1. Ductal Carcinoma In Situ (Stage 0 Breast Cancer)Robert Miller MD www.aboutcancer.com

2. 20% of breast cancers in the US are stage 0 or noninvasive (ducal carcinoma in situ DCIS or lobular carcinoma in situ LCIS) 3. Age Distribution For In Situ versus Invasive NCDB Data 30 25 20 15In Situ Invasive10 50 304050607080 4. Observed 5 Year Survival Breast Cancer 2003-2006 NCDB 100 90 80 7060 50 40 30 20 100 Stage 0Stage IStage IIStage III Stage IV 5. What You Need to Know About Breast Cancer Before Deciding on Treatment Understand the basic anatomy (lobules, ducts and lymph nodes) Biopsy or pathology report tell you about the biology (how aggressive) of the cancer Breast imaging studies (mammograms or ultrasound) CT, MRI, PET Stage (particularly lymph node status) 6. Earliest form of cancer is often DCIS (ductal carcinoma in situ) then it progresses to invasive ductal carcinoma 7. ductal cellsductal carcinoma In situ (DCIS)Invasive ductal carcinoma 8. Normal duct cells inside a milk duct 9. Basement MembraneDCISCancer cells are confined within the milk duct basement membrane so still in situ or non-invasiveNormal Duct cellsCancer Cells 10. Basement MembraneInvasive CancerOnce the cells have invaded through the basement membrane and outside the duct it is called invasive or infiltratingNormal Duct cellsCancer Cells 11. Pathology View of Ductal Carcinoma In Situ 12. Lymph Nodes supraclavicularInternal mammaryaxillaryDCIS should not spread to the lymph nodes unless there is some invasion (may be focal micro-invasion) but 10 to 20 percent of lesions interpreted as DCIS on a core biopsy are upgraded to invasive cancer after excision 13. DCIS Ductal Carcinoma In SituDCISWall of the duct 14. Understanding a Pathology Report1. Invasive or Not (DCIS, LCIS) 2. Histology: what type of cancer3. Grade: fast or slow growing 4. Hormone Receptors: is it sensitive to estrogen or progesterone5. HER2 (human epidermal growth factor receptor 2) a genetic mutation 15. ImagingThe cells often die in place (necrosis) and then calcify. The radiologist is looking for abnormal areas of calcification 16. Mammograms often show areas of calcification, which can be benign or malignantNinety percent of women with DCIS have microcalcifications on mammography and DCIS accounts for 80 percent of all breast cancers presenting with calcifications 17. Mammograms In ductal carcinoma in situ (DCIS), there is normally no mass but just an area of calcification (very small areas called microcalcifications) 18. Microcalcifications can be very subtleBiopsy of this area showed 8mm DCIS 19. Biopsy = DCIS with focal micro-invasion 20. fat glandLarger area of microcalcifications may have invasive cancerPath = 2.9 cm area of high grade DCIS plus invasive ductal cancer 21. Looking for advice on treatment decisions for ductal carcinoma in situ of the breast 22. Treatment Decisions with DCIS 1. Surgery: total mastectomy versus conservation (lumpectomy) and ? nodes 2. Adjuvant Therapy: hormone therapy or as preventative strategy 3. Radiation: whole breast or can it be skipped 23. Treatment DecisionsThe woman should be assisted by a multidisciplinary team, including a surgeon, possibly a plastic surgeon, medical oncologist and a radiation oncologist 24. NCCN.org 25. Complete axillary lymph node resection should not be performed in the absence of evidence of invasive cancer or proven metastatic disease in women apparent pure DCIS. However, a small proportion of patients with apparent pure DCIS will be found to have invasive cancer at the time of their definitive surgical procedure. Therefore, the performance of a sentinel lymph node procedure should be strongly considered if the patient with apparent pure DCIS is to be treated with mastectomy or with excision in an anatomic location compromising the performance of a future sentinel node procedure. 26. Deciding on SurgeryLumpectomyTotal MastectomyThe risk of cancer-related death in women with DCIS is low, estimated at 1.9 percent within 10 years.Mastectomy is curative for over 98 percent of patients with DCIS. Disease recurrence is rare after mastectomy (1 to 2 percent) 27. Breast Conservation Lumpectomy (remove the cancer with a small rim of normal tissue, clear margins)Sentinel node biopsy occasionally will be performed at the same time 28. At the time of the lumpectomy the surgeon tries to remove the cancer with a margin of normal breast tissue around the massX-ray image of the lumpectomy specimen 29. Deciding on Radiation 30. Long-term outcomes of invasive ipsilateral breast tumor recurrences after lumpectomy in NSABP B-17 and B-24 randomized clinical trials for DCIS.Local Relapse in the Breast Over 15 Year Follow Up Lumpectomy Alone 19.4% Lump + Radiation 8.9 10% Lump + Radiation + Tamoxifen 7.3%Survival was the same in all groups Natl Cancer Inst. 2011;103(6):478. 31. Breast-Conserving Treatment With or Without Radiotherapy in Ductal Carcinoma In Situ: 15-Year Recurrence Rates and Outcome After a Recurrence, From the EORTC 10853 Randomized Phase III TrialJCO. 2013.49.5077 32. Fifteen-year results of breast-conserving surgery and definitive breast irradiation for the treatment of ductal carcinoma in situ of the breast. Cause specific survivalOver all survivalYears JCO Mar 1, 1996:754-63 33. Whole breast radiation following lumpectomy reduces the recurrence rates in DCIS by about 50%. Approximately half the recurrences are invasive and half are still DCIS. A number of factors determine the local recurrence risk: palpable mass, large size, higher grade, close or involved margins, and age < 50y. If the patient and physician view the individual risk as low some patients may be treated with excision alone. All data evaluating the three local treatments (lumpectomy alone, lumpectomy plus radiation or total mastectomy) show no difference in patient survival. 34. Van Nuys Index for Treatment of DCIS Score#1#2#3PathOtherComedoSize40mmMargins>10mm1-9mm< 1mmScore 3 4 : Lumpectomy alone (local control is 100% vs 97%) Score 5 7: Lumpectomy + Radiation (local control from 68% up to 85%) Score 8-9: Mastectomy Cancer 1996 Jun 1;77(11):2267-74 35. Van Nuys Index for Treatment of DCIS Score#1#2#3PathOtherComedoSize40mmMargins>10mm1-9mm< 1mmScore 3 4 : Lumpectomy alone (local control is 100% vs 97%) Score 5 7: Lumpectomy + Radiation (local control from 68% up to 85%) Score 8-9: Mastectomy Cancer 1996 Jun 1;77(11):2267-74 36. Updated Van Nuys Prognostic Index Parameter1 Point2 Points3 PointsSize40mmGrade1/II1/II NecrosisIIIMargin10mm1-9mm6040-60