This document discusses treatment pathways for stage IIIA and IIIB breast cancer. It describes the tumor and node characteristics of these stages. Neoadjuvant chemotherapy is recommended to downsize tumors before surgery. Surgery options include breast conservation or mastectomy. Post-operative radiation and chemotherapy are also used. Hormone therapy may be given depending on receptor status. Receptor status helps determine prognosis and additional targeted therapies. Molecular subtyping further classifies breast cancers to help guide treatment approaches. Axillary lymph node dissection is discussed as an important part of staging and treatment.

1. DEBJYOTI GHOSH

2. • Breast cancer with gross locoregional disease.
• Stage IIIa and IIIb tumors with:
 T3 tumors with N1, N2 and N3 nodes
 T4 tumors with any N nodes
 Any T tumors with N2 and N3 nodes
• Tumor characteristics: T3(Tumor > 5 cm), T4a, T4b, T4c,
T4d tumor
• Node characteristics: N2 or N3(Bulky and fixed nodes).
Clinically apparent internal mammary and supraclavicular
nodes.

3. CLINICAL FEATURES
Fungating mass and ulcer
over the swelling with
serous discharge

4. INVESTIGATIONS:
• Core biopsy from breast lump
• Mammography of both breasts
• Bone scan
• Chest X-Ray
• Liver Function Test
• USG/CT abdomen
• CT brain

6. TREATMENT:
• Pre-operative chemotherapy followed by surgery and
radiation
• Neoadjuvant chemotherapy results in downsizing of
tumor and easy resectability
• Hormonal therapy is also given depending on
hormone receptor status
• Surgery: Breast Conservation Surgery or Modified
Radical Mastectomy
• Post operative radiation therapy to breast flap and all
lymph node fields

7. • Recommended schedules:
 FAC
 AC
 AC followed by Taxane
• Newer drugs: Trastuzumab, Navelbine, Capecitabine and
Gemcitabine
NEOADJUVANT CHEMOTHERAPY
NEOADJUVANT ENDOCRINE THERAPY
• Tamoxifen
• Letrozole

8. SURGERY:
• Surgery after chemotherapy monitoring
• Treatment of primary tumor is surgical
• Breast Conservation Surgery or Modified Radical
Mastectomy
• Criteria for Breast Conservation Therapy

9. TREATMENT PATHWAYS FOR STAGE IIIA AND IIIB BREAST
CANCER

10. RECEPTOR STATUS
• Breast cancer cells may or may not have many different types
of receptors
• Three most important receptors are: Estrogen Receptor(ER),
Progesterone Receptor(PR), Human Epidermal Growth Factor
Receptor(HER2/neu)
• These receptors are present partially or absent totally called
TRIPLE NEGATIVE or BASAL-LIKE
• Presence of these receptors determine the chemotherapy and
the prognosis

11. ESTROGEN RECEPTORS
• Depend on estrogen hormone to grow
• 2 different forms – α and β , each encoded by a separate gene
• ERα – Endometrium, Breast Cancer cells, Ovarian stromal
cells, Hypothalamus and afferent ducts in males
• ERβ – Ovarian granulosa cells, Kidney, Brain, Bone, Heart,
Lungs, Intestinal mucosa and Prostate
• As per visualization research, small fraction of ERs reside in
cytoplasm, most in the nucleus

12. PROGESTERONE RECEPTORS
•The progesterone receptor (PR, also known as NR3C3 or
nuclear receptor subfamily 3, group C, member 3), is a
protein found inside cells.
• Activated by the steroid hormone progesterone
• In humans, PR is encoded by a single PGR gene residing on
chromosome 11q22
• Has 2 main forms, A and B, that differ in their molecular
weight

13. HER2 STATUS
• HER2 positive: Cancers that have too much HER2 protein
or extra copies of the HER2 gene. Respond
to drugs that target HER2
• HER2 negative: Cancers that don’t have excess HER2. Do
not respond to treatment by drugs that
target HER2

14. TRIPLE POSITIVE
• This term is used to describe cancers that are ER-positive,
PR-positive, and have too much HER2. These cancers can
be treated with hormone drugs as well as drugs that target
HER2.
• The medication tamoxifen helps stop cancer from coming
back by blocking hormone receptors, preventing hormones
from binding to them. It’s sometimes taken for upto 5 years
after initial treatment for breast cancer.
• A class of medicine called aromatase inhibitors actually
stops estrogen production. These include anastrozole,
exemestane, and letrozole. They’re only used in women
who’ve already gone through menopause.

15. TRIPLE NEGATIVE
• If the breast cancer cells don’t have estrogen or
progesterone receptors and don’t have too much HER2, they
are called triple-negative.
• Tend to occur more often in younger women
• Tend to grow and spread more quickly than most other
types of breast cancer.
• Hormone therapy or drugs that target HER2 are not
helpful in treating these cancers.

16. MOLECULAR SUBTYPE
• Newer approaches look at ER, PR, HER2 together, along
with the tumor grade, to categorize breast cancer into
several conceptual molecular classes that have
different prognoses and may have different responses to
specific therapies.
• DNA microarrays have assisted this approach.

17. • Proposed molecular subtypes include:
 Basal-like: ER-, PR- and HER2-; triple negative breast
cancer (TNBC) Most BRCA1 breast cancers are basal-like
 Luminal A: ER+ and low grade
 Luminal B: ER+ but often high grade
 Luminal ER-/AR+: Recently identified androgen
responsive subtype which may respond to antihormonal
treatment with bicalutamide
 Normal Breast like
 ERBB2/HER2+: Has amplified HER2/neu
 Claudin-low: A more recently described class; often
triple-negative, but distinct in that there is low expression
of cell-cell junction proteins including E-cadherin

18. AXILLARY LYMPH NODE DISSECTION
• Approximately 30% of patients with clinically non-
palpable lymph nodes have positive lymph nodes in ALND
specimen
• The presence and number of lymph nodes involved affect
staging, management and prognosis
• Precursor of ALND is SENTINEL LYMPH NODE BIOPSY

19. PRINCIPLES OF AXILLARY DISSECTION
It is removal of different levels of axillary lymph nodes with axillary fat and fascia
WHY AXILLARY
DISSECTION IS DONE?
WHICH LEVELS? TECHNICAL PRINCIPLES
• For staging • Level I – 60% • Any incision but caudal hair-
line is preferred
• To assess the prognosis –
number of nodes/size of
nodule
• Level I,II – 20-25%
• Level I,II,III – 15-20%
• Nerve to serratus anterior
should be safeguarded
• As a treatment – regional
control of the disease
• Medial & lateral pectoral nerves
should be retained when
dissection is done with
mastectomy
• To plan the adjuvant
therapy –
irradiation/chemo/hormone
•Level I and II
dissection
Low dissection has less
chances of
lymphoedema
• Drain should be kept
• All lymph nodes should be
labelled and sent for HPE. Usually
20-32 nodes are present in axilla.
Minimum of 10 nodes should be
dissected. Fat dissolving agents
used for node identification

20. THANK YOU