Ductal carcinoma in situ

Last updated

Breast cancer in situ
Other namesIntraductal carcinoma
Lobules and ducts of the breast.jpg
Ducts of the mammary gland, the location of ductal carcinoma
Specialty Oncology
Histopathologic image from ductal cell carcinoma in situ (DCIS) of breast (hematoxylin and eosin stain) Breast DCIS histopathology (1).jpg
Histopathologic image from ductal cell carcinoma in situ (DCIS) of breast (hematoxylin and eosin stain)

Ductal carcinoma in situ (DCIS), also known as intraductal carcinoma, is a pre-cancerous or non-invasive cancerous lesion of the breast. [1] [2] DCIS is classified as Stage 0. [3] It rarely produces symptoms or a breast lump that can be felt, typically being detected through screening mammography. [4] [5] It has been diagnosed in a significant percentage of men (see male breast cancer). [6]

Contents

In DCIS, abnormal cells are found in the lining of one or more milk ducts in the breast. In situ means "in place" and refers to the fact that the abnormal cells have not moved out of the mammary duct and into any of the surrounding tissues in the breast ("pre-cancerous" indicates that it has not yet become an invasive cancer). In some cases, DCIS may become invasive and spread to other tissues, but there is no way of determining which lesions will remain stable without treatment, and which will go on to become invasive. [7] DCIS encompasses a wide spectrum of diseases ranging from low-grade lesions that are not life-threatening to high-grade (i.e. potentially highly aggressive) lesions.

DCIS has been classified according to the architectural pattern of the cells (solid, cribriform, papillary, and micropapillary), tumor grade (high, intermediate, and low grade), or the presence or absence of comedo histology; [8] or, in the case of the apocrine cell-based in situ carcinoma, apocrine ductal carcinoma in situ, it may be classified according to the cell type forming the lesion. [9] DCIS can be detected on mammograms by examining tiny specks of calcium known as microcalcifications. Since suspicious groups of microcalcifications can appear even in the absence of DCIS, a biopsy may be necessary for diagnosis.

About 20–30% of those who do not receive treatment develop breast cancer. [10] [11] DCIS is the most common type of pre-cancer in women. There is some disagreement on its status as cancer; some bodies include DCIS when calculating breast cancer statistics, while others do not. [12] [13]

Terminology

Ductal carcinoma in situ (DCIS) literally means groups of "cancerous" epithelial cells which remain in their normal location (in situ) within the ducts and lobules of the mammary gland. [14] Clinically, DCIS is considered to be a premalignant (i.e. potentially malignant) condition, [15] because the biologically abnormal cells have not yet crossed the basement membrane to invade the surrounding tissue. [14] [16] When multiple lesions (known as "foci" of DCIS) are present in different quadrants of the breast, this is referred to as "multicentric" disease. [8]

For statistical purposes, DCIS is sometimes counted as a "cancer", but this is not always the case. [13] [17] When classified as a cancer, it is referred to as a "non-invasive" or "pre-invasive" form. [14] [18] It is described by the National Cancer Institute as a "noninvasive condition". [13]

Signs and symptoms

A drawing of ductal carcinoma in situ in the anatomical context of the whole breast Diagram showing ductal carcinoma in situ (DCIS) CRUK 115.svg
A drawing of ductal carcinoma in situ in the anatomical context of the whole breast
A drawing of a breast duct containing ductal carcinoma in situ Nci-vol-4353-300 ductal carcinoma in situ.jpg
A drawing of a breast duct containing ductal carcinoma in situ

Most of the women who develop DCIS do not experience any symptoms. The majority of cases (80-85%) are detected through screening mammography. The first signs and symptoms may appear if the cancer advances. Because of the lack of early symptoms, DCIS is most often detected at screening mammography.

