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Locally Advanced Breast Cancer
Jessica W. T. Leung, MD; Wei Tse Yang, MBBS
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Pathology

          • Clinical Issues

            TERMINOLOGY

            • Abbreviations

              • Locally advanced breast cancer (LABC)
            • Definitions

              • LABC: Stage III breast cancer, excluding inflammatory breast cancer (reported separately due to distinct clinical presentation/behavior)
                • T3: Primary invasive tumor > 5 cm
                • T4: Tumor any size with direct extension to skin &/or chest wall; invasion of dermis alone does not qualify as T4 (requires skin ulceration &/or skin nodules)
                • N2: Matted axillary nodes; ipsilateral internal mammary nodes in absence of axillary metastasis
                • N3: Ipsilateral metastatic infra- or supraclavicular nodes or clinically apparent (includes imaging) internal mammary nodes and axillary nodes
                • Anatomic stage IIIA: T0-2N2M0 or T3N1-2M0
                • Anatomic stage IIIB: T4N0-2M0
                • Prognostic staging considers tumor grade and receptor status, may better predict outcome
              • Chest wall invasion: Serratus anterior &/or intercostal muscle invasion
                • Pectoralis muscle invasion should be reported but is not classified as chest wall invasion

            IMAGING

            • General Features

              • Mammographic Findings

                • Ultrasonographic Findings

                  • MR Findings

                    • Nuclear Medicine Findings

                      • Image-Guided Biopsy

                        • Imaging Recommendations

                          DIFFERENTIAL DIAGNOSIS

                            PATHOLOGY

                            • General Features

                              • Staging, Grading, & Classification

                                • Gross Pathologic & Surgical Features

                                  CLINICAL ISSUES

                                  • Presentation

                                    • Demographics

                                      • Natural History & Prognosis

                                        • Treatment

                                          DIAGNOSTIC CHECKLIST

                                          • Consider

                                            • Image Interpretation Pearls

                                              Selected References

                                              1. Pan H et al: Palliative local surgery for locally advanced breast cancer depending on hormone receptor status in elderly patients. Clin Breast Cancer. 19(1):e247-e260, 2019
                                              2. Altundag K: Locally advanced non-inflammatory breast cancer may be misdiagnosed as inflammatory breast cancer. Eur J Surg Oncol. 44(8):1280, 2018
                                              3. Everett AS et al: The evolving role of postmastectomy radiation therapy. Surg Clin North Am. 98(4):801-17, 2018
                                              4. Gajjala SR et al: Whole-body 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET/CT) for staging locally advanced breast cancer: a prospective study from a tertiary cancer centre in south India. Indian J Med Res. 147(3):256-62, 2018
                                              5. Tanić M et al: Molecular signature of response to preoperative radiotherapy in locally advanced breast cancer. Radiat Oncol. 13(1):193, 2018
                                              6. Vondeling GT et al: Burden of early, advanced and metastatic breast cancer in The Netherlands. BMC Cancer. 18(1):262, 2018
                                              7. Wang M et al: Evaluation of the prognostic stage in the 8th edition of the American Joint Committee on Cancer in locally advanced breast cancer: An analysis based on SEER 18 database. Breast. 37:56-63, 2018
                                              8. Yee C et al: Radiotherapy for patients with unresected locally advanced breast cancer. Ann Palliat Med. 7(4):373-84, 2018
                                              9. Grimm LJ et al: Can breast cancer molecular subtype help to select patients for preoperative MR imaging? Radiology. 274(2):352-8, 2015
                                              10. Mazilu L et al: Optimizing the indication for breast-conservative surgery (BCS) in patients with locally-advanced breast cancer. Chirurgia (Bucur). 108(4):478-81, 2013
                                              11. Berg WA et al: Breast cancer: comparative effectiveness of positron emission mammography and MR imaging in presurgical planning for the ipsilateral breast. Radiology. 258(1):59-72, 2011
                                              12. Edge SB et al: AJCC Cancer Staging Handbook. 7th ed. New York: Springer, 2011
                                              13. Loo CE et al: Magnetic resonance imaging response monitoring of breast cancer during neoadjuvant chemotherapy: relevance of breast cancer subtype. J Clin Oncol. 29(6):660-6, 2011
                                              14. Niikura N et al: Initial staging impact of fluorodeoxyglucose positron emission tomography/computed tomography in locally advanced breast cancer. Oncologist. 16(6):772-82, 2011
                                              15. Prat A et al: Practical implications of gene-expression-based assays for breast oncologists. Nat Rev Clin Oncol. 9(1):48-57, 2011
                                              16. Chung A et al: Axillary staging in the neoadjuvant setting. Ann Surg Oncol. 17(9):2401-10, 2010
                                              17. Partridge SC et al: Association between serial dynamic contrast-enhanced MRI and dynamic 18F-FDG PET measures in patients undergoing neoadjuvant chemotherapy for locally advanced breast cancer. J Magn Reson Imaging. 32(5):1124-31, 2010
                                              18. Zhang YJ et al: Clinically apparent internal mammary nodal metastasis in patients with advanced breast cancer: incidence and local control. Int J Radiat Oncol Biol Phys. 77(4):1113-9, 2010
                                              19. Whitman GJ et al: Workup and staging of locally advanced breast cancer. Semin Radiat Oncol. 19(4):211-21, 2009
                                              20. Houssami N et al: Accuracy and surgical impact of magnetic resonance imaging in breast cancer staging: systematic review and meta-analysis in detection of multifocal and multicentric cancer. J Clin Oncol. 26(19):3248-58, 2008
                                              21. Newman EA et al: Sentinel lymph node biopsy performed after neoadjuvant chemotherapy is accurate in patients with documented node-positive breast cancer at presentation. Ann Surg Oncol. 14(10):2946-52, 2007
                                              22. Rosen EL et al: FDG PET, PET/CT, and breast cancer imaging. Radiographics. 27 Suppl 1:S215-29, 2007
                                              23. Rouzier R et al: Breast cancer molecular subtypes respond differently to preoperative chemotherapy. Clin Cancer Res. 11(16):5678-85, 2005
                                              24. Berg WA et al: Diagnostic accuracy of mammography, clinical examination, US, and MR imaging in preoperative assessment of breast cancer. Radiology. 233(3):830-49, 2004
                                              25. Londero V et al: Locally advanced breast cancer: comparison of mammography, sonography and MR imaging in evaluation of residual disease in women receiving neoadjuvant chemotherapy. Eur Radiol. 14(8):1371-9, 2004
                                              26. Lønning PE et al: Microarrays in primary breast cancer--lessons from chemotherapy studies. Endocr Relat Cancer. 8(3):259-63, 2001
                                              27. Herrada J et al: Relative value of physical examination, mammography, and breast sonography in evaluating the size of the primary tumor and regional lymph node metastases in women receiving neoadjuvant chemotherapy for locally advanced breast carcinoma. Clin Cancer Res. 3(9):1565-9, 1997
                                              Related Anatomy
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                                              Related Differential Diagnoses
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                                              References
                                              Tables

