•	63-year-old woman with a 6-cm, ER/PR-negative, HER2-negative, poorly differentiated IDC of the right breast
•	Received neoadjuvant CAF x 3, excellent response (tumor decreased to 1.5-cm)
•	Underwent lumpectomy and AND (1/16 positive nodes) and XRT
•	Received adjuvant CAF x 3
•	Two years after initial diagnosis developed discomfort in right arm and infraclavicular region
•	Physical examination: Infraclavicular mass, palpable axillary nodes, mild swelling of arm and infraclavicular region
•	Biopsy of mass: ER/PR-negative, HER2-negative, poorly differentiated infiltrating ductal carcinoma
•	Bone scan: Negative
•	Chest CT: 7-cm mass in the right pectoral region (involving the pectoralis muscle), enlarged axillary nodes (See Figure 1a)
Key discussion points:
	Local versus systemic therapy for local recurrence
	Taxane/platinum chemotherapy combinations
	Treatment of women with Stage IV NED
	The role of tumor markers and imaging as follow-up in metastatic disease

Dr Love: Debu, this woman initially presented with locally advanced disease and is now presenting with local recurrence after breast conservation. What are your thoughts?

Dr Tripathy: Generally speaking, the standard treatment for patients with local recurrence has always been surgical excision. Treatment beyond that has not been studied in prospectively randomized trials, so my first approach would be to attempt to provide local therapy.

Additional imaging, specifically an MRI, looking at the depth of penetration into the muscle, might help determine resectability of the lesion. Hopefully, a dissection could be done without removing a significant amount of pectoral muscle, but if there is pectoral muscle involvement, there needs to be some resection of the muscle.

Dr Love: This woman received neoadjuvant chemotherapy for her primary tumor. If her recurrence weren’t amenable to surgery, would you consider giving her chemotherapy prior to attempting to resect the recurrence to make the surgery easier?

Dr Tripathy: Although I generally do not like to use chemotherapy in these situations, if there was sufficient muscle involvement and the surgeon felt the resection would be easier with a smaller mass, neoadjuvant chemotherapy — probably with single agent paclitaxel or docetaxel — would be a reasonable option.

After the mass was removed, I would generally not use additional chemotherapy, especially in a patient like this who has already received a significant amount of chemotherapy. A caveat is that biologically speaking — people have proposed, but never tested — the interval of time since the patient received chemotherapy might guide the decision. The longer the time interval that has assed, the more likely there is retained chemosensitivity. As a general concept, I believe this is true. In the metastatic setting, we generally see higher responses and better outcome in patients with a longer disease-free interval. However, transferring that to the pure adjuvant setting has not been done. Even though we all vacillate in cases like this, my enthusiasm about chemotherapy is less when the time interval is shorter; therefore, in this particular case, my enthusiasm would be rather low.

Dr Love: Dr Argawal, what did the surgeon say about the possibility of resecting the mass?

Dr Argawal: After reviewing the CT scan, they felt the mass was inoperable without radiotherapy or chemotherapy because of significant invasion into the pectoralis major muscle.

Dr Love: Andy, how would you have thought through this case?

Dr Seidman: You have to ask yourself and the entire multidisciplinary healthcare team whether the goal of therapy is palliation or cure. Most people would expect the goal here to be palliation. Disease-free interval can be an important predictor for a long-term outcome. This woman’s high risk of distant metastases — based on her initial presentation — would temper my enthusiasm about administering chemotherapy to treat distant metastases. However, if resection is needed for palliation, and the surgeon felt this lesion was unresectable, chemotherapy would be warranted.

This is one of the few scenarios in which I might employ combination chemotherapy, because the higher response rate and greater chance of shrinking the tumor could make a palpable difference for that surgeon — and be the difference between resectability with clear margins or not.

Dr Love: Which chemotherapy combination would you use?

Dr Seidman: The basic ingredient would be a taxane, and many other agents could be added. We have Phase II data for taxanes and carboplatin (Table 2) and equally impressive data for the taxanes and gemcitabine. We also have limited data for taxanes and vinorelbine. Because this patient received fluorouracil two years ago, I probably wouldn’t use capecitabine. I would likely use carboplatin or gemcitabine.

Dr Love: What are your major clinical concerns in this situation?

Dr Seidman: Brachial plexopathy, subclavian vein thrombosis and all of the upper extremity problems that go along with this woman’s presentation come to my mind immediately. Most of us rely on radiotherapy as a solution — often when it is too late. Here, we are considering the possibility of chemotherapy followed by resection of both the axillary nodes — which is a challenge when the axilla has been dissected — and of this infraclavicular mass with part of the pectoralis muscle. Certainly radiotherapy would be a part of the whole recipe.

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