Ductal Carcinoma In Situ of Breast

Ductal Carcinoma In Situ of Breast

Article
Women's Health
Diseases & Conditions
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Contributed byKrish Tangella MD, MBAMar 20, 2022

What are the other Names for this Condition? (Also known as/Synonyms)

  • Intraductal Carcinoma of Breast
  • Mammary Ductal Carcinoma In Situ
  • Stage 0 Breast Cancer

What is Ductal Carcinoma In Situ of Breast? (Definition/Background Information)

  • Ductal Carcinoma In Situ (DCIS) of Breast is a non-invasive malignant breast tumor. It is also called Intraductal Carcinoma of Breast. In this condition, the malignant tumor cells are confined to the breast ducts. It is often suggested that DCIS of Breast is a precursor lesion for invasive breast cancer
  • Depending on the nuclear grade of the tumor cells when observed under the microscope by a pathologist, Ductal Carcinoma In Situ of Breast can be classified as:
    • Low nuclear-grade DCIS
    • Intermediate nuclear-grade DCIS
    • High nuclear-grade DCIS
  • A vast majority of lesions are detected radiologically, since often Ductal Carcinoma In Situ of Breast does not cause a distinct or readily observable mass (tumor) on self-examination of breast. Hence, it is important to undertake screening mammograms to examine the breasts and detect breast tumors early
  • The cause of formation of Ductal Carcinoma In Situ of Breast is not well-established. The condition is mostly observed in middle-aged and older women. In some women, the condition may be asymptomatic and remain undetected. In others, DCIS may present a palpable mass and nipple discharge
  • The treatment of Ductal Carcinoma In Situ of Breast generally involves complete removal of the tumor via breast-conserving surgery or simple mastectomy. This may be followed by either radiation therapy and/or hormone therapy based on the healthcare provider’s evaluation
  • The prognosis of Mammary Ductal Carcinoma In Situ is usually excellent with adequate surgical treatment and regular follow-up. However, in case of a recurrence or transformation to invasive carcinoma of breast, the prognosis depends on several factors and may vary from one individual to another

Who gets Ductal Carcinoma In Situ of Breast? (Age and Sex Distribution)

  • Ductal Carcinoma In Situ of Breast is seen in young, middle-aged, and older adults. Most cases are noted in women above 50 years of age
  • The mean age of individuals at the time of diagnosis is between 50-59 years; 
  • Even though males may be affected, a higher number of cases are reported in women than men
  • All racial and ethnic groups are affected, and no specific predilection is seen

What are the Risk Factors for Ductal Carcinoma In Situ of Breast? (Predisposing Factors)

The risk factors for Ductal Carcinoma In Situ of Breast is similar to invasive carcinoma of breast that include:

  • Women have a much greater chance of developing breast cancer than men
  • Advancing age: The risk increases for women over the age of 55 years
  • Family history: Women with a mother, sister, or daughter diagnosed with breast cancer have a higher risk for developing the condition
  • Inherited gene mutations: Mutations in certain genes (BRCA1 or BRCA2) can lead to a much higher risk
  • Radiation therapy: Receiving radiation therapy to the chest or breast area can also increase the risk. It is noted that the risk for developing breast cancer later in life is the greatest for radiation therapy administered during puberty
  • Obesity: Being overweight or obese elevates the risk after menopause
  • Alcohol use: Consuming alcohol more than one drink per day; the more the alcohol consumed, the greater is the risk
  • Menstrual cycle: Women who got their period before the age of 12 years, and those who reached menopause after age 55 have an increased risk
  • Postmenopausal hormone therapy: Women taking hormone replacement therapy medications containing both estrogen and progesterone for menopause have a higher risk of developing breast cancer
  • Reproductive history: Having the first child after the age of 35, or never having children
  • Physical inactivity: A lack of physical exercise (leading a sedentary life) can increase the risk
  • Breastfeeding: Not breastfeeding one's child can increase the risk for developing the condition

It is important to note that having a risk factor does not mean that one will get the condition. A risk factor increases one’s chances of getting a condition compared to an individual without the risk factors. Some risk factors are more important than others.

