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
• Halstead radical mastectomy
• Extended radical mastectomy
• Modified radical mastectomy
• Breast conservation therapy
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
• 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
• Stage I & II
• ? Stage III
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
• In a small breast not much to achieve in
cosmesis
• Recurrence comes as Cancer en Cuirasse
POST MRM NO RADIOTHERAPY
• SATELLITE NODULES
OVER THE CHEST WALL
• NO TREATMENT IS
EFFECTIVE
• PALIATIVE INTENT OF
RADIOTHERAPY
Large Breast Realities
• In a large breast recurrences not easily
diagnosed
• A recurrence is viewed as a second primary
SPECIAL CONSIDERATIONS
• Family history
• Primary tumour histology
• Margin evaluation
• Extensive intraductal component
METHODS
• Lumpectomy +Axillary dissection +RT
• Lumpectomy+SLN biopsy +RT
• QUART- Quadrantectomy +Axillary
dissection +RT
• CTART- Chemotherapy +RT
Axillary Dissection
• Better control of locoregional recurrence
• Accurate staging of disease
• To decide adjuvant therapy
• Prognosis
GUIDELINES OF SURGERY
• Incision
• Technique
• Closure
• Axillary Dissection
NEW INVESTIGATION
MODALITIES
• MRI
• Intra-op ultra-sound
• Touch preparation cytology
• Percutaneous needle biopsy
NEW TECHNIQUES OF
TUMOUR MANAGEMENT
• Radio Frequency Ablation –RFA
• Cryosurgery
• Focused Ultrasound
• Percutaneous tumour extraction
ROLE OF NEOADJUVANT
• Induction chemotherapy
• Drugs
• Selection and monitoring of induction
chemotherapy patients
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
• Intraoperative radiotherapy
• Post operative radiotherapy
• Brachytherapy
SPECIAL CASES
• Hereditory breast cancer
• Macromastia
• Occult breast cancer
• Pregnancy
• Bilateral breast cancer
RESULTS
• BCT / MRM T1 & T2
• TUMOUR CONTROL RATE • 80 TO 90 %
• 5 YR RELAPSE FREE • 70 TO 88 %
SURVIVAL
• RECURRANCE
• ONLY CONS SURGERY • 15 TO 40 %
• CONS SURGERY + RT • 2 TO 10 %
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