Dr Mukhilesh R MS PG

In Situ Breast CancerEarly Breast Cancer

VS

• Oncologically equivalent.• Better aesthetic outcome.• Psychological advantage with

breast preservation

Still require mastectomy….

• Extensive calcification on mammography

• Clear margins cannot be obtained.

• C/I to irradiation

• previous chest wall irradiation

• Pregnancy

• scleroderma / active lupusPatient preference to mastectomy / desire to avoid

irradiation

• Curvilinear incision – above nipple.

• Radial incision – below nipple.

• If previous bx- scar to be included.

• Adequate clearance.• Specimen orientation.• HPE–hormone status/HER-

2neu

Treatment of axillary node do not alter disease free / overall survival.

Helps to stage the disease, identify the prognosis and need for adjuvant therapy.

Node negative by physical and imaging studies.Not recommended

T3/T4 tumourinflammatory breast capregnancyDCIS without

mastectomyprior axillary surgeryafter preop

chemotherapyCan be done

old age / obesitymale breast caprior excisonal bxbefore preop chemo

In the operating room , 3-5 ml of isosulphan blue injected parenchyma or subareolar

• Hand held gamma counter to identify the location.

• 3-4 cm curved transverse incision below hair line is made and deepened, identify blue lymphatic channels.

• As sentinel lymph node is approached signal increases.

• Frozen section / touch imprint / permanent HPE.

• 10 sec in vivo and 10 sec ex vivo count to be obtained.

• All blue lymph nodes and those with >10% of 10 second ex vivo count are to be removed.

• Entire surgical bed to be scanned.

• Should be <10% 0f 10 sec ex vivo count.

• Complications :• Infection • Seroma• Hematoma• Axillary paresthesia• Dereased range of

motion• Lymphedema of arm.

• Pathologic processing of the sentinel nodes – requires standardisation.

• Intraoperative assessment of node varies in each institution.

• Adverse prognostic factors • Blood vessel or lymph vessel

invasion• High nuclear grade• High histologic grade• HER – 2 /neu over

expression• Negative hormone receptors

• Tamoxifen – hormone positive >1cm

• Trastuzumab – HER-2/neu positive + node positive tumor.