TransMed: DCIS

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

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PATHOLOGICAL CHARACTERISTICS

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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

LOCAL / SURGICAL MANAGEMENT

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

Simple Mastectomy

Wide Resection with Documented Clear Margins and Radiotherapy

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

SYSTEMIC TREATMENT: CHEMOTHERAPEUTIC PROTOCOLS

None

SYSTEMIC TREATMENT: HORMONAL PROTOCOLS

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

TECHNICAL NOTES

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

REFERENCES

Rosen PP et al.,. Intraepithelial (preinvasive or in situ) Carcinoma. In: Rosai J, Sobin LH, Editors. Tumors of the Mammary Glands. Atlas of tumor pathology. Washington, DC: Armed Forces Institutes of Pathology, 1993:119-55.
Carter D, Smith RRL, Carcinoma In Situ of the Breast. Cancer 1977; 40:1189-93.
Fryberg ER, Balnd KL, In Situ Breast Carcinoma, Adv Surg 1993; 26:29-72.
Von Rueden DG, Wilson RE, Intraductal Carcinoma of the Breast, Surg Gynecolo Obstet 1984; 158:105-11.
Fryckberg ER et al., Current Concepts for Management of Early (In Situ and Occult Invasive) Breast Carcinoma. In : Band KI, Copeland EM, Editors, The Breast: Comprehensive Management of Benign and Malignant Diseases. Philadelphia: Saunders, 1991:731-Invasive Breast Carcinoma: Result of a National Survey by the American College of Surgeons. Ann Surg 1980;192:139-47.
Carpenter R et al., Management of Screen Detected Ductal Carcinoma In Situ of the Female Bbreast. Br J Surg 1989; 76:564-7.
Silverstein MJ et al., Duct Carcinoma In Situ: 227 Cases Without Microinvasion, Eur J Cancer 1992; 28:630-4.
Arnesson LG et al., Follow-up of Two Treatment Modalities for Ductal Cancer In Situ of the Breast, Br J Surg 1989;76:672-5
Solin et al., Ten Year Results of Breast Conserving Surgery and Definitive Irradiation for Intraductal Carcinoma of the Breast, Cancer 1991; 68:2337-44.
White J et al., Outcome and Prognostic Factors for Local Recurrence in Mammographically Detected Ductal Carcinoma In Situ of the Breast Treated with Conservative Surgery and Radiation Therapy, Int J Radiat Onc Biol Phys 1995; 31:791-7.
Fisher B. et al., Lumpectomy Compared with Lumpectomy and Radiation Therapy for the Treatment of Intraductal Breast Cancer, N Engl J Med 1993;217:207-25
Solin LJ et al. Ten year results of breast conserving surgery and definitive irradiation for intraductal carcinoma of the breast. Cancer 1991; 68:2337-44.
Silverstein M et al., Axillary Lymphadenectomy for Intraductal Carcinoma of the Breast, Surg Gyneco Obst 1991; 172:211-4.
Ottesen GL et al., Ductal Carcinoma In Situ of the Female Bbreast: Short Term Results of a Prospective Nationwide Study, The Danish breast cancer cooperative group,Am J Surg Patho; 1992; 161183-96.
Poller DN et al., Ideas in Pathology: Ductal Carcinoma In Situ of the Breast: a Proposal for a New Simplified Histological Classification Association Between Cellular Proliferation and c-erB-2 Protein Expression, Mod Pathol 1994; 7:257-62.
Swallow CJ et al., Ductal Carcinoma In Situ of the Breast: Progress and Controversy, In Current Pbs in Surgery; 1996:33:553-608.