ER/PR+HER2- metastatic breast cancer treated with letrozole ribocilib for 2 years until progression. No visceral disease on imaging. PMH hypertension.
What is the best next step?
NGS testing for PIK3CA and ESR1
NGS testing for PIK3CA and ESR1
May allow options such as:
Elacestrant
Alpelisib/Capivasertib
54 year old with triple negative breast cancer 2 years ago got neoadjuvant chemothearpy, lumpectomy and radiation.
Now presnets with new pulmonary nodules confirming metastatic disease. She receives docetaxel while additional testing is pending. Within a few days she has redness and pain over her left breast and under left arm.
What is the best next step?
Hold docetaxel until rash improves then rechallenge.
Radiation recall dermatitis is an inflammatory skin reaction that develops in areas of previoulsy irradiated skin after certain meds such as chemotherapy.
Hold or dose reducing or steroids can help.
72 year old woman presents to discuss therapy options for recently diagnosed DCIS. Eight years earlier she had DCIS in the same breast and underwent lumpectomy/radiation therapy the completed 5 years of tamoxifen (3 years ago). Now mastectomy demonstrated DCIS with negative sentinel node biopsy. She has a history of osteoporsis on denosumab.
What is the best next step?
what is observation?
DCIS doesn't have metastatic potential
Therapy is directed at preventing cancer in the ipsilateral breast which has now been removed by mastectomy. Endocrine therapy could lower contralateral breast risk of cancer but she recently did 5 years of endocrine therapy.
67 year old with rt breast mass 4x3cm. biopsy shows benign phyllodes tumor. RT mastectomy reveals phyllodes tumor measuring 5.5 cm with negative margins. Tumor is ER+/PR+.
What is the best next step?
Observation
very low risk of metastatic recurrence. chemo is not indicated unless biopsy shows malignant features. They can be ER/PR positive but there is no evidence to support endocrine thearpy adjuvantly.
59 year old with metastatic ER/PR+ HER2- Breast cancer diagnosed 3 years ago. Has been on Abemaciclib/Letrozole for 3 years and is now progressing in the liver. Blood work is unremarkable. Repeat biopsy confirms ER/PR+ HER2- disease.
NGS is negative for PIK3CA and positive for ESR1.
What treatment should you recommend?
What is:
Elacestrant
Class: Oral selective estrogen receptor degrader
can be used after progression on at least one line of endocrine therapy and CDK 4/6i
EMERALD trial: elacestrant (3.8 months) improved PFS over fulvestrant or AI (1.9 months)
33 year old woman 22 weeks pregnant detects a breast mass. Imaging shows 4 cm mass and 3 enlarged axillary noes. Biopsy shows IDC ER+PR-HER2+.. She wishes to maintain her pregnancy.
What systemic therapy should you recommend?
Doxorubicin/Cyclophosphamide followed by paclitaxel (AC-T)
HER2 directed and endocrine thearpy are contraindicated in pregnancy. AC is feasible and taxanes are safe during 2nd/3rd trimester. AC-t can be given after 3rd trimester and continued until 3-4 weeks before delievery.