Conny Vrieling, MD, PhD
Locally Advanced Breast Cancer and Inflammatory Breast Cancer
No Disclosures
Role of postmastectomy radiotherapy
Year Patients FU (years)
Mastectomy +chemo
(or tam)
Mastectomy + chemo (or tam)
+ locoreg RT
Reference
British Columbia
1979 - 1986 318 20 OS 37%LRRFS 74%
47%90%
Ragaz, JNCI 2005
DBCG 82b and c
1982 - 1990 3,083 10 (b)10 (c)
18
OS 45%OS 36% LRR 49%
54%45%14%
Nielsen, JCO 2006
Loco-regional control and survival benefit
Nielsen, JCO, 2006
Risk group analysis
• 1000 patients, DBCG 82 b et c
• Median follow-up 17 years
• Good prognosis group (199 patients)– max 3 nodes +, tumor size < 2 cm, grade I, ER/PR +, Her2 neg– at least 4 out of 5 criteria
• Intermediate group (593 patients)
• Poor prognosis group (208 patients)– > 3 nodes +, tumor size > 5 cm, grade III– at least 2 out of 3 criteria
Kyndi, Radiother Oncol, 2009
Risk group analysis
Kyndi, Radiother Oncol, 2009
Radiotherapy after neo-adjuvant chemotherapy and mastectomy
• Should all patients with locally advanced breast cancer, following neoadjuvant chemotherapy, be treated with postoperative radiotherapy?
• Or, should this decision depend on the tumor response as found at the time of surgery?
Mamounas, JCO, 2012
Int J Rad Oncol Biol Phys, 2007
Prospective trial
• NSABP B-51/RTOG 1304
• A randomized phase III clinical trial evaluating post-
mastectomy chest wall/post-lumpectomy and regional nodal
radiotherapy in patients with positive axillary nodes before
neo-adjuvant chemotherapy who convert to pathologically
negative axillary nodes after neo-adjuvant chemotherapy
Conclusions - who to treat?
• Patients with T3,N1 or T4 tumors
• Patients with 4 or more positive lymph nodes
• Consider postmastectomy radiotherapy for patients with 1 to 3 positive nodes
• Patients with LABC who are treated with neoadjuvant chemotherapy followed by mastectomy
• Positive resection margins
Inflammatory breast cancer
In general:Start with neo-adjuvant chemotherapy
If patient is operable:Surgery and loco-regional radiotherapy
If patient is still inoperable:Radiotherapy, followed, if possible, by surgery
Inflammatory breast cancer
Goal of radiotherapy:Improve locoregional control
A survival benefit has not definitely been proven
Technique: Wide margins!!