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. 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. 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. 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
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. 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
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. 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
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. 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. 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. 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. 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
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
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. 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. 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. 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
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. Indications;
All node +’ve patients
Primary tumour >1cm in size
Poor prognostic factors
Advanced Ca Breast
Inflammatory Ca Breast
Metastatic Ca Breast
Drugs;
SR_Ca_Breast_Rx 31
CMF Regime CAF Regime MMM Regime
Cyclophosphamide Cyclophosphamide Methotrexate
Methotrexate Adriamycin Mitomycin-C
5-Fluorouracil 5-Fluorouracil Mitozantrone
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. 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. 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. 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
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
SR_Ca_Breast_Rx 40
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
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. 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. 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
47. Complications of Implants;
Pain, exposure of implant and rupture
Displacement, extrusion
Infection
Capsular contraction
SR_Ca_Breast_Rx 47
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