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Book Details
Abstract
Breast Surgery meets the needs of surgeons in higher training and practising consultants for a contemporary and evidence-based account of this sub-specialty that is relevant to their general surgical practice. It is a practical reference source incorporating the most current information on recent developments, management issues and operative procedures. The text is thoroughly referenced and supported by evidence-based recommendations wherever possible, distinguishing between strong evidence to support a conclusion, and evidence suggesting that a recommendation can be reached on the balance of probabilities.
For this Sixth Edition the authorship team across the series has been expanded to include additional European and World experts, with an increased emphasis on global practice. Throughout all six volumes the contents have been extensively revised in line with recently published evidence. Detailed supportive key references are provided and are also included within the comprehensive list of references in the accompanying ebook. Links to recommended online videos have been added where appropriate.
- The Companion to Specialist Surgical Practice series provides a current and concise summary of the key topics within the major sub-specialties of general surgery.
- Each volume highlights evidence-based practice both in the text and within the extensive list of references at the end of every chapter.
This new edition of Breast Surgery has a revised structure that better reflects the patient pathway through the breast service. New authors have brought new insights into rapidly evolving areas including more sophisticated breast assessment, the increasing options for breast conservation using oncoplastic techniques, and primary medical therapy. An emphasis on patient assessment and surgical techniques are the cornerstone of this revised edition.
Table of Contents
| Section Title | Page | Action | Price |
|---|---|---|---|
| Front Cover | Cover | ||
| Inside Front Cover | ES2 | ||
| Breast Surgery | i | ||
| Copyright | ii | ||
| Contents | iii | ||
| Series Editors’ preface | v | ||
| Editors’ preface | vii | ||
| Evidence-based practice in surgery | ix | ||
| Contributors | xi | ||
| 1 Anatomy and physiology of the breast | 1 | ||
| Normal breast development: embryology and physiology | 1 | ||
| Embryology | 1 | ||
| Clinical considerations | 1 | ||
| Puberty | 2 | ||
| Clinical considerations | 2 | ||
| Pregnancy and lactation | 4 | ||
| 2 Assessment of patient with breast symptoms | 11 | ||
| Triple assessment | 11 | ||
| Clinical evaluation | 11 | ||
| Clinical history | 11 | ||
| Clinical examination | 12 | ||
| Lump | 13 | ||
| Axillary lump | 13 | ||
| Pain | 14 | ||
| Discharge (Figs 2.4–2.6) | 14 | ||
| Nipple retraction | 16 | ||
| Change in breast shape | 16 | ||
| Skin changes | 17 | ||
| Gynaecomastia | 17 | ||
| Radiological assessment | 19 | ||
| Mammography | 19 | ||
| Additional mammographic techniques | 20 | ||
| Tomosynthesis | 20 | ||
| Contrast-enhanced spectral mammography (CESM) | 20 | ||
| Ultrasound | 20 | ||
| Additional ultrasound techniques | 21 | ||
| Automated whole breast ultrasound (ABUS) | 21 | ||
| Magnetic resonance imaging | 21 | ||
| MRI as a screening tool | 21 | ||
| CT scanning | 22 | ||
| Isotope bone scan | 22 | ||
