Location and extent of positive resection margins and ductal carcinoma in situ in lumpectomy specimens of ductal breast carcinoma examined with a microscopic three-dimensional view

The location of positive margins in lumpectomy specimens for ductal carcinoma could be predicted due to the common pattern of the geographic relationship between the intraductal and invasive carcinomas. To test this hypothesis, 62 lumpectomy specimens for ductal carcinoma of the breast were submitted for this study. The specimens were microscopically examined by serially sectioning them into giant sections in a plane parallel to the chest wall (frontal plane). The margins were identified as proximal (closest to the nipple), distal (opposite to proximal), and peripheral (nonproximal or distal). We found that the location of positive or close margins was proximal in 6 cases, peripheral in 13 cases, and none were found to be distal. Ductal carcinoma in situ (DCIS) was found to be located in the area adjacent to the invasive carcinoma. The invasive carcinoma was located at the periphery of the intraductal carcinoma. All six specimens with invasive carcinoma without DCIS had free margins. Nine of 16 specimens (56%) with extensive intraductal carcinoma (EIC) component and 7 of 40 (18%) with DCIS but negative EIC contained positive or close margins involved by DCIS. One case with multifocal invasive carcinoma measuring 3.5 cm in diameter and with DCIS but EIC negative had margins involved by both DCIS and invasive carcinoma. In conclusion, in ductal carcinoma, invasive carcinoma arose at the peripheral areas of the DCIS. DCIS tends to spread toward the nipple and the peripheral margins of the resected specimens. Incomplete excision of the ductal carcinoma and the wide positive margins are most likely caused by the failure to estimate the extent and location of DCIS.     

The oncologic safety of breast-conserving surgery for breast ductal carcinoma in situ

Objective To evaluate the safety of breast-conserving surgery for ductal carcinoma in situ( DCIS) . Methods One hundred and nineteen patients with pathologically confirmed DCIS were analyzed retrospectively.     

The current treatment of ductal carcinoma in situ

A consensus conference was held in April, 1999, to help sift through the maze of controversy surrounding the treatment of mammographically detected ductal carcinoma in situ (DCIS). Members of the panel included approximately 30 DCIS experts, who addressed issues relating diagnosis, treatment, treatment of breast (and axilla), adjuvant theraphy, among others. The panel agreed that the goal of treatment for DCIS is breast conservation and attempted to divide the population of patients with DCIS into subsets who are appropriately treated by mastectomy, radiation theraphy, or by excision alone. Major criteria for breast conservation include small size of area of DCIS, clear surgical margins, and favorable biology. Neither axilliary dissection nor sentinel node biopsy is appropriate for DCIS treated by breast conservation. The role of tamoxifen is currently under study, and although approved by the FDA for "risk reduction," its use in patients with DCIS is uncertain.     

Impact of core biopsy on the management of screen-detected ductal carcinoma in situ of the breast

Background: Screen‐detected ductal carcinoma in situ (DCIS) usually presents as clinically impalpable microcalcification. Although core biopsy is well established as a diagnostic modality for invasive breast cancers, few reports address its impact on the management of screen‐detected DCIS. We examined the sensitivity of core biopsy in diagnosing screen‐detected DCIS, as well as its role in facilitating one‐step surgery in the community, especially a breast‐conserving approach. Methods: Through the Monash BreastScreen database, we reviewed the management of 148 patients diagnosed with pure DCIS over a 4‐year period. Particular attention was paid to the sensitivity and surgical margin status of 63 patients who underwent initial assessment with core biopsy, compared to patients who underwent excisional biopsy or fine needle aspiration cytology (FNAC). Results: Core specimens in 63 patients yielded positive histology in 57 (90%), allowing for breast‐conserving surgery in 45 and mastectomy in 12. Negative margins were obtained in 73% of those treated by breast‐conserving surgery, compared to 51% negative margins among those who underwent excisional biopsy initially. Overall, 45 of 57 patients with a positive core biopsy histology (79%) underwent one‐step surgery. Those assessed by FNAC had a 48% incidence of non‐diagnostic/benign cytology. Conclusions: Core biopsy facilitates one‐step surgery for screen‐detected DCIS, and potentially reduces the number of surgical procedures. Stereotactic core biopsy for suspicious microcalcifications should replace hookwire‐guided excisional biopsy and FNAC as the diagnostic modality of choice.     

