DUCTAL CARCINOMA IN SITU - case study

1.      SUMMARY

            Ductal carcinoma in situ (DCIS) is a non invasive breast cancer originating from cells that line the mammary ducts and if it not treated, DCIS can become invasive.  DCIS usually does not cause any symptoms if it is microcalcifications.  But patient could be having hard immobilized lump that maybe a mass in the breast.  This case study is regarding one woman 55 years of age, who came to the hospital for further investigation and treatment after she knew that she was having suspicious lesion in her right breast from her last mammogram done.  Patient was asked to do right mammogram for diagnosis.  Mammogram finding shows suspicious cluster microcalcifications on right upper outer quadrant of the breast.  Patient then was suggested to go for breast ultrasound as an adjunct to mammogram.  Ultrasound finding shows multiple benign cysts in both breasts and fibroadenoma in the right breast.  Based on the characteristics of the lesion from mammogram examination, radiologist concluded that the microcalcifications found in the right breast fall into BI-RADS category four which is suspicious abnormality.  Then, stereotactic biopsy of the right breast calcifications was performed and laboratory report shows result of DCIS.  Because of the confirmed DCIS, hook wire localization was performed and right breast surgery was carrying out.  Patient also was advised to take hormone therapy, tamoxifen to lower the risk of recurrent breast cancer in both breasts.  Patient was advised to come for checkup annually as a preventive measure.

2.      INTRODUCTION

            The breasts are made up of specialized tissue that produces milk which is glandular tissue as well as fatty tissue.  The part of the breast that produce milk is organized into 15 to 20 sections, called lobes.  Within each lobe, there are smaller structures called lobules, the place where milk is produced.  The milk travels through a network of tiny tubes called ducts, and the ducts join together into larger ducts, which finally exit the through the nipple (human anatomy, 2012).  Other than that, connective tissue and ligaments provide support to the breast while nerves provide sensation to the breast.  Also, the breast contains blood vessels, lymph vessels, and lymph nodes (human anatomy, 2012).           

            There are two main types of breast cancer which are ductal carcinoma and lobular carcinoma.  Ductal carcinoma is the type of cancer that origin in the ducts.  The ducts are the tubes that move milk from the breast to the nipple (Chen, 2012).  Whereas lobular carcinoma origin in the lobules, which is part of the breast that produce milk (Chen, 2012).  Breast cancer can be invasive or non invasive.  Invasive means that the cancer has spread from the ducts or lobules to other tissues in the breast while non invasive means that it has not yet spread to other breast tissue (Chen, 2012). There are two types of non invasive breast cancer, which are ductal carcinoma in situ (DCIS) and lobular carcinoma in situ (LCIS).      

            Most breast cancers are of ductal carcinoma type.  According to American Cancer Society, each year about 60000 cases of DCIS are diagnosed in the United States, accounting for about one out of every five new breast cancer cases (ductal carcinoma in situ, 2012).

2.1  Definition of Ductal Carcinoma In Situ

            Ductal carcinoma in situ (DCIS) is a non invasive breast cancer where an abnormal growth of cancer cells is still within the area where it started (Komen, 2012).  The term in situ means ‘in place’.  DCIS is also known as intraductal carcinoma.  When the cells of the milk duct lining grow out of control, DCIS will develop, but the cancer only stay within the breast duct and have not invaded the surrounding breast tissue (Komen, 2012).  It can affect one area of the duct, unifocal or more than one area of the duct, multifocal.  DCIS if not treated, may spread beyond the duct over time and can turn into invasive breast cancer.

2.2   Types of Ductal Carcinoma In Situ

            Patients will know which types of DCIS they have from the pathology report.  The doctors usually give treatment to these patients based on types of DCIS. According to Komen (2012), there are five types of DCIS. First type is called cribiform.  Cribiform is a grouping of cells with holes.  Second type is called solid, which is a grouping of cells with no spaces.  Next is called papillary type where the cells look like a large, flowerlike growths.  Micropapillary is another type of DCIS, which the cells look similar to the papillary cells but smaller in sizes.  Last one is In comedo type where the center of the duct is plugged with dead cell making it look white.  This last type is most aggressive type of DCIS and can become invasive breast cancer in the future.

