乳腺导管原位癌和乳腺导管原位癌伴微浸润的分子分型差异性研究

背景与目的：乳腺导管原位癌伴微浸润（ductal carcinoma in situ with microinvasion,DCISMI）是乳腺导管原位癌（ductal carcinoma in situ,DCIS）发展到浸润性乳腺癌（invasive breast cancer,IDC）的中间阶段,该研究旨在分析乳腺DCIS和DCIS-MI这两类早期乳腺癌不同临床病理学特征和各个分子分型间的差异。方法：本回顾性研究纳入了317例DCIS患者,其中227例（71.6%）为纯DCIS患者,90例（28.4%）为DCIS-MI患者。所有患者根据其DCIS成分而非微浸润成分的免疫组织化学检查结果分成腔面A型［雌激素受体（estrogen receptor,ER）和（或）孕激素受体（progesterone receptor,PR）阳性,人类表皮生长因子受体2（human epidermal growth factor receptor 2,HER-2）阴性］、腔面B型［ER和（或）PR阳性,HER-2阳性］、HER-2过表达型（ER和PR阴性,HER-2阳性）和基底样型（ER和PR阴性,HER-2阴性）。结果：DCIS-MI患者的肿瘤大小倾向更大（P=0.059）,病理核分级显著更高（P=0.002）。和DCIS患者相比,乳腺DCIS-MI患者中腔面A型比例较低而基底样型比例较高（P=0.001）。结论：乳腺DCIS和DCIS-MI间分子分型分布不同,临床病理特征迥异,提示DCIS-MI是DCIS发展的新阶段,有了“质”的改变,本结论有待后续更大样本量的研究进行验证。     

Impact of medical and demographic factors on long-term quality of life and body image of breast cancer patients.

BACKGROUND: The impact of various medical and demographic factors on the quality of life (QoL) of breast cancer patients has been discussed controversially. We investigated the influence of six different factors on long-term QoL and body image of women with primary breast cancer. PATIENTS AND METHODS: Two-hundred and seventy-four breast cancer patients were administered the QoL questionnaire following a mean interval of 4.2 years after primary diagnosis. All women had been primarily treated for stage I to III breast cancer without evidence of distant metastases. QoL was evaluated by using the QLQ-C30 questionnaire Version 2.0. Supplementary scales included body image, satisfaction with surgical treatment, cosmetic result and fear of recurrence. We analyzed the impact of tumor stage, surgical treatment, adjuvant radiotherapy, adjuvant cytotoxic therapy, age and length of follow-up period on the examined outcome parameters. RESULTS: At the time of the follow-up examination, patients showed minor impairment of QoL (mean 67.8) and body image (mean 24.8), but more fear of recurrence (mean 60.7). None of the studied factors had a significant impact on overall QoL (P >0.05) according to the QLQ-C30 questionnaire. In contrast, with the exception of the factors 'cytotoxic therapy' and 'radiotherapy' all investigated variables influenced at least one of the additional psychological scales (P <0.05). The primary surgical treatment modality had the strongest impact and affected all four scales. Patients treated with breast conservation reported a more favorable body image, compared to those treated with mastectomy (17.2 versus 37.5, P <0.01), more satisfaction with surgical treatment (4.0 versus 10.7, P = 0.01), rated a better cosmetic result (75.5 versus 57.1, P <0.01), but presented more fear of recurrence (63.9 versus 55.3, P = 0.04). CONCLUSION: Current QoL questionnaires do not sufficiently cover all relevant aspects of QoL, but might be complemented by breast cancer specific aspects such as body image and fear.     

Ductal carcinoma in situ (DCIS) of the breast: perspectives on biology and controversies in current management

The incidence of ductal carcinoma in situ (DCIS) has increased because of increasing use of sensitive imaging modalities. MRI is commonly used for the detection of breast cancer but has not yet been validated in randomized trials. There have not been randomized trials addressing optimal margins of excision or axillary sampling. Whole breast radiation after lumpectomy decreases the risk of recurrence but may be omitted in selected patients. Adjuvant Tamoxifen reduces the risk of recurrence but has no impact on overall survival rates.     

