management of dcis

KWH Experience

Dr. Carmen Ho

Breast cancer as most common cancer in women in Hong Kong

DCIS as precursor of invasive cancer Heterogeneous group with diverse malignant

potential

Incidence of DCIS increased with mammographic screening 3/100,000 to 34/100,000 in 50-69 years old

Steenbergen. Breast Cancer Res Treat.2009.

Best treatment for DCIS remains a controversy

Mastectomy vs. breast conserving treatment + RTRT reduces local recurrence rate

(13.4% vs. 3.9%)NSABP B-17

Similar local recurrence and survivalNSABP B-04

Acceptance of BCT in Chinese (survey)29-49%

Chua et al. Breast J. 2005

BCT rate in HK for breast cancer : 22-30%

Yau et al. Int J Radiat Oncol Biol Phys. 2008

Retrospective study Period : January 2002 – April 2009 Inclusion

Patients diagnosed with DCIS after surgical excision Patients with micro- or invasive features were not

included 212 patients included

Age : 57.2 (37.8 – 87.5)

Median FU : 31.0 months (0.3 - 81.4 months)

Bilateral disease : 22 7 with bilateral disease on presentation

Table 1: Patient Characteristics

Presentation

Mammographic abnormality 130 (62%)

Breast lump 58 (27%)

Nipple discharge 17 (8%)

Nipple abnormality 3 (1%)

Mastalgia 4 (2%)

Average size : 2.02cm (0.1 – 7 cm)

SizeScreen detected group : 1.32cmSymptomatic group : 2.47cm

(P<0.01)

Operation

Mastectomy 80

Mastectomy with immediate reconstruction 28

Breast conserving treatment 104

Wide local excision 27

ROLL 31

Wire guided excision 42

Microdochectomy 4

BCT offered to 175 patients

Unicentric tumor <3cm Appropriate tumor to breast ratioAcceptance of adjuvant radiotherapy

104 patients accepted BCT (59.4%)

75% were screen detected

96.2% (100/104) have adjuvant RT

4 patients with small foci (<0.6cm) and low grade DCIS

1 has IBTR 5 years later as DCIS

32 patients (31.7%) receiving BCT have close margin (<3mm)5 patients underwent re-excision8 required subsequent mastectomy Boost dose of radiotherapy All free of local recurrence

Sentinel LN biopsy was done in 98 patientsPositive sentinel LN noted in 3 patientsAxillary dissection was performed

198 / 212 (93.4%) remained disease free

Screen detected : 95.4% (124/130)

Symptomatic : 90.2% (74/82)

4 patients with BCT have ipsilateral breast tumor recurrence (3.8%)

3 recurred as invasive ductal carcinoma, subsequent mastectomy performed

1 recurred as DCIS with ROLL done

All remained disease free after salvage treatment

1 patient diedPresented with blood stained nipple

dischargeMicrodochectomy performed : DCIS with

involved margin Simple mastectomy performed

DCIS (high grade with comedo necrosis) 6 months after mastectomy, developed

bone metastasis

Emphasize on importance of screening mammogram

Acceptance of BCT + RT as treatment 75% patients receiving BCT were screen detected

69% with clear margin (>3mm)

Positive sentinel LN in 3.0% patients with DCIS

Risk of local recurrence after BCT 3.8% with median FU 31.0 months

Success of salvage treatment after IBTR