Breast cancer Case 1: pregnancy; Case 2: diagnostics; case 3: Her2 testing; Case 4: receptors

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07/16/23

Case1:
Pregnancy in women previously diagnosed with ER+ disease may be detrimental by means of endocrine stimulation. However, a case control study on patients with pregnancy after breast cancer revealed no survival difference between ER- and + patients.
predicated the patient’s age, risk of recurrence, adjuvant therapy, and ovarian reserve, many Oncologists will offer 2 years of anti-estrogen therapy prior to taking a patient off of treatment so she can pursue pregnancy.
As a reminder, tamoxifen is teratogenic and it should not be given to a pregnant patient.
Reference: Matteo Lambertini et al. Long-term Safety of Pregnancy Following Breast Cancer According to Estrogen Receptor Status. J Natl Cancer Inst 2018 Apr; 110: 426–429.

Case 2:
In general, systemic imaging for patients with clinical stage I, II and III breast cancer should be performed based clinical picture and whether a patient has concerning signs or symptoms.
If labs are drawn on a patient and they are found to have abnormal values ie, elevation of Alkaline Phosphatase or Liver function testing; then imaging can be ordered to rule out metastases.
For early stage breast cancer, bone scans and CT imaging can pick up false positive findings.
Reference: http://www.nccn.org/profession....als/physician_gls/pd

Case 3
This patient has a high-grade tumor that is ER- and PR-. One would offer adjuvant chemotherapy to her. The main question is whether she is Her2 positive or not.
In 2018, updated guidelines regarding Her2 testing in breast cancer were made by the American Society of Clinical Oncology; College of American Pathologists human epidermal growth factor receptor 2; HER2 testing. The NCCN endorses the ASCO CAP Her2 testing guidelines.
HER2 is defined as positive by IHC 3+ when more than 10% of the cells harbor a complete membrane staining, and by ISH if the number of HER2 gene copies is more or equal to 6, or the HER2 chromosome 17;CEP17ratio is more or equal to 2 and HER2 copies more or equal to 4, or HER2CEP17 less than 2 and HER2 copies more or equal to 6
Reference: AC Wolff et al. Human Epidermal Growth Factor Receptor 2 Testing in Breast Cancer: American Society of Clinical Oncology/College of American Pathologists Clinical Practice Guideline Focused Update. Journal of Clinical Oncology 36, no. 20 July 10 2018, 2105-2122

Case 4.
Receptor status ER, PR, and Her2 can evolve when going from the localized to metastatic setting. Data shows that these three receptors can be unstable throughout tumor progression.
Changes in ER has been shown to occur in up to 40% of cases while changes in Her2 in up to 38%.
This patient likely has metastatic breast cancer that is triple negative. However, there is a chance that her tumor is now ER+ or Her2+; if so, she will have an additional menu of therapeutic options available to her.
Given that she has no signs of entering a visceral crises and is clinically stable, you have time to order a biopsy and confirm pathology/receptor status on this patient.
If she is felt to have triple negative disease, then it will be important to check for actional genetic mutation as these might provide more therapeutic options.
Reference: Foukakis T et al. When to order a biopsy to characterise a metastatic relapse in breast cancer. Ann Oncol 2012; 23: 349-353