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Since there is uncertainty as to which patients will develop a more aggressive breast cancer, all patients are treated as soon as the diagnosis is made. This means the very edge of the cut surface of the specimen needs to be free of cancer cells. Although there have been no studies conducted that directly compare breast-conserving therapy to mastectomy with DCIS, numerous retrospective studies have demonstrated identical cause-specific survival to mastectomy.
Radiation therapy will treat these residual tumors and will reduce the risk for local recurrence (tumor returning back in the breast).
Both ductal carcinoma in situ (DCIS) and invasive cancer are known to be multifocal and multicentric. If the area of DCIS is small enough, you will probably be treated with a lumpectomy, which is breast-conserving surgery that removes only the area of the breast containing the cancer. If the DCIS is serious enough to require a mastectomy, you will not receive radiation unless lab tests reveal some remaining cancer in or near the edge of the removed breast tissue. Hormonal therapy may be recommended to women with DCIS if lab tests show that the cancer cells have hormone receptors. Chemotherapy is not needed for DCIS, because this type of cancer has not invaded other tissue.
When you have had DCIS, you are at higher risk for the cancer coming back or for developing a new breast cancer than a person who has never had breast cancer before. The DCIS will be examined to find out areas of involvement, the cancer size, the margins of resection, findings of the post-biopsy radiology testing, and whether there is any bloody nipple discharge. Each tumor has its own set of characteristics, and doctors refer to this as the "personality" of the cancer. A family history of breast cancer will also affect your treatment options, as will your access to a radiation oncologist, a reconstructive surgeon, and your own decision-making style. Your doctor will discuss breast-conserving and breast-removing surgery, and possibly radiation—depending on your situation. The decision about whether you need a lumpectomy or mastectomy, with or without radiation, depends mostly on the extent of DCIS in the breast.
Occasionally, a sentinel lymph node evaluation is useful, even though DCIS rarely spreads beyond the breast. The American Cancer Society estimates that more than 62,000 news cases of carcinoma in situ will be diagnosed this year.
Ductal carcinoma in situ (or DCIS) refers to the most common type of noninvasive breast cancer in women. Suspected DCIS is often confirmed by a breast biopsy in which a small sample of cells is removed for further examination under a microscope.
Note: Though DCIS is a serious condition requiring careful attention, it is not an emergency medical situation. The term, ductal carcinoma in situ (DCIS), refers to a family of cancers that occur in the breast ducts. Comedo type DCIS (also referred to as Comedocarcinoma) tends to be more aggressive than the non-comedo types of DCIS. Breast conserving therapy (BCT), typically a lumpectomy (removal of the mass and a small margin of surrounding breast tissue) followed by radiation treatment. A simple mastectomy (removal of the affected breast and often a small part of the underarm lymph nodes).
If a biopsy reveals a high grade of cancer (determined by a pathologist who examines tissues from the biopsy), the cancer may grow or spread more rapidly to other areas of the body. Physicians do not typically remove the axillary (underarm) lymph nodes in DCIS patients because the cancer is usually confined to the breast ducts. Though not common at this time, some centers are offering sentinel node biopsy to women who have very large DCIS tumors or who have more aggressive "comedo" type tumors. Lumpectomy refers to the surgical removal of a cancerous lump (or tumor) in the breast along with a small margin of the surrounding normal breast tissue. Patients are usually able to go home one to two days following lumpectomy, and most are able to perform normal activities within two weeks.
Lumpectomy (and sometimes mastectomy) usually requires six to seven weeks of radiation therapy immediately following surgery. Most of these common side effects are generally short-term, and many patients do not experience significant discomfort after their radiation treatments. To perform a simple mastectomy, a surgeon makes an incision along the perimeter of the breast (closest to the tumor area), leaving most of the skin intact. Because mastectomy involves the removal of significantly more body tissue than a lumpectomy, recovery is slower. Today, many women and their physicians are choosing lumpectomy over mastectomy to treat DCIS.
Breast reconstruction is an important topic for women to discuss with their doctors before cancer treatment begins.
