1. Overview of breast cancer
Sun Yat-Sen Cancer Center

2. Outline 現況 Epidemiology Diagnosis, stage Treatment Surgery Radiation
Hormone therapy
Chemotherapy

3. Breast cancer (乳癌) 臺灣乳癌好發年齡在40~50歲之間，較歐美國家的好發年齡約提早十歲。 是世界重要的健康公共議題
台灣地區主要癌症死亡原因。乳癌的發生率為第一位，死亡率是排名第4位的女性癌症。
民國98年，女性及男性乳房惡性腫瘤發生個案數分別占全部惡性腫瘤發生個案數的10.24%及0.06%，女性及男性乳房惡性腫瘤死亡人數占全部惡性腫瘤死亡人數的3.98%及0.03%。發生率的排名於女性為第1位、男性為第32位；死 亡率的排名於女性為第4位、男性為第34位。
民國98年初次診斷為女性及男性 乳房惡性腫瘤者分別為8,926人及48人；當年死因為女性及男性乳房惡性腫瘤 者分別為1,588人及10人。
從1970–1996 之間，乳癌發生率增加2-3倍。
Cancer Registry Annual Report in Taiwan Area 2001 Department of Health, Executive Yuan, ROC 2009
臺灣乳癌好發年齡在40~50歲之間，較歐美國家的好發年齡約提早十歲。

5. Taiwan: Cancer Registration (year of diagnosis is 2002; a total of 10 hospitals reported 2,174 cases that includes complete follow-up data for five years)
USA: National Cancer Database, Survival Report, 2008 (years of diagnosis are for a total of 299,900 cases that covers complete follow-up data for five years)

6. Normal Breast A. Breast Duct System B. Lobules C. Breast Duct System
D. Nipple
E. Fat
F. Chest Muscle
G. Ribs
A. Cells lining duct
B. Basement membrane
C. Open central duct

7. Invasive ductal carcinoma(IDC)
A. Breast Duct System
B. Lobules
C. Breast Duct System
D. Nipple
E. Fat
F. Chest Muscle
G. Ribs
A. Cells lining duct
B. Cancer cells, breaking through the basement membrane
C. Basement membrane

8. DCIS and LCIS DCIS（Ductal Carcinoma in situ,管內癌），及
Premalignant change
Turn out to be cancer in ongoing years
LCIS (Lobular carcinoma is situ,原位小葉癌）
Not a premalignent change
A sign, which indicate risk of breast ca

9. Symptoms In early breast ca Late breast ca Easily self palpated
Nipple discharge
May accompanied with axillary LN
Late breast ca
Local usually symptomatic
Depends on metastatic sites

14. 14

15. 15

16. 16

17. Epidemiology
Increases with age, although the rate of increase slows after menopause.
Early menarche, late menopause, and nulliparity increase the risk of breast cancer.
Atypical lobular or ductal hyperplasia.
Other risk factors
Early exposure to ionizing radiation
long-term postmenopausal estrogen-replacement therapy
Alcohol consumption.
The most important risk factor is a family history of breast cancer.( 5 to 10%)
breast–ovarian cancer syndrome, the Li–Fraumeni syndrome, and Cowden's disease.
家族遺傳性的癌症症候群中，有一名叫Li-Fraumeni syndrome者，其遺傳中之問題基因即是p53。在此症候群中之病人，會罹患多種癌症，尤其是骨骼和肌肉的惡性肉瘤、腎上腺癌、腦瘤、乳癌和白血病等。p53 奇特的一個地方是別的腫瘤抑制基因突變之後都是失去功能，但是有的p53突變卻使它獲得新功能，可以啟動他種基因。由此點看來，p53也可算是一種致癌基因。 Cowden's Disease：在臉部皮膚易有毛髮膜細胞瘤(Trichilemmomas)，多發性角化丘疹，口腔內也有多發性丘疹其形狀似鵝卵石。常伴隨胃腸道息肉、甲狀腺腫瘤、卵巢囊腫和乳房纖維瘤。

18. Biology
BRCA1 and BRCA2 germ-line mutations ( 50 – 85% lifetime risk of breast cancer, ovarian cancer, or both ).
In sporadic breast cancer (including p53, bcl-2, c-myc, and c-myb),
HER-2/neu and cyclin D1 are overexpressed.
Factors that stimulate or inhibit growth and proliferation of breast-cancer cells.
Gonadal steroid hormones (estrogens, progestins, and androgens)
Growth factors (epidermal growth factor, transforming growth factors and insulin-like growth factors I and II)

