-: Breast cancer is the commonest cancer of human race.
It is rapidly increasing in its incidence
throughout the globe.
It is important to appreciate the principles involved
in the care of patients presenting with early disease.
For over a century, Dr. William S. Halsted
and his principles, initiated in the form of radical surgery
or Halsted radical mastectomy, reigned throughout the world.
This concept of radical surgery was modified
by Dr. David Patey in London when he demonstrated
that removal of the pectoralis major muscle is not needed
in most patients with breast carcinoma,
as it is not involved.
The modification of Patey mastectomy incorporated
preservation of the pectoralis major muscle.
The concept of radiation
to the involved breast was introduced way back in 1916
when Dr. Keynes, an army medical officer
in British army demonstrated the use of radiation
to the involved breast, thus initiating the principle
of wide local excision of the tumor
along with radiation to the diseased breast
and irradiating the local additional lymph nodes
in the axillary, internal mammary chain,
and supraclavicular lymph nodes.
This perhaps was the first attempt to conserve the breast
in the form of wide local excision
and radiation to diseased breast.
We have witnessed a paradigm shift
in the care of patients with early breast cancer,
starting from radical Halsted mastectomy
to modified radical mastectomy
preserving the pectoralis major muscle,
and then performing just diseased quadrant
in the form of quadrantectomy, radiotherapy,
and actually dissection initiated
by Dr. Umberto Veronesi of Milan.
And as the time passes, we are witnessing more
and more conservation of the diseased organ,
and perhaps the future lies in development of treatment
of breast cancer without any use of knife at all.
Let us define early breast cancer.
Patients presenting with T1 or T2 tumours,
that is up to five centimeter tumor size
with tumor confined to the breast tissue,
and usually with either no axillary nodal involvement,
or very early nodal involvement,
that is N0 or N1 disease is usually considered
as early breast carcinoma.
The management of patient
with early breast cancer can be considered
as care of the breast and care of axilla.
Let us go through some of the initial trials
in the form of breast conservation.
The first trial in Milan was conducted
by Dr. Umberto Veronesi, which is famous
in the form of Milan one trial or QUART trial.
In this study, Dr. Veronesi randomized patients
with early breast carcinoma up to two centimeter in size
into two groups, one group treated by radical mastectomy
which was the standard of care in those times,
and the other group was treated by quadrantectomy,
that is removal of the involved quadrant of the breast,
taking about two to three centimeter tumour margin
or around the tumor, along with full axillary dissection
and radiotherapy to the diseased breast.
This was called the QUART treatment.
The early results at 10 to 13 years of follow-up
of 701 patients of Milan one trial demonstrated
a local recurrence of 2% in Halsted mastectomy group
and 3.6% in the QUAD group, statistically similar
between the two groups.
The distant metastasis again was similar in the two groups,
thus this trial demonstrated the safety
and efficacy of breast conservation
as compared to Halsted radical mastectomy.
Later, Dr. Veronesi embarked upon a modification
of this trial popular by the name Milan two trial.
In Milan two trial, so patients undergoing QUAD,
which is an a acronym four quadrantectomy,
axillary dissection, and radiotherapy were compared
with the group undergoing TART,
which is an acronym for tumourectomy,
axillary dissection, and radiotherapy.
360 patients were randomized for QUART treatment,
whereas 345 patients were randomized to receive tumourectomy,
which is defined as tumour excision
with one centimeter of healthy tissue margin all around it.
This trial demonstrated a slightly higher local difference
in patients undergoing limited margin
of one centimeter in the TART group.
8% of local difference was witnessed at the end
of five years of follow up, compared to 3% in patients
undergoing quadrantectomy.
Distant metastasis of 12%, however, was similar
in the two groups.
So if we compare the results
of QUAD or quandrantectomy, axillary dissection,
and radiotherapy with tumorectomy, axillary dissection,
and radiotherapy or TART, we find that taking
two to three centimeter tumor margin is associated
with about local recurrence of 8% at 20 years of follow-up,
whereas tumourectomy with one centimeter margin was
associated with very high local recurrence of 20% or more
at the end of eight years.
Radical mastectomy in Milan one trial had
a very small local recurrence of 2.3%
at the end of 20 years of follow-up.
So we learn from these trials that width
of the tumor margin excised does matter,
and affects the local regional difference,
however, survival is similar in these groups.
