I. Early diagnosis of breast cancer
1. Physical examination ultrasound mammography breast ductoscopy MR.
2.Emphasis on timely detection of occult breast cancer (mammographic calcification, nipple overflow, nipple eczema, axillary lymph node enlargement).
3.Lactoscopic localization of intraductal lesions for surgical excisional examination.
4. 80% of the cost of tumor treatment is wasted on late treatment, while the current early diagnosis and tumor screening are not given enough attention!
Progress of surgical treatment of breast cancer
1. Breast conservation, plastic breast conservation, simultaneous and deferred breast reconstruction are the future directions of breast surgery.
2. Axillary staging: sentinel lymph node biopsy (2013 progress) as well as axillary lymph node dissection.
Sentinel lymph node (SLN) biopsy is the standard treatment for cN0 stage breast cancer patients (not done for non-cN0). A large body of literature confirms that axillary lymph node dissection (ALND) is not required for patients with negative sentinel lymph nodes, and recent studies have found that axillary lymph node dissection is not necessary for some SLN-positive patients.
(1) The ACOSOGZ0011 trial demonstrated no significant difference in 6-year local control and survival rates for anterior lymph node dissection compared with axillary lymph node dissection (ALND) in patients with negative anterior lymph node biopsies, and mortality was lower in those with anterior lymph node dissection.
(2) For patients with positive sentinel lymph nodes who meet the ACOSOGZ0011 admission criteria (stage cT1-2N0, ≤2 positive SLNs, treated with total breast irradiation after breast-conserving surgery) there is no significant difference in long-term local control rates and survival with sentinel lymph node dissection compared to axillary lymph node dissection (ALND), and ALND is not mandatory.
(3) ALND may not be necessary for patients with positive sentinel lymph nodes who do not meet the ACOSOGZ0011 admission criteria (not receiving radiotherapy after mastectomy, receiving partial breast irradiation or undergoing chemotherapy, etc.), but further studies are needed.
III. Postoperative radiotherapy for breast cancer
1. Indications for postoperative radiotherapy
Breast-conserving surgery, except: patients over 70 years old, pathological stage I, hormone receptor positive, cut edge negative, in view of the low absolute recurrence rate, slow regression of breast edema, pain and other adverse effects after whole-breast radiotherapy, can consider endocrine therapy alone and not radiotherapy.
Modified radical surgery.
(1) The maximum diameter of the primary tumor is ≥5cm, or the tumor invades the breast skin and chest wall.
(2) Axillary lymph node metastasis ≥ 4.
(3) T1/T2 with one to three lymph node metastases,Current data also support the value of postoperative radiotherapy. Patients who include at least one of the following factors may be at higher risk of recurrence, and postoperative radiotherapy is more relevant: age ≤40 years, metastases >20% in axillary lymph node dissection with <10 lymph nodes, hormone receptor negative, HER-2/neu overexpression, etc.
Timing of breast reconstruction and radiotherapy.
2. Sequential arrangement of radiotherapy and chemotherapy, endocrine therapy
Breast-conserving surgery.
Postoperative radiotherapy for patients without indications for adjuvant chemotherapy is recommended within 8 weeks postoperatively. Because of the dynamic changes in the volume of the operative cavity in the early postoperative period, especially in patients containing seroma in the operative cavity, it is not recommended to start radiotherapy within 4 weeks after surgery. Patients receiving adjuvant chemotherapy should be started within 2 to 4 weeks after the last chemotherapy. There is no consensus on the timing of endocrine therapy in conjunction with radiotherapy.
Modified radical surgery: postoperative radiotherapy should be started within 2 to 4 weeks after completion of final chemotherapy. Individual patients with contraindications to adjuvant chemotherapy can start postoperative radiotherapy after the incision heals and upper limb function is restored. There is no consensus on the timing of endocrine therapy and radiotherapy, which can be carried out at the same time or after radiotherapy.
3. Radiotherapy positioning for breast-conserving surgery
It is recommended to place four to six inert metal clips (e.g. titanium clips) as positioning markers for radiation therapy on the tumor bed with additional irradiation (inform the patient before surgery); if the plastic breast-conserving glandular flap displacement is not consistent with the skin incision, it is recommended to give inert metal markers to the glandular stump as well.
Neoadjuvant treatment for breast cancer (chemotherapy, targeted therapy, endocrine therapy)
Indications.
(1) Clinical stage IIIA (excluding T3, N1, M0), IIIB, IIIC.
(2) Clinical stage IIA, IIB, IIIA (T3, N1, M0 only), neoadjuvant chemotherapy can also be considered for patients who wish to shrink the mass and downgrade the stage of breast conservation.
Significance.
① Neoadjuvant chemotherapy is the standard treatment for locally advanced breast cancer or inflammatory breast cancer, which can downgrade the tumor to facilitate surgery, or change inoperable to operable.
PCR can be encountered but not sought.
③The rate of breast conservation can be improved for patients with large tumors and a desire to preserve breast.
Follow-up treatment
Some breast cancers are not sensitive to the initial treatment regimen of neoadjuvant chemotherapy: if the tumor does not change or instead increases after 2 cycles of chemotherapy, the need to change the chemotherapy regimen (in vivo drug sensitivity testing) or use other therapies should be considered according to the actual situation.
Her-2 strong positive, FISH, CISH test positive breast cancer neoadjuvant therapy introduced trastuzumab PCR rate increased nearly double.
After receiving effective neoadjuvant chemotherapy, even if the tumor is clinically complete, it is important to receive established follow-up treatment, including surgery, and to decide on further adjuvant treatment options based on post-surgical pathology results.
Histological staging and grading of the residual tumor, and immunohistochemical results such as ER, PR and HER-2 are available for reference. Whether the pathological data obtained preoperatively or postoperatively, as long as there is one positive ER, PR or HER-2, the corresponding endocrine therapy or trastuzumab treatment can be given.
V. Adjuvant chemotherapy for breast cancer (based on molecular typing, risk of recurrence, and endocrine responsiveness to develop the regimen)
1.Update of molecular typing of breast cancer.
2. Triple-negative breast cancer.
By genetic analysis, triple negative breast cancer (TNBC) is able to be classified into six clusters-basal cell-like 1 (BL1), basal cell-like 2 (BL2), immunomodulatory (IM), mesenchymal-like (M), mesenchymal-like stem (MSL), and tube-like androgen receptor (LAR), and unstable cluster (UNS). Patients with triple-negative breast cancer are known to respond differently to treatment with chemotherapy, and the investigators identified 130 TNBC gene expression microsequences.
All patients received neoadjuvant chemotherapy with sequential paclitaxel and anthracycline-based regimens, and all of these patients had evaluable pathologic complete remission (pCR) data. study results showed that BL1 subtype had the highest pCR rate (52%) and BL2 and LAR had the lowest pCR rates at 0% and 10%, respectively. tNBC subtype and pCR status were significantly correlated (p =0.044). The likelihood ratio test suggested that TNBC subtype was an independent predictor of pCR status.
3. Doxorubicin + cyclophosphamide
The investigators studied the effectiveness and toxic effects of doxorubicin combined with cyclophosphamide or paclitaxel monotherapy in patients with early-stage breast cancer. The results of the study showed that doxorubicin combined with cyclophosphamide was more effective than paclitaxel in patients with early-stage breast cancer, but the toxic effects of paclitaxel treatment were less than those of the doxorubicin combined with cyclophosphamide regimen.