Optimizing the Management of HER2+ Inflammatory Breast Cancer - Episode 1

Reviewing a Case of HER2+ Inflammatory Breast Cancer

May 29, 2018

Debu Tripathy, MD:This is a 60-year-old woman who has a history of right-sided breast cancer. The cancer is clinically of the inflammatory type with edema and redness, and the patient is also found to have an axillary lymph node at the time of diagnosis. This case of a patient presenting with what looks like clinical inflammatory breast cancer first needs to be approached with diagnostic confirmation. Typically, we would do an image-guided core biopsy of the mass and, in this case, given the imaging showing axillary adenopathy, probably a fine needle aspiration of the lymph node, as well. Of course, we confirm that this is carcinoma, as suspected, and obtain biomarker information: hormone receptor status and HER2 status.

The initial diagnostic studies with the core biopsy do confirm a high-grade carcinoma. The tumor is estrogen receptor—positive, progesterone receptor–negative, and HER2-positive. On that basis, given the fact that this patient has inflammatory breast cancer, the treatment generally would be neoadjuvant or preoperative therapy. As this is a HER2-positive breast cancer, our best treatment is going to be combination antibody therapy with trastuzumab and pertuzumab. This combination was actually approved in the neoadjuvant setting initially and, more recently, in the adjuvant setting. Of course, it has been approved in the metastatic setting for quite some time.

One of the more common regimens we use is the combination of docetaxel/carboplatin, along with trastuzumab and pertuzumab. This is a perfectly reasonable option that the patient receives. Other options would include anthracycline-based therapy: doxorubicin and cyclophosphamide, typically followed by a taxane with trastuzumab and pertuzumab.

Inflammatory breast cancer itself is not that common. It probably represents 2% or 3% of all cancers. However, node-positive breast cancer certainly is a common presentation. About a third of cases do present with positive nodes. In certain populations, younger populations—maybe in urban populations—that number is even higher. Of all the cancers, about a fifth of them are HER2-positive. Inflammatory HER2-positive disease with all of those features may not be that common, but certainly the treatment paradigms that we use to treat these types of cancers can be applied here. The key issue in treating patients is the subtype of breast cancer based on hormone receptors and HER2 positivity, as well as the clinical and pathologic stage.

Transcript edited for clarity.


60-year-old Woman WithHER2+ Inflammatory Breast Cancer

  • A 60-year-old woman presented to her gynecologist with redness, tenderness, and swelling of her right breast over the last 2 weeks
    • PMH: HTN managed with HCTZ/triamterene
    • FH: unremarkable
    • PE: palpable mass in the right inferior breast with skin thickening; no palpable lymphadenopathy
    • ROS: clear, no fever
  • Breast ultrasound revealed a solid right-sided 3.8-cm mass at the 10:00 position with no posterior acoustic shadowing; abnormal enlargement of 2 right axillary lymph nodes
  • Core needle biopsy of the breast mass revealed high grade infiltrating ductal carcinoma;HER2+
  • Fine needle biopsy of a right axillary node confirmed carcinoma
  • Punch biopsy of the skin showed dermal lymphatic invasion with carcinoma cells
  • PET/CT staging showed increased uptake over right breast, diffusely, and with at least 2 nodes seen in the right axillary basin; no evidence of distant metastases
  • Clinical staging: T4dN1M0
  • She received neoadjuvant therapy consisting of dose-dense AC X 4-THP X 4; physical exam was consistent with a complete clinical response
  • She then underwent right modified radical mastectomy; pathology showed a complete pathologic response
  • Following surgery, she was treated with adjuvant trastuzumab + pertuzumab to complete one year of monoclonal antibody therapy
  • The patient completed radiation therapy to the right chest wall and regional nodes
  • She was placed on letrozole