Born in 04/1941. Diagnosed with grade 1 follicular lymphoma in 03/30/2017. PET-CT on 04/27/2017 showed increased uptake in neck, mediastinum, axillae, hilar lungs, spleen, retroperitoneum, retrocrural, pelvis, inguinal, bone marrow - classified as stage IV AS. Recommendation to proceed with Rituximab + Bendamustina.

1. Junta Multidisciplinaria de
Oncología – Clínica Astorga
Casos propuestos por Mauricio Lema – 16.05.2017

2. 1916 2006
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19961986
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19761966
5060
19561946
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19361926
90100
2016
Nacida en 10/1920. Con resección transuretral de tumor vesical, R2, en
24/04/2016, en una paciente que no es candidata a quimioterapia por su
edad, deterioro de la función renal, y desempeño limitado. Se clasifica
como un cT3b cN0 cM0 - Estadío III:
Considero que no es candidata a quimioterapia ni a cistectomía. Pero
tampoco es inteligente dejarla sin control de la enfermedad. Se
recomienda evaluación por radioterapia con radioterapia.

3. 1916 2006
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19961986
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19761966
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19361926
90100
2016
• Born on 10/1920.
• 24/04/2017 TURBT – R2,
• Impaired renal dysfunction (CrCl 30 mL/min)
• PS2 (due to orthopedic reasons)
• cT3b cN0 cM0 - Stage III:
• Considerations, and recommendation
• Not a good candidate for chemotherapy
• High risk for symptomatic relapse due residual tumor in bladder.
• Consideration for radiation therapy for local control

4. 1916 2006
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19961986
3040
19761966
5060
19561946
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19361926
90100
2016
Nacida en 05/1956. Se le practicó nefrectomía parcial y resección de tumor
ileal en 01/04/2017 por un carcinoma de células renales de 1.5 cm (pT1
cN0 cM0 - Estadío IA) y un GIST ileal de riesgo bajo (2.9 cm, menos de 5
mitosis por 50 CAP, Ki 67: 1%), ambos R0:
Considero que el tratamiento está terminado. Específicamente, no se
recomienda terapia adyuvante ni para el carcinoma de células renales, ni
para el GIST. Se recomienda seguimiento con TAC en 26 semanas.
C64X(ESMO PG2016)
Escudier, B., Porta, C., Schmidinger, M., Rioux-Leclercq, N., Bex, A., Khoo, V., … ESMO Guidelines Committee.
(2016). Renal cell carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†. Annals
of Oncology, 27(suppl_5), v58–v68. https://doi.org/10.1093/annonc/mdw328

5. 1916 2006
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19961986
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19761966
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19561946
7080
19361926
90100
2016
Born on 05/1956.
4/1/2017 - Partial nephrectomy and ileal tumor resection
RCC: 1.5 cm renal cell carcinoma - pT1 cN0 cM0 - Stage IA)
GIST: 2.9 cm low-risk ileal GIST - Less than 5 mitosis per 50 CAP, Ki
67: 1%), both R0:
Recommendation
No need for adjuvant therapy in either malignancy.
C64X(ESMO PG2016)
Escudier, B., Porta, C., Schmidinger, M., Rioux-Leclercq, N., Bex, A., Khoo, V., … ESMO Guidelines Committee.
(2016). Renal cell carcinoma: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up†. Annals
of Oncology, 27(suppl_5), v58–v68. https://doi.org/10.1093/annonc/mdw328

6. 1916 2006
1020
19961986
3040
19761966
5060
19561946
7080
19361926
90100
2016
Nacida en 07/1971. Con carcinoma ductal infiltrante de mama derecha
diagnosticado en 29/04/2017. Se clasifica como un cT1b (7 mm), cN1(f)
cM0 - Estadío IB. Pendientes los resultados de inmunohistoquímica:
Se recomienda quimioterapia neoadyuvante con antraciclinas y taxanos.
Mientras se establece la inmunohistoquímica, se inicia AC con dosis
densas.
Pendiente la RM y la marcación con clip.
Theme: Neoadjuvant CT may be superior in EBC
C509(Neoadjuvant chemotherapy may improve some outcomes in EBC): Abt, N. B., Flores, J. M., Baltodano, P. A.,
Sarhane, K. A., Abreu, F. M., Cooney, C. M., … Rosson, G. D. (2014). Neoadjuvant Chemotherapy and Short-term
Morbidity in Patients Undergoing Mastectomy With and Without Breast Reconstruction. JAMA Surgery, 149(10),
1068. https://doi.org/10.1001/jamasurg.2014.1076

