A 46 year old lady, had a left breast carcinoma 13 years ago- underwent left breast conservative therapy ( wide local excision + axillary dissection + whole breast radiotherapy), followed by tamoxifen (only completed 3 years and defaulted treatment).
Now presenting with recurrence at left breast and multiple right axillary node metastasis (both confirmed invasive carcinoma by core needle biopsy) , however right breast is normal.
Mammogram- multicentric left breast lesions, right breast normal
CT scan- no other distant metastasis except contralatetal axillary mets.
ER/PR positive
HER2 negative
Left breast tumor resectable and she's a good surgical candidate
What are our options?
A) Neoadjuvant chemotherapy followed by surgery(left mastectomy) and hormonal therapy
B) Salvage left mastectomy and right axillary dissection followed by adjuvant chemotherapy and hormonal therapy
C) Bilateral mastectomy and right axillary dissection followed by adjuvant chemotherapy and hormonal therapy
D) Salvage left mastectomy followed by adjuvant chemotherapy and hormonal therapy
E) Other options??
Thank you
To my view, apart from age at first diagnosis-i.e. 33-yrs old, this does not look as an BRCA1/2 familial breast cancer, but rather a typical luminal A disease with late (after 13 years) recurrence, and apparently still remains luminal A. Although initial stage, number of lymph nodes involved, as well as ER/PR/c-erbB2 status, are not provided, I suspect that it was a pT2N0MO - grade 1/2 tumor with HR(+)/c-erbB2(-) markers and low Ki-67, to do so well with local therapy + Tamoxifen (x3 years) alone...! Right axillary node disease is presumably the result of contralateral axillary node metastatic spread from internal mammary nodes, involved either initially or from dissemination of the locally recurrent tumor.
From a therapeutic standpoint, given that we have to deal with Luminal A disease, I think that neo-adjuvant chemotherapy has little role, as it has very low chances to achieve a pathologic CR, and therefore as a treatment-related prognostic parameter, to change significantly the outlook of this patient over adjuvant chemotherapy, unless clinically the bulk of the right axillary nodes is large. Alternatively, endocrine therapy with an LHRH analogue, if she is still pre- or peri-menopausal, plus an aromatase inhibitor-preferably a steroidal-such as Exemestane might be administered for about 12 weeks before local definitive therapy.
As for loco-regional therapy, I think a salvage left mastectomy plus right axillary dissection will be required followed by right axillary irradiation for best local control. Given the high number of involved axillary nodes, I would favor adjuvant chemotherapy with dose-dense (dd) ACx4 --> dd Paclitaxel x 4, followed by right axillary RT and an LHRH analogue if she is still pre- or peri-menopausal and Exemestane (both for 5 years), or an aromatase inhibitor, i.e. Letrozole 2.5mg: 1x1/day x 5-10 years.
I forgot to say that current studies of neo-adjuvant therapy evaluating aromatase inhibitors + CDK4/6 inhibitors look very promising...!!!