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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 SURVIVAL • RECURRANCE • ONLY CONS SURGERY • CONS SURGERY + RT • 70 TO 88 % • 15 TO 40 % • 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