MULTIDISCIPLINARY TREATMENT APPROACH TO LOCALLY ADVANCED NONINFLAMMATORY BREAST-CANCER USING CHEMOTHERAPY AND RADIOTHERAPY WITH OR WITHOUT SURGERY

Between April 1982 and December 1987, 82 locally advanced non-metastatic and non-inflammatory breast cancers were treated (42 stage IIIA, 40 stage IIIB). The median follow-up is 70 months from the beginning of the treatment. The initial treatment consisted of 4 courses of chemotherapy (doxorubicin, vincristine, cyclophosphamide, 5-fluorouracil) followed by irradiation (45 Gy to the breast and nodal area). A fifth course of chemotherapy was given after radiation therapy. Three different locoregional approaches were proposed depending on the tumoral response. In 32 patients (39%) with residual tumor larger than 3 cm in diameter or located behind the nipple or with multifocal tumors, mastectomy and axillary dissection were performed. Fifty other patients (61%) benefited from conservative treatment: 32 patients (39%) achieved complete remission and received a boost to the initial tumor bed; 18 patients (22%) who had a residual mass less than or equal to 3 cm in diameter were treated by tumorectomy and axillary dissection followed by a boost to the tumorectomy site. After completion of local therapy, all patients received a sixth course of chemotherapy. A maintenance adjuvant chemotherapy regimen without anthracycline was prescribed (12 monthly cycles). Three- and 5-year disease-free survival rates were 81.7% and 72% respectively. Five-year locoregional relapse rate (with or without other sites of failure) was 8.8%. In a multivariate analysis, disease-free survival was significantly influenced by the N-stage (p < 0.0001), initial tumor size (p = 0.01), and tumor response after initial chemotherapy (p = 0.02). Five-year breast conservation probability was 58.4%. Primary chemotherapy followed by radiotherapy in preoperative doses might permit the selection of some patients for conservative treatment instead of radical surgery but following axillary dissection and conservative treatment, the locoregional complications were not infrequent. Arm lymphedema was noted in 20% (10/50) of cases treated with axillary dissection and in 3% (1/32) without axillary dissection. Cosmetic results were satisfactory in only 61.5 % of patients following tumorectomy and radiotherapy and in 54.5 % of patients treated by radiotherapy alone. There was a substantial incidence of failures occurring more than 5 years after primary treatment and the impact of this aggressive multidisciplinary treatment on long-term survival rate remains to be established.