Management of Early Breast Cancer Stage i &

7/29/2019 Management of Early Breast Cancer Stage i &

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MANAGEMENT OF EARLYBREAST CANCER STAGE I & II


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INVESTIGATIONS

AIM:-

i) Early diadnosis of the caseii) To detect distant metastasis if present

1. Mammography:-

It is nothing but an x-ray examination of the breast.

Uses: a) screening procedure- clinically undetected cancer

- High risk population

b) in older patients where during palpation large and

fatty breast makes diagnosis difficultc) opposite breast

d) in case of a swelling of breast where clinicaldiagnosis is uncertain


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Inference:

Benign lesion: well circumscribed,

homogenous and surrounded by a zone offatty tissue. Calcification is coarse and

present at the periphery.

Carcinoma: margins are poorly defined, edgesare either spiculated or irregular. Fine,

stippled calcification in the soft tissue and

periductal region is very suggestive.


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MAMMOGRAM


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2. XERORADIOGRAPHY:

Here image is recorded on selenium coated film

producing a positive impression.3. ULTRASOUNDOF BREAST:

If the lesion is solid or cystic, margins of the lesions,

internal echoes, compressibility, dimensions.

Carcinoma- irregular margins, irregular internal

echoes, irregular posterior shadowing, non

compressibility, lat/hz dimension >1

Benign- smooth, rounded with well defined margins,with weak internal echo and compressibility.

-Young females, pregnancy and lactation.


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USG


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3.FNAC:-

It is done with 23 guage needle using FNAC

aspiration special syringe.It is difficult to differentiate between in situ and

invasive breast cancer by FNAC.

FNAC Scoring:

C0: no epithelial cells

C1: scanty epithelial cells, benign

C2: benign cells

C3: atypical cells

C4: suspicious cells

C5: malignant cells


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FNAC


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5. FROZEN SECTION BIOPSY:

If FNAN fails after two trials or in case of negative

FNAC.

6. CORECUT/TRUCUT BIOPSY:

It gives clear histological evidence and also confirms

DCIS.

14-18 guage spring loaded needle is used. Multiplepunctures are needed.

7. EXCISION B IOPSY:

It is done when FNAC is inconclusive and facility for

frozen section is not available.

Here incision is planned in such a way that it will be

included in eventual mastectomy.


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CORE BIOPSY


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8. MRI OF BREAST:

Patient lies in prone position with breasts

placed over the breast coils, both

precontrast and postcontrast, MRI is taken.

Gandolinium chelate is given as a rapid i.v.

bolus inj. Contrast medium present in

capillaries and extravascular extracellular

space provides enhancement.

9. EDGE B IOPSY:

Done only when there is ulceration and

fungation.


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MRI


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10. TUMOUR MARKERS:

CA 15/3, CEA, CA 27-29

11. NUCLEAR MEDICINE BREAST IMAGING

TECHNIQUE:

It requires single gamma or double gamma

radiotracers and provide functional or metabolic

information of breast tumours.Single-gamma, 99mtechnetium sestamibi and 99mtc

tetrafosmin are used.

12. CHEST X-RAY:

To look for pleural effusion, cannon ball secondaries,

Mediastinal metastasis.


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13. ER (oestrogen receptors):

ER +ve: good prognosis, treatment

response is good and hormone therapy isbeneficial.

14. PR status or Her 2 Neu receptors or cErb

B2: also done to assess prognosis.15.Bone x-ray

16. Bone scan

17. CT

18. Biochemical study


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SENTINEL LYMPH NODE B IOPSY

Sentinel node is the first node encountered bytumour cells and the histological status of the

sentinel node predicts the status of the distant

lymph nodes.

So the SLN is defined as the lymph node which is in

a direct drainage pathway from the primary

tumour.

SLNB is done in all the cases of early breast cancer,T1 and T2 without clinically palpable node.


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-Advantages:

i) It is a minimally invasive technique

ii) It can give an idea if axillary nodes areinvolved or not

iii) This approach can obviate the need for

axillary node dissection-Procedure

- The lymph node which is most medially

placed of the pectoral group is often thesentinel node. If this node is involved then

question of axillary sampling or clearance

comes in.


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SLNB


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TREATMENT OF EARLY CARCINOMA

BREAST:

AIM:

To achieve possible cure

Control of local disease in breast and axilla

Breast conservation Prevention of distant metastasis

To prevent local recurrence


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Local treatment ranges from lumpectomy to

super radical mastectomy.

1. BREAST CONSEVATION SURGERY

If the patient prefers to be treated by total

mastectomy it should be adhered to.


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Indications

-lump N1-Poorly differentiated

-Multicentric or multifocal

tumour

-Earlier breast irradiation-Central tumour

-With distant metastasis

-Fixicity of the tumour to the

underlying muscles oroverlying skin

-Extensive intraductal Ca


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A . LUMPECTOMY (TYLECTOMY):

The term means removal of the tumour with a

minimal margin of normal breast tissue around it.