The standard options for breast reconstruction include: skin expansion followed by the use of implants, or flap reconstruction. However, several studies have shown that women treated with breast conserving therapy who have local recurrence of DCIS are not at any significantly greater risk of dying from the disease than women treated with mastectomy. Lobular Carcinoma In Situ (LCIS) is a change in the cells of the milk lobules – the tiny sacs or glands in the breast that make milk. Ductal Carcinoma In Situ (DCIS) is a change in the cells that line the milk ducts, which are the "tubes" that bring milk from the milk lobules to the nipple. If left untreated, sometimes DCIS will spread outside the milk duct and turn into an invasive or infiltrating cancer.
Invasive or infiltrating lobular breast cancer (ILC) occurs when the cells in the milk lobule become abnormal.
Inflammatory breast cancer behaves differently than ductal breast cancer and must be treated differently.
It is important to control the growth of the imflammatory breast cancer cells, and chemotherapy is often recommended first.
It is important to control the growth of the inflammatory breast cancer cells, and chemotherapy is often recommended first. Tissue removed from the breast, lymph nodes or other parts of the body are sent to a laboratory to be viewed by a pathologist, a doctor who identifies diseases by studying cells and tissues under a microscope.
A copy of the pathology report is sent to your doctor and becomes part of your medical record.
Ductal carcinoma in situ (DCIS): early cancer cells growing in the lining of the milk duct in the breast. Lobular carcinoma in situ (LCIS): early cancer cells growing in the milk lobule of the breast.
If invasive cancer was found, there may be surrounding DCIS as well (see definition above), which will be noted in this section.
Angiolymphatic invasion: cancer cells have entered the small blood vessels or lymphatic vessels in the breast. Biopsy site: if a prior biopsy has been done, it will be noted whether the biopsy site is seen in the sample.
Nipple: if the nipple was removed (with a mastectomy), it will be noted if cancer is present in the nipple. Sentinel node biopsy: if a sentinel lymph node biopsy was done, the report will note the number of lymph nodes containing cancer cells (positive lymph nodes), the size of the lymph nodes, and the total number of lymph nodes removed with the sentinel lymph node biopsy. Axillary lymph node dissection: if cancer cells were found in the sentinel lymph nodes, the report will note the number of additional lymph nodes removed, the number containing cancer cells (positive lymph nodes), and the size of the lymph nodes.
Extracapsular extension: if cancer cells were found in the lymph nodes, the report will note whether the cancer cells are completely inside the lymph node (absent) or whether they extended outside of the lymph node (present). Pathologic tumor stage (AJCC): a scale used by pathologists to summarize features of the tumor (T), number of lymph nodes with cancer (N), and metastatic sites (M).
Comments: includes specific pathologic findings and clarifications of what was seen in the pathologic specimen. This section gives specific details on what was given to the pathologist at the surgery and what it looks like without a microscope. Estrogen and progesterone receptors: the tissue will be sent to an outside laboratory to be tested for estrogen and progesterone hormone receptors in the cancer cells. HER2 staining intensity: The tissue will be sent to an outside laboratory to be tested to see if the cancer cells contain an overactive gene called HER2.

Once your cancer is diagnosed, your doctors will want to know exactly how big the cancer is and whether it has spread to the lymph nodes or other parts of your body. The lining of the milk duct contains abnormal cells, but the cells have not spread to the surrounding breast tissue or to the lymph nodes. Tumor is smaller than 2 cm (about 1 inch) and no cancer cells are found in the lymph nodes or in other parts of the body. Tumor is smaller than 2 cm (about 1 inch), and cancer cells are found in the lymph nodes but not in another part of the body. Tumor is 2-5 cm (about 1-2 inches), and cancer cells may or may not be found in the lymphy nodes but not in another part of the body. Tumor is greater than 5 cm (about 2 inches), and cancer cells are not found in the lymph nodes or another part of the body. Tumor is greater than 5 cm (about 2 inches), and cancer cells have spread to lymph nodes but not to another area of the body.
