DR MORROW: This is a 43-year-old woman who presents with a 2.5-cm mass in a C-cup breast and a palpable axillary lymph node.
Core biopsy of the tumor mass shows that it’s a Grade III infiltrating ductal carcinoma — ER-, PR- and HER2-negative — and fine needle aspiration of the lymph node is positive for carcinoma. The patient is currently a candidate for breast-conserving therapy, which is what she wants to have done.
Is there a reason to give this patient neoadjuvant therapy just because she has triple-negative, poor-prognosis disease, given that there has never been a survival advantage shown for neoadjuvant versus adjuvant? And why do all medical oncologists seem to believe that’s the preferred choice outside of a clinical trial, obviously?
DR LOVE: Dr Brufsky?
DR BRUFSKY: We’ll start with NSABP-B-27. As you know, the most recent analysis does show in the younger patients — I don’t know if they’re triple-negative or not — but in the younger patients there’s a small but significant benefit in terms of PFS, not necessarily OS, in giving the neoadjuvant therapy. That would be one reason. But I agree. Other than that, there’s none.
DR LOVE: Let’s take it to the next step. Same patient.
DR MORROW: This patient actually came to me having already received dose-dense ACT and re-presented with a breast mass which was no longer palpable, a normal axillary physical exam and a negative sentinel node biopsy performed elsewhere, as well, and a lumpectomy with positive margins. Now that we’ve achieved such excellent surgical outcome, is an axillary dissection indicated in this patient?
DR LOVE: Edith?
DR PEREZ: You’re tough. But I think now that we have the data presented by Judy Boughey from the ACOSOG, now Alliance, trial, looking at the issue of sentinel node detection after neoadjuvant therapy, at least we have some data that can be used. In that trial, I think the high false-negative rate of sentinel node detection for the overall group of patients was too high for me to say that sentinel node alone is enough for this patient’s management. But the issue is: Are we going to change anything in this particular patient, if she were to have more nodes?
There are 2 parts to your question. Would I know the status of the axilla just by doing a full dissection? Yes, because of the false-negative rate of sentinel nodes. Will it change management? No. Because it wouldn’t change management, then I probably wouldn’t do it.
DR MORROW: I think that the one thing that is not clear to me about the ACOSOG trial as presented is: How many people truly had palpable nodes, implying more bulky disease versus ultrasound-detected disease? But while the overall false-negative rate was only 12.6%, which is an acceptable number when 2 or more sentinel nodes were removed, when 1 sentinel node was removed it was 31.5%. So the false-negative rate generally in the axilla reflects an axillary first failure rate that’s about one third that. And 10% is too high. So, for that reason alone, I would dissect this axilla.
The other reason is to help in radiation planning because the area right now of when do you deliver node field irradiation in breast conservation is one that is politely described as in a state of flux.
DR LOVE: Maybe you can take it to the final question about this patient.
DR MORROW: This patient did undergo a re-excision with clear margins. She had 4 positive lymph nodes remaining in her axilla. Clearly she has poor-prognosis disease. This is one of these scenarios where the urge to do more seems to be irresistible for many people. So is there actually any data to justify giving this woman additional chemotherapy?
DR LOVE: Lisa?
DR CAREY: She received well-delivered anthracycline/taxane-based chemotherapy. Had one of those been omitted, then I think you could make an argument, if she hadn’t had an anthracycline, to give it. But if she had dose-dense ACT, we have no data to support additional chemotherapy in the adjuvant setting.
DR LOVE: I’m just kind of curious what happened with this lady. What is the medical oncologist saying about additional chemo?
DR MORROW: She is not getting any additional chemotherapy, happily.