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DCIS: Ductal Carcinoma In Situ

 

 

DCIS - YEAR 1998

DCIS is the earliest form of demonstratable breast carcinoma. It is noninvasive and is usually detected incidentally or via mammography. DCIS is a malignancy of the epithelial cells lining the lactiferous ducts without penetration by these cells of the ductal basement membrane. With the use of conventional light microscopy, electron micrograph may reveal basement membrane invasion. In DCIS there is no invasion of the periductal stromal tissue.

RADIOLOGICAL CHARACTERISTICS

CLICK HERE TO VIEW THE DCIS RADIOLOGY SECTION & MAMMOGRAMS

PATHOLOGICAL CHARACTERISTICS

Link to DCIS PathologyCLICK HERE TO VIEW THE DCIS PATHOLOGY SECTION & SLIDES

DCIS PATHOLOGY SECTION (TABLE OF CONTENTS)
  • Pathological Definition of DCIS
  • Gross Pathology of DCIS
  • Classification of DCIS
    • By Predominant Architecture
    • By Nuclear Features
  • Prognosis of DCIS using the Van Nuys Classification

 


 

DCIS: GENERAL CHARACTERISTICS
Percentage of all Breast Malignancies 25 to 30%
Relationship to LCIS None
Relationship to Minimally Invasive Breast CA None
Relationship to Invasive Breast CA Precursor
Incidence of Multicentricity 18 to 66% of all series(mean 35%)
Invasive Component None
Clinical Detection Most Uncommon
Mammographic Detection Most Common
Bilateral DCIS Uncommon (10 to 15 %)
Synchronous Invasive Cancer Up to 20 %
Subsequent Invasive Cancer (Biopsy proven DCIS) 10% at 5 Years
Metastatic Potential 0

 

DCIS: PROGNOSTIC FACTORS
Factor Poor Prognostic Index Better Prognostic Index
Size Large, palpable lesions Mammographic lesions
Histological Pattern Comedo Type Non Comedo Type
Grade High Nuclear Grade Low Nuclear Grade
Genetic Profile HER-2/neu Uncertain Uncertain
DNA Flow Cytometry Aneuploid, High S phase Diploid, Low S Phase
Van Nuys Prognostic Score (see Pathology Section) 8 - 9 Points 3 - 4 Points

 

DCIS: TREATMENT

Every patient diagnosed with DCIS should be given the following three therapeutic options with accompanying disclosures regarding the subsequent results.

  1. Simple Mastectomy
  2. Wide Resection with Documented Clear Margins and Radiotherapy
  3. Wide Resection with Documented Clear Margins
Therapeutic Option 1: Simple Mastectomy for DCIS (with or without Reconstruction)
Reference Studies Multiple (Kinne et al.,Fowble et al.,Rosner et al,Fisher et al,Vezeridis et al.)
Recurrence Rate 1% to 10%
Mortality Rate from Breast Carcinoma 0, 1.7%,2.3% and 8%
Recommended for
-Young, Premenopausal, Comedo Type DCIS, Tumors > 4.0cm
-Diffuse microcalcifications of the breast - MULTICENTRIC DCIS
-Inability to perform a wide excision with clear margins
Notes This is the safest management for DCIS - No Axillary Lymph Node Dissection

 

Therapeutic Option 2: Wide Excision (Documented Clear Margins) and Radiotherapy
Problems with this Option Lack of long term studies and small number of patients
Reference Studies Silverstein et al. DCIS:227 cases without microinvasion. Eur J Cancer 1992;28:630-4
Disease Free Survival (7 yrs)
Mastectomy Group (Tumor > 4cm): 98 %
Local Excision and Radiotherapy (Tumor < 4cm): 84%
Recurrence Rate (calc) 7% at 5 years in NSABP B-17, 16 % at 7 years in Silverstein's.
Invasive Recurrence 45% of all recurrences
Cancer Free Survival At 10 years: 97 %
Overall Survival Compared to Mastectomy Group Same
Recommended for: Nonpalpable lesion and small size DCIS (< 2 cm)
NOTES Clear Margins Status is ESSENTIAL

 

Therapeutic Option 3: Wide Excision Only
Problems with this Option High Recurrence Rate, studies lack clear margin documentation
Reference Studies Schartz et al, Lagios et al, Price et al
Local Recurrences
-at 60 months: 13 % (small mammographic lesions)
-Overall all tumors: Up to 63 %
-NSABP B-06: at 84 months: 43 % (palpable lesions, questionable margins)
-NSABP B-17: at 5 years, 16.4%
Invasive Recurrence 50% of all recurrences
Mortality N/A
Recommended for: Small tumors < 2.5 cm, mammographic, nonpalpable DCIS, non comedo type in older patients (with no residual demonstrable disease on postop mammogram and clear margins)

 

Axillary Lymph Nodes Dissection: Not Indicated with Noninvasive Component

None

Tamoxifen No Beneficial Effect Documented at this time
Reference Studies NSABP B-24: Incomplete

 

TECHNICAL NOTES
  1. Some form of DCIS may have no clinical significance as some women at autopsy were found to harbor DCIS (15%)
  2. An accurate diagnosis and accurate margins cannot be obtained on frozen section. Final histological diagnosis and margins should be obtained by permanent section.
  3. Always obtain a post biopsy or post lumpectomy mammogram six months later.
REFERENCES

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