management of early breast cancer stage i &
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MANAGEMENT OF EARLYBREAST CANCER STAGE I & II
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INVESTIGATIONS
AIM:-
i) Early diadnosis of the caseii) To detect distant metastasis if present
1. Mammography:-
It is nothing but an x-ray examination of the breast.
Uses: a) screening procedure- clinically undetected cancer
- High risk population
b) in older patients where during palpation large and
fatty breast makes diagnosis difficultc) opposite breast
d) in case of a swelling of breast where clinicaldiagnosis is uncertain
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Inference:
Benign lesion: well circumscribed,
homogenous and surrounded by a zone offatty tissue. Calcification is coarse and
present at the periphery.
Carcinoma: margins are poorly defined, edgesare either spiculated or irregular. Fine,
stippled calcification in the soft tissue and
periductal region is very suggestive.
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MAMMOGRAM
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2. XERORADIOGRAPHY:
Here image is recorded on selenium coated film
producing a positive impression.3. ULTRASOUNDOF BREAST:
If the lesion is solid or cystic, margins of the lesions,
internal echoes, compressibility, dimensions.
Carcinoma- irregular margins, irregular internal
echoes, irregular posterior shadowing, non
compressibility, lat/hz dimension >1
Benign- smooth, rounded with well defined margins,with weak internal echo and compressibility.
-Young females, pregnancy and lactation.
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USG
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3.FNAC:-
It is done with 23 guage needle using FNAC
aspiration special syringe.It is difficult to differentiate between in situ and
invasive breast cancer by FNAC.
FNAC Scoring:
C0: no epithelial cells
C1: scanty epithelial cells, benign
C2: benign cells
C3: atypical cells
C4: suspicious cells
C5: malignant cells
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FNAC
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5. FROZEN SECTION BIOPSY:
If FNAN fails after two trials or in case of negative
FNAC.
6. CORECUT/TRUCUT BIOPSY:
It gives clear histological evidence and also confirms
DCIS.
14-18 guage spring loaded needle is used. Multiplepunctures are needed.
7. EXCISION B IOPSY:
It is done when FNAC is inconclusive and facility for
frozen section is not available.
Here incision is planned in such a way that it will be
included in eventual mastectomy.
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CORE BIOPSY
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8. MRI OF BREAST:
Patient lies in prone position with breasts
placed over the breast coils, both
precontrast and postcontrast, MRI is taken.
Gandolinium chelate is given as a rapid i.v.
bolus inj. Contrast medium present in
capillaries and extravascular extracellular
space provides enhancement.
9. EDGE B IOPSY:
Done only when there is ulceration and
fungation.
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MRI
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10. TUMOUR MARKERS:
CA 15/3, CEA, CA 27-29
11. NUCLEAR MEDICINE BREAST IMAGING
TECHNIQUE:
It requires single gamma or double gamma
radiotracers and provide functional or metabolic
information of breast tumours.Single-gamma, 99mtechnetium sestamibi and 99mtc
tetrafosmin are used.
12. CHEST X-RAY:
To look for pleural effusion, cannon ball secondaries,
Mediastinal metastasis.
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13. ER (oestrogen receptors):
ER +ve: good prognosis, treatment
response is good and hormone therapy isbeneficial.
14. PR status or Her 2 Neu receptors or cErb
B2: also done to assess prognosis.15.Bone x-ray
16. Bone scan
17. CT
18. Biochemical study
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SENTINEL LYMPH NODE B IOPSY
Sentinel node is the first node encountered bytumour cells and the histological status of the
sentinel node predicts the status of the distant
lymph nodes.
So the SLN is defined as the lymph node which is in
a direct drainage pathway from the primary
tumour.
SLNB is done in all the cases of early breast cancer,T1 and T2 without clinically palpable node.
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-Advantages:
i) It is a minimally invasive technique
ii) It can give an idea if axillary nodes areinvolved or not
iii) This approach can obviate the need for
axillary node dissection-Procedure
- The lymph node which is most medially
placed of the pectoral group is often thesentinel node. If this node is involved then
question of axillary sampling or clearance
comes in.
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SLNB
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TREATMENT OF EARLY CARCINOMA
BREAST:
AIM:
To achieve possible cure
Control of local disease in breast and axilla
Breast conservation Prevention of distant metastasis
To prevent local recurrence
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Local treatment ranges from lumpectomy to
super radical mastectomy.
1. BREAST CONSEVATION SURGERY
If the patient prefers to be treated by total
mastectomy it should be adhered to.
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Indications
-lump N1-Poorly differentiated
-Multicentric or multifocal
tumour
-Earlier breast irradiation-Central tumour
-With distant metastasis
-Fixicity of the tumour to the
underlying muscles oroverlying skin
-Extensive intraductal Ca
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A . LUMPECTOMY (TYLECTOMY):
The term means removal of the tumour with a
minimal margin of normal breast tissue around it.
