BREAST CANCER TREATMENTS

11. BREAST CANCER TREATMENTS.

Cancer treatment may be local or systemic:
Local treatments involve only the area of the disease. Surgery and radiation are forms of local treatment.
Systemic treatments affect the entire body. Chemotherapy, hormonal therapy and targeted therapy are the forms of systemic treatments.
Earlier diagnosis might lead to increased cure rates with such local treatment; however, early micro-metastasis is a characteristic feature of the neoplasm or cancer, indicating that a systemic approach such as chemotherapy is required.
Most women receive a combination of treatments. For women with stage 0, 1, 2 or 3 breast cancer, the main goal is to treat the cancer and prevent it from recurring.

The treatment according to the stage of the cancer as follows:

• Stage 0 Cancer in situ: DCIS and LCIS – Lumpectomy plus radiation.
• Sage 1 and 2 – Mastectomy with some sort of lymph nodes removal is standard treatment. Chemotherapy, hormone therapy and biologic therapy may also be recommended following surgery.
• Stage 3: Radical mastectomy possibly followed by chemotherapy, hormone therapy and biologic therapy..
• Stage 4: The goal is to improve symptoms and help them live longer. Treatment may involve surgery, radiation, chemotherapy or combination of such treatment. Chemotherapy provides only palliative rather than curative therapy at present. In most cases, stage 4 breast cancer cannot be cure.

SURGERY
Surgery is usually the first line of attack against breast cancer.
Possible surgical procedures include the following:
Lumpectomy: The surgeon removes only the tumor [the lump] and some of the normal tissue that surround it, but not the whole breast.. Sometimes armpit [underarm] lymph nodes are remove for examination.

Fig. 8: Surgery of breast cancer with segmental

mastectomy or lumpectomy.

Mastectomy :

• Radical mastectomy: Removes the entire breast, the nipple, the skin, the muscle under the breast, and the lymph nodes in the armpit. The radical mastectomy is seldom done anymore, except that the cancer had spread to the nearby structure such as the muscle, the ribs, the lymph nodes beneath the breast or to the skin or for advanced stage 3 breast cancer..

Fig 9: Woman with Radical Mastectomy:

A Pink highlighted area are indicated tissue removal at

mastectomy.

B Axillary [armpit] lymph nodes: level I

C Axillary lymph nodes: level II

D Axillary lymph nodes: level III

E Supraclavicular lymph nodes.

F Internal mammary lymph nodes.

• Modified radical mastectomy: Surgeon removes the entire breast, the nipple, some skin and some of the lymph nodes in the armpit. The muscle under the breast is left in place. It is indicated for stage 1 and 2 breast cancer.

Fig. 10:Woman with modified radical mastectomy:

A Pink highlighted area indicated tissue removed at

mastectomy.

B Axillary lymph nodes: level I

C Axillary lymph nodes: level II

D Axillary lymph nodes: level III.

• Total or simple mastectomy: Removal of the breast tissue only, without removal of the lymph nodes or any muscle tissue beneath the breast.

Fig.: 11 Woman with total [simple] mastectomy

A Pink highlighted area indicates tissue removed at

mastectomy

B Axillary lymph nodes: level I

C Axillary lymph nodes: level II

D Axillary lymph nodes: level III.

• Skin-sparing mastectomy is a technique that preserves as much of the breast skin as possible. The surgeon removes the breast tissue through the small opening that is created. The remaining pouch of skin provides the best save and form to accommodate an implant or a reconstruction using your own tissue. Many women chose this type of mastectomy in order to get the most realistic and pleasing results from immediate breast reconstruction. Most women are eligible for skin-sparing mastectomy. However, there are some exceptions: If the patients have decided will not have immediate breast reconstruction. A skin-sparing mastectomy is not safe if there is the cancer cells are close to the skin or that the cancer may involve the skin, such as in inflammatory breast cancer.

OPERATIONAL PROCEDURES OR STEPS OF MASTECTOMY.

What is happened to the patients breast in mastectomy surgery ?
The skin incisions shown in Fig.8 will suffice for all intents and purposes; it can be extended and amplified to meet the special needs of a given case. Ample exposure and through anatomic dissections are essentials. The axilla [armpit] should be dissected first.

This procedure is about radical mastectomy, another types of mastectomy are the modification of the radical mastectomy according to the stage of the breast cancer.

• Step 1: The skin along the entire margin of the incision is freely dissected up from the under lying tissue to an extent.
• Step 2: Expose the pectoral fascia in the line of the upper incision. Lift the skin and fat off the muscle until the furrow is reached; this furrow marks the dividing line of pectoral major muscle.
• Step 3: Dissection of the greater pectoral muscle almost as far as its humoral [upper arm] attachment. The entire mass [pectoral major muscle and mammary gland] is dissected away from the ribs.
• Step 4: Expose the outer edge of the pectoral minor in it’s entirely. The gland and major pectoral muscle now are attached only by connective tissue and armpit fat.
• Step 5: Cleaning out the armpit. Expose the armpit vein. The armpit vein usually is a large single trunk but often is found as two branches. The nerves of the brachial plexus surround the armpit vein. A number of tributary veins enter it from the armpit fat; the largest and most important of these is the scapular vein which accompanies the scapular artery.
• Step 6: Ligate or tie and divide all tributary vessels in this locality: this is to go hand to hand with the removal of all fat, lymph nodes and other elements.
• Step 7: Close the wound. Introduce a rubber or cigarette drain through a stab wound. Hemostasis [control of bleeding] must be perfect. The skin should be closed with interrupted sutures. [cont.]