Primary radiation therapy for locally advanced breast cancer

Non-Surgical Definitive Treatment for Operable Breast Cancer: Current Status and Future Prospects

This article reviews the results of various non-surgical curative treatments for operable breast cancer. Radiotherapy is considered the most important among such treatments, but conventional radiotherapy alone and concurrent chemoradiotherapy do not achieve high cure rates. As a radiosensitization strategy, intratumoral injection of hydrogen peroxide before radiation has been investigated, and high local control rates (75-97%) were reported. The authors treated 45 patients with whole-breast radiotherapy, followed by stereotactic or intensity-modulated radiotherapy boost, with or without a radiosensitization strategy employing either hydrogen peroxide injection or hyperthermia plus oral tegafur-gimeracil-oteracil potassium. Stages were 0-I in 23 patients, II in 19, and III in 3. Clinical and cosmetic outcomes were good, with 5-year overall, progression-free, and local recurrence-free survival rates of 97, 86, and 88%, respectively. Trials of carbon ion radiotherapy are ongoing, with promising interim results. Radiofrequency ablation, focused ultrasound, and other image-guided ablation treatments yielded complete ablation rates of 20-100% (mostly ≥70%), but long-term cure rates remain unclear. In these treatments, combination with radiotherapy seems necessary to treat the extensive intraductal components. Non-surgical treatment of breast cancer is evolving steadily, with radiotherapy playing a major role. In the future, proton therapy with the ultra-high-dose-rate FLASH mode is expected to further improve outcomes.

New enzyme-targeting radiosensitizer (KORTUC II) treatment for locally advanced or recurrent breast cancer

Kochi oxydol radiation therapy for unresectable carcinomas II (KORTUC II) is currently the most widely used radiosensitizer in Japan. This sensitizer is a solution consisting of 0.83% sodium hyaluronate and 0.5% hydrogen peroxide. The mixture is injected intratumorally just before radiation therapy (RT) several times. KORTUC II has the effect of neutralizing antioxidant enzymes, while increasing the oxygen tension into the tumor tissue, and achieves marked local effects without notable adverse events. The present report describes cases in which KORTUC II was used to treat patients with locally advanced breast cancer (LABC) or recurrent breast cancer (LRBC). The present study included 30 patients with LABC (n=9) or LRBC (n=21) aimed at local control of tumors, who were followed up for ≥3 months after treatment. The irradiation dose and extent fields were determined by the attending physicians considering various patient factors, such as a performance status, prognosis and presence or absence of adjuvant therapy. The median irradiation dose was 60.4 Gy3.5 (43.6-76.1 Gy3.5) based on the calculation of equivalents of 2 Gy fractions, and the median total number of sensitizer injections was 5 (2-7) times. The median maximum tumor shrinkage was 97.0% and 15 patients (50%) were assessed to have achieved a clinical complete response. The proportion with loco-regional control at 1, 2 and 3 years was 100, 94.7 and 75.4%, respectively, and progression free survival after RT at 1 and 2 years was 59.0 and 24.1%, respectively. KORTUC II exhibited high rates of local tumor control for LABC and LRBC. KORTUC II is expected to be an inexpensive and promising RT method because it is safe and has an excellent radio-sensitizing effect.

Primary Radiotherapy versus Surgery and Radiotherapy in the Management of Postmenopausal Locally Advanced Breast Cancer

From 1978 through 1984, 103 postmenopausal patients with locally advanced breast cancer (T4 N1-2-3 MO) were treated by definitive radiotherapy (XRT, 35 patients) or mastectomy and postoperative radiotherapy (RM+XRT, 68 patients). A control group of 35 of the 68 RM+XRT patients was selected by matching several prognostic variables with the XRT group. Patients were followed for 4 to 10 years. At 5 years the probabilities of overall survival and relapse-free survival were 49.9% and 33.2% for XRT patients and 49.2% and 42.8% for RM+XRT patients, respectively (with no significant difference). The probability to remain free of local-regional progression at 5 years, with censoring of deaths, was 71.9% in the XRT group and 79.8% in the RM+XRT group. Of the patients treated with definitive radiotherapy, those who received 60 Gy or more to the primary tumor had a significantly better 5-year rate of local control: 88.0 % vs. 68.0 %, p < 0.05. Our results suggest that adequate doses of radiotherapy can provide long-term local-regional control in a large proportion of survivors and can spare mastectomy in most patients, without however achieving substantial improvements in the poor survival results.

Plexus and peripheral nerve metastasis

Cancer in the form of solid tumors, leukemia, and lymphoma can infiltrate and metastasize to the peripheral nervous system, including the cranial nerves, nerve roots, cervical, brachial and lumbosacral plexuses, and, rarely, the peripheral nerves. This review discusses the presentation, diagnostic evaluation, and treatment options for metastatic lesions to these components of the peripheral nervous system and is organized based on the anatomic distribution. As skull base metastases (also discussed in Chapter 14) result in cranial neuropathies, these will be covered in detail, as well as cancers that directly infiltrate the cranial nerves. Particular emphasis is placed on the clinical, imaging, and electrodiagnostic features that differentiate neoplastic plexopathies from radiation-induced plexopathies. Neurolymphomatosis, in which malignant lymphocytes invade the cranial nerves, nerve roots, brachial and lumbosacral plexuses, and peripheral nerves, is a rare manifestation of lymphoma and leukemia. Diagnoses of neurolymphomatosis are often missed or delayed given its varied presentations, resulting in poorer outcomes. Thus this disease will also be discussed in depth.

Role of radiation therapy in palliative care of the patient with cancer

Radiotherapy is a successful, time-efficient, well-tolerated, and cost-effective intervention that is crucial for the appropriate delivery of palliative oncology care. The distinction between curative and palliative goals is blurred in many patients with cancer, requiring that treatments be chosen on the basis of factors related to the patient (ie, poor performance status, advanced age, significant weight loss, severe comorbid disease), the cancer (ie, metastatic disease, aggressive histology), or the treatment (ie, poor response to systemic therapy, previous radiotherapy). Goals may include symptom relief at the site of primary tumor or from metastatic lesions. Attention to a patient's discomfort and transportation limitations requires hypofractionated courses, when feasible. Innovative approaches include rapid response palliative care clinics as well as the formation of palliative radiotherapy specialty services in academic centers. Guidelines are providing better definitions of appropriate palliative radiotherapy interventions, and bone metastases fractionation has become the first radiotherapy quality measure accepted by the National Quality Forum. Further advances in the palliative radiation oncology subspecialty will require integration of education and training between the radiotherapy and palliative care specialties.

