1
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Zaborowski AM, Wong SM. Neoadjuvant systemic therapy for breast cancer. Br J Surg 2023; 110:765-772. [PMID: 37104057 PMCID: PMC10683941 DOI: 10.1093/bjs/znad103] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Accepted: 04/02/2023] [Indexed: 04/28/2023]
Affiliation(s)
| | - Stephanie M Wong
- Department of Surgery and Oncology, McGill University Medical School, Montreal, Quebec, Canada
- Segal Cancer Centre, Sir Mortimer B. Davis Jewish General Hospital, Montreal, Quebec, Canada
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2
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García-Calvo L, Martí Álvarez C, Gutiérrez AH, García AB, Muñoz RA, Sánchez-Méndez JI. Sentinel Node Biopsy in Patients With Breast Carcinoma Without Axillary Involvement at Diagnosis Receiving Primary Systemic Therapy. Clin Breast Cancer 2023:S1526-8209(23)00140-4. [PMID: 37331894 DOI: 10.1016/j.clbc.2023.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/27/2023] [Accepted: 05/27/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND Primary systemic therapy (PST) has acquired great importance in breast cancer (BC) in the last few years. In this scenario, even if it is accepted to perform SLNB before PST, most of the guidelines remark the advantages of this practice after it, such as avoiding another surgery to the patient, a rapid start of the treatment and no need of axillary dissection in cases of pathologic complete response (pCR). Nevertheless, the lack of knowledge of the initial axillary state and the need to practice axillary dissection with any axillary disease are claimed to be some other disadvantages. There are no randomized studies yet that can conclude the optimal timing of SLNB in PST, so for the moment we may settle for our common practice. PATIENTS AND METHODS We studied all the cases attended in the Breast Unit that joined the inclusion criteria between 2011 and 2019 in our hospital and we compared the group with SLNB before PST with the group with SLNB after PST in terms of unnecessary axillary dissection and description features. RESULTS We included 223 female patients diagnosed with BC and without clinical nor radiological axillary disease (cN0), who had received NAC and SLNB performed before or after it. We observed a higher proportion of high-grade histological tumors (G3), tumors with aggressive phenotypes (Basal like and Her 2 enriched), and younger women in the group of SLNB before NAC compared with the SLNB after NAC group (P < .01). Despite this, we did not find any difference in the number of positive SLNBs or in the number of ALND performed between the 2 groups. We found a higher proportion of ALND with all the lymph node (LN) negatives in the SLNB before NAC group. CONCLUSION Taking into account that in the observation period we did not use ACOSOG Z0011 criteria with all the SLNBs, we figure out what would have been the real results nowadays following these criteria. In this scenario we conclude that patients with luminal phenotype seemed to benefit from practicing SLNB before NAC in terms of avoiding axillary dissections. We could not make any conclusion in the rest of the phenotypes. However, prospective studies are needed to confirm if this affirmation could be proved.
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Affiliation(s)
- Laura García-Calvo
- Department of Gynecology and Obstetrics, Breast Pathology Unit, Campo Grande Hospital, Valladolid, Spain.
| | - Covadonga Martí Álvarez
- Department of Gynecology and Obstetrics, Breast Pathology Unit, La Paz University Hospital, Madrid, Spain
| | - Alicia Hernández Gutiérrez
- Universidad Autónoma Department, Madrid, Spain; Hospital La Paz Institute for Health Research, IdiPAZ, Madrid, Spain; Gynecology and Obstetrics Department, Gynecologic Oncology Unit, La Paz University Hospital, Madrid, Spain
| | | | - Rocío Arnedo Muñoz
- Gynecology and Obstetrics Department, Rey Juan Carlos University Hospital, Madrid, Spain
| | - José I Sánchez-Méndez
- Department of Gynecology and Obstetrics, Breast Pathology Unit, La Paz University Hospital, Madrid, Spain; Universidad Autónoma Department, Madrid, Spain; Hospital La Paz Institute for Health Research, IdiPAZ, Madrid, Spain
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Ranganath R, Hui M, Uppin S, Jena S, Shantappa R. An Audit of Breast Conservation Surgery for Breast Cancer - a 7-Year Experience from Southern India. Indian J Surg Oncol 2023; 14:492-496. [PMID: 37324291 PMCID: PMC10267059 DOI: 10.1007/s13193-022-01532-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2021] [Accepted: 04/06/2022] [Indexed: 11/28/2022] Open
Abstract
To audit the use of breast conservation surgery for breast cancer treatment in a tertiary care centre over a 7-year period, and also to chart the clinical, demographic and pathological characteristics of breast cancer patients treated in the setting of a referral centre in a middle income (MDI) group country. A retrospective analysis of the case records of all patients of invasive breast cancer treated at our institute between January 2014 and December 2020 was done after obtaining approval from the Institute Ethics Committee (IEC). The number of patients seen, age, parity, menopausal status, family history of cancer, laterality, site of tumour in the breast, the symptomatology, clinical stage and presence or absence of metastases was the clinical parameters examined. The pathological stage and grade of the tumour, receptor status, treatment offered according to stage and the patterns of failure with respect to the surgery performed were recorded. Statistical analysis was a direct head to head comparison of the percentage proportions of the different variables. A total of 685 patients of breast cancer were treated between January 2014 and December 2020. A total of 53% of the cohort was more than 45 years old and 56.7% were post menopausal. A total of 58.8% of the patients presented with a cancer in the left breast and in the upper outer quadrant. Nearly 41% of the tumours were more than 4 cm in size. The most common receptor profile in our patient population was ER positive, PR positive and HER 2 negative. A total of 27.7% of the patients were offered neo-adjuvant chemotherapy and 63.06% underwent upfront surgery. A total of 19.7% of all surgeries performed (overall) were breast conservation surgeries (BCS). The use of BCS showed an increasing trend over the 7 years studied rising from 16.79 to 25% (annually). The local failure rate for BCS was 11.8% but the incidence of distant metastases was not significantly different compared to the patients who underwent a mastectomy. Breast conservation is safe and feasible in a referral setting even in a middle income nation with multi-disciplinary treatment planning and needs to be adopted widely to preserve the body image and self esteem of patients with breast cancer.
