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Metastatic spinal cord compression is an oncologic emergency, and the most frequent initial symptom is radicular backpain. Urgent diagnostics with acute MRI and early treatment is essential to prevent permanent neurologic damage. Treatment is mainly palliative. For patients who have a good prognosis, the treatment of choice is decompressive surgery followed by radiotherapy, but only few patients are candidates to surgery due to significant comorbidities and poor performance status. Optimal therapy is required to maintain high quality of life at an acceptable risk, as argued in this review.

There is 10-30% risk of developing isolated locoregional recurrence (ILRR) after mastectomy for primary breast cancer. Currently, there is no standard treatment for ILRR and therefore patients with ILRR cause an oncological task. This review investigates existing literature concerning relevant randomized trials of adjuvant medical treatment with chemotherapy, anti-hormonal and anti HER2 treatments for patients radically treated for ILRR. Certain groups of patients may benefit from adjuvant systemic treatment. However larger randomized trials are needed.

This article is based on a systematic literature search and meta-analyses of clinical data regarding effects of bisphosphonates (BP) and denosumab (DS) on preventing skeletal related events (SRE) in patients with bone metastases from solid tumours. Although there are pharmacological differences between the different types of BP no major differences were observed between BP in preventing SRE or in adverse events. Treatment with DS has in three randomised trials showed a greater effect than BP in preventing SRE. The optimal choice of bone-anti-resorptive agent should depend on the patient's general condition, renal function and treatment logistics.

Bone metastases are a frequent condition leading to fractures, hypercalcaemia and spinal compression. The treatment will depend on the possibility to treat the cancer. Secondly local treatment should be considered. To relief pain radiotherapy, given as 1 fraction with 8 Gy, is an effective treatment. Radiotherapy can also be used to treat complications from the metastasis. The use of bisphosphonates is now established in the treatment of breast cancer with bone metastasis to prevent complications from bone metastasis. Surgery is a growing possibility both as treatment of manifest fractures and prophylactic. Selection of patients to surgery is important to keep complication rate low.

The treatment of loco-regional recurrence (LRR) after breast cancer is based on the achievement of loco-regional control by radical surgery and adjuvant postoperative radiotherapy. Antiestrogens used as treatment in patients with steroid receptor positive LRR can increase disease free survival. Adjuvant chemotherapy is not applied to patients with LRR who have had radical loco-regional salvage treatment. Further studies are needed to elucidate this issue.

This review discusses the evidence for endocrine treatment in postmenopausal patients with metastatic breast cancer. First line treatment with non-steroid aromatase inhibitors (AI) yields response rates of 30% and improves progression free survival, but not overall survival, compared to tamoxifen. With second line treatment using steroid AI, estrogen antagonists or selective estrogen receptor modulators prolonged disease stabilisation is achieved in 40% of patients. With third line treatment using steroid AI and estrogen antagonists disease stabilisation is achieved in up to 30% of patients.

In general, chemotherapy improves recurrence-free and overall survival in patients with early breast cancer, but the possible benefits should be weighted against toxicities and the socio-economic burden for the individual patient. The benefits appear to be less in patients with hormone receptor positive tumours aged 59 or older and endocrine therapy alone might be preferred in these patients. A regimen containing anthracyclines and taxanes, the most active drugs in primary breast cancer, is preferable if chemotherapy is to be used, e.g. epirubicin and cyclophosphamide followed by docetaxel.

2-5% of breast cancers are locally advanced (LABC). The standard treatment is neoadjuvant chemotherapy (NC) with an anthracycline-based regimen followed by surgery and adjuvant therapy. Pathological complete response (pCR) to NC is correlated to survival. However, only a small percentage of patients achieve pCR and the prognosis is poor. Addition of paclitaxel or docetaxel increases clinical and pathologic response rates. In addition trastuzumab seems effective. Prediction of treatment response may be guided by novel biotechnological approaches.

The main goal of neoadjuvant treatment for large operable or locally-advanced breast cancer is downstaging tumors. It may allow breast-conserving surgery on tumors that are unsuitable at initial presentation or convert some inoperable breast cancers into tumors that are operable. Neoadjuvant antihormonal therapy for receptor positive tumors is an effective and safe alternative to chemotherapy in elderly postmenopausal women. This paper presents an updated overview of the results from early phase II studies of neoadjuvant endocrine therapy, randomized trials of tamoxifen as primary treatment versus primary operation, and randomized phase III trials which compare tamoxifen and aromatase inhibitors.

This review discusses the indications and purposes of treatment for metastatic breast cancer with chemotherapy and monoclonal antibody against the erbB-2 receptor(trastuzumab). There is no curative treatment for this condition, but first line chemotherapy with anthracyclines or taxanes improves the overall survival and offers palliation of disease-related symptoms. For patients with HER-2 positive tumour the combination of chemotherapy and trastuzumab can increase the response rates and survival. Palliation of symptoms is also achievable with second line chemotherapy. For patients with symptoms and good performance status, third line treatment should be considered, but there are no standard recommendations.

Adjuvant hormonal therapy results in substantial improvements in disease-free and overall survival for women with operable breast cancer. Many randomised trials of adjuvant tamoxifen have been published, and an updated overview of their results is presented in this paper. The third-generation aromatase inhibitors have recently been compared with tamoxifen. These studies are also reviewed in this paper. The Danish Breast Cancer Cooperative Group recommends adjuvant hormonal therapy consisting of tamoxifen for 2.5 years followed by the aromatase inhibitor for 2.5 years, or 5 years of the aromatase inhibitor for women with contraindications to tamoxifen.

