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Annals of Surgical Oncology 9:228-234 (2002)
© 2002 Society of Surgical Oncology

ORIGINAL ARTICLES

A Prospective Trial of Preoperative Chemotherapy in Resectable Breast Cancer: Predictors of Breast-Conservation Therapy Feasibility

Lisa A. Newman, MD, Aman U. Buzdar, MD, S. Eva Singletary, MD, Henry M. Kuerer, MD, PhD, Thomas Buchholz, MD, Frederick C. Ames, MD, Merrick I. Ross, MD and Kelly K. Hunt, MD

From the Departments of Surgical Oncology (LAN, SES, HMK, FCA, MIR, KKH), Medical Breast Oncology (AUB), and Radiation Oncology (TB), The University of Texas M. D. Anderson Cancer Center, Houston, Texas.

Correspondence: Address correspondence and reprint requests to: Kelly K. Hunt, MD, FACS, Associate Professor of Surgery, Department of Surgical Oncology, University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd., Box 444, Houston, TX 770300-4009; Fax: 713-792-4689; E-mail: khunt{at}mail.mdanderson.org


   ABSTRACT
TOP
 ABSTRACT
INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Background: The role of preoperative chemotherapy for breast cancer is evolving. We initiated a prospective trial of sequential preoperative paclitaxel and doxorubicin–based combination chemotherapy in patients with stage I (tumor >1 cm), II, or IIIA disease and evaluated its effect on breast-conservation therapy (BCT) eligibility.

Methods: Pathology findings for the initial 100 consecutive patients who underwent surgery were analyzed.

Results: The median tumor size at presentation was 2.4 cm, and 39% of patients were deemed eligible for BCT. After chemotherapy, the median tumor size decreased to 1.0 cm (P < .001), and 59% of patients seemed BCT eligible (BCT conversion rate 34% among patients initially assessed as BCT ineligible; P < .001). Final pathology confirmed BCT feasibility in 90% of patients assessed as BCT candidates before surgery. The pathology from mastectomy specimens revealed BCT feasibility in 11 (27%) of 41 patients deemed BCT ineligible. Multivariate analysis revealed lobular histology, multicentricity, and calcifications, but not age, initial tumor size, or nodal status to predict final pathology indicating BCT ineligibility.

Conclusions: Induction chemotherapy improves BCT eligibility for breast cancer patients. Improved breast imaging methods after chemotherapy are necessary to improve accuracy in predicting the feasibility of BCT, especially in patients presenting with diffuse calcifications or multicentricity.

Key Words: Breast cancer • Induction chemotherapy • Lumpectomy • Breast-conservation surgery


   INTRODUCTION
TOP
 ABSTRACT
 INTRODUCTION
MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 
Preoperative chemotherapy (also called induction or neoadjuvant chemotherapy) is now standard for patients with locally advanced breast cancer.1 This treatment approach converts many patients with initially unresectable disease to reasonable surgical candidates, with acceptable rates of locoregional disease control. Furthermore, the safety of induction chemotherapy for patients with resectable breast cancer has been confirmed by results of the National Surgical Adjuvant Breast Project (NSABP) B-18 study,2,3 which demonstrated overall similar outcomes for patients randomized to preoperative versus postoperative doxorubicin-based chemotherapy. It has been noted by several investigators that the extent of response in the breast does seem to correlate with improved survival. Therefore, the potential benefits of monitoring tumor response in vivo, as well as the improved eligibility for breast-conserving surgery that accompanies the preoperative approach, have motivated the implementation of various induction chemotherapy protocols for patients with early-stage disease.

It is generally accepted that multicentric tumors or those associated with diffuse microcalcifications at presentation are indicative of an excessive tumor burden in the breast, and breast-conservation therapy (BCT) is contraindicated in these instances regardless of the response to preoperative systemic therapy. Other clinical tumor features, such as lobular histology, an extensive intraductal component, and young age, are also known to hinder success rates with BCT. Little is known, however, about the effect of these factors on BCT eligibility after induction chemotherapy. The goal of this study was to determine predictors of BCT feasibility in a cohort of patients with resectable breast cancer receiving sequential paclitaxel and doxorubicin–based combination chemotherapy in the context of a prospective clinical trial.


