MANAGEMENT OF BREAST CARCINOMA

Sridevi Rajeeve
2008 Batch
1SR_Ca_Breast_Rx

2SR_Ca_Breast_Rx
Early Breast Cancer(EBC): Stage I & II, T1N1, T2N1, T3N0
Locally Advanced Breast Cancer(LABC): Stage IIIA & IIIB
Metastatic Breast Cancer: Stage IV

Management of Ca Breast
Options available;
I. Surgery
II. Radiotherapy
III. Hormone Therapy
IV. Chemotherapy
Multi-pronged approach adopted
Single approach ineffectual
SR_Ca_Breast_Rx 4

I. SURGICAL Approaches
1. Total (Simple) Mastectomy
2. Total Mastectomy with Axillary Clearance
3. Modified Radical Mastectomy [MRM]
1) Patey’s Operation
2) Scanlon’s Operation
3) Auchincloss’ MRM
4. Radical Mastectomy of Halsted
5. Conservative Breast Surgeries
1) Wide Local Excision [WLE]
2) Lumpectomy
3) Quadrantectomy
4) Toilet Mastectomy
5) Skin-Sparing/Keyhole Mastectomy [SSM]
SR_Ca_Breast_Rx 5

1. TOTAL/SIMPLE MASTECTOMY
Tissues removed:
Tumour, entire breast, areola,
nipple, skin over breast, Axillary tail
of Spence, Pectoral fascia
Tissues retained:
NO Axillary Dissection
Subjected to Radiotherapy later
SR_Ca_Breast_Rx 6

2. TOTAL MASTECTOMY with
AXILLARY CLEARANCE
Common procedure
Tissues removed:
TM + Axillary fat, Axillary fascia,
Level I and II Axillary LN
SR_Ca_Breast_Rx 7

3. MODIFIED RADICAL MASTECTOMY
1) Patey’s Operation
 Tissues removed:
TM + Clearance of Level I,
II & III Axillary LN +
Pectoralis minor
 Tissues preserved:
Nerve to Serratus anterior,
Nerve to Latissimus dorsi,
Intercostobrachial nerve,
Axillary Vein, Cephalic
Vein, Pectoralis major
SR_Ca_Breast_Rx 9

Procedure:
Elliptical incision made on medial aspect of 2nd and 3rd ICS
enclosing the nipple, areola and tumour which extends
laterally into Axilla along the Anterior Axillary fold. Upper
and lower skin flaps are raised. Breast with tumour is
raised from the medial aspect of Pectoralis major.
Dissection is proceeded laterally while ligating pectoral
vessels. In axilla, lateral border of Pectoralis minor is
divided from Coracoid process to clear Level II LN. Level III
cleared subsequently. Pectoralis minor removed
2) Scanlon’s Operation: Pectoralis minor incised
Level III LN removed
3) Auchincloss’ MRM: Pectoralis minor left intact
Level III LN not removed
SR_Ca_Breast_Rx 10

4. RADICAL MASTECTOMY of HALSTED
Tissues removed:
Tumour, entire breast, areola,
nipple, skin over tumour,
Pectoralis major & minor
muscles, fat, fascia, Level I,II,III
Axillary LN, few digitations of
Serratus anterior muscle
Tissues retained:
Axillary vein
Bell’s nerve (N.to Serr.ant)
Cephalic vein
SR_Ca_Breast_Rx 13
Complications:
Lymphoedema
Lymphangiosarcoma (>3 years)

5. BREAST CONSERVATIVE SURGERIES
1. Wide Local Excision (WLE)/ Partial
Mastectomy
Removal of unicentric tumour with 1cm
clearance margin.
Incision: Over tumour + Axillary
Dissection + RT
2. Quadrantectomy:
Removal of entire quadrant with ductal
system with 2-3cm normal breast tissue
clearance. Part of QUART Therapy
(Quadrantectomy + Axillary dissection + RT)
Not advocated now.
3. Skin Sparing Mastectomy
4. Lumpectomy (=WLE)
Term rarely used
SR_Ca_Breast_Rx 14