Any size tumor that has spread to lymph nodes that have grown together (fixed or matted lymph nodes), but not to another area of the body.
Tumor is any size and has spread behyond the breast and lymph nodes to other parts of the body (usually bone, liver, lung or brain).
The standard treatment of DCIS includes a lumpectomy (preserving the breast) with radiation therapy or a mastectomy (complete removal of the breast). Breast conservation is not an option due to the extent of the disease throughout the breast. Despite complete resection of the tumor during lumpectomy, some women with DCIS remain at a higher risk of recurrence unless they undergo additional radiation therapy. Overall, in patients who undergo radiation therapy, the relative risk of a recurrence by either DCIS or invasive cancer is reduced by 50%. There are other cases where DCIS is an indolent disease and will not progress to invasive cancer. And it is sometimes called "pre-cancer." You may also hear it referred to as Tis, which means that the cancer is non-invasive. However, if the cancer is large or appears in several places throughout the breast, then breast-removing surgery (mastectomy) may be necessary.
At this time, the only hormonal treatment recommended for women with this kind of DCIS is tamoxifen. Breast-removing surgery (mastectomy) is only required for DCIS that is large or occurs in several places in the breast. The "personality" of DCIS is judged by the cancer grade of dead cells in the tumor, pattern of growth, microinvasion, hormone-receptor status, and how the stage of the disease might change in certain situations. There may be a role for hormonal therapy, to help reduce your risk of breast cancer in the future. A common type of carcinoma in situ called DCIS (ductal carcinoma in situ or intraductal carcinoma) accounts for nearly 25% of all breast cancer diagnoses. In situ, or "in place," describes a cancer that has not moved out of the area of the body where it originally developed.
Stage 0 breast cancer is a contained cancer that has not spread beyond the ductal system (to the lymph nodes or other areas of the body). Women have a sufficient period of time to educate themselves and weigh all possible treatment and reconstructive options before any decisions need to be made. DCIS patients with multiple areas of cancer within the breast are often encouraged to choose a mastectomy. Early studies of these specific DCIS tumors at major institutions such as Memorial-Sloan Kettering Cancer Center in New York, do show that sentinel lymph node biopsy may be beneficial for some DCIS patients since a small area of microinvasion in some area of the breast is possible when DCIS is extensive and or has a high grade.
A lumpectomy may be called a quandrantectomy when up to one fourth of the breast is surgically removed.
The surgeon makes a small incision over the breast lump, carefully excises (cuts free) the lump, and removes it from the breast along with at least 1 cm of surrounding tissue.
Radiation is treatment with high-energy rays or particles used to ensure the destruction of any remaining cancer after an operation. Radical mastectomy involves the removal of the affected breast, the pectoral chest muscles, all chest and underarm lymph nodes, and fat and skin from the chest.
A simple mastectomy involves removing the affected breast and sometimes a small part of the underarm lymph nodes. Most of the time, the nipple is not removed during simple mastectomy, although milk ducts leading to the nipple are cut.
Patients often stay at the hospital for several days, though some are released 24 to 48 hours after surgery. Though both procedures have equal survival rates, mastectomy does carry the psychological burden of waking up without a breast (if breast reconstruction is not immediate).
More recently, tamoxifen has been used to treat early stage breast cancer after primary treatment (lumpectomy or mastectomy). Skin expansion involves the insertion of a balloon expander beneath the skin and chest muscles following mastectomy. However, it is not meant to replace the individual attention, advice, and treatment plan of your oncologist and medical team.
In LCIS, the cells do not look like normal lobular cells, and there are too many of these abnormal cells. We do know, however, that women who have had LCIS are more likely to develop breast cancer than women who have not had LCIS.
They do not spread outside the milk duct into the surrounding breast tissue, lymph nodes or other parts of the body.