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Affiliation(s)
- R. Ranganath
- Department of Surgical Oncology, Nizam’s Institute of Medical Sciences, Hyderabad, TG India
| | - Monalisa Hui
- Department of Pathology, Nizam’s Institute of Medical Sciences, Hyderabad, TG India
| | - Shantveer Uppin
- Department of Pathology, Nizam’s Institute of Medical Sciences, Hyderabad, TG India
| | - S. Jena
- Department of Surgical Oncology, Nizam’s Institute of Medical Sciences, Hyderabad, TG India
| | - Rajshekar Shantappa
- Department of Surgical Oncology, Nizam’s Institute of Medical Sciences, Hyderabad, TG India
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4
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Pramod N, Nigam A, Basree M, Mawalkar R, Mehra S, Shinde N, Tozbikian G, Williams N, Majumder S, Ramaswamy B. Comprehensive Review of Molecular Mechanisms and Clinical Features of Invasive Lobular Cancer. Oncologist 2021; 26:e943-e953. [PMID: 33641217 DOI: 10.1002/onco.13734] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Accepted: 02/12/2021] [Indexed: 12/15/2022] Open
Abstract
Invasive lobular carcinoma (ILC) accounts for 10% to 15% of breast cancers in the United States, 80% of which are estrogen receptor (ER)-positive, with an unusual metastatic pattern of spread to sites such as the serosa, meninges, and ovaries, among others. Lobular cancer presents significant challenges in detection and clinical management given its multifocality and multicentricity at presentation. Despite the unique features of ILC, it is often lumped with hormone receptor-positive invasive ductal cancers (IDC); consequently, ILC screening, treatment, and follow-up strategies are largely based on data from IDC. Despite both being treated as ER-positive breast cancer, querying the Cancer Genome Atlas database shows distinctive molecular aberrations in ILC compared with IDC, such as E-cadherin loss (66% vs. 3%), FOXA1 mutations (7% vs. 2%), and GATA3 mutations (5% vs. 20%). Moreover, compared with patients with IDC, patients with ILC are less likely to undergo breast-conserving surgery, with lower rates of complete response following therapy as these tumors are less chemosensitive. Taken together, this suggests that ILC is biologically distinct, which may influence tumorigenesis and therapeutic strategies. Long-term survival and clinical outcomes in patients with ILC are worse than in stage- and grade-matched patients with IDC; therefore, nuanced criteria are needed to better define treatment goals and protocols tailored to ILC's unique biology. This comprehensive review highlights the histologic and clinicopathologic features that distinguish ILC from IDC, with an in-depth discussion of ILC's molecular alterations and biomarkers, clinical trials and treatment strategies, and future targets for therapy. IMPLICATIONS FOR PRACTICE: The majority of invasive lobular breast cancers (ILCs) are hormone receptor (HR)-positive and low grade. Clinically, ILC is treated similar to HR-positive invasive ductal cancer (IDC). However, ILC differs distinctly from IDC in its clinicopathologic characteristics and molecular alterations. ILC also differs in response to systemic therapy, with studies showing ILC as less sensitive to chemotherapy. Patients with ILC have worse clinical outcomes with late recurrences. Despite these differences, clinical trials treat HR-positive breast cancers as a single disease, and there is an unmet need for studies addressing the unique challenges faced by patients diagnosed with ILC.
