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Locally Advanced Breast Cancer

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. "Night" by Michelangelo, 1524:

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Locally Advanced Breast Cancer

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  1. 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. J. Apffelstaedt

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

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

  6. Stage at presentation at The MammaClinic • Stage: • I: 10 % • II: 30% • III: 30% • IV: 30% • LABC Correlated with: • Poverty • Educational status • Age 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):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. J. Apffelstaedt

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  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. 1989;15(6):486-9.) => Prefer Surgery followed by RT J. Apffelstaedt

  10. Chemotherapy 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. 1998;16(2):80-6). => Prefer preop. chemotherapy 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. 1996;34(5):1019-28). • The place of radical procedures? (Hathaway CL et al: Arch.Surg. 1994;129(6):582-7). J. Apffelstaedt

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

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

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

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