At this point in time, we cannot predict which patients with DCIS will develop invasive or infiltrating cancers. The lobular cancer cells look different from normal lobular cells and multiply without stopping. Cancers that are well differentiated look more like normal cells in the milk lobules, while those that are poorly differentiated have lost many of their normal cell features. Most women will receive a combination of treatments, although not necessarily all four types of treatments. Cancers that are well differentiated look more like normal cells lining the milk duct, while those that are poorly differentiated have lost many of their normal cell features.
Most women will receive a combination of treatments, although not necessarily all four types of treatment. They begin to look different from normal milk duct cells, and the body produces too many of them. If an extensive intraductal component (EIC) is noted, it means that the invasive cancer contains at least 25% DCIS. Ideally there are no cancer cells at the margin (clear or negative margin), only a rim of normal tissue. If an axillary lymph node dissection was planned, the report will note the total number of lymph nodes removed, the number that had cancer and the size of the lymph nodes.
Sometimes a stage may be divided into an A and B category depending upon the characteristics of the tumor or lymph nodes. This stage is also called preinvasive or noninvasive carcinoma, carcinoma in situ, or intraductal carcinoma. This means that the cancer cells have spread, invaded or infiltrated into the tissue surrounding the milk duct or lobule in the breast. This means there is a need to go back for a second surgery in order to clear the breast of cancer cells.
It does not necessarily reflect the aggressiveness of the cancer cells, but their distribution throughout the breast. But you might be able to participate in new studies looking at radiation to just part of the breast. This drug is prescribed to lower the risk of the cancer coming back and to reduce the risk of getting a new cancer. An estimated 178,400 cases of invasive breast cancer are diagnosed each year, and approximately 20% to 30% of breast cancers detected by mammography are carcinoma in situ. With DCIS, the cancer cells are confined to milk ducts in the breast and have not spread into the fatty breast tissue or to any other part of the body (such as the lymph nodes). The cure rate for DCIS is close to 100% provided that an accepted standard method of treatment is followed.

Women should maintain an open dialogue with their physicians to best understand the disease and the variety of treatment options. Sentinel lymph node biopsy is a new procedure that involves removing only the first one to three lymph nodes in the lymphatic chain.
Lumpectomy is attractive to many women because it allows them to maintain most of their breast after surgery. If certain portions of the chest muscles are not removed, the procedure is called modified radical mastectomy. Whenever possible, surgeons attempt to leave the overlying skin intact; or alternatively, they leave a large amount of surrounding tissue to ensure breast reconstruction.
The underlying tissue is gently cut free, removed, and often a drainage tube is inserted in the affected area.
The surgeon will periodically inject a salt-water solution into the balloon to fill the expander for the next several months. Women with ductal carcinoma in situ (DCIS) who are treated with breast-conserving therapy (lumpectomy) are at a slightly higher risk of experiencing a recurrence than those women who are treated with mastectomy (removal of the affected breast). Understanding how cancer works and how your particular cancer affects your body will help you make decisions about your care and what is best for you.
In most cases, the abnormal lobular cells will not be removed, but the doctor may recommend a very thorough breast health screening program. DCIS happens when the cells of this thin layer grow and multiply without stopping and have abnormal features that can be detected only under the microscope. Therefore, it is recommended that DCIS be surgically removed before it can become an invasive cancer. The types of treatment recommended will depend upon the size of the cancer, whether the cancer is in the lymph nodes, features of the cancer cells themselves and your general health.
The ductal cancer cells look different from normal milk duct cells, and the body produces too many of them. The cancer cells spread outside the milk duct into the surrounding breast tissue and the small lymphatic vessels in the breast, particularly those in the skin of the breast.
The pathologist will measure the distance between the cancer and the edge of normal tissue. Knowing the stage of your cancer will help your doctors develop the best treatment plan for you.
A woman may choose this option over a lumpectomy if she is unwilling to undergo radiation therapy. Women with DCIS can be left with these tumor foci despite obtaining negative resection margins (no tumor cells at the very cut edge of the surgical specimen).
The goal of radiation therapy is to eradicate this residual disease and decrease the incidence of local recurrence.
