[Lani]

Probably not all ER+her2+ breast cancers are alike--perhaps some have topoIIa amplified, some not, and many other differences. When they are all lumped together the average of them do better with herceptin and chemo than with chemo alone and when ER+ tumors (both her2+--about 10% of them--and her2negative tumors, the other 90% of them) are considered as a whole on AVERAGE they hardly respond to chemo. This is probably because subsets are not identified and the results are skewed.

Perhaps there are a group of her2+ER+ tumors that would do fine with herceptin and fulvestrant (more likely than with herceptin and an AI, according to Dr. Slamon) without chemo, but all we can say now, is that when all her2+ tumors ER+ or not were lumped together in the HERA, NO American combined, TCH (BCRG009) and Fin Her trials that upon analysis of all lumped together the % improvement in recurrence and survival did not differ between those who were ER+ vs ER- ON AVERAGE.

Noone is an average. Someday, hopefully, each tumor will be evaluated individually and treated differently.

To more fully respond to your question--It seems a subgroup of her2+ tumors respond particularly well to anthracyclines (perhaps the TOPO IIa amplified group) and another group respond particularly well to herceptin and taxanes (perhaps the cMyc group and perhaps all subgroups, but we don't know for sure yet). They have not yet dissected this out with respect to ER+ vs ER- from the talks I have heard/papers I have read.

And no, if only a needle biopsy and not an open or excisional biopsy or node biopsy were done, methylene blue would not have been used, from what I understand.