2.3  Etiology

            The causes of DCIS are actually not clear.  DCIS forms when genetic mutations happen in the DNA of breast duct cells.  These genetic mutations cause the cells to appear abnormal; however the cells not yet have the ability to break out of the breast duct (ductal carcinoma in situ, 2011).  From ductal carcinoma in situ (2011), was mentioned that researchers were not sure exactly what triggers the abnormal cell to growth and become DCIS and likely some factors may play a part such as family history, patient’s environment, lifestyle, and genes which most common gene defect are found in the BRCA1 and BRCA2 genes and if a parent passes to the daughter a defective gene, the daughter have an increased risk of breast cancer (Chen, 2012).

2.4  Sign and Symptoms

            Early breast cancer usually does not show any symptoms.  Chen (2012) noted that symptoms only occur as the cancer grows and this include breast lump that is hard, felt like an uneven edge, and usually does not hurt.  Other symptoms such as change in the size, shape, or feel of the breast or nipple and have fluid coming from the nipple (Chen, 2012).  This fluid maybe bloody or look like pus.

            In advanced breast cancer, symptoms will include bone pain, breast pain and discomfort, skin ulcers, swelling in the armpit area, and weight loss (Chen, 2012).

3.      CASE REPORT

3.1  Patient History

      55 years old, Chinese women came to see the breast surgeon, Dr Azlina Firzah at Pantai Hospital, Kuala Lumpur after she realised that she was having suspicious lesion in her right breast.  She already did bilateral mammogram six month before at the other private centre.  After confirmation on the result of her mammogram, her physician recommended her to see a breast surgeon for further investigation and treatment.  Her physician also recommended that she proceed another mammogram after six month to see the progress.   

      Patient is a married lady with two children.  She has first degree family history of breast cancer which was her mother.  She’s already menopause since two years ago at age 53 and had not taken any hormone replacement therapy (HRT).  She has no history of breast surgery but has history of biopsy of right lump back in 1989.  Her first mammogram was done at the age of 31. 

      From her mammogram images done six month earlier from other center, the breast surgeon noted that there were microcalcifications seen in the right breast.  However, the images were not very clear because that medical center only have film screen mammography.  The breast surgeon requested the patient to repeat mammogram of the right breast using digital mammography to see the calcifications more clearly and also to determine the progress as well as ultrasound of both breasts as an adjunct to mammogram.

3.2   Diagnosis

3.2.1        Mammogram

            Reported by radiologist, Dr Asokan Raman Nair, mammogram of the right breast shows there are scattered microcalcifications seen.  There is however a loose cluster seen in upper outer quadrant with linear branching in one area.  No associated mass is detected.  For conclusion, compared to previous mammogram, the loose cluster in upper outer quadrant has increased and this requires further evaluation.  Appendix one shows diagnostic imaging report of mammogram. 

3.2.2        Ultrasound

            Patient did the breast ultrasound on the same day.  Ultrasound of both breasts were performed and reported by radiologist, Dr Asokan Raman Nair.

            Result of the ultrasound showed that on the right breast, a few small cysts were seen along nine to 12 o’clock measuring less than five milimeter.  No focal solid mass lesion seen.  While on the left breast, an eight millimeter cyst is seen in subareolar area along six o’clock.  A single solid 8 x 6 mm well defined nodule is seen along three o’clock.  There are also two tiny cysts along 12 o’clock.  On both breasts, there were no enlarged lymph node seen.  For conclusion, 8 x 6 mm solid well defined nodule in the left breast has benign features consistent with a fibroadenoma.  Appendix two shows diagnostic report of breast ultrasound.        

3.2.3        Biopsy

            Based on mammogram report, patient was advised to undergo stereotactic guided right breast biopsy.  Radiologist, Dr Asokan Raman Nair performed the biopsy.  The loose cluster of microcalcification in right outer mid quadrant was localized and stereotactic guided percutaneous biopsy was done under aseptic technique.  Four cores of tissue obtained.  Specimen radiograph shows calcification in three of the cores.  No complication occurs during and after biopsy. 

