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Non-invasive Breast cancer

Elshami M.Elamin, MD Medical Oncologist Central Care Cancer Center www.cccancer.com Wichita, KS, USA www.cccancer.com. Non-invasive Breast cancer. LCIS. Clusters of ductules or acini filled, distorted and distended by proliferating epithelial cells. Normal mammogram

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Non-invasive Breast cancer

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  1. Elshami M.Elamin, MD Medical Oncologist Central Care Cancer Center www.cccancer.com Wichita, KS, USA www.cccancer.com Non-invasive Breast cancer

  2. 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

  6. 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. Histologic subtypes of DCIS High N G Microinvasion • Micropapillary 20% 30% • Papillary 7% 7% • Comedo (Her2/neu +) 89% 63% • Solid, Cripriform 0% 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. TREATMENT

  11. 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

  12. 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

  13. 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. Re-resection to obtain a negative margins • Mastectomy if negative margins are not feasible

  15. 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

  17. 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

  18. Risk of recurrence of DCIS • Palpable mass • Larger size • Higher Grade • Close or involved margins • Age <50

  19. DCIS post-surgical treatment • Ipsilateral breast: • Tamoxifen X 5yrs • Following L/RT especially if ER +ve • Benefit for ER negative is uncertain

  20. 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 alone 11 14 • Excision + RT 4 5 Surg Oncol Clin North Am 2:75,1993

  22. NSABP B-24 • Tamoxifen followin L/RT: • 5% absolute reduction in recurrence risk • 37% reduction in relative risk of recurrence

  23. 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%

  24. DCIS post-surgical treatment • Contalateral breast: • Counseling regarding consideration of Tamoxifen for risk reduction

  25. NSABP Breast cancer preventive trial • Tamoxifen reduce invasive cancer by 75% • Tamoxefin reduces benign breast disease

  26. Thanks

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