| Popis: |
Before the era of mammography, DCIS was an infrequent find and diagnosis was mainly clinical: it showed itself as palpable mass, nipple bloody discharge, or Paget’s disease of NAC [1, 2]. Surgeons were dealing with large DCIS, for whose the only surgical option was radical (traditional or modified) mastectomy (that was, at that time, the only operation considered oncologically safe); reconstruction was never performed, resulting in considerable cosmetic mutilation. Development and diffusion of mammography led to a critical change in this trend: at the time of diagnosis, DCIS became increasingly small. In the meantime, the success of breast-conserving surgery (BCS), which was proved safe for DCIS [3], brought to a decrease in the use of mastectomy for this type of breast neoplasm: today, 75% of ductal carcinomas in situ are treated with BCS [4], and the few cases of mastectomy are followed by breast reconstruction. Once clinical trials proved the oncological safety of all the surgical options cited above, attention was focused on the factors that would influence recurrence rate in DCIS, because recurrence is invasive in 50% of cases and 10–20% of invasive recurrences become metastatic [5–7]. Over the years, several predictive factors for recurrence were identified (age [8–10], family history, BRCA gene mutation, clinical presentation, nuclear grade [8, 9], histological subtype, comedo necrosis, size [8, 9], margin status [8, 9], radiotherapy [11], systemic therapy [12]). In 1996, Silverstein identified the most important predictive factors and combined them in an algorithm, the Van Nuys Prognostic Index, in order to identify the most suitable treatment for every single DCIS. Basing on size, margin status, histological features, and patient’s age, the recommended treatment could be excision alone (VPNI score 4–6), excision followed by adjuvant radiotherapy (VPNI score 7–9), or mastectomy (VPNI score 10–12) (see Fig. 7.1). |
