Breast case

[Reaganite]

31 y/o T2NO er/pr positive, vus in brca 2, no significant cancer history in family. Already got lumpectomy x 2 (initial + margins). Mastectomy never discussed as option. Have polled some surg onc colleagues at top tier places and probably 60/40 in favor of offering mastectomy. Thoughts?

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[Bequerel]

They always taught us in residency that BRCA is not a contraindication to breast conserving surgery, but in my 8 years of private practice, I’ve never seen a young patient not opt for double mastectomy when given the option. I know I would to if I were in that situation. Are there funding issues that preclude her from reconstruction?

 

[Soapcat]

when the pt already has T2, and keeps getting pos margins after 2 resections, i'd wonder about the 'true' extent of disease burden in the remaining breast - how big is her breast? anyway, i would personally favor mastectomy -> recon at this point.

 

[thecarbonionangle]

This patient has an aggressive insidious cancer. It is screaming this at you. Remove the breast.

 

[Burt Radnolds]

I feel like the case has morphed with each subsequent post. She does not "keep getting" positive margins, she was cleared after a single repeat lumpectomy. She also does not have a known BRCA mutation, but a VUS, not equivalent.

However, I do agree with some of the expressed concern. Enough smoke to strongly consider mastectomy. She should be presented with the recurrence risks of those with true BRCA mutations and be allowed to make an informed decision. If she would like to proceed with breast conservation, it is within reason and she should be followed via a high risk protocol subsequently.

 

[TheWallnerus]

An old saw of mine is that we are board certified in the weak force... and in being weak.

I just don't agree that mastectomy offers any advantage here; I feel the vector of the data leans toward BCS advantage. The mastectomy "knee jerk" (even in young patients) should be questioned. If I were the patient, I would choose BCS. However, that's me being the hypothetical patient with the knowledge/beliefs I have; the average patient will suss a mastectomy advantage. The "average" rad onc, or surg onc, will, as shown above, be similar and lean "60/40 in favor" of mastectomy.

1. Effect of Breast Conservation Therapy vs Mastectomy on Disease-Specific Survival for Early-Stage Breast Cancer
2. ECCO 2017: Some Patients With Early-Stage Breast Cancer May Benefit More From Breast-Conserving Therapy Than Mastectomy
3. Breast conserving therapy and mastectomy revisited: Breast cancer-specific survival and the influence of prognostic factors in 129,692 patients
4. Andrew Seidman, MD, and Sabine Seisling, PhD, on Early-Stage Breast Cancer Outcomes: Breast-Conserving Therapy vs Mastectomy
5. Overall survival according to type of surgery in young (≤40 years) early breast cancer patients: A systematic meta-analysis comparing breast-conserving surgery versus mastectomy.
6. Noninferior Outcome After Breast-Conserving Treatment Compared to Mastectomy in Breast Cancer Patients With Four or More Positive Lymph Nodes

 

[Palex80]

1. It‘s a Variant of Unknown Significance. Management of the breast in VUS carriers is not the same as those with known pathogenic mutations.

2. Are current margins clear? If current margins are now negative, I would proceed with postoperative radiotherapy of the breast. If margins are still positive, it depends on how good BCS can be attempted again. If cosmesis is going to bad after a third surgery, then mastectomy should be offered.

To all who advocate for mastectomy now, regardless of cosmesis: If you recommend mastectomy for the affected breast, you should recommend it for the other breast too (+/- ovaries, I think BRCA2 bears lower risk than BRCA1, but correct me if I am wrong). The risk of contralateral breast cancer in a patient with a known pathogenic BRCA mutation is higher than the risk of ipsilateral breast cancer recurrence following BCS+RT.

 

[evilbooyaa]

Agree with Palex and scarb. VUS BRCA2 doesn't automatically mandate mastectomy. Neg Margins at second surgery I would radiate. If still positive then sure I would recommend mastectomy from my side rather than a THIRD lumpectomy.
Certainly reaonable to offer mastectomy now though, but ideally I would've done that AFTER the initial margin+ lumpectomy, rather than now take the patient back for a 3rd surgery. Wouldn't do bilaterals for VUS for BRCA2.

when the pt already has T2, and keeps getting pos margins after 2 resections, i'd wonder about the 'true' extent of disease burden in the remaining breast - how big is her breast? anyway, i would personally favor mastectomy -> recon at this point.

This patient has an aggressive insidious cancer. It is screaming this at you. Remove the breast.

These are excessively scared responses - nowhere does it state margins are still positive, and VUS BRCA2 is not same as BRCA2. Patient equally likely has a cancer that was diagnosed with mammo/US alone without MRI and got a lumpectomy which lead to a focal + margin. ILC or IDC?