Case Recap
A 37-year-old female, who is being treated for infertility, notes a mass at 12 o'clock in the right breast. Physical exam finds a palpable 1.5 - 2.0 cm mass located 3 cm from the nipple. Mammogram shows the mass and an area of calcifications suspicious for ductal carcinoma in situ (DCIS) involving an area of approximately 2.5 cm. Core biopsy revealed a high grade infiltrating ductal carcinoma (IDC).
The patient received neoadjuvant chemotherapy which consisted of 3 courses (each sequential dose dense) with Adriamycin, Taxotere, and Cytoxan. After chemotherapy, the patient had a complete clinical response (CCR) and partial response by imaging. Ultrasound showed an area measuring 4 mm, suspicious for residual tumor. Mammogram showed some calcifications suspicious for residual DCIS.
Five months after the initial diagnosis, a partial mastectomy removing 6.5 cm of tissue was performed. The excision was guided by a radiologic marker placed before the start of chemotherapy. Pathologic examination revealed residual 0.3 cm IDC as well as high nuclear grade ductal carcinoma in situ (DCIS) approximately 4 cm in size. Axillary dissection revealed 11 negative nodes. The margins of resection were as follows: DCIS -- Within one millimeter of anterior and inferior; Invasive -- Negative margins.
Survey Results
A self-selected response pool of ASBD members completed an online survey with the following results. Of respondents, 70% were surgeons or surgical oncologists, 20% were medical oncologists, 6% radiologists/imagers, and 4% radiation oncologists.
The vast majority of respondents (88%) believe that lumpectomy is acceptable surgical treatment following neoadjuvant therapy. For those considering lumpectomy as acceptable, 90% rely on the size of the lesion to guide their decision regarding BCS. The majority of respondents (78%) expect a 5-year survival of between 75% and >95%.
Table 1 shows the percentage of respondents considering various factors as indications for neoadjuvant therapy. Table 2 shows the percentage of respondents recommending treatment options following neoadjuvant therapy and lumpectomy.
Respondents were divided regarding the appropriateness of neoadjuvant therapy in this case with 52% of respondents believing that neoadjuvant therapy was appropriate; 48% were unsure or believed that it was not appropriate treatment.
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Table 1: Indications for Neoadjuvant Therapy
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Factor
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% Respondents Reporting
Factor as Indication
for Neoadjuvant Therapy
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Tumor size alone
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50%
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Tumor size relative to breast size
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85%
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| Patient age |
17%
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Tumor state
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27%
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Histologic grade
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17%
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Patient history
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10%
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Table 2: Next Steps in Treatment
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Treatment Option
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% Respondents
Recommending
Treatment Option
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Radiation and chemotherapy
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34%
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Radiation alone
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34%
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| Other treatments |
32%
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