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Increased Likelihood of Mastectomy in Human

Epidermal Growth Factor Receptor 2-positive

Ductal Carcinoma In Situ


Dr. Mahendra



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.


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.


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.


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

Exclusion criteria were unknown HER2neu

status and invasive carcinoma on final pathology.

Primary independent variable was HER2neu



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
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


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
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

HER2neu-positive patients have significantly
higher grade DCIS (87.5% are high grade vs
32.84% of HER2neu-negative pa-tients, P <
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.


Table 3 presents lesion size on imaging,

mastectomy rate, and actual size on final


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.


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.


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.


In conclusion, patients with HER2-positive DCIS

had greater extent of disease by imaging and
were more likely to undergo mastectomy than

A study with a larger sample size may reveal

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