Also, not having a risk factor does not mean that an individual will not get the condition. It is always important to discuss the effect of risk factors with your healthcare provider.

What are the Causes of Ductal Carcinoma In Situ of Breast? (Etiology)

The exact cause of development of Ductal Carcinoma In Situ (DCIS) of Breast is currently not well understood. This pre-invasive and early stage breast cancer is also referred to as Stage 0 Breast Cancer.

Molecular studies have shown certain genetic abnormalities, although these have not been correlated with an increased risk for progression of invasive breast carcinoma or its recurrence following its surgical removal. The genetic and chromosomal abnormalities noted include:

  • Low nuclear-grade tumors often present loss of chromosome 16q and gain of chromosome 1q
  • High nuclear-grade tumors may show:
    • Chromosome material loss of 8p, 11q, 13q, and 14q
    • Chromosome material gains of 5p, 8q, 17q, and 20q
    • Amplifications of chromosomes 11q13, 17q12, and 17q22-q24
  • DCIS is also known to exhibit gene methylation that is often observed in invasive breast carcinoma

What are the Signs and Symptoms of Ductal Carcinoma In Situ of Breast?

In some individuals, no signs and symptoms of Ductal Carcinoma In Situ (DCIS) of Breast may be initially observed. In other cases, the following may be noted:

  • Presence of a palpable mass in some cases
  • Nipple discharge
  • Paget’s disease of nipple
  • The tumor can be multifocal - involving multiple foci in the same breast (several areas of breast present DCIS)
  • Most commonly DCIS is unilateral (involving one breast); rarely, it is bilateral (involving both breasts)

Approximately, 22% of women with DCIS in one breast can either develop the condition (DCIS) or invasive cancer in the other breast (contralateral breast).

How is Ductal Carcinoma In Situ of Breast Diagnosed?

Ductal Carcinoma In Situ (DCIS) of Breast may be diagnosed in the following manner:

  • Complete physical examination with comprehensive medical and family history evaluation
  • Breast exam to check for any lumps or unusual signs in the breasts
  • Blood tests including complete blood count (CBC) test
  • Mammogram: A mammogram uses X-rays to provide images of the breast. The tumor can cause radiological abnormalities on a mammogram, even though the presence of a breast lump on self-exam may not be apparent. The tumor cells may be with/without calcification on radiological studies. Hence, routine mammograms are very important. It is estimated that 1 in 1,000 screening mammograms may present Ductal Carcinoma In Situ of Breast
  • Galactography: A mammography using a contrast solution, mostly used to analyze the reason behind a nipple discharge
  • Breast ultrasound scan: Using high-frequency sound waves to produce images of the breast
  • Computerized tomography (CT) or magnetic resonance imaging (MRI) scan of the breast
  • Breast biopsy:
    • A biopsy of the tumor is performed and sent to a laboratory for a pathological examination. A pathologist examines the biopsy under a microscope. After putting together clinical findings, special studies on tissues (if needed) and with microscope findings, the pathologist arrives at a definitive diagnosis. Examination of the biopsy under a microscope by a pathologist is considered to be gold standard in arriving at a conclusive diagnosis
    • Biopsy specimens are studied initially using Hematoxylin and Eosin staining. The pathologist then decides on additional studies depending on the clinical situation
    • Sometimes, the pathologist may perform additional studies, which may include immunohistochemical stains and molecular studies to assist in the diagnosis

Biopsies are the only methods used to determine whether an abnormality is benign or cancerous. These are performed by inserting a needle into a breast mass and removing cells or tissues, for further examination. There are different types of biopsies:

  • Fine needle aspiration biopsy (FNAB) of breast mass: In this method, a very thin needle is used to remove a small amount of tissue
  • Core needle biopsy of breast mass: A wider needle is used to withdraw a small cylinder of tissue from an abnormal area of the breast
  • Open tissue biopsy of breast mass: A surgical procedure used less often than needle biopsies, it is used to remove a part or all of a breast lump for analysis

