Download - Non-invasive Breast cancer
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Elshami M.Elamin, MDMedical Oncologist
Central Care Cancer Centerwww.cccancer.comWichita, KS, USA
www.cccancer.com
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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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Thanks