Developing a theoretical framework to illustrate associations among patient satisfaction,body image and quality of life for women undergoing breast reconstruction

Within the field of breast reconstruction there is increasing focus on patient-reported outcomes related to satisfaction, body image, and quality of life. These outcomes are deemed highly relevant because the primary goal of breast reconstruction is to recreate the appearance of a breast (or breasts) that is satisfying to the patient. Prominent researchers have suggested the need to develop improved standards for outcome evaluation which can ultimately benefit patients as well as physicians. The purpose of this article is to summarize key findings in the area of patient-reported outcomes for breast reconstruction and introduce a theoretical framework for advancing research in this field. We conducted an extensive literature review of outcome studies for breast reconstruction focusing on patient-reported results. We developed a theoretical framework illustrating core patient-reported outcomes related to breast reconstruction and factors associated with these outcomes. Our theoretical model highlights domains and distinguishing features of patient satisfaction, body image, and quality of life outcomes for women undergoing breast reconstruction. This model further identifies a broad range of variables (e.g., historical/premorbid influences, disease and treatment-related factors) that have been found to influence patient-reported outcomes and need to be taken into consideration when designing future research in this area. Additional attention is given to examining the relationship between patient reported outcomes and outside evaluation of breast reconstruction. Our proposed theoretical framework suggests key opportunities to expand research in this area with the goal of optimizing body image adjustment, satisfaction, and psychosocial outcomes for the individual patient.     

The management of ductal carcinoma in situ of the breast: a screened population-based analysis

Background A recent SEER study identified significant variations in the care of women with DCIS, yet several potential confounding variables were not included. We report a patterns of care study of women with DCIS to better understand the gap between evidence-based knowledge and the management of DCIS. Methods We studied all cases of DCIS diagnosed through the Ontario Breast Screening Program from 1991 to 2000. Data was obtained by database linkage and chart abstraction. A logistic regression model using generalized estimating equations to adjust for clustering was used. Results About 320,236 women were screened and 727 individuals were diagnosed with DCIS. The rate of mastectomy was 30% and was associated with multifocality (OR: 3.5 [1.7, 7.1], P = 0.0005), tumor size (OR: >2 cm vs. ≤1 cm: 2.7 [1.3, 5.9], P = 0.01), high nuclear grade (OR: 2.4 [1.1, 5.2], P = 0.03) and surgeon’s practice pattern. The rate of axillary dissection (AND) decreased from 36% in 1991–1993 to 20% in 1998–2000. AND was associated with mastectomy, year of surgery and hospital volume (OR: 2.7 [1.3, 5.6], P = 0.01). The use of radiation (XRT) following breast-conserving surgery increased from 39% in 1991␣to 51% in 2000. XRT was associated with age<70 years, high nuclear grade (OR: 2.7 [1.2, 6.3], P = 0.02) and tumor size > 1 cm (OR: 2.4 [1.3, 4.4], P = 0.006). Half of cases with margins <1 cm did not receive XRT. Conclusions Our study corroborates previous reports on the persistent rates of mastectomy and axillary nodal dissection and the limited use of XRT in the treatment of DCIS.     

乳腺导管原位癌的单中心预后分析

背景与目的:目前中国乳腺导管原位癌(ductal carcinoma in situ,DCIS)的发病率逐年升高,而现有治疗策略主要基于欧美大型随机对照研究.探索中国人群中DCIS患者的临床特征、复发模式和预后影响因素,以便优化临床决策.方法:回顾性分析2008年1月—2017年1月复旦大学附属肿瘤医院收治的1185例...     

Advances and controversies in management of breast ductal carcinoma in situ (DCIS)

Ductal carcinoma in situ (DCIS) is a non-obligate precursor of invasive breast cancer. It accounts for 25% of all breast cancers diagnosed, as a result of the expansion of breast cancer screening and is associated with a high survival rate. DCIS is particularly clinically challenging, due to its heterogeneous pathological and biological traits and its management is continually evolving towards more personalized and less aggressive therapies. This article suggests evidence-based guidelines for proper DCIS clinical management, which should be discussed within a multidisciplinary team in order to propose the most suitable approach in clinical practice, taking into account recent scientific studies.Here we include updated multidisciplinary treatment protocols and techniques in accordance with the most recent contributions published on this topic in the peer-reviewed medical literature, and we outline future perspectives.     

Ductal carcinoma in situ of the breast in younger women: A subgroup of patients at high risk

Background

After breast conservative treatment (BCT), young age is a predictive factor for recurrence in patients with Ductal Carcinoma In Situ (DCIS) of the breast. The purpose of this study was to evaluate predictive factors for recurrence and outcomes in these younger women (under 40 years) treated for pure DCIS.

