TREATMENT Mastectomy -traditionally, treatment of breast ca has been surgical -19 century, surgical treatment : local excision ~ total mastectomy : radical mastectomy (remove axillary LN)

-20 century : extensions and modifications of the radical mastectomy (removal of more local and regional tissue) : lymph node supraclavicular, mediastinal, internal mammary

Modified radical mastectomy -preserves the pectoralis major muscle -no need for skin grafting -no difference in survival rate between radical mastectomy with modified radical mastectomy -better functional and cosmetic result

Total mastectomy -removal of the entire breast, nipple, and areolar complex without the underlying muscles or axillary lymph nodes -low-lying LN in the upper outer portion and low axilla are included -higher risk of the axillary recurrence -regional recurrence will occur in at least 15% to 20%

Adjuvant radiation therapy -the combination of total mastectomy with radiation therapy (Mcwhirther) -earlier trial, adjuvant radiation therapy improves local control but not survival rates

- NSABP(National Surgical Adjuvant Breast Project) :patients were randomly assigned to therapy consisting of total, radical mastectomy, or total mastectomy with radiation therapy :no difference in survival rates :whereas radiation therapy and axillary treatment improved local and regional control

Conservative therapy with or without radiation therapy -radiation therapy or local excision alone : a high local failure rate -radical mastectomy vs. quadrantectomy & axillry LN dessection & radiation (<2 cm, not central, no axillary LN disease(T1N0M0)) :after 15 years, no significant difference in either local control or overall survival rates

-NSABP (satge I or II) :three group- a)modified radical mastectomy b)segmental mastectomy & axillary LN dissection c) b)+post op radiation therapy :lowest local recurrence: c) :no significant in overall survival rate :effective for management of patients with stage I and II

-axillary LN status and the number of involved nodes is the most important prognostic indicator for patients with primary breast cancer -axillary LN dissection :the purposes of staging and the planning of adjuvant chemotherapy

Adjuvant systemic therapy -to eliminate occult metastases during early postop period -reduce the risk of local and distant recurrence -prolong survival in selected breast ca patient -reduce the odds of death by about 25% per year in both node-negative and node-positive patients (negative > positive)

-choosing the patients who should receive adjuvant therapy can be a difficult decision : prognostic and predictive factors identifying patients at risk for recurrence quantifying that risk -recommended for women with a greater than 10% chance of relapse within 10 years

-the patient ’ s risk of recurrence :nodal involvement, tumor size, nuclear grade estrogen and progesterone receptor status histologic type, proliferative rate, a variety of biologic markers -high risk prognostic factor :benefit from adjuvant cytotoxic or hormonal therapy

-lymph node metastasis : 10 YSR in palpable mass with no systemic Tx -50~60% -the number of LN involved -the presence of extracapsular invasion -tumor size : < 1cm – 27% (10 YSR) > 1 cm – only 9% (10 YSR)

-hormonal receptor status :prognosis & response to hormonal therapy :if positive, improved survival -histological grade -specific tumor biologic marker :HER-2/neu, p53, Ki-67, S-phase fraction

-regimen CMF : cyclophosphamide, methotrexate, 5-fluorouracil -regimen AC : anthracycline, cyclophosphamide : prefered because of short duration (4 cycles for 3 months versus 6 cycles for 6 months) & better tolerance -Taxane (paclitaxel) : benefits were similar in both premenopausal and postmenopausal women

Hormonal therapy -Tamoxifen, an estrogen analogue : pre- or postmenopausal women -20 mg gd daily : reduce -recurrence 50%, death 25% -Tamoxifen + cytotoxic chemoTx : improves survival in women with positive axillary LN and positive estrogen receptor expresson