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Meeting
Highlights: 2000
Interactive Report
Ductal
Carcinoma In Situ (DCIS)
5.
50-year-old woman with 1.5 centimeter area of microcalcifications
on mammogram very suggestive of DCIS. Your suggested next step in
management:
| Needle
aspiration cytology |
1% |
| Core
biopsy |
9% |
| Abby
biopsy |
2% |
| Mammotome
biopsy |
28%
|
| Excisional
biopsy |
29% |
| Stereotactic
biopsy |
31% |
| Other |
0% |
Patrick
Borgen, MD
If you include
mammotome and stereotactic, it looks like about half of them would
be a stereotactic biopsy, and that's very mainstream. We feel very
strongly about going into the OR with as much information as possible,
and we certainly do a wider excision if we know it's DCIS. So, this
is a very mainstream cross section of what's happening in America.
6.
58-year-old woman with 0.8 centimeter well-differentiated cribriform
DCIS. Margins are one centimeter or more. Your suggested next step
in management:
| Re-excision
|
1% |
| Mastectomy |
5% |
| Mastectomy
plus tamoxifen |
2% |
| Breast
radiation |
15%
|
| Breast
radiation plus tamoxifen |
52%
|
| No further
therapy |
20% |
| Other |
5% |
7.A.
38-year-old woman . . .
7.B. 79-year-old woman . . .
with 0.8 centimeter poorly differentiated comedo DCIS. Margins are
clear, but within one millimeter in some places. Your suggested
next step in management:
| |
A
|
B
|
| Re-excision |
20%
|
48%
|
| Re-excision
plus tamoxifen |
30%
|
2%
|
| Mastectomy
plus tamoxifen |
4%
|
5%
|
| Breast
radiation |
1%
|
5%
|
| Breast
radiation plus tamoxifen |
30%
|
25%
|
| No
further therapy |
0%
|
8%
|
| Other
|
15%
|
7%
|
8.
58-year-old woman with 0.8 centimeter . . .
A. well-differentiated
cribriform DCIS. Margins are clear, but within one millimeter in
some places.
B. poorly
differentiated comedo DCIS. Margins are one centimeter or more.
C. poorly
differentiated comedo DCIS. Margins are clear, but within one millimeter
in some places.
Your
suggested next step in management:
|
|
A
|
B
|
C
|
| Re-excision |
33%
|
2%
|
26%
|
| Re-excision
plus tamoxifen |
27%
|
3%
|
31%
|
| Mastectomy
plus tamoxifen |
2%
|
9%
|
7%
|
| Breast
radiation |
4%
|
10%
|
2%
|
| Breast
radiation plus tamoxifen |
28%
|
73%
|
23%
|
| No
further therapy |
0%
|
2%
|
0%
|
| Other
|
6%
|
1%
|
11%
|
Patrick
Borgen, MD
These case questions
really illustrate the complexity of treating breast cancer. Looking
just at the NSABP B-17 trial, you would conclude that all the patients
in these questions might benefit from radiation. And you couldn't
select which ones would not benefit. Despite that important trial,
there's still a selective approach out there based on the work of
Mel Silverstein and others that influences practice. Margins do
matter and the amount of tissue you take out matters. Comedo versus
non-comedo is also important. The age of the patient is important.
These results are an excellent reflection that there is an important
selectivity to the use of radiation therapy and the use of tamoxifen
in DCIS. This is a very positive trend that we're looking at here,
because it means people are really giving thought to what they're
doing.
9.
58-year-old woman with two lesions on mammogram, which core biopsy
reveals are well-differentiated cribriform DCIS.
A. One
lesion is in the upper outer quadrant, the other in the lower inner
quadrant.
B. Both lesions are in the upper outer quadrant and are two
centimeters apart.
Your
suggested management:
|
|
A
|
B
|
| Excision
of both lesions |
28%
|
60%
|
| Mastectomy |
32%
|
15%
|
| Mastectomy
plus tamoxifen |
34%
|
16%
|
| Breast
radiation |
1%
|
1%
|
| Breast
radiation plus tamoxifen |
2%
|
4%
|
| No
further therapy |
0%
|
0%
|
| Other
|
3%
|
4%
|
Patrick
Borgen, MD
Case A.
The work of Roland Holland and others have taught us that this is
a rare situation. DCIS is predominantly a segmental disease. But
when we do see patients with two independent, unrelated lesions,
we lean those patients heavily towards mastectomy. That is the standard
of care for truly multiple primary, different-quadrant breast cancers
—whether they're invasive or in situ. Certainly I would lean
one towards mastectomy. I certainly wouldn't treat a 58-year-old
with two lesions with excision alone.
We don't know
very muchabout radiation therapy in the face of two primary cancers.
We certainly don't know much about tamoxifen in the face of two
primary cancers. I think that you could be criticized for performing
breast conservation therapy for two primary cancers.
In the 1991
consensus statement, it was clear that multiple primary cancers
were an indication for mastectomy. And I think that applies to DCIS
until we learn otherwise. So, in our practice, there's a very high
likelihood that we would lean towards mastectomy.
Case B.
We've all seen DCIS that spans two to five centimeters and, in the
generous breast, you can encompass that in your lumpectomy. I would
certainly go through the options of attempting to conserve the breast,
maybe by bracketing the calcium in the core biopsy site and then
certainly radiating the patient afterwards. So, in this question,
if the patient is motivated to save the breast, I certainly would
give that a try.
Getting back
to this medical-legal issue, how hard the surgeon fights to save
the breast seems to keep emerging. And one of the things you risk
in a case like this is in reviewing the mastectomy specimen, the
pathologist says, "Gee, you know, there wasn't much DCIS. There
was only five millimeters here and five millimeters there."
So, for this situation, the motivation of the patient drives you
a bit.
10.
78-year-old woman with two lesions on mammogram. Core biopsy reveals
that both are well-differentiated cribriform DCIS. Both lesions
are in the upper outer quadrant and are two centimeters apart. Your
suggested management:
| Re-excision |
77% |
| Mastectomy |
7% |
| Mastectomy
plus tamoxifen |
7% |
| Breast
radiation |
1% |
| Breast
radiation plus tamoxifen |
4% |
| No further
therapy |
0% |
| Other |
4% |
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Ductal Carcinoma in SITU (DCIS)
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