March 31, 2020


Case: A 54-Year-Old Woman With Stage 2HER2+ Breast Cancer

Initial presentation

  • A 54-year-old, postmenopausal woman presented with a painless palpable mass on the right upper outer quadrant of her right breast
  • PMH/SH: unremarkable, no family history of cancer
  • PE: ~ 4-cm palpable right breast mass, clinically node negative, no visible sink involvement

Clinical workup

  • Labs: WNL
  • Ultrasound showed a right breast mass, and two axillary lymph nodes
  • Mammogram confirmed a right—sided, poorly defined speculated 4.2-cm mass
  • PET/CT showed increased uptake in the right breast diffusely, with 2 FDG—avid axillary lymph node involvement; no evidence of distant metastases
  • Ultrasound—guided FNA biopsy of the breast mass confirmed grade 3 infiltrative ductal carcinoma
    • Hormone receptor/HER2 Status:HER2+:3+ by IHC,80%ER+, PR-
  • Stage T2N1M0; ECOG PS 0

Treatment and Follow-Up

  • The patient was started on preoperative docetaxel + carboplatin + trastuzumab + pertuzumab (TCHP), and pegfilgrastim every 3 weeks for 6 cycles;
    • Achieved clinical complete response
  • She underwent right mastectomy; residual disease: 1 positive axillary lymph node, and 1-cm RD in the right breast; 4 sentinel lymph nodes removed, 1 positive for disease; she also received post mastectomy radiation therapy of her chest wall and regional lymphatics
  • She was started on trastuzumab emtansine every 3 weeks for 14 cycles + aromatase inhibitor PMRT + letrozole planned for 10 years
  • Extended adjuvant neratinib was initiated
    • Week 1: 160 mg (4 tablets) PO qDay; week 2: 200 mg (5 tablets) PO qDay; week 3: 240 mg (6 tablets) PO qDay for 1 year
    • IV zoledronic acid every 6 months was added to her regimen for 3-5 years