Breast cancer bone metastases: Disulumab has superior efficacy, and early use will bring more benefits to patients!

*Only for medical professionals to read and reference Dr.
Li Li won the second prize in the Breast Cancer Special Show of "Case One" Classic Case Show.
What is the highlight of this case? Follow this article to understand
.

One hundred "cases" and one case collection activity is sponsored by the Beijing Xisk Clinical Oncology Research Foundation, the Chinese Society of Clinical Oncology (CSCO), and co-organized by the medical community.
Through the model of case collection, it builds academic communication bridges and focuses on standardized tumor diagnosis and treatment.
, Collect standardized diagnosis and treatment cases from the majority of young and middle-aged doctors, especially primary doctors, to promote the process of standardized tumor diagnosis and treatment
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From September 25th to 29th, the 24th National Conference on Clinical Oncology and the 2021 CSCO Academic Annual Meeting were held
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On the afternoon of September 25th, the Beijing Hisco Clinical Oncology Research Foundation's grassroots special session, the final evaluation site of this year's 100 "cases" pick one item-the classic case show SHOW (Lung Cancer & Breast Cancer Special) was officially unveiled
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In the breast cancer session, Professor Jiang Zefei from the General Hospital of the People’s Liberation Army, Professor Yin Yongmei from Jiangsu Provincial People’s Hospital, and Professor Zhang Qingyuan from the Tumor Hospital of Harbin Medical University served as consultants.
Professor Rui, Professor Qin Wenxing from Shanghai Changzheng Hospital, Professor Zhang Jian from Fudan University Cancer Hospital, and Professor Gong Chengcheng from Fudan University Cancer Hospital served as the mentor group to comment on selected cases and discuss hot topics
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In the end, after fierce competition, the breast cancer bone metastasis case shared by Dr.
Li Li from the First Affiliated Hospital of Henan University of Technology won the first prize of the breast cancer special
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The Oncology Channel of the medical community organizes the diagnosis and treatment of the cases and the comments of the instructors, hoping to learn from and help everyone
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Figure 1.
Dr.
Li Li’s case sharing The basic situation of the case: a female patient, 66 years old, went to see the doctor on April 7, 2021 for “6 years after right breast cancer surgery, left lower extremity pain for more than 6 months, worsening for 1 day”
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History of present illness: In January 2015, he went to Jiaozuo Tongren Hospital for “radical mastectomy + axillary lymph node dissection” at Jiaozuo Tongren Hospital due to a right breast mass
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Postoperative pathology: Invasive ductal carcinoma, some of which are acne carcinoma, axillary and breast lymph node metastasis are (3/5) and (1/3) respectively; immunohistochemistry: ER (++), PR (+), HER- 2 (weak +)
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One cycle of adjuvant chemotherapy with anthracyclines was performed after surgery (the specific plan is unknown).
The chemotherapy was terminated spontaneously due to obvious gastrointestinal reactions.
The oral Chinese medicine decoction was taken outside the hospital, and no endocrine therapy drugs were used
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In 2020-11, the patient presented to the orthopedics department of our hospital because of low back pain, radiation to the left lower extremity and intermittent claudication
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Vertebral MRI showed that there were multiple abnormal signals in the appendages of thoracic 10, lumbar 1-5 vertebrae or appendage bone, which were considered malignant and possibly large; CT-guided needle biopsy of lumbar 4 vertebral body occupying lesions was performed
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Pathological response: (Lumbar 4 vertebral body) Consider breast cancer metastasis
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He was discharged after no anti-tumor treatment
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One day ago, the patient had obvious pain in the left lower extremity and was unable to sleep at night.
His NRS score was 7 points.