Exclusive and adjuvant radiotherapy in breast cancer patients with synchronous metastases

Background

Data from the Surveillance, Epidemiology, and End Results program and the European Concerted Action on survival and Care of Cancer Patients (EUROCARE) project indicate that about 6% of women newly diagnosed with breast cancer have stage IV disease, representing about 12 600 new cases per year in the United States in 2005. Historically, local therapy of the primary tumor in this setting has been aimed solely at symptom palliation. However, several studies suggest that surgical excision of the primary tumor can prolong these patients' survival.

Discussion

Exclusive locoregional radiotherapy is an alternative form of locoregional treatment in this setting and may represent an effective alternative to surgery in this setting. Here we discuss current issues regarding exclusive and adjuvant locoregional radiotherapy in breast cancer patients with synchronous metastases.

Summary

Several studies suggest that surgery or exclusive irradiation of the primary tumor is associated with better survival in breast cancer patients with synchronous metastases and that exclusive locoregional radiotherapy may represent an effective alternative to surgery in this setting. Results of well-designed prospective studies are needed to re-evaluate treatment of the primary breast tumor in patients with metastases at diagnosis, and to identify those patients who are most likely to benefit.

Feasibility study of safe breast conservation in large and locally advanced cancers with use of radiopaque markers to mark pre-neoadjuvant chemotherapy tumor margins

BACKGROUND

The lack of objective documentation of pre-neoadjuvant chemotherapy (NACT) margins after chemotherapy is a major constraint in performing safe breast-conserving surgery (BCS) in patients with locally advanced breast cancer (LABC). Using a novel method of marking pre-NACT tumor margins with indigenous silver wire markers, this prospective pilot study attempted to assess the feasibility of safe BCS in LABC patients by performing excision wide of the marked pre-NACT margins.

METHODS

LABC patients had sterile silver wire markers placed at all tumor margins percutaneously. Patients were then treated with NACT followed by wide local excision (WLE) incorporating pre-NACT margins (ex vivo on mastectomy specimen or in vivo in patients opting for BCS). The histology of the margins wide of the post-WLE cavity (pre-NACT) and post-NACT tumor was used to assess adequate disease clearance and safety of BCS.

RESULTS

Altogether, 40 stage III breast cancer patients (mean tumor size 7.9 cm) were studied; none had marker-related complications. Following NACT, the tumor size assessed by markers showed average regression by 1.5 cm. The pre-NACT margins were histologically negative in 95% of the surgical specimens. In 2 (5%) patients both pre-NACT and post-NACT margins were positive; post-NACT margins were infiltrated in 14 (35%).

CONCLUSIONS

The post-NACT WLE that is wide of the marked pre-NACT margins can achieve uninfiltrated margins in 95% of cases. If post-NACT margins are used to guide the WLE, 35% patients would have infiltrated margins, some of which would remain undetected, putting patients at high risk of local recurrence. This novel indigenous method of identifying tumor margins with sterile silver wire markers is safe, inexpensive, practical, and effective; and it may help perform safe BCS in a large proportion of LABC patients.

ACR appropriateness criteria on postmastectomy radiotherapy expert panel on radiation oncology-breast

This summary focuses on the role of postoperative radiation therapy in patients treated with modified radical mastectomy for invasive breast cancer, particularly in patients receiving systemic therapy.

Breast cancer with synchronous metastases: survival impact of exclusive locoregional radiotherapy

PURPOSE

Several studies suggest that surgical excision of the primary tumor improves survival among patients with stage IV breast cancer at diagnosis. Exclusive locoregional radiotherapy (LRR) is an alternative form of locoregional treatment (LRT) in this setting. We retrospectively studied the impact of LRT on the survival of breast cancer patients with synchronous metastases.

PATIENTS AND METHODS

Among 18,753 breast cancer patients treated in our institution between 1980 and 2004, 598 patients (3.2%) had synchronous metastasis at diagnosis. Demographic data, tumor characteristics, metastatic sites, and treatments were prospectively recorded. The impact of LRT on overall survival (OS) was evaluated by multivariate analysis including known prognostic factors.

RESULTS

Among 581 eligible patients, 320 received LRT (group A), and 261 received no LRT (group B). LRT consisted of exclusive LRR in 249 patients (78%), surgery of the primary tumor with adjuvant LRR in 41 patients (13%), and surgery alone in 30 patients (9%). With a median follow-up time of 39 months, the 3-year OS rates were 43.4% and 26.7% in group A and group B (P =.00002), respectively. The association between LRT and improved survival was particularly marked in women with visceral metastases. LRT was an independent prognostic factor in multivariate analysis (hazard ratio [HR] = 0.70; 95% CI, 0.58 to 0.85; P = .0002). The adjusted HR for late death (>or= 1 year) was 0.76 (95% CI, 0.61 to 0.96; P = .02).

CONCLUSION

In our experience, LRT, consisting mainly of exclusive LRR, was associated with improved survival in breast cancer patients with synchronous metastases. Exclusive LRR may thus represent an active alternative to surgery.

Neoadjuvant and Adjuvant Chemotherapy with Doxorubicin and Docetaxel in Locally Advanced Breast Cancer

Fifty patients with histologically confirmed stage III breast cancer were enrolled in this study of doxorubicin 50 mg/m2 and docetaxel 75 mg/m2 intravenously infused over 1 hour every 21 days with granulocyte colony-stimulating factor for 4 cycles. This was followed by surgery (mastectomy or lumpectomy) and 4 more cycles of doxorubicin/docetaxel postoperatively, then radiation and tamoxifen as indicated. Forty-six of the 50 patients (92%) completed neoadjuvant chemotherapy, and 38 patients (76%) completed adjuvant chemotherapy. Clinical response (defined as > 50% decrease in size of tumor) was achieved after 2 cycles in 37 patients (74%) and after 4 cycles in 42 of the 46 patients (91%) who finished neoadjuvant chemotherapy. Pathologic complete response (pCR; no pathologic invasive cancer) at the primary site was obtained in 7 of 46 patients (15%); 11 had no residual gross disease but did have microscopic persistence or microscopic complete response (mCR), for a combined pCR and mCR of 18 of 46 patients (39%). No treatment-related deaths occurred, but 3 patients died during treatment: 1 from progressive disease, 1 from a gastrointestinal bleeding, and 1 from unexplained sudden cardiac death. Dose-limiting toxicities were hematologic (grade 3 neutropenia in 5 patients and grade 4 in 23 patients). Congestive heart failure developed in 4 of 50 patients (8%), with a mean decrease in left ventricular ejection fraction (LVEF) of 20% in affected patients and 1 asymptomatic decrease in LVEF of 25%. At last follow-up, 10 patients had died of progressive disease, and 1 each from sudden cardiac death and lower gastrointestinal bleeding. In locally advanced breast cancer, neoadjuvant doxorubicin/docetaxel is a very active regimen that achieved pCR of 15% and a combined pCR and mCR of 39%, for an overall clinical response rate of 91%. Adjuvant chemotherapy was complicated by dropouts and congestive heart failure. This regimen should be used with close monitoring of cardiac function.

