Updated: 12/26/2021

Ductal Carcinoma In Situ (DCIS)

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  • Snapshot
    • A 58-year-old woman presented to her primary care physician after a screening mammogram revealed calcifications in the left breast. Physical exam revealed no palpable breast lumps or axillary lymphadenopathy.
  • Introduction
    • Overview
      • a neoplastic lesion confined to the breast duct
      • a true premalignancy
        • 50% develop into invasive ductal carcinoma if untreated
          • risk is for both the ipsilateral and contralateral breast
  • Epidemiology
    • Incidence
      • 32.5 in 100,000 women
      • represents ~20% of breast cancer diagnoses in the U.S.
    • Risk factors
      • increasing age
      • nulliparity
      • family history of breast cancer
      • age ≥ 30 or older at birth of first child
      • obesity
  • ETIOLOGY
    • Genetics
      • inheritance
        • increased risk with BRCA1 and BRCA2 mutations
      • mutations
        • 75% of DCIS is estrogen (ER)/progesterone (PR) receptor-positive
    • Associated conditions
      • Paget disease of the breast
        • overlying breast skin changes that may occur in association with DCIS
          • skin crusting and itching
  • Presentation
    • Symptoms
      • asymptomatic
    • Presentation
      • typically no palpable mass on exam
      • +/- nipple discharge
      • +/- overlying breast skin crusting
  • Imaging
    • Mammography
      • indications
        • screening
          • DCIS often detected on screening mammogram
      • findings
        • calcifications
          • in 90% of DCIS
          • linear calcifications associated with more aggressive DCIS
          • granular calcifications associated with less aggresive DCIS
        • breast mass
          • uncommon but occassionally found on mammography (~8% of cases)
    • Ultrasound
      • indications
        • to guide biopsy if lesion is visible on US
      • findings
        • microlobulated mild hypoechoic mass with ductal extension
    • Core or excisional biopsy
      • indications
        • diagnosis following detection of calcifications on mammogram
          • using stereotactic guidance
      • findings
        • proliferation of neoplastic cells within the mammary ductal system
        • 11% will have findings of microinvasion
  • Differential
    • Lobular carcinoma in situ (LCIS)
      • key distinguishing factor
        • e-cadherin expression on histology
          • positive in DCIS and negative in LCIS
    • Invasive carcinoma
      • key distinguishing factor
        • evidence of invasion on biopsy
  • Treatment
    • Medical
      • radiation
        • indications
          • postoperative following lumpectomy
      • endocrine therapy
        • indications
          • ER/PR-positive DCIS to reduce chance of developing invasive cancer
            • especially in patients who did not undergo bilateral mastectomy
        • modalities
          • tamoxifen
      • close follow-up and screening mammography
        • indications
          • all DCIS patients to detect future development of invasive carcinoma
    • Surgical
      • lumpectomy
        • indications
          • relatively smaller masses compared to size of breast
          • ability to get negative margins
            • multicentric disease involving more than one quadrant is a relative contraindication
        • followed by radiation
          • can skip radiation if low-grade DCIS that is < 1-2 cm
      • mastectomy (typically bilateral)
        • indications
          • invasive components on biopsy
          • multicentric disease
          • relatively large masses compared to size of breast
          • patients who prefer bilateral mastectomy in order to reduce risk of future invasive carcinoma
  • Complications
    • Development of invasive carcinoma
      • ~6% risk of recurrence of invasive carcinoma after DCIS treatment in both contralateral and ipsilateral breast
    • Death
  • Prognosis
    • Excellent
      • ~1.7-3% mortality in treated patients

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