| Molecular imaging | 22 | ||
| Radiation-induced cancers | 22 | ||
| Image-guided breast intervention | 23 | ||
| Techniques | 23 | ||
| Fine-needle aspiration | 23 | ||
| Core biopsy | 23 | ||
| Vacuum-assisted diagnostic biopsy (VAB) | 23 | ||
| Vacuum-assisted excision (VAE) | 24 | ||
| INTACT device | 24 | ||
| Guidance techniques for image-guided intervention | 24 | ||
| Marker clip placements | 24 | ||
| Number of samples | 24 | ||
| Biopsy results | 24 | ||
| Key references | 25 | ||
| 3 Benign breast conditions | 27 | ||
| Introduction | 27 | ||
| Congenital abnormalities | 27 | ||
| Aberrations of normal breast development and involution (ANDI) | 27 | ||
| Aberrations of breast development | 27 | ||
| Fibroadenomas | 27 | ||
| Management | 28 | ||
| Tubular and lactating adenomas | 29 | ||
| Macromastia, so-called virginal or juvenile hypertrophy | 29 | ||
| Aberrations in the early reproductive period | 29 | ||
| Pain and nodularity | 29 | ||
| Mastalgia | 29 | ||
| Assessment | 29 | ||
| Treatment | 29 | ||
| Breast pain overview | 30 | ||
| Aberrations of involution | 30 | ||
| Palpable breast cysts | 30 | ||
| Imaging | 30 | ||
| Management | 30 | ||
| Sclerotic/fibrotic lesions | 30 | ||
| Duct ectasia | 30 | ||
| Benign neoplasms and proliferations | 31 | ||
| Epithelial hyperplasia | 31 | ||
| Atypical hyperplasia on core needle biopsy | 31 | ||
| Ductal papillomas | 31 | ||
| Multiple intraductal papilloma syndrome | 31 | ||
| Phyllodes tumours | 32 | ||
| Lipomas | 32 | ||
| Granular cell tumours | 32 | ||
| Breast infections | 33 | ||
| Neonatal infection | 34 | ||
| Lactational infection | 34 | ||
| Non-lactational infections | 34 | ||
| Periareolar infection | 34 | ||
| Treatment | 34 | ||
| Mammary duct fistula | 34 | ||
| Treatment | 35 | ||
| Peripheral breast infection | 35 | ||
| Granulomatous lobular mastitis | 35 | ||
| Skin-associated infection | 35 | ||
| Post-surgical infection | 37 | ||
| Infection associated with breast implants | 37 | ||
| Other infections and inflammatory conditions | 37 | ||
| Other benign conditions seen in the breast | 37 | ||
| Hamartoma | 37 | ||
| Nipple adenoma | 37 | ||
| Bloody nipple discharge in pregnancy | 38 | ||
| Eczema of the nipple | 38 | ||
| Raynaud’s disease of the nipple | 38 | ||
| Jogger’s nipple | 39 | ||
| Pseudoangiomatous stromal hyperplasia of the breast (PASH) | 39 | ||
| Fibromatosis | 39 | ||
| Montgomery's gland problems | 39 | ||
| Fat necrosis | 39 | ||
| Diabetic mastopathy | 39 | ||
| Sclerosing lymphocytic lobulitis | 40 | ||
| Haematomas | 40 | ||
| Para-areola cysts | 40 | ||
| Mondor's disease | 40 | ||
| Morphoea | 40 | ||
| Arteritis and aneurysm | 40 | ||
| Sarcoidosis | 41 | ||
| Keloids of the breast skin | 41 | ||
| Factitial disease | 41 | ||
| Nipple discharge | 41 | ||
| Investigation | 42 | ||
| Operations commonly performed in benign breast conditions | 42 | ||
| Microdochectomy | 42 | ||
| Total duct excision or division | 43 | ||
| Common complications of cosmetic breast surgery | 43 | ||
| Breast augmentation complications | 44 | ||
| Capsular contraction | 44 | ||
| Rippling/palpable implant edge | 44 | ||
| Implant rupture | 44 | ||
| Breast reduction problems | 45 | ||
| Fat necrosis | 45 | ||
| Inclusion cyst | 45 | ||
| Key references | 45 | ||
| 4 Breast pathology | 46 | ||
| Introduction | 46 | ||
| Macroscopic assessment of specimens | 46 | ||
