Early Breast Cancer. New treatment
There are several contraindications to breast preservation so you can judge when a woman walks in your office, may she be a candidate for breast preservation or not. If you have a large tumor, usually greater than 5 cm, most of the time they cannot be preserved. There are some considerations for neo-adjuvant chemotherapy but the vast majority of women would be best served by a mastectomy. If you have two palpable lesions in separate quadrants of the breast, usually they are not a candidate for breast preservation because too much of the breast tissue needs to be removed for a cosmetically acceptable result and most of the time, that breast could not be controlled with radiation therapy afterwards. If the patient is in the first two trimesters of pregnancy, she is best served by a modified radical mastectomy because radiation therapy should not be given when a patient is pregnant. If she is in the last trimester and radiation therapy can be delayed until the baby has been delivered, then breast preservation may be considered. If the woman has had prior breast radiation either for breast cancer or for lung cancer on that breast, she can’t have that breast preserved. If she had breast cancer on the other side and was preserved with radiation, there is nothing wrong with treating the other breast with radiation therapy. There are sometimes social or medical conditions precluding radiation, the patient can’t get to the treatments six days a week, they are bedridden, they are in a nursing home, those are patient’s who would best be served by a mastectomy.
This is a mammogram of a woman that should not have breast preservations. I think the calcifications that you see are pretty obvious from the back of the room and these all indicate very extensive infiltrating and intraductal carcinoma, and this patient would be best served by a mastectomy. There are some relative contraindications to breast preservation. If a patient has a history of collagen vascular disease, especially lupus, their skin can have an extreme reaction to the radiation therapy, sometimes to the point of necrosis requiring reconstruction, so that patient needs a very careful discussion about risks benefits of radiation therapy before you proceed. If there are multiple tumors in the same quadrant of the breast, you have to kind of judge how much of that quadrant is involved by tumor, how big the tumors are, how far apart they are and if you feel that the tumors are too large to be adequately excised, then that patient would be best served by a mastectomy. There is some older thinking about patient’s that shouldn’t be preserved that are kind of old wives tale. First of all, if you have positive axillary lymph nodes, there is no reason that patient cannot have breast preservation. If the tumor is underneath the nipple, there is no reason that patient cannot have breast preservation. If there is a strong family history, there is no evidence, at least at this point that a young woman with a strong family history cannot be treated with breast preservation. There is no long term data suggesting that their local control is poorer even in a BRCA 1 or 2 family.
This is a classic mammogram of a patient who is an excellent candidate for breast preservation. She has a small mass in the upper portion of her breast, very well defined, the rest of the breast is relatively fatty with no other lesions noted. The lesion is excised with needle localization and you can see the spiculations of the mass with a margin of normal breast tissue around it. This patient would then receive radiation therapy, as a radiation oncologist, I have to tell you a little bit about that, you treat the entire breast, you may or may not treat the regional nodes. Radiation treatment therapy is now for the most part done with CT based treatment planning, these are just localization marks on the patient. You can see that the biopsy cavity is here and the surgeon outlined it in clips. We can then make very detailed plans and these little blue lines show that the radiation is going only within these lines and the rest of the body is not even being treated, especially the heart. This is what a patient looks like on the last day of treatment. There is skin reaction and you can imagine that’s where the port would be in a little bit of a square. That skin reaction peaks usually toward the last week or so of radiation therapy and then heals within the first month after treatment.