Breast Disease pp 115-123 | Cite as

Ductal Carcinoma In Situ

  • Priscilla McAuliffeEmail author


Ductal carcinoma in situ (DCIS) is defined as abnormally proliferating malignant cells confined to the breast milk ducts by the basement membrane. The prognosis of DCIS with microinvasion (DCISM) is intermediate between DCIS and invasive ductal cancer. DCIS is diagnosed most commonly as a mammographic abnormality but can occasionally present as a palpable breast mass. Therapy for DCIS is personalized for each patient, based on tumor-to-breast size ratio, mammographic appearance, margin width, and patient preference. The benefits and risks of breast-conserving therapy versus mastectomy should be discussed in detail. Overall survival after breast-conserving therapy is equivalent to mastectomy. Re-excision is recommended for positive margins and, while debated, pathologic margins less than 2 mm. For breast conservation therapy, radiation therapy is recommended to reduce the risk of local recurrence. Mastectomy is indicated in patients with persistently positive margins after attempts at breast conservation, in those with a contraindication to radiation therapy, and in patients with diffuse, malignant-appearing calcifications or if a patient’s anxiety about local recurrence outweighs the impact of a mastectomy on quality of life. Patients undergoing mastectomy for DCIS should have sentinel lymph node biopsy. Immediate breast reconstruction should be considered for patients undergoing mastectomy. Endocrine therapy such as tamoxifen is offered for 5 years to women with estrogen receptor-positive DCIS. Patients with DCIS should have annual clinical breast exams and annual mammographic imaging of all remaining breast tissue.


Ductal carcinoma in situ DCIS Microinvasion NSABP B-24 IBIS NSABP B-17 NSABP B-35 


