Sudan Journal of Medical Sciences (SJMS) | Sudan JMS: Volume 13 (2018), Issue No. 3 | pages: 219–229

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1. Introduction

Neoadjuvant chemotherapy treatment (NACT) is now the standard treatment for locally advanced breast cancer (LABC) in several centers worldwide [1–3]. It reduces the size of the primary tumor, thus offering the option of breast-conserving surgery in patients who couldn't have this advantage before [4]. By down-staging tumors, NACT may likely improve available surgical options.

Numerous randomized clinical trials confirmed the equivalence of Neoadjuvant and adjuvant chemotherapy in terms of disease-free and overall survival rates [5]. Pathological complete response (pCR), which is defined as absence of residual and in-situ disease in the breast and the axillary nodes, has recently emerged as a powerful prognostic marker for overall and disease-free survival following NACT [6,7]. Attaining a pCR after NACT has been shown by several investigators to be a good marker for improved long-term outcome [8–10].

LABC is not a usual presentation among females in the Western world; however, in Sudan, this stage is not only uncommon, but it also more prevalent among younger patients [11].

2. Objectives

This work aimed to assess the short-term response of Sudanese patients with LABC to NACT and its impact on operability and the types of the surgery performed.

3. Patients and Methods

This is a descriptive analytical hospital-based study. A consecutive one hundred forty-seven (147) patients who were presented with LABC to the Plastic and Reconstructive Surgery Unit at Soba University hospital (SUH) from January 2012 to December 2014 were reviewed. They were assessed initially at SUH and then referred to Radio-isotope Center, Khartoum (RICK) for receiving NACT. The study was approved by the Scientific and Research Committee of Soba University hospital (SUH).

LABC is defined as stage IIIA (T0-N2; T1/2-N2; T3-N1/2), stage IIIB (T4, N0-2), and stage IIIC disease (any T, N3). Patient with early breast cancer (stage I/II), metastatic breast cancer (stage IV) proven clinically and/or radiologically and those who haven't had regular follow-up during the study period in both RICK and SUH were excluded from study.

According to the national protocol of Neoadjuvant chemotherapy, the aim of the treatment was standardized. For patients with operable lesions and not suitable for breast conserving surgery (BCS), the chemotherapy was delivered until BCS could be performed. For patients with inoperable lesions, the chemotherapy was delivered until curative surgery could be achieved.

The clinical response was assessed at the start, after each two cycles and at the end of the treatment to document and classify the response. Assessment of the clinical response was based on Union for International Cancer control (UICC) criteria with definitions as follows: complete response (CR) = complete clinical resolution of tumor; partial response (PR) = 50% or greater diminution of bi-dimensional tumor; minimal response (MR) = 25% to 50% diminution of tumor; stable disease (SD) = no more than 25% increase or decrease in tumor size; progressive disease (PD) = more than 25% increase in tumor [12].

The pathological response was also assessed. Complete pCR was defined as a complete disappearance of invasive breast cancer in the final histological specimen of the primary tumor. Partial pathological response was defined as a reduction of more than 50% of the initial tumor size, whereas stable pathological disease was defined as a reduction of less than 50% of the initial tumor size, and progressive disease was defined as any increase in initial tumor size during cycles of chemotherapy [12]. Data were processed and analyzed using the SPSS software package (version 21 windows). To determine the statistical significance of differences, the Pearson test was used and probability test (P-value) with p< 0.05 was considered as significant at 95% confidence interval.

