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Chapter 11

after transverse rectus abdominus myocutaneous (TRAM) flap reconstruction. All were described as initially having had extensive DCIS, and four patients had undergone a skin-sparing mastectomy. Five of the recurrent lesions were palpable. Two of four patients who underwent axillary dis- section had nodal metastases. The report did not mention whether breast glandular tissue was associated with the re- current carcinoma lesions. Introduction to Breast-Conserving Therapy Despite the widespread reliance on mastectomy, alterna- tive therapies involving excisional surgery and radiotherapy were examined as early as the 1930s. After reviewing the re- cord of his cases of intraductal comedocarcinoma, Blood- good 8 commented that “the striking feature is that none of the cases of pure comedo adenocarcinoma was associated with metastasis to the axillary nodes, and not a single patient died of cancer.” He described four patients with “pure” or noninvasive comedocarcinoma who were “completely ex- cised with postoperative irradiation” and remained well up to 3 years later. These observations led him to conclude that “when the tumor is small and a FS shows a pure comedo neoplasm, it is sufficient to excise only the tumor.” 8 Occasional patients treated by local excision were men- tioned in reviews of DCIS published in the 1960s and 1970s. Farrow 356 reported on 25 patients treated by local excision alone. Histologic features of the DCIS were not specified. Further carcinoma developed in the same breast 1 to 8 years after excision in 5 of the 25 women. The subsequent lesions were “within or nearby the previous local excisional site.” In 1971, Ashikari et al. 72 mentioned two patients, one of whom refused surgery and a second with a medical contra- indication who were treated by local excision and did not develop recurrent carcinoma. Four of 64 patients with DCIS described by Westbrook and Gallager 73 received only radia- tion therapy after biopsy because of patient preference or comorbid conditions. The changing trend in the treatment of DCIS in the United States was reported by Winchester et al. 20 in 1997, who analyzed data of more than 39,000 women diagnosed between 1985 and 1993. The use of breast conservation therapy increased from 31% to 54%, and overall 33.4% of patients did not undergo mastectomy during the 8-year interval. Radiotherapy was employed in 38% of patients treated by breast-conserving surgery in 1985 and in 54% in 1993. Axillary dissection was performed in 49% of cases with or without mastectomy, but the frequency of this procedure decreased from 52% in 1985 to 40% in 1993. Joslyn 357 reviewed SEER data from various regions of the United States from 1973 through 2000 to document trends in the treatment of DCIS. The utilization of breast-conserving surgery increased in all regions surveyed, ranging from 49.5% in Utah to 76.9% in Connecticut for the period from 1997 through 2000. Women younger than 45 years at the time of diagnosis were treated by breast-conserving surgery signifi- cantly less often than those 45 years of age and older. Women who received radiotherapy in addition to breast-conserving

surgery had significantly lower breast cancer mortality than those treated by breast-conserving surgery alone.

Breast Conservation by Excision Only—Retrospective Data

Long-term follow-up of DCIS treated by local excision alone was documented in several retrospective reports. The pa- tients were identified in reviews of breast biopsies initially deemed to be benign but found to contain foci of DCIS on review. One of the earliest series consisted of eight patients with DCIS detected by Kiaer 358 in a review of patients with “fibroadenomatosis” (proliferative breast changes). “Follow- up revealed that 6 of these 8 patients had died of mammary carcinoma which had become clinically manifest 1-1/2 to 16 years after the first operation.” 359 Two of nine patients treated by local excision for DCIS developed breast recur- rences in a series described by Millis and Thynne. 359 Another series consisted of 10 patients, who, in ret- rospect, had low-grade papillary or micropapillary DCIS identified in 8,609 biopsies from 1940 to 1950. 360 During fol- low-up averaging 21.6 years, 7 (70%) of the 10 patients were found to have subsequent carcinoma in the same breast after an average interval of 9.7 years. Six of the seven subsequent carcinomas were invasive. Four of these women developed metastatic carcinoma, which was fatal in two instances. In a later report, the series was expanded to 15 patients, 8 (53%) of whom developed subsequent carcinoma. 361 Harvey and Fechner 362 reviewed 879 breast biopsies from 1962 to 1966 reported to be benign. They identified six patients with pre- viously undiagnosed papillary DCIS, all of whom remained well, with four followed for less than 5 years and two for less than 2 years. Page et al. 363 found 28 women with DCIS treated by exci- sion only in a review of 11,760 biopsies from 1950 to 1968. The DCIS were described as low-grade cribriform and mi- cropapillary types. Invasive carcinoma developed in the ipsilateral breasts of 7 of 25 women who had follow-up of at least 3 years. All subsequent carcinomas were at or near the site of the original intraductal lesion. The observed fre- quency of subsequent invasive carcinoma was 11 times the expected rate. A second report by these investigators with follow-up averaging nearly 30 years found that 9, or 32%, of 28 women subsequently developed ipsilateral invasive carcinoma. 364 This frequency was 9.1 times expected (95% CI, 4.73 to 17.5). Further investigation of the series with a median follow-up of 31 years revealed invasive carcinoma in 11 (39.3%) of the 28 women. Eight subsequent carcinomas were diagnosed within 15 years of the original biopsy, and three were detected after intervals of 23, 29, and 42 years, respectively. Eusebi et al. 365 found 28 examples of previously un- diagnosed DCIS in a review of 4,397 biopsies performed from 1965 to 1971. Twenty-one of the lesions were forms of micropapillary carcinoma, four were cribriform, one papillary-cribriform, and two had comedocarcinoma. Two patients had ipsilateral recurrences. One of these women who originally had comedocarcinoma developed an invasive