Transcript Breast Conservation Surgery

BREAST CONSERVATIVE
THERAPY
• Dr Shailesh Puntambekar
• Consulting onco surgeon
• Associate professor , department of surgery,
KEM Hospital, Pune, India
In the good old days we made a clean
breast of malignant disease.In the
modern era there is no
TIT for T(h)AT
HISTORY
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Halstead radical mastectomy
Extended radical mastectomy
Modified radical mastectomy
Breast conservation therapy
BCS:Why?
• Ca Breast is a local manifestation of a
systemic disease.Local radicality does not
change survival
• Cosmetic Considerations
• Preservation of the nipple ,an important
sensate focus
• Mastectomy is a socially devastating
surgery for the downtrodden Indian woman
and signals an end to her married life.The
relevance of BCS in the Indian scene cannot
be overemphasised.
INDICATIONS
• Stage I & II
• ? Stage III
CONTRAINDICATIONS
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Pregnancy
Multicentric disease
Diffuse indeterminate micro-calcification
Previous RT
Large tumour/ breast ratio
Collagen vascular disease
Large breast size
Central tumour
Small Breast Realities
• In a small breast not much to achieve in
cosmesis
• Recurrence comes as Cancer en Cuirasse
POST MRM NO RADIOTHERAPY
• SATELLITE NODULES
OVER THE CHEST WALL
• NO TREATMENT IS
EFFECTIVE
• PALIATIVE INTENT OF
RADIOTHERAPY
Large Breast Realities
• In a large breast recurrences not easily
diagnosed
• A recurrence is viewed as a second primary
SPECIAL CONSIDERATIONS
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Family history
Primary tumour histology
Margin evaluation
Extensive intraductal component
METHODS
• Lumpectomy +Axillary dissection +RT
• Lumpectomy+SLN biopsy +RT
• QUART- Quadrantectomy +Axillary
dissection +RT
• CTART- Chemotherapy +RT
Axillary Dissection
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Better control of locoregional recurrence
Accurate staging of disease
To decide adjuvant therapy
Prognosis
GUIDELINES OF SURGERY
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Incision
Technique
Closure
Axillary Dissection
NEW INVESTIGATION
MODALITIES
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MRI
Intra-op ultra-sound
Touch preparation cytology
Percutaneous needle biopsy
NEW TECHNIQUES OF
TUMOUR MANAGEMENT
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Radio Frequency Ablation –RFA
Cryosurgery
Focused Ultrasound
Percutaneous tumour extraction
ROLE OF NEOADJUVANT
• Induction chemotherapy
• Drugs
• Selection and monitoring of induction
chemotherapy patients
SEQUENCING OF
CHEMOTHERAPY AND RT
• 6 Cycles of CMF followed by RT
• RT followed by 6 cycles of CMF
• 3 Cycles of CMF followed by RT followed
by 3 cycles of CMF (sandwich therapy)
RADIOTHERAPY IN BCT
• Intraoperative radiotherapy
• Post operative radiotherapy
• Brachytherapy
SPECIAL CASES
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Hereditory breast cancer
Macromastia
Occult breast cancer
Pregnancy
Bilateral breast cancer
RESULTS
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BCT / MRM T1 & T2
• TUMOUR CONTROL RATE • 80 TO 90 %
• 5 YR RELAPSE FREE
SURVIVAL
• RECURRANCE
• ONLY CONS SURGERY
• CONS SURGERY + RT
• 70 TO 88 %
• 15 TO 40 %
• 2 TO 10 %
Newer Frontiers
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Laparoscopic Axillary Dissection
Laparoscopic Int Mammary Clearance
Technically feasible
Clearance equal to standard technique
Acceptability only after it stands the test of
time
Thank You