Microdochectomy for elderly patient of ductal carcinoma in situ

We report an elderly patient with ductal carcinoma in situ (DCIS). The patient was an 82-year-old woman who had spontaneous nipple discharge. We did not detect the origin of nipple discharge by CT, MRI, mammography, ductal endoscopy, and ultrasonography. Microdochectomy was performed under the local anesthesia. A resected specimen led to a diagnosis of a DCIS positive for estrogen receptor and progesteron receptor, and negative for HER2/neu protein expression. After operation, she was administered aromatase inhibitor. After three years and two months from the operation, she is well without metastases. The less invasive operation by local anesthesia is useful for elderly breast cancer patients. This case suggested that microdochectomy is useful for DCIS in elderly patients.     

Margin width and local recurrence after breast conserving surgery for ductal carcinoma in situ

Introduction

Ductal Carcinoma in situ (DCIS) represents 5% of symptomatic and 20–30% of screen detected cancers. Breast conserving surgery (BCS) ± radiotherapy is performed in over 70% of women with DCIS. What constitutes an adequate margin for BCS remains unclear.

Breast-conserving treatment for ductal carcinoma in situ: Impact of boost and tamoxifen on local recurrences

PurposeDuctal carcinoma in situ represents 15 to 20% of all breast cancers. Breast-conserving surgery and whole breast irradiation was performed in about 60% of the cases. This study reports local recurrence rates in patients with ductal carcinoma in situ treated by breast-conserving surgery and whole breast irradiation with or without boost and/or tamoxifen and compares different therapeutic options in two European countries.Patients and methodsFrom 1998 to 2007, 819 patients with pure ductal carcinoma in situ were collected, both in France (266) and Italy (553). Median age was 56. All underwent breast-conserving surgery and whole breast irradiation; 391 (48%) received a boost (55% in France and 45% in Italy, P = 0.017) and 173 (22.5%) tamoxifen (4.5% in France and 32% in Italy, P < 0.0001).ResultsWith a 90-month median follow-up, there were 51 local recurrences (6.2%), including 27 invasive (53%). The 5- and 10-year local recurrence rates were 4% and 8.6%. Two patients developed axillary recurrence and 12 (1.5%) metastases (seven after invasive local recurrence); 41 (5%) patients had contralateral breast cancer. In the multivariate analysis, high nuclear grade and lack of tamoxifen are the most powerful predictors of local recurrence, with 2.6 (95% confidence interval [95% CI]: 1.74–3.89, P = 0.0012) and 2.85 (95% CI: 1.42–5.72, P = 0.04) odds ratio (OR) estimates, respectively. Age, margin status and boost did not influence local recurrence rates.ConclusionsThis study confirms the ductal carcinoma in situ treatment heterogeneity among countries and the unfavourable prognostic role of nuclear grade. Tamoxifen reduces local recurrence rates and might be considered for some subgroups of patients, but further confirmation is required. The boost usefulness still remains unclear.     

Recurrence after breast ablation for ductal carcinoma in situ.

Three patients are described having locally recurrent invasive breast cancer after breast ablation for ductal carcinoma in situ (DCIS). All had initially extensive type ductal carcinoma in situ without evidence of invasion in adequately sampled microscopical studies. One patient developed a scar recurrence and lung metastases 2 years after surgery; one patient showed a scar recurrence 3 years after operation and one patient had a recurrence in the chest wall 27 years after surgery. Although generally stated that ablative therapy offers a 100% cure in case of DCIS, these cases illustrate that local recurrence may occur. Possible causes and preventions are discussed.     

Radiotherapy for ductal carcinoma in situ

AimsThe introduction of breast screening mammography has led to an increase in the diagnosis of ductal carcinoma in situ (DCIS). Mastectomy gives high rates of local control. However, most cases are suitable for local excision. The aim of this article is to review the role of radiotherapy in the treatment of DCIS after breast conserving surgery.Material and methodsA review of the literature relating to radiotherapy and DCISResultsThe published trials show that adjuvant radiotherapy after breast conserving surgery halves the ipsilateral recurrence rates of DCIS and invasive cancer. No subgroups have been reliably identified that do not benefit from adjuvant radiotherapy. Risk factors for recurrence are discussed.DiscussionAll patients with DCIS have potential benefit to gain from adjuvant radiotherapy. However, radiotherapy also has adverse effects and represents over-treatment from many women. Support should be given to current trials which are assessing endocrine treatment of DCIS, and whether radiotherapy can reasonably be omitted in lower risk disease.     

