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 Table of Contents  
ORIGINAL ARTICLE
Year : 2022  |  Volume : 28  |  Issue : 1  |  Page : 79-82

A study to determine the incidence of coexisting carcinoma In situ in mastectomy specimens with invasive breast carcinoma


1 Department of General Surgery, GG Hospital, Thiruvananthapuram, Kerala, India
2 Department of General Surgery, Amala Institute of Medical Sciences, Thrissur, Kerala, India

Date of Submission12-Mar-2022
Date of Decision11-May-2022
Date of Acceptance11-May-2022
Date of Web Publication14-Jul-2022

Correspondence Address:
Dr. Bineesh Prakash
GG Hospital, Murinjapalam, Thiruvananthapuram - 695 011, Kerala
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ksj.ksj_8_22

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  Abstract 


Background: In situ breast carcinoma is a pre-invasive cancer that has not breached the epithelial basement membrane. This was previously a rare but is becoming increasingly common. It may be ductal carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS). DCIS is a precursor of invasive carcinoma, whereas LCIS is not a precursor but only a predictor of invasive carcinoma. In those with LCIS, 50% of the carcinomas occur in the contralateral breast. Aim: This paper aims to study the incidence of DCIS and LCIS in mastectomy specimens of invasive carcinoma breast. Materials and Methods: This is a subjective study of 226 patients in a tertiary care hospital over a period of 18 months. Patients with invasive breast carcinoma undergoing mastectomy were included. Patients with invasive breast carcinoma and those who have undergone any breast surgeries in the past were excluded. The histopathology reports were analysed for finding out DCIS and LCIS coexisting with invasive carcinoma of the breast. Results: The patients had a mean age of 56–11.025 years. 59.7% were in the 41–60-year age group. DCIS coexisted with invasive carcinoma in 28.3% (64). LCIS was absent in all cases of invasive carcinoma. Amongst those with DCIS, high-grade DCIS was found in 65.6% (42) and low-grade DCIS in 34.4% (22). Amongst the DCIS group, comedo type was present in 46.9% (30), followed by cribriform type 31.2% (20), solid type 18.8% (12) and papillary type 3.1% (2). Conclusion: DCIS was found to coexist with invasive carcinoma in 28.3% of cases, whereas LCIS was absent in all cases of invasive carcinoma.

Keywords: Breast Imaging-Reporting and Data System, carcinoma breast, lobular carcinoma in situ, mastectomy ductal carcinoma in situ


How to cite this article:
Prakash B, Mohanan P K. A study to determine the incidence of coexisting carcinoma In situ in mastectomy specimens with invasive breast carcinoma. Kerala Surg J 2022;28:79-82

How to cite this URL:
Prakash B, Mohanan P K. A study to determine the incidence of coexisting carcinoma In situ in mastectomy specimens with invasive breast carcinoma. Kerala Surg J [serial online] 2022 [cited 2022 Sep 24];28:79-82. Available from: http://www.keralasurgj.com/text.asp?2022/28/1/79/350908




  Introduction Top


In situ breast carcinoma is a pre-invasive cancer that has not breached the epithelial basement membrane. This was previously a rare, usually asymptomatic, finding in breast biopsy specimens but is becoming increasingly common; it now accounts for over 20% of breast cancers in Western world.[1] In situ carcinoma may be ductal (DCIS) or lobular (LCIS), the latter often being multifocal and bilateral. LCIS is regarded as a risk factor for the development of breast cancer, whereas DCIS is a precursor of invasive carcinoma. In those with LCIS, 50% of the carcinomas occur in the contralateral breast. Although mastectomy is curative, this constitutes overtreatment in many cases. The best treatment for in situ carcinoma is the subject of a number of ongoing clinical trials.

