Resection margin status in lumpectomy specimens for duct carcinoma of the breast: correlation with core biopsy and mammographic findings.

BACKGROUND: The strategy for surgical treatment of breast carcinoma proven by biopsy is mainly based on the physical and mammographic examinations. To investigate if the pathological findings in core biopsy are contributory to planning the surgical strategy, we correlated the status of ductal carcinoma in situ (DCIS) in the core needle biopsy of breast, the mammographic changes and the status of resection margins in the subsequent lumpectomy. STUDY DESIGN: Consecutive 130 core needle biopsies with prior mammography and subsequent lumpectomy were reviewed. Biopsies were divided into: group I, DCIS; group II, DCIS and infiltrating carcinoma (IC); and group III, IC. Mammographic findings were categorized into four groups: (a) nonspecific findings; (b) calcification (Ca(++)); Ca(++) and mass, and mass only. The status of margins in correlating lumpectomy specimens was reviewed. Close margin was defined as a free margin at less than 0.1cm from the carcinoma. RESULTS: The rates of positive or close margins in three groups I, II, and III were 13/18, 18/48, and 2/64 (P < 0.001); and in mammography groups of nonspecific finding, Ca(++), Ca(++) mass and mass only were 5/6, 7/15, 8/37, and 13/72 (P < 0.001), respectively. Of the total of 14 cases with positive margins of more than 0.5 cm in length, 8, 4, and 2 cases were from group I, II, and II, respectively. In addition, 13 of 21 cases with nonspecific changes or with only Ca(++) in mammograms belonged to the group I; 10 of these 13 cases were associated with positive margins. Forty-one of 72 cases presenting as a mass only in mammograms belonged to the group III; only 2 of these 41 cases were associated positive margins. CONCLUSIONS: Correlation of the extent of carcinoma with pre-operative histopathological findings was better than with mammography. Core biopsies containing only DCIS, particularly in cases with nonspecific findings or with only Ca(++) in mammograms, represent a group of breast carcinoma that pose the high risk for incomplete resection in lumpectomy. Surgical management of patients having these cores includes wider resection margins than would otherwise be taken. Most core biopsies with only IC were associated with negative margins.     

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.     

Resection margin status in lumpectomy specimens of infiltrating lobular carcinoma

Aims.To study the status of resection margins in specimens from patients with infiltrating lobular carcinoma (ILC) treated with lumpectomy. Materials and methods.Sixty-six consecutive cases of ILC were compared with the same number of consecutive cases of infiltrating ductal carcinoma (IDC). All cases were treated with lumpectomy. Results.ILCs were divided into 42 cases of typical ILC, 15 variants of ILC (alveolar or solid types) and 9 cases of mixed ILC and IDC. These groups were associated with positive or close resection margins in 22 (52%), 5 (33%) and 3 (33%) cases, respectively. For the group of IDC with partial mastectomies, matched for patient's age and tumor size, positive or close resection margins were observed in 26%. ILCs, measuring less than 2 cm in greatest diameter and having low nuclear grade, had rates of positive or close margins comparable with those of IDC. Typical ILCs, measuring more than 2 cm in diameter, had rates of positive or close margins of 70%. All cases with a positive extensive intraductal component had positive margins. Furthermore, in all types of ILC, tumors with a high nuclear grade tended to be associated with a high rate of positive margins. Conclusions.The status of resection margins in lumpectomy specimens for infiltrating lobular carcinoma is related to the extensive intraductal component status, tumor size and grade, and the presence of variants of ILC or mixed ILC and IDC. Most of these factors can be determined preoperatively by mammography and histopathological evaluation of breast core biopsies, therefore, aiding in planning the surgical strategy of mastectomy.     

Experience with the Advanced Breast Biopsy Instrumentation (ABBI) system

BACKGROUND: The Advanced Breast Biopsy Instrumentation (ABBI) System is designed to excise nonpalpable breast lesions under stereotactic control. We report our experience with special regard to the histological evaluation of margins. PATIENTS AND METHODS: Breast biopsies using the ABBI system were performed on 101 patients with microcalcifications. In histologically-proven breast cancer, a re-excision was performed. RESULTS: Malignant lesions were found in thirteen patients (3 CLIS, 5 DCIS, 5 invasive ductal carcinoma). The margins were positive in two specimens with DCIS. In subsequent lumpectomies one patient with invasive cancer had residual intraductal cancer. All the patients with DCIS had residual cancer, even those with negative margins of the ABBI-specimen. Only minor complications were observed with the ABBI procedure. CONCLUSION: The ABBI system is a safe, minimally invasive stereotactic breast biopsy technique. It saves open biopsies in atypical hyperplasia and CLIS. In cases of DCIS or invasive cancer re-excision is inevitable.     

