o o o o o o

To cure the carcinoma Diagnosis of the carcinoma Reduce chance of local recurrence Conservation of local form Reduce risk of metastatic spread Psychological support

Based on two criterias Characteristics of carcinoma Staging

On the basis of characteristics

Invasive  Non-invasive

AGE GENETICS(BRCA-1 and BRCA-2,HER2,PTEN,P53) MENSTRUAL PERIODS FAMILY HISTORY ORAL CONTRACEPTIVE USE HRT RACE AND ETHNICITY ALCOHOL WEIGHT

TREATMENT MODALITIES

Surgery Radiation therapy Adjuvant systemic therapy Hormonal therapy Chemotherapy

INTRODUCTION TO TREATMENT MODALITIES

Includes Breast conserving surgery

(Breast carcinoma + normal healthy tissue + radiotherapy+Axillary surgery)

Mastectomy
(it is indicated for tumors >4cm ,central , multifocal, DCIS)

It consists of two types Lumpectomy Quadrantectomy



Both of these operative procedures are combined with axillary surgery via a separate incision in axilla

INDICATIONS

STAGE-I & STAGE-II

ABSOLUTE CONTRAINDICATIONS First/second trimester of pregnancy Two/more gross tumors in separate quadrants Diffuse intermediate or malignant microcalcifications History of therapeutic irradiation of breast RELATIVE CONTRAINDICATIONS Large tumor to breast ratio History of collagen vascular disease Large breast size Tumors located beneath the nipple

removal of the breast cancer and a portion of normal tissue around the breast cancer lump. Some of the nearby lymph nodes may also be removed.it is followed by radiotherapy
Lumpectomy has its own advantages and disadvantages. Advantages : preserve much of the appearance and sensation of the breast especially if the tumor is small. Very often, a breast reconstruction surgery may not be needed at all. Disadvantages of Lumpectomy Lumpectomy needs to be followed by 4-6 weeks of radiotherapy. The time taken for radiation may delay breast reconstructive surgery. Risks of cancer recurring in the remaining part of the breast is high.

Scar on the upper outer quadrant of breast of a 39 year old lady after lumpectomy

It involves removal of entire segment of breast that contains the tumor

Various options Sentinel node biopsy Removal of level I,II & III nodes

Staging Treat axilla Presence of single metastatic disease is good marker for prognosis Treatment doesnot effect long term survival

INDICATIONS
women who have already had radiation therapy to the affected breast women with 2 or more areas of cancer in the same breast that are too far apart to be removed through 1 surgical incision, while keeping the appearance of the breast satisfactory women whose initial lumpectomy along with (one or more) reexcisions has not completely removed the cancer women with certain serious connective tissue diseases such as scleroderma, which make them especially sensitive to the side effects of radiation therapy women with a tumor larger than 5 cm (2 inches) that doesn't shrink very much with neoadjuvant chemotherapy women with a cancer that is large relative to her breast size women who have tested positive for a deleterious mutation on the BRCA1 or BRCA2 gene and opt for prophylactic removal of the breasts male breast cancer patients

Simple mastectomy
(all breast tissue+Nipple areolar complex+skin)

Extended simple mastectomy

(simple mastectomy+level 1 axillary lymph node)

Modified Radical mastectomy

(whole breast + large portion of skin having nipple areolar +all fat and fascia of axilla + LN upto lvl 2)

Halstead radical mastectomy

(All breast tissue +nipple aroelar complex +pec. Major and minor and lvl 1,2,3 LN)

Skin sparing mastectomy:In this surgery, the breast

tissue is removed through a conservative incision made around the areola

ADVANTAGES

Complete removal of cancer cells Risk of recurrence is low

DISADVANTAGES

Permanent loss of breast Longer recovery time Breast reconstruction or prosthesis is necessary

MASTECTOMY OF RIGHT BREAST A CARCINOMA PATIENT

In modern day practise breast implantation after mastectomy is necessary. Done via  Silicone gel implant under pec. Major  LD flap  TRAM flap

After mastectomy indicated in selected patients in whom risk of local recurrence is high and includes

Patients with large tumors 2. Those with large no. of positive nodes 3. Those having extensive lymphovaascular invasion
1.

IMMEDIATE Tiredness Sore skin over breast Redness of the skin ulcers diarrhea nausea

DELAYED Less elasticity of the affected skin Hyperpigmentation of skin Secondary carcinomas like soft tissue sarcomas

Includes(6-12 cycles of these regimens) CMF (cyclophosphamide,methotrexate,5 fluorouracil) CAF (cyclophosphamide,adriamycin,5-flourouracil) AC (doxorubicin,cyclophosphamide)

Newer agents include  Herceptins( active against c-erbB2 receptors)  Bevacizumab(a vascular growth factor receptor inhibitor)  Lapitinab(combined growth factor receptor inhibitor)

Neoadjuvant chemotherapy(given before surgery to

shrink the tumors and make the operation easier for both the surgeon as well as the patient)

Adjuvant chemotherapy(given after the surgery to treat

any cancer cells which may still be present in the body in the chest wall of lymph nodes or which has spread elsewhere in the body)

Palliative chemotherapy( to control (but not cure) the

cancer in women in whom the cancer has spread beyond the breast and localized lymph nodes)


     

side effects of chemotherapy can include

Feeling sick (nausea) Hair loss or thinning Sore mouth Diarrhoea Changes to periods (menstrual cycle) Sore eyes they may feel as if they have grit in them.

Tamoxifen(anti estrogenic, is most widely used agent and

used incase tumor is positive for estrogen receptors)

Aromatse inhibitors (anastrazole) LHRH antagonists (induce a reversible ovarian

suppression)


     

Include
Hot flushes Joint pain Muscle ache Headache Depression Increased risk of bone fracture

Includes LCIS DCIS

LCIS
Diagnostic biopsy + Observation Prophylactic bilateral total mastectomy without axillary node dissection Tamoxifen if estrogen receptor poisitive

DCIS
Breast conserving surgey + radiation with or without tamoxifen Total mastectomy with or without tamoxifen

Breast conserving surgery without radiation

Early invasive carcinomas include (Stage-I,Stage-IIA and STAGE-IIB

Primary treatment options

 

Breast conserving surgery + LN dissection +radiation therapy Modified radical mastectomy


   

Adjuvant therapy
After surgery radiation therapy Systemic chemotherapy Hormone therapy(tamoxifen,aromatase inhibitors Herceptin + systemic chemotherapy

STAGE III-B and STAGE-IIIC

Hormone therapy

STAGE-IV and Metastatic

Hormone therapy

Chemotherapy

Chemotherapy

Surgery + LN dissection and radiation Targeted therapies(herceptin)

Targeted therapy(herceptin)

Radiation therapy/surgery

Operable stage-III(in which tumor is not fixed

to chest wall) is treated by modified radical mastectomy followed by adjuvant chemo and radiotherapy to chest wall or hormonal therapy for estrogen positive cases

Inoperable stage-III treated by neoadjuvant

chemotherapy+ modified radical mastectomy + adjuvant chemo and radiotherapy

Cancer is not curative at this stage and we can offer only symptomatic treatment in these cases