Conference report

The Consensus Conference on the Treatment of In Situ Ductal Carcinoma of the Breast, 22–25 April 1999

Staging of the axilla in women with ductal carcinoma in situ (DCIS) is a point of controversy. We aimed to assess whether there is a group of patients in whom axillary assessment can be avoided and whether the likelihood of underdiagnosis of infiltrating carcinoma is sufficient to justify this evaluation.

This was a multicenter, prospective, observational study of patients who were operated on between 2008 and 2018 in three Spanish hospitals, with a diagnosis by radiological or excisional biopsy of DCIS and clinically and radiologically negative axilla.

A total of 530 patients with a preoperative diagnosis of DCIS were studied. An axillary assessment was performed in 77% of the patients. In 397 patients, selective sentinel lymph node biopsy was performed. Axillary involvement was found in 7.2% of all patients, which dropped to 2.15% if we only included DCIS diagnosed after a definitive anatomical pathology analysis. Underdiagnosis was correlated with the type of biopsy performed: the risk was 1.34 times as high if the biopsy was performed with a core needle. The risk of lymph node metastasis was higher when there was lymphovascular invasion and when mastectomy was performed.

We propose an axilla management algorithm in patients with a preoperative diagnosis of DCIS. The patients who would benefit from sentinel lymph node biopsy would be those who are not candidates for breast-conserving surgery, those with a BIRADS 5 lesion biopsied by core-needle biopsy, and those whose definitive diagnosis is lymphovascular invasion.

Le CCIS (carcinome canalaire in situ) représente 15,2 % des cancers du sein. Une chirurgie conservatrice associée à une radiothérapie adjuvante est généralement recommandée. Le taux de reprise chirurgicale est important, de 30 à 60 %. L’enjeu de l’oncoplastie est de réaliser une exérèse de qualité sur le plan carcinologique en gardant un résultat esthétique satisfaisant. Cette revue de la littérature a pour but d’évaluer la place de l’oncoplastie dans la prise en charge des CCIS. Parmi les facteurs de risque de récidive, l’envahissement tumoral des berges d’exérèse est décisif. Les marges saines communément admises pour le CCIS sont de 2 mm, bien qu’il n’y ait pas de consensus international. Des études récentes montrent qu’une marge de 10 mm serait plus optimale. Le préjudice esthétique engendré par la chirurgie, souvent accentué par la radiothérapie, a un impact défavorable sur la qualité de vie des femmes : l’oncoplastie permet de le limiter. Les techniques de plastie mammaire, développées dans la prise en charge conservatrice des lésions invasives, permettent de repousser les limites du traitement conservateur en enlevant un plus gros volume tumoral en marges saines. Peu de données existent concernant l’oncoplastie dans la prise en charge des CCIS. Elle permettrait d’augmenter le volume d’exérèse de 20 % et de diminuer significativement le taux de marges envahies, et donc de reprise chirurgicale. Les patientes en sont satisfaites. Les indications précises restent à définir notamment en fonction de l’âge, de la taille, et de la présence de comédonécrose. L’oncoplastie devrait être développée dans la prise en charge spécifique des CCIS.

DCIS (Ductal carcinoma in situ) constitutes 15,2% of breast cancers. Conservative surgery coupled with adjuvant radiotherapy is often recommended. The rate of revision surgery is high, from 30 to 60%. The concern is a high quality resection within clear margins with a satisfactory aesthetic result. The objective of this review is to precise the place of oncoplastic surgery in DCIS care. Among risk factors of recurrence, tumoral invasion of surgical margins is capital. In histology, clear margins usually adopted for DCIS are 2 mm, even though there is no international consensus. Recent studies show that a 10 mm limit would be better. Aesthetic damage caused by surgery, often increased by radiotherapy, has a negative impact on women quality of life : oncoplastic surgery may minimize it. Techniques of plastic surgery, arranged into level 1 and 2, allow pushing back conservative treatment limits by removing a larger tumor with clear margins. Often used in invasive cancers, few data exist regarding oncoplastic surgery and DCIS. It allows to increase the dimensions of surgical resection by 20% and to decrease positive margins significantly therefore the rate of revision surgeries. Patients are satisfied with it. Specific indications need to be clarified according to age, size and “comedonecrosis” presence. Oncoplastic surgery should be developed in DCIS specific care.

Factors influencing the treatment of ductal carcinoma in situ with mastectomy and reconstruction are poorly understood.

A retrospective cohort study of 196 patients presenting to one institution was performed.

Forty-seven patients (24.0%) were treated with mastectomy, while 149 (76.0%) underwent breast-conserving surgery. Of the mastectomy patients, 28 (59.6%) elected for reconstruction. On bivariate analysis, patients who opted for mastectomy were younger than those treated with breast-conserving surgery (median age, 51.8 vs 56.5 years; P = .017) and had higher grade tumors (50.0% vs 34.6% grade 3, P = .009). Among patients treated with mastectomy, those who opted for reconstruction were younger than those forgoing reconstruction (49.4 vs 56.9 years, P = .024). Race, ductal carcinoma in situ tumor size, and histologic subtype were not associated with the decision to pursue mastectomy or reconstruction (P > .05 for all).

In patients with ductal carcinoma in situ, the decision to pursue mastectomy and reconstruction appears to be driven by younger patient age and higher tumor grade.

