Tratamentul chirurgical și reconstrucția mamară imediată după chimioterapie în cancerul de sân triplu-negativ – prezentare de caz

Introduction

Triple-negative breast cancer (TNBC) represents approximately 15-20% of all breast cancers, and it is characterized by the absence of estrogen receptors (ER), progesterone receptors (PR) and human epidermal growth factor receptor (HER2) expression^(1,2). This biological entity is associated with aggressive behavior, higher recurrence rates and with a poorer prognosis compared with other molecular subtypes⁽³⁾.

Beyond achieving oncological control, modern breast cancer management increasingly emphasizes the preservation of quality of life and psychosocial well-being. The development of skin-sparing and nipple-sparing surgical techniques, together with advances in implant-based reconstruction, has expanded the possibilities for obtaining favorable esthetic outcomes without compromising oncological safety in carefully selected patients. Immediate breast reconstruction has therefore become an important component of multidisciplinary treatment, contributing not only to anatomical restoration but also to improved patient satisfaction and body image perception⁽⁴⁾.

Neoadjuvant chemotherapy represents an important component in the management of this type of breast cancer⁽⁵⁾.

The aim of this paper is to present a case of TNBC treated with neoadjuvant chemotherapy, followed by subcutaneous mastectomy, axillary lymphadenectomy and immediate breast reconstruction using B-Lite implants and a Braxon acellular dermal matrix.

Case presentation

We present the case of a 36-year-old female patient, who reported no significant personal medical history or family history of breast or ovarian cancer.

At presentation, the patient was in good general condition, conscious, cooperative and afebrile. The systemic clinical examination showed no abnormalities, except for total iatrogenic alopecia following chemotherapy.

Local examination revealed breasts symmetrical in volume and shape, with regular contour and no retractions or protrusions. The overlying skin was normally colored, without erythema, edema or ulceration. The nipple-areolar complexes were normal and symmetrical, with dimensions and coloration appropriate for the patient’s age.

Palpation revealed soft, elastic and uniform breast tissue, except in the right upper-outer quadrant where a spherical tumor growth approximately 2 cm in diameter was identified. The lesion had poorly defined margins, semi-solid consistency and adherence to deeper planes.

Paraclinical investigations and diagnosis

Anamnesis revealed that the first symptoms appeared in March 2025, following breast self-palpation. Initially, due to the clinical presentation, a hematoma was suspected. For this reason, the first breast ultrasound was performed abroad on 8 April 2025.

1. Ultrasound (8 April 2025)

Right breast: normal skin and subcutaneous tissue. A solid hypoechoic lesion with irregular, lobulated margins, measuring 1.1/1.6/1.7 cm, was identified at the 10 o’clock position, 2 cm from the right nipple. Doppler ultrasound showed intra- and perilesional vascular signal. No calcifications were observed. No skin thickening or nipple retraction.

Left breast: no abnormalities.

Axilla: thickening of lymph nodes in the right axillary extension was observed.

Based on the ultrasound findings, fine-needle aspiration biopsy (FNAB) was indicated.

2. FNAB (29 April 2025)

Macroscopic: three punctures were performed at the level of the right breast nodule.

Microscopic: samples contained a large number of pleomorphic ductal cells with an increased nucleus-to-cytoplasm ratio, irregular nuclear membranes, and coarse chromatin. Most cells showed prominent nucleoli, and were arranged in dense clusters, while others were arranged in acinar patterns. Numerous normal and abnormal mitotic figures were observed.

Conclusion: cytomorphology revealed the presence of infiltrative breast carcinoma with a tendency toward high grade.

Following the cytomorphological diagnosis, the staging investigations were completed with contrast-enhanced computed tomography (CT) of the head, thorax and abdomen.

3. CT scan of the head, thorax and abdomen with contrast (22 May 2025)

Thorax: an iodophilic mass with poorly defined margins measuring 20/17 mm was identified in the upper-outer quadrant of the right breast, suggestive of malignant tumor substrate. Suspicious right intramammary lymphadenopathy in the upper-outer quadrant, measuring 11/10 mm, and right axillary lymph nodes, measuring 15/8 mm, were also noted.

After returning to Romania, the patient requested a second opinion. Mammography and ultrasound were repeated, and a histopathological examination was performed on samples obtained through core-needle biopsy.

4. Mammography (5 June 2025)

Breasts with homogeneous increased density. No suspicious microcalcifications, opacities or architectural distortions. Focal density asymmetry in the union of the external quadrants, approximately supero-external, due to the presence of a dense nodular plaque measuring 2.49/2.32 cm, with poorly defined margins. Bilateral glandular tissue extension into the axilla. Intensely opaque right axillary lymph nodes. BIRADS 4B.

5. Ultrasound (6 June 2025)

Right upper-outer quadrant at 2 cm from the nipple: a hypoechoic, heterogeneous lesion measuring 1.42/1.74/2.32 cm, with partially irregular contour.

