Therapeutic management of intracystic papillary carcinoma of the breast: the roles of radiation and endocrine therapy

BACKGROUND: The role of radiation and endocrine therapy in the treatment of intracystic papillary carcinoma (IPC) remains unclear. The aim of the current study was to review the management of IPC in order to determine factors associated with use of adjuvant therapies. METHODS: A retrospective review of our surgical and pathology databases from 1995-2006 identified 45 women with IPC. These patients were further divided into those with pure IPC (n = 21), IPC with associated ductal carcinoma in situ (DCIS) (n = 18), and IPC with associated microinvasion with or without DCIS (n = 6). Patient characteristics were compared between groups using the chi-square test. RESULTS: Patients with IPC and microinvasion were more likely to undergo an axillary staging procedure (6/6, 100%) compared to patients with pure IPC (6/21, 29%) or IPC with DCIS (5/18, 28%) (P < .001). Patients with pure IPC were less likely to have radiation therapy than patients with IPC and DCIS or microinvasion (P < .001). However, within the subset of patients with pure IPC, women less than 50 years of age were more likely to have radiation therapy than those older than 50 years (P < .001). Patients with IPC and DCIS or microinvasion had significantly increased use of endocrine therapy versus patients with pure IPC (P < .01). CONCLUSIONS: In our patient population, those patients with IPC and associated DCIS or microinvasion are treated with adjuvant radiation and endocrine therapy on the basis of this associated pathology. The use of adjuvant radiation and/or endocrine therapy should be considered in patients with pure IPC who are of young age (<50 years).     

乳腺导管原位癌的超声特征

目的探讨乳腺导管原位癌(DCIS)的超声表现特征。方法回顾性分析经病理证实的54例乳腺DCIS的超声表现,包括病灶形态、大小、边缘、边界、内部回声、后方回声、微钙化、导管改变及血供,并与病理结果进行对比。结果54例均经术后病理证实为乳腺DCIS,其中高级别34例,中级别13例,低级别7例;5例伴微浸润灶,均未见腋窝淋巴结转移。声像图表现为片状低回声型20例(20/51,39.22%)、结节状肿块型17例(17/51,33.33%)、导管扩张型8例(8/51,15.69%)、单纯微钙化型6例(6/51,11.76%),3例假阴性,检出率94.44%(51/54)。超声正确诊断44例,准确率81.48%(44/54)。结论乳腺DCIS超声表现具有一定特征性;正确认识其超声征象能有效提高诊断符合率。     

Treatment trends for ductal carcinoma in situ of the breast

Background: As a result of clinical trial publications, breast conservation treatment has been increasingly used for invasive breast cancer. The patterns of care for ductal carcinoma in situ (DCIS) were analyzed for the years 1985, 1986, 1988, 1990, and 1991 to determine whether the same treatment principles had been applied to patients with noninvasive disease. Methods: Data submitted on 20,556 patients with DCIS during the 5 study years were analyzed with regard to basic demographics and treatment trends. Results: Breast-conserving surgery for DCIS increased from 20.9% in 1985 to 35.4% in 1991. Modified radical mastectomy remained constant at 42%. Axillary node surgery increased from 52% in 1985 to 58.5% in 1991. The use of radiation therapy for patients with partial mastectomy and no lymph node dissection ranges from 24.2% in 1990 to 37.7% in 1985, with 31.1% receiving radiation therapy in 1991. Patients undergoing lymph node dissection with partial mastectomy were more than twice as likely to receive postoperative radiation therapy than were patients without lymph node dissection. Conclusions: Modified radical mastectomy remains the most common surgical procedure, despite the eligibility of many women for breast conservation treatment. As of 1991 the majority of women were still undergoing axillary lymph node surgery despite a node positivity rate of ≈1%. Radiation therapy is significantly underused in patients with partial mastectomy, especially when no nodes were removed. Clinical trial results and professional education for DCIS treatment should change these trends. Presented at the 47th Annual Cancer Symposium of The Society of Surgical Oncology, Houston, Texas, March 17–19, 1994.     

