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Breast Carcinoma - Management

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All about the management of Carcinoma Breast

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Breast Carcinoma - Management

  1. 1. Sridevi Rajeeve 2008 Batch SR_Ca_Breast_Rx 1
  2. 2. Early Breast Cancer(EBC): Stage I & II, T1N1, T2N1, T3N0 Locally Advanced Breast Cancer(LABC): Stage IIIA & IIIB Metastatic Breast Cancer: Stage IV SR_Ca_Breast_Rx 2
  3. 3. I II III SR_Ca_Breast_Rx 3
  4. 4. Management of Ca Breast Options available; I. Surgery II. Radiotherapy III. Hormone Therapy IV. Chemotherapy Multi-pronged approach adopted Single approach ineffectual SR_Ca_Breast_Rx 4
  5. 5. I. SURGICAL Approaches 1. Total (Simple) Mastectomy 2. Total Mastectomy with Axillary Clearance 3. Modified Radical Mastectomy [MRM] 1) Patey’s Operation 2) Scanlon’s Operation 3) Auchincloss’ MRM 4. Radical Mastectomy of Halsted 5. Conservative Breast Surgeries 1) Wide Local Excision [WLE] 2) Lumpectomy 3) Quadrantectomy 4) Toilet Mastectomy 5) Skin-Sparing/Keyhole Mastectomy [SSM] SR_Ca_Breast_Rx 5
  6. 6. 1. TOTAL/SIMPLE MASTECTOMY Tissues removed: Tumour, entire breast, areola, nipple, skin over breast, Axillary tail of Spence, Pectoral fascia Tissues retained: NO Axillary Dissection Subjected to Radiotherapy later SR_Ca_Breast_Rx 6
  7. 7. 2. TOTAL MASTECTOMY with AXILLARY CLEARANCE Common procedure Tissues removed: TM + Axillary fat, Axillary fascia, Level I and II Axillary LN SR_Ca_Breast_Rx 7
  8. 8. SR_Ca_Breast_Rx 8
  9. 9. 3. MODIFIED RADICAL MASTECTOMY 1) Patey’s 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, Cephalic Vein, Pectoralis major SR_Ca_Breast_Rx 9
  10. 10. Procedure: Elliptical incision made on medial aspect of 2nd and 3rd ICS enclosing the nipple, areola and tumour which extends laterally into Axilla along the Anterior Axillary fold. Upper and lower skin flaps are raised. Breast with tumour is raised from the medial aspect of Pectoralis major. Dissection is proceeded laterally while ligating pectoral vessels. In axilla, lateral border of Pectoralis minor is divided from Coracoid process to clear Level II LN. Level III cleared subsequently. Pectoralis minor removed 2) Scanlon’s Operation: Pectoralis minor incised Level III LN removed 3) Auchincloss’ MRM: Pectoralis minor left intact Level III LN not removed SR_Ca_Breast_Rx 10
  11. 11. SR_Ca_Breast_Rx 11
  12. 12. SR_Ca_Breast_Rx 12
  13. 13. 4. RADICAL MASTECTOMY of HALSTED Tissues removed: Tumour, entire breast, areola, nipple, skin over tumour, Pectoralis major & minor muscles, fat, fascia, Level I,II,III Axillary LN, few digitations of Serratus anterior muscle Tissues retained: Axillary vein Bell’s nerve (N.to Serr.ant) Cephalic vein SR_Ca_Breast_Rx 13 Complications: Lymphoedema Lymphangiosarcoma (>3 years)
  14. 14. 5. BREAST CONSERVATIVE SURGERIES 1. Wide Local Excision (WLE)/ Partial Mastectomy Removal of unicentric tumour with 1cm clearance margin. Incision: Over tumour + Axillary Dissection + RT 2. Quadrantectomy: Removal of entire quadrant with ductal system with 2-3cm normal breast tissue clearance. Part of QUART Therapy (Quadrantectomy + Axillary dissection + RT) Not advocated now. 3. Skin Sparing Mastectomy 4. Lumpectomy (=WLE) Term rarely used SR_Ca_Breast_Rx 14
  15. 15. SR_Ca_Breast_Rx 15
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  17. 17. Other procedures Toilet Mastectomy  In locally advanced tumour (LABC), tumour with breast tissue removed – prevent fungation  Post-chemotherapy  Significance: (?) Extended Radical Mastectomy  Radical Mastectomy + Removal of Internal Mammary Nodes (ipsilateral +/- contralateral) Not done at present SR_Ca_Breast_Rx 17
