What is the management plan for a female patient with a 7cm breast mass in the upper outer quadrant infiltrating the chest wall who desires conservative breast surgery?

Management Plan for Breast Mass with Chest Wall Infiltration

The optimal management plan for a female patient with a 7cm breast mass in the upper outer quadrant infiltrating the chest wall who desires conservative breast surgery is neoadjuvant chemoradiotherapy followed by wide local excision (WLE).

Initial Assessment and Staging

• Patients with large tumors (>4cm) infiltrating the chest wall are typically classified as locally advanced breast cancer and are not initially candidates for breast conservation surgery 1
• Chest wall infiltration indicates a T4 classification, which traditionally would require mastectomy 1
• Complete clinical and radiological staging is essential before initiating treatment to accurately assess tumor extent and plan the optimal approach 2

Neoadjuvant Therapy Approach

Why Neoadjuvant Therapy?

• Neoadjuvant therapy (chemotherapy and/or radiotherapy) can downstage large tumors, converting patients who would require mastectomy into candidates for breast conservation 1, 2
• Preoperative chemotherapy has been shown to increase breast conservation rates from 59.8% to 67.8% in patients with large tumors 1
• For T4 tumors with chest wall involvement, neoadjuvant therapy is particularly important to achieve adequate tumor reduction before attempting conservative surgery 1, 3

Recommended Neoadjuvant Protocol

• Combined chemoradiotherapy before surgery provides the best chance of tumor downstaging for chest wall infiltrating tumors 3
• Neoadjuvant chemotherapy followed by preoperative radiation has shown to permit selection of patients with locally advanced breast cancer for conservative treatment 3
• This approach allows assessment of tumor response, which is a significant predictor of overall survival and disease-free survival 3

Surgical Planning After Neoadjuvant Therapy

• After completion of neoadjuvant therapy, careful restaging should be performed to assess response 2
• For patients with good response (residual tumor ≤3cm without chest wall infiltration), wide local excision with axillary dissection becomes feasible 3
• Technical considerations for successful breast conservation after neoadjuvant therapy include:
  • Placement of clips before chemotherapy to mark the primary tumor site 2, 4
  • Use of breast tattooing to delimit initial tumor size and margins 2
  • Intraoperative radiological and pathological evaluation of the specimen to ensure clear margins 2

Important Considerations and Caveats

• Clear surgical margins are essential to minimize local recurrence risk, which significantly impacts overall survival 3
• Local recurrence rates after breast conservation following neoadjuvant therapy range from 5-16%, compared to 5.4% after mastectomy 3
• Patients should be informed that if adequate response is not achieved or if clear margins cannot be obtained, conversion to mastectomy may still be necessary 1
• Oncoplastic surgical techniques should be considered to optimize both oncological and cosmetic outcomes 2

Post-Surgical Management

• Adjuvant radiotherapy to the breast and regional nodes is mandatory after breast conservation surgery 1
• Completion of planned chemotherapy regimen if not completed preoperatively 1
• Endocrine therapy should be added if the tumor is hormone receptor-positive 1

Follow-up Protocol

• Regular clinical examination every 4-6 months for 5 years, then annually 1
• Annual mammography 1
• Monitoring for local recurrence, particularly in the first two years after treatment 1

This management approach offers the best chance of achieving the patient's desire for breast conservation while maintaining oncological safety in the context of a locally advanced breast cancer with chest wall infiltration.