Comparison of two breast carcinomas: ductal carcinoma in situ and lobular carcinoma in situ.
Breast cancer continues to be the most frequently diagnosed cancer in women in the United States. Although there has been a decrease in morality, breast cancer remains second as a cause of cancer deaths in women (American Cancer Society, 2013). Due to the incidence of breast cancer and public education efforts regarding breast screening, nurses as well as the general public have some knowledge of breast cancer. However, there appears to be a limited understanding of the various types of breast cancer, their respective treatments, and prognoses. The purpose of this article is to discuss two types of breast carcinoma in situ.
Because breast cancer is not a single disease, diagnosis often leads to confusion. Once a diagnosis of breast cancer is confirmed through biopsy, most cancers are identified as invasive carcinomas. The diagnosis of breast cancer requires further testing for staging. These cancers are classified according to stage I through IV, and the treatment plan is developed related to staging. Treatment options are numerous; as the numerical stage of the cancer increases, typically the treatment options become more aggressive and the prognosis becomes less favorable (National Comprehensive Cancer Network [NCCN], 2011).
In 2009, the most recent year for which statistics are available, over 211,700 women were diagnosed with breast cancer (Centers for Disease Control and Prevention, 2012). Although the majority of breast cancers are diagnosed as invasive breast cancers, a different grouping of breast cancer includes stage 0 or the carcinomas in situ. According to the American Cancer Society (ACS) (2013a), "an estimated 232,340 new cases of invasive breast cancer are expected to be diagnosed among women in the United States in 2013" (p. 9). An additional 64,640 new diagnoses of breast carcinoma in situ are expected in 2013. Of the new cases of in situ cancers, 85% are predicted to be ductal carcinoma in situ (DCIS) and 15% to be diagnosed as lobular carcinoma in situ (LCIS) (ACS, 2013a). In fact, the incidence of DCIS has risen dramatically in the United States, possibly due to the increased use of screening mammography (Rudolph et al., 2009; van Steenbergen et al., 2009; Virnig, Tuttle, Shamliyan, & Kane, 2010). The distinction of in situ cancers as ductal or lobular is based on their growth pattern and anatomical location within the mammary system. Characteristically, the two cancers differ in mammography detection, morphology, biological behavior, and the anatomical location in the breast (Bleidweiss, 2012; Lakhani et al., 2006). To further obscure understanding of the disease, the two in situ cancers can be divided into sub-categories based on their individual tissue characteristics.
Patients are justifiably anxious when faced with a diagnosis of breast cancer; however, a better comprehension of the carcinomas in situ and their management may help reduce anxiety regarding the disease. A thorough understanding of these two very different types of in situ cancers will help nurses to educate and support patients diagnosed with DCIS or LCIS through their decision making and treatment process.
Ductal Carcinoma in situ
Ductal carcinoma in situ is confined entirely to the ductal system of the breast. It includes a group of lesions that differ in their clinical presentation, tissue appearance, and biological potential (Lakhani et al., 2006; Virnig et al., 2010). Although several classification systems have been used for DCIS, all generally categorize the cancers into high, intermediate, and low-grade pathology. The tissue analysis categorizes the cancers into grades that address the following factors: cellular appearance, estrogen and progesterone-receptor status, rate of proliferation and expression of the HER2 oncogene, and mutations of the p53 tumor suppressor gene (NCCN, 2011; O'Malley, 2010). Ductal carcinoma in situ is known to represent a precursor to invasive breast cancer (Bland, 2011; O'Malley, 2010; Virnig et al., 2010). The classification of DCIS is important in that the characteristics and tissue grades of the lesion seem to be a predictor for patients who are more likely to have a recurrence of breast cancer following breast conservation treatment techniques.
Clinically, DCIS may present as a palpable lesion or as a characteristic appearance on routine screening mammography, with the presence of microcalcifications as the most common abnormality (Bland, 2011; Choi, Kim, Park, Cha, & Lee, 2011). A significant number of patients may present with subtle changes in the appearance of the breast with or without a palpable lesion (Bland, 2011). A follow-up tissue biopsy of DCIS will reveal characteristic pathology and subsequent grading of the lesion from which evidence-based treatments are indicated.
Treatment for DCIS depends upon the tissue characteristics and grade of the lesion, and may comprise several options. These include a breast conservation lumpectomy that generates clear margins, lumpectomy followed by radiation of the involved breast, and chemoprophylaxis with tamoxifen (Nolvadex[R]) or raloxifene (Evista[R]). Ductal carcinoma in situ is a significant precursor for invasive ductal carcinoma. According to Bland (2011),
... because of their known status as precursors of invasive ductal carcinoma, surgery plus radiation therapy are mandatory for treatment of DCIS lesions. Findings from five prospective randomized trials suggest that the addition of radiation therapy to breast conserving surgery consistently reduced ipsilateral breast cancer at 5 and 10 year follow up. (p. 288)
Chemoprophylasis with tamoxifen or raloxifene may be added for patients whose lesions are estrogen and progesterone receptor-positive (NCCN, 2011). A simple mastectomy is always an option for DCIS. Because DCIS is known as a direct precursor lesion to invasive breast cancer, women with a family history of a first-degree relative with breast cancer and/or an additional known genetic factor may elect to undergo controversial prophylactic bilateral simple mastectomy. This is not the recommended approach for small volume DCIS (Bland, 2011).