                                              Tables

                                              KEY FACTS

                                              • Terminology

                                                • Imaging

                                                  • Top Differential Diagnoses

                                                    • Pathology

                                                      • Clinical Issues

                                                        TERMINOLOGY

                                                        • Abbreviations

                                                          • Locally advanced breast cancer (LABC)
                                                        • Definitions

                                                          • LABC: Stage III breast cancer, excluding inflammatory breast cancer (reported separately due to distinct clinical presentation/behavior)
                                                            • T3: Primary invasive tumor > 5 cm
                                                            • T4: Tumor any size with direct extension to skin &/or chest wall; invasion of dermis alone does not qualify as T4 (requires skin ulceration &/or skin nodules)
                                                            • N2: Matted axillary nodes; ipsilateral internal mammary nodes in absence of axillary metastasis
                                                            • N3: Ipsilateral metastatic infra- or supraclavicular nodes or clinically apparent (includes imaging) internal mammary nodes and axillary nodes
                                                            • Anatomic stage IIIA: T0-2N2M0 or T3N1-2M0
                                                            • Anatomic stage IIIB: T4N0-2M0
                                                            • Prognostic staging considers tumor grade and receptor status, may better predict outcome
                                                          • Chest wall invasion: Serratus anterior &/or intercostal muscle invasion
                                                            • Pectoralis muscle invasion should be reported but is not classified as chest wall invasion

