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1. Early Breast Cancer + DCIS
Management
Dr.B.Srinivas Reddy

3. Management
is based on:
• Clinical extent – stage
• Nodal status
• Pathological characteristic of tumor
• Receptor status
• Age of the patient (Menopausal status)
• Individual patient preference

4. Treatment
options
• Loco-regional therapy
(primary/ axilla)
- Surgery
- Radiotherapy
• Systemic therapy
- chemotherapy
- Hormonal therapy
- Targeted therapy

6. Surgery
•Primary tumor
•Axilla

7. Management
of primary
tumor
•Two basic procedures:
•Complete local excision
(CLE)
•Mastectomy

8. Breast
Conserving
Surgery
• The aim of treatment is to maximize disease
control and decrease the impact of breast
cancer on the quality of life
• Breast conserving surgery demands CLE ,
which by definition means clear histological
margins with a rim of normal breast tissue
around the periphery of primary tumor on all
sides.
• Includes lumpectomy and quadrantectomy.

10. Contraindications to BCS
• Radiation therapy during
pregnancy (1st trimester)
• Widespread disease
• Diffuse suspicious
microcalcifications
• Extensive intraductal carcinoma
Absolute:

11. Relative contraindications:
Tumor size >5cm .
Recurrence in a previously conserved breast
Focally positive margins in the absence of EIC.
H/O previous irradiation to chest
Germline mutations that predispose to breast cancer development
Active collagen vascular disease (scleroderma)

12. Mastectomy
Total or Simple mastectomy
:Breast without nodal dissection
Modified Radical Mastectomy:
Breast + ALND
Radical Mastectomy : Breast +
pectoralis major + ALND
Extended radical mastectomy :
Breast + pectoralis major + ALND
+ IMC dissection
Skin sparing mastectomy : Total
or MRM with preservation of
significant component of native
skin of breast to optimize the
aesthetic result of immediate
reconstruction.

13. Indications of Mastectomy
Multicentric disease
( > 1 quadrant / 2 or
more foci > 4cms
apart)
Diffusely positive
margins not cleared
with re-excision
Prior radiation
therapy to the
breast
Active collage
vascular disease ,
particulary
scleroderma
Widespread
indeterminate
micro-calcifications
within the breast
Patient choice

14. Management of the Axilla
Aims
Assessment of nodal
status
• For evaluation of prognosis
• To determine adjuvant
therapy
Eradication of
metastatic disease
within the axillary
nodes
Includes
Sentinel lymph node
biopsy(SLNB)
Axillary Lymph node
dissection

18. Pathological specimen
Laterality of the
breast and
procedure
Histological grade Histological type
Margins of
resection
Size of tumor
Presence and
extent of in-situ
carcinoma (DCIS)
Microcalifications
Lymph node status
(number positive
/harvested - size of
positive nodes)
Pericapsular breach
/Extranodal
extension
Hormone Receptor
status (ER/PR/
Her2neu)

19. Radiotherapy
After BCS
After Mastectomy

20. RT Doses
Conventional fractionation:
• - 45 to 50Gy/25# @1.8 Gy/# , 5 fractions per week.
Hypofractionation:
• -40 to 42.5 Gy/15 to 16# @2.66 Gy/#, 5 fractions per week.
Tumor bed boost:10-16 Gy @ 2 Gy/#

21. Indications of RT to axilla
Any node positive
Any node with extra-capsular extension
Sentinel lymph node positive with no axillary dissection
Inadequate axillary dissection

22. Adjuvant
Systemic
therapy
Chemotherapy
Hormonal Therapy
Targeted Therapy

23. Chemotherapy
Nearly all patients with EBC
require chemotherapy
Standard of care regimens include
an anthracycline (unless contra-
indicates) with or without taxane.
Her2 directed therapy is
recommended for all patients with
her2+ve disease