19. How to describe a breast ca
TNM stage
Tumor morphology
Grade
VLI
PNI
Special receptor
Hormone receptor: ER and PR
Her2/Neu

20. TNM N
N0: no axilla LAPs
N1:1-3
N2:4-9
N3>10
M: M0 or M1

21. I
T1N0
IIA
T1N1
T2N0
IIB
T2N1
T3N0
IIIA
T1N2
T2N2
T3N1
T3N2
IIIB
T4N0
T4N1
T4N2
IIIC N3

22. 疾病種類
輔助療法
乳癌但無浸潤的情形
包括管內癌（Ductal Carcinoma in situ, DCIS），及原位小葉癌（Lobular carcinoma is situ,LCIS）
不需要
乳癌有浸潤的情形，無淋巴轉移腫瘤小於1mm 。
最大直徑小於1cm浸潤性腺管癌，及浸潤性小葉癌
浸潤性腫瘤，但組織病理預後相對是較好，如髓質癌、黏液素癌、小管癌。腫瘤最大直徑小於3cm。
腫瘤最大直徑大於1cm浸潤性腺管癌，及浸潤性小葉癌。
化療、荷爾蒙療法
浸潤性腫瘤，但組織病理預後相對是較好，如髓質癌、黏液素癌、小管癌。腫瘤最大直徑大於3cm。
乳癌有浸潤的情形且有腋下淋巴轉移
無論腫瘤大小、或病理報告的任何腫瘤

23. Tumor morphology Grade Vascular lymphatic invasion(VLI)
Tubule Formation
Nuclear Pleomorphism
Mitotic Count
Vascular lymphatic invasion(VLI)
Perineural invasion(PNI)
Both indicate aggressive behavior

24. VLI A. Veins in breast B. Lymph channels in breast
A. Cells lining duct
B. Cancer cells, breaking through the basement membrane.
C. Broken basement membrane
D. Cancer entering a lymph channel.
E. Cancer entering a vein.
F. Normal breast tissue.

25. Receptor status Hormone receptor Her2/neu Estrogen receptor (%)
Progesterone receptor (%)
>10% predict response to hormone tx
Her2/neu
Associate with invasion, metastasis…
Predict poor prognosis
IHC stain, FISH

26. The EGFR (erbB) family Ligands Receptor domain Extracellular Membrane
NRG2
NRG3
Heregulins
EGF
TGF-
Amphiregulin
No specific ligands
Ligands
Heregulins
Receptor domain
Extracellular
Membrane
Intracellular
Tyrosine kinase
domain
The epidermal growth factor receptor (EGFR) belongs to a family of four closely related cell surface receptors: EGFR (HER1 or erbB1), erbB2 (HER2/neu), erbB3 (HER3), and erbB4 (HER4).1
These receptors are transmembrane glycoproteins comprising an extracellular ligand-binding domain and an intracellular domain with tyrosine kinase activity.1
Several ligands bind to the EGFR, including EGF and TGF-α. There are no defined ligands for erbB2; erbB3 and erbB4 bind heregulins and neuregulins.1
Dimerization of erbB receptors may occur as follows:
EGFR homodimerization
EGFR heterodimerization with erbB2 or erbB3 receptors
erbB4 heterodimerization with erbB2.1
Dimer formation will dictate the resultant signaling cascade.1
Reference
Wells A. Int J Biochem Cell Biol 1999; 31: K K K
erbB1 HER1
EGFR
erbB2
HER2 neu
erbB3
HER3
erbB4
HER4

27. Current assay of HER2/neu
Immunohistochemistry
‘0’ (negative)
‘1+’ (negative)
‘2+’ (equivocal)
‘3+’ (positive)
Fluorescence in situ hybridization (FISH)
HER2 gene no amplification FISH negative
HER2 gene amplification FISH positive

28. Definition of risk categories for patients with node-negative breast cancer Annals Oncol 2005; 16:
Low risk
Node negative AND all of the following features: Pathologic tumour size ≤2cm, AND Grade 1 AND Absence of peritumoural vascular invasion, AND HER2/neu gene neither over-expressed nor amplified, AND Age ≥35 years
Intermediate risk
Node negative AND at least one of the following features: Pathologic tumour size >2cm, OR Grade 2-3, OR Presence of peritumoural vascular invasion, OR HER2/neu gene over-expressed or amplified, OR Age <35 years
Node positive (1-3 nodes involved) AND HER2/neu gene neither over-expressed nor amplified
High risk
Node positive (1-3 nodes involved) AND HER2/neu gene over-expressed or amplified Node positive (4 or more involved nodes)

