Surgery in Ductal Carcinoma In Situ (DCIS) Part 1

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • The three main options are:
    • Mastectomy
    • Breast conserving surgery (BCS)
    • Active surveillance?
  • Mastectomy for DCIS:
    • Has excellent long-term local control:
      • 98% at 10 years
    • NO need for any adjuvant treatment
    • Excellent long-term breast cancer specific survival (BCSS):
      • 99% at 10 years:
        • Comparable with BCS
  • Breast conserving surgery (BCS):
    • Long-term local control:
      • Inferior local control:
        • 85% to 90% at 10 years with adjuvant therapy (radiation therapy and endocrine therapy):
          • 10% to 15% in breast local recurrence with the addition of adjuvant therapy
      • Optimally we will need for adequate margins:
        • 2 mm
      • Consider biology (overlooked)
      • Excellent long-term BCSS:
        • 99% at 10 years:
          • Comparable with mastectomy
      • We need adequate assessment of disease extent:
        • MRI is not particularly helpful:
          • Accuracy of 54.7%
          • Mean difference 3.85 cm between MRI and pathology
      • Effective localization strategies:
        • Bracketing, measurements, intraoperative ultrasound
      • Need for a good functional and cosmetic outcome
      • Think of radiation therapy ahead of time
  • NO breast surgery for DCIS?
    • Low risk DCIS is usually very indolent and will not prepress to invasive disease
    • Ongoing trials are accruing data:
      • LORIS, LORD, COMET, LARRIKIN:
        • Are expected to address this question:
          • All this trials are evaluating:
            • Low and intermediate grade DCIS
            • Screening detected DCIS
            • Age cut-offs varying (40, 45, 46, 55)
    • What about vacuum assisted excision (VAE)?
      • In low grade DCIS that the lesion was completed excised with the vacuum assisted device does it need to undergo lumpectomy?
        • Especially low grade lesion with indolent biopsy
  • Surgical management of DCIS in older patients:
    • Age (but not frailty) seems to be a driver for less surgery:
      • 75 to 79 years vs 70 to 74 years:
        • OR; 95% CI: 1.46; 1.01, 2.12
      • > 80 years vs 75 to 79 years:
        • OR; 95% CI: 2.51; 1.14, 5.53)
    • Still, more surgery is performed in older patients for DCIS than invasive breast cancer (IBC):
      • DCIS: OR: 0.24; 0.22, 0.26
      • IBC: OR: 0.19; 0.18, 0.20
    • This may be related to the lack of diffusion of the data on the benefit of endocrine therapy in this group of patients
  • Conclusions:
    • Breast surgery should aim at local control and against disease progression
    • The underlook biology should be more central in decision-making
    • The balance is delicate and patients should be actively informed
#Arrangoiz #Doctor #Surgeon #CancerSurgeon #BreastSurgeon #MountSinaiMedicalCenter #MSMC #Miami #Mexico
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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