President’s Address

In breast cancer surgery, there has been a major shift toward less invasive local treatment: from extended or radical mastectomy to modified radical mastectomy, from modified radical mastectomy to breast conserving therapy, and from routine axillary lymph node dissection to sentinel lymph node biopsy. Many breast surgeons have experienced an evolutionary progression of surgical management of breast cancer. However, there is an increasing demand for minimally invasive and non-surgical treatment methods for patients with small breast cancer. Radiofrequency (RF) ablation is the most promising among non-surgical ablation techniques in the treatment of breast cancer, although it is still in the investigative stage. Nevertheless, surgery still plays an integral role in the treatment of breast cancer, because local therapy is important for enhancing survival in the presence of systemic therapy. In clinical practice, surgical oncologists must individualize treatments, selecting a surgical or non-surgical procedure that provides the best local control, does not compromise the chances of cure, and achieves the best cosmetic results.     

Progress and controversies: Radiation therapy for invasive breast cancer

Answer questions and earn CME/CNE Radiation therapy is a critical component of the multidisciplinary management of invasive breast cancer. In appropriately selected patients, radiation not only improves local control, sparing patients the morbidity and distress of local recurrence, but it also improves survival by preventing seeding and reseeding of distant metastases from persistent reservoirs of locoregional disease. In recent years, considerable progress has been made toward improving our ability to select patients most likely to benefit from radiotherapy and to administer treatment in ways that maximize clinical benefit while minimizing toxicity and burden. This article reviews the role of radiation therapy in invasive breast cancer management, both after breast‐conserving surgery and after mastectomy. It focuses particularly on emerging evidence that helps to define the clinical situations in which radiotherapy is indicated, the appropriate targets of treatment, and optimal approaches for minimizing both the toxicity and the burden of treatment, all in the context of the evolving surgical and systemic management of this common disease. It includes a discussion of new approaches in breast cancer radiotherapy, including hypofractionation and intensity modulation, as well as a discussion of promising avenues for future research. CA Cancer J Clin 2014;64:135–152. ^© 2013 American Cancer Society .     

Improvement of survival and prospect of cure in patients with metastatic breast cancer

Patients with metastatic breast cancer have traditionally been considered incurable with conventional treatment. However, 5?C10% of those patients survive more than 5?years, and 2?C5% survive more than 10?years. Recent studies suggest that the survival of patients with metastatic breast cancer has been slowly improving. In this review, we examine the possible curative approach for a certain group of patients with metastatic breast cancer. We identify that patients most likely to benefit from such an aggressive approach are young and have good performance status, adequate body functional reserve, long disease-free interval before recurrence, oligometastatic disease, and low systemic tumor load. An aggressive multidisciplinary approach including both local treatment of macroscopic disease and systemic treatment of microscopic disease can result in prolonged disease control in certain patients with metastatic breast cancer. Whether patients with prolonged disease control are ??cured?? remains controversial.     

Overview of anal cancer for the surgeon

Cancers of the anal canal represent a diverse group of pathology and require a multidisciplinary approach for treatment. For the most common anal canal cancer, anal SCC, the primary therapy is CMT with systemic chemotherapy and radiation. The surgeon plays a key role in the diagnosis and follow-up after treatment, with surgical intervention reserved for residual or recurrent disease. The overall prognosis for this disease is favorable. For anal adenocarcinoma, aggressive surgical resection remains the mainstay of therapy, with radiation therapy and chemotherapy used to aid in local disease control and for treatment of metastatic disease. A high rate of distant failure in this disease is responsible for the poor long-term prognosis. Anorectal melanoma has a high rate of distant failure and a poor overall survival rate. Surgical intervention is focused on local disease control with preservation of sphincter function. The biggest improvements in survival for this disease will come with more effective systemic therapy.     

手术治疗在乳腺癌综合治疗中的地位

 非手术治疗技术的进展使乳腺癌局部和全身控制的效果进一步提高,但是手术治疗仍具有重要作用。早期乳腺癌可选择保乳治疗（部分可选择经乳晕切口的保乳术）、保留皮肤的乳房切除加即刻再造或改良根治术等个体化治疗。局部晚期的乳腺癌可先行新辅助治疗,然后行外科手术治疗。复发、转移乳腺癌的手术治疗对于控制局部症状、改善生活质量具有重要意义,最近的研究还表明可以带来生存获益。目前乳腺癌治疗策略仍然是以外科手术为主的综合治疗,无论从提高生存率还是改善生活质量方面来看,外科手术在乳腺癌的多学科治疗中仍占据核心地位。     

