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Observação do carcinoma ductal in situ (CDIS)? Recentes avanços no manejo do CDIS.
Dr. Antonio Frasson
Some patients are diagnosed with “cancer" that does not progress
DCIS in 0.5 to 3.6 cases per 1000 women screened
Annual incidence of DCIS in the US : 60,000
Proportion of these cases represents overdiagnosis that would not otherwise progress to an adverse outcome
Overdiagnosis results in overtreatment?
Usually diagnosed by calcifications on mammography in asymptomatic
patient
Carlos Chavez de Paz Villanueva et al. JAMA Surgery Published online July 12, 2017.
PubMed Central, Figure 2: Mol Oncol. 2013 Oct; 7(5): 859–869. Published online 2013 Jul 12.
Actual theory evolution: Bottleneck
Insights from single cell genomic: CDIS SBACS 2018
Insights from single cell genomics: Multiclonal Invasion
CDIS upstaging
Grimm L et al, ASO 2017
James W. Jakub et al. Ann Surg Oncol. 01 Aug 2017.
DCIS grade on biopsy:
mass lesion,
grade, multicentric disease,
largest linear dimension
Counseling regarding axillary staging at the time of definitive surgery
Nomogram to predict upstaging of DCIS to invasive disease
K.E. Williams et al. Annals of Oncology Advance Access published February 12, 2015
Luminal B
HER2: HR 6.72 Luminal B: HR 5.52
DCIS molecular phenotypes predict recurrence
HER 2
Invasive recurrence predictors:
High ki67 expression
Molecular phenotypes
HR 13.4 Luminal B HR 11.4 HER2-type X Luminal A
HR 10.3 triple negative
LUMINAL A
K.E. Williams et al. Annals of Oncology Advance Access published February 12, 2015
The Future: Molecular Predictors of Recurrence and Invasive Risk
Ipsilateral breast events in DCIS treated with surgical excision without radiation
Wood WC, et. Al. Oncology (Williston Park). 2014 May;28 Suppl 2:C2, 1-8, C3.
Personalized decision making for patients with DCIS following local excision
DCIS Score < 39 low risk
DCIS Score 39 to 54 intermediate risk
DCIS Score 55 to 100 high risk
Wood WC, et. Al. Oncology (Williston Park). 2014 May;28 Suppl 2:C2, 1-8, C3.
IPSILATERAL BREAST EVENTS
INVASIVE CANCER
10.6%
26.7%
25.9%
12.3%
19.2%
3.7%
Wood WC, et. Al. Oncology (Williston Park). 2014 May;28 Suppl 2:C2, 1-8, C3.
What happens if you don’t “treat” DCIS?
A.J. Maxwell et al. / European Journal of Surgical Oncology xxx (2018) 1e7
1998-2010 89 patients
DCIS: Core biopsy Without out study
Follow up 59 m
18%
High grade DCIS Calcifications Young patient
No endocrine therapy
Cumulative incidence of invasive cancer by DCIS grade
1286 patients > 70 y = 31%
55-69 y = 32% < 55 y = 47%
SEER: 1992-2014
N: 1286 DCIS without therapy
Median age: 60 y
Median follow up: 5.5y
Tumor grade I/II -> 10y IBC ipsilateral 12,2%
Tumor grade III-> 10y IBC ipsilateral 17,6%
DCIS G1 > observation, active surveillance
DCIS G3 > surgery
A.J. Maxwell et al. / European Journal of Surgical Oncology xxx (2018) 1e7
2.0-2.3% of patients in the USA choose active surveillance for management of
their disease
Trials of non-operative management DCIS breast cancer
ALLIANCE
U. BIRMINGHAM,
UK
EORTC
In selected cases, “nothing is better than something”
DCIS is a heterogeneous group of diseases with variability in outcomes and biology.
The generally excellent prognosis in low risk DCIS is an opportunity for de-escalation for some low risk DCIS
CONCLUSIONS
Surgery is currently the mainstay of therapy for CDIS
Molecular diagnostics may have a future role in identifying this low risk cohort
