MANAGEMENT OF EARLY BREAST CANCER

1. MANAGEMENT OF EARLY BREAST CANCER BY GEMY MARIA GEORGE 2002 BATCH

2. Early breast cancer 1.STAGE 0 INSITU CARCINOMA DCIS,LCIS 2.STAGE I T1N0M0 3.STAGE II A- T0N1M0 T1N1M0 T2N0M0 B -T2N1M0.

3. TRIPLE ASSESSMENT • CLINCAL ASSESSMENT. • RADIOLOGICAL IMAGING. • TISSUE DIAGNOSIS

4. INVESTIGATIONS • ROUTINE BLOOD EXAMINATION-Hb,TC, DC, ESR • BT,CT • ECG • CXR

5. BREAST IMAGING • MAMMOGRAPHY • USG • MRI

6. MAMMOGRAPHY • DELIVERS LOW VOLTAGE HIGH AMPERAGE X-RAYS • AVERAGE DOSE -0.1cGy • 2 TYPES- • SCREENING & DIAGNOSTIC

7. SCREENING FOR ASYMPTOMATIC WOMEN AGED>40 YRS ANNUALLY. YOUNGER WOMEN IN HIGH RISK GROUP DIAGNOSTIC FOR A WOMAN WHO HAS A COMPLAINT( LUMP,PAIN, NIPPLE DISCHARGE….) PAST HISTORY OF BREAST CANCER A FINDING ON SCREENING MAMMOGRAM THAT REQUIRES FURTHER EVALUATION. MAMMOGRAPHY

8. FEATURES OF MALIGNANCY • CLUSTERED MICROCALCIFICATION. • DENSITY ABNORMALITIES – • Architectural distortions • Fibronodular densities • Spiculated masses • Asymmetries.

9. USG • PRIMARY ROLE IS TO DIFFERENTIATE SOLID & CYSTIC LESIONS. • ANOTHER USE IS IN GUIDED BIOPSY

10. DISADVANTAGES • DOES NOT DISPLAY MICRO CALCIFICATION…. • SENSITIVITY IS LIMITED IN FATTY BREAST. • HIGH FALSE POSITIVITY

11. MRI • TO DISTINGUISH SCAR FROM RECURRANCE. • GOLD STANDARD FOR IMAGING BREAST WITH IMPLANTS. • FOR WORK-UP OF AXILLARY METASTATIC LYMPHADENOPATHY..

12. BIOPSY • FNAC • TRU-CUT BIOPSY • INCISION BIOPSY • EXCISION BIOPSY • SENTINEL LN BIOPSY

13. FNAC • PERFORMED WHEN A CLINICALLY PALPABLE MASS IS EVIDENT. • USES 21G NEEDLE & 10ml SYRINGE. • ASPIRATE IS SMEARED INTO SLIDE & FIXED.

14. ADVANTAGES immediate results, no incision, minimal discomfort, no tumor spillage. DISADVANTAGES -can’t diff. insitu& invasive ca, false negative results(15%). FNAC-contd…

15. TRU-CUT BIOPSY • PROVIDES MORE DETAILED HISTOPATHOLOGIC INFORMATION. • DIFFERENTIATES BETWEEN INSITU & INVASIVE CA. • STAINING FOR RECEPTOR STATUS.

16. INCISION BIOPSY • FOR PATIENTS WITH LARGE PRIMARY( >5cm)LESIONS. • INCISION OF A SMALL PORTION OF TISSUE THAT IS NOT NECRTIC. • PERMITS HISTOLOGIC & HORMONAL RECEPTOR STATUS ANALYSIS.

17. EXCISION BIOPSY • REMOVAL OF ENTIRE LESION & A MARGIN OF NORMAL BREAST PARENCHYMA.

18. SENTINEL LN BIOPSY • First node in ipsilateral axilla or internal mammary chain to drain the tumor. • Technetium radiolabelled sulfur colloid or isosulfan blue dye or a combination of both is used to id sentinel nodes.

19. MANAGEMENT OF INSITU CA PRE INVASIVE CA THAT HAS NOT BREACHED THE EPITHELIAL BASEMENT MEMBRANE.

20. STAGE 0 -DCIS • 10-20% BILATERAL. • TRUE PRECURSOR OF INVASIVE CA.(30-50% RISK ) • DCIS MAY BE CLASSIFIED BY VAN NUYS PRONOSTIC INDEX.

21. Van Nuys Prognostic Index • AGE score 1- >61 yrs ; 2- 40-60 yrs ; 3-<39 yrs • Tumor size score 1 -< 15mm ; 2 - 16-40mm; 3 - >41mm • Margin width score 1->10mm ; 2- 1-9mm; 3 - <1mm • Pathological classification score 1 – non high grade DCIS without necrosis 2 – non high grade DCIS with necrosis 3 – high grade DCIS with or without necrosis

22. DCIS • OPTIONS- • EXCISION • EXCISION + RT • MASTECTOMY

23. STAGE 0-LCIS • ACCIDENTAL FINDING IN BIOPSY. • MULTIFOCAL & BILATERAL . • 25% RISK OF INVASIVE CA IN 25 YEARS • OPTIONS • LIFE LONG FOLOW UP • BILATERAL MASTECTOMY

24. MANAGEMENT OF EARLY INVASIVE CA • AIM • LOCOREGIONAL CONTROL. • SYSTEMIC CONTROL. • CONSERVATION OF LOCAL FORM & FUNCTION

25. TREATMENT • MULTIMODALITY TREATMENT • SURGERY • RADIOTHERAPY • CHEMOTHERAPY • HORMONAL THERAPY • OVARIAN ABLATION

26. SURGERY • HALSTED RADICAL MASTECTOMY • EXCISION OF BREAST • AXILLARY LYMPH NODES • PECTORALIS MAJOR & MINOR MUSCLES • NO LONGER INDICATED

27. MRM WITH OR WITHOUT BREAST RECONSTRUCTION.

28. BREAST CONSERVATIVE SURGERY

29. WHY BREAST CONSERVATIVE SURGERY ? • OVER ALL SURVIVAL SIMILAR • SAVES THE BREAST • BUT PROPER PATIENT SELECTON IS IMPORTANT.

