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

RT

EBRT

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)