Multimodality therapy of stage III adenocarcinoma of the breast

Locally advanced noninflammatory breast cancer

Treatment of locally advanced noninflammatory breast cancer has changed markedly over the past 50 years. Haagensen's description of the clinical signs that define inoperable and operable tumors was the first realization that radical surgery alone could not cure the majority of women with locally advanced disease. Studies of the use of local therapy alone (surgery or radiation therapy) confirmed that most patients developed both distant metastatic disease and a high rate of local-regional failure. Combination surgery and radiation therapy regimens improved local control but did not influence long-term survival. The advent of successful multimodal regimens incorporating systemic treatment (chemotherapy or chemohormonal therapy) as well as local therapy (surgery and radiation) has significantly improved disease-free and overall survival as well as local-regional control. The benefits of neoadjuvant and adjuvant chemotherapy regimens have been debated. Neoadjuvant therapy allows clinical and pathologic assessment of tumor response to the chemotherapy regimen. In addition, local-regional control seems to be improved, and reductions in the size of the primary tumor allow breast-preserving procedures, even in patients initially not believed to be candidates for resection. Longer follow-up of these conservatively treated patients will be needed, however, to determine whether local-regional control is preserved.

Management of locally advanced breast cancer

The management of locally advanced breast cancer with single modality therapy has been associated with a high rate of systemic failure. A multimodality treatment strategy that includes induction cytotoxic chemotherapy, surgery, radiation therapy, and, possibly, hormonal ablation therapy is the current preferred management approach. As our knowledge and understanding of the mechanisms involved in mitogenic signal transduction improve, it is likely that less toxic, more efficacious agents will emerge.

Recent advances in the treatment of breast cancer

Multidisciplinary efforts have defined a number of prognostic factors and newer strategies to improve the outcome of patients with breast cancer. Conservative surgery has led to improved functional and cosmetic results. The development of a number of effective adjuvant regimens has led to improved survival. In patients with stage I disease, several biological characteristics of tumor have been identified that are associated with increased risk of relapse. A multimodality approach to patients with locally advanced disease and inflammatory cancer has resulted in improved survival. A number of hormonal and cytotoxic drug contaminations can palliate metastatic disease, with a small fraction of patients remaining in extended remission. Dose-intensive programs may lead to further improvements in survival of selected patients with this disease.

Results of initial doxorubicin, 5-fluorouracil, and cyclophosphamide combination chemotherapy for inflammatory carcinoma of the breast

Forty-three patients with nonmetastatic inflammatory breast carcinoma have been treated by initial doxorubicin, 5-fluorouracil, and cyclophosphamide (FAC) combination chemotherapy. After three chemotherapy cycles, responding patients underwent surgery. Chemotherapy was then completed for nine cycles of FAC followed by locoregional radiation therapy. All patients received tamoxifen 40 mg/day for 1 year from the time of diagnosis. Thirty-eight patients (88%) had a clinical response to chemotherapy and underwent surgery. On histologic examination 17 patients had a residual tumor mass less than 1 cm diameter or a complete tumor disappearance; lymph nodes dissection was negative in 15 patients. With a median follow-up of 48 months, the predicted 5-year disease-free survival (DFS) is 48% (median DFS, 46 months). Analysis of prognosis factors shows that age, menopausal status, and histologic grade have no predictive value. The DFS and overall survival were significantly improved by the presence of hormonal receptors and a low number of positive lymph nodes (less than 4) at surgery. The most significant prognosis factor was the residual tumor mass after initial chemotherapy with an 80% predicted 5-year DFS for the responding patients versus 30% for the no responding patients (P less than 0.001).

Locally advanced breast cancer current status and future directions

Patients described as having locally advanced breast cancer comprise a heterogeneous group of patients with variable clinical presentations. Systematic evaluation of patients with these presentations has been limited, with much of our current understanding based on retrospective reviews. Prospective pilot studies have demonstrated the feasibility of multimodality therapy. However, there have been few well-conducted randomized trials in this setting. Comparison of results among studies is made difficult by the varying eligibility criteria and the way in which the data are reported. The use of common and consistent definitions of operable and inoperable disease is necessary for a more uniform understanding of the therapeutic interventions necessary for a given patient within this broad category of Stage III or locally advanced breast cancer. There are a variety of opportunities for clinical research activities in this group of patients including tests of hormonal recruitment or synchronization, high dose chemotherapy requiring autologous bone marrow transplantation, perioperative or preoperative chemotherapy, and alternating chemotherapy with short course radiotherapy. The integration of clinical information with biological characteristics of the tumor such as cytokinetics, oncogene amplification, and hormone receptors will be an important and necessary focus of future investigation in this disease.

Prognostic significance of lymph node status in stage III breast cancer

Case histories of 103 patients with locally advanced (stage III) breast cancer have been reviewed. Ninety of the patients were judged operable. The median follow-up time was 52 months. The 5-year survival rate for the whole group was 54%. The 5-year relapse-free survival rates for the pN0, pN1 and pN2-3 were 91, 50 and 19% respectively and the 5-year survival rates for the groups were 86, 53 and 30% respectively. These results underline the heterogeneity and the very different prognoses for the different subgroups in stage III breast cancer patients. A reevaluation of the staging system is therefore suggested.