4. Results

One hundred forty-seven (147) patients receiving neoadjuvant chemotherapy for LABC were reviewed. All were females, the mean age of the patients at the time of diagnosis was 43 ± 7 years and 79 patients (53.7%) were pre-menopausal. More than half of the patients (51%) were presented with a breast lump, 29(19.7%) patients had nipple discharge as a chief complaint, whereas 28(19.0%) were presented initially with skin changes and ulcers and 15 patients (10.2%) were presented primarily with axillary changes and swelling. The mean tumor diameter measured clinically before neoadjuvant chemotherapy was 7 ± 3 cm (range 3–15 cm). Tumor stage and nodal status were summarized in (Tables 1 and 2, respectively). No association was found between age and tumor size (P = 0.11); however, a significant association was observed between age and nodal status (P = 0.0002) with 53% of those aging more than 45 years having a late nodal stage (N2 and N3). Regarding histopathological type of the tumors, 132 patients (88.2%) had invasive ductal carcinoma (IDC) and only 15 patients had invasive lobular carcinoma. Other less common histopathological variants were not reported in this series. Estrogen receptors (ER) showed positivity in 80 patients (54.4%) with 55(68.8%) of those with positive ER being below 45 years of age, and progesterone receptors being positive in 78 patients (45%).

Based on clinical evaluation and echocardiographic findings, patients were classified into three groups. Group A consisted of 52 patients who received 5-Fluorouracil 500mg/m2 I.V, Adiramycin (Doxorubicin) 50mg/m2 I.V, and Cyclophosphamide 500mg/m2 (FAC) for six cycles on a 21-day period, followed by Paclitoxel800 mg/m2 for 12 weeks; group B includes 47 patients who were treated with the 5-Flurouracil 500mg/m2 I.V, epirubricin90mg/m2 I.V, and Cyclophosamide 600mg/m2 (FEC) for four cycles with three weeks off, and then they received Paclitaxel 100mg/m2 for six weeks; group C were patients who received doxorubicin 600mg/m2 Cyclophosamide 600mg/m2 I.V and Taxanes (Doxetaxel) 100mg/m2(TAC) regimen and included patients with cardiac diseases based on echocardiography reports in whom other regimens were contraindicated. In addition, Prednisolone, antiemetic, and antibiotics were given when they were clinically indicated.

Thirty (20.4%) patients achieved a clinical complete response (CR). Complete clinical response (CR) was associated significantly with initial tumor sizes; 56.7% of CR was achieved in patients with tumor stages (T1 and T2 with tumor size < 5 cm). Partial response was observed in 92 (62.6%) patients, while static response was achieved in 20 (13.6%) patients, and five (3.4%) patients had developed a progressive disease (Table 3). Clinical response was not found to be affected by the age and tumor histopathology type. Complete pathological response (pCR) was achieved in 25 (17%) patients in whom no residual disease was seen in postoperative pathological specimens. A significant association was found between pCR and nodal disease and negativity of ER (P< 0.001 in both) (Table 4).

Table 1

Relation between age with initial tumor size (T stage) (n = 147).


Age (years) Initial tumor Size (T stage)*
T1 T2 T3 T4 Total
< 35 1 4 16 5 26
35–45 0 10 21 21 52
> 45 2 13 41 13 69
Total 3 27 78 39 147
Note: *P = 0.11 (> 0.05).
Table 2

Relation between age with nodal status (N stage) (n = 147).


Age (years) Nodal status (N stage)*
N0 N1 N2 N3 Total
< 35 0 13 6 7 26
35–45 7 6 32 7 52
> 45 3 29 28 9 69
Total 10 48 66 23 147
Note: *P = 0.0002 (< 0.05).
Table 3

Association between clinical response and initial tumor size (T stage) (n = 147).


Clinical Response
Complete Partial Stable Progressive Total
Initial tumor size (in cm)* T1 < 2 2 1 0 0 3
T2 2–5 15 10 2 0 17
T3 > 5 12 57 9 0 78
T4 (any size, skin/chest involvement) 1 24 9 5 39
Total 30 92 20 5 147
Note: *P< 0.001.
Table 4

Association between pathological complete response (pCR) and nodal status and ER status (n = 147).


Pathological Response
Complete Partial Stable Total
Nodal Status* N0 7 3 0 10
N1 10 32 6 48
N2 5 58 3 66
N3 3 16 4 23
Total 25 109 13 147
ER Status** Positive 3 72 6 83
Negative 22 37 7 64
Total 25 109 13 147
Note: *P< 0.001; **P< 0.001.

The type of chemotherapy regimen used was neither found to affect clinical response nor pathological response (P-values were 0.196 and 0.087. respectively).

