Hormone Therapy
Which of the following is classified as a steroidal aromatase inhibitor?
A. Exemestane
B. Letrozole
C. Anastrozole
D. Fulvestrant
E. Toremifene
A. Exemestane
12.
A 36-year-old female is s/p mastectomy and SLNB for a left-sided, Stage I, ER+/PR+/Her2- invasive ductal carcinoma. Out of three lymph nodes retrieved, none harbor any cancer. An Oncotype Dx test is ordered and comes back low risk (Recurrence score=4), so no adjuvant chemotherapy is offered. She is currently on tamoxifen 20 mg daily. She is referred over to Genetic counseling. A full genetic panel is sent and she is found to have a BRCA2 mutation. Which is not a typical malignancy that is associated with having a BRCA2 mutation?
A. Breast Cancer
B. Ovarian Cancer
C. Pancreatic cancer
D. Endometrial Cancer
E. Prostate cancer F. Melanoma
D. Endometrial Cancer
17.
A 56-year-old female comes to see you prior to her scheduled lumpectomy and SLNB for a clinical lymph node negative Stage I left-sided breast cancer. Mammogram revealed a 0.8 cm left breast mass. Imaging did not reveal any concerning left axilla LAD.
Biopsy of the mass reveals a ER+/PR+, Her2 negative IDC. The Nottingham score is 5 and Ki67=5%. Labs are sent for including Liver function tests, basic panel and Alkaline phosphatase. All of these labs are normal. She denies any concerning symptoms. Before she goes for surgery, what staging testing should you perform?
A. Bone scan
B. CT Chest and Abdomen
C. CXR along with U/S of the axilla
D. PET-CT
E. No further imaging needed
E. No further imaging needed
No role of systemic imaging in early stage breast cancer
A 52-year-old female comes to see you to discuss adjuvant treatment options for her breast cancer. She is s/p right mastectomy with SLNB. Pathology reveals an Invasive ductal, 0.5 cm triple negative cancer. Her Her2+ was 1+ on IHC. Of note, Her2 testing on both her biopsy and surgical specimen revealed Her2 negativity. Two lymph nodes are retrieved, none of which harbor cancer. Her surgical margins are negative. She has a Grade III tumor with a Ki67=90%. Which therapy do you offer?
A. Docetaxel + Cyclophosphamide
B. Dose dense Adriamycin/Cyclophosphamide followed by dose dense Taxol
C. Send for OncotypeDx
D. Observation
E. Single agent Taxol
D. Observation
For patients with triple negative disease who are lymph node negative with tumors ranging in size from 0.6 cm to 1 cm, one should consider adjuvant chemotherapy.
For patients with triple negative disease who are lymph node negative with tumors > 1 cm, one would strongly recommend adjuvant chemotherapy.
Which of the following agents has been shown to
improve overall survival in HER2+ early stage breast
cancer for patients treated with neoadjuvant
chemotherapy and trastuzumab?
A. Pertuzumab
B. Neratinib
C. Lapatinib
D. Trastuzumab emtansine
E. None of the above
D. Trastuzumab emtansine
Katherine trial showed OS benefit(HR=0.70) with TDM-1.
A 64-year-old female is s/p right breast mastectomy and SLNB for a Stage I breast infiltrating ductal carcinoma. Her invasive tumor is 0.8 cm in size, Grade I, Ki67=5%, ER=45%, PR=30% and Her2 negative. Of the 2 sentinel lymph nodes removed, none harbors any breast cancer. Chemotherapy is not offered as her Oncotype Dx score was 17.
She is interested in anti-estrogen therapy, but has known osteopenia with a T score of -2.2 and -2.3 in her hip and spine, respectively. Which of the following should be recommended?
A. No anti-estrogen therapy needed given the small size of her tumor
B. No anti-estrogen therapy needed as ER is only 45% positive
C. Tamoxifen should be administered given her borderline osteoporosis
D. Anastrozole should be given along with Calcium/Vitamin D/Bisphosphonate. Strong consideration should be made to give a Bisphosphonate
E. Exemestane is superior to anastrozole and should be given
D. Anastrozole should be given along with Calcium/Vitamin D/Bisphosphonate. Strong consideration should be made to give a Bisphosphonate.