   MATERIALS AND METHODS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
RESULTS
 DISCUSSION
 REFERENCES
 
Patients with stage I (primary tumor >1 cm in diameter), II, or III breast cancer were eligible to participate. Eligible patients had to have at least one site of measurable disease. Patients with a history of excisional biopsy could participate if residual disease in the breast or axillary nodal metastases was documented with needle biopsy. All patients were evaluated and staged by a multidisciplinary team of medical, surgical, and radiation oncologists and diagnostic radiologists. Disease status was assessed at presentation, and response was determined during treatment and again before surgery by physical examination, mammography, and breast/nodal basin sonography.

Preoperative treatment consisted of paclitaxel, fluorouracil, cyclophosphamide, and doxorubicin. Patients were randomized to receive either weekly paclitaxel (150 mg/m2 over 16 weeks for node-positive disease and 80 mg/m2 over 12 weeks for node-negative disease) or paclitaxel given at 21-day intervals (225 mg/m2) for four cycles. After completion of paclitaxel, all patients received four cycles of fluorouracil (500 mg/m2), cyclophosphamide (500 mg/m2), and doxorubicin (50 mg/m2). Medical records were reviewed for the first 100 patients enrolled on this protocol who underwent definitive surgery.

Response to treatment was scored as complete if there was no clinical or radiographic evidence of disease after chemotherapy. Pathologic extent of disease was quantified at the time of definitive surgery by determining the size of residual invasive tumor in the breast, the presence versus absence of residual ductal carcinoma-in-situ, the margin status, and the presence versus absence of axillary nodal metastases.

Eligibility for BCT was assessed at presentation and again before surgery, after the completion of chemotherapy. Patients receiving BCT were judged as having successful treatment if the margins on the final lumpectomy specimen were free of disease. The feasibility of BCT in patients undergoing mastectomy was determined by pathologic extent of residual disease in the mastectomy specimen. Patients with unifocal disease (invasive and noninvasive combined) <4 cm in greatest dimension were deemed as having been candidates for BCT.

Statistical significance was determined by the t-test, {chi}2 analysis, and multivariate analysis. Two-tailed P values of .05 or less were considered statistically significant.


   RESULTS
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
DISCUSSION
 REFERENCES
 
Clinical characteristics of the study population at presentation are listed in Table 1. The median age was 52 years. Most study participants had early-stage disease. The median tumor size was 2.4 cm, and approximately one half of the patients had axillary node metastases. More than 80% of the primary tumors had invasive ductal histology, and 81% were diagnosed with the aid of core-needle biopsy. Twenty patients had multicentric disease, and 19 had diffuse microcalcifications on mammogram (including six patients with both multicentric tumors and widespread calcifications). Forty-three patients had axillary node metastases documented by ultrasound-guided fine-needle aspiration biopsy.


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  		TABLE 1. Clinical features of the patient population at presentation
 
The median tumor size decreased from 2.4 cm at initial presentation to 1.0 cm after chemotherapy (P < .001). Before chemotherapy, 39% of patients were assessed as being BCT eligible, 31% were deemed BCT eligible only if the primary tumor was downstaged by induction chemotherapy, and 30% were considered BCT ineligible because of diffuse microcalcifications, multicentric disease, or both.

At the completion of chemotherapy, 59% of patients were deemed eligible for BCT, and 20 of the 61 patients initially deemed BCT ineligible were converted to BCT eligibility on the basis of clinical findings before surgery. The BCT eligibility conversion rate was therefore 34% (P < .001). Of the 59 patients deemed to be eligible for BCT after induction chemotherapy, final pathology confirmed eligibility in 53 patients (90%).

Thirty-nine patients actually underwent BCT; 24 of these patients were BCT candidates at presentation, and the remaining 15 were successfully downstaged by chemotherapy. A total of 20 patients were deemed BCT candidates after preoperative chemotherapy but underwent mastectomy on the basis of patient preference; 41 patients were deemed to be BCT ineligible at the time of preoperative evaluation, and all of these patients underwent mastectomy.

Of the 41 patients treated with mastectomy because they were deemed to be BCT ineligible, 11 patients (27%) were found to be candidates for BCT on the basis of the extent of disease found in the mastectomy specimens. Six of these patients who were incorrectly assessed as BCT ineligible were advised against BCT on the basis of diffuse calcifications, and five were thus advised on the basis of multicentricity on presentation.

