What is 51 yr female with ductal ca in situ managed by- and explain in detail?
Ans. is 'b' i.e., Simple mastectomy Breast conserving surgery and Simple mastectomy, both can be done in this patient. Though Simple mastectomy offers lesser risk of recurrence, it induces the psychological trauma of loss of breast. Hence breast consenting surgery would be the best management in this young patient.Treatment of Ductal Ca in situ (DC1S)o DCIS carries a high risk for progression to an invasive cancer. Schwartz writes - "The risk of invasive breast cancer is increased nearly five fold in women with DCIS. The invasive cancers are observed in the ipsilateral breast, usually in the same quadrant as the DCIS that was originally detected, suggesting that DCIS is an anatomic precursor of invasive ductal carcinoma ".o The treatment of intraductal lesion is controversial. It can be t/t by eitherSimple mastectomy orBreast conservation with wide excision (lumpectomy) with radiation therapyo Choice of operation depends on both surgeon and patient preference', however following points must be kept in mind.o Simple mastectomy is the gold standard procedure with no need of radiation and less recurrence rate (-2%), but there is loss of breast, a big psychological trauma to the patient,o Breast conserving procedures are better cosmetically but recurrence rate is more.The patient also has to be monitored regularly both clinically and by mammography for any recurrent disease.Those in favour of conservative procedure, however say that local recurrences if occur, can be successfully managed with salvage mastectomy.o Simple mastectomy is recommended for the following DCISDCIS with evidence of widespread disease (involving two or more quadrants)Mammographically identified mu Dicentric disease or diffuse suspicious calcification.Persistent positive margins after reexcision.Unacceptable cosmesis to obtain negative margins.A patient not motivated to preserve her breast.For patients who are high risk for recurrenceSize greater than 4 cmComedo appearance on histologyNegative estrogen receptor statusHigh grade tumorFor patients with contraindications to radiation therapyPrior radiation to the breast regionPresence of collagen vascular disease {SLE, Scleroderma)First or second trimester pregnancyo Adjuvant Tamoxifen therapy is may be give to ER positive DCIS patients. (The use of hormonal therapy in ER- positive DCIS decreases the risk for local recurrence and also reduces the risk for development of new contralateral and ipsilateral breast cancers).o ''Sentinel node biopsy is currently recommended when mastectomy is performed for DCIS because up to 10% of patients with DCIS on a diagnostic biopsy will be found to have invasive cancer in their mastectomy specimen".-- Sabiston 18/e po Because the risk for metastatic disease in patients with DCIS is 1%, systemic chemotherapy is not required.o Breast conservative surgery (lumpectomy) without radiation can be an option for -Low-grade DCIS of the solid, cribriform, or papillary subtype that is <0.5 cm in diameter if the margins of resection are widely free of disease.Treatment of lobular carcinoma in situ (LOS)o LCIS is not an anatomical precursor of invasive disease like DCIS, rather it is considered as a risk factor for invasive breast carcinoma (which can be either invasive ductal or lobular type),o The risk for invasive cancer is equal for both breast, so there is no benefit to excise LCIS.o Treatment of LCIS isObservation with or without tamoxifenThe goal of treatment is to detect the invasive cancer at an early stage which will develop in about 25 to 35% of these womenFor patients who are unwilling to accept the increased risk of breast cancer may be offered bilateral simple mastectomy.o Also RememberThe majority of invasive cancer which subsequently develop in LCIS are of ductal nature (~65%) not lobular.One more difference between LCIS & DCISLCIS is seen in female breasts only whereas DCIS can be seen in both male and female breasts.