Duktal Karsinoma İn Situ da Cerrahi Yaklaşım
Özet
Duktal karsinoma in situ (DKİS), meme duktusunun bazal membranını invaze etmeyen, çoğunlukla asemptomatik ve östrojen reseptörü pozitif seyreden intraduktal bir lezyondur. Tedavi edilmediğinde %20-30 oranında invaziv kansere dönüşebilen bu heterojen hastalıkta güncel cerrahi stratejiler; meme koruyucu cerrahi (MKC) ve mastektomi seçeneklerini kapsamaktadır. Geçmişte altın standart kabul edilen mastektominin yerini, günümüzde multimodel yaklaşımlar ve radyoterapinin (RT) katkısıyla, kozmetik başarıyı artıran onkoplastik cerrahi ve MKC almıştır. Cerrahi sınır yönetimi tartışmalı bir alan olmakla birlikte, özellikle RT alan hastalarda lokal nüksü belirgin şekilde azaltan 2 mm'lik negatif sınır eşiği uluslararası kılavuzlarda kabul görmektedir. Aksiller yaklaşımda ise rutin aksiller diseksiyonun yeri olmayıp, metastaz riskinin son derece düşük olması nedeniyle sentinel lenf nodu biyopsisi (SLNB) yalnızca mastektomi planlanan ya da geniş doku mobilizasyonu gerektiren olgularda önerilmektedir. Yaklaşık %50'si invaziv kanser olarak gelişen lokal nüks durumlarında ise hastanın önceki RT öyküsüne göre mastektomi ya da tekrarlayan MKC tercih edilmektedir. Tarama mamografilerinin yaygınlaşmasıyla DKİS tanısı artarken, tedavi yönetiminde agresif yaklaşımlardan kaçınarak hasta bazlı kararlar verilmelidir.
Ductal carcinoma in situ (DCIS) is an intraductal lesion characterized by cellular atypia without invading the basal membrane of the breast duct, which is mostly asymptomatic and estrogen receptor positive. In this heterogeneous disease, which progresses to invasive cancer in 20-30% of untreated cases, current surgical options include breast-conserving surgery (BCS) and mastectomy. While mastectomy was historically the gold standard, it has been replaced by BCS and oncoplastic surgery, which enhances cosmetic outcomes combined with radiotherapy (RT). Although surgical margin management remains controversial, a 2 mm negative margin threshold is widely accepted in international guidelines, providing equivalent local control especially for patients receiving RT. Regarding axillary management, routine axillary dissection has no role, and sentinel lymph node biopsy (SLNB) is not routinely recommended due to low metastasis rates, except for patients undergoing mastectomy or extensive oncoplastic tissue mobilization. Local recurrence, which presents as invasive cancer in 50% of cases, is managed with mastectomy or repeated BCS depending on the prior RT history. As screening mammography increases DCIS detection, establishing patient-specific surgical strategies according to guidelines while avoiding overly aggressive interventions remains crucial.
Referanslar
Koh VC, Lim JC, Thike AA, et al. Characteristics and behaviour of screen-detected ductal carcinoma in situ of the breast: comparison with symptomatic patients. Breast Cancer Res Treat. 2015;152(2):293– 304.
E. M. Ward, C. E. DeSantis, C. C. Lin et al., “Cancer statistics: breast cancer in situ,” CA: a cancer journal for clinicians, vol. 65, no. 6, pp. 481–495, 2015.
W. Zhou, K. Jirström, R. M. Amini et al., “Molecular subtypes in ductal carcinoma in situ of the breast and their relation to prognosis: a population-based cohort study,” BMC Cancer. 2013; 13(1):512.
Barnes NL, Dimopoulos N, Williams KE, Howe M, Bundred NJ. The frequency of presentation and clinico-pathological characteristics of symptomatic versus screen detected ductal carcinoma in situ of the breast. Eur J Surg Oncol. 2014;40(3):249–54.
Holmberg L, Garmo H, Granstrand B, et al. Absolute risk reductions for local recurrence after postoperative radiotherapy after sector resection for ductal carcinoma in situ of the breast. J Clin Oncol. 2008;26(8):1247–52.
