management of dcis fei-fei liu radiation oncologist/senior scientist
TRANSCRIPT
Management of Management of DCISDCIS
Fei-Fei LiuFei-Fei LiuRadiation Oncologist/Senior ScientistRadiation Oncologist/Senior Scientist
Learning Objectives
1. Describe DCIS.2. Acquire familiarity of local
management for DCIS.3. Understand the role of systemic
treatment for DCIS.4. Appreciate some of the emerging
issues.5. Like radiation oncologists.
DCIS
Definition
Proliferation of malignant ductal epithelial cells which have not breached the BM.
DCIS
• Rising incidence due to screening
• 15-20% of all newly-diagnosed breast tumours– 90% of DCIS are
mammographically detected
DCIS
Diagnosis
• Mostly made on mammography
• Role of mri – – Might be more sensitive, but lacks
specificity– useful to r/o multiple lesions
DCIS
Classifications
Very complex; no single accepted system.
Tissue processing protocolis complex; hence notgeneralizable.
Learning Objectives
1. Describe DCIS.2. Acquire familiarity of local
management for DCIS.3. Understand the role of systemic
treatment for DCIS.4. Appreciate some of the emerging
issues.5. Like radiation oncologists.
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
Four RCT of Lump + RT for DCIS
UKCCRC; Lancet 362:95, 2003
Why Does Controversy Persist?
RCTs demonstrate benefit to RT in all subgroups but:
– margin width was not measured– tumour sizes missing
Identification of a LOW RISK Group
Van Nuys data
Margin WidthNo RT RT RR> 10 mm .03 .02 1.14
1 to <10 mm .20 .12 1.49< 1 mm .58 .30 2.54
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
RT Is No Longer Given As Such
Modern Day Breast RT
• Tangential parallel pair
• Intensity Modulated Radiation Therapy (IMRT)
• Achieve optimal dose homogeneity in target volume (breast)
CT-Simulation
• Diagnostic CT unit with rapid spiral acquisition
• Full 3D dataset• Virtual simulation
software
CT Based Simulation & Planning
Standard Breast Tangents
115%
110%
105%
100%
95%
90%
Goal: Dose UniformityWedges IMRT
Pignol et al, JCO 26:2085, 2008
Improved Acute Skin Reaction with IMRT
Doses of RT
1. 4240 cGy/16#/3.5 wks+ boost (10 Gy/5#s)
2. 5000 cGy/25#/5 wks+ boost (10 Gy/5#s)
Quiz #1
Which famous personality had DCIS?
1. Melissa Etheridge2. Liona Boyd 3. Belinda Stronach4. Michael Jackson
Learning Objectives
1. Describe DCIS.2. Acquire familiarity of local
management for DCIS.3. Understand the role of systemic
treatment for DCIS.4. Appreciate some of the emerging
issues.5. Like radiation oncologists.
Tamoxifen in the Management
of DCIS
The Role of Tamoxifen in the Management of DCIS: NSABP B-
24
• N = 1804• Local excision + RT
Placebo TamoxifenP
All Breast Cancer 13.4% 8.2% 0.0009
Ipsilateral BCInvasive 4.2% 2.1% 0.03Non-invasive 5.1% 3.9% 0.43
Contralateral BC3.4% 2.0% 0.01
UKDCIS Trial: Effect of Tamoxifen
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
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
NSABP B-24: Toxicity
3000 women; opened Jan 03
IBIS TrialTam vs. Anastrozole
4000 ER+ve DCIS post-menowomen
Quiz #
What is the IMRT acronym?
1. Intermittent Moderate RT2. Infinite Modulated RT3. Incredibly Modern RT4. Intensity Modulated RT
Learning Objectives
1. Describe DCIS.2. Acquire familiarity of local
management for DCIS.3. Understand the role of systemic
treatment for DCIS.4. Appreciate some of the emerging
issues.5. Like radiation oncologists.
Kuere et al; JCO 27:279, 2009
Take-Home Points
1. DCIS accounts for ~20% of newly-diagnosed BC
2. Surgery (mostly lumpectomy)
3. RT reduces the risk of local recurrence
4. There may a subset of women with DCIS that do not benefit from RT
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.
Any Questions?