A phase 3 randomized control study in which breast cancer patients were randomized to either exemestane or anastrozole. A companion study to image MA 27 then compared changes in bone mineral density.
At baseline, patient had the T-scores greater than -2.0 or at least 1 T score less than -2.0. All patients received vitamin D/calcium in those with baseline T-scores greater than -2.0 recent bisphosphonates. Patients with T-scores less than -2.2 there is no significant change in the hip bone mineral density .The results of the study confirm that adjuvant treatment with aromatase inhibitors can be considered for breast cancer patients who have T-scores less than -2.0.
A 56-year-old female comes to see you to discuss adjuvant treatment options for her Stage I Right breast IDC. Two weeks ago, she underwent a mastectomy with SLNB. Her tumor was 1 cm in size and Grade II, no LVI, and Ki67=15%. ER and PR both are over 90% and Her2=1+ on IHC. The surgical margins are negative.
Three sentinel lymph nodes were removed. Two were negative and 1 has isolated tumor cells. She is deemed post-menopausal based on her clinical history and laboratory testing. What do you recommend for adjuvant therapy?
A. Radiation therapy followed by Anastrozole
B. Chemotherapy with dose dense A/C-->Taxol given her positive lymph node. Subsequently, she should be offered Anastrozole
C. Chemotherapy with Docetaxel/Cyclophosphamide given her positive lymph node. Subsequently, she should be offered Anastrozole
D. Oncotype Dx testing. Give Anastrozole 1 mg daily E. Fulvestrant
D. Oncotype Dx testing. Give Anastrozole 1 mg daily
A 76-year-old female comes to see you to discuss adjuvant chemotherapy for her recent diagnosis of breast cancer. She was diagnosed with Stage IIIA right-breast cancer. Clinically she had a tumor mass measuring 6 cm in size. There was no radiologic evidence of pathologic appearing LN. Biopsy of the right breast mass reveals that the tumor is triple negative. The patient deferred on receiving neoadjuvant chemotherapy.
She undergoes a Right mastectomy and SLNB (3 LN examined with 1 harboring cancer).She has underlying Type II DM with Grade II neuropathy. She is not interested in any taxane-based therapy (Taxol or Taxotere) as she read online that is can make her neuropathy worse. Subsequent to her surgery, she presents to discuss adjuvant chemotherapy. She has an outstanding performance status. An Oncotype Dx test is sent for and it comes back with a score of 29. What do you tell her regarding chemotherapy?
A. Offer no chemotherapy as her age is a predictor of lack of benefit
B. Offer no chemotherapy given the results of her Oncotype Dx testing
C. Offer no chemotherapy, but consider Pembrolizumab
D. Offer chemotherapy and give single agent Capecitabine
E. Offer chemotherapy and give Adriamycin/Cyclophosphamide x 4 cycles
E. Offer chemotherapy and give Adriamycin/Cyclophosphamide x 4 cycles.
As she refused taxane based therapy AC is reasonable
A 72-year-old female is found to have calcifications of her left breast on screening mammogram. Biopsy of this area reveals an ER-, PR-, Her2+ cancer. She undergoes a lumpectomy with SLNB. Pathology reveals a 0.8 cm IDC. SLNB retrieves 2 lymph nodes that are both negative for cancer. She overall is very healthy. She meets with the radiation oncology team and they have recommended RT.
She meets with Medical Oncology who discusses possible adjuvant therapy. After going over the pros/cons, she is interested in pursuing adjuvant therapy. She is overall healthy but remains wary of long-term side effects of chemotherapy. What should be recommended?
