Author: 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.

Radiation Fractionation

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Three important areas form the foundation for the evolving use of altered fractionation:
    • Tissue response
    • Duration of treatment
    • Fraction size and number
  • Acutely responding tissues:
    • Are rather active in ongoing cellular proliferation
    • Most tumors (except perhaps prostate cancer, breast cancers, and melanoma) and some normal tissues such as skin, mucous membranes, and gastrointestinal epithelium:
      • Share this characteristic:
        • These tissues are most affected by the overall treatment duration rather than by the size or number of fractions used
  • Late-responding tissues:
    • Have a low proliferative rate and include the spinal cord, brain, bone, and cartilage
    • These tissues are most affected by the:
      • Size and number of fractions rather than by treatment duration:
        • Therefore are spared by decreasing the dose per fraction of radiation delivered
  • Because most tumors consist of rapidly dividing cells:
    • Local tumor control is strongly dependent on the overall treatment duration rather than on the size or number of fractions
  • When squamous cell carcinoma of the head and neck is exposed to radiation:
    • The less radiosensitive cells within the lesion:
      • Can undergo rapid proliferation:
        • Approximately 3 to 5 weeks after treatment commences
        • This accelerated repopulation can overwhelm the ongoing treatment effects of radiation:
          • Which ultimately can lead to local failure
        • The clinical significance of this phenomenon is that even with significant regression of the primary tumor mass:
          • Local failure still ultimately could result from proliferation of these resistant clones
        • Therefore it is essential to complete treatment in as short a time as possible so that accelerated repopulation is minimized:
          • Increasing the chance for local control
      • For this reason, split-course radiation:
        • Which incorporates a treatment break during the course of radiotherapy is not recommended
  • Based on the aforementioned principles:
    • The goal of altered fractionation schemes:
      • Is to improve the therapeutic ratio by maximizing the tumoricidal effect and minimizing acute and late toxicities while using readily available low-LET radiation
  • Two major categories of altered fractionation schemes exist:
    • Hyperfractionation
    • Accelerated fractionation
  • They share basic radiobiological principles yet have their own particular features (Table)
  • Accelerated fractionation:
    • Is the strategy of choice for rapidly proliferative tumors
    • Accelerated fractionation is based on the concept that the shortened overall treatment time:
      • Would reduce the opportunity for accelerated repopulation effectively
  • Hyperfractionation:
    • Is preferred for slowly proliferating tumors
    • Hyperfractionation improves the therapeutic ratio primarily through:
      • Redistribution of tumor cells into more radiosensitive phases as a result of multiple fractions
      • Differential sparing of late-responding normal tissues because of a decrease in the size of the dose per fraction

Contralateral Prophylactic Mastectomy (CPM) American Society of Breast Surgeon Guidelines

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Current consensus guidelines from the American Society of Breast Surgeons:
    • Do not recommend CPM for women with sporadic breast cancers
  • A Cochrane review of 8 studies evaluating patients who underwent CPM:
    • Concluded that while CPM reduces risk of contralateral breast cancer:
      • It is not associated with improved survival
  • Reasons for not recommending CPM include:
    • A low estimated risk of cancer in the contralateral breast (2% to 6% over 10 years)
    • Increased complication rates
    • Studies showing that CPM does not improve survival or recurrence from the index cancer
  • References:
    • Lostumbo L, Carbine N, Wallace J, Ko H. Prophylactic mastectomy for the prevention of breast cancer. Cochrane Database Syst Rev 2004(4):CD002748.
    • Boughey JC, Attai DJ, Chen SL, et al. Contralateral prophylactic mastectomy consensus statement from the american society of breast surgeons: additional considerations and a framework for shared decision making. Ann Surg Oncol. 2016;23(10):3106-3111

