Chapter 55 Breast Cancer Tis Flashcards
Non invasive carcinoma of breast(Stage Tis) includes
Paget’s disease of nipple Lobular carcinoma in situ Ductal carcinoma in situ
Characteristics of LCIS
Multicentric breast involvement Loose, discohesive epithelial cells large in size, variable in shape, normal cytoplasm to nucleus ratio Overlap of histologic morphology
LCIS Percentage of multicentric distribution in mastectomy specimens? Bilateral involvement of breast? Percentage representation of noninvasive cancer?
90% 35-59% <15%
LCIS usually which harmone positive?
ER+
LCIS Average age of diagnosis?
45 years Premenopausal at diagnosis
What are clinical or mammographic characteristics of LCIS?
No clinical or mammographic indicators It is often detected as an incidental biopsy findings
LCIS is considered a marker of increased risk for subsequent development of
Ductal carcinoma Bilateral breast Direct precursor lesion to invasive lobular carcinoma is unresolved (NSABP B-17 trial for reference)
Role of MRI as a useful screening tool to detect development of invasive disease in LCIS
3.8-4.5% breast cancer detection rate (NCCN 2009 reference)
What is the widely accepted management of breast with mixed LCIS,DCIS or Invasive carcinoma?
Manage breast according to dominant malignant histology
LCIS as a sole histologic diagnosis, what is most widely accepted clinical practice?
Close observation and mammographic surveillance
Role of RT in management of LCIS?
NO ROLE
High risk patient for bilateral prophylactic mastectomy?
Young age Diffuse high grade lesion Significant family history
Less radical prophylactic approach in high risk LCIS patients?
Tamoxifen has shown reduction of invasive carcinoma by 56%
Presentation/ characteristics of Paget’s disease of nipple
Crusting and eczematous changes of nipple-areola complex Itching and burning of nipple and areole Presence of Paget’s cells located throughout epidermis
Describe Paget’s cells
Large Hyperchromatic Round to oval nuclei with abundant amphophilic to clear cytoplasm Mitosis commonly seen Cells found in cluster or individually in basal layers
Percentage of underlying malignancy in Paget’s disease
>95?
Motility factor released by epidermal keratinocytes that results in chemotaxis of Paget’s cells that migrate to overlying nipple epidermis.
Heregulin-alpha
Differential diagnosis of Paget’s disease
Superficial spreading melanoma Pagetoid SCC in situ Clear cells of toker
Percentage of palpable mass at diagnosis in Paget’s disease
50% Of which >90% cases invasive carcinoma
What percentage and histology in presentation of non palpable mass in Paget’s disease
66-86% DCIS
Mammographic findings in Paget’s disease of nipple
Palpable mass Normal mammograms reported in as many as 50%
Management of Paget’s disease
Local treatment, systemic and regional node disease should be based on associated disease
EORTC 10873 study for Paget’s disease of nipple
Complete excision with tumor free surgical margin and whole breast RT Median follow up 6.4 years Majority are DCIS without palpable mass 5 years local recurrence rate 5.2%
Risk factor for DCIS
Family history Delayed age of first live birth and nulliparity History of benign breast biopsy Alcohol
Percentage of new cases of DCIS present with mammogram
95%
Findings of mammographic abnormalities in DCIS
Microcalcifications most typical
DCIS Linear and segmental calcifications? Linear and branching calcifications? Fine and granular calcifications?
DCIS in 80% of cases High grade DCIS and necrosis Low grade DCIS
Role of MRI in DCIS
Highest sensitivity particularly High-grade DCIS Extent of DCIS involvement aiding treatment planning
Nipple discharge and negative mammogram. How to distinguish underlying DCIS vs Papilloma?
Galactography
5 subtypes of DCIS
Comedo Solid Cribiform Micropapillary Papillary Less common Apocrine Neuroendocrine Signet ring cystic hypersecretory carcinoma Clinging DCIS
DCIS Working Party of the EORTC Features that convey prognostic significance
Nuclear grade Presence of necrosis Polarization Architectural patterns Margin status Lesion size Extent of microcalcification Correlation between specimen x-ray and mammographic findings
Faverly et al DCIS growth pattern within ductal free and lmplication for surgical excision
Unicentric Multicentric(2 distinct areas separated by >4cm) Continuous Discontinuous or Multifocal(2 or more areas separated by <4cm)
What genetic abnormality in DCIS demonstrate synchronous invasive breast cancer
Loss of heterozygosity
Which subtype of DCIS share loss of heterozygosity with synchronous invasive lesion
77% nocomedo 80% comedo
Molecular markers in DCIS All High grade Low grade
ER 70% high grade 25% low grade 90% HER 50% P53 25%
Occult micro invasive breast cancer are most common in
DCIS >2.5cm in diameter Present with palpable masses or nipple discharge High grade DCIS or Comedonecrosis
DCIS is not a single disease
DCIS encompass diverse group of lesion that differ in regards to clinical presentation, mammographic features, extent and distribution with breast, histologic characteristics, biologic markers
Factors identified in local failure risks in DCIS
Symptomatic presentation Lesion size Histopathologic subtype Nuclear/cytologic grade Central necrosis Margin status Patient age
LRR and CSMR in mastectomy for DCIS
LRR 96-100% CSMR <=4%
What could be cause of local treatment failure after mastectomy for DCIS
Unrecognized invasive carcinoma Incomplete removal of breast tissue with subsequent formation of new primary
Role of PORT following mastectomy or skin sparing mastectomy in DCIS
High grade with pathologic margin <1mm
Name trials in DCIS Lumpectomy vs Lumpectomy+RT
NSABP B-17 EORTC 10853 UK/ANZ SweDCIS
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