Palpable DCIS

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medgator

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Seeing a 40 y/o F tomorrow coming from out of state, with a Hx of B mastectomies, presenting with a large R breast mass. Her core Bx showed G3 DCIS. Her mastectomy pathology showed ADH on the L side; however, R sided path of multiple foci of G3 IDC (measuring between 0.1 to 0.3 cm) and an 8.5 cm G3 DCIS (no mention of microinvasion on report). A SLN Bx was performed with 2 nodes being negative. No LVI. Negative margins. Final stage is pT1aN0(sn). She is triple-positive, receiving TCH currently.

My question is, that big of a mass being just DCIS sounds incredibly fishy to me. How can there be no evidence of invasive carcinoma in that big of a mass?? Should I send the path for a 2nd opinion? I am inclined to do so. What is the role for PMRT in a patient like this? If the DCIS component shows evidence of microinvasion in the 8.5 cm mass, I feel like I should offer her PMRT given her age, grade of the tumor and the size of this lesion. She has had BRCA testing which is negative.

I found a few interesting studies on the matter.

http://www.asco.org/ASCOv2/Meetings/Abstracts?&vmview=abst_detail_view&confID=111&abstractID=86469

http://www.ncbi.nlm.nih.gov/pubmed/16918134

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I wouldn't give it, and would only consider it if she also had a close or + margin.

I think the point of the articles you linked to (and it's well taken), is that some women with palpable or large DCIS should have SLNs done if they aren't getting mastectomy (in which case, they should automatically get one), in case they have microinvasion in the lumpectomy specimen, b/c they appear to have a higher risk than run of the mill DCIS. Then, that way, it can help guide adjuvant chemotherapy recs in case the lymph node shows up positive. But, this isn't hard and fast - there are some that don't even recommend SLN bx in patient's with T1mic disease, as the estimates of axillary dz range from low single digits to around 20%.

So, if you take out the DCIS part of it, it's T1aN0M0 disease, and you would never offer PMRT to these patients. For DCIS, the local control benefit doesn't confer a survival benefit. So, in her, I don't know what her recurrence rate is, but I'd think it is low unless margins are compromised (8.5cm is rare and unusual and the data for post-mastectomy patients treated with DCIS does not say that size of disease correlates with local recurrence, if a margin-free mastectomy is performed). The risk of treatment, to me, outweigh any benefits.

Below are the articles I've cited for reasons to tx or not tx after mastectomy for DCIS.

http://www.ncbi.nlm.nih.gov/m/pubmed/18954711/
http://www.ncbi.nlm.nih.gov/m/pubmed/22975615/
http://www.hindawi.com/journals/ijso/2012/423520/
 
I wouldn't give it, and would only consider it if she also had a close or + margin.


Below are the articles I've cited for reasons to tx or not tx after mastectomy for DCIS.

http://www.ncbi.nlm.nih.gov/m/pubmed/18954711/
http://www.ncbi.nlm.nih.gov/m/pubmed/22975615/
http://www.hindawi.com/journals/ijso/2012/423520/

Margins are 3 mm (negative IMO). Your first article suggests she has other risk factors present but that again, the recurrence rates are low. My concern is whether there is something else hiding in that 8.5 cm mass that was not seen when it was read as DCIS by the pathologist. But I get your point that even if there was Tmic in that large DCIS mass, it would not be an indication to treat unless the mass itself was a true IDC
 
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I recall that the largest study of DCIS outcomes s/p mastectomy stopped short of recommending postop XRT.
Also, palpable DCIS is a known entity. For DCIS treated by breast conservation, palpable disease is adverse risk feature.
 
I would not treat her.

I finished treating a patients last week with a 6,5 cm big DCIS. She underwent mastectomy and had a positive margin, so I treated her. But if the margin had been clear, I wouldn't have.
 
Negative margins, negative nodes - even though I understand the desire to treat this young woman with ugly disease, I just don't think the data exist to support doing it and I wouldn't treat her.

I am really suspicious that there was a larger invasive component than was reported - I wonder what the Van Nuys folks would've found?
 
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