Review Note
Last Update: 02/18/2024 05:30 AM
Current Deck: Part 2::6. High Yield Questions::Breast
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Twelve months after completion of therapy (mastectomy, comprehensive radiotherapy), the patient presents with subcutaneous nodules over the left chest wall. Biopsy confirms recurrent triple negative breast cancer. She has no other evidence of disease.
c. What are the treatment options for management of this problem? In your answer, outline the optimal indications and limitations of each modality. (3)
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1. Supportive management
Indications – all patients should receive supportive management especially with wound care in the setting of cutaneous metastasis. Adequate analgesia should be offered for painful nodules
Limitations – underlying cause of symptoms may not be addressed
2. Systemic therapies
a. Palliative Chemotherapy
Indications – all patients with triple negative breast cancer who are fit enough should be considered for first line chemotherapy with taxane, anthracycline or capecitabine.
Limitations – chemo toxicity. Variable effect on metastatic nodules due to malignant pleomorphism and heterogeneity.
b. Targeted therapy
Indications – selection of agent is determinant on genomic profile of the tumour. PARP inhibitor (Olaparib) for BRCA1/2 mutation. Topoisomerase I inhibitor (Sacituzumab govitecan) can be considered as a later line treatment.
Limitations – variable tolerance and efficacy. Systemic toxicity exists.
c. Immunotherapy
Indications: MSI-high tumours, high PD-L1 tumours.
Limitations: autoimmunity reactions. May not be effective in low MST/PD-L1 tumour
3. Local therapies
a. Surgical excision and skin graft
Indications – low volume of disease, resectable and ameanable for graft/adequate wound healing
Limitations – high rates of disease recurrence (20%) and subdermal spread. Potentially poor wound healing following previous mastectomy and radiotherapy
b. Palliative radiotherapy
Indications – symptomatic nodules. Fungating nodules
Limitations – reirradiation carries increased risk of dermatitis, poor healing and fibrosis.
c. Other experimental local therapies
- photodynamic therapy, electrochemotherapy, intra-lesional chemotherapy
Indication: where surgery or radiotherapy is not feasible to palliate symptoms
Limitations – specialised centres and skills required. No robust data on efficacy.
Further information, not for memorising (no card)
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