Le carcinome canalaire in situ (CCIS) est une lésion mammaire fréquente (10 % des cancers du sein). Le traitement de référence consiste dans la plupart des cas en une mastectomie partielle (MP) associée à une irradiation adjuvante. Cependant, en cas de marges envahies (< 2 mm), une reprise chirurgicale est nécessaire. Le but de notre étude était de déterminer le taux de reprise pour des berges envahies dans les CCIS et de définir d’éventuels facteurs de risque préopératoires de berges non saines.

Il s’agit d’une étude rétrospective incluant 63 patientes. Nous avons réuni les cas de CCIS au CHRU de Lille ainsi qu’au centre hospitalier de Valenciennes du 1^er janvier 2007 au 1^er janvier 2012.

Cinquante patientes ont eu une MP et 28 patientes (56 %) ont dû avoir une ou deux interventions complémentaires pour obtenir des marges d’exérèse saines. La taille anatomopathologique de la tumeur (> 10 mm) apparaît comme étant un facteur de risque de berges d’exérèse envahies.

Peu d’études ont cherché à définir des facteurs de risque de berges non saines pour les CCIS. Les principaux facteurs de risque retrouvés dans la littérature sont les suivants : la présence de comédonécrose, une taille supérieure à 10 mm, une tumeur palpable, l’absence de réalisation d’une biopsie préchirurgicale, les lésions de bas grade. Notre étude a permis de confirmer l’influence d’une taille tumorale supérieure à 10 mm comme facteur de risque de berges non in sano.

Ductal carcinoma in situ (DCIS) is a common breast lesion (10% of breast cancers). In most of the cases the standard treatment is a partial mastectomy combined with adjuvant irradiation. However, when positive margins (< 2 mm) occur, surgical re-excision is necessary. The purpose of our study was to determine the rate of reoperation for positive margins in DCIS and identify potential preoperative risk factors of unhealthy margins.

This is a retrospective study of 63 patients. We collected cases of DCIS at the Lille and Valenciennes’ hospitals from the 1st of January 2007 till the 1st of January 2012.

Fifty patients have had a partial mastectomy and 28 patients (56%) have had one or two complementary interventions to get healthy resection margins. The pathologic tumor size (> 10 mm) appears to be a risk factor for positive margins.

Few studies were aimed at identifying risk factors for unhealthy margins for DCIS. The main risk factors found in the literature are: the presence of comedonecrosis, tumor greater than 10 mm, a palpable tumor, the absence of a preoperative biopsy, the low-grade lesions. Our study confirmed the influence of tumor size greater than 10 mm as a risk factor for positive margins.

To examine, in a retrospective study, whether the initial posttreatment mammogram offers any benefit to patients.

Patients were selected who had radiation after breast-conservation therapy from 1995 through 2005 and had follow-up mammography at the University of California-Los Angeles (UCLA) within 1 year of completing radiotherapy. Results of the initial follow-up mammogram were analyzed to determine the yield of this initial mammogram.

Between 1995 and 2005, 408 patients treated with breast-conserving therapy and radiation had follow-up mammograms at UCLA within 1 year of completion of radiation. Median age at radiation completion was 56.9 years. Median interval between radiation and the initial mammogram was 3.1 months. Ten patients were found to have suspicious findings on the initial postradiation mammogram, prompting biopsy, but only 2 were found to have recurrent cancer. None of those lesions were palpable. In both cases the recurrences were ductal carcinoma in situ. Thus, the yield of the initial postoperative mammogram as compared with physical examination findings is estimated at 0.49 recurrences detected per 100 mammograms performed (95% confidence interval 0.059–1.759).

The yield of the initial postradiation mammography at UCLA seems to be low, and only noninvasive carcinomas were found. Our data support the rationale to avoid the initial short-interval postradiation mammography and evaluate patients at 12 months.

Purpose: In ductal carcinoma in situ (DCIS) of the breast, conservative surgery plus radiotherapy (CS+RT) decreases risk of recurrence compared with CS alone. Although nearly one third of patients are reported as treated with CS alone, it is unclear whether this potentially “undertreated” group represents high- or low-risk patients. We evaluated national patterns of DCIS treatment from 1996 to 2001 by patient risk profile.

Methods and Materials: In a retrospective cohort of DCIS patients from the Surveillance, Epidemiology, and End Results data, patients were risk stratified on the basis of age at diagnosis, tumor grade, tumor size, and comedo histology. Treatment included CS alone, CS+RT, or mastectomy. Patients were followed for the development of ipsilateral invasive or in situ event.

Results: Of 14,202 patients, 19% were low-risk, 46% moderate-risk, and 35% high-risk. A total of 28% received CS alone, 40% CS+RT, and 31% mastectomy. Overall, only 17% of high-risk patients but 44% of low-risk patients received CS alone (p < 0.001). In multivariable analysis, older age, smaller tumor size, and treatment in San Francisco/Los Angeles predicted treatment with CS alone (p < 0.01). Yet despite the tendency to receive CS alone, patients in San Francisco/Los Angeles did not experience an increased risk of ipsilateral event (hazard ratio = 0.79; 95% confidence interval, 0.55–1.12).

Conclusion: Patient risk profiles rationally affect treatment choice in DCIS patients, and the vast majority of high-risk patients do not receive CS alone. Additional follow up is needed to determine whether geographic variation in care influences long-term outcomes.