Is Radiation Indicated in Patients with DCIS and Close/Positive Mastectomy Margins?

Metastatic invasive breast cancer recurrence following curative-intent therapy for ductal carcinoma in situ

BACKGROUND

The development of an invasive breast cancer recurrence outside of the breast parenchyma following curative-intent therapy for ductal carcinoma in situ (DCIS) is rare. We describe the patient and tumor characteristics associated with such recurrences.

METHODS

A retrospective review was conducted of 621 patients who were treated for DCIS between 2004 and 2009. Patient, tumor, and treatment characteristics were collected. Descriptive statistics were utilized for data summary and data were compared using χ(2), where appropriate.

RESULTS

Of 621 patients who underwent curative-intent therapy for DCIS, 12 (1.9%) developed an invasive metastatic recurrence. Primary local therapy at the time of the initial DCIS diagnosis included 11 patients who underwent mastectomy and one who had lumpectomy and adjuvant radiotherapy. The metastatic recurrences were in chest wall and/or ipsilateral axillary lymph nodes only (n = 6) or distant sites with or without ipsilateral axillary or supraclavicular lymph nodes (n = 6). Of the 12 patients with invasive recurrence, eight had high grade DCIS with comedo necrosis at initial diagnosis. The biomarker profiles of the invasive recurrences included 55% estrogen receptor positivity, 45% progesterone receptor positivity, and 73% Her2/neu amplification. Patient age, tumor grade, presence of comedo necrosis, biomarker profile, and surgical treatment were not predictive of recurrence.

CONCLUSION

Invasive metastatic recurrence following adequate local therapy for DCIS is uncommon and likely represents progression of unidentified invasive disease at the time of diagnosis. The majority of invasive recurrences were Her2/neu amplified. Further studies are necessary to determine if such a unique biomarker profile correlates with metastatic recurrence.

Analyzing the risk of recurrence after mastectomy for DCIS: a new use for the USC/Van Nuys Prognostic Index

BACKGROUND

Patients with ductal carcinoma in situ (DCIS) who are treated with mastectomy seldom recur locally or with metastatic disease. When patients with DCIS recur with invasive cancer, they are upstaged and their lives are threatened. We questioned whether histopathologic data could be used to predict these infrequent events.

METHODS

We reviewed a prospective database of 1,472 patients with pure DCIS. All patients were scored from 4 to 12 using the USC Van Nuys Prognostic Index, an algorithm based on DCIS size, nuclear grade, necrosis, margin width, and patient age. Probabilities of recurrence and death were calculated using the Kaplan-Meier method.

RESULTS

A total of 496 patients with pure DCIS were treated with mastectomy. None received any form of postmastectomy adjuvant treatment. Average follow-up was 83 months. Eleven patients developed recurrences, all of whom scored 10-12 using the USC/VNPI. No patient who scored 4-9 recurred. All 11 patients who recurred had multifocal disease and comedo-type necrosis. The probability of disease recurrence after mastectomy for patients scoring 10-12 was 9.6% at 12 years, compared with 0% for those scoring 4-9. There was no difference in overall survival.

CONCLUSIONS

There were no recurrences among mastectomy patients who scored 4-9 using the USC/VNPI. Patients scoring 10-12 were significantly more likely to develop recurrence after mastectomy. At risk were young patients with large, high-grade, and multifocal or multicentric tumors. For every 100 patients with USC/VNPI scores of 10-12, 10 patients will recur by 12 years and 2-3 will develop metastatic disease.

Recurrence after Mastectomy for Ductal Carcinoma in Situ

Mastectomy has long been a standard option for patients with ductal carcinoma in situ (DCIS). It is preferentially chosen by some women and may be suggested for individuals with recurrent, multifocal, or multicentric disease. We chose to evaluate our recent experience with mastectomy for DCIS. A retrospective review was conducted of 83 patients (87 breasts) from 1995 to 2006 who underwent mastectomy for DCIS. Mastectomy for DCIS was performed in 49 postmenopausal, 33 premenopausal, and one male patient. The average age was 53 years and the mean follow up was 4.5 years. Sentinel lymph node (SLN) biopsy was performed on 44 cases; positive nodes were identified in two. Intraoperative analyses of SLN were all negative. Only one patient had ipsilateral recurrence of the skin (1.1%). DCIS with microinvasion was noted in 32 per cent of the patients; none of these patients had ipsilateral recurrence. Three patients had positive microscopic margins; none have recurred to date. These results confirm the usefulness of mastectomy for patients with DCIS. We recommend SLN biopsy without intraoperative touch prep analysis. Additional treatment may not be required in patients with microinvasion, positive or close margins because our series shows no local recurrence in these patients.