Following NACT, BCS was performed in 78 patients (53.1%) who had sufficient reduction to allow BCS, while 64 (43.5%) patients had modified radical mastectomy, and in 25 patients (39.1%) Latissimus Dorsi flap (LD) was used to close the defect following mastectomy, myo-cutaneous flap in 16 patients and muscle flap in 9 patients. A curative surgery could not be achieved in five patients who had developed a progressive disease during the course of neoadjuvant therapy. Hormonal therapy was given to all patients with positive ER receptors.

5. Discussion

NACT permits breast conservation in some patients who would otherwise require mastectomy [12]. The median age of patients in this study was 43 years and 42% of the patients were premenopausal, which is comparable to other reports [13–15].

The average number of NACT cycles ranged from four to six cycles depending on patient's response. However, the literature reported considerable variations in numbers of cycles of chemotherapy that are usually given in neoadjuvant setting [16,17]. Three regimens of NACT were employed in this study. However, both clinical and pathological responses were not found to be affected by the type of regimen used (P-values are 0.196 and 0.087, respectively); this is similar to many series [18,19], in contradiction to others that showed a better response with Taxanes-based regimens [20,21].

Complete pathological response (pCR) was achieved in 17%, which is in the range of other series [18,22], although significant variations exist in pCR values in the literature ranging from 4% to 40% [23–25]. These variations could be attributable to the use of different chemotherapy regimens and or the ethnical and racial differences [26,27]. Age and family history were not associated with complete pathological response in this series, which is in line with what was reported in the previous studies [28–30]. On the other hand, the authors found an association between the nodal stage and pCR (P< 0.001) as the late nodal disease (N2, N3) was associated with poor pathological response, a finding which is similar to what was found by many other workers [30,31].

Complete clinical response (CR) was achieved in 20.4% of the patients; it was significantly associated with initial tumor size (T stage) as 56.7% of complete clinical response was observed among patients with an initial tumor size of less than 5 cm (T1 and T2) (P = 0.001). These findings are in agreement with previous reports that proved better clinical responses with smaller tumors [27,29]. Clinical response was not found to be affected by the age and tumor histopathology type which is comparable to the previous series [29,30].

Estrogen receptor (ER) status was associated with a better pCR, as 65% of patients with pCR had a negative ER (P< 0.001) in keeping with previous reports [31,32]; however, this finding disagrees with other reports that found a better pCR with ER-positive tumors [13]. Nevertheless, there is an evidence to suggest that ER-negative tumors are more likely to achieve better pCR, following NACT in comparison to ER-positive ones, as an inverse relationship exists between ER expression and tumor proliferation; with ER-positive cancers showing a low proliferation rate, whereas ER-negative breast cancers having a high proliferation rate, which is correlated with a better short-term response to NACT [29,30].

Seventy-eight (53.1%) patients had achieved a sufficient clinical down-staging to allow BCS; these results are quite comparable with other international reports [33–35], but higher than that reported previously in one study from Sudan (33.3%) [13]. In fact, the literature has reported different rates of BCS after NACT ranging from 16% to 80% [15]. These variations could be attributable to the differences in the types of chemotherapy regimens used, the studied population, and the study designs [36]. Nevertheless, there are certain factors that predict eligibility of a conserving surgery after NACT, with the tumor size being the most important one [37]. It is interesting to note that some workers have designed validated nomograms to predict the probability of residual tumor size and eligibility for a conserving surgery after NACT; these nomograms would be useful when counseling patients about treatment options [37].

To appreciate the findings of this study, some limitations have to be addressed; the authors had a short-term follow-up period so they could not assess the mid- and long-term effects of NACT. Besides, the study was conducted in only one center, and further prospective multi-center studies are recommended to ascertain the findings of this study.

6. Conclusion

NACT has shown satisfactory short-term results in Sudanese patients with LABC as it can reduce the tumor size rendering initially inoperable tumors to be operable, and it can also increase the chance of BCS in other patients with operable tumors that were initially not suitable for conserving surgery. Further studies to assess the long-term effects of NACT on disease recurrence and survival rates are recommended.