Sentinel lymph node biopsy and management of the axilla in ductal carcinoma in situ

Ductal carcinoma in situ (DCIS) of the breast historically has been a disease detected by physical examination, diagnosed by open surgical biopsy, and treated by mastectomy and axillary dissection. It is now increasingly detected by screening mammography, diagnosed by needle core biopsy, and treated by lumpectomy, with axillary dissection having been abandoned and sentinel node biopsy being used in axillary staging. However, outcomes related to sentinel node biopsy in DCIS have not been validated in well-controlled clinical trials. Current guideline recommendations are to use sentinel node biopsy when needle core biopsy is highly suspicious for invasive cancer or where there is a high-risk DCIS when lumpectomy identifies invasive breast cancer with the DCIS, or when mastectomy is performed for extensive DCIS. Routine use of sentinel node biopsy for DCIS is not supported.     

The efficiency of MarginProbe in detecting positive resection margins in epithelial breast cancer following breast conserving surgery

IntroductionUp to 30% of patients undergoing lumpectomy for breast cancer are in need for re-excision due to either close or involved margins. We evaluated the yield of Margin Probe© (MP; Dilon Technologies, USA) in a cohort of patients undergoing lumpectomy for both palpable and non-palpable tumors.MethodsFollowing lumpectomy, margins were evaluated with MP and readings were compared to the lumpectomies’ pathological evaluation irrespective of whether additional margins were removed during surgery. Involved margins or the presence of DCIS within 1 mm of the resection margins were considered as positive margins.Results48 patients with 51 tumors underwent lumpectomy. Thirteen of the 51 lumpectomies had pathological close or involved margins. MP identified 3 out of the 13 positive margins. False-positive readings were recorded in 97 out of 287 margins. The sensitivity, specificity, positive predictive value and negative predictive value were 23.1% (95%CI 5.0% 53.8%), 66.4% (95%CI 60.7%–71.9%), 3% (95%CI 0.6%–8.5%), and 95.1% (95%CI 91.1%–97.6%) respectively.ConclusionsMP cancer detection rate is relatively low while high false-positive rate leads to unnecessary shavings in almost all patients. Evaluation of MP performance should be based on comparing MP read to pathology report.     

Ductal Carcinoma in Situ: A French National Survey. Analysis of 2125 Patients

BackgroundDuctal carcinoma in situ (DCIS) represents 15% of all breast cancers in France. The first national survey was conducted in 2003. The present multi-center real-life practice survey aimed at assessing possible changes in demographic, clinical, pathologic, and treatment features.Material and MethodsFrom March 2014 to September 2015, patients diagnosed with DCIS from 71 centers with complete information about age, diagnostic features, and treatment modalities were prospectively included.ResultsA total of 2125 patients with a median age of 58.6 years from 71 centers were studied. DCIS was diagnosed by mammography in 87.5% of cases. Preoperative biopsy was performed in 96% of cases. The median tumor size was 15 mm. Nuclear grade was low, intermediate, and high in 12%, 36%, and 47% of cases, respectively. Margins were considered to be negative in 83% of cases. Overall mastectomy and lumpectomy rates were 25% and 75%, respectively. The immediate breast reconstruction rate was 50%. Sentinel node biopsy and axillary dissection rates were 41% and 2.6%, respectively. After lumpectomy, 97% of patients underwent radiotherapy, and 32% received a boost dose. Only 1% of patients received endocrine therapy. Compared with our previous survey, the median tumor size remained the same, and the proportion of high-grade lesions increased by 9%. The mastectomy rate decreased by 4%.ConclusionsThe clinical practice identified in this survey complies with French DCIS guidelines. About 10% of patients with low-grade DCIS may be eligible to participate in treatment de-escalation trials.     

