- 1. Sridevi Rajeeve2008 BatchSR_Ca_Breast_Rx 1
2. Early Breast Cancer(EBC): Stage I & II, T1N1, T2N1,
T3N0Locally Advanced Breast Cancer(LABC): Stage IIIA &
IIIBMetastatic Breast Cancer: Stage IVSR_Ca_Breast_Rx 2 3.
IIIIIISR_Ca_Breast_Rx 3 4. Management of Ca BreastOptions
available;I. SurgeryII. RadiotherapyIII. Hormone TherapyIV.
ChemotherapyMulti-pronged approach adoptedSingle approach
ineffectualSR_Ca_Breast_Rx 4 5. I. SURGICAL Approaches1. Total
(Simple) Mastectomy2. Total Mastectomy with Axillary Clearance3.
Modified Radical Mastectomy [MRM]1) Pateys Operation2) Scanlons
Operation3) Auchincloss MRM4. Radical Mastectomy of Halsted5.
Conservative Breast Surgeries1) Wide Local Excision [WLE]2)
Lumpectomy3) Quadrantectomy4) Toilet Mastectomy5)
Skin-Sparing/Keyhole Mastectomy [SSM]SR_Ca_Breast_Rx 5 6. 1.
TOTAL/SIMPLE MASTECTOMYTissues removed:Tumour, entire breast,
areola,nipple, skin over breast, Axillary tailof Spence, Pectoral
fasciaTissues retained:NO Axillary DissectionSubjected to
Radiotherapy laterSR_Ca_Breast_Rx 6 7. 2. TOTAL MASTECTOMY
withAXILLARY CLEARANCECommon procedureTissues removed:TM + Axillary
fat, Axillary fascia,Level I and II Axillary LNSR_Ca_Breast_Rx 7 8.
SR_Ca_Breast_Rx 8 9. 3. MODIFIED RADICAL MASTECTOMY1) Pateys
Operation Tissues removed:TM + Clearance of Level I,II & III
Axillary LN +Pectoralis minor Tissues preserved:Nerve to Serratus
anterior,Nerve to Latissimus dorsi,Intercostobrachial
nerve,Axillary Vein, CephalicVein, Pectoralis majorSR_Ca_Breast_Rx
9 10. Procedure:Elliptical incision made on medial aspect of 2nd
and 3rd ICSenclosing the nipple, areola and tumour which
extendslaterally into Axilla along the Anterior Axillary fold.
Upperand lower skin flaps are raised. Breast with tumour israised
from the medial aspect of Pectoralis major.Dissection is proceeded
laterally while ligating pectoralvessels. In axilla, lateral border
of Pectoralis minor isdivided from Coracoid process to clear Level
II LN. Level IIIcleared subsequently. Pectoralis minor removed2)
Scanlons Operation: Pectoralis minor incisedLevel III LN removed3)
Auchincloss MRM: Pectoralis minor left intactLevel III LN not
removedSR_Ca_Breast_Rx 10 11. SR_Ca_Breast_Rx 11 12.
SR_Ca_Breast_Rx 12 13. 4. RADICAL MASTECTOMY of HALSTEDTissues
removed:Tumour, entire breast, areola,nipple, skin over
tumour,Pectoralis major & minormuscles, fat, fascia, Level
I,II,IIIAxillary LN, few digitations ofSerratus anterior
muscleTissues retained:Axillary veinBells nerve (N.to
Serr.ant)Cephalic veinSR_Ca_Breast_Rx
13Complications:LymphoedemaLymphangiosarcoma (>3 years) 14. 5.
BREAST CONSERVATIVE SURGERIES1. Wide Local Excision (WLE)/
PartialMastectomyRemoval of unicentric tumour with 1cmclearance
margin.Incision: Over tumour + AxillaryDissection + RT2.
