Breast Cancer Update for Surgeons, Issue 1, 2017 (Video Program)Case discussion: A man in his late thirties presents with neglected locally advanced, ER-positive, HER2-positive BC
4:06 minutes.
TRANSCRIPTION:
DR GRADISHAR: This is a Hispanic guy in his later thirties who came to see me for a second opinion, because he works on trains. He fixes locomotives, whatever. But in any case, he had presented elsewhere sometime within the last year or two with locally advanced neglected breast cancer, something we don’t typically see in men, because it’s usually somewhat easier to detect. So it was locally advanced, not going through the chest or anything like that, but palpable nodes and a palpable mass. He was biopsied, and he had HER2-positive disease, strongly positive, and he was ER-positive. So they treated him with TCHP, and interestingly enough, he apparently did not get much of a response, which is not our typical experience with patients who truly have HER2-positive disease. And they ultimately took him to surgery, and he still had a fair bit of bulky disease in the breast. He had positive lymph nodes. He completed a full year of trastuzumab, and he was placed on endocrine therapy. And more recently, he developed bony pain. And it’s at that point that he presented to me. So he had been biopsied elsewhere, bone biopsies not always being the best source of material, but that’s all they had. And it did show, in the limited amount of tumor cells that they identified in the bone, that he was ER-positive, but less positive than before, and he was HER2-poor. I think it was, like, 1+ or something. DR LOVE: As you mentioned, it’s pretty unusual to have a patient with HER2-positive disease not respond. How did you and your pathologist put together what was going on? Do you think that the first assay was a false positive? DR GRADISHAR: We got the material in the block, and it was positive, which is really, again, very unusual that he didn’t have much of a clinical response. And it’s actually quite troubling. And the problem we’re faced with now is in the bone, because there’s a paucity of tumor cells there that we’re not absolutely confident that we actually know what the status of his markers are at this point. DR LOVE: Could I just ask you, because I’ve heard this before. Could you elaborate a little bit more about the issue of biopsies in the bone, particularly in terms of ER and HER2? DR GRADISHAR: Yes. So number 1, if it’s diffusely involved, maybe you get lucky and you get enough cells that you can actually look at. But in this case, when we reviewed this on Monday in our tumor board, when they looked at the specimen from the bone biopsy, they just had a paucity of cells. So when they did the markers, the markers were different than the original. And they were questioning whether it was an issue of decalcification or what the issue was, or if the tumor actually had changed that dramatically over that short period of time, going from 3+ to basically 1+, or was it simply a function of not having enough material to be confident? So we were very interested in looking at the primary disease to make sure that they didn’t make a mistake there. And they didn’t. It looks like HER2-positive disease. So we elected to treat him with T-DM1. And that’s what he’s starting on. And consideration would have been reasonable to just put him on endocrine therapy. So we’ll see how this turns out. This is a complicated, unusual case. And the fact that it’s a guy with metastatic disease right from the get-go, that’s not the most common scenario. DR LOVE: Wow! That is really an amazing case. |