Question : How Does The Use Of Mri Or Slnb Impact Important Outcomes In Patients Diagnosed With Dcis
Breast MRI is increasingly used in the pretreatment evaluation of patients with invasive breast cancer. The treatment of invasive cancer may be modified by MRI findings that may lead to wider excisions, unilateral mastectomy, and/or treatment of the contralateral breast. The use of breast MRI for patients with DCIS is not yet established. Because the presence of multicentric disease is generally considered a contraindication to breast-conserving surgery , MRI can influence treatment recommendations for some patients. Among patients with DCIS, three studies found that the sensitivity of detecting multicentric disease is higher with MRI compared with mammography . These studies have reported sensitivities for detecting multicentric disease with MRI to range from 42% to 94%, whereas the sensitivities of mammogram range from 26% to 40%.
Because current technology evaluates both breasts, MRI can potentially identify occult contralateral breast cancer. This finding would necessitate excision or contralateral mastectomy. In the largest study to date that included 196 patients, Lehman et al. reported that MRI detected occult contralateral breast cancer in five patients .
Lumpectomy With Radiation Therapy
In this procedure, the surgeon will remove the tumor and some healthy breast tissue close by as a precaution.
Sometimes they may also remove the lymph nodes and request a biopsy to confirm that the cancer has not spread. Healthcare professionals call this a sentinel lymph node biopsy . They are more likely to do this if the tumor is large.
After surgery a person will receive radiation therapy to destroy any remaining cells.
Inserting A Metal Marker
If you have a biopsy, sometimes a small metal clip called a marker is placed in the breast where the biopsy samples were taken. This is so the area can be found again if another biopsy or surgery is needed. It can safely be left in the breast and does not need to be removed, even if no further procedures are needed.
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Difficult Decisions For Patients
Toro de Stefani is one of 60,000 U.S. women diagnosed with DCIS each year. Each must decide on a treatment option.
Current guidelines that recommend lumpectomy and radiation are causing concerns that the condition may be overtreated, since most cases never become invasive.
This gives medical professionals enormous uncertainty about how to advise women on an individual basis, says Thompson, professor of Surgery at MD Anderson. And therefore, historically the treatments have ranged from active surveillance on one end of the pectrum all the way to mastectomies on the other.
Thompson says DCIS diagnoses have increased as breast imaging has become more accurate and frequent. The National Institutes of Health estimates that by 2020, more than 1 million women in the U.S. will be living with a DCIS diagnosis, compared to 500,000 in 2005.
Before mammograms became common, many women had the condition for years without being aware of it, because it grows so slowly and causes no symptoms.
Perhaps, surprisingly, given that breast screening has been around for three or four decades, were only now really coming to grips with the fact that we often diagnose some conditions like DCIS as breast cancer even though theyre not conventional, invasive breast cancers, Thompson says.
Hes participating in three DCIS research studies that he hopes will make treatment decisions easier.
How Is Dcis Diagnosed
If a doctor sees the calcifications on your mammogram, he or she will recommend more tests, which could include a breast biopsy. During the biopsy, a doctor or other health care provider takes samples of cells or tissues from your body. The cells are examined by a pathologist a doctor who checks for signs of disease in body tissues. The pathologist looks at the cells under a microscope to see if cancer is present.
A particular kind of biopsy called a stereotactic core needle biopsy can diagnose DCIS. This is a nonsurgical, outpatient procedure. After giving you medicine to numb the breast area, the doctor or technologist collects cells from the area of concern using a needle guided by mammography.
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Necrosis And Calcification Are Common
When a sample of the comedo carcinoma lesion is removed for biopsy study, one will find it has a characteristic necrotic tissue with calcification, that almost feels cord-like. If the breast duct is physically squeezed, a material will be expressed which might be described as cheesy-like, almost like toothpaste. That paste is caused by the degeneration of the central cells of the early-stage tumor, and it is quite easily expressed from the rest of the tumor.
Comedo Dcis Requires More Aggressive Treatment But The Outlook Is Just As Positive
Ductal carcinoma in situ of the breast is generally believed to represent about 20%-30% of all breast cancers detected by clinical screening and mammography, and comedo breast carcinoma in situ would be a smaller subset of this group. But it has to be remembered that DCIS of all types have a cure rate of near 100%. Comedo carcinoma might make treatment a little more aggressive, but overall the outlook is almost always highly positive. Remember that the overall mortality from DCIS of any kind is extremely low, at around 2%.
Everything you need to know about Comedo Carcinoma is all listed above. But here are just a couple other Q& As for you
- What is NON-comedo ductal carcinoma in situ? This is a subgroup of DCIS. This group comprises of relatively less aggressive types with low nuclear grade. It also can have multiple patterns which often co-exist, these types include: cribriform, micropapillary, papillary, and solid.
- What are the treatment options? Breast-conserving surgery and radiation therapy with or without tamoxifen, total mastectomy with or without tamoxifen, or breast-conserving surgery without radiation therapy.
References
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How Is Dcis Detected And Diagnosed
Most DCIS is detected from a mammogram that shows abnormal calcifications in the breast. The doctor may need to conduct additional imaging tests, such as ultrasound or MRI. These are used to determine the full extent of the disease.
