Talk to Cancer Specialist / Oncologist on Oncology - Enhertu Vs Fulvestrant

Her fish was Her2 negative, she took abemacilib and fulvestrant before emhertu

Back in 2020, it was 3 positive but this time when it came back it turned out negative. On sturnum bone, and during first line treatment the cancer went down to bileduct, and markers were also not going down, thats why drs changed it to Enhertu, with her2 ca15-3 marker going down but slow, however CEA is not coming down fast… atleast enhertu showed response . But now after latest PET scan, dr said lets add fulvestrant as well coz your mother has two type of disease

Dr. Reena Kumari Sunil - Cancer Specialist / Oncologist

MBBS , FCPS ( Medical Oncology) | Karachi | Book Appointment

36 Positive Reviews

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Can u plz share both reports

which shows the following results:
A. Strongly positive for Cytokeratin 7 and Cam 5.2.
B. Focally positive for both Gata3 and Oestrogen receptors.
C. Negative for Synaptophysin.

Immunohistochemistry (two Antibodies)
Addendum Immunohistochemical report (30 October 2024):
- A recommended panel of following immunohistochemical markers was performed on block # H 5897-24 in one of our referral
laboratory for staining only with satisfactory external controls, which shows the following results:
GATA3: Strong positive in tumour cells.
CK7: Strong positive in tumour cells.
E-Cadherin: Negative in tumour cells (which proves this carcinoma is lobular in origin).
GCDFP-15: Negative in tumour cells.
ER: Strong positive in tumour cells with a proportion of 70% to 80%.
PR: Negative in tumour cells.
HER-2/neu: Equivocal (score 2+) Please see comments.
Ki-67 (proliferative index): 30% to 40% positive nuclei approximately.
Biopsies from sternal nodule:
- Morphological and immunohistochemical features are consistent with metastatic deposits from mammary carcinoma of
pleomorphic lobular subtype.
Comments:
- Equivocal (score 2+) Her-2 IHC staining needs molecular FISH testing for Her-2 gene, which will be performed on same
specimen after receiving a new request with an approved/ prepaid code L8502 (FISH ONE PROBE).
- Previous histopathology and outside ancillary studies reports were also reviewed and correlated.

Dr call it low her2 , let me share the reports in a moment

Immunohistochemistry (two Antibodies)
Addendum Immunohistochemical report (30 October 2024):
- A recommended panel of following immunohistochemical markers was performed on block # H 5897-24 in one of our referral
laboratory for staining only with satisfactory external controls, which shows the following results:
GATA3: Strong positive in tumour cells.
CK7: Strong positive in tumour cells.
E-Cadherin: Negative in tumour cells (which proves this carcinoma is lobular in origin).
GCDFP-15: Negative in tumour cells.
ER: Strong positive in tumour cells with a proportion of 70% to 80%.
PR: Negative in tumour cells.
HER-2/neu: Equivocal (score 2+) Please see comments.
Ki-67 (proliferative index): 30% to 40% positive nuclei approximately.
Biopsies from sternal nodule:
- Morphological and immunohistochemical features are consistent with metastatic deposits from mammary carcinoma of
pleomorphic lobular subtype.
Comments:
- Equivocal (score 2+) Her-2 IHC staining needs molecular FISH testing for Her-2 gene, which will be performed on same
specimen after receiving a new request with an approved/ prepaid code L8502 (FISH ONE PROBE).
- Previous histopathology and outside ancillary studies reports were also reviewed and correlated.

Dr. Saeed Ur Rehman - Cancer Specialist / Oncologist

MBBS,FCPS, MRCPUK, MRCPI, SCE, Saudi Fellowship Medical Oncology, Medicine | Karachi | Book Appointment

47 Positive Reviews

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So she is suffering from metastatic breast ca ER +VE and HER2 new negative on FISH.

Now tell me ,what kind of chemotherapy or previous lines of treatment, she had until now?