29. Diagnostic Approaches
Mammography
25 to 30 % decrease in mortality (>= age of 50 years and probably also in women between the ages of 40 and 50 years.
High-risk families ( BRCA1 or BRCA2 mutations)
start at 25 years of age
5 years earlier than the earliest age at which breast cancer was diagnosed in a family member
The American Cancer Society and the National Cancer Institute recommend annual screening mammography for women older than 40 years who have a standard risk of breast cancer.

30. Diagnostic Approaches
20years ago, incisional or excisional biopsies were the standard methods for confirming the diagnosis.
Today, fine-needle aspiration or core needle biopsy is the standard.
Ultrasound-guided core needle biopsy, stereotactic biopsy, and magnetic resonance–directed biopsy have become important diagnostic tools, especially for women with suspicious but nonpalpable breast masses.

31. Treatment Localized breast cancer Metastatic breast cancer
Surgery is mainstay
Halsted, 1882, radical mastectomy
John Hopkins
Metastatic breast cancer
Systemic treatment

32. Radical mastectomy
A. Entire breast and a chest wall muscle is removed.
LNs in the level 1 (B) and level 2 (C ), and even sometimes more distant lymph node groups (D, E and F) were also removed.

33. Modified radical mastectomy (MRM)
A. Entire breast is removed
Classically some lymph nodes in the level 1 (B) and level 2 (C ) were removed, called an axillary lymph node dissection.
MRM = simple mastectomy + ALND

34. Breast conserving surgery
Also called lumpectomy
RT should be followed

35. Surgical evolution Radical mastectomy
Modified radical mastectomy: 1970s
Lumpectomy + RT, 1970s
NSABP B-06, NEJM 1985
Lumpectomy vs. MRM
Milan Cancer Institute, NEJM 1977
Lumpectomy vs. RM

36. Radical mastectomy : breast Conserving therapy
Equivalent survival with BCT (breast-conserving therapy) as compared to mastectomy.
lumpectomy (wide excision of the tumor with preservation of the breast) with radiotherapy is the preferred treatment.
Radiotherapy, an integral part of BCT, is inappropriately withheld from some women, especially those older than 65 years.
Noninvasive (in situ) ductal and lobular breast cancer can also be treated adequately with lumpectomy and radiotherapy.
Early Breast Cancer Trialists' Collaborative Group. N Engl J Med 1995; 333:1444. 36

37. Individual and Pooled Odds Ratios for Survival at 10 Years in Women with Breast Cancer Treated by Breast-Conserving Therapy as Compared with Mastectomy. Cancer 1977;40:Suppl: 37

38. Axillary Lymph-Node Dissection
Recurrence is higher with positive axillary lymph nodes and increases with each additional positive node.
Axillary lymph-node dissection
only provides prognostic information
most of the morbidity associated with breast surgery.
remains the standard of care for all women with invasive breast cancer or large noninvasive tumors (>2.5 cm).
Sentinel-lymph-node mapping ( radioactive substance or a blue dye is injected into the area around the tumor)
The lower ipsilateral axilla is explored through a small incision and the lymph node that has taken up the dye or radioactive substance is excised.
The positive predictive value (100 %), negative predictive value (> 95 %). 38

39. Adjuvant Radiotherapy
Radiotherapy is an integral part of breast-conserving treatment.
Administering chemotherapy before radiotherapy resulted in higher survival rates when given postoperatively.
Postmastectomy radiotherapy reduces the incidence of local and regional recurrences by 50 to 75 % ( not increase survival).
Only for women at high risk for local or regional recurrence ( large tumors invading the skin of the breast, chest wall, positive axillary lymph nodes).
Benefit for high-risk premenopausal women. Fewer local and regional recurrences and overall survival was significantly better among the women treated with radiotherapy and chemotherapy. 39

40. Ten-Year Cancer-free Survival and Overall Survival among Women Treated with Chemotherapy with or without Radiotherapy after Mastectomy
Table 2. Ten-Year Cancer-free Survival and Overall Survival among Women Treated with Chemotherapy with or without Radiotherapy after Mastectomy. 40
Hortobagyi, G. N. N Engl J Med 1998;339: 40