            The specimen was sent to histopathology laboratory for the result.  Histopathology report showed that the interpretation of right suspicious microcalcifications was ductal carcinoma in situ (DCIS).    

3.3  Patient’s Progress

      Patient was informed about the histopathology report where it was confirmed DCIS of the right breast.  Surgery and hookwire localization of right breast lesion was suggested by breast surgeon before the cancer become invasive.  Patient agreed to do hookwire localization procedure and breast surgery. It was performed on the same day. 

      Hookwire localization (HWL) of the right breast lesion was performed by radiologist.  Two hookwires inserted to the anterior inferior and posterolateral margins under aseptic technique and stereotatic guidance.  Patient was taken to operation room for the operation where the breast surgeon took out area of suspicious breast tissue under guidance that has been marked by two hookwires.  After that, the surgical specimen was sent to radiograph under mammogram.  Mammogram report showed microcalcification was observed within the surgical specimen.  Lastly, the surgical specimen was sent to histopathology laboratory for interpretation of right breast wide local excision (WLE) with HWL and result shows low to intermediate grade DCIS, no invasive carcinoma, and margins are free.  Appendix three shows histopathology report of the right surgical specimen.     

4.        DISCUSSION

            Appendix four shows figure 1 – 3, appendix five shows figure 4 – 8, appendix six shows figure 9 -12. 

            Rusiecki et al. (2005) noted that the risk factors of breast cancer are hormone related risk factors, lifestyle factor, and genetic risk factor.  Hormone related risk factors include age at menarche, parity, age at first full-term pregnancy, breastfeeding history, menopausal status, and age at menopause.  Lifestyle factor is like alcohol consumption and elevated body mass index.  Genetic risk factor is family history.  For this patient, one of the risk factor mentioned can be the cause of breast cancer.  Mentioned that patient already menopause and according to Henderson (2006) most breast cancer occur during the postmenopausal years.  Very much earlier, patient already did mammogram when she was 31 years old and even though, those days they found lump in her breast and did biopsy, report came back as normal.  While this time when she is 55 years old, there is ductal carcinoma in situ (DCIS) found in her right breast and according to Washbrook (2006), ageing is one of the single greatest risk factor for the development of new breast cancer and  most of the women diagnosed with breast cancer over the age of 55. 

            Another important factor is family history.  Henderson (2006) stated that a more substantial and clinically important increase in risk is associated with breast cancer in a first-degree relative who is mother, sister, or daughter.  For this patient, her mother had a history of breast cancer, which increases her risk to get breast cancer.   For patients who are at high risk for developing breast cancer such as this patient with a strong family history of breast cancer, screening from age 30 is recommended (mammograms in special circumstances, 2013).  This is why her first mammogram done was when she was 31 years old.      

            For this patient, the breast surgeon asked to repeat mammogram of the right breast because of two factors.  First,  because the films that patient brought from the other medical center was not clear and second, the surgeon want to see the progress of calcifications noted because it was already been six months after the last mammogram.  After six months, patient is allowed to do mammogram again but only on affected breast.  It is not necessary to exposed non affected breast with radiation for short period of time from the last mammogram.      

            The previous medical center only has film screen mammography instead of digital mammography.  This is why the mammogram images were not very clear when compared with digital mammogram images.  For the screen film mammography, x-ray beams are captured on a film cassette while digital mammography, x-ray beams are captured on a specially designed digital camera and a computer to produce an image (types of mammography, 2012).   Researchers reported that there is an increase in the rate of cancer detection with mammography in women with dense breasts after changing the facility from film screen to digital mammography (Evans & Harris, 2009).  Moreover, this patient’s breast is practically dense.

            Patient did unilateral mammogram, which means only one side of breast being radiographed, which is right breast.   The standard images have been taken.  They are right cranio caudal (cc) view and right medio lateral obliques (MLO) view as shown in figure one and two.   Because there were microcalcifications found on the right breast, additional view was taken which is magnification view of the right breast on cc view or can be called as right cc mag, this can be seen in figure three.  According to Peart (2005), magnification technique is extremely useful in evaluating calcifications.     

