Surgical considerations after neoadjuvant chemotherapy: Breast conservation therapy

The increasing use of chemotherapy before surgery has affected a number of local-regional treatment decisions including surgical and radiation management of the breast, management of axillary lymph nodes, and the indications for postmastectomy radiation. In this monograph, we will focus on surgical and radiation management as components of breast conservation therapy. The early randomized trials that compared neoadjuvant to adjuvant chemotherapy in breast cancer demonstrated that rates of breast conservation can be increased when chemotherapy is sequenced first. This was a direct consequence of high response rates seen with neoadjuvant treatment, which permitted downstaging of a large primary tumor to a volume that permitted breast-conserving surgery. Some initial studies found higher rates of breast recurrences with this approach but over time, with improved multidisciplinary coordination and proper patient selection, rates of breast recurrences have improved to the excellent levels achieved when surgery is performed first. New clinical trials are also ongoing to define the role of sentinel lymph node surgery and regional lymph node radiation.