The value of the Van Nuys Prognostic Index in ductal carcinoma in situ of the breast: a retrospective analysis

The Van Nuys Prognostic Index 1996 (VNPI), based upon tumor size, pathological grade and tumor margins, is a guideline for the treatment of ductal carcinoma in situ (DCIS). It was thought to strongly decrease overtreatment. In 2003, age was added to the index as a fourth prognostic factor. We examined changes in treatment modality after applying the VNPI retrospectively and investigated if the addition of age to the Index causes a shift in treatment. The influence of each prognostic factor on disease-free survival (DFS) was calculated. We performed a retrospective file study of DCIS patients treated between 1985 and 2003 at the University Hospital, Antwerp. Patients were assigned a Van Nuys Score 1996 and 2003. The influence of tumor size, pathological grade, tumor margins and age on DFS was calculated with the Kaplan-Meier method and the log-rank test. We identified 104 DCIS cases with a median follow-up of 36 months. Twelve patients showed recurrence (11.5%), of whom seven were invasive (58%). Seventeen of the 29 women diagnosed before 1997 were undertreated according to the VNPI 1996 and six of them showed recurrence. The remaining three recurrences were correctly treated. Seventy-five patients diagnosed after 1997 were all treated according to the VNPI 1996 and only three had a recurrence. The introduction of age caused no significant shift in treatment modalities. Significant differences in DFS were seen between large (>41 mm) and small (<15 mm) tumors (p = 0.0074), old (>60 years) and young (<40 years) patients (p = 0.024) and Van Nuys Subgroup 2 and 3 (p = 0.04). Tumor margins and pathological grade showed no significant difference in DFS. The VNPI can be a useful tool in the treatment of DCIS. However, this Index is not evidence-based, using a relatively small retrospective series of patients. The validity of the modified VNPI must be prospectively confirmed with large numbers of DCIS patients.     

Infiltrating ductal carcinoma and ductal carcinoma in situ associated with mammary hamartoma

Mammary hamartoma is a rare nonmalignant lesion. Only 11 cases of carcinoma associated with hamartoma have been previously described in the literature. We describe a case of infiltrating ductal carcinoma (IDC) and ductal carcinoma in situ (DCIS) associated with hamartoma in a 35-year-old woman. Mammography showed the features of a typical hamartoma with suspicious microcalcifications arising in it. The patient underwent a radical modified mastectomy. It is likely that hamartoma is a coincidental finding. The identification of suspicious microcalcifications in a typical mammographic image of a hamartoma should prompt continued examination to exclude an underlying tumor.     

Sentinel node procedure is warranted in ductal carcinoma in situ with high risk of occult invasive carcinoma and microinvasive carcinoma treated by mastectomy

Abstract:  Axillary lymph node dissection in patients with ductal carcinoma in situ (DCIS) of the breast is not warranted because DCIS has no metastatic potential. However, the risk of microinvasive carcinoma (MIC) exists in large DCIS treated by mastectomy. The aim of this series is to evaluate the incidence of lymph node metastases in DCIS and DCIS-MIC. We analyzed retrospectively patients treated in six French cancer centers for pure DCIS or DCIS-MIC. Surgical procedures were lumpectomy or mastectomy associated with an axillary sentinel node (SN) procedure. We included 161 patients suffering from pure DCIS (116/161, 72%) or DCIS-MIC (45/161, 28%). Mean age was 56 years (32–78). We observed underestimation between core biopsy and histological result in 43/142 cases (30%). These data show an association between lesion size, solid subtype, high-grade DCIS, and underestimation. Forty-eight breast conservative procedures were performed and 113 mastectomies (70%). SN procedure was performed using blue dye, technetium, or both. In our series, we selected patients with a high risk of occult invasive carcinoma: high grade (55%), mean size (27 mm), and mastectomy (112). Six SN were found positive (3.7%). In the five patients treated with complete axillary dissection, the SN was the only positive node. SN in DCIS is an interesting procedure but not necessary for all patients. We need to focus on the subgroup with or a high risk of occult MIC: extensive calcifications or palpable mass, DCIS diagnosed by core biopsy and underestimation, multifocality, high grade, large tumor size, MIC, and mastectomy.     