We summarise the physical and pharmacokinetic properties of the radionuclides used. The effect on pain from bone metastases caused by prostate cancer, breast cancer, and lung cancer is well documented. A review of the literature does not substantiate a clinically significant difference in the palliative effect produced by any of the radionuclides used. The effect achieved with nuclides is the same as that seen after external radiation. Radionuclides seem to reduce the number of new painful sites from bone metastases, and, as such, use of nuclides is expected to reduce the need for repeated external palliative radiation.

Routine follow-up of patients operated for primary breast cancer is a very expensive service, and it is necessary to clarify what purpose it serves. There is no evidence that routine follow-up of mastectomised patients influences morbidity, mortality, or quality of life. Only patients entering clinical trials or quality programmes should thus be followed-up. However, there is agreement in the literature that these patients should be offered follow-up in order to diagnose loco regional recurrences. Lumpectomised patients may be cured, if recurrence in the ipsilateral breast is detected at an early stage. Therefore, these patients should be followed up at regular visits. It is recommended that patients should be offered clinical examination every six months for the first five years, and once a year thereafter until ten years have elapsed since the primary treatment. Except for mammography of residual mamma at intervals of 12-18 months, there is no indication for any further paraclinical investigations.

The aim of the study was to identify and compare risk factors for development of metastases from breast cancer at specific anatomical sites. The sites were grouped into ten categories, simultaneous occurrences at several sites being common. The influence of various risk factors for recurrence at one specific site can be modelled by well-established survival analysis techniques such as the Cox regression model. Recently, a generalization has been proposed that allows for joint occurrences at more than one site. The prognostic influences of various risk factors on recurrence at different sites may be compared using these models. Both methods were applied to data from the Danish Breast Cancer Cooperative Group on recurrence after breast cancer; the risk factors examined were degree of anaplasia, number of positive lymph nodes, site of primary tumour, skin or deep fascial invasion, age of the patient and adjuvant treatment regimens. Adjuvant therapy had the same effect on recurrence at all sites. For chemotherapy, this effect was marginally significantly positive. The number of positive lymph nodes was associated with an increased risk of metastases at all sites except the brain, where an opposing trend was found. The degree of anaplasia was associated with a somewhat increased risk of metastases at all sites, again the brain was an exception, here the effect of degree of anaplasia was significantly more pronounced. Application of the new types of models resulted in fewer differences between the relative influence of the prognostic factors than are implied by the use of the traditional regression models.

This review reports the results of chemotherapy in advanced bladder cancer with emphasis on the latest studies concerning combination chemotherapy containing cisplatin and methotrexate. The main conclusion is, that chemotherapy has a tumor-reducing effect on both metastatic disease and local/regional recurrences, but it remains to be proven whether overall long-term survival is affected. Among patients who respond to chemotherapy, the survival seems to be prolonged, 10-15% of these patients achieving more than two years of disease-free survival. The most effective treatment regimes contain cisplatin and methotrexate. It is assumed that many patients with muscle-invasive bladder tumors have microscopic dissemination of the disease at the time of diagnosis, and chemotherapy has been given to these patients as primary treatment alone or as an adjuvant to cystectomy or radiotherapy. These studies have not been able to show any benefit in terms of prolonged survival of patients receiving chemotherapy. The results of on-going randomised studies are still awaited. It is concluded that chemotherapy to patients with both primary and metastatic bladder cancer is still an experimental treatment, which should only be used in the context of investigational studies.

Attempts were made to assess the value of various methods of demonstration of bone metastases in patients with recurrence of cancer of the breast. A material of 123 patients with suspected or verified recurrence of cancer of the breast was submitted to a programme of investigation consisting of conventional X-ray survey of the axial skeleton and thorax, bone tissue scintigraphy, bone marrow scintigraphy, bone biopsy and aspiration of marrow and blood status including serum alkaline phosphatase. 54% and 29% of the patients had bone, metastases as assessed radiographically and by biopsy, respectively. In patients with radiographically demonstrated bone metastases, the predictive value of positive (PV-pos) whole-body scintigraphy was 79%. The findings on bone tissue scintigraphy and bone marrow scintigraphy were in agreement with the radiographic findings in 78% and 72%, respectively, and with the biopsy findings in 71% and 74%, respectively, of the cases. All of the cases of metastases verified by biopsy were identified also by radiographic examination and by bone tissue scintigraphy. The predictive value of negative bone tissue scintigraphy (PV-neg) was 76% and of bone marrow scintigraphy 65%. With biopsy as the final proof, bone tissue scintigraphy, bone marrow scintigraphy and radiography were found to have PV-pos values of 96%, 89% and 95%, respectively and PV-neg values of approximately 50% for all three forms of examination. Bone marrow scintigraphy has thus no diagnostic advantages as compared with bone tissue scintigraphy.(ABSTRACT TRUNCATED AT 250 WORDS)

The clinical course of recurrent breast cancer was compared in 117 patients with recurrence diagnosed at routine follow-up visits and 100 patients with recurrence detected in the interval between two scheduled follow-up visits. The interval recurrences were diagnosed after self-appointments (37 cases), after referral by general practitioners (31 cases) or other departments (32 cases). The two groups of patients were comparable with respect to age, menopausal status, initial stage of disease, and the type of adjuvant systemic therapy. The interval group of patients had a longer recurrence-free interval and also more symptoms than the routine group. The anatomical distribution of metastases was comparable in the two groups. The interval group of patients had a shorter survival after recurrence compared to the routine group (median 16 versus 25 months, p = 0.07). The survival from initial diagnosis was comparable in the two groups (48 versus 58 months, p = 0.67). Using multivariate Cox regression analysis, the influence of interval as compared with routine recurrences was evaluated in relationship to other prognostic variables (initial stage, recurrence-free interval, presence of visceral metastases, number of metastatic sites). In this model, the stage of disease, the recurrence-free interval, and presence of visceral metastases were the only significant independent prognostic factors.