Nerves that Could Potentially be Injured During Breast and Axillary Surgery

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Intercostobrachial nerve:
    • This nerve is a cutaneous branch of the intercostal nerves:
      • Most commonly the second intercostal nerve:
        • Which gives off a lateral cutaneous nerve:
          • Which continues as the intercostobrachial nerve
    • The intercostal nerves arise from:
      • The anterior rami of the thoracic spinal nerves
    • The intercostobrachial nerve pierces the serratus anterior:
      • Crosses the axilla to the medial side of the upper arm
    • The intercostobrachial nerve is commonly in the surgical field during axillary lymph node dissections and may be severed during surgery, or subject to traction or postsurgical inflammation:
      • Thus leading to intercostobrachial neuralgia
  • The larger intercostal nerves:
    • Can be preserved with meticulous dissection
  • Neuropathic symptoms:
    • May be limited to numbness or tingling:
      • But may also include a burning sensation
  • Techniques such as a regional nerve block:
    • Have been described to alleviate symptoms in severe cases
  • In a study of 200 patients who underwent axillary dissection:
    • 76% had symptoms of intercostobrachial neuralgia postoperatively
    • Of these patients, 82% reported improvement or resolution of these symptoms within 1 year:
      • Reflecting the richness of the sensory nerve supply to the axilla and upper arm
  • The thoracodorsal nerve:
    • Is a branch of the posterior cord of the brachial plexus:
      • It supplies motor function to the latissimus dorsi
    • If injured, patients experience weakness with arm abduction, lateral flexion, and difficulty with activities such as climbing, swimming, and using the arms to pull the body up
  • The medial cord of the brachial plexus:
  • Gives rise to the medial pectoral nerve:
    • Which innervates both the pectoralis minor muscle and the pectoralis major muscle
  • The medial pectoral nerve typically pierces the pectoralis minor muscle:
    • But may wrap around the lateral aspect of the pectoralis minor before traveling on to innervate the distal pectoralis major muscle
  • The lateral cord of the brachial plexus:
    • Gives rise to the lateral pectoral nerve:
      • Which innervates the pectoralis major muscle
    • This nerve travels along the medial border of the pectoralis minor muscle:
      • Then along the undersurface of the pectoralis major muscle along with the pectoral branch of the thoracoacromial artery to supply the proximal pectoralis major muscle
  • The medial pectoral nerve bundle:
    • Is often encountered during axillary dissection as it is located lateral to the lateral pectoral nerve
  • If either of these nerves is injured:
    • Pectoralis muscle atrophy can occur:
      • Which can present as a late complication of surgery, with weakness of shoulder adduction, interior rotation, and flexion
  • The long thoracic nerve:
    • Typically arises from anterior rami of the cervical spinal nerve roots C5 to C7
    • It courses along the chest wall and supplies the serratus anterior muscle
    • Injury to this nerve causes a winged scapula
  • References:
    • Sclafani LM, Baron RH. Sentinel lymph node biopsy and axillary dissection: added morbidity of the arm, shoulder and chest wall after mastectomy and reconstruction. Cancer J. 2008;14(4):216-222.
    • Wisotzky EM, Saini V, Kao C. Ultrasound-guided intercostobrachial nerve block for intercostobrachial neuralgia in breast cancer patients: a case series. Prev Med Rep, 2016;8(3):273-277.
    • Roses DF, Brooks AD, Harris MN, Shapiro RL, Mitnick J. Complications of level I and II axillary dissection in the treatment of carcinoma of the breast. Ann Sur. 1999;230(2):194-201.
    • Porzionato A, Macchi V, Stecco C, Loukas M, Tubbs RS, De Caro R. Surgical anatomy of the pectoral nerves and the pectoral musculature. Clin Anat. 2012;25(5):559-575.

Inflammatory Breast Cancer (IBC)

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Inflammatory breast cancer (IBC):
    • Is a clinical syndrome in women with invasive breast cancer that is characterized by:
      • Erythema and edema (peau d’orange) of a third or more of the skin of the breast
    • The differential diagnosis includes:
      • Cellulitis of the breast or mastitis
    • Because most IBC cases are first seen by healthcare providers not necessarily familiar with IBC:
      • The absence of complete response to a trial of antibiotic therapy should heighten suspicion of IBC and prompt further investigation:
        • Further trial of antibiotics is not warranted in the absence of clinical signs of infection and previous adequate antibiotic therapy
    • Workup includes physical exam and imaging:
      • Imaging may not reveal a mass:
        • But thickening of the skin is frequently seen
      • The most common signs of IBC on mammography include:
        • Thickening of the skin (84%)
        • Trabecular thickening (81%)
        • Asymmetric focal density (61%)
        • Microcalcifications (56%)
      • Mammography is the least sensitive diagnostic tool available for IBC:
        • Whereas ultrasound and MRI are more sensitive:
          • In a series published by Yang, et al., sonography demonstrated a mass or architectural distortion in 95% of patients with associated global skin and subcutaneous thickening and dilated lymphatics
          • MRI can also show skin thickening and is more sensitive than mammography in detecting an underlying mass:
            • The same series by Yang and colleagues found that a primary breast lesion was present in every MRI obtained in patients with IBC as either nonmass or mass-like enhancement
    • IBC is a clinical diagnosis:
      • Dermal biopsy confirmation is not mandatory:
        • Dermal lymphatic invasion is seen only in approximately 60% of IBC cases:
          • It is neither required, nor sufficient by itself for a diagnosis of inflammatory breast cancer
    • Treatment is multidisciplinary trimodality therapy consisting of neoadjuvant chemotherapy, modified radical mastectomy, and local regional radiation:
      • Yet, the median survival at 5 years for patients presenting with primary IBC is still only approximately 55%
  • References
    • Yang WT, Le-Petross HT, Macapinlac H, et al: Inflammatory breast cancer: PET/CT, MRI, mammography, and sonography findings. Breast Cancer Res Treat. 2008;109(3):417-426.
    • Somio G, Jones V. Inflammatory breast cancer. In: Klimberg S, Bland K, eds. The Breast: Comprehensive Management of Benign and Malignant Disease. Philadelphia, PA: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2011:832-838.
#Arrangoiz #CancerSurgeon #BreastSurgeon #SurgicalOncology #MountSinaiMedicalCenter #MSMC #Miami #Mexico