                                                        IMAGING

                                                        • General Features

                                                          • Mammographic Findings

                                                            • Ultrasonographic Findings

                                                              • MR Findings

                                                                • Nuclear Medicine Findings

                                                                  • Image-Guided Biopsy

                                                                    • Imaging Recommendations

                                                                      DIFFERENTIAL DIAGNOSIS

                                                                        PATHOLOGY

                                                                        • General Features

                                                                          • Staging, Grading, & Classification

                                                                            • Gross Pathologic & Surgical Features

                                                                              CLINICAL ISSUES

                                                                              • Presentation

                                                                                • Demographics

                                                                                  • Natural History & Prognosis

                                                                                    • Treatment

                                                                                      DIAGNOSTIC CHECKLIST

                                                                                      • Consider

                                                                                        • Image Interpretation Pearls

                                                                                          Selected References

                                                                                          1. Pan H et al: Palliative local surgery for locally advanced breast cancer depending on hormone receptor status in elderly patients. Clin Breast Cancer. 19(1):e247-e260, 2019
                                                                                          2. Altundag K: Locally advanced non-inflammatory breast cancer may be misdiagnosed as inflammatory breast cancer. Eur J Surg Oncol. 44(8):1280, 2018
                                                                                          3. Everett AS et al: The evolving role of postmastectomy radiation therapy. Surg Clin North Am. 98(4):801-17, 2018
                                                                                          4. Gajjala SR et al: Whole-body 18F-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET/CT) for staging locally advanced breast cancer: a prospective study from a tertiary cancer centre in south India. Indian J Med Res. 147(3):256-62, 2018
                                                                                          5. Tanić M et al: Molecular signature of response to preoperative radiotherapy in locally advanced breast cancer. Radiat Oncol. 13(1):193, 2018
                                                                                          6. Vondeling GT et al: Burden of early, advanced and metastatic breast cancer in The Netherlands. BMC Cancer. 18(1):262, 2018
                                                                                          7. Wang M et al: Evaluation of the prognostic stage in the 8th edition of the American Joint Committee on Cancer in locally advanced breast cancer: An analysis based on SEER 18 database. Breast. 37:56-63, 2018
                                                                                          8. Yee C et al: Radiotherapy for patients with unresected locally advanced breast cancer. Ann Palliat Med. 7(4):373-84, 2018
                                                                                          9. Grimm LJ et al: Can breast cancer molecular subtype help to select patients for preoperative MR imaging? Radiology. 274(2):352-8, 2015
                                                                                          10. Mazilu L et al: Optimizing the indication for breast-conservative surgery (BCS) in patients with locally-advanced breast cancer. Chirurgia (Bucur). 108(4):478-81, 2013
                                                                                          11. Berg WA et al: Breast cancer: comparative effectiveness of positron emission mammography and MR imaging in presurgical planning for the ipsilateral breast. Radiology. 258(1):59-72, 2011
                                                                                          12. Edge SB et al: AJCC Cancer Staging Handbook. 7th ed. New York: Springer, 2011
                                                                                          13. Loo CE et al: Magnetic resonance imaging response monitoring of breast cancer during neoadjuvant chemotherapy: relevance of breast cancer subtype. J Clin Oncol. 29(6):660-6, 2011
                                                                                          14. Niikura N et al: Initial staging impact of fluorodeoxyglucose positron emission tomography/computed tomography in locally advanced breast cancer. Oncologist. 16(6):772-82, 2011
                                                                                          15. Prat A et al: Practical implications of gene-expression-based assays for breast oncologists. Nat Rev Clin Oncol. 9(1):48-57, 2011
                                                                                          16. Chung A et al: Axillary staging in the neoadjuvant setting. Ann Surg Oncol. 17(9):2401-10, 2010
                                                                                          17. Partridge SC et al: Association between serial dynamic contrast-enhanced MRI and dynamic 18F-FDG PET measures in patients undergoing neoadjuvant chemotherapy for locally advanced breast cancer. J Magn Reson Imaging. 32(5):1124-31, 2010
                                                                                          18. Zhang YJ et al: Clinically apparent internal mammary nodal metastasis in patients with advanced breast cancer: incidence and local control. Int J Radiat Oncol Biol Phys. 77(4):1113-9, 2010
                                                                                          19. Whitman GJ et al: Workup and staging of locally advanced breast cancer. Semin Radiat Oncol. 19(4):211-21, 2009
                                                                                          20. Houssami N et al: Accuracy and surgical impact of magnetic resonance imaging in breast cancer staging: systematic review and meta-analysis in detection of multifocal and multicentric cancer. J Clin Oncol. 26(19):3248-58, 2008
                                                                                          21. Newman EA et al: Sentinel lymph node biopsy performed after neoadjuvant chemotherapy is accurate in patients with documented node-positive breast cancer at presentation. Ann Surg Oncol. 14(10):2946-52, 2007
                                                                                          22. Rosen EL et al: FDG PET, PET/CT, and breast cancer imaging. Radiographics. 27 Suppl 1:S215-29, 2007
                                                                                          23. Rouzier R et al: Breast cancer molecular subtypes respond differently to preoperative chemotherapy. Clin Cancer Res. 11(16):5678-85, 2005
                                                                                          24. Berg WA et al: Diagnostic accuracy of mammography, clinical examination, US, and MR imaging in preoperative assessment of breast cancer. Radiology. 233(3):830-49, 2004
                                                                                          25. Londero V et al: Locally advanced breast cancer: comparison of mammography, sonography and MR imaging in evaluation of residual disease in women receiving neoadjuvant chemotherapy. Eur Radiol. 14(8):1371-9, 2004
                                                                                          26. Lønning PE et al: Microarrays in primary breast cancer--lessons from chemotherapy studies. Endocr Relat Cancer. 8(3):259-63, 2001
                                                                                          27. Herrada J et al: Relative value of physical examination, mammography, and breast sonography in evaluating the size of the primary tumor and regional lymph node metastases in women receiving neoadjuvant chemotherapy for locally advanced breast carcinoma. Clin Cancer Res. 3(9):1565-9, 1997