60 yo, 2.1-cm node-neg IDC, ER-neg/HER2+, adj AC 
TH: Tx if lumpectomy bed recurrence 2 y later and NED?
A 60-year-old woman, s/p lumpectomy for a 2.1-cm IDC, negative nodes: The patient receives AC TH, but 2 years later a small lesion is removed from the breast in the lumpectomy bed that proves to be a recurrence. No other disease is detected clinically or on imaging. The primary tumor and the recurrence appear similar histologically and are ER-negative, HER2-positive. What systemic treatment would you recommend?
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Kimberly L Blackwell, MD |
| Professor of Medicine Director, Breast Cancer Program Duke Cancer Institute Durham, North Carolina |
PH (T = pac)
For this 60-year-old woman with HER2-positive disease who has a recurrence in the lumpectomy bed, I would administer 6 cycles of paclitaxel, trastuzumab and pertuzumab and continue the pertuzumab and the trastuzumab for at least a year.
If the patient had a recurrence in the chest wall after a mastectomy, I would recommend the same treatment.
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Lisa A Carey, MD |
| Richardson and Marilyn Jacobs Preyer Distinguished Professor for Breast Cancer Research Chief, Division of Hematology and Oncology Physician-in-Chief North Carolina Cancer Hospital Associate Director for Clinical Research Lineberger Comprehensive Cancer Center Chapel Hill, North Carolina |
I would administer TCH to a patient with ER-negative, HER2-positive disease with a recurrence in the lumpectomy bed. Also, I might consider recommending a little less chemotherapy by use of the Stephen Jones regimen of docetaxel/cyclophosphamide combined with trastuzumab.
For a patient in the same situation, if the tumor recurred in the chest wall I would offer the same recommendation.
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Julie R Gralow, MD |
| Professor, Medical Oncology Jill Bennett Endowed Professorship in Breast Cancer University of Washington School of Medicine Director, Breast Medical Oncology University of Washington School of Medicine/Seattle Cancer Care Alliance Member, Clinical Research Division Fred Hutchinson Cancer Research Center Seattle, Washington |
I would use a HER2-targeted approach for this 60-year-old patient with a lumpectomy bed recurrence because I believe from the side-effect profile it would be best in terms of minimizing her symptoms. I would prefer to treat with T-DM1, but if I cannot obtain approval because we do not have any supporting data, then I would consider the trastuzumab and lapatinib combination. I’m on the fence about adding chemotherapy, probably capecitabine, to the dual HER2-targeted therapy. I struggle with the treatment for these patients because I don’t want to overtreat or undertreat.
If the recurrence were in the chest wall I would recommend the same treatment because I believe the tumor has the same aggressive biology.
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Clifford Hudis, MD |
| Chief, Breast Cancer Medicine Service Solid Tumor Division Department of Medicine Memorial Sloan-Kettering Cancer Center Professor of Medicine Weill Cornell Medical College New York, New York |
If the recurrence were in the breast, I would administer a second course of adjuvant chemotherapy and trastuzumab. The results of the CALOR trial demonstrated that adjuvant chemotherapy could be beneficial in patients with a locoregional recurrence of breast cancer.
For a patient who had a chest wall recurrence after 2 years, my treatment recommendation would be the same.
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Ian E Krop, MD, PhD |
| Associate Physician Dana-Farber Cancer Institute Assistant Professor of Medicine Harvard Medical School Boston, Massachusetts |
I would offer a patient with an in-breast recurrence treatment with chemotherapy and trastuzumab/pertuzumab for 1 year. I would not be as dogmatic that she should receive any therapy and would also be comfortable not administering any therapy.
I would administer the same treatment for a patient that had a chest wall recurrence. This patient has a high risk for an additional recurrence. The reason I would recommend chemotherapy, either docetaxel or vinorelbine, is the chance for a long-term disease-free interval. I’m not optimistic that trastuzumab and single-agent chemotherapy will make a big difference. The benefits of adding pertuzumab to chemotherapy and trastuzumab have been demonstrated in the CLEOPATRA trial.
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Kathy D Miller, MD |
| Co-Director, IU Simon Cancer Center Breast Cancer Team Ballvé Lantero Scholar in Oncology Associate Professor of Medicine Department of Personalized Medicine Division of Hematology/Oncology The Indiana University Melvin and Bren Simon Cancer Center Indianapolis, Indiana |
I would treat the in-breast recurrence as if it were a new primary tumor and would administer TCH to the patient.
If this patient’s recurrence happened to have been in the chest wall, I would have a discussion with the patient. We don’t have any good data for patients in this situation. The CALOR trial, which investigated the benefit of chemotherapy for patients who experienced a local or regional recurrence, did not take into account HER2 status and HER2-targeted therapies. I would consider either not administering any therapy or would recommend chemotherapy with HER2-targeted therapy.
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Joyce O’Shaughnessy, MD |
| Co-Director Breast Cancer Research Program Baylor-Charles A Sammons Cancer Center Texas Oncology US Oncology Dallas, Texas |
PH (T = docetaxel)
If the tumor recurred in the lumpectomy bed I would recommend treatment with docetaxel/pertuzumab and trastuzumab for 6 months followed by pertuzumab and trastuzumab for 2 years.
I would opt for the same treatment if the recurrence were in the chest wall.
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Hope S Rugo, MD |
| Professor of Medicine Director Breast Oncology and Clinical Trials Education University of California, San Francisco Helen Diller Family Comprehensive Cancer Center San Francisco, California |
For the 60-year-old patient who has a recurrence in the lumpectomy bed, I would recommend HER2-targeted treatment with trastuzumab and chemotherapy. I can obtain approval for trastuzumab/lapatinib and capecitabine in this scenario, so that would be one option. Pertuzumab, in place of lapatinib, or T-DM1 would also be options if they could be accessed. Otherwise I would consider recommending TCH or an alternative chemotherapy-based approach that includes trastuzumab. If the MARIANNE trial demonstrates benefit, a combination of T-DM1 and pertuzumab will be a good option in the future. For in-breast recurrence I would recommend treatment for a year.
If the recurrence were in the chest wall, I would consider administering a course of docetaxel with pertuzumab and trastuzumab. I might administer 4 cycles of docetaxel and then continue with the dual antibody therapy. Another option for a patient who does not wish to receive chemotherapy would be to administer trastuzumab and lapatinib with a few cycles of capecitabine and then continue lapatinib/trastuzumab. However, lapatinib would have more toxicity than pertuzumab. I would administer treatment to a patient with a chest wall recurrence longer than I would for a patient who has an in-breast recurrence. For in-breast recurrence I would recommend treatment for a year.