elshami m.elamin, md medical oncologist central care cancer center wichita, ks, usa
TRANSCRIPT
Elshami M.Elamin, MDMedical Oncologist
Central Care Cancer Centerwww.cccancer.comWichita, KS, USA
www.cccancer.com
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
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LCIS
Associated with lobular and tubular carcinomas
Decrease after menopause
Risk of invasive cancer is low 21% in 15yrs
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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
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Pleomorphic LCIS
Pleomorphic LCIS is aggressive variant May behave as DCIS Consider complete excision with negative
margins
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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
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Histologic subtypes of DCIS
High N G Microinvasion
Micropapillary 20% 30% Papillary 7% 7% Comedo (Her2/neu +) 89% 63% Solid, Cripriform 0% 0%
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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
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Diagnosis of DCIS
Multiview mammography + US Characteristic mammographic findings
Diffuse, Linear, extensive pleomorphic calcifications
FNA is not ideal Needle localization biopsy +/- specimen
radiography
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Before starting treatment
Careful pathologic evaluation for: Negative marginsType and sizeMultifocality and microinvasionAll suspicious areas
Consider specimen radiographyPost-Excision mammography
Whenever uncertainty about adequacy of excision
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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
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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
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Re-resection to obtain a negative margins
Mastectomy if negative margins are not feasible
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MastectomyMastectomy
Mastectomy +/- SLND +/- Reconstruction Non-palpable DCIS:
Mastectomy without axillary dissection 100% long term survival
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Patients found to have invasive disease at mastectomy or re-excision:
Should be managed as stage I or II LN staging
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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
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Risk of recurrence of DCIS
Palpable mass Larger size Higher Grade Close or involved margins Age <50
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DCIS post-surgical treatment
Ipsilateral breast: Tamoxifen X 5yrs
Following L/RT especially if ER +ve Benefit for ER negative is uncertain
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LumpectomyLumpectomy
Excision + RT NSABP-B-17 (Lumpectomy + RT)
5Y EFS: 84.4% vs 75.8% (P 0.001) No change in OS
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DCIS: Recurrence Rate
Noninv % Inv % Excision alone 11 14 Excision + RT 4 5
Surg Oncol Clin North Am 2:75,1993
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NSABP B-24
Tamoxifen followin L/RT: 5% absolute reduction in recurrence risk 37% reduction in relative risk of recurrence
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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%
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DCIS post-surgical treatment
Contalateral breast: Counseling regarding consideration of
Tamoxifen for risk reduction
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NSABP Breast cancer preventive trial
Tamoxifen reduce invasive cancer by 75% Tamoxefin reduces benign breast disease
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