Conflict of Interest

None declared

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

References

1 

Redden M. H., Fuhrman G. M., Neoadjuvant Chemotherapy in the Treatment of Breast Cancer, Surgical Clinics of North America, Year: 2013, Volume: 93, Issue: 2, Page: 493-499. DOI: 10.1016/j.suc.2013.01.006

2 

Mieog J. S. D., Van Der Hage J. A., Van De Velde C. J. H., Neoadjuvant chemotherapy for operable breast cancer, British Journal of Surgery, Year: 2007, Volume: 94, Issue: 10, Page: 1189-1200. DOI: 10.1002/bjs.5894

3 

Untch M., Konecny G. E., Paepke S., von Minckwitz G., Current and future role of neoadjuvant therapy for breast cancer, The Breast Journal, Year: 2014, Volume: 23, Issue: 5, Page: 526-537. DOI: 10.1016/j.breast.2014.06.004

4 

Fisher B., Brown A., Mamounas E., Wieand S., Robidoux A., Margolese R. G., Cruz A. B.Jr., Fisher E. R., Wickerham D. L., Wolmark N., DeCillis A., Hoehn J. L., Lees A. W., Dimitrov N. V., Effect of preoperative chemotherapy on local-regional disease in women with operable breast cancer: Findings from national surgical adjuvant breast and bowel project B-18, Journal of Clinical Oncology, Year: 1997, Volume: 15, Issue: 7, Page: 2483-2493. DOI: 10.1200/JCO.1997.15.7.2483

5 

Mauri D., Pavlidis N., Ioannidis J. P., RESPONSE: Re: Neoadjuvant Versus Adjuvant Systemic Treatment in Breast Cancer: A Meta-Analysis, JNCI: Journal of the National Cancer Institute, Year: 2005, Volume: 97, Issue: 11, Page: 858-859. DOI: 10.1093/jnci/dji148

6 

Becker J. M., Dayton M. T., Fazio V. W., Beck D. E., Stryker S. J., Wexner S. D., Wolff B. G., Roberts P. L., Smith L. E., Sweeney S. A., Moore M., Prevention of postoperative abdominal adhesions by a sodium hyaluronate-based bioresorbable membrane: a prospective, randomized, double-blind multicenter study, Journal of the American College of Surgeons, Year: 1996, Volume: 183, Issue: 4, Page: 297-306.

7 

Kuerer H. M., Newman L. A., Smith T. L., Ames F. C., Hunt K. K., Dhingra K., Theriault R. L., Singh G., Binkley S. M., Sneige N., Buchholz T. A., Ross M. I., McNeese M. D., Buzdar A. U., Hortobagyi G. N., Singletary S. E., Clinical Course of Breast Cancer Patients With Complete Pathologic Primary Tumor and Axillary Lymph Node Response to Doxorubicin-Based Neoadjuvant Chemotherapy, Journal of Clinical Oncology, Year: 1999, Volume: 17, Issue: 2, Page: 460-460. DOI: 10.1200/JCO.1999.17.2.460

8 

Feldman L. D., Hortobagyi G. N., Buzdar A. U., Ames F. C., Blumenschein G. R., Pathological Assessment of Response to Induction Chemotherapy in Breast Cancer, Cancer Research, Year: 1986, Volume: 46, Issue: 5, Page: 2578-2581.

9 

Kennedy S., Merino M. J., Swain S. M., Lippman M. E., The effects of hormonal and chemotherapy on tumoral and nonneoplastic breast tissue, Human Pathology, Year: 1990, Volume: 21, Issue: 2, Page: 192-198. DOI: 10.1016/0046-8177(90)90128-R

10 

Gilks C. B., Correspondence re: Sharkey FE, Addington SL, Fowler LJ, Page CP. Effects of preoperative chemotherapy on the morphology of resectable breast carcinoma. Mod Pathol 1996;9:893-900., Modern pathology : an official journal of the United States and Canadian Academy of Pathology, Inc, Year: 1997, Volume: 10, Issue: 2, Page: 155-156.

