DCIS: Margins and the USC/VNPI Van Nuys USC Hoag Melvin J. Silverstein, M.D Gross Endowed Chair in Oncoplastic Surgery Director, Hoag Breast Program Newport Beach, CA Clinical Professor of Surgery Keck School of Medicine University of Southern California
No Ink on Tumor is Adequate Clinical Investigation: Breast Cancer Society of Surgical OncologyeAmerican Society for Radiation Oncology Consensus Guideline on Margins for Breast-Conserving Surgery With Whole-Breast Irradiation in Stages I and II Invasive Breast Cancer Invasive Cancer Treated with Radiation Therapy Meena S. Moran, MD,* Stuart J. Schnitt, MD, y Armando E. Giuliano, MD, z Jay R. Harris, MD, x Seema A. Khan, MD, k Janet Horton, MD, { Suzanne Klimberg, MD, # Mariana Chavez-MacGregor, MD,** Gary Freedman, MD, yy Nehmat Houssami, MD, PhD, zz Peggy L. Johnson, xx and Monica Morrow, MD kk +/- Chemo/Hormonal *Department of Therapeutic Radiology, Yale School of Medicine, Yale University, New Haven, Connecticut; y Department of Pathology, Harvard Medical School, Boston, Massachusetts; z Department of Surgery, Cedars Sinai Medical Center, Los Angeles, California; x Department of Radiation Oncology, Harvard Medical School, Boston, Massachusetts; k Department of Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois; { Department of Radiation Oncology, Duke University Medical Center, Durham, North Carolina; # Department of Surgery, University of Arkansas for Medical Sciences, Fayetteville, Arkansas; **Department of Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas; yy Department of Radiation Oncology, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania; zz School of Public Health, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia; xx Advocate in Science, Susan G. Komen, Wichita, Kansas; and kk Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York Received Oct 3, 23. Accepted for publication Nov 6, 23. International Journal of Radiation Oncology biology physics www.redjournal.org Nothing to do with Pure DCIS Particularly when Treated with Excision Alone
Update Data through 23 673 DCIS Patients 86 Months Median Follow Up
Local Recurrence-Free Survival.2.8.6.4.2 563 Mastectomy 42 Radiation Therapy All p <. 689 Excision Only 2.3% 8% 29% 2 3 4 5 6 7 8 9 2 Years 673 DCIS
Breast Cancer Specific Survival.2.8.6 No Difference REGARDLESS of Treatment.8%.4.2 563 Mastectomy 42 Radiation Therapy 689 Excision Only p = NS 2 3 4 5 6 7 8 9 2 Years 673 DCIS
Overall Survival.2 8%.8.6 No Difference REGARDLESS of Treatment.4.2 563 Mastectomy 42 Radiation Therapy 689 Excision Only p = NS 2 3 4 5 6 Years 7 8 9 2 673 DCIS
987 to the Present Published > Papers Fighting Over-Diagnosis and Over-Treatment DCIS
NCCN Practice Guidelines 28 DCIS Lumpectomy without lymph node surgery + whole breast radiation therapy DCIS or Total mastectomy with or without sentinel node biopsy +/- reconstruction or Lumpectomy e without lymph node surgery without radiation therapy
Margins
33 Original NEJM Patients Margins mm Median Follow-up 5. Years 2% 3% p = NS 4 Radiation Therapy 93 Excision Only
Margins are like money, more is better, when treating DCIS with excision alone Keynote Address American Society of Breast Surgeons Annual Meeting La Jolla, California May 4, 2
Because of that Statement and the NEJM Paper, I Incorrectly Became the Leading Proponent for mm Margins For All Breast Cancers: DCIS and Invasive Word Spread I Would Accept Nothing Less Than mm I Re-Excised or Converted to Mastectomy for < mm
