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No lump… but still cancer
No lump… but still cancer DCIS it is the most common type.
It probably won’t be found on breast examination, yours or your doctor’s—it is rarely found as a lump.

What Is DCIS?
Answer: Ductal carcinoma in situ. It occurs in the female breast, it is the least malignant breast cancer, and it is the most common type—usually found on mammography. That means it probably won’t be found on breast examination, yours or your doctor’s—it is rarely found as a lump. Sometimes it announces itself by bloody nipple discharge, but most often not.

That means you should get your yearly mammogram routinely.

Your primary care physician will complete a history and a physical. He/she will inquire about the family history of cancer, previous therapeutic radiation, history of collagen vascular disease, the presence of breast implants, date of last menstrual period, use of estrogenic substances, previous gynecologic surgery and possible pregnancy. Examination will look for breast lump, regional node enlargement, and appearance of the nipples in both breasts. The entire breast should be carefully examined to determine if areas of tumor are present elsewhere in the breast because the presence of tumors will influence the decision about the extent of surgery. The other breast should be evaluated via mammography because bilateral DCIS occurs in about 6% of women.
The diagnosis of DCIS is suggested by micro calcifications seen on mammography. Depending on type, number, and distribution of the micro calcifications, the radiologist may make the diagnosis or suggest it as a possibility. Not all calcifications mean breast cancer.

Magnification/spot compression magnification increase imaging resolutions and better depict the shapes of calcifications, their extent, and their number. But the patterns on mammography are not diagnostic by themselves. Definitive diagnosis depends on microscopic examination of a tissue sample. The use of MRI for diagnosis is still not proven. Ultrasound is often used for localization for the use of needle biopsy Stereotactic core needle biopsy is the first step for biopsying suspicious, non-palpable mammography abnormalities. Ultrasound-guided biopsy is useful for non-palpable masses and micro calcifications that are seen on sonogram. Small breasts or widely separated calcifications may make the stereotactic biopsy an unsuitable approach. Other issues such as bleeding problems, marked obesity, and cardiopulmonary disease also may contraindicate that approach. If the lesion is not palpable or sonographically visible, presurgical localization using a wire guide is needed to help the surgeon remove the tissue from the correct area. This procedure is another possible option before definitive surgery; the surgeon must know where he needs to go.

The goals of any surgery are total removal of suspicious or known malignant tissue with minimal aesthetic deformity. The surgical attempt ultimately is to take the specimen out in one piece so that the pathologist who looks at the tissue can tell if there is tumor at or near the surgical edges of the specimen. This and a postoperative mammogram are complementary means of assessing completeness of the excision. By definition, DCIS is confined to ducts in the breasts. Up to 20% of patients who have DCIS diagnosed by image-guided biopsy will have invasive carcinoma identified when the entire lesion is removed. But after complete excision of the DCIS lesion, unrecognized invasive carcinoma is rare. Long-term survival of DCIS patients who undergo surgery alone is 97-99%. Auxiliary lymph node assessment in patients who have a diagnosis of DCIS is not routinely undertaken.

One Patient’s Experience*
In 1997, my annual mammogram showed an unexpected sprinkling, like a spill of salt, in my left breast. After a repeat mammogram and sonogram, the radiologist recommended a biopsy.

My surgeon said he doubted he would find anything at all; the images probably were harmless calcifications. Nonetheless, he scheduled me for a wire-guided biopsy to pinpoint the suspicious area seen on a two-dimensional image. .

The phone rang two days later; what I had was DCIS, which, he said, might be treated as pre-cancerous. But my DCIS was high-grade necrotic comedo, viewed as having the greatest risk of becoming “something worse.” A team was assembled—a surgeon, an oncologist, a radiation oncologist and my gynecologist—and the initial recommendation was wide excision followed by radiation..

Plans changed. The wide excision resulted in none of 40 slides having clean margins. My choices were a wider excision followed by radiation, or a mastectomy. Being a woman with modest breast size, I already felt somewhat mutilated. And I was having second thoughts about radiation, based on family experience. I opted for a mastectomy and reconstruction..

Ten years passed. Last year, the annual mammogram of my right breast revealed some more sprinkles of salt, and I developed a bloody nipple discharge. This time, there was no question in my mind about conservation. I had a second mastectomy and sentinel node biopsy. The node was clear..

Unfortunately, I scar very exuberantly. As a result, reconstruction efforts (tissue expanders followed by saline implants) have been less than ideal..

* The patient is my wife, Tracey Edgerly Meloni
The Surgery Dilemma
The question is always “How much surgery?” That decision will hinge on the mammographic appearance, physical findings, family history, personal medical history, biopsy findings (breast and possible axilla), findings at surgery, and the patient’s opinion after she understands what the details are and why the doctors make their recommendations. Nothing is set in cement, but there are still such things as better-or-worse decisions. In addition, there is the recognition that we still don’t know everything.

After surgery comes the question of whether and how strongly post-op radiation is recommended. Statistically patients do better with radiation treatment. But it, too, is not guaranteed—just statistically better. The addition of Tamoxifen also decreases the risk of local recurrence, especially when the tumor is estrogen receptor positive. This condition is determined by special tests performed by the pathologist.

Treatment Options
DCIS is the breast cancer most amenable to surgical cure. The risk of metastasis at time of diagnosis is negligible. The goal of treatment is prevention of the recurrence of either invasive or non-invasive cancer. Treatment consists of surgery with or without radiation therapy, and surgery is either mastectomy or breast-sparing lumpectomy. There are also types of radiation. From here on it gets a little complicated, because ultimately the patient, the surgeon, the oncologist and the radiation physician get together to arrive at a treatment plan.

The patient’s challenge is to listen to the physicians’ opinions, reasons for those opinions, and to fit them into her idea of how she wants to live. The patient’s opinions going in are what she wants her breasts to look like after surgery. Whether she will be willing to change her mind depends upon what she hears. A woman with large breasts may not mind having a one-inch block of tissue removed, whereas a woman with small breasts may feel that half of her breast is being removed. Maybe a mastectomy is a better choice for the latter, rather than a lumpectomy.

  • Mastectomy vs. breast conservation: Mastectomy cure rates approach 100%, but may be overkill for many with DCIS. Results from breast conserving surgery alone indicate a recurrence rate of 10-15% at five years.
  • Breast-conserving surgery plus radiation therapy: Radiation reduces tumor recurrence by 58% and invasive recurrence by about 60%. But the overall survival rates with and without radiation are the same.
  • Tamoxifen appears to have little impact in preventing recurrence following lumpectomy without radiation therapy.
The one factor for which there appears to be agreement is the need for post-biopsy mammogram because there is a high risk of recurrence in the presence of residual malignant-appearing calcification.

After all is said and done, no matter what, routine mammograms and physician follow-ups are mandatory.

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"No lump… but still cancer"
   authored by:
C. Robert Meloni, M.D., FACP, FACE, is board certified in both internal medicine and endocrinology. He is a graduate of Harvard College (BS), Georgetown University (MS), and New York Medical College (MD). The former Chairman and President of the Nort...

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