Topic: DCIS with comedo necrosis

crazydaisy,

I agree with barry that if you have a lumpectomy, there is no reason to have a sentinel node biopsy at the same time.  For someone who has a mastectomy for higher grade or comedo necrosis DCIS, usually an SNB will be done at the time of surgery.  This is because an SNB can't be done after a mastectomy - the breast is needed for the injection of the dye.  So if a microinvasion is found in amongst the DCIS, then after a mastectomy an SNB is no longer possible and more nodes would need to be removed.  This would put the patient at higher risk for lympedema.  So doing an SNB at the time of a mastectomy makes sense.  But, for someone having a lumpectomy for DCIS, there is no reason to check the nodes until a microinvasion is found.  DCIS itself cannot invade the nodes.  So I agree that waiting for the pathology report is a good idea.  If there is no microinvasion, then you've avoided unnecessary surgery and you haven't put yourself at risk for lymphedema.  But if there is a microinvasion, an SNB can be done as a follow-up surgery.

As for recurrence rates, I just posted about this in another DCIS thread.  Comedo necrosis is a key factor that increases recurrence risk, but there are other factors (age of patient, size of area affected, size of margin) that are also important.  http://community.breastcancer.org/topic/68/conversation/694477?page=1#idx_14

I think for you the biggest factor that affects your treatment plan may be the size of the area that has DCIS.  With comedo necrosis, you really want to be sure to have good wide margins, and 4cm is already quite large, without adding in good margins around the whole affected area.  So that might lead to the recommendation of a mastectomy instead of a lumpectomy w/radiation.  And then, back to my earlier point, if you have a mastectomy, because of the comedo necrosis, it probably will be advised that you have the SNB at the same time.

 Hi crazydaisy,

I was dx w/DCIS, grade 3 w/comedonecrosis in 4/07. Was only 7mm in one area.  Had lumpectomy w/SNB, followed by radiation. Was 61 at time of dx. Onc. prescribed tamox but as I had hysterectomy for endometrial cancer in 2/07, have not filled prescription.  Am still on fence about it.  I tend to agree w/Beesie that SNB is unwarranted for DCIS but think that's "standard of care" at the hospital I went to.  I'm 6 mos. out of treatment & still have tenderness at SNB area at times.   Best of luck to you in whatever you decide to do & keep us posted on what's happening with you and your treatment.

Joan

I'm thankful for SNB for DCIS. They thought I had a 2 cm dcis with comedo necrosis and after choosing a bilateral, they found 3 invasive tumors among the dcis and other areas of the breast. Thank goodness they did a SNB(clean)then or else they would have gone back in and taken many more than 1 or 2. The tumors were small and hiding very deep almost to the chest wall. For me, they couldn't scrape enough breast tissue to give me peace of mind when I heard it was actually invasive not in situ. My other breast had extensive ADH and my BS said with my age at the time(40) and very far away, hormone-wise from menopause, I was a ticking time bomb. She told me that I definitely chose the right surgery as even 3 lumpectomies would not have gotten all the DCIS and IDC and since some was hiding in dense areas that they thought were clean, they would have missed something anyway. I only wanted to deal with this once with one surgery.

I'm not saying this to scare anyone but it was my experience and I think anyone with comedo necrosis should be aware that this sometimes happens. I chose a bilateral mast for many many good reasons but none of reasons were what it best turned out to be for.

My sister in law had lumpectomy with SNB and has had more trouble than me although her initial recovery was quicker. Our surgeries were only a few months apart so it's been interesting to make comparisons. She has mild lymphedema and a lot of pain and numbness. I can now feel it when I apply deodorant to my armpit that had the SNB and I wasn't ticklish there since my surgery but the other night, my teen tested it out and darn, I'm sensitive enough to be tickled! 

Hi CrazyDaisy

I posted to you on a couple of other threads as well.  Good for you getting all the info you can.  I read and read everything I could get my hands on for a while when first dx.  This is the best site on the net.

My DCIS diagnosis was bad from right from the sterotactic biopsy, we knew we were dealing with Nuclear Grade 3 and comedonecrosis and a widespread area.  But I definately wanted to go for lumpectomy first.  Lump+Rads=Mast if of course the cosmetic outcome won't be too bad.  After the surgery margins also became an issue.  On the VNPI I also score an 11.