  1. 1.
    Desantis C, et al. Breast cancer statistics, 2013. CA Cancer J Clin. 2014;64(1):52–62.PubMedGoogle Scholar
  2. 2.
    Zujewski JA, et al. Ductal carcinoma in situ: trends in treatment over time in the US. Breast Cancer Res Treat. 2011;127(1):251–7.PubMedGoogle Scholar
  3. 3.
    Lynge E, et al. Variation in detection of ductal carcinoma in situ during screening mammography: a survey within the International Cancer Screening Network. Eur J Cancer. 2014;50(1):185–92.PubMedGoogle Scholar
  4. 4.
    Virnig BA, et al. Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes. J Natl Cancer Inst. 2010;102(3):170–8.PubMedGoogle Scholar
  5. 5.
    Kuerer HM, et al. Ductal carcinoma in situ: state of the science and roadmap to advance the field. J Clin Oncol. 2009;27(2):279–88.PubMedGoogle Scholar
  6. 6.
    Erbas B, et al. The natural history of ductal carcinoma in situ of the breast: a review. Breast Cancer Res Treat. 2006;97(2):135–44.PubMedGoogle Scholar
  7. 7.
    Benson JR, Wishart GC. Predictors of recurrence for ductal carcinoma in situ after breast-conserving surgery. Lancet Oncol. 2013;14(9):e348–57.PubMedGoogle Scholar
  8. 8.
    Solin LJ, et al. A multigene expression assay to predict local recurrence risk for ductal carcinoma in situ of the breast. J Natl Cancer Inst. 2013;105(10):701–10.PubMedPubMedCentralGoogle Scholar
  9. 9.
    Omer ZB, et al. Impact of ductal carcinoma in situ terminology on patient treatment preferences. JAMA Intern Med. 2013;173(19):1830–1.PubMedGoogle Scholar
  10. 10.
    Bombonati A, Sgroi DC. The molecular pathology of breast cancer progression. J Pathol. 2011;223(2):307–17.PubMedGoogle Scholar
  11. 11.
    Allred DC, et al. Ductal carcinoma in situ and the emergence of diversity during breast cancer evolution. Clin Cancer Res. 2008;14(2):370–8.PubMedGoogle Scholar
  12. 12.
    Lee S, et al. Differentially expressed genes regulating the progression of ductal carcinoma in situ to invasive breast cancer. Cancer Res. 2012;72(17):4574–86.PubMedPubMedCentralGoogle Scholar
  13. 13.
    Burstein HJ, et al. Ductal carcinoma in situ of the breast. N Engl J Med. 2004;350(14):1430–41.PubMedGoogle Scholar
  14. 14.
    Seth A, et al. Gene expression profiling of ductal carcinomas in situ and invasive breast tumors. Anticancer Res. 2003;23(3A):2043–51.PubMedGoogle Scholar
  15. 15.
    Ma XJ, et al. Gene expression profiles of human breast cancer progression. Proc Natl Acad Sci U S A. 2003;100(10):5974–9.PubMedPubMedCentralGoogle Scholar
  16. 16.
    Lagios MD, et al. Mammographically detected duct carcinoma in situ. Frequency of local recurrence following tylectomy and prognostic effect of nuclear grade on local recurrence. Cancer. 1989;63(4):618–24.PubMedGoogle Scholar
  17. 17.
    Silverstein MJ, et al. Prognostic classification of breast ductal carcinoma-in-situ. Lancet. 1995;345(8958):1154–7.PubMedGoogle Scholar
  18. 18.
    Holland R, et al. Extent, distribution, and mammographic/histological correlations of breast ductal carcinoma in situ. Lancet. 1990;335(8688):519–22.PubMedGoogle Scholar
  19. 19.
    Kurtz JM, et al. Local recurrence after breast-conserving surgery and radiotherapy. Frequency, time course, and prognosis. Cancer. 1989;63(10):1912–7.PubMedGoogle Scholar
  20. 20.
    Adamovich TL, Simmons RM. Ductal carcinoma in situ with microinvasion. Am J Surg. 2003;186(2):112–6.PubMedGoogle Scholar
  21. 21.
    Guth AA, et al. Microinvasive breast cancer and the role of sentinel node biopsy: an institutional experience and review of the literature. Breast J. 2008;14(4):335–9.PubMedGoogle Scholar
  22. 22.
    de Mascarel I, et al. Breast ductal carcinoma in situ with microinvasion: a definition supported by a long-term study of 1248 serially sectioned ductal carcinomas. Cancer. 2002;94(8):2134–42.PubMedGoogle Scholar
  23. 23.
    Mirza NQ, et al. Ductal carcinoma-in-situ: long-term results of breast-conserving therapy. Ann Surg Oncol. 2000;7(9):656–64.PubMedGoogle Scholar
  24. 24.
    Kuhl CK, et al. MRI for diagnosis of pure ductal carcinoma in situ: a prospective observational study. Lancet. 2007;370(9586):485–92.PubMedGoogle Scholar
  25. 25.
    Menell JH, et al. Determination of the presence and extent of pure ductal carcinoma in situ by mammography and magnetic resonance imaging. Breast J. 2005;11(6):382–90.PubMedGoogle Scholar
  26. 26.
    Berg WA, et al. Diagnostic accuracy of mammography, clinical examination, US, and MR imaging in preoperative assessment of breast cancer. Radiology. 2004;233(3):830–49.PubMedGoogle Scholar
  27. 27.
    Rosen EL, et al. BI-RADS MRI enhancement characteristics of ductal carcinoma in situ. Breast J. 2007;13(6):545–50.PubMedGoogle Scholar
  28. 28.
    Lehman CD, et al. MRI evaluation of the contralateral breast in women with recently diagnosed breast cancer. N Engl J Med. 2007;356(13):1295–303.PubMedGoogle Scholar
  29. 29.
