Breast conservative therapy
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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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BREAST CONSERVATIVE THERAPY

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Breast conservative therapy

BREAST CONSERVATIVE THERAPY

  • Dr Shailesh Puntambekar

  • Consulting onco surgeon

  • Associate professor , department of surgery, KEM Hospital, Pune, India


Breast conservation surgery

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

HISTORY

  • Halstead radical mastectomy

  • Extended radical mastectomy

  • Modified radical mastectomy

  • Breast conservation therapy


Bcs why

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


Breast conservation surgery

  • 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

INDICATIONS

  • Stage I & II

  • ? Stage III


Contraindications

CONTRAINDICATIONS

  • Pregnancy

  • Multicentric disease

  • Diffuse indeterminate micro-calcification

  • Previous RT

  • Large tumour/ breast ratio

  • Collagen vascular disease

  • Large breast size

  • Central tumour


Small breast realities

Small Breast Realities

  • In a small breast not much to achieve in cosmesis

  • Recurrence comes as Cancer en Cuirasse


Post mrm no radiotherapy

POST MRM NO RADIOTHERAPY

  • SATELLITE NODULES OVER THE CHEST WALL

  • NO TREATMENT IS EFFECTIVE

  • PALIATIVE INTENT OF RADIOTHERAPY


Large breast realities

Large Breast Realities

  • In a large breast recurrences not easily diagnosed

  • A recurrence is viewed as a second primary


Special considerations

SPECIAL CONSIDERATIONS

  • Family history

  • Primary tumour histology

  • Margin evaluation

  • Extensive intraductal component


Methods

METHODS

  • Lumpectomy +Axillary dissection +RT

  • Lumpectomy+SLN biopsy +RT

  • QUART- Quadrantectomy +Axillary dissection +RT

  • CTART- Chemotherapy +RT


Axillary dissection

Axillary Dissection

  • Better control of locoregional recurrence

  • Accurate staging of disease

  • To decide adjuvant therapy

  • Prognosis


Guidelines of surgery

GUIDELINES OF SURGERY

  • Incision

  • Technique

  • Closure

  • Axillary Dissection


New investigation modalities

NEW INVESTIGATION MODALITIES

  • MRI

  • Intra-op ultra-sound

  • Touch preparation cytology

  • Percutaneous needle biopsy


New techniques of tumour management

NEW TECHNIQUES OF TUMOUR MANAGEMENT

  • Radio Frequency Ablation –RFA

  • Cryosurgery

  • Focused Ultrasound

  • Percutaneous tumour extraction


Role of neoadjuvant

ROLE OF NEOADJUVANT

  • Induction chemotherapy

  • Drugs

  • Selection and monitoring of induction chemotherapy patients


Sequencing of chemotherapy and rt

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

RADIOTHERAPY IN BCT

  • Intraoperative radiotherapy

  • Post operative radiotherapy

  • Brachytherapy


Special cases

SPECIAL CASES

  • Hereditory breast cancer

  • Macromastia

  • Occult breast cancer

  • Pregnancy

  • Bilateral breast cancer


Results

BCT / MRM T1 & T2

TUMOUR CONTROL RATE

5 YR RELAPSE FREE SURVIVAL

RECURRANCE

ONLY CONS SURGERY

CONS SURGERY + RT

80 TO 90 %

70 TO 88 %

15 TO 40 %

2 TO 10 %

RESULTS


Newer frontiers

Newer Frontiers

  • 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

Thank You


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