But we went ahead with lumpectomy and radiation and I am happy with that so far.  My mammogram in November showed no new areas of concern and I'll push for another mammo in 6 months.

My surgeon never suggested a mastectomy, he is very pro breast conservation and less invasive procedures.  He wouldn't do an SNB before the pathology from the breast came back either and as it turned out there were no micro invasions found in all that DCIS.

So far, so good.

Hey, I see you are in Port Perry, I'm actually in Eastern Ontario myself.  We get to deal with OHIP!!  Some plusses and minusses on that score for sure.

Nan

Hi Nan, thanks for joining this thread. Your outcome is very encouraging, we need to hear that as well as we need to hear the possible other side, just so those of us with this DX aren't walking with our heads down and know to ask our doctors about all the aspects of DCIS. I guess we can say we are lucky to have OHIP. It has it's flaws but thank god it's there when we need it. Where in ONT. are you?? 

Hi, I thought I'd throw in my story.  I had a bad mammogram in June '06, but this was a week before moving, so it took a little time to wheedle for biopsies at the new place.  So I was finally diagnosed in August '06.  High grade DCIS with comedo necrosis, cribriform blah, blah, blah.  Had a couple of wide excision biopsies that didn't get clean margins - SNB with the 2nd w.e.  At that point, my doctor recommended the mastectomy, because she couldn't guarantee that she would get clean margins with yet another biopsy.  By that time I was ready to agree to that.  Let's get it over with.  My boob was looking pretty bad at that point, it's been lumpy all my life - easy decision for me.  The SNB took 10 nodes, all clear.  I have full range of motion and only some patchy numbness.  It's just a strip of the underside of my arm and the lower portion of my armpit.  Doesn't bother me one bit.  But I know that it does bother some people.

I did the unilateral mastectomy (after MRI confirmed that left side was okay and BRCA 1/2 negative).  Expander/implant route.  He spared what skin he could, but told me he had to go around the biopsy scar.  (yes, change in doctor, blah)  The pathology on the mast. revealed no more cancer.  None.  I'm totally okay with that.  Great, in fact.

So I'm a year and a half out and still okay.  And after what I've read, I'm glad I didn't have to go the radiation route.  I would have too because I thought terribly about mastectomies before I had one myself.

Stephanie

Hi Crazydaisy found this don't know if it will give you any info, but I sure had a shock my margin were 1mm and now I have some questions to ask.  I also had necrosis. Pearl

Introduction

Ductal carcinoma in situ (DCIS) is a noninvasive, precancerous condition. DCIS can progress to become invasive cancer, but estimates of the likelihood of this vary widely. Some people include DCIS in breast cancer statistics. The frequency of the diagnosis of DCIS has increased markedly in the United States since the widespread use of screening mammography. In 1998, DCIS accounted for about 18% of all newly diagnosed invasive plus noninvasive breast tumors in the United States.

Very few cases of DCIS present as a palpable mass; 80% are diagnosed by mammography alone.[1] DCIS comprises a heterogeneous group of histopathologic lesions that have been classified into several subtypes based primarily on architectural pattern: micropapillary, papillary, solid, cribriform, and comedo. Comedo-type DCIS consists of cells that appear cytologically malignant, with the presence of high-grade nuclei, pleomorphism, and abundant central luminal necrosis. Comedo-type DCIS appears to be more aggressive, with a higher probability of associated invasive ductal carcinoma.[2]

Treatment Option Overview

Until recently, the customary treatment of DCIS was mastectomy.[1] The rationale for mastectomy included a 30% incidence of multicentric disease, a 40% prevalence of residual tumor at mastectomy following wide excision alone, and a 25% to 50% incidence of breast recurrence following limited surgery for palpable tumor, with 50% of those recurrences being invasive carcinoma.[1,3] The combined local and distant recurrence rate following mastectomy is 1% to 2%. No randomized comparisons of mastectomy versus breast-conserving surgery plus breast radiation are available.

