Duct carcinoma in situ: A gordian knot untied

Abstract

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. © 2011 Springer Science + Business Media.