11 

Elgaili E. M., Abuidris D. O., Rahman M., Michalek A. M., Mohammed S. I., Breast cancer burden in central Sudan, International Journal of Women's Health, Year: 2010, Volume: 2, Issue: 1, Page: 77-82.

12 

Cance W. G., Carey L. A., Calvo B. F., Sartor C., Sawyer L., Moore D. T., Rosenman J., Ollila D. W., Graham M.II, Long-term outcome of neoadjuvant therapy for locally advanced breast carcinoma: Effective clinical downstaging allows breast preservation and predicts outstanding local control and survival, Annals of Surgery, Year: 2002, Volume: 236, Issue: 3, Page: 295-303. DOI: 10.1097/00000658-200209000-00006

13 

Alawad A. A. M., Evaluation of clinical and pathological response after two cycles of neoadjuvant chemotherapy on Sudanese patients with locally advanced breast cancer., Ethiopian Journal of Health Sciences, Year: 2014, Volume: 24, Issue: 1, Page: 15-20. DOI: 10.4314/ejhs.v24i1.2

14 

Fisher B., Bryant J., Wolmark N., Mamounas E., Brown A., Fisher E. R., Wickerham D. L., Begovic M., DeCillis A., Robidoux A., Margolese R. G., Cruz A. B., Hoehn J. L., Lees A. W., Dimitrov N. V., Bear H. D., Effect of preoperative chemotherapy on the outcome of women with operable breast cancer., Journal of Clinical Oncology, Year: 1998, Volume: 16, Issue: 8, Page: 2672-2685. DOI: 10.1200/JCO.1998.16.8.2672

15 

Yadav B. S., Sharma S. C., Singh R., Singh G., Patterns of relapse in locally advanced breast cancer treated with neoadjuvant chemotherapy followed by surgery and radiotherapy, Journal of Cancer Research and Therapeutics, Year: 2007, Volume: 3, Issue: 2, Page: 75-80. DOI: 10.4103/0973-1482.34683

16 

Chen A. M., Meric-Bernstam F., Hunt K. K., Thames H. D., Oswald M. J., Outlaw E. D., Strom E. A., McNeese M. D., Kuerer H. M., Ross M. I., Singletary S. E., Ames F. C., Feig B. W., Sahin A. A., Perkins G. H., Schechter N. R., Hortobagyi G. N., Buchholz T. A., Breast conservation after neoadjuvant chemotherapy: The M.D. Anderson cancer center experience, Journal of Clinical Oncology, Year: 2004, Volume: 22, Issue: 12, Page: 2303-2312. DOI: 10.1200/JCO.2004.09.062

17 

Rustogi A., Budrukkar A., Dinshaw K., Jalali R., Management of locally advanced breast cancer: Evolution and current practice, Journal of Cancer Research and Therapeutics, Year: 2005, Volume: 1, Issue: 1, Page: 21-30. DOI: 10.4103/0973-1482.16086

18 

Bear H. D., Anderson S., Smith R. E., Geyer C. E.Jr., Mamounas E. P., Fisher B., Brown A. M., Robidoux A., Margolese R., Kahlenberg M. S., Paik S., Soran A., Wickerham D. L., Wolmark N., Sequential preoperative or postoperative docetaxel added to preoperative doxorubicin plus cyclophosphamide for operable breast cancer: National surgical adjuvant breast and bowel project protocol B-27, Journal of Clinical Oncology, Year: 2006, Volume: 24, Issue: 13, Page: 2019-2027. DOI: 10.1200/JCO.2005.04.1665

19 

Veronesi U., Bonadonna G., Zurrida S., Galimberti V., Greco M., Brambilla C., Luini A., Andreola S., Rilke F., Raselli R., Merson M., Sacchini V., Agresti R., Conservation surgery after primary chemotherapy in large carcinomas of the breast, Annals of Surgery, Year: 1995, Volume: 222, Issue: 5, Page: 612-618. DOI: 10.1097/00000658-199511000-00002

