This document discusses the management of early and locally advanced breast cancer. For early breast cancer, primary surgery involves lumpectomy or mastectomy followed by adjuvant treatment if needed based on tumor characteristics. Breast conserving surgery aims to preserve the breast while achieving comparable survival to mastectomy with low recurrence rates. Neoadjuvant therapy can help reduce tumor size for breast conservation. Locally advanced breast cancer may be treated with neoadjuvant chemotherapy to reduce the risk of recurrence and improve surgical outcomes. Neoadjuvant endocrine therapy is also an option for some postmenopausal women. Adjuvant radiation, chemotherapy, and hormone therapy are used based on tumor markers and response to neoadjuvant treatment. Regular

1. Management of early and locally
advanced breast cancer
Abhilash

2. Early breast cancer
• Stage I
• Stage II A
• Subset of Stage II B (T2N1)
Locally advanced breast cancer
• Stage II B
• Stage IIIA to IIIC

3. Early breast cancer
Primary Surgery for breast
and regional nodes–
Lumpectomy or Mastectomy
+/-RT
• BCSMastectomy
Adjuvant treatment if needed
based on tumor
characteristics.
• Tumor size
• Tumor grade
• ER/PR/HER2
• LN status

4. Breast conserving surgery
• To preserve the breast without sacrificing oncological
outcome
BCS= LUMPECTOMY + adjuvant RT
Goals of BCS
1. Cosmetically acceptable
2. Survival comparable to mastectomy
3. Low recurrence rates

5. Patient selection for BCS
• Comorbid conditions/ Age is not a contraindication.
• Nipple, skin retraction is not a contraindication – but resection
of NAC should be factored in decision making.
• Extensive intraductal component is not a contraindication.
• Lymph node positivity is not a contraindication.
• Tumor location is not a contraindication.
• Not contraindicated in dense breast tissue.
• Large tumor in a small breast is a relative contraindication
• Collagen vascular disease is a contraindication.

6. Absolute contraindication for BCS
●Multicentric disease
●Large tumor size in relation to breast
●Presence of diffuse malignant-appearing
calcifications on imaging (ie, mammogram or
MRI)
●Prior history of chest wall RT
●Persistently positive margins despite attempts
at re-excision

7. Role of neoadjuvant therapy in BCS
• Chemotherapy or hormonal therapy to reduce
size of the tumor
• Clip placement in tumor bed.
• Not to be considered if multicentric with
extensive skin changes and dermal lymphatic
involvement.

8. Indications for mastectomy in early
breast cancer
• Not a candidate for BCS.
• Patient choice.

11. Adjuvant therapy in early breast
cancer

13. Adjuvant chemotherapy

17. Locally advanced breast cancer

18. Goal of neoadjuvant chemotherapy
• Reduce risk of distant recurrence.
• Improve surgical outcome in patients
– Inoperable disease.
– Operable disease desiring breast conservation

19. Candidates for neoadjuvant
therapy
• T4 lesions.
• HER2 positive – high pCR to NACT with
transtuzumab.
• Triple negative disease – High pCR rates
compared to HER2 negative ER/PR+ (27-45%
vs 10%)
• Breast cancer in pregnancy.
• Early disease if BCS not possible due to small
breast.

20. Pretreatment evaluation before
NACT
• Core biopsy – ER/PR/HER2
• Radio-opaque clips to be placed for
subsequent assessment of surgical specimen
and for RT planning.
• Metastatic workup.
• Axillary node evaluation and staging has to be
done. SLNB/axillary US with FNA - to be done
if no palpable nodes or FNA from palpable
node is negative.

21. Neoadjuvant treatment options
• Triple negative disease – NACT 
BCS/mastectomy.
• Post menopausal women – if not a candidate
for chemo/surgery  Hormonal therapy.
• HER2 positive – NACT + transtuzumab

22. Neoadjuvant endocrine therapy
• Aromatase inhibitor or tamoxifen
• 4-6 months.
• May be as effective as NACT in
postmenopausal women.

23. Adjuvant RT
• For all BCS
• For post total mastectomy with high risk of
recurrence.
1. Positive margins,
2. lymphovascular invasion,
3. >4 axillary nodes with tumour,
4. size > 5 cm
5. high grade tumour.

24. Adjuvant chemotherapy
• Lymph nodes positive
• Tumour > 1 cm
• Grade 2 or 3
• ER/PR negative

25. Adjuvant therapy
• If post NACT Surgery –
– ER/PR + , hormonal therapy
– ER/PR - ,Chemotherapy
– HER2 , transtuzumab
• If post neoadjuvant endocrine therapy
Surgery endocrine therapy +/- NACT

26. Hormone therapy based on menopausal
status

28. Follow-up