Treatment

BCS vs Surgery

Silverstein et al – non randomized study

Patients with tumours smaller than 4cm or with negative margins underwent BCS with radiation.
Patients with tumours larger than 4 cm or positive margins underwent mastectomy
Disease free survival more in Mastectomy. Overall survival no difference.
50% of recurrences are invasive carcinomas.

BCS techniques: DCIS is usually impalpable.

Mammographicaly or sonographically Radioactive I125 seeds are placed.

Gamma probe is used to remove the specimen
Non radioactive methods are ultrasound / magnetic seeds.

Intraoperative radiological assessment of sectioned specimen to look for micorcalcifications at the cut
edge of the specimen minimzed the need for second procedure for margin control .( Chagpar et al )

Holland et al : 44% of DCIS extend more than 2cm, than their mammographic extent when reassessed
under a microscope.

NCCN guidelines 2016 : close margins , 1mm is inadequate and should be rexcised. But in patients where
the border of the disease is the fibroglandular boundary ( chest wall ) or skin, radiation boost is given
the surgical scar is an alternative to reexcision.

2015 multidisciplinary panel concluded that 2mm margin was adequate in BCS, whole breast irradiation
for DCIS .

Radiation:

NSABP ( National Surgical Adjuvant Breast and Bowel Project )

EORTC trial

United kingdom coordinating committee on cancer research

RTOG 9804 trial ( poor study due to poor accrual )

SweDCIS

All studies showed a reduction in noninvasive and invasive ipsilateral breast tumours incidence in the
group that underwent radiation after BCS.

Whole breast irradiation is the norm and is well tolerated.

Complications: radiation induced skin changes including discoloration, fibrosis and telengectasias.
Rare : Heart and lung disease, angiosarcoma.
Partial breast irradiation :

Rationale : Most recurrences occur in the region of previous surgery for DCIS
Accelerated Paritial Breast irradiation : high dose given over short period of time (4-5days)
Type of brachytherapy : Single dose intraoperative radiotherapy, Localized conformal 3D radiotherapy
Brachytherapy via multiple catheters placed in the breast parenchyma
beads or seed implants, balloon catheter inserted after BCS.

2013 Oliviotto and colleagues warned clincians against using ABPI due to poor cosmesis and radiation
toxicity.

NSABP/RTOG 0413 randomized phase three trial in 2005 to assess Local tumour control via 3D XRT,
brachytherapy or single entry intracavity delivery when compared to WBI.

Patients in the group are women who underwent margin negative lumpectomy of DCIS (<3cm), invasive
stage 1 or 2 breast cancer with limited nodal disease ( less than or equal to three )

ASBS APBI registry trial – 92% had favorable cosmetic results, 5 year locoregional control was
comparable to NSABP b-19 trial .