The value of breast lumpectomy margin assessment as a predictor of residual tumor burden in ductal carcinoma in situ of the breast

BACKGROUND: Margin width is considered the most important risk factor for local recurrence in ductal carcinoma in situ (DCIS) of the breast. The purpose of this report is to assess the predictive utility of lumpectomy specimen margin assessment for the presence and extent of residual DCIS. METHODS: Specimens from 253 DCIS cases with lumpectomy and reexcision were studied to determine to the probability of residual DCIS on reexcision. The probability of residual tumor was evaluated with respect to tumor size, margin status, nuclear grade, presence of necrosis, patient age, and the extent of specimen processing (number of sections/volume tissue). Lesions were grouped by size: less than or equal to 2 mm, greater than 2-15 mm, greater than 15-40 mm, or greater than 40 mm. Margin width was recorded as the distance of DCIS to the closest specimen edge or, for positive margins, scored as: extensive (margin involvement in > or =8 sections or >4 low-power fields [LPFs]), moderate (5-7 sections or 2-4 LPFs), minimal (2-4 sections or 1 LPF), or focal (1 section, single focus). The amount of residual tumor was graded by maximum dimension on a semiquantitative basis. RESULTS: Initial excision margin significantly predicted for the presence of residual tumor on reexcision. Residual tumor was found on reexcision in 85% of extensively positive, 68% of moderately positive, 46% of minimally positive, 30% of focally positive, 41% of greater than 0-1 mm, 31% of greater than 1-2 mm, and 0% of greater than 2 mm margins (P < 0.0001). On univariate analysis, margin width and lesion size of initial excision specimens significantly predicted for the presence of residual DCIS on reexcision. Age, grade, necrosis, and extent of specimen processing were not significant prognostic factors. On multivariate analysis, both initial margin width (P < 0.0001) and lesion size (P = 0.02) significantly predicted for residual DCIS. As for amount of residual tumor, margin width and initial lesion dimension both significantly predicted for medium to large residuum, whereas age 45 years or younger was of borderline significance on univariate analysis. On multivariate analysis, margin width and lesion size on initial excision both remained significant predictors of larger volume residual tumor. CONCLUSIONS: The margin status of a DCIS lumpectomy specimen is the most important predictive factor for both the presence and amount of residual disease.     

Grade of recurrent in situ and invasive carcinoma following treatment of pure ductal carcinoma in situ of the breast

The grade of recurrent in situ and invasive carcinoma occurring after treatment of pure ductal carcinoma in situ (DCIS) has been compared with the grade of the original DCIS in 122 patients from four different centres (The Royal Marsden Hospitals, London and Sutton, 57 patients; Guy's Hospital, London, 19 patients; Nottingham City Hospital, 31 patients and The Royal Liverpool Hospital, 15 patients). The recurrent carcinoma was pure DCIS in 70 women (57%) and in 52 women (43%) invasive carcinoma was present, which was associated with an in situ element in 43. In all, 19 patients developed a second recurrence (pure DCIS in 11 and invasive with or without an in situ element in eight). The majority of invasive carcinomas followed high-grade DCIS. There was strong agreement between the grade of the original DCIS and that of the recurrent DCIS (kappa=0.679), which was the same in 95 of 113 patients (84%). The grade of the original DCIS showed only fair agreement with the grade of recurrent invasive carcinoma (kappa=0.241), although agreement was stronger with the pleomorphism score of the recurrent carcinoma (kappa=0.396). There was moderate agreement, in recurrent invasive lesions, between the grade of the DCIS and that of the associated invasive element (kappa=0.515). Other features that showed moderate or strong agreement between the original and recurrent DCIS were necrosis and periductal inflammation. The similarity between the histological findings of the original and subsequent DCIS is consistent with the concept that recurrent lesions represent regrowth of residual carcinoma. In addition, although agreement between the grade of the original DCIS and that of any subsequent invasive carcinoma was only fair, there is no suggestion that low-grade DCIS lesions progress to higher grade lesions or to the development of higher grade invasive carcinoma. This is in agreement with immunohistochemical and molecular data indicating that low-grade and high-grade mammary carcinomas are quite different lesions.     

