title: Surgery following neoadjuvant chemotherapy for HER2-positive locally advanced breast cancer. Time to reconsider the standard attitude.
abstract: BACKGROUND
  While the addition of targeted therapy to neoadjuvant chemotherapy (NACT) dramatically increases the rate of pathological complete response in HER2-positive breast cancer, no reduction in the rate of mastectomy has been observed in randomised studies.
  
  
  METHODS
  A retrospective single centre analysis of all patients treated with anti HER2-based NACT for T2-4 breast cancer, focusing on patients treated with mastectomy.
  
  
  RESULTS
  Among 165 patients treated between June 2005 and July 2012, surgery was performed immediately post-NACT in 152 cases (92%). Breast-conserving surgery could be performed for 108 of the patients (71%), with a 4-year local relapse-free survival of 97%. A mastectomy was performed in two cases following patients' wishes and in 37 cases based on pre-NACT findings (n = 18) or post-NACT outcomes (n = 19). For 21 out of the 37 cases, a good pathological response was observed, and multidisciplinary reanalysis suggests that breast-conserving surgery outright may have been sufficient for 12 patients. Finally, a salvage mastectomy based on post-lumpectomy pathological results was decided in five cases (11%). The 4-year metastasis-free survival was 84% for all patients operated on after NACT (n = 152).
  
  
  CONCLUSIONS
  Given the good efficacy of anti HER2-based NACT, breast-conserving surgery should be standard practice for most patients. Total mastectomy on the other hand should be restricted to a few patients, mainly those with positive margins on the lumpectomy specimen.
authors.affiliation: Department of Medical Oncology, Institut Bergonié, Bordeaux, France. Electronic address: m.debled@bordeaux.unicancer.fr.
authors.forename: Marc
authors.initials: M
authors.lastname: Debled
authors.affiliation: Department of Pathology, Institut Bergonié, Bordeaux, France.
authors.forename: Gaëtan
authors.initials: G
authors.lastname: MacGrogan
authors.affiliation: Department of Radiotherapy, Institut Bergonié, Bordeaux, France.
authors.forename: Christelle
authors.initials: C
authors.lastname: Breton-Callu
authors.affiliation: Department of Radiology, Institut Bergonié, Bordeaux, France.
authors.forename: Stéphane
authors.initials: S
authors.lastname: Ferron
authors.affiliation: Department of Radiology, Institut Bergonié, Bordeaux, France.
authors.forename: Gabrielle
authors.initials: G
authors.lastname: Hurtevent
authors.affiliation: Department of Surgery, Institut Bergonié, Bordeaux, France.
authors.forename: Marion
authors.initials: M
authors.lastname: Fournier
authors.affiliation: Department of Surgery, Institut Bergonié, Bordeaux, France.
authors.forename: Lionel
authors.initials: L
authors.lastname: Bourdarias
authors.affiliation: Department of Medical Oncology, Institut Bergonié, Bordeaux, France.
authors.forename: Hervé
authors.initials: H
authors.lastname: Bonnefoi
authors.affiliation: Department of Medical Oncology, Institut Bergonié, Bordeaux, France.
authors.forename: Louis
authors.initials: L
authors.lastname: Mauriac
authors.affiliation: Department of Surgery, Institut Bergonié, Bordeaux, France.
authors.forename: Christine
authors.initials: C
authors.lastname: Tunon de Lara
mesh_terms: D000328:Adult; D000368:Aged; D061067:Antibodies, Monoclonal, Humanized / Q000008:administration & dosage; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000627:therapeutic use; D001943:Breast Neoplasms / Q000188:drug therapy* / Q000201:enzymology / Q000473:pathology / Q000601:surgery*; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D008408:Mastectomy; D015412:Mastectomy, Segmental; D008875:Middle Aged; D020360:Neoadjuvant Therapy / Q000379:methods; D009367:Neoplasm Staging; D018719:Erb-b2 Receptor Tyrosine Kinases / Q000096:biosynthesis*; D012189:Retrospective Studies; D000068878:Trastuzumab; D055815:Young Adult
chemical_list: D061067:Antibodies, Monoclonal, Humanized; D018719:Erb-b2 Receptor Tyrosine Kinases; D000068878:Trastuzumab; C508053:ERBB2 protein, human
keywords: Breast; Breast-conserving surgery; HER2; Mastectomy; Neoadjuvant; Trastuzumab