ORLANDO--Preoperative chemotherapy in breast cancer patients can
leave a surgeon in the dark as to the specific amount of normal
tissue to remove if the chemotherapy eliminates the tumor or renders
it no longer palpable. A simple tattoo outlining the original tumor
site can be a great aid in helping surgeons determine the type of
surgery to be performed after the therapy.
Dr. Umberto Veronesi, speaking at the 15th Annual International
Breast Cancer Conference, presented some caveats for consideration
before and during surgery that follows chemotherapy.
In addition to defining the original tumor site, he said, the surgeon
must also obtain a clinical evaluation of the extent of regression, a
reliable gross evaluation of the residual mass, a reliable frozen
section examination, and an assessment of the significance of
Chemo May Destroy the Tumor
Dr. Veronesi, scientific director at the Instituto Europeo di
Oncologia, Milan, uses a tattoo, with the aid of mam-mography, to
designate the original tumor site. Chemotherapy may destroy the
tumor, leaving it nonpalpable, yet there may still be a foci of
"If youre not experienced, you may make a mistake,"
he said. "You need to excise a wide area, which represents the
area before chemotherapy." The tattoo leaves no doubt as to the
site of the original tumor. However, as a further precaution, the
pathologist may need toexamine anywhere from 5 to 15 frozen sections
to confirm the extent of tumor regression.
Microcalcifications should be noted, since they do not disappear
after chemotherapy. "They instead tend to shrink and aggregate
so that the total area they occupied is reduced," Dr. Veronesi
explained. This can be an "important index of the regression
process and an excellent guide for the operation." He also said
that intraoperative x-ray examination may be used to confirm how
completely the tumor mass was removed.
The final decision as to the type of surgery that is performed after
neoadju-vant therapy should be made in the operating room. Evaluation
of the tumor regression, examination of the resection margins,
assessment of tumor size in relation to breast size, and assessment
of microcalcifications all need to be taken into account, Dr.
The final caveat concerns chemore-sistant cells. Dr. Veronesi said
that 90% of the patients studied experienced chemo-regression.
However, in the rest of the women, the tumors did not regress and
"In the rare cases of total resistance to chemotherapy, the
condition must be discovered as early as possible so that an
immediate mastectomy can be performed," he said.
The objectives of neoadjuvant chemotherapy are to reduce the extent
of surgery, reduce the risk of local failure, and provide information
for chemosensitivity or a chemoresistant rate of response. Keeping in
mind the above caveats, Dr. Veronesi feels that preoperative
chemotherapy offers an improved therapeutic strategy and, for most
patients, will improve results of breast-conserving surgery when that
is a viable option.