Other procedures
Toilet Mastectomy
 In locally advanced tumour
(LABC), tumour with breast
tissue removed – prevent
fungation
 Post-chemotherapy
 Significance: (?)
Extended Radical Mastectomy
 Radical Mastectomy +
Removal of Internal Mammary
Nodes (ipsilateral +/-
contralateral)
 Not done at present
SR_Ca_Breast_Rx 17

COMPLICATIONS of M.R.M/MASTECTOMY
Injury/ Thrombosis of Axillary Vein
Seroma
Shoulder Dysfunction
Pain and Numbness
Flap Necrosis and infection
Lymphoedema and its problems
Axillary hyperaesthesia
Winged Scapula
SR_Ca_Breast_Rx 18

LYMPHANGIOSARCOMA (Stewart-
Treve’s Syndrome)
In ipsilateral upper limb
Develops in people with
Lymphoedema after Mastectomy with
Axillary clearance.
3-5 years after development of
Lymphoedema
Presentation: Multiple subcutaneous
nodules
Requires Forequarter Amputation
Poor prognosis
SR_Ca_Breast_Rx 19

II. RADIOTHERAPY Approach
Indications;
1. Conservative Breast Surgery adjuvant [Breast]
2. Total Mastectomy [Axilla]
3. High-risk of relapse patients
1) Invasive Carcinoma
2) Extensive in-situ Carcinoma
3) Age < 35 years
4) Multifocal disease
4. Bone secondaries [Palliative]
5. Atrophic Schirrous Carcinoma [Curative]
6. Pre-Operatively (reduce tumour size and downstage)
7. >4 +’ve Axillary LN, Pectoral fascia involvement, positive
surgical margins, Extra-nodal spread
SR_Ca_Breast_Rx 20

Chest Wall Axilla Post-BCS
T3 tumour>5cm
Residual disease
LABC
Positive margin/close
surgical margin <2cm
Conservative surgery
Inflammatory
Carcinoma
>4 nodes +’ve
Extra-nodal spread
Axillary status
unknown/ not assessed
MANDATORY!
Local + Axilla
Tangential fields: 50 Gy-
25 fractions-5 weeks
Another 10 Gy to
tumour bed
Internal Mammary and
Supra-clavicular area may
be included in the
radiation field
SR_Ca_Breast_Rx 21

External Radiotherapy
 Over Breast area, axilla, Internal mammary and Supra-
clavicular area
 Total dosage: 5000 cGy units
 200-cGy units daily 5 days a week for 6 weeks
Internal Radiotherapy
SR_Ca_Breast_Rx 23

III. HORMONE-THERAPY Approach
Principles;
 Used in ER/PR +’ve patients only
 All age groups included now
 Relatively safe
 Easy to administer
 Adequate prophylaxis against Ca of opposite breast
 Useful in Metastatic Carcinoma
 Reduces recurrence – improves quality of life and
longevity
SR_Ca_Breast_Rx 25

Includes;
Medical
i. Oestrogen Receptor Antagonists – Tamoxifen 20 mg
ii. Progesterone receptor Antagonist
iii. Oral Aromatase Inhibitors – Letrozole 2.5 mg OD, Anastrozole, Exemestane;
Aminoglutethimide [Medical Adrenalectomy]
iv. Androgens – inj.Testosterone propionate 100mg IM three times a week,
Fluoxymestrone 30 mg daily
v. LHRH Agonists – Goserelin (Zoladex) [Medical Oophorectomy]
vi. Progestogens – Medroxypregesterone acetate 400 mg
Surgical
i. Ovarian Ablation by
a. Surgery (Bilateral Oophorectomy)
b. Radiation
ii. Adrenalectomy
iii. Pituitary ablation
SR_Ca_Breast_Rx 26

