BREAST CONSERVATIVE THERAPY

• Dr Shailesh Puntambekar

• Consulting onco surgeon

• Associate professor , department of surgery, KEM Hospital, Pune, India

In the good old days we made a clean breast of malignant disease.In the

modern era there is no

TIT for T(h)AT

HISTORY

• Halstead radical mastectomy

• Extended radical mastectomy

• Modified radical mastectomy

• Breast conservation therapy

BCS:Why?

• Ca Breast is a local manifestation of a systemic disease.Local radicality does not change survival

• Cosmetic Considerations

• Preservation of the nipple ,an important sensate focus

• Mastectomy is a socially devastating surgery for the downtrodden Indian woman and signals an end to her married life.The relevance of BCS in the Indian scene cannot be overemphasised.

INDICATIONS

• Stage I & II

• ? Stage III

CONTRAINDICATIONS

• Pregnancy• Multicentric disease• Diffuse indeterminate micro-calcification• Previous RT• Large tumour/ breast ratio• Collagen vascular disease• Large breast size• Central tumour

Small Breast Realities

• In a small breast not much to achieve in cosmesis

• Recurrence comes as Cancer en Cuirasse

POST MRM NO RADIOTHERAPY

• SATELLITE NODULES OVER THE CHEST WALL

• NO TREATMENT IS EFFECTIVE

• PALIATIVE INTENT OF RADIOTHERAPY

Large Breast Realities

• In a large breast recurrences not easily diagnosed

• A recurrence is viewed as a second primary

SPECIAL CONSIDERATIONS

• Family history

• Primary tumour histology

• Margin evaluation

• Extensive intraductal component

METHODS

• Lumpectomy +Axillary dissection +RT

• Lumpectomy+SLN biopsy +RT

• QUART- Quadrantectomy +Axillary dissection +RT

• CTART- Chemotherapy +RT

Axillary Dissection

• Better control of locoregional recurrence

• Accurate staging of disease

• To decide adjuvant therapy

• Prognosis

GUIDELINES OF SURGERY

• Incision

• Technique

• Closure

• Axillary Dissection

NEW INVESTIGATION MODALITIES

• MRI

• Intra-op ultra-sound

• Touch preparation cytology

• Percutaneous needle biopsy

NEW TECHNIQUES OF TUMOUR MANAGEMENT

• Radio Frequency Ablation –RFA

• Cryosurgery

• Focused Ultrasound

• Percutaneous tumour extraction

ROLE OF NEOADJUVANT

• Induction chemotherapy

• Drugs

• Selection and monitoring of induction chemotherapy patients

SEQUENCING OF CHEMOTHERAPY AND RT

• 6 Cycles of CMF followed by RT

• RT followed by 6 cycles of CMF

• 3 Cycles of CMF followed by RT followed by 3 cycles of CMF (sandwich therapy)

RADIOTHERAPY IN BCT

• Intraoperative radiotherapy

• Post operative radiotherapy

• Brachytherapy

SPECIAL CASES

• Hereditory breast cancer

• Macromastia

• Occult breast cancer

• Pregnancy

• Bilateral breast cancer

RESULTS

• BCT / MRM T1 & T2 • TUMOUR CONTROL RATE

• 5 YR RELAPSE FREE SURVIVAL

• RECURRANCE • ONLY CONS SURGERY• CONS SURGERY + RT

• 80 TO 90 %

• 70 TO 88 %

• 15 TO 40 %• 2 TO 10 %

Newer Frontiers

• Laparoscopic Axillary Dissection

• Laparoscopic Int Mammary Clearance

• Technically feasible

• Clearance equal to standard technique

• Acceptability only after it stands the test of time

Thank You