Can Surgery Replace Chemotherapy for Triple-Negative Breast Cancer?

Can triple-negative breast cancer be changed to tumor resection after infection following the first chemotherapy?

Hello Dr.
Lai, my friend's mother-in-law is nearly 70 years old.
Last year, she discovered a hard lump in her right breast, and during a hospital examination, the tumor was found to be about 5 cm in size, with several lymph nodes involved in the axilla.
The doctor recommended surgical removal followed by chemotherapy, but the elderly woman was unwilling to proceed.
By mid-July of this year, it was found that the tumor had grown larger, measuring 7 cm, and it was diagnosed as triple-negative breast cancer.
The recommendation was to start chemotherapy first.

In early August, she underwent her first chemotherapy session, but a few days later, due to the side effects, she developed septic shock.
After being hospitalized, the source of infection was traced to an artificial blood vessel, caused by Staphylococcus aureus.
She was hospitalized for two weeks, and after discharge, she returned for a follow-up assessment a week later.
Due to the infection issue, it was deemed unsuitable to reinsert the artificial blood vessel, and now the doctor is recommending surgical removal of the tumor.
So, Dr.
Lai, I would like to ask you if it is acceptable for an elderly patient who has undergone one round of chemotherapy to switch to surgery for tumor removal.
Given that the tumor is 7 cm and there are several lymph nodes involved, is it possible to completely remove the tumor? Since there will be a wound, what are the risks of reinfection with Staphylococcus aureus leading to septic shock again? What specific precautions should be taken? Thank you, Dr.
Lai!

Ruby Chen, 40~49 year old female. Ask Date: 2016/09/02

Dr. Lai Yicheng reply Oncology

Dear Ms.
Ruby Chen,
Thank you for your letter.
Here are my responses:
1.
Tumors that can be surgically removed generally have better outcomes when followed by chemotherapy and radiation therapy.
However, this depends on the surgical method and the extent of resection.
If the tumor is relatively small, complete surgical removal is easier.
For larger tumors, it is advisable to follow the sequence of chemotherapy → surgery → chemotherapy combined with radiation therapy.
Ultimately, the decision should be based on the patient's specific tumor condition, in consultation with the attending physician, family, and the patient.
2.
As long as the attending physician is skilled and the extent of metastasis is limited, complete removal is possible.
The patient's condition remains the primary consideration.
3.
Attention must be paid to infection control, as it indicates that the patient may be physically weakened.
The risk of septic shock arises from bacterial infections, so monitoring wound changes and the patient's inflammatory response is crucial.
Nutritional intake and support from family (both psychological and physiological) are important.
Thank you for your inquiry.

Sincerely,
Dr.
Lai Yi-Cheng
Department of Radiation Oncology
Changhua Hospital

Reply Date: 2016/09/02

More Info

When it comes to the treatment of triple-negative breast cancer (TNBC), the approach can be complex, particularly in older patients or those with comorbidities. In the case you presented, the patient initially underwent chemotherapy but experienced severe side effects, including septic shock due to an infection. This situation raises important questions about the appropriateness of surgery as an alternative to continued chemotherapy.

Surgery vs. Chemotherapy in TNBC:
Triple-negative breast cancer is known for its aggressive nature and lack of targeted therapies, making chemotherapy a cornerstone of treatment. The standard approach often involves neoadjuvant chemotherapy (chemotherapy before surgery) to shrink the tumor, followed by surgery to remove the tumor and any affected lymph nodes. This method can improve surgical outcomes and potentially allow for breast-conserving surgery instead of mastectomy.

However, in cases where chemotherapy leads to severe side effects, such as the septic shock experienced by the patient, the treatment plan may need to be adjusted. Surgery can be considered, especially if the tumor is large and has not responded adequately to chemotherapy. In this scenario, the decision to proceed with surgery should be made carefully, considering the patient's overall health, the extent of the disease, and the potential risks involved.

Risks of Surgery:
1. Infection Risk: Given the patient's history of infection and septic shock, there is a heightened concern about the risk of postoperative infections. The surgical team will need to take extra precautions to minimize this risk, such as using prophylactic antibiotics and ensuring optimal wound care.

2. Tumor Clearance: The size of the tumor (7 cm) and the involvement of lymph nodes complicate the surgical approach. While it is possible to achieve clear margins with a skilled surgical team, the likelihood of complete tumor removal depends on the tumor's characteristics and its relationship to surrounding tissues. If the tumor is too large or has spread extensively, achieving clear margins may be more challenging.

3. Postoperative Recovery: The patient's overall health status, including any comorbidities, will influence recovery. The surgical team will need to monitor the patient closely for any signs of complications, including infections or delayed healing.

Considerations for Future Treatment:
If surgery is performed successfully, the patient may still require adjuvant chemotherapy or radiation therapy to address any residual disease and reduce the risk of recurrence. The treatment plan should be tailored to the patient's specific situation, taking into account the tumor's response to previous therapies and the patient's preferences.

Conclusion:
In summary, while surgery can be a viable option for patients with triple-negative breast cancer who cannot continue chemotherapy due to severe side effects, it is essential to weigh the risks and benefits carefully. A multidisciplinary team approach, involving oncologists, surgeons, and infectious disease specialists, will be crucial in managing the patient's care effectively. The patient's safety and quality of life should remain the top priority throughout the treatment process.

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