1. Management of DCIS
KWH Experience
Dr. Carmen Ho

2. Ductal carcinoma in situ (DCIS)
Breast cancer as most common cancer in women in Hong Kong
DCIS as precursor of invasive cancer
Heterogeneous group with diverse malignant potential
Incidence of DCIS increased with mammographic screening
3/100,000 to 34/100,000 in years old
Steenbergen. Breast Cancer Res Treat.2009.
Best treatment for DCIS remains a controversy
Steenbergen. Netherland study

3. Management of DCIS Acceptance of BCT in Chinese (survey)
Mastectomy vs. breast conserving treatment + RT
RT reduces local recurrence rate
(13.4% vs. 3.9%)
NSABP B-17
Similar local recurrence and survival
NSABP B-04
Acceptance of BCT in Chinese (survey)
29-49%
Chua et al. Breast J. 2005
BCT rate in HK for breast cancer : 22-30%
Yau et al. Int J Radiat Oncol Biol Phys. 2008
Small breast
Screening program in 1990s
Availablitiy of RT
People’s concept of mastectomy being the only curative treatment
BCT rate in the West ~30-40%

4. Dcis management kwh experience

5. KWH experience in DCIS Retrospective study
Period : January 2002 – April 2009
Inclusion
Patients diagnosed with DCIS after surgical excision
Patients with micro- or invasive features were not included
212 patients included
Age : 57.2 (37.8 – 87.5)
Median FU : 31.0 months ( months)
Bilateral disease : 22
7 with bilateral disease on presentation

6. Table 1: Patient Characteristics
Presentations
Table 1: Patient Characteristics
Presentation
Mammographic abnormality
130 (62%)
Breast lump
(27%)
Nipple discharge
(8%)
Nipple abnormality
(1%)
Mastalgia
(2%)

7. PREsentations Average size : 2.02cm (0.1 – 7 cm) Size
Screen detected group : 1.32cm
Symptomatic group : 2.47cm
(P<0.01)

8. treatment Operation Mastectomy 80
Mastectomy with immediate reconstruction 28
Breast conserving treatment
104
Wide local excision 27
ROLL 31
Wire guided excision 42
Microdochectomy 4
108 patients with Mx
104 with BCT

9. Treatment BCT offered to 175 patients Unicentric tumor <3cm
Appropriate tumor to breast ratio
Acceptance of adjuvant radiotherapy
104 patients accepted BCT (59.4%)
75% were screen detected
Failed BCT
ROLL 1
Microdochectomy 3
Wire guided 3
BCT 1

10. Adjuvant Radiotherapy
96.2% (100/104) have adjuvant RT
4 patients with small foci (<0.6cm) and low grade DCIS
1 has IBTR 5 years later as DCIS

11. OUTcome 32 patients (31.7%) receiving BCT have close margin (<3mm)
5 patients underwent re-excision
8 required subsequent mastectomy
Boost dose of radiotherapy
All free of local recurrence
Sentinel LN biopsy was done in 98 patients
Positive sentinel LN noted in 3 patients
Axillary dissection was performed
Role of Sentinel LN biopsy in DCIS
-3.7% LN involvement in post operative diagnosis of DCIS
-7.4% LN involvement in preoperatove diagnosis of DCIS
Br J Surg May;95(5):

12. Disease free 198 / 212 (93.4%) remained disease free
Screen detected : 95.4% (124/130)
Symptomatic : 90.2% (74/82)

13. Local recurrence
4 patients with BCT have ipsilateral breast tumor recurrence (3.8%)
3 recurred as invasive ductal carcinoma, subsequent mastectomy performed
1 recurred as DCIS with ROLL done
All remained disease free after salvage treatment

14. Disease related mortality
1 patient died
Presented with blood stained nipple discharge
Microdochectomy performed : DCIS with involved margin
Simple mastectomy performed
DCIS (high grade with comedo necrosis)
6 months after mastectomy, developed bone metastasis

15. Discussion Emphasize on importance of screening mammogram
Acceptance of BCT + RT as treatment
75% patients receiving BCT were screen detected
69% with clear margin (>3mm)
Positive sentinel LN in 3.0% patients with DCIS
Risk of local recurrence after BCT 3.8% with median FU 31.0 months
Success of salvage treatment after IBTR
Percentage of close margin in the west
10-15% in Western series
Kestin et al. Cancer 2000.

16. Thank you