41. Impact of surgical evolution
Local control: no survival benefit
Local control: RM>MRM>BCT+RT>BCT
Survival no different
Why? distant metastasis is the main cause
Distant “micrometastasis”
Not from local residual dz
Does exist at diagnosis
Adjuvant systemic treatment

43. Adjuvant systemic treatment
Hypothesis:
Eradicate micrometastasis
From effective tx for overt(macro) metastasis
Chemotherapy
Hormone therapy

44. Adjuvant chemotherapy
CMF, first generation, 1970s
Cyclophosphamide
Methotrexate
5-FU
Benefit in
Distant recurrence
Survival

45. Adjuvant chemotherapy
CAF or CEF, 2nd generation, 1980s
Cyclophophamide
Adramycin(or Epirubicin)
5-FU
More toxic than CMF
CAF better than CMF in high-risk group
Axilla LN+
LN-, but tumor large or other risk factor

46. Adjuvant chemotherapy
Benefits both premenopause and postmenopause
Benefit is greater in younger as compared to older women.
< 50 , polychemotherapy reduced the risk of disease relapse and death by 37 and 30%, respectively.
10 % absolute improvement in 15-year survival (42 versus 32 %).
Age 50 to 69, the risk of relapse or death was decreased by 19 and 12 %.
3 % absolute gain in 15-year survival (50 versus 47 %).
> age 70 , the benefits of chemotherapy are still uncertain because few studies have included women in this age group.
Lancet 2005; 365:1687 46

47. Early Days: Alkylating Agents and Antimetabolites
In 1976, Bonadonna and colleagues from Milan, Italy, reported that postoperative CMF improved DFS and OS in women with node-positive breast cancer
At the same time, the NSABP was evaluating adjuvant L-phenylalanine mustard and fluorouracil
In Scandinavia, Nissen Meyer was evaluating adjuvant cyclophosphamide
CMF, cyclophosphamide, methotrexate, 5-fluorouracil; DFS, disease-free survival; NSABP, National Surgical Adjuvant Breast and Bowel Project; OS, overall survival.
I will begin with a brief history of adjuvant therapy in breast cancer. In the early years, we studied alkylating agents and antimetabolites in adjuvant therapy trials. In 1976, Bonadonna and colleagues from Milan, Italy, reported that postoperative cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) improved disease‑free survival and overall survival in women with node‑positive breast cancer. At the same time, the National Surgical Adjuvant Breast and Bowel Project (NSABP) in the United States and Canada was evaluating adjuvant L‑phenylalanine mustard and 5-fluorouracil, and in Scandinavia, Meyer and colleagues were evaluating postoperative adjuvant cyclophosphamide. 47 47

48. Duration of Chemotherapy CA Cancer J Clin 1995;45:199-226 EBCTCG
 Duration of Chemotherapy CA Cancer J Clin 1995;45: EBCTCG. Lancet 1992;339:71-85
less than 3 months was inferior to treatment for 4 to 6 months
Longer than 6 months was no more effective than treatment for four to 6 months.
The combinations standard therapy
fluorouracil, doxorubicin, and cyclophosphamide (FAC 6 cycles)
fluorouracil, epirubicin, and cyclophosphamide (FEC 6 cycles)
(AC 4 cycles); and CMF (6 cycles).
intermittently at intervals of three to four weeks.
Addition of 4 cycles of paclitaxel (duration, 12 to 16 weeks) to 4 cycles of AC improved both disease-free survival and overall survival rates.
In premenopausal women
Ovarian ablation = combination chemotherapy or tamoxifen.
This benefit persists for 15 years after treatment. 48

49. The choice of regimen
Ththere is a modest but significant benefit for anthracycline-containing compared to nonanthracycline-containing adjuvant chemotherapy (CMF).
Both premenopausal and postmenopausal women with node-positive breast cancer should consider a taxane-containing chemotherapy regimen. 49

50. Adjuvant chemotherapy
Incorporate Taxane
TAC, 3rd generation, mid-1990s
Taxotere
Adriamycin
Cyclophosphamide
More toxic than CAF
Better than CAF in high-risk group
Need more time to observe

51. Adjuvant Herceptin Effective in Her2+ pts
ICH3+
FISH+
Herceptin + adjuvant chemotherapy
Optimal role to be defined
Concurrent or sequential?
Maintenance ? Duration ?

