slide1
Download
Skip this Video
Download Presentation
Monica Morrow MD Chief, Breast Surgery Service Anne Burnett Windfohr Chair of Clinical Oncology Memorial Sloan-Kettering Cancer Center

Loading in 2 Seconds...

play fullscreen
1 / 37

Monica Morrow MD Chief, Breast Surgery Service Anne Burnett Windfohr Chair of Clinical Oncology Memorial Sloan-Kettering - PowerPoint PPT Presentation


  • 247 Views
  • Uploaded on

18 th Annual Perspectives in Breast Cancer New York, NY. Memorial Sloan-Kettering Cancer Center 1275 York Avenue, New York, NY 10065. 18 August 2012. Treatment Decision Making for DCIS. Monica Morrow MD Chief, Breast Surgery Service Anne Burnett Windfohr Chair of Clinical Oncology

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Monica Morrow MD Chief, Breast Surgery Service Anne Burnett Windfohr Chair of Clinical Oncology Memorial Sloan-Kettering' - content


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1

18th Annual Perspectives in Breast Cancer

New York, NY

Memorial Sloan-Kettering Cancer Center

1275 York Avenue, New York, NY 10065

18 August 2012

Treatment Decision Making for DCIS

Monica Morrow MD

Chief, Breast Surgery Service

Anne Burnett Windfohr Chair of Clinical Oncology

Memorial Sloan-Kettering Cancer Center

controversies in dcis management
Controversies in DCIS Management
  • Is nipple sparing mastectomy appropriate?
  • Is RT necessary for all DCIS?
  • When is SN biopsy indicated?
  • What about endocrine rx?
mastectomy in dcis
Mastectomy in DCIS
  • Indicated when DCIS is too extensive to be encompassed with a cosmetic resection.
  • Outcome
    • Metaanalysis 21 studies, 1574 patients
    • Local recurrence 1.4% (0.7-2.1%)
    • Skin sparing mastectomy n = 223
    • Local recurrence 3.1%

Boyages J, Cancer 1999;85:616

Carlson G, JACS 2007;204:1074

what about nipple sparing mastectomy
What About Nipple Sparing Mastectomy?
  • Concerns
  • NSM leaves behind ductal tissue + breast tissue in order to preserve blood supply.
  • Occult nipple involvement present in 6-31% of cancers.
  • Most studies of NSM are in invasive cancer.
clinical outcomes nsm european institute of oncology 3 02 12 07
Clinical Outcomes NSMEuropean Institute of Oncology 3/02-12/07
  • Median f/u: 50 months
  • All patients received 16 Gy to NAC
  • CAUTION: At 20 mo f/u, no NAC recurrences, 1.4% LR

Petit JY, Ann Oncol 2012;23:2053-8

Petit JY, Br Ca Res Treat 2009;117:333

nsm in dcis
NSM in DCIS
  • Increased risk of LR due to retained breast tissue and poor exposure.
  • Contraindicated in patients with extensive DCIS necessitating mastectomy, localized DCIS in subareolar space.
what do i really think about nsm
What do I really think about NSM?
  • It’s a great operation for a woman
  • who doesn’t actually need a mastectomy.
slide11

Metaanalysis Trials of Excision ± RT

in DCIS

n = 3729

10 yr IBTR

EBCTCG JNCI Monograph 2010;41:162

slide12

Metaanalysis Trials of Excision ± RT

in DCIS

10 yr Survival Outcomes

EBCTCG JNCI Monograph 2010;41:162

slide13

Conclusions of Randomized Trials

  • RT reduces the risk of LR by 50%.
  • Patient subsets NOT benefitting from RT have not been identified.
slide14

Academic U.S. Physicians

Recommending RT For DCIS

Ceilley E, Cancer 2004;101:1958

concerns regarding randomized trials
Concerns Regarding Randomized Trials

Detailed tissue processing/method of pathology evaluation not specified.

Post-excision mammography not mandated.

Impact of margin width on RT benefit not assessed.

slide16

Does wide excision + detailed pathology exam

result in local control equivalent to excision + RT?

local recurrence margins 10 mm
Local Recurrence: Margins ≥ 10 mm

Silverstein M, NEJM 1999;340:1455

e5194 excision alone tamoxifen for dcis eligibility
E5194: Excision Alone ± Tamoxifen for DCIS Eligibility

