Credit To Bailey Love s Short Practice of Surgery 27th Edition,O James Garden 2018_Principles

1. BREAST CANCER
MANAGEMENT
Capt Ye Linn Aung
Assistant lecturer
Defence Services Medical Academy,Myanmar
7/Feb/2021

4. Management of operable breast cancer
• In situ breast cancer
• low or intermediate grade DCIS- excised completely not require
any follow up treatment
• high grade DCIS-postoperative radiotherapy
• Large areas of DCIS are usually treated by mastectomy +-
reconstruction.

5. The multidisciplinary team approach
• Surgeon,
• Medical oncologist,
• Reconstructive Surgeon
• Radiotherapist
• Health professionals such as the clinical nurse specialist.

6. Operable breast tumours
• The breast alone or have mobile involved ipsilateral
axillary lymph nodes (T1, T2, T3, N0, N1, M0)

7. Local therapy
• BREAST-CONSERVING SURGERY
• Wide local excision- removing the tumour plus a margin of normal
breast tissue
• Lumpectomy- benign tumour is excised and in which a large
amount of normal breast tissue is not resected
• A quadrantectomy- removing the entire segment of the breast that
contains the tumour
• to obtain clear margins, classified as 1 mm in the UK and
no ink on tumour in the US
• Both of these operations are usually combined with
axillary surgery, usually via a separate incision in the
axilla

8. • AXILLARY SURGERY
• sentinel node biopsy,
• L/N sampling,
• removal of the nodes behind and lateral to the pectoralis minor (level
II)
• a full axillary dissection (level III)
• Micrometastases 2 mm, one or two involved sentinel lymph
nodes they are getting radiotherapy to the breast require no
further axillary treatment
• involved sentinel nodes not having whole breast radiotherapy,
and patients with >2 sentinel nodes -by surgery (axillary
clearance or axillary dissection), or with radiotherapy
• >4 axillary lymph nodes-radiotherapy to the chest wall and the
supraclavicular region

9. Sentinel node biopsy.

10. • Radiotherapy
• Indications for chest wall radiotherapy after mastectomy
• large tumours
• large numbers of positive nodes or
• extensive lymphovascular invasion
• Intraoperatively or postoperative course
• local recurrence are higher for local radiotherapy than
with whole breast radiotherapy

11. • Indications for mastectomy
• large tumours (in relation to the size of the breast),
• central tumours beneath or involving the nipple,
• multifocal disease,
• local recurrence
• patient preference
• When radiotherapy is not possible
• women who have incomplete excision after one or more attempts at
breast-conserving surgery
• Modified radical mastectomy(Patey mastectomy)
• the whole breast;
• a large portion of skin, the centre of which overlies the
• tumour but which always includes the nipple;
• all of the fat, fascia and lymph nodes of the axilla.
• Should be followed by chest-wall radiotherapy in women at
high risk of local recurrence.

13. • Systemic therapy
• after surgery and/or radiotherapy (adjuvant)
• before surgery and/or radiotherapy (neoadjuvant).
• Types
• Chemotherapy,
• Hormone therapy and
• Targeted treatments such as the anti-HER2 drug trastuzumab

14. • ADJUVANT CHEMOTHERAPY
• first-generation regime such as a 6-monthly cycle of
cyclophosphamide, methotrexate and 5-fluorouracil (CMF).
• modern second- and third-generation regimes include an
anthracycline (doxorubicin or epirubicin) and the newer agents
such as the taxanes
• Taxanes (taxol and taxotere) combined with an anthracycline
appear more effective than anthracyclines alone
• benefits of chemotherapy are greatest in women under the age of
50 years

15. • ADJUVANT HORMONE THERAPY
• Contain
• oophorectomy,
• tamoxifen
• the aromatase inhibitors letrozole, anastrozole
• Exemestane
• Oophorectomy-under 50 years of age with ER+ cancer
• surgically,
• by radiation or
• by the administration of gonadotrophin releasing hormone (GnRh)
analogues such as goserelin

16. • Tamoxifen
• 20 mg once daily. At least 5 years
• Reduced risk of contralateral breast cancer by 40–50%.
• effective in both pre- and postmenopausal women
• Aromatase inhibitors
• block the conversion of androgens to oestrogen in postmenopausal
women
• More effective than tamoxifen in postmenopausal women
• Anti-HER2 therapy
• a worse prognosis than those that are HER2-negative
• ‘Trastuzumab given to patients whose cancer over-expresses the
oncogene HER2 reduces recurrence by up to 50%.’