In a few cases, DCIS may cause:

Causes

The specific causes of DCIS are still unknown. The risk factors for developing this condition are similar to those for invasive breast cancer. [21]

Some women are however more prone than others to developing DCIS. Women considered at higher risks are those who have a family history of breast cancer, those who have had their periods at an early age or who have had a late menopause. Also, women who have never had children or had them late in life are also more likely to get this condition.

Long-term use of estrogen-progestin hormone replacement therapy (HRT) for more than five years after menopause, genetic mutations (BRCA1 or BRCA2 genes), atypical hyperplasia, as well as radiation exposure or exposure to certain chemicals may also contribute in the development of the condition. [22] Nonetheless, the risk of developing noninvasive cancer increases with age and it is higher in women older than 45 years.

Diagnosis

80% of cases in the United States are detected by mammography screening. [23] More definitive diagnosis is made by breast biopsy for histopathology.

Treatment

There are different opinions on the best treatment of DCIS. [28] Surgical removal, with or without additional radiation therapy or tamoxifen, is the recommended treatment for DCIS by the National Cancer Institute. [29] Surgery may be either a breast-conserving lumpectomy or a mastectomy (complete or partial removal of the affected breast). [30] If a lumpectomy is used it is often combined with radiation therapy. [13] Tamoxifen may be used as hormonal therapy if the cells show estrogen receptor positivity. [13] Research shows that survival is the same with lumpectomy as it is with mastectomy, whether or not a woman has radiation after lumpectomy. [31] Chemotherapy is not needed for DCIS since the disease is noninvasive. [32]

While surgery reduces the risk of subsequent cancer, many people never develop cancer even without treatment and the associated side effects. [30] There is no evidence comparing surgery with watchful waiting and some feel watchful waiting may be a reasonable option in certain cases. [30]

Radiation therapy

Use of radiation therapy after lumpectomy provides equivalent survival rates to mastectomy, although there is a slightly higher risk of recurrent disease in the same breast in the form of further DCIS or invasive breast cancer. Systematic reviews (including a Cochrane review) indicate that the addition of radiation therapy to lumpectomy reduces recurrence of DCIS or later onset of invasive breast cancer in comparison with breast-conserving surgery alone, without affecting mortality. [33] [34] [35] The Cochrane review did not find any evidence that the radiation therapy had any long-term toxic effects. [33] While the authors caution that longer follow-up will be required before a definitive conclusion can be reached regarding long-term toxicity, they point out that ongoing technical improvements should further restrict radiation exposure in healthy tissues. [33] They do recommend that comprehensive information on potential side effects is given to women who receive this treatment. [33] The addition of radiation therapy to lumpectomy appears to reduce the risk of local recurrence to approximately 12%, of which approximately half will be DCIS and half will be invasive breast cancer; the risk of recurrence is 1% for women undergoing mastectomy. [36]

Mastectomy

There is no evidence that mastectomy decreases the risk of death over a lumpectomy. [37] Mastectomy, however, may decrease the rate of the DCIS or invasive cancer occurring in the same location. [7] [37]

Mastectomies remain a common recommendation in those with persistent microscopic involvement of margins after local excision or with a diagnosis of DCIS and evidence of suspicious, diffuse microcalcifications. [38]

Sentinel node biopsy

Some institutions that have encountered high rates of recurrent invasive cancers after mastectomy for DCIS have endorsed routine sentinel node biopsy (SNB). [39] However, research indicates that sentinel node biopsy has risks that outweigh the benefits for most women with DCIS. [40] SNB should be considered with tissue diagnosis of high-risk DCIS (grade III with palpable mass or larger size on imaging) as well as in people undergoing mastectomy after a core or excisional biopsy diagnosis of DCIS. [41] [42]

Prognosis

With treatment, the prognosis is excellent, with greater than 97% long-term survival. If untreated, DCIS progresses to invasive cancer in roughly one-third of cases, usually in the same breast and quadrant as the earlier DCIS. [43] About 2% of women who are diagnosed with this condition and treated died within 10 years. [44] Biomarkers can identify which women who were initially diagnosed with DCIS are at high or low risk of subsequent invasive cancer. [45] [46]

Epidemiology

Histopathologic types of breast cancer, with relative incidences and prognoses. "Ductal carcinoma in situ" is near top. Pie chart of incidence and prognosis of histopathologic breast cancer types.png
Histopathologic types of breast cancer, with relative incidences and prognoses. "Ductal carcinoma in situ" is near top.

