*For medical professionals only
MDT团队汇聚，共话Luminal B型晚期乳腺癌诊疗规范！
On September 23, 2024, the sixteenth issue of "Big Coffee Style Multidisciplinary Diagnosis and Treatment Interactive Column for Breast Cancer" will meet you online as scheduled. Professor Shao Zhimin from Fudan University Cancer Hospital served as the chairman of the conference, and Professor Shao Wanting from the First Affiliated Hospital of Zhejiang University School of Medicine shared the clinical practice of recurrent and metastatic breast cancer, and conducted in-depth discussion and analysis on the sharing, aiming to further standardize the coping strategies for estrogen receptor (ER) heterogeneity in breast cancer and promote the development of MDT model in breast cancer. The important contents of the conference are summarized as follows for the benefit of readers.
The chairman of the conference is Professor Shao Zhimin from Fudan University Cancer Hospital
MDT Member
Clinical practice sharing of advanced breast cancer with low expression of HR+/HER2
The clinical practice sharing session was chaired by Professor Fu Peifen from the First Affiliated Hospital of Zhejiang University School of Medicine, and Professor Shao Wanting from the First Affiliated Hospital of Zhejiang University School of Medicine reported on the diagnosis and treatment of Luminal B type B (HER2-negative) advanced breast cancer. For middle-aged and non-menopausal women, neoadjuvant chemotherapy followed by radical resection of right breast cancer, postoperative pathology showed heterogeneity of ER and progestogen (PR), and adjuvant radiotherapy and ovarian function suppression (OFS) + aromatase inhibitor (AI) + CDK4/6 inhibitor therapy, DFS could be 20 months. If the patient has gastric metastases, liver metastases, and bone metastases, and MRD shows PIK3CA and TP53 mutations, the ADC drug gosatuzumab (SG) is used.
Professor Fu Peifen from the First Affiliated Hospital of Zhejiang University School of Medicine
Professor Shao Wanting from the First Affiliated Hospital of Zhejiang University School of Medicine
MDT Multidisciplinary Discussion
The MDT multidisciplinary discussion session was chaired by Professor Fan Lei from Fudan University Cancer Hospital, and the two MDT teams analyzed and discussed the efficacy of neoadjuvant chemotherapy for Luminal B breast cancer with multi-organ metastasis, postoperative adjuvant treatment regimens, the identification and treatment of breast cancer gastric metastases and gastric primary tumors, the differences in the immunophenotypes of each metastasis, and the treatment strategies after recurrence.
Professor Fan Lei from Fudan University Cancer Hospital
ER and PR status of postoperative specimens of breast cancer patients, and their heterogeneity in metastases
- Professor Li Jun briefly described the changes in the status of ER and PR in this type of patient before and after treatment. She pointed out that the immunohistochemistry of the primary lesion in patients with this type of breast cancer showed no difference in ER and PR morphology, and there were differences in immunophenotype. Postoperative immunohistochemistry showed that ER heterogeneity was large, HER2 was never expressed to HER2(1+), and the ER and PR states of stomach and liver showed spatial heterogeneity, while the phenotypes of primary lesions and metastatic lesions were different, indicating that there was temporal heterogeneity between ER and PR states. In addition, the ER and PR of the primary lesions of this type of breast cancer patients were weak~moderately positive, and the primary masses were diffuse into sheets with glandular duct formation and cord-like changes, which showed that there was little difference in the cell dysmorphia of the primary lesions, and the structural dysmorphia was obvious, so that the heterogeneity of ER and PR in the primary lesions and metastases could be distinguished.
- Professor Yu Baohua said that most of the gastric metastases of breast cancer originate from invasive lobular carcinoma, and a few originate from invasive ductal carcinoma. Secondly, since the primary lesion may also have ER and PR expression, the origin of gastric metastases from the breast cannot be judged from the expression status of ER and PR in gastric metastases.
Timing and diagnosis and treatment strategies for evaluating the efficacy of neoadjuvant therapy
- Professor Li Zhi said that the neoadjuvant treatment of patients with this type of Luminal B breast cancer was evaluated as partial progression (PR).
- Professor Chen Li pointed out that the re-puncture assessment of the lesion after neoadjuvant therapy is of great significance throughout the treatment process, and this work is also a routine procedure of the center. For the timing of evaluating the efficacy of neoadjuvant therapy, we generally perform biopsy after 2 courses of neoadjuvant therapy in breast cancer patients. For patients with HR+ breast cancer, the efficacy can be evaluated according to the tumor regression and hormonal changes after neoadjuvant therapy. In addition, it is also important to re-evaluate the changes in expression intensity such as molecular typing, ER, and PR after treatment to predict treatment sensitivity and heterogeneity.
In addition, according to the response of neoadjuvant chemotherapy in patients with HR+ breast cancer of this type, such as non-pathological complete response (non-pCR) and 4 lymph node metastases, CDK4/6 inhibitor + endocrine therapy can be used for such HR+ high-risk patients.
Controversy over adjuvant radiotherapy + systemic therapy drugs after breast cancer surgery
- Professor Yan Senxiang and Professor Chen Xingxing both said that patients with this type of breast cancer should undergo prophylactic adjuvant radiotherapy after surgery, and conventional irradiation of the chest wall, upper and lower clavicle and inner breast area at a dose of 50Gy.
- Professor Chen Xingxing pointed out that the consensus shows that in view of the lack of evidence for this combination strategy, it can be treated with reference to the results of large-scale clinical studies in clinical practice, such as sequential radiotherapy for CDK4/6 inhibitor abeciclib; Radiotherapy followed by capecitabine, or concurrent application; The immunotherapy drug palbociclib was used at the same time as radiotherapy.
Predictive value of PIK3CA and TP53 mutations
- Professor Jiang Yizhou said that TP53 mutations account for about 50% of malignant tumors, but their prognostic value is still unclear. PIK3CA mutation is associated with poor prognosis of HR+ breast cancer, and patients can try PI3Kα inhibitor therapy in the future.
Choice of first-line treatment strategy
- Professor Zhang Wenjuan and Professor Fan Lei both said that in view of the strong heterogeneity of breast tumors and the insensitivity to endocrine therapy, the follow-up can be treated with Fudan classification for first-line treatment, or participate in the clinical study of first-line treatment of triple-negative breast cancer (TNBC).
- Professor Xu Suzhen said that for the treatment options of this type of patients, individuals prefer to use the first-line treatment strategy of HR+ advanced breast cancer. According to the analysis of experts, first-line treatment of advanced TNBC is better for this patient. And because the patient was accompanied by PIK3CA mutation, he was subsequently treated with chemotherapy + PI3Kα inhibitor regimen.
- Professor Fu Peifen pointed out that based on the results of the patient's immune marker detection, the ADC drug SG treatment was finally selected.
At the end of the meeting, Professor Shao Zhimin said that patients with advanced breast cancer with rapid progression of this type of disease have brought many clinical tips, such as how to screen the dominant population for Luminal breast cancer in the future, and how to accurately treat breast cancer patients with tumor heterogeneity. In view of this, the Breast Cancer Precision Therapy Collaboration Group (BCTOP) aims to accurately classify and solve treatment difficulties, and looks forward to carrying out more forward-looking clinical studies with the close cooperation of major teams to provide new treatment opportunities for breast cancer patients, which is also the future development direction. We hope that everyone will work together to create a bright future for cancer treatment.
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* This article is only for the purpose of providing scientific information to medical professionals and does not represent the views of this platform