Management of locally advanced breast cancer

I. INTRODUCTION Locally advanced breast cancer (LABC) includes several clinical presentations associated with a high rate of local and systemic recurrence when treated with local therapy alone. This includes tumors that are very large but respectable, tumors that have technically difficult to establish tumor-free margins due to skin or chest wall involvement, and tumors of any size associated with extensive axillary adenopathy or regional nonaxillary lymph nodes. The definition of LABC generally includes the following clinical presentations and their corresponding stages (Table 1) as defined by the American Joint Committee on Cancer (Beahrs, 1992): Large primary tumors (5 cm) occurring without axillary lymph node metastases (stage IIB) or with ipsilateral movable axillary lymph node metastases (stage IIIA) Tumors of any size associated with axillary lymph node metastases that are fixed to one another or to other structures (stage IIIA) Tumors of any size that show extension to the chest wall or skin, including edema, ulceration, or satellite skin nodules (stage IIIB) Inflammatory carcinoma (stage IIIB) Tumors of any size associated with ipsilateral internal mammary nodes (stage IIIB) Tumors of any size associated with ipsilateral supraclavicular lymph nodes (stage IV) without other evidence of systemic metastases The approach to the patient with LABC generally includes the following: Diagnostic biopsy or fine-needle aspiration A workup to exclude the presence of occult systemic metastases Primary systemic chemotherapy (also called “neoadjuvant therapy”) 474 MALIK AND SPARANO Table 1 Clinical Staging of Breast Cancer Stage Tumor Nodes Metastases IIB T3 N0 M0 IIIA T0, T1, T2 N2 M0 T3 N, N2 M0 IIIB T4 Any N M0 Any T N3 M0 Surgical treatment of the primary tumor Additional systemic “adjuvant” chemotherapy Irradiation to the breast or chest wall and regional lymphatics Hormonal therapy (e.g., tamoxifen) for 5 years if the tumor is estrogen and/or proges- terone receptor positive In this chapter, the literature supporting this proposed treatment approach is reviewed, with a particular emphasis on randomized phase II and III trials and large single or multiinstitutional trials.