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Affiliation(s)
- Nikhil Pramod
- Stefanie Spielman Comprehensive Breast Center, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Akanksha Nigam
- Stefanie Spielman Comprehensive Breast Center, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Mustafa Basree
- University of Pikeville Kentucky College of Osteopathic Medicine, Pikeville, Kentucky, USA
| | - Resham Mawalkar
- Stefanie Spielman Comprehensive Breast Center, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Saba Mehra
- University of Toledo - Health Science Campus, Toledo, Ohio, USA
| | - Neelam Shinde
- Stefanie Spielman Comprehensive Breast Center, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Gary Tozbikian
- Stefanie Spielman Comprehensive Breast Center, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Nicole Williams
- Stefanie Spielman Comprehensive Breast Center, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Sarmila Majumder
- Stefanie Spielman Comprehensive Breast Center, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Bhuvaneswari Ramaswamy
- Stefanie Spielman Comprehensive Breast Center, The Ohio State University Comprehensive Cancer Center, Columbus, Ohio, USA
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Cen C, Chun J, Kaplowitz E, Axelrod D, Shapiro R, Guth A, Schnabel F. Margin Assessment and Re-excision Rates for Patients Who Have Neoadjuvant Chemotherapy and Breast-Conserving Surgery. Ann Surg Oncol 2021; 28:5142-5148. [PMID: 33635409 DOI: 10.1245/s10434-020-09524-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2020] [Accepted: 12/10/2020] [Indexed: 01/22/2023]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) has enabled more patients to be eligible for breast-conservation surgery (BCS). Achieving negative lumpectomy margins, however, is challenging due to changes in tissue composition and potentially scattered residual carcinoma in the tumor bed. Data regarding BCS after NAC have shown variable re-excision rates. MarginProbe (Dilon Technologies, Newport News, VA, USA) has been shown to identify positive resection margins intraoperatively and to reduce the number of re-excisions in primary BCS, but has not been studied in NAC+BCS cases. This study aimed to investigate the clinicopathologic characteristics, margin status, and re-excision rates for NAC+BCS patients with and without the use of MarginProbe. METHODS The Institutional Breast Cancer Database was queried for patients who received NAC and had BCS from 2010 to 2019. The variables of interest were demographics, tumor characteristics, pathologic complete response (pCR), MarginProbe use, and re-excision rates. RESULTS The study population consisted of 214 patients who had NAC, 61 (28.5 %) of whom had NAC+BCS. The median age of the patients was 53.5 years. A pCR was achieved for 19 of the patients (31.1 %). Of the remaining 42 patients, 9 (21 %) had close or positive margins that required re-excision. Re-excision was associated with a larger residual tumor size (p = 0.025) and estrogen receptor (ER)-positive disease before NAC (p = 0.041). MarginProbe use was associated with a lower re-excision rate for the patients who had NAC+BCS (6 % vs. 31 %, respectively). CONCLUSION The patients with a larger residual tumor burden and ER-positive disease had a greater risk for inadequate margins at surgery. MarginProbe use was associated with a lower re-excision rate. Techniques to reduce the need for re-excision will support the use of BCS after NAC.
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Affiliation(s)
- Cindy Cen
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Jennifer Chun
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Elianna Kaplowitz
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Deborah Axelrod
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Richard Shapiro
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Amber Guth
- Department of Surgery, New York University Langone Health, New York, NY, USA
| | - Freya Schnabel
- Department of Surgery, New York University Langone Health, New York, NY, USA.
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6
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Walcott-Sapp S, Srour MK, Lee M, Luu M, Amersi F, Giuliano A, Chung A. Can Radiologic Tumor Size Following Neoadjuvant Therapy Reliably Guide Tissue Resection in Breast Conserving Surgery in Patients with Invasive Breast Cancer? Am Surg 2021; 86:1248-1253. [PMID: 33284669 DOI: 10.1177/0003134820964209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Optimum tissue resection volume for patients with invasive breast cancer undergoing breast conserving surgery following neoadjuvant therapy (NAT) is not known. We compared positive margin and in-breast tumor recurrence (IBTR) between 2 groups that were created based on radiologic tumor size (RTS (cm3)) at diagnosis, RTS post-NAT, and volume of tissue resected (VTL): Pre-NAT group, patients with VTL closer to RTS at diagnosis, and post-NAT group, patients with VTL closer to post-NAT RTS. 82 patients with 84 breast cancers treated with NAT between 2007 and 2017 who had pre- and post-NAT imaging were identified from a prospectively maintained database. RTS at diagnosis, RTS post-NAT, and VTL were determined. Clinical and treatment characteristics, IBTR, and disease-free survival (DFS) were compared between pre-NAT (n = 51) and post-NAT (n = 33) groups. Compared to post-NAT patients, pre-NAT patients had smaller RTS at presentation (9.2 vs. 33.5 cm3, P < .001) and post-NAT (1.2 vs. 8.2 cm3, P = .024). At median follow-up of 4 years, there were no differences between groups in pathologic tumor size, positive margin rate, adjuvant therapy, IBTR, or DFS. Resection volumes that matched RTS on post-NAT imaging were not associated with increased positive margins or IBTR. It may be appropriate to use post-NAT imaging to guide lumpectomy volume.
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Affiliation(s)
| | | | - Minna Lee
- UCLA Jonsson Cancer Center, Los Angeles, CA, USA
| | - Michael Luu
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Farin Amersi
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | | | - Alice Chung
- Cedars-Sinai Medical Center, Los Angeles, CA, USA
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7
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Woeste MR, Bhutiani N, Donaldson M, McMasters KM, Ajkay N. Evaluating the effect of neoadjuvant chemotherapy on surgical outcomes after breast conserving surgery. J Surg Oncol 2020; 123:439-445. [PMID: 33259649 DOI: 10.1002/jso.26301] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/27/2020] [Accepted: 11/05/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND Neoadjuvant chemotherapy (NAC) increases breast-conserving surgery (BCS) rates with comparable locoregional control and survival outcomes to adjuvant therapy. More women are receiving NAC and achieving pathologic complete responses (pCR). This study sought to evaluate the effect of NAC on surgical outcomes after the adoption of a "no-ink-on-tumor" margin policy in patients undergoing primary BCS (PBSC). METHODS An IRB approved database was queried for women undergoing BCS for invasive breast cancer after March 2014. We compared patients who underwent NAC followed by BCS versus PBCS. Demographic, tumor, treatment, and outcome variables were compared using both univariate and multivariable analysis. RESULTS A total of 162 patients were evaluated. NAC patients had significantly lower re-excision rates (0% NAC vs. 9% PBCS, p = .03), margin positivity (0% NAC vs. 5% PBCS, p = .01), and greater patient satisfaction with breast cosmesis (97 NAC vs. 77 PBCS, p = .01). On multivariable analysis, NAC was not an independent predictor of lower final resection volume, total complications, or greater satisfaction with breasts when controlling for age and T category at diagnosis. CONCLUSION NAC followed by BCS may offer less margin positivity, lower re-excision rates, and greater patient satisfaction when compared to a contemporary PBCS cohort in the "no-ink-on-tumor" era.
