Trial of Trastuzumab Deruxtecan in Previously Treated HER2

Inclusion Criteria: 1. Must be competent and able to comprehend, sign, and date an Institutional Review Board (IRB) approved ICF before performance of any study-specific procedures or tests. 2. Men or women ≥18 years old. 3. Pathologically documented breast cancer that is unresectable or metastatic. 4. 4.Tumor biopsies have always shown HER2-IHC 0 (\<10% membrane staining, including 0 null and 0 ultralow) in all prior biopsies and never previously HER2-positive (IHC 3+ or ISH+) or HER2-low (1+, or 2+ ISH-) on prior pathology testing according to American Society of Clinical Oncology College of American Pathologists (ASCO-CAP) guidelines. 5. Either HR-positive or HR-negative status of the tumor per ASCO-CAP guidelines are allowed. 6. Patients with HR-positive disease must have progressed or be intolerant to CDK 4/6 inhibitors plus endocrine therapy, and patients with HR-negative disease must have received 1 line of therapy in the metastatic setting (progression on or within 6 months of neoadjuvant or adjuvant therapy will be accounted for as 1 line of prior therapy). There is no limit on number of subsequent lines of therapy for study entry. . 7. Patients must have never been previously treated with any anti-HER2 therapy, including prior trastuzumab deruxtecan, other HER2-directed ADCs, HER2 antibodies or HER2 tyrosine kinase inhibitors 8. Clinical or radiologic progression (during or after most recent treatment) or intolerance to therapy prior to enrollment in this trial 9. Adequate archival tumor sample \<3 years-old available for assessment of HER2 status by IHC and by HS-HER2 quantitative assay. If archival tissue is not available or inadequate for assessment (e.g. decalcified bone, cytology, or other), a newly obtained biopsy from a metastatic site (or breast tissue if locally advanced/unresectable disease as the only site of advanced disease) is required on enrolment. 10. Presence of at least 1 measurable lesion based on Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1. 11. ECOG PS ≤ 2. 12. Left ventricular ejection fraction (LVEF) ≥50% within 28 days prior to C1D1. 13. Adequate bone marrow function (Table 1) within 28 days before C1D1, defined as: 1. Platelet count \>≥100,000/mm3 (Platelet transfusion is not allowed within 1 week prior to Screening assessment). 2. Hemoglobin level ≥9.0 g/dL (red blood cell transfusion is not allowed within 1 week prior to Screening assessment). 3. Absolute neutrophil count ≥1500/mm3 (granulocyte colony-stimulating factor administration is not allowed within 1 week prior to Screening assessment). 14. Adequate renal function (Table 1) within 28 days before C1D1, defined as: a. Creatinine clearance ≥30 mL/min, as calculated using the Cockcroft-Gault Equation. 15. Adequate hepatic function (Table 1) within 28 days before C1D1, defined as: 1. Aspartate aminotransferase (AST)/alanine aminotransferase (ALT) ≤ 3×ULN (\< 5×ULN in participants with liver metastases). 2. Total bilirubin ≤1.5 × ULN if no liver metastases or \<3 × ULN in the presence of documented Gilbert's syndrome (unconjugated hyperbilirubinemia) or liver metastases at baseline. 16. Adequate blood clotting function( defined below) within 28 days before C1D1, defined as International normalized ratio or Prothrombin time and either partial thromboplastin or activated partial thromboplastin time ≤ 1.5 × ULN. 1. Platelet function greater than or equal to 100000/mm3 (Platelet transfusion is not allowed within 1 week prior to C1D1). 2. Hemoglobin greater than or equal to 9.0 g/dL NOTE: Participants requiring ongoing transfusions or growth factor support to maintain haemoglobin ≥9.0 g/dL are not eligible. Red blood cell transfusion is not allowed within 1 week prior to C1D1. 3. Absolute neutrophil count greater than or equal to 1500/mm3. (granulocyte-colony stimulating factor administration is not allowed within 1 week prior to C1D1). 4. Alanine aminotransferase and aspartate aminotransferase less than or equal to 3×ULN (\< 5×ULN in participants with liver metastases). 5. Total bilirubin less than or equal to 1.5×ULN if no liver metastases or \< 3×ULN in the presence of documented Gilbert's syndrome (unconjugated hyperbilirubinemia) or liver metastases at baseline. 6. Serum albumin greater than or equal to 2.5 g/dL 7. Creatine clearance greater than or equal to 30 mL/min as determined by Cockcroft Gault (using actual body weight). 8. International normalised ratio or Prothrombin time and either partial thromboplastin or activated partial thromboplastin time less than or equal to 1.5 x upper limit of normal 17. Adequate treatment washout period before C1D1, defined below: 1. Major surgery minimum washout period of greater than or equal to 4 weeks 2. Radiation therapy including palliative stereotactic radiation therapy to chest minimum washout period greater than or equal to 4 weeks 3. Palliative stereotactic radiation therapy to other anatomic areas including whole brain radiation minimum wash out period of greater than or equal 2 weeks 4. Anti-Cancer chemotherapy \[Immunotherapy (non-antibody based therapy)\], hormonal therapy, antibody-based therapy, or retinoid therapy minimum washout period greater than or equal to 3 weeks 5. Anti-Cancer chemotherapy \[Immunotherapy (non-antibody based therapy)\], hormonal therapy, antibody-based therapy, or retinoid therapy minimum washout period greater than or equal 3 weeks 6. Targeted agents and small molecules minimum washout period greater than or equal 2 weeks or 5 half-lives, whichever is longer 7. Cell-free and Concentrated Ascites Reinfusion Therapy (CART), peritoneal shunt or drainage of pleural effusion, ascites or pericardial effusion minimum washout period greater than or equal to 2 weeks prior to screening assessment 8. Any monoclonal antibody treatment minimum washout period greater than or equal to 3 elimination half-lives of the inhibi