Adam Brufsky, MD, PhD: Choices of Therapy in Breast Cancer

What are your choices of therapy?

This is a lady who presented with de novo metastatic breast cancer, and about 5% to 10% of women will present like that in North America. It's far more common in other areas of the world. This lady presented with widespread bone metastases, as well as a lung lesion. This lung lesion was biopsied and was found to be ER-positive and HER2-negative, and these are the things we need to know before we treat somebody. It's often very important when someone has a diagnosis of not only of de novo disease, but actually disease that has recurred to be sure that those markers are present.

The choices in this case are either continued anti-hormonal therapy, and this lady was placed on fulvestrant and did well on it for about a year or 2 and now has progressed. She could receive fulvestrant, she could receive chemotherapy and a lot of us would consider capecitabine, some of us would consider intravenous chemotherapy with a taxane or an anthracycline, especially with a visceral lung lesion.

ER+/HER2-Breast Cancer: Case 2

Mary is a 62-year-old woman, who in mid-2014 complained of rib pain. Rib plain films revealed a lytic lesion of the left 5th rib. Bone scan revealed multiple areas of uptake in the lumbosacral spine and ribs.

PET-CT revealed lytic lesions in the lumbosacral spine and ribs, and a 3 cm right upper lobe lesion in the lung with a PET SUV value of 6, indicating malignancy

A mammogram and ultrasound of the left breast revealed a 2 cm speculated mass in the upper outer quadrant of the left breast

Core needle biopsy of this lesion revealed infiltrating ductal carcinoma, ER 80%, Her2 negative

She was placed on denosumab 120 mg SQ monthly, and anastrozole 1 mg orally daily. Her pain resolved within 1 month, and on follow-up CT at 4 months her bone lesions appeared sclerotic and her lung lesion had reduced to 2 cm. Her anastrozole and denosumab were continued

In mid-2015 she again complained of worsening low back pain and left hip pain. Repeat PET-CT demonstrated new lytic lesions in the left iliac crest as well as an enlargement of the lung lesion to 4 cm.

She was placed on fulvestrant 500 mg IM monthly and denosumab was continued. Within 2 months her pain improved, and a repeat CT of the chest in late 2015 demonstrated reduction of the lung lesion to 2 cm

In March 2016 she complained of new right scapular pain. A PET-CT revealed new lytic lesions of the left scapula and right ribs, and a new lung nodule in the left upper lobe 1 cm in diameter with an increase in the right upper lobe lesion to 3 cm