Ductal Carcinoma in Situ of the Breast

This book provides up-to-date information on all aspects of ductal carcinoma in situ of the breast, including epidemiology, imaging, pathologic and biologic features, interventional diagnostics, nonpalpable lesion localization, and treatment. Surgical procedures are described in detail, covering breast conservation techniques, conservative mastectomies, breast reconstruction options, and axillary surgery. Guidance is provided on how to ensure adequacy of surgical excision and avoid local recurrence when performing breast conservation surgery and how to minimize morbidity from axillary surgery. The role and techniques of partial and whole breast irradiation are described, and the use of adjuvant systemic therapy options, including endocrine therapy and chemotherapy, is explained. A concluding chapter addresses the issue of recurrence and its current management. This book, designed for ease of consultation, will be of value for all involved in the multidisciplinary care of patients with ductal carcinoma in situ of the breast, including surgeons, medical oncologists, pathologists, radiologists, and radiotherapists. Foreword 5 Contents 6 Contributors 8 1: History of the DCIS of the Breast and the Evolution of Knowledge Based on Ductal Tree Anatomy 10 1.1 Foreword: The Need for a Conceptual Map 10 1.1.1 The Space 11 1.1.2 The Time 12 1.2 Natural History: Where Are We? 13 1.2.1 A Factual Synopsis of the Carcinogenesis Process 13 1.2.2 Outcome of DCIS Lesions 16 1.2.3 What We Know About Natural History 17 1.3 Space: A Revisited Anatomy 20 1.3.1 Understanding the Misunderstood Subgross Anatomy 20 1.3.2 The Sick Lobe Theory (SLT) 23 1.3.3 Centricity and Focality May Be Elusive Models 25 1.4 Time: From Stop-Motion to Movie 27 1.4.1 Time(s) Can Change 27 1.4.2 Timing of Multifocality/Multicentricity 28 References 31 2: Epidemiology and Risk Factors 32 2.1 Introduction 32 2.2 Epidemiology 33 2.3 Risk Factors 36 2.3.1 Family History 36 2.3.2 Age 37 2.3.3 Genetic Risk Assessment 37 2.3.4 Ethnicity 38 2.3.5 Reproductive Factors 39 2.3.6 Hormone Replacement Therapy 39 2.3.7 Dietary and Metabolic Factors 39 2.3.8 Drugs 40 2.3.9 Density of Breast Tissue 40 2.3.10 Subsequent Breast Cancer 40 References 41 3: DCIS Imaging 47 3.1 Introduction 47 3.2 Mammographic Appearances of DCIS 48 3.3 MR Imaging Appearances of DCIS 53 3.3.1 Morphologic Features of DCIS 54 3.3.2 Kinetic Characteristics of DCIS 57 3.4 US Appearance of DCIS 57 3.4.1 Calcified DCIS 58 3.4.2 Noncalcified DCIS 59 3.4.3 DCIS Diagnosed at MR Imaging: Directed (Second-Look) US 61 References 62 4: Interventional Diagnostic in DCIS 65 4.1 Introduction 65 4.2 Percutaneous Cytology 66 4.2.1 Collection Technique 67 4.2.2 Cytological Diagnostic Conclusions 68 4.2.3 Indications 68 4.3 Percutaneous Biopsy 69 4.3.1 Preliminary Evaluation 71 4.3.2 US Breast Biopsy 71 4.3.3 Stereotactic Breast Biopsy 72 4.3.4 Procedure 73 4.3.5 Extractions Systems 73 4.3.6 Instruments 75 4.3.7 Magnetic Resonance-Guided Breast Biopsy 78 4.3.8 Sample Handling for the Pathologist 79 4.3.9 Medical Reporting 80 References 80 5: DCIS: Pathology and Biological Features 82 5.1 Pathological Definition of DCIS 82 5.2 Histological Classification 82 5.3 DCIS Carcinogenesis and Progression 85 5.4 The Concept of “DIN” 88 5.5 Pathological Prognostic Markers 88 5.6 Molecular Assessment of DCIS and Future Approaches 91 References 92 6: Non-palpable Lesions Localization in DCIS 97 6.1 Introduction 97 6.2 Wire-Guided Localization Technique 98 6.2.1 Indications 98 6.2.2 Description of the Surgical Procedure 99 6.3 ROLL Technique 101 6.3.1 Indications 102 6.3.2 Description of the Surgical Procedure 102 6.4 Alternative Methods of Localization 104 6.4.1 Radioactive-Seed Localization 104 6.4.2 Ultrasound-Guided Surgery 105 6.5 Discussion 106 References 108 7: The Surgical Treatment of DCIS: from Local Excision to Conservative Breast Surgery and Conservative Mastectomies 112 7.1 The Evolution of Surgical Treatment for DCIS: From Silverstein to Current Guidelines 112 7.2 Choice of the Operation 113 7.2.1 Anamnesis 113 7.2.2 Physical Examination 114 7.2.3 Radiology 115 7.2.4 Core Biopsy 116 7.3 The Problem of Intraoperative Identification 116 7.3.1 Non-palpable Lesion Localization 116 7.3.2 Intraoperative Margin Definition 116 7.4 The Surgical Techniques 118 7.4.1 Conservative