Dr. Veronesi also compared the role of radiotherapy
to patients undergoing breast conservation
in the form of a trial called QUAD, that is treatment
by quadrantectomy with 2 centimeter margin,
axillary dissection, and no radiotherapy.
The results of this Milan three trial
with 567 patients randomized
with a six year follow-up data demonstrated
very low difference, 3% in quadrantectomy,
radiotherapy group, versus 13% local regional recurrence
in the QUAD group.
Distant metastasis were similar in the two groups.
The message learned from this trial is very clear,
that is radiotherapy is mandatory in patients
undergoing breast conservation,
otherwise, we have a very high local regional recurrence,
even in patients with early breast carcinoma.
This slide depicts the probability curves
of cumulative incidents of local recurrence
in four treatment groups.
In the X axis, we have the follow-up in years.
On the Y axis, we have percent cumulative incidence
of local recurrence.
In the Halsted mastectomy group enjoyed
the least local recurrence.
Patients undergoing quadrantectomy had
slightly higher recurrence.
Those undergoing tumorectomy with one centimeter margin,
that is TART group, had much higher recurrence,
and so did the patients with quadrantectomy
without radiotherapy.
This group of patients without radiotherapy suffered
from highest local recurrence,
again demonstrating the role played
by radiotherapy in breast conservation.
Let us now consider the principles involved
in breast conservation.
Of course, we have to honour the desire of the patient.
If the patient presents with a small tumour
less than four centimeters in size,
and she's desirous of preserving her mammary gland,
we have to honour her desire,
and provide breast conservation with good cosmesis.
We should be cognizant of the size of the tumour
in relation to the size of the mammary gland,
that is we should be aware of breast to tumour ratio.
If tumour is small and breast is large,
we can certainly provide excellent cosmetic results
with negative margin.
However, if breast is a small and tumour is large,
we should consider the option
of either pre-operative chemotherapy
to reduce the tumour size, or consider mastectomy.
Ideal indication for breast conservation is
a lady presenting with a single tumour
in one quadrant of the breast.
And we should again emphasize the need of radiotherapy
whenever breast conservation is performed.
While offering the option of breast conservation,
we should explain to the patient and her relatives
about the risk of slightly higher local recurrence
in the tune of about 1% each year of follow-up.
Studies from the Oxford meta-analysis have revealed
that if you prevent four local recurrences at year five
of follow up, you save one life at 15 years of follow up,
so we should consider this fact
while offering breast conservation to our patients.
Multicentricity, that is presence of two
or more tumor facial located
more than four centimeter apart is
a certain contraindication to breast conservation.
Breast conservation in the form
of wide local excision can be performed
in the form of volume displacement.
Where volume of breast tissue excised amounts to about 20%
or less, we can repair the defect by just approximating
the breast parenchymal pillars together.
This is called volume displacement
as opposed to volume replacement.
Where the amount of tissue removed measures
more than 20% of the whole breast,
we have to fill this defect
by local regional flap from outside the breasts.
This is called volume replacement.
Oncoplasty is a recent term applied
for patients undergoing wide local excision.
Oncoplasty is defined as tumour excision
with wide margins followed by repair of the defect
by local rearrangement of the breast tissue in such a manner
as to maintain the location and symmetry
of nipple-areolar complex.
Oncoplastic is a philosophy,
and every patient should be offered this type
of breast conservation achieving excellent cosmetic results.
We should also offer the option
of skin and nipple sparing mastectomy,
especially if tumour size is large
in relation to size of the mammary gland.
There are various types of oncoplastic procedures.
They are labeled as either volume displacement
and volume replacement.
We should also consider the option
of full mastectomy and reconstruction using
a local or distant flap, or use of silicon implants.
Let us go through some of the photographs where
we have performed wide local excision of tumour
followed by breast conservation and reconstruction.
This lady presented with a small tumour 2.5 centimeter
in diameter marked with the red margin
in the upper outer quadrant towards the axillary tail.
This was excised with two centimeter margin
and a local flap was then mobilized to fill this defect
as shown in the following diagrams.
The skin overlying the tumour was very close,
within five millimeter from the tumour,
hence a circular disc of a skin was excised,
regional nodal dissection in the form
of full axillary clearance was carried out,
because there were positive axillary nodes,
and this defect was then closed by mobilization
of this lateral thoracodorsal flap.
And the lady presenting with a very small tumour,
11 millimeter in size in the upper outer quadrant,
we approached it through a lateral parenchymal excision,
and repaired the defect with excellent cosmetic result.