DCIS is often detected with mammographies but can rarely be felt. With the increasing use of screening mammography, noninvasive cancers are more frequently diagnosed and now constitute 15% to 20% of all breast cancers. [38]

Cases of DCIS have increased five-fold between 1983 and 2003 in the United States due to the introduction of screening mammography. [44] In 2009 about 62,000 cases were diagnosed. [44]

Related Research Articles

<span class="mw-page-title-main">Mastectomy</span> Surgical removal of one or both breasts

Mastectomy is the medical term for the surgical removal of one or both breasts, partially or completely. A mastectomy is usually carried out to treat breast cancer. In some cases, women believed to be at high risk of breast cancer have the operation as a preventive measure. Alternatively, some women can choose to have a wide local excision, also known as a lumpectomy, an operation in which a small volume of breast tissue containing the tumor and a surrounding margin of healthy tissue is removed to conserve the breast. Both mastectomy and lumpectomy are referred to as "local therapies" for breast cancer, targeting the area of the tumor, as opposed to systemic therapies, such as chemotherapy, hormonal therapy, or immunotherapy.

<span class="mw-page-title-main">Breast cancer</span> Cancer that originates in mammary glands

Breast cancer is a cancer that develops from breast tissue. Signs of breast cancer may include a lump in the breast, a change in breast shape, dimpling of the skin, milk rejection, fluid coming from the nipple, a newly inverted nipple, or a red or scaly patch of skin. In those with distant spread of the disease, there may be bone pain, swollen lymph nodes, shortness of breath, or yellow skin.

<span class="mw-page-title-main">Paget's disease of the breast</span> Medical condition

Paget's disease of the breast is a rare skin change at the nipple nearly always associated with underlying breast cancer. Paget's disease of the breast was first described by Sir James Paget in 1874. The condition is an uncommon disease accounting for 1 to 4% of all breast cancers cases. 92% to 100% of patients with Paget's disease of the breast have an underlying breast cancer.

Inflammatory breast cancer (IBC) is one of the most aggressive types of breast cancer. It can occur in women of any age. It is referred to as "inflammatory" due to its frequent presentation with symptoms resembling a skin inflammation, such as erysipelas.

<span class="mw-page-title-main">Lumpectomy</span> Limited surgical removal of breast tissue

Lumpectomy is a surgical removal of a discrete portion or "lump" of breast tissue, usually in the treatment of a malignant tumor or breast cancer. It is considered a viable breast conservation therapy, as the amount of tissue removed is limited compared to a full-breast mastectomy, and thus may have physical and emotional advantages over more disfiguring treatment. Sometimes a lumpectomy may be used to either confirm or rule out that cancer has actually been detected. A lumpectomy is usually recommended to patients whose cancer has been detected early and who do not have enlarged tumors. Although a lumpectomy is used to allow for most of the breast to remain intact, the procedure may result in adverse affects that can include sensitivity and result in scar tissue, pain, and possible disfiguration of the breast if the lump taken out is significant. According to National Comprehensive Cancer Network guidelines, lumpectomy may be performed for ductal carcinoma in situ (DCIS), invasive ductal carcinoma, or other conditions.

<span class="mw-page-title-main">Invasive carcinoma of no special type</span> Medical condition

Invasive carcinoma of no special type, invasive breast carcinoma of no special type (IBC-NST), invasive ductal carcinoma (IDC), infiltrating ductal carcinoma (IDC) or invasive ductal carcinoma, not otherwise specified (NOS) is a disease. For international audiences this article will use "invasive carcinoma NST" because it is the preferred term of the World Health Organization (WHO).