In view of the success of breast-conserving surgery combined with breast radiation for invasive carcinoma, this conservative approach was extended to the noninvasive entity. To determine whether breast-conserving surgery plus radiation therapy was a reasonable approach to the management of DCIS, the National Surgical Adjuvant Breast and Bowel Project (NSABP) and the European Organisation for Research and Treatment of Cancer (EORTC) have each completed prospective randomized trials in which women with localized DCIS and negative surgical margins following excisional biopsy were randomized to either breast radiation (50 Gy) or to no further therapy.[4-7] Of the 818 women enrolled in the NSABP B-17 trial, 80% were diagnosed by mammography, and 70% of the patients' lesions were 1 cm or less. At the 12-year actuarial follow-up interval, the overall rate of in-breast tumor recurrence was reduced from 31.7% to 15.7% when radiation therapy was delivered (P < .005). Radiation therapy reduced the occurrence of invasive cancer from 16.8% to 7.7% (P = .001) and recurrent DCIS from 14.6% to 8.0% (P = .001).[7][Level of evidence: 1iiDi] Nine pathologic features were evaluated for their ability to predict for in-breast recurrence, but only comedo necrosis was determined to be a significant predictor for recurrence.

Similarly, of the 1,010 patients enrolled in the EORTC-10853 trial, mammography-detected lesions in 71% of the women. At a median follow-up of 10.5 years, the overall rate of in-breast tumor recurrence was reduced from 26% to 15% (P < .001) with a similarly effective reduction of invasive (13% to 8%, P = .065) and noninvasive (14% to 7%, P = .001) recurrence rates.[7][Level of evidence: 1iiDi] In this analysis, parameters associated with an increased risk of in-breast recurrence included age 40 years or younger, palpable disease, intermediate or poorly differentiated DCIS, cribriform or solid growth pattern, and indeterminate margins. Elsewhere, margins of less than 1 mm have been associated with an unacceptable local recurrence rate, even with radiation therapy.[8] In both of the studies reported here, the effect of radiation therapy was consistent across all assessed risk factors.

Given that lumpectomy and radiation therapy are generally applicable for most patients with DCIS, can a subset of patients be identified with such a low risk of local recurrence that postoperative radiation therapy can be omitted? To identify such a favorable group of patients, several pathologic staging systems have been developed and tested retrospectively, but consensus recommendations have not been achieved.[9-12] The Van Nuys Prognostic Index, which combines three predictors of local recurrence (i.e., tumor size, margin width, and pathologic classification), was used to retrospectively analyze 333 patients treated with either excision alone or excision and radiation therapy.[12] Using this prognostic index, patients with favorable lesions, who received surgical excision alone, had a low recurrence rate (i.e., 2% with a median follow-up of 79 months). A subsequent analysis of these data was performed to determine the influence of margin width on local control.[13] Patients whose excised lesions had margin widths 10 mm or larger in every direction had an extremely low probability of local recurrence with surgery alone (4% with a mean follow-up of 8 years). These reviews are retrospective, noncontrolled, and are subject to substantial selection bias. By contrast, no subset of patients was identified in the prospective NSABP trial that did not benefit from the addition of radiation therapy to lumpectomy in the management of DCIS.[2,4]

To determine if tamoxifen adds to the efficacy of local therapy in the management of DCIS, the NSABP performed a double-blind prospective trial (NSABP-B24) of 1,804 women.[14] Patients were randomly assigned to lumpectomy, radiation therapy (50 Gy), and placebo versus lumpectomy, radiation therapy, and tamoxifen (20 mg/day for 5 years).[14] Positive or unknown surgical margins were present in 23% of patients. Approximately 80% of the lesions measured not larger than 1 cm, and more than 80% were detected mammographically. Breast cancer events were defined as the presence of new ipsilateral disease, contralateral disease, or metastases. Women in the tamoxifen group had fewer breast cancer events at 5 years than did those on a placebo (8.2% vs. 13.4%; P = .009).[14][Level of evidence: 1iDi] With tamoxifen, ipsilateral invasive breast cancer decreased from 4.2% to 2.1% at 5 years (P = .03). Tamoxifen also decreased the incidence of contralateral breast neoplasms (invasive and noninvasive) from 0.8% per year to 0.4% per year (P = .01). The benefit of tamoxifen extended to those patients with positive or uncertain margins.[15] (Refer to the PDQ summary on Breast Cancer Prevention for more information.)

