Breast Ca difficult case: close margins for DCIS

[Kroll2013]

Dear colleagues,
I need your opinion concerning ,y patient's case;
she is a 35 years old patient, with no comorbidities. her paternel aunt was diagnosed of breast ca at 42.
that presented with multi-centric disease of the left breast ( micro calcifications and atypical outer quadrant nodule of 7mm on mammography.
first she underwent a partial mastectomy: that showed foci of invasive poorly differentiated ductal carcinoma, nuclear grade 2, SBR II with extensive intermediate grade DCIS, 3 cm in greatest dimension, LVI+, margins were positive.
she was re-operated of Modified radical mastectomy and ALND.
final pathology: negative axillary LNs, Residual infiltrating ductal carcinoma, grade I, 2.7mm (pT1a), associated with a prominent Intra-ductal component of Papillary, Micro-papillary grade II, and cribriform grade III, measuring 8*6*4 cm, lobular cancérisation present, Nipple invasion present, LVI present, Skin negative, Inked surgical margins negative for tumor, close margin (<1mm) for DCIS to anterior, antero-inferior margins.
HR+, Her2 negative
no need for CT after gene tests were done.

IS ADJUVANT PMRT NEEDED FOR THIS PATIENT?


ty

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[evilbooyaa]

1) She needs genetic eval
2) Generally no indication for PMRT for positive DCIS margin in a mastectomy.

However, in the setting of multifocal invasive ductal, with a continuous tumor specimen (mostly DCIS with pockets of invasive disease) the concern is invasive disease just on the other side of the cut border of DCIS. I think offering re-excision is reasonable with goal of avoiding RT. Surgeon won't want to and you're in a tough position. I would personally lean away from doing PMRT for DCIS since the margin was negative, even in this concerning of a situation. But I truly think you can go either way and it would be not unreasonable. Remainder of margins are widely negative (even for DCIS)?

 

[gmsquid]

Dear colleagues,
I need your opinion concerning ,y patient's case;
she is a 35 years old patient, with no comorbidities. her paternel aunt was diagnosed of breast ca at 42.
that presented with multi-centric disease of the left breast ( micro calcifications and atypical outer quadrant nodule of 7mm on mammography.
first she underwent a partial mastectomy: that showed foci of invasive poorly differentiated ductal carcinoma, nuclear grade 2, SBR II with extensive intermediate grade DCIS, 3 cm in greatest dimension, LVI+, margins were positive.
she was re-operated of Modified radical mastectomy and ALND.
final pathology: negative axillary LNs, Residual infiltrating ductal carcinoma, grade I, 2.7mm (pT1a), associated with a prominent Intra-ductal component of Papillary, Micro-papillary grade II, and cribriform grade III, measuring 8*6*4 cm, lobular cancérisation present, Nipple invasion present, LVI present, Skin negative, Inked surgical margins negative for tumor, close margin (<1mm) for DCIS to anterior, antero-inferior margins.
HR+, Her2 negative
no need for CT after gene tests were done.

IS ADJUVANT PMRT NEEDED FOR THIS PATIENT?


ty

The concern for me is the nipple invasion and lvsi. Katz IJROBP 2001 shows a high rate of local recurrence in the setting of nipple invasion. I would have to reread the paper thoroughly to see if it discusses the risk in node negative or only node positive disease but nipple invasion is generally associated with a high risk of LRR even after mastectomy.

 

[nkmiami]

Dear colleagues,
I need your opinion concerning ,y patient's case;
she is a 35 years old patient, with no comorbidities. her paternel aunt was diagnosed of breast ca at 42.
that presented with multi-centric disease of the left breast ( micro calcifications and atypical outer quadrant nodule of 7mm on mammography.
first she underwent a partial mastectomy: that showed foci of invasive poorly differentiated ductal carcinoma, nuclear grade 2, SBR II with extensive intermediate grade DCIS, 3 cm in greatest dimension, LVI+, margins were positive.
she was re-operated of Modified radical mastectomy and ALND.
final pathology: negative axillary LNs, Residual infiltrating ductal carcinoma, grade I, 2.7mm (pT1a), associated with a prominent Intra-ductal component of Papillary, Micro-papillary grade II, and cribriform grade III, measuring 8*6*4 cm, lobular cancérisation present, Nipple invasion present, LVI present, Skin negative, Inked surgical margins negative for tumor, close margin (<1mm) for DCIS to anterior, antero-inferior margins.
HR+, Her2 negative
no need for CT after gene tests were done.

IS ADJUVANT PMRT NEEDED FOR THIS PATIENT?


ty

I had a case like this and spoke with breast expert at upenn and ended up radiating (they did email several articles) LVI and positive margins I think justify xrt in young pt. There is typically residual breast tissue after mastecomy- do you want to leave it unirradiated in the setting of this kind of field cacnerization.

 

[gmsquid]

The concern for me is the nipple invasion and lvsi. Katz IJROBP 2001 shows a high rate of local recurrence in the setting of nipple invasion. I would have to reread the paper thoroughly to see the risk in node negative disease but nipple invasion is generally associated with a high risk of LRR even after mastectomy.

Looking at the Katz paper again it only looks at the setting of node positive disease for nipple invasion. It’s definitely a tough case. I don’t know of much data in this setting. The DCiS is not what I’m worried about.

