Treatment of breast cancer in situ. Ductal breast cancer in situ

Treatment of ductal carcinoma in situ must be extremely thorough: despite the apparent “innocence” of this tumor, we must not forget that it is prone to recurrence, and in an invasive form. At the Top Ichilov Clinic, ductal breast cancer is treated by experienced specialists who use all their knowledge and skills to not give the tumor the slightest chance.

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(ductal carcinoma DCIS) is the most common form of non-invasive breast cancer. Many doctors claim that ductal carcinoma in situ is safe for women because the tumor does not spread to healthy breast tissue. Israeli experts do not agree with such a statement. Firstly, carcinoma in situ can develop into an invasive form, and secondly, ineffectively treated ductal cancer increases the risk of developing a relapse of the disease, but in its aggressive form. Specialists at the Israeli clinic Top Ichilov have been effectively treating DCIS for many years. Complex treatment and an individual approach to each patient are the key to a low percentage of breast cancer recurrences in patients at Top Ikhilov MC.

Treatment of ductal breast cancer in Israel

is often called precancer, so being treated by an incompetent doctor who does not know about the high risk of relapse of the disease and believes that the tumor can simply be removed and forgotten about is deadly. In Israel, at the Top Ichilov MC, doctors exclusively practice complex therapy aimed at completely removing all cancer cells and reducing the risk of tumor re-development in the future. Complex treatment consists of the following procedures:

Surgical excision of the tumor - lumpectomy. The clinic’s surgeons adhere to international standards for performing this operation: the edges of the tumor removed from the gland must be “clean,” that is, free of cancer cells. Thus, by capturing a certain amount of healthy tissue, doctors prevent cancer cells from “hiding” in the gland and starting to develop.
Radiation therapy. According to Israeli doctors, postoperative radiation therapy must be carried out without fail, because irradiation of the body allows you to destroy atypical cells if they suddenly remain after the operation.
Hormonal therapy. It is carried out if DCIS is a hormonal-dependent tumor.

This approach to the treatment of patients with ductal breast cancer is considered the most optimal today and is practiced in medically developed countries such as Israel, Germany, and the USA.

Diagnosis of ductal carcinoma in situ

Diagnosis of ductal breast cancer in Israel is carried out using highly informative and at the same time painless and atraumatic methods for the patient. At the Top Ichilov Clinic, the following diagnostic program is used to confirm the diagnosis of “ductal carcinoma in situ”:

Mammography, in which, in the case of ductal breast cancer, the doctor identifies microcalcifications on the mammogram.
Fine needle aspiration biopsy. A small amount of tissue is “pumped out” from the thickness of the mammary gland using a syringe with a thin needle. After such an intervention, the patient does not even have a small scar.
Core needle biopsy. A larger diameter needle is inserted through a small incision in the skin of the gland and more tissue is taken. The small scar after the needle is inserted disappears in just a couple of weeks.

Cost of the operation

The exact price can only be announced after all necessary procedures have been determined.

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Before deciding which treatment is right for you, your doctor should find out some details about the course of your cancer. Treatment for ductal cancer depends on the following factors:

Prevalence of ductal carcinoma

The prevalence of ductal carcinoma in situ is determined using diagnostic methods such as mammography, ultrasound and MRI. At the same time, microcalcifications can also be found around the tumor.

Damage area

How many areas are affected by cancer and how close are they to each other?

unifocal cancer – cancer affects one area in one quadrant,
multifocal cancer – cancer affects several areas in one quadrant,
multicentric cancer – cancer spreads in more than one quadrant.

If the cancer affects more than one area of the breast, the doctor will find out:

whether only one quadrant is affected (multifocal cancer),
whether multiple quadrants are affected (multicentric cancer),
distance between affected areas.

Careful examination is necessary before surgery to determine the exact extent of tumor spread. This is also important after surgery to ensure that the tumor is completely removed.

Tumor size

The extent of ductal carcinoma is also determined by the size of the tumor, which is calculated by the pathologist. Knowing the size of the tumor helps the doctor choose the best treatment option. The removed portion of the breast sent for examination by a pathologist is called a specimen. Typically, the test results will indicate the size of this sample, and sometimes the size of the tumor may also be indicated.

In the case of re-excision - repeated removal of areas suspicious for cancer after the primary operation, if ductal cancer is again discovered:

the sizes of tumors add up if the affected areas are nearby,
if the affected areas are separated from each other, the dimensions are given separately (this is multifocal or multicentric cancer).