The diagnostic challenge of low-grade ductal carcinoma in situ

BackgroundDiagnostic agreement among pathologists is 84% for ductal carcinoma in situ (DCIS). Studies of interpretive variation according to grade are limited.MethodsA national sample of 115 pathologists interpreted 240 breast pathology test set cases in the Breast Pathology Study and their interpretations were compared to expert consensus interpretations. We assessed agreement of pathologists' interpretations with a consensus reference diagnosis of DCIS dichotomised into low- and high-grade lesions. Generalised estimating equations were used in logistic regression models of rates of under- and over-interpretation of DCIS by grade.ResultsWe evaluated 2097 independent interpretations of DCIS (512 low-grade DCIS and 1585 high-grade DCIS). Agreement with reference diagnoses was 46% (95% confidence interval [CI] 42–51) for low-grade DCIS and 83% (95% CI 81–86) for high-grade DCIS. The proportion of reference low-grade DCIS interpretations over-interpreted by pathologists (i.e. categorised as either high-grade DCIS or invasive cancer) was 23% (95% CI 19–28); 30% (95% CI 26–34) were interpreted as a lower diagnostic category (atypia or benign proliferative). Reference high-grade DCIS was under-interpreted in 14% (95% CI 12–16) of observations and only over-interpreted 3% (95% CI 2–4).ConclusionGrade is a major factor when examining pathologists' variability in diagnosing DCIS, with much lower agreement for low-grade DCIS cases compared to high-grade. These findings support the hypothesis that low-grade DCIS poses a greater interpretive challenge than high-grade DCIS, which should be considered when developing DCIS management strategies.     

Mammographically detected duct carcinoma in situ. Frequency of local recurrence following tylectomy and prognostic effect of nuclear grade on local recurrence

Seventy-nine patients with mammographically detected foci of duct carcinoma in situ (DCIS) of histologically confirmed extents of 25 mm or less, were treated by tylectomy without irradiation or axillary dissection. Adequacy of excision was confirmed histologically, by radiographic-pathologic correlation and by postoperative mammographic examination. Eight patients (10.1%) have recurred locally in the immediate vicinity of the biopsy site. Four patients developed recurrent in situ disease identified mammographically, and all were initially treated by reexcision. One of these patients subsequently elected to undergo mastectomy; no residual in situ or invasive disease was detected in the breast or in axillary lymph nodes. Four patients developed recurrent invasive disease; 50% of these recurrences were detected mammographically. All patients were treated by mastectomy with node dissection. Three had confirmed minimal invasive carcinomas and were N0, one patient had a 13-mm invasive lobular carcinoma with a single Group I micrometastasis. All patients, including those treated for a recurrence, are presently free of disease but three patients died of heart disease. Nuclear grade would appear to identify subsets of DCIS more likely to produce local failure after tylectomy alone. Duct carcinoma in situ with high-grade nuclear morphology and comedo-type necrosis was associated with a 19% local recurrence rate after an average interval of 26 months; only one of ten patients with intermediate-grade DCIS developed a local recurrence at 87 months; and none of 33 patients with DCIS of micropapillary/nonnecrotic cribriform type and low-grade nuclear morphology developed local recurrence in the follow-up period.     

Overdiagnosis and overtreatment of breast cancer: Rates of ductal carcinoma in situ: a US perspective

The incidence of breast ductal carcinoma in situ (DCIS) in the USA exceeds that of other countries. This cannot be explained entirely by the frequency of mammographic screening in the USA and may result from differences in the interpretation of mammograms and/or the frequency with which biopsies are obtained. Although the percentage of DCIS patients treated with mastectomy has decreased, the absolute number is unchanged and the use of lumpectomy with whole-breast radiotherapy has increased in inverse proportion to the decrease in mastectomy. Treatment of DCIS with tamoxifen is still limited.     

The significance of low-grade prostate cancer on needle biopsy. A radical prostatectomy study of tumor grade, volume, and stage of the biopsied and multifocal tumor.

Twenty-one cases showing only low Gleason grade prostate carcinoma on needle biopsy were identified. In 15 cases radical prostatectomy was performed with the entire prostate embedded for thorough evaluation of grade, volume, and stage of tumor at the needle biopsy site as well as of multifocal tumor. Eight specimens had solitary low grade and low volume tumor, with only one of these cases showing minimal capsular penetration and the others confined to the prostate. Four cases had low-grade tumor at the biopsy site, yet multifocal higher grade tumor. All of these tumor nodules were low volume and confined to the prostate. In three cases there was both low-grade and high-grade tumor in the nodule sampled by needle biopsy. In two of these cases the tumor was large and in the third it was small but mostly higher grade, with two of these cases showing capsular penetration. Although transrectal ultrasound and repeat needle biopsy would most likely have identified either the tumors' large size or high-grade component in these latter three cases, it is unlikely that these techniques would have identified the cases of multifocal higher grade tumor because of their relatively small size. Furthermore, preoperative serum prostate specific antigen levels and clinical stage failed to distinguish those cases with higher grade tumor. Because of the difficulty in identifying these areas of high-grade tumor preoperatively, it is uncertain whether expectant therapy could be recommended even for patients with very low-grade cancer on needle biopsy.     