            Patient’s breast is dense breast which fall into BIRADS four density.  The American College of Radiology (ACR) has developed a way of describing the breast density.  This is by using Breast Imaging Reporting and Data System (BI-RADS) and this patient’s breast density fall into BI-RADS two category.  Breast density is classified by BI-RADS into four groups.  BI-RADS one, ‘the breast is almost entirely fat’.  BI-RADS one means that fibrous and glandular tissues makes up less than 25 percent of the breast.  BI-RADS two, ‘there are scattered fibroglandular densities’, means that fibrous and glandular tissue makes up from 25 to 50 percent of the breast.  BI-RADS three, ‘the breast tissue is heterogeneously dense’ and has more areas of fibrous and glandular tissue which is from 51 to 75 percent throughout the breast.  Lastly, BI-RADS four, ‘the breast tissue is extremely dense’ with more than 75 percent fibrous and glandular tissue made up the breast (mammogram report – BIRADS, 2013).

             There are four quadrants of the breasts which are upper outer quadrant, upper inner quadrant, lower outer quadrant, and lower inner quadrant.  Cranio caudal (cc) view of the breasts show outer and inner quadrant, figure one.  Outer quadrant is the portion adjacent to the armpit area while inner quadrant is the portion adjacent to the chest wall.  Medio lateral oblique (MLO) view of the breasts shows upper quadrant and lower quadrant, figure two.  Portion above the nipple is upper quadrant while below the nipple is lower quadrant.  The loose cluster of micocalcifications with linear branching in one area that was reported seen on the right breast, in cc view it is located on right outer quadrant of the breast and there is another calcifications seen located on right mid quadrant.  This can be seen in figure one.  While in MLO view, as show in figure two the loose cluster of micocalcifications is located on right upper quadrant, just above the nipple and some other calcifications located on right lower quadrant.  Overall the loose cluster is located on upper outer quadrant of the right breast and the other calcifications are on lower mid quadrant.  Many researchers stated that from their studies most of the cancer found is at the upper outer quadrant.  Kwong (2003) mentioned that it is the most common place on the breast to have tumor is the upper outer quadrant where 36 percent of tumors are found.

            Small calcium deposits in the soft tissue of the breast are called breast calcifications and they are very common in women and almost associated with a benign breast condition which unrelated to cancer (Halls, 2010).  Breast calcification appears as white dot on mammogram and according to radiologist it is not a cause of concern.  Microcalcifications are also calcium deposits but they are much smaller and much less common (Halls, 2010).  According to Halls (2010), microcalcifications tend to be the result of a genetic mutation in the breast tissue.  Potentially malignant depends on their size, distribution, form, and density.      

            According to Peart (2005), radiologist analyzed calcifications on the basis of their size, number, distribution, and morphology.  Morphology means the study of the forms of things.  Calcifications can be clustered, single, unilateral, or bilateral.  Clustered means there are multiple calcifications and it is described as three to five calcifications within an area no larger than 0.5 to one centimeter.   Clustered calcifications also can be called as group calcifications.  As reported by radiologist, Dr Asokan Raman Nair, from mammogram images there is loose cluster of mirocalcifications seen.  This can be seen clearly in figure three.  Nalawade (2009) noted that clustered calcifications may be seen in benign or malignant conditions.  If the cluster is a loose cluster which is less than ten per centimeter square feet, it is more likely to represent a benign condition, whereas malignant condition represented by compact cluster  which is more than 20 per centimeter square feet (Nalawade, 2009).  Radiologist also reported that the loose cluster of calcifications seen in upper outer quadrant is with linear branching in one area, see figure three.  According to Nalawade (2009), linear or also can be called segmental calcifications are suspicious calcifications arranged in a line or showing a branching pattern, which suggesting deposits in a duct.  These calcifications tend to be distributed in a linear manner because most common malignancies are ductal, which begin in the terminal ducts.

