Management of early and locally advanced breast cancer

Abhilash

Early breast cancer

• Stage I

• Stage II A

• Subset of Stage II B (T2N1)

Locally advanced breast cancer• Stage II B

• Stage IIIA to IIIC

Early breast cancer

Primary Surgery for breast and regional nodes–Lumpectomy or Mastectomy +/-RT

• BCSMastectomy

Adjuvant treatment if needed based on tumor characteristics.

• Tumor size

• Tumor grade

• ER/PR/HER2

• LN status

Breast conserving surgery

• To preserve the breast without sacrificing oncological outcome

BCS= LUMPECTOMY + adjuvant RT

Goals of BCS1. Cosmetically acceptable2. Survival comparable to mastectomy3. Low recurrence rates

Patient selection for BCS

• Comorbid conditions/ Age is not a contraindication.

• Nipple, skin retraction is not a contraindication – but resection of NAC should be factored in decision making.

• Extensive intraductal component is not a contraindication.

• Lymph node positivity is not a contraindication.

• Tumor location is not a contraindication.

• Not contraindicated in dense breast tissue.

• Large tumor in a small breast is a relative contraindication

• Collagen vascular disease is a contraindication.

Absolute contraindication for BCS

●Multicentric disease

●Large tumor size in relation to breast

●Presence of diffuse malignant-appearing calcifications on imaging (ie, mammogram or MRI)

●Prior history of chest wall RT

●Persistently positive margins despite attempts at re-excision

Role of neoadjuvant therapy in BCS

• Chemotherapy or hormonal therapy to reduce size of the tumor

• Clip placement in tumor bed.

• Not to be considered if multicentric with extensive skin changes and dermal lymphatic involvement.

Indications for mastectomy in early breast cancer

• Not a candidate for BCS.

• Patient choice.

Adjuvant therapy in early breast cancer

Adjuvant chemotherapy

Locally advanced breast cancer

Goal of neoadjuvant chemotherapy

• Reduce risk of distant recurrence.

• Improve surgical outcome in patients

– Inoperable disease.

– Operable disease desiring breast conservation

Candidates for neoadjuvanttherapy

• T4 lesions.

• HER2 positive – high pCR to NACT with transtuzumab.

• Triple negative disease – High pCR rates compared to HER2 negative ER/PR+ (27-45% vs 10%)

• Breast cancer in pregnancy.

• Early disease if BCS not possible due to small breast.

Pretreatment evaluation before NACT

• Core biopsy – ER/PR/HER2

• Radio-opaque clips to be placed for subsequent assessment of surgical specimen and for RT planning.

• Metastatic workup.

• Axillary node evaluation and staging has to be done. SLNB/axillary US with FNA - to be done if no palpable nodes or FNA from palpable node is negative.

Neoadjuvant treatment options

• Triple negative disease – NACT BCS/mastectomy.

• Post menopausal women – if not a candidate for chemo/surgery Hormonal therapy.

• HER2 positive – NACT + transtuzumab

Neoadjuvant endocrine therapy

• Aromatase inhibitor or tamoxifen

• 4-6 months.

• May be as effective as NACT in postmenopausal women.

Adjuvant RT

• For all BCS

• For post total mastectomy with high risk of recurrence.

1. Positive margins,

2. lymphovascular invasion,

3. >4 axillary nodes with tumour,

4. size > 5 cm

5. high grade tumour.

Adjuvant chemotherapy

• Lymph nodes positive

• Tumour > 1 cm

• Grade 2 or 3

• ER/PR negative

Adjuvant therapy

• If post NACT Surgery –

– ER/PR + , hormonal therapy

– ER/PR - ,Chemotherapy

– HER2 , transtuzumab

• If post neoadjuvant endocrine therapySurgery endocrine therapy +/- NACT

Hormone therapy based on menopausal status

Follow-up