CARCINOMA BREAST: CURRENT CONCEPTS IN MANAGEMENT

Dr. Santhosh John Abraham, Dr. Anusha Varghese

 

Carcinoma breast is the commonest malignancy in women all over the world. In the UK the incidence has gone up to 1 in 9.There is annual increase in incidence by 2%. Since the malignancy is getting detected relatively early and there is availability of effective chemotherapy and hormonal treatment, the longevity of survival has been substantially improved in the recent past. Though in India, we do not have any community-based statistics, all the available data from the various hospitals show an increasing incidence in cancer breast. It is now well established that carcinoma breast is a systemic disease and the aim of treatment is to improve the disease free survival of the patient. Every attempt is to be taken for an early detection of disease. Mammogram and Ultrasound evaluation of the breast are the most important tools in the evaluation of breast with no palpable lumps whereas a Fine

Needle Aspiration Cytology (FNAC) is the most important tool to assess a palpable breast lump. Mammogram is a non-invasive soft tissue X-ray of the breast taken in cranio-caudal and lateral oblique views after breast compression. It is not an accepted modality of investigation as a mass-screening programme but should be used in high-risk category. It helps to detect, localize and characterize the breast cancers mainly by various types of calcifications. Combined with USS breast it can predict malignancy with almost 90-95% accuracy. Mammogram machine to be useful needs breast

fixation and localization devices to take guided FNAC or biopsy. FNAC of the breast is the investigation of choice to evaluate any palpable breast lesion. The accuracy rate of FNAC in breast is 96- 98%. A core biopsy of the lesion will not only confirm tissue diagnosis but also will provide

tissue for study of various prognostic factors. Once the diagnosis is established the decision regarding treatment is taken after evaluating the patient, the local tumour and breast factors, the axillary and the metastatic status. Surgery and Radiotherapy are aimed at loco regional control of the disease while chemotherapy and hormonal manipulations are aimed at controlling the systemic disease. A judicious combination and sequencing of these various modalities is needed for the best outcome. The Halstedian concept of cancer breast treatment is part of history today. Conservatism

is generally the rule in carcinoma breast equally applicable to the surgery on breast and on axilla. Whenever breast conservative surgery is done the breast needs to be irradiated. Absolute contra-indications for breast conservation include : 1.Previous irradiation to breast and chest wall. 2.Pregnancy. 3. Failure after a previous conservation.4.Co-existent connective tissue disorders. Relative contra-indications for breast conservation

include 1.Presence of multifocal / multicentric disease. 2. Certain unfavourable sites like centrally located lesions.3. Adverse tumour: breast volume ratio resulting in unacceptable final cosmesis. 4.Patients who are educationally backward and hence cannot understand the importance of follow up.5.Economically unsound with resultant inability to afford more expensive treatment. 6. Patientís desire. Interference of the axilla is the most important cause of morbidity in breast cancer management. It is now thought that nodal metastasis in breast cancer occurs in a predictable

fashion and hence the first draining lymph node (Sentinel lymph node) is histologically proven to be non-metastatic there is no need for any further axillary nodal clearance. Sentinel node can be located by dye injection technique or with the help of a gamma probe. Indications for axillary irradiation are also redefined and include 1. Four positive nodes.2. Half of the nodal yield is positive for metastasis. 3. Perinodal infiltration. 4. Unknown

axillary status. Though early detection with more conservative approach is accepted, the need for mastectomy in the western world even today is to

the tune of 40% and that in our part of the world is more than 75%. Mastectomy leaves a formidable cosmetic defect, which has a bearing on

the womenís body image, self-esteem, way of dressing and social outlook, all contributing to a bad psychological status. The disfigurement following mastectomy is corrected to a large extent by primary breast reconstruction. There are different techniques for post mastectomy primary breast reconstruction. 1. Implants. 2. Autologous tissue transfer- pedicled flaps and free tissue transfer. The workhorse in primary breast reconstruction

is Transverse Rectus Abdominis Myocutaneous flap (TRAM). It provides excellent contour, colour and texture match and does not interfere with adjuvant local treatment like XRT or with early detection of local recurrence. TRAM provides an excellent breast mound. Nipple-areolar reconstruction can be done by tattooing, local flaps or by free labia minora transfer.