A. Send for Oncotype Dx to risk stratify her case
B. Offer radiation alone as data shows the benefit of trastuzumab for patients who have breast cancers >1 cm in size
C. Offer A/C—>Paclitaxel + Trastuzumab
D. Offer Trastuzumab alone
E. Discuss weekly Paclitaxel + Trastuzumab x 12 weeks followed by Trastuzumab to complete 1 year.
E. Discuss weekly Paclitaxel + Trastuzumab x 12 weeks followed by Trastuzumab to complete 1 year.
One single arm,nonrandomized study evalauted 406 females with HER2+, LN negative cancers. The tumors were <3 cm in size.Patients were given weekly Paclitaxel +Transtuzumab x 12 weeks and followed by Transtuzumab alone to complete 1 year. After a median follow up of 3.6 years, 10 of 406(2.5%) patients experienced a recurrence or death. The 3 year DFS was 98.7%(P<0.0001).
In this study, Over 50% of patients had a tumor<1 cm in size.
You are treating a 41 year old woman who has
undergone lumpectomy for a 1.2 cm, grade 1,
sentinel node‐negative breast cancer that is ER+
(>95%), PR+ (> 90%) and HER2-negative.
In discussing her necessary endocrine adjuvant
therapy, you would note which of the following:
A. Ovarian suppression would not improve her disease‐free survival compared to tamoxifen alone
B. Ovarian suppression would improve her disease-free survival if paired with an AI
C. Ovarian suppression would improve her disease-free survival if paired with tamoxifen
D. Ovarian suppression would only improve her disease‐free survival if her Oncotype-DX score was greater than 25
A. Ovarian suppression would not improve her disease‐free survival
compared to tamoxifen alone.
As the tumor is small (T1)and node negative(Low Risk)
The ATLAS study evaluated the benefit of 10 years vs. 5 years of tamoxifen for early breast cancer patients who were ER+. Results of over 6800 female patients have been reported. Which of the following is false regarding the results of this study?
A. With over 15-year follow-up, there was a 2.8% OS benefit
B. The relative reduction in recurrence was greater in years 10-14 compared to years 5-9
C. 10 years of tamoxifen led to an equivalent risk of endometrial cancer compared to 5 years
D. 10 years of tamoxifen had a higher risk of Pulmonary embolism compared to 5 years
E. None
C. 10 years of tamoxifen led to an equivalent risk of endometrial cancer compared to 5 years
The results of 6846 women with ER+ disease was reported. Extending therapy to 10 years reduced the risk of breast cancer recurrence (617 vs. 711 recurrences; P=.002), reduced breast cancer mortality (331 vs. 397 deaths; P=.01) and reduced overall mortality (639 vs. 722 deaths; P=0.01).
Breast cancer mortality during years 5–14 was 12.2% vs.15% in favor of women with extended tamoxifen therapy. The risk of endometrial cancer is higher with longer exposure to tamoxifen (3.1% vs. 1.6%). One will need to monitor for the development of uterine cancer especially if 10 years of tamoxifen is given. Specifically, a patient will need a thorough evaluation if she develops post-menopausal bleeding.
A 42-year-old female is s/p left breast mastectomy for a recently diagnosed left-sided breast cancer. Her invasive tumor is 2 cm. Two sentinel lymph nodes were removed and both are negative for cancer. The tumor is ER=95%, PR=15%, and Her2=2+. She has a Grade II tumor and the Ki67=75%. What should be recommended at this time?
A. FISH testing for receptor status
B. Oncotype Dx testing
C. Post-mastectomy radiation
D. Docetaxel + Cyclophosphamide
E. Proceed with tamoxifen
A. FISH testing for receptor status
This patient has a breast cancer that is Her2 2+ on IHC. This is an indeterminate score and she should undergo FISH testing. If the tumor on FISH testing has a ratio ≥2.0, then the patient will be considered Her2+ and should receive adjuvant trastuzumab-based therapy.
Trastuzumab (+/- Pertuzumab) is critically important to offer patients who have Her2+ disease. These medications will be given on conjunction with chemotherapy.
Oncotype would be very reasonable for this ER+, Lymph node negative patient to see if chemotherapy is even needed; however, the Her2 status needs clarification via FISH first. If this patient is Her2+, she needs trastuzumab-based therapy. Oncotype Dx testing is not indicated for patients who have Her2+ disease.