<span class="mw-page-title-main">Microcalcification</span> Calcium deposits in the breast

Microcalcifications are tiny deposits of calcium salts that are too small to be felt but can be detected by imaging.

Breast cancer management takes different approaches depending on physical and biological characteristics of the disease, as well as the age, over-all health and personal preferences of the patient. Treatment types can be classified into local therapy and systemic treatment. Local therapy is most efficacious in early stage breast cancer, while systemic therapy is generally justified in advanced and metastatic disease, or in diseases with specific phenotypes.

<span class="mw-page-title-main">Breast cancer screening</span> Medical screening of asymptomatic, healthy women for breast cancer

Breast cancer screening is the medical screening of asymptomatic, apparently healthy women for breast cancer in an attempt to achieve an earlier diagnosis. The assumption is that early detection will improve outcomes. A number of screening tests have been employed, including clinical and self breast exams, mammography, genetic screening, ultrasound, and magnetic resonance imaging.

<span class="mw-page-title-main">Breast-conserving surgery</span> Surgical operation

Breast-conserving surgery refers to an operation that aims to remove breast cancer while avoiding a mastectomy. Different forms of this operation include: lumpectomy (tylectomy), wide local excision, segmental resection, and quadrantectomy. Breast-conserving surgery has been increasingly accepted as an alternative to mastectomy in specific patients, as it provides tumor removal while maintaining an acceptable cosmetic outcome. This page reviews the history of this operation, important considerations in decision making and patient selection, and the emerging field of oncoplastic breast conservation surgery.

Comedocarcinoma is a kind of breast cancer that demonstrates comedonecrosis, which is the central necrosis of cancer cells within involved ducts. Comedocarcinomas are usually non-infiltrating and intraductal tumors, characterized as a comedo-type, high-grade ductal carcinoma in situ (DCIS). However, there have been accounts of comedocarcinoma which has then diversified into other cell types and developed into infiltrating (invasive) ductal carcinoma. Recurrence and survival rates differ for invasive breast cancer which has originated as comedocarcinoma compared with other types of cancer cells.

Lobular carcinoma <i>in situ</i> Medical condition

Lobular carcinoma in situ (LCIS) is an incidental microscopic finding with characteristic cellular morphology and multifocal tissue patterns. The condition is a laboratory diagnosis and refers to unusual cells in the lobules of the breast. The lobules and acini of the terminal duct-lobular unit (TDLU), the basic functional unit of the breast, may become distorted and undergo expansion due to the abnormal proliferation of cells comprising the structure. These changes represent a spectrum of atypical epithelial lesions that are broadly referred to as lobular neoplasia (LN).

<span class="mw-page-title-main">Male breast cancer</span> Medical condition

Male breast cancer (MBC) is a cancer in males that originates in their breasts. Males account for less than 1% of new breast cancers with about 20,000 new cases being diagnosed worldwide every year. Its incidence rates in males vs. females are, respectively, 0.4 and 66.7 per 100,000 person-years. The worldwide incidences of male as well as female breast cancers have been increasing over the last few decades. Currently, one of every 800 men are estimated to develop this cancer during their lifetimes.

The term nonpuerperal mastitis describes inflammatory lesions of the breast (mastitis) that occur unrelated to pregnancy and breastfeeding.

<span class="mw-page-title-main">Atypical ductal hyperplasia</span> Medical condition

Atypical ductal hyperplasia (ADH) is the term used for a benign lesion of the breast that indicates an increased risk of breast cancer.

