Ductal carcinoma in situ of the breast--current management

Subclinical Ductal Carcinoma in Situ of the Breast: Treatment with Conservative Surgery and Radiotherapy

Aims and Background

In spite of the fact that ductal carcinoma in situ (DCIS) of the breast is a frequently encountered clinical problem, there is no consensus about the optimal treatment of clinically occult (i.e., mammographic presentation only) DCIS. Interest in breast conservation therapy has recently increased. Few data are available in Italy on the conservative treatment with surgery and adjuvant postoperative radiotherapy.

Methods

A retrospective multi-institutional study was performed in 15 Radiation Oncology Departments in northern Italy involving 112 women with subclinical DCIS of the breast treated between 1982 and 1993. Age of the patients ranged between 32 and 72 years (median, 50 years). All of them underwent conservative surgery: quadrantectomy in 89, tumorectomy in 11, and wide excision in 12 cases. The most common histologic subtype was comedocarcinoma (37%). The median pathologic size was 10 mm (range 1 to 55 mm). Axillary dissection was performed in 83 cases: all the patients were node negative. All the patients received adjunctive radiation therapy with 60Co units (77%) or 6 MV linear accelerators (23%) for a median total dose to the entire breast of 50 Gy (mean, 49.48 Gy; range, 45-60 Gy). Seventy-six cases (68%) received a boost to the tumor bed at a dose of 8-20 Gy (median 10 Gy) for a minimum tumor dose of 58 Gy.

Results

At a median follow-up of 66 months, 8 local recurrences were observed, 4 intraductal and 4 invasive. All recurrent patients had a salvage mastectomy and are alive and free of disease at this writing. The 10-year actuarial overall, cause-specific, and recurrence-free survival was of 98.8%, 100%, and 91%, respectively.

Conclusions

The retrospective multicentric study, with a local control rate of more than 90% at 10 years with 100% cause-specific survival, showed that conservative surgery and adjuvant radiation therapy is a safe and efficacious treatment for patients with occult, non-palpable DCIS.

Pathology of ductal carcinoma in situ of the breast: current status

Ductal carcinoma in situ (DCIS) now accounts for around 20-25% of mammographically detected breast cancers. There is strong evidence to show that classification schemes for DCIS should be based primarily on nuclear grade and necrosis as these two features have been shown to be prognostically important as well as having high interobserver reproducibility among pathologists. Newer classifications of DCIS that employ these features, such as the Van Nuys DCIS Classification, are of prognostic importance in predicting recurrence of DCIS after breast conservation and show high levels of reproducibility. For treatment of DCIS via breast conservation a high pre-operative diagnostic rate is desirable, only achievable via needle-guided core biopsy. If local excision without radiotherapy is to be given there is strong evidence to support the requirement for a 10 mm tumour-free margin. Assurance that a margin is tumour-free requires sequential specimen processing which is both time consuming and costly, but which can be justified in cost and morbidity terms as radiotherapy may not be required for those patients with a 10 mm tumour-free margin. Other methods of specimen examination involve examination of mammographically directed tissue slices or alternative methods of excision margin assessment such as "onion skinning" of the specimen. Endocrine therapy will doubtless become more important for adjuvant therapy of DCIS as well as chemoprophylaxis in the future.

Ductal carcinoma in situ recurrent on the chest wall after mastectomy

Two patients with local recurrence on the chest wall subsequent to mastectomy for ductal carcinoma in situ (DCIS) are presented. One recurrence was invasive carcinoma and the second was DCIS. Excision and chest wall irradiation, together with chemotherapy in the first patient, have provided subsequent disease-free survivals of 6 and 12 years respectively. Although mastectomy for DCIS is almost always curative, the possibility of local recurrence requires careful surveillance.

Quality of life in patients with ductal carcinoma in situ of the breast treated with conservative surgery and postoperative irradiation

AIM OF THE STUDY

To evaluate the quality of life (QL) in patients with ductal carcinoma in situ of the breast treated with conservative surgery and postoperative irradiation.

MATERIAL AND METHODS

A self-completed questionnaire covering many disease-, symptom-, and treatment-specific issues was administered to 106 conservatively treated patients affected by non-infiltrating breast cancer. The questionnaire was based on a series of 34 items assessing five main fields of post-treatment adjustment: physical well being, sexual adaptation, aesthetic outcome, emotional/psychological well being, relational behaviour. Furthermore, the patients were requested to evaluate the degree of information provided by the medical staff concerning surgical procedures and radiation therapy, and to evaluate the effects of the treatment on their social and overall life.

RESULTS

The questionnaire was completed by 83 patients (78%), who had a median follow-up of 54.5 months. This final sample had a median age of 50 years (range 29-88) at the time of treatment and 54 years (range 32-94) at the time of study. The patients claimed to be in good physical condition. Data relating to sexual life were provided by 93% of the sample. Some limitations in sexuality, some interference with sexual desire, and some modifications during intercourse were reported by 5, 6, and 5 patients, respectively. The subjective evaluations of the cosmetic results of the therapies were generally good. Only 13 patients (16%) reported the perception of a worsened body image. Forty-six percent of the sample (38 patients) declared that they felt tense, 48% (39 patients) nervous, 29% (38 patients) lonely, 59% (41 patients) anxious, and 41% (34 patients) depressed. Only seven patients (8%) declared that the treatment had had a bad effect on their social life, and 15 (18%) thought that their current life had been affected by the treatment. The amount of information received concerning the disease and treatment (surgery and radiotherapy) was considered sufficient by 79%, 75%, and 79% of the sample, respectively.

CONCLUSIONS

This study revealed a good QL in patients treated with breast conservation and postoperative irradiation, with a preserved favourable body image and a lack of negative impact on sexuality. Radiation therapy did not lead to any significant additional problems capable of affecting the QL.