Predictors of invasion in patients with core-needle biopsy-diagnosed ductal carcinoma in situ and recommendations for a selective approach to sentinel lymph node biopsy in ductal carcinoma in situ

BACKGROUND: Among patients with core-needle biopsy (CNB)-diagnosed ductal carcinoma in situ (DCIS), the guidelines for the selection of patients to undergo sentinel lymph node (SLN) biopsy are not well defined, and many patients with no invasion undergo an unnecessary SLN biopsy. The objective of this study was to identify the predictors of invasion in patients with CNB-diagnosed DCIS and, thus, to help determine the most appropriate candidates for SLN biopsy. METHODS: The authors retrospectively evaluated 200 consecutive patients with CNB-diagnosed DCIS who underwent final excision at their institution between May 1, 2002 and June 30, 2005. Demographic data, the size and type of lesion on imaging studies, histologic features of DCIS on CNB, the number of cores taken, and the number of cores involved by DCIS were correlated with invasion on excision and SLN biopsy outcome. RESULTS: Forty-one of 200 patients (21%) had invasive carcinoma diagnosed on final excision. Parameters that correlated with invasion were a mass lesion, lesion size >1.5 cm, high nuclear grade, and the presence of lobular cancerization on CNB. A multivariate logistic regression model was developed to predict invasion. At the time of breast surgery, 103 of 200 patients (52%) underwent SLN biopsy, and 34 had invasion diagnosed on final excision. Three patients had 1 positive SLN each. CONCLUSIONS: A mass lesion, lesion size >1.5 cm, and the presence of lobular cancerization on CNB were significant, independent predictors of invasion in patients with DCIS. The authors recommended the inclusion of these predictors in the guidelines for selecting patients for SLN biopsy to reduce the number of unnecessary procedures.     

乳腺导管原位癌与导管原位癌伴微浸润的临床比较

目的 分析乳腺导管原位癌(DCIS)及原位癌伴微浸润(DCIS-MI)患者治疗模式变化、临床特征、治疗结果及预后因素。方法 回顾性分析中国医学科学院肿瘤医院1999-2013年收治的866例女性患者资料。DCIS患者631例,DCIS-MI患者235例。用Kaplan-Meier法计算局控(LC)、无瘤生存(DFS)、总生存(OS)率,并Logrank检验和单因素预后分析。结果 DCIS及DCIS-MI两组之间OS、LC及DFS相近(P>0.05)。单因素分析显示Her-2阳性为OS及DFS影响因素,保乳未放疗患者LC和DFS劣于全乳切除术患者。结论 导管原位癌和导管原位癌伴微浸润总体生存结果类似,Her-2阳性为OS及DFS预后不良因素,保乳未放疗患者的LC和DFS劣于全乳切除术。     

乳腺导管原位癌与导管原位癌伴微浸润的临床比较

目的 分析乳腺导管原位癌(DCIS)及原位癌伴微浸润(DCIS-MI)患者治疗模式变化、临床特征、治疗结果及预后因素。方法 回顾性分析中国医学科学院肿瘤医院1999-2013年收治的866例女性患者资料。DCIS患者631例,DCIS-MI患者235例。用Kaplan-Meier法计算局控(LC)、无瘤生存(DFS)、总生存(OS)率,并Logrank检验和单因素预后分析。结果 DCIS及DCIS-MI两组之间OS、LC及DFS相近(P>0.05)。单因素分析显示Her-2阳性为OS及DFS影响因素,保乳未放疗患者LC和DFS劣于全乳切除术患者。结论 导管原位癌和导管原位癌伴微浸润总体生存结果类似,Her-2阳性为OS及DFS预后不良因素,保乳未放疗患者的LC和DFS劣于全乳切除术。     