  18. 18. COMPLICATIONS of M.R.M/MASTECTOMY Injury/ Thrombosis of Axillary Vein Seroma Shoulder Dysfunction Pain and Numbness Flap Necrosis and infection Lymphoedema and its problems Axillary hyperaesthesia Winged Scapula SR_Ca_Breast_Rx 18
  19. 19. LYMPHANGIOSARCOMA (Stewart- Treve’s Syndrome) In ipsilateral upper limb Develops in people with Lymphoedema after Mastectomy with Axillary clearance. 3-5 years after development of Lymphoedema Presentation: Multiple subcutaneous nodules Requires Forequarter Amputation Poor prognosis SR_Ca_Breast_Rx 19
  20. 20. II. RADIOTHERAPY Approach Indications; 1. Conservative Breast Surgery adjuvant [Breast] 2. Total Mastectomy [Axilla] 3. High-risk of relapse patients 1) Invasive Carcinoma 2) Extensive in-situ Carcinoma 3) Age < 35 years 4) Multifocal disease 4. Bone secondaries [Palliative] 5. Atrophic Schirrous Carcinoma [Curative] 6. Pre-Operatively (reduce tumour size and downstage) 7. >4 +’ve Axillary LN, Pectoral fascia involvement, positive surgical margins, Extra-nodal spread SR_Ca_Breast_Rx 20
  21. 21. Chest Wall Axilla Post-BCS T3 tumour>5cm Residual disease LABC Positive margin/close surgical margin <2cm Conservative surgery Inflammatory Carcinoma >4 nodes +’ve Extra-nodal spread Axillary status unknown/ not assessed MANDATORY! Local + Axilla Tangential fields: 50 Gy- 25 fractions-5 weeks Another 10 Gy to tumour bed Internal Mammary and Supra-clavicular area may be included in the radiation field SR_Ca_Breast_Rx 21
  22. 22. SR_Ca_Breast_Rx 22
  23. 23. External Radiotherapy Over Breast area, axilla, Internal mammary and Supra-clavicular area  Total dosage: 5000 cGy units  200-cGy units daily 5 days a week for 6 weeks Internal Radiotherapy SR_Ca_Breast_Rx 23
  24. 24. SR_Ca_Breast_Rx 24
  25. 25. III. HORMONE-THERAPY Approach Principles;  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 and longevity SR_Ca_Breast_Rx 25
  26. 26. Includes; Medical i. Oestrogen Receptor Antagonists – Tamoxifen 20 mg ii. Progesterone receptor Antagonist iii. 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 daily v. LHRH Agonists – Goserelin (Zoladex) [Medical Oophorectomy] vi. Progestogens – Medroxypregesterone acetate 400 mg  Surgical i. Ovarian Ablation by a. Surgery (Bilateral Oophorectomy) b. Radiation ii. Adrenalectomy iii. Pituitary ablation SR_Ca_Breast_Rx 26
  27. 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, vaginal atrophy 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. 28. Letrozole  Non-steroidal competitive inhibitor of Aromatase Reduces Oestrogen levels by 98%  More expensive, more effective, fewer side-effects Indications: 1. Adjuvant Endocrine therapy in Post-menopausal women with hormone sensitive breast cancer 2. Metastatic disease 3. 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 and osteoporosis. SR_Ca_Breast_Rx 28
  29. 29. Novel drugs - Biologicals 1. TRANSTUZUMAB (Herceptin)  Monoclonal Ab. Blocks Her-2/Neu receptors (Tyrosine kinase receptor)  Useful only in Her-2/Neu +’ve cases Metastatic d/s  Intravenous infusion 4mg/kg loading, 2mg/kg maintenance dose for 1 year 2. BEVACIZUMAB Vascular Growth Factor receptor inhibitor 3. LAPITINAB Combined Growth Factor receptor inhibitor SR_Ca_Breast_Rx 29
  30. 30. IV. CHEMOTHERAPY Approach Types; A. Adjuvant Chemotherapy  Administration of Cytotoxics after surgery  Eliminate clinically undetectable distant spread B. Neoadjuvant Chemotherapy  Administration of Cytotoxics in large operable tumours before surgery  Reduce loco-regional tumour burden – downstage  Amenable to surgical resection after 3 doses C. Palliative Chemotherapy  Advanced Ca Breast  Metastatic Ca Breast SR_Ca_Breast_Rx 30
  31. 31.  Indications; All node +’ve patients Primary tumour >1cm in size Poor prognostic factors Advanced Ca Breast Inflammatory Ca Breast Metastatic Ca Breast  Drugs; CMF Regime CAF Regime MMM Regime Cyclophosphamide Cyclophosphamide Methotrexate Methotrexate Adriamycin Mitomycin-C 5-Fluorouracil 5-Fluorouracil Mitozantrone SR_Ca_Breast_Rx 31