Methods

From 1974 to 2003, 207 cases were collected in 12 French Cancer Centers. Median age was 36.3 years and median follow-up 160 months. Seventy four (35.8%) underwent mastectomy, 67 (32.4%) lumpectomy alone and 66 (31.9%) lumpectomy plus radiotherapy.

Results

37 recurrences occurred (17.8%): 14 (38%) were in situ and 23 (62%) invasive. After BCT, the overall rate of recurrence was 27% (33% in the lumpectomy plus radiotherapy group vs. 21% in the lumpectomy alone group). Comedocarcinoma subtype (p = 0.004), histological size more than 10 mm (p = 0.011), necrosis (p = 0.022) and positive margin status (p = 0.019) were statistically significant predictive factors for recurrence. The actuarial 15-year rates of local recurrence were 29%, 42% and 37% in the lumpectomy alone, lumpectomy and whole breast radiotherapy and lumpectomy + whole breast radiotherapy with additional boost groups respectively. After recurrence, the 10-year overall survival rate was 67.2%.

Conclusion

High recurrence rates (mainly invasive) after BCT in young women with DCIS are confirmed. BCT in this subgroup of patients is possible if clear and large margins are obtained, tumor size is under 11 mm and necrosis- and/or comedocarcinoma-free.     

乳腺导管原位癌个体化局部治疗的研究进展和前景

乳腺X线片的广泛应用,使乳腺导管原位癌(DCIS)的早期诊断率显著升高。DCIS的局部治疗模式也不断发展,从乳房切除术到乳房保留术续贯全乳放疗,再到大分割放疗及部分乳腺短程照射的应用。虽然全乳放疗疗效明确,但其在低危DCIS的应用价值仍存在争议。DCIS局部治疗的未来研究将集中于建立更精确的局部复发风险分层系统指导个体...     

Invasive breast cancer following ductal and lobular carcinoma in situ of the breast

We considered the risk of subsequent invasive breast cancer in a population-based series of 579 carcinomas in situ (CIS) of the breast (482 ductal, 88 lobular) registered between 1977 and 2002 in the Swiss Canton of Vaud. A total of 55 cases of invasive breast cancer were observed vs. 12.3 expected, corresponding to a standardized incidence ratio (SIR) of 4.5 (95% confidence interval [CI], 3.4-5.8). The SIR was 4.6 after ductal and 4.2 after lobular CIS, was similar with passing time since CIS diagnosis, but was higher (SIR = 5.5) for women aged <55 years. At 20 years following CIS, the cumulative risk of invasive breast cancer was 26%, similar for lobular and for ductal CIS. The incidence of invasive breast cancer following CIS showed no consistent pattern of trends with age, all rates in subsequent age groups ranging between 10 and 18 in 1,000. This is compatible with the occurrence of a single mutational event in a population of susceptible women.     

从原位癌到微小浸润：乳腺肿瘤的临床病理分析及对外科治疗的影响

背景对乳腺原位癌（CIS）是否应进行前哨淋巴结活检（SLNB）目前仍处于争议中。临床诊疗中常遇到：一些在术前穿刺或术中活检被诊断为原位癌且未进行SLNB的患者,术后却经病理确诊为乳腺微小浸润性癌（MIBC）。此时,是否二次手术进行腋窝淋巴结状态评估对外科医师来说是一个困难的选择。一方面,MIBC淋巴结转移风险尚不明确;另一方面,再次手术时SLNB的准确性及可操作性往往受到质疑,多数情况下腋窝淋巴结清扫成为唯一的选择。目的识别原位癌伴发微小浸润的危险因素;比较CIS和MIBC腋窝淋巴结的转移风险;探索选择合适的病例直接进行术中前哨淋巴结活检以避免二次手术的合理性。方法对接受手术且经病理确诊的乳腺原位癌（493例）及微小浸润癌（199例）患者的临床病历资料进行回顾性的统计分析;采用Pearson卡方检验和Fisher确切概率法进行组间比对;通过单因素分析和多因素Logistic回归识别原位癌伴发微小浸润的危险因素。结果原位癌组中出现4例小叶原位癌（LCIS）,其余均为导管原位癌（DCIS）,而MIBC所伴发的原位癌均以DCIS为主。单因素分析显示,X线片BI-RADS≥4级的钙化,肿瘤﹥2.5 cm,高级别DCIS,ER（－）,PR （－）,HER-2（+++）是原位癌伴微小浸润的危险因素（P均﹤0.05）;Ki-67≥20%也可能与发生微小浸润有关（P=0.057）。使用Logistic回归将重要协变量（年龄）与上述危险因素一起进行多因素分析显示,年龄﹥50岁（P=0.034）,肿瘤﹥2.5 cm（P=0.033）,高级别DCIS（P=0.011）等是原位癌伴微小浸润的独立危险因素。此外,相对于2.0%的原位癌淋巴结转移概率,MIBC的淋巴结转移概率为5.5%,二者比较差异具有统计学意义（P=0.029）。结论 MIBC淋巴结转移风险为5.5%,多伴发于患者年龄超过50岁的较大范围的高级别DCIS中。目前来说,对合并这些高风险因素的原位癌患者直接进行SLNB是一种合理和稳妥的诊治手段,可以有效避免二次手术的发生并为下一步治疗提供依据。     

