1. A 48-year-old lady presented with a left breast lump. Mammography revealed Left breast- 3.5 x 2 cms mass with microcalcifications BIRADS-V and right breast- normal BIRADS-I. PET CT scan whole body was done which showed FDG avid left breast lesion measuring about 3.5 x 2.2 x 1.8 cms with no evidence of FDG avid locoregional or distant metastatic disease. Left breast biopsy showed Invasive Ductal Carcinoma and immunohistochemistry showed ER- negative, PR- negative, Her2neu- positive (3+), Ki67- 60%. What should be preferred further line of management?

• Surgery followed by 6 cycles of Adjuvant TCH (Docetaxel + Catboplatin + Trastuzumab) chemotherapy & total 1 year of Trastuzumab
• Surgery followed by 6 cycles of Adjuvant TCHP (Docetaxel + Catboplatin + Trastuzumab + Pertuzumab) chemotherapy and total 1 year of Trastuzumab + PertuzumabSurgery followed by 6 cycles of Adjuvant TCHP (Docetaxel + Catboplatin + Trastuzumab + Pertuzumab) chemotherapy and total 1 year of Trastuzumab + Pertuzumab
• 6 cycles of Neoadjuvant TCH (Docetaxel + Catboplatin + Trastuzumab) chemotherapy followed by surgery followed by further plan
• 6 cycles of Neoadjuvant TCHP (Docetaxel + Catboplatin + Trastuzumab+ Pertuzumab) chemotherapy followed by surgery followed by further plan

2. A 57-year-old lady was diagnosed as invasive carcinoma breast right, cT3 cN1 cM0, ER- negative, PR- negative, Her2neu- equivocal (2+), Ki67 40%, Her2neu positive by FISH and treated with 6 cycles of TCHP (Docetaxel + Catboplatin + Trastuzumab+ Pertuzumab) chemotherapy followed by right modified radical mastectomy (MRM) and final surgical histopathological examination report showed invasive ductal carcinoma, pT1 pN0 disease, tumour size- 1.8 x 1.3 x 1 cms, margins negative, no LVI, no PNI, Node=0/18. What should be the further line of management?

• Complete 1 year of Trastuzumab + Pertuzumab
• Complete 1 year of Trastuzumab
• 14 cycles of T-DM1
• 14 cycles of T-Dxd

3. A 62-year-old lady presented with a right breast lump and cough. Biopsy of the right breast lump showed invasive ductal carcinoma and immunohistochemistry showed ER- positive (10%), PR- negative, and Her2neu- positive (3+). PET CT scan whole body was done which showed FDG avid right breast lesion, right axillary nodes and bilateral lung nodules likely metastatic. She was started on palliative chemotherapy with Docetaxel + Trastuzumab + Pertuzumab (THP). After 3 cycles, PET CT was done which showed partial response, therefore, the same chemotherapy was continued and she completed 6 cycles of THP chemotherapy.

After 6 cycles of THP chemotherapy, a PET CT scan whole body was done which showed disease progression (increased size and number of lung nodules, new liver lesions and two new brain lesions). She received stereotactic radiotherapy for brain lesions. What should be preferred further line of management?

• T-DM1
• T-Dxd
• Lapatinib + Capecitabine
• Trastuzumab + Pertuzumab + Vinorelbine

4. A patient with a breast lump measuring 3 x 4 cms in size underwent a biopsy which showed invasive ductal carcinoma and immunohistochemistry showed ER-positive (80%), PR- positive (10%), Her2neu- equivocal (2+). What should be the investigation of choice to know about Her2neu status?

• Dual Probe FISH
• RT-PCR
• Flow Cytometry
• Sanger Sequencing

5. A 48-year-old lady presented with a left breast lump measuring 6 x 5 cms in size and left axillary nodes fixed. Mammography was done which showed left breast- BIRADS-V lesion and left axillary nodes with loss of hila. FNAC of breast lump was done which showed invasive carcinoma. A chest X-ray was done which was normal. Ultrasound abdomen and pelvis was done which was normal. She underwent left modified radical mastectomy and the final histopathological examination report showed invasive ductal carcinoma, pT3N2 disease, tumour size- 6 x 5 x 3.5 cms, LVI present, PNI- present, 7 out of 15 nodes were involved with malignancy. Immunohistochemistry was done which showed ER- negative, PR- negative, and Her2neu- positive (3+). She was treated with 6 cycles of adjuvant TCH (Docetaxel + Carboplatin + Trastuzumab) chemotherapy followed by loco-regional radiotherapy followed by 1 year of trastuzumab. Was this patient managed in the correct manner? Which of the following statements is correct?

• Trucut biopsy of breast lump should be done in place of FNAC and immunohistochemistry should be done before planning surgery.
• Contrast enhanced CT thorax + abdomen + pelvis or PET CT scan whole body should be done for complete staging before planning surgery as patient has clinically fixed axillary nodes. Chest X ray and ultrasound abdomen + pelvis is not sufficient.
• Locally advanced Her2neu positive breast cancer patients should be treated with neoadjuvant chemotherapy along with anti Her2 therapy before surgery and upfront surgery is not advisable for such patients.
• All of the above