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| {{Infobox_Disease |
| | #REDIRECT [[Ductal carcinoma]] |
| Name = {{PAGENAME}} |
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| Image = Breast DCIS histopathology (1).jpg |
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| Caption = Histopathologic image from ductal cell carcinoma in situ (DCIS) of breast. Hematoxylin-eosin stain. |
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| DiseasesDB = |
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| ICD10 = {{ICD10|C|50||c|50}}, {{ICD10|D|05||d|00}} |
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| ICD9 = {{ICD9|174}}-{{ICD9|175}}, {{ICD9|233.0}} |
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| ICDO = {{ICDO|8500|2}}-{{ICDO|8500|3}} |
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| OMIM = |
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| MedlinePlus = |
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| eMedicineSubj = |
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| eMedicineTopic = |
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| MeshID = D018270 |
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| }}
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| [[Image:BreastCancer.jpg|thumb|200px|right|[[Mastectomy]] specimen containing a very large '''invasive ductal carcinoma''' of the breast.]]
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| [[Image:Breast cancer gross appearance.jpg|thumb|200px|right|Typical macroscopic ([[gross examination|gross]]) appearance of the cut surface of a [[mastectomy]] specimen containing an '''invasive ductal carcinoma''' of the breast (pale area at the center).]]
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| {{SI}}
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| {{CMG}}
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| {{EH}}
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| ==Overview==
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| '''Mammary ductal carcinoma''' is the most common type of [[breast cancer]] in [[women]]. It comes in two forms: '''infiltrating ductal carcinoma''' (IDC), an invasive, [[malignant]] and abnormal proliferation of [[neoplasm|neoplastic]] cells in the breast tissue and '''ductal carcinoma [[in situ]]''' (DCIS), a noninvasive, possibly malignant neoplasm that is still confined to the lactiferous ducts, where breast cancer most often originates.
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| ==Intraductal carcinoma==
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| '''Intraductal carcinoma of the breast''' (Ductal [[Carcinoma in situ|Carcinoma In Situ]], DCIS) is the most common type of noninvasive breast cancer in women. Ductal carcinoma refers to the development of [[cancer cells]] within the [[mammary gland|milk ducts]] of the breast. ''[[In situ]]'' means "in place" and refers to the fact that the cancer has not moved out of the duct and into any surrounding tissue. <p>
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| As screening mammography has become more widespread, DCIS has become one of the most commonly diagnosed breast conditions, now accounting for 20% of screening detected breast cancer <ref>{{cite journal |author=Ernster VL, Ballard-Barbash R, Barlow WE, ''et al'' |title=Detection of ductal carcinoma in situ in women undergoing screening mammography |journal=J Natl Cancer Inst |volume=94 |issue=20 |pages=1546–54 |year=2002 |month=Oct |pmid=12381707 |doi= |url=http://jnci.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=12381707}}</ref>. It is often referred to as "stage zero breast cancer." In countries where screening mammography is uncommon, DCIS is sometimes diagnosed at a later stage, but in countries where screening mammography is widespread, it is usually diagnosed on a mammogram when it is so small that it has not yet formed a palpable lump. DCIS is not traditionally regarded as being harmful in itself, however there is evidence of metastases in up 2% of cases of DCIS <ref>{{cite journal |author=Kelly TA, Kim JA, Patrick R, Grundfest S, Crowe JP |title=Axillary lymph node metastases in patients with a final diagnosis of ductal carcinoma in situ |journal=Am J Surg |volume=186 |issue=4 |pages=368–70 |year=2003 |month=Oct |pmid=14553852 |doi= 10.1016/S0002-9610(03)00276-9|url=http://linkinghub.elsevier.com/retrieve/pii/S0002961003002769}}</ref>.
