Does neoadjuvant chemotherapy increase breast conservation in operable breast cancer: an Egyptian experience

Abstract

Introduction: The role of adjuvant chemotherapy in breast cancer is well established, as are its indications. Likewise, the role of neoadjuvant chemotherapy in locally advanced breast cancer is well established. The use of neoadjuvant chemotherapy in operable breast cancer has only recently become of interest to researchers.

Patients and methods: This study included 34 cases of operable breast cancer that were given four cycles of neoadjuvant chemotherapy in the form of FEC100 then subjected to surgery. The surgery done was either breast conserving surgery or modified radical mastectomy. All patients completed the treatment regimen and no patients were excluded from the study. All surgical specimens were studied pathologically for chemotherapy effect.

Results: An overall objective response was observed in 70.6% of the patients. Seven patients (20.6%) experienced a clinical complete response (cCR), 17 patients (50.0%) had partial response, nine patients (26.5%) had no change of their disease and only one patient had disease progression. Of the seven patients who had a cCR, only four patients (11.8%) had pathologic complete response (pCR), while pCR for the whole group was 14.7%(5/34). Tumour size of more than 2 cm was observed in 28 patients (82.4%) at time of presentation, while tumour size of 2 cm or less was seen in six patients (17.6%) only. After completion of the course of chemotherapy, 23 patients (67.6%) were observed to have tumours of 2 cm or less that allowed for less extensive resections. Twenty-three patients underwent breast conservative surgery (67.6%) while modified radical mastectomy was performed in 11 patients (32.4%).

Conclusion: The use of neoadjuvant chemotherapy in operable breast cancer in this study was associated with tumour and axillary downstaging, which increased the proportion of cases undergoing breast conservation, with acceptable side effects and reasonable cost. During the limited follow-up time of this study no loco regional recurrences were recorded and one distant treatment failure was recorded. Its impact if any on overall or disease-free survival was not addressed in this study. Larger multi-centre randomized studies with a long follow-up are needed to compare the overall and disease-free survival benefit of this treatment modality, especially in different subtypes stratified by pathological response.

Figure 1:

Completion of lumpectomy (note resection of pectoral fascia)

Figure 2:

Bisected lumpectomy specimen with grossly adequate margins

Figure 3:

Full axillary dissection, showing vein and nerve to serratus anterior

Figure 4a:

Lymph node, showing partial replacement by evidence of tumour regression (H&E x200)

Figure 4b:

High-power view of Figure 4a, showing from right to left fibrosis, aggregates of foamy histiocytes and necrosis (H&E x400)