Hypofractionation Radiation Therapy

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Hypofractionation:
    • Larger fraction size (600 to 800 cGy) compared with conventional fractionation (180 to 200 cGy)
    • Fractions delivered several days apart
    • Lower total dosage (2100 to 3200 cGy) than
      conventional fractionation (7000 cGy)
    • Shortened overall treatment duration
      compared with conventional fractionation
  • Hypofractionation:
    • Is the administration of high-dose-per-fraction (HDPF) radiation:
      • In which only one or two fractions are given per week
    • This technique has evolved for the treatment of malignant melanoma:
      • Which generally is perceived as being radioresistant
  • Conventional fractions of 200 cGy delivered 5 days a week:
    • Allow normal tissues and tumor cells to recover during the intervals between fractions
  • Experimental in vitro data have shown that malignant melanoma cells are better at repairing radiation-induced sublethal damage compared with other cells:
    • This finding may explain the long-standing notion that melanoma is intrinsically “radioresistant”
  • HDPF regimens:
    • Deliver higher doses of radiation per fraction (600 cGy twice a week or 800 cGy once weekly):
      • With the aim of overcoming the reparative capacity of the tumor cells by increasing the damage per fraction
  • In retrospective analyses, response rates have been shown to correlate with dose per fraction but not with the total dose delivered:
    • However, a prospective randomized trial (RTOG 83–05) found no therapeutic advantage in a comparison of HDPF (800 cGy once a week up to a total dose of 3200 cGy) and conventional fractionation (250 cGy daily, 5 days a week, for a total of 5000 cGy):
      • Although no therapeutic advantage was seen, the shorter delivery time of HDPF radiation allows earlier initiation of systemic therapies if applicable
  • Moderately hypofractionated radiation (225 cGy per fraction):
    • Has demonstrated superior results for early-stage larynx cancers treated with radiotherapy alone:
      • This is currently considered the standard of care in this setting
  • Additionally, a regimen commonly referred to as quad shot:
    • Which was originally developed for advanced pelvic tumors:
      • Is sometimes applied for palliation of tumors in the head and neck
    • This involves cycles of a 1480 cGy course of radiotherapy delivered in four fractions over the course of 2 days:
      • Which can be repeated multiple times over a period of weeks or months depending on the treatment response
      • Aside from the demonstrated efficacy of this regimen, it also allows significant advantages in terms of patient convenience in the palliative setting

Breast Cancer-Related Lymphedema (BCRL):

