Treatment Options for Ductal Carcinoma in Situ

Surgery for Ductal Carcinoma in Situ

The surgical treatment options for women with ductal carcinoma in situ (DCIS) include:

• Simple mastectomy - surgical removal of a breast leaving the underlying muscles and lymph nodes intact.
• Breast-conserving surgery - during breast conserving surgery (also known as a lumpectomy), the tumor is surgically removed while leaving the remaining breast tissues, nipple, and areola intact.

Historically, DCIS was treated with mastectomy while breast-conserving surgery is a more recent treatment option for women with DCIS. Mastectomy is a curative treatment for approximately 98% of women with DCIS. Although the rates of local or regional recurrence are much lower after mastectomy as compared to breast-conserving surgery, there does not appear to be any significant differences in terms of survival between these two surgical treatment options for patients with DCIS. Breast cancer related deaths 10-years after the diagnosis of DCIS is only 1 to 2 % regardless of the type of surgery (mastectomy or lumpectomy) employed.

Mastectomy may be recommended by your surgeon as the surgical treatment of choice in certain situations. Examples include:

• If large areas of DCIS are present that cannot be surgically removed while preserving the cosmetic appearance of the breast.

• If multiple areas of DCIS are present in the same breast that cannot be removed by a single incision.

• If the patient is not considered a good candidate for radiation therapy. This includes:

• If the patient has undergone previous radiation therapy to the breast or chest area.

• If the patient has an underlying connective tissue diseases (e.g., scleroderma, systemic lupus erythemotosus).

• If the patient is pregnant at the time that radiation therapy would be necessary.

As noted previously, most women who are diagnosed with DCIS by screening mammography have no clinical symptoms of the disease (such as a palpable breast mass). Because most DCIS lesions that are detected mammographically are small, there has been a shift in recent years from mastectomy to breast-conserving surgery. In fact, at the present time, in the United States most women with DCIS are treated with breast-conserving surgery.

Irrespective of whether DCIS is treated by mastectomy or breast-conserving surgery, dissection of the axillary lymph nodes (the lymph nodes located under the armpit) is not routinely indicated in patients with DCIS. This is because the risk of metastases (spread) of DCIS to the axillary lymph nodes is less than 5% and recent research has demonstrated that the risk of axillary metastases is even lower for patients with small, mammographically detected DCIS.

The role of sentinel lymph node biopsy and mapping in the management of patients with DCIS has recently been the subject of considerable discussion in the medical literature. Sentinel lymph node biopsy is a procedure whereby a radioactive substance, called a "tracer" is injected around the tumor site. Following injection of the tracer, a blue dye is also injected around the tumor site. The radioactive tracer and the dye are carried by the lymph fluid to the first lymph node, called the sentinel lymph node, that drains lymph from the tumor. The sentinel lymph node is the primary lymph node that is most likely to contain cancer cells if the tumor has metastasized from the breast. In general, routine sentinel lymph node biopsy and mapping is not currently advocated for most patients with DCIS. The main indication for this procedure includes:

• Patients with high-grade DCIS who are at the highest risk for developing invasive cancer

• Patients with clinical symptoms of DCIS such as a palpable breast mass

• Patients with DCIS who require a mastectomy since this procedure cannot be performed after a mastectomy in the event that the tumor has spread to the lymph nodes.