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Increased Likelihood of Mastectomy in Human

Epidermal Growth Factor Receptor 2-positive


Ductal Carcinoma In Situ

Oleh

Dr. Mahendra

Introduction

HUMAN EPIDERMAL GROWTH factor receptor


2(HER2neu) is overexpressed in approximately 15
to 20 per cent of invasive breast carcinomas.

Patients with HER2neu-positive invasive


carcinoma tend to have more diffuse disease,
larger tumors, higher grade le-sions, and more
aggressive tumor behavior including higher
recurrence2, 3 and poorer survival.4

Some literature reports that HER2neu-positive


DCIS is more likely to be high grade5 and more
likely to have foci of microinvasion.

Introduction

Similar to invasive disease, mastectomy and


lump-ectomy with radiation both offer good
local control.

Studies have shown that multifocality is an


independent risk factor for the development
of local recurrence after breast-conserving
surgery for DCIS13 and that patients with
multifocal DCIS are three times more likely to
undergo mastectomy than lumpectomy.

Introduction

Other factors found to increase the


mastectomy rate in DCIS are younger age,
higher grade, and larger tumors.

This studys objective is to investigate the


correlation be-tween HER2neu-positive status
and more diffuse DCIS by comparing
preoperative imaging, tumor size, and rate of
mastectomy of HER2neu-positive versus
-negative patients.

Methods

Data were gathered on all patients


undergoing breast surgery at the University of
California, San Diego from 2002 to 2011, We
queried this database for all patients with
DCIS.

Exclusion criteria were unknown HER2neu


status and invasive carcinoma on final pathology.

Primary independent variable was HER2neu


status.

Methods

Methods
Chi-squared analyses were performed comparing
de-mographic information and outcomes between
HER2neu-positive and -negative patients as well
as mastectomy and lumpectomy patients.
A single breast radiologist who was blinded to the
HER2neu status of the patients reviewed all
imaging
Multivariate analyses were then performed to
control for covariates determining odds ratio of
mastectomy, controlling for age, race, and
marital status.
Pathology was reviewed for final size of the
lesion.

Results

There were 406 total patients with DCIS treated


between 2002 and 2011.
Two hundred twenty-eight cases were excluded for
unknown HER2neu status;
11 patients (12 cases) were excluded for invasive
cancer on final pathology.
Thirty-two of these 166 cases were HER2neupositive (19%).
Fifty-three total patients (32%) underwent
mastectomy.
HER2neu-positive patients tend to be younger than
HER2neu-negative, but this is not significant (P 4
0.422); there is no significant difference in race (P 4
0.694).

Results
HER2neu-positive patients have significantly
higher grade DCIS (87.5% are high grade vs
32.84% of HER2neu-negative pa-tients, P <
0.001).
HER2neu-negative disease is 85 per cent ER/PRpositive, whereas HER2neu-positive dis-ease is
only 59 per cent ER/PR-positive (P < 0.001).
There is no significant difference in age, race, or
marital status between patients who undergo
mastectomy or lump-ectomy. Patients who
undergo mastectomy have higher grade DCIS
and are more often ER/PR-negative.

Results

Table 3 presents lesion size on imaging,


mastectomy rate, and actual size on final
pathology.

Discussion

The results of this study indicate that HER2neu-positive DCIS


lesions are more diffuse on imaging and more frequently treated
with mastectomy.

The current study found that HER2neu-positive tumors were


associated with larger appearance on imaging than HER2neunegative; many groups report that larger tumors should be treated
with mastectomy.15 This study as well as Rakovitch et al.14 report
that patients who are HER2neu-positive are three times more likely
to undergo mastectomy than HER2neu-negative patients.

Surgical options include mastectomy, lumpectomy, and


lumpectomy plus radiation. Surgeons have used the used various
models to try to predict preoperatively which patients will be good
candidates for lumpectomy versus mastectomy.

Discussion

the Van Nuys Prognostic Index (VNPI), is a simple


scoring method that has been used in the United States
for more than 10 years to stratify patients with different
risks of local recurrence to de-cide which patients are
good candidates for breast conservation radiation.

Discussion

This study is retrospective, which introduces


selection bias.

Lastly, the study is unable to provide definitive


explanation of why Her2neu-positive tumors are
significantly more extensive, whether it is actual
lesion size or detectability on mammogram.

Discussion

In conclusion, patients with HER2-positive DCIS


had greater extent of disease by imaging and
were more likely to undergo mastectomy than
HER2neu-negative.

A study with a larger sample size may reveal


that HER2neu-positive DCIS is more diffuse and
multifocal, a question that deserves further
investigation.