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Affiliation(s)
- Matthew R Woeste
- Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Neal Bhutiani
- Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Marilyn Donaldson
- Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Kelly M McMasters
- Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Nicolás Ajkay
- Division of Surgical Oncology, Department of Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
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Tasdöven I, Karadeniz Çakmak G, Emre AU, Engin H, Bahadır B, Bakkal HB, Güllüoğlu MB. Intraoperative ultrasonography-guided surgery: An effective modality for breast conservation after neo-adjuvant chemotherapy. Breast J 2020; 26:1680-1687. [PMID: 33443786 DOI: 10.1111/tbj.13992] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 06/05/2020] [Accepted: 07/10/2020] [Indexed: 11/28/2022]
Abstract
Margin status is one of the significant prognostic factors for recurrence in breast-conserving surgery (BCS). The issue that merits consideration for oncologic safety and cost-effectiveness about the modalities to assure clear margins at initial surgical intervention remains controversial after neo-adjuvant chemotherapy (NAC). The presented study aimed to assess the impact of intraoperative ultrasound (IOUS)-guided surgery on accurate localization of tumor site, adequacy of excision with clear margins, and healthy tissue sacrifice in BCS after NAC. Patients who had IOUS-guided BCS ater NAC were reviewed. No patient had preoperative localization with wire or radiotracer. Intraoperative real-time sonographic localization, sonographic margin assessment during resection, macroscopic and sonographic examination of specimen, and cavity shavings (CS) were done as the standard procedure. No frozen assessment was performed. One hundred ninety-four patients were included, in which 42.5% had pCR. IOUS-guided surgery accomplished successful localization of the targeted lesions in all patients. Per protocol, all inked margins on CS specimens were reported to be tumor-free in permanent histopathology. No re-excision or mastectomy was required. For a setting without CS, the negative predictive value (NPV) of IOUS rate was 96%. IOUS was found to over and underestimate tumor response to NAC both in 2% of patients. IOUS-guided surgery seems to be an efficient modality to perform adequate BCS after NAC with no additional localization method. Especially, when CS is integrated as a standard to BCS, IOUS seems to provide safe surgery for patients with no false negativity and a high rate of NPV.
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Affiliation(s)
- Ilhan Tasdöven
- Department of Surgery, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Güldeniz Karadeniz Çakmak
- Department of Surgery, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Ali Ugur Emre
- Department of Surgery, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Hüseyin Engin
- Department of Oncology, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Burak Bahadır
- Department of Pathology, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
| | - Hakan Bekir Bakkal
- Department of Radiation Oncology, The School of Medicine, Zonguldak Bulent Ecevit University, Zonguldak, Turkey
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Murugappan K, Saboo A, Kuo L, Ung O. Paradigm shift in the local treatment of breast cancer: mastectomy to breast conservation surgery. Gland Surg 2018; 7:506-519. [PMID: 30687624 PMCID: PMC6323252 DOI: 10.21037/gs.2018.09.01] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 09/03/2018] [Indexed: 01/16/2023]
Abstract
There have been fundamental changes in the approach to breast cancer management over the last century but the primary objective of achieving oncological safety remains unchanged. This evolution is highlighted with a summary of the key evidences in support of the oncological safety of breast conserving surgery (BCS) in early breast cancer (EBC) management. We will also discuss the increasingly pivotal role that neoadjuvant chemotherapy (NACT) may play, in the local treatment of EBC and locally advanced breast cancer (LABC) and the long-term surgical and oncological outcomes.
