Dados do Trabalho

Título

BRCA1: considerations about treatment in N3 breast cancer patients

Apresentação do caso

30 years old pre-menopausal woman with family history for breast and melanoma cancer noticed a lump in her left breast. She was evaluated and diagnosed a left breast IDC T3N3M0 triple negative with Ki 67 45%, LVI negative, PNI negative, grade 2 with BRCA1 mutation, PDL-1 positive (1%) and PET-CT with positive internal mammary nodes.
In Dec/2019, she began 4 cycles of neoadjuvant dose dense AC chemotherapy followed by 12 cycles of weekly carboplatin and paclitaxel. After 3 weeks of stable disease and due to Keynote 522 trial publication, pembrolizumab was associated with the carboplatin and paclitaxel regimen. The treatment showed grade 3 hematologic side effects (anemia and febrile neutropenia with hospitalization needed) and clinical complete response.
She received left nipple-sparing mastectomy with SNB in Jun/2020: ypT0ypN1a.
She began adjuvant pembrolizumab in Jun/2020 and 50.40 Gy post mastectomy radiationtherapy (PMRT) and regional nodal irradiation (RNI - including internal mammary chain) with volumetric modulated arc therapy (VMAT) in 25 fractions from Jul-Sept/2020. She completed 9 cycles of adjuvant immunotherapy in Dec/2020. The only side effect to mention was neutropenia grade 1 that paused the radiation treatment for one week.
She is being followed with no side effects and the 6 months post-treatment radiologic exams are normal and PET-CT (Jan/2021) is negative.

Discussão

Breast cancer patients with N3 IIIc stage which would not be among the inclusion criteria for neoadjuvant therapy in the Keynote-522 study probably because of the higher recurrence risk and worse prognosis, lack of effective therapy and immunotherapy could be an option.
FDA recently approved Pembrolizumab for neo and adjuvant triple negative breast cancer.
The grade 3 hematologic side effect is experienced in 76.8% in the immunotherapy group versus 72.2% in the chemo only group in the Keynote 522 trial and complete pathological response (ypT0/is) is 64.8% in the pembrolizumab group versus 51.2% in the control group.
The well tolerable adjuvant (PMRT and RNI) with immunotherapy is due to VMAT thecnology.

Comentários finais

In summary, patients with locally advanced breast cancer IIIc and BRCA mutation are challenging because of the poor prognosis. However, new therapies, among them the use of platinants, immunotherapy and new surgery and radiotherapy techniques, seek to expand this frontier of knowledge and improve oncological outcomes while seeking to manage side effects.

Palavras-chave

BRCA mutation / Imunnotherapy/ VMAT