|
Treatment of Cancer Breast:
Operable
Stage I & II
Radical mastectomy or its modifications
With or without adjuvant therapy
Inoperable
Stage III & IV
Simple mastectomy
with adjuvant therapy
m Adjuvant Therapy =
1- Radiotherapy 2- Hormonal therapy 3- Chemotherapy
[I] Operations:
(1) Radical mastectomy: " Halsted 's operation "
ÄWe remove:
a- The whole breast with 2 inches safety margin of the skin from the palpable tumour border.
b- Deep fascia extending from the clavicle to 1st intersection of rectus and from the sternum to ant. border of latissimus dorsi.
c- Two pectoral muscles.
d- Whole axillary content of fat or fascia or L.N.
ÄWe preserve:
1- Nerve. to serratus ant .
2- Nerve to latissimus dorsi "can be sacrified"
3- Brachial plexuses with brachial artery .
4- Cephalic vein to drain the limb if axillary vein is ligated or thrombosed.
ÄComplications: Early
S ® shock
H ® Haemorrhage
I ® Infection, Injury to N. to serratus ant. Causing winging of the scapula
P ® pulmonary complications
® puffiness (oedema) of the arm
due to extensive clearance to the axilla Late
(1) Axillary recurrence ®
late Browny oedema of the arm
(2) local recurrence.
(3) Contracture scar.
It is better to begin dissection from axilla WHY?
1) Explore axilla 1st and assess operability.
2) Decrease the lymphatic spread.
3) Decrease the time of exposure of chest wall.
(2) Modifications of radical mastectomy:
[A] Extended radical mastectomy "super radical mastectomy"
Ä We remove: As radical mastectomy +
- 1/2 of the sternum on the same side.
- 2nd, 3rd, 4th costal cartilage. - The Int.-mammary L.Ns.
But it carry high mortality and morbidity
So, this operation is unacceptable.
Local Excision (Tumerectomy)
Wide local excision
Quadrantectomy
[B] Modified radical Mastectomy "Patey's operation"
- As radical but pectoral muscles is left intact.
- It gives the same cure rate as radical operation.
- It gives better cosmetic and functional results
So, it is now more popular and more accepted.
[C] Other combination therapy technique:
1- MC-Whirter's technique:
- Simple mastectomy + post-operative irradiation
- Claimed to have the same results of radical op. 2- Subcutaneous mastectomy + Hormonal therapy:
® Indicated only in very small or in situ tumour. We remove almost all breast tissue except skin. Then we do augmentation mammoplasty.
3- Quadrantectomy, Axillary dissection And RadioTherapy (QUART technique) is popularized by professor Umberto Veronisi.
4- Local excision (tumourectomy with 1-2 cm of surrounding breast tissue) and wide local excision have been tried with limited indications but it caries high incidence of local recurrence. Axillary dissection and lymph nodes clearance through a separate incision is usually done.
5- Local excision and sentinal node biopsy is a new technique which is under evaluation. It is done perioperative by injection of patent blue dy or radio-isotope labeled albumen near the tumour and localization of the sentinal lymph node either visual, Intraoperative or by gamma camera preoperative. This lymph node is excised and sent for hisopathology. If no malignancy is detected, axillary clearance may be not necessary as skip lesions are thought to occur in less than 3% of cases.
[II]Adjuvant Therapy:
(1) Radiotherapy:
Ä Types:
a) Pre-operative irradiation: * indicated in:
1- CA. breast in male ® Need skin grafting.
2- CA. in small breast female ® Need skin grafting.
Ä Disadvantages:
1- Delay the time of operation.
2- Renders the tissues more vascular.
3- False relieve the patient refuse surgery.
Ä Advantage: prevent post-operative local recurrence > post-opertive Irradion.
b- Post operative irradiation:
Ÿ Not needed after radical mastectomy if the axillary L.Ns. are free (stage I).
Ÿ Mc whirter 's technique ® Not universally accepted.
c- Palliative irradiation:
Ä Indications:
Ÿ Inoperable cases. Ÿ Postoperative recurrence. Ÿ 2ry deposits.
(2) Hormonal Therapy:
Ä The Idea:
Ÿ 50% of cases of CA breast depend on hormone in its growth "Hormone dependent".
Ÿ If we change the hormonal media on which the tumour grows it may regress.
ØThe relationship between hormone receptor status of breast tumor and patient response to endocrine therapy: Estrogen Receptor
Progesterone Receptor
Response
+
+
-
-
+
-
+
-
78%
34%
45%
10%
m Drugs: Oestrogen androgen and corticosteroids were used in the past.
Ä Tamoxifen, now, is the most widely used, hormonal, treatment in breast cancer. Its effect is favourable in most cases except in oestrogen receptor negative premenopausal women. It has also effect in reduction of risk of occurrence of cancer in the contralateral side. The optimal duration of treatment is extended now from 2 years to 5 years.
Ä Hormonal manipulations (endocrinal ablation therapy):
1- Ovarectomy ® Medical: by Tamoxifen "Anti-oestrogen (Nolvadx)
® Surgical: "bilateral oophorectomy"
2- Adrenalectomy ® Medical by Aminoglutethimide.
® Surgical "bilateral adrenalectomy.
3- Pituitarectomy ® Radiative by Yttrium transnasal implantation.
® Surgical "Hypophysectomy"
Ä Selection of the Operation:
1- Pre menopausal patients up to 5 ys. after menopause usually given Tamoxifen 20:40mg/daily.
· If give good response then do bil. oophorectomy.
· If no response or relapse give Aminoglutethimide.
2- If there is good response to Aminoglutethimide.
· We can do bilateral adrenalectomy "but it is major operation"
3- Hypophysectomy gives better response than adrenalectomy for the same indications.
(3) Chemotherapy:
A) Adjuvant to surgery given postoperative.
B) Intra-operative irrigation of the wound.
C) Palliation in advanced cases by instillation into pleural cavity in malignant effusion.
· Drugs given either ® Single agent "5- Flurouracil
Or ® Combined chemotherapy "CMF"
C ® Cyclophosphamide.
M ® Methotrexate.
F ® 5- Flurouracil.
SOURCE: Prof. AYMAN SALEM'S BOOK
Copyright: (Vascular Society of Egypt ) & (Medical Educational web)
Not to be reproduced without permission of Vascular Society of Egypt
|