Treatment Options for Patients with DCIS

1. Breast-conserving surgery and radiation therapy with or without tamoxifen.
   
   
2. Total mastectomy with or without tamoxifen.
   
   
3. Breast-conserving surgery without radiation therapy. A large national clinical trial (RTOG-9804) comparing breast-conserving surgery and tamoxifen with or without radiation therapy was closed due to poor accrual and results are pending.
   
   

References

1. Fonseca R, Hartmann LC, Petersen IA, et al.: Ductal carcinoma in situ of the breast. Ann Intern Med 127 (11): 1013-22, 1997.  [PUBMED Abstract]
   
   
2. Fisher ER, Dignam J, Tan-Chiu E, et al.: Pathologic findings from the National Surgical Adjuvant Breast Project (NSABP) eight-year update of Protocol B-17: intraductal carcinoma. Cancer 86 (3): 429-38, 1999.  [PUBMED Abstract]
   
   
3. Lagios MD, Westdahl PR, Margolin FR, et al.: Duct carcinoma in situ. Relationship of extent of noninvasive disease to the frequency of occult invasion, multicentricity, lymph node metastases, and short-term treatment failures. Cancer 50 (7): 1309-14, 1982.  [PUBMED Abstract]
   
   
4. Fisher B, Dignam J, Wolmark N, et al.: Lumpectomy and radiation therapy for the treatment of intraductal breast cancer: findings from National Surgical Adjuvant Breast and Bowel Project B-17. J Clin Oncol 16 (2): 441-52, 1998.  [PUBMED Abstract]
   
   
5. Fisher B, Land S, Mamounas E, et al.: Prevention of invasive breast cancer in women with ductal carcinoma in situ: an update of the national surgical adjuvant breast and bowel project experience. Semin Oncol 28 (4): 400-18, 2001.  [PUBMED Abstract]
   
   
6. Julien JP, Bijker N, Fentiman IS, et al.: Radiotherapy in breast-conserving treatment for ductal carcinoma in situ: first results of the EORTC randomised phase III trial 10853. EORTC Breast Cancer Cooperative Group and EORTC Radiotherapy Group. Lancet 355 (9203): 528-33, 2000.  [PUBMED Abstract]
   
   
7. Bijker N, Meijnen P, Peterse JL, et al.: Breast-conserving treatment with or without radiotherapy in ductal carcinoma-in-situ: ten-year results of European Organisation for Research and Treatment of Cancer randomized phase III trial 10853--a study by the EORTC Breast Cancer Cooperative Group and EORTC Radiotherapy Group. J Clin Oncol 24 (21): 3381-7, 2006.  [PUBMED Abstract]
   
   
8. Chan KC, Knox WF, Sinha G, et al.: Extent of excision margin width required in breast conserving surgery for ductal carcinoma in situ. Cancer 91 (1): 9-16, 2001.  [PUBMED Abstract]
   
   
9. Page DL, Lagios MD: Pathologic analysis of the National Surgical Adjuvant Breast Project (NSABP) B-17 Trial. Unanswered questions remaining unanswered considering current concepts of ductal carcinoma in situ. Cancer 75 (6): 1219-22; discussion 1223-7, 1995.  [PUBMED Abstract]
   
   
10. Fisher ER, Costantino J, Fisher B, et al.: Response - blunting the counterpoint. Cancer 75(6): 1223-1227, 1995. 
    
    
11. Holland R, Peterse JL, Millis RR, et al.: Ductal carcinoma in situ: a proposal for a new classification. Semin Diagn Pathol 11 (3): 167-80, 1994.  [PUBMED Abstract]
    
    
12. Silverstein MJ, Lagios MD, Craig PH, et al.: A prognostic index for ductal carcinoma in situ of the breast. Cancer 77 (11): 2267-74, 1996.  [PUBMED Abstract]
    
    
13. Silverstein MJ, Lagios MD, Groshen S, et al.: The influence of margin width on local control of ductal carcinoma in situ of the breast. N Engl J Med 340 (19): 1455-61, 1999.  [PUBMED Abstract]
    
    
14. Fisher B, Dignam J, Wolmark N, et al.: Tamoxifen in treatment of intraductal breast cancer: National Surgical Adjuvant Breast and Bowel Project B-24 randomised controlled trial. Lancet 353 (9169): 1993-2000, 1999.  [PUBMED Abstract]
    
    
15. Houghton J, George WD, Cuzick J, et al.: Radiotherapy and tamoxifen in women with completely excised ductal carcinoma in situ of the breast in the UK, Australia, and New Zealand: randomised controlled trial. Lancet 362 (9378): 95-102, 2003.  [PUBMED Abstract]
    
    

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Oh, good catch, 2bubbas.  That's a bit of a heated topic around here, isn't it? 

