Understanding and Treating DCIS (ductal carcinoma in situ) of the Breast

1. Ductal Carcinoma In Situ
(Stage 0 Breast Cancer)
Robert Miller MD
www.aboutcancer.com

2. 20% of breast
cancers in the US
are stage 0 or noninvasive (ducal
carcinoma in situ
DCIS or lobular
carcinoma in situ
LCIS)

3. Age Distribution For In Situ versus Invasive
NCDB Data
30
25
20
15
In Situ
Invasive
10
5
0
30
40
50
60
70
80

4. Observed 5 Year Survival Breast
Cancer 2003-2006 NCDB
100
90
80
70
60
50
40
30
20
10
0
Stage 0
Stage I
Stage II
Stage III Stage IV

5. What You Need to Know About Breast Cancer
Before Deciding on Treatment
• Understand the basic anatomy (lobules, ducts and lymph nodes)
• Biopsy or pathology report tell you about the biology (how
aggressive) of the cancer
• Breast imaging studies (mammograms or ultrasound)
CT, MRI, PET
• Stage (particularly lymph node status)

9. Earliest form of cancer
is often DCIS (ductal
carcinoma in situ) then
it progresses to
invasive ductal
carcinoma

10. ductal cells
ductal carcinoma In situ
(DCIS)
Invasive ductal carcinoma

11. Normal duct cells inside
a milk duct

12. Basement Membrane
DCIS
Cancer cells are confined
within the milk duct
basement membrane so still
in situ or non-invasive
Normal
Duct cells
Cancer Cells

13. Basement Membrane
Invasive
Cancer
Once the cells have invaded
through the basement
membrane and outside the
duct it is called invasive or
infiltrating
Normal
Duct cells
Cancer Cells

14. Pathology View of Ductal Carcinoma In
Situ

15. Lymph Nodes
supraclavicular
Internal mammary
axillary
DCIS should not spread to the lymph nodes unless there is some invasion
(may be focal micro-invasion) but 10 to 20 percent of lesions interpreted as
DCIS on a core biopsy are upgraded to invasive cancer after excision

16. DCIS
Ductal Carcinoma In
Situ
DCIS
Wall of
the duct

18. Understanding a Pathology
Report
1. Invasive or Not (DCIS, LCIS)
2. Histology: what type of cancer
3. Grade: fast or slow growing
4. Hormone Receptors: is it sensitive to estrogen or
progesterone
5. HER2 (human epidermal growth factor receptor 2) a
genetic mutation

19. Imaging
The cells often die in
place (necrosis) and
then calcify. The
radiologist is looking
for abnormal areas of
calcification

20. Mammograms often show areas of
calcification, which can be benign or
malignant
Ninety percent of women with DCIS have microcalcifications on
mammography and DCIS accounts for 80 percent of all breast
cancers presenting with calcifications

21. Mammograms
In ductal carcinoma in situ (DCIS), there is
normally no mass but just an area of
calcification (very small areas called
microcalcifications)

22. Microcalcifications
can be very
subtle
Biopsy of this
area showed
8mm DCIS

23. Biopsy = DCIS with focal micro-invasion

24. fat
gland
Larger area of
microcalcifications may
have invasive
cancer
Path = 2.9 cm
area of high grade
DCIS plus invasive
ductal cancer

25. Looking for advice on treatment decisions for
ductal carcinoma in situ of the breast

26. Treatment Decisions with
DCIS
1. Surgery: total mastectomy versus conservation
(lumpectomy) and ? nodes
2. Adjuvant Therapy: hormone therapy or as
preventative strategy
3. Radiation: whole breast or can it be skipped

27. Treatment Decisions
The woman should be assisted by a multidisciplinary team, including a
surgeon, possibly a plastic surgeon, medical
oncologist and a radiation oncologist

29. NCCN.org

34. Complete axillary lymph node resection should not be
performed in the absence of evidence of invasive cancer
or proven metastatic disease in women apparent pure
DCIS.
However, a small proportion of patients with apparent pure
DCIS will be found to have invasive cancer at the time of
their definitive surgical procedure. Therefore, the
performance of a sentinel lymph node procedure should be
strongly considered if the patient with apparent pure DCIS
is to be treated with mastectomy or with excision in an
anatomic location compromising the performance of a
future sentinel node procedure.

35. Deciding on Surgery
Lumpectomy
Total Mastectomy
The risk of cancer-related death in women with DCIS is low, estimated at
1.9 percent within 10 years.
Mastectomy is curative for over 98 percent of patients with DCIS.
Disease recurrence is rare after mastectomy (1 to 2 percent)

36. Breast Conservation
Lumpectomy
(remove the cancer
with a small rim of
normal tissue, clear
margins)
Sentinel node biopsy
occasionally will be
performed at the
same time

37. At the time of the lumpectomy the
surgeon tries to remove the cancer
with a margin of normal breast tissue
around the mass
X-ray image of the lumpectomy specimen

38. Deciding on Radiation

40. Long-term outcomes of invasive ipsilateral
breast tumor recurrences after
lumpectomy in NSABP B-17 and B-24
randomized clinical trials for DCIS.
Local Relapse in the Breast Over 15 Year
Follow Up
Lumpectomy Alone
19.4%
Lump + Radiation
8.9 – 10%
Lump + Radiation + Tamoxifen 7.3%
Survival was the same in all
groups
Natl Cancer Inst. 2011;103(6):478.