Overall, radiologist concluded that there are scattered microcalcifications in the right breast.  Scattered microcalcifications also can be called diffused microcalcifications.  These diffuse or scattered calcifications are seen all over the breast, can be bilateral and they are almost always benign (Nalawade, 2009).  However, the calcifications that concerned the radiologist the most was the loose cluster in upper outer quadrant because it has increased since the last mammogram. 

            According to Peart (2005), characteristics of benign calcifications are smooth contours, high uniform density, evenly scattered homogenous, sharply outlined, spherical, or oval, pear-like densities that resemble teacups or pearl drops on the lateral projection, bilateral and evenly scattered following the course of the ducts throughout much of the parenchyma, ring like or hollow, eggshell like, and large bizarre size.  This patient also has benign calcification in mid lower quadrant of the right breast.

            As for malignant calcifications, there are three mammographic characteristics (Peart, 2005).  First is casting-type calcifications which can be seen on the mammogram as fine linear, branching calcifications that are fragmented with irregular contours.  High grade poorly differentiated large cell DCIS is frequently associated with casting-type microcalcifications (Peart, 2005).  Second characteristic is granular-type calcifications that are irregular in form, size, and density.  Low grade small cell DCIS is often associated with granular microcalcifications (Peart, 2005).  Third characteristic is powderish calcifications which are multiple clusters of calcifications.  As for this patient, according to radiologist, the loose cluster microcalcifications seen are granular-type characteristic because the calcifications are irregular in form and size.

            Based on the characteristics of the microcalcifications seen on mammogram, radiologist concluded that the lesion found in the right breast fall into BI-RADS category four which is suspicious abnormality.  BI-RADS is a standard way of describing mammogram findings which was developed by the American College of Radiology.  There are few categories to describe mammogram findings using BI-RADS.  BI-RADS category one, ‘negative’ used when nothing bad was found and no significant abnormality to report.  BI-RADS category two, ‘benign finding’ used when radiologist choose to describe a finding known to be benign such as fibroadenomas.  BI-RADS category three, ‘probably benign finding’ shows finding that have a very good chance of being benign but it is not proven benign, so follow up after six month is recommended.  BI-RADS category four, ‘suspicious abnormality’ shows finding that do not look like cancer but could be cancer and radiologist always recommended for biopsy for this category.  BI-RADS category five, ‘highly suggestive of malignancy’ shows finding that looks like cancer and have high chance of being cancer.  For this category, biopsy is very strongly recommended (mammogram report – BIRADS, 2013).  

             Even though most calcifications cannot be seen with ultrasound, ultrasound of both breasts was still suggested as an adjunct to mammography.  This is to find any other lesions and lymph node that cannot be seen in mammogram and to further evaluate the breast and surrounding breast tissue.  Other reason of doing breast ultrasound is to see whether the calcifications mentioned in mammogram is invisible or not in ultrasound. 

             Anatomy of the breast shown in ultrasound are skin, three layers of breast tissue, muscle layer, chest wall, pectoralis muscle, nipple, axillary tail, and ribs (Lopchinsky, Van, & Kattaron, 2000).  There are three layers of breast tissue in breast ultrasound images.  The first layer is premammary fat layer which situated below the skin, second layer called mammary layer, and third layer where near to the chest wall is retro mammary layer.  Sonographically, breast tissue layers in pre menopausal women different from breast tissue layers in post menopausal women.  For this patient, her breast ultrasound images showed breast tissue layers that are in postmenopausal women.   

            In ultrasound, lesions can be divided according to their shape, margins, echo characteristics, echo texture, and effect on the through transmissions of sound (Kopans, 2007).  Benign lesions shape usually are round, oval, or smoothly lobulated. Whereas malignant lesions are irregular in shape, ill defined, or very lobulated.  Radiologist mentioned that images that are brighter from highly reflective surfaces are called hyperechoic while areas that are less reflective will appear as darkened regions are said to be hypoechoic.  Areas that have similar echogenicity are said to be isoechoic to each other.  Kopans (2007) noted that cancers usually always hypoechoic compared to the tissue surrounding them and they are even lower in echogenicity than fat.  Occasionally cancers are isoechoic with the surrounding tissue.  Benign lesions on the other hand are hyperechoic (Kopans, 2007).