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| <p>
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| DCIS is usually discovered through a [[mammogram]] as very small specks of calcium known as [[microcalcification]]s. However, not all microcalcifications indicate the presence of DCIS, which must be confirmed by biopsy. DCIS may be multifocal, and treatment is aimed at excising all of the abnormal duct elements, leaving "clear margins", an area of much debate. After excision treatment often includes local radiation therapy. With appropriate treatment, DCIS is unlikely to develop into invasive cancer. Surgical excision with radiation lowers the risk that the DCIS will recur or that invasive breast cancer will develop.<p>
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| ===Treatment options for DCIS===
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| DCIS patients have two surgery strategy choices. They are lumpectomy (most commonly followed by radiation therapy) or mastectomy.<p>
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| [[Lumpectomy]] is surgery that removes only the cancer and a rim of normal breast tissue around it. For women with only one area of cancer in their breast, and a tumor under 4 centimeters that was removed with clear margins, lumpectomy followed by radiation is often equivalent to mastectomy for mortality related to their cancer, albeit at the higher risk of local disease recurrence on the breast/chest wall. The addition of radiation therapy to lumpectomy in DCIS reduces the risk of local recurrence by about 58% as compared to excision alone. Lumpectomy with radiation is estimated to carry between a 12-19% chance at 15 years for local recurrence of breast cancer (approximately a 0.5% to 1.0% risk per year), which would require a "salvage mastectomy".
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| Patients with family history of breast cancer and those presenting with breast cancer who are less than 40 years old face higher risks of local recurrence with breast conservation techniques. Extensive DCIS of high grade, large size, and resected with minimal surgical margins, even with radiotherapy, results in recurrence rates of at least 50% and would be better served with a mastectomy procedure.<p>
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| [[Mastectomy]] may also be the preferred treatment in certain instances:
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| * Two or more tumors exist in different areas of the breast (a "multifocal" cancer).
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| * Failure to achieve adequate margins on attempted lumpectomy.
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| * The breast has previously received [[radiation]] (XRT) treatment.
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| * The tumor is large relative to the size of the breast.
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| * The patient has had [[scleroderma]] or another disease of the connective tissue, which can complicate XRT treatment.
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| * The patient lives in an area where XRT is inaccessible
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| * The patient is apprehensive about their risk of local recurrence
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| * The patient is less than 40 or has a strong family history of breast cancer
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| The system for analysing the suitability of DCIS patients for the options of breast conservation without radiation, breast conservation with radiation, or mastectomy is called the VanNuys Prognostic Scoring Index (VNPI). This VNPI analyzes DCIS features in terms of size, grade, surgical margins, and patient age and assigns "scores" to favourable features. <p>
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| Tamoxifen or another hormonal therapy is recommended for some women with DCIS to help prevent breast cancer. Hormonal therapy further decreases the risk of recurrence of DCIS or the development of invasive breast cancer. However, they have potentially dangerous side effects, such as increased risk of endometrial cancer, severe circulatory problems, or stroke. In addition, hot flashes, vaginal dryness, abnormal vaginal bleeding, and a possibility of premature menopause are common for women who were not yet menopausal when they started treatment.<p>