DCIS is diagnosed by a needle biopsy. Pathologists examine the abnormal cells to determine the grade of the DCIS and the hormone-receptor status. DCIS is classified as low, intermediate, or high grade, depending on how abnormal the cells look under a microscope. High-grade DCIS cells are the most abnormal and grow the fastest.
Hormone-receptor status refers to whether the cancer cells have receptors for estrogen, progesterone, or both. The presence of these receptors on the DCIS suggests that these hormones fuel the growth of the cells, which affects how well the DCIS responds to certain hormone-blocking drugs.
Other Factors That May Affect Survival Rates For Ductal Carcinoma In Situ
Hormone Replacement Therapy and Age of Menarche
There has been extensive research in the past regarding the connection between women taking hormone replacement therapy after menopause and invasive breast cancer.
However, there are very few studies that have examined the risk of HRT associated with Ductal Carcinoma In-Situ. A 2012 study examined 1,179 post-menopausal women with Carcinoma-In-Situ.
The study found no association between DCIS and use of Hormone Replacement Therapy . Furthermore, there was no association with current use of HRT or the duration of use of these hormones.
However, the study concludes that larger clinical trials are needed to truly assess if there are any associations between HRT and DCIS.
In addition, the age of menarche has not been shown, so far, to be associated with DCIS incidence. Indeed, it is more likely for women over 60 to develop DCIS.
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Is Dcis A Type Of Cancer
This is a controversial topic, partly due to the language. It has the word carcinoma in the name, and it is classified as stage 0 cancer. So DCIS isnt life-threatening, but it has the potential to become invasive cancer.
You may hear DCIS described in different ways such as a pre-invasive, intraductal, non-invasive cancer.
Sentinel Node Biopsy And Mastectomy For Dcis
A sentinel node biopsy is a procedure used to check whether or not invasive breast cancer has spread to the lymph nodes in the underarm area . The surgeon removes 1-5 nodes.
Having a sentinel node biopsy during a mastectomy helps some people with DCIS avoid an axillary dissection. Once a mastectomy has been done, a person cant have a sentinel node biopsy.
If it turns out theres invasive breast cancer in the tissue removed during the mastectomy, a sentinel node biopsy will have already been done.
If a sentinel node biopsy wasnt done and invasive breast cancer is found, an axillary dissection may be needed. An axillary dissection removes more axillary lymph nodes than a sentinel node biopsy. Because it disrupts more of the normal tissue in the underarm area, axillary dissection is more likely to affect arm function and cause lymphedema.
So, even though a sentinel node biopsy may not be needed with DCIS, most people who have a mastectomy for DCIS will have a sentinel node biopsy done at the same time.
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What If My Report On Ductal Carcinoma In Situ Mentions Margins Or Ink
When the entire area of DCIS is removed, the outside surface of the specimen is coated with ink, sometimes even with different colors of ink on different sides of the specimen. The pathologist looks at slides of the DCIS under the microscope to see how close the DCIS cells get to the ink . If DCIS is touching the ink , it can mean that some DCIS cells were left behind, and more surgery or other treatments may be needed. Sometimes, though, the surgeon has already removed more tissue to help make sure that this isnt needed. If your pathology report shows DCIS with positive margins, your doctor will talk to you about what treatment is best.
Risk Of Developing Invasive Breast Cancer After Dcis
After treatment for DCIS, theres a small risk of:
- DCIS recurrence
- Invasive breast cancer
These risks are higher with lumpectomy plus radiation therapy than with mastectomy . However, overall survival is the same after either treatment .
Higher grade DCIS appears more likely than lower grade DCIS to progress to invasive cancer after treatment .
With close follow-up, invasive breast cancer is usually caught early and can be treated effectively.
Learn more about tumor grade.
If youve been diagnosed with DCIS, Susan G. Komen® has Questions to Ask Your Doctor resources that may be helpful. For example, we have a Questions to Ask Your Doctor About Breast Cancer Surgery resource and a Questions to Ask Your Doctor About Radiation Therapy and Side Effects resource.
You can download and print these resources and take them with you to your next doctor appointment. Theres plenty of space to write down the answers to these questions, which you can refer to later.
There are other Questions to Ask Your Doctor resources on many different breast cancer topics you may wish to download. They are a nice tool for people recently diagnosed with breast cancer, who may be too overwhelmed to know where to begin to gather information.
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Treatment And Prognosis For Breast Comedo Carcinoma Dcis
If comedo carcinoma is found in an in situ status in the breast ducts, it has been suggested that following surgical removal, the risk of local recurrence is slightly higher than for non-comedo DCIS. This is one of the reasons that treated of comedo breast carcinoma often involves radiotherapy in addition to lumpectomy, whereas for most DCIS radiation therapy is not used. The risk for in-breast recurrence of comedo breast carcinoma in situ at 5 years after lumpectomy and radiotherapy is approximately 8%.
