Locally advanced breast cancer: is surgery warranted following chemotherapy?

Breast surgery after neoadjuvant treatment. Is it necessary?

The optimum management of women with advanced loco-regional breast cancer (T3-4, N1-2) is controversial. Neoadjuvant therapy in the form of chemotherapy and or radiotherapy is popular and results in an encouraging local response in over 70% of patients. However, should subsequent surgery (either mastectomy or breast conservation treatment) be undertaken in women who respond? We present a prospective evaluation of 15 patients with T3-4, N1-2 tumours (including 1 bilateral cancer) who underwent mastectomy after achieving a complete clinical response to neoadjuvant treatment. All patients had 6 cycles of chemotherapy and 10 also received 50 Gy radiotherapy. In addition to clinical examination, the response to neoadjuvant treatment was assessed by mammography (in all cases) and by magnetic resonance imaging (MR) (in eight patients). Careful histopathological assessment of the breast was undertaken to determine the extent of residual disease. In all patients histological malignancy was recognized within the breast. The size varied from 0.6 to 6.5 cm in maximum diameter with three grade I, eight grade II and five grade III tumours. Axillary lymph nodes were positive in seven patients. In conclusion, surgery is indicated for control of residual disease in locally advanced breast cancer regardless of the response to neoadjuvant treatment. Our preliminary observations suggest a potential role for breast MR in defining the extent of residual disease which may aid in the planning of surgery.