The Response, Operability, and Type of Surgery Following Neoadjuvant Chemotherapy in Sudanese Patients with Locally Advanced Breast Cancer
Background:Neoadjuvant chemotherapy (NACT) treatment has become the standard treatment for locally advanced breast cancer (LABC) in many centers worldwide.
Objectives: This study evaluates the short-term response of patients with LABC to NACT and its impact on operability and the type of surgery.
Patients and Methods: This is a descriptive analytical hospital-based study including 147 patients with LABC who were presented to Plastic and Reconstructive Surgery Unit at Soba University hospital (SUH), between January 2012 and December 2014, and were treated with NACT. Clinical and pathological responses to neoadjuvant chemotherapy were evaluated according to Union for International Cancer Control criteria, operability, and the type of surgery performed was also recorded. Results: All patients were females, the mean age was 43 ± 7 years, of them 53.7% were pre-menopausal, 51% presented with a breast lump, 19.7% with nipple discharge, and 19% with skin changes and ulceration. The mean initial tumor size was 7 cm ± SD. Following NACT, complete clinical response was reported in 30 patients (20.4%), partial clinical response in 92(62.6%), stable clinical response in 20 (13.6%), and five (3.4%) had progressive clinical response. Initial smaller tumors (size < 5 cm) showed a better clinical response to NACT as 76.7% of complete clinical response was achieved.
Pathological complete response was achieved in 25(17%) patients, pathological partial response in 102(74.1%), and pathological stable disease in 13(8.8%). Following NACT, breast conserving surgery was performed in 78(53.1%) patients, Modified Radical Mastectomy in 64(43.5%), 25 of them had Latissimus Dorsi, and five patients were not offered surgery as they developed progressive disease during the study period.
Conclusion: Following NACT, it was possible to perform surgery in more than 96% of patients with LABC.
 Redden, M. H. and Fuhrman, G. M. (2013). Neoadjuvant chemotherapy in the treatment of breast cancer. Surgical Clinics of North America, vol. 93, no. 2, pp. 493– 499. DOI: 10.1016/j.suc.2013.01.006
 Mieog, J. S., Van der Hage, J. A., and Van De Velde, C. J. (2007). Neoadjuvant chemotherapy for operable breast cancer. British Journal of Surgery, vol. 94, no. 10, pp. 1189–1200. DOI: 10.1002/bjs.5894
 Untch, M., Konecny, G. E., Paepke, S., et al. (2014). Current and future role of neoadjuvant therapy for breast cancer. Breast (Edinburgh, Scotland), vol. 23, no. 5, pp. 526–537. DOI: 10.1016/j.breast.2014.06.004
 Fisher, B., Brown, A., Mamounas, E., et al. (1997). Effect of preoperative chemotherapy on local-regional disease in women with operable breast cancer: Findings from National Surgical Adjuvant Breast and Bowel Project B-18. Journal of Clinical Oncology, vol. 15, pp. 2483–2493. DOI: 10.1200/JCO.1918.104.22.1683
 Mauri, D., Pavlidis, N., and Ioannidis, J. (2005). Neoadjuvant versus adjuvant systemic treatment in breast cancer: A meta-analysis. Journal of the National Cancer Institute, vol. 97, no. 3, pp. 188–194. DOI: 10.1093/jnci/dji021
 Sataloff, D. M., Mason, B. A., Prestipino, A. J., et al. (1995). Pathologic response to induction chemotherapy in locally advanced carcinoma of the breast: A determinant of outcome. Journal of the American College of Surgeons, vol. 180, no. 3, pp. 297–306.
 Kuerer, H. M., Newman, L. A., Smith, T. L., et al. (1999). Clinical course of breast cancer patients with complete pathologic primary tumour and axillary lymph node response to doxorubicin-based neoadjuvant chemotherapy. Journal of Clinical Oncology, vol. 17, no. 2, pp. 460–469. DOI: 10.1200/JCO.1922.214.171.1240
 Feldman, L. D., Hortobagyi, G. N., Buzdar, A. U., et al. (1986). Pathological assessment of response to induction chemotherapy in breast cancer. Cancer Research, vol. 46, no. 5, pp. 2578–2581.