30. BREAST CONSERVATIVE SURGERY SELECTION CRITERIA • Patient desire for retaining the breast • Tumor characteristics – if after a WLE acceptable cosmesis is achievable. • Single clinical or mammographic lesion. • No signs of LABC or metastasis. • Able to deliver post op RT • Able to follow up.

31. CONTRAINDICATIONS • TUMOUR CHARACTERISTICS • Multicentric • Multifocal • Large tumor to breast ratio • Persistent +ve margins even after reasonable WLE • Diffuse calcification… • CONTRAINDICATIONS TO RADIOTHERAPY • H/o previous irradiation to breast field– lymphomas • 1st and 2nd trimester of pregnancy • Active collagen vascular diseases

32. SURGERY • WIDE EXCISION • QUADRANTECTOMY

33. WIDE LOCAL EXCISION • REMOVAL OF TUMOUR PLUS A RIM OF ATLEAST 1cm OF BREAST TISSUE.

34. QUADRANTECTOMY • REMOVAL OF ENTIRE SEGMENT OF BREAST WHICH CONTAINS TUMOUR

35. EXCISION DONE WITH FROZEN SECTION TO CHECK MARGINS BEFORE CLOSURE. Patient whose margins are involved need a further local excision or a mastectomy.

36. WHAT TO DO WITH AXILLA ? • 2 OPTIONS • SLNB • AXILLARY DISSECTION

37. SENTINEL LYMPH NODE BIOPSY • MANAGEMENT OF AXILLA IN PATIENTS WITH CLINICALLY NODE NEGATIVE DISEASE. • THIS METHOD LOCALISES THE FIRST NODES THAT THE TUMOUR DRAINS TO.

38. Indication- Any patient with early breast ca without palpable LN Contraindications- Suspicious axillary LN LABC Inflammatory ca Multicentric disease Prior axillary dissection Previous mammoplasty. SLN BIOPSY

39. SLNB • Tc LABELED SULFUR COLLOID- • ISOSULPHAN BLUE DYE • COMBINATION

40. SLNB • IF POSITIVE- DO EITHER ALND OR RT TO AXILLA . • IF NEGATIVE- AVOIDS THE COMPLCATION OF ALND.

41. AXILLARY DISSECTION • Local disease control. • Proper staging of the axilla. • Marker for prognosis. • To decide on adjuvant systemic therapy. • To improve survival.

42. ALND • REMOVES LEVEL 1 & 2. • LEVEL 3 LN REMOVAL- • NO BENEFIT • MORE LYMPHOEDEMA.

43. BCS WITH RT • BCS ALWAYS COMBINED WITH RT – TO CHEST WALL. • EXCISION OF BREAST CANCER WITHOUT RT LEADS TO AN UNACCEPTABLE LOCAL RECURRENCE RATE.

44. POST OPERATIVE RADIOTHERAPY • Breast is irradiated to a dose of 4500 cGy to whole breast & frequently including an additional boost of radiation to the excision site. • Axillary surgery should not be combined with radiotherapy to axilla because of high chances of lymphoedema.

45. MASTECTOMY • PATIENT PREFERENCE. • LARGE TUMOURS. • CENTRAL TUMORS BENEATH OR INVOLVING NIPPLE. • MULTIFOCAL DISEASE. • LOCAL RECURRANCE .

46. MODIFIED RADICAL MASTECTOMY • PATEY’ : • REMOVAL OF THE WHOLE BREAST, • A LARGE PORTION OF THE SKIN , THE CENTRE OF WHICH OVERLIES THE TUMOUR,BUT ALWAYS INCLUDES THE NIPPLE, • ALL OF FAT, FASCIA AND LYMPH NODES OF THE AXILLA, • AND PECTORALIS MINOR.

47. MRM • SCANLON: PECTORALIS MINOR IS DIVIDED BUT NOT REMOVED. • AUCHINCLOSS : PECTORALIS MINOR IS ONLY RETRACTED DURING SURGERY.THIS LIMITS THE REMOVAL OF HIGH AXILLARY LYMPH NODES.

48. TOTAL (SIMPLE) MASTECTOMY • REMOVAL OF BREAST ONLY WITH NO DISSECTION OF THE AXILLA EXPECT FOR THE REGION OF AXILLARY TAIL OF THE BREAST. FOLLOWED BY RT TO AXILLA . • DONE FOR FUNGATING & LOCALLY ADVANCED BREAST CANCER.

49. SKIN SPARING MASTECTOMY • Variant of simple mastectomy. • For selected patients with small tumours followed by immediate reconstruction of the breast. • Only nipple-areolar complex of skin is removed. • A - keyhole incision • B – tissue removed

50. MRM WITH RT ? • NO RT NEEDED IF AXILLA IS NEGATIVE. • GIVEN IF THE TUMOUR WAS HIGH GRADE,LARGE,HEAVILY NODE POSITIVE,OR IF THERE WAS EXTENSIVE LYMPHOVASCULAR INVASION.