The final tumor size is estimated when:

all ductal cancer was removed,
the edges of the excised tissue are “clean”,
Mammography no longer reveals the area of pathology.

Tumor size in ductal cancer is not related to the stage of the cancer, unlike in invasive cancer, where tumor size and stage are related. Ductal cancer always means stage 0 cancer, but it can occur in different sizes and in different areas of the breast.

The size and extent of ductal carcinoma influences the choice of treatment. for example, for a small tumor, an organ-sparing operation is performed - lumpectomy. A large tumor size for ductal cancer is a reason to use a mastectomy.

The nature of the resection margins

The nature of the edges of the excised tumor also provides information about the extent of ductal cancer. If the edges of the excised tumor contain cancer cells or these edges are very close to the tumor, then repeated excision is usually performed. Different medical centers may have different standards regarding the “cleanliness” of tumor margins. but generally 2mm is considered the minimum acceptable distance. The greater the distance from the tumor to the edges of the excised tissue, the lower the risk of developing cancer.

Radiation research methods after biopsy

If ductal cancer was detected in the area of grouped microcalcifications, then usually after 2 weeks of surgery a mammography of the area of the affected breast is performed. this is done to ensure that microcalcifications have disappeared.

If you think that having a mammogram at this time will be painful for you (because it requires compression of the breast), you can ask your doctor for pain medication.

If examination of the excised tumor reveals a significant area of lesion with positive excision margins, more mammograms may reveal the area of lesion in the breast. Sometimes MRI is also used for this.

If new pathological foci are not identified, then repeated excision is performed. If there are several suspicious areas with pathological lesions, and you still want to preserve the breast if possible, then the doctor will evaluate these newly identified lesions. But it is important to understand that if ductal cancer is widespread, the margins of the excised tumor are positive (when cancer cells are detected), and a suspicious lesion is detected on mammography after surgery, the doctor is usually inclined to perform a mastectomy.

Bloody discharge from the nipple

The presence of bloody discharge from the nipple may indicate that there is cancer in the main milk ducts. An examination such as MRI helps to identify the presence of other areas affected by ductal carcinoma, and whether they are fused together or separated from each other. If in this case there is extensive spread of ductal carcinoma into the main milk ducts, mastectomy is usually the method of choice. However, if ductal cancer is found only in one area of the breast, and bloody discharge occurs from this area, then organ-sparing surgery - lumpectomy - is possible.

Carcinoma in situ is the most common type of non-invasive breast cancer. The detection rate of this disease is 20-40% of all detected cases of breast cancer. The prognosis of this disease is good; non-invasive breast cancer is not life-threatening for a woman and, in some sources, is even called precancer.

Non-invasive carcinoma is called because this form of cancer does not spread beyond its location - the ducts or lobules of the mammary gland. Designation in situ translated as “in its place.” A woman's breasts are made up of lobules (glands that produce milk), milk ducts, and connective tissue. Carcinoma can be located in the ducts of the mammary gland or in the lobules.

How can non-invasive carcinoma be detected?

Mammography reveals nodules (microcalcifications) resulting from the deposition of calcium salts. After removal of carcinoma, a quarter of women develop invasive cancer in the same breast.

Can non-invasive cancer become invasive and, therefore, life-threatening for the patient?

No, but invasive cancer can develop in the same gland (in women who have had precancer, this probability increases greatly and amounts to 25-35%). 80% of invasive malignant tumors were initially ductal and about 10% lobular.

How to treat non-invasive cancer?

Mastectomy- removal of the mammary gland in which a malignant tumor develops is an almost 100% guarantee of cure for the disease.

However, for non-invasive cancer, the purpose of this operation is controversial. Even with invasive forms of carcinoma, surgeons suggest prescribing organ-preserving treatment.

However, there are absolute indications for mastectomy:

Large tumor size (more than 5 cm)
Multiple foci of carcinomas
Contraindications to radiation therapy

Are axillary lymph nodes removed for breast carcinoma? No, lymphadenectomy is usually not performed in patients with ductal carcinoma, since metastasis to the lymph nodes is unusual for this form of the disease.

Radiation therapy, like mastectomy, is an overtreatment for 40% of patients with precancer. Therefore, each individual case should be carefully studied in order to prescribe individually appropriate therapy.

Showed good results treatment with hormonal drugs. Hormone therapy significantly reduces the likelihood of relapses in the same mammary gland.

