Treatment of Carcinoma Breast

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Treatment of Carcinoma Breast

surgery radiotherapy chemotherapy

Surgery
 Central role

Radical

Modified Radical

Conservative procedures

surgeries
 Radical mastectomy (Halsted)
 Extended Radical mastectomy  Modified Radical mastectomy (Patey)

 Breast conservative surgeries

Edwin smith papyrus (800 BC)

"There is no treatment."

Jean Louis Petit (1605)

structures removed
 Tumor  Entire breast, nipple, areola, skin over tumor
 P.major & minor  Complete Axillary LN dissection ( up to level 3),

fat , fascia  ICB nerve, few serrations of serratus

Structures retained
 Axillary vein, artery, brachial plexus
 Long thoracic N (Bell)  Thoracodorsal N

 Cephalic vein

1971 Fisher et al

National Surgical Adjuvant Breast and Bowel Project (NSABP) B-04 trial

“radical mastectomy had no survival benefit over mastectomy with radiation”

Modified radical mastectomy (patey’s)

Stewart incision

 Scanlon’s operation

 Auchincloss MRM

Conservative breast surgery
 Wide local excision (1 cm margin)

df. lumpectomy
 Quadrentectomy (QUART)
 Axillary dissection through separate incision

 Always combined with radiotherapy except

node - low grade tumors

BCS CONTRAINDICATIONS- ABSOLUTE
 Pregnancy
 Prior irradiation  Persistent +ve margins

 2 or more quadrants of primary tumor or

diffuse malignant appearing micro calcifications

BCS CONTRAINDICATIONS-relative
 CVD( except RA)
 Multiple primary/ calcifications in same

quadrant
 Large breast to tumor ratio  Large tumor (>4cm)

 Central tumor

others
 Subcutaneous / skin sparing / keyhole

mastectomy
 Simple mastectomy

 Toilet mastectomy
 Extended radical mastectomy

Sentinel lymph node biopsy

 Only micromets escape frozen section
 Completion Axillary node dissection  Full Axillary node dissection

COMPLICATIONS
 Injury/ thrombosis of Axillary V  shoulder dysfunction

 Winged scapula
 Flap necrosis/ infection

 Pain, numbness, hyperesthesia
 lymph edema

RADIOTHERAPY

 To prevent local recurrence

INDICATIONS (ASCO)
 T3 (>5 cm)
 Positive post mastectomy margins

 4 or more LN  BCS

EBRT RT Brachytherapy

Intra cavitory brachytherapy

Interstitial brachytherapy

Dose
 4500 Gy to chest wall ( 25 fractions of 150 Gy

over 5 weeks)
 Booster dose 1000 Gy to tumor bed

 1500 to axilla if needed
 Accelerated partial breast irradiation

Mew modalities
 Intensely modulated RT

 Targeted intraoperative RT

COMPLICATIONS
EARLY  Swelling, pain, edema  Skin exfoliation, fatigue LATE  Persistent beast edema, pain, swelling, pigmentation  Pulmonary fibrosis  Rib fracture  Lymph edema, sarcoma  Cardiac disease

CHEMOTHERAPY

micromets
 CONVENTIONAL 1. LN involved
2. high grade  HORMONAL- all ER/PR positive cases

 BIOLOGICAL- all ERB B2 positive cases

ER

HER 2 NEU ( ERB B2)

Hormonal
 SERM- tamoxifen  Aromatase inhibitor- letrozole
 Antigonadotropin- Danazole  LHRH agonist- med oophorectomy

 Pure anti estrogens & progestins
 Surgical/ radiological ablation

BIOLOGICAL
 Trastuzumab (herceptin)
 Bevacizumab  lapitinab

chemotherapy
 ADJUVANT ( for EBC)

FEC regimen  5- FU 500mg/m2  Epirubicin 75 mg/m2  Cyclophosphamide 500 mg/m2

6 cycles repeated every 28 days

Neoadjuvant (for LABC)
FACT regimen  5- FU 500mg/m2  ADRIAMYCIN 50mg/m2  Cyclophosphamide 500 mg/m2
6 cycles repeated every 28 days FOLLOWED BY
 Paclitaxel 175mg/m2 for 2 cycles

Old
 CMF( Bonnadona)

 AC-T

STD TREATMENT PROTOCOLS

CIS
 Surgery
 Radiation if high Van Nuys score

EBC
 Surgery (MRM/BCS + Axillary N sampling)
 RT if BCS or margins +

 CT if LN+ or high grade
 Hormonal & herceptin to all deserving

patients

LABC
 Neoadjuvant CT
 Followed by surgery

 RT
 Hormonal & herceptin to all deserving

patients  If no response, exp trials or palliative therapy

ABC
 Palliative
 Systemic therapy is mainstay 1. Hormonal therapy mainly

2. Cytotoxic therapy only in young , rapid growth

of tumors  RT & surgery seldom done  ‘Toilet mastectomy’  Local RT & internal fixation to bone mets

BREAST reconstruction
 Saline, silicone Implants

TRAM,DIEP,LD FLAP

SPECIAL SITUATIONS

MALE BREAST CA

PREGNANCY
 Surgery (no BCS)  CT (2ND trimester onwards)
 Wait 2 years

Follow up (NCCN)

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