How would you manage a patient who develops pleural and skin metastases shortly after completing neoadjuvant ddAC-T and surgery for a locally advanced triple negative breast cancer?

Any solid tumor refractory to frontline chemotherapy has three pathways moving forward:

1. Clinical trial

2. NGS on tissue to identify FDA approved targets (specifically BRCA in this case)

3. Standard second line therapies.

Under option 3: For PD-L1 > or = 1%, the combination of atezolizumab and nab-paclitaxel is approved based on IMpassion130 and can still be offered for patients with neuropathy. Other options to consider include carboplatin based doublets and other second line chemotherapy listed in the NCCN compendium. An MRI brain to rule out brain mets will also be prudent.

With pleural disease, this is definitively distant mets. I think this is important as sometimes those with local skin only recurrence can still be treated with curative intent. I would agree with testing for BRCA mutation for PARP inhibitor, genomic testing, and looking for clinical trials. If none of these yield a treatment option, with PD-L1 low, I would recommend a chemotherapy regimen such as carbo/gemcitabine or capecitabine, and reserve radiation to the chest wall for symptom management. Of note, IMMU-132 could also be considered, but does also cause neuropathy.

Do you think adding neoadjuvant immunotherapy would’ve helped? Thanks.

I agree with the above pathways. I would also like to add that if post-operative radiation has not yet been done, this would be a next viable option.

Capecitabine is a good option unless they are BRCA mutation positive, then I'd consider a PARP inhibitor.