Narasimha Erskine

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In the United States, 63,300 new cases of in situ cancer will be diagnosed in 2012 compared to 229,060 cases of invasive cancer. In situ cases are not included in breast cancer statistics because they represent an increasing proportion of breast cancer cases. In situ cancer accounted for 3-4% of all breast cancers in the early 1980's.

Most in situ cancers are not related to the disease. Between 2004 and 2008 83% of in situ cancer diagnoses were made by DCIS.

The incidence of the disease has increased over time. Between 1973 and 1982 the rate increased 2%.

At the same time that mammography screening was increasing, the DCIS rate increased by about 28% per year. After this, the rate increased at a slower rate.

Incidence rates of in situ breast cancer have remained stable since 1999, but have increased in younger women. The trends in mammography screening peaked in 2000 and may be related to the stabilization in incidence among women over 50 years old.

An abnormal mammogram is the first thing to look for if you have DCIS. DCIS will rarely be seen as a mass.

A nipple discharge which is bloody, pink or serous in nature is a symptom.

LCIS can be found as an "incidental finding" on a breast biopsy for other findings. LCIS is found in a small percentage of breast biopsies.

The majority of LCIS occurs in pre-menopausal women.

There is a differential diagnosis for nipple discharge.

Risk factors for breast cancer are similar to those of DCIS.

White women are more likely to have LCIS than black women.

Core needle biopsy of a mammographic abnormality is the most common method of diagnosis of DCIS. Spot compression and magnified mammogram views of the abnormality are used to evaluate suspicious findings on mammograms.

The most common mammographic abnormality is the clustering of fine microcalcifications which are clustered and pleomorphic in shape.

spiculated densities are less common. A physical exam should be done to make sure there are no breast problems.

A ductogram can be used to identify the area of the tumor which is a filling defect in the duct or a cut off of the duct with contrast, or a narrowing of the duct. The medical history should include a family history of cancer and other risk factors.

The final confirmation of a mammographic abnormality will be provided by the sample of the excision, not the evidence of a disease. The size of the involved area of DCIS and margin width on the specimen will be determined by the pathology exam.

It is important to rule out invasion with a rigorous evaluation. The tumors should be evaluated with staining to see if they have estrogen and progesterone receptors.

Adjuvant tamoxifen can be used to reduce the risk of local recurrence of tumors that are hormone positive.

There is interest in identifying markers that can be used to predict local recurrence.

One of the markers that has been studied is Her2neu, which has been found to be involved in breast cancer, and there is a targeted drug called trastuzumab. Approximately 40% of cases are positive for Her2Neu. Since there is no therapeutic intervention made based on these results, a routine examination for Her2neu is not recommended. There are clinical trials that are looking at the role of trastuzumab.

The diagnosis of LCIS is usually a finding on a mammographic abnormality. If LCIS is found on a core needle, excisional biopsy must be performed to confirm that there is no breast cancer in the sample.

Bilateral mammograms should be obtained with focused diagnostic views.

If mass lesions are seen on mammography, then a sputum should be obtained. The breasts and regional nodes should be examined. A detailed family history of cancer and hormones should be included in a medical history.

Stage 0 is where LCIS and DCIS are staged. Tumor size is important for planning treatment, but it does not affect the staging determination.

Both Stage 0 and Stage 2 are managed differently.

The table shows the staging of breast cancer.

It is not necessary to have therapy for LCIS immediately. There is always time for an evaluation and work-up to determine which treatments will work best.

The patient can get a consultation with radiation oncology, plastic surgery, and surgical oncology services to fully understand her options and risks.

surgical procedures.

With or without immediate reconstruction, DCIS can be treated with breast conserving surgery or mastectomy.

The decision for type of surgery is based on the extent of the breast cancer, whether clear margins can be achieved with partial mastectomy, and patient preference.

Skin sparing techniques can be used to facilitate reconstruction with excellent cosmesis. It is important that the anterior margins of the mastectomy are clear of tumors.

If skin is not removed from large areas of microcalcifications, a positive margin on the specimen may be achieved.

Radiation therapy.

Radiation is usually indicated for breast conserving surgery to reduce the risk of local recurrence.

Clinical trials have shown a reduction in local recurrence of 50-60%. The absolute benefit for certain tumors is not high.

The role of radiation therapy should be determined by factors.

The Van Nuys index assigns points to each feature to determine a total score. Local recurrence rates for patients with scores of 3-6 are 1% at 5 years and 3% at 10 years.

The index has not been used in randomized trials to compare radiation and no radiation.

Adding radiation to surgery is controversial.

The trial randomized women who had undergone partial mastectomy or lumpectomy with clear margins to no further treatment than whole breast radiation.

In 1993, the group had a local recurrence of 7% and a median follow-up of 43 months. The most significant reduction was in the incidence of invasive recurrence.

The results were updated in 1998.

The local recurrence rate was 27% for lumpectomy alone and 12% for lumpectomy with radiation at this point. 4% of the radiation benefit was for the reduction of risk for cancer recurrences, which was the highest persistent benefit. Overall survival between the two groups was the same.

32% of patients with lumpectomy alone had local recurrence at 12 years of follow-up compared to 16% with lumpectomy with radiation.

The investigators found no subgroup that did not benefit from the radiation. Positive margins and comedonecrosis were associated with higher local recurrence rates. The local recurrence rate was 15% for lumpectomy with radiation compared to 26% for lumpectomy alone, in the EORTC 10853 trial.

The whole breast was irradiated over a period of 6 weeks. The use of partial breast radiation has been used to reduce the duration and extent of breast radiation.

As the techniques for accelerated partial breast irradiation have evolved there has been rapid adoption prior to the publication of randomized trials.

The American Society for Radiation Oncology issued guidelines for the use of accelerated partial breast irradiation.

There are 3 categories of patients, suitable, precautionary and unsuitable. The patients of the disease were not included in the suitable category. Patients with small DCIS lesions were included in the cautionary group, while patients with larger-size DCIS were categorized as unsuitable.

In response to the recommendations, investigators have reported their experience with APBI. The Mammosite registry trial had experience with DCIS. The patients were treated with a balloon catheter for 5 days after they received radiation. The radiation is delivered to a limited field.

The actuarial 5-year incidence of local recurrence was 3.4% for 194 patients with DCIS, with a median follow-up of 54 months. Nearly 50% of the DCIS are affected by comedonecrosis.

There are surgical margins.

The width of the margin for breast surgery is controversial.

It is generally agreed that less than 1mm is not ideal. The ideal margin width is not as clear.

A 2mm radial margin is preferred by most surgeons. Margin width is considered more with breast cancer than with DCIS.

This is related to the growth pattern in a linear and branching pattern.

There is a low recurrence rate and low benefit of radiation with larger resection margins. Young age, high tumor grade, and large tumors give more importance to radiation than the margins would suggest. The greatest benefit from radiation is found in cases with margins under 1mm.

A recent analysis suggests that patients with Van Nuys scores of 3-6 can be treated with excision alone and have local recurrence rates of less than 6%.

Patients who score 8 and have margins equal to 3mm, and patients who score 9 and have margins equal to 5mm, are all included in the rate of local control achieved by the addition of radiation.