            For this patient, radiologists noted that on the right breast, there are a few small cysts are seen along nine to 12 o’clock as shown in figure four to six and on the left breast cyst is seen in subareolar area along six o’clock as per figure seven and there are two tiny cysts along 12 o’clock which can be seen in figure eight.  In breast ultrasound images, radiologist referred the location of the lesion base on clockwise.  For both right and left breasts, 12 o’clock and six o’clock is always determining superior and inferior part of the breast.  For right breast, nine o’clock determine lateral part of the breast while three o’clock determine medial part of the breast.  Medial part is the part near to the chest wall.  However for left breast, it is opposite where nine o’clock determine the medial part of the breast and three o’clock in lateral part of the breast.  For this patient, on the right breast, the cysts were found along nine to 12 o’clock meaning that the cysts were located in the superior lateral quadrant of the right breast.  While on the left breast, an eight millimeter cyst that is seen along six o’clock is located in the inferior quadrant and the one that is seen along 12 o’clock is actually located in the superior quadrant.  A single solid well defined nodule seen along 3 o’clock of the left breast which is located in of fibroadenoma.  This can be seen in figure seven.    

            According to Peart (2005), a fibroadenoma is benign tumor common in women at any age.  According to radiologist, all the cysts found in ultrasound together with fibroadenoma are benign and nothing to do with suspicious calcifications seen in mammogram and it is an accidental finding.  The biggest cyst is on the left breast as shown in figure seven, measuring eight millimeter and it is oval and well circumscribed in shape.  This cyst is anechoic and has smooth margins.  It also has posterior acoustic enhancement and is sharp in anterior and posterior borders.  Two tiny cysts along 12 o’clock on the left breast are also oval in shape and anechoic.  Is the same to all the cysts in the right breasts which measures less than five millimeter.  The fibroadenoma seen on left breast as show in figure seven, measuring 8 x 6 mm is lobular in shape.  It is wider than it is taller.  This fibroadenoma shows an echogenic pseudocapsule.  This also shown as hyperechoic lesion.

            The most common circular oval lesions are cysts and fibroadenomas, and the breast ultrasound is the most useable tool in assessing these and other circular or oval lesions (Peart, 2005).  Characteristics of benign circular and oval lesions in ultrasound are ellipsoid shape which means the lesion is wider than it is long, has thin capsule where there is a thin echogenic capsule often surrounds the lesions, it is compressibility because benign tumors are easily compressed, have an acoustic shadowing sometimes for fibroadenoma, and hyperechogenic.

            Based on all the features of the cysts from an ultrasound, radiologist Dr Asokan Raman Nair (personal communication, June 11, 2013) stated that, that is simple cyst.  According to Kruger (2013), when a cyst contains internal low level echoes or lack of some features of simple cyst, then it is called a complicated breast cyst.  Cyst are usually transonic with posterior acoustic enhancement and an irregular internal margins or lesions that are not smoothly circumscribed or defined are not simple cysts (Kruger, 2013). 

            Because the cysts and fibroadenoma are small in size and didn’t give patient any problem, no treatment needed for it.  The cysts and fibroadenoma were not the concern of the breast surgeon, what concern the breast surgeon is the cluster of the microcalcifications seen on the right breast through mammogram.  Because of that, stereotactic guided right breast biopsy was performed under mammographic guidance.  The stereotactic equipment uses angled images to triangulate the depth of a lesion within the breast and to calculate its position in three dimensions.  The microcalcifications were localized and stereotactic guided percutaneous biopsy was done under aseptic technique.  Specimens radiograph shows calcifications in three of the cores, as shows in figure 12.  The pathologist examines biopsy specimens. To make a firm diagnosis of DCIS, the pathologists investigate whether the malignancy has invaded tissue surrounding the ducts and a diagnosis of DCIS shows the tumor remains only in its original place, means in situ.       

