• 33-year-old female
• 20/40 weeks of pregnancy with 7 cm right breast mass
• Core biopsy: grade 3 ER4 PR0 HER2 3+ ductal breast cancer
• Stage T3, N1, MX
• Staging liver ultrasound showed indeterminate lesion in liver

• Struggled with chemotherapy-induced nausea and vomiting ++
• Sadly, had no disease response but delivered healthy baby girl at 37 weeks
• Staging post-delivery confirmed multiple liver lesions up to 4.5 cm and low volume bone disease

Treatment: paclitaxel, trastuzumab and pertuzumab (switched to nab-paclitaxel due to hypersensitivity) with denosumab

• Partial response in liver with sclerotic response seen in bone disease

Treatment: high-dose palliative radiotherapy to right breast and axilla (as patient not keen on mastectomy)

Treatment: maintenance IV trastuzumab/pertuzumab and denosumab. Tamoxifen added once taxane discontinued 

• Venous access an increasing issue (SC trastuzumab/pertuzumab not available locally until later in 2021) 

CT showed minor progression in liver disease 

Treatment: T-DM1

Complained of further headaches: 

• Imaging at this time showed a solitary 26 mm irregular multi-lobulated intraparenchymal mass of the inferior left cerebellum 

• Of note, had previously complained of headaches in 2020 and MRI brain imaging had been normal 

Posterior fossa craniectomy for resection of cerebellar metastasis 

• Pathology showed metastatic adenocarcinoma in keeping with known breast primary 

Post-operative stereotactic radiation therapy to posterior fossa 

• T-DM1 paused intermittently, but had partial response in liver 

• CT scans began showing increasing signs of chronic liver disease, thought related to T-DM1 (new small oesophageal varices, some collateral vessels appearing and changes in liver contour) 

• Bilirubin and ALP also rising 

Surveillance MRI brain showed new small enhancing focus in resection cavity thought to be progression (rather than radionecrosis) measuring 7x11x3 mm 

• Interestingly, MRI also showed T1 hyperintensity in basal ganglia in keeping with chronic liver disease 

Decision made to switch to tucatinib, capecitabine and trastuzumab due to progressive hepatotoxicity and CNS progression  

• Available in Scotland since 2022 as 3L + therapy 

• Remains on tucatinib, trastuzumab and capecitabine, now on cycle 20 

• MRI brain showed initial improvement then stable disease (last August 2024) and CT body scan shows ongoing stable disease; largest lesion in liver now only 14mm 

• Liver function remains stable, on lower dose of tucatinib due to LFTs 

Patient perspective: She continues to lead a very full, active life (PS0) as a mother of two, working part-time. Her daughter recently turned 5 and starts school this Autumn. 

Some of her greatest fears are further alopecia, cannulation and treatment-related emesis