| Carcinoma in situ | 47 | ||
| Invasive cancer | 50 | ||
| Histological type | 50 | ||
| Histological grade | 52 | ||
| Tumour size | 52 | ||
| Lymphovascular invasion (LVI) | 53 | ||
| Lymph node status | 53 | ||
| TNM staging | 55 | ||
| Predictive biomarkers | 55 | ||
| Oestrogen receptor | 55 | ||
| HER2 | 56 | ||
| Triple-negative breast cancer | 56 | ||
| Prognostication | 57 | ||
| Other multiparameter tests for risk stratification | 57 | ||
| Conclusion | 59 | ||
| Key references | 59 | ||
| 5 Epidemiology, risk factors and prevention strategies | 61 | ||
| Risk factors for breast cancer | 61 | ||
| Age, geography | 61 | ||
| Age at menarche and menopause | 61 | ||
| Age at first pregnancy | 62 | ||
| Breast density | 62 | ||
| Previous benign breast disease | 63 | ||
| Diet and alcohol | 64 | ||
| Weight and height | 64 | ||
| Breastfeeding | 64 | ||
| Exogenous hormones | 65 | ||
| Physical activity | 65 | ||
| Genetics | 65 | ||
| Family history | 65 | ||
| BRCA1 and 2 genes | 65 | ||
| Other genes | 67 | ||
| Risk assessment | 67 | ||
| Prevention of breast cancer | 67 | ||
| Therapeutic options | 67 | ||
| Tamoxifen | 67 | ||
| Raloxifene | 70 | ||
| Lasofoxifene/Arzoxifene | 70 | ||
| Aromatase inhibitors | 71 | ||
| Adjuvant trials | 71 | ||
| Prevention trials | 71 | ||
| Other agents | 71 | ||
| Surgical options | 72 | ||
| Key references | 72 | ||
| 6 Breast screening | 74 | ||
| Introduction | 74 | ||
| Single- versus double-view mammography | 74 | ||
| Age extension of breast screening | 75 | ||
| Controversies of breast screening | 75 | ||
| NHS Breast Screening Programme (NHSBSP) | 76 | ||
| Quality standards | 76 | ||
| First stage of screening | 76 | ||
| Second-stage screening | 76 | ||
| Higher-risk surveillance through NHSBSP | 76 | ||
| Interval cancers | 76 | ||
| Updates in breast screening | 81 | ||
| Surgery for clinically occult breast lesions | 82 | ||
| Guided excision | 82 | ||
| Oncoplastic considerations for screen-detected lesions | 85 | ||
| 7 Breast-conserving surgery: the balance between good cosmesis and local control | 86 | ||
| Introduction | 86 | ||
| Selection of patients for breast conservation | 87 | ||
| Factors affecting local recurrence after breast-conserving surgery | 88 | ||
| Patient-related factors | 89 | ||
| Tumour-related factors | 89 | ||
| Tumour phenotype | 90 | ||
| Tumour size | 91 | ||
| Tumour grade | 91 | ||
| Histological type | 91 | ||
| Lymphatic/vascular invasion | 91 | ||
| Extensive in situ component | 91 | ||
| Multiple tumours | 91 | ||
| Treatment-related factors | 92 | ||
| Breast-conserving surgery | 93 | ||
| Special technical details: wide local excision | 93 | ||
| Excising impalpable cancers | 95 | ||
| Factors influencing cosmetic outcome after breast-conserving surgery | 96 | ||
| Patient factors | 98 | ||
| Tumour factors | 98 | ||
| Location of tumour | 98 | ||
| Surgical factors | 98 | ||
| Re-excision and number of procedures | 100 | ||
| Axillary surgery | 100 | ||
| Postoperative complications | 100 | ||
| Breast-conserving surgery after neoadjuvant therapy | 100 | ||
| Radiotherapy | 100 | ||
| Other treatment effects | 101 | ||
| Treatment of poor cosmetic results after breast-conserving surgery | 101 | ||
| Significance and treatment of local recurrence | 102 | ||
| Key references | 104 | ||