Fisher ER, Land SR, Saad RS, et al. Pathologic variables predictive of breast events in patients with ductal carcinoma in situ. Am J Clin Pathol. 2007;128(1):86–91.
Zhang X., Dai H., Liu B., Song F., Chen K. Predictors for local invasive recurrence of ductal carcinoma in situ of the breast: A meta-analysis. Eur. J. Cancer Prev. 2016;25:19–28.
Erbas B, Provenzano E, Armes J, et al. The natural history of ductal carcinoma in situ of the breast: a review. Breast Cancer Res Treat. 2006;97(2):135–44.
Ozanne EM, Shieh Y, Barnes J, et al. Characterizing the impact of 25 years of DCIS treatment. Breast Cancer Res Treat. 2011;129(1):165–73.
Wapnir IL, Dignam JJ, Fisher B, et al. Long-term outcomes of invasive ipsilateral breast tumor recurrences after lumpectomy in NSABP B-17 and B-24 randomized clinical trials for DCIS. J Natl Cancer Inst. 2011;103(6):478–88.
Liu Y, Ide Y, Inuzuka M, et al. BRCA1/BRCA2 mutations in Japanese women with ductal carcinoma in situ. Mol Genet Genomic Med. 2019; 7(3): e493.
Stuart KE, Houssami N, Taylor R, Hayen A, Boyages J. Long-term outcomes of ductal carcinoma in situ of the breast: a systematic review, meta-analysis and meta-regression analysis. BMC Cancer. 2015;15:890.
Carter SA, Lyons GR, Kuerer HM, et al. Operative and oncologic outcomes in 9861 patients with operable breast cancer: single institution analysis of breast conservation with oncoplastic reconstruction. Ann Surg Oncol. 2016;23(10):3190–8.
Behluli I, Le Renard PE, Rozwag K, Oppelt P, Kaufmann A, Schneider A. Oncoplastic breast surgery versus conventional breast-conserving surgery: a comparative retrospective study. ANZ J Surg 2019;89:1236-41.
Clough KB, van la Parra RFD, Thygesen HH, et al. Ann Surg. 2018 Jul;268(1):165-171. Oh MY, Kim Y, Kim J, Cheun JH, Jung JG, Kim HK, Lee HB, Han W. J Breast Cancer. 2021;24(6):520-30.
Tuttle TM, Jarosek S, Habermann EB, et al. Increasing rates of contra- lateral prophylactic mastectomy among patients with ductal carcinoma in situ. J Clin Oncol. 2009;27(9):1362–7.
De Lorenzi F, Di Bella J, Maisonneuve P et al. Oncoplastic breast surgery for the management of ductal carcinoma in situ (DCIS): is it oncologically safe? A retrospective cohort analysis. Eur J Surg Oncol.2018;44:957-62.
Doke K, Butler S, Mitchell MP. Current Therapeutic Approaches to DCIS. J Mammary Gland Biol Neoplasia. 2018 Dec;23(4):279-91.
Doherty C, Pearce S, Baxter N. Et al. Trends in immediate breast reconstruction and radiation after mastectomy: a population study. Breast J. 2020; 26: 446-53.
Galimberti V, Vicini E, Corso G, et al. Nipple-sparing and skin-sparing mastectomy: Review of aims, oncological safety and contraindications. Breast. 2017;34:82-4.
Dunne C, Burke JP, Morrow M, et al. Effect of margin status on local recurrence after breast conservation and radiation therapy for ductal carcinoma in situ. J Clin Oncol. 2009;27(10):1615–20.
Wang S-Y, Chu H, Shamliyan T, et al. Network meta-analysis of margin threshold for women with ductal carcinoma in situ. J Natl Cancer Inst. 2012;104:507–516.