Long-term follow-up for locally advanced and inflammatory breast cancer patients treated with multimodality therapy

PURPOSE

To determine long-term event-free (EFS) and overall survival (OS) for patients with stage III breast cancer treated with combined-modality therapy.

PATIENTS AND METHODS

Between 1980 and 1988, 107 patients with stage III breast cancer were prospectively enrolled for study at the National Cancer Institute and stratified by whether or not they had features of inflammatory breast cancer (IBC). Patients were treated to best response with cyclophosphamide, doxorubicin, methotrexate, fluorouracil, leucovorin, and hormonal synchronization with conjugated estrogens and tamoxifen. Patients with pathologic complete response received definitive radiotherapy to the breast and axilla, whereas patients with residual disease underwent mastectomy, lymph node dissection, and radiotherapy. All patients underwent six additional cycles of adjuvant chemotherapy.

RESULTS

OS and EFS were obtained with a median live patient follow-up time of 16.8 years. The 46 IBC patients had a median OS of 3.8 years and EFS of 2.3 years, compared with 12.2 and 9.0 years, respectively, in stage IIIA breast cancer patients. Fifteen-year OS survival was 20% for IBC versus 50% for stage IIIA patients and 23% for stage IIIB non-IBC. Pathologic response was not associated with improved survival for stage IIIA or IBC patients. Presence of dermal lymphatic invasion did not change the probability of survival in clinical IBC patients.

CONCLUSION

Fifteen-year follow-up of stage IIIA and inflammatory breast cancer is rarely reported; IBC patients have a poor long-term outlook.

Management of Women who Present with T4 Breast Cancer

The purpose of this study was to review the clinical presentation and outcome of women who present with large or locally invasive (T4) breast carcinoma. This retrospective study was conducted at the University of Mississippi Medical Center, a state tertiary care referral institution. One hundred twenty-nine women between the ages of 28 and 85 years (mean, 55 years) presented with T4 breast carcinoma. Follow-up was available for 128 women. Only 23 women have survived (18%), 5 of whom (21.7%) have metastatic disease. Mean survival for those who died was 21.6 months, compared to 76.3 months for survivors. Survival was not influenced by tumor characteristics ( P > 0.5), but was strongly influenced by nodal status ( P < 0.001) and by the presence of metastases at the time of diagnosis ( P < 0.001). Survival was strongly related to mode of therapy ( P < 0.01), but this was principally related to very high mortality rates in women who received no therapy (100%), surgery only (92.3%), or chemotherapy only (95%). The best survival was seen in women who received chemotherapy prior to surgery (40%); their survival was superior to that of women treated initially by surgery, followed by chemotherapy (16.3%, P = 0.04). However, when women who presented with metastatic disease were excluded, survival was not different between these two groups ( P = 0.18). Despite public education efforts and the wide availability of screening programs for breast carcinoma, many women still present with locally advanced disease. Outcome can be favorable in the absence of node involvement or metastatic disease, even in the presence of large, fungating tumors. Multimodality therapy gives the best results, but early surgery may be required for progression of disease during chemotherapy or because of extensive ulceration at initial presentation.

Locally advanced breast cancer: is surgery necessary?

A retrospective analysis of the treatment of locally advanced breast cancer (LABC) was undertaken at Stanford Medical Center to assess the outcome of patients who did not undergo surgical removal of their tumors. Between 1981 and 1998, 64 patients with locally advanced breast cancer were treated with induction chemotherapy, radiation with or without breast surgery, and additional chemotherapy. Sixty-two (97%) patients received cyclophosphamide, doxorubicin, and 5-fluorouracil (CAF) induction chemotherapy. Induction chemotherapy was followed by local radiotherapy in 59 (92%) patients. Based on the clinical response to chemotherapy and patient preference, 44 (69%) patients received no local breast surgery. Radiotherapy was followed by an additional, non-doxorubicin-containing chemotherapy in all patients. The mean age of patients was 49 years. Of the 65 locally advanced breast cancers in 64 patients, 26 (41%) were stage IIIA, 35 (55%) were stage IIIB, and 4 (6%) were stage IV (supraclavicular lymph nodes only). Response to induction chemotherapy was seen in 59 patients (92%), with 29 (45%) achieving a complete clinical response and 30 (47%) a partial clinical response. With a mean follow-up of 51 months (range 7-187 months), 43 patients (67.2%) have no evidence of recurrent disease. Eight (12.5%) have recurred locally, and 21 (32.8%) have recurred with distant metastasis. Actuarial 5-year survival is 75%, disease-free survival is 58%, and local control rate is 87.5%. These data indicate that the routine inclusion of breast surgery in a combined modality treatment program for LABC does not appear necessary for the majority of patients who experience a response to induction chemotherapy.

Surgery for T4 Breast Carcinoma: Implications for Local Control

Despite increasing public awareness and widespread availability of mammography, many patients will present with locally advanced breast cancers. The role of surgery remains controversial. Between 1993 and 1998, 47 of 393 (11.9%) breast cancer patients presented with T4 (inflammatory or locally advanced) carcinoma. We reviewed multimodality management, clinical response to neoadjuvant therapy, perioperative course and complications, and local control. Forty-six women and one man were diagnosed with clinical T4 breast cancer. There were 24 white and 23 African-American patients. Mean age at presentation was 54.5 (range, 31–88) years. Twenty-three patients had clinical metastases to axillary nodes, and five had distant metastases at the time of diagnosis. For these women, intent was for personal hygiene and control of pain. Neoadjuvant chemotherapy was given for 34 of 47 (72%) with 25 of 34 (73.5%) having partial or complete clinical response. There was no response or progression of disease in 9 of 34(26.5%). Forty-six patients underwent radical or modified radical mastectomy, whereas a single patient underwent breast conservation treatment. Twelve required tissue transfer for wound coverage. Although eight developed minor wound complications (cellulitis/flap separation), there were no major wound complications. Pathologically negative margins were achieved in all but one patient. To date, five women have developed local recurrence in either the chest wall (three) or axilla (two). Average time to local recurrence was 7.8 months. There is no evidence of local failure in the remaining 87 per cent. Locally advanced breast cancer is a common occurrence in certain populations. Multi-modality management remains the standard of care. Surgical resection may allow for successful local control and, in certain situations, long-term cure.

