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CURRENT MANAGEMENT

OF
BREAST CANCER
Muchlis Ramli,MD
Sub.Div.Surgical Oncology-Dept of Surgery
University of Indonesia,Jakarta

Magnitude of Breast Cancer Problem

Incidence :
USA
: 80-100/100.000/year
Japan : 30-40/100.000/year
Korea : 20-25/100.000/year
World : 29,8/100.000/year
Indonesia
: second highest incidence by
PBR 11,57%.

Magnitude of Breast Cancer


Stage Distribution :

Stage

Korea
%

Indonesia
%

6,2

25,3

II

52,8

16

IIIa

11.0

23

IIIb

2,5

40

IV

2.2

19

Its tendency increasing of


breast cancer incidence in
the world and also in
Indonesia

*Change of concept of breast cancer

Change of Treatment procedure due to :

Successful Early detection :


Change of principle in treatment :
- From radical surgery to more concervative
- From single modality to rational combine
modality.

Treatment Decission:
Properly
Evaluate and assesment of prognostic factors priorly
decision making be taken.
Prognostic factors :
1. Tumor factor
- stage
- histology :type;subtype;grading
- hormonal dependency
2. Host factor
- age : pre/post menopause
- underlying disease
3. Treatment retalted factors
- Human resource (Doctors)
- Equipment

Dont forget to give


Inform consens
To

* the patient
* family

Modalities of treatment
Surgery
Radiation
Chemotherapy
Hormonal therapy
Imunotherapy
Combination

Surgery has a long story in Breast Cancer


Treatment
Egyptian period 1600 BC
Edwin Smith Papyrus
Hypocrates
Galen (131-201)
Medieval period
- Christian
- Jewish
- Arabic

Surgical treatment with burning or removal


with sharpened instrument
Cancer crab leg all of root could be
exterpated

Razes

Condoned excisian of the breast cancer only if


it completely removed

Renaissance
Modern period
- WS. Halsted (1852-1922)
- Willy Meyer (1854-1932)
Bernard Fisher ( 1970)

- Radical mastectomy
- Supraradical
- Modified radical
- Simple mastectomy
- BCT
Breast cancer is systemic disease
Systemic & local treatment are important.
Combine modality treatment :
- Adjuvant
- Neo Adjuvant

Type of surgery
Radical mastectomy
Entended (supra)radical mastectomy
Simple mastectomy + irradiation
Modified radical mastectomy
Breast concerving treatment
Sentinel node

Extended Radical Mastectomy Versus Radical


Mastectomy-Survival at 15 years

15 year
Treatment

Overall

survival
Disease Free

RM

51%

49%

ERM

51%

47%

Laquor J et all, 1976

Extended Radical Mastectomy Versus Simple


Mastectomy +RT Survival Data

5 year survival

10 year survival

Clinical
Stage

SM & RT

ERM

SM & RT

ERM

70%

74%

50%

55%

II

50%

47%

32%

34%

Urban JA, Baker HW, 1952

RadicalMastectomy Versus Extended Radical


Mastectomy-Primary Operable Breast Cancer,
1965-1970

5 years %

10 years %

No

Alive

NED

Alive

NED

Axilla

176

89

82

83

75

Axilla +

175

70

62

57

50

TOTAL

351

80

72

70

63

Axilla

64

82

75

73

66

Axilla +

41

78

61

59

49

TOTAL

105

80

69

67

60

RM

ERM

Cody HS III, Urban JA, 1986

Extended Radical Mastectomy Versus Simple


Mastectomy + RT-10 year local Recurrence Rate
(Parasternal,Chest Wall,Axillary)

Clinical Stage

SM & RT

ERM

19%

20%

II

29%

32%

Urban JA, Baker HW, 1952

Extended Radical Mastectomy versus


Radical Mastectomy-Overall Survival

5 years

10 years

15 years

RM

69%

60%

51%

ERM

75%

60%

51%

Laqour J et all, 1976

Radical Mastectomy Versus Modified


Radical Mastectomy-5 Year Survival

Treatment

Overall

Disease Free

RM

70%

58%

MRM

70%

58%

Law HL Et all, 1975

Radical Mastectomy Versus Simple Mastectomy + RT-10


Year Survival and Locoregional Reccurence Rates

Overall
Survival

Disease Free
Survival

RM Alone

58%

47%

4.4%

1.4%

SM & RT

59%

48%

1.1%

3.1%

SM Alone

54%

42%

7.7%

1.1%

Clinical Stage I

Wise L et all, 1983

Local Chest Wall


Scar Recurrence

Axillary
Recurrence

Breast Concerving Treatment


(Limited surgery + radiation therapy)

o Lumpectomy/segmentegtomy/quadrantec

tomy with axillary dissection.


o Primary radiation
Goal : - locoregional control
- cosmetic and quality of life

Cases selection for BCT


1. Patient
1.1 want to be concerve to breast,after inform concens
accepted
1.2 Volume of the breast is fovarable for BCT ; in
comparing with tumor diameter.
2. Tumor
2.1 diameter of tumor less then 3 cm
2.2 stage T0N1M0 ;T1N0M0 ;T1N1M0 ;T2N0-1M0
2.3 Location of the tumor not in the cencral
2.4 Histologi Not DCIS (controversies)
2.5 Tumor is not multiple
2.6 Mamography doesnt show wide scattered
microcalsification or multicentricity.

