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Presentation Guidelines
Agarwal
Prof. P. N.
Carcinoma
Locally Advanced Breast
What is LABC ?
• Bulky primary breast tumors and/or extensive
adenopathy
• Includes T3/T4 & N2/N3 disease.
• Now includes isolated supraclavicular metastasis
• 6% of CA breast in US presents as Stage III
disease.
• In review of CA breast pts. in LNJP, >60% pts.
presented as LABC
Diagnostic Work Up

• Fine needle aspiration cytology


• Core biopsy - to confirm invasion, ER/PR
& Her-2-Neu status
• Diagnostic open biopsy if core biopsy
nondiagnostic
• Punch biopsy if skin involvement
• If adenopathy, FNAC of L.N. for staging
Diagnostic Work Up (contd.)

• Bilateral Mammography - multicentric


disease is a contraindication to BCT

• Axillary USG - for nodal status & image


guided FNA (20% false negative results).
Metastatic work up
• Baseline bone scan
• Chest, abdomen & pelvic CT scans are
recommended for detection of metastasis
• Directed radiographs to sites of new bone
pains.
• CT head for new neurological symptoms.
• Yield in early CA breast is 2-3% but in
LABC it is 30%
Evolution of Treatment
• Haagensen & Stout - radical mastectomy in
LABC led to dismal results
• Reported 5 yr local recurrence & survival
rates of 46% & 6%.
• They defined inoperable LABC -
Extensive breast skin edema/satellitosis,
Intercostal/parasternal nodules,
Arm edema,
Supraclavicular metastasis, or
Evolution of Treatment

• Therapeutic doses of chest wall irradiation


also gave poor results- 5 yr local recurrence
rates 46-72% & survival 16-30%

• Combined treatment with radiation +


surgery also failed.
Chemotherapy

• Neoadjuvant / Induction chemotherapy


revolutionized LABC care.
• Early concerns were - surgical complication
rate, prognostic value of axillary staging &
overall survival after delayed surgery.
• It has been shown that neoadjuvant therapy
does not worsen survival but improves
resectability.
Optimum Pre-op. Chemotherapy
• NSABP - 27 study preliminary results
reveal pCR of 26% with addition of
docetaxel.

• The Aberdeen trial compared 8 cycles of


chemotherapy - Doxorubicin based ( pCR
16%) and Doxorubicin + docetaxel ( pCR
34% ).
Optimum Pre-op. Chemotherapy

• Optimal chemotherapy for CA breast


consists of 4-8 cycles of chemotherapy with
2 of major drugs ( Doxorubicin + Taxanes)
included in each cycle. ( Bull Cancer 2006
Nov1;13(11):1121-9 ).
Current Treatment

• Currently, optimal control is achieved with


preoperative chemotherapy followed by
surgery & radiotherapy.
• Doxorubicin based CT is the most widely
used induction regime.
• 30% pCR has been reported with preop.
Doxorubicin, Cytoxan, 5-FU & weekly
Taxol.
Component 5 yr local 5 yr survival
Rx approach s recurrence

Single modality Surgery 46% 6%

XRT 50% 35%


Dual Modality XRT  Sx 70% 30%
Sx XRT 70% 32%
CT  Sx 18% 49%
CT  XRT 36% 35%
Sx  CT 20% 65%
Triple Modality CT  Sx  5-9% 64-89%
XRT

Sx CT  9% 66%
XRT
Hormonal Therapy

• Neoadjuvant endocrine therapy for ER+


LABC is also an active area of research.

• 3- 4 months of therapy are preferred for an


adequate response assessment

• Aromatase inhibitors like Letrozole are


more effective than Tamoxifen.
Breast Conservation Therapy

• Criteria for BCT in postneoadjuvant LABC:


• Patient desire for breast preservation
• Absence of multicentric disease
• Absence of diffuse microcalcifications
• Absence of skin involvement consistent with
inflammatory breast cancer
• Residual tumor mass amenable to a margin-
negative lumpectomy resection
BCT (contd.)

• Several prospective RCTs have confirmed


acceptable rates of local recurrence among
LABC pts undergoing BCT after NACT.

• The NSABP B-18 investigators did note a


trend toward higher local recurrence rates
among patients requiring preoperative
downstaging in order to become
lumpectomy eligible (15% versus 7%).
Immediate Breast Reconstruction

• LABC traditionally has been perceived as a


contraindication to IBR.
• Newman found no adverse effects on
surgical complication rate / adjuvant
chemotherapy
• IBR with implants was associated with
more RT related complications, nearly half
necessitating removal of implants.
IBR (Contd.)

• Delayed reconstruction is usually preferred


in LABC as PMRT is mostly required.

• For extensive chest wall defect at


mastectomy, LD flap is the most common
approach - provides durable, radiation
tolerant coverage.
Locoregional Irradiation

• Pts. who have at least 4 metastatic lymph


nodes
• 5 cm of residual disease in the breast after
chemotherapy
• All lumpectomy patients require breast
irradiation
PMRT (Contd.)

• A conservative approach is to recommend


radiation to all patients that present with
LABC
• However, patients with little or no residual
breast/axillary disease after chemotherapy
may not derive a significant benefit from
regional nodal irradiation
• Existing data is limited in this aspect.
Postoperartive Systemic Therapy

• Hormone receptor positive breast cancer


should receive at least 5 years of either
tamoxifen or an aromatase inhibitor
• Aromatase inhibitors given only to
postmenopausal females
• Tumors overexpressing HER2/neu require
adjuvant Trastuzamab
Locoregional recurrences

• Chest wall recurrence is a grave event


indicating aggressive tumor biology.

• Managed with aggressive resection

• 5 yr survival was 35% - 47%


Standard Of Care

• Presently, the standard therapy is NACT


followed by surgery ( mastectomy/BCT )
and PMRT & endocrinal therapy as
indicated in a particular case.
• This has led to 5 yr. local recurrence rate of
5 - 9% and survival of 64 - 89%.
Overall survival curves for patients with inflammatory breast cancer
undergoing combined modality treatment according to whether a
pathologic complete response (Path CR) was achieved based on the
pathologic findings at the time of mastectomy. Int J Radiat Oncol Biol
Phys 2003;55:1200.
THANK YOU

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