A comparison of physical examination findings, sonography, and mammography in quantifying primary breast tumor size at presentation and before surgery is listed in Table 2. Sonography and mammography yielded similar primary tumor measurements, and the preoperative measurements correlated well with the pathologic findings. Physical examination tended to overestimate the extent of disease at presentation and tended to underestimate the extent of disease after chemotherapy. All three modalities were incorrect in more than half of the cases in which the clinical assessment was judged as a complete response.


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  		TABLE 2. Correlation of clinical tumor features with pathologic response after chemotherapy
 
Of the 43 patients with fine-needle aspiration–documented axillary nodal metastases at presentation, 42 underwent axillary lymph node dissection, and 14 (33%) were found to have been converted to pathologically node negative. Fifty patients had a preoperative axillary sonogram that was judged as negative for disease, and 19 of these patients (38%) were found to be node positive at subsequent axillary lymph node dissection.

Thirty-two patients underwent lymphatic mapping procedures (including 19 with concomitant axillary lymph node dissection), and the sentinel lymph node identification rate was 97% (sentinel node localized in 31 of 32 patients).

A total of 21 patients (21%) had a complete pathologic response (no residual invasive disease) in both the breast and axilla. Ten of these patients did have residual ductal carcinoma-in-situ in the breast specimen. The median pathologic tumor size after induction chemotherapy was 1.2 cm, and a complete pathologic response in the breast only was found in 28 patients (28%).

Multivariate analysis was performed to determine predictors of BCT ineligibility after induction chemotherapy. This analysis was based on the extent of disease found in the breast at pathologic examination (Table 3). If lobular histology, multicentricity, or diffuse calcifications on mammogram were present, BCT was feasible in only 20% to 35% of cases. Conversely, if these features were absent, BCT was feasible after induction chemotherapy in approximately 75% of cases. Age, initial tumor size, and nodal status were not significant predictors of BCT feasibility.


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  		TABLE 3. Predictors of breast conservation therapy (BCT) feasibility
 

   DISCUSSION
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
REFERENCES
 
The realization that primary surgical management of locally advanced and inflammatory breast cancer resulted in excessive locoregional and distant treatment failure rates prompted investigations of multimodality therapeutic approaches. Induction (preoperative) chemotherapy has emerged as the accepted standard of care for these complex cases.1,4 The evolution of clinical research in this area has confirmed the conceptual advantages of induction chemotherapy and, in addition, has allayed concerns that delaying surgery might be detrimental to patient outcome.

The major reservation regarding the use of preoperative chemotherapy was that the surgeon might lose a window of opportunity to obtain durable locoregional control of disease. Additionally, clinicians questioned the prognostic value of the axillary nodal status after chemotherapy and feared that induction chemotherapy would increase surgical complication rates. These concerns have proved to be largely unfounded.

Several investigators1,4,5 have demonstrated that response rates to induction chemotherapy are 70% to 80%, and progressive disease in the breast or nodal basins is rare, occurring in only 2% to 3% of cases. The overwhelming majority of patients therefore become better operative candidates with this treatment sequence.

McCready et al.6 demonstrated that the axillary nodal status retains its prognostic value after preoperative chemotherapy. In this study, outcome was evaluated for 136 patients with T3 or T4, N2 or N3 locally advanced breast cancer after three to six cycles of fluorouracil, doxorubicin, and cyclophosphamide. The extent of residual nodal metastases was a strong predictor of outcome, and those patients with histologically negative nodes were found to have an excellent outcome.

Broadwater et al.7 demonstrated that surgical complication rates are similar in patients receiving preoperative or postoperative chemotherapy. These investigators looked at surgical morbidity in 106 patients with locally advanced breast cancer who received preoperative fluorouracil, doxorubicin, and cyclophosphamide and compared the outcome with that of 91 consecutive patients who underwent mastectomy before chemotherapy. Induction chemotherapy compared with primary surgery did not result in increased rates of postoperative wound infection (7% vs. 4%; P = .62), wound necrosis (11% vs. 6%; P = .29), or delays in instituting postoperative chemotherapy (30% vs. 20%; P = .27). Moreover, patients receiving induction chemotherapy had significantly lower rates of postoperative seroma formation (15% vs. 28%; P = .04).

