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Management of DCIS

Management of DCIS. Fei-Fei Liu Radiation Oncologist/Senior Scientist. Learning Objectives. Describe DCIS. Acquire familiarity of local management for DCIS. Understand the role of systemic treatment for DCIS. Appreciate some of the emerging issues. Like radiation oncologists. DCIS.

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Management of DCIS

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  1. Management of DCIS Fei-Fei Liu Radiation Oncologist/Senior Scientist

  2. Learning Objectives • Describe DCIS. • Acquire familiarity of local management for DCIS. • Understand the role of systemic treatment for DCIS. • Appreciate some of the emerging issues. • Like radiation oncologists.

  3. DCIS Definition Proliferation of malignant ductal epithelial cells which have not breached the BM.

  4. DCIS • Rising incidence due to screening • 15-20% of all newly-diagnosed breast tumours • 90% of DCIS are mammographically detected

  5. DCIS Diagnosis • Mostly made on mammography • Role of mri – • Might be more sensitive, but lacks specificity • useful to r/o multiple lesions

  6. DCIS Classifications Very complex; no single accepted system.

  7. Tissue processing protocol is complex; hence not generalizable.

  8. Learning Objectives • Describe DCIS. • Acquire familiarity of local management for DCIS. • Understand the role of systemic treatment for DCIS. • Appreciate some of the emerging issues. • Like radiation oncologists.

  9. Management of DCIS Options • Simple Mastecomy • no RCT of SM vs. lump • large or diffuse lesions • involvement of resection margins • no role for AxLND • Lumpectomy + RT

  10. Four RCT of Lump + RT for DCIS

  11. UKCCRC; Lancet 362:95, 2003

  12. Why Does Controversy Persist? RCTs demonstrate benefit to RT in all subgroups but: • margin width was not measured • tumour sizes missing

  13. Identification of a LOW RISK Group Van Nuys data Margin Width No RT RT RR > 10 mm .03 .02 1.14 1 to <10 mm .20 .12 1.49 < 1 mm .58 .30 2.54

  14. Canadian Clinical Practice Guidelines for DCIS • BCS should be followed by RT • Mastectomy • large or diffuse lesions • involvement of resection margins • No axillary dissection • Omission of RT: small, low grade, no necrosis, negative margins Olivotto et al, CMAJ 165:912, 2001

  15. RT Is No Longer Given As Such

  16. Modern Day Breast RT • Tangential parallel pair • Intensity Modulated Radiation Therapy (IMRT) • Achieve optimal dose homogeneity in target volume (breast)

  17. CT-Simulation • Diagnostic CT unit with rapid spiral acquisition • Full 3D dataset • Virtual simulation software

  18. CT Based Simulation & Planning

  19. Standard Breast Tangents

  20. Goal: Dose Uniformity Wedges IMRT 115% 110% 105% 100% 95% 90%

  21. Improved Acute Skin Reaction with IMRT Pignol et al, JCO 26:2085, 2008

  22. Doses of RT • 4240 cGy/16#/3.5 wks + boost (10 Gy/5#s) 2. 5000 cGy/25#/5 wks + boost (10 Gy/5#s)

  23. Quiz #1 Which famous personality had DCIS? • Melissa Etheridge • Liona Boyd • Belinda Stronach • Michael Jackson

  24. Learning Objectives • Describe DCIS. • Acquire familiarity of local management for DCIS. • Understand the role of systemic treatment for DCIS. • Appreciate some of the emerging issues. • Like radiation oncologists.

  25. Tamoxifen in the Management of DCIS

  26. The Role of Tamoxifenin the Management of DCIS: NSABP B-24 • N = 1804 • Local excision + RT Placebo Tamoxifen P All Breast Cancer 13.4% 8.2% 0.0009 Ipsilateral BC Invasive 4.2% 2.1% 0.03 Non-invasive 5.1% 3.9% 0.43 Contralateral BC 3.4% 2.0% 0.01

  27. UKDCIS Trial: Effect of Tamoxifen

  28. Why the Difference? Trial Design • 33% of patients in Tamoxifen arm of the UK trial had RT • All patients in B24 had RT before TAMOXIFEN • Exclusion of positive margins in the UK trial

  29. Why the Difference? Patient Population • 34% of patients in B24 were <50 years vs. 9% in the UK Trial • Both trials showed greatest benefit of Tamoxifen in women <50 years

  30. NSABP B-24: Toxicity

  31. IBIS Trial Tam vs. Anastrozole 4000 ER+ve DCIS post-meno women 3000 women; opened Jan 03

  32. Quiz # What is the IMRT acronym? • Intermittent Moderate RT • Infinite Modulated RT • Incredibly Modern RT • Intensity Modulated RT

  33. Learning Objectives • Describe DCIS. • Acquire familiarity of local management for DCIS. • Understand the role of systemic treatment for DCIS. • Appreciate some of the emerging issues. • Like radiation oncologists.

  34. Kuere et al; JCO 27:279, 2009

  35. Take-Home Points DCIS accounts for ~20% of newly-diagnosed BC Surgery (mostly lumpectomy) RT reduces the risk of local recurrence There may a subset of women with DCIS that do not benefit from RT

  36. Conclusions 5. Prospective validation of BCS alone is needed 6. Improvements in techniques of surgical resection, pathologic evaluation of DCIS, and adherence to synoptic reporting of DCIS will help identify potential candidates for BCS alone.

  37. Any Questions?

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