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Breast Cancer

Breast Cancer

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Published by: wonderwall_867133 on Oct 24, 2010
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BREAST CANCER The treatment of a patient with breast cancer rests with diagnosis, multidisciplinaryassessment and a combination of local and systemic therapy. Whether a patient isdiagnosed as a result of symptoms or through screening, the approach is the same.The assessment of clinical, radiological and pathological findings is required:
Clinical examination
may help distinguish cyst from solid lump.
Mammography
may identify malignant calcification or other features of concern, or the presence of a cyst. This may be complemented by ultrasound,and MRI may help if the findings are equivocal.
Cytology
from fine needle aspirate (FNA) and/or histopathology from a core biopsyincluding measurement of tumour grade, oestrogen receptor status (ER) and in somecases progesterone receptor (PR) and/or Her-2 status. These can be performed(probably more accurately) on a definitive resection specimen (wide local excision or mastectomy).Once a diagnosis of invasive cancer is made, further staging is performed (Box 11.11, p. 259).Local diseasePatients are treated with a combination of radical local therapy and systemic anti-cancer therapy. If breast conservation is possible and desired by the patient, surgicalexcision is performed if it is likely to remove all known disease. In other cases, particularly when there is extensive pre-invasive cancer, mastectomy may be needed.If the relative size of a tumour to the breast is too big for breast conservation, analternative approach is to give systemic anti-cancer therapy before surgery, which has been shown to reduce the need for mastectomy with no effect on overall survival.Successful breast conservation is followed by locoregional radiotherapy, although inolder women with low-risk cancers the added benefit may not outweigh thedisadvantages. All women should be considered for adjuvant systemic therapy, either hormonal or chemo-therapy or both (Box 11.21). For women with
very
low-risk tumours, the benefit of this may be too small to justify it in all cases.11.21 POST-OPERATIVE THERAPY IN EARLY BREASTCANCER 'Chemotherapy, ovarian ablation in pre-menopausal women, and tamoxifen inoestrogen receptor-positive tumours all reduce recurrence and mortality from breastcancer.'For further information:http://www.cochrane.org"target="_blank">www.cochrane.org
 
http://www.ctsu.ox.ac.uk/projects/ebctcg.shtml"target="_blank">www.ctsu.ox.ac.uk/projects/ebctcg.shtmlThe exact choice of systemic therapy is beyond the scope of this chapter, but wherechemotherapy is indicated it most commonly consists of an anthracycline, either incombination or in sequence with either an alkylator such as cyclophosphamide or ataxane. When the likelihood of benefit is small, treatments should not be offeredexcept as a last resort. Patients with breast cancers that do not express any hormonalreceptors (ER- and PR-negative cancers) should not be offered adjuvant endocrinetherapy such as tamoxifen or an aromatase inhibitor, as it will only increase the risk of toxicity. Similar predictors of response to chemotherapy are not at present defined, but may be in the future.Metastatic disease
 
The treatment is primarily systemic with chemotherapy and/or hormonal therapy;there is little role for surgery. Local treatment to an ulcerating primary may be given(such as radiotherapy or 'toilet' mastectomy), but most will improve with effectivesystemic therapy. However, when previous hormonal therapies have failed to work, or if the patient's disease is rapidly growing and involving vital organs such as liver or lung, effective control is more likely with chemotherapy.
Cervical cancer
ENDOMETRIAL AND CERVICAL CANCER For many years, a large part of the workload of radiotherapy departments has been thetreatment of cancer of the cervix and endometrium. These are the sites mostcommonly treated with intra-cavitary radioactive isotopes, usually caesium.Applicators may be inserted into the vagina and/or the uterus under a generalanaesthetic to guide placement and maintain the position of the isotope. For reasons of radioprotection, an afterloading technique is usually used whereby the radioactivesources are inserted into the preplaced applicators automatically using a system suchas a Selectron (Fig. 11.11).CARCINOMA OF THE CERVIXThe most common is squamous cell carcinoma. The disease is usually staged usingthe FIGO (Fédération Internationale de Gynécologie et d'Obstétrique) staging system.Investigations include an examination under anaesthetic and cystoscopy to assesslocal extent, as well as staging by intravenous urography (IVU), chest X-ray and blood tests.Figure 11.11
Selectron treatment of cervical cancer.
An X-ray taken after theinsertion of metal applicators into the vaginal vault and endometrium. Radioactivesources will be inserted into the applicators remotely (afterloading technique). Thefine lines are in gauze packing, to keep the applicators in place.Treatment depends on the stage:
 Pre-malignant disease
(cervical intra-epithelial neoplasia, CIN): local ablationwith laser therapy or diathermy.
Microinvasive disease
: cone biopsy or a simple hysterectomy in older patients past child-bearing age will be curative in the majority of cases.
 Invasive but localised disease
: radical surgery with a Wertheim's hysterectomy or radical radiotherapy offers potential cure. There are advantages and disadvantagesassociated with both of these treatments and patient preference is an importantconsideration. Often radiotherapy is offered to older patients and those not fit for surgery.In selected cases where there is a high risk of recurrence, there may be a role for post-operative radiotherapy. Where there is incurable disease, chemotherapy with acombination such as methotrexate and cisplatin may be beneficial.CARCINOMA OF THE CORPUS UTERIThe mainstay of treatment is surgery. An examination under anaesthetic and dilatationand curettage are essential as part of the staging investigations. The FIGO staging

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