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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.
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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
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 % RESULTS
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