Lobular Carcinoma in situ
Lobular carcinoma in situ arises from the lobules and terminal ducts of the breast, and comprises a small percentage of breast carcinomas in situ. Lobular carcinoma in situ, when compared to DCIS, rarely is identified with a palpable lesion clinically, rarely is identified on mammography or by gross pathological examination, and is almost always an incidental finding on core or excisional breast biopsy for evaluation of another lesion (Bland, 2011). Because LCIS is an asymptomatic, incidental finding, the true prevalence in the general population is unknown. The most frequent age of diagnosis is 40-50, with a large majority of the cases occurring in premenopausal women. Hormonal factors appear to have a greater effect on LCIS, as a large percentage (60%-90%) of the lesions are estrogen- and progesterone-receptor positive (Lakhani et al., 2006).
LCIS is believed to be a dormant lesion with a very low malignant potential, and is known as a risk factor rather than a precursor for the development of ipsilateral and contralateral invasive breast cancer (Gao, Carter, Tseng, & Chivukula, 2010; O'Malley, 2010). Women with LCIS have a greater risk of developing invasive ipsilateral or contralateral breast cancer than the general population, with the absolute lifetime risk of approximately 1% per year (Lakhani et al., 2006; NCCN, 2011). Because of this low malignant potential, surgery is seldom indicated or recommended for the treatment of LCIS.
Diagnosis of LCIS is most frequently incidental during diagnostic breast biopsy for a palpable lesion or a lesion detected on screening mammography, usually related to microcalcificatons (Choi et al., 2011; Purdie et al., 2010). When LCIS is an incidental finding on tissue biopsy, negative margins are not needed for LCIS; however, when there is an invasive component, attention to margins surrounding the lesion is imperative. Interestingly, 60%-80% of patients undergoing mastectomy for a different form of breast cancer will express LCIS as tissue pathology, and additional bilateral expression of the disease will be present in 23%-35% of those patients (Sabel & Collins, 2013).
A great deal of the misunderstanding about in situ carcinoma entails the differences in treatment for DCIS and LCIS. While DCIS requires treatment ranging from lumpectomy to lumpectomy and adjuvant radiation therapy, or lumpectomy and radiation plus chemoprevention, the approach to LCIS is more conservative. All LCIS lesions should be evaluated further through re-excision if they present as an incidental finding on core needle biopsy (Hussain & Cunnick, 2011). Because LCIS is not a precursor lesion, it is not necessary to intervene with wide surgical excision producing negative margins, as multifocal LCIS is a common finding. Wide margins are not the goal of excisional biopsy. On the other hand, it is crucial that tissue is sampled to determine the presence of an invasive lobular or ductal carcinoma (Flegg, Flaherty, Bicknell, & Jain, 2010).
Due to the uncertainty regarding its biological significance, the management of LCIS varies. One option for management includes close, ongoing surveillance with history and physical examinations every 6-12 months for a lifetime (NCCN, 2011; O'Malley, 2010). In light of the lifetime risk of invasive breast cancer, careful observation is important for any woman who is known to be at increased risk for developing the disease. Magnetic resonance imaging (MRI) is known to be more sensitive when compared to mammography in detecting invasive breast cancers in high-risk women. However, current American Cancer Society guidelines (2013b) indicate women with LCIS are at moderate risk, and there are insufficient data to recommend MRI for this group of women. The role of MRI for surveillance of patients with lobular neoplasia in association with additional risk factors continues to be evaluated (Venkitaraman, 2010).
The anti-estrogen effects of selective estrogen receptor modulators (SERMs), such as tamoxifen and raloxifene, also may be used to reduce the risk of developing invasive breast cancer in women with LCIS (NCCN, 2011). The groundbreaking Breast Cancer Prevent Trial of 1997 found a reduction in the risk of developing invasive breast cancer in pre-menopausal women with LCIS who were given tamoxifen as chemoprevention for 5 years following diagnosis (National Cancer Institute [NCI], 2010; NCCN, 2011). Tamoxifen has been approved in the United States as a chemoprevention drug for breast cancer, including LCIS; however, its use is associated with possible serious adverse effects, such as thromboembolic events and endometrial cancer. Women may believe the risks outweigh the benefits of chemoprevention and elect not to take the drug. The Study of Tamoxifen and Raloxifene (1999-2006) found raloxifene to be as effective as tamoxifen in post-menopausal women with LCIS (NCCN, 2011; NCI, 2006; Vogel et al., 2006). Raloxifene, also approved in the United States as chemoprevention for persons at high risk for developing breast cancer (including LCIS), has the advantage of a significantly lower risk for the serious adverse effects of thromboembolism and endometrial cancer (Freedman et al., 2011).