    Hollingsworth AB, et al. Breast magnetic resonance imaging for preoperative locoregional staging. Am J Surg. 2008;196(3):389–97.PubMedGoogle Scholar
  30. 30.
    Morrow M. Magnetic resonance imaging in the breast cancer patient: curb your enthusiasm. J Clin Oncol. 2008;26(3):352–3.PubMedGoogle Scholar
  31. 31.
    Solin LJ, et al. Relationship of breast magnetic resonance imaging to outcome after breast-conservation treatment with radiation for women with early-stage invasive breast carcinoma or ductal carcinoma in situ. J Clin Oncol. 2008;26(3):386–91.PubMedGoogle Scholar
  32. 32.
    Bedrosian I, et al. Changes in the surgical management of patients with breast carcinoma based on preoperative magnetic resonance imaging. Cancer. 2003;98(3):468–73.PubMedGoogle Scholar
  33. 33.
    Darling ML, et al. Atypical ductal hyperplasia and ductal carcinoma in situ as revealed by large-core needle breast biopsy: results of surgical excision. AJR Am J Roentgenol. 2000;175(5):1341–6.PubMedGoogle Scholar
  34. 34.
    Dillon MF, et al. Predictors of invasive disease in breast cancer when core biopsy demonstrates DCIS only. J Surg Oncol. 2006;93(7):559–63.PubMedGoogle Scholar
  35. 35.
    Rutstein LA, et al. Predictors of residual invasive disease after core needle biopsy diagnosis of ductal carcinoma in situ. Breast J. 2007;13(3):251–7.PubMedGoogle Scholar
  36. 36.
    Balch CM, Singletary SE, Bland KI. Clinical decision-making in early breast cancer. Ann Surg. 1993;217(3):207–25.PubMedPubMedCentralGoogle Scholar
  37. 37.
    Fowble B. Conservative surgery and radiation in the treatment of early (stages I and II) breast cancer. Long-term results. Helv Chir Acta. 1989;55(6):831–6.PubMedGoogle Scholar
  38. 38.
    Vezeridis MP, Bland KI. Management of ductal carcinoma in situ. Surg Oncol. 1994;3(6):309–25.PubMedGoogle Scholar
  39. 39.
    Boyages J, Delaney G, Taylor R. Predictors of local recurrence after treatment of ductal carcinoma in situ: a meta-analysis. Cancer. 1999;85(3):616–28.PubMedGoogle Scholar
  40. 40.
    Silverstein MJ, et al. Duct carcinoma in situ: 227 cases without microinvasion. Eur J Cancer. 1992;28(2–3):630–4.PubMedGoogle Scholar
  41. 41.
    Wagner JL, et al. Prospective evaluation of the nipple-areola complex sparing mastectomy for risk reduction and for early-stage breast cancer. Ann Surg Oncol. 2012;19(4):1137–44.PubMedGoogle Scholar
  42. 42.
    Fitzsullivan E, et al. Incidence and consequence of close margins in patients with ductal carcinoma-in situ treated with mastectomy: is further therapy warranted? Ann Surg Oncol. 2013;20(13):4103–12.PubMedPubMedCentralGoogle Scholar
  43. 43.
    Neuschatz AC, et al. The value of breast lumpectomy margin assessment as a predictor of residual tumor burden in ductal carcinoma in situ of the breast. Cancer. 2002;94(7):1917–24.PubMedGoogle Scholar
  44. 44.
    Moran MS, et al. Society of Surgical Oncology-American Society for Radiation Oncology consensus guideline on margins for breast-conserving surgery with whole-breast irradiation in stages I and II invasive breast cancer. J Clin Oncol. 2014;32(14):1507–15.PubMedPubMedCentralGoogle Scholar
  45. 45.
    Hadzikadic Gusic L, et al. Margin width is not predictive of residual disease on re-excision in breast conserving therapy. J Surg Oncol. 2014;109(5):426–30.PubMedGoogle Scholar
  46. 46.
    Julian TB, et al. Is sentinel node biopsy necessary in conservatively treated DCIS? Ann Surg Oncol. 2007;14(8):2202–8.PubMedGoogle Scholar
  47. 47.
    Klauber-DeMore N, et al. Sentinel lymph node biopsy: is it indicated in patients with high-risk ductal carcinoma-in-situ and ductal carcinoma-in-situ with microinvasion? Ann Surg Oncol. 2000;7(9):636–42.PubMedGoogle Scholar
  48. 48.
    Lyman GH, et al. Sentinel lymph node biopsy for patients with early-stage breast cancer: American society of clinical oncology clinical practice guideline update. J Clin Oncol. 2014;32(13):1365–83.PubMedGoogle Scholar
  49. 49.
    DiSipio T, et al. Incidence of unilateral arm lymphoedema after breast cancer: a systematic review and meta-analysis. Lancet Oncol. 2013;14(6):500–15.PubMedGoogle Scholar
  50. 50.
    McLaughlin SA, et al. Prevalence of lymphedema in women with breast cancer 5 years after sentinel lymph node biopsy or axillary dissection: objective measurements. J Clin Oncol. 2008;26(32):5213–9.PubMedPubMedCentralGoogle Scholar
  51. 51.
    Mansel RE, et al. Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC Trial. J Natl Cancer Inst. 2006;98(9):599–609.PubMedGoogle Scholar
  52. 52.
    Langer I, et al. Morbidity of sentinel lymph node biopsy (SLN) alone versus SLN and completion axillary lymph node dissection after breast cancer surgery: a prospective Swiss multicenter study on 659 patients. Ann Surg. 2007;245(3):452–61.PubMedPubMedCentralGoogle Scholar
  53. 53.
    Fisher ER, et al. Pathologic findings from the National Surgical Adjuvant Breast Project (NSABP) Protocol B-17. Intraductal carcinoma (ductal carcinoma in situ). The National Surgical Adjuvant Breast and Bowel Project Collaborating Investigators. Cancer. 1995;75(6):1310–9.PubMedGoogle Scholar
