General recommendations -adjuvant systemic therapy :with tamoxifen or multiple-chemotherapy agent :lower the incidence of recurrence by about 30%

- in postmenopausal women :hormone-response positive, including node- positive patient-> tamoxifen alone :hormone-resistant disease -> cytotoxic therapy

#caution: when using chemotherapeutic agents

-the risk of recurrence is low :derive little benefit from the use of adjuvant systemic therapy -the risk of recurrence is high :receive the greatest benefit

-the reduction of recurrence < side effect

The current recommendations for adjuvant systemic therapy in breast cancer

-premenopausal women :LN involvement-adjuvant combination chemotherapy (cytotoxic therapy + tamoxifen)

:without evidence of axillary LN involvement but. size(>1cm), aneuploid, estrogen receptor(-) -combination chemotherapy

-postmenopausal women

:negative LN, positive hormone receptor -adjuvant tamoxifen therapy

:positive LN -tamoxifen alone, multidrug cytotoxic therapy or a combination

:LN metastasis, negative hormone receptor -adjuvant chemotherapy

:adjuvant chemotherapy is not recommended -favorable, small nonpalpable tumor, palpable tumor (<1cm)

:the toxicity of chemotherapy and its effect on quality of life must be carefully evaluated

Prognosis -advanced, metastatic breast ca :palliative treatment -palliative radiotherapy :soft tissue or bony metastasis to control pain or avoid fracture :isolated bone metastasis, chest wall recurrence brain metastases, spinal cord compression

-systemic disease may be controlled by hormonal or cytotoxic therapy :but, quality of life – endocrine > cytotoxic

-favorable: disseminated disease functional organ ablation (ovary. pituiatry adrenal gland) drug that block hormonal function

-estrogen receptor (+) :response rate –as high as 60% estrogen receptor (-) : 5~10% :but, except elderly patients who are unable to tolerate cytotoxic therapy

-cytotoxic chemotherapy :life-threatening organ involvement (brain, lung, liver) hormone Tx is unsuccessful the diseaseis progressed after hormone Tx estrogen receptor (-)

-response rate :single (doxorubicin)-40~50% combination- 60~80%

-side effect :nausea, vomiting controlled with central-acting antiemetics

Special breast cancer

Paget’s disease -Sir James Paget :a nipple lesion similar to eczema associated with an underlying breast malignancy

-Paget cell :large cell with irregular nuclei extensions of an underlying carcinoma into the major ducts of the nipple-areolar complex

-no visible change: initial invasion (often nipple discharge)

-prognosis: depends on the underlying malignancy

-treatment: total mastectomy LN dissection radiotherapy with resection of the tumor and nipple-areolar complex

Inflammatory carcinoma -initially appears to be acute inflammation with redness & edema -no distinct palpable mass: infiltrates the breast with ill-defined margin -biopsy: shows metastatic cancer in the subdermal lymphatics -setallite nodule within the parenchyma -poorly differentiated -mammography: skin thickenig with an infiltrative process

-mastectomy usually fails & does not improve survival rates

-the best result: combination chemotherapy and radiation therapy

-mastectomy: remain free of metastatic disease after initial chemotherapy and radation

In situ carcinoma -lobar and ductal carcinoma : basement membrane of the duct do not invade the surrounding tissue lack the ability to spread

-so, lobar carcinoma insitu is not a malignancy Untreated it may not become a new cancer, whereas ductal carcinoma in situ will

-but lobar carcinoma in situ should be considered a risk factor for the development of cancer in either breast

-because of their unusual natural history, they represent a special form of breast cancer

-if treated by biopsy alone :25~30% invasive breast cancer

Lobar carcinoma in situ -premenopausal women -multifocal lesion (one or both breast) -be managed with excisional Bx followed by careful observation and mammography

-not malignancy but a risk factor for malignancy

-occasionally, bilateral prophylactic mastectomy

Ductal carcinoma in situ -more common in postmenopausal women -palpable mass -detected mammography (cluster, branch, Y-shape)

-intraductal disease :do not invade beyond the basement membrane but ductal carcinoma in situ (30~50%-> invasion)

Breast cancer in pregnancy -approximately one in 3,000 pregnancies the 2nd most common with pregnancy (the 1st cervical cancer)

-when pregnant patient are matched stage for stage with nonpregnant patient, survival rates seem equivalent

-treatment; be highly individualized the patient’s age & desire to have the child

-localized disease (during the 1st & 2nd trimester) :difinitive surgery & radiation (shieling abdomen) adjuvant chemoTx- prefer not to give -localized disease (during 3rd trimester) :initially, excison using local anesthesia after delivery, standard therapy

-during lactation :should be suppressed be treated definitively -advanced, incurable cancer :palliative therapy continued or interrupted -the therapy nesessary and the desires of the mother