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Breast cancer-related lymphedema (BCRL):
    • Has been a significant concern for breast cancer patients undergoing axillary surgery
  • The development of BCRL is associated with:
    • Significantly lower physical and psychosocial well-being and increased health care utilization
  • The risk of BCRL:
    • Is a function of the extent of axillary intervention:
      • Ranging from about 12% following a sentinel node biopsy to about 30% after an axillary lymph node dissection (ALND)
  • The highest risk of BCRL (51%) has been reported in patients with inflammatory breast cancer:
    • Who receive trimodality therapy (neoadjuvant taxane-containing chemotherapy, modified radical mastectomy, and adjuvant radiation):
      • Therefore, adjuvant radiotherapy is associated with an increased risk of BCRL
  • The value of routine screening for BCRL in patients at risk is controversial
  • There is growing evidence that subclinical lymphedema:
    • Defined as relative volume change of the affected arm of 5% to 10% compared to the baseline measurement:
      • Is strongly associated with the development of more symptomatic BCRL:
        • Which correlates with a relative volume change of greater than 10%
  • Consequently, identifying patients with subclinical lymphedema is a potential opportunity for early intervention and long-term improvement in quality of life
  • Furlan et al prospectively evaluated 85 breast cancer patients (n=40 had an ALND and n=45 had a sentinel node biopsy) by obtaining serial circumferential arm measurements preoperatively, then 1 month, 3, 6, 12, and 24 months after surgery:
    • Study results showed that the earliest signs of subclinical lymphedema were detected no sooner than the 6-month assessment, and those with subclinical lymphedema were promptly referred for decongestive therapy
  • An international randomized trial comparing bioimpedance spectroscopy (BIS) and tape measurement to detect subclinical lymphedema:
    • Showed that BIS had a higher sensitivity and was associated with an earlier referral for decongestive therapy
    • In the same study, earlier administration of decongestive therapy was associated with a lower risk of progression to symptomatic BCRL
    • The practical aspects of implementing BCRL screening with BIS versus tape measurements and other techniques warrant further study
  • References
    • Coriddi M, Kim LN, Haglich K, et al. The impact of lymphedema on patient-reported outcomes after breast reconstruction: a preliminary propensity score-matched analysis. Ann Surg Oncol. 2023;30(5):3061-3071. doi: 10.1245/s10434-022-12994-z
    • Cheville A, Lee M, Moynihan T, et al. The impact of arm lymphedema on healthcare utilization during long-term breast cancer survivorship: a population-based cohort study. J Cancer Surviv. 2020;14(3):347-355. doi: 10.1007/s11764-019-00851-0
    • Bucci LK, Brunelle CL, Bernstein MC, et al. Subclinical lymphedema after treatment for breast cancer: risk of progression and considerations for early intervention. Ann Surg Oncol. 2021;28(13):8624-8633. doi: 10.1245/s10434-021-10173-0
    • Farley CR, Irwin S, Adesoye T, et al. Lymphedema in inflammatory breast cancer patients following trimodal treatment. Ann Surg Oncol. 2022;29(10):6370-6378. doi: 10.1245/s10434-022-12142-7
    • Furlan C, Matheus CN, Jales RM, Derchain SFM, Bennini JR Jr, Sarian LO. Longitudinal, long-term comparison of single-versus multipoint upper limb circumference periodical measurements as a tool to predict persistent lymphedema in women treated surgically for breast cancer: an optimized strategy to early diagnose lymphedema and avoid permanent sequelae in breast cancer survivors. Ann Surg Oncol. 2021;28(13):8665-8676. doi: 10.1245/s10434-021-10290-w
    • Ridner SH, Dietrich MS, Boyages J, et al. A comparison of bioimpedance spectroscopy or tape measure triggered compression intervention in chronic breast cancer lymphedema prevention. Lymphat Res Biol. 2022;20(6):618-628. doi: 10.1089/lrb.2021.0084

