1. Case Discussion

2. Case #1 64 year-old postmenopausal, no PMHx Routine MMG: 2cm nodule in RUQ, with microcalcifications Biopsy: IDC grade 2 with areas of DCIS, ER 70%, PR 30%, Her2- Breast conserving surgery: IDC 1.6cm Histologic Grade 2 SLN (1): + (1mm) ER 60%, PR 20%, Her2-, Ki67 16% DCIS, high grade, in several areas, involving margin

3. Case #1 Question #1: Regarding locorregional therapy, what would you recommend now? 1) Operate breast for negative margins and lymph node dissection? 2) RT to breast and axilla 3) Operate breast for negative margins followed by RT 4) Hipofractionated RT

4. If there were 3/3 + LN, would you: 1) Recommend LND 2) Recommend RT to breast/axilla (tangential) 3) Recommend RT to breast and axilla 4) Recommend mastectomy and LND Case #1 Question #2:

5. Case #1 Question #3: Regarding adjuvant systemic therapy, what would you do? 1) Recommend chemotherapy with 4 cycles of TC, then HT 2) Spare patient from chemo and give letrozol 3) Give anthracycline and taxane followed by HT 4) Decide chemo after MammaPrint 5) Decide chemo after OncotypeDx

6. Case #1 Question #4: Oncotype came back with a score of 24 (intermediate risk). You would: 1)4 cycles of TC followed by HT 2)ACT followed by HT 2) Spare patient from chemo and give HT alone 3) Order MammaPrint 4) Ask the patient to decide what she wants do do

7. Case #2 33 year-old premenopausal, aunt with breast cancer at age 50, breast implant Felt a lump in the axilla MMG/US: 2.8cm nodule LLQ, with abnormal LN 2.5cm MRI: 3cm nodule, 3 lymph nodes in axilla, largest 2.5cm Biopsy: IDC grade 3, with lymphovascular invasion ER negative, PR negative, HER2 negative, Ki67 40% Neoadjuvant treatment: ACx3 >> patients feels “ tumor is growing” US: stable disease (both tumor and axilla)

8. Case #2 Question #1: What would you do now? 1) Finish AC#4 then give Paclitaxel x12 2) Switch to Paclitaxel and add Carboplatin 3) Switch to Navelbine and Capecitabine 4) Operate now and finish chemo with Taxane and Carboplatin later

9. Case #2 Question #2: Patient received Paclitaxel x12 with Carbo AUC6 x3. BRCA 1/2 and PALB2: NO mutation S/P Breast conserving surgery with LN dissection: IDC 1.5cm, micro- metastasis (1mm focus) in 1/9 LNs What would you do now? 1) Give 6 months of Capecitabine followed by RT 2) Give RT 3) Give RT followed by 6 months of Capecitabine 4) Give Capecitabine x 6 months concomitantly with RT in 1st month

10. Case #2 Question #3: Imagine after the first cycle of neoadjuvant AC you learn she has BRCA1 mutation. She is 33, has 2 children. What would you do? 1) Bilateral adenomastectomy with LND followed by adjuvant RT to breast and SC fossa 2) Bilateral adenomastectomy with LND followed by adjuvant RT to breast and SC fossa and internal mammary nodal region 3) BCS, if feasible, followed by adjuvant RT. Prophylactic surgery later 4) Bilateral adenomastectomy and LND. No adjuvant RT

11. Case #3 53 year-old postmenopausal, no PMHx Felt lump in L breast after skipping MMG for 3 years MMG and US: 3 cm nodule in LUQ, suspicious LN in axilla Biopsy: IDC grade 3, ER 20%, PR negative, HER2 +++ FNA axillary LN: + malignant cells cT2 N1 M0

12. Case #3 Question #1: What would you do now? 1)Operate up front since she is already eligible for BCS 2)Give neoadjuvant Pertuzumab + Trastuzumab + Docetaxel 3)Give neoadjuvant Trastuzumab + Pertuzumab + Docetaxel + Carboplatin 4)Give neoadjuvant AC > TH + Pertuzumab 5)Give neoadjuvant AC > TH

13. She received neoadjuvant TCH (Pertuzumab was not approved at that time) >> clinical CR Breast conserving surgery + resection of 5 LNs: IDC, 0.6cm (HER2+++, ER 10%), LN-neg (0/5) Received RT Finished 1 year of Trastuzumab, continued with Letrozol 8 months after finishing Trastuzumab: 4 lung nodules (up to 1.6 cm) Biopsy: carcinoma, HER2+++, ER/PR negative Metastatic HER2+ BC 8 mo after adjuvant Trastuzumab Case #3 Follow up:

14. How would you treat this patient now? 1)Pertuzumab + Trastuzumab + Docetaxel 2)T-DM1 3)Trastuzumab and Paclitaxel 4)Lapatinib and Capecitabine Case #3 Question #2:

15. If she had received neoadjuvant Carboplatin + Docetaxel + Trastuzumab + Pertuzumab, what would you give her now? 1) Pertuzumab + Trastuzumab + Docetaxel 2) T-DM1 3) Trastuzumab and Paclitaxel 4) Lapatinib and Trastuzumab 5) Trastuzumab + Capecitabine Case #3 Question #3:

16. Thank you