ABSTRACT

Despite of decrease in breast cancer frequency and mortality in developed countries in last decade, its incidence and mortality rates have been increased in low-middle income countries. These increasing trend will continue in next years and, breast cancer will be an important health problem in Turkey and other developing countries.

The rate of locally advanced breast cancer (LABC) in developed countries with organized population based screening mammography programs is about 5%, but this rate is more than 50% in low-middle income countries. The systemic metastases rate is 5-10% in patients with LABC. And, these patients should be searched for systemic diseases with additional studies (such as, systemic bone scanning, thorax and abdominal CT, etc.).

Neoadjuvant chemotherapy (NAC) has been accepted as a standart treatment in patients with LABC. Advantages of NAC are in vivo evaluation of tumor response to chemotherapeutic drugs, early start to treatment of systemic disease, increase in breast conserving surgery rate, and increase in operability of advanced local-regional cancer But, progression of locoal/regional disease due to no response to NAC, lack of data on prechemotherapy pathologic tumor size and axillary lymph node status are disadvantages of NAC.

LABC includes stage IIB, and stages IIIA,B and C breast cancers.Tru-cut biopsy should be performed before NAC to evaluate histologic tumor type, hormonal receptors, and HER-2 receptor. Prognostic and predictive factors in patients with LABC are mostly similar to patients with early breast cancer. But, especially pathologic response rate to NAC is the most important prognostic and predictive factor. Second generation chemotherapeutic agents (paclitaxel, docetaxel etc.) and trastuzumab have increased complete pathologic response rate in these patients more than 50%.

Breast conserving surgery has been performed in selected patients with LABC. Indications of breast conserving surgery are patient desire for breast preservation, absence of multicentric disease (tumors in separate quadrants of the breast) at time of presentation or preoperatively, absence of diffuse microcalcifications on mammogram, absence of skin involvement consistent with inflammatory breast cancer, and residual tumor mass amenable to a margin negative lumpectomy resection. But, local recurrences rate is higher (14-34%).

Application of sentinel lymph node biopsy (SLNB) in cases of LABC has been approached more cautiously, because of concerns that tumor embolization from a bulky lesion in the breast might obstruct and alter lymphatic drainage pathways. And, also NAC might cause fibrosis in lymphatic channels and sentinel lymph node(s). These could contribute to identification of an incorrect sentinel node, or to a failed mapping procedure altogether. For these reasons, SLNB false negative rates before and after NAC in patients with LABC are more than 10%, and SLNB is not a standart procedure in these patients.