Ductal Carcinoma Insitu

  • Ductal carcinoma in situ (DCIS):
    • Is a malignant intra-ductal proliferation of epithelial cells within the tubular-lobular system of the breast:
      • With no microscopic evidence of permeation across the basement membrane
  • There appears to be a progression between:
    • Flat epithelial atypia, atypical ductal hyperplasia (ADH), and DCIS:
      • In which DCIS is final step prior to the development of invasive disease
  • The clinical risk factors and molecular aberrations related with malignant transformation:
    • Are almost indistinguishable between DCIS and invasive cancer
  • The concurrence of DCIS and invasive carcinoma within one lesion suggests that:
    • DCIS is a precursor lesion to invasive carcinoma
  • Evidence of the ability of DCIS to progress is that:
    • 50% of all recurrences after breast-conserving surgery (BCS) for DCIS, with or without adjuvant treatment, are invasive
  • Data is sparse on the natural history of DCIS:
    • But some series have reported the outcomes for women many years after undergoing a surgical biopsy that was interpreted as benign that contained an unrecognized area of DCIS:
      • These data identified that approximately 20% to 53% of these women developed:
        • Ipsilateral invasive carcinoma
    • Sanders et al. reported on 28 women with unrecognized low-grade DCIS in the surgical biopsy specimen:
      • Of which 11 developed invasive carcinoma:
        • All of these cancers developed in the same breast and quadrant as the biopsy containing the DCIS
    • The vast majority of these invasive cancers developed within 10 years, but three were diagnosed after 20 years
    • Collins et al, in the Nurses’ Health Study, singled out 13 women who were found to have DCIS on reexamination of the surgical biopsies that were previously diagnosed as benign:
      • Ten of these women subsequently developed breast cancer
        • All were ipsilateral
        • Four were DCIS and six were invasive
        • The interval between the biopsy and the progression to invasive cancer was on average nine years
  • Approximately one in eight women (12%) in the United States (US) will be diagnosed with breast cancer in her lifetime:
    • 20% to 25% of these newly diagnosed cases will be DCIS (Siegel 2015, CA Cancer J Clin)
  • In 2020, an estimated 51, 400 cases of DCIS will be diagnosed in US
  • Universal screening mammography:
    • Has resulted in a 10-fold increase in the incidence of DCIS since the mid-1980s:
      • But since 2003:
        • The incidence of DCIS has decreased in women age 50 years and older:
          • Conceivably secondary to decline in the use of hormone replacement therapy
        • While the incidence in women younger than 50 continues to increase:
          • Altekruse SF, Kosary CL, Krapcho M, et al.: SEER Cancer Statistics Review, 1975-2007. Bethesda, Md: National Cancer Institute, 2010. Also available online. Last accessed April 3, 2020
    • Roughly one in every 1,300 mammograms performed in US:
      • Will lead to a diagnosis of DCIS:
        • Representing 17% to 34% of all mammographically detected breast cancers
    • Before the institution of widespread screening mammography in the mid-1980s:
      • Most of the cases of DCIS were not identified until a palpable tumor developed:
        • But today:
          • 80% to 85% of DCIS cases are screen detected
  • The incidence of DCIS in necropsy studies is higher than in the general population:
    • Proposing that not all DCIS lesions become clinically significant:
      • Supporting concerns that most of the increase in DCIS incidence is due to the detection of non-aggressive subtypes:
        • That are unlikely to progress to invasive cancer
  • Most women with DCIS are diagnosed at a median age:
    • That ranges from 47 to 63 years:
      • Similar to that reported for patients with invasive carcinoma
    • However, the age of peak incidence for DCIS (96.7 per 100,000 women):
      • Occurs between the ages of 65 and 69 years:
        • Which is younger than that for invasive breast cancer:
          • For which peak incidence (453.1 per 100,000 women):
            • Occurs between the ages of 75 and 79 years
  • The incidence of first-degree relatives having breast cancer (i.e., 10% to 35%) as well as deleterious mutations in the breast cancer associated (BRCA) genes:
    • Are similar for patients with DCIS as for women with invasive breast cancer
  • Other risk factors for DCIS include:
    • Older age
    • Proliferative breast disease
    • Increased breast density
    • Nulliparity
    • Older age at first live birth
    • History of breast biopsy
    • Early menarche
    • Late menopause
    • Long-term use of postmenopausal hormone replacement therapy
    • Elevated body mass index in postmenopausal women
      • Are the same as those for invasive breast cancer, but in many cases:
        • The relationship between a given characteristic and invasive cancer is stronger than the relationship between that characteristic and DCIS

#Arrangoiz #BreastSurgeon #CancerSurgeon #SurgicalOncologist #Surgeon #BreastExpert #DCIS #IntraductalCarcinoma #DuctalCarcinomaInsitu #Stage0 #Miami #Mexico #MountSinaiMedicalCenter

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