carcinoma mammario metastatico caso clinico n.2 stefania gori oncologia medica- perugia
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Carcinoma mammario metastaticoCASO CLINICO n.2
Stefania Gori
Oncologia Medica- Perugia
Caso clinico n.2Agosto 2009: Donna di anni 37 anni, premenopausa, operata
altrove di quadrantectomia mammaria Sx + dissezione ascellare per ca. duttale infiltrante
pT2 pN3(20LN+/24) M0; STADIO IIIC• G3 • ER=0%, PgR=0%• Ki67=60%• HER2= 3+ IHCSettembre 2001: Programma terapeutico (altrove): CT adiuvante (FECTaxano) seguita da RT Aveva ricevuto 1° ciclo di F600E90C600
Caso clinico n.2Vengono richiesti: RM encefalo con gadolinio: negativa PET /TC total body (9 ottobre 2009): metastasi LN mediastinici metastasi ossee: - sterno e collo femore dx
IV STADIO
Trattamenti
Ottobre 2009
IV stadio
RT femore dx +ZometaTrastuzumabPaclitaxel
Febbraio 2010
RC
Zometa+trastuzumab
Trattamenti
Ottobre 2009
IV stadio
RT femore dx +ZometaTrastuzumabPaclitaxel
Febbraio 2010
RC
Zometa+trastuzumab
Nov 2010
PD
SNCLNOsso
Novembre 2010:RM encefalo T1 con gadolinio
A- Trattamento locale terapia sistemica
B- Terapia sistemica trattamento locale
1- Metastasi cerebrali di 6 e 13 mm di diametro (centro semiovale e corteccia frontale dx) asintomatiche, in pt con progressione extracranica asintomatica (ossea e linfonodale).Quale sequenza di trattamento?
Dicembre 2010
RT stereotassica su entrambe le lesioni
(dose di riferimento:18 Gy)
Systemic therapy in brain metastases from HER2+ BC:
when?
1-3 brain lesions
Local treatment
Multiple (>3) brain lesions
Systemic therapy
WBRT
The choice of systemic therapy must be tailored on the following factors: Performance Status and previous agents received
Systemic therapy
WBRT
Extracranial disease and ..
Systemic therapy
STUDY N Prior cranial RT
Prior trastuzumab
Prior
Cape
Response criteria
CNS ORR
TTP-PFS
OS
Boccardo F,ASCO 2008 #1094
Capri G, Ann Oncol 2010
138 NR YES YES:
42%
Investigator-assessed
18% 2.8 mo(median time on study)
NR
Sutherland SBJC 2010;102:995
34 YES (94%) YES YES:
35%
RECIST 21% 5.1 mo NR
Huang C ASCO 2010 #1111
26 YES (100%) YES NO RECIST 34% 8.4 mo NR
Metro GAnn Oncol 2011
22 YES (87%) YES NO WHO 32% 5.1 mo 27.9 mo
Lin NU,CCR 2009;15:1452-9
50* YES (100%) YES NO Composita (≥50% vol )
20% 3.6 mo NR
Lin NU,J Neurooncol 2011 online
13 YES (100%) YES NO Composita (≥50% vol )
38% NR NR
Bachelot T,ASCO 2011, # 509
45 NO YES(93%)
NO Composita (≥50% vol )
67% 5.5 mo 91% alive at 6 mo
RETROSPECTIVE STUDIES
PHASE II PROSPECTIVE STUDIES
Lapatinib+Capecitabine (all pts pretreated with CT)
* Optional extension phase after cerebral progression
PRE-Trastuzumab era
POST-Trastuzumab era
p
Park YH, BJC 2009
Progression in the brain 46% 60% ns
Progression in extra-CNS sites
37% 12% 0.014
Unknown 17% 28% -
Bendell JC, Cancer 2003
Progression in the brain - 52% -
Progression in extra-CNS +/- CNS sites
- 48% -
Brain metastases in HER2+ breast cancerCauses of death
Systemic therapy in brain metastases from HER2+ BC:
when?
1-3 brain lesions
Local treatment
Multiple (>3) brain lesions
Systemic therapy
WBRT
The choice of systemic therapy must be tailored on the following factors: Performance Status and previous agents received
Systemic therapy
WBRT
Extracranial disease and ..
Systemic therapy
A- Trastuzumab-based therapy
B- Lapatinib +capecitabine
C- Chemotherapy only
2- Quale terapia sistemica?
Brain metastases in HER2-positive Trastuzumab-pretreated MBC
SYSTEMIC THERAPY OPTIONS- Sept 2011
Newly diagnosed brain metastases and
no PD at extracranial sites
Newly diagnosed brain metastases and
PD at extracranial sites
1.Bachelot T, ASCO 2011 #505; 2.Metro G, Gori S, Ann Oncol 2011; 3.Lin NU, Clin Cancer Res 2009;4.Lin NU, J Neurooncol 2011 online
•Lapatinib + capecitabine phase II trial- Bachelot ASCO 20111
retrospective study 2
•Lapatinib + capecitabine
phase II trials 3,4; retrospective studies Brain progression after RT
•Trastuzumab-based therapy (?) retrospective data
•Lapatinib + capecitabine phase II trial- Bachelot ASCO 20111
retrospective study 2
Trattamenti
Dic 2010:
RT stereotassicacerebrale
Lapatinib+capecitabina
Nov 2011RC
Marzo 2011 RC
Ottobre 2009
IV stadio
RT femore dx
ZometaTrastuzumab+Paclitaxel
Febbraio 2010
RC
Zometa+trastuzumab
Nov 2010
PD
SNCLNOsso
PET/TC RM encefalo
PET/TC RM encefalo
Novembre 2011
Grazie!