If a patient is 3+ on IHC for Her2, then the tumor is deemed to be HER2+ and the patient should receive trastuzumab-based therapy.
A 34-year-old female has a history of Stage III breast cancer. Several months ago, she self-palpated a right-breast mass and this was biopsied. Pathology revealed a ER+, PR-, and Her2- negative IDC. She has a Grade III tumor and the Ki67 is 95%. She had a right total mastectomy and completion axilla dissection; she had a total of 10 lymph nodes that harbored cancer.
She underwent 4 cycles of dose dense A/C and then 4 cycles of dose dense Taxol. She completed post-mastectomy radiation therapy. She has resumed menses s/p chemotherapy. Expanded genetic testing was performed and she was not found to have a germline mutation. What do you offer as adjuvant therapy?
A. LHRH agonist therapy + exemestane
B. Tamoxifen
C. LRHH agonist therapy
D. LHRH agonist therapy + tamoxifen
E. Exemestane
D. LHRH agonist therapy + Exemestane
SOFT and TEXT trials- Ovarian suppression in high risk premenopausal ER positive patients.
A 62-year-old female has been recently diagnosed with Stage I Right-sided breast cancer. Her case is being discussed at Multidisciplinary clinic.
She is s/p right breast lumpectomy and was found to have a 1.8 cm IDC that is ER+ (90%), PR+ (85%) and Her2 negative. She has a Grade III tumor and a Ki67 of 55%. Zero of 2 lymph nodes are involved. Her tumor is sent for Oncotype Dx testing and it comes back as 35. She has a strong family history of breast cancer. For this reason, she undergoes Genetic testing and is found to have a ATM mutation (monoallelic). Which of the following sequence of therapies is most appropriate for her?
A. Chemotherapy (Taxotere/Cytoxan x 4 cycles), Radiation, and Aromatase inhibitor x 5-10 years
B. Radiation and Aromatase inhibitor x 5-10 years
C. Chemotherapy (Taxotere/Cytoxan x 4 cycles) and Aromatase inhibitor x 5-10 years
D. Aromatase inhibitor x 5-10 years
E. None
A. Chemotherapy (Taxotere/Cytoxan x 4 cycles), Radiation, and Aromatase inhibitor x 5-10 years
In node negative Hormone positive breast cancer, TC is reasonable.
You are treating a 46 y.o. woman who presented with a L breast mass. Core biopsy disclosed poorly differentiated invasive ductal carcinoma, ER negative, PR negative, andHER2 negative (i.e. triple negative).
Which of the following statements best characterizes her treatment options.
A. Six cycles of docetaxel plus cyclophosphamide (TC) is equivalent
to an anthracycline/taxane regimen (TaxAC) in triple negative disease.
B. Chemotherapy given neoadjuvantly rather than adjuvantly results
in better relapse-free survival.
C. Carboplatin added to AC and taxane‐based neo-adjuvant chemotherapy does not improve pathologic response to therapy
(pCR).
D. Compared with adjuvant, neo-adjuvant chemotherapy improves breast conservation rates and risk stratification for relapse-free
survival.
D. Compared with adjuvant, neoadjuvant chemotherapy improves breast conservation rates and risk stratification for relapse-free
survival.
A 61-year-old female is s/p lumpectomy for a Right-sided breast cancer. Her tumor measures 2.4 cm in size and 0/2 lymph nodes are involved on SLNB. Her margins are negative. Her tumor is ER=96%, PR=98% and Her2 Negative. She has a Grade II tumor with a Ki67=54%. An Oncotype Dx test is sent and the score comes back as 34. She is slated to receive chemotherapy with Docetaxel and Cyclophosphamide x 4 cycles. What do you tell her about GCSF support during chemotherapy?
