Neoadjuvante systemische therapie bij het primair operabel mammacarcinoom: meer voordelen dan alleen borstsparende behandeling

Objective

To analyse the extent to which primary systemic therapy (PST) achieves the main goals in patients with operable primary breast cancer, these goals being breast-conserving therapy and pathological complete remission (pCR), and to evaluate the response.

Design

Retrospective.

Method

In a retrospective analysis of 254 patients treated with PST in 2000-2007 in the Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, patients with inoperable disease (T4 and/or N3) were excluded. The response was mostly evaluated using contrast-enhanced MRI, whereby the chemotherapy regimen was switched if the reduction in the largest diameter of contrast washout was less than 25. pCR was defined as no evidence of invasive cancer in the breast and axilla in the resection specimen.

Results

In patients with ductal carcinoma and lobular carcinoma an increase in breast-conserving therapy was seen in 32 and 17 of patients respectively. The pCR rate was 12 and 2 respectively. Secondary mastectomy because of irradical resection was required in 3 and 50 respectively. Multivariate analysis indicated that molecular type, defined on the basis of the expression of hormone receptors and human epidermal growth factor receptor 2 (HER2), i.e. luminal (oestrogen receptor-positive), basal (hormone receptor-negative and HER2-negative) and HER2-positive tumours treated with trastuzumab was the only independent predictor of pCR; 2, 28 and 35 respectively (p = 0.004). In 43 patients the chemotherapy regimen was adjusted because the tumour did not respond sufficiently. A favourable clinical response was observed in 72 (31/43) of these patients.

Conclusion

The observed increase in the number of breast-conserving therapies after PST was clinically relevant. PST may be more effective when contrast-enhanced MRI is used for interim evaluation, based on which the treatment may be switched. There was a clear difference in histological and molecular types of tumour and therefore the choice of treatment may be adjusted accordingly.

Ned Tijdschr Geneeskd. 2008;152:2519-25