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| Unlike women with invasive breast cancer, women with DCIS do not undergo chemotherapy and have traditionally not been advised to have their lymph nodes tested or removed. Some institutional series reporting significant rates of recurrent invasive cancers after mastectomy for DCIS, have recently endorsed routine sentinal node biopsy (SNB) in these patients. <ref>{{cite journal |author=Tan JC, McCready DR, Easson AM, Leong WL |title=Role of sentinel lymph node biopsy in ductal carcinoma-in-situ treated by mastectomy |journal=Ann Surg Oncol. |volume=14 |issue=2 |pages=638–45 |year=2007 |month=Feb |pmid=17103256 |doi=10.1245/s10434-006-9211-9 |url=}}</ref>, while other have concluded it be reserved for selected patients. Most agree that SNB should be considered with tissue diagnosis of high risk DCIS (grade III with palpable mass or larger size on imaging) as well as in patients undergoing mastectomy after a core or excisional biopsy diagnosis of DCIS. <ref>{{cite journal |author=van Deurzen CH, Hobbelink MG, van Hillegersberg R, van Diest PJ |title=Is there an indication for sentinel node biopsy in patients with ductal carcinoma in situ of the breast? A review |journal=Eur J Cancer. |volume=43 |issue=6 |pages=993–1001 |year=2007 |month=Apr |pmid=17300928 |doi=10.1016/j.ejca.2007.01.010 |url=}}</ref><ref>{{cite journal |author=Yen TW, Hunt KK, Ross MI, ''et al'' |title=Predictors of invasive breast cancer in patients with an initial diagnosis of ductal carcinoma in situ: a guide to selective use of sentinel lymph node biopsy in management of ductal carcinoma in situ |journal=J Am Coll Surg. |volume=200 |issue=4 |pages=516–26 |year=2005 |month=Apr |pmid=15804465 |doi=10.1016/j.jamcollsurg.2004.11.012 |url=}}</ref> Experts are not sure whether all women with DCIS would eventually develop invasive breast cancer if they live for a long time and are not treated.<p>
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| ==Invasive Ductal Carcinoma==
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| '''Invasive Ductal Carcinoma''' (IDC) is the most common form of invasive breast cancer. It accounts for 80% of all types of breast cancer. On a [[mammography|mammogram]], it is usually visualized as a mass with fine spikes radiating from the edges. On [[physical examination]], this lump usually feels much harder or firmer than benign breast lesions. On [[microscopic examination]], the cancerous cells invade and replace the surrounding normal tissues. IDC is divided in several [[histology|histological]] subtypes.
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| ===Prognosis for IDC===
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| The [[prognosis]] of IDC depends, in part, on its histological subtype. Mucinous, papillary, cribriform, and tubular carcinomas have longer survival, and lower recurrence rates. The prognosis of the most common form of IDC, called "IDC Not Otherwise Specified", is intermediate. Finally, some rare forms of breast cancer (e.g. sarcomatoid carcinoma, [[inflammatory breast cancer|inflammatory carcinoma]]) have a poor prognosis.
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| Regardless of the histological subtype, the prognosis of IDC depends also on its [[Cancer staging|staging]], [[Grading (tumors)|histological grade]], expression of hormone receptors and of [[oncogenes]] like [[HER2/neu]].
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| ===Treatment options for IDC===
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| Treatment of IDC usually starts with surgery to remove the main tumor mass and to sample the [[lymph nodes]] in the axilla. The [[cancer staging|stage]] of the tumor is ascertained after this first surgery. [[Adjuvant therapy]] (i.e. treatment after surgery) usually includes [[chemotherapy]], [[radiotherapy]], hormonal therapy (e.g. [[Tamoxifen]]) and targeted therapy (e.g. [[Trastuzumab]]). More surgery is occasionally needed to complete the removal of the initial tumor or to remove recurrences.
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| The treatment options offered to an individual patient are determined by the form, stage and location of the cancer, and also by the age, history of prior disease and general health of the patient. Not all patients are treated the same way.
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| ==References==
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| {{reflist|2}}
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| ==Additional Resources==
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| * Original text on IDC from [http://woman-health.org/virtual/Infiltrating_Ductal_Carcinoma Infiltrating Ductal Carcinoma], licensed under the [[GNU Free Documentation License]].
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| * [http://www.center4research.org/wmnshlth/2006/dcis10-06.html DCIS, LCIS, and Other Stage 0 Breast Cancer, National Research Center for Women & Families]
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| {{Breast cancer}}
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| {{Epithelial neoplasms}}
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| {{Breast neoplasia}}
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| {{SIB}}
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| [[Category:Breast cancer]]
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| [[bs:Duktalni invazivni karcinom dojke]]
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| [[it:Carcinoma duttale infiltrante]]
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| [[Category:Surgery]]
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| [[Category:Oncology]]
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