[Systemic treatment of brain metastases from breast cancer: cytotoxic chemotherapy and targeted therapies]

Efficacy of lapatinib combined with capecitabine in patients with HER2-positive metastatic breast cancer in a real-world study

The aim of the present study was to determine the efficacy and safety of lapatinib-based treatment for patients with human epidermal growth factor receptor-2-positive (HER2⁺) metastatic breast cancer (MBC). The aim of the present real-world study was to investigate the medical records and follow-up information of 92 patients with HER2⁺ MBC who received a lapatinib-based regimen at the recurrent/metastatic stage, 78 of whom had been pretreated with trastuzumab. The results demonstrated that the median progression-free survival (PFS) was 5.8 months and the overall survival (OS) was 21.5 months, with an objective response rate (ORR) of 21.7%, disease control rate (DCR) of 87.0% and clinical benefit rate (CBR) of 47.8%. In the patients receiving a lapatinib-based regimen as first-, second- and third/later-line treatment, the median PFS was 10.4, 5.2 and 5.1 months (P=0.048), the median OS was 32.9, 29.1 and 13.0 months (P<0.001), the ORR was 38.9, 23.3 and 13.60%, and the DCR was 100, 83.3 and 84.1%, respectively. In the trastuzumab-resistant (n=71) and trastuzumab-sensitive (n=21) patients, the median PFS was 5.2 and 9.1 months (P=0.032), and the median OS was 21.4 and 44.3 months (P=0.003), respectively. In the patients who received lapatinib plus chemotherapy (n=68), the median PFS with lapatinib plus capecitabine (n=38) was 8.1 months, as compared with the 5.1 months with lapatinib plus other chemotherapy agents (n=30; P=0.005). The median PFS of 14 patients with brain metastases was 8.4 months, with an ORR of 35.7% and a DCR of 85.7%. Multivariate analysis revealed that the line of lapatinib-based treatment and its combination with capecitabine or a different agent were independent prognostic factors for the median PFS in patients with HER2⁺ MBC. A limited number of adverse events were observed with the combination of lapatinib and capecitabine. Therefore, the findings of the present study suggested that lapatinib-based treatment is effective in patients with HER2⁺ MBC (even in trastuzumab-pretreated patients), and the combination of lapatinib with capecitabine may be recommended due to its good efficacy, convenience and tolerability.

Methods and results of local treatment of brain metastases in patients with breast cancer

This article presents methods and results of surgical treatment and radiation therapy of brain metastases in breast cancer patients (brain metastases from breast cancer BMF-BC). Based on the literature data, it was shown that patients with single BMF-BC, aged less than 65 years, with Karnofsky score (KPS) of 70 or more and with cured or controlled extracranial disease are the best candidates to surgical treatment. Irrespective of the extracranial disease control status, there are indications for surgery in patients with symptomatic mass effect (tumour diameter larger than 3 cm) and patients with obstructive hydrocephalus from their BMF-BC. Stereotactic radiosurgery (SRS) has some advantages over surgery, with similar effectiveness: it may be used in the treatment of lesions inaccessible to surgery, the number of lesion is not a limiting factor if each lesion is small (< 3) and adequate doses can be delivered, it is not contraindicated in patients with active extracranial disease, it does not interfere with ongoing systemic treatment, and it does not require general anaesthesia or hospitalisation. A disadvantage of SRS, as compared to whole brain radiotherapy (WBRT), in patients with BMF-BC is the possibility of subsequent development of new lesion in the non-irradiated field. Thus the majority of the BMF-BC patients are not good candidates to surgery or SRS; WBRT alone or combined with a systemic treatment still plays a major role in the treatment of these patients.

[Interest of biological documentation on brain metastatic disease in breast cancer: A case report]

Breast cancer, after lung cancer, is the second major cause of brain metastases. In breast cancer, the prognosis is closely linked to the molecular subtype of the primary tumor. Targeted therapies, with or without cytotoxic treatment, have significantly modified overall survival in these patients. We report, the case of a patient suffering from breast cancer with brain metastasis in whom the biological documentation of the metastatic disease permitted to tailor the systemic treatment. Analysis of the surgical specimen revealed an immunohistochemical HER2 positive staining, which was not found in the primary tumor and therefore warranted trastuzumab administration. Another interesting insight based on this case report was to underline the phenotypic heterogeneity of the metastatic disease and its potential dynamic course as illustrated by the dissociated response to trastuzumab on body TEP-TDM in this particular patient. This case report also highlights the new place of the neurosurgeon in brain metastases management, not only as a participant in local treatment but also as a physician who is in fact involved in the delineation of the global oncological strategy in these patients as well as medical oncologists and radiation oncologists.

[Radiotherapy of brain metastases according to the GPA score (Graded Prognostic Assessment)]

The management of patients with brain metastases remains a difficult and controversial subject. For years, the standard treatment has been whole-brain radiation therapy alone, but its validity is now under question because of improvements in surgery and the development of radiosurgery or novel targeted therapies and also because whole-brain radiation therapy is responsible for long term neurocognitive toxicity. Therefore it is important to assess diagnosis-specific prognostic factors and indexes when scheduling treatments. The GPA score (Graded Prognostic Assessment), established for various histologic tumor types, includes five prognostic factors: age, Karnofsky Performance Status, presence of extracranial metastases, number of brain metastases and also genetic subtype for breast cancer. We propose an adaptation of the management of brain metastases according to the GPA score.