Rather than start up the debate anew, for those interested, here are links to two recent threads where this was discussed:

http://community.breastcancer.org/topic/68/conversation/641034?page=1

http://community.breastcancer.org/topic/68/conversation/696681

Hi 2bubbas:  I see what you mean by the precancerous nonsense. Your right DCIS is cancer and I really don't understand how they can say it's precancerous, I wonder do they do that to men with prostrate cancer. Just curious and now have to look it up.  Thanks for adding your point or I would never really have understood what the whole cancer, precancer conflicts were about. And Beesie thanks for the links to the other posts they really helped me "get it" I learn something new everyday on this site and I'm so grateful for all the really smart women on it. Pearl49

Oh Voo I'm sorry about your dad and your brother, thanks for letting me know that the same thing does exist with prostrate cancer. What I don't understand is why they are making him wait especially with your dads' history of cancer.  You werent' rambling, want to see rambling read some of my post they get longer and some days dumber all the time. I just sort of post what I'm thinking some days. I wish the best for your brother it must be so hard just waiting all the time. Poor guy, I'm sure he knows how we feel waiting and wondering as well.pearl49

Beesie - I've read a bunch of your posts and you are so knowledgeable!  Are you sure you're not a doctor?  I believe that you are right, the high PSA score in itself is not precancerous. 

You know, I actually don't know whether he has an enlarged prostate or ever had a biopsy.  I believe his score is 9 or something.  My dad's score was around 30, something ridiculously high like that.

So, I suppose high PSA is more akin to people who end up in that loop where you have an abnormal mammo or breast exam and they decide to do mammos on you every 3 mos.  I have a friend going through that right now. 

Hi eightblueeyes......how'd you pick that name?? That sucks that you found out only on your path report. Did you not get that info from a biopsy earlier? I know the docs don't discuss it all...I remember reading my report too and going over it with a fine tooth comb.....then I sat down with the doc to ask about anything I did not know......I knew I had high grade before he told me because I read it prior to seeing him and had my own copy of the report.

larousse - that's why they want good (negative) margins. They slice and dice the tissue to ensure that there isn't any microinvasion in the tissue outside the DCIS. The odds are with you that it was pure DCIS and that they did the pathology correctly.  The high grade coupled with the comedo & necrosis means that you really want to have the rads & tamox.

I wouldn't (and didn't) go for mastectomy with only one spot of DCIS less than one cm and wide margins.  But that's just me.

Good luck with rads.

My DCIS is multifocal but in the same area of the breast, grade 3 with comedo necrosis and after 2 lumpectomies, they did get clear margins.  My follow up with my surgeon was today and we discussed my choices as 1)mastectomy or 2)rads w/ tamox.  The rads are only to insure no recurrence in that same area of the breast.  I do have a history (mother with breast cancer) and he said it is a good idea to talk to everone (onc, radiologist, plastic surgeon) to decide what is best for me.  I have been gathering info from everywhere, including great info from this board and I am seeing the oncologist tomorrow. I think the mastectomy will end up being my choice.  At first, I thought this was too aggresive but now I think it is making sense.  I am not a gambler, and I am 50 years old.  I don't want to spend the next decade holding my breath every mammogram and this ordeal has taken a toll on my nerves.  (i was diagnosed 1/25/08, my nodes are clear)

Sharona.   

Sharona,
I see, margins, the big factor for the big decision. In your case, with family history, I would also consider the safer route. The onc I talked to today about my angst, told me that I should talk to a plastic surgeon just to get a better idea of what is involved.
Safer but not easy route from what I have gathered.

Good luck.