Early Breast Cancer. New Treatments
Ductal carcinoma in situ is obviously enough abnormal cells in the ducts. This is a little different than lobular carcinoma in situ in the way that it presents and in it’s management. The incidence of ductal carcinoma in situ is dramatically rising, about 10 years ago, it was about 2% of cancers that were diagnosed in women and many of those were palpable. Because of screening mammography, picking up these little tiny microcalcifications, the incidence of DCIS has risen to about 20 to 30% of all cancers and will probably continue to rise. The classic presentation are little tiny abnormal microcalcifications on a mammogram. There are five subtypes of ductal carcinoma in situ with some thinking that the comedo subtype, comedo meaning necrosis is the most aggressive. Lymph nodes are never involved with ductal carcinoma in situ because the tumor cells are still confined to the basement membrane so they cannot go through the basement membrane, they don’t have access to the regional lymphatics, so axillary lymph node dissection does not need to be performed. This is a picture of ductal carcinoma in situ, this is actually a cribriform type because it has these holes in it with a little bit of necrosis in the center, and you can see that the cells are still very well confined within this duct. The management of ductal carcinoma in situ is different than lobular carcinoma in situ. The patient needs a bilateral mammogram, a biopsy, and then because most of the time you find these little microcalcifications and remove them, you need to do a post biopsy mammogram to make sure they are gone. You don’t want residual microcalcifications left in the breast. If a ductal carcinoma is wide spread, meaning that either the microcalcifications are all over the breast or the area that is removed is large and there is ductal carcinoma in situ throughout the breast, then the best treatment choice is a simple mastectomy with or without reconstruction and one might consider discussion of tamoxifen. If ductal carcinoma in situ is in one quadrant of the breast, the patient still has an option of simple mastectomy, that is a personal choice, the patient may have a lumpectomy and we’ll talk about lumpectomy alone in a minute.
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The most common treatment is lumpectomy or removal of the ductal carcinoma in situ with negative margins followed by radiation therapy and then again, one might have a discussion about tamoxifen. Lumpectomy and radiation therapy was first used for invasive disease and it wasn’t later until we started using it for ductal carcinoma in situ. The control in the breast is about 80 to 92%, depending on patient selection and the carefulness of the physician in determining who is a candidate for breast preservation. Survival for ductal carcinoma in situ is 96 to 100%, this is a highly curable disease. Follow-up of these patient’s is about 10 years and the benefits of tamoxifen will be discussed in a moment. This is just a graft to show four series of patient’s this is a local control with excision plus radiation therapy and then this is the ultimate survival, so you can see that survival is excellent when a lumpectomy and radiation therapy are used. In the NSABP 24 trial, women were randomized to either receive placebo versus tamoxifen. All the women got a lumpectomy and radiation therapy up front, half got the tamoxifen and half got the placebo. Tamoxifen which is shown in red decreased the risk of invasive recurrence. The yellow bar indicates placebo and the red indicates tamoxifen. If you looked at all the recurrent cancers, both in situ and invasive, tamoxifen decreased the rate of all cancers. The ones you worry about are the invasive ones because those are potentially life threatening and it decreased the risk of invasive cancers in about half of the patient’s. So tamoxifen for the diagnosis of ductal carcinoma in situ is at least warranted in a discussion.