Rescue Mastectomy in a Patient With Locally Advanced Triple-Negative Breast Cancer and Severe Biochemical Hypothyroidism: A Multidisciplinary Ethical and Surgical Dilemma.

Severe hypothyroidism is traditionally considered a contraindication to elective major surgery due to the risk of perioperative metabolic decompensation and myxedema coma. However, in oncologic settings, delaying surgery may result in irreversible loss of resectability and adverse outcomes. Evidence guiding surgical decision-making in patients with advanced cancer and severe endocrine dysfunction remains limited. We report the case of a patient with triple-negative breast cancer initially staged as IIA who discontinued neoadjuvant chemotherapy and subsequently developed rapid locoregional progression to stage IIIB. Despite reinduction with chemotherapy and immunotherapy, the tumor remained refractory, and rescue mastectomy was indicated as the only remaining oncologic option. Preoperative assessment unexpectedly revealed severe biochemical hypothyroidism with markedly elevated thyroid-stimulating hormone levels and reduced free thyroxine, raising concern for perioperative metabolic decompensation and myxedema coma. Given the risk of permanent loss of operability associated with surgical delay and the prolonged time required to achieve full biochemical euthyroidism, a multidisciplinary decision was made to proceed with surgery after partial endocrine optimization using oral levothyroxine. Following extensive informed consent and anesthetic planning, rescue mastectomy with wide elliptical skin excision was performed without intraoperative or postoperative complications. The patient had an uneventful recovery, with negative surgical margins and no need for postoperative ventilatory support. This case highlights the challenges of managing severe biochemical hypothyroidism in time-sensitive oncologic surgery. When surgery represents the only viable therapeutic option, individualized multidisciplinary decision-making and shared risk assessment may justify proceeding despite incomplete metabolic optimization. Rescue surgery may be considered in carefully selected high-risk patients when the oncologic benefit outweighs the potential perioperative risk.