Duct Carcinoma In Situ: A Gordian Knot Untied

  • Michael D. Lagios


Ductal carcinoma in situ (DCIS) has exponentially increased in frequency since the introduction of mammography 30 years ago and now comprises 25% of all new breast cancers. The majority of currently detected DCIS are clinically occult, detected only by imaging modalities and average ≤10 mm in extent. Management of such DCIS is evolving and subject of great controversy; recommended treatments vary from simple resection to resection combined with irradiation, tamoxifen, and a sentinel lymph node biopsy. It is now recognized that the major risk of properly treated DCIS is local recurrence alone with a small risk of recurrence as invasive cancer.

Numerous studies have shown that local recurrence in DCIS is related to the grade, extent (size), margin status, and age of the patient. Yet the randomized trials of radiation therapy are noninformative in regards to these prognostic factors since they were not empowered to define or evaluate them. Prospective nonrandomized studies, on the other hand, have shown that these factors can be successfully used to stratify DCIS patients into subsets with significantly different risks of local recurrence. Patient subsets can be identified for whom the fractional benefit of irradiation and/or tamoxifen is so small that it is clinically insignificant. The Van Nuys Prognostic Index is an exemplar algorithm of this type. A common feature of the successful prospective studies is meticulous mammographic/pathologic correlation and a serial sequential method of tissue processing, a technique strongly recommended by the new College of American Pathologist Guidelines. Acceptance of these newer pathologic approaches will permit determination of a VNPI for an individual patient and decrease the use of unnecessary and expensive treatment modalities for all patients.


