What is the recommended treatment for a patient with high-grade ductal carcinoma in situ (DCIS) with a maximal dimension of 3 mm, nuclear grade 3, estrogen receptor (ER) negative, and progesterone receptor (PR) negative, with microcalcifications and necrosis?

From the Guidelines

For a patient with high-grade ductal carcinoma in situ (DCIS) with a maximal dimension of 3 mm, nuclear grade 3, ER/PR negative status, and presence of microcalcifications and necrosis, the recommended treatment is breast-conserving surgery (lumpectomy) with clear margins followed by whole breast radiation therapy. Despite the small size (3 mm), the high nuclear grade, hormone receptor negativity, and presence of necrosis are high-risk features that warrant adjuvant radiation to reduce recurrence risk 1. The presence of chronic inflammation, mild, does not significantly alter the treatment approach in this case. Sentinel lymph node biopsy is not routinely recommended for pure DCIS since the risk of nodal involvement is very low 1. Given the ER/PR negative status, endocrine therapy (such as tamoxifen or aromatase inhibitors) would not be beneficial in this case. Close surveillance after treatment is important, including regular clinical breast exams and annual mammography. The rationale for radiation after lumpectomy is that it significantly reduces the risk of both invasive and non-invasive ipsilateral breast recurrences by approximately 50% 1. The high-grade features and hormone receptor negativity indicate a more aggressive biology that benefits from the addition of radiation, even with this small lesion size. Some studies suggest that a margin width of at least 2 mm is adequate for DCIS treated with radiation therapy 1, but the most recent guidelines recommend considering boost in cases with larger areas of DCIS or other factors associated with increased risk of recurrence, including margins <2 mm and the presence of comedonecrosis 1. In this case, given the high-grade features and presence of necrosis, a margin width of at least 2 mm and consideration of a radiation boost would be recommended. Overall, the treatment approach should be individualized based on the patient's specific characteristics and preferences, with a focus on minimizing recurrence risk while maintaining quality of life.

From the Research

Treatment Options for Ductal Carcinoma In Situ (DCIS)

The recommended treatment for a patient with high-grade ductal carcinoma in situ (DCIS) with a maximal dimension of 3 mm, nuclear grade 3, estrogen receptor (ER) negative, and progesterone receptor (PR) negative, with microcalcifications and necrosis, depends on several factors.

• Treatment options include mastectomy, wide-excision breast-conserving surgery (BCS) plus radiotherapy, or BCS alone 2.
• Mastectomy is indicated when lesions are large or diffuse, or when there is persistent involvement of the margins, especially with high-grade malignant lesions 2.
• BCS requires wide excision and should be followed by mammography of the involved breast if the specimen radiograph does not clearly include all microcalcifications 2.
• Radiotherapy following BCS significantly reduces local recurrence rates 2, 3.
• The presence of necrosis, high-grade cytologic features, or comedo subtype are risk factors that derive the greatest improvement in local control with the addition of radiotherapy to BCS 3.

Role of Adjuvant Endocrine Therapy

• There is no scientific evidence that adjuvant endocrine therapy reduces the incidence of ipsilateral breast invasive recurrence or breast cancer mortality in the context of adequate local treatment of DCIS 4.
• Adjuvant endocrine therapy can be considered after a rigorous multidisciplinary discussion and patient counseling in a carefully selected subgroup of patients with high-risk estrogen receptor-positive DCIS 4.
• However, in this case, the patient's DCIS is ER and PR negative, so adjuvant endocrine therapy is not indicated.

Chronic Inflammation

• The presence of chronic inflammation, mild, does not change the treatment recommendations for DCIS 5, 2, 6, 3.
• The treatment of DCIS is based on the characteristics of the tumor, such as size, grade, and receptor status, rather than the presence of chronic inflammation.

Recommendations

• Based on the patient's high-grade DCIS with a maximal dimension of 3 mm, nuclear grade 3, ER and PR negative, with microcalcifications and necrosis, the recommended treatment is wide-excision BCS plus radiotherapy or mastectomy 2, 3.
• The patient should be carefully evaluated and discussed in a multidisciplinary setting to determine the best treatment option.