Preoperative breast MRI in the surgical treatment of ductal carcinoma in situ

Accurate determination of the size or extent of ductal carcinoma in situ (DCIS) by imaging is uncertain, and incomplete resection of tumor results in involved margins in up to 81% of cases. This study examined the accuracy of magnetic resonance imaging (MRI) for assessment of DCIS size, and evaluated the effect of preoperative breast MRI on achievement of tumor-free surgical margins after breast-conserving surgery (BCS). One-hundred and fifty-eight female patients with DCIS were identified from a prospective database: 60 patients (62 cases) had preoperative breast MRI, and 98 patients did not have MRI. The accuracy of tumor size assessed by MRI was determined by comparison with histopathologic size. All patients underwent BCS initially. The rate of involved margins after resection was compared in MRI and no-MRI groups. The overall correlation between MRI size and histopathologic size was high (p < 0.0001). MRI assessment of size was significantly more accurate when DCIS was high grade (p < 0.0001) or intermediate grade (p = 0.005) versus low grade (p = 0.187). The rate of tumor-involved margins was not significantly different in MRI and no-MRI groups (30.7% and 24.7%, respectively; p = 0.414). The rate of mastectomy was significantly higher in the MRI group than the no-MRI group (17.7% versus 4.1%; p = 0.004). These findings indicate that MRI can detect DCIS, especially when lesions are high or intermediate grade, but that MRI does not accurately predict the size of DCIS. In this study, MRI did not improve the surgeon's ability to achieve clear margins following BCS.     

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.     

Impact of hormonal status on ductal carcinoma in situ of the breast: Outcome and prognostic factors

Ductal carcinoma in situ (DCIS) of the breast is a heterogeneous disease which is increasingly diagnosed through improved screening measures. Multiple prognostic scores have been devised to predict the risk of local recurrence (LR), and the optimal adjuvant management for DCIS is still debated. Hence, the aim of this analysis is to investigate the factors contributing to the prognosis of DCIS, in particular the role of its hormonal status. From 2005 to 2016, a total of 1221 female patients diagnosed with DCIS at the National Cancer Centre Singapore and Singapore General Hospital were studied. The mean age of diagnosis was 54 years of age (sd = 11.0), with estrogen receptor (ER)–positive DCIS tumors presenting earlier (mean age 54 vs 57 years of age; P < .001). DCIS with negative hormonal status (HS) correlates significantly with a larger size (mean 23.5mm vs 13.0 mm, P < .001) and higher grade of tumor (P < .001). Patients with positive HS were more likely to undergo breast conservation surgery over a mastectomy, in contrast to patients with negative HS (P < .001). Patients with negative HS had a poorer prognosis, with a shorter time of overall survival time (HR = 26.3, P = .020). In conclusion, our study shows that the hormonal status, age of diagnosis, and positive margins are important prognostic factors for DCIS, at least in our Asian population.     

