TREATMENT OF

EARLY BREAST
CANCER

PRESENTED BY: THASKEENA

GUIDE: DR. ABHIRAM

TREATMENT OF EARLY BREAST

CANCER PAGE 4
TABLE OF CONTENTS
1. Treatment algorithm 1
2. Surgery 2
3. Mastectomy 3-9
4. BCS 10-14
5. Treatment of axilla 15-18
6. Radiotherapy 19-21
7. Chemotherapy 22
8. Hormonal therapy 23-24
9. Targeted treatment 25
10. Summary 26-27
Early breast
carcinoma-
TNM stage l
and ll

2 PRINCIPLES
To reduce local
recurrence
To reduce risk of
metastic spread

1
SURGERY
1. PRIMARY
TUMOUR
Complete local
excision(CLE)
Mastectomy
2. AXILLA

2
 MASTECTOMY
Radical Mastectomy- Breast+ Pectoralis
muscles+ ALND
Total or simple mastectomy- Breast
without LN dissection
Modified Radical Mastectomy (MRM)-
Breast+ ALND
- Patey
- Scanlon
- Auchincloss 3


RADICAL William Halsted- 1889

MASTECTOMY Radical? Breast tissue+
skin+ muscles+ axillary LN

4
SIMPLE or TOTAL
MASTECTOMY

Breast with no dissection

of axilla except axillary tail
and few anterior LN

5
6
7
INDICATIONS
large tumours
central tumours
multifocal disease
local recurrence
patient preference MASTECTOMY
8
Complications
Seroma or lymph
collection

Secondary infection
Flap necrosis
Haemorrhage
Pain and numbness in the
axilla
Shoulder dysfunction
Injury / Thrombosis of
axillary veins
Injury to axillary veins
Winging scapula
Lymphedema of arm
9
BREAST CONSERVATON
SURGERY
Removing the tumour and a
margin of breast tissue
Includes lumpectomy and
quadrantectomy
QUART therapy by Veronesi--
quadrantectomy+ axillary
block dissection+
radiotherapy to breast and
axilla
10
LUMPECTOMY
Indicated in
tumour less than 4
cm with well
differentiated
histology
Axilla is treated
with ALND(if
palpable) / SLNB( if
negative)

11
12
CONTRAINDICATIONS
ABSOLUTE RELATIVE
Microcalcifications Active Connective
Multicentricity Tissue Disease
Inflammatory breast cancer Tumours >5cm

Pregnancy Positive pathologic

Previously irradiated breast margins
Genetic
predisposition

13
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TREATMENT OF AXILLA
AXILLARY CLEARANCE -- Removal of all levels of axillary LN
AXILLARY LYMPH NODE --Removal of minimum 10 axillary LN
without baring axillary vein
DISSECTION ( ALND)
INDICATIONS
T3 lesions
Clinically positive axillary nodes
USG guided fine needle
aspiration of axillary LN proving
metastasis

15
SENTINEL LYMPH NODE BIOPSY (SLNB)

SENTINEL LYMPH NODE?

PROCEDURE- DYE-> PATENT BLUE/ TECHNETIUM-99M-LABELLED ALBUMIN
WHERE TO INJECT- PERITUMOUR AREA
DETECTION- INCISION -> HANDHELD GAMMA CAMERA-> BLUE STAINING->
NODE BIOPSY/ IMPRINT CYTOLOGY
16
 CONTRAINDICATIONS
INDICATIONS

Inflammatory breast disease
Early T1-T2 invasive Clinically positive axillary LN
breast cancer and USG guided fine needle
clinically negative aspiration of axillary LN proving
axillary nodes metastasis
DCIS undergoing
Prior axillary sampling
mastectomy
Post chemotherapy
Ipsilateral recurrent
Post radiotherapy to axilla
breast cancer after BCT
Multifocal breast carcinoma
Allergy to blue dye localisation

17
https://youtu.be/6buF0hDvqwE

18
 INDICATIONS
RADIOTHERAPY Breast conservation surgery

All T3 and T4 lesions

T1 and T2 lesions-
-Positive resected margins
after surgery
-Inadequate ALND
-Positive axillary LN
- Pectoralis major involvement
- Inner quadrant tumours

Radiation dosage- 45-50 gray in 25- 28 fractions 1.8-2 Gy

with a boost of 10- 16 Gy in 2Gy doses 19
20
Radiation field Radiation field after BCS
after MRM

Whole breast radiation (WBRT)

Chest wall
WBRT with boost radiation in
Internal mammary LN
Supraclavicular node - age <50 years
Axillla - Grade 3 tumours
- Vascular invasion
Accelerated partial breast
irradiation
- >50 years
- Unicentric unifocal non- lobular breast
cancer
- < 3 cm
- No vascular invasion
21
CHEMOTHERAPY
ADJUVANT CHEMOTHERAPY NEOADJUVANT
CHEMOTHERAPY
(Post operatively)
(Preoperatively)
A) First line drugs
1. Anthracycline based- FAC
-FEC
6 cycles every 21 days
2. Anthracycline+ Taxane- ACT+/- D
4 cycles of AC every 21 days followed by 4 cycles of P
every 21 days
3. CMF
B) Second line regimens- Carboplatin, Capecetabine,
Gemcitabine, Eribulin
22
HORMONAL THERAPY
Indication->ER+ ve Tumours
Pharmacological Agents -
A) Premenopausal
-Tamoxifene
- Raloxifene
B) Post menopausal
- Aromatase inhibitors-
>Anastrazole, letrozole,
exemestane
23
24
TARGETED TREATMENT
Adjuvant Trastuzumab therapy
Trastuzumab: monoclonal antibody
against TK receptor(HER2 receptor)
Not given with anthracyclines
1 year
Loading dose: 4 mg/ kg body weight
Maintenance dose: 2 mg/ kg/ body
weight for a week

25
 Summary
Surgery - primary treatment- MRM/ BCS
Axilla- ALND/SLNB
Pathology report evaluation of specimen
Chemotherapy- 6 weeks of surgery
HER2 positive- Trastuzumab
Hormonal therapy- Tamoxifen(Premenopausal)/
AI(postmenopausal) for 5 years
Radiotherapy- 50 gray over 25 fractions given after
chemotherapy 26
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