Stage IIIB triple-negative breast cancer: complete response after LVAD-supported neoadjuvant immunotherapy

What happened, in summary

This 63-year-old woman was transferred for advanced heart failure evaluation after an anterior ST-segment elevation myocardial infarction led to cardiogenic shock, severe left ventricular dysfunction, and inability to come off dobutamine after multivessel coronary intervention. During the inpatient workup for heart transplantation or durable support, mammography found a suspicious right breast mass, and ultrasound also showed an abnormal right axillary lymph node. Biopsy confirmed invasive ductal carcinoma with right axillary node involvement. The tumor was triple-negative: ER-negative, PR-negative, and HER2-negative. Ki-67 was very high at 95%, and nuclear grade was 3. She was diagnosed with Stage IIIB ductal carcinoma. Her heart disease had to be stabilized before curative-intent cancer treatment could begin. Eight days after transfer, she underwent HeartMate 3 LVAD implantation as destination therapy. After rehabilitation, she started neoadjuvant paclitaxel, carboplatin, and pembrolizumab. Doxorubicin and cyclophosphamide were omitted because of underlying cardiomyopathy. Treatment was well tolerated apart from fatigue. Six months after LVAD implantation, she underwent right total mastectomy with right axillary sentinel lymph node biopsy in a cardiac operating room with coordinated cardiac and breast surgery teams. A postoperative hematoma required exploration and removal of 200 mL of clotted blood. Pathology showed complete response to neoadjuvant therapy, with no residual malignancy. She then completed radiation therapy and 1 year of adjuvant pembrolizumab. As of July 2025, her breast cancer remained in remission 2.5 years after mastectomy, and she had no heart failure hospitalizations 3 years after LVAD implantation. The case is notable for sequencing curative-intent triple-negative breast cancer care around durable cardiac mechanical support.