Ductal carcinoma in situ and atypical ductal hyperplasia of the breast diagnosed at stereotactic core biopsy

Abstract: Stereotactic core needle biopsy (SCNB) allows specific histopathologic diagnoses to be made without surgery and has been demonstrated to be an accurate, cost-effective method of diagnosing breast disease, particularly nonpalpable lesions. However, recent studies have concluded that the diagnosis of atypical ductal hyperplasia (ADH) by means of SCNB has resulted in nearly equal odds that a coexisting malignant lesion will be missed. Furthermore, others have concluded that SCNB diagnosed as DCIS cannot reliably indicate the absence of tumor invasion in surgical excision. Between 1993 and 1998, 1,221 consecutive SCNB of mammographically identified lesions were performed using a 14-gauge automated device with an average of 5.3 cores obtained per lesion. ADH was identified in 19 (1.6%) lesions and DCIS in 89 (7.3%). Surgical biopsy was performed in 89 of these patients and histopathologic results from SCNB and surgical biopsies were reviewed and correlated. In 12 cases of ADH diagnosed by SCNB, surgical biopsy showed ADH in 8 (67%) cases and DCIS in the other 4 (33%) cases. In 77 cases of DCIS diagnosed by SCNB, a surgical biopsy showed DCIS in 55 (71%) cases, 6 more cases (8%) had DCIS with focal microinvasion, and 15 (19%) had invasive ductal carcinoma. In one case no residual tumor was found at surgery. In the author's patient population, the diagnosis of ADH at SCNB indicates high probability of DCIS or residual ADH in the surgical biopsy. The diagnosis of DCIS at SCNB is confirmed in the majority of surgical biopsies; however, a significant number of cases may show microinvasion or invasive carcinoma.     

Value of sentinel lymph node biopsy in breast ductal carcinoma in situ upstaged to invasive carcinoma

Abstract:  The role of sentinel lymph node (SLN) biopsy in patients with initial diagnosis of ductal carcinoma in situ (DCIS) is still a dilemma. Different studies are trying to define predicting factors of invasive cancer in DCIS. The aim of this study was to confirm the value of SLN biopsy in DCIS because of the invasive upstaging risk on final histology. Patients with initial diagnosis of DCIS and with axillary SLN biopsy were selected. All diagnoses were confirmed by biopsy of mammographic lesions. Surgical treatment was lumpectomy or mastectomy associated with SLN biopsy. Imprint stains were performed, and then serial sections were stained with hematoxylin and eosin (H&E) and with immunohistochemistry (IHC). A complete axillary lymph node dissection (ALND) was performed during the same surgery when a node metastasis was found. Eighty patients were enrolled in the study. Of the 61 patients who were initially diagnosed with DCIS, 12 (20%) were upstaged to microinvasive or invasive carcinoma and 9 (15%) had a metastatic SLN. Patients upstaged to invasive carcinoma had macrometastatic SLN immediately fed by a complete ALND. SLN micrometastases and isolated cells were detected by IHC and secondary complete ALND found an additional metastatic lymph node in one patient. Tumor size larger than 30 mm and mastectomy were the only significative predicting factors of upstaged disease (p < 0.0001) in our study. In patients with initial diagnosis of large DCIS programmed for mastectomy, SLN biopsy should be discussed in order to detect underlying invasive disease and to spare patients a second operating time.     

乳腺导管原位癌研究的进展

近年来随着乳腺癌筛查及早期诊断技术的发展,乳腺导管原位癌(duetal carcinoma insitu,DCIS)的检出率明显升高.然而,目前人们对DCIS的生物学特性及其自然病程知之甚少,因而临床对于DCIS如何合理进行有关诊断治疗一直存在争议.     

Male ductal carcinoma in situ presenting as bloody nipple discharge: a case report and literature review

Male breast carcinoma accounts for 1% of all diagnosed breast carcinoma. Pure ductal carcinoma in situ in men is extremely rare. Unfortunately, male breast cancer is often diagnosed at a late stage because of the minimal awareness of presenting symptoms by the patient and sometimes by the health care provider. Because of this late presentation, the overall prognosis is less favorable. This case is presented to emphasize the importance of recognizing bloody nipple discharge as a clinical sign of male ductal carcinoma in situ and an opportunity for early diagnosis.     