Local Recurrence Nuclear Grade Breast Conservation Therapy Invasive Focus Zonal Necrosis 
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  1. 1.
    Margolin FR, Lagios MD. Mammographic detection of early breast cancer: ten years experience in a community hospital. West J Med. 1986;144:46–8.PubMedGoogle Scholar
  2. 2.
    Rosner D, Bedwani RN, Vana J, et al. Non-invasive breast cancer: results of a national survey by the American College of Surgeons. Ann Surg. 1980;192:139–47.PubMedCrossRefGoogle Scholar
  3. 3.
    Lagios MD, Westdahl PR, Margolin FR, et al. Duct carcinoma in situ: relationship of extent of noninvasive disease to the frequency of occult invasion, multicentricity, lymph node metastases, and short-term treatment failures. Cancer. 1982;50:1309–14.PubMedCrossRefGoogle Scholar
  4. 4.
    Lagios MD, Margolin FR, Westdahl PR, 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;63:619–24.CrossRefGoogle Scholar
  5. 5.
    Lagios MD. Duct carcinoma in situ: pathology and treatment. Surg Clin N Am. 1990;70: 853–71.PubMedGoogle Scholar
  6. 6.
    Silverstein MJ, Lagios MD, Craig PH, et al. A prognostic index for ductal carcinoma in situ of the breast. Cancer. 1996;77:2267–74.PubMedCrossRefGoogle Scholar
  7. 7.
    Fisher B, Constantino J, Redmond C, et al. Lumpectomy compared with lumpectomy and radiation therapy for the treatment of intraductal breast cancer. N Eng J Med. 1993;328:1581–6.CrossRefGoogle Scholar
  8. 8.
    Bijker N, Peterse JL, Duschateau L, et al. Risk factors for recurrence and metastasis after breast-conserving therapy for ductal carcinoma in situ. Analysis of European Organization for Research and Treatment of Cancer Trial 10853. J Clin Oncol. 2001;19:2263–71.PubMedGoogle Scholar
  9. 9.
    Fisher B, Land S, Mamounas E, et al. Prevention of invasive breast cancer in women with ductal carcioma in situ: an update of the National Surgical Adjuvant Breast and Bowel Project experience. Sem Oncol. 2001;28:400–18.CrossRefGoogle Scholar
  10. 10.
    Julien JP, Bijker N, Fentiman IS, et al. Radiotherapy in breast-conserving treatment for ductal carcinoma in situ: first results of the EORTC randomized phase III trial 10853. Lancet. 2000;355:528–33.PubMedCrossRefGoogle Scholar
  11. 2010.
    Vicini FA, Kestin LL, Goldstein NS, Chen PY, et al. Impact of young age on outcome in patients with ductal carcinoma in situ treated with breast-conserving therapy. J Clin Oncol. 2000;18:296–306.PubMedGoogle Scholar
  12. 12.
    Silverstein MJ, Poller DN, Waisman JR, et al. Prognostic classification of breast ductal carcinoma in situ. Lancet. 1995;345:201054–7.Google Scholar
  13. 13.
    Committee C. Consensus conference on the classification of ductal carcinoma in situ. Cancer. 1997;80:1789–802.Google Scholar
  14. 14.
    Solin LJ, Yeh IT, Kurt J, et al. Ductal carcinoma in situ (intraductal carcinoma) of the breast treated with breast-conserving surgery and definitive irradiation: correlation of pathologic parameters with outcome of treatment. Cancer. 1993;71:2532–42.PubMedCrossRefGoogle Scholar
  15. 15.
    Sloan JP, Amendoeira I, Apostolikas N, et al. Consistency achieved by 23 European pathologists in categorizing ductal carcinoma in situ of the breast using fice classifications. European Commission Working Group on Breast Screening Pathology. Hum Pathol. 1998;29:1056–62.Google Scholar
  16. 16.
    Boland GP, Chan KC, Knox WF, et al. Value of the Van Nuys Prognostic Index in prediction of recurrence of ductal carcinoma in situ after breast-conserving surgery. Br J Surg. 2003;90:426–32.CrossRefGoogle Scholar
  17. 17.
    Tjin Asjoe F, Altintas S, Huizing MT, et al. The value of the Van Nuys Prognostic Index in ductal carcinoma in situ of the breast: a retrospective analysis. Breast J. 2007;13:359–67.Google Scholar
  18. 18.
    De Mascarel I, MacGrogan G, Mathoulin-Pelissier S, et al. Breast ductal carcinoma in situ with micro invasion. a definition supported by a long-term study of 1248 serially sectioned ductal carcinomas. Cancer. 2002;94:2134–42.PubMedCrossRefGoogle Scholar
  19. 19.
    Wong JS, Kaelin CM, Troyan SL, et al. Prospective study of wide excision alone for ductal carcinoma in situ of the breast. J Clin Oncol. 2006;24:1031–6.PubMedCrossRefGoogle Scholar
  20. 20.
    Consensus Committee. Image-detected breast cancer: state of the art diagnosis and treatment. J Am Coll Surg. 2001;193:297–302.CrossRefGoogle Scholar
  21. 21.
    Silverstein MJ, Lagios MD, Recht A, et al. Image-detected breast cancer: state of the art diagnosis and treatment. J Am Col Surg. 2005;201:586–97.CrossRefGoogle Scholar
  22. 22.
    Macdonald HR, Silverstein MJ, Lee LA, et al. Margin width as the sole determinant of local recurrence after breast conservation in patients with ductal carcinoma in situ of the breast. Am J Surg. 2006;192:420–2.PubMedCrossRefGoogle Scholar
  23. 23.
    Silverstein MJ, Lagios MD, Groshen S, et al. The influence of margin width on local control in patients with ductal carcinoma in situ (DCIS) of the breast. N Eng J Med. 1999;340:1455–61.CrossRefGoogle Scholar
  24. 24.
    Silverstein MJ. An argument against routine use of radiotherapy for ductal carcinoma in situ. Oncology. 2003;17:152010–33.Google Scholar
  25. 25.
    Lagios MD. Practical pathology of ductal carcinoma in situ: How to derive optimal data from the pathologic examination. In: Silverstein MJ, Recht A, Lagios MD, editors. Ductal carcinoma in situ of the breast. 2nd ed. Philadelphia: Lippincott Williams & Wilkins; 2002. p. 207–21.Google Scholar
  26. 26.
    Fisher ER, Costantino J, Fisher B, et al. Pathologic findings from the national surgical adjuvant breast protocol B-17; intraductal carcinoma (duct carcinoma in situ). Cancer. 1995;75:1310–9.PubMedCrossRefGoogle Scholar
  27. 27.
    Houghton J, George WE, Cuzick 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: Randomized controlled trial. Lancet. 2003;362:95–102.PubMedCrossRefGoogle Scholar
  28. 28.
    Emdin SO, Granstand B, Ringberg A, et al. DCIS: radiotherapy after sector resection for ductal carcinoma in situ of the breast. Results of a randomized trial in a population offered mammographic screening. Acta Oncol. 2006;45:536–43.PubMedCrossRefGoogle Scholar
  29. 29.
    Viani GA, Stefano EJ, Afonso SL, et al. Breast-conserving surgery with and without radiotherapy in women with ductal carcinoma in situ: a meta-analysis of randomized trials. Rad Oncol. 2007;2:28.CrossRefGoogle Scholar
  30. 30.
    Lester SC, Connolly JL, Amin MB et al. Protocal for the reporting of ductal carcinoma in situ. Arch pathol Lab Med, 2009; 133:13–14.Google Scholar

Copyright information

© Springer New York 2010

Authors and Affiliations

  1. 1.Breast Cancer Consultation ServiceTiburonUSA

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