<span class="mw-page-title-main">Breast biopsy</span> Surgical diagnostic procedure for breast tumours

A breast biopsy is usually done after a suspicious lesion is discovered on either mammography or ultrasound to get tissue for pathological diagnosis. Several methods for a breast biopsy now exist. The most appropriate method of biopsy for a patient depends upon a variety of factors, including the size, location, appearance and characteristics of the abnormality. The different types of breast biopsies include fine-needle aspiration (FNA), vacuum-assisted biopsy, core needle biopsy, and surgical excision biopsy. Breast biopsies can be done utilizing ultrasound, MRI or a stereotactic biopsy imaging guidance. Vacuum assisted biopsies are typically done using stereotactic techniques when the suspicious lesion can only be seen on mammography. On average, 5–10 biopsies of a suspicious breast lesion will lead to the diagnosis of one case of breast cancer. Needle biopsies have largely replaced open surgical biopsies in the initial assessment of imaging as well as palpable abnormalities in the breast.

Dynamic angiothermography (DATG) is a technique for the diagnosis of breast cancer. This technique, though springing from the previous conception of thermography, is based on a completely different principle. DATG records the temperature variations linked to the vascular changes in the breast due to angiogenesis. The presence, change, and growth of tumors and lesions in breast tissue change the vascular network in the breast. Consequently, through measuring the vascular structure over time, DATG effectively monitors the change in breast tissue due to tumors and lesions. It is currently used in combination with other techniques for diagnosis of breast cancer. This diagnostic method is a low-cost one compared with other techniques.

<span class="mw-page-title-main">Breast imaging</span>

In medicine, breast imaging is a sub-speciality of diagnostic radiology that involves imaging of the breasts for screening or diagnostic purposes. There are various methods of breast imaging using a variety of technologies as described in detail below. Traditional screening and diagnostic mammography uses x-ray technology and has been the mainstay of breast imaging for many decades. Breast tomosynthesis is a relatively new digital x-ray mammography technique that produces multiple image slices of the breast similar to, but distinct from, computed tomography (CT). Xeromammography and galactography are somewhat outdated technologies that also use x-ray technology and are now used infrequently in the detection of breast cancer. Breast ultrasound is another technology employed in diagnosis and screening that can help differentiate between fluid filled and solid lesions, an important factor to determine if a lesion may be cancerous. Breast MRI is a technology typically reserved for high-risk patients and patients recently diagnosed with breast cancer. Lastly, scintimammography is used in a subgroup of patients who have abnormal mammograms or whose screening is not reliable on the basis of using traditional mammography or ultrasound.

Papillary carcinomas of the breast (PCB), also termed malignant papillary carcinomas of the breast, are rare forms of the breast cancers. The World Health Organization (2019) classified papillary neoplasms of the breast into 5 types: intraductal papilloma, papillary ductal carcinoma in situ (PDCIS), encapsulated papillary carcinoma (EPC), solid-papillary carcinoma (SPC), and invasive papillary carcinoma (IPC). The latter four carcinomas are considered here; intraductal papilloma is a benign neoplasm. The World Health Organization regarded solid papillary carcinoma as having two subtypes: in situ and invasive SPC.

<span class="mw-page-title-main">Pure apocrine carcinoma of the breast</span> Medical condition

Pure apocrine carcinoma of the breast (PACB) is a rare carcinoma derived from the epithelial cells in the lactiferous ducts of the mammary gland. The mammary gland is an apocrine gland. Its lactiferous ducts have two layers of epithelial cells, a luminal layer which faces the duct's lumen and a basal layer which lies beneath the luminal layer. There are at least four subtypes of epithelial cells in these ducts: luminal progenitor cells and luminal mature cells which reside in the luminal layer and mammary stem cells and basal cells which reside in the basal layer. Examination of the genes expressed in PACB cancer cells indicate that most of these tumors consist of cells derived from luminal cells but a minority of these tumors consist of cells derived from basal cells.