Locally advanced breast cancer in Saudi Arabia: high frequency of stage III in a young population

In the Kingdom of Saudi Arabia (KSA), breast cancer constitutes 18% of all cancers in Saudi women. Whilst locally advanced breast cancer disease is unusual in Western countries, it constitutes more than 40% of all non-metastatic breast cancer in KSA. The relative frequency of locally advanced disease among our breast cancer population and the lack of a uniform consensus in the literature about its optimal management have prompted this retrospective analysis of the medical records of patients with Stage III breast cancer patients seen at King Faisal Specialist Hospital and Research Center between 1981 and 1991. In all, 315 patients were identified. Their median age +/- SD was 46 +/- 11.6 years which is distinctly different from the 60-65 years median age in industrial Western nations. Most patients were younger than 50 years (64%) and premenopausal (62%). Patients were approximately equally divided between Stage IIIA and Stage III B. Patients received multimodality treatment, including surgery, adjuvant chemotherapy, tamoxifen, and adjuvant radiotherapy. Sixty-one patients were excluded from survival analysis as they were considered lost to follow-up. Of the remaining 254 patients, 73 (29%) were alive and disease free, and 18 patients (7%) were alive but with evidence of the disease. The remaining 163 (64%) had died from breast cancer or its related complications. Their median overall survival (OS) was 54 months, (95% CI, 27 to 121 months) and the median progression-free survival (PFS) was 28.8 months (95% CI, 14.2 to 113 months). Cox proportional hazard model identified Stage III B and the number of positive axillary lymph nodes as poor predictors of OS and PFS. Radiotherapy was the only adjuvant modality that affected survival favourably. The prognosis of patients with Stage III disease remains poor despite the use of a multimodality approach. The overall young age of our patients may have contributed to the poor outcome. Moreover, the adverse effect of Stage III B disease (as compared with Stage III A) and axillary nodal status was evident. Whilst the favourable effect of radiotherapy on survival was demonstrated, the lack of independent efficacy of other modalities (adjuvant chemotherapy and tamoxifen) or the apparent deleterious effect of neoadjuvant chemotherapy should be addressed with discretion in such retrospective analysis. Optimal management of patients with locally advanced breast cancer disease should be appraised in well designed, prospective, randomised studies.

Impact of clinical, pathologic, and treatment-related factors on outcome in patients with locally advanced breast cancer treated with multimodality therapy

The authors reviewed the experience at their institution treating patients with locally advanced breast cancer using multimodality therapy to identify clinical, pathologic, and treatment-related factors affecting outcome. One hundred patients with locally advanced breast cancer were treated with definitive therapy at William Beaumont Hospital. Three patients had stage IIB disease, 45 patients had stage IIIA disease, and 52 patients had IIIB disease. Thirteen patients had inflammatory breast carcinoma. Seventy-four patients (74%) received trimodality therapy consisting of systemic therapy, radiation therapy, and surgery. Systemic therapy was delivered to 90 patients. Eighty-three patients (83%) received adjuvant radiation therapy. Eighty-five patients underwent mastectomy (85%). Multiple clinical, pathologic, and treatment-related factors were analyzed for their impact on outcome. The median follow-up was 47 months. Overall, the 5-year actuarial rates of local control, disease-free survival, overall survival, and cause-specific survival were 81%, 43%, 53%, and 55%, respectively. The 5-year actuarial cause-specific survival rates for patients with inflammatory breast carcinoma, stage IIIA disease, and stage IIIB disease were 25%, 55%, and 53%, respectively. On multivariate analysis, local control was improved with radiation therapy (p = 0.008) and the absence of inflammatory breast carcinoma (p = 0.008). Disease-free survival was improved with the addition of radiation therapy (p = 0.001) and with less than four positive lymph nodes (p = 0.003). Distant metastasis-free survival was improved in patients without inflammatory breast carcinoma (p = 0.0249) and with less than four involved lymph nodes (p = 0.0135). Cause-specific survival and overall survival were adversely affected by the presence of inflammatory breast carcinoma (p = 0.0135 and p = 0.0325, respectively) or four or more involved lymph nodes (p = 0.0082 and p = 0.012, respectively). Radiation therapy appears to be a critical component in the overall treatment of patients with locally advanced breast cancer by improving the rates of local control and disease-free survival. Other adverse factors for survival include four or more positive lymph nodes and inflammatory breast carcinoma.

The importance of postoperative radiation therapy in multimodality management of locally advanced breast cancer: a phase II trial of neoadjuvant MVAC, surgery, and radiation

PURPOSE

To determine the impact of postoperative radiation on locoregional relapse and overall survival rate in a multimodality protocol for locally advanced breast cancer (LABC).

MATERIAL AND METHODS

Of the patients entered in the protocol, 55 were evaluable. Treatment consisted of: neoadjuvant MVAC (methotrexate, vinblastine, adriamycin, and cisplatin) until a maximum response had been achieved; modified radical mastectomy; 6 courses of postoperative adjuvant MVAC chemotherapy, and chest wall irradiation (CWXRT). Multivariate analysis of locoregional response and overall survival was done.

RESULTS

Of the total, 42 patients received chest wall radiation; 28 of these also received radiation to regional lymph nodes. Chest wall doses ranged from 45 Gy to 50.4 Gy to the whole chest wall, with 31 patients receiving an additional chest-wall boost. The incidence of locoregional relapse with and without radiation was 7% vs. 31%, respectively (p = 0.026). An overall survival benefit was seen in those receiving radiation, with a mean overall survival of 50 months vs. 20 months, and a 3-year overall survival of 88% vs. 46% with and without radiation, respectively (p = 0.003). Multivariate analysis showed that overall survival was affected by the presence of pathological CR (p = .047), the number of pre-operative chemotherapy cycles (p = .036) and whether or not they received radiation (p = 0.003). Neither the interval between surgery and radiation, technique of radiation, nor radiation modality significantly affected local control.

CONCLUSION

The significant improvement in local regional control and overall survival with the addition of radiation suggests that radiation should be an integral part of multimodality management of locally advanced breast cancer.

Possibility of conservative local treatment after combined chemotherapy and preoperative irradiation for locally advanced noninflammatory breast cancer

PURPOSE

The aims of this prospective study were to evaluate the outcome and the possibility of breast conservation therapy for patients with locally advanced noninflammatory breast cancer after primary chemotherapy followed by external preoperative irradiation.