A perplexing presentation of a breast carcinoma: a case report

Breast cancer is a devastating disease for women. In this paper, we present a breast carcinoma presenting in a bizarre location. It was initially presumed that the patient had skin cancer, but the lesion turned out to be breast cancer presenting as a superficial mass on the skin of the breast.     

Intracystic papillary carcinoma in the male breast

Intracystic papillary carcinoma is an uncommon noninvasive breast cancer with an excellent prognosis. We report the case of a 74-year-old man. Of the diagnostic tests performed, ultrasonography and pneumocystography were useful for establishing a diagnostic suspicion, however, puncture cytology was inaccurate. Excisional biopsy was necessary to confirm the disease, but also to indicate that local treatment was sufficient.     

Assessment of treatment for patients with primary ductal carcinoma in situ in the breast

Background: Current mammographic technology has resulted in increased detection of ductal carcinoma in situ (DCIS). It is necessary to assess which patients presenting with DCIS are good candidates for breast conservation and which of these patients should receive adjuvant radiation. Methods: We accrued clinical data for 124 patients with a primary diagnosis of DCIS from 1979 through 1994. Primary therapy was a mastectomy for 18 patients, and a lumpectomy for 106 patients. Only 18 of the latter group of patients received adjuvant radiotherapy. For the 88 lumpectomy-alone patients (median follow-up, 5.2 years), we evaluated the effects of clinical (age and initial presentation) and pathologic (nuclear grade, architecture, parenchymal involvement, calcifications, and measured margins) factors on recurrence of DCIS or the development of invasive breast cancer. Results: Patients who underwent lumpectomy with or without adjuvant radiotherapy (median follow-up, 5.0 years) were significantly more likely to have recurrence of DCIS (P=.05) than those who underwent mastectomy (median follow-up, 6.7 years): 18% (19/106) versus 0% (0/18), respectively; lumpectomy-alone patients experienced a 19% (17/88) rate of DCIS recurrence. All recurrent DCIS was ipsilateral. For lumpectomy-alone patients, the factors associated with ipsilateral recurrence of DCIS were extent of involvement of the parenchyma (P=.01, for univariate;P=.07, for multivariate) and initial presentation (P=.05, for univariate;P=.07, for multivariate). Eleven lumpectomy-alone patients developed invasive breast cancer (6 ipsilateral, 5 contralateral); none of the 18 lumpectomy patients who received adjuvant radiation developed invasive disease. None of the factors investigated, including primary surgery and adjuvant radiotherapy, were associated with a significant effect on the development of invasive disease. Conclusions: Longer follow-up is required to determine if the benefits of either mastectomy or radiotherapy following lumpectomy persist. There is a suggestion that patients under 40 years of age or women who present with nipple discharge might be considered for either adjuvant radiotherapy following lumpectomy or a simple mastectomy.     

Patterns of care for ductal carcinoma in situ of the breast: Queensland's experience over a decade

ObjectivesTo review management of ductal carcinoma in situ (DCIS) of the breast in Queensland, with reference to breast conserving surgery (BCS) and adjuvant radiation therapy (RT). In addition, we examined the incidence of invasive breast cancer recurrence and factors predictive of invasive recurrence.Materials and methodsA retrospective review of the Queensland Oncology Repository identified women with resected DCIS (TisN0) ± adjuvant RT between 2003 and 2012. Time to invasive breast cancer recurrence was analysed using the Kaplan Meier method. Median follow-up was 4.9 years.Results3038 women had surgery. 940 (31%) had mastectomy and 2098 (69%) underwent BCS. Of 2098 women having BCS, 1100 (52%) received BCS alone and 998(48%) received adjuvant RT. The use of RT significantly increased over the decade from 25% to 62% (p=<0.001). Clinicopathological factors associated with RT use on multivariate analysis included age ≤70, higher socioeconomic status, larger tumour size, higher nuclear grade and surgical margins ≤5 mm. Invasive breast cancer recurrence at 5 years was 1.7% [95% CI 1.0–3.0] in RT group versus 2.8% [95% CI 2.1–3.8] in BCS alone group. Factors associated with increased risk of invasive recurrence on multivariate analysis were age <40 and surgical margins ≤2 mm.ConclusionThe use of adjuvant RT in Queensland significantly increased between 2003 and 2012. Selection of patients for RT was based on clinicopathological factors associated with higher recurrence risk. Although longer follow-up is required, the selective use of radiation therapy after BCS is associated with a low rate of invasive breast cancer recurrence at 5 years.     

