Parvis Gamagami

The Influence of Margin Width on Local Control of Ductal Carcinoma in Situ of the Breast

BACKGROUND Ductal carcinoma in situ is a non-invasive carcinoma that is unlikely to recur if completely excised. Margin width, the distance between the boundary of the lesion and the edge of the excised specimen, may be an important determinant of local recurrence. METHODS Margin widths, determined by direct measurement or ocular micrometry, and standardized evaluation of the tumor for nuclear grade, comedonecrosis, and size were performed on 469 specimens of ductal carcinoma in situ from patients who had been treated with breast-conserving surgery with or without postoperative radiation therapy, according to the choice of the patient or her physician. We analyzed the results in relation to margin width and whether the patient received postoperative radiation therapy. RESULTS The mean (+/-SE) estimated probability of recurrence at eight years was 0.04+/-0.02 among 133 patients whose excised lesions had margin widths of 10 mm or more in every direction. Among these patients there was no benefit from postoperative radiation therapy. There was also no statistically significant benefit from postoperative radiation therapy among patients with margin widths of 1 to <10 mm. In contrast, there was a statistically significant benefit from radiation among patients in whom margin widths were less than 1 mm. CONCLUSIONS Postoperative radiation therapy did not lower the recurrence rate among patients with ductal carcinoma in situ that was excised with margins of 10 mm or more. Patients in whom the margin width is less than 1 mm can benefit from postoperative radiation therapy.

Prognostic classification of breast ductal carcinoma-in-situ

We present a new prognostic classification designated the Van Nuys classification for ductal carcinoma-in-situ (DCIS). The classification combines high nuclear grade and comedo-type necrosis to predict clinical recurrence. Three groups of DCIS patients were defined by the presence or absence of high nuclear grade and comedo-type necrosis: 1--non-high-grade DCIS without comedo-type necrosis, 2--non-high-grade DCIS with comedo-type necrosis, 3--high-grade DCIS with or without comedo-type necrosis. There were 31 local recurrences in 238 patients after breast-conservation surgery 3.8% (3/80) in group 1, 11.1% (10/90) in group 2, and 26.5% (18/68) in group 3. The 8-year actuarial disease-free survivals were 93%, 84%, and 61%, respectively (all p < or = 0.05). The Van Nuys classification defines three distinct and easily recognisable groups, each of which has a different likelihood of local recurrence if treated with breast conservation.

Axillary lymph node dissection for T1a breast carcinoma. Is it indicated

Background. Axillary dissection has been a routine part of breast cancer treatment for more than 100 years. Axillary node involvement is the single most important prognostic variable in patients with breast cancer. Recently, routine node dissection has been eliminated for intraductal carcinoma because so few patients had positive nodes. With the availability of numerous histologic prognosticators and the development of new immunochemical prognostic indicators, it is time to consider eliminating routine node dissection for lesions more advanced than duct carcinoma in situ (DCIS) but with extremely low likelihood of axillary involvement.

Intraductal carcinoma of the breast (208 cases): Clinical factors influencing treatment choice

Two hundred eight cases of intraductal breast carcinoma (DCIS) were selectively treated; 97 with mastectomy, 96 with radiation therapy, and 15 using excisional biopsy only. Mastectomy patients tended to have larger tumors, involved biopsy margins, palpable and often multifocal tumors. Breast preservation patients tended to have smaller, often occult, tumors with clear surgical margins. Before 1983, mastectomy was more common; during and after 1983, breast preservation was more common. Comedocarcinomas were the most frequent tumors. They were the largest, had the highest percentage of microinvasion (20%), and had the highest recurrence rate (8%). Noncomedo DCIS had a recurrence rate of 1%, one of 103 tumors. The recurrence rate for comedocarcinomas treated with radiation therapy was nearly three times higher than for those treated with mastectomy (11% versus 4%). One of 164 (0.6%) axillary lymph node dissections yielded positive nodes. Nine patients have recurred: two in the mastectomy group and seven in the breast conservation group (P < 0.1). Eight of nine recurrences were the comedo subtype (P < 0.05). Three patients developed metastatic disease, two of whom have died. Axillary dissection for intraductal carcinoma of the breast is unlikely to yield involved nodes and is not indicated for most cases. It should be reserved for lesions revealing microinvasion. Conservative therapy for comedocarcinoma must be viewed with caution.

Ten-year results comparing mastectomy to excision and radiation therapy for ductal carcinoma in situ of the breast

The 10-year results of 300 patients with ductal carcinoma in situ (DCIS) without microinvasion are reported; 167 treated with mastectomy and 133 treated with excision and radiation therapy. There was a significant difference in disease-free survival at 10 years, in favour of those treated with mastectomy, 98% versus 81% (P = 0.0004). Multivariate analysis confirmed nuclear grade as the only significant predictor of local recurrence (P = 0.02) or invasive local recurrence (P = 0.03) in patients with DCIS treated with excision and radiation therapy. There was no difference in breast cancer-specific survival or overall survival between the two treatment groups.

