1. Locally Advanced Breast Cancer
Aspects of Surgical Management
J. Apffelstaedt
The MammaClinic
Cape Town, South Africa
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The MammaClinic
J. Apffelstaedt

2. 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

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

4. 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

5. 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

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

7. 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):
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):
=> Local control improved by surgery and radiotherapy Toonkel LM et al, Int.J Radiat.Oncol.Biol.Phys ;12(9):
The MammaClinic
J. Apffelstaedt

8. The MammaClinic J. Apffelstaedt Radiotherapy only n Local Control
Lopez et al(69) 17
76%
Perez et al(42)
200 %
Bartelink et al(35)*
373 %
Borger et al(63)
209
48%
Graham et al(67) 62 %
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

9. 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 ;15(6):486-9.)
=> Prefer Surgery followed by RT
The MammaClinic
J. Apffelstaedt

10. 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

11. 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 ;16(2):80-6).
=> Prefer preop. chemotherapy
The MammaClinic
J. Apffelstaedt

12. 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 ;34(5): ).
The place of radical procedures? (Hathaway CL et al: Arch.Surg ;129(6):582-7).
The MammaClinic
J. Apffelstaedt

13. The MammaClinic
J. Apffelstaedt

14. The MammaClinic
J. Apffelstaedt

15. The MammaClinic
J. Apffelstaedt

16. The MammaClinic
J. Apffelstaedt

17. The MammaClinic
J. Apffelstaedt

18. The MammaClinic
J. Apffelstaedt

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

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

21. 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