DCIS ≥ 3mm in size

Minimum margin width ≥ 3mm

Specimen completely embedded, sequentially sectioned

Post-excision mammogram free of calcification

Hughes L, J Clin Oncol 2009;27:5319

patient characteristics e5194
Patient Characteristics: E5194

Hughes L, J Clin Oncol 2009;27:5319

intergroup trial of excision alone
Intergroup Trial of Excision Alone

Mean f/u 6.3 years

Hughes L, J Clin Oncol 2009;27:5319

slide21

Local Failure According to Pathology

After Lumpectomy and Radiation

Solin L, J Clin Oncol 1996;14:754

effect of margin width no rt
Effect of Margin Width – No RT

Hughes L, J Clin Oncol 2009;27:5319

rtog 9084 rt vs observation for good risk dcis
RTOG 9084: RT vs Observation for “Good Risk” DCIS

Mammographic or incidental DCIS

Low or intermediate grade

Size (mammographic) ≤ 2.5 cm

Margins ≥ 3 mm

Eligibility

McCormick B, ASCO 2012

rtog 9084 schema
RTOG 9084 Schema

Stratify

Age

< 50

≥ 50

Margins

Negative re-excision

3-9 mm

≥ 10 mm

Size

≤ 1 cm

> 1 cm-2.5 cm

Grade

Low

Intermediate

Tamoxifen

No

Yes

RANDOMIZE

Observation

RT

No Boost

local failure ipsilateral breast
Local Failure Ipsilateral Breast

5-Years Rates:

3.2%

0.4%

local recurrence after excision rt in good prognosis dcis
Local Recurrence After Excision +/- RT in Good Prognosis DCIS

5 yr LR

Hughes L, J Clin Oncol 2009;27:5319

McCormick B, ASCO 2012

conclusions e5194 rtog 9084
Conclusions E5194 + RTOG 9084

Rates of LR after excision alone differed significantly among 2 populations with “favorable” DCIS selected with standard histopathologic criteria.

Benefit for RT is present even in this good-risk subset.

slide29

A QUANTITATIVE MULTIGENE RT-PCR ASSAY FOR PREDICTING RECURRENCE RISK AFTER SURGICAL EXCISION ALONE WITHOUT IRRADIATION FOR DUCTAL CARCINOMA IN SITU (DCIS): A PROSPECTIVE VALIDATION STUDY OF THE DCIS SCORE FROM ECOG E5194 Solin LJ, Gray R, Baehner FL, Butler S, Badve S, Yoshizawa C, Shak S, Hughes L, Sledge G, Davidson N, Perez EA, Ingle J, Sparano J, Wood W Eastern Cooperative Oncology Group (ECOG)North Central Cancer Treatment Group (NCCTG)Genomic Health, Inc (GHI)2011 San Antonio Breast Cancer Symposium

slide30

DCIS Recurrence Score:

Unanswered Questions

  • Do patients in the low-risk group benefit from RT? Is it predictive as well as prognostic?
  • Does it apply to the wider population of women with DCIS?
  • Validation needed
sentinel node biopsy in dcis
Sentinel Node Biopsy in DCIS
  • DCIS lacks the ability to metastasize.
  • Rationale for axillary surgery is risk of unsampled invasive cancer.
  • ~15% risk of invasion after core bx diagnosis of DCIS.
risk of axillary recurrence in dcis
Risk of Axillary Recurrence in DCIS

NSABP B17: 7 of 623 pts with axillary recurrence

1 s/p axillary dissection

3 with invasive IBTR

3 of 620 with DCIS at 15 yrs

NSABP B24: 6 of 1799 pts at 11.6 yrs

1 with undiagnosed microinvasion

Julian, Ann Surg Oncol 2006

risk of axillary recurrence in dcis1
Risk of Axillary Recurrence in DCIS

Julian, Ann Surg Oncol 2006

slide34

When Should Axillary Nodes

Be Examined in DCIS?

  • • Microinvasive carcinoma
  • Metastases in 3% - 20% of cases.
  • • DCIS treated by mastectomy.
  • Opportunity lost if invasion found.
  • • Done as a second procedure if invasion found after lumpectomy.
  • Prior biopsy does not interfere with mapping.
benefit of tamoxifen in er dcis
Benefit of Tamoxifen in ER+ DCIS

NSABP B24 n = 732

Allred DC, J Clin Oncol 2012;30:1268-73

slide36

Other Therapies in DCIS

  • • Exemestane
  • MAP 3 — 112 of 4560 had DCIS
  • HR 0.47 (95% CI, 0.27-0.79)
  • No subset analysis
  • Data on other AIs coming from NSABP B35, IBIS II
  • Raloxifene
  • Equivalent to tamoxifen in STAR overall, better side- effect profile
  • DCIS analysis RR 1.46 (95% CI, 0.90-2.41)

Goss PE, NEJM 2011;364:2381-91

Vogel VJ, JNCI Monogr 2010:181-6

conclusions endocrine rx
Conclusions: Endocrine Rx
  • Endocrine therapy is an option for women desiring to minimize future breast cancer events.
  • Most favorable risk-benefit ratio is in premenopausal women with 2 breasts.
ad