Radiation Therapy in Head and Neck Cancer

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • A randomized study by the radiation therapy oncology group (RTOG) 90–03:
    • Evaluated the use of low-LET radiation alone
      with four fractionation schemes for the treatment of squamous cell carcinoma of the head and neck
    • Patients included in this trial underwent radiation therapy as a single modality, without the use of chemotherapy
    • The sites included the oral cavity, oropharynx, hypopharynx, and supraglottic larynx
    • The stages were limited to III and IV (with no distant metastases):
      • However, the base of the tongue and the hypopharynx subsites included stage II patients as well
    • The four arms were as follows:
      • Conventional fractionation:
        • The conventional fractionation schedule that entails use of 180 to 200 cGy per fraction
        • One fraction per day, 5 days per week for 6 to 7 weeks for a total dosage of 6500 to 7000 cGy has evolved empirically over many years
      • Hyperfractionation:
        • Hyperfractionation is preferred for slowly proliferating tumors
        • Hyperfractionation improves the therapeutic ratio primarily through:
          • Redistribution of tumor cells into more radiosensitive phases as a result of multiple fractions
          • Differential sparing of late-responding normal tissues because of a decrease in the size of the dose per fraction
        • Hyperfractionation:
          • Smaller fraction size (115 to 120 cGy) compared with conventional fractionation (180 to 200 cGy)
          • BID to TID fractionation
          • Larger total dosage (7440 to 8460 cGy) than conventional fractionation (7000 cGy)
          • Similar overall treatment duration as
            conventional fractionation
      • Accelerated fractionation with split:
        • Accelerated fractionation is the strategy of choice for rapidly proliferative tumors
        • Accelerated fractionation is based on the concept that the shortened overall treatment time would reduce the opportunity for accelerated repopulation effectively
        • Accelerated fractionation:
          • Similar fraction size as conventional fractionation (180 to 200 cGy)
          • BID to TID fractionation
          • Similar total dosage as conventional
            fractionation
          • Shortened overall treatment
            duration compared with conventional fractionation
      • Accelerated fractionation with a concomitant boost
  • The RTOG 90-03:
    • Had a significantly improved 2-year locoregional control and disease-free survival rate with:
      • Accelerated fractionation with a concomitant boost compared with conventional fractionation and accelerated fractionation with a split
    • Patients treated with hyperfractionation also had a trend toward improved results:
      • However, a phase III Groupe Oncologie Radiotherapie Tete et Cou cooperative trial did not show a benefit when altered fractionation was combined with chemotherapy
      • In fact, patients treated with accelerated fractionation with concurrent chemotherapy experienced more toxicities than did patients treated with conventional fractionation with concurrent chemotherapy
  • The RTOG 99-14 trial:
    • Asked the same question about whether chemotherapy given concurrently with concomitant boost radiation can further improve on locoregional control
    • Because of the encouraging preliminary results, RTOG 01-29 was conducted to answer the question of whether altered fractionation should be used in the setting of chemotherapy
    • The results of this two-arm prospective randomized trial of more than 700 patients was was reported:
      • Showing that when chemotherapy is given concurrently with radiation:
        • There is no added benefit of using altered fractionation compared with standard once-daily radiation
      • Furthermore, the long-term grade 3 to 4 late toxic effects of chemotherapy from RTOG 99-14 with concomitant boost radiation was extremely high at 42%
      • Gastrostomy tube dependence rates anytime during follow-up, at 1 year, and at 2 years were 83%, 41%, and 17%, respectively
      • However, it should be mentioned that these patients were treated with older, conventional nonconformal radiation techniques, such as Cobalt 60
      • Since the introduction of IMRT, which allows for significant reduction in radiation dose to normal tissues, treatment-associated toxicities have improved
  • Three randomized studies comparing conventional radiation technique versus IMRT for head and neck cancer:
    • Have indeed shown that there are lower late complications with IMRT
    • Furthermore, there is no evidence that IMRT causes compromise in locoregional control

Axillary Web Syndrome

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Axillary web syndrome:
    • Appears to be a common complication following axillary surgery
    • It consists of the appearance of a visible web of axillary skin overlying palpable cords of tissue:
      • That are made taut and painful by shoulder abduction
    • These cords can result in painful abduction of the shoulder and reduced range of motion
    • It typically results from axillary lymphadenectomies for treatment of breast cancer or melanoma
    • In general, axillary web syndrome is poorly defined and misunderstood:
      • In a large systematic review:
        • The incidence ranged from 0.6% to 85.4%
      • Extent of surgery (number of nodes removed), low body mass index, and age have been reported as possible risk factors for development of this syndrome
      • Although smoking, receipt of neoadjuvant chemotherapy, and radiation may play a role in its development:
        • These factors have not been described in the literature
      • In the majority of cases:
        • Axillary web syndrome:
          • Appears to develop within 2 to 8 weeks of axillary surgery
      • Although patients generally do well with resolution of their symptoms:
        • Current evidence for the treatment of axillary web syndrome is insufficient to provide clear guidance for clinical practice
      • Suggested interventions have included:
        • Early education
        • Physiotherapy
        • Thermal therapy
        • Medications
        • Surgery
  • References:
  • Koehler LA, Haddad TC, Hunter DW, Tuttle TM. Axillary web syndrome following breast cancer surgery: symptoms, complications and management strategies. Breast Cancer. 2018;11:13-19.
  • Yeung WM, McPhail SM, Kuys SS. A systematic review of axillary web syndrome (AWS). J Cancer Surviv. 2015;9(4):576-598

Inflammatory Breast Cancer (IBC)