| 8 Oncoplastic breast-conserving surgery | 105 | ||
| Introduction | 105 | ||
| What about oncological outcomes? | 105 | ||
| Selection of cases for oncoplastic breast-Łconserving surgery | 106 | ||
| Causes of deformity after breast-conserving surgery | 106 | ||
| Oncoplastic techniques in breast-conserving surgery | 107 | ||
| Volume displacement or replacement? | 107 | ||
| Volume displacement | 107 | ||
| Volume replacement | 107 | ||
| Timing of oncoplastic breast surgery | 108 | ||
| Basic techniques in breast-Łconserving surgery | 108 | ||
| Round block and tennis racket techniques | 108 | ||
| Incisions | 109 | ||
| Direct oncoplastic excisions with centralisation of NAC | 110 | ||
| Direct oncoplastic excisions with removal of NAC | 111 | ||
| Direct ellipses excisions | 111 | ||
| Therapeutic mammaplasty | 111 | ||
| Therapeutic reduction mammaplasty | 112 | ||
| Therapeutic mastopexy | 112 | ||
| Techniques of therapeutic mammaplasty by site of cancer | 112 | ||
| Inferior pole tumours | 112 | ||
| Medial and lateral tumours | 113 | ||
| Tumours in the upper pole of the breast | 114 | ||
| Tumours involving the NAC | 114 | ||
| Volume replacement techniques | 114 | ||
| Intercostal and lateral thoracic artery perforator flaps | 114 | ||
| Planning a LICAP or LTAP flap | 115 | ||
| Flap dissection | 115 | ||
| Anterior intercostal artery perforator flaps (AIAP) and medial intercostal artery perforator (MICAP) flaps | 116 | ||
| Thoracodorsal pedicle-based flaps | 117 | ||
| Thoracodorsal artery perforator (TAP) flap (Fig. 8.21) | 117 | ||
| Free flaps in breast-conserving surgery | 118 | ||
| Omental flaps | 118 | ||
| Case examples | 118 | ||
| Case example 1 | 118 | ||
| Case example 2 | 118 | ||
| Case example 3 | 119 | ||
| Case example 4 | 119 | ||
| Case example 5 | 119 | ||
| Case example 6 | 119 | ||
| Case example 7 | 120 | ||
| 9 Mastectomy | 122 | ||
| Introduction | 122 | ||
| Completeness of mastectomy | 122 | ||
| General considerations in planning a mastectomy | 123 | ||
| Smoking | 123 | ||
| Considerations for simple mastectomy | 124 | ||
| Planning a simple mastectomy | 125 | ||
| Technique | 125 | ||
| Managing the potential dog ear | 126 | ||
| Goldilocks mastectomy | 126 | ||
| Bilateral simple mastectomy | 127 | ||
| Undesirable scar patterns | 127 | ||
| Radical mastectomy | 127 | ||
| Considerations for mastectomy with immediate reconstruction | 127 | ||
| Planning a mastectomy with reconstruction | 128 | ||
| Tissue-based reconstruction | 128 | ||
| Circumareolar | 128 | ||
| Wise pattern | 128 | ||
| Dome | 128 | ||
| 10 Management of the axilla | 134 | ||
| Introduction | 134 | ||
| Axillary node clearance | 134 | ||
| Technique | 134 | ||
| Complications | 135 | ||
| Less invasive techniques for axillary staging | 135 | ||
| Sentinel node biopsy technique | 137 | ||
| Choice of dye | 137 | ||
| Injection site | 137 | ||
| Intraoperative evaluation | 137 | ||
| Preoperative imaging and evaluation of lymph nodes | 138 | ||
| Controversial situations | 138 | ||
| Ductal carcinoma in situ (DCIS) | 138 | ||
| Prophylactic Mastectomy | 138 | ||
| Axillary dissection in node-positive patients vs radiotherapy | 138 | ||
| Management of the axilla after neoadjuvant chemotherapy | 139 | ||
| Management of patients presenting with axillary lymph node metastases and an unknown primary | 140 | ||
| Conclusion | 141 | ||
