Locally Advanced Breast Cancer Aspects of Surgical Management J. Apffelstaedt The MammaClinic Cape Town, South Africa These Power Point presentations are free to download only for academic purposes, with due acknowledgements to authors and this website. The MammaClinic J. Apffelstaedt

Crypt of Giuliano de Medici, Church of San Lorenzo, Florence, Italy. "Night" by Michelangelo, 1524: Crypt of Giuliano de Medici, Church of San Lorenzo, Florence, Italy. Diagnosis: Stage IIIB breast cancer left The MammaClinic J. Apffelstaedt

Haagensen CD, Stout AP: Carcinoma of the Breast II - Criteria of Operability. Ann Surg 1943, 116: 1032. The MammaClinic J. Apffelstaedt

Criteria of Operability Bulky axillary disease Skin Manifestations: Edema Ulceration Satellite Nodules Fixation Chest Wall Fixation Inflammatory Carcinoma Haagensen CD, Stout AP: Carcinoma of the Breast II - Criteria of Operability. Ann Surg 1943, 116: 1032. The MammaClinic J. Apffelstaedt

TNM Stage III Disease Tumors > 5 cm with nodes Any tumor with N2/3 nodes Skin manifestations Chest wall fixation Inflammatory Carcinoma => Significant hererogenicity Hermanek P, Sobin LH. TNM classification of malignant tumours. International Union Against Cancer 1987; 4th Edition Berlin, Springer Verlag:93-9. The MammaClinic J. Apffelstaedt

Stage at presentation at The MammaClinic II: 30% III: 30% IV: 30% LABC Correlated with: Poverty Educational status Age The MammaClinic J. Apffelstaedt

What is the Place of Surgery? “Intensive chemotherapy can restore the majority of patients to “no evidence of disease”Booser D,. Semin.Oncol.1992;19(3):278-85. But: Complex, expensive regimens employed Pathologic complete responses <10% + Radiotherapy: Pathologic complete responses still <20% Shanta V et al: BC. Clin Oncol 1991;3(3):137-40. => Local control improved by surgery and radiotherapy Toonkel LM et al, Int.J Radiat.Oncol.Biol.Phys. 1986;12(9):1583-7. The MammaClinic J. Apffelstaedt

The MammaClinic J. Apffelstaedt Radiotherapy only n Local Control Lopez et al(69) 17 76% Perez et al(42) 200 31 - 91% Bartelink et al(35)* 373 39 - 66% Borger et al(63) 209 48% Graham et al(67) 62 31 - 47% Koning et al(55) 118 53-58% Surgery only Abdel-Wahab et al(48) 13 69% Olson et al(41) 148 Surgery and Radiotherapy 42 93% Cavanese et al(26) 60 70% Hortobagyi et al(14)** 176 79-100% 81 80% Karlsson(62) 128 Merajver et al(31) 89 72-77% Morell et al(23) 55 89% Brito et al(11) 70 81% 175 78-80% 164 85% The MammaClinic J. Apffelstaedt

Sequencing I: Radiotherapy and Surgery Radiotherapy followed by surgery: 25% wound infection 34% delayed healing 63% seroma 22% lymphoedema (Badr-el-Din et al: Local postoperative morbidity following pre-operative irradiation in LABC. Eur J Surg Oncol. 1989;15(6):486-9.) => Prefer Surgery followed by RT The MammaClinic J. Apffelstaedt

Chemotherapy Regimen pCR rate Long-term survival CMF < 10% 10 - 20% Anthracyclins 10 – 30% 20 – 40% A-Tax 30 – 40% 40 – 60% The MammaClinic J. Apffelstaedt

Sequencing II: Chemotherapy and Surgery Complications not increased with anthracyclins nor taxanes (Broadwater JR et al. Ann Surg 1991;213(2):126-9). Own experience: Infections in MTX regimens tripled Oncologic outcome not affected (Cunningham JD et al. Cancer Invest. 1998;16(2):80-6). => Prefer preop. chemotherapy The MammaClinic J. Apffelstaedt

Extent of Surgery Place of Sentinel Node Procedures Omission of axillary dissection (Kuerer HM et al. Am J Surg 1998;176(6):502-9). Breast Conservation (Touboul E et al. Int.J Radiat.Oncol.Biol.Phys. 1996;34(5):1019-28). The place of radical procedures? (Hathaway CL et al: Arch.Surg. 1994;129(6):582-7). The MammaClinic J. Apffelstaedt

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Radical Procedures 113 patients Stage IIIB Radical mastectomies Myocutaneous flap RT 91 % local control The MammaClinic J. Apffelstaedt

Breast Reconstruction Added morbidity minimal Avoid Prostheses (Sultan MR et al. Ann Plast Surg 1997;38(4):345-9). The MammaClinic J. Apffelstaedt

Conclusions Increasing Awareness Surgery essential part of therapy Hormonal therapy underutilized Challenges: Breast Conservation Breast Reconstruction Selective Management of the Axilla Increasing Awareness The MammaClinic J. Apffelstaedt