Factors associated with decision to pursue mastectomy and breast reconstruction for treatment of ductal carcinoma in situ of the breast

Background

Factors influencing the treatment of ductal carcinoma in situ with mastectomy and reconstruction are poorly understood.

Methods

A retrospective cohort study of 196 patients presenting to one institution was performed.

Results

Forty-seven patients (24.0%) were treated with mastectomy, while 149 (76.0%) underwent breast-conserving surgery. Of the mastectomy patients, 28 (59.6%) elected for reconstruction. On bivariate analysis, patients who opted for mastectomy were younger than those treated with breast-conserving surgery (median age, 51.8 vs 56.5 years; P = .017) and had higher grade tumors (50.0% vs 34.6% grade 3, P = .009). Among patients treated with mastectomy, those who opted for reconstruction were younger than those forgoing reconstruction (49.4 vs 56.9 years, P = .024). Race, ductal carcinoma in situ tumor size, and histologic subtype were not associated with the decision to pursue mastectomy or reconstruction (P > .05 for all).

Conclusions

In patients with ductal carcinoma in situ, the decision to pursue mastectomy and reconstruction appears to be driven by younger patient age and higher tumor grade.     

X线检查阴性乳腺导管原位癌的临床病理特点

【摘要】〓目的〓探讨乳腺X线检查(MG)阴性的乳腺导管原位癌(DCIS)及DCIS伴微浸润(DCIS-MI)的临床及诊断特点。方法〓对我院2012年1月~2013年8月32例MG检查阴性的DCIS及DCIS-MI的临床病理资料进行回顾性分析。结果〓MG阴性导管原位癌临床表现为单纯乳头溢液占71.9%(23/32),乳腺肿块占15.6%(5/32)例,良性钙化12.5%(4/32)例。MG检查阴性导管原位癌中腺体高密度、低核分级、PR阳性、HER2(-)或(+)病例的比例明显高于同期MG检查阳性组,且差异有统计学意义(P<0.05)。补充其他诊断检查的结果显示,乳腺超声敏感性为18.7%(6/32),磁共振(MRI)敏感性可达为87.5%(28/32),对表现为乳头溢液的病例,乳管镜诊断的敏感性为52.2%(12/23)。结论〓MG阴性的导管原位癌临床病理生物学指标相对较好,MRI检查可进一步提高其检出率,乳管镜对于乳头溢液的病例是有益的补充检查手段。     

Margin width as the sole determinant of local recurrence after breast conservation in patients with ductal carcinoma in situ of the breast

BACKGROUND: A previous study showed a 3% local recurrence risk at 8 years in ductal carcinoma in situ (DCIS) patients treated with excision alone with surgical margins of 10 mm or greater. This study updates those data. METHODS: A total of 272 DCIS patients treated conservatively with 10 mm or greater margins were reviewed in a prospective database. RESULTS: Among 212 excision-alone patients, there were 9 DCIS and 3 invasive recurrences. The 12-year probability of any local recurrence was 13.9%; of invasive recurrence it was 3.4%. Among 60 excision plus radiation patients, there was 1 local (invasive) recurrence (P = .06). The 12-year probability of local recurrence was 2.5%. CONCLUSIONS: Local recurrence in DCIS patients treated with excision alone with margins of 10 mm or greater compares favorably with local recurrence in DCIS patients with nontransected margins and treated with postoperative radiation. The risk of invasive recurrence among widely excised DCIS patients is extremely low.     