A patient with a larger tumor
in upper outer quadrant with positive axillary nodes,
she was treated by a single incision approach,
where tumorectomy
along with axillary dissection was carried out.
Paget's disease is a special type
of early breast carcinoma presenting
as erosion or destruction of the nipple.
This is treated either by breast conservation
if there is no underlying lesion within the breast,
or by simple mastectomy if it is associated
with a deep located tumor in the breast.
So if mammogram is normal, and if there's no other lump
other than just erosion of the nipple, biopsy of the,
a wedge biopsy of the nipple confirmed
the diagnosis of Paget's disease.
This was followed by a sentinel node biopsy
and central core excision.
Central core excision involves removal
of the nipple-areolar complex, removing a core of the tumour
like a cup of ice cream down to the pectoral muscle,
and then placing the like titanium clips
on four walls of the residual cavity,
and one clip is placed on the posterior wall
on the muscle to facilitate post-operative radiotherapy.
The wound can then be closed
by persistent sutures or some local flap
like the dorsi flap can be performed.
If defect is large,
a mini latissimus dorsi can also be placed.
This lady with a similar central core excision was treated
by excision of the tumour followed by closure
of the defect in the transverse manner.
Slightly larger tumour involving the nipple-areolar,
extending up to the upper inner area.
Part of the breast was treated by wide excision
and central core excision, followed by repair
with the mini latissimus dorsi myocutaneous flap,
taken from upper part of her back, based on dorsal artery,
and placed in the defect,
providing excellent cosmetic outcome.
Nipple-areolar sparing mastectomy can also be carried out
for patients presenting with small tumour
up to three centimeter in size,
located more than two centimeter away
from the nipple-areolar complex.
There are certain contraindications which should be kept
in mind, such as Paget's disease of the nipple,
inflammatory carcinoma, and extensive intra-ductal carcinoma
as revealed by diffuse microcalcification on the mammogram.
Prior radiotherapy to the breast is also considered
a relative contraindication
for performing the skin and nipple-areolar mastectomy.
If tumour is very small, impalpable, seen only on a mammogram
as in this lady, this is located in the mammography room
with the help of a specially designed hook wire.
Then lady is mobilized to the operative room
where excision of this tumour
with the wire in-situ is carried out,
and this specimen radiography then reveals
complete excision of the lesion with the wire in center.
There are various other options available for removal
of the small tumors within the breast.
One such technique is called round block technique.
Here, tumour located at 12 o'clock position was excised,
along with a rim of skin around the nipple-areolar.
The defect was then closed
by approximating this edge of the skin
to the areola, achieving excellent cosmetic outcome.
If patient presents with in-situ carcinoma
or ductal carcinoma in-situ,
or DCIS as we call it, there can be two types
of presentation of DCIS, without a lump,
noted only on mammographic microcalcification, or with a
lump.
If there is no palpable lump,
it is usually excised under wire guidance,
and if tumour is positive for estrogen receptor,
we provide adjuvant therapy in the form
of five years of Tamoxifen 20 milligram daily.
If there is an associated lump, tumour can be excised
with two centimeter margin,
and again followed by radiotherapy to the breast,
and then Tamoxifen again can be offered
as adjuvant endocrine therapy
if tumour demonstrates estrogen receptor positivity.
Diffuse microcalcification on the mammogram is an indication
for sentinel node biopsy followed by mastectomy.
Let us talk a bit about evaluation
of the axilla in patients presenting
with early breast carcinoma.
If there is no palpable lymphadenopathy,
we perform sonography of the axilla.
Any suspicious node found on sonography is then biopsied.
Presence of metastasis in the axillary node is an indication
for full axillary dissection.
However, if the node biopsy is negative
or there are no suspicious nodes found on the sonography,
we perform sentinel node biopsy.
In summary, the care of ladies presenting
with early breast cancer is now to follow
an evidence-based, guideline-directed approach.
Providing outcome-oriented care of our mothers
and sisters offers excellent care and cosmesis.
We initially start with triple assessment,
followed by a multidisciplinary approach,
discussing the various options,
breast conservation versus mastectomy
in presence of a team of experts from medical oncology,
radiation oncology, breast care nurse, plastic surgeons,
and breast care surgeons.
The option of conservation
versus mastectomy should be offered
to all the patients, and their pros and cons explained
to the patient and their family members.
Sentinel node mapping should be proposed in women presenting
with clinically and sonographically negative axilla.
We should always respect the patient's feeling
while offering various treatment options.
Thank you.