A 53-year-old female presents with metastatic, triple-negative, BRCA1 positive breast cancer. She was initially diagnosed a year ago with bilateral triple-negative breast cancer without distant metastasis. Soon after diagnosis, she underwent bilateral mastectomy and bilateral sentinel node biopsies. Pathology revealed a right-breast 1.3-cm mass, which was ER negative, PR negative, and HER2 negative with negative lymph nodes. The left breast revealed 1.2-cm mass and triple-negative N1 with micro-invasion without lymphovascular invasion. No metastasis found at the time. Subsequent genetic testing was positive for BRCA1 mutation. The patient then underwent adjuvant chemotherapy with Taxotere and cyclophosphamide. For a year, she had regular visits with no issues but recently started to experience mild right upper-quadrant pain. Imaging revealed large liver metastases, the largest of which measured 5 cm. How would you proceed with treatment?
HEALTHCASTS COMMUNITY RESPONSE
This patient case was posted to the Healthcasts peer-to-peer community. 268 unique opinions were contributed in February 2020. The case was reviewed and assessed in March 2020. The following is a summary of physician responses.
Further testing, imaging recommended to determine treatment path
Markers can change 10%-15% of the time
Approximately (75/28%) recommended that the liver lesion be biopsied to confirm the pathology of the tumor and its markers to determine if it is indeed metastases of the breast cancer or another primary tumor. “Markers can change 10%-15% of the time,” wrote one respondent. “The tumor in the liver should be biopsied and tested for HER2 ER/PR’s,” explained another, “in the off-chance there is discordance with the original presentation.” Yet another wrote, “Need liver biopsy, if feasible, to rule out different primary and to repeat receptors which can change between primary and metastatic recurrence.”
Also, a few respondents (13/5%) said they would order imaging for the patient—PET scan, MRI of brain, chest CT, bone scan were mentioned—to rule out metastases elsewhere in her body.
PD-L1 expression status is needed
Several respondents (50/19%) said they would have the patient’s tissue analyzed for PD-L1 (positive or negative) to further target the patient’s treatment. Research has shown that PD-L1 is expressed in several solid malignancies including cancers of the liver, bladder, colon, lung, and head and neck.1 Primary breast cancers also express PD-L1, with expression generally higher in triple-negative breast cancer, which was our patient’s initial diagnosis.1
In the case of positive PD-L1, the first-line therapy most often cited by respondents was of the combination of atezolizumab (Tecentriq) and paclitaxel protein-bound (Abraxane) (21%/56). The PARP-1 inhibitors olaparib (Lynparza) and talazoparib (Talzenna) were also cited repeatedly (19%/51 and 9%/23, respectively), as both first- and second-line treatment.
Other suggestions: carboplatin (Paraplatin) + PARP-1 inhibitor, carboplatin + gemcitabine (Gemzar), adriamycin (Doxorubicin)
Chemoembolization, radiation, or radiofrequency ablation were offered as possible treatments by a handful of respondents (8/3%). The same number wrote that they may propose a liver resection to the patient (8/3%).
Another option: Enrollment in a clinical trial
Respondents (11/4%) also offered another option: suggest that the patient consider enrolling in a clinical trial. “Her prognosis is not good,” one added.
 1. Khosravi-Shahi P, et al. Asia Pac J Clin Oncol. 2018.14(1):32-39.