Ductal Carcinoma In Situ: Diagnosis, Treatment, and Monitoring

Ductal Carcinoma In Situ (DCIS)

Hello Dr.
Chou,
At the end of last year, I discovered a hard lump in my breast.
I went to Shin Kong Wu Ho-Su Memorial Hospital for examination and biopsy, and the report indicated it was benign.
The doctor advised me not to undergo surgery and to just monitor it.
However, due to frequent discomfort and pain, I decided to have surgery at Chang Gung Memorial Hospital at the beginning of this year.
At that time, no additional biopsy was performed; after the ultrasound, a surgery date was scheduled directly.
After the surgery, it was found that the lump had already undergone changes and was diagnosed as ductal carcinoma in situ, but there was no detailed explanation regarding whether it was basal layer or lobular carcinoma in situ.
The time from the biopsy to the surgery was less than three months.

Are ultrasound and biopsy not accurate enough to track the progression of the disease? (As it was not detected at that time.) Would mammography be more accurate? During my follow-up visit, I requested the doctor to perform a mammogram, but he did not agree! The information I found indicates that after surgery for carcinoma in situ, radiation therapy or five years of Tamoxifen is needed, but the doctor only advised me to continue monitoring.
Does this increase the likelihood of disease recurrence, or is it because I am only 28 years old and not suitable for such treatments?
I have a benign fibroadenoma in one breast, which has grown by 0.2 cm since my last check-up six months ago, now measuring 1.5 cm.
If it continues to grow at my next follow-up, should I consider surgery to remove it? Is there a direct relationship between the size of the tumor and the menstrual cycle? During today’s ultrasound, it was noted that my ducts are obstructed in multiple areas, which is causing discomfort and pain.
How can I improve or prevent this? Can the so-called cysts in the breast potentially transform into tumors?
Thank you sincerely for taking the time to read this.
:)

candy, 20~29 year old female. Ask Date: 2015/09/01

Dr. Zhou Jiazhen reply Breast and Thyroid

Dear Candy,
1.
Ultrasound has a higher diagnostic rate for palpable lumps.
If there is suspicion, a core needle biopsy is recommended.
If the result is benign, surgical removal of the tumor or short-term follow-up is suggested (if there is suspicion from ultrasound or physical examination, even if the biopsy is benign, tumor removal is still recommended).
If the biopsy is malignant, partial or total mastectomy is required.
2.
The sensitivity and accuracy of mammography vary depending on breast density.
It is currently recommended to start screening at age 40.
For younger women, due to denser breast tissue, the sensitivity and accuracy are lower, so mammography is not recommended; instead, ultrasound examination should be prioritized.
3.
The surgical treatment for ductal carcinoma in situ (DCIS) and invasive breast cancer is similar, with most opting for partial mastectomy or total mastectomy (depending on size, location, and whether it is multifocal).
After partial mastectomy, radiation therapy is recommended.
The decision to use tamoxifen for 5 years depends on whether the DCIS has hormone receptors (ER(+) or PR(+)).
If both are negative, medication is not necessary.
4.
Fibroadenomas are mostly benign and rarely become malignant.
They may enlarge before menstruation and decrease afterward, but if there is persistent enlargement or symptoms, surgical removal is generally advised.
5.
Breast tenderness is often related to hormonal balance and may affect ovarian function, potentially causing pain.
Recommendations include: (1) reducing intake of high-fat foods and animal fats; (2) limiting caffeine consumption; (3) maintaining a regular lifestyle, avoiding late nights and insomnia, managing stress and emotional fluctuations; (4) avoiding exposure to environmental hormones, such as phthalates.
6.
Simple blisters are generally not related to adenomas and do not become malignant, but cysts may undergo malignant changes and should be monitored regularly.
Wishing you peace and health.
Sincerely,
Dr.
Chou Chia-Cheng
Director of Surgery, Taoyuan Hospital, Ministry of Health and Welfare

Reply Date: 2015/09/01

More Info

Understanding Ductal Carcinoma In Situ (DCIS) involves a comprehensive approach to diagnosis, treatment, and ongoing monitoring. DCIS is a non-invasive breast cancer that is confined to the ducts of the breast and has not spread to surrounding breast tissue. Your experience highlights several important aspects of managing this condition.

Diagnosis of DCIS
In your case, the initial ultrasound and biopsy indicated a benign condition, which can sometimes occur due to the limitations of imaging techniques. While ultrasound is a useful tool for evaluating breast lumps, it may not always provide definitive information about the nature of a lesion. Mammography, on the other hand, is often more sensitive in detecting microcalcifications associated with DCIS. It is crucial to understand that no single imaging modality is perfect; therefore, a combination of imaging techniques is often recommended for a comprehensive evaluation.

Treatment Options
After your surgery, where DCIS was confirmed, the standard treatment typically includes either radiation therapy or hormone therapy, such as Tamoxifen, especially if the DCIS is of a higher grade or if there are multiple areas of involvement. The decision to pursue these treatments often depends on various factors, including the size of the tumor, the presence of hormone receptors, and individual patient characteristics, such as age and overall health.
Your concern about the lack of immediate post-operative treatment recommendations may stem from your age and the specific characteristics of your DCIS. At 28 years old, some physicians may opt for a more conservative approach, focusing on close monitoring rather than aggressive treatment, especially if the DCIS is low-grade and there are no concerning features.

Monitoring and Follow-Up
Regular follow-up is essential in managing DCIS. This typically includes clinical breast exams and imaging studies, such as mammograms, to monitor for any changes. If your healthcare provider is not recommending mammography, it may be worth discussing your concerns further. Mammograms can detect changes that may not be visible on ultrasound, and they are an important part of breast cancer surveillance.

Fibroadenomas and Other Concerns
Regarding your benign fibroadenoma, it is common for these to change in size, particularly in relation to hormonal fluctuations during the menstrual cycle. If the fibroadenoma continues to grow, surgical removal may be considered, especially if it causes discomfort or anxiety.
Your question about cysts transforming into tumors is valid; while most breast cysts are benign, any changes in size or characteristics should be evaluated by a healthcare professional. Regular monitoring and imaging can help differentiate between benign and potentially malignant changes.

Pain and Discomfort
The discomfort you are experiencing may be related to hormonal changes, particularly if you have noted a correlation with your menstrual cycle. Breast tissue can become more sensitive and painful due to hormonal fluctuations. Maintaining a healthy lifestyle, including regular exercise and a balanced diet, may help alleviate some discomfort. Additionally, discussing pain management strategies with your healthcare provider can be beneficial.

Conclusion
In summary, your journey with DCIS and the associated concerns about monitoring and treatment is complex and requires a tailored approach. It is essential to maintain open communication with your healthcare team, express your concerns, and advocate for the follow-up care you believe is necessary. Regular monitoring, appropriate imaging, and a clear understanding of your treatment options will empower you in managing your breast health effectively. If you feel uncertain about your current treatment plan, seeking a second opinion from a breast specialist may provide additional clarity and reassurance.

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