Perspectives in Breast Cancer Pathology
Michael D. Lagios, MD

Risk of DCIS recurrence by Oncotype DCIS technology - some concerns
Predicting patients with DCIS who will recur locally: we’ve been trying to do that for 30 years. But now we can, the Holy Grail has been recovered in the form of Oncotype DCIS, or so we’ve been told. A single genetic test capable of identifying risk of local recurrence after breast conservation for mammographically detected DCIS would obviate the need to factor in DCIS grade, size, margin width and age.

The Oncotype DCIS gene signature assay was validated in a registration trial (Solin et al 2013) which strictly defined permissible size 25 mm or less for low-intermediate grade and 10 mm or less for high grade and margin widths (3 mm or more).
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Tamoxifen as An Adjuvant Agent for Ductal Carcinoma In Situ (DCIS)
Tamoxifen has been considered a standard adjuvant agent, for local control in DCIS patients undergoing breast conservation with or without irradiation. This viewpoint derived from the initial results of NSABP-B24, which claimed a significant benefit for ipsilateral local control and contralateral chemoprevention.

Both trials, which had employed tamoxifen as an adjuvant agent in DCIS patients (NSABP-B24 and UK/ANZ) have been updated in 2011 (Wapnir et al 2011 and Cuzick et al 2011), and have initiated some pointed commentary (Cadiz and Kuerer 2012; Warrick and Allred 2012).
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The Clinical Significance of Immunohistochemically Detectable Epithelial Cells in Sentinel Lymph Node and Bone Marrow in Breast Cancer
The application of immunohistochemical techniques capable of detecting single epithelial cells in the sentinel lymph node and in the bone marrow of breast cancer patients has resulted in much confusion among treating oncologists. Many breast cancer patients, particularly those with immunohistochemically positive sentinel nodes, have been upstaged and treated as if they had significant metastatic disease. Such single cell metastases are often regarded as entirely comparable to gross metastases a million-fold or greater in size for which many decades of outcome data confirm prognostic significance.
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Factors Influencing the Accuracy of a Core Biopsy Diagnosis of Atypical Hyperplasia - A Perspective on a Frequent Problem
One of the few diagnostic limitations of stereotactic biopsy evident in initial reports of its utility (Jackman et al, 1994, 1999; Liberman et al, 1995) was a 48-58% rate of underdiagnosing DCIS or DCIS with invasion as demonstrated in a subsequent open biopsy. This initial experience has generated a widely recognized mandate for the necessity of an open biopsy for any diagnosis of ADH in a stereotactic biopsy. However, this mandate is an oversimplification. In fact, use of more precise pathologic and mammographic guidelines can markedly reduce the need for reexcision of stereotactic biopsies demonstrating ADH.
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Contradictory treatment recommendations for ductal carcinoma in situ (DCIS)

The vast majority of women with DCIS are told that in addition to surgical excision, radiation therapy and tamoxifen (or an aromatase inhibitor in postmenopausal patients) will be required for local control of their disease in program of breast conservation. Yet, half of US women with DCIS who elect breast conservation forgo radiation therapy, an option recognized by the NCCN and others. These competing recommendations sow much confusion and anxiety in patients. This problem reflects the contrast between the historical, but limited results of the randomized trials of radiation therapy for DCIS, and modern prospective studies which have utilized a different approach.
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