Screening mammography was introduced as a standard tool for breast cancer detection since 1960s. However, mammogram also had many drawbacks, including the detection and biopsy of many non-palpable lesions that eventually proved to be benign, resulting in psychological stress to many women and a substantial contribution to burden of costs on health-care systems.[2] Therefore, in an attempt to reduce unnecessary biopsies, the American College of Radiology (ACR) developed the Breast Imaging-Reporting and Data System (BI-RADS). The BI-RADS was developed in 1993 by the ACR to standardise the terminology used in reporting mammographic findings and provide a quality assurance tool. BI-RADS indicates the level of suspicion of breast cancer, improving communication between radiologists and clinicians. Recent advancements in ultrasonography (US) equipment has significantly increased the value of US in breast imaging, especially in women under the age of 40.[2]

Before 2000, breast magnetic resonance imaging (MRI) was regarded as a poor imaging tool for ductal carcinoma in situ (DCIS). Three remarkable changes in breast MRI occurred, which changed this assessment: (1) a shift from high temporal to high spatial imaging, revealing specific morphological features on MRI suspicious for DCIS; (2) a shift from diagnostic studies of patients with cancers identified on mammography to screening studies of high-risk patients, allowing more accurate comparisons of mammography versus MRI in detecting the full spectrum of breast cancers regardless of appearance on mammography; and (3) a shift from emphasis on masses to improved understanding of features of non-mass-like malignant lesions, distinct from benign background parenchymal enhancement patterns. Over the last decade, it has been confirmed that of all imaging tools, MRI has the highest sensitivity in detection of DCIS (compared to mammography and ultrasound). The rationale of this study lies in the fact that the chance of breast carcinoma in situ, especially DCIS, turning into an invasive breast carcinoma is 30%–40%.[3] It aims to determine the incidence of coexisting breast carcinoma in situ in mastectomy specimens of patients with invasive breast carcinoma undergoing surgery and to assess the presence of coexisting breast carcinoma in situ by histopathological examination in mastectomy specimens of invasive breast carcinoma patients.


  Materials and Methods Top


It was a descriptive study conducted in a tertiary care hospital amongst patients with invasive breast carcinoma undergoing mastectomy from January 2018 to June 2019. Patients with invasive breast carcinoma who underwent chemotherapy or radiotherapy or hormonal therapy prior to surgery and those who had undergone any breast surgeries in the past were excluded. Sample size was calculated as:

n = Z2PQ/D2 = (1.96) 2 pq/d2

p = prevalence = 0.298 (prevalence of breast carcinoma in situ amongst all breast cancers) (3)

q = 1 − 0.298 = 0.702

d = 20% of pn = 226.

The patients with invasive breast carcinoma undergoing mastectomy with or without axillary clearance were assessed at the time of admission and their mastectomy specimens examined histopathologically. All patients satisfying the inclusion criteria will be included in the study based on histopathology report. Detailed history and clinical examination will be done based on the pro forma. The subjects were briefed about the study and informed written consent was obtained. The data obtained were coded and entered in Microsoft Excel sheet and analysed using the statistical software, Statistical Package for Social Sciences (SPSS Version 23. IBM, India 2021). Results are expressed in percentage and proportions.


  Results Top


The mean age of the study group was 56.00 years, with a standard deviation (SD) of 11.025 years, the majority 135 (59.7%) of subjects lying in the 41–60-year age group [Table 1].
Table 1: Age distribution of carcinoma breast

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The majority of patients presented with complaints of breast lump, 210 (92.9%), while 10 (4.4%) presented with breast pain and 6 (2.7%) presented with bloody discharge [Table 2].
Table 2: Presenting complaints

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The majority of subjects with lesions were found to have an age of menarche at 15 years (32.7%), followed by 14 years (25.7%) and 13 years (16.8%), as shown in [Table 3].
Table 3: Distribution of age at menarche

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[Table 4] shows that majority of our subjects attained menopause at the age of 45–48 years (51.3%).
Table 4: Distribution of age at menopause

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The average age at first child birth of the study population was within the range of 21–23 years (39.8%), as shown in [Table 5].
Table 5: Distribution of age at first child birth

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Amongst the 226 study subjects, only 9 (4%) were nulliparous [Table 6].
Table 6: Distribution of number of pregnancies

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The study population did not have either smoking or alcohol intake as addictions. Amongst our study subjects, the incidence of breast carcinoma was more on the left side – 150 (66.4%). 7.5% of patients had a family history of breast cancer and 1.3% of patients had a family history of ovarian cancer. 8% gave a history of intake of oral contraceptive pills and 2.2% gave a history of hormone replacement therapy.