A. Her chemotherapy regimen is low risk for causing neutropenic fever; No GCSF needed
B. Her chemotherapy regimen is low risk for causing neutropenic fever; GCSF needed
C. Her chemotherapy regimen is intermediate risk for causing neutropenic fever; No GCSF needed
D. Her chemotherapy regimen is intermediate risk for causing neutropenic fever; GCSF needed
E. Her chemotherapy regimen is high risk for causing neutropenic fever; GCSF needed
E. Her chemotherapy regimen is high risk for causing neutropenic fever; GCSF needed
If a patient has a >20% chance of Febrile Neutropenia with chemotherapy, you should offer GCSF support.
If a patient has a 10-20% chance of developing neutropenic fever, then you should consider offering G-CSF support (if he/she has other concerning underlying risk factors that may lend itself to developing neutropenic fever).
If a patient has a low risk of developing neutropenic fever (<10%) then no G-CSF support is needed.
The breast cancer regimens that are high risk of causing neutropenic fever include:
Dose-dense Adriamycin/Cytoxan followed by Taxol
Docetaxel, Doxorubicin and Cyclophosphamide
Docetaxel and Cyclophosphamide
A 42-year-old female was recently diagnosed with likely stage II right breast cancer. On routine mammogram, she was found to have a 3 cm right-breast mass with no clinical evidence of axilla LAD. Genetic testing reveals that she harbors a BRCA1 mutation.
The patient undergoes a biopsy of the 3 cm mass and the results are pending. Which of the following is the most likely type of breast cancer that she has?
A. ER+, PR+, Her2-
B. ER+, PR-, Her2-
C. ER+, PR+, Her2+
D. ER-, PR-, Her-
E. ER-, PR-, Her2+
D. ER-, PR-, Her-
There are several differences between BRCA1 and BRCA2 related tumors.
BRCA1-related breast cancers are mostly triple negative.
BRCA2 breast cancers are mostly ER+
A 71-year-old female presents for a second opinion to discuss adjuvant treatment options for her recently diagnosed breast cancer. She had a mastectomy with SLNB that revealed a 1.8 cm Invasive ductal carcinoma with 0/2 sentinel lymph nodes involved with cancer. She has a Grade 1 tumor with a Ki67=10%. Her tumor is ER=90%, PR=90% and Her2 negative. The surgical margins are > 5 mm.
An OncotypeDx was sent by the previous Oncologist and it came back with a score of 25. The recommendation from the prior Oncologist was to offer Docetaxel/Cyclophosphamide x 4 cycles to be followed by an Aromatase inhibitor x 5 years. The patient is very active for her age and prizes her quality of life. What do you recommend?
A. Agree with the recommendation of the same chemotherapy
B. Would offer chemotherapy, but would offer dose dense Adriamycin/Cyclophosphamide followed by dose dense Taxol
C. Would offer anti-estrogen therapy alone with Anastrozole
D. Would offer Letrozole + Palbociclib
E. None
C. Would offer anti-estrogen therapy alone with Anastrozole.
TAILOR RX Trial: No benefit of chemotherapy in patients<50 years if RS< or equal to 25.
A 62-year-old female presents to see a Medical Oncologist to discuss adjuvant therapy for her recent diagnosis of breast cancer. She is s/p right-sided mastectomy and SLNB for a Right-breast IDC that is ER-, PR- and Her2=2+. These markers were performed on her biopsy. Her final pathology report reveals a 4.5 cm tumor with 0/3 lymph nodes involved on SLNB. She is ER- and PR-. Her tumor is high grade.
Her2 status is repeated on her surgical specimen given the high-grade nature of her disease. IHC of Her2+ on her final pathology surgical specimen was 2+. A dual-probe ISH assay was done and reveals a HER2/chromosome enumeration probe 17 (CEP17) ratio of <2.0 and the average HER2 copy number is ≥6 signals per cell. A second reviewer evaluates the tumor and agrees with the first pathologist. What do you recommend?
A. Give Taxol and Herceptin
B. Give Taxotere, Carboplatin, Herceptin +/- Perjeta
C. Give Taxotere and Cytoxan
D. No adjuvant therapy is needed
E. Recount ISH by having a 3rd reviewer, blinded to previous ISH results, count at least 20 cells that include the area of invasive cancer with IHC 2+ staining
B. Give Taxotere, Carboplatin, Herceptin +/- Perjeta
A patient is considered HER2/chromosome enumeration probe 17 (CEP17) ratio of <2.0 and the average HER2 copy number is ≥6 signals per cell.