 Kennedy, S., Merino, M. J., Swain, S. M., et al. (1990). The effects of hormonal and chemotherapy on tumoral and nonneoplastic breast tissue. Human Pathology, vol. 21, no. 2, pp. 192–198.
 Sharkey, F. E., Addington, S. L., Fowler, L. J., et al. (1996). Effects of preoperative chemotherapy on the morphology of resectable breast carcinoma. Modern Pathology: An official journal of the United States and Canadian Academy of Pathology, Inc.,vol. 9, no. 9, pp. 893–900.
 Elgaili, E. M., Abuidris, D. O., Rahman, M., et al. (2010). Breast cancer burden in central Sudan. International Journal of Women’s Health, vol. 2, pp. 77–82.
 Cance, W. G., Carey, L. A., Calvo, B. F., et al. (2002). Long-term outcome of neoadjuvant therapy for locally advanced breast carcinoma: Effective clinical downstaging allows breast preservation and predicts outstanding local control and survival. Annals of Surgery, vol. 236, no. 3, pp. 295–303.
 Alawad, A. A. (2014). Evaluation of clinical and pathological response after two cycles of neoadjuvant chemotherapy on Sudanese patients with LABC. Ethiopian Journal of Health Sciences, vol. 24, no. 1, pp. 15–20.
 Fisher, B., Bryant, J., Wolmark, N., et al. (2002). Effect of preoperative chemotherapy on the outcome of women with operable breast cancer. Annals of Surgery, vol. 236, no. 3, pp. 295–302. DOI: 10.1097/01.SLA.0000027526.67560.64
 Yadav, B. S., Sharma, S. C., Singh, R., et al. (2007). Patterns of relapse in locally advanced breast cancer treated with neoadjuvant chemotherapy followed by surgery and radiotherapy. Journal of Cancer Research and Therapeutics, vol. 3, no. 2, pp. 75–80.
 Chen, A. M., Meric-Bernstam, F., Hunt, K. K., et al. (2004). Breast conservation after neoadjuvant chemotherapy: The MD Anderson cancer center experience. Journal of Clinical Oncology, vol. 22, no. 12, pp. 2303–2312. DOI: 10.1200/JCO.2004.09.062
 Rustogi, A., Budrukkar, A., Dinshaw, K., et al. (2005). Management of locally advanced breast cancer: Evolution and current practice. Journal of Cancer Research and Therapeutics, vol. 1, no. 1, pp. 21–30.
 Bear, H. D., Anderson, S., Smith, R. E., et al. (2006). Sequential preoperative or postoperative docetaxel added to preoperative doxorubicin plus cyclophosphamide for operable breast cancer: National Surgical Adjuvant Breast and Bowel Project Protocol B-27. Journal of Clinical Oncology, vol. 24, no. 13, pp. 2019–2027. DOI:
 Veronesi, U., Bonadonna, G., Zurrida, S., et al. (1995). Conservation surgery after primary chemotherapy in large carcinomas of the breast. Annals of Surgery, vol. 222, no. 5, pp. 612–618.
 Dieras, V., Fumoleau, P., Romieu, G., et al. (2004). Randomized parallel study of doxorubicin plus paclitaxel and doxorubicin plus cyclophosphamide as neoadjuvant treatment of patients with breast cancer. Journal of Clinical Oncology, vol. 22, no. 24, pp. 4958–4965. DOI: 10.1200/JCO.2004.02.122
 Heys, S. D., Hutcheon, A. W., Sarkar, T. K., et al. (2002). Neoadjuvant docetaxel in breast cancer: 3-year survival results from the Aberdeen trial. Clinical Breast Cancer, vol. 3, no. 2, pp. S69–S74.
 Min, S. Y., Lee, S. J., Shin, K. H., et al. (2011). Loco-regional recurrence of breast cancer in patients treated with breast conservation surgery and radiotherapy following neoadjuvant chemotherapy. International Journal of Radiation Oncology * Biology * Physics, vol. 81, pp. 697–705. DOI: 10. 1016/j.ijrobp.2010.10.014
 Guarneri, V., Broglio, K., Kau, S. W., et al. (2006). Prognostic value of pathologic complete response after primary chemotherapy in relation to hormone receptor status and other factors. Journal of Clinical Oncology, vol. 24, pp. 1037–1044.