Additional Histological Characteristics Of Breast Comedo Carcinoma
There is some histological evidence to support the observation that breast comedo carcinomas in situ are usually estrogen receptor negative. As a result, there would generally be little benefit to treated comedo breast carcinoma with anti-estrogen chemotherapy . Chemical therapy for DCIS is a controversial area anyways, but is almost certainly not advised for breast comedo DCIS. Comedo breast carcinoma in situ is also frequently associated with a higher HER2/neu gene amplification or protein over expression, and a higher proliferation rate. Researchers suggest that apoptosis, which means programmed cell death is one reason for the clinically more aggressive behavior of comedo breast carcinoma in situ. It is suggested that the genetic control mechanisms which regulate proliferation and apoptosis have somehow been compromised in comedo DCIS.
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Treatment Options For Dcis: Lumpectomy Or Mastectomy
In most cases, the first line of treatment when DCIS is diagnosed is some form of breast surgery.
There are two basic surgical approaches for DCIS treatment:-
Lumpectomy is usually adequate if the area of breast abnormality is very small or only one abnormality is found on a mammogram.
Also, lumpectomy is usually recommended if the DCIS is of a less aggressive type such as non-comedo DCIS.
Lumpectomy is most effective for DCIS patients with small, low-grade DCIS which is easily identifiable on mammogram. In some cases the amount of DCIS is so small that the first exploratory biopsy is enough to remove all of the carcinoma and a subsequent lumpectomy is not required.
Lessening The Wait Time Can Reduce Stress
Waiting for results can be stressful, and advanced breast centers keep that in mind and try to minimize the time between testing and results.
At Johns Hopkins, we are sensitive to the anxiety a possible diagnosis of DCIS creates for our patients, Sun says. If the radiologist who read your mammogram suspects you have DCIS, he or she will arrange for you to have a stereotactic biopsy as soon as possible. Biopsy results are usually returned in about a week.
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Patients And Study Design
We searched our surgical records from December 2006 to June 2008 for patients with a histology of pure DCIS for our study. Pure DCIS was determined histopathologically as intraductal carcinoma without stromal invasion. Inclusion criteria were as follows: curative surgical treatment, performance of sentinel lymph node biopsy, and no primary chemotherapy. Patients with metachronous ipsilateral breast cancer were excluded. Furthermore, we also searched for patients having an IDC-predominant invasive lesion with the same profile as mentioned above. IDC-predominant invasive lesions are those with a predominant IDC including one or more invasive foci, each of which is not more than 0.5 cm in size.
What Is The Optimal Treatment For A Local Recurrence
Although local recurrences are uncommon after initial treatment for DCIS, they can be psychologically devastating for the patient, particularly if it is an invasive recurrence. The treatment of a recurrence depends on the initial treatment of DCIS, whether the recurrence is DCIS or invasive, and whether the patient has received radiotherapy to the breast. After diagnosis is confirmed histologically, a screen for distant metastatic disease is usually performed.
For a patient treated by BCS alone, management options may include re-excision followed by radiation or mastectomy with or without breast reconstruction. If BCS and XRT were used initially, then mastectomy is usually the only option available. If mastectomy alone was the original treatment modality, then surgical removal of a chest wall recurrence may be possible, followed by chest wall RT, but this situation is extremely rare. Treatment of the axilla and consideration of systemic therapy is also required. Most recurrences can be salvaged by mastectomy. One study showed that following mastectomy, subsequent freedom from chest wall recurrence was high .
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Invasive Ductal Carcinoma Diagnosis
IDC is usually found as the result of an abnormal mammogram. To diagnose cancer, youâll get a biopsy to collect cells for analysis. The doctor will remove a bit of tissue to look at under a microscope. They can make a diagnosis from the biopsy results.
If the biopsy confirms you have cancer, youâll likely have more tests to see how large the tumor is and if it has spread:
- CT scan. It’s a powerful X-ray that makes detailed pictures inside your body.
- PET scan. The doctor injects a radioactive substance called a tracer into your arm. It travels through your body and gets absorbed into the cancer cells. Together with a CT scan, this test can help find cancer in lymph nodes and other areas.
- MRI. It uses strong magnets and radio waves to make pictures of the breast and other structures inside your body.
- Bone scan. The doctor injects a tracer into your arm. They take pictures to find out if cancer has traveled to your bones.
- Chest X-ray. It uses low doses of radiation to make pictures of the inside of your chest.
What Is The Difference Between Normal Dcis And Comedo Dcis
There are some biological differences between conventional DCIS and comedo breast carcinoma in situ. For one thing, comedo carcinomas have a different expression pattern of tenascin, which is a large extra cellular matrix protein. Cytologically, comedo breast carcinoma in situ will typically have an altered basal lamina, and also a looser and more disorganized collagenous matrix. In general, one finds an increase in stromal cellularity in breast comedo carcinomas, including the presence of fibroblasts, lymphocytes, histiocytes and small blood vessels. The lateral intercellular spaces between large myoepithelial cells that border the basal lamina are often expanded in comedo breast carcinoma in situ, when compared to those of non-comedo DCIS. Some of these features may play a role in a perceived greater infiltrative potential for comedo DCIS when compared to non-comedo DCIS.
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