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Stephen B. Edge and David G. Sheldon

The purpose of axillary surgery in breast cancer is to provide prognostic information to guide the choice of adjuvant systemic therapy. Axillary surgery for ductal carcinoma in situ (DCIS) was abandoned in the 1980s because of the extremely low risk of lymph node metastases and high survival rates. Most women with metastases probably harbored an unrecognized focus of invasion or had metastases subsequent to an invasive local recurrence. Increased use of the less morbid sentinel node biopsy (SNB) for axillary staging of invasive cancer and the recognition that many patients will harbor micrometastases in nodes only recognized by cytokeratin immunohistochemistry (IHC) led two groups to perform SNB with IHC in women with DCIS. One group included all subtypes of DCIS and found metastases in 13% (half of which were detected only on IHC). The other group studied only patients with “high-risk” DCIS. They found metastases in 12% (7 of 9 by IHC only). These groups recommend SNB for women with DCIS. However, the use of SNB in DCIS should be tempered by the uncertainty of the prognostic significance of IHC-detected metastases, the conflicting results of these 2 studies, and the real potential to cause more harm than good from the morbidity of the procedure, the application of unnecessary axillary dissection, and the use of unwarranted adjuvant systemic chemotherapy. These results should be used to generate hypotheses for clinical trials addressing these problems. However, SNB for DCIS remains investigational and should not be generally applied.

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Donna Trauth and Lori J. Goldstein

Adjuvant chemotherapy clearly demonstrates a reduction in mortality in breast cancer. However, the added benefit from the addition of taxanes remains uncertain. Paclitaxel and its cousin docetaxel have proven activity in the treatment of metastatic breast cancer. Toxicity has been tolerable when taxanes are used as single agents or in combination with anthracyclines. Several clinical trials are currently underway evaluating the role of taxanes in the adjuvant setting. Preliminary results from large phase III studies are promising; however, mature data are required before conclusions can be drawn. This article reviews the trials currently underway, evaluating the efficacy, dosage, scheduling, and regimens of taxanes in the adjuvant treatment of breast cancer.

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Richard L. Theriault

Breast cancer frequently metastasizes to bone. Metastases result in skeletal morbidity including pathologic fractures, the need for radiation or surgery to bone, spinal cord compression and hypercalcemia. The pathophysiology of bone destruction is related to activation of osteoclasts by tumor-derived and bone marrow microenvironmental factors. One prominent osteoclast–activating factor associated with breast cancer is parathyroid hormone-related peptide (PTHrP). Bisphosphonates have been shown to impair osteoclast activity by decreasing recruitment from the monocyte macrophage cell line, inhibiting osteoclast function at the bone site and causing osteoclasts to undergo apoptosis. Clinical studies with bisphosphonates show an improvement in the control of hypercalcemia and a reduction in skeletal related morbidity with administration of pamidronate and zoledronic acid. Bisphosphonates have become the standard of care for osteolytic metastases associated with breast cancer. Recent data with zoledronic acid found that skeletal related morbidity may be reduced regardless of the radiographic picture of skeletal metastases. Thus, zoledronic acid may be valuable in osteolytic and osteoblastic disease as well as in disease with an osteolytic or osteoblastic radiographic appearance. In breast cancer with osteolytic disease, zoledronic acid may be more effective than pamidronate in reducing skeletal morbidity and prolonging the time to first skeletal event.

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Stephanie K. Patterson

Large, randomized controlled trials have proven the efficacy of mammography in reducing breast cancer mortality. However, the known deficiencies of mammography have led to the development of new technologies. Magnetic resonance imaging (MRI), digital mammography, computer-assisted diagnosis, positron-emission tomography (PET), technetium 99m sestamibi, and expanding roles for breast ultrasound have been explored as tools in breast cancer detection and evaluation. This article discusses these modalities and their current uses.

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Adam L. Cohen and John H. Ward

not powered for efficacy, a nonsignificant 30% decrease in breast neoplasms was seen with tamoxifen and a significant 62% ( P = .03) decrease in breast neoplasms was seen with fenretinide. The combination had an equivalent rate of breast events to