TIMING OF IRRADIATION AFTER CONSERVATION

SURGERY
Breast irradiations delay longer than 16 weeks results in higher
incidence of breast relapse.
Irradiation should be started within 6 weeks from breast surgery for
patients NOT receiving chemotherapy,and within 16 weeks for
those receiving ADJUVANT chemotherapy.
FOLLOW UP OF PATIENTS TREATED WITH CONSERVATION
SURGERY & IRRADIATION
Monthly breast self examination.
Clinical examination every 3-4 months for the first three years,every 6
months through the fifth year & yearly thereafter.
In patients with DCIS or invasive lesions ,a base line mammmogram
within 4-6 months of completion of treatment then 6 months to one
year for 2-3 years & yearly thereafter.
When there is strong evidence of suspicious microcalcification,masses
or architectural distortions of the breast after conservation surgery &
irradiations ,BIOPSY should be done.
MANGMENT OF LOCALLY ADVANCEAD (T3 & T4),
INFLAMMATORY & RECURRENT TUMORS
LABC is defined by AJCOCSC as
Stage 111 –A & 111-B
Stage 1V disease includes
m
Ipsilateral supraclavicular nodal involvement in the absence of
other sites of distant disease.

Clinical / pathological findings of LABC

Tumor size greater than 5 cm
Clinically or pathologically positive axillary lymph nodes
Tumor of any size with direct extension to ribs,intercostal muscle
or skin.
Edema ,ulceration of skin of breast ,or satellite skin nodules confined
to the same breast.
Inflammatory Carcinoma.
Metastases to ipsilateral internal mammary lymph nodes or ipsilateral
axillary lynph nodes fixed to one another or other structures.
NATURAL HISTORY AND CLINICAL PRESANTATION
1. LABC.
LABC may evolve from a mass to infiltration of the deep
lymphatics of dermis,causing edema of skin.
More pronounced edema indicate superficial and deep
lymphatic involvement
Fixation of skin over the tumor and localized redness
occurs ,followed by ulceration and infiltration of overlying
skin.
Skin retraction may be caused by tumor invasion of coopers
ligament
Extensive involvement includes satellite nodules,and
carcinoma in cuirasse,in which the skin becomes plaque
like & yellowish ,red or grey.
2 Inflammatory carcinoma
Clinically presence of
Warmth
Erythema
Peaud orange in the involved breast
constitute the inflammatory carcinoma
Pathologically
presence of tumor emboli in the dermal lymphatics
Primary inflammatory carcinoma:
has acute presentation with erythema over the breast and
concomitant edema and ridges ,frequently without a palpable
masses
DIAGNOSTIC WORK UP
Special attention must be given to physical examination to
document locoregional extent of tumor.
Laboratory studies include
Complete blood cell count
Serum chemistry profile
Liver function test
if LFTs are abnormal then CT Scan of abdomen should be
obtained
Radiographic studies
Chest X-Ray
Bone Scan
PROGNOSTIC FACTORS
Increased local recurrence is associated with
larger or more diffuse tumors
presence of edema
number of involved axillary nodes
Estrogen/progestrone receptors negative patients have a
significantly lower survival rates
Her-2-neu over expression is associated with poor prognosis.
Tumor & axillary node response to Neo-adjuvant chemotherapy is
indicator of disease free survival.
GENERAL MANAGEMENT
Multiagent chemotherapy plays a primary role.
Role of radiation therapy and surgery is important in optimizing
locoregional tumor control .
If disease is technically resectable surgery should be preferred,
borderline resectable and unresectable disease can be treated with
irradiation alone.
Neo-adjuvant chemotherapy before surgery and irradiation plays a
prominent role.
 TREATMENT SCHEME FOR LABC
M etastatic Breast C ancer

