55 yr old female patient presents with fungating breast mass of size 3 cm in diameter with palpable ipsilateral two axillary lymph nodes and no evidence of distant metastases?
Ans. is 'b' i.e., Modified radical mastectomy with axillary lymph node dissection * 55 yr old female patient with fungating breast mass of size 3 cm in diameter with palpable ipsilateral two axillary lymph nodes and no evidence of distant metastases - is a case of stage IIA breast carcinoma.* This patient comes under the category of early invasive breast carcinoma so management with modified radical mastectomy and axillary lymph node dissection is the appropriate treatment.Stage I & II breast cancers (Early invasive breast cancers) are managed by:1) Primary therapy for local management &2) Adjuvant therapy* Primary therapy consists of:# Mastectomy with assessment of axillary lymph node status (or modified radical mastectomy) or# Breast conservation (lumpectomy, wide local excision or quadrantectomy) with assessment of axillary lymph node status + radiotherapy.* Various trials have found both these methods to be equally effective. Breast conservation is the preferred form of treatment because of cosmetic advantages. However there are certain contraindications for conservative surgery (described in subsequent question).* Management of axillary lymph nodes :# Earlier dissection of axillary lymph nodes (level I and II) was performed to assess the lymph node status (i.e. presence or absence of occult metastasis)# Now Sentinel lymph node biopsy is considered the standard for evaluation of the axillary lymph nodes for metastasis in women who have clinically negative lymph nodes, (the sentinel lymph node is the first regional lymph node to receive tumor cells that metastasize along the lymphatic pathway from the primary breast cancer)# Axillary Lymph node dissection is performed for clinically palpable axillary lymphnodes or metastatic disease detected in sentinel lymph node biopsy.* Adjuvant chemotherapy is given to :# All node-positive cancers# Node negative cancers if > 1 cm in size# Node negative cancer > .5 cm in size with adverse prognostic factors such as :* Blood vessel or lymph vessel invasion* High nuclear grade* High histological grade* HER 2/neu overexpression* Negative hormone receptor status* Adjuvant hormone therapy (tamoxifen) is added to all those with estrogen receptor positive tumors# HER-2/neu expression is determined for all patients with newly diagnosed breast cancer and may be used to provide prognostic information in patients with node-negative breast cancer and predict the relative efficacy of various chemotherapy regimens. Trastuzumab is the HER-2/neu-targeted agent that is added to the adjuvant therapy is the tumor shows overexpression of HER-2/neu receptors.Advanced Local-Regional Breast Cancer (Stage III)(Neoadjuvant chemotherapy + MRM + adjuvant radiation therapy +chemotherapy + antiestrogen therapy)* Here the disease is advanced on the chest wall or in regional lymph nodes (or both), with no evidence of metastasis to distant sites. Such patients are recognized to be at significant risk for the development of subsequent metastases, and treatment addresses the risk for both local and systemic relapse.* In an effort to provide optimal local-regional disease-free survival as well as distant disease-free survival for these women, surgery is integrated with radiation therapy and chemotherapy.* Neoadjuvant chemotherapy (administration of therapeutic agents prior to the main treatment) should be considered in the initial management of all patients with locally advanced stage III breast cancer.* Surgical therapy for women with stage III disease is usually a modified radical mastectomy, followed by adjuvant radiation therapy and chemotherapy. Antiestrogen therapy (tamoxifen) is added for hormone receptor positive tumors.* Chemotherapy is used to maximize distant disease-free survival, whereas radiation therapy is used to maximize local-regional disease-free survival.* In selected patients with stage III A cancer, neoadjuvant (preoperative) chemotherapy can reduce the size of the primary cancer and permit breastconserving surgery.Distant Metastases (Stage IV)(mainly palliative treatment)* Treatment for stage IV breast cancer is not curative but may prolong survival and enhance a woman's quality of life.* Hormonal therapies that are associated with minimal toxicity are preferred to cytotoxic chemotherapy. Appropriate candidates for initial hormonal therapy include women with hormone receptor-positive cancers; women with bone or soft tissue metastases only; and women with limited and asymptomatic visceral metastases.* Systemic chemotherapy is indicated for women with hormone receptor-negative cancers, symptomatic visceral metastases, and hormonerefractory metastases.* Bisphosphonates, which may be given in addition to chemotherapy or hormone therapy, should be considered in women with bone metastases.
Radical mastectomy
Modified radical mastectomy with axillary lymph node dissection
Hormonal therapy
Palliative therapy
Breast