Diagnosis and management of primary breast sarcoma

Primary sarcoma of the breast is an extremely rare and heterogeneous disease. The rarity of this tumour limits most studies to small retrospective case reviews and case reports and has made clinicopathological study difficult. This article reviews the current literature on the diagnosis and management of breast sarcoma. The optimal treatment of breast sarcoma involves a multidisciplinary team prior to the initiation of treatment. Patients with tumours less than 5 cm that are easily resectable should undergo complete resection to the extent required to provide negative surgical margins. Negative surgical margins are more important for local recurrence and overall survival than the extent of surgical resection. Thus, neoadjuvant chemotherapy should be considered in order to shrink the tumour and help obtain negative surgical margins. Whether chemotherapy is indicated is primarily determined by tumour size. There is evidence that tumours larger than 5 cm are associated with an elevated risk of systemic failure and a poor prognosis. After surgical resection, patients with chemosensitive tumours should undergo additional adjuvant chemotherapy to treat micrometastatic disease. Radiation therapy should be used to improve local control in cases in which the tumour is larger than 5 cm and in cases with positive surgical margins. We propose to treat the patients according to the clinical practice guidelines in use for soft tissue sarcomas and address them to a reference centre for sarcoma. The appropriate treatment of breast sarcoma requires a multidisciplinary team approach necessitating experienced sarcoma surgeons, pathologists, radiotherapists and medical oncologists. Treating rare tumours in the same place should permit us to standardise pathological data and to include patients into multicentric radiotherapy or chemotherapy protocols to improve overall survival.     

Local therapy and survival in breast cancer with distant metastases

This review article presents an evaluation of the effects of local therapy on survival of breast cancer patients with distant metastases along with a discussion of their relevance. Primary and recurrent breast cancers with distant metastases are systemic diseases with poor prognosis. However, several retrospective studies have demonstrated that surgical removal of the primary breast tumor has a favorable impact on the prognosis of stage IV breast cancer patients. Similarly, it has been reported that surgical resection of metastatic lesions in the lung as well as the liver yields unexpectedly promising results. The interaction of local treatment and systemic therapy may be important, because surgery and radiotherapy are only local treatments. However, it remains uncertain whether these encouraging findings are due to the surgical procedure itself or preoperative patient selection. Only a randomized prospective study can definitively show whether local treatment can prevent death from stage IV disease or recurrent breast cancer with distant metastases. Until data from prospective studies are available, clinicians must weigh retrospective experiences and clinical judgment in deciding whether to offer surgery or radiotherapy to these patients.     

Primary soft tissue sarcoma of the breast

Opinion statement Primary soft tissue sarcoma (STS) of the breast is a rare and heterogeneous disease. The rarity of this tumor limits most studies to small retrospective case reviews and case reports. The optimal treatment of primary STS of the breast can best be determined through multidisciplinary discussions prior to the initiation of therapy. Whether chemotherapy is indicated is primarily determined by tumor size. There is evidence that tumors larger than 5 cm are associated with an elevated risk of systemic failure and a poor prognosis [1-3]. Negative surgical margins are more important for local recurrence and overall survival than is the extent of surgical resection [1]. Thus, neoadjuvant chemotherapy should be considered in order to shrink the tumor and help obtain negative surgical margins. After surgical resection, patients with chemosensitive tumors should undergo additional adjuvant chemotherapy to treat micrometastatic disease. Patients with tumors less than 5 cm that are easily resectable should undergo complete resection to the extent required to provide negative surgical margins. Radiation therapy should be used to improve local control in cases in which the tumor is larger than 5 cm and in cases with positive surgical margins [4-6]. The appropriate treatment of primary STS of the breast requires a multidisciplinary approach necessitating experienced surgeons, pathologists, radiotherapists, and medical oncologists.     

The role of locoregional therapy in inflammatory breast cancer

Inflammatory breast cancer (IBC) is the most aggressive form of invasive breast cancer. The disease is associated with extensive local disease at the time of initial diagnosis requiring multidisciplinary treatment including neoadjuvant systemic therapy, surgery and comprehensive locoregional therapy. The clinical and pathological response to induction chemotherapy represents an important prognostic factor. IBC is otherwise associated with a high incidence of locoregional recurrence suggesting a critical role also for local modalities, particularly radiotherapy. The use of different schedules of treatment and possible combination approaches are reviewed and discussed.     