Some women with LCIS may elect prophylactic bilateral simple mastectomy followed by immediate reconstruction as a treatment option. Due to the increased risk for LCIS in the contralateral breast, unilateral prophylactic mastectomy has not been a recommended approach (NCCN, 2011). Because no randomized trials have compared the efficacy of a program of careful surveillance versus prophylactic bilateral mastectomy in treatment of women at high risk for breast cancer, most experts believe bilateral mastectomy to be a rather extreme approach to the moderate level of risk for developing breast cancer associated with LCIS in women without other co-existing risk factors (Anderson, Calhoun, & Rosen, 2006). McLaughlin, Lillquist, and Edge (2009) explored the trends for prophylactic mastectomy from 1995 to 2005. They concluded mastectomy appeared to be uncommon as an approach to cancer prevention among high-risk women, yet contralateral mastectomy to treat women diagnosed with breast cancer is increasing. Because mastectomy has a significant physical and psychological impact on women's lives, the decision to pursue prophylactic surgery must be based on individual factors. This decision by the patient must follow careful education regarding all treatment options, along with risks and benefits of each option. See Table 1 for a comparison of DCIS and LCIS.
Breast carcinoma in situ has a favorable prognosis, with the approach to its management dependent on the histology of the lesion. Generally, DCIS is diagnosed more easily and will be treated more aggressively, as it is known to be a precursor for invasive ductal carcinoma of the breast. In contrast, LCIS is often an incidental finding on breast biopsy for other reasons and will be treated more conservatively because it is viewed as a risk factor rather than a precursor of future invasive breast carcinoma. Continuous efforts and ongoing progress continue to allow a better understanding of breast cancer and effective modes of treatment to increase long-term survival from the disease.
Acknowledgments: The author thanks Edward C. Elliott, MD, FACR, FCAP, Radiation Oncologist, and Benjamin T. Esparaz, MD, FACP, Medical Oncologist, Cancer Care Specialists of Central Illinois, for their support and thoughtful review of this manuscript.
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Mary Jane Linton, EdD, MSN, RN, CNE, CNL, is Professor, Millikin University, School of Nursing, Decatur, IL.
TABLE 1. Characteristics of Ductal Carcinoma In Situ and Lobular Carcinoma In Situ Classification of Lesion Ductal Carcinoma in situ Diagnosis Clinical presentation Palpable lesion often present (Bland, 2011; Choi et al., 2011) Mammography Visible lesion (Bland, 2011; Choi et al., 2011) Biopsy Core needle or excisional biopsy required to follow-up on palpable lesions or mammography findings (Flegg et al., 2010; NCCN, 2011) Prognostic factors Precursor to invasive breast cancer in ipsilateral breast (Bland, 2011) Treatment Surgery Breast conservation surgery (BCT): lumpectomy with clear margins (Bland, 2011) Radiation Adjuvant radiation therapy following lumpectomy (Bland, 2011) Surveillance Surveillance every year for lifetime (and every 6 months for 5 years, and then annually post radiation if BCT); annual mammogram (NCCN, 2011) Selective Estrogen Receptor Follow up SERMs optional if Modulators (SERMS) estrogen-receptor positive (NCCN, 2011) Mastectomy Unilateral simple mastectomy or bilateral simple mastectomy (personal choice) (Bland, 2011) Classification of Lesion Lobular Carcinoma in situ Diagnosis Clinical presentation Asymptomatic clinically (Bland, 2011; Choi et al., 2011; Purdie et al., 2010) Mammography Non-visible (Bland, 2011; Choi et al., 2011; Purdie et al., 2010) Biopsy Incidental finding associated with other breast pathology; requires follow-up surgical excisional biopsy (Bland, 2011; Choi et al., 2011; Purdie et al., 2010) Prognostic factors Risk factorfor invasive breast cancer in ipsilateral and contralateral breast (Gao et al., 2010; O'Malley, 2010) Treatment Surgery Lumpectomy to determine co-existing presence of ductal or invasive lobular carcinomas; clear margins not necessary for LCIS (Flegg et al., 2010; Sabel & Collins, 2013) Radiation Adjuvant radiation not indicated (Sabel & Collins, 2013) Surveillance Surveillance every 6-12 months for lifetime; annual mammogram (NCCN, 2011; O'Malley, 2010) Selective Estrogen Receptor Follow up SERMs optional; most Modulators (SERMS) lesions are estrogen-receptor positive (NCCN; 2011; NCI, 2006; Vogel et al., 2006) Mastectomy Prophylactic bilateral simple mastectomy (personal choice) (McLaughlin et al., 2009; NCCN, 2011; Sabel & Collins, 2013)
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|Title Annotation:||Advanced Practice|
|Author:||Linton, Mary Jane|
|Date:||Jul 1, 2013|
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