Cases selection for BCT


3. Equipment :
- For Irradiation is available
- Well organized multi disiplinary approach
( Surgeon ; Patologist ; Radiotheraphy )

Survival Rates

Five years

Ten Years

Stage

Local Excision
+ RT

Radical
Mastectomy
+ RT

96%

81%

68%

69%

II

74%

70%

53%

59%

Wise L et all, 1971

Local Excision
+ RT

Radical
Mastectomy
+ RT

Five-and-Ten year Disease Free Survival Rates,


1955-1980

Conservation
+ RT

Surgery

5 year

10 year

Radical or
Mastectomy

5 year

Modified Radical
Alone

10 year

Mininal Breast
Cancer

97%

92%

97%

95%

Stage I
T1 N0

85%

78%

88%

80%

Stage II
T1 N1
T2N0N1

78%

73%

77%

65%

Montaque ED et all, 1984

Sentinel Node Biopsy

Objective : To identify the first node that receive

lymph from tumor area.


By injecting methylene blue or 99 m Tc labeled
human colloid albumin
Negative sentinel node indicate axillary dissection
is not necessary.
Positive sentinel node indicate further axillary
dissection is needed.
Improving axillary staging

Sentinel Node Biopsy


Indication

: early breast cancer


Identification rate
: 98,7% (371 of 376
cases).
Correctly predicted the status of axilla :96,8 %
(false positive 3,2%)
Giuliano : 42,3% of negative by HE
POSITIVE by anticylokeratin antibody

Sentinel Node Biopsy

To prevent the unnecessary axillary

disection
Short hospitalized
Prevent : - Limited arm mobility
- Lymph edema of the arm

Management of Early Breast Cancer

T 1 - 2 N0 - 1
Surgery (with/without adjuvant)

*
*
*
*
*

Radikal mastectomy
Modified Radical Mastectomy
BCT
(Sentinel node biopsy)
Adjuvant therapy : d.o
- Node (+)/(-)
- Er/Pr
- Age

Adjuvant Therapy for Node Negative

Menopausal status

Hormonal Receptor

High Risk

Premenopause

Er (+)/Pr (+)
Er (-) and Pr (-)

Chemo + Tam/Oov
Chemo

Post menopause

Er (+)/Pr (+)
Er (-) and Pr (-)

Tam + Chemo
Chemo

Old age

Er (+)/Pr (+)
Er (-) and Pr (-)

Tam + Chemo
Chemo

Adjuvant Therapy for Positive Node

Menopausal status

Hormonal Receptor

High Risk

Premenopausal

Er (+)/Pr (+)
Er (-) and Pr (-)

Chemo + Tam/Oov
Chemo

Post menopausal

Er (+)/Pr (+)
Er (-) and Pr (-)

Chemo + Tam
Chemo

Old age

Er (+)/Pr (+)
Er (-) and Pr (-)

Tam + Chemo
Chemo

Adjuvant chemotherapy
Lymph node positive
Lymph node negative but,high risk factors

Age < 40 tahun


High grade
Er/Pr negatif
Progressive tumor
High Tymidin index

Advanced Breast Cancer


Locally advanced breast cancer (LABC)

Operable

: T3 N0-1 M0

Inoperable

: T3b-4 N0-1 M0
T0-4 N2-3 M0

Distant metastase

In stage III, although located at presentation,


but there is high incidence subsequently of
distant metastase (micro metastase)
up to 70%

Is still surgery has a role in the


treatment of LABC ?

Recent advances in LABC


management
With the concept of :
Breast cancer is systemic disease since the
early stage (Bernard Fisher)
LABC (stage III) has a high incidence
subsequently of distant metastase (or micro
metastase)
Systemic disease could be eradicated with
systemic treatment

Combine Modality Treatment

There are two strategic in Combine


Modality Treatment
1. Adjuvant chemotherapy in which chemotherapy
given following locoregional treatment
2. Neoadjuvant chemotherapy in which
chemotherapy given prior locoregional
treatment and maybe continued after ward
The aim of adjuvant chemotherapy is to

eradicated of micro metastase


The aim of neoadjuvant chemotherapy is :
to shrink tumor burden
to eradicate of micro metastase

With neoadjuvant chemotherapy for LABC

Hartobagyi
: 63% 5 yrs SR
MD Anderson : 66% 5 yrs SR
Institutionally
: Not yet applied in Dr. Cipto Mangunkusumo
Hospital
Treatment
No. of patients
5 years S.R. (%)

LABC
S

2453

36

2386

29

S + R

4249

33

C + S + R

1923

63

398

334

S + R

142

C + S + R

708

47

Inflammatory Breast Cancer

Tjindarbumi, Tjahyadi, Ramli, et.al. Longitudinal Clinicopathological follow up of Breast Cancer Patient from 1988 to
1996 MJI vol.. 8 No.2 1999.