Axillary lymph node dissection for intraductal breast carcinoma‐is it indicated?

One hundred patients with intraductal breast carcinoma (DCIS) were treated with either mastectomy (49 patients) or radiation therapy (51 patients). All patients underwent axillary lymph node dissection (average number of nodes removed, 16) as part of their treatment. No patient had any positive axillary lymph nodes. There has been one recurrence in each treatment group (median follow‐up, 27 months) and no deaths. Intraductal breast carcinoma has little potential for metastasis to axillary lymph nodes.

Outcome after invasive local recurrence in patients with ductal carcinoma in situ of the breast.

PURPOSE To detail the outcome, in terms of local recurrence, local invasive recurrence, distant recurrence, and breast cancer mortality for patients previously treated for ductal carcinoma in situ (DCIS). PATIENTS AND METHODS Clinical, pathologic, and outcome data were collected prospectively for 707 patients with DCIS accrued from 1972 through June 1997. RESULTS There were 74 local recurrences; 39 were noninvasive (DCIS) and 35 were invasive. Fifty-one percent of patients with invasive recurrences presented with stage 1 disease; the remainder presented with more advanced disease. Invasive local recurrence after mastectomy was a rare event that occurred in 0.8% of patients. Invasive recurrence after breast preservation was more common and occurred in 7.4% of patients. The 8-year probability of breast cancer mortality after breast preservation was 2.1%, a number that is likely to increase with longer follow-up. The 8-year breast cancer-specific mortality and distant-disease probability for the subgroup of 74 patients with locally recurrent disease was 8.8% and 20.8%, respectively. If only the 35 invasive recurrences are considered as events, the 8-year breast cancer-specific mortality and distant-disease probability was 14.4% and 27.1%, respectively. CONCLUSION Invasive local recurrence after breast-preservation treatment for patients with DCIS is a serious event that converts patients with previous stage 0 disease to patients with disease that ranges from stage I to stage IV. These results, however, indicate that most DCIS patients with local recurrence can be salvaged.

Duct carcinoma in situ: 227 cases without microinvasion

From 1979 to 1990, 227 patients with intraductal carcinomas (DCIS) without microinvasion were selectively treated; the least favourable (large lesions with involved biopsy margins) with mastectomy, the most favourable (small lesions with clear margins) with breast preservation. The preservation group was further subdivided into those who received radiation therapy (excision and radiation) and those who did not (excision alone). In the mastectomy group, there were 98 patients (43%) with an average lesional size of 3.3 cm; 41% had multifocal lesions, 15% had multicentric lesions. There has been one local invasive recurrence and no deaths. The 7-year actuarial disease-free survival is 98% with mastectomy. In the excision and radiation group, there were 103 patients (45%) with an average lesional size of 1.4 cm. 10 patients have had local recurrences (5 invasive and 5 noninvasive) one of whom has died. The 7-year actuarial disease-free survival is 84%, a statistically significant difference when excision and radiation is compared with mastectomy (P = 0.038). In the excision alone group, there were 26 patients (11%) with an average lesional size of 1.0 cm. There have been two local recurrences (8%), one of which was invasive and no deaths. The 7-year actuarial disease-free survival is 67%, but only 3 patients have been followed for more than 4 years. A total of 163 axillary node dissections were done; all were negative. Since DCIS without microinvasion rarely metastasizes to axillary lymph nodes, routine dissection should not be performed. Patients in this series with intraductal carcinoma treated with excision and radiation recurred locally at a statistically higher rate than those treated with mastectomy, in spite of the fact that those chosen for excision and radiation had clinically more favourable lesions. 6 of 12 (50%) local recurrences in conservatively treated patients were invasive. There was, however, no significant difference in overall survival in any subgroup regardless of treatment.

Can intraductal breast carcinoma be excised completely by local excision? Clinical and pathologic predictors

Background. Microscopic evaluation of excised intraductal breast carcinoma (DCIS) specimens using a serial subgross technique reveals that in many patients the lesion is larger than expected, often making complete excision impossible with less than a true quadrantectomy. Data is presented on 181 patients with DCIS in whom the initial biopsy was performed using a more cosmetic wide local excision rather than a true quadrantectomy.

Hooked‐wire‐directed breast biopsy and overpenetrated mammography

Six hundred fifty‐three biopsies were performed for clinically occult, mammographically detected breast abnormalities. One hundred forty‐seven cancers (22.5%) were found. Eighty‐nine of those cancers (60.5%) were noninvasive. None of the in situ lesions had involved axillary lymph nodes. Of the 58 invasive cancers, only six (10.3%) had metastases to axillary nodes. Fifty‐four patients (36.7%) were treated by mastectomy while 93 patients (63.3%) were treated conservatively, 20 by biopsy only, and 73 by lumpectomy, axillary node dissection, and radiation therapy. Only four patients (0.7%) had significant complications. Cancer 59:715‐722, 1987.