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Reproduced with permission from Dietz J et al. (2002).

A variety of reconstructive techniques are available today aimed at minimising the mutilation effect of mastectomy without compromising the oncological clearance (Ahmed et al, 2005).

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Reproduced with permission from Dietz J et al. (2002).

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  1. A variety of reconstructive techniques are available today aimed at minimising the mutilation effect of mastectomy without compromising the oncological clearance (Ahmed et al, 2005).

  2. (A) A schematic representation of the post-operative appearance after transverse rectus abdominis myocutaneous (TRAM) flap reconstruction. (B) A 35-year-old patient after skin-sparing mastectomy and immediate TRAM. Reproduced with permission from Dietz J et al. (2002).

  3. (A) A schematic representation of latissimus dorsi (LD) flap breast reconstruction. (B) A 38-year-old patient after modified radical mastectomy with immediate reconstruction using the LD flap and submuscular saline implant. Reproduced with permission from Dietz J et al. (2002).

  4. There is no standard or preferred way of reconstruction (Ahmed et al., 2005).

  5. Data from Gazet et al. (1991,1996).

  6. Post-mastectomy radiotherapy (PMRT) has been shown to optimise locoregional control and improve survival. However, although all three recent PMRT randomised trials utilised internal mammary nodal irradiation, its exact contribution to the survival benefit is unclear. CMF, cyclophosphamide, methotrexate and 5-fluorouracil. Data from Ragaz et al. (1997) and Overgaard et al. (1997,1999).

  7. Several trials of accelerated partial breast irradiation (APBI) were developed in the early 1990s. These showed higher local recurrence rates of 15–18%, but served to underscore the importance of tailoring APBI to a selected group of patients with low risk of local recurrence. ILC, invasive lobular carcinoma; EIC, extensive intraductal component. Data from Ribeiro et al. (1993), Fentiman et al. (2004), and Perera et al. (2003).

  8. Careful attention to histopathology and quality assurance of treatment delivery is essential to ensure APBI is applied appropriately. To this end, both the American Brachytherapy Society (Arthur et al., 2002) and the American Society of Breast Surgeons (ASBS, 2003) have published recommendations for patient selection criteria for accelerated partial breast irradiation (APBI).

  9. There are emerging data that accelerated partial breast irradiation (APBI) may be a safe and effective technique in breast cancer treatment but this approach requires longer term randomised evidence, particularly with regards to its equivalence with whole-breast radiotherapy (WBRT) in terms of local recurrence rates and cosmetic outcomes. EBRT, external beam radiotherapy; HDR, high dose rate; PDR, pulsed dose rate. Data from NSABP B-39/RTOG 0413 Protocol, Strnad & Polgar (GEC-ESTRO Working Group), Vaidya et al. (2004), and Veronesi et al. (2003).

  10. The EBCTCG confirmed that polychemotherapy produced substantial and highly significant proportional reductions in relation to the risk of relapse and death from breast cancer. The effects of treatment were described as either proportional or absolute benefits. For women under 50 years at randomisation, the absolute reduction in risk of relapse was 10.4% for node-negative and 15.4% for node-positive disease. The reduction was also significant for mortality (absolute improvements in 10-year survival of 5.7% and 12.4% for node-negative and -positive disease, respectively). CMF, cyclophosphamide, methotrexate and 5-fluorouracil. Reproduced with permission from the EBCTCG (2005).

  11. For women aged 50–69 years, the absolute reduction in relapse was approximately 5.5% for both node-negative and node-positive individual, and rates in mortality showed absolute improvements in 10-year survival of 6.4% and 2.3% for node-negative and -positive, respectively. CMF, cyclophosphamide, methotrexate and 5-fluorouracil. Reproduced with permission from the EBCTCG (2005).

  12. Early trials examining the use of anthracyclines were small, or used substandard anthracycline doses and/or regimens, and hence it required an overview to confirm their benefit over cyclophosphamide, methotrexate and 5-fluorouracil (CMF). Reproduced with permission from the EBCTCG (2005).

  13. AC, doxorubicin, cyclophosphamide; FAC, 5-fluorouracil, cyclophosphamide, doxorubicin; FEC, 5-fluorouracil, cyclophosphamide, epirubicin; HR, hazard ratio; OS, overall survival; T, docetaxel; TAC, docetaxel, doxorubicin, cyclophosphamide; TC, docetaxol, cyclophosphamide. Data from Nabholtz et al. (2002), Jones et al. (2003), Roche et al. (2004), and Bear et al. (2003).

