Management of Patients with Her2+ve Brain metastases Her2+ve - PowerPoint PPT Presentation

Management of Patients with Her2+ve Brain metastases • Her2+ve patients 15% of all breast cancer • Even with adjuvant trastuzumab 10-15% relapse • Trastuzumab does not cross BBB • Management dependent on number of metastases • Patients should be closely followed up

Management of Patients with Her2+ve Brain metastases • Patients can have a better prognosis • Important to control systemic and brain disease • Management of patients must be multidisciplinary • Case studies

Breast GPA graded prognostic assessment Basal ER - Her 2 - Luminal A ER + Her 2- Her2 ER - Her2 + Luminal B ER + Her2 + Sperduto Red J ournal 2012 82(5)

NHSCB/D5/1 guidance on SRS/SRBT – MDT; local, neuro, stereotactic – PS KPS>70 – Diagnosis of cancer established and absent or controllable primary disease – No pressure symptoms (or surgery) – Pre treatment scans vol <20cc (<3cm)** – Life expectancy from extracranial disease >6months • Treat new lesions - >3months and above • Retreat lesions - >6 months and above

Case presentation 1 LR 31.1.63 42 at diagnosis. CA Lt Brst. Lt WLE +ANC J une 2005 T1(18) N0 G3 ER+ HER2+ Nov10: Liver lung Ophthalmic and Bone mets. Feb’12 : Brain mets-widespread. Given WBRT Apr’12: 4cm mediastinal mass. Pamidronate xeloda lapatinib.

Case presentation 1 Aug’12: Scanning PR mediastinum and brain. Oct’12: Chemo break due to side effects Feb’13: Progressive liver mets. Stable brain mets. TDM -1 trial Oct ’ 13: CR liver and excellent PR brain.

13/ 2/ 12 14/ 4/ 12 14/ 8/ 12 1/ 10/ 12 18/ 2/ 13 diagnosis post WBRT 4/ 12 X+L Chemo break Start TDM -1

Feb 2013 Oct 2013

Case presentation 2 KS 17.6.77 33 at diagnosis CA Rt Brst. M asty +ANC Nov 2010 T2 N3 G3 ER+ HER2+ Apr’12: Headaches – oligomets. No visceral mets. Excision Rt cerebellar met. WBRT 30Gy/ 10fractions-PR Options gamma knife or alternative HER2 therapy. Xeloda lapatinib given to shrink mets. Sept’12 PR. Nov’12: increased Lt frontal & parietal lesions. Gamma knife

4/ 4/ 12 23/ 5/ 12 28/ 8/ 12 21/ 11/ 12 4/ 2/ 13 diagnosis Post WBRT 3/ 12 X+L Post ɣ knife 6/ 12 X+L

Case presentation 2 • April ’ 13 progression left frontal lobe metastasis & new right cerebellar lesion • Excision left frontal metastasis May 2013 • Gamma knife cerebellar lesion June 2013 • MRI Sept 2013 no progression. No visceral mets.

4/ 2/ 13 23/ 4/ 13 12/ 9/ 13 post Post ɣ knife excision & ɣ knife progression

Brain metastases cases Discuss options in specialist MDT Follow pts and treat appropriately just as we do with their systemic disease Patients may well live for many months or years with appropriate therapy