Quadrantectomy:Removal of entire quadrant with ductalsystem with
2-3cm normal breast tissueclearance. Part of QUART
Therapy(Quadrantectomy + Axillary dissection + RT)Not advocated
now.3. Skin Sparing Mastectomy4. Lumpectomy (=WLE)Term rarely
usedSR_Ca_Breast_Rx 14 15. SR_Ca_Breast_Rx 15 16. SR_Ca_Breast_Rx
16 17. Other proceduresToilet Mastectomy In locally advanced
tumour(LABC), tumour with breasttissue removed preventfungation
Post-chemotherapy Significance: (?)Extended Radical Mastectomy
Radical Mastectomy +Removal of Internal MammaryNodes (ipsilateral
+/-contralateral)Not done at presentSR_Ca_Breast_Rx 17 18.
COMPLICATIONS of M.R.M/MASTECTOMYInjury/ Thrombosis of Axillary
VeinSeromaShoulder DysfunctionPain and NumbnessFlap Necrosis and
infectionLymphoedema and its problemsAxillary hyperaesthesiaWinged
ScapulaSR_Ca_Breast_Rx 18 19. LYMPHANGIOSARCOMA (Stewart-Treves
Syndrome)In ipsilateral upper limbDevelops in people
withLymphoedema after Mastectomy withAxillary clearance.3-5 years
after development ofLymphoedemaPresentation: Multiple
subcutaneousnodulesRequires Forequarter AmputationPoor
prognosisSR_Ca_Breast_Rx 19 20. II. RADIOTHERAPY
ApproachIndications;1. Conservative Breast Surgery adjuvant
[Breast]2. Total Mastectomy [Axilla]3. High-risk of relapse
patients1) Invasive Carcinoma2) Extensive in-situ Carcinoma3) Age
< 35 years4) Multifocal disease4. Bone secondaries
[Palliative]5. Atrophic Schirrous Carcinoma [Curative]6.
Pre-Operatively (reduce tumour size and downstage)7. >4 +ve
Axillary LN, Pectoral fascia involvement, positivesurgical margins,
Extra-nodal spreadSR_Ca_Breast_Rx 20 21. Chest Wall Axilla
Post-BCST3 tumour>5cmResidual diseaseLABCPositive
margin/closesurgical margin 4 nodes +veExtra-nodal spreadAxillary
statusunknown/ not assessedMANDATORY!Local + AxillaTangential
fields: 50 Gy-25 fractions-5 weeksAnother 10 Gy totumour
bedInternal Mammary andSupra-clavicular area maybe included in
theradiation fieldSR_Ca_Breast_Rx 21 22. SR_Ca_Breast_Rx 22 23.
External RadiotherapyOver Breast area, axilla, Internal mammary and
Supra-claviculararea Total dosage: 5000 cGy units 200-cGy units
daily 5 days a week for 6 weeksInternal RadiotherapySR_Ca_Breast_Rx
23 24. SR_Ca_Breast_Rx 24 25. III. HORMONE-THERAPY
ApproachPrinciples; Used in ER/PR +ve patients only All age groups
included now Relatively safe Easy to administer Adequate
prophylaxis against Ca of opposite breast Useful in Metastatic
Carcinoma Reduces recurrence improves quality of life
andlongevitySR_Ca_Breast_Rx 25 26. Includes;Medicali. Oestrogen
Receptor Antagonists Tamoxifen 20 mgii. Progesterone receptor
Antagonistiii. Oral Aromatase Inhibitors Letrozole 2.5 mg OD,
Anastrozole, Exemestane;Aminoglutethimide [Medical
Adrenalectomy]iv. Androgens inj.Testosterone propionate 100mg IM
three times a week,Fluoxymestrone 30 mg dailyv. LHRH Agonists
Goserelin (Zoladex) [Medical Oophorectomy]vi. Progestogens
Medroxypregesterone acetate 400 mg Surgicali. Ovarian Ablation bya.
Surgery (Bilateral Oophorectomy)b. Radiationii. Adrenalectomyiii.