  14. AC, doxorubicin, cyclophosphamide; HR, hazard ratio; OS, overall survival; T, paclitaxel. Data from Henderson et al. (2003) and Mamounas et al. (2003).

  15. Following the success of trastuzumab in metastatic breast cancer, four large international multicentre trials were designed to test the efficacy of trastuzumab as adjuvant treatment either with or following chemotherapy. *Group B from N9831 and Group A from HERA were excluded from the analysis. AC, doxorubicin, cyclophosphamide; LN, lymph node. Data from Romond et al. (2005), Piccart-Gebhart et al. (2005), and Slamon et al. (2005).

  16. *Excluding group B from N9831. †Hazard ratio (HR) calculated for a first event. ‡HR calculated for death. DFS, disease-free survival; HR, hazard ratio; NS, not significant; OS, overall survival; T, trastuzumab-treated arm. Data from Romond et al. (2005) and Piccart-Gebhart et al. (2005).

  17. ACTH, doxorubicin, cyclophosphamide, docetaxel, trastuzumab; DFS, disease-free survival; HR, hazard ratio; NS, not significant; OS, overall survival;T, trastuzumab-treated arm; TCH, docetaxel, carboplatin, trastuzumab. Data from Slamon et al. (2005).

  18. There are international consensus guidelines based on clinicopathological features and outcomes, which are regularly updated to help inform local guidelines and individual clinicians. The 2005 St Gallen guidelines have defined low-, intermediate- and high-risk categories. Adapted from Piccart et al. (2005).

  19. The 2005 St Gallen guidelines recommend adjuvant treatment according to risk and endocrine responsiveness.*Depending on clinician and patient discussion. ET, endocrine therapy; CT, chemotherapy. Adapted from Piccart et al. (2005).

  20. AC, doxorubicin, cyclophosphamide; CAF, cyclophosphamide, doxorubicin, 5-fluorouracil; CEF, cyclophosphamide, epirubicin, 5-fluorouracil; CMF, cyclophosphamide, methotrexate, 5-fluorouracil; CT, chemotherapy; FEC, 5-fluorouracil, cyclophosphamide, epirubicin; TAC, docetaxel, doxorubicin, cyclophosphamide. Adapted from Piccart et al. (2005).

  21. References Ahmed S, Snelling A, Bains M et al.Breast reconstruction. BMJ 2005: 330:943–948. American Society of Breast Surgeons (ASBS). Consensus Statement for Accelerated Partial Breast Irradiation. Available at: www.breastsurgeons.org/officialstmts/officialstmt3.shtml. Arthur DW, Vicini FA, Kuske RR et al. Accelerated partial breast irradiation: an updated report from the American Brachytherapy Society. Brachytherapy 2002; 1:184–190. Bear HD, Anderson S, Brown A et al. The effect on tumour response of adding sequential pre-operative docetaxel to pre-operative doxorubicin and cyclophosphamide: preliminary results from National Surgical Adjuvant Breast and Bowel Project B27. J Clin Oncol 2003; 21:4165–4174. Dietz J, Moore H, Crownover R et al. Atlas of Cancer. Edited by M Markman, J Crowe. Philadelphia, PA: Current Medicine LLC, 2002. Early Breast Cancer Trialists Collaborative Group (EBCTCG). Effects of chemotherapy and hormonal therapy for early breast cancer on recurrence and 15 years survival: an overview of the randomised trials.Lancet 2005; 365:1687–1717. Fentiman IS, Deshmane V, Tong D et al. Caesium137 implant as sole radiation therapy for operable breast cancer: a phase II trial. Radiother Oncol 2004; 71:281–285. Gazet JC, Coombes RC, Ford HT et al. Assessment of the effect of pretreatment with neoadjuvant therapy on primary breast cancer. Br J Cancer 1996; 73:758–762. Gazet JC, Ford HT, Coombes RC. Randomised trial of chemotherapy versus endocrine therapy in patients presenting with locally advanced breast cancer (a pilot study). Br J Cancer 1991; 63:279–282. Henderson IC, Berry DA, Demetri GD et al.Improved outcomes from adding sequential paclitaxel but not from escalating doxorubicin dose in an adjuvant chemotherapy regimen for patients with node-positive primary breast cancer. J Clin Oncol 2003; 21:976–983. Jones SE, Savin MA, Asmar L et al. Three year results for a prospective trial of adjuvant chemotherapy for patients with stage 1-3 operable, invasive breast cancer comparing four courses of doxorubicin/cyclophosphamide to four courses of docetaxel cyclophosphamide. Presented at: 29th ASCO Annual Meeting, Chicago, USA. 31 May–3 June 2003; Abstract 59. Mamounas EP, Bryant J, Lembersky BC et al.Paclitaxel (T) following doxorubicin/cyclophosphamide (AC) as adjuvant chemotherapy for node-positive breast cancer: results from NSABP B-28. Presented at: 29th ASCO Annual Meeting, Chicago, USA. 31 May–3 June 2003; Abstract 12. Nabholtz J-M, Pienkowski T, Mackey J et al.Phase III trial comparing TAC (docetaxel, doxorubicin, cyclophosphamide) with FAC (5-fluorouracil, doxorubicin, cyclophosphamide) in the adjuvant treatment of node positive breast cancer (BC) patients: interim analysis of the BCIRG 001 study. Proc Am Soc Clin Oncol 2002; 21:Abstract 141. NSABP. Clinical Trials Overview: Protocol B-39/RTOG 0413. Available at: www.nsabp.pitt.edu/B-39.asp. Overgaard M, Hansen PS, Overgaard J et al. Postoperative radiotherapy in high-risk premenopausal women with breast cancer who receive adjuvant chemotherapy. N Engl J Med 1997; 337:949–955.