18. • NEOADJUVANT THERAPY
• patients with large or locally advanced tumours that would
otherwise require a mastectomy who may become suitable for
breast conserving surgery
• in patients with inoperable cancers that may become operable
• Response rates
• 30–40% of patients with triple negative cancers
• 60% in HER2-positive cancers
• less than 10% in ER+ cancers.

19. Complications of treatment
• Haematoma and infection
• Nerve injuries
• damages the intercostobrachial nerve-numbness and paraesthesia
down the upper inner aspect of the arm
• long thoracic nerve-winging of the scapula
• Thoracodorsal nerve- atrophy of the latissimus dorsi muscle
• axillary surgery-frozen shoulder,lymphoedema
• Radiotherapy-erythematous reaction of skin,fibrosis
around shoulder
• Chemotherapy-Hair loss or alopecia, fatigue and lethargy,
Nausea and vomiting
• anthracycline-containing chemotherapy, can result in cardiac failure
I

20. • BREAST RECONSTRUCTION
• immediate or delayed reconstruction
• easiest type of reconstruction is using a silicone gel implant under
the pectoralis major muscle
• If the skin at the mastectomy site is poor (e.g. following
radiotherapy) or if a larger volume of tissue is required
• latissimus dorsi muscle (an LD flap) (Figure 53.29) or using the
transversus abdominis muscle (a TRAM flap)
• Tattooing of the reconstructed nipple

21. Reconstruction with latissimus
dorsi flap
Transversus abdominus muscle flap.

22. Management of locally advanced
breast cancer
• is characterised by infiltration of the skin or chest wall by
tumour or matted involved axillary nodes
• including inflammatory breast cancer,

23. • Primary systemic therapy, followed by surgery and
radiotherapy or radiotherapy alone, has improved local
control
• Consider chemotherapy in patients who are young, have
inflammatory cancers or have ER disease
• Consider neoadjuvant endocrine therapy in the elderly or
those who have ER+ cancers
• Radiotherapy can be given following primary
chemotherapy, concurrently with hormonal therapy, or as
an initial treatment
• Consider surgery if disease becomes operable following
primary systemic therapy or after radiotherapy.

24. Inflammatory breast cancer.

25. Management of metastatic or advanced
breast cancer
• Can be present at diagnosis or may develop following
treatment for an apparently localised breast cancer
• Aim of treatment is to improve survival and produce effective
symptom control with minimal side effects
• The primary aim is to improve symptoms as well as improve
the quantity and quality of life
• Consider hormone therapy if there is a long disease-free
interval and the tumour is hormone receptor-positive
• Consider chemotherapy if there is a short disease-free interval,
vital organs are affected and/or the tumour is oestrogen
receptor negative
• Treat HER2+ breast cancer with trastuzumab and consider
combining it or sequencing with newer anti-HER2 agents.

26. • CHEMOTHERAPY
• Balance-high response rate and limiting side effects
• Common use-Anthracyclines(adriamycin and epirubicin) and the
taxanes (taxol and taxotere).
• response rates-approximately 40–60%, median time to relapse of
6–10 months

27. • HORMONAL TREATMENT
• for patients with ER+ metastatic breast cancer
• In premenopausal women
• oophorectomy (surgical, radiation- or drug-induced by GnRh
analogues) combined with tamoxifen
• In postmenopausal women include
• Aromatase inhibitors (anastrozole, letrozole and exemestane).
• Response rates are 25%

28. • LOCAL TREATMENTS IN METASTATIC BREAST
CANCER
• to excise any fungating lesion
• Simple ‘toilet’ mastectomy and basic skin cover with grafting
• Radiotherapy is an option for local disease control

29. • METASTATIC DISEASE: SPECIFIC PROBLEMS
Bone metastases may require local radiotherapy, bisphosphonates or
orthopaedic intervention, combined with a change of systemic
hormonal therapy or chemotherapy
Hypercalcaemia causes nausea, constipation, thirst, polyuria,
weakness, pain and personality change, and is treated by rehydration
followed by bisphosphonates
Spinal cord compression should be treated by surgical
decompression if feasible, or by steroids and radiotherapy
Pleural effusions are best treated by tube drainage, followed by
instillation of bleomycin, tetracycline or talc and a change of systemic
therapy
Discrete lung metastases may not cause acute symptoms but
lymphangitis carcinomatosa can cause severe bronchospasm and
dyspnoea, which may be relieved by steroids, bronchodilators and
chemotherapy
Liver metastases cause general debility, nausea and lack of appetite;
they are usually treated by chemotherapy but hormone therapy with
aromatase inhibitors is an option for postmenopausal women with ER
rich cancers
Brain metastases are treated initially with steroids, followed by
radiation.Surgery is an option for isolated single metastases.