Given LN positive, eligible for Perjeta.
Which of the following patients is ideally most suited to receive neoadjuvant chemotherapy?
A. A 42-year-old female with multifocal DCIS
B. A 58-year-old female with T2 N0 classical ILC tumor that is strongly ER+, Her2 –
C. A 44-year-old with a T1a N0, triple negative cancer with the tumor measuring 0.2 cm in size
D. A 46-year-old with a T4 N1 IDC, ER-, PR-, Her2-
E. A 34-year-old with a T1b N0 cancer (Tumor=0.8 cm) that is ER+, Her2 negative
D. A 46-year-old with a T4 N1 IDC, ER-, PR-, Her2-
Stage T4 breast cancers are better served with upfront chemotherapy to improve pCR.
A 36-year-old female was diagnosed with Stage I Right-sided breast cancer over 2 years ago. She underwent a mastectomy and SLNB. She was found to have an Invasive ductal carcinoma measuring 1 cm in size with 0/2 lymph nodes involved on SLNB. She is strongly ER and PR positive and Her2-.
Her tumor is sent for Oncotype Dx testing and she is found to have a score of 9, so no chemotherapy is offered. Her Medical Oncology team discusses offering either tamoxifen or Lupron/AI. She started on therapy with tamoxifen and has been on it for 2 years and has tolerated it well. She was recently married and desperately wants to have children. What do you recommend?
A. Stop tamoxifen now so she can attempt to become pregnant
B. Continue tamoxifen for a total of 5 years prior to letting her attempt to become pregnant
C. Continue tamoxifen for a total of 10 years prior to letting her attempt to become pregnant
D. Continue tamoxifen and allow her to become pregnant
E. Pregnancy is an absolute contraindication given her history of ER+ breast cancer
A. Stop tamoxifen now so she can attempt to become pregnant
A multicenter case-control study of 333 patients with pregnancy after breast cancer compared to 894 non pregnant patients. There was no difference in disease free survival at 7.2 years between pregnant and non-pregnant ER + patients.
A 42-year-old female is s/p right lumpectomy and SLNB for a recently diagnosed breast cancer. The biopsy of the breast mass prior to surgery revealed a high-grade breast cancer, however, there was not enough tissue to send for the requisite receptors. The final pathology report from the lumpectomy revealed the following:
Poor fixation
1 cm invasive tumor
ER=0%, PR=0%, Her2=1+ on IHC, Ki67=95%, and Grade III
Margins are negative
0 of 2 lymph nodes involved with cancer
Which of the following should be considered at this time?
A. Chemotherapy with Docetaxel and Cyclophosphamide
B. Chemotherapy with dose dense Adriamycin/Cyclophosphamide followed with Paclitaxel
C. Oncotype Dx
D. FISH testing for Her2+
E. Radiation therapy
D. FISH testing for Her2+
To reduce false-negative IHC results, high-grade tumors with poor fixation and negative hormone receptor status may be considered for further analysis by FISH.
ASCO/CAP guidelines detail a range of histopathologic features suggestive of possible discordance that should make one consider retesting for Her2 status.
IHC 1+ samples associated with high-grade and elevated Ki67 should be considered for FISH testing.
According to the 2018 updated guidelines, repeat HER2 testing may be performed on the excisional biopsy if the tumor is grade 3, the amount of invasive tumor in the core biopsy is small, the resection contains morphologically distinct high-grade carcinoma, or there are quality concerns related to the HER2 testing performed on the core biopsy.
The patient in this question certainly has a very high-grade tumor. In addition, there was poor fixation of the tumor. Therefore, repeat Her2 testing is reasonable.
