Surgical adjuvant treatment of locally advanced breast cancer

Prospective Evaluation of Response Outcomes of Neoadjuvant Chemotherapy in Locally Advanced Breast Cancer

Introduction Breast cancer is a global health problem, with more than 1 million cases of breast cancer diagnosed worldwide each year, and is the most common cancer among Indian women. Locally advanced breast cancer (LABC) accounts for 10-20% in the Western world while in India it accounts for 40-50% of all cases. Locally advanced breast cancer is a very common clinical scenario especially in developing countries possibly due to various factors like lack of education and poor socioeconomic status. Women with the locally advanced disease require multimodality therapy and coordinated treatment planning. This study aimed to prospectively study the clinical profile of the LABC patients presenting to our institute and also to evaluate the role of neoadjuvant chemotherapy in downstaging the tumor. Materials and Methods Seventy patients diagnosed with locally advanced breast cancer were enrolled in this prospective study. After thorough preoperative workup, patients were either taken up for upfront surgery or neoadjuvant chemotherapy followed by surgery. Post chemotherapy clinical response of the tumor and postoperative histopathological evaluation of the specimen was performed. Results The mean age of the patients in our study was 45 years. Out of 70 patients, 18 underwent upfront surgery, and 52 received neoadjuvant chemotherapy followed by surgery. A total of 44 cases had a clinical response to chemotherapy with 9% having a complete response. The incidence of margin positivity in the postoperative specimen was significantly lower in patients who received neoadjuvant chemotherapy. Conclusion  Locally advanced breast cancer accounted for the predominant number of breast cancer patients mostly females in their middle age. Neoadjuvant chemotherapy was effective in downstaging the tumor in the majority of cases, although complete clinical response was lower in our study. The rate of margin positivity in mastectomy specimens can also be reduced if chemotherapy is considered prior to mastectomy.

Management of patients with locally advanced breast cancer

The indications and benefits of postmastectomy radiation therapy (PMRT) continue to evolve. Advances in systemic adjuvant therapy and targeted therapy for breast cancer are likely to play an increasingly important role in control of locoregional as well as distant disease. Ongoing scrutiny of patterns of chest wall failure will be required to define the net benefit derived from PMRT. This article discusses the 2001 American Society of Clinical Oncology guidelines for PMRT and current practices using PMRT in selected groups of patients who have breast cancer.

Locally advanced breast cancer in developing countries: the place of surgery

Most breast cancer patients in developing countries still present with locally advanced breast cancer (LABC). Because surgery is the most widely available treatment modality, we examine its place in the management of LABC. Historically, single local treatment modalities have had disappointing results, and multimodality therapy has become the norm for combatting LABC. Combining surgery and radiotherapy will lead to superior local control rates. Surgery should precede radiotherapy. Preoperative systemic treatment-with the possible exception of cyclophosphamide, methotrexate, 5-fluououracil (CMF) chemotherapy-does not influence surgical complication rates. Hormonal therapy is understudied and underutilized; its benefits become apparent only in prolonged follow-up. Sequencing of local and systemic treatments does not influence oncologic outcome, but failure to respond to preoperative systemic therapy may identify patients with a poor prognosis. With multimodality management including hormonal therapy, chemotherapy, radiotherapy, and surgery, local control rates of more than 80% and 5-year survival rates of more than 50% have become the norm.

Original p53 status predicts for pathological response in locally advanced breast cancer patients treated preoperatively with continuous infusion 5-fluorouracil and radiation therapy

PURPOSE/OBJECTIVE

1) To test feasibility of preoperative continuous infusion (c.i.) 5-Fluorouracil (5-FU) and radiation (RT) in locally advanced breast cancer. 2) To study clinical and pathological response rates of 5-FU and radiation. 3) To attempt preliminary correlations between biological probes and pathological response.