Risk factors for estrogen receptor positive ductal carcinoma in situ of the breast in African American women

BackgroundCompared to U.S. white women, African American women are more likely to die from ductal carcinoma in situ (DCIS). Elucidation of risk factors for DCIS in African American women may provide opportunities for risk reduction.MethodsWe used data from three epidemiologic studies in the African American Breast Cancer Epidemiology and Risk Consortium to study risk factors for estrogen receptor (ER) positive DCIS (488 cases; 13,830 controls). Results were compared to associations observed for ER+ invasive breast cancer (n = 2,099).ResultsFirst degree family history of breast cancer was associated with increased risk of ER+ DCIS [odds ratio (OR): 1.69, 95% confidence interval (CI): 1.31, 2.17]. Oral contraceptive use within the past 10 years (vs. never) was also associated with increased risk (OR: 1.43, 95%CI: 1.03, 1.97), as was late age at first birth (≥25 years vs. <20 years) (OR: 1.26, 95%CI: 0.96, 1.67). Risk was reduced in women with older age at menarche (≥15 years vs. <11 years) (OR: 0.62, 95%CI: 0.42, 0.93) and higher body mass index (BMI) in early adulthood (≥25 vs. <20 kg/m² at age 18 or 21) (OR: 0.75, 95%CI: 0.55, 1.01). There was a positive association of recent BMI with risk in postmenopausal women only. In general, associations of risk factors for ER+ DCIS were similar in magnitude and direction to those for invasive ER+ breast cancer.ConclusionsOur findings suggest that most risk factors for invasive ER+ breast cancer are also associated with increased risk of ER+ DCIS among African American women.     

A review of the management of ductal carcinoma in situ following breast conserving surgery

Ductal carcinoma in situ (DCIS) is a heterogeneous, pre-malignant disease accounting for 10–20% of all new breast tumours. Evidence shows a statistically significant local control benefit for adjuvant radiotherapy (RT) following breast conserving surgery (BCS) for all patients. The baseline recurrence risk of individual patients varies according to clinical-pathological criteria and in selected patients, omission of RT may be considered, following a discussion with the patient. The role of adjuvant endocrine therapy remains uncertain. Ongoing studies are attempting to define subgroups of patients who are at sufficiently low risk of recurrence that RT may be safely omitted; investigating RT techniques and dose fractionation schedules; and defining the role of endocrine therapy. Future directions in the management of patients with DCIS will include investigation of prognostic and predictive biomarkers to inform individualised therapy tailored to the risk of recurrence.     

Extensive pure ductal carcinoma in situ of the breast: Identification of predictors of associated infiltrating carcinoma and lymph node metastasis before immediate reconstructive surgery

AimTo identify predictors for infiltrating carcinoma and lymph node involvement, before immediate breast reconstructive surgery, in patients with an initial diagnosis of extensive pure ductal carcinoma in situ of the breast (DCIS).Patients and methodsBetween January 2000 and December 2009, 241 patients with pure extensive DCIS in preoperative biopsy had underwent mastectomy. Axillary staging (sentinel node and/or axillary dissection) was performed in 92% (n = 221) of patients. Patients with micro-invasive lesions at initial diagnosis, recurrence or contralateral breast cancer were excluded.ResultsRespectively 14% and 21% of patients had a final diagnosis of micro-invasive carcinoma (MIC) and invasive ductal carcinoma (IDC). Univariate analysis showed that the following variables at diagnosis were significantly correlated with the presence of either MIC or IDC in the mastectomy specimen: palpable tumor (p = 0.002), high grade DCIS (p = 0.002) and detection of an opacity by mammography (p = 0.019). Axillary lymph node (ALN) involvement was reported in 9% of patients. Univariate analysis suggested that a body mass index higher than 25 (p = 0.007), a palpable tumor (p = 0.012) and the detection of an opacity by mammography (p = 0.044) were associated with an increased rate of ALN involvement.ConclusionSkin-sparing mastectomy and immediate breast reconstruction (IBRS) has become increasingly popular, especially for patients with extended DCIS of the breast. This study confirmed that extended DCIS is associated with a substantial risk of finding MIC or IDC on the surgical specimen but also ALN involvement. Adjuvant systemic treatment and/or radiotherapy could be indicated for some of these patients after the surgery. Patients should be informed of the rate of 1) complications associated to IBRS that will potentially delay the introduction of systemic or local therapy 2) complications associated to radiotherapy after IBRS.     

