Early Breast Carcinoma

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 (yrs)

BCS survival

Mastectomy survival

p value

Milan (n=701) 18

65

65

ns

Inst Gustavo 15 (n=179) NASBP 12 B06 (n=1843) NCI (n=237) 19

73

65

ns

63

59

ns

77

75

ns

EORTC (n=903) Danish trial (n=905)

8

54

61

ns

6

79

82

ns

Indian Studies Author, Institut Period Journal/yr e

BCT%

Mittra I et al IJS 2003

TMH

19972001

906; 4% 2% 4% 1997 vs operable vs operable 34% 2001 2.4% LABC & LABC

Deo et al NMJI 2005

AIIMS

19932002

102/902 (11.31%)

2.9% focal- <1% reexcised

Tewari et al WJS 2006

IMS BHU 19971999

25/194 (14.6%)

-

No recurr

Our Experience

AIIMS

331/973 (34%)

3%

2.5%%

20022007

Margin LR positivity

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

•Blue & Hot • Any palpable node adjacent to sn

Hot node

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