Neoadjuvant chemotherapy in the treatment of stage II and III breast cancer.

The current attractiveness of neoadjuvant chemotherapy lies in its ability to downstage both the primary tumor and the axilla, making many patients good candidates for breast-conserving surgical techniques. This has been an important achievement in a patient group whose tumors are often considered inoperable. Attention has more recently turned to the use of neoadjuvant chemotherapy in patients with operable tumors. In patients with resectable stage II and III breast tumors, neoadjuvant chemotherapy has been demonstrated to provide effective downstaging of the primary tumor, and subsequent breast-conserving surgery results in excellent local control. In addition, neoadjuvant chemotherapy has been shown to downstage axillary lymph nodes from positive to negative in a significant number of cases. This raises the question of whether patients who have clinically negative axillae after neoadjuvant chemotherapy need to risk the morbidity associated with axillary lymph node dissection. Axillary irradiation may provide adequate regional control in patients who are clinically node negative. In addition, sentinel lymph node dissection has been shown to provide accurate assessment of the axilla in patients who have received neoadjuvant chemotherapy. An important ramification of the concept of neoadjuvant chemotherapy is that surgery that takes place after the completion of systemic therapy can become minimally invasive, accomplished in an outpatient setting without the need for an operating room suite.