394
Chapter 11
surgery had significantly lower breast cancer mortality than
those treated by breast-conserving surgery alone.
Breast Conservation by Excision
Only—Retrospective Data
Long-term follow-up of DCIS treated by local excision alone
was documented in several retrospective reports. The pa-
tients were identified in reviews of breast biopsies initially
deemed to be benign but found to contain foci of DCIS on
review. One of the earliest series consisted of eight patients
with DCIS detected by Kiaer
358
in a review of patients with
“fibroadenomatosis” (proliferative breast changes). “Follow-
up revealed that 6 of these 8 patients had died of mammary
carcinoma which had become clinically manifest 1-1/2 to
16 years after the first operation.”
359
Two of nine patients
treated by local excision for DCIS developed breast recur-
rences in a series described by Millis and Thynne.
359
Another series consisted of 10 patients, who, in ret-
rospect, had low-grade papillary or micropapillary DCIS
identified in 8,609 biopsies from 1940 to 1950.
360
During fol-
low-up averaging 21.6 years, 7 (70%) of the 10 patients were
found to have subsequent carcinoma in the same breast after
an average interval of 9.7 years. Six of the seven subsequent
carcinomas were invasive. Four of these women developed
metastatic carcinoma, which was fatal in two instances. In a
later report, the series was expanded to 15 patients, 8 (53%)
of whom developed subsequent carcinoma.
361
Harvey and
Fechner
362
reviewed 879 breast biopsies from 1962 to 1966
reported to be benign. They identified six patients with pre-
viously undiagnosed papillary DCIS, all of whom remained
well, with four followed for less than 5 years and two for less
than 2 years.
Page et al.
363
found 28 women with DCIS treated by exci-
sion only in a review of 11,760 biopsies from 1950 to 1968.
The DCIS were described as low-grade cribriform and mi-
cropapillary types. Invasive carcinoma developed in the
ipsilateral breasts of 7 of 25 women who had follow-up of
at least 3 years. All subsequent carcinomas were at or near
the site of the original intraductal lesion. The observed fre-
quency of subsequent invasive carcinoma was 11 times the
expected rate. A second report by these investigators with
follow-up averaging nearly 30 years found that 9, or 32%,
of 28 women subsequently developed ipsilateral invasive
carcinoma.
364
This frequency was 9.1 times expected (95%
CI, 4.73 to 17.5). Further investigation of the series with a
median follow-up of 31 years revealed invasive carcinoma in
11 (39.3%) of the 28 women. Eight subsequent carcinomas
were diagnosed within 15 years of the original biopsy, and
three were detected after intervals of 23, 29, and 42 years,
respectively.
Eusebi et al.
365
found 28 examples of previously un-
diagnosed DCIS in a review of 4,397 biopsies performed
from 1965 to 1971. Twenty-one of the lesions were forms
of micropapillary carcinoma, four were cribriform, one
papillary-cribriform, and two had comedocarcinoma. Two
patients had ipsilateral recurrences. One of these women
who originally had comedocarcinoma developed an invasive
after transverse rectus abdominus myocutaneous (TRAM)
flap reconstruction. All were described as initially having
had extensive DCIS, and four patients had undergone a
skin-sparing mastectomy. Five of the recurrent lesions were
palpable. Two of four patients who underwent axillary dis-
section had nodal metastases. The report did not mention
whether breast glandular tissue was associated with the re-
current carcinoma lesions.
Introduction to Breast-Conserving Therapy
Despite the widespread reliance on mastectomy, alterna-
tive therapies involving excisional surgery and radiotherapy
were examined as early as the 1930s. After reviewing the re-
cord of his cases of intraductal comedocarcinoma, Blood-
good
8
commented that “the striking feature is that none of
the cases of pure comedo adenocarcinoma was associated
with metastasis to the axillary nodes, and not a single patient
died of cancer.” He described four patients with “pure” or
noninvasive comedocarcinoma who were “completely ex-
cised with postoperative irradiation” and remained well up
to 3 years later. These observations led him to conclude that
“when the tumor is small and a FS shows a pure comedo
neoplasm, it is sufficient to excise only the tumor.”
8
Occasional patients treated by local excision were men-
tioned in reviews of DCIS published in the 1960s and 1970s.
Farrow
356
reported on 25 patients treated by local excision
alone. Histologic features of the DCIS were not specified.
Further carcinoma developed in the same breast 1 to 8 years
after excision in 5 of the 25 women. The subsequent lesions
were “within or nearby the previous local excisional site.”
In 1971, Ashikari et al.
72
mentioned two patients, one of
whom refused surgery and a second with a medical contra-
indication who were treated by local excision and did not
develop recurrent carcinoma. Four of 64 patients with DCIS
described by Westbrook and Gallager
73
received only radia-
tion therapy after biopsy because of patient preference or
comorbid conditions.
The changing trend in the treatment of DCIS in the
United States was reported by Winchester et al.
20
in 1997,
who analyzed data of more than 39,000 women diagnosed
between 1985 and 1993. The use of breast conservation
therapy increased from 31% to 54%, and overall 33.4% of
patients did not undergo mastectomy during the 8-year
interval. Radiotherapy was employed in 38% of patients
treated by breast-conserving surgery in 1985 and in 54% in
1993. Axillary dissection was performed in 49% of cases with
or without mastectomy, but the frequency of this procedure
decreased from 52% in 1985 to 40% in 1993.
Joslyn
357
reviewed SEER data from various regions of the
United States from 1973 through 2000 to document trends in
the treatment of DCIS. The utilization of breast-conserving
surgery increased in all regions surveyed, ranging from 49.5%
in Utah to 76.9% in Connecticut for the period from 1997
through 2000. Women younger than 45 years at the time of
diagnosis were treated by breast-conserving surgery signifi-
cantly less often than those 45 years of age and older. Women
who received radiotherapy in addition to breast-conserving