The proven safety of preoperative chemotherapy, coupled with the excellent rates of tumor downstaging, motivated efforts to evaluate the feasibility of BCT in patients with locally advanced disease. Singletary et al.8 reviewed mastectomy findings in 143 patients with locally advanced breast cancer who had received preoperative chemotherapy and found that 23% had been converted to BCT eligibility on the basis of pathologic findings. Favorable parameters included a residual primary tumor size of 4 cm or less, absence of multicentricity, and complete resolution of skin changes. A subsequent study from the M. D. Anderson Cancer Center evaluated outcome after induction chemotherapy and BCT for 93 patients with locally advanced or large primary breast cancers and found a local recurrence rate of <10%. This was comparable to the local recurrence rate seen in patients with early-stage breast cancer treated with a breast-conserving approach.9

Bonnadonna et al.10 expanded the applications of induction chemotherapy to the setting of patients with relatively large but nonetheless technically early-stage and resectable breast cancers and confirmed the anticipated result that induction chemotherapy improved eligibility for BCT. In this series, 165 patients with primary breast tumors >3 cm in diameter received three cycles of doxorubicin-based chemotherapy. The authors reported a 77% tumor response rate and an 81% BCT rate.

The NSABP B-18 trial2,3 broadened the indications for induction chemotherapy even further by randomizing more than 1500 women with stage I to IIIA breast cancer to receive preoperative versus postoperative chemotherapy. This study demonstrated a statistically significant increase in BCT use for the preoperative chemotherapy arm (68% vs. 60%). The conversion rate to BCT eligibility with induction chemotherapy was greatest in the patients with tumors larger than 5 cm at diagnosis.

Despite the success of tumor downstaging with preoperative chemotherapy, published studies have thus far failed to demonstrate a consistent survival advantage associated with the delivery of preoperative chemotherapy in comparison to standard postoperative adjuvant chemotherapy. Findings from several randomized studies2,3,11–17 comparing preoperative and postoperative chemotherapy for breast cancer are listed in Table 4.


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  		TABLE 4. Randomized studies of neoadjuvant versus adjuvant chemotherapy for breast cancer
 
Subset analysis of induction chemotherapy trials does reveal a statistically significant improvement in survival for patients found to have a complete pathologic response (defined as absence of invasive disease in the breast and node negativity) at the time of definitive cancer surgery. Kuerer et al.18 evaluated 372 patients with locally advanced breast cancer treated on induction chemotherapy protocols at the M. D. Anderson Cancer Center and reported 5-year survival rates of nearly 90% for the 43 patients with a complete pathologic response, compared with 64% for the remaining patients who had lesser responses (P < .01). Similarly, Fisher et al.3 found that in the NSABP B-18 trial, 5-year relapse-free survival was 85.7% for the subset of patients with a complete pathologic response.

Unfortunately, the conventional induction chemotherapy regimens based on an anthracycline agent yield a complete pathologic response in only 12% to 13% of cases. It therefore seems reasonable to hypothesize that availability of alternative chemotherapy regimens that result in larger numbers of complete pathologic responders should contribute to improved outcome for the entire cohort of treated patients.

Thus, two major advantages of induction chemotherapy are clear: response to treatment is an excellent surrogate marker of chemotherapy effectiveness in eradicating micrometastases, and induction chemotherapy will improve the ability to offer BCT by permitting smaller volume lumpectomies. It is hoped that new clinical research trials using induction chemotherapy will include novel systemic therapy regimens that achieve higher complete pathologic response rates. In addition, improved breast imaging is needed to more accurately assess the extent of response to treatment before surgery, allowing for the ability to predict BCT eligibility. Finally, sensitive methods are needed to measure response to treatment more rapidly than clinical observation over a few cycles of the selected regimen, thereby potentially sparing the patient from the toxicities of higher cumulative doses of an ineffective regimen.

A variety of protocols have already been implemented that seek to identify the efficacy of various novel chemotherapy regimens in the neoadjuvant setting. The NSABP is currently evaluating the combination of doxorubicin and docetaxel. The M. D. Anderson Cancer Center has previously reported results of a prospective trial comparing doxorubicin with paclitaxel administered in the standard 21-day cycles and found similar tumor response rates.19 Preliminary data suggest that a weekly paclitaxel schedule allows substantial increases in dose intensity, and this enhanced therapeutic efficacy may account for the excellent response rates seen in some small studies of patients with metastatic and locally advanced breast cancer.20,21 These findings were the rationale for the design of the induction chemotherapy regimen used in this study, which randomized patients to paclitaxel given in weekly versus 21-day cycles. Incorporation of second- and third-line chemotherapy agents (such as vinorelbine and gemcitabine), as well as innovative monoclonal antibody–based therapies (such as trastuzumab), into the neoadjuvant arena are other potential avenues of research.