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Affiliation(s)
- Kowsi Murugappan
- Royal Brisbane Breast Surgery Unit, Department of General Surgery, RBWH, Brisbane, Australia
- University of Queensland, Brisbane, Australia
| | - Apoorva Saboo
- Royal Brisbane Breast Surgery Unit, Department of General Surgery, RBWH, Brisbane, Australia
| | - Lu Kuo
- University of Queensland, Brisbane, Australia
| | - Owen Ung
- Royal Brisbane Breast Surgery Unit, Department of General Surgery, RBWH, Brisbane, Australia
- University of Queensland, Brisbane, Australia
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10
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Valachis A, Mamounas EP, Mittendorf EA, Hayashi N, Ishitobi M, Natoli C, Fitzal F, Rubio IT, Tiezzi DG, Shin HC, Anderson SJ, Hunt KK, Matsuda N, Ohsumi S, Totomi A, Nilsson C. Risk factors for locoregional disease recurrence after breast-conserving therapy in patients with breast cancer treated with neoadjuvant chemotherapy: An international collaboration and individual patient meta-analysis. Cancer 2018; 124:2923-2930. [DOI: 10.1002/cncr.31518] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 03/05/2018] [Accepted: 03/18/2018] [Indexed: 01/19/2023]
Affiliation(s)
- Antonios Valachis
- Centre for Clinical Research Sormland; Uppsala University; Uppsala Sweden
| | - Eleftherios P. Mamounas
- Comprehensive Breast Program; University of Florida Health Cancer Center-Orlando Health; Orlando Florida
| | - Elizabeth A. Mittendorf
- Department of Breast Surgical Oncology; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Naoki Hayashi
- Department of Breast Surgery; St. Luke's International Hospital; Tokyo Japan
| | - Makoto Ishitobi
- Department of Breast Surgery; Osaka International Cancer Institute; Osaka Japan
- Department of Endocrine Surgery; Osaka International Cancer Institute; Osaka Japan
| | - Clara Natoli
- Department of Oral, Medical and Biotechnological Sciences; University G. D'Annunzio; Chieti-Pescara Italy
| | - Florian Fitzal
- Department of Surgery, Breast Health Center; Medical University Vienna; Vienna Austria
| | - Isabel T. Rubio
- Breast Surgical Oncology, Breast Cancer Center; University Hospital VAll d'Hebron; Barcelona Spain
| | - Daniel G. Tiezzi
- Breast Disease Division, Department of Gynecology and Obstetrics, Ribeirao Preto Medical School; University of Sao Paulo; Sao Paulo Brazil
| | - Hee-Chul Shin
- Department of Surgery; Chung-Ang University Hospital; Seoul South Korea
| | - Stewart J. Anderson
- National Surgical Adjuvant Breast and Bowel Project Biostatistical Center, Department of Biostatistics, University of Pittsburgh Graduate School of Public Health; University of Pittsburgh; Pittsburgh Pennsylvania
| | - Kelly K. Hunt
- Department of Breast Surgical Oncology; The University of Texas MD Anderson Cancer Center; Houston Texas
| | - Naoko Matsuda
- Department of Breast Surgery; St. Luke's International Hospital; Tokyo Japan
| | - Shozo Ohsumi
- Department of Breast Oncology; NHO Shikoku Cancer Center; Matsuyama Japan
| | - Athina Totomi
- Centre for Clinical Research Sormland; Uppsala University; Uppsala Sweden
| | - Cecilia Nilsson
- Centre for Clinical Research; Vastmanlands County Hospital; Vasteras Sweden
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11
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Breast-conserving surgery following neoadjuvant therapy-a systematic review on surgical outcomes. Breast Cancer Res Treat 2017; 168:1-12. [PMID: 29214416 PMCID: PMC5847047 DOI: 10.1007/s10549-017-4598-5] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/07/2017] [Indexed: 01/14/2023]
Abstract
Purpose Neoadjuvant chemotherapy (NACT) is increasingly used in breast cancer treatment. One of the main goals of NACT is to reduce the extent of local surgery of the breast and axilla. The aim of this study was to determine surgical outcomes for patients receiving breast-conserving therapy (BCT) after NACT, including margin status plus secondary surgeries, excision volumes, and cosmetic outcomes. Methods A systematic review was performed in accordance with PRISMA principles. Pubmed, MEDLINE, Embase, and the Cochrane Library were searched for studies investigating the results of BCT following NACT. The main study outcomes were margin status, additional local therapies, excision volumes, and cosmetic outcomes. Non-comparative studies on NACT were also included. Exclusion criteria were studies with less than 25 patients, and studies excluding secondary mastectomy patients. Findings Of the 1219 studies screened, 26 studies were deemed eligible for analysis, including data from 5379 patients treated with NACT and 10,110 patients treated without NACT. Included studies showed wide ranges of tumor-involved margins (2–39.8%), secondary surgeries (0–45.4%), and excision volumes (43.2–268 cm3) or specimen weight (26.4–233 g) after NACT. Most studies were retrospective, with a high heterogeneity and a high risk of bias. Cosmetic outcomes after NACT were reported in two single-center cohort studies. Both studies showed acceptable cosmetic outcomes. Interpretation There is currently insufficient evidence to suggest that NACT improves surgical outcomes of BCT. It is imperative that clinical trials include patient outcome measures in order to allow monitoring and meaningful comparison of treatment outcomes in breast cancer.
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12
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Diaz-Botero S, Espinosa-Bravo M, Gonçalves VR, Esgueva-Colmenarejo A, Peg V, Perez J, Cortes J, Rubio IT. Different Prognostic Implications of Residual Disease After Neoadjuvant Treatment: Impact of Ki 67 and Site of Response. Ann Surg Oncol 2016; 23:3831-3837. [DOI: 10.1245/s10434-016-5339-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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13
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Rubio IT. Sentinel lymph node biopsy after neoadjuvant treatment in breast cancer: Work in progress. Eur J Surg Oncol 2015; 42:326-32. [PMID: 26774943 DOI: 10.1016/j.ejso.2015.11.018] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2015] [Accepted: 11/25/2015] [Indexed: 11/19/2022] Open
Abstract
Sentinel lymph node biopsy has replaced axillary lymph node dissection (ALND) in those patients with clinically node negative axilla and nowadays, patients with low burden disease in the SLNs may spare an ALND without compromising their oncologic outcomes. In the last decade, indications of neoadjuvant treatment (NAT) have been extended to patients with operable disease and with the use of targeted therapies, rates of pathologic complete response (pCR) after NAT have increased. In the neoadjuvant setting, SLN after NAT is feasible and accurate in clinically node negative patients and it has been explored in different randomized prospective studies in patients with clinically positive axilla in the continuous effort to avoid the morbidity of ALND. The importance of identifying patients with residual axillary disease may serve not only as indicator for selecting patients with pCR to be spared an ALND but also for selecting patients for additional therapy. Future research is needed to more accurately identify residual axillary disease and the SLN after NAT is the driver for this achievement.
