1. Breast conservation in Locally advanced breast cancer Department of Endocrine Surgery College of Medicine Amrita Institute of Medical Sciences Kochi, Kerala. S. Vaidyanathan These Power Point presentations are free to download only for academic purposes, with due acknowledgements to authors and this website.

3. BCT in LABC not a standard procedure Strategies being evolved

4. Neoadjuvant Chemotherapy (NACT) Heralded as future of breast cancer treatment. (NSABP18 and EORTC trials) FAC/Anthracycline related groups Positive tumor response Down staged tumor Mastectomy / BCT No survival benefit

5. NACT- facts Fact Need for Mastectomy reduced Clinical response important predictor of response p CR of primary and nodes predicts outcome Does not offer survival benefit Does not increase risk of local recurrence Level of evidence Level I Level II

6. Sequence in LABC Neoadjuvant chemotherapy Locoregional surgery – Mastectomy / BCT Completion chemotherapy Locoregional RT (?) Tamoxifen if ER +ve

7. BCT in LABC - the evidence 120 patients LABC – non inflammatory 4 courses of induction CT Preoperative RT 5 th course of anthracycline (Le Rouge, Touboul et al. J.Radiation Oncology, biology and physics;2004: 59:1069-53)

8. Evidence -contd Mastectomy + AD – Residual tumor > 3 cm, central, bifocal – 49 BCS + AD+ boost to excision site - Residual tumor < 3cm – 39 Radiation to tumor bed - Complete clinical response / Partial response over 90% - 32

9. Evidence outcome Mastectomy Group BCS groupRT group 10 yr local recurrence 4%23%13% Conclusion : BCS feasible in LABC but associated with high local recurrence

10. BCS in LABC High local recurrence Clinical response vs Pathologic complete response. 80% - 15%. (Fischer et al, J.of Oncology.1998:16; 267-85) Therapy induced tumor regression – patchy and not concentric Volume of tissue resected smaller than volume of original tumor. Davidson and Morrow, J. National cancer institute. 2005: 97;159-60

11. Pathological response 1. Complete response – (p CR) – no residual invasive cells in the breast and axillary contents 2. Partial response – (p PR) – less than 10 microscopic foci of invasive cells 3. No response –( p NR)- All other cases

12. BCS in LABC Strategies to Improve outcome Improve pathological response - concurrent chemoradiation - Taxanes – Single / Sequential Dannenburg and Formenti trials Improvement of pathological response

13. Predictors of therapeutic response Dynamic MRI Stereotactic localization of tumor margins Molecular markers to choose chemotherapy - p53 negative – 5FU/ RT -HER -2 neu negative – Paclitaxel /RT

14. Current recommendations for Surgery in LABC Initial tumor size < 6 cm Post NACT tumor size < 3 cm Without extensive nodal disease (Le Rouge, Touboul et al. J.Radiation Oncology, biology and physics;2004: 59:1069-53)

15. LABC - surgical options Recommendations of Tata Memorial Hospital Complete response –Clinical/ mammogram Index Quadrantectomy+AD Partial response –Radiological residual disease # BCT + AD # Simple mastectomy + AD Static / Progressive disease # SM + AD # Reconstruction for skin cover # Post op radiation Inoperability RT – reassess for excision

16. Conclusions Multimodal therapy - new hope for patients with LABC Caution with aggression !