What is Ductal Carcinoma In Situ?
When cancer cells develop in the milk duct, it is called Ductal Carcinoma In Situ (DCIS) or Stage 0 breast cancer. In situ means the cancer has not metastasized and stays in its place. However, sometimes it can become invasive and spread to nearby tissues.
DCIS is Stage 0 Cancer which has no lymph node invasion, no distant metastases
What is the diagnosis for DCIS?
The procedure during the diagnosis includes
1. Physical examination of the breast
2. Genetic counseling for people with family history
3. Pathologic review
4. Magnetic resonance imaging ( MRI) of the breast with IV contrast: MRI performed preoperatively can help find the extent of the disease. After locating the cancerous tissue, a needle is used to excise the sample from the body. We can also analyze how the cancerous cells respond to treatment post-operatively.
In an MRI, There is a possibility of a false positive (Indicating the cancer is present when it's not)
Therefore, surgery should not be entirely dependent on the result of Magnetic resonance imaging (MRI).
MRI follow-up: For patients who've had breast cancer before, MRI can be considered if they have dense breasts, were diagnosed before age 50, or have a higher risk of getting another breast cancer based on family history or inherited risk.
What are the treatment plan for Ductal In Situ Carcinoma (DCIS)
After analyzing the tumor, the two possible treatments could be
the treatment can be either BCS without lymph node or mastectomy.
Treatment Plan 1: Breast Conservation Surgery
What is Breast Conservation Surgery (BCS)?
Breast conservation surgery refers to excising the cancerous cells in the breast only. Often radiation is followed after Breast conservation surgery to avoid recurrence.
Principles of Radiation Therapy (RT)
Radiation therapy needs to be individualized.
1. First step should be Computed tomography (CT) to identify the target area. It should be done weekly to locate the target tissue.
2. For breast/chest wall and nodes, photons with or without electrons are used
3. Treatment planning should be such that the target tissue is irradiated homogeneously(, also to avoid radiation to nearby normal tissues.
4. Radiation therapy (RT) can be followed by chemotherapy
Whole breast Radiation therapy (WBRT)
WBRT has been shown to decrease the chances of recurrence. It is done in such a way as to avoid radiation to normal tissues as much as possible. In this procedure, the whole breast is irradiated and even a booster dose is given.
A boost dose can be given after removing the lump with particles such as electrons, photons, or brachytherapy ( placing radioactive material inside the body ).
A short and strong radiation dose is given for patients more than 50 years of age, with early-stage breast cancer with no invasion to the lymph nodes.
Chest wall radiation
The unit of measurement of the dose of radiation is Gray (Gy)
The radiation therapy dose for Chest wall radiation is 45-50.4 at 1.8-2 Gy/fx meaning a total of 45-50.4 amount of radiation is given to the patient in 1.8 - 2 fractions
For those with no breast reconstruction
40 Gy at 2.67 Gy/fx or 42.5 Gy at 2.66 Gy/fx is given.
Material such as a Bolus is used to ensure proper penetration of the radiation through the skin, especially for Inflammatory breast cancer (IBC)
Nodal region radiation
The regional lymph node should be irradiated with 45-50.4 Gy at 1.8- 2 Gy /fx. For people without breast reconstruction receives 40 Gy at 2.67 Gy/fx or 42.5 Gy at 2.66 Gy/ Fx
Additional boost can be given to nearby enlarged lymph nodes that have not been excised surgically
Adjuvant systemic therapy
The patients who are treated with preoperative systemic therapy may be treated post-operatively.Adjuvant RT depends on the severity of the disease when it was diagnosed and it's also viewed under a microscope or how it looks under the microscope after preoperative treatment
after the preoperative systemic therapy
Radiation Therapy (RT) followed by Chemotherapy
1.CMF ( cyclophosphamide/methotrexate/fluorouracil) and RT may be given at the same time or CMF followed by RT.
2.Capecitabine and Olaaparib were given after RT
3.Endocrine therapy (Stopping the growth of cancer cells by blocking or interfering with the way 4.hormones bind to cancerous cells) with RT can also be given.
5.To avoid side effects endocrine therapy is given post-RT or can be given simultaneously with RT.
HER 2 targeted therapy( Used to inhibit the activity of HER 2 protein ) with endocrine therapy may be given with Radiation therapy.
Accelerated Partial Breast radiation (APBI)
Since the treatment is completed in 4-5 days, hence it is called accelerated Partial breast radiation.
It is given after Breast conservative surgery.If the person is BRCA negative ( the gene is not inherited)
and comes under the ASTRO guideline, then they can opt for APBI
These guidelines are :
1. Patient over 50 years
2. Small size, negative margins, no invasion to blood vessels and takes up Estrogen i.e the cancer is ER positive
3. smaller or equal to 2.5 cm in size and clear edge or negative margin
Treatment plan 2
Total mastectomy with or without SLNB ( Sentinel lymph node biopsy).
A lymph node adjacent to cancerous tissue is called a sentinel lymph node
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