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Affiliation(s)
- I T Rubio
- Hospital Universitario Vall d'hebron, Barcelona, Spain.
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Rubio IT. Sentinel lymph node metastasis after neoadjuvant treatment in breast cancer: Any size matters? World J Clin Oncol 2015; 6:202-206. [PMID: 26677431 PMCID: PMC4675903 DOI: 10.5306/wjco.v6.i6.202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2015] [Revised: 08/09/2015] [Accepted: 09/28/2015] [Indexed: 02/06/2023] Open
Abstract
One of the advantages of neoadjuvant chemotherapy (NAC) treatments is its ability to convert patients who need a mastectomy in breast conservative surgery. NAC has also increased the conversion of node positive patients into node negative in around 40% allowing the use of sentinel node biopsy (SLN) in this setting. Timing of SLN biopsy after NAC has been a subject of debate. In patients with clinically node negative before NAC, rates of success and false negative rates of SLN after NAC are similar to those in the adjuvant setting, so SLN after NAC in previous negative axilla has been incorporated in the staging of the axilla. More controversial is its use in patients with positive axillary nodes before NAC who convert to node negative after NAC. Several randomized studies have reported the identification rates and the false negative rates of the SLN after NAC, concordant in the importance of surgical technique. As there is an agreement in the abandon of the immunohistochemistry (IHC) for SLN in the adjuvant setting as SLN IHC detected metastasis appear to have no impact on overall survival, in patients with SLN after NAC the inclusion of isolated tumor cell (ITC) as positive nodes lowers the false negative rates of the technique, suggesting the importance of assessing the SLN by IHC after NAC and considering it as residual disease. Longer follow up is needed to determine the prognostic implications of ITC in the SLN after NAC.
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Yamazaki N, Wada N, Yamauchi C, Yoneyama K. High expression of post-treatment Ki-67 status is a risk factor for locoregional recurrence following breast-conserving surgery after neoadjuvant chemotherapy. Eur J Surg Oncol 2015; 41:617-24. [PMID: 25771264 DOI: 10.1016/j.ejso.2015.01.036] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2014] [Revised: 01/23/2015] [Accepted: 01/28/2015] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION During the past decade, neoadjuvant chemotherapy (NAC) has been increasingly used in patients to reduce large tumors to a size eligible for breast-conserving therapy (BCT). However, the association between NAC and Ki-67 has not yet been fully elucidated. The aim of this study was to evaluate the prognostic significance of Ki-67, specifically after NAC followed by BCT, particularly in terms of locoregional recurrence (LRR). METHODS A total 217 patients who received BCT after NAC were retrospectively analyzed. In these patients, immunohistochemistry analyses defined four tumor subtypes, Luminal A, Luminal B, Triple negative, and HER2 type. Ki-67 was examined by immunohistochemistry in both pretreatment core needle samples and post-treatment surgical excision specimens. High Ki-67 expression was defined as >20%. The prognostic factors LRR, locoregional relapse-free survival (LRRFS), and overall survival (OS) were analyzed. RESULTS In total, LRR developed in 14 patients, and the 5 year-LRRFS was 94.2%. Post-treatment high Ki-67 expression, triple negative, the presence of lymphovascular invasion, and histological grade 3 were significantly high in LRR for prognostic factors (P < 0.05). There were significant differences in Kaplan-Meier method for LRRFS curves according to these three factors for patients receiving BCT following NAC (P < 0.05). There was a significant difference in the 5 year-OS for patients with and without LRR (41.7% vs. 93.9%, P < 0.001). CONCLUSION Post-treatment high Ki-67 expression could be one of the important prognostic factors of LRR, and require careful follow-up on LRR at the time of surveillance.
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Affiliation(s)
- N Yamazaki
- Department of Breast Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - N Wada
- Department of Breast Surgery, National Cancer Center Hospital East, Kashiwa, Japan.