Rationalization and regionalization of treatment for ductal carcinoma in situ of the breast

PURPOSE: In ductal carcinoma in situ (DCIS) of the breast, conservative surgery plus radiotherapy (CS+RT) decreases risk of recurrence compared with CS alone. Although nearly one third of patients are reported as treated with CS alone, it is unclear whether this potentially "undertreated" group represents high- or low-risk patients. We evaluated national patterns of DCIS treatment from 1996 to 2001 by patient risk profile. METHODS AND MATERIALS: In a retrospective cohort of DCIS patients from the Surveillance, Epidemiology, and End Results data, patients were risk stratified on the basis of age at diagnosis, tumor grade, tumor size, and comedo histology. Treatment included CS alone, CS+RT, or mastectomy. Patients were followed for the development of ipsilateral invasive or in situ event. RESULTS: Of 14,202 patients, 19% were low-risk, 46% moderate-risk, and 35% high-risk. A total of 28% received CS alone, 40% CS+RT, and 31% mastectomy. Overall, only 17% of high-risk patients but 44% of low-risk patients received CS alone (p < 0.001). In multivariable analysis, older age, smaller tumor size, and treatment in San Francisco/Los Angeles predicted treatment with CS alone (p < 0.01). Yet despite the tendency to receive CS alone, patients in San Francisco/Los Angeles did not experience an increased risk of ipsilateral event (hazard ratio = 0.79; 95% confidence interval, 0.55-1.12). CONCLUSION: Patient risk profiles rationally affect treatment choice in DCIS patients, and the vast majority of high-risk patients do not receive CS alone. Additional follow up is needed to determine whether geographic variation in care influences long-term outcomes.     

Telomerase activity in ductal carcinoma in situ of the breast

Telomerase plays an important role in maintaining the stability of the chromosomes. Activity of telomerase has been detected in proliferating and immortalized cell lines and in a number of malignant tumors including invasive breast cancer. The aim of the study was to examine telomerase activity in ductal carcinoma in situ (DCIS), which is considered to be a precursor lesion of infiltrating breast carcinoma, using a PCR-based telomerase activity protocol (TRAP). We examined 35 samples obtained from histologically confirmed breast biopsies, including 13 normal breast tissues, 11 infiltrating ductal carcinoma (IDC), nine DCIS, and two DCIS with microinvasion. Telomerase activity was demonstrated in 8/9 samples of DCIS, both samples of DCIS with microinvasion, and all but one sample of IDC. Normal breast tissue had no demonstrable telomerase activity. Our results indicate that telomerase is activated frequently in early breast carcinogenesis, although its utilization as a biomarker in DCIS is questionable.     