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Inflammatory breast cancer (IBC ):
    • Is a clinical diagnosis characterized by:
      • The rapid progression of an enlarged breast with skin changes including:
        • Redness, edema, and peau d’orange
    • Skin punch biopsy:
      • Will demonstrate lymphovascular tumor emboli:
        • In approximately 75% of cases:
          • But the absence should not rule out a diagnosis
    • Staging scans, including a CT chest / abdomen / pelvis, PET scan, and / or bone scan:
      • Should be completed prior to initiating treatment
  • Inflammatory breast cancer:
    • Is a clinical stage T4d
    • It is the most fatal form of breast cancer:
      • Accounting for 7% of all breast cancer deaths:
        • Real-world observational data have demonstrated that inflammatory breast cancer has significantly worse survival compared to other non-metastatic locally advanced and metastatic non-inflammatory breast cancers
      • Despite this, 5-year survival of IBC patients has increased from:
        • 40% to 50% in the 1990’s to almost 70% in 2008
  • Recent national and international guidelines for IBC:
    • Recommend full staging:
      • PET / CT preferred over CT chest / abdomen / pelvis + bone scan and bilateral breast and axillary nodal imaging
    • Followed by neoadjuvant systemic therapy, modified radical mastectomy (including level I and II lymph node dissection), and radiation
    • Adjuvant targeted therapy and hormonal therapy should be considered in appropriate cases
    • Notably, lumpectomy is contraindicated, and breast reconstruction should be delayed
    • Multi-modal therapy for IBC has resulted in the best overall survival rates
  • For HER2-negative breast cancers:
    • Preoperative chemotherapy regimens should include sequential doxorubicin and cyclophosphamide followed by a taxane:
      • To achieve the highest pathologic complete response rate
  • For HER2-positive breast cancers:
    • Chemotherapy should be used with dual anti-HER2-directed therapy with pertuzumab and trastuzumab to achieve the best pathologic complete response rate
  • References
    • National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology. Breast Cancer. Available with login at: https://subscriptions.nccn.org.
    • Fouad TM, Barrera AMG, Reuben JM, Lucci A, Woodward WA, Stauder MC, et al. Inflammatory breast cancer: a proposed conceptual shift in the UICC-AJCC TNM staging system. Lancet Oncol. 2017;18(4):e228-e232.
    • Ueno NT, Espinosa Fernandez JR, Cristofanilli M, Overmoyer B, Rea D, Berdichevski F, et al. International consensus on the clinical management of inflammatory breast cancer from the Morgan Welch Inflammatory Breast Cancer Research Program 10th Anniversary Conference. J Cancer. 2018;9(8):1437-1447.
    • Rueth NM, Lin HY, Bedrosian I, Shaitelman SF, Ueno NT, Shen Y, et al. Underuse of trimodality treatment affects survival for patients with inflammatory breast cancer: an analysis of treatment and survival trends from the National Cancer Database. J Clin Oncol. 2014;32(19):2018-2024.

Pregnancy-Associated Breast Cancer

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Pregnancy-associated breast cancer:
    • Is fortunately a rare entity:
      • In which breast cancer is diagnosed during the pregnancy or the first year after delivery
  • The surgical care of these patients is the same as non-pregnant patients:
    • Sentinel node biopsy:
      • Can safely be performed during pregnancy:
        • Therefore, axillary dissection is not warranted
      • However, only radioactive dye should be used
    • Patients can safely undergo breast-conserving surgery:
      • With radiation occurring after delivery
  • Anthracycline-based chemotherapy:
    • Is safe during the 2nd and 3rd trimester:
      • A study by Litton, et al:
        • Showed children exposed to chemotherapy in utero had normal development and the rate of congenital abnormalities were similar to national averages
  • Biologic and hormonal therapies:
    • Are contraindicated during pregnancy
  • While termination is not mandatory to allow treatment of the malignancy:
    • Close monitoring by an obstetrician experienced in high-risk pregnancies:
      • Is recommended to monitor the fetus and to determine the best time to complete chemotherapy to ensure that the patient does not deliver during a nadir, thus minimizing risk at the time of delivery
  • References:
    • Guidroz JA, Scott‐Conner CE, Weigel RJ. Management of pregnant women with breast cancer. J Surg Oncol. 2011;103(4):337-340.
    • Shah NM, Scott DM, Kandagatla P, et al. Young women with breast cancer: fertility preservation options and management of pregnancy-associated breast cancer. Ann Surg Oncol. 2019;26(5):1214-1224.
    • Murthy RK, Theriault RL, Barnett CM, et al. Outcomes of children exposed in utero to chemotherapy for breast cancer. Breast Cancer Res. 2014;16(6):500.
    • Shachar SS, Gallagher K, McGuire K, et al. multidisciplinary management of breast cancer during pregnancy. Oncologist. 2017;22(3):324–334. Erratum in: Oncologist. 2018;23(6):746.