Mammographic density and breast cancer after ductal carcinoma in situ

Women with ductal carcinoma in situ (DCIS) are at substantially increased risk for a second breast cancer, but few strong predictors for these subsequent tumors have been identified. We used Cox regression modeling to examine the association between mammographic density at diagnosis of DCIS of 504 women from the National Surgical Adjuvant Breast and Bowel Project B-17 trial and risk of subsequent breast cancer events. In this group of patients, mostly 50 years old or older, approximately 6.6% had breasts categorized as highly dense (i.e., > or =75% of the breast occupied by dense tissue). After adjusting for treatment with radiotherapy, age, and body mass index, women with highly dense breasts had 2.8 (95% confidence interval [CI] = 1.3 to 6.1) times the risk of subsequent breast cancer (DCIS or invasive), 3.2 (95% CI = 1.2 to 8.5) times the risk of invasive breast cancer, and 3.0 (95% CI = 1.2 to 7.5) times the risk of any ipsilateral breast cancer, compared with women with less than 25% of the breast occupied by dense tissue. Our results provide initial evidence that the risk of second breast cancers may be increased among DCIS patients with highly dense breasts.     

Recurrent ductal carcinoma in situ after total mastectomy.

A case report is presented of a woman with recurrent DCIS occurring several years following a total mastectomy, the diagnosis of which was aided by a subpectoral saline implant. A discussion of factors associated with recurrence and a review of the literature is provided. A role for selective use of mammography in screening postmastectomy reconstructed breasts in patients at high risk for recurrence is suggested.     

Risk of ischemic heart disease after radiotherapy for ductal carcinoma in situ

Purpose

Body composition parameters including low muscle mass, muscle attenuation (which reflects muscle quality) and adipose tissue measurements have emerged as prognostic factors in cancer patients. However, knowledge regarding the possibility of excessive muscle loss during specific systemic therapies is unknown. We describe the changes in body composition and muscle attenuation (MA) during taxane- and anthracycline-based regimens and its association with overall survival (OS) in metastatic breast cancer patients.

Methods

The lumbar skeletal muscle index (LSMI) was used as marker of muscle mass. LSMI, MA, subcutaneous adipose tissue (SAT), visceral adipose tissue (VAT) and intramuscular adipose tissue (IMAT) were measured before and after first-line treatment with paclitaxel (n = 73) or 5-fluorouracil-doxorubicin-cyclophosphamide (FAC) (n = 25) using CT-images. Determinants of the change of LSMI and MA were analyzed using multiple linear regression. OS was assessed using Cox proportional hazard models.

Results

MA significantly decreased during paclitaxel treatment (? 0.9 HU, p = 0.03). LSMI (p = 0.40), SAT (p = 0.75), VAT (p = 0.84) and IMAT (p = 0.10) remained stable. No significant alterations in body composition parameters during FAC-treatment were observed. Previous (neo-)adjuvant chemotherapy contributed to larger loss of MA during the current treatment. Body composition changes during chemotherapy were not associated with OS.

Conclusions

MA decreased during treatment with paclitaxel, while muscle mass was stable. Body composition changes are not associated with survival in the absence of progressive disease.

     

New preoperative MRI marking technique for a patient with ductal carcinoma in situ

We herein present a case of non-palpable ductal carcinoma in situ (DCIS) treated with successful breast-conserving surgery (BCS) using MR markers made with commercially available materials in the supine position. The patient was a 40-year-old woman found to have a non-mass lesion by routine screening ultrasonography (US). The margin of the lesion was unclear by the US examination, whereas contrast-enhanced MR mammography (MRM) revealed a clear margin of the lesion. After the resection line was determined by under US guidance, the area was marked by original markers for MRI using the pills of Breath Care inside a Penrose drain. MRM was performed in the supine position (supine MRM), which is similar to the posture used for surgery. The lesion was located within the resection area, but it was not at the center of the resection area; thus, the resection lines were modified using information obtained by MRM. The histological evaluation of the BCS specimen demonstrated a wide extension of the DCIS. The lesion was located at the center of the resection specimen, and the surgical margin was free. In conclusion, since our procedure can be performed easily, it is useful for evaluating the extent of the lesion as determined by the US examination in difficult cases.     

