Surgical issues and preoperative systemic therapy.

Overview

Neoadjuvant chemotherapy is the standard treatment approach for patients with locally advanced breast cancer, where primary disease downstaging clears improves operability. Previously unresectable disease may then be controlled by mastectomy, and some patients may even become eligible for lumpectomy. The disease downstaging benefits as well as the ability to determine chemosensitivity, have motivated expanded applications for neoadjuvant chemotherapy to include selected cases of early-stage breast cancer. In this setting, many women will become improved candidates for breast conservation surgery performed via smaller-volume lumpectomies. Optimal utilization of the neoadjuvant chemotherapy approach requires special attention by the surgeon regarding diagnostic biopsies (percutaneous needle biopsies are preferred); preoperative planning (insertion of radio-opaque clips to mark tumor bed prior to completion of chemotherapy response; careful imaging to determine extent of disease); and final surgical decision-making (including comprehensive preoperative imaging to decide between lumpectomy and mastectomy).