乳腺浸润性导管癌前驱病变的病理形态学诊断

目的 探讨乳腺浸润性导管癌前驱病变的诊断及鉴别诊断要点.方法 收集乳腺癌前驱病变86例,光镜下观察苏木素-伊红(HE)切片,将病变分为:导管上皮不典型增生(ADH)组,导管原位癌(DCIS)组,包括低、中度、高度DCIS,并观察ADH和DCIS的细胞特征及形态结构.结果 ADH组35例,18例显示在普通型导管增生(UDH)的背景上混杂有非典型细胞或特征性结构;另17例与低度DCIS有相似的结构和细胞学特征.DCIS组51例,低度者(17例)细胞结构单一,界限清楚,大小、形态一致,异型性不明显,无坏死及核分裂像;中高度者(分别为14例和20例)细胞极性消失,异型性明显,中度为灶状坏死,高度为大片粉刺样坏死;结构上有实体型、筛状型、粉刺型及混合型.结论 ADH与DCIS的诊断主要依赖细胞和结构特征;部分ADH虽与低度DCIS相似,但仍有差异.     

The use of ductal lavage as a screening tool in women at high risk for developing breast carcinoma

BACKGROUND: The purpose of the study was to determine if ductal lavage could predict the occurrence of breast cancer as well as further stratify patients at high-risk for developing breast cancer. METHODS: Ductal lavage was performed in 116 high-risk patients (Gail Risk score > or = 1.7%, previous breast cancer, strong family history, previous suspicious biopsy specimen). If atypia or papillary cells were identified, a standard protocol of evaluation was initiated. RESULTS: Two hundred twenty-three lavages were performed on 116 patients. Twenty-seven lavages in 25 patients yielded atypical or papillary-like cells. The 15 patients who underwent further evaluation for atypia had no evidence of cancerous or precancerous lesions. All patients were followed-up: 2 developed breast cancer, both of whom had had normal previous lavage. No patient with abnormal lavage developed cancer during follow-up. CONCLUSIONS: We find ductal lavage to be of limited value in the screening of high-risk patients and have removed it from our treatment algorithm.     

Thyroid Metastases from Gallbladder Cancer

Background  Gallbladder cancer is an aggressive malignancy and radical resection is the only curative therapy available. Metastatic disease in the thyroid is rarely seen; however, different studies have confirmed that the most common primary tumor source is the kidney. Case Report  Thyroid metastases from tumors originating in the gastrointestinal tract have been reported. We report a patient with gallbladder cancer (T2N1M0) treated with radical resection and postoperative chemoradiation who developed thyroid metastases.     

Outcome after invasive recurrence in patients with ductal carcinoma in situ of the breast

BACKGROUND: Local recurrence is used as a marker of treatment failure for patients with ductal carcinoma in situ (DCIS). As follow-up lengthens, distant recurrence, breast cancer-specific survival (BCSS), and overall survival must be monitored. METHODS: A prospective database was used to analyze 1031 patients with DCIS. Patients having invasive recurrence after DCIS treatment were compared with patients having infiltrating ductal carcinoma (IDC). End points included distant recurrence, BCSS, and overall survival. RESULTS: Overall, patients with DCIS had a BCSS of 99%. BCSS was 85% for patients with invasive recurrences. DDFS in this group was 80%. Stage I IDC patients had a BCSS of 91%, whereas it was 38% in those with stage I IDC and invasive recurrences. CONCLUSIONS: Most patients with DCIS that recur can be salvaged. For the small subgroup of patients who recur with invasive breast cancer, survival is similar to that of patients with stage IIA IDC.