Assessment of treatment for patients with primary ductal carcinoma in situin the breast

Background: Current mammographic technology has resulted in increased detec tion of ductal carcinoma in situ (DCIS). It is necessary to assess which pa tients presenting with DCIS are good candidates for breast conservation and which of these patients should receive adjuvant radiation. Methods: We accrued clinical data for 124 patients with a primary diagnosis of DCIS from 1979 through 1994. Primary therapy was a mastectomy for 18 pa tients, and a lumpectomy for 106 patients. Only 18 of the latter group of p atients received adjuvant radiotherapy. For the 88 lumpectomy-alone patient s (median follow-up, 5.2 years), we evaluated the effects of clinical (age and initial presentation) and pathologic (nuclear grade, architecture, pare nchymal involvement, calcifications, and measured margins) factors on recur rence of DCIS or the development of invasive breast cancer. Results: patients who underwent lumpectomy with or without adjuvant radioth erapy (median follow-up, 5.0 years) were significantly more likely to have recurrence of DCIS (P = .05) than those who underwent mastectomy (median fo llow-up, 6.7 years): 18% (19/106) versus 0% (0/18), respectively; lumpectom y-alone patients experienced a 19% (17/88) rate of DCIS recurrence. All rec urrent DCIS was ipsilateral. For lumpectomy-alone patients, the factors ass ociated with ipsilateral recurrence of DCIS were extent of involvement of t he parenchyma (P = .01, for univariate; P = .07, for multivariate) and init ial presentation (P = .05, for univariate; P = .07, for multivariate). Elev en lumpectomy-alone patients developed invasive breast cancer (6 ipsilatera l, 5 contralateral); none of the 18 lumpectomy patients who received adjuva nt radiation developed invasive disease. None of the factors investigated, including primary surgery and adjuvant radiotherapy, were associated with a significant effect on the development of invasive disease. Conclusions: Longer follow-up is required to determine if the benefits of e ither mastectomy or radiotherapy following lumpectomy persist. There is a s uggestion that patients under 40 years of age or women who present with nip ple discharge might be considered for either adjuvant radiotherapy followin g lumpectomy or a simple mastectomy.