Breast exam[ edit ] A pictorial example of breast self-examination in six steps. Steps involve visual inspection of the breasts with the arms in different positions. Step 4 is palpation of the breast. Step 5 is palpation of the nipple.
J Cancer ; 8 Kuerer1Benjamin D. Barcenas3, Lumarie Santiago6, Mary E. How to cite this article: Many groups now use this guideline as an absolute indication for additional surgery. Utilization of these multidisciplinary treatment protocols and techniques may not be exportable and extrapolated to all hospitals, breast programs and systems as they can be complex and resource intensive.
DCIS, ductal carcinoma in situ, breast cancer, surgery, pathology, radiotherapy, margins. Introduction Patients with negative margins after breast conserving surgery BCS for ductal carcinoma in situ DCIS are at lower risk of local recurrence LR compared with patients with positive margins; however the optimal margin width has been a topic of debate for many decades.
The current management of DCIS includes a wide array of treatment options in patients and physicians struggle with decision making in order to avoid overtreatment or under treatment.
On the other hand we continue to debate what constitutes an adequate margin of resection among patients undergoing BCS followed by whole breast radiation therapy WBRT [ 1 - 4 ]. To complicate this further, recent meta-analyses and consensus guideline for invasive breast cancer with and without DCIS have defined an adequate margin of resection of no tumor on ink yet the newest consensus guideline for DCIS defines a 2 mm margin as the standard for an adequate margin in DCIS treated with WBRT [ 5 - 7 ].
The main goal of developing the guideline was to assist clinicians and patients in the decision-making process based on the best available evidence.
The DCIS consensus guideline is based in a study-level meta-analysis that evaluated the effect of margin width and LR with the aim of defining a minimum negative margin to maximize local control [ 5 ].
The studies included in the meta-analysis were selected from 1, overall available studies.
A total of studies were assessed for eligibility with 20 retrospective studies selected for inclusion. The studies selected represented 7, patients treated from The median follow-up was 6. The meta-analysis included two different statistical analyses, the LR proportion was modeled using random-effects logistic meta-regression frequentist approach and a network meta-analysis that allowed for multiple margins distance per study Bayesian approach.
In the Bayesian analysis OR relative to positive margins for 2 mm 0. The width reported in the studies included in the meta-analysis did not allow the investigators to analyze the impact of margins Based on these results, the meta-analysis concluded the margin distances above 2 mm are not significantly associated with further reduction in odds of LR 3.
Margins of at least 2 mm are associated with a reduced risk or LR and margins wider that 2 mm are not associated with lower LR, thus the evidence does not support the routine practice of obtaining margins wider than 2 mm [ 7 ].
The consensus also evaluated data on endocrine therapy, radiation therapy and patient and tumor characteristics.
While endocrine therapy reduces breast adverse outcomes, there is no association between therapy and margins, similarly the details associated with the dose, frequency and boost should not be dependent of margin status. The guideline multidisciplinary panel recognized that there are a number of factors associated with the risk of LR including histologic pattern, comedonecrosis, size of DCIS, and even gene expression profiles.
Currently there are no data addressing whether recommended margin width should be influenced by these factors. An area of specific clinical interest that the guideline addresses is the common scenario of patients with DCIS and microinvasion defined as no invasive focus larger than 1mmin this cases, based on expert opinion, the panel considered that the DCIS margin guideline should be used given that the majority of the lesion was DCIS and that the systemic management of these patients resembles that of DCIS and not invasive carcinomas.
Conversely, among patients with invasive carcinoma with a DCIS component, the recommendation is to follow the invasive cancer guideline [ 6 ], given that the natural history and treatment of these lesions is more similar to invasive cancers where majority of patients receive systemic therapy.
The panel noted in some cases, where an extensive intraductal component is seen, a post-excision mammography could be needed and some patients may require re-excision. The authors emphasize that the guideline only applies to patients with DCIS treated with BCS and WBRT, and the recommendations therefore cannot be extrapolated to patients treated with accelerated partial breast irradiation.
The National Comprehensive Cancer Network guidelines now also state that margins of at least 2 mm are associated with a reduced risk of ipsilateral breast tumor recurrence IBTR relative to narrower negative margin widths in patients receiving WBRT [ 11 ].
Therefore, our group was particularly interested in defining the absolute risk of local recurrence in contemporary patients with less than 2 mm margins treated for DCIS with BCS with and without radiotherapy at MD Anderson.
Specifically, risk of IBTR at 5-years was 3. We recently updated this cohort with additional patients and longer follow-up and analyzed outcomes.BI-RADS. The breast imaging reporting and data system (BI-RADS) is a standardized criterion aiding clinical decisions based on identified masses, their morphology and calcifications, their size, number, and morphology.
Although mammography is the only test with evidence demonstrating breast cancer mortality reduction, its utility is challenged by false-positive recalls leading to additional imaging and invasive benign biopsies, interval invasive cancers, and overdiagnosis.
Balancing the benefit-to-harm ratio of screening strategies has generated substantial debate, particularly over what constitutes a. Aetna considers other minimally invasive image-guided breast biopsy procedures (i.e., those not mentioned above) experimental and investigational (e.g., PET-guided breast biopsy (Naviscan)) because their effectiveness has not been established.
The American Association of Physicists in Medicine is a member society concerned with the topics of medical physics, radiation oncology, imaging physics, health physics, hospital physics, medical radiation, physics careers, ionizing radiation, brachytherapy and diagnostic imaging.
Tomosynthesis, also digital tomosynthesis (DTS), is a method for performing high-resolution limited-angle tomography at radiation dose levels comparable with projectional r-bridal.com has been studied for a variety of clinical applications, including vascular imaging, dental imaging, orthopedic imaging, mammographic imaging, musculoskeletal imaging, and chest imaging.
Piero Boraschi, Francescamaria Donati, Federica Pacciardi, Davide Ghinolfi, Fabio Falaschi.