52. Adjuvant hormone therapy
GNRH agonists
(A) Premenopausal
(B) Postmenopausal LH
FSH
Breast
carcinoma
Antiestrogen
Breast
carcinoma
Antiestrogen
Adrenal
Estrogen
Estrogen
When selecting patients for hormonal therapy, age and receptor status are important considerations. As you can see on the right side of this slide, the preferential hormonal treatments in older postmenopausal women are antiestrogens or inhibitors of the aromatase enzyme.
Androstenedione
Aromatase
inhibitor
Adapted with permission from Tellez C, et al. Surg Oncol Clin North Am. 1995;4:
Ovary
GNRH = Gonadotropin-releasing hormone; LH = Luteinizing hormone; FSH = Follicle-stimulating hormone.
Peripheral
aromatization 52 52

53. Hormone therapy — Adjuvant hormone therapy
For presence of ER or progesterone (PgR) receptors.
Premenopausal women
Surgical removal (or irradiation) of the ovaries
Tamoxifen
Luteinizing hormone releasing hormone (LHRH) analogs (eg, goserelin [Zoladex®], leuprolide [Lupron®]).
For postmenopausal women
Tamoxifen or aromatase inhibitors (anastrozole [Arimidex®], letrozole [Femara®], exemestane [Aromasin®]). 53

54. Tamoxifen hormone therapy EBCTCG The Lancet 2005; 365:1687-1717
ER (+) only
5 yrs of adjuvant tamoxifen reduces the annual breast cancer death rate by 31%, largely irrespective of the use of chemotherapy and of age (<50, 50–69, ≥70 years), progesterone receptor status, or other tumor characteristics.
The annual breast cancer mortality rates are similar during years 0–4 and 5–14.
The cumulative reduction in mortality is more than twice as big at 15 years as at 5 years
5 years vs 1-2 yrs
2p<0·00001 for recurrence
2p=0·01 for breast cancer mortality 54

55. Adjuvant hormone therapy
Aromatase inhibitor
Effective in post-menopausal state
Aromatase, in fat tissue,
Convert androgen to estrogen
Main estrogen source in post-menopausal
Exemestane : Aromasin
Letrozole: Femara
Anastrozole: Arimidex
More effective than Tamoxifen 55

58. Comparative Toxicity: Tamoxifen and Aromatase Inhibitors
ATAC
Significantly higher toxicity with tamoxifen vs anastrazole
   • Vaginal bleeding or discharge
   • Hot flashes
   • Endometrial cancer
   • Ischemic cerebrovascular events
   • Venous thromboembolic events
Significantly higher toxicity with anastrozole vs tamoxifen
   • Arthralgia
   • Fractures 58

59. Comparative Toxicity: Tamoxifen and Aromatase Inhibitors
Significantly higher toxicity with tamoxifen vs exemestane
   • Gynecologic symptoms
   • Vaginal bleeding
   • Muscle cramps
   • Thromboembolic events
Significantly higher toxicity with exemestane vs tamoxifen
   • Arthralgia, Myalgia, Arthritis/osteoarthritis
   • Limb pain, Carpal tunnel, Paraesthesia
   • Myocardial infarction
   • Diarrhea 59

60. Aromatase inhibitors
Upfront therapy (an AI initially instead of tamoxifen)
Sequential therapy (switch to an AI after 2-3 years of tamoxifen)
Extended therapy (an AI after 5 years of tamoxifen). 60

61. Adjuvant ovarian suppression
Effective in pre-menopausal state
Type
Surgical ablation
RT ablation
GnRH analogue: Goserelin, Leupride
Exact role to be defined
Combination with chemotherapy?
Combination with AI or TAM?

62. Concurrent chemotherapy : Sequential chemotherapy
Proc Am Soc CLIN Oncol 21: 37a, 2002 (abstr 143) 62

63.  Does chemotherapy add benefit to tamoxifen for postmenopasual women with ER-positive disease ?
Combined chemotherapy and tamoxifen therapy for postmenopausal women with node-positive ER-positive disease EBCTCG overview analysis
Decreased the annual risk of recurrence and death by 35 and 34%, vs tamoxifen alone.
Tamoxifen should be started after chemotherapy is completed, and not given concurrently.
The benefit of adding chemotherapy to tamoxifen is less clear for women with ER-positive node-negative
are inconclusive 63