Is it worth seeing a mammologist after removal of breast carcinoma in situ?

Obligatory observation by a mammologist throughout your life. This category of patients should undergo mammography annually, and every 6 months for the first 2 years after treatment. You need to visit a mammologist once every six months.

Ductal carcinoma in situ is a precancerous lesion of the breast (obligate or nonobligate) with a relative risk of developing into invasive cancer of 8-11 points. Only 10% of ductal breast carcinomas in situ are associated with some clinical findings.

Ductal breast cancer in situ - this form of intraductal proliferation is characterized by increased proliferative properties and cellular atypia, as well as a tendency, although not always obligate, to progress to invasive cancer.

Mammographic diagnosis is based mainly on the presence of microcalcifications.

There are several classifications of ductal carcinomas in situ, based on the use of the nuclear structure of proliferating cells, the severity of necrosis and microcalcifications in the breast tumor, and cellular polarization. Currently, it is customary to distinguish 3 degrees of ductal carcinoma in situ, depending, first of all, on the degree of nuclear atypia and the presence and extent of intraductal necrosis and, secondly, on mitotic activity and the presence of calcifications.

Calcifications associated with differentiated variants of ductal carcinoma in situ are usually lamellar, crystalline, and resemble psammoma bodies. Calcifications associated with poorly differentiated cancer in situ, amorphous type, are formed in areas of necrosis of tumor cells. On mammograms they appear as homogeneous lines, often branching, or coarse granular clusters.

Highly differentiated variant of ductal breast cancer in situ

Low grade - a highly differentiated variant of ductal breast cancer in situ. It consists of small monomorphic cells growing inside the duct in the form of arcades, micropapillary, cribriform and solid structures. The cell nuclei are the same size, have “regular” chromatin and an inconspicuous nucleolus. Mitotic figures are rare. Microcalcifications are usually of the psammoma type.

Descended cells may occur within the ductal lumens, but the presence of necrosis and comedo foci in the structures of low-grade ductal carcinoma in situ is not malignant.

Low-grade ductal carcinoma in situ with micropapillary structures is more often associated with multicentric breast disease than other forms.

Intermediate degree of differentiation of ductal breast cancer in situ

Cellular characteristics in most cases are similar to the low-grade variant, the cells also form micropapillary, cribriform and solid structures, but some ducts contain intraductal necrosis.

This option also includes breast tumors with an intermediate degree of nuclear atypia, i.e. with protruding nucleoli and coarse chromatin in the nuclei, necrosis may or may not be present. Microcalcifications are amorphous or lamellar, similar to those found in both low- and high-grade variants of ductal carcinoma in situ.

High grade - poorly differentiated variant of ductal breast cancer in situ

The formation may be more than 5 mm in diameter. It consists of typical morphological structures of intraductal cancer, but is distinguished by a high degree of atypia of proliferating cells. Cells can lie in one line, lining the inner surface of the duct, and form micropapillary, cribriform or solid structures. Cell nuclei are polymorphic, weakly polarized, with irregular contours, rough lumpy chromatin and protruding nucleoli. Mitoses are common, although their presence is not required for diagnosis. There are amorphous microcalcifications. The presence of comedonecrosis is characteristic - abundant necrotic masses surrounded by solid proliferations of large polymorphic cells. However, the presence of necrosis is also not essential for diagnosing a highly malignant variant. The degree of nuclear polymorphism of the cells plays a decisive role, and even a simple layer of sharply anaplastic cells lining the duct gives grounds for the diagnosis of “ductal breast cancer in situ, high grade.”

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Ductal breast cancer in situ- ductal carcinoma in situ, DCIS. - a common form of non-invasive breast cancer. The risk of developing ductal carcinoma in situ in women is the same as the risk of developing invasive cancer. Risk factors for the development of ductal cancer: absence of pregnancy in a woman, late pregnancy (after 30 years), early onset of menstruation, late onset of menopause, hereditary factor - a case of breast cancer in first-degree relatives (mother, sisters, daughter), long period ( more than 5 years) of hormone replacement therapy, especially with combined therapy with estrogens and progesterones, the presence of abnormal genes responsible for the development of breast cancer (BRCA1 or BRCA2).

