Multicentric DCIS

[medicineradman]

Ive got a patient who had two separate lumpectomies in the left breast (she has large breast) for two separate quadrants that biopsy revealed ADH (microcalcs seen on imaging). Turns out she had DCIS in both, very small percent of the sample however. In one specimen the margin is 1 mm. Focal area of necrosis part of the DCIS in one sample. So she is considered to have multicentric DCIS given her two quadrants that are involved.

Guidelines say multicentric DCIS is a contraindication to BCT. Personally I feel mastectomy would be pretty radical in her situation, its not like she has EIC, just 2 small areas of DCIS. I think she should get post op imaging, go back for resection to clear the margin and so long as there is no residual she could proceed to RT. If there are persistently unable to clear the margin then consider mastectomy. Does that sound reasonable? She actually doesn't want radiation either; would you recommend mastectomy in her case if they are able to clear her margins >3 mm and she refused RT? This is all left sided. Thank you

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[ramsesthenice]

You didn't tell us age, grade, or receptor status but she sounds like she has a pretty good risk of recurrence. Not having evaluated her it's hard to say. Is this widely multicentric or is this two lesions close by but in different quadrants?

I may be in the minority (at least where I trained) but DCIS is DCIS. There is no survival advantage. If someone is dead set on keeping their breasts and against radiation that's their call as long as they understand their risk of invasive recurrence. Unless it's really a nasty phenotype I personally don't usually recommend changing surgical plans based on willingness to also have RT or not for DCIS (in contrast to invasive).

 

[medgator]

You didn't tell us age, grade, or receptor status but she sounds like she has a pretty good risk of recurrence. Not having evaluated her it's hard to say. Is this widely multicentric or is this two lesions close by but in different quadrants?

I may be in the minority (at least where I trained) but DCIS is DCIS. There is no survival advantage. If someone is dead set on keeping their breasts and against radiation that's their call as long as they understand their risk of invasive recurrence. Unless it's really a nasty phenotype I personally don't usually recommend changing surgical plans based on willingness to also have RT or not for DCIS (in contrast to invasive).

Not just you

http://mobile.nytimes.com/2015/09/2...eeps-challenging-the-status-quo.html?referer=

 

[RadOncDoc21]

Insurance companies are training docs well. I do think DCIS is less aggressive but still should be called a "carcinoma."

I mean come on what's next... GBM's are now "fuzzy wuzzy's."

 

[medicineradman]

Insurance companies are training docs well. I do think DCIS is less aggressive but still should be called a "carcinoma."

I mean come on what's next... GBM's are now "fuzzy wuzzy's."

that's actually pretty interesting, that insurance companies are behind the less screening/less treatment phenomenon. I guess they've got the primary care docs pretty well wrapped up. But I think if we want to fight it that is a good angle.

In any case, this patient is 54, ER +, one area in LUQ and one area in LLQ, I thought necrosis in the sample indicated grade 3(?). I would agree w the above, I think a informed discussion is the important thing. I think the no survival advantage is important to decision making. But she is young and over time her risk of recurrence is high. Will have her discuss further w her surgeon. Thanks

 

[Palex80]

Mastectomy seems like a good option here to me.

 

[Mandelin Rain]

I would just recommend mastectomy with reconstruction to her and get her back to the surgeon. If she refuses mastectomy, I would recommend clearing margin and radiation as long as she understands it's not really standard and may limit/impact subsequent reconstructive efforts should she recur. If she says no that both, she's no longer your problem and the med onc can give hormonal therapy.