24. Chemotherapy regimens
• Dose dense AC  Weekly / 2 weekly paclitaxel
• Docetaxel + cyclophosphamide
• AC  Docetaxel / TAC (every three weeks)
• If residual disease (in TNBC) after NACT with Taxane + anthracycline
+alkylating agent :adjuvant capecitabine
Preferred for
Her2 –ve:
• AC  TH
• TCH (docetaxel +carboplatin + trastuzumab)
• If any residual disease after Neoadjuvant therapy with above : adjuvant
Ado – trastuzumab emtansine (T-DM1) x 1 year
Preferred for
Her2 +ve:

25. Hormonal
Therapy
Medical:GnRH agonists (Leuprolide , Goserilin)
SERM: Tamoxifen , Tormemifene , Raloxifene
AI : Exemestane , letrozole , Anastrazole
Pure estrogen receptor antagonists: Fulvestrant
Ovarian Ablation
Surgical : oopherectomy
Radiotherapy

26. Endocrine/hormonal therapy
All patients with ER/PR +ve disease should receive adjuvant hormonal therapy
• Post – Menopausal : AI
Duration : 5 years minimum ; strong consideration should be given to
completing 10 years
For high risk premenopausal patients (i.e N+ve , Her2+ve , age <40 years, large
high grade tumors) , to consider adding ovarian suppression to AI/Tamoxifen

27. Toxicity of Tamoxifen and AI
Tamoxifen
•Vaginal complications
•Endometrial cancer
•Thromboembolic
events
Aromatase Inhibitors
•Cardiac complications
•Arthralgia/myalgia
•Osteoporotic fractures
•Hot flushes

28. Targeted therapy
Her2 : Trastuzumab ,
Pertuzumab , Ado-
trastuzumab emtansine
(T-DM1) , lapatinib
CDKi : Palbociclib ,
Ribociclib , Abemaciclib
Anti Her2 therapy
generally incorporated
with neoadjuvant or
adjuvant systemic
therapy for 1 year.

29. Carcinoma in situ: Management
CIS of the breast (stage 0 ) includes
-Lobular carcinoma insitu (LCIS) - Ductal carcinoma in situ(DCIS)
CIS represents non-invasive cancer defined by confinement of
malignant cells within basement membrane

30. Management :DCIS
Surgery:BCS / mastectomy
Radiotherapy
Hormonal therapy

31. Breast
conservation
for DCIS
• BCS is the standard of care for all patients
shown to have DCIS
• 2mm margin is adequate ; however wider
margins should be considered for patients at
a higher risk of recurrence (eg –
comedonecrosis , high grade DCIS, young
age , ER/Pr –ve)
• For all patients , adjuvant RT reduced the
rates of ipsilateral breast tumor recurrence
(IBTR) ,but has no impact on survival.

32. Lymph node
dissection in
DCIS
• ALND and SLN mapping not routinely warranted
• 3-13% of patients with DCIS have isolated tumor cells in sentinel axillary
lymph nodes
• Sentinel lymph node mapping may be used in selected patients with a
hgher likelihood of occult invasive cancer
• Extensive disease
• High – grade DCIS
• Palpable masses
• Recurrent disease
• Receptor negative

33. RT in DCIS
Indication : after
BCS
Benefit more in
Young women
High grade and
comedonecrotic
DCIS

34. Lobular
carcinoma in
situ
Comprise 15% of in-situ disease
Risk of development of invasive
cancer is 20-25% when followed
over a duration of 15 years
Risk appears to be nearly equal
for both breasts

35. Management
of LCIS : sole
histologic
diagnosis
Role of surgery
Local excision and
subsequent
surveillance
Mastectomy
Bilateral prophylactic
mastectomy in high
risk:
Young age
Diffuse high-grade
lesion
Significant family
history
BRCA1/2 mutation

36. Follow-Up
CBC and baseline mammogram
6 to 12 months after initial
therapy and atleast annually
thereafter (ASCO guidelines)
If treated with endocrine
therapy , monitor for
endometrial pathology and
other known adverse effects

37. Thank You