MANAGEMENT OF EARLY BREAST CANCER STAGE I & II

INVESTIGATIONS
AIM:i) Early diadnosis of the case ii) 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 difficult c) opposite breast d) in case of a swelling of breast where clinical diagnosis is uncertain

Inference: Benign lesion: well circumscribed, homogenous and surrounded by a zone of fatty tissue. Calcification is coarse and present at the periphery. Carcinoma: margins are poorly defined, edges are either spiculated or irregular. Fine, stippled calcification in the soft tissue and periductal region is very suggestive.

MAMMOGRAM

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.

USG

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

FNAC

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. Multiple punctures are needed. 7. EXCISION BIOPSY: 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.

CORE BIOPSY

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 BIOPSY: Done only when there is ulceration and fungation.

MRI

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.

13. ER (oestrogen receptors): ER +ve: good prognosis, treatment response is good and hormone therapy is beneficial. 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

SENTINEL LYMPH NODE BIOPSY

Sentinel node is the first node encountered by tumour 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.

-Advantages: i) It is a minimally invasive technique ii) It can give an idea if axillary nodes are involved 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 the sentinel node. If this node is involved then question of axillary sampling or clearance comes in.

SLNB

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

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.

 Indications -lump<4cm -No signs of local advancementT1,T2,<4cm -Clinically ve axillary node -Well differentiated tumour -Adequate sized breast to allow proper RT to breast -Feasibility of axillary dissection and RT to intact breast

Contraindication -Tumour >4cm -+ve axillary node> N1 -Poorly differentiated -Multicentric or multifocal tumour -Earlier breast irradiation -Central tumour -With distant metastasis -Fixicity of the tumour to the underlying muscles or overlying skin -Extensive intraductal Ca

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. Procedure If margins show no clearance then patient probably requires total mastectomy. So prior consent for mastectomy should be taken.

LUMPECTOMY

BCS

Along with this axillary dissection through separate incision and RT to breast and chest wall area is given. C. QUADRANTECTOMY: An even more aggressive procedure involves removal of the whole segment of the breast containing the tumour. It is a part of QUART therapyquadrantectomy, axillary dissection of level I and II nodes with separate axillary incision and post op RT to breast (5000 cGY ) and axilla (1000 Cgy ). It was started by Umberto Veronesi from Milan.

D.SKIN 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 very limited skin removal. Total glandular mastectomy Axillary dissection using either same or separate incision.

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 mastectomy: Along with the tumour, entire breast, areola, nipple, skin over the breast, including axillary tail are removed.

INCISION FOR SIMPLE MASTECTOMY

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 (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 removing pectoralis minor, it is incised to approach the affected level III nodes.

PATEYS OPERATION

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: Tumour Entire breast, nipple, areola, skin over the tumour with margin Pectoralis major and minor muscles Fat, fascia, lymph nodes of axilla Few digitations of serratus anterior

Structures retained are: Axillary vein, Bells nerve ( nerve to serratus anterior), cephalic vein Position: Patient lies supine near the edge of the table with the arm of the affected side abducted to right angle and placed on arm rest. Technique

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 also removed along with axillary node dissection.

 Management of axillary nodes when clinically not palpable: 1 SLNB: If node is positive for tumour then axillary dissection is done. 2 axillary sampling: aim is to remove largest nodes in axilla which are likely to be involved.

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 area Total dose 5000 cGY units 200-cGY units daily 5 days a week for 6 weeks

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

CHEMOTHERAPY: Ajuvant chemotherapy Neoadjuvant chemotherapy Palliative chemotherapy

CMF regime CAF regime MMM regime

Cyclophospahmide Cyclophosphamide Methotrexate Methotrexate Adriamycin Mitomycin 5-FU 5-FU mitozantrone

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