Ductal carcinoma in-situ: An update for clinical practice
ABSTRACT Ductal carcinoma in-situ (DCIS) is a heterogeneous entity with an elusive natural history. The objective of radiological, histological and molecular characterisation remains to reliably predict the biological behaviour and optimise clinical management strategies. Increases in diagnostic frequency have followed the introduction of mammographic screening and increased utility of magnetic resonance imaging. However, progress remains limited in distinguishing non-progressive incidental lesions from their progressive and clinically relevant counterparts. This article reviews current management strategies for DCIS in the context of recent randomized trials, including the role of sentinel lymph node biopsy (SLNB), adjuvant radiotherapy (RT) and endocrine treatment.
Literature review facilitated by Medline, PubMed, Embase and Cochrane databases.
DCIS should be managed in the context of a multidisciplinary team. Local control depends upon adequate surgical clearance with margins of at least 2 mm. SLNB is not routinely indicated and should be reserved for those with concurrent or recurrent invasive disease. SLNB can be considered in patients undergoing mastectomy (MX) and those with risk factors for invasion such as palpability, comedo morphology, necrosis or recurrent disease. RT following BCS significantly reduces local recurrence (LR), particularly in those at high-risk. There remains a lack of level-1 evidence supporting the omission of adjuvant RT in selected low-risk cases. Large, multi-centric or recurrent lesions (particularly in cases of prior RT) should be treated by MX with the opportunity for immediate reconstruction. Adjuvant Tamoxifen may reduce the risk of LR in selected cases with hormone sensitive disease.
Further research is required to determine the role of contemporary RT regimes and endocrine therapies. Biological profiling and molecular analysis represent an opportunity to improve our understanding of the tumour biology of this condition and rationalise its treatment. Reliable identification of low-risk lesions could allow treatment to be less radical or safely omitted.
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ABSTRACT: Oncoplastic surgery has been widely developed during the last decade. The combination of a large tumor resection performed by the breast surgeon and the immediate breast reconstruction by the plastic surgeon has numerous advantages. This technique provides safer resection with larger margins and immediate aesthetic results. During the last decade, we have used an algorithm in oncoplastic surgery: Small and moderate size breast tumors (T1-2) are considered the best indications for conserving breast surgery. Depending on the breast size and tumor/breast size relation, determinesthe reconstructive technique is used. A glandular flap, as a part of breast reduction techniques, was raised from the breast itself to fill defects after tumorectomy in large-size breast. However, contralateral breast reduction is necessary to achieve breast symmetry. In the case of smaller breast size, partial breast reconstruction is performed using pedicled flaps (LD or muscle sparing LD, TDAP, LICAP, SAAP) harvested from the back and/or the axillary region. Adequate symmetry is obtained without operating on the contralateral breast. Adjuvant radiotherapy can be started after 4-6 weeks postoperatively. In total 119 patients, in whom bilateral breast remodeling techniques and pedicled flaps were used in 26 and 93 patients respectively. In three cases, margins were involved with the tumor. Wider excision was done in two patients. Total mastectomy was performed in the third patient. With an average follow-up of 4 years, further surgery was indicated in only three patients because of fat necrosis. Converting to total mastectomy with immediate breast reconstruction with a DIEAP flap was necessary in one patient at 2 years after the initial partial breast reconstruction with a TDAP because of major fat necrosis. Aesthetic results and patient satisfaction are promising, however, longer follow-up is still required to confirm our 4-year-follow-up outcome. Oncoplastic surgery offers a better cosmetic outcome as partial breast reconstruction, using various techniques, when performed during the same procedure. In partial breast reconstruction, therapeutic mammaplasty techniques offer creative options for large and pendulous breast. On the other hand, perforator flaps, which spare latissimus dorsi muscle function, provide valuable method for small size breasts.Breast (Edinburgh, Scotland) 08/2013; 22S2:S100-S105. DOI:10.1016/j.breast.2013.07.019 · 2.58 Impact Factor
Article: Current Treatment of DCIS[Show abstract] [Hide abstract]
ABSTRACT: Abstract: Ductal carcinoma in-situ DCIS is a heterogeneous entity in breast neoplasm with unpredictable biological behavior. This poses challenge in the management of DCIS. Various trials on DCIS have shown good outcome with integral treatment of adequate surgery, radiotherapy and hormonal therapy. Identification of subgroup of DCIS for radiotherapy and hormonal therapy could improve recurrence rate, contralateral tumours incidence and perhaps overall survival. Various risk score calculations could help to direct radiotherapy and hormonal treatment verses surgery alone and to avoid over treatment. Oncotype DX assay could be a new way of risk calculation to direct types of DCIS treatment. The recent increased use of MRI could increase the detection of DCIS and a more accurate extent of disease estimation. This article is a summary of major literatures and major trials result for DCIS.Journal of Cancer Therapy 02/2014; 5(2):179-181. DOI:10.4236/jct.2014.52022
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ABSTRACT: The use of clinical features to allocate adjuvant therapy in the treatment of ductal carcinoma in situ with breast-conserving therapy remains controversial. A review of patients with ductal carcinoma in situ treated with breast-conserving therapy was performed. The recurrence rate was examined in relation to patient age, tumor characteristics, Van Nuys Prognostic Index, and the receipt of prescribed adjuvant therapies. Six percent of patients (17 of 294) had developed local recurrences after a median follow-up period of 63 months. Fifty-nine percent of patients (91 of 154) with estrogen receptor-positive tumors were did not receive prescribed tamoxifen. Thirty-one percent of patients (45 of 147) with Van Nuys Prognostic Index scores ≥7 did not receive recommended radiation therapy. Receipt of prescribed adjuvant therapy did not result in a decrease in the rate of local recurrence. Patient age was the only factor associated with local recurrence on univariate but not on multivariate analysis (P = .374). A low rate of local recurrence was achieved despite a large number of patients' not receiving prescribed adjuvant therapies.American journal of surgery 07/2013; 206(5). DOI:10.1016/j.amjsurg.2013.03.008 · 2.41 Impact Factor