Tamoxifen
 SERM (Selective Estrogen Receptor Modulator)
 Blocks cytosolic ER in breast tissue
 Dose: 10 mg BD or 20 mg OD for 5 days
 T1/2: 7 days. Shows effects after 4 weeks
 Cheap, easily available, effective
 Indications:
 Carcinoma Breast
 Fibroadenosis
 Male infertility
 Desmoid tumours
 Side-effects:
 ‘Tamoxifen Flare’: Flushing, tachycardia, sweating, pruritis vulva, vaginal
atrophy and dryness (pre-menopausal), vaginal discharge (post-
menopausal), fluid retention, weight gain
 Agonistic action: Endometrium (Ca), Bone (Osteoporosis, pathological
#), Coagulation system (DVT, TIA, CVA, MI)
SR_Ca_Breast_Rx 27

Letrozole
 Non-steroidal competitive inhibitor of Aromatase
Reduces Oestrogen levels by 98%
 More expensive, more effective, fewer side-effects
Indications:
1. Adjuvant Endocrine therapy in Post-menopausal women with
hormone sensitive breast cancer
2. Metastatic disease
3. Recurrent disease
 Dosage: 2.5 mg OD for 5 years or for 3 years after Tamoxifen
 Side-effects: Vaginal atrophy, bleeding p.v, CVS problems and
osteoporosis.
SR_Ca_Breast_Rx 28

Novel drugs - Biologicals
1. TRANSTUZUMAB (Herceptin)
 Monoclonal Ab. Blocks Her-2/Neu receptors (Tyrosine
kinase receptor)
 Useful only in Her-2/Neu +’ve cases Metastatic d/s
 Intravenous infusion 4mg/kg loading, 2mg/kg
maintenance dose for 1 year
2. BEVACIZUMAB
Vascular Growth Factor receptor inhibitor
3. LAPITINAB
Combined Growth Factor receptor inhibitor
SR_Ca_Breast_Rx 29

IV. CHEMOTHERAPY Approach
Types;
A. Adjuvant Chemotherapy
 Administration of Cytotoxics after surgery
 Eliminate clinically undetectable distant spread
B. Neoadjuvant Chemotherapy
 Administration of Cytotoxics in large operable tumours before
surgery
 Reduce loco-regional tumour burden – downstage
 Amenable to surgical resection after 3 doses
C. Palliative Chemotherapy
 Advanced Ca Breast
 Metastatic Ca Breast
SR_Ca_Breast_Rx 30

 Indications;
All node +’ve patients
Primary tumour >1cm in size
Poor prognostic factors
Advanced Ca Breast
Inflammatory Ca Breast
Metastatic Ca Breast
 Drugs;
SR_Ca_Breast_Rx 31
CMF Regime CAF Regime MMM Regime
Cyclophosphamide Cyclophosphamide Methotrexate
Methotrexate Adriamycin Mitomycin-C
5-Fluorouracil 5-Fluorouracil Mitozantrone

Chemotherapy Regimes
 CAF and CMF – commonly used, monthly/3 weeks cycles
for 6 months
 Taxanes
 Eg: PACLITAXEL and DOCETAXEL
 G2/M phase arrestors
 Use: Metastatic Ca Breast
 1st line: CMF > CAF > MMM
 2nd line: Taxanes
 3rd line: Gemcitabine
SR_Ca_Breast_Rx 32

EARLY CARCINOMA BREAST [ECB] -
Management
 Breast Conservation Surgery – Wide Local Excision/ QUART/
SSM; RT locally
 Patey’s Operation [MRM]
 Tamoxifen 10mg BD
 Sentinel Lymph Node Biopsy [SNLB]
 Regular follow-up with
 Radioisotope Bone scan
 CEA tumour marker
 Indications for Total Mastectomy in EBC;
 Tumour size >5cm
 Multicentric tumour
 High-grade (poorly-differentiated) tumour
 Tumour margin not clear after BCS
SR_Ca_Breast_Rx 33

