title: Surgical issues surrounding use of aromatase inhibitors.
abstract: There are important surgical issues related to the use of the third generation aromatase inhibitors in both the neoadjuvant and adjuvant settings. Neoadjuvant hormone therapy is effective at downstaging tumours, particularly large tumours initially thought to be inoperable or requiring mastectomy. Randomised trials have shown that the newer aromatase inhibitors letrozole and anastrozole increase the numbers of women who are suitable for breast-conservation compared with tamoxifen, and that letrozole is superior to tamoxifen in terms of clinical response. Aromatase inhibitors are most effective in ER-rich tumours and are clinically and biologically effective in both HER2 positive and negative tumours, whereas HER2 positive tumours show a level of resistance to tamoxifen. In neoadjuvant studies comparing aromatase inhibitors with tamoxifen, the duration of use has been 3-4 months, by which time any response is usually evident but longer treatment periods produce continued shrinkage and response. The re-excision rate following breast conservation surgery after neoadjuvant hormone therapy is favourable compared with the rates following immediate wide local excision. Local recurrence rates are acceptable in patients undergoing neoadjuvant therapy and breast-conserving surgery providing post-operative radiotherapy is given. Adjuvant aromatase inhibitors, as well as having an effect on metastatic disease and survival, reduce local and regional recurrence.
authors: Academic Office, Edinburgh Breast Unit, Western General Hospital, Edinburgh EH4 2XU, Scotland, UK. jmd@ed.ac.uk
authors: J Michael
authors: JM
authors: Dixon
authors: Lorna
authors: L
authors: Renshaw
authors: Juliette
authors: J
authors: Murray
authors: E Jane
authors: EJ
authors: Macaskill
authors: Oliver
authors: O
authors: Young
authors: William R
authors: WR
authors: Miller
mesh_terms: D018931:Antineoplastic Agents, Hormonal / Q000627:therapeutic use*; D047072:Aromatase Inhibitors / Q000627:therapeutic use*; D001943:Breast Neoplasms / Q000188:drug therapy / Q000601:surgery*; D005260:Female; D006801:Humans; D020360:Neoadjuvant Therapy; D009367:Neoplasm Staging; D016032:Randomized Controlled Trials as Topic; D018719:Erb-b2 Receptor Tyrosine Kinases / Q000032:analysis; D016896:Treatment Outcome
chemical_list: D018931:Antineoplastic Agents, Hormonal; D047072:Aromatase Inhibitors; D018719:Erb-b2 Receptor Tyrosine Kinases