Transcript Euhus_DCIS_2012

Ductal Carcinoma in situ
David M. Euhus, MD, FACS
Professor of Surgery
Director, Clinical Cancer Genetics
UT Southwestern Medical Center at Dallas
Ductal and Lobular Anatomy of the Breast
Estrogen Receptor Negative
Luminal Cell
Myoepithelial Cell
Stem/Progenitor Cell
Estrogen Receptor Positive
Luminal Cell
Estrogen Receptor Negative
Luminal Cell
Myoepithelial Cell
Stem/Progenitor Cell
Estrogen Receptor Positive
Luminal Cell
Pathology of Precancerous
Changes and DCIS
Normal
Hyperplasia
Atypical Hyperplasia
Types of DCIS
Cribriform
Micropapillary
Solid
Comedo
DCIS versus Invasive Breast Cancer
• Ductal Carcinoma in situ
– Means milk duct cancer “in place”
– Cancer cells fill the milk ducts but do not “invade”
through the wall of the milk duct
– Stage 0 breast cancer
• Invasive Breast Cancer
– Cancer cells invade through the wall of the milk duct
– Can get into lymphatic channels and lymph nodes
– Can get into blood stream and other organs
DCIS Trends Over Time
DCIS is Usually Diagnosed on a
Mammogram
Risk Factors
DCIS
Invasive
Cancer
60 -74
75 – 79
Caucasian
Caucasian
Family History
Yes
Yes
Mammographic Density
Yes
Yes
Obesity
No
Yes
No children
Yes
Yes
Late age at childbirth
Yes
Yes
Hormone replacement
No
Yes
Peak Age
Race
Should I have a Breast MRI After I
am Diagnosed with DCIS?
• About 10% of breast MRIs will prompt
additional imaging or a biopsy (3/4 of
those biopsies will be benign).
• MRI may overestimate the size of the
DCIS leading to more extensive surgery.
• I only order an MRI if the mammogram or
exam make me suspicious that there is
more there than meets the eye.
Should I have a Sentinel Lymph Node
Biopsy as Part of My DCIS Surgery?
• If DCIS was initially diagnosed by core
needle biopsy there is a 15% chance that
there is actually an invasive breast cancer
in the neighborhood.
• If all you have is DCIS there is <1%
chance that the SLN will be positive.
• I don’t do SLN biopsy for pure DCIS if the
patient is having a lumpectomy.
• I do SLN for DCIS if the patient is having a
mastectomy.
What are the Options for Treating
DCIS?
• Breast Conserving Surgery
– Lumpectomy + Radiation
– + Tamoxifen (for ER+ DCIS)
• Mastectomy
What Happens if I decide Not to Get
Treatment for a DCIS?
• 28 Small low grade cases treated by biopsy only
• 24 year median follow-up
Page DL, Cancer 1995;76:1197-200
Breast Conserving Surgery (“Lumpectomy”)
Up oh. Margins are positive for DCIS
Re-excise
It is sometimes difficult to get clear margins
If I Have a Lumpectomy for DCIS do I Have to
Have 6 ½ Weeks of Radiation Treatments?
• Radiation is not as effective against DCIS
as it is against invasive cancer.
• But radiation can cut the recurrence rate in
half.
Some women are appropriately treated with 5 days of focused radiation
DCIS < 2 cm
Age > 50
Not high grade
Negative margins
CyberKnife
Ballon Catheter Radiation
If I Have a Lumpectomy for DCIS can I skip
the Radiation Treatments All Together?
• Van Nuys Prognostic Index
– DCIS size < 1.5 cm
– Negative margin > 1 cm
– Not high grade
– No comedo necrosis
– Age > 61
• OncoTypeDx DCIS Recurrence Score
A New Test for Estimating Recurrence Risk
After Lumpectomy with No Radiation
OncoTypeDX
Score
Any Recurrence Invasive Recurrence
Low Risk
12%
5%
Intermediate Risk
25%
9%
High Risk
27%
19%
In my mind the recurrence risk is too high even with a low score.
I have not used this test.
http://www.genomichealth.com/en-US/OncotypeDX.aspx
Double Mastectomy for DCIS
More and more women with DCIS are choosing to have both breasts removed
- About 5% of all DCIS patients
- About 18% of women who need one mastectomy
Bilateral Nipple-preserving Mastectomy
What is the Risk of Recurrence
after DCIS Treatment?
• After lumpectomy and radiation there is a 10 –
24% chance that DCIS will recur.
– Half of these recurrences are invasive cancer
• After mastectomy the risk of recurrences is 2%
• The chance of dying of breast cancer after DCIS
treatment is <2%
– May be a bit higher for African-American women.
Do Some Women with DCIS Have
a Higher Recurrence Risk?
Factors Associated with Greater Recurrence Risk
•
•
•
•
•
•
Not getting “negative” margins at surgery
Younger age (e.g. <45)
High grade DCIS (very disorganized cells)
Estrogen receptor negative DCIS
Her-2/neu positive DCIS
Larger DCIS
Are there Medications to Prevent DCIS of
Reduce the Recurrence Rate?
• Tamoxifen (for ER positive)
– Reduces DCIS rate by 50% in high risk women
– Reduces recurrence after treatment by 40%
• Raloxifene
– Does not appear to reduce DCIS risk
– No recurrence data; not used
• Aromatase Inhibitors
– Clinical trials being done now
• Herceptin (for Her-2/neu positive)
– Clinical trials being done now
Summary
• DCIS is diagnosed almost exclusively from
mammographic screening.
• Inadequately treated DCIS can become
invasive breast cancer.
• Not every DCIS presents a health threat.
• We can’t tell which ones are not a threat.
• Treating DCIS significantly reduces the
risk for invasive breast cancer.
• The challenge is not to over treat.
Summary for Young Women
• DCIS is very uncommon in young women
• Recurrence rates tend to be higher in
young women.
• A DCIS diagnosis does not impact survival
• Lumpectomy + radiation (+ tamoxifen for
ER positive DCIS) is a treatment option.
• More young women are choosing double
mastectomy.