PRIMARY CHEMOTHERAPY AND PRESURGICAL RADIATION-THERAPY IN PATIENTS WITH STAGE-II, LOCALLY-ADVANCED,NONINFLAMMATORY BREAST MALIGNANCIES MEASURING MORE THAN 3 CM IN DIAMETER

The potential indications for tumorectomy and the outcome in patients with stage II, locally-advanced, noninflammatory breast malignancies m easuring more than 3 cm in diameter treated initially with chemotherap y (CT) followed by presurgical external beam radiation therapy (RT) we re evaluated by a review of 147 cases treated between 1982 and 1990. M ean follow-up since treatment initiation was 94 months, Induction ther apy consisted of four CT courses (doxorubicin, vincristine, 5-fluorour acile, and cyclophosphamide) followed by radiation therapy (45 Gy over 4 1/2 weeks to the breast and same-side lymph nodes) then by a fifth chemotherapy course. Locoregional therapy was then selected according to the tumor response, Fifty-two patients with a residual tumor that m easured more than 3 cm in diameter or was retroareolar In location or was plurifocal underwent mastectomy with axillary node clearance. Of t he 95 remaining patients (65%), 48 (33%) were in complete remission an d were treated by additional radiation therapy to the tumor bed with n o surgery, and 47 (32%) had a residual tumor no larger than 3 cm in di ameter and underwent tumorectomy with removal of a wide margin and axi llary node clearance, followed by additional radiation therapy to the tumor bed. After locoregional therapy completion, all the patients rec eived a sixth CT course followed by adjuvant maintenance CT without an thracycline. Actuarial five-and ten-year loco-regional failure rates w ere 15% and 20%, respectively, after radiation therapy without surgery , 14% and 22.6% after tumorectomy and radiation therapy, and 6% and 6% after mastectomy. None of these differences were significant. After b reast conservation therapy, the five-and ten-year rates of survival wi thout locoregional recurrence were 85.4% and 78.5%, respectively. Mult ivariate analysis showed that the success rate after breast conservati on therapy was significantly influenced by the size of the tumor at ba seline. Overall and disease-free survival rates were 78.8% and 65.8% a fter five years and 71.2%, and 59.9% after ten years. Five-and ten-yea r overall survival rates were similar in the mastectomy and breast con servation groups (P=0.89). Local recurrence was associated with 3 sign ificant decrease in five-and ten-year overall survival (P<0.0001). Mul tivariate analysis identified two factors with a significant influence on survival, namely tumor response after induction CT and clinical st age. Edema of the upper limb was seen in 11% (11/99) of the patients w ho had axillary node clearance and 4% (2/48) of these who did not. Cos metic results were satisfactory in 65% of cases after tumorectomy and radiation therapy and in 73.5% of cases after radiation therapy withou t surgery. Our data suggest that the response to primary CT followed b y presurgical RT of locally-advanced noninflammatory or stage II breas t malignancies measuring more than 3 cm in diameter can be used to sel ect patients eligible for breast conservation therapy. The impact of t his treatment modality on survival requires further study.