 Singletary, S. E., McNeese, M. D., and Hortobagyi, G. N. (1992). Feasibility of breastconservation surgery after induction chemotherapy for locally advanced breast carcinoma. Cancer, vol. 69, no. 11, pp. 2849–2852.
 Parmar, V., Krishnamurthy, A., Hawaldar, R., et al. (2006). Breast conservation treatment in women with locally advanced breast cancer: experience from a single Centre. International Journal of Surgery, vol. 4, pp. 106–114. DOI: 10.1016/j.ijsu.2006.01.004
 Woodward, W. A., Huang, E. H., McNeese, M. D., et al. (2006). AfricanAmerican race is associated with a poorer overall survival rate for breast cancer patients treated with mastectomy and doxorubicinbased chemotherapy. Cancer, vol. 107, no. 11, pp. 2662–2668. DOI: 10.1002/cncr.22281
 Machiavelli, M. R., Romero, A. O., Pérez, J. E., et al. (1998). Prognostic significance of pathological response of primary tumor and metastatic axillary lymph nodes after neoadjuvant chemotherapy for locally advanced breast carcinoma. The Cancer Journal From Scientific American Article Archives, vol. 4, no. 2, pp. 125–131.
 Kuerer, H. M., Newman, L. A., Smith, T. L., et al. (1999). Clinical course of breast cancer patients with complete pathologic response to doxorubicin- based neoadjuvant chemotherapy. Journal of Clinical Oncology, vol. 17, no. 2, pp. 460–469.
 Jones, R. L., Salter, J., A’Hern, R., et al. (2010). Relationship between ER status and proliferation in predicting response and long-term outcome to neoadjuvant chemotherapy for breast cancer. Breast Cancer Research and Treatment, vol. 119, no. 2, pp. 315–323. DOI: 10.1007/s10549-009-0329-x
 Newman, L. A. (2004). Management of patients with locally advanced breast cancer. Current Oncology Reports, vol. 6, no. 1, pp. 53–61
 DarbEsfahani, S., Loibl, S., Roller, M., et al. (2009). Identification of biologybased breast cancer types with distinct predictive and prognostic features: Role of steroid hormone and HER2 receptor expression in patients treated with neoadjuvantanthracycline/taxane-based chemotherapy. Breast Cancer Research,
vol. 11, no. 5; R69. DOI: 10.1186/bcr2363
 McCready, D. R., Hortobagyi, G. N., Kau, S. W., et al. (1989). The prognostic significance of lymph node metastases after preoperative chemotherapy for locally advanced breast cancer. The Archives of Surgery, vol. 124, no. 1, pp. 21–25. DOI: 10.1001/archsurg.1989.01410010027005
 Botti, C., Vici, P., Lopez, M., et al. (1995). Prognostic value of lymph node metastases after neoadjuvant chemotherapy for large-sized operable carcinoma of the breast. Journal of the American College of Surgeons, vol. 181, no. 3, pp. 202–208.
 Newman, L. A., Buzdar, A. U., Singletary, S. E., et al. (2002). A prospective trial of preoperative chemotherapy in resectable breast cancer: Predictors of breastconservation therapy feasibility. Annals of Surgical Oncology, vol. 9, no. 3, pp. 228–234.
 Bhattacharyya, T., Sharma, S., Yadav, B., et al. (2014). Outcome of neoadjuvant chemotherapy in locally advanced breast cancer: A tertiary care centre experience. Indian Journal of Medical and Paediatric Oncology, vol. 35, no. 3, pp. 215–220. DOI: 10.4103/0971-5851.142038
 Vlastos, G., Mirza, N. Q., Lenert, J. T., et al. (2000). The feasibility of minimally invasive surgery for stage IIA, IIB and IIIA breast carcinoma patients after tumor down-staging with induction chemotherapy. Cancer, vol. 88, no. 6, pp. 1417–1424.
 Rouzier R., Pusztai, L., Garbay, J. R., et al. (2006). Development and validation of nomograms for predicting residual tumor size and the probability of successful conservative surgery with neoadjuvant chemotherapy for breast cancer. Cancer, vol. 107, pp. 1459–1466.