mastectomy in "in situ" carcinoma of the breast: surgey of choice or the only possibility ?
Autori: A. Lucchini, S. Passerini, P. P. Puviani, G. L. Liera,
F. Pirondi, A. Savioli, M. Franzini
Ospedale Comprensoriale di Guastalla (Reggio Emilia)
Divisione di Chirurgia Generale Primario: Dr. M. Franzini
The increased use of conservative surgery to treat infiltrating
breast cancer at T1 stage and the progressive increase of "in situ"
carcinomas which are brought to the attention of surgeons, has cast
some doubt on the legitimacy of systemic recourse to total mastectomy
for this latter group of breast cancers.
We offer the results obtained in our Division over the past five years
as a starting out point for reflection.
"In situ" carcinomas (ISC) of the breast are
defined as neoplasms in which the proliferation of malign epitelial
cells occurs inside the ducts (ISDC) or inside the terminal
part of the glandular lobules (ISLC) without invading the
glandular stroma (1).
As a matter of fact, studies made with the electronic microscope have
shown breaks in the basal membrane which were not highlighted by the
normal optical microscope.
However, this did not necessarily involve an aggressive potential
(1,5). Thus, by definition, they are biologically less
aggressive neoplasms than infiltrating carcinomas.
Relatively few in number up to about 15 years ago, they were treated
with the same procedure as any other breast tumor, i. e. with total
The widespread use of mammographic screening in patients over 40 and
the subsequent revelation of infraclinic lesions, has almost
quadrupled the number of cases of ISC discovered.
In recent case studies, ISC accounted for 15-20% of all breast
This evidence of a constantly increasing number of cases and the
introduction of conservative surgery to treat infiltrating stage T1
breast carcinomas has made the choice of therapy for the treatment
of ISC extremely important.
Total mastectomy, still today the treatment of choice for ISDC
according to the FONCAM protocol, is no longer considered by numerous
Authors (5,6,7,8) as always essential for neoplasms which are
often much smaller and less aggressive than infiltrating carcinomas
and whose multiplicity of foci is often highlighted by mammography.
These same Authors believe that careful radiological, clinical and
histopathological examination, bearing in mind histological subtype
and any areas of microinfiltration, allows cases of ISC to be
identified in which conservative surgical procedures can be beneficial
without any necessary additional radiation therapy.
The published case studies, in this context, are comforting. However
essential control clinical studies are so far missing and it is these
which will generate the definitive proof of the usefulness of this
The purpose of this present study is to evaluate the results obtained
in our Division and to offer them as further food for thought.
And this despite our full awareness of the smallness of the sampling
and the shortness of the follow up which combine to make them
MATERIAL AND METHODS
Between 1983 and 1988 we observed 22 cases of breast ISC out of a
total of 270 breast neoplasms. The average age was 56 and the range
was from 25 to 79. In 12 cases (55%) the suspicion of ISC
stemmed from mammography; in 7 cases (32%) by the clinical
discovery of a neoformation and in 3 cases (13%) by
secretion from the nipple.
In 18 cases the histotype was ISDC and in 4 cases ISLC, with ratio
Histological examination of frozen sections confirmed the difficulty
of reaching a correct diagnosis (3). In fact microinfiltration
outbreaks were highlighted in 4 cases but only when the frozen
sections were examined.
Sixteen quadrantectomies with lymph gland dissection at the 1st and
2nd axillary level and 6 mastectomies with the Madden modification
This latter operation was used for 2 patients whose neoformation was
over 3 cm in diameter and showed microinfiltration foci at the
histological examination. It was also used on 4 patients where the
mammography showed suspicious nests of microcalcification in more
than one quadrant.
The axillary lymph nodes were positive in only one patient subjected
to mastectomy for a 3 cm ISDC with invasive microfoci.
RESULTS AND CONCLUSIONS
All the patients were followed up with an annual mammography and
quarterly clinical check ups. We noted just a single relapse
(6.25%) in the quadrantectomy group during the observation
The relapse appeared 18 months after the operation for a 2 cm diameter
ISDC. Two patients at 36 and 43 months developed a neoplasm in the
Both were ductal infiltrating carcinomas, while the first neoplasms
were a ISLC and a ISDC. Both patients were given a quadrantectomy
and complementary radiation therapy.
No neoplastic progression was noted.
ISC therapy had undoubtedly been negatively affected by the fact that
up to 15 years or so ago, its incidence in the literature as a
percentage was fairly low and thus little attention was given to it
in studies on breast cancer.
However we should point out that the basic problem has still to be
answered, i. e. are ISC preinvasive neoplasms destined to evolve
clinically into more aggressive tumors or should they be regarded
merely indicating the risk of development of invasive carcinomas?
At the current state of our knowledge we can only affirm that:
ISDC is undoubtedly more frequent than ISLC;
ISLC is often characterized by a multiplicity of foci and
bilaterality and is frequently associated with a subsequent invasive
carcinoma of the breast or of the controlateral breast;
ISDC, on the other hand, involves a single quadrant and can be
associated with a subsequent homolateral infiltrating carcinoma in
the same quadrant originally involved with the ISDC (2,3,4);
in ISDC the frequency of infiltration microfoci, highlighted by
the electronic microscope, increases the possibility of lymph gland
On the basis of the case studies reported in the literature and above
all, taking into account the possibility of performing conservative
surgery as in T1 stage ductal infiltrating carcinoma, systematic
recourse to mastectomy no longer seems justifiable in all cases of
In fact, in ISDC with a diameter of over 3 cm where frequently foci
of microinfiltration are highlighted, total mastectomy with lymph
gland dissection is undoubtedly necessary.
For the same reason, if in ISDC mammography shows nests of
microcalcification in a number of quadrants, total mastectomy should
certainly be used because of the polycentricity.
On the other hand, we feel that small size ISDC where the X-ray
examination shows a single focus and where there are no
micro-breaks in the basal membrane, can be treated with
conservative surgery, i. e. with quadrantectomy and complementary
These conclusions, supported by the results reported in the
literature, have induced us to use a conservational therapy with
complementary radiation therapy for "in situ" ductal
The results obtained, though the case study is limited in number
and the follow up period still relatively short, are encouraging.
However only controlled clinical studies will be able to demonstrate
the true reliability of this therapeutic approach.
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