20 

Diéras V., Fumoleau P., Romieu G., Tubiana-Hulin M., Namer M., Mauriac L., Guastalla J.-P., Pujade-Lauraine E., Kerbrat P., Maillart P., Pénault-Llorca F., Buyse M., Pouillart P., Randomized parallel study of doxorubicin plus paclitaxel and doxorubicin plus cyclophosphamide as neoadjuvant treatment of patients with breast cancer, Journal of Clinical Oncology, Year: 2004, Volume: 22, Issue: 24, Page: 4958-4965. DOI: 10.1200/JCO.2004.02.122

21 

Heys S. D., Hutcheon A. W., Sarkar T. K., Ogston K. N., Miller I. D., Payne S., Smith I., Walker L. G., Eremin O., Neoadjuvant docetaxel in breast cancer: 3-year survival results from the Aberdeen trial, Clinical Breast Cancer, Year: 2002, Volume: 3, Issue: 2, Page: S69-S74. DOI: 10.3816/CBC.2002.s.015

22 

Min S. Y., Lee S. J., Shin K. H., Park I. H., Jung S.-Y., Lee K. S., Ro J., Lee S., Kim S. W., Kim T. H., Kang H.-S., Cho K. H., Locoregional recurrence of breast cancer in patients treated with breast conservation surgery and radiotherapy following neoadjuvant chemotherapy, International Journal of Radiation Oncology • Biology • Physics, Year: 2011, Volume: 81, Issue: 5, Page: e697-e705. DOI: 10.1016/j.ijrobp.2010.10.014

23 

Guarneri V., Broglio K., Kau S., Cristofanilli M., Buzdar A. U., Valero V., Buchholz T., Meric F., Middleton L., Hortobagyi G. N., Gonzalez-Angulo A. M., Prognostic Value of Pathologic Complete Response After Primary Chemotherapy in Relation to Hormone Receptor Status and Other Factors, Journal of Clinical Oncology, Year: 2006, Volume: 24, Issue: 7, Page: 1037-1044. DOI: 10.1200/JCO.2005.02.6914

24 

Singletary S. E., McNeese M. D., Hortobagyi G. N., Feasibility of breast‐conservation surgery after induction chemotherapy for locally advanced breast carcinoma, Cancer, Year: 1992, Volume: 69, Issue: 11, Page: 2849-2852. DOI: 10.1002/1097-0142(19920601)69:11<2849::AID-CNCR2820691134>3.0.CO;2-P

25 

Parmar V., Krishnamurthy A., Hawaldar R., Nadkarni M. S., Sarin R., Chinoy R., Nair R., Dinshaw K. A., Badwe R. A., Breast conservation treatment in women with locally advanced breast cancer - Experience from a single centre, International Journal of Surgery, Year: 2006, Volume: 4, Issue: 2, Page: 106-114. DOI: 10.1016/j.ijsu.2006.01.004

26 

Woodward W. A., Huang E. H., McNeese M. D., Perkins G. H., Tucker S. L., Strom E. A., Middleton L., Hahn K., Hortobagyi G. N., Buchholz T. A., African-American race is associated with a poorer overall survival rate for breast cancer patients treated with mastectomy and doxorubicin-based chemotherapy, Cancer, Year: 2006, Volume: 107, Issue: 11, Page: 2662-2668. DOI: 10.1002/cncr.22281

27 

Machiavelli M. R., Romero A. O., Pérez J. E., Prognostic significance of pathological response of primary tumor and metastatic axillary lymph nodes after neoadjuvant chemotherapy for locally advanced breast carcinoma, The Cancer Journal From Scientific American Article Archives, Year: 1998, Volume: 4, Issue: 2, Page: 125-131.

