Treatment of Carcinoma Breast
description
Transcript of Treatment of Carcinoma Breast
Treatment
of Carcinoma Breast
surgery
radiotherapy
chemotherapy
Surgery
Central role
Radical
Modified Radical
Conservative procedures
surgeries
Radical mastectomy (Halsted)
Extended Radical mastectomy
Modified Radical mastectomy (Patey)
Breast conservative surgeries
Edwin smith papyrus (800 BC)
"There is no treatment."
Jean Louis Petit (1605)
structures removed
Tumor
Entire breast, nipple, areola, skin over tumor
P.major & minor
Complete Axillary LN dissection ( up to level 3), fat , fascia
ICB nerve, few serrations of serratus
Structures retained
Axillary vein, artery, brachial plexus
Long thoracic N (Bell)
Thoracodorsal N
Cephalic vein
1971
Fisher et al
National Surgical Adjuvant Breast and Bowel Project (NSABP) B-04 trial
“radical mastectomy had no survival benefit over mastectomy with radiation”
Modified radical mastectomy(patey’s)
Stewart incision
Scanlon’s operation
Auchincloss MRM
Conservative breast surgery
Wide local excision (1 cm margin) df. lumpectomy
Quadrentectomy (QUART)
Axillary dissection through separate incision
Always combined with radiotherapy except node - low grade tumors
BCS CONTRAINDICATIONS- ABSOLUTE
Pregnancy
Prior irradiation
Persistent +ve margins
2 or more quadrants of primary tumor or diffuse malignant appearing micro calcifications
BCS CONTRAINDICATIONS-relative
CVD( except RA)
Multiple primary/ calcifications in same quadrant
Large breast to tumor ratio
Large tumor (>4cm)
Central tumor
others
Subcutaneous / skin sparing / keyhole mastectomy
Simple mastectomy
Toilet mastectomy
Extended radical mastectomy
Sentinel lymph node biopsy
Only micromets escape frozen section
Completion Axillary node dissection
Full Axillary node dissection
COMPLICATIONS
Injury/ thrombosis of Axillary V
shoulder dysfunction
Winged scapula
Flap necrosis/ infection
Pain, numbness, hyperesthesia
lymph edema
RADIOTHERAPY
To prevent local recurrence
INDICATIONS (ASCO)
T3 (>5 cm)
Positive post mastectomy margins
4 or more LN
BCS
RT
EBRT
Brachytherapy
Intra cavitory brachytherapy
Interstitial brachytherapy
Dose
4500 Gy to chest wall ( 25 fractions of 150 Gy over 5 weeks)
Booster dose 1000 Gy to tumor bed
1500 to axilla if needed
Accelerated partial breast irradiation
Mew modalities
Intensely modulated RT
Targeted intraoperative RT
COMPLICATIONS
EARLY
Swelling, pain, edema
Skin exfoliation, fatigue
LATE
Persistent beast edema, pain, swelling, pigmentation
Pulmonary fibrosis
Rib fracture
Lymph edema, sarcoma
Cardiac disease
CHEMOTHERAPY
micromets
CONVENTIONAL
1. LN involved
2. high grade
HORMONAL- all ER/PR positive cases
BIOLOGICAL- all ERB B2 positive cases
ER
HER 2 NEU ( ERB B2)
Hormonal
SERM- tamoxifen
Aromatase inhibitor- letrozole
Antigonadotropin- Danazole
LHRH agonist- med oophorectomy
Pure anti estrogens & progestins
Surgical/ radiological ablation
BIOLOGICAL
Trastuzumab (herceptin)
Bevacizumab
lapitinab
chemotherapy
ADJUVANT ( for EBC)
FEC regimen
5- FU 500mg/m2
Epirubicin 75 mg/m2
Cyclophosphamide 500 mg/m2
6 cycles repeated every 28 days
Neoadjuvant (for LABC)
FACT regimen
5- FU 500mg/m2
ADRIAMYCIN 50mg/m2
Cyclophosphamide 500 mg/m2
6 cycles repeated every 28 days
FOLLOWED BY
Paclitaxel 175mg/m2 for 2 cycles
Old
CMF( Bonnadona)
AC-T
STD TREATMENT PROTOCOLS
CIS
Surgery
Radiation if high Van Nuys score
EBC
Surgery (MRM/BCS + Axillary N sampling)
RT if BCS or margins +
CT if LN+ or high grade
Hormonal & herceptin to all deserving patients
LABC
Neoadjuvant CT
Followed by surgery
RT
Hormonal & herceptin to all deserving patients
If no response, exp trials or palliative therapy
ABC
Palliative
Systemic therapy is mainstay
1. Hormonal therapy mainly
2. Cytotoxic therapy only in young , rapid growth of tumors
RT & surgery seldom done
‘Toilet mastectomy’
Local RT & internal fixation to bone mets
BREAST reconstruction
Saline, silicone Implants
TRAM,DIEP,LD FLAP
SPECIAL SITUATIONS
MALE BREAST CA
PREGNANCY
Surgery (no BCS)
CT (2ND trimester onwards)
Wait 2 years
Follow up (NCCN)