Elshami M.Elamin, MD Medical Oncologist Central Care Cancer Center Wichita, KS, USA
LCIS Clusters of ductules or acini filled, distorted and distended by proliferating epithelial cells. Normal mammogram Non palpable, incidental finding at biopsy Multifocal, multicentric, bilateral 3
LCIS Associated with lobular and tubular carcinomas Decrease after menopause Risk of invasive cancer is low 21% in 15yrs 4
Treatment Surgery: Excision with close observation Ipsilateral mastectomy without LN dissection + biopsy of contralateral breast Bilateral mastectomy Especially if BRCA mutation or strong FH Observation Tamoxifen or Raloxifene No role for RT 5
Pleomorphic LCIS Pleomorphic LCIS is aggressive variant May behave as DCIS Consider complete excision with negative margins 8/25/2015 6
DCIS Presents as palpable mass Abnormal mammogram 72% = microcalcifications 10% = tissue density, 12% both Peak incidence: yrs > 4.5 cm DCIS has 42% incidence of invasion 7
Histologic subtypes of DCIS High N G Microinvasion Micropapillary20%30% Papillary7%7% Comedo (Her2/neu +) 89%63% Solid, Cripriform0%0% 8
Multicentricity/Multifocality Multicentricity: Second separate DCIS at least 5 cm from primary site 25% in microscopic, 37% in palpable DCIS More common in micropapillary Multifocality: Within same quadrant or within 5 cm of primary site 9
Diagnosis of DCIS Multiview mammography + US Characteristic mammographic findings Diffuse, Linear, extensive pleomorphic calcifications FNA is not ideal Needle localization biopsy +/- specimen radiography 10
Before starting treatment Careful pathologic evaluation for: Negative margins Type and size Multifocality and microinvasion All suspicious areas Consider specimen radiography Post-Excision mammography Whenever uncertainty about adequacy of excision 8/25/
SLND and DCIS Complete ALND is not required in the absence of invasive component or proven mets Consider SLND if: The pt is to be treated with mastectomy or excision in anatomic location compromising the performance of future SLND 8/25/
Lumpectomy Wide excision + RT 5-20% local failure 50% of recurrences are invasive Patients with low risk could be treated with lumpectomy alone Wide excision alone for favorable histology 10-22% local failure rate Schmitt NEJM 1988, Lagios Cancer
Re-resection to obtain a negative margins Mastectomy if negative margins are not feasible 8/25/
Mastectomy Mastectomy +/- SLND +/- Reconstruction Non-palpable DCIS: Mastectomy without axillary dissection 100% long term survival 16
Patients found to have invasive disease at mastectomy or re-excision: Should be managed as stage I or II LN staging 8/25/
DCIS surgical margins Margins >10 mm Widely accepted as negative May cause less cosmetic outcome Margins < 1 mm is considered inadequate At chest wall or skin do not mandate re-excision May treat with higher boast dose of RT Margins 1-10 mm The wider the margins associated with lower local recurrence 8/25/
Risk of recurrence of DCIS Palpable mass Larger size Higher Grade Close or involved margins Age <50 8/25/
DCIS post-surgical treatment Ipsilateral breast: Tamoxifen X 5yrs Following L/RT especially if ER +ve Benefit for ER negative is uncertain 8/25/
Lumpectomy Excision + RT NSABP-B-17 (Lumpectomy + RT) 5Y EFS: 84.4% vs 75.8% (P 0.001) No change in OS 21
DCIS: Recurrence Rate Noninv %Inv % Excision alone1114 Excision + RT45 Surg Oncol Clin North Am 2:75,
NSABP B-24 Tamoxifen followin L/RT: 5% absolute reduction in recurrence risk 37% reduction in relative risk of recurrence 8/25/
Update of B17 and B 24 Lumpectomy/RT/Tam: RT reduce invasive recurrence by 59% Tam add 27% reduction RT/Tam reduce invasive recurrence by 70% 8/25/
DCIS post-surgical treatment Contalateral breast: Counseling regarding consideration of Tamoxifen for risk reduction 8/25/
NSABP Breast cancer preventive trial Tamoxifen reduce invasive cancer by 75% Tamoxefin reduces benign breast disease 8/25/
8/25/ Thanks