Abstract
DCIS continues to increase in incidence as the number of women invited to population breast screening programmes increases. This means that more women are treated every year for DCIS. More women diagnosed with DCIS currently receive some form of treatment and the issue is whether this treatment is necessary and appropriate. There are few data on the natural history of untreated DCIS. Studies from Nashville by Page [1] show 28% of patients with low grade DCIS develop invasive disease by 6 years and 40% have developed invasive disease by 30 years. Data from Van Nuys [2] suggest that the rate of progression in high grade DCIS is much higher, with 60% of women with incompletely excised high grade disease developing progression or invasive cancer by 5 years. The results of studies on treatment of DCIS can be summarised as follows: • Excision alone is associated with a high rate of local recurrence in approximately 3.8% per year, of which 1.6% per year is invasive disease. • Radiotherapy reduces the recurrence rate in the progression to invasive cancer by between 50 and 60%. • Recurrence rates are lower when radiotherapy is given to patients whose lesion is completely excised with clear margins. The evidence that wider margins is associated with better local control rates does not stand up to scrutiny. Surgeons in the UK are divided as to what they consider to be an adequate clear margin width. • Tamoxifen reduces recurrence rates in oestrogen receptor-positive DCIS but not oestrogen receptor-negative DCIS. • No patients with localised DCIS should have axillary surgery. As the numbers of patients with DCIS increases, so the number of women being treated by breast-conserving surgery and mastectomy increases. The challenge is to limit the surgery so as to reduce morbidity and select those patients who will have most to gain from radiotherapy and tamoxifen.
Highlights
Neoplastic tissue contains elevated levels of choline-containing metabolites [1,2]
We examined the extent to which the lower mammographic sensitivity found in hormone replacement therapy (HRT) users could be explained by any association of HRT use with higher density and more difficult to detect cancers
The results suggest that applying compression does not ensure breast thickness reduction and observing physical changes does not guarantee that breast thickness has been minimised
Summary
Neoplastic tissue contains elevated levels of choline-containing metabolites (tCho) [1,2]. The presence of spiculation arising from a mass detected at mammography makes malignancy a probable diagnosis This is confirmed by this review of the first 8 years of screening in East Sussex where only 3.6% of masses with spiculation were benign at excision (24 out of 668), compared with 33.3% of masses without spiculation (102 out of 306). When breast core biopsy reveals lobular neoplasia (lobular carcinoma in situ [LCIS] or atypical lobular hyperplasia [ALH]) a management dilemma follows, as uncertainty regarding the significance of LCIS/ALH exists. Is this an indicator of increased risk of breast cancer or should it be considered a marker for more serious local pathology? Is this an indicator of increased risk of breast cancer or should it be considered a marker for more serious local pathology? Should surgical excision be undertaken in these cases?
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