METHODS AND MATERIALS

Between April 1982 and June 1990, 97 patients with locally advanced nonmetastatic and noninflammatory breast cancer were treated. The median follow-up was 93 months from the beginning of treatment. The induction treatment consisted of four courses of chemotherapy (doxorubicin, vincristine, cyclophosphamide, 5-fluorouracil) followed by preoperative irradiation (45 Gy to the breast and nodal areas). A fifth course of chemotherapy was given after irradiation therapy. Three different loco-regional approaches were proposed, depending on the tumoral response. In 37 patients (38%) with residual tumor larger than 3 cm in diameter or located behind the nipple or with bifocal tumors, mastectomy and axillary dissection were performed. Sixty other patients (62%) benefited from conservative treatment: 33 patients (34%) achieved complete remission and no surgery was done but additional radiation boost was given to the initial tumor bed; 27 patients (28%) who had a residual mass less than or equal to 3 cm in diameter were treated by wide excision and axillary dissection followed by a boost to the excision site. After completion of local therapy, all patients received a sixth course of chemotherapy. A maintenance adjuvant chemotherapy regimen without anthracycline was prescribed (12 monthly cycles).

RESULTS

The 5-year actuarial loco-regional relapse rate was 16% after radiotherapy alone, 16% following wide excision and radiotherapy, and 5.4% following mastectomy. The 5-year loco-regional relapse rate was significantly higher after conservative local treatment (wide excision and radiotherapy, and radiotherapy alone) than after mastectomy (p= 0.04). After conservative local treatment, the 5-year breast conserving rate of patients with loco-regional disease-free status was 84%. For all patients included in this study, the 5-year breast-conserving rate of those who were loco-regional disease-free was 52%. In multivariate analysis, the possibility of breast conservative treatment was significantly related to the initial tumor size and age (more conservative treatment for tumor size < 6cm and age < 50 years). Five- and 10-year overall survival rates and disease-free survival rates were 80, 69, 73, and 61% respectively. Five- and 10-year overall survival rates were not influenced by the local treatment (conservative vs. nonconservative local treatment, p = 0.9). On the other hand, local failure significantly decreased the 5- and 10-year overall survival rates (p , 0.0001). In multivariate analysis, three factors had a significant impact on overall survival and disease-free survival: tumor response after induction chemotherapy, initial tumor size, and clinical stage. Arm lymphedema was noted in 12.5% (8 out of 64) of the patients treated with axillary dissection and in 3% (1 out of 33) without axillary dissection. Cosmetic results were satisfactory in 79% of patients after wide excision and radiotherapy and in 71% of patients treated by radiotherapy alone.

CONCLUSIONS

Induction chemotherapy followed by preoperative irradiation may permit the selection of some patients with locally advanced breast cancer for conservative treatment. However, the impact of this treatment modality on long-term survival remains to be established.

Inflammatory breast carcinoma

Inflammatory breast cancer (IBC) is a rare subtype of breast cancer traditionally associated with an extremely poor prognosis. The appearance of the effected breast can be misleading, with the incorrect diagnosis of an infective process, rather than a malignant disease, further delaying treatment. Compared with the results achieved by monotherapy with either surgery, radiotherapy or chemotherapy; multimodality treatments have achieved significant improvements in both disease-free and overall survival. The purpose of this article is to provide a comprehensive review of the current literature and highlight those areas where potential advances in the overall management of IBC have been made.

Locally advanced non-metastatic breast cancer: analysis of prognostic factors in 125 patients homogeneously treated with a combined modality approach

125 stage III breast cancer patients, including 51 cases of inflammatory carcinoma, were treated with the following combined modality approach: three courses of primary 5-fluorouracil, doxorubicin, cyclophosphamide (FAC) chemotherapy followed by locoregional treatment and subsequent adjuvant chemotherapy consisting of three courses of FAC alternating with three courses of cyclophosphamide, methotrexate, 5-fluorouracil (CMF). Clinical response to primary FAC was 65% (complete 10%). Residual tumour mass in the mastectomy specimen was > 1 and < or = 1 cm in 82 and 18% of cases, respectively. Complete pathological response following primary chemotherapy was achieved in only 3.5% of cases. After primary FAC and local treatment, 97% of patients were disease-free. Overall survival (S) and progression-free survival (PFS) at 5 years were 56 and 34%, respectively. Univariate analysis showed that age, receptor status and clinical and pathological response to primary chemotherapy did not appear to influence treatment outcome significantly, whereas stage, presence of inflammatory disease and number of involved nodes had a significant impact on both S and PFS.

The prognosis of stage III breast cancer treated with postoperative radiotherapy and adriamycin-based chemotherapy with and without tamoxifen. Eight year follow-up results of a randomized trial

Sixty-one patients with primary node positive stage III breast cancers were randomized to receive postoperative radiotherapy and doxorubicin-based chemotherapy (eight cycles of CAFt: cyclophosphamide, adriamycin, oral ftorafur) with or without tamoxifen as adjuvant treatment. The five-year overall survival for all patients was 49% (with tamoxifen 48% and without tamoxifen 50%) and disease-free survival 33% (with tamoxifen 27% and without 39%). Local control for all patients was only 64% despite the postoperative radiotherapy. There was no significant difference between these two treatment groups in overall and disease-free survival or local control. The prognosis of stage III breast cancer remains grim despite modern adjuvant therapy. In addition to more effective systemic treatment more effective local therapy is also needed in order to obtain satisfactory local control. The most important studies in stage III breast cancer with 5-year survival results are reviewed here.

Management of locally advanced carcinoma of the breast. I. Noninflammatory

BACKGROUND

The treatment of patients with locally advanced noninflammatory breast cancer has evolved substantially over the past 30 years. From 1968 to 1989, 281 women were treated at Mallinckrodt Radiation Oncology Center with four different treatment methods. Median follow-up was 6.2 years (range 3-22 years); no patient was lost to follow-up.

METHODS

Retrospective review of records and analysis of data on a computer file were carried out. Thirty-five patients were treated with irradiation alone, 33 with irradiation and adjuvant chemotherapy, 81 with mastectomy and irradiation, and 132 with mastectomy, irradiation, and chemotherapy (triple-modality).

RESULTS

Actuarial 5- and 10-year disease free survival (DFS) rates were 45% and 36%, respectively, with triple-modality therapy, 31% and 10% with irradiation and chemotherapy, 32% and 19% with irradiation and mastectomy, and 19% and 11% with irradiation alone. Cause specific survival (CSS) paralleled DFS in the four groups. Locoregional tumor control at 5 years was 91% for irradiation, mastectomy, and chemotherapy, 80% for irradiation and mastectomy, 54% for irradiation and chemotherapy, and 31% for irradiation alone. Systemic therapy and/or irradiation given before mastectomy yielded better locoregional tumor control, DFS, and CSS (not statistically significant). No difference in results was noted with radical, modified radical, or total mastectomy. In the triple-modality group, no chest wall failures occurred with chest wall doses greater than 5040 cGy. Grade 2 or higher treatment sequelae were noted in 10-42% of patients, depending on treatment modality.