  54. 54.
    Fisher B, et al. Prevention of invasive breast cancer in women with ductal carcinoma in situ: an update of the National Surgical Adjuvant Breast and Bowel Project experience. Semin Oncol. 2001;28(4):400–18.PubMedGoogle Scholar
  55. 55.
    Julien JP, et al. Radiotherapy in breast-conserving treatment for ductal carcinoma in situ: first results of the EORTC randomised phase III trial 10853. EORTC Breast Cancer Cooperative Group and EORTC Radiotherapy Group. Lancet. 2000;355(9203):528–33.PubMedGoogle Scholar
  56. 56.
    Donker M, et al. Breast-conserving treatment with or without radiotherapy in ductal carcinoma In Situ: 15-year recurrence rates and outcome after a recurrence, from the EORTC 10853 randomized phase III trial. J Clin Oncol. 2013;31(32):4054–9.PubMedGoogle Scholar
  57. 57.
    Houghton J, et al. Radiotherapy and tamoxifen in women with completely excised ductal carcinoma in situ of the breast in the UK, Australia, and New Zealand: randomised controlled trial. Lancet. 2003;362(9378):95–102.PubMedGoogle Scholar
  58. 58.
    Jeruss JS, et al. Update on DCIS outcomes from the American Society of Breast Surgeons accelerated partial breast irradiation registry trial. Ann Surg Oncol. 2011;18(1):65–71.PubMedGoogle Scholar
  59. 59.
    Lund MJ, et al. Parity and disparity in first course treatment of invasive breast cancer. Breast Cancer Res Treat. 2008;109(3):545–57.PubMedGoogle Scholar
  60. 60.
    Silber JH, et al. Characteristics associated with differences in survival among black and white women with breast cancer. JAMA. 2013;310(4):389–97.PubMedGoogle Scholar
  61. 61.
    Yao N, et al. Radiation therapy resources and guideline-concordant radiotherapy for early-stage breast cancer patients in an underserved region. Health Serv Res. 2013;48(4):1433–49.PubMedPubMedCentralGoogle Scholar
  62. 62.
    Bickell NA, et al. Missed opportunities: racial disparities in adjuvant breast cancer treatment. J Clin Oncol. 2006;24(9):1357–62.PubMedGoogle Scholar
  63. 63.
    Silverstein MJ, et al. The influence of margin width on local control of ductal carcinoma in situ of the breast. N Engl J Med. 1999;340(19):1455–61.PubMedGoogle Scholar
  64. 64.
    Wapnir IL, et al. Long-term outcomes of invasive ipsilateral breast tumor recurrences after lumpectomy in NSABP B-17 and B-24 randomized clinical trials for DCIS. J Natl Cancer Inst. 2011;103(6):478–88.PubMedPubMedCentralGoogle Scholar
  65. 65.
    Wong JS, et al. Eight-year update of a prospective study of wide excision alone for small low- or intermediate-grade ductal carcinoma in situ (DCIS). Breast Cancer Res Treat. 2014;143(2):343–50.PubMedGoogle Scholar
  66. 66.
    Rudloff U, et al. Nomogram for predicting the risk of local recurrence after breast-conserving surgery for ductal carcinoma in situ. J Clin Oncol. 2010;28(23):3762–9.PubMedGoogle Scholar
  67. 67.
    Hughes LL, et al. Local excision alone without irradiation for ductal carcinoma in situ of the breast: a trial of the Eastern Cooperative Oncology Group. J Clin Oncol. 2009;27(32):5319–24.PubMedPubMedCentralGoogle Scholar
  68. 68.
    Allred DC, et al. Adjuvant tamoxifen reduces subsequent breast cancer in women with estrogen receptor-positive ductal carcinoma in situ: a study based on NSABP protocol B-24. J Clin Oncol. 2012;30(12):1268–73.PubMedPubMedCentralGoogle Scholar
  69. 69.
    Vogel VG, et al. National surgical adjuvant breast and bowel project update: prevention trials and endocrine therapy of ductal carcinoma in situ. Clin Cancer Res. 2003;9(1 Pt 2):495S–501S.PubMedGoogle Scholar
  70. 70.
    Cuzick J, et al. Anastrozole for prevention of breast cancer in high-risk postmenopausal women (IBIS-II): an international, double-blind, randomised placebo-controlled trial. Lancet. 2014;383(9922):1041–8.PubMedGoogle Scholar
  71. 71.
    Kong I, et al. Age at diagnosis predicts local recurrence in women treated with breast-conserving surgery and postoperative radiation therapy for ductal carcinoma in situ: a population-based outcomes analysis. Curr Oncol. 2014;21(1):e96–e104.PubMedPubMedCentralGoogle Scholar
  72. 72.
    Silverstein MJ, et al. Outcome after invasive local recurrence in patients with ductal carcinoma in situ of the breast. J Clin Oncol. 1998;16(4):1367–73.PubMedGoogle Scholar
  73. 73.
    Romero L, et al. Outcome after invasive recurrence in patients with ductal carcinoma in situ of the breast. Am J Surg. 2004;188(4):371–6.PubMedGoogle Scholar

Copyright information

© Springer Nature Switzerland AG 2019

Authors and Affiliations

  1. 1.Department of Surgery, Division of Surgical OncologyUniversity of Pittsburgh School of MedicinePittsburghUSA
  2. 2.Magee-Women’s Surgical AssociatesPittsburghUSA
  3. 3.Women’s Cancer Research Center of UPMC Hillman Cancer CenterPittsburghUSA

Personalised recommendations