Surgery for Locally Advanced Breast Cancer
Surgery plays a less important role in Stage III breast cancer. A large majority of patients with Stage III breast cancer will have axillary lymph node involvement, and a significant proportion will have distant metastases present at the time of diagnosis.
The primary aim of surgery in this setting is to achieve local control. Surgery alone has a high failure rate for locally advanced breast cancer, and the long-term survival rate is dismal. Features predicting poor outcome with surgery alone include skin edema, fixation and ulceration, and chest-wall fixation. The diagnosis is usually made using core needle biopsy.
Occasionally, incisional biopsy is needed, and skin biopsy will confirm the diagnosis of inflammatory breast cancer. Currently, the usual treatment involves the use of induction chemotherapy with an adriamycin-based regime, followed by surgery.
Primary chemotherapy has the advantage that the response to treatment can be monitored.
In addition, BCT may become possible after tumor downstaging. Further chemotherapy is used following the surgery if there was good response to the chemotherapy, and once the chemotherapy is complete, adjuvant radiation therapy may be used.
The best local control rates are seen with surgery and radiation therapy following induction chemotherapy.
Patrick I. Borgen and Bruce Mann
Breast conservation therapy for invasive carcinoma of the breast. Current Problems in Surgery 1995; 33:189-256.
References
- Veronesi U, Saccozzi R, Del Vecchio M et al. Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiation therapy in patients with small cancers of the breast. N Engl J Med 1981; 305:6-11.
This is the landmark report of the first randomized prospective trial of breast-conservation therapy. - Fisher B, Bauer M, Margolese R et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 1985; 312:665-73.
This is the first report of the major North American trial of breast-conservation therapy from the NSABP. - Borgen PI, Heerdt AS, Moore MP et al. Breast conservation therapy for invasive carcinoma of the breast. Current Problems in Surgery 1995; 33:189-256.
This is a review of all aspects of breast-conservation therapy. - Fisher B, Costantino J, Redmond C et al. Lumpectomy compared with lumpectomy and radiation therapy for the treatment of intraductal breast cancer. N Engl J Med 1993: 1581-6.
This is the major trial of conservative therapy for DCIS - Adair F, Berg J, Joubert L et al. Long-term follow-up of breast cancer: the 30-year report. Cancer 1974; 33:1145-50.
This is an older report from the days before adjuvant therapy that demonstrates the effectiveness of surgery in node-positive disease. - Fisher B, Redmond C, Fisher E et al. Ten year result of a randomized clinical trial comparing radical mastectomy and total mastectomy with of without irradiation. N Engl J Med 1985; 312:674-81.
This is a very influential trial that showed that less-extensive surgery had similar results to radical mastectomy. - Warmuth MA, Bowen G, Prosnitz LR et al. Complications of axillary lymph node dissection for carcinoma of the breast: a report based on a patient survey. Cancer 1998; 83:1362-8.
This report gives a good idea of the range of complications after axillary dissection.