The different types of DCIS of Breast that may be observed by a pathologist under the microscope may include:

  • Apocrine ductal carcinoma in situ
  • Neuroendocrine ductal carcinoma in situ
  • Signet-ring ductal carcinoma in situ
  • Clear cell ductal carcinoma in situ
  • Squamous cell type ductal carcinoma in situ (very rare)

The differential diagnosis to exclude conditions with similar presentations include:

  • Atypical ductal hyperplasia of breast
  • Florid usual ductal hyperplasia of breast
  • Invasive cribriform carcinoma of breast
  • Usual ductal hyperplasia of breast

Many clinical conditions may have similar signs and symptoms. Your healthcare provider may perform additional tests to rule out other clinical conditions to arrive at a definitive diagnosis.

What are the possible Complications of Ductal Carcinoma In Situ of Breast?

The complications of Ductal Carcinoma In Situ of Breast may include:

  • Emotional stress due to the presence of a premalignant condition
  • Increased risk for the development of invasive breast carcinoma
  • Recurrences following surgery may be observed (recurrent ductal carcinoma in situ)
  • Side effects of treatment

How is Ductal Carcinoma In Situ of Breast Treated?

Surgery is the most common form of treatment recommended for Ductal Carcinoma In Situ (DCIS) of Breast, and it that involves a complete excision of the tumor. The surgery may be of the following types:

  • Lumpectomy or breast-conserving surgery (BCS): It is a least invasive breast cancer surgery in which the tumor along-with a small portion of the surrounding tissue is removed; as much normal breast as possible is retained. BCS is the preferred procedure for individuals with early-stage breast cancers such as DCIS
  • Simple mastectomy: Surgery to remove all of the breast tissue is considered for large DCIS or when it has extensively involved the breast. This may involve a removal of the breast, nipple, areola, and sentinel lymph nodes (lymph nodes closest to the tumor)

Surgery may be followed by other treatment modalities based on the healthcare provider’s evaluation.

  • Radiation therapy is usually considered following invasive procedures to remove DCIS to mainly decrease the risk for recurrence of the tumor. In some cases, radiotherapy may not be administered for women undergoing mastectomies
  • Hormone therapy may include treatment with tamoxifen or exemestane/anastrozole (aromatase inhibitors administered for postmenopausal women). Typically, hormone therapy is given for women with hormone receptor-positive DCIS

How can Ductal Carcinoma In Situ of Breast be Prevented?

Currently, no specific preventive measures are available for Ductal Carcinoma In Situ of Breast. In general, it is important to be aware of the following:

  • Learning to do regular ‘breast self-exams’ in order to help identify any unusual lumps or signs in the breast
  • Maintain a healthy body weight and exercise regularly
  • Implement and follow a well-balanced diet; a high intake of fiber via fresh fruits and vegetables helps in a healthy lifestyle
  • Avoid or completely stop smoking
  • If taking alcohol, only drink in moderation; limit to one or (maximum) two drinks a day
  • Limit combination hormone therapy used to treat symptoms of menopause. It is advised that individuals be aware of the potential benefits and risks of such hormonal medications
  • Cancer screenings can help detect any breast cancer during the early stages

What is the Prognosis of Ductal Carcinoma In Situ of Breast? (Outcomes/Resolutions)

  • The prognosis is Ductal Carcinoma In Situ of Breast is generally excellent with early treatment (surgery) in a vast majority of cases. In some cases, DCIS may recur and hence it is important to remain vigilant and hold periodic follow-up screenings
  • In case of a late diagnosis of the condition, the risk for progression of DCIS to invasive breast carcinoma is high. In such cases, the overall prognosis depends on the stage of the tumor, among other factors

Additional and Relevant Useful Information for Ductal Carcinoma In Situ of Breast:

The following DoveMed website links are useful resources for additional information:

https://www.dovemed.com/healthy-living/womens-health/

https://www.dovemed.com/diseases-conditions/cancer/

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Krish Tangella MD, MBA picture
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Krish Tangella MD, MBA

Pathology, Medical Editorial Board, DoveMed Team

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