  22. References Overgaard M, Jensen MB, Overgaard J et al. Postoperative radiotherapy in high-risk postmenopausal breast cancer patients given adjuvant tamoxifen: Danish Breast Cancer Cooperative Group DBCG 82c randomised trial. Lancet 1999; 353:1641–1648. Perera F, Yu E, Engel J et al. Patterns of breast recurrence in a pilot study of brachytherapy confined to the lumpectomy site for early breast cancer with six years' minimum follow-up. Int J Radiat Oncol Biol Phys 2003; 57:1239–1246. Piccart MJ, de Valeriola D, Dal Lago L et al. Adjuvant chemotherapy in 2005: standards and beyond. Breast 2005; 14:439–445. Piccart-Gebhart MJ, Proctor M, Leyland-Jones B et al. Trastuzumab after adjuvant chemotherapy in HER-2 positive breast cancer. N Engl J Med 2005; 353:1659–1672. Ragaz J, Jackson SM, Le N et al. Adjuvant radiotherapy and chemotherapy in node-positive premenopausal women with breast cancer. N Engl J Med 1997; 337:956–962. Ribeiro GG, Magee B, Swindell R et al. The Christie Hospital breast conservation trial: an update at 8 years from inception. Clin Oncol 1993; 5:278–283. Roché H, Fumoleau P, Spielmann M et al.Five years analysis of the PACS 01 trial: 6 cycles of FEC100 vs 3 cycles of FEC100 followed by 3 cycles of docetaxel (D) for the adjuvant treatment of node positive breast cancer.Breast Cancer Res Treat 2004; 88(Suppl 1):S16. Romond EH, Perez EA, Bryant J et al. Trastuzumab plus adjuvant chemotherapy for operable HER-2-positive breast cancer. N Engl J Med 2005; 353:1673–1684. Slamon D, Eiremann W, Robert N et al.Phase III randomised trial comparing doxorubicin and cyclophosphamide followed by docetaxel (ACT) with doxorubicin and cyclophosphamide followed by docetaxel and trastuzumab (ACTH) with docetaxel, carboplatin and trastuzumab (TCH) in HER-2 positive early breast cancer patients; BCIRG 006 Study. Presented at: 28th Annual San Antonio Breast Cancer Symposium, San Antonio, TX. 8–11 December, 2005; Abstract 1. Strnad V, Polgar C; GEC-ESTRO Working Group. Phase III multicenter trial – interstitial brachytherapy alone versus external beam radiation therapy after breast conserving surgery for low risk invasive carcinoma and low risk duct carcinoma in situ (DCIS) of the female breast. Study protocol. Available at: www.apbi.uni-erlangen.de/outline/outline.html. Vaidya JS, Tobias JS, Baum M et al.Reducing radiotherapy dose in early breast cancer: The concept of conformal intraoperative brachytherapy. Br J Radiol 2004; 77:279–284. Veronesi U, Gatti G, Luini A et al. Full-dose intraoperative radiotherapy with electrons during breast-conserving surgery. Arch Surg 2003; 138:1253–1256.

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