Breast Cancer Update for Surgeons, Issue 1, 2017 (Video Program)Case discussion: A 36-year-old woman with a 4-cm triple-negative IDC who desires BCS receives neoadjuvant cisplatin on a clinical trial
5:04 minutes.
TRANSCRIPTION:
DR KING: This is a 36-year-old who was diagnosed with a clinical T2N0 triple-negative cancer. She presented to us with a mammogram and ultrasound workup demonstrating this lesion. And I said clinically she was node-negative, and her ultrasound of her axilla was node-negative. As she was young, presenting with triple-negative disease, she did undergo genetic counseling and genetic testing. She did not carry an inherited predisposition to triple-negative disease and, therefore, she was eligible for one of our preoperative trials for triple-negative breast cancer. And so this particular trial that she elected to participate in was a trial of neoadjuvant cisplatin versus paclitaxel for triple-negative cancer. And this trial is looking at the HRD assay, the homologous recombination deficiency assay, to see if pathologic complete response rates to cisplatin or paclitaxel correlate with homologous recombination deficiency in women with triple-negative breast cancer. DR LOVE: And you referred to the fact that you did genetic testing. Of course, that was BRCA testing. And the BRCA germline-associated breast cancers are known to have HRD, although I’m not sure I completely understand what it is. That gets tied into the use of platinum and PARP inhibitors, I guess, at least experimentally. And I imagine that’s the basis for this study. DR KING: Yes. The known hereditary BRCA mutation tumors do tend to have deficiency of DNA repair mechanisms. And HRD is one of those repair mechanisms. So if somebody has a germline BRCA1 mutation, then their tumor will be HRD deficient and potentially more susceptible to agents that cause DNA damage. But we also know that there are some sporadic triple-negative breast cancers that also have HRD deficiency. And so the idea is, can we use an assay to identify those women, because they may also be good candidates for these agents. DR LOVE: Another issue is the issue of neoadjuvant therapy in general in a patient like this. Now, this patient’s primary tumor was 4 centimeters? DR KING: Yes. DR LOVE: And what about breast conservation? How large was her breast? What were her thoughts about it? What were your thoughts about breast conservation? DR KING: Yes. So I was strongly in favor of her having preoperative therapy, whether it was on or off protocol, because she did have a roughly 4-cm tumor at the 6:00 pole of her breast. She was a borderline candidate for conservation for sure, given her breast size and the tumor size. And given the triple-negative phenotype, it was highly likely that we would get some shrinkage, at least, if not a complete pathologic response with preoperative therapy. So she was motivated to attempt breast conservation, and so, therefore, I was motivated for her to have preoperative therapy to see if we could optimize our cosmetic result. DR LOVE: Now, I noticed in your write-up, you had that her axillary exam was negative, but you still went ahead and did an ultrasound of the axilla. Is that typically how you approach imaging of the axilla in a patient with a negative clinical axilla who’s going to get neoadjuvant therapy? DR KING: So I typically do not, but she came to us with her imaging having been done already outside. So in a clinically negative axilla, and particularly in someone — she’s young and quite thin. So I was confident, as confident as one can be in their clinical axillary exam. I do not do routine axillary imaging. It’s quite controversial, as you know. If you take a survey or read the literature, there’s a wide range of opinions regarding the rationale for that. And a lot of the enthusiasm towards doing axillary imaging or dedicated imaging of any type to identify patients with potentially positive nodes comes from, I think, 2 directions. One is, there are, of course, 2 very important ongoing trials right now of patients who we know are node-positive who undergo preoperative therapy and then become clinically node-negative, looking at whether we can alternate axillary node dissection for axillary radiation in those that remain node-positive at surgery. And then the second trial, looking at those that are, in fact, negative at surgery, looking at whether we can potentially tailor our radiation therapy. Radiation oncologists around the country, they have become quite vocal about wanting that dedicated axillary imaging before preop therapy even in women who are clinically node-negative, because they would like that information in their treatment planning post-therapy. So you’ll hear lots of different opinions about it, but I do not routinely do it. DR LOVE: So what happened with this lady? What’s her current situation? DR KING: So she is undergoing her preoperative therapy. She’s having a very nice response. |