The impact of adding radiation treatment after breast conservation surgery for ductal carcinoma in situ of the breast

Ductal carcinoma in situ (DCIS; intraductal carcinoma) is most commonly detected as suspicious microcalcifications on routine screening mammography in an asymptomatic woman. As most women with newly diagnosed DCIS are eligible for breast conservation treatment, a major decision for most women is whether or not to add radiation treatment after surgical excision (lumpectomy). In four prospective randomized clinical trials, the addition of radiation treatment after lumpectomy reduced the risk of local recurrence by approximately 50%, both for overall local recurrence and for the subset of invasive local recurrence. Nonetheless, efforts have continued to attempt to identify a subset of patients with favorable DCIS who are at sufficiently low risk of local recurrence that omitting radiation treatment is reasonable. Prospective and retrospective studies have demonstrated excellent long-term outcomes at 10 and 15 years after breast conservation treatment with radiation. Careful follow-up, including yearly surveillance mammography, after initial breast conservation treatment with radiation is warranted for the early detection of potentially salvageable local and local-regional recurrences.     

Impact of estrogen receptor expression and other clinicopathologic features on tamoxifen use in ductal carcinoma in situ

BACKGROUND: Recent data have demonstrated that benefit from adjuvant tamoxifen therapy for patients with ductal carcinoma in situ (DCIS) is limited to estrogen receptor (ER)-positive lesions. The objective of the current study was to correlate clinicopathologic features of DCIS with ER expression and the impact of this information on tamoxifen counseling. METHODS: Women with DCIS who were treated from 2001 to 2004 were evaluated. Routine ER staining was initiated in January 2003. RESULTS: Ninety-four women (mean age, 57.6 years) were analyzed. The mean DCIS size was 0.98 cm. ER-staining was performed in 55 lesions, and 76% were ER-positive. All Grade 1 and 2 DCIS lesions were ER-positive, compared with 54% of high-grade lesions (P<.001); no other clinicopathologic feature significantly predicted ER status. Overall, 58 patients (62%) were offered tamoxifen, and the rates were similar for the pre-ER and post-ER staining periods. In the pre-ER staining period, surgical treatment and grade were associated with offering tamoxifen (75% of patients who underwent breast conservation vs. 40% of patients who underwent mastectomy; P = .03; 78% of patients with Grade 1 or 2 lesions vs. 45% of patients with Grade 3 lesions; P = .04). In the post-ER staining period, however, only ER status was correlated significantly with offering tamoxifen (71% of patients with ER-positive lesions vs. 31% of patients with ER-negative lesions; P = .01). Approximately 66% of patients who were offered tamoxifen agreed to treatment (approximately 33% of the total DCIS study sample). No clinicopathologic features predicted for tamoxifen acceptance by patients in either the pre-ER or post-ER staining periods. CONCLUSIONS: Seventy-five percent of DCIS lesions were ER-positive. ER staining significantly influenced the likelihood that clinicians would offer tamoxifen to patients with DCIS, but it had no impact on whether patients accepted treatment.     

Local outcomes in ductal carcinoma in situ based on patient and tumor characteristics

The term ductal carcinoma in situ (DCIS) encompasses a heterogeneous group of lesions that differ in their clinical behavior. Clinical factors such as symptomatic presentation and young age are associated with an increased risk of local recurrence in patients with DCIS managed with breast-conserving therapy. Treatment factors such as wider surgical margins, the use of radiation therapy, and the use of tamoxifen reduce the local recurrence risk. Pathological characteristics such as larger lesion size, high nuclear grade, comedo necrosis, and involved margins are associated with an increased risk of local recurrence in many studies. However, there are complex interactions between these pathological risk factors and other parameters such as treatment and length of follow-up. In fact, the magnitude of the effect of these pathological features on local recurrence risk is modified by these other factors. Analysis of genetic and molecular alterations as well as study of the microenvironment associated with DCIS are important avenues of research that may provide new insights into DCIS recurrence and progression risk, and this in turn may lead to new strategies for treatment and prevention.