There is a high risk of recurrence.

Without radiotherapy the recurrence rate is 37%

B. WIDE LOCAL EXCISION:

Segentectomy, partial mastectomy

It is removal of unicentric tumour with 2cm clearance

margin.

ProcedureIf margins show no clearance then patient probably

requires total mastectomy. So prior consent for

mastectomy should be taken.


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LUMPECTOMY


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BCS

Along with this axillary dissection through


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Along with this axillary dissection throughseparate incision and RT to breast andchest wall area is given.

C. QUADRANTECTOMY:

An even more aggressive procedure involvesremoval of the whole segment of the breast

containing the tumour.It is a part ofQUARTtherapy-

quadrantectomy, axillary dissection of level Iand II nodes with separate axillary incision

and post op RT to breast (5000 cGY ) andaxilla (1000 Cgy ). It was started by UmbertoVeronesi from Milan.


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D.SK IN SPARING MASTECTOMY ( SSM):

It is like a key hole surgery of breast.

Indication- central tumour, multicentric,extensive intraductal, T1, not feasible for

conservation

Excision of nipple-areola complex with verylimited skin removal.

Total glandular mastectomy

Axillary dissection using either same orseparate incision.


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Indication for total mastectomy in early breast

cancer:

When tumour > 4cm

Multicentric tumour

Poorly differentiated tumour

Tumour margin is not clear of tumour after

BCS.

1. Total mastectom y:

Along with the tumour, entire breast, areola,

nipple, skin over the breast, including

axillary tail are removed.


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INCISION FOR SIMPLE

MASTECTOMY


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There is no axillary dissection.

Patient is subjected to RT later for axilla

2. TOTAL MASTECTOMY WITH AXILLARY

CLEARANCE:

Total mastectomy is done along with removal

of axillary fat, fascia and lymph nodes.

Level I and II nodes are removed.

3 MODIFIED RADICAL MASTECTOMY


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3. MODIFIED RADICAL MASTECTOMY

(MRM):

Pateys operation:

It is total mastectomy along with clearance of

all levels of axillary nodes and removal of

pectoralis minor muscle.

Procedure

Scanlons operation:

Modified pateys wherein instead of removingpectoralis minor, it is incised to approach the

affected level III nodes.


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PATEYS OPERATION


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Auchincloss modified radical mastectomy:

Here pectoralis minor muscle is left intact and

level III lymph nodes are not removed.Halsted radical mastectomy:

Structures removed are:

TumourEntire breast, nipple, areola, skin over the

tumour with margin

Pectoralis major and minor musclesFat, fascia, lymph nodes of axilla

Few digitations of serratus anterior


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Structures retained are:

Axillary vein, Bells nerve ( nerve to serratusanterior), cephalic vein

Position:

Patient lies supine near the edge of thetable with the arm of the affected side

abducted to right angle and placed on armrest.

Technique


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4. Extended radical mastectomy:

This technique includes removal of internal

mammary group of lymph nodes as well.

In SUPER-RADICAL MASTECTOMY internal

mammary group, mediastinal and

supraclavicular lymph nodes are alsoremoved along with axillary node dissection.


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Management of axillary nodes when

clinically not palpable:

1 SLNB: If node is positive for tumour thenaxillary dissection is done.

2 axillary sampling: aim is to remove largest

nodes in axilla which are likely to beinvolved.

Adjuvant therapy after surgery


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Adjuvant therapy after surgery

RADIOTHERAPY:

INDICATIONS:

-after BCS

-after total mastectomy, external irradiation is given to axilla

-patients with high risk of local relapse-inflammatory carcinoma

-as pre-op RT to reduce the size of tumour

External RT: given over breast area, internal mammary and

supraclavicular areaTotal dose 5000 cGY units

200-cGY units daily 5 days a week for 6 weeks


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HORMONE THERAPY:

PRINCIPLES:

-it is used in ER/PR +ve patients-It gives prophylaxis against carcinoma of opposite

breast

i) tamoxifen: antioestrogen 20mg

ii) Medroxyprogesterone 400mg

iii) Aminoglutethimide: aromatase inhibitor

iv) Arimidex: aromatase inhibitor

v) Letrozole: aromatase inhibitor

vi) Diethylstilbesterol: oestrogen

vii) Fluoxymestrone: androgen


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CHEMOTHERAPY:

Ajuvant chemotherapy

Neoadjuvantchemotherapy

Palliative chemotherapy

CMF regime CAF regime MMM regime

CyclophospahmideMethotrexate

5-FU

CyclophosphamideAdriamycin

5-FU

MethotrexateMitomycin

mitozantrone


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THANK YOU!

Management of Early Breast Cancer Stage i &

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