 

[medgator]

Just throwing this out there... hot off the presses

Association of Radiotherapy With Survival After Lumpectomy or Mastectomy for DCIS

 

[OTN]

I would treat with PMRT. Pre-menopausal + LVSI + close DCIS margin. LVSI keeps surfacing as a predictor of chest wall recurrence.

 

[scarbrtj]

This is a case for protons.

 

[medgator]

Dear colleagues,
I need your opinion concerning ,y patient's case;
she is a 35 years old patient, with no comorbidities. her paternel aunt was diagnosed of breast ca at 42.
that presented with multi-centric disease of the left breast ( micro calcifications and atypical outer quadrant nodule of 7mm on mammography.
first she underwent a partial mastectomy: that showed foci of invasive poorly differentiated ductal carcinoma, nuclear grade 2, SBR II with extensive intermediate grade DCIS, 3 cm in greatest dimension, LVI+, margins were positive.
she was re-operated of Modified radical mastectomy and ALND.
final pathology: negative axillary LNs, Residual infiltrating ductal carcinoma, grade I, 2.7mm (pT1a), associated with a prominent Intra-ductal component of Papillary, Micro-papillary grade II, and cribriform grade III, measuring 8*6*4 cm, lobular cancérisation present, Nipple invasion present, LVI present, Skin negative, Inked surgical margins negative for tumor, close margin (<1mm) for DCIS to anterior, antero-inferior margins.
HR+, Her2 negative
no need for CT after gene tests were done.

IS ADJUVANT PMRT NEEDED FOR THIS PATIENT?


ty

What is ER/PR status btw? If ER-, I am even more inclined to offer PMRT

 

[knuckles]

Would you all do CW only? Not really strong indication for RNI.

 

[medgator]

Would you all do CW only? Not really strong indication for RNI.

Yup, I would just treat cw

 

[evilbooyaa]

Maybe I was tunnel visioning on the DCIS margin too much given the title. Nipple invasion with IDC with LVSI is certainly worth a discussion about PMRT. I'd agree that it will lower her chance of LR. Likely wouldn't affect OS.

CW only, no indication for RNI IMO.

 

[gmsquid]

Maybe I was tunnel visioning on the DCIS margin too much given the title. Nipple invasion with IDC with LVSI is certainly worth a discussion about PMRT. I'd agree that it will lower her chance of LR. Likely wouldn't affect OS.

CW only, no indication for RNI IMO.

She’s young to so her risk of recurrence is higher. So there may be a survival advantage.

I would pay close attention on the ct sim to the imn nodes to make sure there isn’t anything suspicious before omitting regional nodes. Something about the case makes me nervous.

 

[medgator]

Maybe I was tunnel visioning on the DCIS margin too much given the title. Nipple invasion with IDC with LVSI is certainly worth a discussion about PMRT. I'd agree that it will lower her chance of LR. Likely wouldn't affect OS.

CW only, no indication for RNI IMO.

Based on the ebctcg meta analysis, local control can impact OS long term in invasive disease.

Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10 801 women in 17 randomised trials

I think that might happen in this case given how young this pt is

 

[scarbrtj]

Based on the ebctcg meta analysis, local control can impact OS long term in invasive disease.

Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10 801 women in 17 randomised trials

I think that might happen in this case given how young this pt is

It's acronym time. I hate acronym time!

AFAIK and IMHO the EBCTCG trial to cite here would be one re: mastectomy, not BCT. Of course in this meta-analysis of the randomized trials when looking at PMRT for T1N0 (how many T1s were there? not a lot), there was no benefit. We can quote non-randomized data perhaps showing a trend toward some benefits with PMRT for Stage I N0 breast "high risk" patients (I don't know of any great or N-heavy data for PMRT in "high-risk" T1aN0 patients). But is this patient Stage I or stage zero? I guess technically she's Stage I. But she presents with something like 99.99% DCIS (perhaps IDLE one day!) and 0.01% invasive. Retrospective data seemed to suggest you didn't need PMRT for high-risk IDLEs, er, DCIS. I would say this: if she is ER+ (I think OP is saying she is?), data does not support PMRT here. In reality, randomized data has been very clear re: lack of LC or OS benefits. Again, IMHO. But back to my point that this patient is 99.99% Stage zero, if she behaves as stage zero, even with the close margin and high DCIS grade, mastectomy without RT should give her a low local failure rate and great OS. If you think she will behave as invasive... that is, if you think her T1a node-neg tumor that was LVI+ grade 2 at excision and grade 1 at re-excision is going to need PMRT, that's an interesting opinion. IMHO.

And... the other 140-thousand patient trial that you posted above is certainly good ammunition for lumpectomy+XRT in DCIS and may even quiet the Mel Silverstein/Van Nuys crowd (I doubt it... btw, one of the first VNPI papers featured Monica Lewinsky's dad as a co-author). On the other hand, in this SEER analysis from Aug 2018, among its 140,366 DCIS patients studied exactly zero got mastectomy and radiation. And for the comparison of lumpectomy+XRT vs mastectomy alone in terms of OS due to the EXTREME number of patients, it was statistically significant: at 15 years the OS for lump+XRT was about 98.3% and 98.0% for mastectomy alone (See suppl material below). To me, that says for a young woman with a left-sided DCIS tumor, don't give her XRT after mastectomy!

I guess OP is also saying this woman would not benefit from bilateral mastectomy based on her tests?

EDIT: I'm assuming all the "big" (the 3cm and 8cm lesions) stuff was the DCIS and that her final stage is pT1aN0 (ER+, +LVI, Gr 2, +EIC)