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Ductal Carcinoma In Situ: Biological and Therapeutic Implications of Classification

ammographic imaging technology has transformed ductal carcinoma in situ (DCIS) from a rarely encountered, clinically insignificant process treated uniformly by mastectomy and node dissection, into an increasingly common entity that now accounts for 2040% of all new breast cancer accessions, and for which there are numerous proposed treatments, most controversial (1). What was generally extensive disease detected by palpation or nipple discharge, now presents as a small focus of clinically occult microcalcifications. As a result efforts at breast conservation therapy (BCT) are increasingly being focused on DCIS with many patients now undergoing lumpectomy with or without irradiation. The immediate impact of BCT for DCIS, either with or without irradiation, has been a great increase in the local recurrence rate. From a low of 1-2% following mastectomy (2, S), local recurrences have increased to 30-50% following BCT. The large number of local recurrences generated interest in the possible correlation between the histologic subtype and recurrence and led to a classification of DCIS utilizing nuclear grade (4). Based on nuclear grade and the extent of necrosis, that classification divided DCIS into two high grade, an intermediate grade, and a low grade subtypes. The two high grade subtypes were collapsed for analysis into one ( 5 ) . Subsequent investigators have independently developed classifications based on nuclear grade, necrosis, or