Ductal carcinoma in situ in core biopsies containing invasive breast cancer: correlation with extensive intraductal component and lumpectomy margins

BACKGROUND AND OBJECTIVES: The diagnosis of invasive breast cancer is most commonly made on image-guided core biopsy (CB). The presence of extensive intraductal component (EIC), as identified on subsequent lumpectomy, is associated with an increased risk of positive margins and need for further surgery. CBs demonstrating invasive breast cancer may also contain ductal carcinoma in situ (DCIS), although the significance of this finding is unclear. The objective of this study was to examine the implications of DCIS found in the original CB, specifically related to the risk of EIC and/or positive lumpectomy margins. METHODS: All patients at a single academic institution who underwent initial breast conserving surgery for invasive breast cancer diagnosed on image-guided CB between 05/00 and 04/02 were included in the study. A systematic, blinded review of all CB and lumpectomy specimens was performed using standardized criteria for DCIS, EIC, and margins. RESULTS: A total of 95 patients were included in the study, with a mean of 5 (median 5) CB/patient. Of these, 43 (45%) patients had DCIS identified in their CB; in 34 (79%) of these patients, the DCIS was mixed with the invasive cancer. No differences in tumor size or lumpectomy volume were identified between patients with or without DCIS on CB. However, patients with DCIS were noted to be significantly younger. Overall, EIC was identified in 13 (14%) patients; the risk of EIC was significantly higher in patients with DCIS identified in CB than in those with invasive carcinoma alone (30% vs. 0%, respectively; P < 0.0001). Expectedly, the incidence of positive margins on lumpectomy was higher in patients with EIC (38% vs. 16%; P = 0.05). A trend, although not statistically significant, towards positive margins was also noted in patients with DCIS on CB compared to those with invasive carcinoma alone (24% vs. 15%, P = 0.3). CONCLUSIONS: The identification of DCIS in conjunction with invasive cancer on CB appears important; the absence of DCIS in a CB sample excludes the possibility of eventually identifying EIC. Knowledge of DCIS in CBs with invasive carcinoma may be helpful for surgeons in planning gross resection margins at lumpectomy.     

乳腺导管原位癌的间质微浸润危险因素分析

目的：分析乳腺导管原位癌（ductal carcinoma in situ,DCIS）间质微浸润的危险因素,探讨导管原位癌伴微浸润（ductal carcinoma in situ with microinvasion,DCIS-MI）患者的腋窝淋巴结术式。方法：回顾性分析2013年2 月至2016年2 月南京大学医学院附属金陵医院经手术后病理证实为DCIS、DCIS-MI 共45例患者临床资料,依据是否伴微浸润分为DCIS与DCIS-MI 组,对患者年龄、就诊时是否绝经、肿瘤大小等因素行统计学分析。结果：就诊时未绝经（P = 0.006）、肿物直径≥ 3.15cm（P = 0.006）、有恶性肿瘤家族史（P = 0.002）的患者更易发生肿瘤间质微浸润。结论：具有可触及腋窝肿物、未绝经、乳腺巨大肿物、有恶性肿瘤家族史危险因素,同时术前行穿刺或术中冰冻提示DCIS、DCIS伴可疑微浸润的患者存在微浸润可能性大,应予前哨淋巴结活检。触及腋窝肿物为首要症状患者,腋窝淋巴结清扫术应作为首选方式。     

乳腺导管原位癌伴微小浸润的临床分析

目的 随着乳腺X射线摄影技术的进步及普及,使得乳腺导管原位癌伴微小浸润(ductal carcinoma in situ with microinvasion,DCIS-MI)在乳腺癌中比例增高,但所占比例＜1.0％.由于DCIS-MI术前确诊困难,病理和预后不同,同时缺乏大规模的循证医学证据指导治疗方案的选择,并存在着诸多争议,现已成为临床医师及病理医师普遍关注的热点.本研究总结和分析DCIS-MI的临床病理特征,加深对DCIS-MI的认识并探讨其合理的治疗方式.方法 回顾性分析2004-01-01-2014-12-31新疆医科大学附属肿瘤医院收治的318例患者的临床病理资料,其中乳腺导管原位癌(ductal carcinoma in situ,DCIS)患者239例,DCIS-MI患者79例.结果 DCIS与DCIS-MI在核分级(x2=29.699,P＜0.001)、粉刺型(x2=26.242,P＜0.001)、ER(x2=11.807,P=0.001)、PR(x2=7.623,P=0.006)、Ki-67阳性表这率(x2 =5.185,P=0.023)、分子分型(x2=16.570,P＜0.001)和手术方式(x2 =29.713,P＜0.001)方面均不同,差异均有统计学意义.在年龄(x2 =4.563,P=0.102)、民族(x2=2.102,P=0.147)、月经情况(x2=0.455,P=0.500)、肿块位置(x2 =0.267,P=0.605)、临床表现[包括乳房肿决(x2=1.393,P=0.238)、乳头改变(x2=1.345,P=0.246)、无症状(x2 =3.077,P=0.079)]、钙化(x2=0.010,P=0.920)、肿块的大小(x2=3.370,P=0.066)和HER-2阳性表达率(x2=0.317,P=0.574)方面差异均无统计学意义.中位随访时间为66个月,共有4例患者复发,其中DCIS组有2例胸壁复发,复发率为0.8％ (2/239);DCIS-MI组有2例胸壁复发,复发率为2.5％(2/79).DCIS组和DCIS-MI组复发率(x2=1.373,P=0.241)和总生存率(x2=1.397,P=0.237)相比,差异无统计学意义.DCIS与DCIS-MI的复发与手术方式、核分级、微浸润和腋窝淋巴结清除差异均无统计学意义,P＞0.05.结论 DCIS-MI预后较好,是一种少见的乳腺癌亚型.DCIS-MI与DCIS的腋窝淋巴结转移率和预后无差别,提示对DCIS-MI的处理应该按照DCIS的治疗方式进行处理.     

