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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)