BI-RADS MRI enhancement characteristics of ductal carcinoma in situ

To identify the Breast Imaging Reporting and Data System magnetic resonance imaging (MRI) enhancement characteristics of ductal carcinoma in situ (DCIS). A retrospective review of consecutive patients who underwent breast MRI for newly diagnosed breast carcinoma prior to surgery was conducted. This yielded 381 lesions in 361 patients with pathologic confirmation of either DCIS alone, invasive carcinoma alone, or mixed invasive and in-situ disease. Presence or absence of a MRI lesion at the site of the documented carcinoma was recorded, and for all identified MRI lesions the Breast Imaging Reporting and Data System morphology patterns were recorded. MRI features of the different malignancy types were compared utilizing Fisher's exact tests; 64/381 (16.8%) lesions had DCIS, 101/381 (26.5%) had invasive carcinoma, and 216/381 (56.7%) had mixed invasive/in situ carcinoma. A MRI lesion corresponding to the known cancer was identified in 55/64 (85.9%) cases of DCIS, 98/101 (97.0%) cases of invasive carcinoma, and 212/216 (98.1%) cases of mixed invasive and in-situ carcinoma. For pure DCIS lesions, 38/64 (59.4%) exhibited nonmass-like enhancement (NMLE), 9/64 (14.1%) were masses, and 8/64 (12.5%) were a focus. For pure invasive carcinomas 79/101(78.2%) were masses, 16/101 (15.8%) were NMLE, and 3/101 (3.0%) were a focus. For mixed lesions 163/216 (75.5%) were masses, 44/216 (20.4%) demonstrated NMLE, and 5/216 (2.3%) were a focus. The most common NMLE patterns of pure DCIS were segmental distribution and clumped internal enhancement. Although there is overlap in the MRI morphology and enhancement pattern of in situ and invasive breast carcinoma, DCIS more frequently manifests as NMLE than does invasive carcinoma.     

Volume of resection in patients treated with breast conservation for ductal carcinoma in situ

Background: The optimal treatment of ductal carcinoma in situ (DCIS) is one of the most controversial issues in the management of breast cancer. Identification of factors that affect the risk of local recurrence is very important as the incidence of DCIS increases and the use of breast conservation becomes more widespread. Because the extent of resection may affect the relapse rate, we hypothesized that larger volumes of resection (VR) may account for the lower local recurrence rates we have previously found in elderly patients. Methods: Between 1978 and 1990, 173 cases of histologically confirmed DCIS were treated at MSKCC with breast conservation therapy. Of these, complete VR data were available for 126 cases. The VRs thus obtained were divided into two groups, <60 cm³ and 60 cm³, and were evaluated for correlating factors. The patients were divided into three groups by age at diagnosis: younger than 40 years, 40 to 69 years, and 70 years or older. Results: The eldest group had a significantly greater proportion of large VRs (30%) as compared to the middle group (11%) and the youngest group (9%) (P=.03, x²). Although not statistically significant, the large VR group had a lower 6-year actuarial local recurrence rate (5.6%) than did the small VR group (21.3%) (P=.16, log-rank test). This trend was observed even though adjuvant radiotherapy was used less often in patients who had large VRs. Conclusion: Breast conservation surgery for DCIS in elderly patients is more likely to employ a large VR. This may explain, at least in part, the observation that elderly patients have a lower local recurrence rate.Presented at the 50th Annual Cancer Symposium of The Society of Surgical Oncology, Chicago, Illinois, March 20–23, 1997.     