This study demonstrated the limitations of currently available breast and axillary imaging modalities in evaluating the extent of disease after induction chemotherapy. Multicentric disease or diffuse suspicious-appearing calcifications at presentation, on the basis of physical examination, mammography, breast sonography, or a combination of these, are generally accepted contraindications to BCT.22 The extent of residual disease may be particularly difficult to determine after induction chemotherapy in these cases. Our study demonstrated that although the presence of these features did predict for high rates of BCT ineligibility, nearly one third of patients who were denied an attempt at BCT because of these features were actually found pathologically to have had adequate tumor downstaging that rendered them BCT eligible. Similarly, extent of disease is known to be difficult to judge before surgery in tumors with lobular histology. This was confirmed in our study to be a persistent problem with tumors treated with induction chemotherapy. We also found axillary sonography to be less reliable in evaluating residual nodal disease after induction chemotherapy. Alternative imaging modalities, such as breast magnetic resonance imaging and positron emission tomography scanning, are currently under investigation as sensitive indicators of tumor response after induction chemotherapy.23,24

In summary, it is clear that induction chemotherapy results in tumor downstaging that increases the fraction of patients who become eligible for BCT. It is possible that conventional measures of BCT ineligibility are not necessarily appropriate for patients receiving neoadjuvant systemic therapy. However, current imaging modalities are inadequate for realizing the full potential of this treatment sequence, and some patients will ultimately be committed to mastectomy because of inability to accurately assess the extent of disease after preoperative treatment. As applications of induction chemotherapy become more widespread and as innovative preoperative treatment regimens increase response rates, it will become increasingly important to have breast and axillary imaging modalities that can precisely assess treatment response.


   Footnotes
 
Presented at the 54th Annual Cancer Symposium of the Society of Surgical Oncology, Washington, DC, March 15–18, 2001.

Received for publication June 15, 2001. Accepted for publication October 22, 2001.