There is a high risk of recurrence.
Without radiotherapy the recurrence rate is 37%
B. WIDE LOCAL EXCISION:
Segentectomy, partial mastectomy
It is removal of unicentric tumour with 2cm clearance
margin.
ProcedureIf margins show no clearance then patient probably
requires total mastectomy. So prior consent for
mastectomy should be taken.
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LUMPECTOMY
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BCS
Along with this axillary dissection through
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Along with this axillary dissection throughseparate incision and RT to breast andchest wall area is given.
C. QUADRANTECTOMY:
An even more aggressive procedure involvesremoval of the whole segment of the breast
containing the tumour.It is a part ofQUARTtherapy-
quadrantectomy, axillary dissection of level Iand II nodes with separate axillary incision
and post op RT to breast (5000 cGY ) andaxilla (1000 Cgy ). It was started by UmbertoVeronesi from Milan.
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D.SK IN SPARING MASTECTOMY ( SSM):
It is like a key hole surgery of breast.
Indication- central tumour, multicentric,extensive intraductal, T1, not feasible for
conservation
Excision of nipple-areola complex with verylimited skin removal.
Total glandular mastectomy
Axillary dissection using either same orseparate incision.
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Indication for total mastectomy in early breast
cancer:
When tumour > 4cm
Multicentric tumour
Poorly differentiated tumour
Tumour margin is not clear of tumour after
BCS.
1. Total mastectom y:
Along with the tumour, entire breast, areola,
nipple, skin over the breast, including
axillary tail are removed.
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INCISION FOR SIMPLE
MASTECTOMY
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There is no axillary dissection.
Patient is subjected to RT later for axilla
2. TOTAL MASTECTOMY WITH AXILLARY
CLEARANCE:
Total mastectomy is done along with removal
of axillary fat, fascia and lymph nodes.
Level I and II nodes are removed.
3 MODIFIED RADICAL MASTECTOMY
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3. MODIFIED RADICAL MASTECTOMY
(MRM):
Pateys operation:
It is total mastectomy along with clearance of
all levels of axillary nodes and removal of
pectoralis minor muscle.
Procedure
Scanlons operation:
Modified pateys wherein instead of removingpectoralis minor, it is incised to approach the
affected level III nodes.
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PATEYS OPERATION
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Auchincloss modified radical mastectomy:
Here pectoralis minor muscle is left intact and
level III lymph nodes are not removed.Halsted radical mastectomy:
Structures removed are:
TumourEntire breast, nipple, areola, skin over the
tumour with margin
Pectoralis major and minor musclesFat, fascia, lymph nodes of axilla
Few digitations of serratus anterior
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Structures retained are:
Axillary vein, Bells nerve ( nerve to serratusanterior), cephalic vein
Position:
Patient lies supine near the edge of thetable with the arm of the affected side
abducted to right angle and placed on armrest.
Technique
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4. Extended radical mastectomy:
This technique includes removal of internal
mammary group of lymph nodes as well.
In SUPER-RADICAL MASTECTOMY internal
mammary group, mediastinal and
supraclavicular lymph nodes are alsoremoved along with axillary node dissection.
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Management of axillary nodes when
clinically not palpable:
1 SLNB: If node is positive for tumour thenaxillary dissection is done.
2 axillary sampling: aim is to remove largest
nodes in axilla which are likely to beinvolved.
Adjuvant therapy after surgery
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Adjuvant therapy after surgery
RADIOTHERAPY:
INDICATIONS:
-after BCS
-after total mastectomy, external irradiation is given to axilla
-patients with high risk of local relapse-inflammatory carcinoma
-as pre-op RT to reduce the size of tumour
External RT: given over breast area, internal mammary and
supraclavicular areaTotal dose 5000 cGY units
200-cGY units daily 5 days a week for 6 weeks
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HORMONE THERAPY:
PRINCIPLES:
-it is used in ER/PR +ve patients-It gives prophylaxis against carcinoma of opposite
breast
i) tamoxifen: antioestrogen 20mg
ii) Medroxyprogesterone 400mg
iii) Aminoglutethimide: aromatase inhibitor
iv) Arimidex: aromatase inhibitor
v) Letrozole: aromatase inhibitor
vi) Diethylstilbesterol: oestrogen
vii) Fluoxymestrone: androgen
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CHEMOTHERAPY:
Ajuvant chemotherapy
Neoadjuvantchemotherapy
Palliative chemotherapy
CMF regime CAF regime MMM regime
CyclophospahmideMethotrexate
5-FU
CyclophosphamideAdriamycin
5-FU
MethotrexateMitomycin
mitozantrone
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THANK YOU!