MANAGEMENT OF BREAST

CANCER

BY : ALMA FARHANA BINTI ROSLAM

SUPERVISOR : DR HAFIZUDDIN

Options available :
Surgery
Radiotherapy
Hormone Therapy
Chemotherapy

SURGICAL APPROACHES
Total (Simple)
Mastectomy
Total Mastectomy with
Axillary Clearance
Modified Radical
Mastectomy [MRM]
1. Pateys Operation
2. Scanlons Operation
3. Auchincloss MRM

Radical Mastectomy of
Halsted
Conservative Breast
Surgeries
1. Wide Local Excision
[WLE]
2. Lumpectomy
3. Quadrantectomy
4. Toilet Mastectomy
5. Skin-Sparing/Keyhole
Mastectomy [SSM]

The type of mastectomy depends on :

Age
General health
Menopause status
Tumor size
Tumor stage (how far it's spread)
Tumor grade (its aggressiveness)
Tumor'shormone receptor status
Whether or not lymph nodes are involved

1. Total (Simple)
Mastectomy
Tissues removed:
Tumor, entire breast,
areola, nipple, skin
over
breast, Axillary tail of
Spence, Pectoral fascia
Tissues retained:
NO axillary dissection
Subjected to
radiotherapy later

2. Total Mastectomy with Axillary

Clearance (MAC)
Common
procedure
Tissues removed:
TM + Axillary
fat,
Axillary fascia,
Level I
and II axillary
LN

3. Modified Radical
Mastectomy
1) Pateys 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,

3. Modified Radical Mastectomy (1)

2) Scanlons Operation
Pectoralis minor incised
Level III LN removed
3) Auchincloss MRM
Pectoralis minor left intact
Level III LN not removed

4. Radical Mastectomy of
Halsted
Tissues removed:
Tumor, 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
Bells nerve (N.to Serr.ant)
Cephalic vein
Complications:

5. Breast Conservative
Surgeries
Wide Local Excision (WLE)/ Partial Mastectom
Removal of unicentric tumour with 1cm clearance
margin.
Incision : Over tumour + Axillary
Dissection + RT
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.

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

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

HORMONE THERAPY APPROACH (1)

Medical
i.
Oestrogen Receptor
Antagonists Tamoxifen 20
mg
ii. Progesterone receptor
Antagonist
iii. Oral Aromatase Inhibitors
Letrozole 2.5 mg OD,
Anastrozole, Exemestane;

iv.

Aminoglutethimide
[Medical Adrenalectomy]
Androgens
inj.Testosterone
propionate 100mg IM three
times a week,
Fluoxymestrone 30 mg
daily

Surgical
i.
Ovarian Ablation by
a. Surgery (Bilateral
Oophorectomy)
b. Radiation
ii. Adrenalectomy
iii. Pituitary ablation

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

CHEMOTHERAPY APPROACH
(1)
Indications :
All node +ve patients
Primary tumour >1cm in size
Poor prognostic factors
Advanced Ca Breast
Inflammatory Ca Breast
Metastatic Ca Breast

Drugs :
CMF Regime

CAF Regime

MMM Regime

Cyclophosphamide

Cyclophosphamide

Methotrexate

Methotrexate

Adriamycin

Mitomycin-C

5-Fluorouracil

5-Fluorouracil

Mitozantrone

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

 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

EARLY BREAST CA (EBC)

MANAGEMENT
Breast Conservation Surgery Wide Local Excision/
QUART/ SSM; RT locally
Pateys 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

ADVANCED BREAST CANCER

MANAGEMENT
Refers to :
Locally Advanced
Carcinoma Breast
[LACB]
Inflammatory Ca
Breast
Bilateral Ca Breast
Metastatic Ca
Breast

ADVANCED BREAST CANCER

MANAGEMENT (1)

THANK YOU