Noninvasive Breast Cancer Overview

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Noninvasive Breast CancerOverview

• Vic V. Vernenkar, D.O.
• St. Barnabas Hospital
• Department of Surgery
• 2003

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Noninvasive Breast Cancer

• DCIS and LCIS
• DCIS proliferation of epithelial cells confined
  to mammary ducts.
• LCIS confined to the lobules with no invasion of
  BM.
• No risk of metastases.

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DCIS

• DCIS increased threefold with mammography 10-20
  per 100,000.
• 20-44 of all new screen detected neoplasms.
• Age 47-63 years.
• Frequency of family history of breast cancer
  among 1st degree relatives same as invasive
  10-35.

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Pathology of DCIS

• From ductal epithelium.
• Heterogeneous group of lesions with variable
  histologic characteristics.
• Malignant cells proliferate and obstruct the
  duct.
• Five subtypes comedo, solid, cribiform,
  micropapillary, and papillary.

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DCIS
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Pathology of DCIS

• Cribiform, comedo, and micropapillary are the
  most common.
• Van Nuys classification to identify prognostic
  features nuclear grade plus comedo.
• 1- non-high-grade DCIS without comedo.
• 2- non-high-grade DCIS with comedo.
• 3- high grade DCIS with or without comedo.

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Pathology of DCIS

• Group I had 3.8 recurrence after BCS.
• Group II had 11.1 recurrence after BCS.
• Group III had 26.5 recurrence after BCS.
• 8 year disease free survival rates were 93 for
  group I, 84 group II, and 61 in group III.

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Multifocality and Multicentricity

• Multifocality is defined as two or more foci
  separated by 5mm in the same quadrant.
• Multicentricity is defined as DCIS having a
  separate focus outside the index quadrant. It
  varies from 18-60.
• Approximately 96 of recurrences after treatment
  occur in same quadrant, implicating residual
  disease.

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Diagnosis of DCIS

• In past, patients showed up with palpable
  lesions.
• Now most are diagnosed with mammography alone.
• Microcalcifications on mammography.
• DCIS account for 80 of all carcinomas presenting
  as calcifications.

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DCIS Mammography
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DCIS Histology
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Diagnosis of DCIS

• Diagnostic biopsy using steriotactic or vacuum
  assisted is preferred method.
• Limited by breast size, weight, proximity to
  chest wall, bleeding disorders, anticoagulation.
• Always leave a metallic marker for later
  localization
• If positive, needs excisional biopsy to look for
  cancer associated (20 DCIS, 50 ADH, 20).

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The Mammotome
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Stereotactic Biopsy
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Steps During Stereotactic Biopsy
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How Looks on Mammography
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Diagnosis of DCIS

• If cannot get steriotactic, get needle localized
  excisional biopsy.
• Margins are controversial but 1cm more than
  enough.
• Specimen radiography to make sure all
  calcifications are in specimen.
• Clip the cavity, reexcision may be necessary.

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Treatment of DCIS

• Mastectomy or BCS
• Post operative radiation to improve local
  control.
• Postoperative tamoxifen.

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Treatment of DCIS

• The rationale for doing total mastectomy was
  multicentricity and multifocality.
• Choice of therapy based on tumor size, grade,
  micro invasion, margin width, patient preference.
• Most patients are eligible for BCS.
• Mastectomy is indicated for diffuse malignant
  appearing calcifications, positive margins
  (persistent), larger than 3cm, high grade.

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Axillary Node Staging

• DCIS is not invasive so lymph node involvement
  not expected, thus theoretically the role for
  axillary lymph node dissection is limited.
• May do it for patients you do mastectomy for high
  grade lesions, and BCS for high grade lesions.
• SLN positive in 6,10, 12 of high risk pts.

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Radiation for DCIS

• Most get it for local control, its efficacy
  demonstrated in NSABP B-17 trial.
• Radiation reduced incidence of noninvasive tumor
  recurrence from 13 to 8, invasive tumors by 13
  to 4, follow up 8 years.
• At MD Anderson, lesions less than 1cm, low grade,
  margins at least 5mm, got no radiation.

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Hormonal Therapy for DCIS

• Decision to use is individualized
• Vasomotor symptoms, DVT, PE, cataracts,
  endometrial cancer 7 times more, stroke, ovarian
  cysts.
• Decrease rates of recurrence.
• Also benefited patients with positive margins.

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Survival in DCIS

• At 8 years it is 97 overall.
• Local recurrence is 25 with BCS only.
• Local recurrence is 13 with added radiation.
• 4 with mastectomy.
• 50 have invasive tumor with recurrence.

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Surveillance in DCIS

• Postoperative mammogram to make sure no residual
  calcifications.
• 4-6 month post radiation mammogram to establish
  baseline.
• Twice yearly physical exam, annual mammogram for
  first 5 years.

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LCIS

• First described in 1941, during the era that
  followed, mastectomy was used for treatment.
• 17 incidence of invasive cancer if left alone,
  equal in both breasts.
• LCIS is not a cancer , it is a marker for
  increased risk of cancer in both breasts.

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Epidemiology of LCIS

• Diagnosis is made following a purely incidental
  finding, so incidence is difficult to estimate.
• Not detected by palpation or gross pathology, or
  mammography.
• Premenopausal women, 45-50 years of age.
• Estrogens important as postmenopausal regression
  is seen, and its not seen often in elderly.

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Epidemiology of LCIS

• Once diagnosis made, 0-6 chance of synchronous
  invasive breast lesion.
• Most are ductal carcinomas (60-70), therefore it
  seems LCIS does not turn into invasive cancer,
  otherwise it would turn into a lobular cancer.

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Pathology of LCIS

• The diagnosis of LCIS involves the
  differentiation of LCIS from other forms of
  benign disease and from invasive lesions.
• In the absence of total replacement of the
  lobular unit, its called atypical lobular
  hyperplasia.
• Papillomatosis may resemble it, but acinii not
  involved.
• LCIS stays within BM, so its differentiated from
  invasive cancer.

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LCIS
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Pathology of LCIS

• LCIS is multifocal and multicentric.
• If diligently looked for, it is found elsewhere
  in the breast in almost all cases.
• In contralateral breast in 50-90 of cases.

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Diagnosis of LCIS

• Not detected on physical exam or mammography.
• Found on breast biopsy specimen, so clinical
  picture is same as patients that present for
  fibroadenoma, benign ductal disease, DCIS, and
  invasive cancer.
• Remember, if its part of a stereotactic specimen,
  you need to do excisional biopsy.

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Treatment of LCIS

• Close clinical observation
• No data suggesting need for re-excision to
  achieve negative margins.
• Further studies regarding possible subtypes of
  LCIS that may benefit from re-excision needs
  study.
• Mirror image excision not done anymore.

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Treatment of LCIS

• A second option is chemoprevention with
  tamoxifen.
• In NSABP trial P-1, the incidence of breast
  cancer in LCIS who received tamoxifen was 56
  lower than those who were observed alone.
• A third option is bilateral mastectomy, no lymph
  node excision required.