CONCLUSIONS

Triple-modality therapy yielded improved locoregional tumor control, DFS, and CSS compared with other modalities. Patients treated with surgery had better locoregional tumor control than those who received irradiation alone or in combination with chemotherapy, but the impact on DFS and CSS was less impressive. Additional clinical trials are needed to define further the role and optimal use of the various therapeutic modalities in the management of locally advanced breast cancer.

Management of locally advanced carcinoma of the breast. II. Inflammatory carcinoma

BACKGROUND

Inflammatory carcinoma of the breast has been associated with a poor prognosis. Several therapeutic approaches have been under investigation in an effort to improve outcome.

METHODS

This is a retrospective analysis of 179 patients with histologically confirmed inflammatory carcinoma of the breast: 33 treated with irradiation alone, 35 with combined irradiation and chemotherapy, 25 with irradiation and surgery, and 86 with a combination of three modalities.

RESULTS

The 5-year disease free survival (DFS) rates were 40% for patients treated with three modalities, 24% for those treated with irradiation and surgery, and 6% for those treated with irradiation alone or in combination with chemotherapy without a surgical procedure. The 10-year DFS rates were 35%, 24%, and 0%, respectively. Cause specific survival (CSS) curves closely follow the same trends. A clearly superior locoregional tumor control was observed in patients who underwent a surgical procedure: 79% with three modalities, 76% with irradiation and surgery, and only 30% with irradiation alone or in combination with chemotherapy. Distant metastasis occurred in 57% of the group treated with triple-modality therapy, 60% of those treated with irradiation plus surgery, and 85% of the patients treated with irradiation alone or in combination with chemotherapy. There was no significant correlation between the type of mastectomy or doses of irradiation and locoregional tumor control or survival. The significant morbidity of the trimodal therapy (10%), although somewhat higher than that of other modalities (3.2%), was acceptable.

CONCLUSIONS

The addition of mastectomy to irradiation significantly improved locoregional tumor control, DFS, and CSS; differences were statistically significant. The combination of chemotherapy, surgery, and irradiation had a significant impact on locoregional tumor control and incidence of distant metastases compared with surgery plus irradiation, and a lesser impact, although still statistically significant, on DFS and CSS. Further clinical trials are needed to optimize the management of patients with inflammatory breast cancer.

Locally advanced breast cancer: defining an optimum treatment regimen

PURPOSE

This retrospective review examines response, local control and freedom from distant failure for patients with locally advanced breast cancer treated by chemotherapy and radiotherapy without routine surgery.

METHODS AND MATERIALS

67 patients were treated between January 1980 and December 1988 at Westmead Hospital, NSW, Australia. Median follow-up for surviving patients was 56 months. Four successive protocols evolved, each with three phases induction chemotherapy (adriamycin or novantrone, cyclophosphamide) (three cycles), radiotherapy then chemotherapy (cyclophosphamide, methotrexate, 5-fluorouracil) of progressively shorter duration. Radiotherapy and chemotherapy were concurrent in the fourth regimen.

RESULTS

Clinical complete response (disappearance of all known disease) after chemotherapy, radiotherapy and additional chemotherapy was 18%, 55% and 79% respectively. Seven additional patients subsequently underwent mastectomy (N = 2), local excision (N = 1) or a radiation boost (N = 4) for a total complete response rate of 90%. Twenty one patients (31%) failed to achieve a complete response (N = 7) or recurred locally (N = 14). The crude 2-year rate of local recurrence was 50% for tumors > 10 cm (N = 10) and 14% for smaller tumors (n = 57) and was not influenced by protocol. Two-year actuarial freedom from distant failure was 67% at 2 years.

CONCLUSION

Local control can be achieved for patients with locally advanced breast cancer with a primary tumor < 10 cm using chemotherapy and radiotherapy without routine mastectomy.

Management of locally advanced breast cancer

The management of locally advanced breast cancer with single modality therapy has been associated with a high rate of systemic failure. A multimodality treatment strategy that includes induction cytotoxic chemotherapy, surgery, radiation therapy, and, possibly, hormonal ablation therapy is the current preferred management approach. As our knowledge and understanding of the mechanisms involved in mitogenic signal transduction improve, it is likely that less toxic, more efficacious agents will emerge.

Multidisciplinary treatment approach to locally advanced non-inflammatory breast cancer using chemotherapy and radiotherapy with or without surgery

Between April 1982 and December 1987, 82 locally advanced non-metastatic and non-inflammatory breast cancers were treated (42 stage IIIA, 40 stage IIIB). The median follow-up is 70 months from the beginning of the treatment. The initial treatment consisted of 4 courses of chemotherapy (doxorubicin, vincristine, cyclophosphamide, 5-fluorouracil) followed by irradiation (45 Gy to the breast and nodal area). A fifth course of chemotherapy was given after radiation therapy. Three different locoregional approaches were proposed depending on the tumoral response. In 32 patients (39%) with residual tumor larger than 3 cm in diameter or located behind the nipple or with multifocal tumors, mastectomy and axillary dissection were performed. Fifty other patients (61%) benefited from conservative treatment: 32 patients (39%) achieved complete remission and received a boost to the initial tumor bed; 18 patients (22%) who had a residual mass less than or equal to 3 cm in diameter were treated by tumorectomy and axillary dissection followed by a boost to the tumorectomy site. After completion of local therapy, all patients received a sixth course of chemotherapy. A maintenance adjuvant chemotherapy regimen without anthracycline was prescribed (12 monthly cycles). Three- and 5-year disease-free survival rates were 81.7% and 72% respectively. Five-year locoregional relapse rate (with or without other sites of failure) was 8.8%. In a multivariate analysis, disease-free survival was significantly influenced by the N-stage (p < 0.0001), initial tumor size (p = 0.01), and tumor response after initial chemotherapy (p = 0.02). Five-year breast conservation probability was 58.4%.(ABSTRACT TRUNCATED AT 250 WORDS)

Factors affecting outcome in locally advanced breast cancer

Patients presenting with locally advanced breast cancer (LABC) constitute a diverse group for which a variety of treatment modalities have been instituted. To assess which factors have a direct impact on outcome, we reviewed the medical records of 104 patients diagnosed with stage IIIA, stage IIIB and T3N0M0 breast carcinoma. When considered individually (univariate analysis), clinical stage, pathological stage, oestrogen receptor status and type of therapy were significant predictors for disease-free survival (DFS) and overall survival (OS). However, in a multivariate analysis, only clinical stage was a significant predictor for both DFS and OS, while ER status was a significant predictor for OS. There was a high degree of correlation between clinical and pathological staging. Nearly two-thirds of the patients developed a recurrence by 5 years. Loco-regional recurrence was the site of first recurrence in one-third of the patients by 5 years. The prognosis for patients presenting with LABC is poor, and they should be treated aggressively with loco-regional and systemic multimodality therapy. Although groups of patients with improved outcome could be identified by clinical or pathological staging, no group demonstrated an outcome good enough to be spared from multimodality therapy.