METHODS AND MATERIALS

Previously untreated, locally advanced breast cancer patients were eligible: only patients who presented with T3/T4 tumors that could not be resected with primary wound closure were eligible, while inflammatory breast cancer patients were excluded. The protocol consisted of preoperative c.i. infusion 5-FU, 200 mg/m2/day with radiotherapy, 50 Gy at 2 Gy fractions to the breast and regional nodes. At mastectomy, pathological findings were classified based on persistence of invasive cancer: pathological complete response (pCR) = no residual invasive cells in the breast and axillary contents; pathological partial response (pPR) = presence of microscopic foci of invasive cells in either the breast or nodal specimens; no pathological response (pNR) = pathological persistence of tumor. For each patient pretreatment breast cancer biopsies were analyzed by immunohistochemistry for nuclear grade, ER/PR hormonal receptors, her2/neu and p53 overexpression.

RESULTS

Thirty-five women have completed the protocol and are available for analysis. 5-FU was interrupted during radiation in 10 of 35 patients because of oral mucositis in 8 patients, cellulitis in 1, and patient choice in another. Objective clinical response rate before mastectomy was 71% (25 of 35 patients): 4 CR, 21 PR. However, in all 35 patients tumor response was sufficient to make them resectable with primary wound closure. Accordingly, all patients underwent modified radical mastectomy: primary wound closure was achieved in all patients. At mastectomy there were 7 pCR (20%), 5 pPR (14%) and the remaining 23 patients (66%) had pathological persistence of cancer (pNR). Variables analyzed as potential predictors for pathological response (pPR and pCR) were: initial TNM clinical stage, clinical response, nuclear grade, hormonal receptor status, p53 overexpression, and Her2/neu overexpression in the pretreatment tumor biopsy. Only initial p53 status (lack of overexpression at immunohistochemistry) significantly correlated with achievement of a pathological response to this regimen (p = 0.010).

CONCLUSION

The combination of c.i. 5-FU and radiation was well tolerated and generated objective clinical responses in 71% of the patients. With the limitation of the small sample size, the complete pathological response achieved (20%) compares favorably with that reported in other series of neoadjuvant therapy for similar stage breast cancer. These preliminary data suggest that initial p53 status predicts for pathological response (pPR and pCR) to the combination of c.i. 5-FU and radiotherapy in locally advanced breast cancer.

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.

Microvessel density and vessel invasion in lymph-node-negative breast cancer: effect on recurrence-free survival

Microvessel density (MVD) and blood and lymphatic vessel invasion (BLVI) were investigated with regard to their influence on the disease-free survival (DFS) in node-negative breast cancer patients. Paraffin embedded microsections of 230 patients with T1,2 N0 breast cancer were immunohistochemically stained for factor VIII-related antigen. Every cluster consisting of more than highlighted endothelial cells was considered a countable microvessel. MVD was counted in 4 fields of 0.25 mm2 each. All MVD values are given as value for the sum of 4 fields of 0.25 mm2 each, that is, I mm2. BLVI was considered positive, when at least one tumor cell could be identified in a stained lumen. Out of 230 patients, 49 experienced local or distant recurrence and had a mean MVD of 72.4/mm2, whereas 181 patients who lived without recurrent disease had a mean MVD of 45.3/mm2. BLVI was negative in 6.2% of the cases with and in 93.8% of the cases without recurrent disease. BLVI was positive in 59.4% of the cases without and 40.6% of the cases with recurrent disease. MVD and BLVI remained the only significant prognostic factors of DFS in the Cox-Model. Tumor size, histological grade, and hormonal-receptor status were not prognostically relevant in the Cox-model. 10-year-DFS was 93.3% in BLVI-negative/MVD < or = 40/mm2 patients, 88.1% when MVD was high or BLVI was positive and 48.9% in BLVI positive/MVD < or = 40/mm2 patients. Our present data indicate that MVD and BLVI identify a very-low risk group among node-negative breast cancer patients, who will not benefit from systemic adjuvant therapy. MVD and BLVI should be used as stratification criteria in clinical trails on node-negative breast cancer patients.

