LOCALLY ADVANCED BREAST CANCER MANAGEMENT

1. LOCALLY ADVANCED BREAST CANCER
MANAGEMENT
Dr. ADITYA SINGLA

2. NATURAL HISTORY
• Most cases of stage III breast cancer were once stage I.
• In poor countries, more than half of patients have locally
advanced breast cancer –
 Poor education
 Poor screening

3. WHAT IS LOCALLY ADVANCED???

4. INVESTIGATIONS
• Mammography:
 Bilateral
 To r/o multifocal or multicentric disease
 Sensitivity – 90%
 Specificity- 94%

5. INVESTIGATIONS
• Ultrasonography :
 Cyst from solid tumors
 Confirm physical and mammography findings
 Interventional procedures
 If both mammography and USG are negative then the
negative predictive value is 99%.

6. INVESTIGATIONS
• MRI BREAST:
 Dense breast
 Occult primary breast carcinoma
 Women with genetic mutation leading to higher risk of B/L or
C/L breast cancer
 Sensitivity- 79.5%, Specificity- 89.8%
• CECT ABDOMINOPELVIC:
 FROM Stage IIIA onwards.

7. INVESTIGATIONS
• Bone Scan:
 Tumor > 3 cm
 Aggressive histology
 Stage III/ IV
• PET Scan:
 Stage III onwards
 Sensitivity – 93%, specificity- 78%

8. IMAGES
PEAU-D’-
ORANGE
MAMMOGRAPHY DIMPLING

9. LABC TREATMENT LINE

10. TREATMENT
• Surgery or chemo first???
SURGERY FIRST CHEMO FIRST
Removes source of
distant metastases
May allow BCS
Provides original
extent
Allows comparison of
different chemo
regimens
Provides clear
prognostic information
regarding risk of
recurrence/RT
PCR

11. NSABP-18

12. NSABP-18

13. NSABP-18

14. NACT OR ADJUVANT CHEMO??
• A meta-analysis found NO statistical difference in risk of
death/ disease progression/ recurrence.
Mauri D1, Pavlidis N, Ioannidis JP. J Natl Cancer Inst. 2005 Feb 2;97(3):188-94

15. CHEMOTHERAPY
1. 4 AC – 4 TAXANES
2. 6 TAC
3. 3 CEF – 3 DOCETAXEL
4. 6 CEF
5. 6 CAF
6. 6 CMF
7. 4 AC- 4 TAXANES with weekly TRASTUZUMAB

16. TYPES OF SURGERIES
• BCS:
 NSABP B-18, EORTC
 Increase in LR recurrence in patients with NACT f/b BCS.
o C/I of BCS AFTER NACT:
 Clinical N2/N3
 LVSI+
 Multifocal
 Residual disease > 2cm

17. TYPES OF SURGERIES
• MASTECTOMY:
 Total / simple mastectomy
 MRM
 Radical mastectomy
 Extended radical mastectomy
 Skin sparing mastectomy

18. POSTMASTECTOMY RT
• INDICATIONS OF RT:
 Close or positive margins
 T≥ 5 cm
 < 6 nodes removed
 ≥4 nodes positive
o Patients with 1-3 LN positive given RT :
 Age < 40yr
 LVSI+
 Positive LN ratio > 20%
 ECE+

19. POSTMASTECTOMY RT
• LRR rates in patients NOT treated with radiation after MRM
ECOG
1-3 LN+
≥4 LN +
LRR AT 10 YEARS
13%
29%
MD ANDERSON
1-3 LN+
≥4 LN+
12%
27%
NSABP
1-3 LN+
≥4 LN+
11%
25%

20. POSTMASTECTOMY RT
• Post mastectomy RT should be given in all patients with T3/T4
disease irrespective of chemotherapy response.
• In Stage I/II, ≥ 4 LN+ criteria should be followed.

