Towards optimal treatment of ductal carcinoma in situ

Ductal carcinoma in situ(DCIS) is a non-obligate precursor of invasive breast cancer with a variable biological behavior which is difficult to accurately predict using the current clinico-pathological parameters. Randomized controlled trials have demonstrated that adjuvant radiotherapy(RT) reduces the risk of local recurrence after adequate local excision of DCIS. Tamoxifen may be considered as an adjuvant endocrine treatment in patients with high risk estrogen receptor positive disease. There is however a growing consensus that RT can be safely omitted in a subgroup of patients with favorable biological features in order to avoid overtreatment. The sentinel node biopsy is not routinely indicated but should be considered in women undergoing mastectomy for DCIS. The discovery of molecular signatures that accurately predict the biological behavior of this common malignancy will facilitate a personalized treatment approach in the future.

Current Treatment of DCIS

Abstract: Ductal carcinoma in-situ DCIS is a heterogeneous entity in breast neoplasm with unpredictable biological behavior. This poses challenge in the management of DCIS. Various trials on DCIS have shown good outcome with integral treatment of adequate surgery, radiotherapy and hormonal therapy. Identification of subgroup of DCIS for radiotherapy and hormonal therapy could improve recurrence rate, contralateral tumours incidence and perhaps overall survival. Various risk score calculations could help to direct radiotherapy and hormonal treatment verses surgery alone and to avoid over treatment. Oncotype DX assay could be a new way of risk calculation to direct types of DCIS treatment. The recent increased use of MRI could increase the detection of DCIS and a more accurate extent of disease estimation. This article is a summary of major literatures and major trials result for DCIS.

Skin-Sparing Mastectomy and Breast Reconstruction: An Update for Clinical Practice

Aim: To provide an up-to-date review of the literature on skin-sparing mastectomy (SSM) for breast cancer (BC). The article also reviews the oncological safety, effects of radiotherapy (RT) on immediate breast reconstruction (IBR), the indications for preserving the nipple-areola complex (NAC) and the emerging role of allogenic grafts as adjuncts to implant in IBR. Methods: Review of the English literature from 1965 to 2013 was carried out using Medline and PubMed research engines. Results: SSM is oncologically safe in appropriately selected cases of invasive breast cancer (IBC) and ductal carcinoma in-situ (DCIS) including IBC 5 cm, multi-centric tumours, DCIS and for risk-reduction surgery. Inflammatory breast cancer and tumours with extensive skin involvement represent contra-indications to SSM due to an unacceptable risk of local recurrence. Prior breast irradiation or the need for post-mastectomy radiotherapy (PMRT) do not preclude SSM with IBR, however the aesthetic outcome may be compromised by radiation. Preservation of the nipple-areola complex (NAC) has aesthetic and psychological benefits and is safe for peripherally located node negative unifocal tumours. An intraoperative frozen section protocol for the retro-areolar tissue should be performed when NAC preservation is considered. The advent of acellular dermal matrix has enhanced the scope of implant-based immediate reconstruction following SSM. Cell-assisted fat transfer is emerging as a promising technique to optimise the aesthetics outcome. There is no sufficient evidence to support the role of endoscopic mastectomy in clinical practice. Conclusion: Numerous retrospective and prospective studies show that SSM is oncolgically safe in appropriately selected cases and is aesthetically superior to non-SSM mastectomy. New tech-niques such as the use of acellular dermal matrix (ADM) and cell-assisted fat transfer have increased the use of implants for volume replacement following SSM. In the absence of randomized clinical trials, an updated systematic meta-analysis of published studies is required in order to consolidate the evidence.