2. Elshami M.Elamin, MD Medical Oncologist Central Care Cancer Center www.cccancer.com Wichita, KS, USA www.cccancer.com

3. 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

4. LCIS Associated with lobular and tubular carcinomas Decrease after menopause Risk of invasive cancer is low 21% in 15yrs 4

5. 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

6. Pleomorphic LCIS  Pleomorphic LCIS is aggressive variant  May behave as DCIS  Consider complete excision with negative margins 8/25/2015 6

7. DCIS  Presents as palpable mass  Abnormal mammogram  72% = microcalcifications  10% = tissue density, 12% both  Peak incidence: 51 - 59 yrs  > 4.5 cm DCIS has 42% incidence of invasion 7

8. Histologic subtypes of DCIS High N G Microinvasion  Micropapillary20%30%  Papillary7%7%  Comedo (Her2/neu +) 89%63%  Solid, Cripriform0%0% 8

9. 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

10. Diagnosis of DCIS  Multiview mammography + US  Characteristic mammographic findings  Diffuse, Linear, extensive pleomorphic calcifications  FNA is not ideal  Needle localization biopsy +/- specimen radiography 10

12. 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 8/25/2015 12

13. 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 8/25/2015 13

14. 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 1989 14

15.  Re-resection to obtain a negative margins  Mastectomy if negative margins are not feasible 8/25/2015 15

16. Mastectomy  Mastectomy +/- SLND +/- Reconstruction  Non-palpable DCIS:  Mastectomy without axillary dissection  100% long term survival 16

17.  Patients found to have invasive disease at mastectomy or re-excision:  Should be managed as stage I or II  LN staging 8/25/2015 17

18. 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 8/25/2015 18

19. Risk of recurrence of DCIS  Palpable mass  Larger size  Higher Grade  Close or involved margins  Age <50 8/25/2015 19

20. DCIS post-surgical treatment  Ipsilateral breast:  Tamoxifen X 5yrs  Following L/RT especially if ER +ve  Benefit for ER negative is uncertain 8/25/2015 20

21. Lumpectomy  Excision + RT  NSABP-B-17 (Lumpectomy + RT)  5Y EFS: 84.4% vs 75.8% (P 0.001)  No change in OS 21

22. DCIS: Recurrence Rate Noninv %Inv %  Excision alone1114  Excision + RT45 Surg Oncol Clin North Am 2:75,1993 22

23. NSABP B-24  Tamoxifen followin L/RT:  5% absolute reduction in recurrence risk  37% reduction in relative risk of recurrence 8/25/2015 23

24. 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% 8/25/2015 24

25. DCIS post-surgical treatment  Contalateral breast:  Counseling regarding consideration of Tamoxifen for risk reduction 8/25/2015 25

26. NSABP Breast cancer preventive trial  Tamoxifen reduce invasive cancer by 75%  Tamoxefin reduces benign breast disease 8/25/2015 26

27. 8/25/2015 27 Thanks