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Locally advanced breast cancer

Section: Breast Curriculum: Curriculum, page 13

Definition:

  • Defined as inoperable
    • Typically T4
    • Inflammatory
    • N2/N3

Investigations:

  • Triple assessment, including biopsy, IHC for ER and HER-2 status (+/- FISH)
  • Need to mark tumour at time of biopsy as may disappear if given neoadjuvant therapy
  • Need to be sure to get malignant tissue when resected later
  • CT-CAP
  • +/- MRI, Bone scan, PET

Treatment

  • Multimodal therapy usually required
  • Surgery alone → Local recurrence 30-50%; long term cure ≤ 30%
    • Radical mastectomy (Pec Major and level 3 nodes) does not improve survival over total mastectomy - rarely ever indicated
  • Neoadjuvant therapy
    • Downstage 50-80%, may render resectable, or may allow breast conserving therapy as option
    • Aiming for clear margins

Fungating Cancer

  • Consider ‘Toilet Mastectomy’ = Mastectomy for local control (i.e. aims to ↓ bleeding / smell)
  • Options for defect closure:
    • Flap – e.g. Lat Dorsi + TRAM
    • Mesh (if chest wall muscle / bone excised too!) + Flap
    • Skin graft (only suitable if muscle fills the wound bed)

Locoregional Recurrence

Definition

  • Recurrence of Breast Ca within the surgical field (breast/axilla)

Presentation:

  • Often painless nodules under the skin, often close to mastectomy scar
  • May present as erythema or violaceous discolouration of skin only
  • Nodes - brachial plexopathy, decreased UL ROM, arm oedema

Investigations:

  • Always recheck hormone and HER status – can change
  • Re-stage (CT-CAP +/- MRI, Bone scan, CT PET)

Treatment:

  • Completion Mastectomy + RT (if not previously had)
  • If had mastectomy
    • Single spot recurrence – Further excision – full thickness chest wall resection + RT
  • Multi-spot – RT
    • Role of RT in previously irradiated chest wall = Controversial
    • Prognosis – 5YS 40-50%, 10YS 30%

Inflammatory Breast Cancer

Definition

  • Invasive breast cancer with dermal lymphatic invasion and a clinical diagnosis of an inflammatory component
    • Rapid onset of erythema and Peau d’orange
    • Duration of history of < 6 months
    • At least ⅓ of breast skin involved
    • Pathologic confirmation of invasive carcinoma.

Incidence:

  • Constitutes < 3% of all cases

Classification

  • Stage IIIb (T4d)

Clinical

  • Natural history short
  • Overlying skin erythematous, oedematous (peau d’orange) & warm (± pain)
  • Often no distinct mass; breast diffusely involved/enlarged ± rapid growth
  • Most patients have ALN positive and distant mets at diagnosis

Pathology

  • Dermal lymphatic invasion
  • Malignant cells - tumour emboli → local and met disease
  • Majority - hormone receptor NEGATIVE and HER2 POSITIVE
  • Almost always present with positive nodes and ⅓ mets

Differential Diagnoses

  • Acute mastitis
  • Locally advanced non-inflammatory breast cancer
  • Lymphoma or leukaemia with diffuse infiltration

Investigations

  • Bloods - R/O infection, FBC, U+E, LFTs
  • Imaging (bilateral breast and axilla)
    • Mammo - mass, distortion, thickened skin
    • USS breast and axilla
    • CT chest abdomen pelvis- staging
    • Bone scan
  • Biopsy
    • Core of breast lump - receptors, IDC grade
    • Punch biopsy of skin x2 (dermal lymphatic invasion)
    • FNA any obvious nodes

Treatment

  • Neoadjuvent treatment
    • Goal - reduce disease burden to facilitate surgery
    • Anthracycline/Taxane (Doxorubicin and cyclophosphamide + paclitaxel)
      • ACT - anthracycline/taxane
        • Doxorubicin (cardiotoxicity, care taken when given with herceptin)
        • Cyclophosphamide
        • Paclitaxel
      • Trastuzumab if HER2 positive - for 1 year
  • Then surgery
    • Mastectomy and AND
    • Only operate if able to resect macroscopically
    • If inoperable after NACT then give RTX and reassess
    • Skin sparing is contraindicated!
      • Any recon is delayed as all need adjuvant RTX
  • Adjuvant therapy
    • RTX
      • All inflamm breast cancers
    • Chemo
      • None if had neoadj chemo
    • Hormonal
      • Give endocrine (5-10 yrs) and Trastuzumab (1 yr) if receptors allow
      • Often ER/PR NEGATIVE
  • Mx Broad Spiel
    • Goals of treatment for inflammatory breast cancer are to macroscopically resect the cancer and reduce the risk of locoregional recurrence and maximise disease free survival
    • All patients should have neoadjuvant treatment by way of chemo and Herceptin if HER2 positive
    • If they respond well then surgery (mastectomy and AND) followed by adjuvant RTX
    • If they dont respond well then they can have neoadjuvant RTX and reassessment
    • If favorable → surgery
    • If not → palliation

Prognosis

  • Poor prognostic factors
    • Triple negative → because no other txs can be given
    • HER2 neg and ER/PR positive
    • 4 or more LNs positive up front
    • Lack of response to NACT - test tumour biology
    • With all treatment - 5 yr survival is poorer than non-inflammatory

Follow up

  • Routine breast cancer F/U
  • Yearly clinical review, yearly mammogram

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