Getting the right balance in treatment of ductal carcinoma in situ (DCIS)
Abstract
As a result of mammographic detection, ductal carcinoma in situ (DCIS) is an increasing problem in breast clinics. Both histopathology and molecular profiling can identify subtypes likely to progress to invasive disease, but there is no subgroup with a zero likelihood of subsequent invasion. In patients with low/intermediate grade DCIS, if breast irradiation is not being carried out after free margins have been achieved the patient should be aware of the risks of withholding and the benefits and morbidity of adjuvant radiotherapy. Either tamoxifen or an aromatase inhibitor may be of value in those with low/intermediate ER+ve disease if radiotherapy is being withheld. For those patients with extensive or multicentric DCIS, mastectomy is the appropriate treatment. This is best combined with sentinel node biopsy and all such cases should be offered immediate reconstruction.
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Cite this article as:
Fentiman IS. Getting the right balance in treatment of ductal carcinoma in situ (DCIS). Int J Cancer Ther Oncol 2013; 1(2):01029.
DOI: http://dx.doi.org/10.14319/ijcto.0102.9
Keywords
References
Veronesi U, Saccozzi R, Del Vecchio M, et al. Comparing radical mastectomy with quadrantectomy, axillary dissection, and radiotherapy in patients with small cancers of the breast. N Engl J Med 1981; 305: 6-11.
Fisher B, Redmond C, Poisson R, et al. Eight-year results of a randomized clinical trial comparing total mastectomy and lumpectomy with or without irradiation in the treatment of breast cancer. N Engl J Med 1989; 320: 822-8.
Van Dongen JA, Bartelink H, Fentiman IS, et al. Factors influencing local relapse and survival and results of salvage treatment after breast-conserving therapy in operable breast cancer: EORTC Trial 10801, breast conservation compared with mastectomy in TNM stage I and II breast cancer. Eur J Cancer 1992; 28A: 801-5.
Jacobson JA, Danforth DN, Cowan KH, et al. Ten-year results of a comparison of conservation with mastectomy in the treatment of stage I and II breast cancer. N Engl J Med 1995; 332: 907-11.
van Dongen JA, Bartelink H, Fentiman IS, Peterse JL. Ductal carcinoma in situ (DCIS) of the breast –a therapeutic dilemma. Eur J Surg Oncol 1987; 13: 123-126.
Virnig BA, Tuttle TM, Shamliyan T, Kane RL. Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes. J Natl Cancer Inst 2010; 102:170–178.
Pinder SE, Duggan C, Ellis IO, Cuzick J, Forbes JF, Bishop H, Fentiman IS & George WD. A new pathological system for grading DCIS with improved prediction of local recurrence: results from the UKCCCR/ANZ DCIS trial. Br J Cancer 2010; 103: 94-100.
Bijker N, Petersee JL, Duchateau L, Julien J-P, Fentiman IS, et al. Risk factors for recurrence and metastasis after breast conserving therapy for ductal carcinoma in situ: analysis of European Organisation for Research and Treatment of cancer trial 10853. J Clin Oncol 2001; 19: 2263-2271.
Esserman L, Shieh Y, Thompson I. Rethinking screening for breast cancer and prostate cancer. JAMA 2009; 302:1685-1692.
Solin LJ, Gray R, Baehner FL, Butler SM, Hughes LL, et al. A multigene expression assay to predict local recurrence risk for ductal carcinoma in situ of the breast. J Natl Cancer Inst 2013; 105:701–710.
Wapnir IL, Dignam JJ, Fisher B, Mamounas EP, Stewart J. Anderson SJ, et al. Long-term outcomes of invasive ipsilateral breast tumor recurrences after lumpectomy in NSABP B-17 and B-24 randomized clinical trials for DCIS. J Natl Cancer Inst 2011; 103: 478–488.
Cuzick J, Sestak I, Pinder SE, Ellis IO, Forsyth S, Bundred NJ, Forbes JF, Bishop H, Fentiman IS, George WD. Effect of tamoxifen and radiotherapy in women with locally excised ductal carcinoma in situ: long-term results from the UK/ANZ DCIS trial. Lancet Oncol 2011; 12: 21-29.
Donker M, Litiere S, Werutsky G, Julien JP, Fentiman IS, et al. Breast-conserving treatment with or without radiotherapy in Ductal Carcinoma In Situ: 15-year Recurrence Rates and Outcome After a Recurrence, from the EORTC 10853 Randomized Phase III Trial. Journal of Clinical Oncology 2013; 31:4054-4059.
Holmberg L, Garmo H, Granstrand B, et al. Absolute risk reductions for local recurrence after postoperative radiotherapy after sector resection for ductal carcinoma in situ of the breast. J Clin Oncol 2008; 26:1247–1252.
