This document discusses early breast cancer and its management. Early breast cancer includes in situ breast cancer and stages I and IIA breast cancers. The aims of treatment are possible cure, controlling local disease in the breast and axilla, breast conservation, preventing distant metastasis, and preventing local recurrence. Treatment may involve lumpectomy, lymph node assessment, and adjuvant radiation and/or chemotherapy. For a 40-year-old woman with early breast cancer, treatment would involve investigations like blood tests and imaging, followed by lumpectomy, sentinel lymph node biopsy or axillary dissection, and radiation or chemotherapy depending on risk factors. Breast conservation therapy is preferred when possible.

1. SOHINI MITRA
3RD PROFESSIONAL MBBS PART II
EARLY BREAST
CANCER and
TNM STAGING

5. Breast cancer that has not spread beyond the
breast or the axillary lymph nodes. This
includes In Situ breast cancer (Stage O) and
stage I, stage IIA breast cancers.
What is EARLY BREAST
CANCER ??

7. MANAGEMENT OF EARLY
CARCINOMA BREAST
AIMS OF TREATMENT :
 To achieve possible cure
 Control of local disease in breast and axilla
 Breast conservation
ie. Breast form and function
 Prevention of distant metastasis
 To prevent local recurrance
Resection of
primary breast
ca with the
margin of
normal tissue
Adjuvant
radiation
therapy
Regional
lymph node
assessment
B
C
T

8. How will we manage a case of early
carcinoma breast in a 40 yr old lady?
 Investigations:
 Complete blood cell count, complete metabolic
panel, and chest x-ray.
 A bone scan if the alkaline phosphatase or calcium
level is elevated.
 CT scan of the liver if liver function panel is
abnormal.
 CT scan of the thorax to exclude presence of lung
secondaries.

9. Modalities of treatment
 Lumpectomy
 Partial or segmental mastectomy
 Simple mastectomy
 Modified radical mastectomy
 Sentinel lymph node biopsy
 Axillary lymph node dissection
 Radiation therapy
 Chemotherapy

10.  Breast conservation therapy (BCT): partial mastectomy
and SLNB (or axillary lymph node dissection) followed by breast
irradiation.

11. INDICATIONS OF BCT
 T1 , T2 (< 4 CM ), NO ,N1 , M0
 T2 > 4CM IN LARGE BREASTS.
 SINGLE CLINICAL AND MAMMOGRAPHIC LESION
 CLINICALLY NEGATIVE AXILLARY NODES
 WELL DIFFERENTIATED TUMOUR

12.  History and physical examination
 Mammographic evaluation
 Histological assessment of the resected
breast specimen
 Assessment of the patients needs and
expectations
CRITICAL ELEMENTS IN
PATIENT SELECTION FOR
BCT

13. MAJOR ADVANTAGES OF BREAST
CONSERVATION THERAPY
1. An acceptable cosmetic appearance.
2. Lower levels of psychological morbidity.
3. Equivalence in terms of disease outcome in
BCT and mastectomy in selected patients

14. ABSOLUTE CONTRAINDICATIONS OF
BCT
1. PREGNANCY : It is an absolute contraindication
however in many cases it may be possible to
perform BCS in the third trimester .
2. MULTIFOCAL/MULTICENTRIC DISEASE
3. History of PRIOR THERAPEUTIC IRRADIATION
to the breast region .
4. PERSISTENT POSITIVE MARGINS after
reasonable surgical attempts.
5. T4 , N2 , M1 lesions
6. Patients who prefer Mastectomy.

15. RELATIVE CONTRAINDICATIONS
1. A history of COLLAGEN VASCULAR DISEASE
2. TUMOR SIZE : Greater than 4cm to 5cm or large
tumour in a small breast.
3. BREAST SIZE : Treatment by irradiation of women
with large or pendulous breasts is feasable if
reproducibility of patient set up can be ensured,
and the technical capability exists for more than
6MV or greater photon beam irradiation .
4. Women with a STRONG FAMILY HISTORY of
breast cancer or BRCA1 and BRCA2 mutation
carriers.

