Table 1:

Characteristics of the four patients

Patient and type of breast cancer	Radiation dose	Chemotherapy	Number of brain metastases	Surgery
Patient 1 HER-2-/neu-positive stage IIA infiltrating breast cancer ER/PR negative	After her right frontal metastasis was resected, she had whole-brain radiation. Subsequently, her other three brain metastases were resected, and she had stereotactic radiosurgery: right parietal (1500 cGy), right frontal (1500 cGy) and right temporal (1200 cGy). 4 months later, she had SRS again to all four cavities due to new growth at 1600 cGy.	She was status post lumpectomy followed by four cycles of adjuvant Adriamycin and Cytoxan and then nine cycles of weekly Taxol. After her first recurrence, she was started on weekly Herceptin. She developed brain metastases and due to prior extensive radiation treatment, she was initially on Temodar + Lapatinib, but due to progression, and she was switched to Avastin and CPT11.	Four	The right frontal metastasis was resected first and then the three others were subsequently resected.
Patient 2 HER-2/neu-positive, Invasive ductal carcinoma, Grade 3, ER/PR negative, associated with DCIS extensive nuclear grade III	Whole-brain radiation (3750 cGy) + Lapatinib when she developed brain metastases.	Four cycles of Adriamycin + Cytoxan followed by mastectomy, then on weekly Taxol + Herceptin. After WBRT, she had Lapatinib + Herceptin. When this failed, she was on Avastin + CPT11.	Numerous lesions	No surgery
Patient 3 HER-2-/neu-positive high-grade infiltrating carcinoma with lobular and ductal features, it was ER/PR negative, with high-grade DCIS with positive lymphovascular invasion	Cyberknife radiosurgery to the resection cavity for a total dose of 2500 cGy. A brain MRI done 5 months later showed enhancement inferior tract margin of the surgery. The patient then had CyberKnife RS single-fraction boost to 1600 cGy.	Neoadjuvant Taxotere plus Adriamycin for six cycles, and then she had a right mastectomy. She had recurrence and was then started on Herceptin and Xeloda, but then developed a brain metastasis. She was placed on Xeloda plus lapatanib for better penetration of the brain after her CyberKnife treatment. When she progressed, CPT11 + Avastin was administered with Herceptin.	Large right cerebellar mass	Resected
Patient 4 HER-2-/neu- positive Grade 2 invasive breast cancer with lympho vascular invasion	She had radiosurgery to left temporal lesions with 1800 cGy given to the lateral lesion and 1600 cGy to the medial lesion. The chiasm was treated, to 2000 cGy in five fractions. Two months later, she had a right medial temporal lesion as well as a new left cerebellar metastasis. There was also a scalp lesion that was noted in the right parietal area. She then received 2400 cGy. The left cerebellar lesion was treated with 2000 cGy.	After lumpectomy, she received radiation and cyclophosphamide + methotrexate + 5-fluorouracil chemotherapy. She had recurrence 6 years later with metastases to the posterior fossa, leptomeninges, lung, mediastinum, bone and liver, and was status post multiple trials of chemotherapy and hormonal therapies, including Aromasin, Faslodex and Herceptin prior to being on CPT11 + Avastin.	Numerous including leptomeningeal disease	None

ER, estrogen receptor; PR, partial response; SRS, stereotactic radio-surgery; DCIS, ductal carcinoma in situ; WBRT, whole-brain radiation.