Diagnosis of ductal breast cancer in situ

Diagnosis ductal breast cancer in situ not dangerous to a woman's life. This is a non-invasive form of cancer and represents its earliest stage - stage 0, which is sometimes even called “pre-cancer”. Yes, this is cancer, this is uncontrolled cell growth, but this growth is observed only in the lumen of the milk ducts and does not go beyond them. Although this form of cancer is non-invasive, there is always a risk that it will later develop into invasive cancer - that is, one that spreads to normal breast tissue. From 25 to 50% of women who undergo surgical treatment (without radiation therapy) for ductal carcinoma in situ have a chance of developing invasive breast cancer in the future.

In most cases, these recurrences occur 5 to 10 years after the diagnosis of ductal carcinoma in situ. However, new breast cancer can develop even later - after 25 years! It usually occurs in the same location where the ductal carcinoma in situ was. This new cancer can be either non-invasive or invasive. Therefore, the main goal of treatment for ductal carcinoma in situ is to reduce the risk of developing cancer in the future. There are three grades of ductal carcinoma in situ:

Low degree
Average degree
High degree.

Low to moderate differentiation means that the cells of ductal carcinoma in situ are very similar to normal breast duct cells or similar to atypical ductal hyperplasia. The average degree of differentiation is sometimes referred to as moderate. These two grades differ in their tendency to have low cell growth rates.

Women with low- or moderate-grade ductal carcinoma in situ have a higher risk of developing invasive breast cancer in the future (after 5 years) compared with women without ductal carcinoma in situ. But compared with women with high-grade ductal carcinoma in situ, they are the first to have a much lower risk of developing new cancer or its recurrence.

A low degree of differentiation can be manifested by several types of structures:

Solid (solid) structure - cancer cells completely fill the lumen of the milk duct.
Lattice structure - there are gaps between clusters of cancer cells (like holes in Swiss cheese). ◦Papillary structure - the cells in the duct are arranged like a fern leaf.

High grade - High grade ductal carcinoma in situ is characterized by rapid cell growth. Women with high-grade ductal carcinoma in situ have a very high risk of developing invasive breast cancer, either at the time of discovery of ductal carcinoma in situ or in the future. in addition, such patients have an increased risk of early tumor recurrence (within 5 years). Sometimes high-grade ductal carcinoma in situ is called a comedo because of its appearance. They are dead cancer cells that form inside the tumor. The reason for this is the rapid growth of the tumor, as a result of which some cells do not receive enough nutrients.

Diagnosis of ductal carcinoma in situ

Typically, ductal breast cancer in situ does not manifest itself in any way and is not detected during physical examination. However, a small number of women may experience a tumor-like formation or some discharge from the nipple. Most often, ductal carcinoma in situ is detected on mammography. The fact is that “old” cancer cells, dying, do not have time to be completely utilized. As a result, this area is saturated with calcium salts (so-called calcification) - microcalcifications are formed. These microcalcifications are precisely what are detected on a mammogram.

If the doctor considers the mammography results to be suspicious for cancer, the next stage of diagnosis is performed - a biopsy. For ductal carcinoma in situ, two minimally invasive biopsies are performed (more invasive methods are not performed for ductal carcinoma in situ):

Fine-needle aspiration biopsy - in this case, a thin long needle is inserted into the thickness of the breast tissue suspicious for cancer and a syringe is used to “pump out” (aspiration) a small amount of tissue. After this procedure there are no scars left.
Core needle biopsy - this involves inserting a larger diameter needle and removing more tissue from suspicious areas. Before inserting a thick needle, a small incision is usually made on the breast code. Of course, it leaves a small scar, which is practically invisible after a few weeks.

Once tissue samples are obtained, they are examined under a microscope. Typically, the amount of tissue taken from a biopsy is sufficient to test for hormone receptors or determine HER2 status. The biopsy procedure is performed for diagnostic purposes and not to remove cancer. This requires a larger volume of surgical intervention.

Surgical treatment of ductal breast cancer in situ

The most common treatment for ductal carcinoma in situ is to perform a lumpectomy - removal of the breast tumor, followed by a course of radiation therapy.

Lumpectomy - partial removal of the mammary gland for ductal cancer

Other treatments may be used, such as lumpectomy without radiation or mastectomy, which may be either insufficient or too aggressive. Everything, of course, depends on individual characteristics. Common surgical procedures for ductal carcinoma in situ include:

Lumpectomy refers to breast-conserving surgery and involves removing the entire area of ductal carcinoma in situ in the breast. Even if cancer cells are found in this area, but there is no tumor, the entire area where they are found is removed.
Repeated resection (excision) - this type of surgery is used when, after a lumpectomy, cancer cells are found in the edges of the excised tissue.