Right axilla: hypoechoic heterogeneous image measuring 0.61/0.92/0.72 cm, with irregular contour.

Left breast: no solid or cystic lesions.

Left axilla: lymph nodes with lipomatous degeneration, long axis 1.8 cm.

BIRADS 5 right breast.

Conclusions

• Ultrasound abnormality suspicious for neoplasia in the right upper-outer quadrant.
• Ultrasound abnormality suspicious for neoplasia in the right axilla.

6. Histopathological examination (6 June 2025)

Two samples were obtained: one from the breast nodule and one from the axillary lymph nodes. Immunohistochemical examination was also performed. Final diagnosis: triple-negative infiltrating ductal carcinoma. At this point, staging was established as: stage II (T2 N0 M0).

Therapeutic intervention

1. Neoadjuvant chemotherapy

The patient underwent neoadjuvant chemotherapy according to oncological protocols, with a favorable clinical response. After completion of systemic therapy and multidisciplinary oncological board evaluation, surgical intervention was recommended.

• Paclitaxel, a cytotoxic agent from the taxane class, inhibits microtubule depolymerization, thereby blocking cell division.
• Carboplatin, a platinum-based alkylating agent, produces DNA damage in tumor cells, and is particularly effective in TNBC, especially in patients with genomic instability or BRCA mutations, increasing the rate of pathological complete response.
• Pembrolizumab, an anti-PD-1 monoclonal antibody, activates the antitumor immune response by blocking immune evasion mechanisms of neoplastic cells. Its association with chemotherapy has a synergistic effect, increasing tumor lymphocytic infiltration and therapeutic efficacy.

This combination is frequently used in the neoadjuvant setting, and it is associated with increased pathological complete response rates and improved event-free survival, representing a major advancement in the management of triple-negative breast cancer.

The patient initiated the therapy with paclitaxel and carboplatin on 1 July 2025 (first session), returning on 23 July for the addition of pembrolizumab (second session).

Subsequently, the patient continued chemoimmunotherapy on 22 September 2025 (third session) with pembrolizumab, paclitaxel and carboplatin, with the recommendation to return to the clinic on 13 October 2025.

On 13 October 2025, the treatment was continued (fourth session) with pembrolizumab and carboplatin only, due to the lack of paclitaxel and docetaxel in the hospital pharmacy; the patient was advised to return on 3 November 2025.

On 19 November 2025, the patient returned for the fifth session, when pembrolizumab, docetaxel and carboplatin were administered, with the recommendation to return on 10 December 2025.

On 19 December 2025, the last chemotherapy session (sixth session) before surgery was administered. The patient received pembrolizumab, docetaxel and carboplatin, and she was scheduled to return after the surgical intervention with the histopathological result.

Subsequent chemoimmunotherapy sessions continued according to schedule, with the final preoperative chemotherapy session administered on 19 December 2025, consisting of pembrolizumab, docetaxel and carboplatin.

To assess the effect of neoadjuvant therapy and establish the surgical plan, a cerebral and thoraco-abdo­mino-pelvic CT scan was performed on November 11^th, 2025. Imaging confirmed the absence of distant metastases and demonstrated a favorable evolution under neoadjuvant therapy, with tumor size reduced to 7.7/5.4 mm.

2. Surgical treatment

Considering the early stage of the disease, the surgical indication was subcutaneous mastectomy with right axillary lymphadenectomy, followed by reconstruction using B-Lite implants with a volume of 495 cc, each implant being wrapped with Braxon acellular dermal matrix.

The Braxon dermal matrix was prepared according to the manufacturer’s protocol, and it was used to create a complete implant coverage, ensuring stability, optimal tissue support and uniform distribution of tension on the skin flaps. The implant was placed prepectorally.

As for the most recent literature in oncoplastics, immediate implant-based reconstruction in the prepectoral plane has emerged as an increasingly utilized approach in selected breast cancer patients, due to its potential to preserve chest wall anatomy and reduce morbidity associated with muscle manipulation. The use of acellular dermal matrices (ADM) may provide additional implant support and facilitate prosthetic positioning while contributing to adequate soft-tissue coverage. Careful patient selection, assessment of mastectomy flap quality and multidisciplinary planning remain essential factors in achieving favorable reconstructive and oncological outcomes⁽⁶⁾.

Evolution and results

The postoperative course was favorable, with no early or late complications. No infections, skin necrosis or bleeding were recorded.

At the postoperative evaluation performed two months after surgery, the patient presented well-healed surgical wounds, without signs of dehiscence, infection or other local complications.

Postoperative scars were well formed, without erythema, edema or pathological secretions. The patient reported no pain at rest or on palpation, and the postoperative evolution was favorable, with satisfactory functional and esthetic results.   

Corresponding author: Mircea-Bogdan Măciuceanu-Zărnescu E-mail: bmaciuceanu@gmail.com

Conflict of interest: none declared.

Financial support: none declared.

This work is permanently accessible online free of charge and published under the CC-BY licence.