Triple-negative breast cancer

- Total 12% of all breast cancer

- Worst 5 yr survival 77% ( HR-positive, HER 2 neg 5 yr survival 92%)

- Clinical pearl--> abnormal-looking LN by imaging should be percutaneously biopsied; avoid sentinel LN staging before neoadjuvant chemo if that is being planned in order to accurately assess response.

-Distant recurrent rates are similar with adjuvant versus NACT

-RCB should be noted in the post op specimen

-recent meta-analysis of 5,161 patients treated with NAC, 5-year event-free survival among those with TNBC was 91% for RCB-0 (indicating pCR), 80% for RCB-I, 66% for RCB-II, and 28% for RCB-III disease

-CREATE-X trial: capecitabine improved disease-free survival and OS, with a particular benefit among patients with TNBC (5-year disease-free survival, 69.8% in the capecitabine group v 56.1% in the control group; hazard ratio, 0.58; 95% CI, 0.39 to 0.87)

Surgery after NACT-- mastectomy versus breast conserving surgery

risk factors for local recurrence after NAC and breast-conserving therapy:
cN2/3 disease
presence of lymphovascular space invasion
residual tumor > 2 cm
multifocal pattern of residual disease

If multiple risk factors are present, the local recurrence risk after breast conservation exceeds 10% despite optimal surgery and radiation therapy.

What is the rate of recurrence in breast for those undergoing BCS?

Path CR: inbreast recurrence 0 to 2.6% irrespective of subtype

No path CR: in breast recurrence varies with hormone status/ HER 2 status did not matter

HR positive 5%
HR negative 10-13%

Radiation after lumpectomy

hypofractionated whole-breast irradiation (40 Gy in 15 fractions plus a boost of 10-16 Gy in five to eight fractions) is typically recommended

Regional nodal radiation

cT1/2 N0 breast cancer, PMRT/RNI is not generally recommended, provided these tumors remain pathologically node-negative after NAC. Locoregional recurrence of 6% in 10 years.

RNI should be done for those with clinical node positivity who remain node positive. The recurrence is 13 to 40% without radiation.

However, ongoing clinical trial looking at RNI versus no RNI if nodal path CR in cT1-T3 N1 disease. NRG B-51.

Patients with more advanced disease, such as cT4 or N2 or N3, PMRT/RNI is always recommended regardless of pathologic response.

JCO grand rounds

Consensus guidelines on management of axilla

NeoSTOP trial : a phase II anthracycline free chemo regimen