| | - C Yamauchi
- Department of Breast Surgery, National Cancer Center Hospital East, Kashiwa, Japan
| | - K Yoneyama
- Department of Breast Surgery, National Cancer Center Hospital East, Kashiwa, Japan
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Matsuda N, Hayashi N, Ohde S, Yagata H, Kajiura Y, Yoshida A, Suzuki K, Nakamura S, Tsunoda H, Yamauchi H. A nomogram for predicting locoregional recurrence in primary breast cancer patients who received breast-conserving surgery after neoadjuvant chemotherapy. J Surg Oncol 2014; 109:764-9. [DOI: 10.1002/jso.23586] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Accepted: 02/08/2014] [Indexed: 02/06/2023]
Affiliation(s)
- Naoko Matsuda
- Department of Breast Surgical Oncology; St. Luke's International Hospital; Tokyo Japan
| | - Naoki Hayashi
- Department of Breast Surgical Oncology; St. Luke's International Hospital; Tokyo Japan
| | - Sachiko Ohde
- Center for Clinical Epidemiology; St. Luke's Life Science Institute; Tokyo Japan
| | - Hiroshi Yagata
- Department of Breast Surgical Oncology; St. Luke's International Hospital; Tokyo Japan
| | - Yuka Kajiura
- Department of Breast Surgical Oncology; St. Luke's International Hospital; Tokyo Japan
| | - Atsushi Yoshida
- Department of Breast Surgical Oncology; St. Luke's International Hospital; Tokyo Japan
| | - Koyu Suzuki
- Department of Pathology; St. Luke's International Hospital; Tokyo Japan
| | - Seigo Nakamura
- Department of Breast Surgical Oncology; Showa University School of Medicine; Tokyo Japan
| | - Hiroko Tsunoda
- Department of Radiology; St. Luke's International Hospital; Tokyo Japan
| | - Hideko Yamauchi
- Department of Breast Surgical Oncology; St. Luke's International Hospital; Tokyo Japan
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Murawa P, Murawa D, Adamczyk B, Połom K. Breast cancer: Actual methods of treatment and future trends. Rep Pract Oncol Radiother 2014; 19:165-72. [PMID: 24936340 DOI: 10.1016/j.rpor.2013.12.003] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2013] [Accepted: 12/04/2013] [Indexed: 01/17/2023] Open
Abstract
The recent ten to twenty years have seen a substantial progress in the diagnosis and treatment of breast cancer. A rapid development of various curative options has led to the improvement of treatment outcomes, while paying more and more attention to the aspects of quality of life and cosmetic effect. In our publication, we wish to outline certain trends in the development of modern treatment of breast cancer. Among topics discussed are new forms of molecular diagnostics, new approach to the idea of sentinel node biopsy, as well as new techniques for delivery of medical procedures, the increasing use of nomograms, progress in the techniques of breast conservative treatment, modern approach to occult breast lesions, the increasing use of neoadjuvant treatment and intraoperative radiotherapy.
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Affiliation(s)
- Paweł Murawa
- Oncological and General Surgery Department I, Greater Poland Cancer Centre, Poznań, Poland ; Cancer Pathology Department, Oncology Department, Poznań University of Medical Sciences, Poland
| | - Dawid Murawa
- Oncological and General Surgery Department I, Greater Poland Cancer Centre, Poznań, Poland
| | - Beata Adamczyk
- Oncological and General Surgery Department I, Greater Poland Cancer Centre, Poznań, Poland
| | - Karol Połom
- Oncological and General Surgery Department I, Greater Poland Cancer Centre, Poznań, Poland
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Tiezzi DG, Clagnan WS, Mandarano LRM, de Sousa CB, Marana HRC, Tiezzi MG, de Andrade JM. Expression of aldehyde dehydrogenase after neoadjuvant chemotherapy is associated with expression of hypoxia-inducible factors 1 and 2 alpha and predicts prognosis in locally advanced breast cancer. Clinics (Sao Paulo) 2013; 68:592-8. [PMID: 23778413 PMCID: PMC3654340 DOI: 10.6061/clinics/2013(05)03] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2012] [Accepted: 01/03/2013] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE To analyze the expression of hypoxia-inducible factors (hypoxia-inducible factor 1A and hypoxia-inducible factor 2A) and aldehyde dehydrogenase proteins in patients with locally advanced breast carcinoma who were subjected to neoadjuvant chemotherapy. METHODS We included 90 patients with histologically confirmed stage II and III breast carcinoma who were treated with neoadjuvant chemotherapy between 2000 and 2005. Immunohistochemistry for aldehyde dehydrogenase, hypoxia-inducible factor 1A, and hypoxia-inducible factor 2A was performed before and after neoadjuvant chemotherapy. We analyzed the influence of clinical and pathological features on clinical and pathological response, disease-free survival, and overall survival. RESULTS An objective clinical response to neoadjuvant chemotherapy was observed in 80% of patients, with 12% showing a complete pathological response. Among all clinical and pathological parameters, only the expression of hypoxia-inducible factor 1A was associated with a pathological response. A positive association was found between expression of aldehyde dehydrogenase and that of hypoxia-inducible factor 1A before and after chemotherapy. Aldehyde dehydrogenase expression was associated with expression of hypoxia inducible-factor 2A in tumors after neoadjuvant treatment. In a univariate analysis, prognosis was influenced by age, pathological response, metastasis to axillary lymph nodes after neoadjuvant chemotherapy, overexpression of hypoxia-inducible factor 2, and the presence of aldehyde dehydrogenase-positive cells within the primary tumor after neoadjuvant chemotherapy. In a multivariate analysis, only age and the presence of aldehyde dehydrogenase-positive cells after chemotherapy were associated with reduced overall survival. CONCLUSION The presence of aldehyde dehydrogenase-positive cells within the residual tumor after neoadjuvant chemotherapy is associated with an increase in the expression of hypoxia-inducible factor 2A and with poor prognosis in patients with locally advanced breast cancer.
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Affiliation(s)
- Daniel Guimarães Tiezzi
- Universidade de São Paulo, Hospital das Clínicas of the RibeirãoPreto School of Medicine, Breast Disease Division Department of Gynecology and Obstetrics, Ribeirão Preto/SP, Brazil.
