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Patey s Mastectomy Patey s (Radical) Mastectomy Patey

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Patey s Mastectomy Patey s (Radical) Mastectomy Patey s Mastectomy Breast Cancer A relaxed approach to local treatment in the last 20 years Loco Regional ... – PowerPoint PPT presentation

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Title: Patey s Mastectomy Patey s (Radical) Mastectomy Patey


1
Pateys Mastectomy
2
Pateys (Radical) Mastectomy
Sandeep Kumar MS FRCS (Edinburgh) PhD (Wales)
MMSc (Newcastle) Professor of Surgery Department
of Surgery King Georges Medical
University Lucknow, Uttar Pradesh, India
3
Pateys Mastectomy
4
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5
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6
Breast Cancer
  • A relaxed approach to local treatment in the
  • last 20 years
  • Loco Regional Recurrence (LRR) represents a
  • biologic disease rather than a treatment failure

7
NEW Not so New
  • Recognition of the importance of extent and
  • quality of primary surgery in determining
  • outcomes
  • R Residual

8
Local treatment
  • Improved loco regional control
  • Improved survival

Improved local treatment not been a subject of
intensive, high profile randomised clinical trials
9
Breast cancer the survival
Local treatment Systemic treatment
Survival
  • Adjuvant radiotherapy
  • Overgaard et al, NEJM 1997 337949
  • Ragaz et al, NEJM 1997 337956
  • Hellman S, NEJM 1997 337996
  • Radical surgical treatment
  • Quality of life

Survival
Survival
10
Conservation Technique
  • Seek LRR
  • Require intensive radiotherapy
  • Chemotherapy
  • Long term follow-up monitoring

11
Psychological Benefits of
  • Conservation
  • Radiotherapy Outcome
  • Chemotherapy
  • Is this really good s
  • or
  • as hoped ss

12
An Alternative is
  • More radical surgery to maximize local control
  • Immediate breast reconstruction as
    cherished
  • Good loco-regional control related to improved
  • survival rates
  • Avoid adjuvant therapies

13
The Benefits
  • Breast conservation treatment unsuitable for
  • 50 patients Oldhoff
    1992
  • Surgery remains necessary to treat large tumors
  • Surgery for unresponsive to chemotherapy
  • Long term adverse effects of high dose
    radiotherapy Breast Can Res Treat 1998
    47101
  • Lower treatment and monitoring cost

14
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15
Breast Conservation a Commodity
  • Early stage disease a reference bias
  • Epidemiologically downstage screen achieved
  • Large breasts well nourished population
  • Radiotherapy support overburdened
  • Meticulous surgical technique sentinel node
    training
  • Chemotherapy mandate ensured compliance,
    subsidy
  • Intensive follow up education / means

16
LRR / Survival
17
Survival Related to Tumor Size
18
Who developed systemic recurrence ?
19
An outcome at variance
  • Clear survival advantage for those who achieved
    good loco-regional control
  • A hypothesis which has not been a subject of
    high profile prospective RCT

20
Overtaken by new biology
  • Breast cancer is systemic from its onset and
    lymphnode involvement has significance only as an
    indicator of systemic spread
  • Fisher

21
Halstedian paradigm Radicality of
treatment - panacea for cureParadigm shift
Breast cancer - a systemic disease
Fishers rhetoric New millenium paradigm
Loco-regional recurrence - harbinger of
systemic recurrence
22
Equivalence of Radical vs Conservative
  • Equivalent LRR between conservative and radical
    because of
  • multicentric trials - ? quality control in
    surgery
  • Euphemism in Group allocation (Milan - Veronesi)
  • Quadrantectomy, meticulous axillary
    dissection and high dose post-op radiotherapy
    radical mastectomy
  • Powerful, high profile, randomised, multicentric
    and
  • controlled clinical trials neglect assessment of
    surgical
  • technique

23
In Summary
  • Radical local treatment contributes significantly
    to
  • survival
  • Reduced loco-regional recurrence influences
  • survival
  • High quality loco-regional control should be
  • emphasized as is systemic therapy
  • Assessment of surgical techniques should be
    included
  • in studies in which surgery is a component of
    therapy

24
David Patey
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