Management Options for Stage IV Breast Cancer Metastatic to the Brain?

Management Options for Stage IV Breast Cancer Metastatic to the Brain? A 42-year-old woman underwent mastectomy, RT, and chemo for a HER2+ ductal carcinoma; 2 years later, she had radiosurgery, WBI, and chemo for brain metastases. Two nodules remain. What would you do? profAskTheExpert brest,braest, radiation oncology,metastisis, chemotherapy,female,carcinoma,carcimona,caarcinoma,neaplasm,adenocarinoma,carconoma,breasts,adenocarcinona,adenocardinoma,malignant neoplasm,neoplasm malignant breast,breast cancer metastatic,carcioma,carcinomas,metastsatic,woman,malignancy,ca,breeast,women,adenocarcinomas,cancer,breat,neoplasms,breasst,adenocarcinoma,mammary,metastses,metastases,metastates, carcinoma breast metastatic,metastasis,metastatis,carrcinoma Clifford Hudis, MD, Chief, Breast Cancer Medicine Service, Solid Tumor Division, Memorial Sloan-Kettering Cancer Center, Assistant Attending Physician, Memorial Hospital, New York, NY Disclosure: Clifford A. Hudis, MD, has disclosed that he has received grants for clinical research and educational activities and served as a consultant for Amgen, AstraZeneca, Aventis, Bristol-Myers Squibb, Genentech, Lilly, Novartis, Ortho Biotech, Pfizer, and Roche. Medscape Medscape Hematology-Oncology 05/14/2004 7 1 <h3>Question</h3> A 42-year-old woman was treated 3 years ago with mastectomy, irradiation, and 4 cycles of doxorubicin/cyclophosphamide for an ER-negative, HER-2/neu-positive ductal carcinoma. Disease recurred 1 year ago with skeletal metastases and 2 cerebral nodules. She was treated with radiosurgery followed by whole-brain irradiation and paclitaxel plus trastuzumab and pamidronate for systemic disease. She is now asymptomatic, but a brain MRI revealed multiple small nodules. What are the options now? <H3>Response</H3> from , 05/14/2004 With incurable disease, and brain metastases in particular, this patient is being treated with palliative intent. Lacking new symptoms, there is no urgency to treat her presumed progressive disease. However, it is likely that progressive disease in the central nervous system will cause symptoms and diminish her quality of life in the near future. For this reason most clinicians would indeed address this situation proactively. Unfortunately, the options are limited. Additional radiation therapy is generally not possible, although focal treatment is sometimes feasible, and there is no proven role for surgery. Trastuzumab is not known to efficiently cross the blood-brain barrier, which may be the reason why progression in the brain is seen without progression systemically. At the same time, most chemotherapy agents do cross to the cerebrospinal fluid, and the observed progression could be secondary to resistance to paclitaxel. Since interruptions of chemotherapy may not compromise disease control even when the tumor is sensitive, it is probably reasonable in this case to stop paclitaxel and initiate a new drug, such as vinorelbine, in the hope that systemic control would be maintained and that the brain metastases would be better controlled. Even if the change in the MRI scan represented a nonmalignant process, this would not likely compromise her course. Burstein HJ, Harris LN, Marcom PK, et al. Trastuzumab and vinorelbine as first-line therapy for HER2-overexpressing metastatic breast cancer: multicenter phase II trial with clinical outcomes, analysis of serum tumor markers as predictive factors, and cardiac surveillance algorithm. J Clin Oncol. 2003;21:2889-2895. Jahanzeb M, Mortimer JE, Yunus F, et al. Phase II trial of weekly vinorelbine and trastuzumab as first-line therapy in patients with HER2(+) metastatic breast cancer. Oncologist. 2002;7:410-417. Seidman AD, Fornier MN, Esteva FJ, et al. Weekly trastuzumab and paclitaxel therapy for metastatic breast cancer with analysis of efficacy by HER2 immunophenotype and gene amplification. J Clin Oncol. 2001;19:2587-2595.