management ca breast

8/6/2019 Management CA Breast

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o To cure the carcinoma

o Diagnosis of the carcinoma

o Reduce chance of local recurrence

o Conservation of local form

o Reduce risk of metastatic spread

o Psychological support


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Based on two criterias

Characteristics of carcinoma

Staging


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On the basis of characteristics Invasive

Non-invasive


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AGE

GENETICS(BRCA-1 and BRCA-2,HER2,PTEN,P53)

MENSTRUAL PERIODS FAMILY HISTORY

ORAL CONTRACEPTIVE USE

HRT

RACEAND ETHNICITY ALCOHOL

WEIGHT


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TREATMENT MODALITIES


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Surgery

Radiation therapy

Adjuvant systemic therapy

Hormonal therapy

Chemotherapy


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INTRODUCTION TO TREATMENT MODALITIES


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Includes

Breast conserving surgery

(Breast carcinoma + normal healthy tissue +

radiotherapy+Axillary surgery)

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


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It consists of two types

Lumpectomy

Quadrantectomy

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


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INDICATIONS STAGE-I & STAGE-II

ABSOLUTE CONTRAINDICATIONS First/second trimester of pregnancy

Two/more gross tumors in separate

quadrants

Diffuse intermediate or malignantmicrocalcifications

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


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removal of the breast cancerand a portion of normal tissue aroundthe breast cancer lump. Some of the nearby lymph nodes may alsobe 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 breastreconstruction 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.


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

lumpectomy


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It involves removal of entire segment of breast that contains thetumor


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Various options

Sentinel node biopsy

Removal of level I,II & III nodes


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Staging

Treat axilla

Presence of single metastatic disease isgood marker for prognosis

Treatment doesnot effect long term

survival


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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, whilekeeping the appearance of the breast satisfactory women whose initial lumpectomy along with (one or more) re-

excisions has not completely removed the cancer

women with certain serious connective tissue diseases such asscleroderma, which make them especially sensitive to the sideeffects of radiation therapy

women with a tumor larger than 5 cm (2 inches) that doesn't shrinkvery 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 theBRCA1 orBRCA2 gene and opt for prophylactic removal of thebreasts

male breast cancer patients


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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)


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Skin sparing mastectomy:In this surgery, the breasttissue is removed through a conservative incision madearound the areola


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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


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MASTECTOMYOF RIGHT BREAST A CARCINOMA PATIENT


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In modern day practise breast

implantation after mastectomy is

necessary. Done via

Silicone gel implant under pec. Major

LD flap TRAM flap


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After mastectomy indicated in selected

patients in whom risk of local recurrence

is high and includes1. Patients with large tumors

2. Those with large no. of positive nodes

3. Those having extensive lymphovaascular invasion


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IMMEDIATE DELAYED

Tiredness Less elasticity of the affected skin

Sore skin over breast Hyperpigmentation of skin

Redness of the skin Secondary carcinomas like soft

tissue sarcomas

ulcers

diarrhea

nausea


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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)


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Neoadjuvant chemotherapy(given before surgery toshrink the tumors and make the operation easier for both the surgeon as well

as the patient)

Adjuvant chemotherapy(given after the surgery to treatany 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) thecancer in women in whom the cancer has spread beyond the breast andlocalized lymph nodes)


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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.


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Tamoxifen(anti estrogenic, is most widely used agent andused incase tumor is positive for estrogen receptors)

Aromatse inhibitors (anastrazole)

LHRH antagonists (induce a reversible ovariansuppression)


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Include Hot flushes

Joint pain Muscle ache

Headache

Depression

Increased risk of bone fracture


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Includes

LCIS

DCIS


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LCIS DCISDiagnostic biopsy + Observation Breast conserving surgey +

radiation with or without tamoxifen

Prophylactic bilateral total

mastectomy without axillary nodedissection

Total mastectomy with or without

tamoxifen

Tamoxifen if estrogen receptor

poisitiveBreast conserving surgery without

radiation


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Early invasive carcinomas include (Stage-I,Stage-IIA andSTAGE-IIB

Primary treatment options

Breast conserving surgery + LN dissection+radiation therapy

Modified radical mastectomy


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Adjuvant therapy

After surgery radiation therapy

Systemic chemotherapy Hormone therapy(tamoxifen,aromatase

inhibitors

Herceptin + systemic chemotherapy


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STAGE III-B and STAGE-IIIC STAGE-IV and Metastatic

Hormone therapy Hormone therapy

Chemotherapy Chemotherapy

Surgery + LN dissection and

radiation

Targeted therapy(herceptin)

Targeted therapies(herceptin) Radiation therapy/surgery


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Operable stage-III(in which tumor is not fixedto chest wall) is treated by modified radicalmastectomy followed by adjuvant chemo and

radiotherapy to chest wall or hormonal therapy forestrogen positive cases

Inoperable stage-IIItreated by neoadjuvantchemotherapy+ modified radical mastectomy +

adjuvant chemo and radiotherapy


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


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management ca breast

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