Indolent D isease Agressive D isease

Endocrine Therapy C hem otherapy

Pre-m enopausal Progression

Tem oxifen or O varian C ancer Tam oxifen Salvage

Progression R esponse Progression

Secondary or Tertiary
Endocrine Therapy
in R esponders

Prgression
RADIATION THERAPY TECHNIQUES
a- Irradiation of inoperable breast.
These patients should be irradiated to the breast,
supraclavicular nodes and axillary nodes.
Ipsilateral internal mammary lymph nodes should be irradiated
if medial chest wall/breast disease is present or if clinical or
radiographic involvement of the internal mammary node chain.
Breast is treated with photons with tangential fields with
borders similar to those used in early breast cancer.
TECHNICAL CHALLENGES WHILE TREATING INTACT
BREAST WITH LABC
Homogenous irradiations of the breast tissue.
Adequate skin and dermal dose,with bolus usually required for
a significant portion of treatment .
Precise matching between
plane of inferior border of supraclavicular field &
plane of superior border of medial & lateral breast
tangential.
Minimal beam divergence into the lung from medial and
lateral breast tangential fields.
Adequate coverage of internal mammary nodes.
b- Irradiation of chest wall
Irradiation of the chest wall after mastectomy can be accomplished
with tangential photon fields or with appositional electron beams.
Bolus is necessary over the entire field for part of treatment and
should be added to scar alone for an additional part of treatment.
Several electron beam technique can be used as an alternative to
tangential photon treatment ; the simplest is a single appositional field
using 6-12 MeV electrons.
Field borders
Anatomic landmarks defining the field borders for treatment of
breast/chest wall tangential,supraclavicular nodes,internal mammary
nodes are same as for early breast cancer.
Doses
POST MASTECTOMY RADIATION THERAPY
Post mastectomy radiation is recommended for
-lesions larger than 5cm in diameter
-any skin fascial or skeletal muscle involvement
-poorly differentiated tumor
-positive or close surgical margins (less than 3mm )
-lymphatic permeation
-matted lymph nodes
-two or more positive axillary nodes
-gross extra capsular tumor extension
Adjuvant irradiation can be effectively given before,concurrent with or aft
LOCOREGIONAL RECURRENCE AFTER MASTECTOMY
It is the recurrent cancer in the bone, muscle, skin,or subcutaneous
tissue of the chest wall.
Regional involvement may include lymph nodes in the axilla,
supraclavicular,or infraclavicular region;ipsilateral internal mammary
lymph nodes;or retropectoral lymph nodes.
Locoregional recurrence may be isolated or concomitant with distant
metastasis.
Patients with locoregional recurrence may be treated with a
combination of irradiation, surgery, systemic therapy, or
hyperthermia.
Surgical management may consists of local excision for purposes of
debulking or may be extensive ,as in chest wall resection.
While treating chest wall recurrence with irradiation ,entire chest wall
BREAST CARCINOMA IN MALES
If tumor is operable then modified radical mastectomy,with or
without postoperative irradiation .
Stage 111 tumors are managed with combined modality as for
female breast cancer.
BREAST CANCER IN PREGNANCY
Diagnosis of breast cancer in pregnancy presents difficult decisions
for patient, oncologist and obstetrician.
The interest of both mother and child need to be taken into account.
Management will be influenced by the stage of pregnancy and of
disease.
In the first trimester ,termination is normally advised and followed
by standard treatment.
In second trimester choice is between simple mastectomy or
termination of pregnancy followed by standard adjuvant therapy.
In third trimester of pregnancy the breast becomes more
vascular.Small tumors may be treated with wide local excision
followed after delivery by radiotherapy.For larger tumors,simple
SEQUELAE OF THERAPY
It is related to irradiated volume, total dose, and concurrent
chemotherapy.
Most frequent complications are arm/breast edema, breast
fibrosis,painful mastitis,pneumonitis,rib fracture.
Apical pulmonary fibrosis occasionally is noted when regional
lymph nodes are irradiated.
Ischemic heart disease may develop in long term survivors
MANAGEMENT OF METASTATIC DISEASE
Metastatic breast cancer
Indolent disease Aggressive disease
Endocrine therapy Chemotherapy