1. Ductal Carcinoma in situ
David M. Euhus, MD, FACS
Professor of Surgery
Director, Clinical Cancer Genetics
UT Southwestern Medical Center at Dallas

2. Ductal and Lobular Anatomy of the Breast

3. Estrogen Receptor Positive Luminal Cell Estrogen Receptor Negative
Myoepithelial Cell
Stem/Progenitor Cell

4. Estrogen Receptor Positive Luminal Cell Estrogen Receptor Negative
Myoepithelial Cell
Stem/Progenitor Cell

5. Pathology of Precancerous Changes and DCIS
Normal
Hyperplasia
Atypical Hyperplasia
Types of DCIS
Cribriform
Micropapillary
Solid
Comedo

6. DCIS versus Invasive Breast Cancer
Ductal Carcinoma in situ
Means milk duct cancer “in place”
Cancer cells fill the milk ducts but do not “invade” through the wall of the milk duct
Stage 0 breast cancer
Invasive Breast Cancer
Cancer cells invade through the wall of the milk duct
Can get into lymphatic channels and lymph nodes
Can get into blood stream and other organs

7. DCIS Trends Over Time

8. DCIS is Usually Diagnosed on a Mammogram

9. Risk Factors DCIS Invasive Cancer Peak Age 60 -74 75 – 79 Race
Caucasian
Family History
Yes
Mammographic Density
Obesity No
No children
Late age at childbirth
Hormone replacement

10. Should I have a Breast MRI After I am Diagnosed with DCIS?
About 10% of breast MRIs will prompt additional imaging or a biopsy (3/4 of those biopsies will be benign).
MRI may overestimate the size of the DCIS leading to more extensive surgery.
I only order an MRI if the mammogram or exam make me suspicious that there is more there than meets the eye.

11. Should I have a Sentinel Lymph Node Biopsy as Part of My DCIS Surgery?
If DCIS was initially diagnosed by core needle biopsy there is a 15% chance that there is actually an invasive breast cancer in the neighborhood.
If all you have is DCIS there is <1% chance that the SLN will be positive.
I don’t do SLN biopsy for pure DCIS if the patient is having a lumpectomy.
I do SLN for DCIS if the patient is having a mastectomy.

12. What are the Options for Treating DCIS?
Breast Conserving Surgery
Lumpectomy + Radiation
+ Tamoxifen (for ER+ DCIS)
Mastectomy

13. What Happens if I decide Not to Get Treatment for a DCIS?
28 Small low grade cases treated by biopsy only
24 year median follow-up
Page DL, Cancer 1995;76:

14. Breast Conserving Surgery (“Lumpectomy”)

15. Up oh. Margins are positive for DCIS
Re-excise

16. It is sometimes difficult to get clear margins

17. But radiation can cut the recurrence rate in half.
If I Have a Lumpectomy for DCIS do I Have to Have 6 ½ Weeks of Radiation Treatments?
Radiation is not as effective against DCIS as it is against invasive cancer.
But radiation can cut the recurrence rate in half.
Some women are appropriately treated with 5 days of focused radiation
DCIS < 2 cm
Age > 50
Not high grade
Negative margins
CyberKnife
Ballon Catheter Radiation

18. Van Nuys Prognostic Index
If I Have a Lumpectomy for DCIS can I skip the Radiation Treatments All Together?
Van Nuys Prognostic Index
DCIS size < 1.5 cm
Negative margin > 1 cm
Not high grade
No comedo necrosis
Age > 61
OncoTypeDx DCIS Recurrence Score

19. A New Test for Estimating Recurrence Risk After Lumpectomy with No Radiation
OncoTypeDX
Score
Any Recurrence
Invasive Recurrence
Low Risk
12% 5%
Intermediate Risk
25% 9%
High Risk
27%
19%
In my mind the recurrence risk is too high even with a low score.
I have not used this test.

20. Double Mastectomy for DCIS
More and more women with DCIS are choosing to have both breasts removed
- About 5% of all DCIS patients
- About 18% of women who need one mastectomy

21. Bilateral Nipple-preserving Mastectomy

22. What is the Risk of Recurrence after DCIS Treatment?
After lumpectomy and radiation there is a 10 – 24% chance that DCIS will recur.
Half of these recurrences are invasive cancer
After mastectomy the risk of recurrences is 2%
The chance of dying of breast cancer after DCIS treatment is <2%
May be a bit higher for African-American women.

23. Do Some Women with DCIS Have a Higher Recurrence Risk?
Factors Associated with Greater Recurrence Risk
Not getting “negative” margins at surgery
Younger age (e.g. <45)
High grade DCIS (very disorganized cells)
Estrogen receptor negative DCIS
Her-2/neu positive DCIS
Larger DCIS

24. Are there Medications to Prevent DCIS of Reduce the Recurrence Rate?
Tamoxifen (for ER positive)
Reduces DCIS rate by 50% in high risk women
Reduces recurrence after treatment by 40%
Raloxifene
Does not appear to reduce DCIS risk
No recurrence data; not used
Aromatase Inhibitors
Clinical trials being done now
Herceptin (for Her-2/neu positive)

25. Summary
DCIS is diagnosed almost exclusively from mammographic screening.
Inadequately treated DCIS can become invasive breast cancer.
Not every DCIS presents a health threat.
We can’t tell which ones are not a threat.
Treating DCIS significantly reduces the risk for invasive breast cancer.
The challenge is not to over treat.

26. Summary for Young Women
DCIS is very uncommon in young women
Recurrence rates tend to be higher in young women.
A DCIS diagnosis does not impact survival
Lumpectomy + radiation (+ tamoxifen for ER positive DCIS) is a treatment option.
More young women are choosing double mastectomy.