Primary radiotherapy for T4 breast cancer

In Edinburgh in 1982, radiotherapy for patients with T4 breast cancer was modified by an increase in tumour absorbed dose from 42.5-45.0 Gy to 60-75 Gy by using tumour boosts and changing from alternate day to daily fractions. To assess whether this improved local control or survival, the records of all females with T4-N0-3M0 breast cancer referred between January 1978 and December 1985, who received radiotherapy without initial mastectomy or adjuvant chemotherapy, were reviewed. There were 193 patients in the study. Minimum follow-up was 36 months. Actuarial survival at 5 years was 27.1% and median survival 29 months. Local control was achieved by 25.9%. On multivariate analysis, the probability of survival fell with increasing tumour size, advanced clinical node status and the presence of inflammatory change. Radiotherapy technique also affected prognosis. Four-field techniques were associated with a better chance of survival than the breast and axillary jig or other treatment methods. The probability of local control increased with reduced tumour size and showed the same relationship to radiotherapy technique as did survival. Dose was not a significant variable for either survival or local control. No improvement in survival or local control was apparent in comparison with a previous study. It is concluded that radiotherapy alone at a dose of 60 Gy is insufficient to produce durable local control for the majority of women with T4 breast cancer.

Stage III breast cancer: is neoadjuvant chemotherapy always necessary?

Optimal management of locally advanced breast cancer is controversial. Claims of superiority for neoadjuvant systemic therapy are based on comparisons with outdated historical control groups who received no chemotherapy. Between 1978 and 1987, 118 patients with locally advanced breast cancer underwent treatment and follow-up at the Medical College of Virginia. Median follow-up was 44 months (range 3-119 months). Actuarial 5-year survival for the entire group was 54%. This compares favorably with recent series using neoadjuvant chemotherapy in which 5-year survival rates of 40-65% have been reported. Primary tumor size larger than 9 cm, metastases to more than 50% of regional lymph nodes, and the presence of inflammatory disease were significant prognostic indicators. This series represents a contemporary control group of patients with locally advanced breast cancer in whom conventionally accepted guidelines for local and postoperative systemic adjuvant therapy were used. Until the optimal sequence of therapy is determined by prospective randomized trials, series such as this may serve as more appropriate controls to which the results of new therapies could be compared.

The effect of systemic therapy on local-regional control in locally advanced breast cancer

One hundred and seven patients with locally advanced breast cancer were prospectively referred for multimodality treatment on protocol using chemohormonal therapy to maximal response followed by local treatment and maintenance therapy. Forty-eight patients (45%) were diagnosed with Stage IIIA disease, 46 (43%) with Stage IIIB inflammatory cancer, and 13 (12%) with Stage IIIB non-inflammatory disease. Induction therapy consisted of cyclophosphamide, doxorubicin, methotrexate, and 5-fluorouracil with hormonal synchronization using tamoxifen and conjugated estrogens. Local treatment was determined by response to chemotherapy. Patients with a clinical parital response underwent mastectomy followed by local-regional radiotherapy while patients with a clinical complete response were biopsied for pathologic correlation. Those with residual disease received mastectomy followed by radiotherapy while those with a pathologic complete response received radiation only to the intact breast and regional nodes. With a median follow-up of 64 months, patients with IIIA disease had a significantly lower local-regional failure rate compared to IIIB inflammatory patients, with the 5-year actuarial local-regional failure rate as only site of first failure 3% for IIIA disease versus 21% for IIIB inflammatory cancer (p = .02), and local-regional failure as any component of first failure 12% versus 36% (p = .01), respectively. When local-regional failure was analyzed by repeat biopsy, 5/31 (16%) patients with a pathologic complete response treated with radiation only developed a local-regional failure versus 2/53 (4%) with residual disease treated with mastectomy and postoperative radiotherapy. The 5-year actuarial local-regional failure rate as first site of failure was 23% for radiation only versus 5% for mastectomy and post-operative radiotherapy (p = .07). The response to chemotherapy did not reliably predict local-regional control. Both relapse-free survival and overall survival were significantly better for IIIA versus IIIB patients; stratification by repeat biopsy did not however, significantly affect either relapse-free or overall survival.

Results of radical radiotherapy for inflammatory breast cancer

We performed a retrospective review of 65 patients with nonmetastatic clinical inflammatory breast carcinoma treated with radical radiotherapy as the sole local treatment between 1968 and 1986. Chemotherapy was given to 47 patients (72%). The median total radiation dose to the target volume was 6,984 cGy. With a median follow-up in survivors of 41 months, the 5-year actuarial probability of relapse-free survival was 17% and the overall survival was 28%. Thirty patients experienced failure in the treated breast, skin, or draining lymph nodes, for a crude, uncensored local recurrence rate of 46%. Of the factors analyzed, only the response to initial chemotherapy was predictive of local recurrence. Local recurrence was noted in 0 of 3 patients with a complete response (CR) to initial chemotherapy, 5 of 17 patients with a partial response (PR), and 12 of 17 patients with less than a partial response (CR/PR versus less than PR, p = 0.009). We conclude that conventional radical radiotherapy in unselected patients is insufficient to manage the local tumor burden presented by inflammatory breast cancer, even when high doses are employed.

Expedient set-up of tangential breast fields with a simple gantry attachment

A novel technique for setting up tangential fields is described. The technique uses a simple device (Breast Aligner) which attaches to the collimator of the treatment unit. The function of the Breast Aligner is similar to conventional front and back pointers except that the beam edge rather than central ray is defined. By delineating beam entrance and exit points at the posterior field edge, the device greatly simplifies and expedites set-up, and enhances precision of port alignment. Additional advantageous features include: (a) the ability to compensate for small inadvertent variations from the initial set-up position or for patient movement between the set-up of opposing ports, (b) the ability to visually check port alignment in the treatment position immediately before irradiation, and (c) decreased chance of human and equipment error by eliminating the need for measurements and calculations at the time of treatment. Our method can be used for SSD or SAD techniques and, with minor adjustment, is applicable for establishment of coplanar cephalad field borders as required at the junction of a supraclavicular field.

