Breast conservation in Locally advanced breast cancer

Department of Endocrine Surgery

College of MedicineAmrita Institute of Medical Sciences

Kochi, Kerala.

S. Vaidyanathan

These Power Point presentations are free to download only for academic purposes, with due acknowledgements to authors and this website.

• BCT in LABC not a standard procedure

• Strategies being evolved

Neoadjuvant Chemotherapy (NACT)

• Heralded as future of breast cancer treatment. (NSABP18 and EORTC trials)

• FAC/Anthracycline related groupsPositive tumor responseDown staged tumorMastectomy / BCT No survival benefit

NACT- facts

Fact• Need for Mastectomy reduced• Clinical response important

predictor of response• p CR of primary and nodes

predicts outcome• Does not offer survival benefit• Does not increase risk of local

recurrence

Level of evidence• Level I• Level I

• Level I

• Level I• Level II

Sequence in LABC

• Neoadjuvant chemotherapy

• Locoregional surgery – Mastectomy / BCT

• Completion chemotherapy

• Locoregional RT (?)

• Tamoxifen if ER +ve

BCT in LABC - the evidence

• 120 patients LABC – non inflammatory

• 4 courses of induction CT

• Preoperative RT• 5th course of anthracycline

(Le Rouge, Touboul et al. J.Radiation Oncology, biology and physics;2004: 59:1069-53)

Evidence -contd

• Mastectomy + AD – Residual tumor > 3 cm, central, bifocal – 49

• BCS + AD+ boost to excision site - Residual tumor < 3cm – 39

• Radiation to tumor bed -Complete clinical response / Partial response over 90% - 32

Evidence outcome

Mastectomy Group

BCS group RT group

10 yr local recurrence

4% 23% 13%

Conclusion : BCS feasible in LABC but associated with high local recurrence

BCS in LABC High local recurrence

• Clinical response vs Pathologic complete response. 80% - 15%.(Fischer et al , J.of Oncology.1998:16; 267-85)

• Therapy induced tumor regression – patchy and not concentric

• Volume of tissue resected smaller than volume of original tumor. Davidson and Morrow, J. National cancer institute. 2005: 97;159-60

Pathological response

1. Complete response – (p CR) –no residual invasive cells in the breast and axillary contents

2. Partial response – (p PR) –less than 10 microscopic foci of invasive cells

3. No response –( p NR)- All other cases

BCS in LABCStrategies to Improve outcome

• Improve pathological response

- concurrent chemoradiation

- Taxanes – Single / Sequential

• Dannenburg and Formenti trialsImprovement of pathological

response

Predictors of therapeutic response

• Dynamic MRI

• Stereotactic localization of tumor margins

• Molecular markersto choose chemotherapy - p53 negative – 5FU/ RT

-HER -2 neu negative – Paclitaxel /RT

Current recommendations for Surgery in LABC

• Initial tumor size < 6 cm

• Post NACT tumor size < 3 cm• Without extensive nodal disease

(Le Rouge, Touboul et al. J.Radiation Oncology, biology and physics;2004: 59:1069-53)

LABC - surgical optionsRecommendations of Tata Memorial Hospital

• Complete response –Clinical/ mammogram Index Quadrantectomy+AD

• Partial response –Radiological residual disease# BCT + AD# Simple mastectomy + AD

• Static / Progressive disease # SM + AD # Reconstruction for skin cover # Post op radiation

• Inoperability RT – reassess for excision

Conclusions

• Multimodal therapy - new hope for patients with LABC

Caution with aggression !