After recent reoccurance: dr startwd abemacilib 125 daily and fulvestrant injection 15 days twice and then monthly. In 3 months time the tumor didnt responded well, the sturnm bone soze reduce but the Fg activity inceased and her markers were also not coming down, then her bile duct got obstructed , which then turned out the spread of cancer to bileduct, then dr changed the treatment to Enhertu, she took the 3 cycles , her PET report is attached and her response is mixed as per Dr, so now dr saying she has two type of disease, lets add fulvestrant to the treatment along with enhertu and see for next two months… that was also when i asked him about next steps.

First line : Abemacilib+fulvestrant 3 months and now she is on Enhertu 300 mg 3 weeks cycle. The PET i have attached to the question was recent after 3 cycles of Enhertu. Dr suggesting to add fulvestrant as well , considering mix response.. my question is if this is the treatment in her case? As dr said we don’t have other options.. we will see her response in two months then decide..

Sir i am in saudi, trust me i have not left any stone unturned.. but yesterday i met one dr who simply said we arw on wrong track! That has really put me in stress!! I booked appointment in this app paid the booking and till now no one came back to me!! If you or any dr available for a call kindly let me know i can pay your fee direct but help me! I can’t let it go like this!

Sir attached the medical report to question, kindly check

Dr. Saeed Ur Rehman - Cancer Specialist / Oncologist

MBBS,FCPS, MRCPUK, MRCPI, SCE, Saudi Fellowship Medical Oncology, Medicine | Karachi | Book Appointment

47 Positive Reviews

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Summary: Breast ca ER +VE ,HER2 -VR (FISH) post mastectomy, chemotherapy and radiotherapy was on adjuvant letrozole year 3, she progression during the 3rd year of adjuvant letrozole)

She was then treated with fulvestrant + palbociclib as first-line metastatic setting, this indicates Primary endocrine resistance likely aggressive biology (though no visceral crisis currently).

So treatment is following

1.If she has symptoms and visceral crisis ( impair liver function, bone pain on cancer symptoms than she should have chemotherapy best start with capecitabine orally.

2. If no visceral crisis or symptoms than examestine+ everlomus hormonal treatment.
3. Zolandric acid 4 weekly for bones with calcium + vit D tablets
4. Do additional test on biopsy PIK3CA, ESR1( for limited genetic profile)
if you afford do Whole NGS on tissue biopsy.if sample is now new or sample does not contain enough cells than do ctDNA on blood sample and NGS too
5. for biliary issue it could be metastatic from breast, in case of suspected second primary cancer do MRCP .

Thanks
Dr Saeed

Dr. Saeed Ur Rehman - Cancer Specialist / Oncologist

MBBS,FCPS, MRCPUK, MRCPI, SCE, Saudi Fellowship Medical Oncology, Medicine | Karachi | Book Appointment

47 Positive Reviews

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It has mentioned 2nd line fulvastrant and palbociclib.
what was first line.

I belive she has adjuvant hormonal treatment like anastrazole or letrozole after mastectomy and cancer progress within 1 year of adjuvant treatment.
Am I right?

Yes sir she was on litrozole 2.5 mg for 3 years after the first treatment. And yes first treatment was chemo and surgery followed by radiation back in 2020

Dr. Saeed Ur Rehman - Cancer Specialist / Oncologist

MBBS,FCPS, MRCPUK, MRCPI, SCE, Saudi Fellowship Medical Oncology, Medicine | Karachi | Book Appointment

47 Positive Reviews

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So, while on letrozole in year 3 ,she has progressed and started on than fulvastrant and Palbociclib?

Yes sir , since her2 was negative as per fish test result but it didnt worked.. we checked the tumor marker for 3 months and the tumor progressed unfortunately to bike duct as well, and even now showing in bone.. as well.. last PET was done in january and now we did it again.. dr saying may be it was before enhertu , so we continue on enhertu and add fulvestrant to it.

Yes sir you are right