Silverstein MJ, Lagios MD, Groshen S, et al. The influence of margin width on local control of ductal carcinoma in situ of the breast. N Engl J Med. 1999;340:1455–61
Van Zee KJ, Subhedar P, Olcese C, Patil S, Morrow M. Relationship Between Margin Width and Recurrence of Ductal Carcinoma In Situ: Analysis of 2996 Women Treated With Breast-conserving Surgery for 30 Years. Ann Surg. 2015;262:623–31.
Marinovich ML, Azizi L, Macaskill P, et al. The Association of Surgical Margins and Local Recurrence in Women with Ductal Carcinoma In Situ Treated with Breast-Conserving Therapy: A Meta-Analysis. Ann Surg Oncol. 2016 ;23(12):3811-3821.
Morrow M, Van Zee KJ, Solin LJ, et al. Society of surgical oncology-American society for radiation oncology-American society of clinical oncology con- sensus guideline on margins for breast-conserving surgery with whole-breast irradiation in ductal carcinoma in situ. J Clin Oncol. 2016. pii: JCO683573.
National comprehensive cancer network. breast cancer. [Online] https:// www.nccn.org/professionals/physician_gls/pdf/breast.pdf. Version 2.2022. [Accessed:01.04.2022]
Pilewskie M, Morrow M. Margins in breast cancer: How much is enough? Cancer. 2018;124(7):1335-1341.
Chen H, Bai F, Wang M, et al. The prognostic significance of co-existence ductal carcinoma in situ in invasive ductal breast cancer: a large population-based study and a matched case-control analysis. Ann Transl Med. 2019 Sep; 7(18): 484.
Baxter NN, Virnig BA, Durham SB, Tuttle TM. Trends in the treatment of ductal carcinoma in situ of the breast. J Natl Cancer Inst 2004; 96: 443–8.
Kelly TA, Kim JA, Patrick R, Grundfest S, Crowe JP. Axillary lymph node metastases in patients with a final diagnosis of ductal carcinoma in situ. Am J Surg 2003; 186: 368–70.
Zavagno G, Carcoforo P, Marconato R, Franchini Z, Scalco G, Burelli P et al. Role of axillary sentinel lymph node biopsy in patients with pure ductal carcinoma in situ of the breast. BMC Cancer 2005; 5: 28–33.
Klauber-DeMore N, Tan LK, Liberman L, Kaptain S, Fey J, Borgen P et al. Sentinel lymph node biopsy: is it indicated in patients with high-risk ductal carcinoma-in-situ and ductal carcinoma-in situ with microinvasion? Ann Surg Oncol 2000; 7: 636–42.
Ansari B, Ogston SA, Purdie CA, et al. Meta-analysis of sentinel node biopsy in ductal carcinoma in situ of the breast. Br J Surg. 2008;95(5):547–54.
Nicholson S, Hanby A, Clements K, et al. Variations in the manage- ment of the axilla in screen-detected ductal carcinoma in situ: evi- dence from the UK NHS breast screening programme audit of screen detected DCIS. Eur J Surg Oncol. 2015;41(1):86–93.
Choi B, Jegatheeswaran L, Nakhoul M,et al. Axillary staging in ductal carcinoma in situ with microinvasion: A meta-analysis. Surg Oncol. 2021;37:101557.
Narod SA, Iqbal J, Giannakeas V, et al. Breast cancer mortality after a diagnosis of ductal carcinoma in situ. JAMA Oncol. 2015;1(7):888–96.
Cronin PA, Olcese C, Patil S,et al. Impact of age on risk of recurrence of ductal carcinoma in situ: outcomes of 2996 women treated with breast-conserving surgery over 30 years. Ann Surg Oncol. 2016;23(9):2816–24.
Li Q, Wang K, Yang L, et al. Long-term Survival Comparison of Repeated Breast-conserving Surgery Versus Mastectomy for Patients with DCIS with Ipsilateral Breast Tumor Recurrence: A Real-world Longitudinal Study. Clin Breast Cancer. 2021;21(4):360-72.
Hassett MJ, Jiang W, Hughes ME, et al.Treating Second Breast Events After Breast-Conserving Surgery for Ductal Carcinoma in Situ. J Natl Compr Canc Netw. 2018;16(4):387-94.
