Locally Advanced Breast

Cancer
Aspects of Surgical
Management
J. Apffelstaedt

The MammaClinic
Cape Town, South Africa
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The

J. Apffelstaedt

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

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Haagensen CD, Stout AP: Carcinoma of the

Breast II - Criteria of Operability.
Ann Surg 1943, 116: 1032.

The

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Criteria of Operability
Bulky axillary disease
Skin Manifestations:
Edema
Ulceration
Satellite Nodules
Fixation

Chest Wall Fixation

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

The

J. Apffelstaedt

TNM Stage III Disease

Tumors > 5 cm with nodes
Any tumor with N2/3 nodes
Skin manifestations
Chest wall fixation
Inflammatory Carcinoma
=> Significant hererogenicity
Hermanek P, Sobin LH. TNM classification of malignant tumours. International Union
Against Cancer 1987; 4th Edition Berlin, Springer Verlag:93-9.

The

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Stage at presentation
at The MammaClinic
Stage:
I:
II:
III:
IV:

10 %
30%
30%
30%

LABC Correlated with:

Poverty
Educational status
Age

The

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What is the Place of

Surgery?
Intensive chemotherapy can restore the
majority of patients to no evidence of
diseaseBooser D,. Semin.Oncol.1992;19(3):278-85.
But:
Complex, expensive regimens employed
Pathologic complete responses <10%
+ Radiotherapy: Pathologic complete responses still
<20%

Shanta V et al: BC. Clin Oncol 1991;3(3):137-40.

=> Local control improved by surgery and

radiotherapy Toonkel LM et al, Int.J Radiat.Oncol.Biol.Phys. 1986;12(9):1583-7.
The

J. Apffelstaedt

Radiotherapy only

Local Control

Lopez et al(69)

17

76%

Perez et al(42)

200

31 - 91%

Bartelink et al(35)*

373

39 - 66%

Borger et al(63)

209

48%

Graham et al(67)

62

31 - 47%

Koning et al(55)

118

53-58%

Surgery only

Local Control

Abdel-Wahab et al(48)

13

69%

Lopez et al(69)

17

76%

Olson et al(41)

148

76%

Surgery and Radiotherapy

Local Control

Abdel-Wahab et al(48)

42

93%

Cavanese et al(26)

60

70%

Hortobagyi et al(14)**

176

79-100%

Perez et al(42)

81

80%

Karlsson(62)

128

80%

Merajver et al(31)

89

72-77%

Morell et al(23)

55

89%

Brito et al(11)

70

81%

Graham et al(67)

175

78-80%

Olson et al(41)

164

85%

The

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Sequencing I:
Radiotherapy and
Surgery

Radiotherapy followed by surgery:

25% wound infection
34% delayed healing
63% seroma
22% lymphoedema

(Badr-el-Din et al: Local postoperative morbidity following pre-

operative irradiation in LABC. Eur J Surg Oncol. 1989;15(6):486-9.)

=> Prefer Surgery followed by RT

The

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Chemotherapy
Regimen

pCR rate

Long-term
survival

CMF

< 10%

10 - 20%

Anthracyclin 10 30%
s

20 40%

A-Tax

40 60%

The

30 40%

J. Apffelstaedt

Sequencing II:
Chemotherapy and
Surgery
Complications not increased with
anthracyclins nor taxanes

(Broadwater JR et al. Ann Surg 1991;213(2):126-9).

Own experience:
Infections in MTX regimens tripled

Oncologic outcome not affected

(Cunningham JD et al.

Cancer Invest. 1998;16(2):80-6).

=> Prefer preop. chemotherapy

The

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Extent of Surgery
Place of Sentinel Node Procedures
Omission of axillary dissection

(Kuerer HM et al. Am J

Surg 1998;176(6):502-9).

Breast Conservation

(Touboul E et al. Int.J Radiat.Oncol.Biol.Phys.

1996;34(5):1019-28).

The place of radical procedures?

(Hathaway CL et

al: Arch.Surg. 1994;129(6):582-7).

The

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The

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The

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The

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The

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The

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The

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Radical Procedures
113 patients

Survival

Stage IIIB

100%

Radical
mastectomies

80%
60%

Myocutaneous
flap

40%
20%

RT

0%
0

5
Years

The

10

91 % local
control

J. Apffelstaedt

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

The

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Conclusions
Surgery essential part of therapy
Hormonal therapy underutilized
Challenges:
Breast Conservation
Breast Reconstruction
Selective Management of the Axilla

Increasing Awareness
The

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