Ductal carcinoma in situ (DCIS) of the breast represents a group of heterogeneous non-invasive lesions the incidence of which has risen dramatically since the advent of mammography screening. In this review we summarise current treatment trends and up-to-date results from clinical trials studying surgery and adjuvant therapy alternatives, including the recent consensus on excision margin width and its role in decision-making for post-excision radiotherapy. The main challenge in the clinical management of DCIS continues to be the tailoring of treatment to individual risk, in order to avoid the over-treatment of low-risk lesions or under-treatment of DCIS with higher risk of recurring or progressing into invasion. While studies estimate that only about 40% of DCIS would become invasive if untreated, heterogeneity and complex natural history have prevented adequate identification of these higher-risk lesions. Here we discuss attempts to develop prognostic tools for the risk stratification of DCIS lesions and their limitations. Early results of a UK-wide audit of DCIS management (the Sloane Project) have also demonstrated a lack of consistency in treatment. In this review we offer up-to-date perspectives on current treatment and prediction of DCIS, highlighting the pressing clinical need for better prognostic indices. Tools integrating both clinical and histopathological factors together with molecular biomarkers may hold potential for adequate stratification of DCIS according to risk. This could help develop standardised practices for optimal management of patients with DCIS, improving clinical outcomes while providing only the amount of therapy required for each individual patient.

BackroundThe diagnosis of epidermoid cyst is seldom in doubt, and associated malignancy extremely rare, yet it is commonplace for the lesion to be sent to the pathology laboratory for analysis. The aim of this study was to evaluate our current practice with regards to diagnostic accuracy among clinicians, and assess risk of not routinely sending suspected epidermoid cysts for histological examination. Potential cost savings were also estimated and calculated.MethodsRetrospective analysis of clinical and pathology data on all suspected epidermoid cysts excised from a Scottish district general hospital over a 5-year period between January 2011 and October 2015.ResultsFive hundred and thirty-six suspected epidermoid cysts were excised during the study period. Three hundred and ninety-six were sent for histological examination which confirmed a diagnosis of epidermoid cyst in 303 (76.5%) cases. There was good agreement between preoperative suspicion and final histological diagnosis: 80.8% (257/318) among referring clinicians, 81.9% (289/353) among reviewing surgeons, and 88.4% (243/275) where there was preoperative agreement between both. There were no malignant lesions. An average of 80 clinically apparent epidermoid cysts were excised and sent for histology each year at a cost of £4800 per annum.ConclusionThere was close agreement between clinical and final histological diagnosis of epidermoid cyst. Where a characteristic, odorous, toothpaste-like material is present on transection intra-operatively, the diagnosis is confirmed and the lesion can be discarded. We argue that significant cost savings can be achieved by adopting this approach.

1 mm appears a sufficient margin width for BCS in DCIS irrespective of whether patients receive radiotherapy.