Survival data from combined modality treatment of 174


patients treated at The University of Texas MD Anderson
cancer center.

Stage

5-

10-

5-

Median

years

years

years

Disease-

Diseas

Disease

Free

e-Free

-Free

Survival

Surviv

Surviva

al

III A

NA

66%

47% 1

III B

30 months

32%

31%

1 Projected

survival
NA = Not available

Median
Overall
Survival

Overal
l
Surviv
al

NA
48
months

10years
Overall
Surviva
l

80%

64%

45%

28%

Breast Cancer in Indonesia

The incidence of LABC in Indonesia


LABC
: 63-70%
ABC( distance metastase) : 20%
Jakarta
Stage

Call

Call

Project

Project

II

Surabaya

U.Pandang
(Reupassa

Ramli

(Sukarja)

1.3 %

2 %

1.3 %

2.5 %

4.1 %

7.1 %

II

16 %

11.9 %

12.3 %

17.6 %

27.7 %

IIIa

23 %

17.7 %

26.3 %

55.9 %

49.2 %

IIIb

40 %

56.2 %

43.4 %

IV

19 %

11.9 %

14.3 %

19.6 %

15.8 %

0.8 %

2.9 %

Tis
I

Unclassif
ied

Adopted from Ramli M. Epidemiological Review of Breast Cancer in Indonesia

Collaborative Research Indonesia - Japan


on Breast Cancer
110 of 300 breast cancer cases (Batch I) was operable cases.
Stage
I
II

IIIA

IIIB*

Total

T1a N0

Cases
M0

T2a N0

M0

T2b N0

M0

T2a N1a M0

12

T2b N1a M0

T2c N1b M0

T3a N0

33

T3a N1a M0

32

T3a N1b M0

T4a N0

M0

T4a N1b M0

T4a N2

M0

7.32

31

28.2

71

64.5

110

100.0

T1b N1a M0

M0

Total

110

Protocol of Breast Cancer Treatment

Stage Tis
: SM
Stage I & II : RM or MRM adjuvant therapy
No Axillary lymph node consist tumor metastase, No Adj. Therapy
Axillary lymph node consist tumor metastase + Adj. Therapy
Ax. LN. 3 : Adj. Rad.
Ax. LN. 4 : Adj. Rad. + Ch.

Alternative :
SM + Rad. + Adj. Ch.
BCT

Stage IIIa
Stage IIIb
Stage IV

: SM + Rad. + Adj. Ch.


: Rad. +Ch. + H.
: H + Ch. + Pall. Surgery / Pall Rad.

65.4% of operable breast cancer (stage IIIa) treated by

simple mastectomy + radiotherapy (with or without


chemotherapy)

Type of surgery

Cases

Radical Mastectomy

23

21.0

Modified Radical Mastectomy

13

11.8

Simple Mastectomy

72

65.4

Breast Conserving Treatment

1.8

110

100.0

(BCT)
Total

Tjindarbumi, Tjahyadi, Ramli, et.al. Longitudinal Clinicopathological follow up of Breast Cancer


Patient from 1988 to 1996 MJI vol.. 8 No.2 1999.

With that treatment (followed protocol): 5 years


survival rate 57%
Alive with

Alive

Recurrence

without

Deceased

Total

Recurrence
Clinical stage :
I

II

13

12

31

28

13

30

71

13

Radical mastectomy

12

23

Simple Mastectomy

19

23

30

72

Breast Conserving

III
Surgical procedure
:
Modified Radical
Mastectomy

Treatment

Tjindarbumi, Tjahyadi, Ramli, et.al. Longitudinal Clinicopathological follow up of Breast


Cancer Patient from 1988 to 1996 MJI vol.. 8 No.2 1999.

With this protocol, surgery still has main role in


the treatment of LABC.
23% of breast cancer treated with surgery (stage
IIIA), simple mastectomy combining with
radiotherapy with/without chemotherapy

With application Neoadjuvant

Chemotherapy for locally advanced


breast cancer in Indonesia, the role of
surgery in breast cancer treatment
more increasing

CONCLUSION :
1.

* Change of consept in Breast Cancer


Locoregional disease systemic disease
* Improvement of : - Radiotheraphy
- Chemotheraphy
- Hormonaltheraphy
- also biomoleculaer and
technology.
* Successful of early detection program
Change of treatment procedure ;
# Surgery from radical to more conservative
(Radical mastectomy BCT (sentinel node)
# Single modality combine modalities

CONCLUSION :
2. Adjuvant chemotherapy will uncrease the survival rate
and increase disease free internal
3. Neoadjuvant chemotherapy will
- shrink the tumor burden so increase the resectability
- increase the survival rate and disease free interval
4. Application neoadjuvant chemotherapy for LABC in
Indonesia will increase the role of surgery in LABC
treatment.