Ductal Carcinoma In Situ: Recent History and Areas of Controversy

Abstract

The authors provide a perspective on the rapidly evolving field of prognostic analyses designed to quantify the risk of local recurrence in conservatively treated ductal carcinoma in situ (DCIS). These include morphologic features variously defined, nomograms, algorithms and multi-gene expression assays-all of which have completed against the perceived conclusions of the randomized trials of irradiation and Tamoxifen for DCIS: "all subsets benefit". At present the majority of newly diagnosed DCIS can be adequately treated with surgery alone. A number will require irradiation to achieve acceptable local control, and a minority will require mastectomy regardless of adjuvant treatments. Differences in the definition of prognostic factors and in the methods used to establish them is a major reason for the lack of consensus in treatment recommendation.

Local Treatment of Breast Cancer

“…5 Much controversy exists over the extent of treatment or if DCIS is a high-risk condition that only requires close follow-up despite potential future development of an invasive cancer. 12 Nomograms using breast cancer molecular markers 13 and multigene expression 14,15 as prognostic indicators show promise to predict the invasive component. [13][14][15] At the current time and until research yields decisive data, high-grade DCIS is surgically treated and, in the case of a lumpectomy, followed by radiation therapy to further reduce the risk that the lesion will recur either as DCIS or invasive disease.…”

“…[13][14][15] At the current time and until research yields decisive data, high-grade DCIS is surgically treated and, in the case of a lumpectomy, followed by radiation therapy to further reduce the risk that the lesion will recur either as DCIS or invasive disease. [12][13][14] Total or simple mastectomy provides for 90% risk reduction 16 without follow-up radiation therapy.…”

“…[12][13][14][15] Therefore, SLNB will often be performed at the same time as the surgical intervention as a means to examine the axillary nodes. For low-and medium-grade DCIS, SLNB is often not performed.…”

Intraoperative photoacoustic screening of breast cancer: a new perspective on malignancy visualization and surgical guidance

“…Opinions range from <2 mm to >10 mm depending on age, cancer type, and therapies employed. [2][3][4] Nevertheless, in current clinical practice, the procedure often fails, resulting in a positive margin being reported by pathology at a later time and leading to a national (Canadian) re-excision rate of 23%. 5,6 To minimize the risk of cancer recurrence, such a finding usually leads to the need for a second surgery.…”

“…[27][28][29] Furthermore, depending on the standard of practice employed in a particular region or country, the reported 3-mm imaging penetration may or may not be enough to examine the margin to sufficient depth. 3,4,27 From a technical perspective, the limited view reflection mode imaging geometry employed in that study, combined with a highfrequency transducer, invites well-documented PA imaging problems such as limited view and reflection artifacts, and shallow tissue penetration. 30,31 And finally, the study utilized BCS specimens that were fixed in 10% formalin as well as embedded in 2.5% gelatin; these both are time-consuming procedures and hence unrealistic with respect to clinical intraoperative applications.…”