28 

Kuerer H. M., Newman L. A., Smith T. L., Ames F. C., Hunt K. K., Dhingra K., Theriault R. L., Singh G., Binkley S. M., Sneige N., Buchholz T. A., Ross M. I., McNeese M. D., Buzdar A. U., Hortobagyi G. N., Singletary S. E., Clinical course of breast cancer patients with complete pathologic primary tumor and axillary lymph node response to doxorubicin-based neoadjuvant chemotherapy, Journal of Clinical Oncology, Year: 1999, Volume: 17, Issue: 2, Page: 460-469. DOI: 10.1200/JCO.1999.17.2.460

29 

Jones R. L., Salter J., A’Hern R., Nerurkar A., Parton M., Reis-Filho J. S., Smith I. E., Dowsett M., Relationship between oestrogen receptor status and proliferation in predicting response and long-term outcome to neoadjuvant chemotherapy for breast cancer, Breast Cancer Research and Treatment, Year: 2010, Volume: 119, Issue: 2, Page: 315-323. DOI: 10.1007/s10549-009-0329-x

30 

Newman L. A., Management of patients with locally advanced breast cancer, Current Oncology Reports, Year: 2004, Volume: 6, Issue: 1, Page: 53-61. DOI: 10.1007/s11912-996-0010-z

31 

Darb-Esfahani S., Loibl S., Müller B. M., Roller M., Denkert C., Komor M., Schlüns K., Blohmer J. U., Budczies J., Gerber B., Noske A., du Bois A., Weichert W., Jackisch C., Dietel M., Richter K., Kaufmann M., von Minckwitz G., Identification of biology-based breast cancer types with distinct predictive and prognostic features: role of steroid hormone and HER2 receptor expression in patients treated with neoadjuvant anthracycline/taxane-based chemotherapy, Breast Cancer Research, Year: 2009, Volume: 11, Issue: 5, DOI: 10.1186/bcr2363

32 

McCready D. R., Hortobagyi G. N., Kau S. W., Smith T. L., Buzdar A. U., Balch C. M., The Prognostic Significance of Lymph Node Metastases After Preoperative Chemotherapy for Locally Advanced Breast Cancer, JAMA Surgery, Year: 1989, Volume: 124, Issue: 1, Page: 21-25. DOI: 10.1001/archsurg.1989.01410010027005

33 

Botti C., Vici P., Lopez M., Scinto A. F., Cognetti F., Cavaliere R., Prognostic value of lymph node metastases after neoadjuvant chemotherapy for large-sized operable carcinoma of the breast, Journal of the American College of Surgeons, Year: 1995, Volume: 181, Issue: 3, Page: 202-208.

34 

Newman L. A., Buzdar A. U., Eva Singletary S., Kuerer H. M., Buchholz T., Ames F. C., Ross M. I., Hunt K. K., A prospective trial of preoperative chemotherapy in resectable breast cancer: Predictors of breast-conservation therapy feasibility, Annals of Surgical Oncology, Year: 2002, Volume: 9, Issue: 3, Page: 228-234. DOI: 10.1007/BF02573059

35 

Bhattacharyya T., Sharma S., Yadav B., Singh R., Singh G., Outcome of neoadjuvant chemotherapy in locally advanced breast cancer: A tertiary care centre experience, Indian Journal of Medical and Paediatric Oncology, Year: 2014, Volume: 35, Issue: 3, Page: 215-220. DOI: 10.4103/0971-5851.142038

36 

Vlastos G., Mirza N. Q., Lenert J. T., Hunt K. K., Ames F. C., Feig B. W., Ross M. I., Buzdar A. U., Singletary S. E., The feasibility of minimally invasive surgery for stage IIA, IIB, and IIIA breast carcinoma patients after tumor downstaging with induction chemotherapy, Cancer, Year: 2000, Volume: 88, Issue: 6, Page: 1417-1424. DOI: 10.1002/(SICI)1097-0142(20000315)88:6&lt;1417::AID-CNCR20>3.0.CO;2-1

37 

Rouzier R., Pusztai L., Garbay J.-R., Delaloge S., Hunt K. K., Hortobagyi G. N., Berry D., Kuerer H. M., Development and validation of nomograms for predicting residual tumor size and the probability of successful conservative surgery with neoadjuvant chemotherapy for breast cancer, Cancer, Year: 2006, Volume: 107, Issue: 7, Page: 1459-1466. DOI: 10.1002/cncr.22177

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