7. 1916 2006
1020
19961986
3040
19761966
5060
19561946
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19361926
90100
2016
Born on 07/1971.
04/29/2017 – IDC of right breast
cT1b (7 mm), cN1 (f) cM0 - Stage IB.
IHC pending
Recommendation
NACT with ddAC – Taxanes.
IHC results will guide therapy (dd, trastuzumab, carboplatin).
RM and titanium clip placement prior to CT
Theme: Neoadjuvant CT may be superior in EBC
C509(Neoadjuvant chemotherapy may improve some outcomes in EBC): Abt, N. B., Flores, J. M., Baltodano, P. A.,
Sarhane, K. A., Abreu, F. M., Cooney, C. M., … Rosson, G. D. (2014). Neoadjuvant Chemotherapy and Short-term
Morbidity in Patients Undergoing Mastectomy With and Without Breast Reconstruction. JAMA Surgery, 149(10), 1068.
https://doi.org/10.1001/jamasurg.2014.1076

8. 1916 2006
1020
19961986
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19761966
5060
19561946
7080
19361926
90100
2016
Theme: Taxane-only adjuvant chemotherapy may be insufficient in high-
risk EBC
C509 (ABC Sequential AC-T superior to TC in Early Breast Cancer)
Blum, J. L., Flynn, P. J., Yothers, G., Asmar, L., Geyer, C. E., Jacobs, S. A., … Wolmark, N. (2017). Anthracyclines in
Early Breast Cancer: The ABC Trials-USOR 06-090, NSABP B-46-I/USOR 07132, and NSABP B-49 (NRG Oncology).
Journal of Clinical Oncology : Official Journal of the American Society of Clinical Oncology, JCO2016714147.
https://doi.org/10.1200/JCO.2016.71.4147
Theme: Dose-dense in triple negative EBC
C509(MA - Dose-dense CT benefits only ER negative high-risk early-breast cancer): Bonilla, L., Ben-Aharon, I.,
Vidal, L., Gafter-Gvili, A., Leibovici, L., & Stemmer, S. M. (2010). Dose-Dense Chemotherapy in Nonmetastatic
Breast Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials. JNCI Journal of the
National Cancer Institute, 102(24), 1845–1854. https://doi.org/10.1093/jnci/djq409

9. 1916 2006
1020
19961986
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19761966
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19561946
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19361926
90100
2016
Theme: Dose-dense (q1w or q2w) superior to conventional (q3w) adjuvant
taxane in EBC.
C509(S0221 Adjuvant bi-weekly Paclitaxel only superior to weekly in triple-
negative early breast cancer)
Bonilla, L., Ben-Aharon, I., Vidal, L., Gafter-Gvili, A., Leibovici, L., & Stemmer, S. M. (2010). Dose-Dense Chemotherapy in
Nonmetastatic Breast Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials. JNCI Journal of the
National Cancer Institute, 102(24), 1845–1854. https://doi.org/10.1093/jnci/djq409
C509(ECOG1199 - adjuvant weekly paclitaxel improves DFS compared to q3w
Docetaxel)
Sparano, J. A., Wang, M., Martino, S., Jones, V., Perez, E. A., Saphner, T., … Davidson, N. E. (2008). Weekly Paclitaxel in the
Adjuvant Treatment of Breast Cancer. New England Journal of Medicine, 358(16), 1663–1671.
https://doi.org/10.1056/NEJMoa0707056
C509(ECOG1199 - Update: adjuvant weekly paclitaxel improves LT-OS only
in TNBC, compared to q3w docetaxel in EBC)
Sparano, J. A., Zhao, F., Martino, S., Ligibel, J. A., Perez, E. A., Saphner, T., … Davidson, N. E. (2015). Long-Term Follow-Up of the
E1199 Phase III Trial Evaluating the Role of Taxane and Schedule in Operable Breast Cancer. Journal of Clinical Oncology,
33(21), 2353–2360. https://doi.org/10.1200/JCO.2015.60.9271