| Key references | 141 | ||
| 11 Uncommon presentations of cancer affecting the breast | 143 | ||
| Pregnancy-associated breast cancer | 143 | ||
| Pathology | 143 | ||
| Clinical presentation | 143 | ||
| Diagnosis | 143 | ||
| Treatment (Fig. 11.1) | 144 | ||
| Local therapy | 144 | ||
| Axillary staging | 145 | ||
| Systemic therapy | 145 | ||
| Locally advanced and inflammatory breast cancers | 145 | ||
| Termination of and future pregnancy | 145 | ||
| Prognosis | 146 | ||
| Male breast cancer (Fig. 11.2) | 146 | ||
| Pathology | 147 | ||
| Clinical presentation | 147 | ||
| Diagnosis | 147 | ||
| Treatment | 147 | ||
| Local therapy | 148 | ||
| Adjuvant therapy | 148 | ||
| Treatment of metastatic disease | 148 | ||
| Prognosis | 148 | ||
| Paget’s disease of the breast (Fig. 11.3) | 148 | ||
| Diagnosis | 149 | ||
| Treatment (Table 11.1) | 150 | ||
| Prognosis | 150 | ||
| Other breast malignancies | 150 | ||
| Melanoma of the breast | 150 | ||
| Primary breast lymphoma (Fig. 11.4) | 151 | ||
| Angiosarcoma of the breast (Fig. 11.5) | 152 | ||
| Metastasis to the breast (Fig. 11.6) | 152 | ||
| Key references | 153 | ||
| 12 The genetics of breast cancer, risk-reducing surgery and prevention | 155 | ||
| Genetic predisposition | 155 | ||
| BRCA probability models | 157 | ||
| Genetic counselling and Łgenetic testing | 157 | ||
| Current management strategies for BRCA1/2 mutation carriers | 159 | ||
| Therapeutic surgery for breast cancer in BRCA1/2 mutation carriers | 159 | ||
| Risk-reduction strategies for women with a BRCA1 or BRCA2 mutation | 160 | ||
| Risk-reduction mastectomy for BRCA mutation carriers | 161 | ||
| Techniques of NAC-sparing mastectomy | 163 | ||
| Management of breast asymmetry after risk-reduction mastectomy | 165 | ||
| Breast reconstruction in BRCA1/2 mutation carriers | 165 | ||
| Role of sentinel lymph node biopsy in risk-reduction surgery | 167 | ||
| Psychosocial aspects of risk-reduction mastectomy | 168 | ||
| Bilateral risk-reducing salpingo-oophorectomy | 169 | ||
| Use of chemopreventive agents | 169 | ||
| Selective oestrogen-receptor modulators (SERM) | 169 | ||
| Aromatase inhibitors | 169 | ||
| Management of individuals with mutation in less common and moderate penetrance genes | 169 | ||
| Variance of unknown significance (VUS) | 170 | ||
| Summary | 171 | ||
| Key references | 173 | ||
| 13 Breast reconstruction | 174 | ||
| Introduction | 174 | ||
| Timing | 174 | ||
| Immediate breast reconstruction | 174 | ||
| Advantages | 174 | ||
| 14 Treatment of ductal carcinoma in situ | 192 | ||
| Background | 192 | ||
| Risk factors, natural history, pathology and receptors | 192 | ||
| Risk factors | 192 | ||
| Natural history | 192 | ||
| Stem cells | 193 | ||
| Pathology | 193 | ||
| Classification and features | 193 | ||
| Lobular intraepithelial neoplasia (LIN) | 194 | ||
| Receptors and markers | 195 | ||
| Presentation, investigation and diagnosis | 196 | ||
| Presentation | 196 | ||
| Investigation and diagnosis | 196 | ||
| Stereotactic core biopsy and vacuum-assisted biopsy | 196 | ||
| Localisation-guided biopsy | 197 | ||
| Other diagnostic procedures | 197 | ||
| Ductoscopy | 197 | ||
| Magnetic resonance imaging (MRI) | 197 | ||
| Treatment: mastectomy versus breast-conserving surgery | 197 | ||
| Mastectomy | 197 | ||
| Breast-conserving surgery | 197 | ||
| Axillary staging | 198 | ||
