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Background and Treatment of Ductal Carcinoma in situ (DCIS) Author: Stephen B. Strum M.D. Copyright © 1994, Stephen B. Strum M.D. Background DCIS now represents about 20% of all newly accessioned cancers involving mammographic surveillance. Risk of invasion in the residual breast after a biopsy diagnosis of DCIS is related to the size of the DCIS lesion. In lesions less than 55mm only 1 of 111 patients had such invasion (Lagios 1990). In addition, the histopathology of the DCIS is related to the post-excision recurrence rate with virtually no patients having a low grade nuclear type and micropapillary or non-necrotic cribiform subtypes having recurrences post-excision. Patients with comedo subtypes have a higher recurrence rate that appears to be restricted to those patients with lesions larger than 45mm. In a series of 79 patients treated with lumpectomy alone, Lagios reported a 19% local recurrence rate in association with a high-grade nuclear morphology and comedo-type necrosis after an average interval of 26 months. Only /10 patients with intermediate grade DCIS developed a recurrence at 87 months and /33 with DCIS of low-grade and micropapillary/non-necrotic cribiform type developed local recurrence. The overall crude recurrence rate for DCIS of limited extent treated by tylectomy is 10.1% at 4 years. The majority of recurrences have been detected mammographically and all were ipsilateral. Of recurrences, 50% have been non-invasive (3 of 4 have been treated by reexcision). All patients treated for subsequence recurrence have remained free of disease. The frequency of axillary metastases is so low as not to require axillary node sampling. This is especially true of those patients with DCIS lesions smaller than 50mm. In one series having a median extent of 50mm the frequency of axillary metastases was 3.6%. Some form of axillary sampling should be done in patients with extensive DCIS and in patients with high-grade comedo-type DCIS. Untreated, or incompletely excised DCIS progresses to invasive breast cancer in many, but not all, patients. The average rate of recurrence in such patients is 30% with the average time from biopsy to development of breast cancer approaching 10 years. Multicentricity in DCIS is common especially in patients with the comedo-type histology. In the series of Simpson et. al. (Arch Surg 4/92) 78% of patients with comedocarcinoma had multicentric lesions. DCIS in this series did not develop contralateral breast cancer. In other series bilaterality rates range from 0% to 10%. Adjuvant radiation therapy after excision or partial mastectomy for DCIS has presently an unclear role. In NSABP #6 51 patients were found in retrospect to have DCIS with 29 or 57% having RT and 22 or 43% having surgery only. With a mean follow-up of only 3.4 years, local recurrence developed in 2 or 7% of the 29 who received adjuvant RT and in 5 or 23% of the 22 patients who had partial mastectomy only. These numbers are too small and the follow-up too brief to arrive at conclusions. Moreover, in patients with invasive breast cancer and coexistent DCIS there appears to be an increase in recurrence rates. DCIS may be a marker for radioresistant disease. In addition, mammographic interpretation of the irradiated breast is difficult and the tendency of intraductal lesions to precipitate calcium into the lumen of the duct may be lost in the irradiated breast (Simpson et. al.) Treatment The treatment of DCIS is controversial. In some patients, a number of options exist. The finding of significant microcalcifications makes this illness easily detectable by surveillance mammography. If the patient elects to do nothing but repeat mammography every 6 months this would not be unreasonable. The use of prophylactic Tamoxifen(Nolvadex) would be reasonable to prevent recurrence of this entity and hopefully obviate the need for additional surgery or radiation. The side-effects are usually nil and the beneficial effects of Tamoxifen on positive calcium balance and decreased coronary artery disease are a major plus. Some women will have hot flashes on Tamoxifen and occasional vaginal discharge. The risk of increased uterine cancer has been raised but this appears to be of low order and more common in lab animals. Rare occurrences of thrombocytopenia are noted. This would be a reasonable choice, especially with the family history of breast cancer. Quadrantectomy is a recognized effective treatment for DCIS. This would likely cure the disease but would leave the patient with a cosmetic problem with significant difference of breast size. In a large breasted woman this would be a better option. Radiation therapy is effective in preventing recurrence of disease. My concern is change in skin pigmentation and overall breast consistency. Occasional difficulty in evaluation of the mammogram results from RT. The right breast is involved therefore RT would not be a factor in possible effect on the heart. I have not been pleased with the cosmetic effects of RT to the breast. Simple mastectomy would resolve the problem regarding the right breast. It would not be cosmetically acceptable to the patient from what she has told me. In light of her history and the heavy microcalcifications a less radical approach would be reasonable. She should be on beta-carotene 50000 units a day with Vitamin E, 2000 units a day. Supplemental calcium/magnesium should be given to prevent osteoporosis. With the history of breast cancer I would advise patients to decrease their coffee intake or change to herbal tea. Also avoid other xanthine containing compounds such as cocoa and chocolate.

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