ADVANCED CARCINOMA BREAST
Refers to;
 Locally Advanced Carcinoma Breast [LACB]
 Inflammatory Ca Breast
 Bilateral Ca Breast
Metastatic Ca Breast
 Fixed axillary/supra-clavicular LN
SR_Ca_Breast_Rx 34

Management of ACB
LACB
Neoadjuvant Chemotherapy
Response assessment
Non-responders: RT + Surgery
Responders: Surgery (Toilet Mastectomy/MRM)
Inflammatory Ca Breast
‘Mastitis carcinomatosis’/ ‘Lactating Ca of Breast’
T4d LACB (Stage IIIB)
Neoadjuvant ChemoT and RT
Surgery (if downstaged) + Axillary clearance
SR_Ca_Breast_Rx 35

Metastatic Ca Breast
Hematogenous spread to;
Bone: most common. Vertebra – Batson’s (valveless) venous
plexus and posterior intercostal veins, Ribs, Humerus, Femur
Lungs – ‘Cannon-ball’ 20 in parenchyma, Pleural effusion, Chest
wall 20
Liver
Brain
Treatment strategies;
Chemotherapy: CMF/CAF
Radiotherapy
Tamoxifen, Oophorectomy
Transtuzumab, Bevacizumab
Hypercalcemia – Hydration, steroids, Palmidronate 90mg i.v once
a month
Internal fixation of pathological #
SR_Ca_Breast_Rx 37

CARCINOMA BREAST in
PREGNANCY - Management
1st Trimester 2nd Trimester 3rd Trimester
MRM MRM MRM
Axillary node +’ve:
Termination of pregnancy +
Chemotherapy
Chemotherapy carefully After delivery –
Chemotherapy with
suppression of lactation
SR_Ca_Breast_Rx 40
Note the following;
Hormone treatment contra-indicated: Teratogenic
Radiotherapy: No role
MRI is the investigation of choice
Can become pregnant 2 years after completion of therapy as recurrence rates
are highest in 2 years

Follow-up
Clinical examination in detail @ regular intervals
Yearly/2-yearly Mammography of the treated and
contralateral breast is a must
Bone-scan, CT Chest/abdomen, tumour markers are done
only if there is clinical suspicion. Not a regular routine
follow-up at present
SR_Ca_Breast_Rx 41

BREAST RECONSTRUCTION
 Done in young patients with early stage of disease
 Symmetry is the most important factor
 Factors deciding reconstruction;
 Amount of skin retained – SSM best
 Stage of Carcinoma
 Earlier Radiotherapy
 Type of flap used
 Timing
 Immediate Reconstruction: in Early stages with good response to
neoadjuvants. CI in LABC
 Delayed Reconstruction: 3-9 months after surgery. Done in LABC.
Allows post-op RT without prosthesis exposure, avoids fibrosis and
fat necrosis where TRAM flap in used
SR_Ca_Breast_Rx 42

Methods of Reconstruction
1. Breast Implants – Silicone gel
2. Expandable Saline prosthesis
3. Flap with implant/expanders
4. External breast prosthesis
5. Flap reconstruction
1. Latissimus dorsi (LD) flap
2. Contralateral Tranversus Abdominis (TRAM) flap
3. Superior Gluteal flap
4. Ruben’s flap: soft tissue over Iliac crest
SR_Ca_Breast_Rx 43

 Complications of Implants;
 Pain, exposure of implant and rupture
 Displacement, extrusion
 Infection
 Capsular contraction
SR_Ca_Breast_Rx 47
LD Flap TRAM flap
Myocutaneous flap Myocutaneous flap
Subscapular artery Superior Epigastric artery
Easy Ipsilateral or contralateral flap
Can be placed over prosthesis Gives bulk. No need of prosthesis
Reliable, well-vascularised Free TRAM flap into IMA
Low complication rate Mesh placement in abdomen required
Unsightly donor area on back Donor site morbidity & fat necrosis

MANAGEMENT OF BREAST CARCINOMA

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