Because of that Statement and the NEJM Paper, I Incorrectly Became the Leading O Proponent for mm Margins For All Breast Cancers: DCIS and Invasive Word Spread I Would Accept Nothing Less Than mm I Re-Excised or Converted to Mastectomy for < mm
My Postion Has Always Been. Irradiate All Conservatively Treated Patients with Invasive Breast Cancer with Negative Margins 2. I Do Not Irradiate SELECTED Patients with DCIS 3. For Those Not Irradiated, I Prefer a Wider Margin
.2 Local Recurrence By Margin Width 697 DCIS Treated by Excision Alone Probability Recurrence.8.6.4.2 -.2-2 Local Recurrence Decreases as Margin Width Increases p =. 2 6 4 8 Margin Width (mm)
UPDATE
Original NEJM Patients by Rx Margins mm Median Follow-up 5. Years 2% 3% p = NS 4 Radiation Therapy 93 Excision Only
.2 Original 33 NEJM Patients by Rx Margins mm Median Follow-up.9 Years.8 2.3% 8.6%.6.4.2 4 Radiation Therapy 93 Excision Only p = NS 2 3 4 5 6 Years 7 8 9 2
.2 42 BCT DCIS Patients All Margins mm.8 4% 6%.6.4.2 6 Radiation Therapy 36 Excision Only p =.2 2 3 4 5 6 Years 7 8 9 2
.2 42 BCT DCIS Patients All Margins mm.8 4% 6%.6.4 Gold Standard for Excision + RT NSABP B7 = 6% @ 2-Yrs.2 6 Radiation Therapy 36 Excision Only p =.2 2 3 4 5 6 Years 7 8 9 2
.2 42 BCT DCIS Patients All Margins mm.8 4% 6%.6.4 Gold Standard for Excision + RT NSABP B7 = 6% @ 2-Yrs Excision Alone = 32%.2 6 Radiation Therapy 36 Excision Only p =.2 2 3 4 5 6 Years 7 8 9 2
.2 42 BCT DCIS Patients All Margins mm.8.6.4 Gold Standard for Excision + RT NSABP B7 = 6% @ 2-Yrs Excision Alone = 32% 4% 6% 32%.2 6 Radiation Therapy 36 Excision Only p =.2 2 3 4 5 6 Years 7 8 9 2
Margins By Themselves Are OK But if 6% IBTR Too Much Add Tamoxifen Use USC/VNPI
CANCER 996 Margin Width, Size, Grade, Necrosis
Added Age AJS 22
USC / Van Nuys Prognostic Index Score 2 3 Size 5 mm 6-4 > 4 Margin mm - 9 < VN Class Grade /2 without Necrosis Grade /2 with Necrosis Grade 3 Age > 6 4-6 < 4
Looked at Every Individual USC/ VNPI Score (4, 5, 6, 7, 8, 9,,, 2) by Various Margins Widths (, 2, 3, 5, mm) With and Without RT
Developed Treatment Guidelines for Maximum Allowable Recurrence Limits %, 5%, 2% 25%, 3%
.2 Local Recurrence-Free Survival 375 USC/VNPI = 4, 5 or 6 by TREATMENT.8 3.6% 7.2%.6.4.2 84 Radiation Therapy 29 Excision Only p =.39 2 3 4 5 6 Years 7 8 9 2
Local Recurrence-Free Survival 262 USC/VNPI = 7 by TREATMENT.2.8.6.4 Done Radiation Therapy p =.23 4% 29%.2 6 Excision Only 2 3 4 5 6 7 8 9 2 Years
Local Recurrence-Free Survival 9 USC/VNPI = 7, Margins 3 mm.2.8 6%.6.4 9 Excision Alone.2 2 3 4 5 6 7 8 9 2 Years
Local Recurrence-Free Survival 4 USC/VNPI =, or 2.2.8 p =.2.6.4 53%.2 58 Radiation Therapy 56 Excision Only 92% 2 3 4 5 6 7 8 9 2 Years
24 Treatment Guidelines Based on Less than 2% Local Recurrence as Acceptable USC / VNPI Treatment 2-Yr Recur 4, 5 or 6 Excision Alone 8% 7, Margins 3 mm Excision Alone 6% 7, Margins < 3 mm Radiation 4% 8, Margins 3 mm Radiation 4% 8, Margins < 3 mm Mastectomy % 9, Margins 5 mm Radiation 7% 9, Margins < 5 mm Mastectomy %, or 2 Mastectomy 7%
.2 Local Recurrence-Free Survival USC/VNPI 4-9 vs -2 563 Treated by Mastectomy.8.6 p =.29.5% 6.6%.4.2 289 - USC/VNPI = 4-9 (2 Recurrences) 274 - USC/VNPI = -2 (8 Recurrences) 2 3 4 5 6 Years 7 8 9 2
CONCLUSIONS. Excision Alone is Acceptable Treatment for Selected DCIS Patients per NCCN Guidelines 2. 35% of DCIS Patients currently treated with Excision Alone 3. mm Margins Work 4. Best Selection Criteria are Based on Size, Grade, Necrosis, Margin Width and Age (USC/VNPI)
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