Ductal Carcinoma in situ

David M. Euhus, MD, FACSProfessor of Surgery

Director, Clinical Cancer GeneticsUT Southwestern Medical Center at Dallas

Ductal and Lobular Anatomy of the Breast

Estrogen Receptor PositiveLuminal Cell

Estrogen Receptor NegativeLuminal Cell

Myoepithelial Cell

Stem/Progenitor Cell

Estrogen Receptor PositiveLuminal Cell

Estrogen Receptor NegativeLuminal Cell

Myoepithelial Cell

Stem/Progenitor Cell

Pathology of Precancerous Changes and DCIS

Cribriform Micropapillary Solid Comedo

Normal Hyperplasia Atypical Hyperplasia

Types of DCIS

DCIS versus Invasive Breast Cancer

• Ductal Carcinoma in situ– Means milk duct cancer “in place”– Cancer cells fill the milk ducts but do not “invade”

through the wall of the milk duct– Stage 0 breast cancer

• Invasive Breast Cancer– Cancer cells invade through the wall of the milk duct– Can get into lymphatic channels and lymph nodes– Can get into blood stream and other organs

DCIS Trends Over Time

DCIS is Usually Diagnosed on a Mammogram

Risk Factors

DCIS Invasive Cancer

Peak Age 60 -74 75 – 79

Race Caucasian Caucasian

Family History Yes Yes

Mammographic Density Yes Yes

Obesity No Yes

No children Yes Yes

Late age at childbirth Yes Yes

Hormone replacement No Yes

Should I have a Breast MRI After I am Diagnosed with DCIS?

• About 10% of breast MRIs will prompt additional imaging or a biopsy (3/4 of those biopsies will be benign).

• MRI may overestimate the size of the DCIS leading to more extensive surgery.

• I only order an MRI if the mammogram or exam make me suspicious that there is more there than meets the eye.

Should I have a Sentinel Lymph Node Biopsy as Part of My DCIS Surgery?

• If DCIS was initially diagnosed by core needle biopsy there is a 15% chance that there is actually an invasive breast cancer in the neighborhood.

• If all you have is DCIS there is <1% chance that the SLN will be positive.

• I don’t do SLN biopsy for pure DCIS if the patient is having a lumpectomy.

• I do SLN for DCIS if the patient is having a mastectomy.

What are the Options for Treating DCIS?

• Breast Conserving Surgery– Lumpectomy + Radiation– + Tamoxifen (for ER+ DCIS)

• Mastectomy

What Happens if I decide Not to Get Treatment for a DCIS?

• 28 Small low grade cases treated by biopsy only

• 24 year median follow-up

Page DL, Cancer 1995;76:1197-200

Breast Conserving Surgery (“Lumpectomy”)

Up oh. Margins are positive for DCIS

Re-excise

It is sometimes difficult to get clear margins

If I Have a Lumpectomy for DCIS do I Have to Have 6 ½ Weeks of Radiation Treatments?

• Radiation is not as effective against DCIS as it is against invasive cancer.

• But radiation can cut the recurrence rate in half.

CyberKnife Ballon Catheter Radiation

Some women are appropriately treated with 5 days of focused radiation

DCIS < 2 cmAge > 50Not high gradeNegative margins

If I Have a Lumpectomy for DCIS can I skip the Radiation Treatments All Together?

• Van Nuys Prognostic Index– DCIS size < 1.5 cm– Negative margin > 1 cm– Not high grade– No comedo necrosis– Age > 61

• OncoTypeDx DCIS Recurrence Score

A New Test for Estimating Recurrence Risk After Lumpectomy with No Radiation

OncoTypeDX

http://www.genomichealth.com/en-US/OncotypeDX.aspx

Score Any Recurrence Invasive Recurrence

Low Risk 12% 5%

Intermediate Risk 25% 9%

High Risk 27% 19%

In my mind the recurrence risk is too high even with a low score.I have not used this test.

Double Mastectomy for DCIS

More and more women with DCIS are choosing to have both breasts removed- About 5% of all DCIS patients- About 18% of women who need one mastectomy

Bilateral Nipple-preserving Mastectomy

What is the Risk of Recurrence after DCIS Treatment?

• After lumpectomy and radiation there is a 10 – 24% chance that DCIS will recur.– Half of these recurrences are invasive cancer

• After mastectomy the risk of recurrences is 2%• The chance of dying of breast cancer after DCIS

treatment is <2%– May be a bit higher for African-American women.

Do Some Women with DCIS Have a Higher Recurrence Risk?

Factors Associated with Greater Recurrence Risk

• Not getting “negative” margins at surgery

• Younger age (e.g. <45)

• High grade DCIS (very disorganized cells)

• Estrogen receptor negative DCIS

• Her-2/neu positive DCIS

• Larger DCIS

Are there Medications to Prevent DCIS of Reduce the Recurrence Rate?

• Tamoxifen (for ER positive)– Reduces DCIS rate by 50% in high risk women– Reduces recurrence after treatment by 40%

• Raloxifene– Does not appear to reduce DCIS risk– No recurrence data; not used

• Aromatase Inhibitors – Clinical trials being done now

• Herceptin (for Her-2/neu positive)– Clinical trials being done now

Summary

• DCIS is diagnosed almost exclusively from mammographic screening.

• Inadequately treated DCIS can become invasive breast cancer.

• Not every DCIS presents a health threat.• We can’t tell which ones are not a threat.• Treating DCIS significantly reduces the

risk for invasive breast cancer.• The challenge is not to over treat.

Summary for Young Women

• DCIS is very uncommon in young women

• Recurrence rates tend to be higher in young women.

• A DCIS diagnosis does not impact survival

• Lumpectomy + radiation (+ tamoxifen for ER positive DCIS) is a treatment option.

• More young women are choosing double mastectomy.