Locally Advanced Breast Cancer (LABC)

Clinical assessment in LABC-

What is LABC? & LOBC? (large operable breast cancer)

·         T3N1;  any T4, any N2, N3, M0

Inflammatory breast carcinoma-

·         T4D any N M0

Primary Tumour (T)

T3: >5cm in greatest dimension

T4: Tumour of any size with direct extension to

(a)    Chest wall or  (b) skin

T4a: Extension to chest wall, not including PM

T4b: Edema (including peau d’ orange) or ulceration of the skin of the breast, or satellite skin nodules confined to the same breast

T4c: Both T4a and T4b

T4d: inflammatory carcinoma

Stage Groupings- AJCC 6^th edition

Stage 0: Tis N0 M0

I: T1 N0 M0

IIa: T0 N1 M0, T1 N1 M0, T2 N0 M0

IIb: T2 N1 M0, T3 N0 M0

IIIa: T0 N2 M0, T1 N2 M0, T2 N2 M0, T3 N1 M0, T3 N 2 M0

IIIb: T4 N0 M0, T4 N1 M0, T4 N2 M0

IIIc: any T N3 M0

IV: ant T any N M1

Peau d’ orange: fig 1

·         Sometimes elicited by pinching the skin

·         Skin is reddish

·         Multiple spots

Clinical examination (lift the arm up): fig 2

·         Nipple areola complex gone up

·         Peau d’ orange becomes more prominent

·         Going up (of lump) is due to ligament of Cooper infiltration

·         In describing lump  always start from normal side

·         Mention whether other breast and axilla is normal and if involved then describe in detail

·         This is locally advanced breast cancer

·         Retraction of nipple present-

Non-operable LABC: fig 3

·         IIIC is non-operable

·         So down staging by neo adjuvant chemotherapy

·         Operate

·         Thereafter put on adjuvant chemotherapy

LABC in male: fig 4

·         Management is same stage by stage as in female

·         Examination pattern and the staging on the same lines as their female counterpart

·         It is just that most cancers in males are locally advanced at presentation

Inflammatory breast cancer:

·         Lee & Tannenbaum 1924

·         Diagnosis is clinical: increased size of affected breast, diffuse induration, skin erythema, peau d’ orange

·         Not all these features are necessarily present

·         Breast rather than skin biopsy

·         Dermal lymphatic obstruction by tumour

Inflammation in a LABC:

·         Indolent start/ oedema not more than 1/3^rd of breast

·         Outcome same as stage matched LABC

·         Management on the same lines

Clinical assessment:

·         Mandatory for staging

·         Planning of optimum therapy

·         Before initiating the therapy (NACT)

·         Subsequent serial assessments as the therapy progresses

T size and 5 year survival rate(%)

·         <5cm                     65%

·         5-10cm                 36%

·         >10cm                   16%

For accurate T size measurement- use Calliper or measuring tape

T size and association with the axillary lymph nodes

·         <1cm                     25

·         1-2cm                    35

·         2-3cm                    50

·         >3cm                     5-65

Local examination:

·         Accurate assessment of size, fixity, to skin or underlying muscle, presence of peau d’ orange or dimpling.

·         Retraction of nipple or puckering need to be mentioned clearly in the initial assessment chart.

·         Both axillae and supraclavicular fossae examined for presence of lymph nodes and their fixity.

·         In a fungating mass these features are obvious and one may have a pictorial record of the findings for subsequent comparison.

Initial clinical assessment:

·         The routine work up like for any patient of breast cancer

·         Detailed history including family history to arrive at the initial diagnosis and staging.

·         In a LABC further effort made to exclude metastasis.

·         The management changes drastically for a metastatic breast cancer.

·         Triple assessment.

·         Assessment for performance and nutritional status as both significantly affect the outcome in these patients.

·         Local clinical assessment involves a good examination of both breasts starting with the opposite breast first in all position.

The incidence of contralateral breast cancer when a patient presents with unilateral breast cancer is 1.8% (SEER database).

Systemic examination:-

·         Abdomen for any organomegaly particulary liver and/or presence of ascites to rule out an M1 disease.

·         Examination of spine and chest along with breast mandatory.

·         P/V and DRE: mandatory to rule out peritoneal deposits (Blummer shelf) or Kruckenberg ‘s tumour (in pre-menopausal women), ovarian malignancy.

 Clinical assessment as a part of assessing response to NACT: (neo adjuvant chemotherapy)

·         The sensitivity is poor due to excessive local scarring following NACT

·         The response described as complete if the tumour size reduces by more than 50% after 3 cycles of NACT.

·         The clinical assessment may also include use of ultrasound as its natural extension.

Clinical response and outcome-

·         Role of P-glycoprotein expression in predicting response to neoadjuvant chemotherapy in breast cancer.

Clinical assessment as a dynamic phenomenon-

·         Appearance of a metastasis during the follow up after NACT would make the disease metastatic and change the intent.

·         Regular assessment mandatory and is a dynamic rather than a static affair.

Conclusion

·         LABC is a complex group of entities

·         Clinical assessment is a dynamic process

·         Serial assessments predict response and the appearance of a metastasis.

·         Inflammatory breast cancer although included in the LABC is a different entity.

·         Good clinical assessment forms the basis of subsequent assessment of tumour behaviour and response to NACT.

·         USG may serve as an extension of clinical assessment.