A 56-year-old female has a diagnosis of Her2+, ER+ Stage IIA Right-sided breast cancer. Baseline imaging and exam reveals a T2 N0 Right-sided breast cancer. Her tumor measures 4 cm in size. She undergoes neoadjuvant therapy with Docetaxel, Cyclophosphamide, Trastuzumab and Pertuzumab x 6 cycles. Treatment is complicated by marked diarrhea from Pertuzumab. She then undergoes a lumpectomy and SLNB.
Her final pathology reveals a residual 3 cm tumor with 0/2 lymph nodes involved. The Oncology team is not happy with the response the patient had to neoadjuvant therapy. Unfortunately, the patient has Grade IV neuropathy from Docetaxel. For this reason, she is not being considered for T-DM1 as ‘adjuvant’ therapy. Post surgery, she continues with Herceptin alone (no Pertuzumab given her side effects with it). She also has completed Radiation and has started arimidex. The patient reads about Neratinib as another possible option. What is the main side effect with this medication?
A. Leukopenia
B. QT Prolongation
C. Hepatotoxicity
D. Diarrhea
E. Hypothyroidism
D. Diarrhea
EXTRANET Study revealed ER positive patients derived most benefit from adjuvant Neratinib when compared to ER negative patients.
A 40-year-old African-American female with breast cancer is presented at tumor board. She has a mass located at the inferior portion of her left breast. Radiographically, she has prominent left axilla lymphadenopathy. Biopsy of both the breast mass and lymph nodes reveals an ER+/PR+ invasive ductal cancer. Her2 was 2+ on IHC (FISH was 1.3).
There was no dermal lymphatics appreciated on biopsy. Photos of the breast reveal an appearance of peau d’orange and marked erythema. The surgical team feels confident that if they did surgery now they could remove all of the tumor. She did undergo a CT Chest/Abdomen/Pelvis and a bone scan. Fortunately, both exams were negative for distant metastases. Which therapy do you offer?
A. Upfront mastectomy with complete axilla lymph node dissection; Negative dermal lymphatics argues against inflammatory breast cancer
B. Neoadjuvant tamoxifen given her pre-menopausal status
C. Lumpectomy with SLNB
D. Neoadjuvant chemotherapy with dose-dense Adriamycin and Cyclophosphamide x 4 cycles and weekly Paclitaxel x 12 cycles
E. Neoadjuvant LHRH agonist/Aromatase inhibitor neoadjuvant therapy
D. Neoadjuvant chemotherapy with dose-dense Adriamycin and Cyclophosphamide x 4 cycles and weekly Paclitaxel x 12 cycles
Given Inflammatory breast cancer, Neo-adjuvant is reasonable.
A 42-year-old female presents to discuss neoadjuvant treatment options for her recently diagnosed HER2 positive, ER positive, PR positive, right-sided breast cancer. Mammography reveals a 1 cm mass in the right breast at 8 o'clock position. Of note there are no suspicious pathologic appearing lymph nodes in the right axilla. Biopsy of the breast mass reveals a 1 cm tumor. Upfront surgery is offered but she is interested in neoadjuvant therapy. Would you tell her regarding neoadjuvant therapy with pertuzumab?
A. Pertuzumab increases the pathologic complete response rate, and would treat her with neoadjuvant AC followed by T HP.
B. Pertuzumab increases PFS and OS and we will treat her with docetaxel, carboplatin, pertuzumab and transtuzumab.
C. Pertuzumab increases pathologic complete response rate, and we will treat her with weekly paclitaxel and HP
D. Based on the current FDA indication, she would not qualify for neoadjuvant pertuzumab.
E. Given the size of her tumor, she would not qualify for any anti-HER2 therapy
D. Based on the current FDA indication, she would not qualify for neoadjuvant pertuzumab.
NEOSPHERE and TRYPHAENA study led to approval of pertuzumab as neoadjuvant therapy for patients with HER2+ Breast cancer. The pretext of approval was based on improvement of complete pathologic response rate.
of note, a tumor of 2 cm or +LN is the criteria whereby one can deploy Pertuzumab in the neoadjuvant setting.
A Her2 + tumor>1 cm should be offered neo adjuvant transtuzumab-based therapy.