21. TREATMENT ALGORITHM IN LABC
• PRESENTATION
Large palpable mass
Physical examination, b/l mammography, CECT, BONE scan, PET
Core biopsy with receptor status
• OPERABLE/ NOT
YES NO
MRM NACT+/- TRASTUZUMAB
chemo+/-Trastuzumab MRM
RT RT
HT HT

22. INFLAMMATORY BREAST CANCER
• NACT with doxorubicin and Taxanes.
• If excellent response to NACT, the MRM+AC
• Followed by RT:
 50GY/25#/5wks OR
 51GY/17#/3.5wks with 2#/day
 f/b 15GY/10# boost to chest wall.
• HT according to receptor status.

23. RECURRENT BREAST CANCER
• POOR OUTCOME
 < 2yr
 Large initial tumor
 High number of + LN
 ECE
 Recurrence in supra/infra clavicular area
• Treatment Guide
 Taxanes/ doxorubicin/ trastuzumab if not received
 Surgical option if resectable
 RT if not given
 2nd line endocrine therapy

24. RECURRENT BREAST CANCER
• Axillary node relapse – worse outcome
• Axillary dissection f/b radiation if not given and chemo
• For supra/infraclavicular recurrence, systemic therapy .

25. MALE BREAST CANCER
• Elderly men
• BRCA 2
• Mostly ER+ (90%)
• Mostly locally advanced
• Same lines of management

26. 2D RADIATION TECHNIQUE
• POSITION:
 Supine/ prone
 Immobilized with breast board
 I/L arm externally rotated (90-120)
 Patient to be placed at 10-15* angle to flatten the chest wall
 Turns the head to opposite side.

27. IMMOBILIZATION

28. 2D RADIATION TECHNIQUE
• TANGENTIAL FIELDS :
 Upper border- 2nd ICS if supraclav field is used
head of clavicle if SCF not used
 Medial border- 1 cm away from midline
 Inferior border- 2 cm below inframammary folds
 Lateral border- 2 or 3 cm beyond all palpable breast tissue

29. 2D RADIATION TECHNIQUE
• SCF FIELD :
 Upper border- thyro-cricoid groove
 Lower border - just below clavicle/ match upper border of
tangential field
 Medial border- 1cm medial across midline
 Lateral border- upto deltoid insertion

30. 2D RADIATION TECHNIQUE
• WEDGES :
 Beam modifying device
 Improves dose uniformity
 Used in intact breasts
• BOLUS:
 Compensators
 3-5mm bolus placed over chest wall every alternate day
 Universal wax bolus used

31. 2D RADIATION TECHNIQUE
• ENERGY :
 4-6 MV used
• DOSE :
 50GY/25#/5WKS

32. BREAST BOARD

33. PRONE POSITION

34. WEDGES

35. BOLUS

36. 2D RADIATION TECHNIQUE
• CLD :
• Perpendicular distance from the posterior field edge to the
posterior part of the anterior chest wall
• 1.5 cm- 6%
• 2.5cm- 16%
• 3.5cm- 26%
• MHD:
 Maximum perpendicular distance from posterior tangential
field to the posterior part of the anterior chest wall

37. RT INDICATIONS
SCF LN IRRADIATION AXILLARY LN IRRADIATION INTERNAL MAMMARY
NODAL IRRADIATION
N2/N3 SENTINEL LN+
AXILLARY LN+ with
CENTRAL & MEDIAL
LESIONS
>4 LN+ IN AD INADEQUATE ALND STAGE III
1-3 LN+ with HIGH RISK
features
NODE+ with ECE+ SENTINEL LN+ IN IMC
SENTINEL LN +
1-3 LN+ with unfavorable
histology
SLN+ in AXILLA which
drains to IMC
NO ALND

38. 3DCRT
• ADVANTAGES:
 Better dose homogeneity
 More dose to tumor and low dose to normal tissues
 Less dose to lungs and heart
 Better cosmesis

39. IMRT
• Advantages over 3DCRT-
 Better dose homogeneity
 Better coverage of tumor cavity
 Decrease dose to critical organs
• Disadvantages-
 May increase volume of tissue exposed to radiation
 May increase the risk of second malignancy