References

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    - Hayward, M.K.; Louise Jones, J.; Hall, A.; King, L.; Ironside, A.J.; Nelson, A.C.; et al. (2020). "Derivation of a nuclear heterogeneity image index to grade DCIS". Comput Struct Biotechnol J. 18: 4063–4070. doi:10.1016/j.csbj.2020.11.040. PMC   7744935 . PMID   33363702.
  26. ↑ Image annotation by Mikael Häggström, MD, using source image from:
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  27. ↑ Image by Mikael Häggström, MD.
    - Reference for 30% being the most common definition of comedo necrosis by size:
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  35. ↑ Correa, C.; McGale, P.; Taylor, C.; Wang, Y.; Clarke, M.; Davies, C.; Peto, R.; Bijker, N.; Solin, L.; Darby, S.; Darby, S (2010). "Overview of the randomized trials of radiotherapy in ductal carcinoma in situ of the breast". Journal of the National Cancer Institute. Monographs. 2010 (41): 162–177. doi:10.1093/jncimonographs/lgq039. ISSN   1745-6614. PMC   5161078 . PMID   20956824.
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  37. 1 2 Virnig, BA; Shamliyan, T; Tuttle, TM; Kane, RL; Wilt, TJ (September 2009). "Diagnosis and management of ductal carcinoma in situ (DCIS)". Evidence Report/Technology Assessment (185): 4. PMC   4781639 . PMID   20629475. They found women undergoing mastectomy were less likely than women undergoing lumpectomy plus radiation to experience local DCIS or invasive recurrence. Women undergoing BCS alone were also more likely to experience a local recurrence than women treated with mastectomy. We found no study showing a mortality reduction associated with mastectomy over breast conserving surgery with or without radiation
  38. 1 2 "Intraductal carcinoma". Archived from the original on 10 April 2016. Retrieved 28 June 2010.
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  41. ↑ Mannu, GS; Groen, EJ; Wang, Z; Schaapveld, M; Lips, EH; Chung, M; Joore, I; van Leeuwen, FE; Teertstra, HJ; Winter-Warnars, GAO; Darby, SC; Wesseling, J (November 2019). "Reliability of preoperative breast biopsies showing ductal carcinoma in situ and implications for non-operative treatment: a cohort study". Breast Cancer Research and Treatment. 178 (2): 409–418. doi:10.1007/s10549-019-05362-1. PMC   6797705 . PMID   31388937.
  42. ↑ van Deurzen CH, Hobbelink MG, van Hillegersberg R, van Diest PJ (April 2007). "Is there an indication for sentinel node biopsy in patients with ductal carcinoma in situ of the breast? A review". European Journal of Cancer. 43 (6): 993–1001. doi:10.1016/j.ejca.2007.01.010. PMID   17300928.
  43. ↑ Basic Pathology, Robbins (2018). Breast. Copyright © 2018 by Elsevier Inc. p. 743. ISBN   978-0-323-35317-5.
  44. 1 2 3 Kerlikowske, K (2010). "Epidemiology of ductal carcinoma in situ". Journal of the National Cancer Institute. Monographs. 2010 (41): 139–41. doi:10.1093/jncimonographs/lgq027. PMC   5161058 . PMID   20956818.
  45. ↑ Kerlikowske, K.; Molinaro, A. M.; Gauthier, M. L.; Berman, H. K.; Waldman, F.; Bennington, J.; Sanchez, H.; Jimenez, C.; Stewart, K.; et al. (2010). "Biomarker Expression and Risk of Subsequent Tumors After Initial Ductal Carcinoma in Situ Diagnosis". JNCI Journal of the National Cancer Institute. 102 (9): 627–637. doi:10.1093/jnci/djq101. PMC   2864293 . PMID   20427430.
  46. ↑ Witkiewicz AK, Dasgupta A, Nguyen KH, et al. (June 2009). "Stromal caveolin-1 levels predict early DCIS progression to invasive breast cancer". Cancer Biology & Therapy. 8 (11): 1071–1079. doi: 10.4161/cbt.8.11.8874 . PMID   19502809.
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