Pituitary ablationSR_Ca_Breast_Rx 26 27. Tamoxifen SERM (Selective
Estrogen Receptor Modulator) Blocks cytosolic ER in breast tissue
Dose: 10 mg BD or 20 mg OD for 5 days T1/2: 7 days. Shows effects
after 4 weeks Cheap, easily available, effective Indications:
Carcinoma Breast Fibroadenosis Male infertility Desmoid tumours
Side-effects: Tamoxifen Flare: Flushing, tachycardia, sweating,
pruritis vulva, vaginalatrophy and dryness (pre-menopausal),
vaginal discharge (post-menopausal),fluid retention, weight gain
Agonistic action: Endometrium (Ca), Bone (Osteoporosis,
pathological#), Coagulation system (DVT, TIA, CVA,
MI)SR_Ca_Breast_Rx 27 28. Letrozole Non-steroidal competitive
inhibitor of AromataseReduces Oestrogen levels by 98% More
expensive, more effective, fewer side-effectsIndications:1.
Adjuvant Endocrine therapy in Post-menopausal women withhormone
sensitive breast cancer2. Metastatic disease3. Recurrent disease
Dosage: 2.5 mg OD for 5 years or for 3 years after Tamoxifen
Side-effects: Vaginal atrophy, bleeding p.v, CVS problems
andosteoporosis.SR_Ca_Breast_Rx 28 29. Novel drugs - Biologicals1.
TRANSTUZUMAB (Herceptin) Monoclonal Ab. Blocks Her-2/Neu receptors
(Tyrosinekinase receptor) Useful only in Her-2/Neu +ve cases
Metastatic d/s Intravenous infusion 4mg/kg loading,
2mg/kgmaintenance dose for 1 year2. BEVACIZUMABVascular Growth
Factor receptor inhibitor3. LAPITINABCombined Growth Factor
receptor inhibitorSR_Ca_Breast_Rx 29 30. IV. CHEMOTHERAPY
ApproachTypes;A. Adjuvant Chemotherapy Administration of Cytotoxics
after surgery Eliminate clinically undetectable distant spreadB.
Neoadjuvant Chemotherapy Administration of Cytotoxics in large
operable tumours beforesurgery Reduce loco-regional tumour burden
downstage Amenable to surgical resection after 3 dosesC. Palliative
Chemotherapy Advanced Ca Breast Metastatic Ca BreastSR_Ca_Breast_Rx
30 31. Indications;All node +ve patientsPrimary tumour >1cm in
sizePoor prognostic factorsAdvanced Ca BreastInflammatory Ca
BreastMetastatic Ca Breast Drugs;CMF Regime CAF Regime MMM
RegimeCyclophosphamide Cyclophosphamide MethotrexateMethotrexate
Adriamycin Mitomycin-C5-Fluorouracil 5-Fluorouracil
MitozantroneSR_Ca_Breast_Rx 31 32. Chemotherapy Regimes CAF and CMF
commonly used, monthly/3 weeks cyclesfor 6 months Taxanes Eg:
PACLITAXEL and DOCETAXEL G2/M phase arrestors Use: Metastatic Ca
Breast 1st line: CMF > CAF > MMM 2nd line: Taxanes 3rd line:
GemcitabineSR_Ca_Breast_Rx 32 33. EARLY CARCINOMA BREAST [ECB]
-Management Breast Conservation Surgery Wide Local Excision/
QUART/SSM; RT locally Pateys Operation [MRM] Tamoxifen 10mg BD
Sentinel Lymph Node Biopsy [SNLB] Regular follow-up with
Radioisotope Bone scan CEA tumour marker Indications for Total
Mastectomy in EBC; Tumour size >5cm Multicentric tumour
High-grade (poorly-differentiated) tumour Tumour margin not clear
after BCSSR_Ca_Breast_Rx 33 34. ADVANCED CARCINOMA BREASTRefers to;
Locally Advanced Carcinoma Breast [LACB] Inflammatory Ca Breast
Bilateral Ca BreastMetastatic Ca Breast Fixed
axillary/supra-clavicular LNSR_Ca_Breast_Rx 34 35. Management of
ACBLACBNeoadjuvant ChemotherapyResponse assessmentNon-responders:
RT + SurgeryResponders: Surgery (Toilet Mastectomy/MRM)Inflammatory
Ca BreastMastitis carcinomatosis/ Lactating Ca of BreastT4d LACB
(Stage IIIB)Neoadjuvant ChemoT and RTSurgery (if downstaged) +
Axillary clearanceSR_Ca_Breast_Rx 35 36. SR_Ca_Breast_Rx 36 37.
