Management of locally advanced and inflammatory carcinoma of the breast.

From the data presented, there seems little doubt that multimodality systemic and local therapy offers the best chance of long term control and survival in patients with locally advanced noninflammatory and inflammatory carcinoma of the breast. However, the best method of sequencing these modalities remains inadequately defined. The rationale for systemic therapy is that systemic micrometastases are present at diagnosis; since almost all patients die from systemic disease, it would seem preferable to use chemotherapy first, while the disseminated tumor burden is low. Furthermore, this would allow an assessment of local response to the agents administered. However, chemotherapy almost never sterilizes bulky local disease, and local control rates are significantly improved by concurrent or sequential use of a local modality. From the information presented, it would appear that combined operation and radiotherapy may give a better outcome than either modality alone. However, in series in which chemotherapy plus one local modality are used, the five year, local failure rates were 20 to 35 per cent; with the use of two local modalities, the local failure rate was not significantly better (16, 20 and 22 per cent). The full effect of using two local modalities with systemic chemotherapy has not been satisfactorily explored to date. Many groups have suggested that the local control rate is proportional to the dose of radiotherapy given. Since iridium192 implantation permits larger doses of radiotherapy to the local tumor without an apparent increase in toxicity, it holds great promise as a means of improving local control in this disease and should be considered in all instances. Randomized studies comparing iridium192 with operation as an adjunct to external beam radiotherapy are needed. Although there is little doubt that combination systemic chemotherapy is mandatory for improved survival in these patients, the appropriate drugs, combination and scheduling are yet to be defined. Data from studies of metastatic carcinoma of the breast indicate that combinations of two to four drugs, including doxorubicin, give the best response rates. Recently, a number of anthracycline analogues have been studied, in particular mitoxantrone, with response rates comparable to doxorubicin but with less toxicity. These agents could be used effectively in future chemotherapy programs for locally advanced and inflammatory carcinoma of the breast. The place of endocrine manipulation also remains undefined. In general, women who present with carcinoma of the breast later in life are more likely to have hormone receptor positive, endocrine responsive tumors.(ABSTRACT TRUNCATED AT 400 WORDS)