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

alfrasson.af@gmail.com

OBRIGADO