Usefulness of supplementary ultrasound surveillance in the detection of a second breast cancer in patients with ductal carcinoma in situ

IntroductionSupplementary ultrasound surveillance in breast cancer patients can detect additional cancers but is associated with unnecessary biopsies and follow-ups. We aim to determine, in patients with ductal carcinoma in situ (DCIS), the prevalence and factors associated with second breast cancers and the usefulness of supplementary ultrasound surveillance. This is the first study which focused on the usefulness of ultrasound surveillance in DCIS patients.MethodsDCIS patients were retrospectively analyzed to determine the prevalence and factors associated with second breast cancers. The prevalence of patients with benign biopsies, additional ultrasound follow-ups and second breast cancers, resulting from ultrasound surveillance, were calculated.ResultsThree hundred and thirty- two patients were included. 25 (7.5%) patients developed second breast cancers after a mean follow-up of 77.7 months. Breast conservation (P= .0218), involved margins after lumpectomy (P = .0003) and shortened hormonal therapy (P= 0.0369) were associated with second cancers. Of the 314 patients who had ultrasound surveillance, ipsilateral, and contralateral ultrasounds yielded 1.7%/1.3% cancer detection, 5.8%/6.7% benign biopsies and 10.4%/15.3% additional follow-ups. Patients with involved margins after lumpectomy have ipsilateral cancer detection, benign biopsies and additional follow-ups of 4.5%, 4.5%, and 9.1% respectively. A total of 85.4% patients had mammographically dense breasts.ConclusionIn DCIS patients, the rate of second breast cancers was 7.5%. Breast conservation, involved margins after lumpectomy and shortened hormonal therapy were associated with second cancers. Patients with involved margins after lumpectomy have the highest cancer detection rate and minimal unnecessary biopsies and follow-ups. Hence, ipsilateral breast ultrasound surveillance could be personalized for this high-risk group with mammographically dense breasts.     

The presence of an extensive intraductal component following a limited excision correlates with prominent residual disease in the remainder of the breast

Previous studies of patients with infiltrating ductal breast cancer treated with conservative surgery (ie, limited excision) and radiotherapy have indicated that the presence of an extensive intraductal component (EIC) in the excision specimen is highly associated with subsequent breast recurrence. The reason for this association is not clear, but possible explanations include the presence of more extensive disease in the breast or increased radiation resistance among tumors with an EIC (EIC+) compared with those without (EIC-) tumors. To investigate this association further, we related the presence or absence of an EIC in the primary tumors of 214 women who underwent mastectomy to the likelihood of finding additional foci of cancer in their mastectomy specimens using a correlated pathologic-radiologic mapping technique. Primary tumors that were EIC+ were significantly more likely to have carcinoma in the remainder of the breast than those which were EIC--(74% v 42%; P = .00001). This difference was primarily due to the presence of residual intraductal carcinoma. Seventy-one percent of EIC+ patients had residual intraductal carcinoma compared with 28% of EIC-patients (P less than .00001). In particular, 44% of EIC+ patients had "prominent" residual intraductal carcinoma compared with 3% of EIC-patients (P less than .00001). We conclude that patients whose tumors contain an EIC more frequently have a large subclinical tumor burden in the remainder of the breast compared with patients whose tumors do not contain an EIC. This observation may explain the association between EIC and subsequent breast recurrence when patients are treated with a limited excision before radiotherapy.     

Ductal carcinoma in situ of the breast: is breast conserving treatment feasible?

