Neoadjuvant Chemotherapy in Breast Cancer

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • The administration of neoadjuvant chemotherapy (NAC):
    • Offers several advantages in locally advanced breast cancer:
      • It allows for downstaging the disease:
      • Which can potentially allow for less extensive surgery in the breast and axilla
    • It also provides information regarding the responsiveness of the cancer to systemic therapy while the tumor remains in vivo:
      • Which can guide the course of therapy
  • Administering chemotherapy in the neoadjuvant vs. adjuvant setting:
    • Does not change overall survival:
      • As demonstrated in the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-18 and NSABP B-27 trials
  • The patient’s response to chemotherapy:
    • However, does offer prognostic information:
      • Particularly in patients with hormone receptor negative (HR-) disease
  • Patients who achieve pathologic complete response (pCR):
    • Which is typically defined as no residual invasive disease in the breast or axilla:
      • Appear to have improved event-free survival (EFS) and overall survival (OS) compared with patients with residual disease
      • This finding was demonstrated by a recent meta-analysis that included 36 studies including 5,768 patients with HER2 positive breast cancer:
        • This correlation was strongest in patients with HR- disease
      • Further, among patients with HER2 positive disease that do not have a pCR:
        • The degree of residual cancer burden appears to correlate with outcomes
  • Patients with HER2 positive tumors:
    • May complete up to 1 year of HER2-targeted therapy with trastuzamab ± pertuzamab
  • When planning surgery:
    • The pre-treatment volume does not need to be excised if the tumor has responded to chemotherapy:
      • However if multifocal disease is present, the satellite lesion(s) should be localized and excised with the index lesion
    • When considering the appropriateness for breast conservation following NAC, the distance between the lesions, location, and breast size must be considered
    • Placement of clips in the index lesion and any satellite lesions prior to initiation of NAC is critical for appropriate surgical planning post-NAC
  • References:
    • Rastogi P, Anderson SJ, Bear HD. Preoperative chemotherapy: updates of National Surgical Adjuvant Breast and Bowel Project Protocols B-18 and B-27. J Clin Oncol. 2008; 10;26(5):778-785.
    • Broglio KR, Quintana M, Foster M, et al. Association of pathologic complete response to neoadjuvant therapy in HER2-positive breast cancer with long-term outcomes: a meta-analysis. JAMA Oncol. 2016;2(6):751-760.
    • Symmans WF, Wei C, Gould R, et al. Long-term prognostic risk after neoadjuvant chemotherapy associated with residual cancer burden and breast cancer subtype. J Clin Oncol. 2017;35(10):1049-1060.
    • Boughey JC, Peintinger F, Meric-Bernstam F, et al. Impact of preoperative versus postoperative chemotherapy on the extent and number of surgical procedures in patients treated in randomized clinical trials for breast cancer. Ann Surg.2006;244(3):464-470.
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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