From the Guidelines
The next step in management for a patient with a 12 mm infiltrating ductal carcinoma of the breast that is hormone receptor-positive and HER2-negative without axillary lymph node enlargement would be breast-conserving surgery (lumpectomy) with sentinel lymph node biopsy, followed by adjuvant therapy.
Key Considerations
- The patient's tumor is hormone receptor-positive and HER2-negative, which suggests that adjuvant endocrine therapy will be beneficial 1.
- The absence of axillary lymph node enlargement is a good prognostic sign, but it does not eliminate the need for further evaluation and treatment.
- Breast-conserving surgery with sentinel lymph node biopsy is a recommended approach for early-stage breast cancer, as it helps to preserve the breast and minimize morbidity 1.
Adjuvant Therapy
- After surgery, the patient should receive adjuvant endocrine therapy for at least 5 years, typically with tamoxifen 20 mg daily for premenopausal women or an aromatase inhibitor (such as anastrozole 1 mg daily, letrozole 2.5 mg daily, or exemestane 25 mg daily) for postmenopausal women 1.
- Radiation therapy to the affected breast is generally recommended following breast-conserving surgery to reduce the risk of local recurrence.
- The need for adjuvant chemotherapy would depend on additional prognostic factors such as tumor grade, Ki-67 proliferation index, and possibly genomic assays like Oncotype DX, which help determine the risk of recurrence and potential benefit from chemotherapy.
Further Testing
- CT chest abdomen and pelvis, or MRI of the right breast are not necessarily required for further testing, as the primary tumor is relatively small and there is no evidence of axillary lymph node enlargement or distant metastasis.
- Tumor markers or circulating tumor cells should not be used as the sole criteria for determining progression, as recommended by the ASCO guideline update 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Next Steps in Management
For a patient with a 12 mm infiltrating ductal carcinoma (IDC) of the breast, hormone receptor-positive and HER2-negative, without axillary lymph node enlargement, the following steps can be considered:
- Tumor markers: While tumor markers such as CA 15-3 and CA 27.29 can be used to monitor disease recurrence, they are not typically used for initial staging or diagnosis 2.
- CT chest abdomen and pelvis: Imaging studies such as CT scans may be used to evaluate for distant metastases, but are not typically recommended for initial staging of early-stage breast cancer 3.
- MRI of the right breast: Breast MRI may be used to evaluate the extent of disease in the breast, but is not typically recommended for initial staging of small tumors such as this one 4.
- No further testing: For small tumors such as this one, with no evidence of axillary lymph node enlargement, no further testing may be necessary beyond standard staging and evaluation 5, 6.
Considerations for Treatment
The patient's hormone receptor-positive and HER2-negative status suggests that they may be a candidate for adjuvant endocrine therapy, such as tamoxifen or an aromatase inhibitor 2, 3. The patient's lack of axillary lymph node enlargement suggests that they may not require axillary lymph node dissection, and may be a candidate for sentinel lymph node biopsy instead 4.
Additional Evaluations
Evaluation of the tumor's estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor-2 (HER2) status can provide important information for treatment planning 4, 5. The use of genomic assays and other biomarkers may also be considered to help guide treatment decisions 2.