General Surgery Oral Board Review: Axillary Management After Neoadjuvant Chemotherapy for Breast Cancer

Patient Presentation and Initial Assessment

• 📌 A 55-year-old female presented with a 3cm high-grade triple-negative breast cancer in the upper outer right breast with a positive axillary lymph node.
• 🩺 The initial approach involved a thorough history and physical, focusing on systemic symptoms and risk factors for breast cancer.
• 📊 Staging included CT scans of the chest, abdomen, and pelvis, along with a bone scan, which showed no evidence of distant disease.

Treatment Strategy for Triple-Negative Breast Cancer

• 💡 Given the triple-negative status and nodal metastasis, the treatment plan included neoadjuvant chemotherapy followed by surgery and likely radiation therapy.
• 🧬 Genetic counseling and testing were recommended due to the triple-negative breast cancer, though no genetic mutations were found.
• 🚀 The patient underwent neoadjuvant chemotherapy with immunotherapy, leading to the disappearance of the breast mass and normalization of axillary lymph nodes on updated imaging.

Surgical Management Post-Chemotherapy

• 🎯 Surgery for the breast (lumpectomy or mastectomy) and a sentinel lymph node biopsy were recommended, including removal of the previously biopsied node.
• ⚠️ Observation alone was deemed insufficient as imaging cannot definitively rule out residual disease after neoadjuvant chemotherapy.
• ✅ A pathologically complete response was achieved, with no cancer found in the breast or sentinel lymph nodes.

Next Steps and Contingency Planning

• 🏥 Following a complete response, the patient needs referral for radiation therapy.
• ⚡ If residual cancer were found in a sentinel lymph node, a completion axillary lymph node dissection would be recommended, followed by radiation and additional adjuvant systemic therapies.