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Old 04-21-2015, 07:01 AM   #14
vqtilley
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Join Date: Mar 2015
Posts: 13
Re: TDM1 for HER2+ brain mets reocurrence?

Thanks, Rolepaul, and yes, longer term outcomes are vital & often omitted. But are you saying that Nina was the case in the Kalsi article? Not sure but she doesn't sound like the same case, reading the article - this case had WBRT, for example. Certainly resectable BMs appear statistically to respond best to treating first with resection/radiation, which for me was gamma knife, followed by systemic therapy, but the question is which meds and when. I'm aiming for IT Herceptin when my leptomeningeal disease kicks off: there's a clinical trial at Northwestern and friendly med oncs and radiation oncs ready to help me. But postponing that step is highly desirable presently, as I'm seeking hip replacement surgery in May for my sometimes debilitating femur lesion, which the IT treatment would preclude, while still working and trying to have a functioning brain, so any info on BBB penetration and BM efficacy by Kadcyla & letrozole is important at this stage. Very interesting about IT Trastuzumab combined with Pertuzumab: will follow up.

Below is an extract from the Kalsi article profiling the case study:

Case Report
A 28-year-old female presented for treatment of unresectable inflammatory
breast cancer that was positive for estrogen (90%)
and progesterone receptor (40%) with high Ki-67 (> 90%), and
HER2รพ. She initially received 6 cycles of TCH (docetaxel, carboplatin,
and trastuzumab) and progressed during this therapy.
Subsequently, she was referred to our institute and was treated with
multiple lines of therapies, including the combination of a panhistone
deacetylase inhibitor, vorinostat, and lapatinib in a phase II
trial followed by ixabepilone, trastuzumab, and lapatinib. She had an
excellent response and was considered for surgery. However, the
patient was lost to follow-up and presented several months later with
lymphedema due to lymph node progression. At that time, she was
found to have multiple asymptomatic BM and received whole-brain radiation (WBRT), palliative right breast, and ablative ovarian radiation
to a total dose of 20 Gy (in 8 fractions of 2.5 Gy per fraction)
because of transportation limitations for a longer treatment course.
Three months after completion of WBRT and during fulvestrant,
trastuzumab, and lapatinib treatment, she developed progressive BM,
andWBRTwas repeated to a total dose of 20 Gy, also in 8 fractions of
at 2.5 Gy per fraction. She subsequently received multiple lines of
trastuzumab-containing regimens, including gemcitabine, eribulin,
and vinorelbine. Approximately 5 months after the second course of
WBRT, she developed further intracranial progression and underwent
frameless stereotactic radiotherapy to the 2 symptomatic lesions
in her brainstem and left cerebellum, and received 18 Gy in 3 fractions.
After approval of pertuzumab, her treatment was switched to
pegylated liposomal doxorubicin, trastuzumab, and pertuzumab
during which her disease progressed systemically after 3 cycles. The
treatment was switched to T-DM1 and after 3 cycles, her follow-up
brain magnetic resonance imaging (MRI) scan showed a striking
central nervous system (CNS) improvement, including several lesions
that did not receive radiosurgical treatment (Figure 1). The superficial
and deep enhancing metastatic lesions in cerebral and cerebellar
hemispheres, and the brainstem all decreased in size. The largest cerebral
lesion in the thalamus decreased from 20 mm to 9 mm and the
largest cerebellar lesion diminished from 25 mm to 20 mm. The
edema and original midline shift associated with these lesions also
almost entirely resolved."
__________________
Feb 2012: diagnosed with 1 cm lesion rt breast, DCIS left breast, Stage IV ER+/HER2+
Apr 2012: bilateral partial excisions; confirmed met to left proximal femur, long gamma nail inserted to stabilize femur:
May 2012: radiation to femur: chemo with Trastuzumab + taxane.
July 2012 thru Mar 2015: started maintenance regime Herceptin+Arimidex+Denosumab, NED
May 2014: recurrence in right acetabulum: 15 fractions radiation
Jan 2015: lesion in left cerebellum: resection & gamma knife treatment
Mar 2015: major general progression; small mets confirmed in rt axilla, rt breast, T7 vertebra, possible met as isolated spiculated pulmonary nodule left lung[LIST][*]27 Mar 2015: start Kadcyla, discontinue aromotase inhibitors; within two weeks axilla/rt breast lesions are shrinking noticeably[*]18 April: resume letrozole [*]May: all lesions disappeared or dormant[*]June - discontinue Kadcyla due to low platelets[*]Aug & Nov 2015 MRI brain/spinal scans all negative for CNS disease: no recurrence to date
Fall 2015 - stereotactic radiation to lingering T3 lesion to relieve pain; 90% effective within weeks
July 2019 - discontinued Letrozole due to side effects
April 2020 - short course steretactic radiation to 2 cm lesion in upper left lung; subsequent scan finds it reduced
Mar 2021 - 6.5 cm mass found in left lung; FISH finds it is PR-, ER- and strongly HER2+.
16 April 2021 - Resume Kadcyla.
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