In situ and small invasive breast cancer register in Victoria, 1988 to 1992: tumour characteristics and patient management

Background : All cases of in situ and invasive breast cancer are reported to the Victorian Cancer Registry. In 1988 a special subregister of all cases of carcinoma in situ and small invasive cancers up to 10 mm in size was established – the In situ and Small Invasive Breast Cancer Register (ISSIBCR). This was unique in being a population‐based register and only possible because in Victoria, as in some other Australian states, all cancers including in situ disease are reported to the Central Cancer Registry. Methods : Between 1 January 1988 and 31 December 1992, 517 cases of in situ cancers and 892 invasive cancers of ≤ 10 mm in diameter were registered. During the study period, mammography screening was progressively introduced in Victoria and the number of cases, in both categories registered annually, doubled. Results : The method of detection, the pathology and treatment of these lesions are described. It is of interest that 46.5% of the in situ cancers and 68.8% of the invasive cancers were detected either by the patient or her doctor on clinical examination. Total mastectomy was the method of treatment in 35.4% of in situ cancers and 42.0% of small invasive tumours. Only 38.0% of patients with small invasive cancers treated by breast‐conserving surgery had irradiation of the affected breast. Conclusions : This register provides a valuable resource for the follow up of the natural history and outcome of treatment of the affected women.     

浆细胞性乳腺炎并发导管原位癌一例报告

浆细胞性乳腺炎并发乳腺癌临床报道较为少见,本文介绍一例浆细胞性乳腺炎并发导管原位癌病例,临床影像及病理资料全面,通过回顾其病史、诊疗经过及临床结局,结合既往文献报道,探讨提高此类患者术前诊断准确性的临床经验,以及手术治疗相关方案,以期为患者带来更多的生存获益。     

Nipple‐sparing mastectomy as treatment for patients with ductal carcinoma in situ: A 10‐year follow‐up study

The objective was to determine the 10‐year oncological safety of nipple‐sparing mastectomy (NSM) in patients diagnosed with ductal carcinoma in situ (DCIS). The use of NSM preserves the nipple‐areola complex (NAC). As residual fibroglandular breast tissue can remain behind the spared NAC, its use for patient with breast cancer is controversial. The oncologic outcomes and complication rates after performing NSM compared to other techniques are still under debate and a concern when treating patients with breast cancer. We retrospectively reviewed 69 consecutive NSM patients diagnosed with DCIS during 1984‐2016 at the Valencia Institute of Oncology, Valencia, Spain. 13 of 82 reviewed cases were excluded from the analysis owing to the presence of invasive tumor in the final pathologic report. All 69 patients who underwent NSM due to DCIS were included and analyzed. The indications were as follows: unfavorable correlation between tumor size and breast size in 53 patients, 10 patients with multifocal or multicentric tumors and breast cancer recurrence after breast‐conserving surgery in six patients. The reconstruction was performed using a prosthetic implant: saline‐filled implant 33 (47.8%) or tissue expander 36 (52.2%). No frozen section was performed in the patients included in our study. The presence of DCIS was confirmed in 60 patients and in the other nine patients we found no tumor in the mastectomy specimen (removed due to excisional biopsy procedure). High risk features were: tumor grade 3 in 27 (39.2%) cases and comedonecrosis in 32 (46.4%) cases. In 27 patients surgical axillary staging was performed and no residual disease in the axilla was observed. After a mean follow‐up period of 142.6 ± 70.7 months no nipple necrosis was observed. In 15 patients (21.7%) an additional surgical procedure was performed. 48 patients (69.6%) did not receive any adjuvant treatment. Adjuvant hormone therapy was given to 20 patients (29%) and one patients received radiation therapy (1.4%). Eight patients showed a local relapse (11.6%). One patient developed a recurrence within the nipple‐areola region presented as Paget's disease (1.4%). One patient presented a thorax wall relapse after 42 months of disease‐free survival and died because of metastatic dissemination of the tumor. The DFS rate was 88.4% and the overall survival rate was 98.6%. In patients with DCIS that are not candidates to breast‐conserving therapy, NSM is a realistic option of treatment. No case of nipple necrosis was observed. A low rate of nipple relapse (1.4%) and a good survival rate (98.5%) were observed after a median follow‐up of 142.6 months.