Option: Breast Conservation after Primary Systemic Therapy

The primary administration of chemotherapy leads to a reduction in size of tumors, increasing the possibility of breast-conserving surgery in both locally advanced, inoperable and primary operable mamma carcinomas. This, however, increases the rate of local relapse and the rate of mastectomy over the course of the disease, even although the EUSOMA guidelines are not exceeded. Whether the pre-surgical administration of chemotherapy with pathological complete remission actually increases the disease-free rate and overall survival remains to be determined. Further clinical studies are required to establish the reliability of sentinel lymph-node biopsy; currently, axillary lymphadenectomy is still the standard therapy. The response of the tumor to therapy, in correlation with predictive factors and the molecular-genetic profile, could make more individualized treatment regimes possible in the future. There is currently a paradigm shift with regard to the "adjuvant" treatment of breast cancer. Proceeding from the model of a systemic disease (1) requiring systemic therapy accompanied by a reduction in the radicalism of local surgery (2), leads to a multi-modal therapy concept. If numerous adjuvant studies have shown an increase in the disease-free (DFS) and overall survival (OS) rates (3), the same success should also be possible with primary systemic therapy. In this regard, the first study of primary systemic therapy in locally advanced, initially inoperable breast cancer was carried out (4). With regard to the benefit of primary therapy for women undergoing curative treatment, animal experiments showed that, after excision of the primary tumor, significant metastatic deposits proliferated (5) within 24 hours and remained for 7-10 days. At the same time, growth-stimulating factors were found in the blood and the metastatic capillarization increased. Pre-operative chemotherapy reduced proliferation, leading to an increase in the survival time of the animals (6, 7). In addition, carcinomas in an early stage are more chemo-sensitive since, with an increasing number of cells, the probability of chemotherapy-resistant cell clones also increases (7). Given these results, it is understandable that women are offered a primary systemic therapy, with the additional option of breast-conserving surgery. However, balancing a potential reduction in DFS and OS rates for good cosmetic results must be seriously considered. The review examines clinical studies regarding the reliability of surgical methods and the effectiveness of sentinel node lymphadenectomy in breast cancer. Whether there should been a paradigm shift is also discussed. Option: Breast Conservation after Primary Systemic Therapy Both internationally and according to the German national S3 guidelines of the AGO (German Study Group for Oncology), primary systemic therapy is the standard therapy for local, advanced, primary inoperable or inflammatory mamma carcinomas with a level of incidence (LOE) 1c and degree of recommendation A (high recommendation, dependent on the existence of randomized studies with controls (8)). The standard chemotherapy regime comprises anthracyclines or anthracyclines followed by taxanes, for at least 4 cycles. As an alternative in postmenopausal, receptor-positive women, third-generation aromatase blockers can be used as a primary endocrine therapy. If the primary tumor is operable, but cannot be resected in a 1677 Correspondence to: Dr. med. Anke Thomas, Department of Obstetrics and Gynecology, Campus Charité Mitte, Schumannstrasse 20/21, 10117 Berlin, Germany. Tel: +49-30-450564 022, Fax: +49-30450564 922, e-mail: [email protected]