53yr female who is seeing me for 3rd tiebreaker opinion. She has focal asymmetry (suspected to be around 11mm), no US Correlate that was biopsied as triple positive IDC. Mri showed 1.9cm enhancement, no LN. She requested b/l mastectomy due to FH. My typical practice is to recommend upfront surgery for T1c lesions but I know some institutions do neoadjuvant for these lesions with TH or THP. How do you decide on these cases and what data would be best to discuss with this lady? I would prefer surgery upfront then APT particularly since she will be getting b/l mastectomy but let me know what you think.
I agree with you that I would do thp adjuvant as well. What I would suggest if you do this approach is to consider neratinib if her tumor ends up being larger than you originally thought or node positive. If she got tchp she would have a 50% chance of pCR and if not pCR you’d be giving her tdm1. But I think all this is probably an overkill in someone with T1 tumor.
