Locally Advanced Breast Cancer and Inflammatory Breast Cancer€¦ · Radiotherapy after neo-adjuvant chemotherapy and mastectomy •Should all patients with locally advanced breast

Conny Vrieling, MD, PhD

Locally Advanced Breast Cancer and Inflammatory Breast Cancer

No Disclosures

Role of postmastectomy radiotherapy

Year Patients FU (years)

Mastectomy +chemo

(or tam)

Mastectomy + chemo (or tam)

+ locoreg RT

Reference

British Columbia

1979 - 1986 318 20 OS 37%LRRFS 74%

47%90%

Ragaz, JNCI 2005

DBCG 82b and c

1982 - 1990 3,083 10 (b)10 (c)

18

OS 45%OS 36% LRR 49%

54%45%14%

Nielsen, JCO 2006

Loco-regional control and survival benefit

Nielsen, JCO, 2006

Risk group analysis

• 1000 patients, DBCG 82 b et c

• Median follow-up 17 years

• Good prognosis group (199 patients)– max 3 nodes +, tumor size < 2 cm, grade I, ER/PR +, Her2 neg– at least 4 out of 5 criteria

• Intermediate group (593 patients)

• Poor prognosis group (208 patients)– > 3 nodes +, tumor size > 5 cm, grade III– at least 2 out of 3 criteria

Kyndi, Radiother Oncol, 2009

Risk group analysis

Kyndi, Radiother Oncol, 2009

Radiotherapy after neo-adjuvant chemotherapy and mastectomy

• Should all patients with locally advanced breast cancer, following neoadjuvant chemotherapy, be treated with postoperative radiotherapy?

• Or, should this decision depend on the tumor response as found at the time of surgery?

Mamounas, JCO, 2012

Int J Rad Oncol Biol Phys, 2007

Prospective trial

• NSABP B-51/RTOG 1304

• A randomized phase III clinical trial evaluating post-

mastectomy chest wall/post-lumpectomy and regional nodal

radiotherapy in patients with positive axillary nodes before

neo-adjuvant chemotherapy who convert to pathologically

negative axillary nodes after neo-adjuvant chemotherapy

Conclusions - who to treat?

• Patients with T3,N1 or T4 tumors

• Patients with 4 or more positive lymph nodes

• Consider postmastectomy radiotherapy for patients with 1 to 3 positive nodes

• Patients with LABC who are treated with neoadjuvant chemotherapy followed by mastectomy

• Positive resection margins

Inflammatory breast cancer

In general:Start with neo-adjuvant chemotherapy

If patient is operable:Surgery and loco-regional radiotherapy

If patient is still inoperable:Radiotherapy, followed, if possible, by surgery

Inflammatory breast cancer

Goal of radiotherapy:Improve locoregional control

A survival benefit has not definitely been proven

Technique: Wide margins!!