Current management of ductal carcinoma in situ of the breast

 Ductal carcinoma in situ (DCIS) accounts for approximately 20% of all screen-detected breast cancers. Total mastectomy can achieve a 98% cure rate in patients with DCIS, but its impact on quality of life should be weighed against the risk of local recurrence. Skin-sparing mastectomy with immediate reconstruction using autologous tissue can achieve excellent cosmesis and therefore should be considered when mastectomy is indicated. Nevertheless, mastectomy is considered an over-treatment for localized DCIS, and breast conservation is the goal of modern treatment. Three recent randomized controlled trials have demonstrated that adjuvant radiotherapy (RT) after adequate local excision of localized DCIS significantly reduces the incidence of local recurrence. Non-randomized studies suggest that patients with adequately excised small (<15 mm), non-high-grade DCIS not associated with necrosis can be safely spared adjuvant RT. However, this issue requires further evaluation in randomized controlled trials. The role of adjuvant tamoxifen is not well established, especially in relation to the hormone receptor status. Formal axillary dissection is not appropriate for DCIS; however, the potential role of the sentinel node biopsy (SNB) in selected high-risk cases requires further evaluation. The potential role of new selective estrogen receptor (ER) modulators and third-generation aromatase inhibitors in postmenopausal women with ER-positive DCIS, gene and protein expression profiling, and mammary ductoscopy will be the focus of future research.