Breast Surgery

Question 1

What are some mammographic patterns commonly associated with DCIS?

Answer 1

Linear branching or segmental types of pleomorphic microcalcifications are frequently associated with high-nuclear-grade DCIS with comedo necrosis (linear calcification is the most typical for DCIS)

Fine, granular calcifications are primarily associated with low-grade, micropapillary, or cribriform pattern DCIS

Question 2

What forms the synaptic report for DCIS?

Answer 2

• Overall lesion size
  
  • Margins
  • Grade of DCIS
  • Any invasive component
  • Necrosis or no necrosis
  • Presence or absence of calcifications
• Hormone receptors sometimes included

Question 3

What are some features inferring a high risk of recurrence after DCIS excision (for bonus marks, what is the scoring system)?

Answer 3

SIZE >40mm
Margin <1mm
Pathology High nuclear grade with or without necrosis
Age <40

(Van Nuys prognostic index)

Question 4

Indications for mastectomy for DCIS

Answer 4

• Multicentric DCIS
  
  • Large lesion (>4-5cm)
  • Inadequate margin despite re-excision of WLE
  • Cosmesis (e.g. large area in small breast)
  • Patient preference
  • Adjuvant radiotherapy is contraindicated

Question 5

When to perform SLNBx for DCIS?

Answer 5

• Mastectomy
  
  • Concern for potential invasive ductal carcinoma
  • DCIS >4cm
  • High grade
  • Mass forming DCIS
  • DCIS with micro-invasion

Question 6

What are the subtypes of LCIS and how are they managed?

Answer 6

Classic, pleomorphic and florid.
Confer an 8-11X risk of developing invasive breast cancer (~1%/year of life)

Classic - offer patient lifelong surveillance
Pleomorphic/florid - to be treated more like DCIS, higher risk of upgrading to ca on excision.