局部区域复发乳腺癌的治疗进展

和初治的乳腺癌相比,局部区域复发性患者的预后分析和挽救治疗策略选择存在更多的不确定性。本文首先分析了影响保乳手术和乳房切除术后局部-区域复发的高危因素以及相应的复发模式。以再次手术和包括完整复发灶及相应亚临床病灶的放射治疗为主要形式的局部治疗是综合治疗策略的基础,合理的局部治疗可以达到有效的局部疾病控制率并降低二次局部区域复发。虽然既往的前瞻性或回顾性资料对于全身治疗在局部-区域复发乳腺癌治疗中的价值始终没有确认,由多个国际乳腺癌研究组织联合发起的CALOR研究结果的公布第一次证实,在保留合理的内分泌治疗和靶向治疗的前提下,手术+放射治疗联合后续的全身化疗可以进一步提高无病生存率和总生存率,尤其在激素受体阴性的患者中获益更显著。所以结合原发病灶和复发灶的肿瘤标志物给予合理的全身治疗将成为局部区域复发患者综合治疗重要的组成部分。     

The role of post-operative radiotherapy in the treatment of operable breast cancer

Summary In current practice, the management of early stage breast cancer involves a multidisciplinary cooperation among surgeons, radiation therapists, and medical oncologists. The goals of local treatment in this setting are to secure tumor control and to identify patients who are to be treated with adjuvant systemic therapy. For patients treated by mastectomy, the value of post-operative radiotherapy in primary treatment remains controversial. In this review, we examine the evolution of treatment philosophies for operable breast cancer and the results from recent clinical studies in an attempt to assess the current role of post-operative radiotherapy.     

Primary chemotherapy for early breast cancer

The use of primary chemotheraphy represents a novel approach being used with increasing frequency in the management of early breast cancer. Many studies now testify to the usefulness of this modality in increasing the frequency of breast conservation. The acceptance of high-risk breast cancer as a systemic, and therefore predominantly medical rather than a surgical, disease suggests, however, that its role is likely to be far more reaching. While some trials have so far suggested the possibility of a survival benefit for this approach, definitive conclusions are not yet possible and await the final mature results from several large randomized studies. Even if such studies do not show a large extra benefit for primary chemotheraphy over existing adjuvant treatment, the use of the primary tumour as an in vivo model of individual chemosensitivity and the identification of molecular markers as early predictors of response, suggest that this approach will become an integral part of the modern multidisciplinary management of early breast cancer.     

Brain metastases of breast cancer

Brain metastases of breast cancer remain a difficult problem for clinical management. Their incidence appears to be increasing, which is likely due to longer survival times for advanced breast cancer patients as well as additional and improved tools for detection. Molecular features of tumors associated with this syndrome are not yet understood. In general, survival may be improving for brain metastases due to better local control in the CNS, as well as improvements in systemic disease management. Selected patients with brain metastases are able to undergo surgical resection, which has been associated with extended disease control in some patients. However, whole-brain radiation has been the mainstay for treatment for most patients. Stereotactic radiosurgery is playing an increasing role in the primary treatment of brain metastases, as well as for salvage after whole-brain radiation. Recent series have reported median survivals of 13 months or longer with stereotactic radiosurgery. Further improvements in radiation-based approaches may come from ongoing studies of radiosensitizing agents. The ability of systemic treatments to impact brain metastases has been debated, and specific treatment regimens have yet to be defined. New approaches include chemotherapy combinations, biologic therapies and novel drug-delivery strategies.     

Inflammatory breast cancer: the disease, the biology, the treatment

Inflammatory breast cancer (IBC) is a rare and aggressive form of invasive breast cancer accounting for 2.5% of all breast cancer cases. It is characterized by rapid progression, local and distant metastases, younger age of onset, and lower overall survival compared with other breast cancers. Historically, IBC is a lethal disease with less than a 5% survival rate beyond 5 years when treated with surgery or radiation therapy. Because of its rarity, IBC is often misdiagnosed as mastitis or generalized dermatitis. This review examines IBC's unique clinical presentation, pathology, epidemiology, imaging, and biology and details current multidisciplinary management of the disease, which comprises systemic therapy, surgery, and radiation therapy.     

Brain metastases of breast cancer

Brain metastases of breast cancer remain a difficult problem for clinical management. Their incidence appears to be increasing, which is likely due to longer survival times for advanced breast cancer patients as well as additional and improved tools for detection. Molecular features of tumors associated with this syndrome are not yet understood. In general, survival may be improving for brain metastases due to better local control in the CNS, as well as improvements in systemic disease management. Selected patients with brain metastases are able to undergo surgical resection, which has been associated with extended disease control in some patients. However, whole-brain radiation has been the mainstay for treatment for most patients. Stereotactic radiosurgery is playing an increasing role in the primary treatment of brain metastases, as well as for salvage after whole-brain radiation. Recent series have reported median survivals of 13 months or longer with stereotactic radiosurgery. Further improvements in radiation-based approaches may come from ongoing studies of radiosensitizing agents. The ability of systemic treatments to impact brain metastases has been debated, and specific treatment regimens have yet to be defined. New approaches include chemotherapy combinations, biologic therapies and novel drug-delivery strategies.     

Does resection of an intact breast primary improve survival in metastatic breast cancer?