Correa C, McGale P, Taylor C, et al. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). J Natl Cancer Inst Monogr 2010; 2010:162–177.
Wehner P, Lagios MD, Silverstein MJ. DCIS treated with excision alone using the national Comprehensive Cancer Network (NCCN) Guidelines. Ann Surg Oncol 2013; 20: 3175-9.
Fisher B, Dignam J, Wolmark N, et al. Tamoxifen in treatment of intraductal breast cancer: National Surgical Adjuvant Breast and Bowel Project B-24 randomised controlled trial. Lancet 1999; 353: 1993–2000.
Houghton J, George WD, Cuzick J, Duggan C, Fentiman IS, Spittle M; UK Coordinating Committee on Cancer Research; Ductal Carcinoma in situ Working Party; DCIS trialists in the UK, Australia, and New Zealand. Radiotherapy and tamoxifen in women with completely excised ductal carcinoma in situ of the breast in the UK, Australia, and New Zealand: randomised controlled trial. Lancet 2003; 362:95-102.
Wapnir IL, Dignam JJ, Fisher B, et al. Long-term outcomes of invasive ipsilateral breast tumor recurrences after lumpectomy in NSABP B-17 and B-24 randomized clinical trials for DCIS. J Natl Cancer Inst 2011; 103:478–488.
Allred DC, Anderson SJ, Paik S, et al. Adjuvant tamoxifen reduces subsequent breast cancer in women with estrogen receptor–positive ductal carcinoma in situ: a study based on NSABP Protocol B-24. J Clin Oncol 2012; 30:1268-1273.
Cuzick J, Sestak I, Pinder SE, et al. Effect of tamoxifen and radiotherapy in women with locally excised ductal carcinoma in situ: long-term results from the UK/ANZ DCIS trial. Lancet Oncol 2011; 12: 21-9.
StaleyH, McCallum I, Bruce J. Postoperative tamoxifen for ductal carcinoma in situ. Cochrane Database Syst Rev 2012; 10:CD007847.
Cuzick J. Aromatase inhibitors in prevention – data from the ATAC (Arimidex, tamoxifen alone or in combination) trial and the design of IBIS-II (the second International Breast Cancer Intervention Study). Recent Results Cancer Res 2003; 163:96–103.
Dixon JM, Faratian D, White S et al. DCIS and aromatase inhibitors. J Steroid Biochem Mol Biol 2007; 106:173-9.
Chen YY, DeVries S, Anderson J, Lessing J, et al. Pathologic and biologic response to preoperative endocrine therapy in patients with ER-positive ductal carcinoma in situ. BMC Cancer 2009; 9:285.
Davis KL, Barth RJ Jr, Gui J, et al. Use of MRI in preoperative planning for women with newly diagnosed DCIS: risk or benefit? Ann Surg Oncol 2012; 19:3270-4.
Deurloo EE, Sriram JD, Teertstra HJ, et al. MRI of the breast in patients with DCIS to exclude the presence of invasive disease. Eur Radiol 2012; 22:1504-11.
Pilewskie M, Kennedy C, Shappell C, et al. Effect of MRI on the management of ductal carcinoma in situ of the breast. Ann Surg Oncol 2013; 20:1522-9.
Chaudary MA, Reidy JF, Chaudhuri R, Millis RR, Hayward JL, Fentiman IS. A new and improved device for the pre-operative localisation of impalpable breast lesions. Br J Surgery 1990; 77: 1191-1192.
Luini A, Zurrida S, Paganelli G, et al. Comparison of radioguided excision with wire localization of occult breast lesions. Br J Surg 1999; 86:522-5.
Medina-Franco H, Abarca-Perez L, García-Alvarez MN. Radioguided occult lesion localization (ROLL) versus wire-guided lumpectomy for non-palpable breast lesions: a randomized prospective evaluation. J Surg Oncol 2008; 97:108-11.
Mariscal Martínez AM, Sola M, Perez de Tudela A. Nonpalpable breast cancer lesions: randomized comparison with wire localization in patients undergoing conservative surgery and sentinel node biopsy. AJR 2009; 193:1001–1009.
Sarlos D, Frey LD, Haueisen H, Landmann G, Kots LA, Schaer G. Radioguided occult lesion localization (ROLL) for treatment and diagnosis of malignant and premalignant breast lesions combined with sentinel node biopsy: a prospective clinical trial with 100 patients. Eur J Surg Oncol 2009; 35:403-8.
van der Ploeg IM, Hobbelink M, van den Bosch MA. Radioguided occult lesion localisation' (ROLL) for non-palpable breast lesions: a review of the relevant literature. Eur J Surg Oncol 2008; 34:1-5.
