Locally advanced breast cancer: is surgery warranted following chemotherapy?

Various methods of management of locally advanced breast cancer have been proposed, including combinations of chemotherapy, surgery, radiotherapy, immunotherapy and hormone manipulation. This retrospective study evaluated the effectiveness of chemotherapy in the management of locally advanced breast cancer in pre- and perimenopausal women by examining the pathology of the mastectomy specimens. Sixteen women who on initial clinical examination had breast cancers measuring 5 cm or greater underwent chemotherapy prior to surgery. Four women were also treated with radiotherapy prior to surgery. All 16 women underwent mastectomy and axillary clearance. All specimens showed residual tumour in the mastectomy specimen or the regional lymph nodes. Chemotherapy is useful in reducing tumour burden to allow surgical resection, but does not produce centripetal shrinkage of tumour, nor sterilize the breast of cancer. In this small series, the addition of radiotherapy also failed to clear the patient of tumour. Wide surgical excision including the original tumour margins is thus required to achieve locoregional control. Until chemotherapy and radiotherapy regimens can be proved to sterilize the breast of tumour, we caution against the use of any surgery less than total mastectomy if optimal local control is to be achieved for locally advanced breast cancer in pre- and perimenopausal women.