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Decision-making and technical skills to prevent local recurrence after mastectomy for pure ductal carcinoma in situ

 Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Department of Woman and Child Health and Public Health, Multidisciplinary Breast Unit; Rome, Italy

Date of Submission25-Dec-2020
Date of Decision02-Jan-2021
Date of Acceptance05-Jan-2021
Date of Web Publication18-Jun-2021

Correspondence Address:
Gianluca Franceschini,
Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy.Department of Woman and Child Health and Public Health, Multidisciplinary Breast Unit, Rome, Italy. Università Cattolica del Sacro Cuore, Rome
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/jcrt.jcrt_1881_20

PMID: 34213501

How to cite this URL:
Franceschini G, Leone AD, D'Archi S, Masetti R. Decision-making and technical skills to prevent local recurrence after mastectomy for pure ductal carcinoma in situ. J Can Res Ther [Epub ahead of print] [cited 2022 Aug 7]. Available from: https://www.cancerjournal.net/preprintarticle.asp?id=318949

Ductal carcinoma in situ (DCIS) represents up to 20% of newly diagnosed breast cancers due to widespread adoption of screening. Conservative mastectomies with immediate reconstruction are the optimal local treatment in wide DCIS, multicentric disease, inadequate margins after breast-conserving surgery, and other contraindications to breast conservation.[1],[2],[3]

The main goal of treatment is to avoid local failure with possible invasive recurrence that could lead to metastasis in 12%–15% of the cases;[4] various studies demonstrated that young age, high nuclear grade, and inadequate margins increase the risk of local recurrence (LR).[2],[3],[4],[5]

We agree with Donghyun Kim et al. that resection margin status has a great impact on LR after mastectomy for DCIS: patients with positive margin have a 2.91-fold higher risk of LR than those with close margin.[1]

However, appropriate knowledge, surgical training, and expertise are essential requirements to minimize the risk of LR; individual dexterity and technical ability but also decision-making skills and repetitive performance of specific tasks are crucial to optimize oncological outcomes; the modern breast surgeon should always perform standardized steps to reduce the risk of local failure:

  • Accurate preoperative study by ultrasonography and mammography and selective use of magnetic resonance to assess the extent of DCIS, localize microcalcifications, and determine the more appropriate planes of dissection; a multidisciplinary discussion in a dedicated “Surgery Board” is useful to select the best candidates to mastectomy and the most appropriate techniques
  • Careful choice of the most “performing” skin incision designed on the basis of breast morphology and DCIS topography to achieve a better view of glandular tissue and anatomical planes; inframammary crease or lateral–radial incision is preferable in nipple-sparing mastectomy
  • Meticulous dissection of mammary gland performed in the subdermal fascial plane by preserving an adequate subcutaneous thickness to maintain vascular viability and avoid residual glandular tissue; the circummammary ligament is used as an anatomical guide to peripheral limits of mastectomy; and the maneuver of blunt dissection using the fingertips may be helpful to define the correct surgical plane and perform an accurate separation of the gland by all borders
  • Proper attention to conservation of the pectoralis major fascia while removing the mammary gland to ease the reconstructive stage
  • Accurate excision of retroareolar tissue for frozen section analysis in nipple-sparing mastectomy to evaluate the status of nipple–areola complex and minimize the risk of LR
  • Intraoperative radiological and pathological assessment of the removed specimen to define every lesion localized preoperatively and resection margins
  • Careful exploration of cavity postmastectomy to exclude the presence of residual glandular tissue; skin flaps should be visualized and trimmed, if necessary, to remove any residual tissue and ensure uniform flaps.

We strongly believe that adequate scientific knowledge, dedicated training for proper technical skills, and repetitive performance of standardized tasks in a multidisciplinary pathway are the most useful tools to prevent LR and increase the chance of success after mastectomy for DCIS.

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Conflicts of interest

There are no conflicts of interest.

 > References Top

Kim D, Ki Y, Kim W, Park D, Joo J, Jeon H, et al. Comparison of local recurrence after mastectomy for pure ductal carcinoma in situ with close or positive margins: A meta-analysis. J Cancer Res Ther 2020;16:1197-202.  Back to cited text no. 1
Mamtani A, Nakhlis F, Downs-Canner S, Zabor EC, Morrow M, King TA, et al. Impact of age on locoregional and distant recurrence after mastectomy for ductal carcinoma in situ with or without microinvasion. Ann Surg Oncol 2019;26:4264-71.  Back to cited text no. 2
Franceschini G, Terribile D, Magno S, Fabbri C, D'Alba P, Chiesa F, et al. Current controversies in the treatment of ductal carcinoma in situ of the breast. Ann Ital Chir 2008;79:151-5.  Back to cited text no. 3
Cutuli B. Les carcinomes canalaires in situ en 2019: Diagnostic, traitement, pronostic (Ductal carcinoma in situ in 2019: Diagnosis, treatment, prognosis). Presse Med 2019;48:1112-22.  Back to cited text no. 4
Timbrell S, Al-Himdani S, Shaw O, Tan K, Morris J, Bundred N. Comparison of Local Recurrence After Simple and Skin-Sparing Mastectomy Performed in Patients with Ductal Carcinoma In situ. Ann Surg Oncol 2017;24:1071-6.  Back to cited text no. 5


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