10. 1916 2006
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19961986
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19761966
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19561946
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19361926
90100
2016
Theme: Carboplatin may improve outcomes in early-TNBC
C509(Platinum-based neoadjuvant chemotherapy increase pCR in early-
TNBC) Bonilla, L., Ben-Aharon, I., Vidal, L., Gafter-Gvili, A., Leibovici, L., & Stemmer, S. M. (2010). Dose-Dense
Chemotherapy in Nonmetastatic Breast Cancer: A Systematic Review and Meta-analysis of Randomized Controlled
Trials. JNCI Journal of the National Cancer Institute, 102(24), 1845–1854. https://doi.org/10.1093/jnci/djq409
C509(CALGB40603, Phase II trial, neoadjuvant carboplatin improves
pCR in TNBC)
Sikov WM, Berry DA, Perou C, et al: Event-free and overall survival following neoadjuvant weekly paclitaxel and dose-
dense AC +/− carboplatin and/or bevacizumab in triple-negative breast cancer: Outcomes from CALGB 40603
(Alliance). Presented at the San Antonio Breast Cancer Symposium, San Antonio, TX, December 8-12, 2015
C509(GeparSixto, GBG 66: Phase II trial, neoadjuvant carboplatin
improves pCR in TNBC):
von Minckwitz, G., Schneeweiss, A., Loibl, S., Salat, C., Denkert, C., Rezai, M., … Untch, M. (2014). Neoadjuvant
carboplatin in patients with triple-negative and HER2-positive early breast cancer (GeparSixto; GBG 66): a randomised
phase 2 trial. The Lancet Oncology, 15(7), 747–756. https://doi.org/10.1016/S1470-2045(14)70160-3

11. 1916 2006
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19961986
3040
19761966
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19561946
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19361926
90100
2016
Theme: Updated ASCO PG for adjuvant chemotherapy in EBC (04/2017).
C509(ASCO Practice Guideline for EBC)
Denduluri, N., Somerfield, M. R., Eisen, A., Holloway, J. N., Hurria, A., King, T. A., … Wolff, A. C. (2016). Selection of
Optimal Adjuvant Chemotherapy Regimens for Human Epidermal Growth Factor Receptor 2 (HER2) -Negative and
Adjuvant Targeted Therapy for HER2-Positive Breast Cancers: An American Society of Clinical Oncology Guideline
Adaptation of the Cancer Care Ontario Clinical Practice Guideline. Journal of Clinical Oncology : Official Journal of the
American Society of Clinical Oncology, 34(20), 2416–27. https://doi.org/10.1200/JCO.2016.67.0182

12. 1916 2006
1020
19961986
3040
19761966
5060
19561946
7080
19361926
90100
2016
Nacida en 12/1970. Con carcinoma ductal infiltrante de mama izquierda,
triple negativo, cT4d cN1 cM0 - estadío IIIB, diagnosticado en 18/04/2017:
Se recomienda proceder con quimioterapia neoadyuvante con dosis densas
AC (con pegfilgastrim), seguido por carboplatino + paclitaxel, seguido por
cirugía, seguida por radioterapia.

