Q) Which of the following patients with operable breast cancer is the most appropriate candidate for preoperative systemic therapy?
A) A patient with ER-positive, HER2-negative breast cancer with a 1 cm tumor and clinically node-negative disease who desires breast conservation
B) A patient with HER2-positive breast cancer with a 3 cm primary tumor and clinically node-positive disease
C) A patient with triple-negative breast cancer with a 1 cm tumor and clinically node-negative disease who prefers mastectomy
D) A patient with ER-positive, HER2-positive breast cancer with a 1.5 cm tumor and no lymph node involvement
Correct Answer:B) A patient with HER2-positive breast cancer with a 3 cm primary tumor and clinically node-positive disease
Preoperative systemic therapy is generally recommended for:
HER2-positive or triple-negative breast cancer when the tumor is ≥cT2 (≥2 cm) or clinically node-positive (cN1).
Patients with a large tumor relative to breast size who desire breast-conserving surgery.
Patients with clinically node-positive disease (cN+) who may achieve node-negative (cN0) status with systemic therapy.
Option B meets these criteria with both HER2-positive disease and clinically node-positive status, making the patient an ideal candidate for preoperative systemic therapy.
Choice A: A patient with ER-positive, HER2-negative breast cancer with a 1 cm tumor and clinically node-negative disease who desires breast conservation
Explanation: This patient has an ER-positive, HER2-negative tumor that is small (1 cm) and clinically node-negative. These characteristics indicate a low risk of aggressive disease, and preoperative systemic therapy is typically not necessary for small, low-risk tumors. In this case, surgery would likely be the primary treatment option, followed by adjuvant therapy if needed.
Choice C: A patient with triple-negative breast cancer with a 1 cm tumor and clinically node-negative disease who prefers mastectomy
Explanation: Although this patient has triple-negative breast cancer (TNBC), the tumor size is only 1 cm and clinically node-negative. Preoperative systemic therapy is generally reserved for larger tumors (≥cT2) or node-positive disease in TNBC cases to improve outcomes or allow breast conservation. In this scenario, with a small, node-negative tumor, the preferred approach might be surgery first, as systemic therapy may not offer substantial additional benefits.
Choice D: A patient with ER-positive, HER2-positive breast cancer with a 1.5 cm tumor and no lymph node involvement
Explanation: This patient has HER2-positive breast cancer, but the tumor size is only 1.5 cm, which is below the ≥cT2 threshold for recommending preoperative systemic therapy. Additionally, the absence of lymph node involvement (cN0) indicates a lower burden of disease. While HER2-positive patients often benefit from systemic therapy, a neoadjuvant (preoperative) approach may not be necessary unless the tumor or nodal status meets certain thresholds (≥cT2 or ≥cN1).
