6% of CA breast in US presents as Stage III disease. Yield in early CA breast is 2-3% but in LABC it is 30%. Radical mastectomy in LABC led to dismal results. 5 yr local recurrence rates 46-72% and survival 16-30%.
6% of CA breast in US presents as Stage III disease. Yield in early CA breast is 2-3% but in LABC it is 30%. Radical mastectomy in LABC led to dismal results. 5 yr local recurrence rates 46-72% and survival 16-30%.
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as PPT, PDF, TXT or read online from Scribd
6% of CA breast in US presents as Stage III disease. Yield in early CA breast is 2-3% but in LABC it is 30%. Radical mastectomy in LABC led to dismal results. 5 yr local recurrence rates 46-72% and survival 16-30%.
Copyright:
Attribution Non-Commercial (BY-NC)
Available Formats
Download as PPT, PDF, TXT or read online from Scribd
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
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