A healthy, premenopausal woman aged 45 years discovered a lump in her right breast and her right axilla. Physical examination disclosed a 3-cm mass with ill-defined borders in the upper outer quadrant (UOQ) of the right breast, without skin changes, and a 2-cm mobile right axillary lymph node. There was no cervical or supraclavicular adenopathy. Bilateral diagnostic mammography demonstrated a cluster of masses adjacent to the palpable abnormality in the UOQ of the right breast and a prominent right axillary lymph node; ultrasound also demonstrated a cluster of masses in the UOQ of the right breast measuring 1.6 cm and ≥2 enlarged axillary lymph nodes with thickened cortices. An ultrasound-guided core biopsy of the breast mass with clip placement confirmed a high-grade, invasive ductal carcinoma with associated ductal carcinoma in situ. The tumor lacked estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2) expression on immunohistochemistry (IHC) and was HER2-negative by FISH (ie, triple-negative). A fine-needle aspiration biopsy of an abnormal axillary lymph node, with placement of a high-visibility Q-clip, confirmed metastatic carcinoma. Her disease was staged as clinical T2N1 based on the size of the palpable mass and axillary adenopathy: American Joint Committee on Cancer clinical prognostic stage IIB. Her family history included breast cancer in 2 paternal cousins, a paternal aunt, and a paternal grandmother. Multigene panel testing for hereditary cancer showed no deleterious mutations. She was evaluated by a multidisciplinary (surgical, medical, and radiation oncology) team. With a triple-negative cancer involving the axillary lymph nodes, she warranted either neoadjuvant (preoperative) or adjuvant (postoperative) chemotherapy, and the discussion centered on the sequencing of treatments, the surgical options of breast-conservation therapy (BCT) versus mastectomy, the extent of axillary surgery, and the need for postmastectomy radiation. On the basis of the tumor size-to-breast size ratio, she was only a borderline candidate for BCT and, with palpable adenopathy, she would require an axillary lymph node dissection (ALND) were surgery to be pursued as the first treatment modality. A magnetic resonance imaging scan obtained to clarify the extent of disease demonstrated a heterogeneously enhancing mass, representing the biopsyproven malignancy, and an adjacent nonmass-like enhancement measuring 2.9 × 2.0 × 1.6 cm occupying the UOQ of the right breast. Axillary adenopathy was also seen, with the largest node measuring 2.1 cm (Fig. 1). The team recommended neoadjuvant chemotherapy (NAC) with the goal of surgical downstaging to permit breast-conserving surgery and also possibly to avoid ALND. She received preoperative, dose-dense doxorubicin plus cyclophosphamide followed by paclitaxel (ddACT). Her course was complicated by alopecia and the onset of amenorrhea with menopausal symptoms.

中文翻译：

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三阴性乳腺癌治疗的多学科考虑

一名 45 岁的健康绝经前妇女发现她的右乳房和右腋窝有一个肿块。体格检查显示右侧乳房上外象限 (UOQ) 有一个 3 厘米的肿块，边界不明确，无皮肤变化，右侧腋窝淋巴结有 2 厘米可移动。没有颈部或锁骨上淋巴结肿大。双侧诊断性乳房 X 光检查显示一簇肿块与右侧乳房 UOQ 中可触及的异常和突出的右侧腋窝淋巴结相邻；超声还显示右侧乳房的 UOQ 中有一簇 1.6 cm 的肿块和≥2 个增大的腋窝淋巴结，皮质增厚。超声引导下放置夹子的乳房肿块核心活检证实为高级别浸润性导管癌，并伴有相关的原位导管癌。该肿瘤在免疫组织化学 (IHC) 上缺乏雌激素受体 (ER)、孕激素受体 (PR) 和人表皮生长因子受体 2 (HER2) 表达，并且通过 FISH 显示为 HER2 阴性（即三阴性）。对异常腋窝淋巴结进行细针抽吸活检，并放置一个高可见度的 Q 形夹，证实为转移性癌。根据可触及肿块的大小和腋窝淋巴结肿大，她的疾病被分期为临床 T2N1：美国癌症联合委员会临床预后分期 IIB。她的家族史包括 2 个表亲、一位姑姑和一位祖母患乳腺癌。遗传性癌症的多基因面板测试显示没有有害突变。她接受了多学科（外科、医学和放射肿瘤学）团队的评估。由于涉及腋窝淋巴结的三阴性癌症，她需要新辅助（术前）或辅助（术后）化疗，讨论集中在治疗顺序、保乳治疗 (BCT) 与乳房切除术的手术选择上，腋窝手术的范围，以及乳房切除术后放射的需要。根据肿瘤大小与乳房大小之比，她只是 BCT 的临界候选人，并且由于可触及的淋巴结肿大，她需要进行腋窝淋巴结清扫术 (ALND) 作为首选治疗方式。为明确疾病范围而获得的磁共振成像扫描显示一个不均匀增强的肿块，代表活检证实的恶性肿瘤，以及相邻的非肿块样增强，大小为 2.9 × 2.0 × 1。6 cm 占据右乳房的 UOQ。还可见腋窝淋巴结肿大，最大淋巴结为 2.1 cm（图 1）。该团队推荐新辅助化疗 (NAC)，目标是手术降期以进行保乳手术并可能避免 ALND。她在术前接受了剂量密集的阿霉素加环磷酰胺，然后是紫杉醇 (ddACT)。她的病程因脱发和具有更年期症状的闭经而变得复杂。