Management of early breast cancer

Dr V. Seenu
Associate professor
Department of Surgical Disciplines
All India Institute of Medical Sciences
• Early breast cancer: T1/ T2 with N0/N1

• Confirmation of Diagnosis

• Staging Investigations

• Locoregional treatment

• Adjuvant systemic treatment

 Confirmation of Diagnosis

• FNAC

• Trucut biopsy: Conventional or Image

guided

• Mammography
 Staging Investigations
• Chest X ray

• LFT

• US abdomen

• ? Bone Scan / Limited skeletal survey

 Locoregional Treatment

• Breast Conservation Surgery

• Total Mastectomy + ALND

 Breast Conservation Surgery
• WLE + RT + ALND: standard BCS

• WLE + Volume Replacement ( mini

LD flap) + SND +/- ALND

• Newer trends: RF ablation, cryotherapy

 Criteria for BCS
• Patient’s wishes

• Tumor not diffuse & -ve margins achievable

• Adequate breast preservation fo cosmesis

• RT facilities
Principles of BCS
 Contraindications for BCS
Absolute
Multiple tumors in different quadrants
Previous breast irradiation
Relative
Pregnancy
Collagen vascular disease
Large pendulous breasts
 RT following BCS
• Whole breast external beam RT (WBEBT)
with or without tumor bed boost (EBT or
brachytherapy)- Standard

• Accelerated partial breast irradiation

(APBI)
 Minimally invasive approaches
• Cryosurgery

• Laser

• Highly focused US (HFUS)

• RF Ablation
 MECHANISM OF RFA
• 42 – 45oC (hyperthermia) – Cells more susceptible to
chemotherapy and radiation
• 46o C for 60 minutes – irreversible cellular damage.
• 50 - 52o C for 4 – 6 minutes – Cytotoxic
• 50o C is the threshold for induction of coagulation necrosis.
• 105 – 115oC – Tissue boiling, vaporization.
 Equipment
• Radiofrequency generator

• RFA electrode

• Peristaltic pump

• USG
RF ablation
 RF ablation- Our Experience
• 14 pts with tumor <3 cm
• RF ablation followed by BCS
• HPE
No residual tumor-11
Few foci: 2
Gross tumor:1
Trial End point BCS Mastectomy p
(yrs) survival survival value

Milan (n=701) 18 65 65 ns

Inst Gustavo 15 73 65 ns
(n=179)
NASBP 12 63 59 ns
B06 (n=1843)
NCI (n=237) 19 77 75 ns

EORTC 8 54 61 ns
(n=903)
Danish trial 6 79 82 ns
(n=905)
 Indian Studies

Author, Institut Period BCT% Margin LR

Journal/yr e positivity
Mittra I et al TMH 1997- 906; 4% 2%
IJS 2003 2001 4% 1997 vs operable vs operable
34% 2001 2.4% LABC & LABC
Deo et al AIIMS 1993- 102/902 2.9% focal- <1%
NMJI 2005 2002 (11.31%) reexcised
Tewari et al IMS BHU 1997- 25/194 - No recurr
WJS 2006 1999 (14.6%)
Our AIIMS 2002- 331/973 3% 2.5%%
Experience 2007 (34%)
Reasons for low rate of BCS
• Large primary tumors
• Fear of recurrence
• Fear of not turning up for RT/
FUC
• Lack of facilities for RT
• Total mastectomy : classical

• Skin sparing mastectomy with reconstruction

 Management of axilla
• ALND (Complete or Level I & II)
“Gold Standard”

• Sentinel node biopsy

“Newer surgical trend”
ALND (5 nerves sparing)
 Complications of ALND
• Seroma

• Wound Infection
• Frozen Shoulder
• Flap Necrosis
• Post-Mastectomy Pain Syndrome (PMPS)
• Lymphedema
Sentinel Node & Breast Cancer

Sentinel node concept

• Sentinel = a guard, one who keeps
watch or a sentry
• The first node in the regional lymph
node basin that drains the primary
tumor.
Most often, it is a cluster of LNs.
SN Concept
 Sentinel Node

Blue dye Hot node

•Blue & Hot

• Any palpable node adjacent to sn
 Our Results
• Study Period: May 1999-June 2007
• No of Pts: 703
• Age range: 31-82 yrs (mean: 41.4 yrs)
• Menopausal Status : Pre: 323 Post: 380
• Side : R:L:: 360: 343
• T status
T1: 163; T2: 487; Tx: 53
 Results (n=703)

• Identification Rate: 91% (646/703)

• Concordance Rate: 98% (636/646)

• False –ve Rate: 4.6% (11/239)

SN not identified: 8% (n=57)

 SN V/S ALN status (n=703)
Both SLND & ALND -ve : 407
Only SLND +ve : 102
Both SLND & ALND +ve : 126
SLND -ve & ALND +ve : 11
No sentinel node identified : 57
SN Biopsy As Surgical Rx of Axilla
• Tumor < 3cm
• SN identified: 113/127 pts
• SN – ve for mets on FS & IC: 85 pts.
SNB alone
• Follow-up: 19 months (3-48 mths)
1 recurrence: False –ve onFS
 Establishing SN Program
SURGEON

NUCLEAR MED PATHOLOGIST

Feasibility; Validation; On going SN program

 Adjuvant systemic therapy
• Chemotherapy: Doxorubicin based- std
Tumor > 2 cm or LN positive

• Hormonal therapy: only in receptor +ve

Tamoxifen: standard
• Immunotherapy : ??
 Nanotechnology
The area of science that focuses on the
manipulation of the atoms and
molecules leading to the construction
of structures in the nanometer size
range.
• Diagnosis
Nano wires
Nano cantilever arrays

• Treatment
Nano vectors
Nano spheres
Thank You
RF Circuit