Metastatic Ca BreastHematogenous spread to;Bone: most common.
Vertebra Batsons (valveless) venousplexus and posterior intercostal
veins, Ribs, Humerus, FemurLungs Cannon-ball 20 in parenchyma,
Pleural effusion, Chestwall 20LiverBrainTreatment
strategies;Chemotherapy: CMF/CAFRadiotherapyTamoxifen,
OophorectomyTranstuzumab, BevacizumabHypercalcemia Hydration,
steroids, Palmidronate 90mg i.v oncea monthInternal fixation of
pathological #SR_Ca_Breast_Rx 37 38. SR_Ca_Breast_Rx 38 39.
SR_Ca_Breast_Rx 39 40. CARCINOMA BREAST inPREGNANCY - Management1st
Trimester 2nd Trimester 3rd TrimesterMRM MRM MRMAxillary node
+ve:Termination of pregnancy +ChemotherapyChemotherapy carefully
After delivery Chemotherapy withsuppression of lactationNote the
following;Hormone treatment contra-indicated:
TeratogenicRadiotherapy: No roleMRI is the investigation of
choiceCan become pregnant 2 years after completion of therapy as
recurrence ratesare highest in 2 yearsSR_Ca_Breast_Rx 40 41.
Follow-upClinical examination in detail @ regular
intervalsYearly/2-yearly Mammography of the treated
andcontralateral breast is a mustBone-scan, CT Chest/abdomen,
tumour markers are doneonly if there is clinical suspicion. Not a
regular routinefollow-up at presentSR_Ca_Breast_Rx 41 42. BREAST
RECONSTRUCTION Done in young patients with early stage of disease
Symmetry is the most important factor Factors deciding
reconstruction; Amount of skin retained SSM best Stage of Carcinoma
Earlier Radiotherapy Type of flap used Timing Immediate
Reconstruction: in Early stages with good response toneoadjuvants.
CI in LABC Delayed Reconstruction: 3-9 months after surgery. Done
in LABC.Allows post-op RT without prosthesis exposure, avoids
fibrosis andfat necrosis where TRAM flap in usedSR_Ca_Breast_Rx 42
43. Methods of Reconstruction1. Breast Implants Silicone gel2.
Expandable Saline prosthesis3. Flap with implant/expanders4.
External breast prosthesis5. Flap reconstruction1. Latissimus dorsi
(LD) flap2. Contralateral Tranversus Abdominis (TRAM) flap3.
Superior Gluteal flap4. Rubens flap: soft tissue over Iliac
crestSR_Ca_Breast_Rx 43 44. SR_Ca_Breast_Rx 44 45. SR_Ca_Breast_Rx
45 46. SR_Ca_Breast_Rx 46 47. Complications of Implants; Pain,
exposure of implant and rupture Displacement, extrusion Infection
Capsular contractionLD Flap TRAM flapMyocutaneous flap Myocutaneous
flapSubscapular artery Superior Epigastric arteryEasy Ipsilateral
or contralateral flapCan be placed over prosthesis Gives bulk. No
need of prosthesisReliable, well-vascularised Free TRAM flap into
IMALow complication rate Mesh placement in abdomen
requiredUnsightly donor area on back Donor site morbidity & fat
necrosisSR_Ca_Breast_Rx 47 48. SR_Ca_Breast_Rx 48 49.
SR_Ca_Breast_Rx 49 50. Thank youSR_Ca_Breast_Rx 50