For further treatment, he was admitted to the hospital with “postoperative bone metastasis of right breast cancer”
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Past history: Hypertension for more than 10 years, regular oral nifedipine sustained-release tablets 10mg qd treatment, blood pressure control can be controlled, hepatitis B was diagnosed for more than 10 years, no formal treatment
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Deny history of diabetes, hyperlipidemia, history of heart disease, cerebrovascular disease, history of mental illness, endemic disease, occupational disease, history of tuberculosis, history of trauma, blood transfusion, poisoning, history of drug and food allergy, history of vaccination is unknown
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Personal history: Nothing special
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Physical examination and hospital admission diagnosis: Physical examination: PS score: 2 points, clear mind, good spirits, no palpable swelling of superficial lymph nodes throughout the body
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The right breast is absent, the breath sounds in both lungs are clear, no dry and wet rales are heard, the heart rhythm is uniform, the heart rate is 76 beats/min, and no pathological murmurs are heard
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The abdomen was soft, no tenderness, rebound pain, liver, spleen, and ribs were not touched
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The right side of the lumbar spine was bent deformity, local tenderness (+) near the spinous process and the spinous process in the lumbar 4-sacral 1 segment (+), and the muscle strength of the right lower limb was decreased due to congenital poliomyelitis
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Admission diagnosis: ① TXN2M1 stage IV after right breast cancer surgery, thoracic spine 10/11/12 and its appendages, lumbar 1-5 vertebral bodies and its appendages, sacrum, bilateral ilium, right pubic bone, bilateral ischia and bilateral Bone metastasis in the upper femur; ② viral hepatitis B; ③ hypertension; ④ cancer pain
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In order to clarify the stage and molecular classification of the disease, improve the multi-site CT findings: lymph node metastasis in the right subclavian area
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Bone metastasis biopsy immunohistochemistry showed: ER (++), PR (+), HER-2 (++)
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FISH detection: no amplification of HER-2
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Figure 2.
Results of chest CT (left) and thoracolumbar MRI (right).
Current diagnosis: ① TXN2M1 Stage IV Lumina B after right breast cancer surgery, right subclavian lymph node metastasis, thoracic spine 10/11/12 and appendages, waist 1 -5 vertebral body and its appendages, sacral vertebrae, bilateral iliac bones, right pubic bones, bilateral ischia and bilateral upper femur bone metastases; ②hepatitis B; ③hypertension; ④cancer pain
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After diagnosis and treatment 1.
Endocrine therapy selection According to the 2021 CSCO Breast Cancer Diagnosis and Treatment Guidelines [1], for the rescue treatment of hormone-receptor-positive advanced breast cancer, those who have not undergone endocrine therapy are recommended as aromatase inhibitors (AI).
+CDK4/6 inhibitor (1A) and fulvestrant (2A), grade II recommendation is AI (1A) and fulvestrant + CDK4/6 inhibitor (2A)
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Due to poor accessibility of CDK4/6 inhibitors in primary hospitals and few clinical applications, the use of CDK4/6 inhibitors was not considered
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Table 1.
2021 CSCO breast cancer diagnosis and treatment guidelines are recommended for the rescue and treatment of hormone receptor-positive advanced breast cancer and the Phase III FALCON study [2] Fulvestrant and Anastrozole for the first-line endocrine of hormone receptor-positive advanced breast cancer after menopause A head-to-head comparison of treatments found that in the general population, fulvestrant significantly prolonged the median progression-free survival (PFS) by nearly 3 months compared with anastrozole (16.
6 months vs 13.
8 months, HR 0.
797, 95%) CI 0.
637-0.
999, P=0.
0486); In addition, subgroup analysis found that in patients without visceral metastasis at baseline, Fulvestrant prolonged PFS more significantly, up to 8.
5 months (22.
3 months vs 13.
8 months, HR 0.
59, 95%CI 0.
42-0.
84)
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 This patient had hormone receptor-positive advanced breast cancer without visceral metastasis, so Fulvestrant was given as its first-line endocrine therapy
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2.
Bone metastasis treatment selection 2021 "CSCO Breast Cancer Diagnosis and Treatment Guidelines" [1] recommends Disumab as the highest level of category 1A for clinical treatment recommendations and updates to the CSCO AI intelligent assistance system; at the same time, "Breast Cancer Bone Metastasis and Bone Expert consensus on clinical diagnosis and treatment of related diseases"[3] In the recommendation of bone modification drugs, in addition to bisphosphonates such as zoledronic acid and ibandronic acid, the RANKL inhibitor desulumab is also recommended as a level 1 recommendation (1A)
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Moreover, a large phase III study [4] has confirmed that desulumab is significantly better than bisphosphonate for breast cancer bone metastasis
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The study showed that the time from the first bone-related event (SRE) to the first bone-related event (SRE) during the study period was significantly longer in the desulimab group than in the zoledronic acid group (less than 26.
