Locally Advanced Breast Cancer

There are several indications of a locally advanced breast cancer: a stage 3 cancer, with a size larger than two inches and lymph node metastasis; swelling of the skin, or a big, matted cluster of lymph nodes in the armpit; or it might be stuck to the chest muscle, or ulcerating through the skin.
These are all indications that the breast cancer is likely to have spread to elsewhere in the body, at least microscopically and so when they are discovered, surgery isn't always the first step taken. Lymph node sampling isn't necessary. There is frequently a question whether a wide excision is even possible. If you've got very large breasts, it might be, but if your breasts are small, surgeons may not be able to get enough surrounding tissue out without a mastectomy. It the tumor is stuck to the chest muscle or ulcerating through the breast skin, an immediate local treatment might not be feasible at all; removing the muscle or all the skin that is ulcerated might not leave sufficient tissue to sew back together again.
All this generally suggests that it would be wise to start a systemic rather than local treatment, usually in the form of chemotherapy and this is now fairly generally agreed on in the medical community. Normally, the drugs used are Adriamycin and Cytoxan and/or Taxol or Taxotere. This may not eradicate the whole tumor, but if it doesn't, it can still do two things: it can destroy the cancer cells that have spread to various organs and it can shrink the tumor size to a size that can be more easily managed with surgery or radiation. Oftentimes, chemotherapy is continued for three to four cycles and then the situation is re-evaluated. If the tumor has shrunk, a lumpectomy (the surgical removal of a small tumor or a lump); if there is no change, surgeons resort to a surgical technique known as mastectomy, or surgical removal of the breast. Even when the tumor seems to have disappeared, there may still be some cancer cells present. Most doctors always want to at least a lumpectomy on the spot where the tumor where the tumor had been to see what's actually left. If the lumpectomy is clear or shows clean margins, you are a candidate for radiotherapy. Similarly, if doctors can do a lumpectomy and clear margins because the lump is small, that in addition to radiation is a sensible treatment. If there is still a large lump or a lot of cancer at the margins, the best option might be to do a mastectomy with or without immediate breast reconstruction. In the case of an ulceration that doesn't have enough skin to sew back together, breast reconstruction has not only a cosmetic but also a medical advantage: reconstruction provides skin from another part of the body.
After lumpectomy or mastectomy, some women with stage 3 breast cancer receive high-dose chemotherapy and stem cell rescue (bone marrow transplantation). Knowing that many of these locally advanced cancers are very aggressive, many doctors feel that a higher dose of chemotherapy is advisable. Different hospitals have different preferences in treatment order and combinations. Most centers do chemotherapy first and many of them will then do a mastectomy. Some of them will consider breast conservation surgery, if the lump becomes small enough and they usually follow up with radiation therapy. Combinations of treatments in this kind of breast cancer produce better response rates.
Michael Russell