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Balabram D, Araújo FB, Porto SS, Rodrigues JS, Sousa AS, Siqueira AL, Gobbi H. Changes in mastectomy rates at a Brazilian public hospital over 20 years (1989 to 2008). SAO PAULO MED J 2012; 130:360-6. [PMID: 23338732 PMCID: PMC10522311 DOI: 10.1590/s1516-31802012000600002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2012] [Revised: 10/13/2011] [Accepted: 03/16/2012] [Indexed: 02/06/2023] Open
Abstract
CONTEXT AND OBJECTIVE Recently, breast-conserving surgery (BCS) has been replacing mastectomy for breast cancer treatment. The aim of this study was to evaluate the changes in mastectomy and BCS rates and the factors relating to these shifts. DESIGN AND SETTING A retrospective study in a Brazilian public hospital. METHODS Pathological records from female patients who underwent surgery for breast cancer at Hospital das Clínicas, Universidade Federal de Minas Gerais (HC-UFMG), between 1989 and 2008 were reviewed. The mastectomy and BCS rates were calculated. The chi-square test was used to assess factors associated with type of surgical treatment and to compare trends in treatment type over the years. Logistic regression was used for multivariate analysis. RESULTS From 1989 to 2008, 2050 breast cancer surgical specimens were received in our service, corresponding to 1973 patients; 1324 (64.6%) of them were from mastectomy and 726 (35.4%) from BCS. A shift from mastectomy towards BCS was observed (P < 0.001). In multivariate analysis, earlier year of surgery (P < 0.001), larger tumor size (P < 0.001), having at least one positive axillary lymph node (P < 0.001) and patients' age greater than 68 years (P = 0.007) were predictors of mastectomy. CONCLUSIONS There was a shift from mastectomy towards BCS in our institution over the years. This may reflect consolidation of BCS (plus radiotherapy) as an equivalent treatment to mastectomy in terms of survival and a shift to earlier diagnosis for the disease.
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Affiliation(s)
- Débora Balabram
- MD, PhD Student. General Surgeon, Department of Anatomical Pathology, Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.
| | - Fábio Braga Araújo
- Medical Student, Department of Anatomical Pathology, Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.
| | - Simone Souza Porto
- Medical Student, Department of Anatomical Pathology, Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.
| | - Joyce Soares Rodrigues
- Statistics Student, Department of Statistics, Instituto de Ciências Exatas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.
| | - Atila Silva Sousa
- Medical Student, Department of Anatomical Pathology, Faculdade de Medicina da Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.
| | - Arminda Lucia Siqueira
- PhD. Associate Professor, Department of Statistics, Instituto de Ciências Exatas, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.
| | - Helenice Gobbi
- MD, PhD. Associate Professor, Department of Anatomical Pathology, Universidade Federal de Minas Gerais (UFMG), Belo Horizonte, Minas Gerais, Brazil.
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Singh LC, Chakraborty A, Mishra AK, Devi TR, Sugandhi N, Chintamani C, Bhatnagar D, Kapur S, Saxena S. Study on predictive role of AR and EGFR family genes with response to neoadjuvant chemotherapy in locally advanced breast cancer in Indian women. Med Oncol 2011; 29:539-46. [DOI: 10.1007/s12032-011-9952-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2011] [Accepted: 04/08/2011] [Indexed: 11/29/2022]
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Taxane-based chemotherapy enhances response to neoadjuvant treatment for stage II and III breast cancer. Med Oncol 2010; 28 Suppl 1:S65-9. [PMID: 20953738 DOI: 10.1007/s12032-010-9711-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2010] [Accepted: 10/01/2010] [Indexed: 10/18/2022]
Abstract
Reducing primary tumor volume is the main role of neoadjuvant chemotherapy for breast cancer. We evaluated the benefit of adding docetaxel to anthracyclin as neoadjuvant therapy. This study is a retrospective cohort analysis comparing the efficacy of neoadjuvant chemotherapy in patients subjected to docetaxel and epirubicin or 5-fluoruracil, epirubicin and cyclophosphamide combinations (DE and FEC group, respectively). The mean number of chemotherapy delivered was similar in both groups (P = 0.8). A total of 316 patients were treated (151 in FEC group and 165 in DE group). Primary endpoint was the clinical and pathological response to therapy. Breast conserving surgery rate was compared. In T1/2 staged patients, the complete clinical response rate was 7.5% in FEC group and 32% in DE group (P = 0.002), and the breast conserving surgery rate was 72 and 73% in FEC and DE groups, respectively (P = 0.9). In the subset of patients staged as T3 and T4a-c, objective response was higher in DE group (P < 0.0001 and P = 0.008, respectively). Breast conserving surgery rate was 38 and 63% in FEC and DE groups, respectively, in T3 staged patients and, 20.5 and 37% in T4a-c staged patients (P = 0.003 and 0.08). Despite the similar number of chemotherapy cycles delivered in both groups, the presence of microscopic axillary lymph node involvement after chemotherapy was less frequent in DE group. Neoadjuvant chemotherapy with DE combination is more effective in terms of clinical and pathological response propitiating higher breast conserving surgery rate than FEC combination in stage II and III breast cancer.
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Can we predict local recurrence in breast conserving surgery after neoadjuvant chemotherapy? Eur J Surg Oncol 2010; 36:528-34. [DOI: 10.1016/j.ejso.2010.04.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2009] [Revised: 03/08/2010] [Accepted: 04/12/2010] [Indexed: 11/17/2022] Open
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