            According to Komen (2012), proper treatment is needed for DCIS to reduce the chances of developing invasive breast cancer.  Treatment for breast cancer usually involves surgery with or without radiation therapy.  As for this patient, the breast surgeon suggested that she undergo breast surgery immediately.  The breast surgery was done only on the suspicious area using hook wire as guidance.  This is why hook wire localization was performed before surgery.  Two hook wires were inserted to the anterior inferior and posterolateral margins cover the whole area of calcifications.  This can be seen in figure nine and ten.  It was done under aseptic technique and stereotactic guidance.  After the surgery was done, the specimen of breast tissue that have been took out need to be radiographed under mammogram to make sure the surgeons correctly took out all the microcalcifications needed.  For this patient, radiography of surgical specimen shows previously inserted hookwire and microcalcifications noted within the surgical specimen as shown in figure 11.    

            The surgical specimen was also being sent for histopathology laboratory where the report shows sections from the nodule and irregular fibrotic area showed small foci of ducts exhibiting ductal carcinoma in situ component measuring six millimeter in the largest diameter.  The DCIS component is of cribriform type.  Margins are free of DCIS with nearest margin is the deep margin (5 mm).  The DCIS cells are strongly positive for ER and no invasive carcinoma is seen.  ER is estrogen receptors.  The pathologists look for ER because women with DCIS containing this receptor are more likely to respond positively to hormone therapy

             Benign and malignant lesions of the breast are categorized by the level within the duct network in which they occur.  Some processes are categorized as if they arose from the cells of the ducts, while others from the components of the lobules (Kopans, 2007).  For this patient, histopathology report confirmed that the lesion mentioned arose from the cells of the ducts which give the interpretation of the right suspicious microcalcification was ductal carcinoma in situ.  DCIS is the next step in a continuum that passes from hyperplasia or atypical hyperplasia to intraductal carcinoma proceeding on to infiltrating ductal carcinoma (Kopans, 2007).  Different patterns of DCIS are now recognized through histologic cross section.  The better differentiated cribiform types seemed to have a slower progression to invasion, while the more poorly differentiated comedo pattern seems to be more rapidly aggressive (Kopans, 2007).  As for this patient, it was already confirmed cribiform types of DCIS.

            With surgery as a treatment for DCIS, prognosis is usually excellent (Komen, 2012).  According to Chustecka (2011), long term results from two large trials have shown that women with DCIS have an excellent prognosis and are more likely to die from other causes than from breast cancer.  Overall, the 15 years overall survival exceeds 85 percent and the incidence of death from breast cancer was less than five percent (Chustecka, 2011).    

5.      CONCLUSION

            After patient had done the surgery and knowing that this DCIS was from slower progression type and also knowing that this DCIS cells are strongly positive for ER, she was suggested to take hormone therapy as a preventive treatment because women who take hormonal therapy after surgery further reduce their risk of recurrence by half.  This hormone replacement therapy is called tamoxifen.  Tamoxifen can lower the risk of recurrent DCIS and invasive breast cancer in both breasts (Komen, 2012).  Moreover, she has strong family history of breast cancer and tamoxifen is highly recommended to patient with strong family history of breast cancer and patient with genetic mutations that raise the risk of having breast cancer (breast cancer, 2012).

            Even though patient already under treatment, she needs to come for regular checkup every year.  The first check up should be six month after surgery which is necessary.  The breast surgeon will do clinical breast examination and patient will be asked to do mammogram and breast ultrasound again.  Mammogram is to look whether any new calcifications appear in the same breast or in the other breast.  Breast ultrasound need to be done to look at the progress of fibroadenoma and cysts that is already existed in the patient’s breasts and to see if there are any new focal lesion appear.  If the result is normal, patient is highly recommended for annual checkup.

            Other than that, all women are advised to follow healthy life style which can help lower risk in getting breast cancer.  This include do daily exercise of 30 minutes or more a day, weight control because there is connection between obesity and increased risk in developing breast cancer, limit alcohol intake to one drink a day or less, quit smoking if necessary and take healthy diet (prevention of breast cancer, 2009).  Some said that stress level also play an important role in getting risk of breast cancer, so all women need to manage stress and be happy all the time and think of happy thought always which can be a method of therapy that help lower the risk in getting breast cancer.