In some cases, ductal breast cancer in situ can only be detected by mammography or ultrasound, but cannot be felt. In such cases, the tumor is “localized” before surgery. To do this, under X-ray or ultrasound control, a needle is inserted into the suspicious area, through which the tissue is excised. Sometimes MRI may be required for such localization.

Mastectomy - complete removal of the mammary gland for ductal cancer

When the mammary gland is completely removed, a mastectomy is performed. Mastectomy is recommended if:

large ductal carcinoma,
in case of a strong family predisposition to breast cancer,
in case of detection of abnormal genes responsible for the occurrence of breast cancer.

In these cases, mastectomy is used, which reduces the risk of developing invasive breast cancer in the future. Whether breast-conserving surgery is possible in your case depends on factors such as the size of the ductal carcinoma in situ, how many areas of the breast are affected by ductal carcinoma in situ, as well as the “cleanliness” of the excision margins.

If you have multiple areas of the breast affected by ductal carcinoma in situ, some doctors automatically recommend a mastectomy. The reason for this is that there are no studies yet that would confirm in such cases the same effectiveness of breast-conserving surgery as mastectomy. The fact is that such studies are not so easy to conduct. It is impossible to take a group of patients with a similar situation, and offer half of them breast-conserving surgery, and the other half - complete removal of the mammary gland, and then compare the results.

However, if ductal carcinoma in situ is detected in several areas of the breast, this does not mean that there is only one option - mastectomy. If you really want to keep your breasts, you need to talk to your doctor. When breast-conserving surgery may be better than mastectomy:

A woman was found to have two small ductal carcinomas in situ, which are located very close to each other in one of the areas of the breast, and were removed with “clean” edges. In this case, it is possible to use organ-preserving surgery - lumpectomy followed by radiation therapy. A mammogram after surgery can confirm that the area of cancer has been completely removed.
A woman has two small ductal carcinomas in situ in different areas of the breast, with no other features (based on high-quality mammography and MRI). In this case, organ-preserving surgery can also be used. This involves two lumpectomies, and sometimes the tissue may need to be excised again. A mammogram after surgery can confirm that the area of cancer has been completely removed. After the operation, a course of radiation therapy is carried out, with only complete irradiation of the breast.

When the choice is not so obvious and further evaluation of the choice of operation is required:

Ductal carcinoma in situ is small in size, but there are many positive excision margins (that is, detection of cancer cells in the margins). In this case, the edges are re-excised. If the edges of the excised tissue are still not “clean” (positive), then another re-excision is performed.
Ductal carcinoma in situ is moderate in size and has many positive excision margins after lumpectomy or re-excision. In this case, further research is necessary before deciding which type of surgery is right for you in this situation.

When mastectomy may be better than breast-conserving surgery:

Ductal carcinoma in situ affects the entire breast or occupies a large area or several areas of the breast.
A woman has an abnormal gene responsible for breast cancer (BRCA1 or BRCA2) with concomitant ductal carcinoma in situ. In this case, even if the tumor is small, the operation of choice is a mastectomy.
Pathological examination reveals ductal carcinoma in situ, occupying a large area of the breast, as well as positive margins of excised tissue, even though mammography reveals only a medium-sized tumor. In addition, mammography may reveal microcalcifications throughout the breast tissue.
MRI reveals a large area of lesion extending beyond the ductal carcinoma in situ, which was identified on biopsy. This means that before the MRI, a dye was injected into the veins and accumulated in a certain area.
Using biopsy and radiation diagnostic methods, pathological areas of the mammary gland were identified.
A woman had medium to large tissue removed and was found to have high-grade ductal carcinoma in situ.
The woman had medium to large tissue removed with many positive excision margins. in such a situation, repeated excisions are unrealistic.

In all of these situations, as you can see, ductal carcinoma in situ occupied a fairly large part of the breast. Therefore, removal of the entire area is necessary to ensure that all ductal carcinoma in situ is removed. However, simply removing this area leaves a woman with very little breast tissue. In this case, a mastectomy significantly increases the chance that the tumor will be completely removed. And reconstructive surgery after a mastectomy can return a woman to the shape of her breasts. By the way, there are women who, after a mastectomy, do not even want reconstructive surgery. The addition of antiestrogen and radiation therapy to the treatment of ductal carcinoma in situ may slightly improve the outcome of surgical treatment.

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