Surgery 119 7.4.1.1 Lumpectomy 119 7.4.1.2 Traditional Quadrantectomy 119 7.4.1.3 Oncoplastic Surgery 119 Inferior Pedicle Mammoplasty (IPM) 122 Superior Pedicle Mammoplasty with Inverted T Scar 122 V-Mammoplasty 122 J-Mammoplasty 126 Horizontal Mammoplasty or Batwing Mastopexy 126 EMI-Batwing Mastopexy 126 Lateral Mammoplasty or Racquet Technique 126 Grisotti Flap 131 Round-Block Technique by Benelli 131 7.4.1.4 BCS and Substitution with Autologous Tissue 135 7.4.2 Mastectomy 135 7.4.2.1 Radical Mastectomies 136 7.4.2.2 Conservative Mastectomies 136 Nipple-Sparing Mastectomy (NSM) 136 Skin-Sparing Mastectomy (SSM) 143 Skin-Reducing Mastectomy (SRM) 143 References 145 8: Surgical Treatment of DCIS: Breast Reconstruction 148 8.1 Breast Remodeling 149 8.2 Free Dermal Fat Graft 149 8.3 Implant-Based Reconstruction 150 8.4 Autologous Tissue Reconstruction 154 8.5 Nipple-Areola Complex Reconstruction 156 8.6 Contralateral Breast Management 157 8.7 Lipofilling 158 8.8 Reconstruction and Radiation Therapy 159 8.9 Immediate Versus Delayed Reconstruction 159 References 160 9: Sentinel Node Biopsy in Ductal Carcinoma In Situ of the Breast 162 9.1 Introduction 162 9.2 From Certainties to Uncertainties 163 9.3 High-Risk DCIS: When SLNB Could Be Considered 164 9.4 The Presence of Cancer Cells in the SLN of DCIS Patients Is a Debated Issue with a Still Unclear Significance 165 9.5 Review of the Main Studies on the Role of SLNB in DCIS 166 9.6 The Influence of Other Factors: Volume of Procedures and Expertise 168 9.7 An Overview on the Main International Guidelines 169 9.7.1 American College of Radiology 2015 [51] 169 9.7.2 ASCO Clinical Practice Guideline Update 2014 [52–53] 169 9.7.3 NABON 2012 Version 2.0 (Dutch Breast Cancer Guidelines) [54] 169 9.7.4 NICE 2009 [55] 170 9.8 Is SLNB Not Associated to Morbidities? 170 9.9 A New Way of Looking at the Problem 171 References 172 10: Breast Irradiation in DCIS 176 10.1 Introduction 176 10.2 Prognostic Factors 179 10.3 Identification of Patients at Low Risk of Recurrence 181 10.4 Volumes, Doses, and Fractionation 184 References 186 11: Adjuvant Systemic Therapy in DCIS 189 References 195 12: DCIS: The Problem of Recurrence 196 References 202 13: Counseling a Woman with DCIS 205 13.1 Overview 205 13.2 A Radiological Finding 208 13.2.1 The Need of Additional Investigations 208 13.2.2 The Length of Delay 208 13.3 A Proven Diagnosis of DCIS 209 References 212 Index 213 Front Matter ....Pages i-x History of the DCIS of the Breast and the Evolution of Knowledge Based on Ductal Tree Anatomy (Alfonso M. Pluchinotta)....Pages 1-22 Epidemiology and Risk Factors (Paolo Luffarelli, Elena Manna, Lucio Fortunato)....Pages 23-37 DCIS Imaging (Gian Marco Giuseppetti, Francesca Boria, Silvia Baldassarre)....Pages 39-56 Interventional Diagnostic in DCIS (Carlo Mariotti, Eugenia Raffaeli, Enrico Lenti, Marco Gentili, Silvia Baldassarre, Gian Marco Giuseppetti)....Pages 57-73 DCIS: Pathology and Biological Features (Isabella Castellano, Jasna Metović, Riccardo Bussone, Gretha Grilz)....Pages 75-89 Non-palpable Lesions Localization in DCIS (Christian Rizzetto, Luca Seriau, Paolo Burelli)....Pages 91-105 The Surgical Treatment of DCIS: from Local Excision to Conservative Breast Surgery and Conservative Mastectomies (Carlo Mariotti, Eugenia Raffaeli)....Pages 107-142 Surgical Treatment of DCIS: Breast Reconstruction (Carla Cedolini, Serena Bertozzi, Ambrogio Pietro Londero, Pier Camillo Parodi)....Pages 143-156 Sentinel Node Biopsy in Ductal Carcinoma In Situ of the Breast (Matteo Ghilli, Manuela Roncella)....Pages 157-170 Breast Irradiation in DCIS (Francesca Cucciarelli)....Pages 171-183 Adjuvant Systemic Therapy in DCIS (Mirco Pistelli, Rossana Berardi)....Pages 185-191 DCIS: The Problem of Recurrence (Federico Buggi, Annalisa Curcio, Matteo Mingozzi, Daniele Vecchio, Francesco Marongiu, Dario Lelli et al.)....Pages 193-201 Counseling a Woman with DCIS (Alfonso M. Pluchinotta, Xenia Raspanti)....Pages 203-210 Back Matter ....Pages 211-216 Providing up-to-date information on all aspects of ductal carcinoma in situ, this book includes epidemiology, imaging, pathologic and biologic features, interventional diagnostics, nonpalpable lesion localization, and treatment. Surgical procedures and recurrence management are among the topics covered. The book is designed for ease of consultation.