A 49-year-old Chinese female was admitted in January, 2015 for painless mass in left breast. The subsequent biopsy demonstrated invasive breast carcinoma with immunohistochemical results of ER(-), PR(-), HER-2(3+), Ki67(+ 20%) and P53(+ 90%)(Figure1). Systemic evaluation showed bilateral lung metastases (0.1-0.9cm) and hepatic metastases (0.7-1.0cm) in addition with primary left breast cancer (33.9 x 18.3mm) and left axillary lymph node involvement (56.8 x 33.0mm). The patient refused molecular targeted therapy for economic reasons and underwent chemotherapy (six cycles of TAC: Pirarubicin, Cyclophosphamide, Paclitaxel and one cycle of T: Paclitaxel). The response was evaluated as partial remission (PR).
In September, 2015, her hepatic metastases progressed rapidly (1.0-1.9cm). Then she was enrolled in the clinical trial and randomly assigned to the control group (Lapatinib plus Capecitabine). In March, 2017, she complained of dizziness. The brain MRI with contrast revealed a lesion measuring about 3.1 x 2.7cm located in the left frontal lobe with circular enhancement and edema around, consistent with metastasis (Figure 2A,B). Local radiotherapy with a dose of 48Gy/16f was performed to the single BM and her discomfort disappeared. However, 3 months later, her disease progressed (lung metastases: 0.2-2.7cm, liver metastases: 1.2-4.3cm) and the BM shrank to 1.5 x 1.5cm. In August, the patient experienced recurrence in the left chest wall and further progression of liver metastases. Systemic therapy was switched to NP (Vinorelbine and Cisplatin) plus Herceptin. The lesions demontrated PR response to 4 cycles of NP plus Herceptin. Due to gastrointestinal side effects and grade 3 myelosuppression, the fifth and sixth chemotherapy regimen was adjusted to NC (Vinorelbine and Carboplatin) and N (Vinorelbine), respectively.
In February, 2018, she complained of aphasia and intermittent convulsion. The brain MRI with contrast manifested a lesion in the left frontal lobe with obvious ring enhancement. Flair-weighted MRI showed large area of PTBE, resulting in compression and deformation of bilateral ventricle and midline structure shift to the right (Figure 2E,F). Comparing with the brain MRI in November, 2017 (Figure 2C,D), the BM demonstrated slight increase (2.5 x 2.0cm to 3.8 x 2.2cm) while PTBE increased significantly. Conventional intervention with dehydration (mannitol: 250ml, q8h, from 02/01/2018 to 02/07/2018; 250mg, q6h, from 02/08/2018 to 02/10/2018; glycerol fructose: 250ml, q12h, from 02/01/2018 to 02/10/2018) and glucocorticoid (dexamethasone: 20mg daily, from 02/08/2018 to 02/10/2018) was given. However, there was no improvement. The patient developed progressive aphasia and right-side limb activity disorder. Apatinib, with a dose of 250mg daily, was initiated. Surprisingly, after 3 days of use, the aphasia disappeared and she could communicate with others normally. After 10 days of use, her right-side limb activity recovered completely. The subsequent brain MRI (March, 16, 2018) revealed remarkable shrinkage of PTBE and no obvious change in the BM lesion (Figure 2G,H). Now, she takes apatinib 250mg daily and no common apatinib related side effects were observed.