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The Professors Vol. 1 2003: Case
2
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63-year-old woman with a 6-cm, ER/PR-negative,
HER2-negative, poorly differentiated IDC of the right breast
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Received neoadjuvant CAF x 3, excellent response
(tumor decreased to 1.5-cm)
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Underwent lumpectomy and AND (1/16 positive
nodes) and XRT
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Received adjuvant CAF x 3
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Two years after initial diagnosis developed
discomfort in right arm and infraclavicular region
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Physical examination: Infraclavicular mass,
palpable axillary nodes, mild swelling of arm and infraclavicular
region
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Biopsy of mass: ER/PR-negative, HER2-negative,
poorly differentiated infiltrating ductal carcinoma
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Bone scan: Negative
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Chest CT: 7-cm mass in the right pectoral region
(involving the pectoralis muscle), enlarged axillary nodes
(See Figure 1a) |
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Key discussion points: |
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Local versus systemic therapy
for local recurrence |
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Taxane/platinum chemotherapy
combinations |
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Treatment of women with Stage
IV NED |
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The role of tumor markers
and imaging as follow-up in metastatic disease |
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Dr Love: Debu, this woman initially
presented with locally advanced disease and is now presenting with
local recurrence after breast conservation. What are your thoughts?
Dr Tripathy: Generally speaking,
the standard treatment for patients with local recurrence has always
been surgical excision. Treatment beyond that has not been studied
in prospectively randomized trials, so my first approach would
be to attempt to provide local therapy.
Additional imaging, specifically an MRI, looking at the depth
of penetration into the muscle, might help determine resectability
of the lesion. Hopefully, a dissection could be done without removing
a significant amount of pectoral muscle, but if there is pectoral
muscle involvement, there needs to be some resection of the muscle.
Dr Love: This woman received
neoadjuvant chemotherapy for her primary tumor. If her recurrence
weren’t amenable to surgery, would you consider giving her
chemotherapy prior to attempting to resect the recurrence to make
the surgery easier?
Dr Tripathy: Although I generally
do not like to use chemotherapy in these situations, if there was
sufficient muscle involvement and the surgeon felt the resection
would be easier with a smaller mass, neoadjuvant chemotherapy — probably
with single agent paclitaxel or docetaxel — would be a reasonable
option.
After the mass was removed, I would generally not use additional
chemotherapy, especially in a patient like this who has already
received a significant amount of chemotherapy. A caveat is that
biologically speaking — people have proposed, but never tested — the
interval of time since the patient received chemotherapy might
guide the decision. The longer the time interval that has assed,
the more likely there is retained chemosensitivity. As a general
concept, I believe this is true. In the metastatic setting, we
generally see higher responses and better outcome in patients with
a longer disease-free interval. However, transferring that to the
pure adjuvant setting has not been done. Even though we all vacillate
in cases like this, my enthusiasm about chemotherapy is less when
the time interval is shorter; therefore, in this particular case,
my enthusiasm would be rather low.
Dr Love: Dr Argawal, what did
the surgeon say about the possibility of resecting the mass?
Dr Argawal: After
reviewing the CT scan, they felt the mass was inoperable without
radiotherapy or chemotherapy because of significant invasion into
the pectoralis major muscle.
Dr Love: Andy, how would you
have thought through this case?
Dr Seidman: You have to ask
yourself and the entire multidisciplinary healthcare team whether
the goal of therapy is palliation or cure. Most people would expect
the goal here to be palliation. Disease-free interval can be an
important predictor for a long-term outcome. This woman’s
high risk of distant metastases — based on her initial presentation — would
temper my enthusiasm about administering chemotherapy to treat
distant metastases. However, if resection is needed for palliation,
and the surgeon felt this lesion was unresectable, chemotherapy
would be warranted.
This is one of the few scenarios in which I might employ combination
chemotherapy, because the higher response rate and greater chance
of shrinking the tumor could make a palpable difference for that
surgeon — and be the difference between resectability with
clear margins or not.
Dr Love: Which chemotherapy
combination would you use?
Dr Seidman: The basic ingredient
would be a taxane, and many other agents could be added. We have
Phase II data for taxanes and carboplatin (Table 2) and equally
impressive data for the taxanes and gemcitabine. We also have limited
data for taxanes and vinorelbine. Because this patient received
fluorouracil two years ago, I probably wouldn’t use capecitabine.
I would likely use carboplatin or gemcitabine.
Dr Love: What are your major
clinical concerns in this situation?
Dr Seidman: Brachial plexopathy,
subclavian vein thrombosis and all of the upper extremity problems
that go along with this woman’s presentation come to my mind
immediately. Most of us rely on radiotherapy as a solution — often
when it is too late. Here, we are considering the possibility of
chemotherapy followed by resection of both the axillary nodes — which
is a challenge when the axilla has been dissected — and of
this infraclavicular mass with part of the pectoralis muscle. Certainly
radiotherapy would be a part of the whole recipe.
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