41. 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
JCO. 2013.49.5077

42. Fifteen-year results of breast-conserving surgery and definitive
breast irradiation for the treatment of ductal carcinoma in situ of the
breast.
Cause specific survival
Over all survival
Years
JCO Mar 1, 1996:754-63

43. Whole breast radiation following lumpectomy reduces the
recurrence rates in DCIS by about 50%. Approximately half the
recurrences are invasive and half are still DCIS.
A number of factors determine the local recurrence risk: palpable
mass, large size, higher grade, close or involved margins, and age
< 50y.
If the patient and physician view the individual risk as “low” some
patients may be treated with excision alone.
All data evaluating the three local treatments (lumpectomy
alone, lumpectomy plus radiation or total mastectomy) show no
difference in patient survival.

44. Van Nuys Index for Treatment of DCIS
Score
#1
#2
#3
Path
Other
Comedo
Size
<15mm
16-40mm
High
Grade
>40mm
Margins
>10mm
1-9mm
< 1mm
Score 3 – 4 : Lumpectomy alone (local control is 100%
vs 97%)
Score 5 – 7: Lumpectomy + Radiation (local control
from 68% up to 85%)
Score 8-9: Mastectomy
Cancer 1996 Jun 1;77(11):2267-74

45. Van Nuys Index for Treatment of DCIS
Score
#1
#2
#3
Path
Other
Comedo
Size
<15mm
16-40mm
High
Grade
>40mm
Margins
>10mm
1-9mm
< 1mm
Score 3 – 4 : Lumpectomy alone (local control is 100%
vs 97%)
Score 5 – 7: Lumpectomy + Radiation (local control
from 68% up to 85%)
Score 8-9: Mastectomy
Cancer 1996 Jun 1;77(11):2267-74

46. Updated Van Nuys Prognostic
Index
Parameter
1 Point
2 Points
3 Points
Size
<15mm
16-40mm
>40mm
Grade
1/II
1/II Necrosis
III
Margin
10mm
1-9mm
<1mm
Age
>60
40-60
<40
4,5, 6 = Lumpectomy Alone
7, 8, 9 = Lumpectomy + Radiation
10, 11, 12 = Mastectomy
2003 Update PMID 14682107 -- "An argument against routine use of radiotherapy for ductal
carcinoma in situ." (Silverstein MJ, Oncology (Williston Park). 2003 Nov;17(11):1511-33; discussion
1533-4, 1539, 1542 passim.)

47. Online Breast Cancer Calculators
http://aboutcancer.com/breast_calculators.htm
http://www.mskcc.org/cancer-care/adult/breast/prediction-tools

50. Deciding on Radiation

51. CT scan is obtained at the time of simulation
CT images are then imported into
the treatment planning computer.
Note that at the time of the
simulation the patient may receive 3
small tattoo marks

52. Computer generated anatomy images that will identify all the
important structures to be sure the radiation covers the area
of breast cancer and limits the dose to other areas

53. Viewed
from the
side, the
radiation
stops
before
hitting the
lung

54. Typical
technique for
external beam

55. Radiation beam skims over the surface of the
chest wall, ribs and lung

56. External Beam Radiation
Monday through Friday for 5 weeks

57. Radiation
Fields
After a lumpectomy the
whole breast is radiated
for about 5 weeks (the red
box) and then a boost
dose (5 – 7 treatments) is
given to the lumpectomy
site (blue circle)

58. The whole breast
treated 26 to 28 times
The lumpectomy site
is then treated 5 to 7
times

59. Short Term Side Effects of
Breast Radiation
Generally the side effects of breast radiation do not
become noticeable until the woman has received about 10
to 15 treatments, and then become somewhat more
noticeable through the rest of the treatment. The most
common side effects:
•skin irritation - the skin that is radiated gets red, itchy
and may blister (like a sun burn) may lose hair in arm pit
(biafine, prutect, myaderm, aquaphor, silvadene, triamcinalone, Radiaderm)
•breast or chest wall tenderness or mild pain
•tiredness or fatigue (some women feel a little lightheaded)
•are swelling or edema

60. Long Term Side Effects of
Breast Radiation
• Arm swelling or lymphedema is probably less than
3%
• Lung inflammation (pneumonitis) is 5% or less
• Risk of rib fracture is less than 3%
• Risk of nerve damage (brachial plexopathy) < 1%
• Radiation fibrosis to breast
• Risk of causing a new cancer is less than 1%

62. DCIS BREAST CANCER
Robert Miller MD
www.aboutcancer.com