Presentation briefly highlight the key areas of ductal carcinoma insitu and its management

1. Ductal carcinoma in situ
Dr Nadun Danushka
Registrar in surgery
Apeksha Hospital

2. Introduction
• Characterised by proliferation of presumably malignant epithelial cells
with in the mammary ductal system without any evidence of invasion
• DCIS falls between atypical ductal hyperplasia (ADH) and invasive
ductal carcinoma within the spectrum of breast proliferative
abnormalities
• Low and intermediate grade – 16q loss
• High grade – 17q gain

3. Classification
• 2 types – according to comedo necrosis
• Comedo cells – Large pleomorphic nuclei, necrotic material often
calcifiesseen in the mammo
• Non comedo types
• Solid
• Micropapillary
• Papillary
• Cribriform

5. Mammographic features
• Casting-type calcifications
• Soft-tissue opacity either with or without associated calcifications.
• Linear calcifications - comedo-type DCIS
• Corse heterogenous calcifications - non-comedo DCIS.
• In general, the calcification underestimates the distribution of DCIS in
the breast, i.e. not all the DCIS calcifies.

7. Mammography

8. Work up
• Hx &Ex
• Mammography
• Core biopsy
• ER status - to determine potential benefit of endocrine therapies for breast
cancer risk reduction (HER 2 status has not proven to be prognostically
significant in DCIS)
• Genetic counseling for high risk patients for hereditary breast cancer
• MRI breast is optional
• Detects DCIS better than mammogram
• But has not increased negative margins following WLE or decreased "conversion to
mastectomy" rates

9. Role of MRI in DCIS
• Sensitivity of up to 98% for high-grade DCIS
• MRI can overestimate extent of the disease
• If MRI - extensive disease than mammography, those findings should
be verified histologically through MRI-guided biopsy of the more
extensive enhancement
• Conflicting results on MRI reduces re-excision rates and decreases
local recurrence
Remains controversial!

10. Current recommendation…
When additional information is needed during the initial workup,
noting that the use of MRI has NOT been shown to increase likelihood
of negative margins or decrease conversion to mastectomy for DCIS

11. Management
• Generally management based on Van Nuys Prognostic index
• Age (>60, 40-60, 40mm)
• Tumour grade and calcification (non high grade without calcification, non high
grade with calcification, high grade with or without calcification)
• Tumour size (<15mm, 16-40mm, >40mm)
• Resection margin (>10mm, 1-9mm, <1mm)
Usual guideline was
• If score 4,5,6 - WLE only
• If score 7,8,9 - WLE + RT
• If score 10, 11, 12 - Mastectomy +/- Reconstruction

12. Management
• BCS (No Ink on tumour, 2mm)
• Mastectomy
• ALND – NO place
• SLNB –
• Hardly any pure DCIS
• Anatomical location in BCS compromise future SLNB
• Local treatment does not impact overall disease-related survival; therefore,
the individual’s preferences for risk-reduction must be considered.
• DCIS-M (invasive focus ≤1 mm in size) – 2mm

13. Adjuvant options
• WBRT +/- booster
• Accelerated partial breast irradiation (APBI)
• 1–2 cm margin around the cavity.
• Principle - most recurrences occur near the initial tumor location.
• Minimizes exposure to the remainder of the breast, lungs, heart, ribs, and
musculature of the chest and shoulder.
• Indications
• screen-detected DCIS
• low to intermediate nuclear grade
• tumor size ≤2.5 cm
• surgical resection with margins negative at >3 mm

14. • No RT – low risk, ER+, receiving endocrine therapy
• High risk:
• palpable mass
• larger size
• higher grade
• close or involved margins
• age <50yrs

15. Evidences

16. 1. BCS plus WBRT with or without boost
• RCTs - WBRT following BCS reduces recurrence rates in DCIS by about
50% to 70% irrespective of margin width, the risk of recurrence is
substantially higher without WBRT even for predefined low-risk
subsets of DCIS patients
• However OS and breast cancer specific survival were similar
• Population based studies
• significant improvement in OS in high risk DCIS (higher nuclear grade, younger
age, larger tumor size)
• SEER - significant reduction in breast cancer mortality with BCS and WBRT
compared with BCS alone