| Recurrence: rates and predictors | 199 | ||
| Assessment of excision margins | 199 | ||
| High-grade/comedo tumours | 199 | ||
| Histological type and tumour architecture | 200 | ||
| Age at diagnosis | 200 | ||
| Tumour size and palpability | 200 | ||
| Predictive scoring systems for recurrence after conservation surgery | 200 | ||
| Markers of recurrence | 201 | ||
| Adjuvant therapy | 201 | ||
| Radiotherapy | 201 | ||
| Endocrine therapy | 204 | ||
| Follow-up and prognosis | 205 | ||
| Management of recurrence | 206 | ||
| In situ recurrence | 206 | ||
| Invasive recurrence | 206 | ||
| DCIS of the male breast | 206 | ||
| The future | 206 | ||
| Ongoing DCIS trials | 206 | ||
| UK National DCIS audit (Sloane Project) | 207 | ||
| DCIS stem cell therapy | 207 | ||
| Optimising treatment | 207 | ||
| Key references | 208 | ||
| 15 The role of adjuvant systemic therapy in patients with operable breast cancer | 210 | ||
| Introduction | 210 | ||
| Adjuvant endocrine therapy | 210 | ||
| Endocrine therapy in premenopausal women | 210 | ||
| Tamoxifen | 210 | ||
| Endocrine therapy in postmenopausal women | 212 | ||
| Aromatase inhibitors: first-line therapy | 212 | ||
| Comparative toxicities of first-line aromatase inhibitors and tamoxifen | 213 | ||
| Sequential therapy with aromatase inhibitors after tamoxifen | 214 | ||
| Extended adjuvant therapy with aromatase inhibitors: beyond 5 years | 214 | ||
| Other aromatase inhibitor issues | 215 | ||
| Adjuvant chemotherapy | 216 | ||
| Identifying which patients will benefit from adjuvant chemotherapy | 216 | ||
| Age | 216 | ||
| Preserving ovarian function in premenopausal women | 216 | ||
| Nodal status | 216 | ||
| ER status | 217 | ||
| Molecular markers | 217 | ||
| Gene expression assays | 217 | ||
| Chemotherapy schedules | 218 | ||
| Anthracycline-based chemotherapy | 218 | ||
| Dose of anthracyclines | 218 | ||
| Anthracyclines and HER2-positive disease | 219 | ||
| Taxanes | 219 | ||
| Which taxane and which schedule? | 220 | ||
| Duration of chemotherapy | 220 | ||
| Dose density | 220 | ||
| Trastuzumab (Herceptin) | 220 | ||
| Chemotherapy and trastuzumab: concurrent or sequential? | 221 | ||
| Small HER2-positive breast cancers | 222 | ||
| Cardiotoxicity with trastuzumab | 222 | ||
| Triple-negative breast cancer | 222 | ||
| Bisphosphonates | 223 | ||
| Emerging adjuvant therapy | 223 | ||
| Conclusion | 224 | ||
| Key references | 224 | ||
| 16 Neoadjuvant therapy for breast cancer, including surgical considerations | 226 | ||
| Introduction | 226 | ||
| Landmark clinical trials evaluating neoadjuvant chemotherapy in operable breast cancer | 226 | ||
| Response to neoadjuvant chemotherapy | 228 | ||
| Influence of tumour molecular subtype on response to therapy | 228 | ||
| Triple-negative breast cancer | 229 | ||
| HER2-positive breast cancer | 229 | ||
| Hormone receptor-positive breast cancer | 231 | ||
| Imaging surveillance during neoadjuvant therapy | 232 | ||
| Implications for local regional therapy following neoadjuvant therapy | 232 | ||
| Management of the breast primary | 232 | ||
| Management of the axilla (see also Chapter 10) | 233 | ||
| Radiation therapy | 234 | ||
| Future directions | 234 | ||
| Summary | 236 | ||
| Key references | 237 | ||
| 17 Adjuvant radiotherapy for breast cancer | 239 | ||
| Background and history | 239 | ||