Locally advanced breast cancer: defining an optimum treatment regimen

PURPOSE

This retrospective review examines response, local control and freedom from distant failure for patients with locally advanced breast cancer treated by chemotherapy and radiotherapy without routine surgery.

METHODS AND MATERIALS

67 patients were treated between January 1980 and December 1988 at Westmead Hospital, NSW, Australia. Median follow-up for surviving patients was 56 months. Four successive protocols evolved, each with three phases induction chemotherapy (adriamycin or novantrone, cyclophosphamide) (three cycles), radiotherapy then chemotherapy (cyclophosphamide, methotrexate, 5-fluorouracil) of progressively shorter duration. Radiotherapy and chemotherapy were concurrent in the fourth regimen.

RESULTS

Clinical complete response (disappearance of all known disease) after chemotherapy, radiotherapy and additional chemotherapy was 18%, 55% and 79% respectively. Seven additional patients subsequently underwent mastectomy (N = 2), local excision (N = 1) or a radiation boost (N = 4) for a total complete response rate of 90%. Twenty one patients (31%) failed to achieve a complete response (N = 7) or recurred locally (N = 14). The crude 2-year rate of local recurrence was 50% for tumors > 10 cm (N = 10) and 14% for smaller tumors (n = 57) and was not influenced by protocol. Two-year actuarial freedom from distant failure was 67% at 2 years.

CONCLUSION

Local control can be achieved for patients with locally advanced breast cancer with a primary tumor < 10 cm using chemotherapy and radiotherapy without routine mastectomy.

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.

Multimodal therapy in locally advanced breast carcinoma

Among 879 patients treated for breast cancer between 1975 and 1984, advanced disease was found in 125 (14%). A subgroup of 34 (4%) presented with untreated locally advanced disease without demonstrable distant metastases at the time of diagnosis (stage IIIB = T4abed, NX-2,MO). During the first 5 years (1975 through 1979), 17 patients were treated primarily with sequential radiotherapy and chemotherapy (Group A). From 1980 to 1984 (Group B), the management consisted of four courses of induction multi-drug chemotherapy followed primarily by mastectomy and additional chemotherapy. The mean follow-up for the most recent group (Group B) is 48 months. Follow-up was complete. While the local disease control rate was the same for both groups (76%), the survival was remarkably different. Group A patients experienced a median survival of 15 months, and only one survived 5 years. In Group B, the median survival was 56 months with nine patients (53%) alive between 40 and 76 months, seven (41%) of whom are 5-year survivors. While the overall mortality of patients with inflammatory breast cancer was greater in both groups when compared with the group with noninflammatory disease, the survival of patients in Group B was better than in Group A for both inflammatory and noninflammatory cancers (p less than 0.01). Estrogen receptor, nodal, and menopausal status did not influence survival. These data suggest that neoadjuvant chemotherapy improves survival for patients with stage IIIB breast carcinoma and delays the establishment or progression of distant metastases. Mastectomy is an important component in the treatment of this disease.

Locally advanced adenocarcinoma of the breast without distant metastasis treated with multimodal therapies

Locally advanced breast cancer has been treated with a variety of primary treatments with or without adjuvant therapies. This study combines radiation, chemotherapy, and surgery as a multimodal program for Stage III breast cancer. Radiation was started on day 1: 4600 rad were administered to the breast and 4500 rad were administered to the axilla and supraclavicular areas. Chemotherapy was started on day 1 with weekly intravenous injections of 5-fluorouracil (5FU) (300 mg/m2), methotrexate (15 mg/m2), vincristine (0.625 mg/m2), oral cytoxan (60 mg/m2), and prednisone (30 mg/m2 for two weeks, then 20 mg/m2 for two weeks, then 10 mg/m2 for two weeks). The 5FU, methotrexate, and cytoxan were given for 10 months postsurgery. This combination of modalities produced a complete remission in all 13 patients with Stage III breast cancer after two months of therapy. The median disease-free period was two years. The median survival was 44 months. This approach to the management of Stage III breast cancer is worthy of further investigation.