On performing ultrasonography, most of the patients presented with BI-RADS 5 lesion (61.1%) followed by BI-RADS 4 (38.1%), as shown in [Table 7].
Table 7: Sonomammogram

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Histopathologically, most of the patients had invasive ductal carcinoma NOS (92.5%), followed by invasive lobular carcinoma (5.3%), medullary carcinoma (1.3%) and tubular carcinoma (0.9%), as shown in [Table 8].
Table 8: Type of invasive carcinoma

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DCIS was found to coexist with invasive carcinoma in 64 (28.3%) cases, whereas lobular carcinoma in situ (LCIS) was absent in all cases of invasive carcinoma [Table 9].
Table 9: Invasive carcinoma without in situ/with ductal carcinoma in situ/with lobular carcinoma in situ

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Amongst the 64 patients with DCIS, high-grade DCIS was found in 42 (65.6%) and low-grade DCIS in 22 (34.4%). Amongst the DCIS patients, the most common type was comedo 30 (46.9%), followed by cribriform 20 (31.2%), solid 12 (18.8%) and papillary 2 (3.1%).


  Discussion Top


Non-invasive neoplasms of the breast are broadly divided into two major types, LCIS and DCIS. LCIS is regarded as a risk factor for the development of breast cancer, whereas DCIS is a precursor of invasive carcinoma. The aim of the study was to find out the incidence of coexisting breast carcinoma in situ in mastectomy specimens of patients with invasive breast carcinoma undergoing surgery. Our cohort consisted of 226 female patients, with a mean age of 56 years, and the majority were in the 41–60-year age group. Most of the patients presented with complaints of breast lump. The age at menarche of the study subjects were mostly 15 years. Most attained menopause at the age of 45–48 years. The average age at first child birth of the study population was from 21 to 23 years. Only 4% were nulliparous. 66.4% had left breast carcinoma. 7.5% had a family history of breast cancer and 1.3% had a family history of ovarian cancer in their first-degree relatives. There was a history of intake of oral contraceptive pills in 8% of subjects and 2.2% gave a history of hormone replacement therapy. Most of the patients presented with BI-RADS 5 lesion followed by 38.1% with BI-RADS 4 lesion. 92.5% had invasive ductal carcinoma, followed by invasive lobular carcinoma in 5.3%, medullary carcinoma in 1.3% and tubular carcinoma in 0.9%. DCIS was found to coexist with invasive carcinoma in 28.3% of cases, compared to Goh et al. study which had an incidence of 20.6%.[1] LCIS was absent in all cases of invasive carcinoma. Amongst those with DCIS, high-grade DCIS was found in 65.6% and low-grade DCIS in 34.4%. Amongst the DCIS group, comedo type was present in 46.9%, followed by cribriform type in 31.2%, solid type in 18.8% and papillary type in 3.1%.


  Conclusion Top


This study represents a descriptive cohort study to determine the incidence of breast carcinoma in situ in mastectomy specimens of patients with invasive breast carcinoma. In our study, DCIS was found to coexist with invasive carcinoma in 28.3% of cases, whereas LCIS was absent in all cases of invasive carcinoma. The most common type of DCIS was comedo type, followed by cribriform type, solid type and papillary type in the descending order of frequency.

Financial support and sponsorship

Nil.

Conflict of interest

There are no conflicts of interest.



 
  References Top

1.
Goh CW, Wu J, Ding S, Lin C, Chen X, Huang O, et al. Invasive ductal carcinoma with coexisting ductal carcinoma in situ (IDC/DCIS) versus pure invasive ductal carcinoma (IDC): A comparison of clinicopathological characteristics, molecular subtypes, and clinical outcomes. J Cancer Res Clin Oncol 2019;145:1877-86.  Back to cited text no. 1
    
2.
Shapiro S, Strax P, Venet L. Periodic breast cancer screening in reducing mortality from breast cancer. JAMA 1971;215:1777-85.  Back to cited text no. 2
    
3.
Virnig BA, Tuttle TM, Shamliyan T, Kane RL. Ductal carcinoma in situ of the breast: A systematic review of incidence, treatment, and outcomes. J Natl Cancer Inst 2010;102:170-8.  Back to cited text no. 3
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6], [Table 7], [Table 8], [Table 9]



 

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