Between 1968 and 1993, 43 cases of ductal carcinoma in situ of the breast (DCIS) were treated. We examined the extent of the cancer using multiple sections of surgical specimens and considered whether or not breast conserving treatment (BCT) is feasible for treatment of DCIS. In nine out of 40 patients (23%), extent of the cancer was classified as grade III, defined as extension over a 2.5-cm margin around the tumor. Among those nine cases, 67% (6/9) had extensive microcalcification on mammography. With respect to the correlation between the tumor size and the extent of the cancer, 29%(5/17) of the cases with a small size tumor, ie, 1.0 cm or less, showed grade III or greater. All tumors with a size of 1.1-2.0 cm showed grade II or lower, and 50%(4/8) of cases with a tumor size of 2.1 cm or more showed grade III or greater. Concerning the relationship between the histological subtype and the extent of the cancer, 22%(2/9) of comedo carcinomas and 23%(7/30) of noncomedo carcinomas showed grade III or greater. The histological extent thus showed no difference between comedo carcinoma and noncomedo carcinoma. It follows that, when BCT performed on DCIS consists of lumpectomy alone, BCT is feasible when the tumor size is 1.1-2.0 cm. without extensive microcalcification on mammography. However, BCT for comedo carcinoma should be approached with caution because of its malignant behavior, although there was no difference in histological extent between comedo and noncomedo carcinoma.     

Can we know what to do when DCIS is diagnosed?

Utilizing routine histopathologic parameters obtained from appropriately handled lumpectomy and mastectomy specimens, a rational therapeutic plan based on epidemiologic and outcome-based data can be devised for any patient diagnosed with ductal carcinoma in situ (DCIS). In order to make a sound decision when weighing the current treatment options for DCIS--which include excision alone, excision plus radiation, and mastectomy--the following are mandatory: 1) assurance of an accurate diagnosis, 2) assessment of DCIS size and grade, and 3) careful margin evaluation. Accurate grading of DCIS is critical, since high nuclear grade and the presence of necrosis are highly predictive of the inability to achieve adequate margins, of local recurrence, and of the probability of missed areas of invasion. Margin status is the single most important determinant of local control following breast conservation for DCIS; numerous studies have shown that as the margin width increases, the risk of local failure decreases. The pros and cons of irradiating conservatively treated patients with DCIS should be carefully weighed on a case-by-case basis. Despite the 20-year-old dogma that all patients treated with breast conservation should receive postoperative radiation, a subset of patients who can be successfully treated by excision alone has been identified.     

Ductal carcinoma<Emphasis Type="Italic">in situ</Emphasis> and related lesions of the breast: Recent advances in pathology practice

The incidence of ductal carcinoma in situ (DCIS) of the breast has increased significantly in Japanese women. It comprises 14.1% (172/1216) of all primary breast cancers at our institute, and nowadays this histological type is familiar to the surgeons and pathologists of any institute. Several subclassifications have been published recently. Most based on nuclear atypia and the presence of comedonecrosis, and sometimes on the structures of the involved glands. These classifications are correlated with the biological behavior, tumor extent and the risk for local recurrences. The diagnostic accuracy of minimally invasive procedures (aspiration biopsy cytology/core needle biopsy) may differ between subclasses. Atypical ductal hyperplasia (ADH) and microinvasive ductal carcinomas are lesions which resemble but deviate from the DCIS spectrum. The incidence of ADH seems to be lower than in Western countries. Patients with ADH may have a risk for subsequent breast cancer, because ADH is frequently associated with contralateral breast carcinomas. Microinvasion should be treated with caution, but we could not find any metastatic foci in microinvasive ductal carcinomas (T1mic). Tentatively, ADH may be treated similarly to non-comedo (low-grade) DCIS cases, according to our limited clinical experience.     

Local control of ductal carcinoma in situ based on tumor and patient characteristics: the surgeon's perspective

Ductal carcinoma in situ (DCIS) is a disease whose manifestations are largely confined to in-breast pathology. Management strategies therefore focus on various combinations of local therapy: mastectomy, lumpectomy alone, and lumpectomy followed by breast irradiation. Although DCIS does not carry an inherent risk of distant organ metastasis, optimal local control is essential because any in-breast or chest wall recurrence may occur as an invasive lesion. Local recurrence has been reported following breast-conserving surgery as well as mastectomy. Breast radiation is therefore generally recommended following breast-conserving surgery, and in selected circumstances, mastectomy may be the preferred treatment strategy. This article reviews the surgical and associated clinicopathologic issues related to initial biopsy and perioperative planning that should be considered for all DCIS cases to optimize local control.