Breast cancer locally advanced disease

Inflammatory breast cancer is characterized clinically by prominent skin, edema, redness and warmth, visible erysipeloid margin, and induration of the underlying tissue. Biopsies of the involved skin reveal cancer cells in the dermal lymphatics. Inflammatory breast cancer typically has a very rapid onset and although it may look somewhat similar to a neglected mass, its presentation with rapid onset and progression of local symptoms distinguishes it from other cases of locally advanced disease. Prognosis of patients with inflammatory breast cancer is poor, even if the disease is apparently locahzed. 

Most breast cancers diagnosed are small tumors (less than or equal to 2 cm), and disease is localized in all racial and ethnic groups. However, blacks and other minority women have proportionally more cases of disease diagnosed at more advanced stages compared with white women. This is thought to reflect access to and use of screening mammography and timely treatment. 

In most instances, external-beam radiation therapy used in conjunction with breast-conserving procedures involves 4 to 6 weeks of radiation therapy directed to the breast tissue to eradicate residual disease. Complications associated with radiation therapy to the breast are minor and include reddening and erythema of the breast tissue and subsequent shrinkage of total breast mass beyond that predicted on the basis of breast tissue removal. Some clinical situations also require postmastectomy radiation therapy as well (see section on locally advanced breast cancer). 

Locally advanced cancer breast cancer generally refers to breast carcinomas with significant primary tumor and nodal disease but in which distant metastases cannot be documented. A wide variety of clinical scenarios can be seen within this group of patients, including neglected tumors that have spread locally and inflammatory breast cancers that are a unique clinical entity. Many locally advanced breast cancers are diagnosed in patients who have had symptoms for months to years and have neglected to seek medical attention. Patients with inflammatory breast cancer often are treated inappropriately for cellulitis with antibiotics for several weeks to months. 

The goal of therapy with early and locally advanced breast cancer is to cure the disease. Breast cancer is currently incurable after it has advanced beyond local-regional disease. The goal of treatment of metastatic breast cancer is to improve symptoms, maintain quality of life, and extend survival. Thus it is important to choose therapy with good activity while minimizing toxicities. Treatment of metastatic breast cancer with either cytotoxic or endocrine therapy often results in regression of disease and improvements in quality of life. 

Currently, anastrozole and letrozole are efficacious in early-stage, locally advanced, and mefasfafic disease and fhus they present with the most complete data set for the different stages of breast cancer. Although it seems rather unlikely that one will be able to detect differences with respect to clinical effects at the tumour level, the indirect comparison of different AIs suggests a stronger evidence for the use of exemestane compared with other AIs for breast cancer therapy [90]. 

The management of locally advanced breast cancer and inflammatory breast cancer has evolved over the past twenty years. In general, surgery has maintained a role in the combined management of this disease but most studies have tested strategies to increase the extent of pathological response, especially in view of its prognostic implications. 

Kuerer HM, Newman LA, Buzdar AU, et al. Residual metastatic axillary lymph nodes following neoadj uvant chemotherapy predict disease-free survival in patients with locally advanced breast cancer. Am J Surg 1998 176 502-509. 

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