**3. Surgical management of locally advanced breast cancer (LABC)**

Irrespective of screening programmes, 15% of all breast cancer is still diagnosed with the locally advanced stage of the disease (T3-4 and/or N2-3). However, the reported 5-year OS is still 70–80%. Therefore, QoL, as an important outcome measure in the management evaluation, cannot be ignored either in this group of patients.

In the modern multimodal approach, neoadjuvant systemic treatment is the first-line option for these patients. According to all relevant treatment recommendation guidelines, neoadjuvant chemotherapy (NAC) should be offered to all aggressive breast cancer phenotypes (TNBC and HER2 enriched) with a tumour size of over 2 cm or/and axillary lymph node involvement. From the surgical point of view, the major benefit of this approach is tumour downsizing, allowing a higher rate of conservative procedures in the breast and axilla. However, the high rate of treatment response following NAC is still not accompanied by the equivalent increase in BCS in

*Oncoplastic Breast Conservation: A Standard of Care in Modern Breast Cancer Surgical… DOI: http://dx.doi.org/10.5772/intechopen.108944*

everyday clinical practice; that is, the surgical overtreatment is consistently reported in the literature [26, 27].

According to evidence-based practice guidelines, as well as expert consensus guidelines, response-adjusted surgery is the recommended option following NAC; that is, only the residual disease in the breast should be removed following treatment response. For the non-responders, those with a poor response or with scattered patterns of response, the oncoplastic approach has broadened the possibilities for breast conservation. However, care should be taken in those patients with the multifocal residual pattern, lymphatic vascular invasion, residual T size over 2 cm, and extensive nodal involvement following NAC, as a higher risk of local and regional recurrence was reported for the subgroup of patients with multiple above-mentioned factors detected [28].

Nevertheless, extensive *in situ* disease, as well as extensive invasive breast cancer (T3), no longer represents an absolute contraindication for breast conservation. The results reported by Silverstein and Libson [25, 29] indicate that extreme oncoplastic breast conservation is an oncological safe approach for patients with high-volume breast disease. In addition, it allows safe and aesthetically pleasing breast preservation in patients with multifocal and multicentric diseases [30–33]. However, the decision on the type of surgical procedure for the LABC patient should be always made in a multidisciplinary fashion, considering all aspects of multimodal treatment, rather than the technical feasibility of surgery exclusively.

#### **4. Relative contraindications for breast-conserving surgery**

Although good aesthetic results and a large volume of resection can be achieved with oncoplastic BCS, mastectomy may still be required in patients with the multicentric disease when appropriate resection cannot be achieved in a single resection volume, especially for those patients with a higher risk of local relapse, in whom irradiation boost to tumour bed might be required for optimal oncologic outcomes.

Hereditary breast cancer with a proven high-risk genetic mutation, as well as strong family history without a proven high-risk mutation, but with a calculated lifetime risk of contralateral breast cancer of over 30%, may also represent a relative contraindication for BSC. For these patients, a bilateral mastectomy may be recommended, although the evidence of survival benefit is reported only after a long-term follow-up (>15 years) [34, 35]. In addition to young age, patients diagnosed with less aggressive tumour subtypes might as well benefit from the radical bilateral procedure [36]. When considering the risk of local relapse in patients with proven high-risk mutations, the results of scientific reports are unclear. Although there are literature data favouring mastectomy, other studies did not confirm any benefit for local control management in these patients [37].

Another issue requiring clarification in surgical management decision-making is ipsilateral breast recurrence following previous BCS and whole breast irradiation. Although better oncological outcomes following radical procedures have not been confirmed by the results of any randomised control trials, mastectomy is the most often recommended clinical practice for this condition. Nevertheless, several non-randomised clinical trials have reported non-inferiority of BCS for the selected subgroup of patients, even for those cases in which re-irradiation was omitted [38, 39].

In conclusion, when deciding on the type of breast surgery for LABC, multicentric, hereditary and familial breast cancer, as well as for ipsilateral recurrence, the

author recommends a multidisciplinary and highly personalised approach to every case. The scientific evidence is not yet strong enough to support standardisation for optimal management in these patients. Randomised clinical trials are needed for a better understanding of these cases, although the low frequency of the condition and ethical issues involved represent obstacles to the appropriate study design.
