What is the recommended treatment for Ductal Carcinoma In Situ (DCIS), cribriform type with necrosis and calcification, intermediate grade 2/3?

Treatment of Ductal Carcinoma In Situ (DCIS), Cribriform Type with Necrosis and Calcification, Intermediate Grade 2/3

For intermediate-grade DCIS with necrosis and calcification, breast-conserving surgery with radiation therapy followed by tamoxifen for 5 years is the recommended treatment to reduce local recurrence and improve survival outcomes. 1

Understanding the Diagnosis

Ductal carcinoma in situ (DCIS) with cribriform pattern, necrosis, and calcification represents a higher-risk subtype of DCIS. The key features of this diagnosis include:

• Intermediate grade (2/3): Indicates moderate cellular atypia
• Cribriform pattern: Characterized by sieve-like spaces within the ducts
• Necrosis: Particularly concerning as it increases recurrence risk
• Calcification: Common mammographic finding in DCIS

Treatment Algorithm

1. Surgical Management

• Primary approach: Breast-conserving surgery (lumpectomy) with negative margins 2, 1

  • Aim for margins ≥2mm (ideally wider)
  • Negative margins significantly reduce recurrence risk (7% vs 29% for positive margins) 2

• Consider mastectomy if:

  • Lesion is extensive (>4-5 cm)
  • Diffuse suspicious microcalcifications
  • Unable to achieve clear margins after reasonable attempts at re-excision
  • Patient preference 2, 1

2. Radiation Therapy

• Strongly recommended after breast-conserving surgery 2, 1
  • Reduces local recurrence by approximately 50-60%
  • Particularly important for intermediate-grade DCIS with necrosis 1
  • 10-year breast recurrence rates range from 6-23% with radiation vs higher rates without 2

3. Hormonal Therapy

• Tamoxifen 20mg daily for 5 years 3
  • NSABP B-24 trial showed 37% reduction in breast cancer events with tamoxifen 2, 3
  • Reduces both ipsilateral and contralateral breast cancer events
  • Particularly effective for reducing invasive recurrences (43% reduction) 3

Risk Factors for Recurrence

Several factors increase the risk of recurrence after treatment:

• Presence of necrosis: Particularly comedo-type necrosis increases recurrence risk 2
• Intermediate/high nuclear grade: Grade 2/3 has higher recurrence than Grade 1 2
• Margin status: Positive or close margins significantly increase recurrence risk 2
• Young age: Some studies suggest higher recurrence rates in younger women 2

Important Considerations and Pitfalls

1. Underestimation of disease extent: DCIS often extends beyond visible calcifications on mammography. Careful correlation between imaging and pathology is essential 1

2. Risk of upgrade to invasive cancer: Approximately 8% of DCIS diagnosed on core biopsy may be upgraded to invasive cancer at final excision 4

3. Margin assessment: Inadequate margins are associated with significantly higher recurrence rates. Re-excision should be considered for positive or close margins 2

4. Follow-up surveillance: Regular mammographic surveillance is crucial after breast-conserving treatment

5. Overtreatment concerns: While some argue for de-escalation of treatment for low-risk DCIS, intermediate-grade DCIS with necrosis represents a higher-risk category that warrants comprehensive treatment 5

Outcomes

With appropriate treatment, prognosis for DCIS is excellent:

• 10-year cause-specific survival rates of 96-100% 2
• Local recurrence rates of 6-23% at 10 years with breast conservation plus radiation 2
• Approximately 50% of recurrences may be invasive cancer 6

The presence of necrosis and intermediate grade places this DCIS in a higher risk category, making comprehensive treatment with surgery, radiation, and hormonal therapy the most appropriate approach to minimize recurrence risk and optimize survival outcomes.