| Planning and treatment delivery | 239 | ||
| Practicalities and treatment pathways | 240 | ||
| Radiotherapy after breast-conserving surgery | 241 | ||
| Invasive cancer | 241 | ||
| Radiotherapy ‘boost’ | 242 | ||
| Ductal carcinoma in situ (DCIS) | 243 | ||
| Partial breast radiotherapy after breast-conserving surgery | 244 | ||
| Tailored radiotherapy | 244 | ||
| Radiotherapy after mastectomy | 244 | ||
| Radiotherapy and breast reconstruction | 245 | ||
| Postmastectomy radiotherapy (PMRT) after neoadjuvant chemotherapy (NACT) | 245 | ||
| Regional nodal irradiation | 246 | ||
| Axillary radiotherapy | 246 | ||
| Regional nodal radiotherapy | 247 | ||
| Fractionation | 247 | ||
| Toxicity | 247 | ||
| Early toxicity | 247 | ||
| Late toxicity | 248 | ||
| Conclusion | 248 | ||
| Acknowledgements | 249 | ||
| Key references | 249 | ||
| 18 Locally advanced breast cancer | 250 | ||
| Definition | 250 | ||
| Epidemiology | 250 | ||
| Pathobiology and prognosis | 251 | ||
| Work-up and staging | 251 | ||
| Treatment | 252 | ||
| Neoadjuvant chemotherapy | 253 | ||
| Neoadjuvant hormonal therapy | 254 | ||
| Surgery to the breast/skin coverage/reconstruction | 254 | ||
| Axillary surgery | 255 | ||
| Radiotherapy | 255 | ||
| Problems specific to LABC | 255 | ||
| Complex wounds | 255 | ||
| Summary and conclusions | 256 | ||
| Key reference | 256 | ||
| 19 Metastatic breast cancer and palliative care | 257 | ||
| Introduction | 257 | ||
| Presentation and prognosis | 257 | ||
| Staging | 258 | ||
| Treatment | 258 | ||
| Systemic therapy | 259 | ||
| Endocrine therapy | 259 | ||
| Premenopausal women | 259 | ||
| Postmenopausal women | 260 | ||
| Targeted therapies in HR-positive disease | 261 | ||
| Chemotherapy | 262 | ||
| Biological agents | 263 | ||
| HER2-targeted therapy | 263 | ||
| Bone supportive therapy | 263 | ||
| Assessment of response | 264 | ||
| Radiotherapy | 264 | ||
| Management of specific sites of disease | 264 | ||
| Primary tumour | 264 | ||
| Oligometastatic disease | 264 | ||
| Central nervous system metastases | 265 | ||
| Bone metastases | 265 | ||
| Malignant spinal cord compression | 265 | ||
| Pleural effusions and ascites | 265 | ||
| Other interventions | 266 | ||
| Control of symptoms | 266 | ||
| Pain relief | 266 | ||
| Neuropathic pain | 266 | ||
| Nausea and vomiting | 267 | ||
| Constipation | 267 | ||
| Care of the dying patient | 267 | ||
| Key references | 268 | ||
| 20 Psychosocial issues in breast cancer | 269 | ||
| Introduction | 269 | ||
| Delay in presentation | 269 | ||
| Psychosocial issues with breast cancer surgery | 270 | ||
| Decision-making | 270 | ||
| Effects of type of surgery | 270 | ||
| Impact of axillary surgery on quality of life | 271 | ||
| Ductal carcinoma in situ | 271 | ||
| Hormone therapy | 272 | ||
| Exercise | 273 | ||
| Conclusion | 274 | ||
| Summary | 274 | ||
| 21 Management of common breast emergencies and complications | 275 | ||
| Postoperative complications | 275 | ||
| Haematomas and postoperative bleeding | 275 | ||
| Infection following surgery to the breast and axilla | 276 | ||
| Infection around implant | 276 | ||
| Seroma management | 276 | ||
| Breast infection | 277 | ||
| Puerperal mastitis/abscess (see also Chapter 3, Benign Breast Disease) | 277 | ||
| Non-lactating abscess | 277 | ||
| Skin-related infection | 278 | ||
| Index | 281 |