64. Neoajuvant chemotherapy
Large operable tumors
90% of primary operable tumors decrease in size by more than 50 %.
Lumpectomy a possibility for many women who would otherwise have required a mastectomy.
No apparent advantage survival to preoperative chemotherapy as compared with postoperative chemotherapy. 64

65. 65

66. Neoajuvant chemotherapy
Emerging data supports a similar degree of benefit from taxanes in the neoadjuvant setting.
4 cycles of induction AC plus vincristine and prednisolone (CAVP); responders were then randomly assigned to continue CAVP for a total of eight courses, or switch to four cycles of docetaxel.
The number of pCRs (pathologic complete remission) sequential docetaxel vs CAVP (34 versus 16 %).
Initial fail respond to CAVP had a cCR (complete clinical responses) rate of 55% to subsequent docetaxel monotherapy.
Significant five-year OS (97 versus 78 %)
Presented at the 26th annual San Antonio Breast Cancer Symposiom, San Antonio, TX, December 2003 (abstract 11). 66

67. Treatment of metastatic dz
Usual sites: bone, lung, liver, brain
Incurable
Goal: live with dz for longest time
Systemic treatment is mainstay
Chemotherapy
Hormone therapy
Palliative local therapy
Radiotherapy
Palliative surgery

68. Treatment strategy Principle: Why? Save your bullet
Right time, right treatment
Why?
Treatment effectiveness only in limited duration
To avoid unnecessary toxicity
Ultimately incurable

69. Chemotherapy In general, chemotherapy Hormone therapy
Single agent: RR: 20-30%
Combination: doublet: 40-60% triplet: 70-80%
Hormone therapy
Tamoxifen: RR 15-20%
Aromatase inhibitor: RR 30-35%

70. Chemotherapeutic agents
Single agents:
Doxorubicin/Epirubucin
Cyclophosphamide
MTX
5-FU
Taxane(Paclitaxel, Docetaxel)
Navelbine
Gemcitabine

71. Chemotherapy regimens
Combination:
Navelbine-HDFL
Paclitaxel-Cisplatin
Doxorubicin-Cyclophosphamide
Gemcitabine-Paclitaxel/-Trastuzumab/-lapatinib
Combination C/T provide better RR, but overall survival not different

72. Example - 1 55y/o woman, ER/PR +/+, Dz recurred 5yrs after surgery
Only neck and mediastinum LNs
Slowly progressed clinically(!)
Hormone therapy
May do RT for symptomatic site

73. Example - 2 45 y/o woman, ER/PR -/- Dz recurred 3 yrs after operation
Only right supraclavicle LNs
Slowly progressed
RT alone
Observation

74. Example - 3 50 y/o woman, ER/PR +/+
Back, shoulder, hips pain, 3m, progress
Massive bone mets over spine, pelvis, shoulder, and ribs
Systemic chemotherapy, combination
RT for symptomatic sites
Bisphosphonate: Aredia or Zometa

75. Example - 4 55 y/o woman, ER/PR +/+ Dyspnea progressively
Lung mets bilaterally
Systemic chemotherapy, combination

76. Treatment principle For visceral organ crisis
Combination chemotherapy
Failure is not allowed (high RR necessary)
For isolated LN or bone mets
Hormone tx (more chance to try)
RT alone in hormone unresponder

77. Trastuzumab
20-30 % of breast cancers overexpress the HER-2/neu protein.
Preliminary reports support a significant disease-free survival and overall survival benefit from the addition of trastuzumab to anthracyclines and paclitaxel in the adjuvant setting, particularly for women with node-positive breast cancer.
Increase in the risk of cardiac events. Trastuzumab at the earliest sign of cardiotoxicity developed in 2 to 3 % over a two year period. Long-term data in the adjuvant setting is lacking.

78. SUMMARY Surgical resection is required in all invasive breast cancer.
Outcomes are similar with mastectomy and breast conserving therapy (lumpectomy plus breast radiation therapy).
The status of the axillary lymph nodes provides important prognostic information.
Sentinel lymph node dissection is replacing axillary lymph node dissection.
there is no information about the long-term outcome (ie, cancer-specific survival). (compare to full axillary node dissection.)
With positive sentinel node require a completion axillary node dissection.
Adjuvant systemic therapy (chemotherapy, hormone therapy, trastuzumab or a combination) is recommended for node (+), and tumors > 1 cm.
Adjuvant hormone therapy is for ER-positive or PR-positive.