DCIS hasn't started to break through normal tissue, which means it's not life-threatening like cancer. Ongoing studies are looking at whether aromatase inhibitors, another form of hormonal therapy, can help women with DCIS.
DCIS is often first detected by a mammogram (an x-ray examination of soft breast tissues used to identify lumps, cysts, tumors, and other abnormalities). By removing fewer lymph nodes, the chances of pain and lymphedema (chronic swelling) of the arm are reduced.
As stated above, the cure rate of DCIS treatment with lumpectomy is close to 100% if the margin of tissue around the tumor is cancer-free. A seroma (clear fluid trapped in the wound) will usually fill the surgical cavity after the operation and naturally remold the breast’s shape. The skin is carefully closed with stitches or clips, which are usually removed within a week. Tamoxifen is an "anti-estrogen" and works by competing with estrogen to bind to estrogen receptors in breast cancer cells. After the breast skin has been sufficiently stretched, the balloon expander is removed and replaced by a permanent implant. At a certain point, the cancerous cells continue to multiply and form a mass which can be detected. In addition, radiation treatment of the breast is often recommended following removal of the affected tissue. ILC does not mean that the cancer has traveled to other parts of the body beyond the breast, but it has the ability to do so. If cancer cells are detected at the edge of the tissue removed, it is called a positive margin, and more surgery may be required.
The report may also contain a second type of HER2 testing called FISH testing, which will be reported as either positive or negative. The advantage of doing breast conservation or a lumpectomy is one and only, the preservation of the breast. We discussed earlier that DCIS means cancer cells are within the duct and do not have the potential to spread.
But it does not spread OUTSIDE the duct into the normal surrounding breast tissue, to the lymph nodes, or to other organs. DCIS may appear on a mammogram as tiny specks of calcium (called microcalcifications), generally too small to notice by physical examination. For patients with DCIS who undergo mastectomy (see below), the lymph node(s) can, in almost all cases, be removed through the same incision. Because lumpectomy is intended to preserve the physical appearance of the breast, surgeons generally do not perform lumpectomy when over one fourth of the breast must be removed. Patients will be instructed to lie on the treatment table under the radiation machine while radiation therapists monitor the patient from the next room on a closed-circuit television. Radiation is not recommended following a mastectomy (removal of the entire breast) to treat DCIS.
IDC does not mean that the cancer has traveled to other parts of the body beyond the breast, but it has the ability to do so.
If hormone receptors are present, then any hormones circulating in the body may affect the cancer’s growth. Breast conserving therapy implies complete removal of the breast tumor with a concentric margin of surrounding healthy tissue in a cosmetically acceptable manner. The decision to preserve the breast implies a risk for "in breast recurrence" (cancer returning back in the future), or a new primary breast cancer in the same breast. It is important to acknowledge that after diagnosing DCIS by a needle core biopsy (streotactic biopsy) there is the possibility of finding an invasive cancer in approximately 10% to 20% of cases. The intent of radiation therapy delivery in DCIS is to eradicate subclinical foci of residual disease and to minimize the risk for local recurrence following surgery. By blocking estrogen in the breast, tamoxifen helps slow the growth and reproduction of breast cancer cells. With this in mind, it is recommended to proceed with a sentinel node biopsy if a mastectomy has been elected. In TRAM Flap reconstruction, a flap of the lower abdominal wall fat is transferred to the intended breast area with its own blood supply. In rare cases, DCIS may be felt as a thickening or nodule in the breast on self-exam or during a physical exam by a health care provider.
This will avoid the need of an axillary node dissection in the case that the mastectomy specimen reveals an invasive component. Normally the blood supply comes from the rectus muscle(s) attached at the lower edge of the rib cage. We also recommend a sentinel node biopsy in selective breast conserving cases depending on tumor characteristics.
Sometimes, a doctor may decide that there is a chance that cancer may be present, even though it did not show up on the biopsy. Or some women may wish to consider prophylactic mastectomies (surgical removal of the breasts even though no cancer has been found) to reduce their future risk of breast cancer.

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