1. Breast Conservation Surgery
DR Shailesh Puntambekar
KEM Hospital Pune
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2. BREAST CONSERVATIVE THERAPY
Dr Shailesh Puntambekar
Consulting onco surgeon
Associate professor , department of surgery, KEM Hospital, Pune, India

3. In the good old days we made a clean breast of malignant disease
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

5. HISTORY Halstead radical mastectomy Extended radical mastectomy
Modified radical mastectomy
Breast conservation therapy

6. 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

7. 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.

8. INDICATIONS
Stage I & II
? Stage III

9. CONTRAINDICATIONS Pregnancy Multicentric disease
Diffuse indeterminate micro-calcification
Previous RT
Large tumour/ breast ratio
Collagen vascular disease
Large breast size
Central tumour

10. Small Breast Realities
In a small breast not much to achieve in cosmesis
Recurrence comes as Cancer en Cuirasse

11. POST MRM NO RADIOTHERAPY
SATELLITE NODULES OVER THE CHEST WALL
NO TREATMENT IS EFFECTIVE
PALIATIVE INTENT OF RADIOTHERAPY

12. Large Breast Realities
In a large breast recurrences not easily diagnosed
A recurrence is viewed as a second primary

13. SPECIAL CONSIDERATIONS
Family history
Primary tumour histology
Margin evaluation
Extensive intraductal component

14. METHODS Lumpectomy +Axillary dissection +RT Lumpectomy+SLN biopsy +RT
QUART- Quadrantectomy +Axillary dissection +RT
CTART- Chemotherapy +RT

15. Axillary Dissection Better control of locoregional recurrence
Accurate staging of disease
To decide adjuvant therapy
Prognosis

16. GUIDELINES OF SURGERY
Incision
Technique
Closure
Axillary Dissection

17. NEW INVESTIGATION MODALITIES
MRI
Intra-op ultra-sound
Touch preparation cytology
Percutaneous needle biopsy

18. NEW TECHNIQUES OF TUMOUR MANAGEMENT
Radio Frequency Ablation –RFA
Cryosurgery
Focused Ultrasound
Percutaneous tumour extraction

19. ROLE OF NEOADJUVANT Induction chemotherapy Drugs
Selection and monitoring of induction chemotherapy patients

20. 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)

21. RADIOTHERAPY IN BCT Intraoperative radiotherapy
Post operative radiotherapy
Brachytherapy

22. SPECIAL CASES Hereditory breast cancer Macromastia
Occult breast cancer
Pregnancy
Bilateral breast cancer

23. BCS : Procedures Lumpectomy with 2 cm clearance
Lumpectomy with Axillary Dissection
Quadrantectomy with Axillary Dissection

24. Indications for BCS Small/Early Tumors in premenopausal women
Lateral than medial tumors
More important to know the contraindications

25. Contraindications for BCS
Very small Breast
Very large Breast
Advanced / High Grade Disease
Lactating Breast
Multicentricity
Disease in opposite Breast

26. RESULTS BCT / MRM T1 & T2 TUMOUR CONTROL RATE
5 YR RELAPSE FREE SURVIVAL
RECURRANCE
ONLY CONS SURGERY
CONS SURGERY + RT
80 TO 90 %
70 TO 88 %
15 TO 40 %
2 TO 10 %

27. 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

28. Thank You