A 37 yrs old woman with breast cancer who performed BCS ,IDC, T2 NO(SLNB) MO, ER+PR+ HER2-,then chemotherapy followed by radiotherapy and endocrionotherapy by tamoxifen . 3 years laters she comes back with a involved lymph nodes in axilla , systemic work up was negative.
what is your plan for treatment plan?
Back to the axilla for staging and removed the lymph nodes. Then in the same setting, bilateral mastectomy with immediate reconstruction with the plastic surgery involved for expanders placement. Finally, 3-4 months later place breast implants. She will need additional chemo therapy while waiting for the implants. I hope I answered your concern and question.
Given the presentation, again I will complete triple assessment. Anticipating only recurrence at ipsilateral axilla, I will subject the unfortunate lady for mastectomy and axillary dissection with immediate or delayed breast reconstruction. She needs second line chemotherapy. I will render her menopause and start her on aromatase inhibitor.
I would concentrate on axillary recurrence and look at pathologic results of axillary dissection whether to initiate 2nd line chemo or go with endocrine tx
Dear Dr Massimo
we request BRCA at first presentation who was negative .
again you insist about bilateral mastectomy?
TNX
Habibollah,
the recurrence and the age of the patient imply a bilateral. The main reason is also the possibility of multifocality presentation and my 5% incidence of contralateral cancer (ductal or lobular) in my practice. My average age is 44 years old with the youngest at 26. Paper in progress!
Best regards
Massimo
Did you look at the immunohistochemical features of the axillary relapse? I think this is mandatory to decide the systemic treatment, whether hormonal or chemotherapy.
I do not agree with bilateral mastectomy, especially if the patient is not at high-risk.
Best regards
I also disagree with bilateral mastectomy in BRCA(-) patient regardless of age and presence of ipsilateral (in this case axillary) recurrence. No proven overall survival benefit of bilateral mastectomy even in BRCA(+) by the way.
Her recurrence is in the axilla, so I would suggest axillary clearance, followed by 2nd line chemotherapy and hormonal treatment based on the IHC of the axillary relaps. Hope you did breast MRI to exclude also in-breast recurrence.
Best regards
Considering the lady is- free of of breast recurrence and systemic metastases, and not BRCA mutated- in presence of isolated axillary recurrence- my plan will be:
1. US guided FNAC from axillary node(s): if metastatic- a complete axillary dissection.
2. Ovarian ablation
3. second line hormone treatment: aromatase inhibitor OR fulvestrant.
No need for second line chemotherapy at this time. Repeat radiation to breast is not an option. Possibly- isolated irradiation to supraclavicular fossa.
Don't see any need/ advantage of mastectomy/ contralateral prophylactic mastectomy. In absence of systemic metastases- (and so no visceral crisis/ no symptoms)- second line chemotherapy doesn't seem justifiable.
Dear Friends
we made an axillary dissection after documented involved node by FNA.
2/ 10 node was involved
IHC: IDC ER+PR+HER2-
My approach:
1. Confirm metastasis by FNA
2. Exclude disease elsewhere by PET CT/ MRI breast
3. Complete axillary dissection if the recurrence is only in axilla!
Skip metastasis are detected in 10% after Sentinel lymph nodes are reported negative. however, only 1 -2% fail in axilla.
4. As hormone receptor are positive and Her2 is negative, aggressiveness should be evaluated. I use Ki67. Depending on high or low; Chemotherapy + hormone therapy/ only hormone therapy is recommended.
Rationale of additional treatment is doubtful. NSABP trial had shown that timing of axillary dissection has no impact on survival!