4 months, HR 0.
82, 95% CI 0.
71-0.
95, P=0.
01, Superiority); in breast cancer patients with no pain or mild pain at baseline, disulumab compared with zoledronic acid significantly delayed the time of pain progression, and the time of appearance of moderate to severe pain was delayed by 3.
9 months (9.
7 months vs.
5.
8 months, P=0.
002)
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This patient had multiple bone destruction and obvious bone pain, so he was treated with desulumab
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At the same time, patients were given palliative symptomatic treatment, including opioids
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The patient's treatment plan was: ①Fulvestrant injection 500mg q4w; ②Disulumab 120mg q4w; ③Oxycodone hydrochloride sustained-release tablets 10mg q12h, Gabapentin capsules 0.
4 Tid po, ​​Irecoxib tablets 0.
1g bid
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3.
Re-examination results 2021.
7 The patient re-examined after 2 cycles of medication
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Pain in the right lower limb was significantly relieved compared to before.
The NRS score was 1 point, and opioids were discontinued; there were no obvious adverse reactions, and patient compliance was good; tumor markers [carcinoembryonic antigen (CEA), CA125 and CA153] showed a downward trend
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Figure 3.
Summary and reflections on changes in patient tumor markers.
The breast cancer patient in this case has the characteristics of primary patients.
Due to various factors such as limited education, poor economic conditions, and poor information, the patient did not receive standardized diagnosis and treatment after surgery.
Missing the best treatment opportunity leads to recurrence and metastasis of the disease
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For the first-line endocrine therapy of recurrent and metastatic breast cancer, a treatment plan should be selected based on the patient's previous treatment plan, disease-free interval, and disease burden; at the same time, due to the long period of endocrine drug use, attention should be paid to assess the patient's long-term tolerance and adverse reactions
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In addition, SREs often occur in breast cancer patients with bone metastases, leading to many adverse outcomes, such as shortening the survival period and reducing the quality of life
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Bone-modifying drugs are important treatments for breast cancer bone metastases, and they should be used as early as possible and throughout the disease
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Special tutor comments and questions Figure 4.
Special tutor Professor Zhang Jian's comments and questions As a guest tutor, Professor Zhang Jian commented that Dr.
Li Li’s case sharing is clear and well-organized, and he recommends treatment-related guidelines and evidence-based medicine.
Supplements were made to add a lot of color to the case
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Professor Zhang Jian asked two questions: ①When should local treatment (such as radiotherapy) be used for bone metastases? ②What are the precautions for evaluating the curative effect of bone metastasis? Dr.
Li Li replied that if the patient has obvious bone pain and the bone modification drugs and symptomatic treatment drugs are not well controlled, local radiotherapy may be added to the patient; if the patient develops SREs, local treatment may also be added
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The evaluation of the efficacy of bone metastasis is still based on RECIST standards.
The main considerations include whether there is bone calcification and osteogenic changes in imaging examination, and whether there is an increase in alkaline phosphatase and lactate dehydrogenase in serological examination, and it is recommended within three months Review CT or ECT
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References: [1] 2021 edition of "Chinese Society of Clinical Oncology (CSCO) Breast Cancer Diagnosis and Treatment Guidelines".
[2] Robertson JFR, Bondarenko IM, Trishkina E, et al.
Fulvestrant 500 mg versus anastrozole 1 mg for hormone receptor-positive advanced breast cancer (FALCON): an international, randomised, double-blind, phase 3 trial[J].
Lancet.
2016;388(10063):2997-3005.
doi: 10.
1016/S0140-6736(16)32389-3.
[ 3] "Expert consensus on clinical diagnosis and treatment of breast cancer bone metastases and bone-related diseases".
[4] Stopeck AT, Lipton A, Body JJ, et al.
Denosumab compared with zoledronic acid for the treatment of bone metastases in patients with advanced breast cancer: A randomized, double-blind study[J].
J Clin Oncol.
2010;28(35):5132-9.
doi: 10.
1200/JCO.
2010.
29.
7101.
*This article is only used to provide scientific information to medical professionals, not Represent the views of this platform