  32. 32. Chemotherapy Regimes  CAF and CMF – commonly used, monthly/3 weeks cycles for 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: Gemcitabine SR_Ca_Breast_Rx 32
  33. 33. EARLY CARCINOMA BREAST [ECB] - Management  Breast Conservation Surgery – Wide Local Excision/ QUART/ SSM; RT locally  Patey’s 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 BCS SR_Ca_Breast_Rx 33
  34. 34. ADVANCED CARCINOMA BREAST Refers to;  Locally Advanced Carcinoma Breast [LACB]  Inflammatory Ca Breast  Bilateral Ca Breast Metastatic Ca Breast  Fixed axillary/supra-clavicular LN SR_Ca_Breast_Rx 34
  35. 35. Management of ACB LACB Neoadjuvant Chemotherapy Response assessment Non-responders: RT + Surgery Responders: Surgery (Toilet Mastectomy/MRM) Inflammatory Ca Breast ‘Mastitis carcinomatosis’/ ‘Lactating Ca of Breast’ T4d LACB (Stage IIIB) Neoadjuvant ChemoT and RT Surgery (if downstaged) + Axillary clearance SR_Ca_Breast_Rx 35
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  37. 37. Metastatic Ca Breast Hematogenous spread to; Bone: most common. Vertebra – Batson’s (valveless) venous plexus and posterior intercostal veins, Ribs, Humerus, Femur Lungs – ‘Cannon-ball’ 20 in parenchyma, Pleural effusion, Chest wall 20 Liver Brain Treatment strategies; Chemotherapy: CMF/CAF Radiotherapy Tamoxifen, Oophorectomy Transtuzumab, Bevacizumab Hypercalcemia – Hydration, steroids, Palmidronate 90mg i.v once a month Internal fixation of pathological # SR_Ca_Breast_Rx 37
  38. 38. SR_Ca_Breast_Rx 38
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  40. 40. CARCINOMA BREAST in PREGNANCY - Management 1st Trimester 2nd Trimester 3rd Trimester MRM MRM MRM Axillary node +’ve: Termination of pregnancy + Chemotherapy Chemotherapy carefully After delivery – Chemotherapy with suppression of lactation Note the following; Hormone treatment contra-indicated: Teratogenic Radiotherapy: No role MRI is the investigation of choice Can become pregnant 2 years after completion of therapy as recurrence rates are highest in 2 years SR_Ca_Breast_Rx 40
  41. 41. Follow-up Clinical examination in detail @ regular intervals Yearly/2-yearly Mammography of the treated and contralateral breast is a must Bone-scan, CT Chest/abdomen, tumour markers are done only if there is clinical suspicion. Not a regular routine follow-up at present SR_Ca_Breast_Rx 41
  42. 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 to neoadjuvants. CI in LABC  Delayed Reconstruction: 3-9 months after surgery. Done in LABC. Allows post-op RT without prosthesis exposure, avoids fibrosis and fat necrosis where TRAM flap in used SR_Ca_Breast_Rx 42
  43. 43. Methods of Reconstruction 1. Breast Implants – Silicone gel 2. Expandable Saline prosthesis 3. Flap with implant/expanders 4. External breast prosthesis 5. Flap reconstruction 1. Latissimus dorsi (LD) flap 2. Contralateral Tranversus Abdominis (TRAM) flap 3. Superior Gluteal flap 4. Ruben’s flap: soft tissue over Iliac crest SR_Ca_Breast_Rx 43
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  47. 47.  Complications of Implants;  Pain, exposure of implant and rupture  Displacement, extrusion  Infection  Capsular contraction LD Flap TRAM flap Myocutaneous flap Myocutaneous flap Subscapular artery Superior Epigastric artery Easy Ipsilateral or contralateral flap Can be placed over prosthesis Gives bulk. No need of prosthesis Reliable, well-vascularised Free TRAM flap into IMA Low complication rate Mesh placement in abdomen required Unsightly donor area on back Donor site morbidity & fat necrosis SR_Ca_Breast_Rx 47
  48. 48. SR_Ca_Breast_Rx 48
  49. 49. SR_Ca_Breast_Rx 49
  50. 50. Thank you SR_Ca_Breast_Rx 50

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