13. 1916 2006
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19961986
3040
19761966
5060
19561946
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19361926
90100
2016
Born on 12/1970.
04/18/2017 - Locally-advanced TNBC
cT4d cN1 cM0 - stage IIIB, diagnosed on 04/18/2017
Recommendation
ddAC – (Carboplatin) + weekly paclitaxel, followed by surgery and RT
Consider adjuvant capecitabine

14. 1916 2006
1020
19961986
3040
19761966
5060
19561946
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19361926
90100
2016
Nacido en 04/1941. Con antecedente de carcinoma papilar de tiroides
resuelto (manejado por otro equipo). Con linfoma folicular grado I. Fecha
de diagnóstico en 30/03/2017. PET-CT en 27/04/2017 con incremento en la
captación en cuello, mediastino, axilas, hilio pulmonar, bazo,
retroperitoneo, retrocrural, pélvico, inguinal, médula ósea: Se clasifica
como un estadío IV AS:
Se recomienda proceder con Rituximab + Bendamustina
C859(STiL Rituximab + Bendamustine vs R-CHOP in Low Grade Lymphoma)
Rummel, M. J., Niederle, N., Maschmeyer, G., Banat, G. A., von Grünhagen, U., Losem, C., … Study group indolent
Lymphomas (StiL). (2013). Bendamustine plus rituximab versus CHOP plus rituximab as first-line treatment for patients
with indolent and mantle-cell lymphomas: an open-label, multicentre, randomised, phase 3 non-inferiority trial. The
Lancet, 381(9873), 1203-1210. https://doi.org/10.1016/S0140-6736(12)61763-2

15. 1916 2006
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19961986
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19761966
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19361926
90100
2016
Male, born on 04/1941.
PMH: Inactive papillary thyroid carcinoma
30/3/2017 - Grade I follicular lymphoma
27/4/2017 - PET-CT on 04/27/2017 with increased uptake in the neck,
mediastinum, armpits, pulmonary hilum, spleen, retroperitoneum, retrocrural,
pelvic, inguinal, bone marrow:
Stage IV stage AS
Recommendation
R-Bendamustine, followed by maintenance R
C859(STiL Rituximab + Bendamustine vs R-CHOP in Low Grade Lymphoma)
Rummel, M. J., Niederle, N., Maschmeyer, G., Banat, G. A., von Grünhagen, U., Losem, C., … Study group indolent Lymphomas
(StiL). (2013). Bendamustine plus rituximab versus CHOP plus rituximab as first-line treatment for patients with indolent and
mantle-cell lymphomas: an open-label, multicentre, randomised, phase 3 non-inferiority trial. The Lancet, 381(9873), 1203-
1210. https://doi.org/10.1016/S0140-6736(12)61763-2

16. 1916 2006
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19961986
3040
19761966
5060
19561946
7080
19361926
90100
2016
Nacida en 12/1950. Cuadrantectomía con ganglio centinela por carcinoma ductal in-situ, de
alto grado, 5 mm, receptores hormonales NEGATIVOS para estrógeno y progesterona, con
resección R1 en 16/12/2016. Se clasificó como un pTis cN0(sn), Estadío 0. Se le practicó
radioterapia que terminó en 31/03/2017:
No se recomienda tamoxifen adyuvante
C509(NSABP-B24: Adjuvant tamoxifen only benefits HR+ DCIS patients - Post-hoc subgrop
analysis).
Allred, D. C., Anderson, S. J., Paik, S., Wickerham, D. L., Nagtegaal, I. D., Swain, S. M., … Wolmark, N. (2012).
Adjuvant Tamoxifen Reduces Subsequent Breast Cancer in Women With Estrogen Receptor–Positive Ductal
Carcinoma in Situ: A Study Based on NSABP Protocol B-24. Journal of Clinical Oncology, 30(12), 1268–1273.
http://doi.org/10.1200/JCO.2010.34.0141
C509(NSABP B24 - Adjuvant tamoxifen improves BC events in DCIS)
Fisher, B., Dignam, J., Wolmark, N., Wickerham, D. L., Fisher, E. R., Mamounas, E., … Oishi, R. H. (1999). Tamoxifen in
treatment of intraductal breast cancer: National Surgical Adjuvant Breast and Bowel Project B-24 randomised
controlled trial. Lancet (London, England), 353(9169), 1993–2000. http://doi.org/10.1016/S0140-6736(99)05036-9