Ductal carcinoma in situ: value of sentinel lymph node biopsy

BACKGROUND: Ductal carcinoma in situ (DCIS) represents about 20% of newly diagnosed breast carcinomas. Axillary metastasis is often related to undiagnosed DCIS with microinvasion (DCISM). The aim of this study was to confirm the interest of sentinel lymph node (SLN) biopsy in extensive DCIS. METHODS: Patients with a diagnosis of DCIS or DCISM and axillary lymph node evaluation were selected. Surgical treatment included SLN biopsy and/or axillary lymph node dissection (ALND). Serial sections were stained with hematoxylin and eosin (H&E) and with an immunohistochemical (IHC) method. When a micrometastasis was found, the breast specimen was revised searching for occult microinvasion. RESULTS: Hundred and forty patients with initial DCIS were enrolled in the study. Node metastasis was identified in 9 patients (7%) of the 128 patients with DCIS and DCISM. At final histology, 4 (10%) of the 39 patients with pure DCIS and SLN biopsy and 1 (7%) of the 14 patients with DCISM and SLN biopsy had axillary micrometastasis. Four of the 12 patients upstaged to invasive carcinoma had metastatic SLNs. CONCLUSIONS: Sentinel lymph node biopsy is valuable in patients with diffuse DCIS or DCISM who are scheduled for mastectomy in order to search for axillary micrometastases and occult breast microinvasion.     

Tamoxifen added to radiotherapy and surgery for the treatment of ductal carcinoma in situ of the breast: A meta-analysis of 2 randomized trials

Background

Surgical excision with adequate margins is the treatment of choice for ductal, in situ carcinoma of the breast (DCIS). The addition of radiotherapy (RT) halved local in situ and invasive recurrence. The purpose of our meta-analysis is to evaluate the reduction in recurrence (in situ or invasive) with the addition of tamoxifen (T), in particular in patients with DCIS treated with surgery + RT.

Patients and methods

The eligible studies (NSABP-B24 and UK ANZ DCIS trials) included prospective, randomized, controlled trials in which the addition of T had been compared with surgery + RT without T in women with DCIS of the breast. Relative risks (RRs) with 95% confidence intervals (CIs) were calculated for both in situ and invasive recurrence (local and controlateral).

Results

Tamoxifen does not reduce breast cancer-specific or overall mortality when added to loco-regional therapy for DCIS of the breast (surgery plus or minus RT). Tamoxifen reduces overall breast cancer recurrence by 29% in all patients and by 33% in those treated with both surgery and RT. Only ipsilateral invasive (RR 0.61 [95% CI 0.41, 0.92]; p = 0.02) and controlateral in situ relapses (RR 0.40 [95% CI 0.16, 0.96]; p = 0.04) are significantly lowered when T is added to RT. Tamoxifen seems to exert a local synergistic effect with RT. Both young and older women (< and >50 years) achieve some benefit from the addition of T (RR 0.6 and 0.74, respectively).

Conclusion

The addition of T to surgery and RT for DCIS of the breast reduces the risk of local invasive and controlateral in situ relapses, but not the survival. The benefit is independent of age. In conclusion, surgery associated with RT and T is the treatment of choice for patients with (estrogen-receptor positive) DCIS of the breast.