This document discusses neoadjuvant therapy (NAT), which involves giving patients systemic agents before surgical removal of breast tumors. NAT was initially used for locally advanced tumors but is now being used for earlier-stage cancers. Studies have shown NAT and adjuvant therapy provide identical loco-regional control and metastasis-free survival. Advantages of NAT include increased eligibility for breast conservation and allowing assessment of treatment efficacy and tumor response. The document then describes a study of 40 breast cancer patients who received NAT, where pathological assessment after surgery found varying levels of tumor reduction according to the Miller-Payne classification system. Accurate pathological classification and reporting of residual disease after NAT is important for evaluating new treatments and clinical trials.

1. Dr. Imrana Tanvir
Assistant Prof. FMH, Lahore.

2. Neoadjuvant therapy (NAT)
Patients given systemic
agents before definitive
surgical removal of the tumor.

3. Origin of Preoperative
Therapy
Initially neuadjuvant therapy (NAT )was
used for locally advanced tumors only.
As a result 10 yrs survival improved
more than 25%
This survival rate varied with different
therapies.

4. Currently, neoadjuvant therapy
(NAT) is being used for
earlier-stage operable breast
carcinoma and likely to
become standard of care.

5. NSABP Protocol B-18 have shown :
Neoadjuvant or adjuvant therapy gives
identical results for:
-loco-regional control
-metastasis-free survival.

6. So why not prefer neoadjuvant
over adjuvant?

7. Major advantages of
neoadjuvant therapy.
 Increased eligibility for breast conservation.
 The efficacy of systemic therapy can be
assessed in vivo.
 Tumor response provides important clinical
information .
 Allow more rapid assessment of new
treatments.
 Research linking tumor response is
facilitated.

8. Pathologic examination of
breast tumor specimens after
neoadjuvant is challenging.

9. Recently, a detailed review was
conducted at the 2007 National
Cancer Institute State of the
Science meeting.
“Preoperative Therapy in Invasive
Breast Cancer: Reviewing state of
the science and exploring new
research directions.”

10. Our study followed their
recommendations regarding
pathological assessment of
breast carcinoma after
neuadjuvant

11.  40 patients
 Received neoadjuvant therapy. (4
cycles)
 Underwent surgery
 Pathological assessment was
done

12. The objectives:
 To assess pathological changes in the
breast tumor by using Miller Payne
classification in a group of patients
undergoing neoadjuvent chemotherapy.
 To highlight the importance of changing
trends of pathological reporting in patients
receiving neoadjuvent chemotherapy.

13. CRITERIAS FOR ASSESSMENT
Primary Tumor
–size
–Cellularity
–Invasive vs. in situ
–Margins
Axillary Lymph Nodes
–Number of positive nodes
–Size of metastases
–Extranodal extension

16. Gross identification of tumor bed

17. Microscopic identification of
tumor bed

18. MILLER AND PAYNE
CLASSIFICATION.
 Grade 1:No reduction
 Grade 2:Minor loss (≤ 30%)
 Grade 3:Some loss (30% -90%)
 Grade 4:Marked loss (> 90%)
 Grade 5:No residual invasive cancer
(pCR)

19. pCR (yT0;yN0) is a predictor
of better long term outcome

20. 40 patients
Tumor size range 19cm to 1cm Rx: 4 cycles
 Grade 1: 3 cases 7.5%
 Grade 2: 17 cases 42.5%
 Grade 3: 8 cases 20%
 Grade 4: 5 cases 12.5%
 Grade 5: 7 cases 17.5% (pCR)
Reduction in cellularity was variable and observe
maximally in smaller residual tumors.

21. Response in Lymph Nodes
 The most important prognostic
factor in patients who received
neoadjuvant therapy.
 Response in the breast and in
the lymph nodes was generally
similar’

22. MARGINS
 In 2 cases tumor was within 1
mm of the closest margin.
LYMPHOVASCULAR INVASION
 7 cases showed lymphovascular
invasion and 2 cases showed
DCIS.

23. Studies have shown that
lymphovascular invasion and
DCIS is somehow not
responsive to the treatment.

24. RIGHT BREAST, MASTECTOMY / WLE
AND AXILLARY DISSECTION:
 Residual Invasive ductal carcinoma
Grade II
 Size 0.8 x 0.6 cm .
 Miller and Payne Classification Grade
3.
 Intraductal component, 5%

25.  Margins of resection are free of
tumor.
 No lymphovascular invasion is
seen.
 2 out of 12 lymphnodes show
metastatic carcinoma with extra
nodal extension.

26. Conclusions
 Surgical pathologists must be
familiar with the gross
examination, sampling, and
reporting of breast carcinomas
after neoadjuvant therapy.

27. Conclusions
 AJCC, “Miller-Payne” and
Residual Cancer Burden
assessments improve the
classification of residual disease
 Accurate and reliable
classification of residual disease
can assist us with new trials.

28. Conclusions
Consistent recommendations for
pathological assessment and
reporting of residual disease are
needed.