   REFERENCES
TOP
 ABSTRACT
 INTRODUCTION
 MATERIALS AND METHODS
 RESULTS
 DISCUSSION
 REFERENCES
 

  1. Hunt KK, Ames FC, Singletary SE, Buzdar AU, Hortobagyi GN. Locally advanced noninflammatory breast cancer. Surg Clin North Am 1996; 76: 393–410.[CrossRef][Medline]
  2. Fisher B, Brown A, Mamounas E, et al. Effect of preoperative chemotherapy on local-regional disease in women with operable breast cancer: findings from the National Surgical Adjuvant Breast and Bowel Project B-18. J Clin Oncol 1997; 15: 2483–93.[Abstract/Free Full Text]
  3. Fisher B, Wolmark N, Mamounas E, et al. Effect of preoperative chemotherapy on the outcome of women with operable breast cancer. J Clin Oncol 1998; 16: 2672–85.[Abstract]
  4. Hortobagyi GN, Singletary SE, McNeese MD. Treatment of locally advanced and inflammatory breast cancer.In: Harris JR, Lippman ME, Morrow M, Hellman S, eds. Diseases of the Breast. Philadelphia: Lippincott-Raven, 1996: 585–99.
  5. Wolff AC, Davidson NE. Primary systemic therapy in operable breast cancer. J Clin Oncol 2000; 18: 1558–69.[Abstract/Free Full Text]
  6. McCready DR, Hortobagyi GN, Kau SW, Smith TL, Buzdar AU, Balch CM. The prognostic significance of lymph node metastases after preoperative chemotherapy for locally advanced breast cancer. Arch Surg 1989; 124: 21–5.[Abstract]
  7. Broadwater JR, Edwards MJ, Kuglen C, Hortobagyi GN, Ames FC, Balch CM. Mastectomy following preoperative chemotherapy. Ann Surg 1991; 213: 126–9.[Medline]
  8. Singletary SE, McNeese MD, Hortobagyi GN. Feasibility of breast conservation surgery after induction chemotherapy for locally advanced breast cancer. Cancer 1992; 69: 2849–52.[CrossRef][Medline]
  9. Peoples G, Heaton K, Booser D, et al. Breast conservation therapy for large primary and locally advanced breast cancers after induction chemotherapy (abstract No. 25). Society of Surgical Oncology 51st Annual Cancer Symposium, San Diego, CA, March 26–29, 1998.
  10. Bonnadonna G, Veronesi U, Brambilla C, et al. Primary chemotherapy to avoid mastectomy in tumors with diameters of three centimeters or more. J Natl Cancer Inst 1990; 82: 1539–45.[Abstract/Free Full Text]
  11. Mauriac L, Durand M, Avril A, Dilhuydy JM. Effects of primary chemotherapy in conservative treatment of breast cancer patients with operable tumors larger than 3 cm. Ann Oncol 1991; 2: 347–54.[Abstract/Free Full Text]
  12. Mauriac L, MacGrogan G, Avril A, et al. Neoadjuvant chemotherapy for operable breast carcinoma larger than 3 cm: a unicentre randomized trial with a 124-month median follow-up. Ann Oncol 1999; 10: 47–52.[Abstract/Free Full Text]
  13. Semiglazov VF, Topuzov EE, Bavli JL, et al. Primary (neoadjuvant) chemotherapy and radiotherapy compared with primary radiotherapy alone in stage IIB-IIIA breast cancer. Ann Oncol 1994; 5: 591–5.[Abstract/Free Full Text]
  14. Scholl SM, Fourquet A, Asselain B, et al. Neoadjuvant versus adjuvant chemotherapy in premenopausal patients with tumors considered too large for breast conserving surgery: preliminary results of a randomised trial—S6. Eur J Cancer 1994; 30A: 645–52.
  15. Scholl SM, Pierga JY, Asselain B, et al. Breast tumour response to primary chemotherapy predicts local and distant control as well as survival. Eur J Cancer 1995; 31A: 1969–75.[CrossRef]
  16. Powles TJ, Hickish TF, Makris A, et al. Randomized trial of chemoendocrine therapy started before or after surgery for treatment of primary breast cancer. J Clin Oncol 1995; 13: 547–52.[Abstract/Free Full Text]
  17. Makris A, Powles TJ, Ashley SE, et al. A reduction in the requirements for mastectomy in a randomized trial of neoadjuvant chemoendocrine therapy in primary breast cancer. Ann Oncol 1998; 9: 1179–84.[Abstract/Free Full Text]
  18. Kuerer HM, Newman LA, Smith TL, et al. Clinical course of breast cancer patients with complete pathologic primary tumor and axillary lymph node response to doxorubicin-based neoadjuvant chemotherapy. J Clin Oncol 1999; 17: 460–9.[Abstract/Free Full Text]
  19. Buzdar AU, Singletary SE, Theriault RL, et al. Prospective evaluation of paclitaxel versus combination chemotherapy with fluorouracil, doxorubicin, and cyclophosphamide as neoadjuvant therapy in patients with operable breast cancer. J Clin Oncol 1999; 17: 3412–7.[Abstract/Free Full Text]
  20. Davidson NG, Chick JB, Perren TJ, Campbell N, Thompson JM, Chan YT. A phase II study of single agent paclitaxel in patients at first relapse following initial treatment for breast cancer. Clin Oncol 1996; 8: 358–62.
  21. Seidman AD. One-hour paclitaxel via weekly infusion: dose-intensity with enhanced therapeutic index. Oncology 1998; 12: 19–22.
  22. Winchester DP, Cox JD. Standards for diagnosis and management of invasive breast carcinoma. CA Cancer J Clin 1998; 48: 83–107.[Abstract]
  23. Abraham DC, Jones RC, Jones SE, et al. Evaluation of neoadjuvant chemotherapeutic response of locally advanced breast cancer by magnetic resonance imaging. Cancer 1996; 78: 91–100.[CrossRef][Medline]
  24. Avril N, Rose CA, Schelling M, et al. Breast imaging with positron emission tomography and fluorine-18 fluorodeoxyglucose: use and limitations. J Clin Oncol 2000; 18: 3495–502.[Abstract/Free Full Text]



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