17. 1916 2006
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19961986
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90100
2016
Female, born on 12/1950.
12/16/2016 – BCS + SNB for DCIS
Path: 5 mm, R1, ER/PR negative
pTis cN0 (sn), Stage 0.
3/31/2017 – finished RT
Recommendation
Adjuvant tamoxifen NOT indicated.
C509(NSABP-B24: Adjuvant tamoxifen only benefits HR+ DCIS patients - Post-hoc subgrop analysis).
Allred, D. C., Anderson, S. J., Paik, S., Wickerham, D. L., Nagtegaal, I. D., Swain, S. M., … Wolmark, N. (2012). Adjuvant
Tamoxifen Reduces Subsequent Breast Cancer in Women With Estrogen Receptor–Positive Ductal Carcinoma in Situ: A
Study Based on NSABP Protocol B-24. Journal of Clinical Oncology, 30(12), 1268–1273.
http://doi.org/10.1200/JCO.2010.34.0141
C509(NSABP B24 - Adjuvant tamoxifen improves BC events in DCIS)
Fisher, B., Dignam, J., Wolmark, N., Wickerham, D. L., Fisher, E. R., Mamounas, E., … Oishi, R. H. (1999). Tamoxifen in treatment of
intraductal breast cancer: National Surgical Adjuvant Breast and Bowel Project B-24 randomised controlled trial. Lancet (London,
England), 353(9169), 1993–2000. http://doi.org/10.1016/S0140-6736(99)05036-9

18. 1916 2006
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19961986
3040
19761966
5060
19561946
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19361926
90100
2016
Nacida en 09/1962. Carcinoma de mama izquierdo - ductal infiltrante grado 1,
con receptores hormonales positivos para estrógeno y progesterona tratada con
cuadrantectomía y vaciamiento axilar en 18/08/2006 T2 (3 cm) N0 (0 de 11
ganglios resecads) M0 - estadío IIa. Tratada con quimioterapia adyuvante con
fac x6 entre 02/10/2006 y 22/01/2007. Recibió radioterapia externa
posteriormente. No toleró tamoxifén. Con pleurectomía por recidiva tumoral con
receptor hormonal positivo y Her2 negativo, en 03/02/2017. Metástasis óseas,
tejidos blandos y pleurales (no crisis visceral). Inició quimioterapia con
Fulvestrant + Ibandronato. Inicia en fecha: 04/04/2017, con espectacular
respuesta clínica.
Se propone continuar con Fulvestrant + Ibandronato
C509(FALCON: 1st-line Fulvestrant superior to Anastrozole in hormone-naive
HR+, postmenopausal mBC patients).
Bonilla, L., Ben-Aharon, I., Vidal, L., Gafter-Gvili, A., Leibovici, L., & Stemmer, S. M. (2010). Dose-Dense
Chemotherapy in Nonmetastatic Breast Cancer: A Systematic Review and Meta-analysis of Randomized
Controlled Trials. JNCI Journal of the National Cancer Institute, 102(24), 1845–1854.
https://doi.org/10.1093/jnci/djq409

19. 1916 2006
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19961986
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19761966
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19561946
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19361926
90100
2016
Female, born in 09/1962.
8/13/2006 – BCS + ALND for a Grade 1 IDC of the L-Breast
Path: ER/PR+, T2 (3 cm) N0 (0 of 11 nodes resected) M0 - stage IIa
2/10/2006 - 01/22/2007: FAC x6, followed by RT, tamoxifen (inconsistent intake)
2/03/2017 – Pleurectomy: Pleural relapse
- ER/PR+, Her2-
- Bone metastases, soft-tissue metastases
Recommendation
Fulvestrant + bisphosphonate
C509(FALCON: 1st-line Fulvestrant superior to Anastrozole in hormone-naive HR+, postmenopausal mBC
patients).
Bonilla, L., Ben-Aharon, I., Vidal, L., Gafter-Gvili, A., Leibovici, L., & Stemmer, S. M. (2010). Dose-Dense Chemotherapy in Nonmetastatic Breast
Cancer: A Systematic Review and Meta-analysis of Randomized Controlled Trials. JNCI Journal of the National Cancer Institute, 102(24), 1845–
1854. https://doi.org/10.1093/jnci/djq409