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Oncologic Treatment of Breast Cancer

Oncologic treatment Case 1 Ductal carcinoma in situ

Authors: Sarah Gierahn Nielsen, med. student & Hanne Melgaard Nielsen, MD

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Step 1: Patophysiology

Ductal carcinoma in situ (DCIS) is a preinvasive lesion originating within normal breast tissue with histologic progression from atypical hyperplasia to invasive breast cancer.

  • Characterized by the presence of clonal proliferation of neoplastic epithelial cells
  • Without sufficient surgical treatment, 30-50% of DCIS patient will develop invasive carcinomas – most within a 10-year period. [1] Danish and European guidelines suggest, that DCIS, constitute between 10% and 20% of screening-detected suspicious lesions.[2][3]
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Step 2: Recommendations for treatment

Surgical and radiotherapy

  • Golden standard for treatment of DCIS is lumpectomy.
  • Mastectomy is only performed in case of widespread lesions.
  • Postoperative radiotherapy is given after lumpectomy for DCIS as a standard.
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Step 3: Lumpectomy

Indications

  • Non-widespread diffuse or multifocal DCIS
  • Expected cosmetically outcome, that is satisfying
  • Patient acceptance of post-control and possibly radiation treatment
  • Patient acceptance of increased recurrence risk compared with mastectomy
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Step 4: Mastectomy

Indications

  • Large, diffuse and / or multifocal DCIS lesions
  • The expected cosmetically outcome won’t be satisfying
  • Patients not accepting post-checks and possibly radiation treatment
  • Patients not accepting increased recurrence risk associated with lumpectomy
  • Known risk of BRCA1 or BRC2 mutation
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Step 5: Radiotherapy

Postoperative radiotherapy is recommended in a dose, that is sufficient enough to control any microscopic disease left after surgery

  • 40.05Gy in 15 fractions over three weeks
  • Either one of the following tumour bed boost should be considered:
  • 50 Gy/ 25 fr. + 10 Gy/ 5 fr.: 57 Gy / 50 Gy / 25 fr.
  • 50 Gy/ 25 fr. + 16 Gy/ 8 fr.: 63 Gy / 51,52 Gy / 28 fr.
  • 40 Gy/ 15 fr. + 10 Gy/ 5 fr.: 45,75 Gy / 40 Gy / 15 fr.
  • 40 Gy/ 15 fr. + 16 Gy/ 8 fr.: 52,2 Gy / 42,3 Gy / 18 fr
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Step 6: Follow-up

In Denmark, it is recommended, that patients treated for DCIS should be monitored for 3 years in order to detect early, local recurrence or contralateral neoplasia.

  • Patients ≤ 50 years: Patients are offered an annual, clinical mammography until screening age
  • Follow up for patient patients >/= 50 years is determined by whether the patient has had:
  • Mastectomized: Screening mammography of the contralateral breast every second year
  • Lumpectomized: Clinical mammography 18 months after surgery. After this, a decision to transit to regular screening mammography program.

Acknowledgements

IllustratorsCaroline Lilja, med. student


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Case 2

Lobular carcinoma in situ


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