Surgical management of breast cancer after preoperative systemic treatment

Surgery following neoadjuvant systemic therapy involves complex decision making within the entire multidisciplinary team. The selection of which systemic therapy to use (i.e. endocrine therapy, chemotherapy, anti-HER2 agents) and the role of radiotherapy therapy must be carefully considered on a case-by-case basis. Tumour size before, during and after the systemic therapy needs to be carefully and accurately measured by the most appropriate imaging technique(s), before deciding on the final surgical approach. For the small percentage of patients whose tumour progresses during treatment or where there is no volume reduction and the tumour remains unsuitable for breast-conserving surgery, mastectomy with or without reconstruction remains an option. For the remaining patients, there are various surgical options available from standard breast-conserving surgery to oncoplastic breast-conserving surgery. The choice will be determined by a number of factors including the size of the tumour, surgical decision making regarding the need to remove the entire initial tumour volume or residual tumour volume, the size of the breast, the location of the tumour, the radiologic appearance after neoadjuvant therapy and the tumour subtype and patient’s concerns.