16. Reconstructive surgery
 RECONSTRUCTION WITH IMPLANTS
 RECONSTRUCTION WITH A TISSUE FLAP
 DEEP INFERIOR EPIGASTRIC PERFORATOR
(DIEP) RECONSTRUCTION
 RECONSTRUCTION OF THE NIPPLE AND AREOLA

17. WHAT IS SENTINEL
LYMPH NODE ???
 The first axillary node draining the breast(by direct
drainage) is designated as the sentinel lymph node
(SLN)
 It is the first node involved by tumour cells
 Gives an idea about further spread of tumour to other
nodes.
 Sentinel Lymph node Biopsy is done in all cases of
early breast cancers, T1 and T2 without clinically
palpable node
 Not done for multicentric and multifocal tumours.

18. SENTINEL LYMPH NODE BIOPSY
 How to identify the Sentinel Lymph Nodes ?
1. Sentinel node Imaging
2. Blue Dye Injection
3. Gamma Probe Detection

19.  Total (simple) mastectomy with SLNB is for patients with a clinically
negative axilla.
 A skin-sparing mastectomy (preserves skin envelope and
inframammary ridge) may be performed with immediate
reconstruction, resulting in improved cosmesis:
 The nipple-areolar complex, a rim of periareolar breast skin, and any
previous excisional biopsy or partial mastectomy scars are excised.

20. Patients with large tumors
NEOADJUVANT NEOADJUVANT
CHEMOTHERAPY HORMONAL
THERAPY
Reduce the size of the tumor
BCT possible.

21. Therapeutic Approach for Breast Cancer
Stage I & II
Modified radical mastectomy
(+) LN (-) LN (-) LN
Low risk High risk
Hormonal / observe chemotherapy
chemotherapy
High Risk Patients (Stage I):
A. Histologic criteria: 1. Poor cytologic differentiation
2. Lymphatic permeation
3. Blood vessel invasion
4. Poor circumscritption
B. Rapid growth rate, by clinical history or thymidine labeling index
C. Age of the patient
D. Estrogen receptor negative

22. INDICATIONS OF MODIFIED RADICAL
MASTECTOMY IN EARLY BREAST CANCER
When tumour is more than 4cm
Multicentric tumour
Poorly differentiated tumour-high grade
Tumour margin is not clear of tumour after
Breast conservation Surgery

23. OPTIONS FOR STAGING
AXILLARY DISEASE
 SENTINEL LYMPH NODE BIOPSY
 AXILLARY NODE SAMPLING
INDICATIONS
1 . Operable BREAST
CANCER (T1, T2)
2. Clinically node
negative patients
CONTRAINDICATIONS
1. Palpable lymphadenopathy
2. Prior axillary surgery
3. Chemotherapy or Radiation
Therapy
4. Multifocal breast cancer

24.  C. AXILLARY DISSECTION
INDICATIONS FOR AXILLARY DISSECTION
1) Preoperative diagnosis of axillary node metastasis
2) Positive SLN
3) Failed SLN biopsy or a recent inadequate ALND
4) Clinically suspicious nodes identified at surgery
5) Non availability of equipment for SLN biopsy

25.  Adjuvant chemotherapy is given in appropriate
patients after completion of surgery.
 All node-positive patients should receive adjuvant
chemotherapy.
 Regimens are guided by the tumor biomarkers. Typical
regimens comprise four to eight cycles of a combination of
cyclophosphamide and an anthracycline, followed by a
taxane administered every 2 to 3 weeks.
 Patients with ER-positive tumors receive adjuvant hormonal
therapy for 5 years. Tamoxifen is given to premenopausal
women, and aromatase inhibitors are given to
postmenopausal women (aromatase inhibitors are not used
in premenopausal women).

26.  Node-negative patients may have increased disease-free
survival from adjuvant chemotherapy and/or hormonal
therapy.
 Up to 30% of node-negative women die of breast cancer within 10
years if treated with surgery alone.
 Node-negative patients who are at high risk and benefit the most from
adjuvant chemotherapy include those with
1.Tumors greater than 1 cm
2. Higher tumor grade
3. Her2/neu expression
4. Aneuploidy
5. Ki-67 expression
6.Increased percentage in S phase
7. Lymphovascular invasion, and
8. ER/PR-negative tumors.

27.  Polychemotherapy in combination with tamoxifen
was superior to tamoxifen alone in increasing
disease-free and overall survival, especially in ER-
negative patients, regardless of tumor size.
 Adjuvant whole-breast radiation after BCT decreases the
breast cancer recurrence rate from 30% to less than 7% at 5
years.

28. THANK YOU