Introduction
xvii
repeats the scenario of the 1980s and 1990s when there was
a movement to replace LCIS with names such as lobular
neoplasia (LN). The very same reasons were put forth for
this change as are now offered for removing the word carci-
noma from DCIS: changing the name would reduce patient
anxiety and lead to less aggressive therapy. One phase of
this effort was to promulgate the concept that LCIS was
only a marker of breast carcinoma risk and not a precursor
to invasive carcinoma. If this were true, mastectomy, then a
frequent treatment option after the diagnosis was made by
biopsy, would no longer be appropriate.
Research conducted in the past two decades, described
in detail in Chapter 31, clearly demonstrated that LCIS is a
nonobligate precursor to invasive lobular carcinoma. This
means that not every patient with LCIS develops invasive
lobular carcinoma in their lifetime, but when it occurs,
invasive lobular carcinoma arises from LCIS. It is also well
established that patients with LCIS are at increased risk to
develop invasive ductal carcinoma that arises independently
from the LCIS. In the ensuing years, little progress has been
made in distinguishing patients with LCIS who are likely to
experience progression to either type of invasive carcinoma
from those unlikely to have this outcome. Now, approxi-
mately 30 years later, clinical management for LCIS usually
consists of medical therapy and clinical observation for a
disease that is again widely referred to as LCIS.
Thus, in the case of LCIS, concern with “overtreatment”
was expressed in proposals to change the name of the dis-
ease, but other factors played a much more important role
in creating a new treatment paradigm. Most important of
these was a better understanding of the clinical course of the
disease that resulted from retrospective long-term follow-up
studies of untreated patients published in 1978 and sub-
sequent prospective studies that are described in detail in
Chapter 31. Historically, the movement away from mastec-
tomy for the treatment of LCIS coincided with the discovery
of hormone receptor proteins, particularly those involved
in the response of mammary carcinoma to estrogens and
progesterone, and the introduction of selective estrogen
receptor modulators (SERMS) such as tamoxifen that have
significantly reduced the risk of developing invasive carci-
noma in patients with LCIS. While efforts to delete the word
“carcinoma” from LCIS may have prompted controversy
and drawn attention to the need for changes in therapy, it
was better understanding of the clinical and biologic charac-
teristics of the disease, accompanied by new, effective forms
of treatment that brought about the desired result.
The foregoing notwithstanding, the concerns expressed
by Drs. Esserman, Thompson, and Reid raise an important
question about our understanding of the biology of DCIS.
Retrospective, long-term follow-up studies described in
detail in Chapter 11 demonstrated that if left untreated after
a biopsy, about 40% of patients with low-grade DCIS devel-
oped invasive carcinoma. Among the remaining majority
of patients, the absence of subsequent invasive carcinoma
may have been due to complete removal of the DCIS in the
intraepithelial stage, there are substantial differences be-
tween organ sites. Among these differences from a clinical
standpoint, accessibility is a critical issue when it comes to
treatment. Thus, it is possible to directly observe and follow
over time the epithelium of organs with external orifices
such as the uterine cervix, the urinary bladder and the gas-
trointestinal tract. Repeated cytologic samples can be taken
from these sites without performing a surgical procedure
that removes part of the lesion. These organs, and others
such as the prostate gland, can also be monitored with small
biopsy samples. As a consequence, it is possible to track
preinvasive lesions at these sites in order to distinguish
between conditions that can be managed with minimally
invasive procedures and those that require more aggressive
treatment.
On the other hand, despite repeated efforts to improve
mammary ductoscopy, virtually all of the complex glandular
structure of the breast where carcinomas arise is not acces-
sible for direct observation, and current imaging technolo-
gies only reveal structural alterations without identifying
the precise causes of the changes. Sequential imaging that
requires repeated radiation exposure only documents the
evolution of structural changes. For example, a mass lesion
caused by mammary carcinoma usually has an invasive
component, but in some circumstances it may consist
entirely of noninvasive, intraepithelial carcinoma (DCIS)
when excised and thoroughly examined microscopically.
If such a tumor were investigated by needle biopsy and the
sample proved to be DCIS, there is currently no method
(comparable to culposcopy of the uterine cervix) whereby
the nature of the remainder of the tumor could be ascer-
tained without removing it entirely. Applying the paradigm
of the uterine cervix in the forgoing circumstance would
require allowing the mass to remain in the breast and
following it with serial imaging studies. If by chance an
invasive focus already existed in the mass, this procedure
would allow the invasive carcinoma to expand and increase
the likelihood of metastatic spread. If left in place, whether
indolent or not, the incompletely excised lesion would prob-
ably enlarge over time, creating growing anxiety, and yet it
might remain entirely noninvasive. This would clearly be an
unacceptable way to manage DCIS clinically, and changing
the name of the lesion would not solve this conundrum, nor
need it change treatment after the diagnosis. Within the lim-
its of our current knowledge, the cornerstone of clinical care
for intraepithelial ductal carcinoma of the breast (DCIS) is
complete excision and thorough histologic examination of
the lesion when it is detected. At present, no procedure short
of this can provide the full appreciation of the nature and
extent of the lesion that is needed to guide treatment.
In reviewing the proposal to remove the word carcinoma
from the intraepithelial, noninvasive stage of ductal carci-
noma, one is reminded of the famed manager of the New
York Yankees baseball team, Yogi Berra, who is credited
with the remark, “It’s like déjà vu all over again.” In the
current context, the effort to delete carcinoma from DCIS