The recommended primary treatment approach for women with metastatic breast cancer and an intact primary tumor is the use of systemic therapy. Local therapy of the primary tumor is recommended only for palliation of symptoms. However, a series of retrospective studies examining practice patterns for this problem show that about half the women presenting with de novo metastatic disease undergo resection of the primary tumor, and suggest that women so treated survive longer than those who do not undergo resection of the intact primary. In analyses that adjust for tumor burden (number of metastatic sites), types of metastases (visceral, nonvisceral), and the use of systemic therapy, the hazard ratio for death is reduced by 40% to 50% in women receiving surgical treatment of the primary tumor. The benefit of surgical treatment appears to be confined to women whose tumors were resected with free margins. However, these results may simply reflect a selection bias (ie, younger, healthier women with a smaller tumor burden are more likely to receive surgical treatment). In addition, the role of other locoregional therapy such as axillary dissection and radiotherapy is not addressed in these studies. In view of these data, the role of local therapy in women with stage IV breast cancer needs to be reevaluated, and local therapy plus systemic therapy should be compared to systemic therapy alone in a randomized trial.     

Biology and surgical management of Breast Cancer

The surgical treatment of breast cancer has been a source of controversy. The controversy arises from the differences in physicians' philosophies regarding the biology of breast carcinoma. Traditionally, surgeons have emphasized the potential therapeutic value of regional lymph node dissection, maintaining that adequate loco-regional treatment is of prime concern in patients with localized tumors. On the other hand, medical oncologists have always stressed the systemic nature of cancer. However, breast cancer is a very heterogeneous disease with an enormous range of different biologic characteristics, and new information is continually becoming available on the natural history of breast cancer. Therefore, we should seek a more rational theory based on the clinical evidence which can explain the biologic characteristics of breast cancer. We have proposed a new spectrum hypothesis as follows: (a)tumor cells traverse lymphatics to lymph nodes by direct extension, and there is an orderly pattern in the early stage of lymph node metastases; (b)regional lymph nodes are able to trap tumor cells but are ineffective or incomplete barriers to tumor cell spread; (c)regional lymph nodes have biologic importance, and a positive lymph node is an indicator of a host-tumor relationship that correlates with the subsequent appearance of distant disease; (d)lymphatic and hematogenous dissemination occur not serially, but in a parallel fashion; (e)many palpable invasive breast cancers are a systemic disease, but non-invasive or minimally invasive breast cancers are likely to be a local disease; (f)early detection and treatment of in-breast cancer improves survival, but variations in regional therapy are unlikely to have a major influence on survival.     

初诊Ⅳ期乳腺癌的局部治疗研究进展

转移性乳腺癌(Metastatic breast cancer,MBC)是一种难以治愈性疾病,得益于全身治疗的发展和普及,患者整体预后已得到显著改善。而初诊Ⅳ期乳腺癌(De novo stage IV breast cancer)原发灶、转移灶的手术切除能否在系统治疗的基础上带来生存获益,目前存在较大争议,需要结合病人具体情况给予个体化诊治。现就初诊Ⅳ期乳腺癌外科治疗领域的热点问题进行综述。     

Does treatment at the time of locoregional failure of breast cancer alter prognosis?

Locoregional recurrence (LRR) after therapy for early breast cancer is common. Patients with LRR can suffer local consequences such as bleeding, ulceration, pain and arm oedema or symptoms of metastases. Unlike existing treatment guidelines for primary tumours, both local (surgical and radiation) and systemic treatment recommendations are less well defined after LRR. The purpose of this review was to assess whether or not treatment at the time of locoregional failure ultimately alters a patient's prognosis. Unfortunately, the data from both retrospective and prospective studies are inconclusive and therefore the treatment of patients with LRR will continue to be recommended using guidelines similar to those for primary breast cancer. Future studies of factors predicting LRR and metastatic spread may allow better prognostication of patients with LRR which may in turn effect both local and systemic treatment decisions.     

Sarcomas of the breast

Sarcomas of the breast are a rare group of heterogeneous mesenchymal tumors accounting for less than 1% of all breast malignancies. Owing to the rarity of the disease, current knowledge is mostly based on numerous case reports and relatively small retrospective series; unlike epithelial breast cancer, there is no high level evidence to support a standard of care for primary and/or adjuvant therapy. To overcome this relative shortage of data, most therapeutic strategies for breast sarcoma are extrapolated from current treatment for soft tissue sarcoma in other locations, mainly of the extremities and thoracic wall. In general, the therapeutic approach to sarcoma of the breast should be based on a multidisciplinary strategy including surgery, radiation to improve local control and systemic chemotherapy in selected patients. This review discusses the results of the key larger retrospective studies including data on incidence, etiology, presentation, diagnosis, management and prognosis of this challenging rare disease entity.