Patrones de reducción luego de quimioterapia neoadyuvante por cáncer de mama: Implicancias en la cirugía conservadora

Carlos Acevedo; Guianeya Santander; María Musto; Virginia Ortega; Fernando Simonet; Bernardo Aizen; Susana Reyes; Federico Durán

Authors

Carlos Acevedo Hospital Central de las Fuerzas Armadas, Servicio de Mastología. Doctor en Medicina
Guianeya Santander Hospital Central de las Fuerzas Armadas, Servicio de Mastología. Doctor en Medicina
María Musto Hospital Central de las Fuerzas Armadas, Servicio de Mastología. Doctor en Medicina
Virginia Ortega Hospital Central de las Fuerzas Armadas, Servicio de Mastología. Doctor en Medicina
Fernando Simonet Hospital Central de las Fuerzas Armadas, Servicio de Mastología. Doctor en Medicina
Bernardo Aizen Hospital Central de las Fuerzas Armadas, Servicio de Mastología. Doctor en Medicina
Susana Reyes Hospital Central de las Fuerzas Armadas, Servicio de Mastología. Doctor en Medicina
Federico Durán Hospital Central de las Fuerzas Armadas, Servicio de Mastología. Doctor en Medicina

Keywords:

BREAST CANCER, NEOADJUVANT CHEMOTHERAPY, CONSERVATIVE SURGERY

Abstract

Introduction: there are two patterns of tumor response to neoadjuvant chemotherapy: concentric or scattered.
Patients with scattered response are not good candidates for conservative surgery since its tumor microfoci can go unnoticed in the tissue around the main residual tumor. The kind of response has been identified as an ipsilateral recurrence factor after conservative surgery.
Objective: the study aims to evaluate the response percentage for each pattern and sufficiency of the surgical resection margin obtained in the cases of conservative surgery.
Method: the medical records of patients who underwent surgery after neoadjuvant chemotherapy between May 2004 and December 2013 were analysed. The type of chemotherapy and the histopathology reports were thoroughly analysed to determine the reponse pattern, as well as the molecular phenotypes and the degree of tumor for each case.
Results: 14 out of 55 cases (25%) presented a scattered response pattern (ten of them with distant microfoci from the invasive cancer and four with distant microfoci of in situ cancer).
Percentage of pathologic complete response was 15.4%.
There were no significant differences in the response patterns among the different immunophenotypes or among different degrees of tumors, and neither was there a significant difference between those who received taxenes and those who did not receive it.
Conclusions: one fourth of patients in our series presented a scattered reponse pattern after neoadjuvant chemotherapy.
This may be a warning signal for those who advocate for conservative surgery after neoadjuvant treatment, since scattered response increases the risk of insufficient margins and ipsilateral recurrence.

References

(1) Newman LA, Buzdar AU, Singletary SE, Kuerer HM, Buchholz T, Ames FC, et al. A prospective trial of preoperative chemotherapy in resectable breast cancer: predictors of breast-conservation therapy feasibility. Ann Surg Oncol 2002; 9(3):228-34.
(2) Chen AM, Meric-Bernstam F, Hunt KK, Thames HD, Oswald MJ, Outlaw ED, et al. Breast conservation after neoadjuvant chemotherapy: the MD Anderson cancer center experience. J Clin Oncol. 2004; 22(12):2303-12.
(3) Rouzier R, Mathieu MC, Sideris L, Youmsi E, Rajan R, Garbay JR, et al. Breast-conserving surgery after neoadjuvant anthracycline-based chemotherapy for large breast tumors. Cancer. 2004 Sep 1;101(5):918-25
(4) Loibl S, von Minckwitz G, Raab G, Blohmer JU, Dan Costa S, Gerber B, et al. Surgical procedures after neoadjuvant chemotherapy in operable breast cancer: results of the GEPARDUO trial. Ann Surg Oncol 2006; 13(11):1434-42.
(5) Vlastos G, Mirza NQ, Lenert JT, Hunt KK, Ames FC, Feig BW, et al. The feasibility of minimally invasive surgery for stage IIA, IIB, and IIIA breast carcinoma patients after tumor downstaging with induction chemotherapy. Cancer 2000; 88(6):1417-24.
(6) Fitzal F, Riedl O, Mittlböck M, Dubsky P, Bartsch R, Steger G, et al. Oncologic safety of breast conserving surgery after tumour downsizing by neoadjuvant therapy: a retrospective single centre cohort study. Breast Cancer Res Treat 2011; 127(1):121-8.
(7) Tozaki M, Kobayashi T, Uno S, Aiba K, Takeyama H, Shioya H, et al. Breast-conserving surgery after chemotherapy: value of MDCT for determining tumor distribution and shrinkage pattern. AJR Am J Roentgenol 2006; 186(2):431-9.
(8) Bahri S, Chen JH, Mehta RS, Carpenter PM, Nie K, Kwon SY, et al. Residual breast cancer diagnosed by MRI in patients receiving neoadjuvant chemotherapy with and without bevacizumab. Ann Surg Oncol 2009; 16(6):1619-28.
(9) Kim HJ, Im YH, Han BK, Choi N, Lee J, Kim JH, et al. Accuracy of MRI for estimating residual tumor size after neoadjuvant chemotherapy in locally advanced breast cancer: relation to response patterns on MRI. Acta Oncol 2007; 46(7):996-1003.
(10) Denis F, Desbiez-Bourcier AV, Chapiron C, Arbion F, Body G, Brunereau L. Contrast enhanced magnetic resonance imaging underestimates residual disease following neoadjuvant docetaxel based chemotherapy for breast cancer. Eur J Surg Oncol 2004; 30(10):1069-76.
(11) Beriwal S, Schwartz GF, Komarnicky L, Garcia-Young JA. Breast-conserving therapy after neoadjuvant chemotherapy: long-term results. Breast J 2006; 12(2):159-64.
(12) Rouzier R, Mathieu MC, Sideris L, Youmsi E, Rajan R, Garbay JR, et al. Breast-conserving surgery after neoadjuvant anthracycline-based chemotherapy for large breast tumors. Cancer. 2004; 101(5):918-25.
(13) Chagpar AB, Middleton LP, Sahin AA, Dempsey P, Buzdar AU, Mirza AN, et al. Accuracy of physical examination, ultrasonography, and mammography in predicting residual pathologic tumor size in patients treated with neoadjuvant chemotherapy. Ann Surg 2006; 243(2):257-64.
(14) Shin HJ, Kim HH, Ahn JH, Kim SB, Jung KH, Gong G, et al. Comparison of mammography, sonography, MRI and clinical examination in patients with locally advanced or inflammatory breast cancer who underwent neoadjuvant chemotherapy. Br J Radiol 2011; 84(1003):612-20.
(15) Marinovich ML, Macaskill P, Irwig L, Sardanelli F, von Minckwitz G, Mamounas E, et al. Meta-analysis of agreement between MRI and pathologic breast tumour size after neoadjuvant chemotherapy. Br J Cancer 2013; 109(6):1528- 36.
(16) Tomida K, Ishida M, Umeda T, Sakai S, Kawai Y, Mori T, et al. Magnetic resonance imaging shrinkage patterns following neoadjuvant chemotherapy for breast carcinomas with an emphasis on the radiopathological correlations. Mol Clin Oncol 2014; 2(5):783-8.