The MammaClinic

J. Apffelstaedt

Locally Advanced Breast Cancer

Aspects of Surgical ManagementJ. Apffelstaedt

The MammaClinicCape Town, South Africa

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The MammaClinic

J. Apffelstaedt

"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 OperabilityBulky axillary disease Skin Manifestations:

EdemaUlcerationSatellite NodulesFixation

Chest Wall FixationInflammatory 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 hererogenicityHermanek 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

Stage:I: 10 %II: 30%III: 30%IV: 30%

LABC Correlated with:Poverty Educational statusAge

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

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 n Local Control Abdel-Wahab et al(48) 13 69%Lopez et al(69) 17 76%Olson et al(41) 148 76%Surgery and Radiotherapy n Local Control Abdel-Wahab et al(48) 42 93%Cavanese et al(26) 60 70%Hortobagyi et al(14)** 176 79-100%Perez et al(42) 81 80%Karlsson(62) 128 80%Merajver et al(31) 89 72-77%Morell et al(23) 55 89%Brito et al(11) 70 81%Graham et al(67) 175 78-80%Olson et al(41) 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

survivalCMF < 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

The MammaClinic

J. Apffelstaedt

The MammaClinic

J. Apffelstaedt

The MammaClinic

J. Apffelstaedt

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J. Apffelstaedt

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The MammaClinic

J. Apffelstaedt

Radical Procedures 113 patientsStage IIIBRadical mastectomiesMyocutaneous flapRT91 % local control

Survival

0%

20%

40%

60%

80%

100%

0 1 2 3 4 5 6 7 8 9 10

Years

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 Surgery essential part of therapy Hormonal therapy underutilized Challenges:

Breast Conservation Breast Reconstruction Selective Management of the Axilla

Increasing Awareness