BREAST CONSERVATIVE THERAPY

1. BREAST CONSERVATIVE THERAPY • Dr Shailesh Puntambekar • Consulting onco surgeon • Associate professor , department of surgery, KEM Hospital, Pune, India

2. 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

4. HISTORY • Halstead radical mastectomy • Extended radical mastectomy • Modified radical mastectomy • Breast conservation therapy

5. 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

6. 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.

7. INDICATIONS • Stage I & II • ? Stage III

8. CONTRAINDICATIONS • Pregnancy • Multicentric disease • Diffuse indeterminate micro-calcification • Previous RT • Large tumour/ breast ratio • Collagen vascular disease • Large breast size • Central tumour

9. Small Breast Realities • In a small breast not much to achieve in cosmesis • Recurrence comes as Cancer en Cuirasse

10. POST MRM NO RADIOTHERAPY • SATELLITE NODULES OVER THE CHEST WALL • NO TREATMENT IS EFFECTIVE • PALIATIVE INTENT OF RADIOTHERAPY

11. Large Breast Realities • In a large breast recurrences not easily diagnosed • A recurrence is viewed as a second primary

12. SPECIAL CONSIDERATIONS • Family history • Primary tumour histology • Margin evaluation • Extensive intraductal component

13. METHODS • Lumpectomy +Axillary dissection +RT • Lumpectomy+SLN biopsy +RT • QUART- Quadrantectomy +Axillary dissection +RT • CTART- Chemotherapy +RT

14. Axillary Dissection • Better control of locoregional recurrence • Accurate staging of disease • To decide adjuvant therapy • Prognosis

15. GUIDELINES OF SURGERY • Incision • Technique • Closure • Axillary Dissection

16. NEW INVESTIGATION MODALITIES • MRI • Intra-op ultra-sound • Touch preparation cytology • Percutaneous needle biopsy

17. NEW TECHNIQUES OF TUMOUR MANAGEMENT • Radio Frequency Ablation –RFA • Cryosurgery • Focused Ultrasound • Percutaneous tumour extraction

18. ROLE OF NEOADJUVANT • Induction chemotherapy • Drugs • Selection and monitoring of induction chemotherapy patients

19. 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)

20. RADIOTHERAPY IN BCT • Intraoperative radiotherapy • Post operative radiotherapy • Brachytherapy

21. SPECIAL CASES • Hereditory breast cancer • Macromastia • Occult breast cancer • Pregnancy • Bilateral breast cancer

22. 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

23. 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

24. Thank You