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Management of locally advanced breast cancer

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Abstract

The management of locally advanced breast cancer with single modality therapy has been associated with a high rate of systemic failure. A multimodality treatment strategy that includes induction cytotoxic chemotherapy, surgery, radiation therapy, and, possibly, hormonal ablation therapy is the current preferred management approach. As our knowledge and understanding of the mechanisms involved in mitogenic signal transduction improve, it is likely that less toxic, more effications agents will emerge.

Résumé

La dénomination “carcinome du sein localement avancé” (CSLA) regroupe un nombre important de patientes dont le pronostic est variable. En dépit d'un public général et médical de plus en plus averti, 10 à 15% des femmes américaines avaient, en 1991, un CSLA au moment du premier diagnostic. Ceci correspond à 175900 femmes dont 17000 ayant un CSLA. Avec une telle prévalence, la fréquence du CSLA est plus élevée que celle de la maladie de Hodgkin, le cancer différencié de la thyroïde ou le cancer invasif du col utérin. Pouvoir proposer un plan thérapeutique uniforme des CSLA n'est pas facile en raison de la diversité clinique de la maladie (il y a 13 combinaisons possibles et la classification TMN actuelle des stades III comporte des tumeurs minimes avec envahissement axillaire important ainsi que de volumineuses tumeurs avec envahissement axillaire minime). L'analyse rétrospective des résultats est difficile car l'American Joint Committee Staging System a changé au moins quatre fois depuis 1962 et qu'il existe au moins deux autres systèmes de classification de gravité (Manchester et la Columbia Clinical Classification System). Ceci explique pourquoi il est difficile de formuler une approche thérapeutique standardisé pour les femmes ayant un CSLA. Le traitement local, soit par la chirurgie seule, soit par la radiothérapie est associé à un taux de récidive à distance élevée, suggérant que des micrométastases sont présentes dans la majorité des cas. Une stratégie multimodale, comportant une exérèse locale et un traitement systémique agressif est obligatoire.

Resumen

La denominación taxonómica “cáncer mamario localmente avanzado” (CMLA) comprende un significativo número de pacientes con pronósticos variables. A pesar de la incrementada preocupación por el cáncer mamario por parte tanto del público como de los médicos, 10% a 15% de las mujeres con cáncer del seno presentan CMLA en el momento del diagnóstico. En el año 1991, en los Estado Unidos se diagnosticaron 175.900 mujeres con cáncer mamario, de las cuales más de 17.000 presentaban CMLA. Esto significa que la entidad es más frecuente que la Enfermedad de Hodgkin, el carcinoma diferenciado de la glándula tiroides y el carcinoma invasivo del cervix. La diversidad biológica de esta enfermedad impide definir un tratamiento uniforme para el CMLA: existen 13 combinaciones posibles con base en el sistema TNM actual de estadificación para el cáncer mamario Estado III, que van desde tumores mínimos con invasión axilar voluminosa hasta grandes tumores con invasión axilar microscópica. La interpretación retrospectiva de información pertinente al CMLA es difícil, por cuanto el sistema de Estadificación de la Comisión Conjunta (American Joint Committee & Taging System) ha cambiado por lo menos cuatro veces desde 1962, y por lo menos otros dos sistemas de clasificación han sido utilizados: el sistema de Manchester y el sistema de clasificación de la Universidad de Columbia. Tales factores se combinan para hacer muy dificil la evaluación de los resultados del tratamiento o la formulación de un enfoque terapéutico unificado en mujeres con CMLA. El tratamiento local sólo, bien sea por ablación quirúrgica o por radioterapia, se asocia con una tasa elevada de falla sistémica, lo cual sugiere que en la mayoría de los casos exista enfermedad micrometastásica. Por lo tanto, es necesario emplear una estrategia multimodal que acentúe tanto el control local como una agresiva terapia sistémica.

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  1. Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, 10021, New York, New York, USA

    Patrick Ivan Borgen M.D.

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Borgen, P.I. Management of locally advanced breast cancer. World J. Surg. 18, 81–86 (1994). https://doi.org/10.1007/BF00348196

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