locally advanced breast cancer and inflammatory breast cancer€¦ · radiotherapy after...

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Conny Vrieling, MD, PhD Locally Advanced Breast Cancer and Inflammatory Breast Cancer

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Page 1: Locally Advanced Breast Cancer and Inflammatory Breast Cancer€¦ · Radiotherapy after neo-adjuvant chemotherapy and mastectomy •Should all patients with locally advanced breast

Conny Vrieling, MD, PhD

Locally Advanced Breast Cancer and Inflammatory Breast Cancer

Page 2: Locally Advanced Breast Cancer and Inflammatory Breast Cancer€¦ · Radiotherapy after neo-adjuvant chemotherapy and mastectomy •Should all patients with locally advanced breast

No Disclosures

Page 3: Locally Advanced Breast Cancer and Inflammatory Breast Cancer€¦ · Radiotherapy after neo-adjuvant chemotherapy and mastectomy •Should all patients with locally advanced breast

Role of postmastectomy radiotherapy

Year Patients FU (years)

Mastectomy +chemo

(or tam)

Mastectomy + chemo (or tam)

+ locoreg RT

Reference

British Columbia

1979 - 1986 318 20 OS 37%LRRFS 74%

47%90%

Ragaz, JNCI 2005

DBCG 82b and c

1982 - 1990 3,083 10 (b)10 (c)

18

OS 45%OS 36% LRR 49%

54%45%14%

Nielsen, JCO 2006

Page 4: Locally Advanced Breast Cancer and Inflammatory Breast Cancer€¦ · Radiotherapy after neo-adjuvant chemotherapy and mastectomy •Should all patients with locally advanced breast

Loco-regional control and survival benefit

Nielsen, JCO, 2006

Page 5: Locally Advanced Breast Cancer and Inflammatory Breast Cancer€¦ · Radiotherapy after neo-adjuvant chemotherapy and mastectomy •Should all patients with locally advanced breast

Risk group analysis

• 1000 patients, DBCG 82 b et c

• Median follow-up 17 years

• Good prognosis group (199 patients)– max 3 nodes +, tumor size < 2 cm, grade I, ER/PR +, Her2 neg– at least 4 out of 5 criteria

• Intermediate group (593 patients)

• Poor prognosis group (208 patients)– > 3 nodes +, tumor size > 5 cm, grade III– at least 2 out of 3 criteria

Kyndi, Radiother Oncol, 2009

Page 6: Locally Advanced Breast Cancer and Inflammatory Breast Cancer€¦ · Radiotherapy after neo-adjuvant chemotherapy and mastectomy •Should all patients with locally advanced breast

Risk group analysis

Kyndi, Radiother Oncol, 2009

Page 7: Locally Advanced Breast Cancer and Inflammatory Breast Cancer€¦ · Radiotherapy after neo-adjuvant chemotherapy and mastectomy •Should all patients with locally advanced breast

Radiotherapy after neo-adjuvant chemotherapy and mastectomy

• Should all patients with locally advanced breast cancer, following neoadjuvant chemotherapy, be treated with postoperative radiotherapy?

• Or, should this decision depend on the tumor response as found at the time of surgery?

Page 8: Locally Advanced Breast Cancer and Inflammatory Breast Cancer€¦ · Radiotherapy after neo-adjuvant chemotherapy and mastectomy •Should all patients with locally advanced breast
Page 9: Locally Advanced Breast Cancer and Inflammatory Breast Cancer€¦ · Radiotherapy after neo-adjuvant chemotherapy and mastectomy •Should all patients with locally advanced breast

Mamounas, JCO, 2012

Page 10: Locally Advanced Breast Cancer and Inflammatory Breast Cancer€¦ · Radiotherapy after neo-adjuvant chemotherapy and mastectomy •Should all patients with locally advanced breast

Int J Rad Oncol Biol Phys, 2007

Page 11: Locally Advanced Breast Cancer and Inflammatory Breast Cancer€¦ · Radiotherapy after neo-adjuvant chemotherapy and mastectomy •Should all patients with locally advanced breast

Prospective trial

• NSABP B-51/RTOG 1304

• A randomized phase III clinical trial evaluating post-

mastectomy chest wall/post-lumpectomy and regional nodal

radiotherapy in patients with positive axillary nodes before

neo-adjuvant chemotherapy who convert to pathologically

negative axillary nodes after neo-adjuvant chemotherapy

Page 12: Locally Advanced Breast Cancer and Inflammatory Breast Cancer€¦ · Radiotherapy after neo-adjuvant chemotherapy and mastectomy •Should all patients with locally advanced breast

Conclusions - who to treat?

• Patients with T3,N1 or T4 tumors

• Patients with 4 or more positive lymph nodes

• Consider postmastectomy radiotherapy for patients with 1 to 3 positive nodes

• Patients with LABC who are treated with neoadjuvant chemotherapy followed by mastectomy

• Positive resection margins

Page 13: Locally Advanced Breast Cancer and Inflammatory Breast Cancer€¦ · Radiotherapy after neo-adjuvant chemotherapy and mastectomy •Should all patients with locally advanced breast

Inflammatory breast cancer

In general:Start with neo-adjuvant chemotherapy

If patient is operable:Surgery and loco-regional radiotherapy

If patient is still inoperable:Radiotherapy, followed, if possible, by surgery

Page 14: Locally Advanced Breast Cancer and Inflammatory Breast Cancer€¦ · Radiotherapy after neo-adjuvant chemotherapy and mastectomy •Should all patients with locally advanced breast

Inflammatory breast cancer

Goal of radiotherapy:Improve locoregional control

A survival benefit has not definitely been proven

Technique: Wide margins!!