17. RT boost
• The use of RT boost was associated with significantly decreased IBTR
in all age groups (younger patients, more benefit)
• With factors associated with lower IBTR
• Grade
• ER positive status
• use of adjuvant tamoxifen
• margin status
• age
**the benefit of RT boost still remained statistically significant
• The cosmetic status was impacted negatively with the boost versus no
boost

18. 2. BCS alone
• Very low recurrence rate even without RT in low risk individuals
• Stratification of low risk of recurrence modified Van Nuys Prognostic Index based
on tumor grade, size, absence of comedo necrosis, margin width, and age at
diagnosis
• RTOG 9804 trial
• RT omission in the setting of low-risk DCIS
• Significant reduction in local recurrence
• DFS or OS is equal
Low risk
• Low to intermediate-grade DCIS
• measuring less than 2.5 cm
• negative margins of greater than or equal to 3 mm.

19. Accepted margin DCIS
• NO INK ON THE TUMOUR accepted as the negative margin
• At least having a 2mm margin has shown to reduce recurrence in BCS + RT
group
• Margin for WLE alone group is not well established. No randomized trials.
• In a retrospective study the margin width was the most important independent
predictor of local recurrence
• Decreasing local recurrence risk with increasing margin width was most apparent
with margins less than 1 mm compared to greater than or equal to 10 mm
• Margin of 2mm or more is preferred
• If accepted margin is not there → re-excision → if comes positive again →
may require mastectomy

20. 3. BCS plus APBI
• RTOG 9804 Low risk
• ASTRO “suitable” DCIS for ABPI
• screen-detected DCIS
• measuring less than 2.5 cm
• grade I or II disease
• negative margins of 3 mm or more
• Four RCT showed non-inferior in local control compared with WBRT,
with similar toxicity and breast cosmetic outcomes

21. Risk reduction
• Risk reduction therapy for ipsilateral breast following breast conserving surgery
(BCS):
• Consider endocrine therapy for 5 years for patients with ER-positive DCIS, if:
• Treated with BCS and RT (category 1)
• Treated with excision alone (Category 2A)
• The benefit of endocrine therapy for ER-negative DCIS is not known
• Endocrine therapy:
• Tamoxifen for premenopausal patients
• Tamoxifen or aromatase inhibitor for postmenopausal patients with some advantage for
aromatase inhibitor therapy in patients <60 years or with concerns for thromboembolism
• Standard dose of tamoxifen - 20mg/day
• Low-dose tamoxifen (5 mg/day for 3 years) is an option only if patient is symptomatic on the
20-mg dose or if patient is unwilling or unable to take standard-dose tamoxifen

22. Risk reduction
• Risk reduction in contralateral breast
• Available data suggest endocrine therapy provides risk reduction in
contralateral breast in patients with mastectomy or breast conservation with
ER-positive primary tumors. Since a survival advantage has not been
demonstrated, individual consideration of risks and benefits is important
• Counseling regarding risk reduction options
• Risk reduction agents
• Risk reduction surgery
• Life style modifications

23. Follow up
• H&E 6-12 months for 5 years → then annually
• Annual mammogram
• For WLE + RT group → 1st mammogram in between 6-12 months after surgery
• Monitor patients started on endocrine therapy
• ◦ Tamoxifen
• Endometrial cancer risk → gynecological screening
• If PV bleeding → prompt evaluation for endometrial cancer if uterus intact
• If cancer diagnosed → stop the drug → hysterectomy → recommence after hysterectomy
• If no cancer → continue
• Cataract and retinopathy risk → Ophthalmology screening if cataract or vision problems
• Thromboembolism risk → DVT/PE/CVA features or prolonged immobilization → stop tamoxifen
• Hot flashes and other perimenopausal symptoms → symptomatic treatment → continue drug
• Anastrozole (AI)
• Arthralgia → symptomatic treatment → continue the dru

24. Thank you!