Postma EL, Verkooijen HM, van Esser S, Hobbelink MG et al, Efficacy of 'radioguided occult lesion localisation' (ROLL) versus 'wire-guided localisation' (WGL) in breast conserving surgery for non-palpable breast cancer: a randomised controlled multicentre trial. Breast Cancer Res Treat 2012; 136:469-78.
Arentz C, Baxter K, Boneti C, et al. Ten-year experience with hematoma-directed ultrasound-guided (HUG) breast lumpectomy. Ann Surg Oncol 2010; 17 Suppl 3:378-83.
Dunne C, Burke JP, Morrow M, Kell MR. Effect of margin status on local recurrence after breast conservation and radiation therapy for ductal carcinoma in situ. J Clin Oncol 2009; 27:1615-1620.
Wang S-Y, Chu H, Shamliyan T, et al. Network meta-analysis of margin threshold for women with ductal carcinoma in situ. J Natl Cancer Inst 2012; 104:507–516.
Ansari B, Ogston SA, Purdie CA, et al. Meta-analysis of sentinel node biopsy in ductal carcinoma in situ of the breast. Br J Surg 2008; 95: 547-554.
Sakr R, Antoine M, Barranger E, et al. Value of sentinel lymph node biopsy in breast ductal carcinoma in situ upstaged to invasive carcinoma. Breast J 2008; 14: 55-60.
Van la Parra RF, Ernst MF, Barneveld PC, et al. The value of sentinel lymph node biopsy in breast ductal carcinoma in situ (DCIS) and DCIS with microinvasion of the breast. Eur J Surg Oncol 2008; 34: 631-5.
Veronesi U, Paganelli G, Viale G, Luini A, Zurrida S, Galimberti V et al. A randomized comparison of sentinel-node biopsy with routine axillary dissection in breastcancer. N Engl JMed 2003; 349: 546–553.
Ansari B, Ogston SA, Purdie CA, et al. Meta-analysis of sentinel node biopsy in ductal carcinoma in situ of the breast. Br J Surg 2008; 95: 547-554.
Yen TWE, Hunt KK, Ross MI, et al. Predictors of invasive breast cancer in patients with an initial diagnosis of ductal carcinoma in situ: a guide to selective use of sentinel lymph node biopsy in management of ductal carcinoma in situ. J Am Coll Surg 2005; 200: 516-526.
Huo L, Sneige N, Hunt KK, et al. Predictors of invasion in patients with core-needle biopsy-diagnosed ductal carcinoma in situ and recommendations for a selective approach to sentinel node biopsy in ductal carcinoma in situ. Cancer 2006; 107: 1760-8.
Bedwani R, Vana J, Rosner D, et al. Management and survival of female patients with “minimal” breast cancer. Cancer 1981; 47: 2769–2778.
Silverstein MJ, Barth A, Poller DN, et al. Ten-year results comparing mastectomy to excision and radiation therapy for ductal carcinoma in situ of the breast. Eur J Cancer 1995; 31:1425–1427.
Schouten van der Velden AP, van Vugt R, Van Dijck JA, et al. Local recurrences after different treatment strategies for ductal carcinoma in situ of the breast: a population-based study in the East Netherlands. Int J Radiation Oncology Biol Phys 2007; 69:703-10.
Kelley L, Silverstein M, Guerra L. Analyzing the risk of recurrence after mastectomy for DCIS: a new use for the USC/Van Nuys Prognostic Index. Ann Surg Oncol 2011; 18:459–462.
Kroll SS, Schusterman MA, Tadjalli HE, Singletary SE, Ames FC. Risk of recurrence after treatment of early breast cancer with skin-sparing mastectomy. Ann Surg Oncol 1997; 4:193-7.
Naoura I, Mazouni C, Ghanimeh J, Leymarie N, et al. Factors influencing the decision to offer immediate breast reconstruction after mastectomy for ductal carcinoma in situ (DCIS): the Institut Gustave Roussy Breast Cancer Study Group experience. Breast 2013; 22:673-5.
Nahabedian MY, Tsangaris TN Breast reconstruction following subcutaneous mastectomy for cancer: a critical appraisal of the nipple-areola complex. Plast Reconstr Surg 2006; 117:1083-90.
Garcia-Etienne CA, Borgen PI. Update on the indications for nipple-sparing mastectomy. J Support Oncol 2006; 4:225-30.
Petit JY, Veronesi U, Rey P, et al. Nipple-sparing mastectomy: risk of nipple-areolar recurrences in a series of 579 cases. Breast Cancer Res Treat 2009; 114:97-101.
DOI: http://dx.doi.org/10.14319/ijcto.0102.9

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