Locally advanced (noninflammatory) carcinoma of the breast: results and comparison of various treatment modalities

From 1968-1987 237 women with Stage III, noninflammatory breast cancer were treated with various modalities. Ninety-three (39%) had Stage IIIA tumors, and 144 (61%) had Stage IIIB, noninflammatory tumors (AJC, 1983 staging). Median follow-up was 5.4 years (range 2 to 22 years). No patients were lost to follow-up. Thirty-five patients (15%) were treated with irradiation alone, 27 (11%) with irradiation and adjuvant systemic therapy, 80 (34%) with mastectomy and irradiation, and 95 (40%) with combined mastectomy, irradiation, and systemic therapy. Local/regional control by treatment at 5 and 10 years, respectively, was 31% and 31% for irradiation alone, 47% and 47% for irradiation and systemic therapy, 80% and 80% for irradiation and mastectomy, and 93% and 78% for irradiation, mastectomy, and systemic therapy (p less than .0001). Actuarial disease-free survival by treatment was 19% and 12% for irradiation alone, 25% and 18% for irradiation and systemic therapy, 34% and 20% for irradiation and mastectomy, and 41% and 31% for irradiation, mastectomy, and systemic therapy, at 5 and 10 years, respectively (p = .0001). Patients given systemic therapy and/or irradiation prior to mastectomy had a better local/regional control and DFS and actuarial survival, although not achieving statistical significance (p = 0.10). Of the triple modality group of patients, there were no chest wall failures with chest wall doses greater than 5040 cGy (p = 0.3). There were 40/237 (17%) grade 2 or greater treatment sequelae. The administration of chemotherapy significantly increased complications.

Three-dimensional photon treatment planning of the intact breast

Three-dimensional treatment planning for the intact breast was performed on two patients who had undergone CT scanning. A total of 38 treatment plans were evaluated. Multiple plans were evaluated for each patient including plans with and without inhomogeneity corrections, plans using varying photon energies of 60Co, 4 MV, 6 MV, 10 MV, and 15 MV, and three-dimensionally unconstrained plans. Increased hot spots were appreciated in the central axis plane when lung inhomogeneity corrections were used. Additional hot spots were appreciated in off-axis planes towards the cephalad and caudad aspects of the target volume because of lung inhomogeneity corrections and changes in the breast contour. The use of 60Co was associated with an increase in the magnitude and volume of hot spots, whereas the use of higher energy photons such as 10 MV and 15 MV was associated with an unacceptable target coverage at shallow depths. Therefore, for the two patients studied, the use of a medium energy photon beam (such as from a 6 MV linear accelerator) appeared to be the energy of choice for treatment of the intact breast. The three-dimensionally unconstrained plans were able to improve slightly upon the standard plans, particularly with relationship of dose to normal tissue structures. Areas for future research were identified, including the use of tissue compensators.

Selection of breast-preservation therapy for primary invasive breast carcinoma

Breast-preservation treatment for primary breast cancer should not be used for all women. Women frequently excluded from consideration for such treatment or who choose not to have it may be elderly and not concerned about cosmetic appearance or live at a distance so that 6 weeks of daily trips to radiotherapy would be inconvenient or even impossible. Also, if radiotherapeutic expertise or facilities are not available, a breast-preservation program is difficult. In Massachusetts, a full course of just over 6000 cGy (4500 cGy to the whole breast and a 1600-cGy local boost) costs roughly $6000. Thus, breast preservation is more expensive than mastectomy even with reconstruction, as patients still frequently require a hospital admission with general anesthesia for an axillary dissection. Although insurance policies cover such expenses, patients who do not have insurance or have inadequate coverage may find the extra expense of the breast-preservation technique burdensome or impossible. Women with a small breast and a proportionately large cancer may have an unsatisfactory cosmetic outcome after appropriate lumpectomy. The cosmetic result in such patients frequently cannot be predicted beforehand; this fact adds emphasis to the need for a two-step process of lumpectomy and then re-evaluation of the cosmetic outcome as well as pathologic features for decisions regarding breast preservation. Finally, women may have strikingly different attitudes toward breast preservation than expected by the surgeon. For some women, the urge to preserve the breast is so strong that they will accept virtually any risk to achieve this option, whereas for other women, the constant anxiety about a recurrence or undergoing radiation therapy is traumatic enough that they readily accept mastectomy. In our referral surgical oncology practice, roughly 60% of patients are currently treated with breast-preservation techniques; the remainder undergo mastectomy, with immediate reconstruction in approximately three fourths of the cases. The proportion of patients who elect to have breast preservation depends greatly on local medical customs and attitudes; the radiotherapeutic skills available; women's attitudes, which frequently are dependent on the local press and publicity; and the surgeon's interest and enthusiasm for such a program. There is no appropriate proportion of patients who should be treated by breast-preservation techniques, but clearly, the proportion of patients so treated increases with experience, acceptability, publicity, and availability. Thus, the selection of breast-preserving therapy for individual patients is a result of an extraordinary array of factors that need to be considered in each patient.(ABSTRACT TRUNCATED AT 400 WORDS)

Selection of therapy for stage III breast cancer

Locally advanced breast cancer is a heterogenous group including both operable and inoperable lesions. Local surgery or radiation alone produces poor survival rates, indicating micrometastases at diagnosis. Systemic chemotherapy as part of multimodality regimens has increased the length and rate of disease-free survival.

Prognostic factors in locally advanced noninflammatory breast cancer. Long-term results following primary chemotherapy

Since 1973 we have treated T3b-T4 (stage III) breast cancer with various forms of multidisciplinary approaches through prospective trials. The present report analyses the 10-year results of 277 patients. Primary chemotherapy consisted of adriamycin plus vincristine given for three or four cycles prior to high-energy irradiation or surgery. In 205 of 277 (74%) additional chemotherapy was planned following the local-regional modality. Primary chemotherapy yielded complete plus partial remission in 62% (CR 7%). Long-term freedom from progression and overall survival were significantly improved by the addition of chemotherapy following local-regional treatment (radiotherapy or surgery). Further chemotherapy was able to significantly affect treatment outcome when it was analyzed both singly and in the presence of other prognostic variables. Thus, in our experience, the variables significantly affecting the 10-year results were represented by duration of treatment and tumor cell burden expressed by size of primary malignancy and clinical nodal status. Locally advanced breast cancer appears a pleomorphic disease difficult to control over a long period of time because of its frequent presentation with bulky tumor and the very high risk of disseminated micrometastases. Thus, the management of this stage of disease almost invariably requires a multidisciplinary approach.

Clinical trials in locally advanced breast cancer

Survival after treatment of locally advanced breast cancer is poor and resembles that for untreated breast cancer. Although retrospective comparisons have suggested that the addition of systemic treatment might be beneficial, a literature survey of the controlled clinical trials failed to show consistent survival benefits of any treatment modality. The local control, or time to local progression, on the other hand seems to be improved by increasing the dose of radiotherapy, or by the addition of endocrine or cytostatic treatment. Further studies should be undertaken to find better means to subdivide patients in different treatment groups. Since the present treatment modalities are unlikely to improve survival more than marginally, clinical studies are necessary to search for the best palliative treatment, until experimental work provides us with better treatment tools.