Expanding the Indications for Breast Conservative Surgery in Locally Advanced Breast Cancer Patients

Abstract

INTRODUCTION: In patients submitted to neoadjuvant chemotherapy (NC), the breast conservative surgery (BCS) rates vary from 37 to 82%, but it occurs in 1.7% to 28% of patients with locally advanced breast cancer (LABC). New techniques of breast surgery like oncoplastic techniques (OT) and skin-sparing mastectomy (SSM) can security improve the indications of BCS in patients with LABC, but there are limited publications with this kind of patients. MATERIAL AND METHODS: A prospective controlled trial, NCT 00820690 (www.clinical.trials.gov), approved by the Ethics committee (135/2008) evaluated patients with LABC, submitted to NC. Patients with LABC, tumors clinical measured and clinical stage III were eligible for inclusion. Prior to and after the NC the breast was clinically and radiologically evaluated.The surgeons evaluated the possibility of performing BCS before and after the NC. Tumor margin, response to NC, the relationship of tumor size-breast size, comorbidities and desire of the patient were considered for OT evaluation. Skin tattoo was performed in tumor skin projection, which was resected during the surgery. We analyze indications, surgeries performed and safety of BCS, based on margins and local recurrence. RESULTS: According to Consort, 78 patients were enrolled to NC regimen. Invasive ductal carcinoma was present in 93.8% of the tumors. The median tumor size before NC was 6.9 cm (3-14). Based of clinical stage, 61.5% were IIIa, 33.3% IIIb and 5.1% IIIc. 64.0% were submitted to mastectomy, 10.3% quadrantectomies, 15.4% SSM, 7.7% pedicle techniques, 2.6% other OT. All margins were free in patients submitted to quadrantectomy. BCS was performed in 36.0%. Based on pathologic response, 39.7% had concentric tumor decrease, 23.8% tumor fragmentation, 10.3 stable disease, 7.7% progression and 8.9 had complete pathologic response. The median follow up is 19 months (8-40) and 80.8% are alive and free of disease. Local recurrence occurred in 7.7% of the patients, all in patients submitted to mastectomy. DISCUSSION: The surgical planning before and after NC is essential. For safety and oncologic reasons, associated with irregular pathologic response, the resection of all tumor bed area is recommended. CONCLUSION: OT increases the concept of BCS in LABC patients, which improves surgical planning, free margins rate and cosmetic results without increasing local recurrence.