A who's who of breast cancer experts from Jefferson Medical College of Thomas Jefferson University, Philadelphia, and medical institutions around the world have designed a system for classifying Ductal Carcinoma In Situ (DCIS), a controversial malignancy found in the breast, as a first step toward improving patient treatment for this type of early breast cancer. DCIS currently represents 20 to 25 percent of all breast cancers diagnosed.
In a paper to be published concurrently by three medical journals, Cancer, Human Pathology and The Breast Journal, the international Consensus Conference Committee outlines a classification system for DCIS that takes into account how the cancer's cells appear under the microscope (nuclear grade), the amount of tissue death (necrosis), the cells' arrangement (polarization) and their physical shape (architecture).
The consensus conference, which was hosted at Jefferson and chaired by Gordon Schwartz, M.D., MBA, professor of Surgery, Jefferson Medical College of Thomas Jefferson University.
"Now when DCIS is encountered in Timbuktu, it will be classified the same way as in Philadelphia or Washington, D.C., or London," said Dr. Schwartz.
The committee designed the classification system during a weekend- long conference held April 25-28 at Jefferson Hospital in Philadelphia. The conference was supported by the Breast Health Institute and the Fashion Institute International both of Philadelphia, as well as Thomas Jefferson University Hospital and Jefferson Medical College.
The committee members include pathologists, mammographers, surgeons, a radiation oncologist and a biostatistician, from Jefferson and medical institutions around the globe:
Pathologists:
- Dr. Darryl Carter
Yale University School of Medicine, New Haven, Conn. - Dr. James Connolly
Beth Israel Deaconess Medical Center, Boston, Mass. - Dr. Ian Ellis
City Hospital NHS Trust, Nottingham, United Kingdom - Dr. Vincenzo Eusebi
Universita di Bologna, Bologna, Italy - Dr. Gerald Finkel
Clinical Professor of Pathology, Anatomy and Cell Biology, Jefferson Medical College, Philadelphia, Pa. - Dr. Fred Gorstein
The Jacob and Sophie Rubin Professor and vice chairman of the department of Pathology, Anatomy and Cell Biology, Jefferson Medical College, Philadelphia, Pa. - Dr. Roland Holland
University Hospital Nijmegen Nijmegen, The Netherlands - Dr. Robert V.P. Hutter
Saint Barnabas Medical Center, Livingston, N.J. - Dr. Michael Lagios, conference co-chairman
St. Mary's Medical Center, San Francisco, Calif. - Dr. Shahla Masood
University of Florida Health Science Center, Jacksonville, Fla. - Dr. Rosemary R. Millis
Guy's Hospital, London, United Kingdom - Dr. Frances P. O'Malley
London Health Science Centre London, Ontario, Canada - Dr. Juan Palazzo
Assistant Professor of Pathology, Anatomy and Cell Biology, Jefferson Medical College, Philadelphia, Pa. - Dr. Arthur S. Patchefsky
Fox Chase Cancer Center, Philadelphia, Pa. - Dr. Juan Rosai
Memorial Sloan-Kettering Cancer Center, New York, N.Y. - Dr. Stuart J. Schnitt
Beth Israel Deaconess Medical Center, Boston, Mass. - Dr. Roland Schwarting
Associate professor of Pathology, Anatomy and Cell Biology Jefferson Medical College, Philadelphia, Pa. - Dr. John P. Sloane
Royal Liverpool University Hospital, Liverpool, United Kingdom - Dr. Fattaneh A. Tavassoli
Armed Forces Institute of Pathology, Washington, D.C.
Mammographers:
- Dr. Stephen A. Feig, professor of Radiology, and director of the
Jefferson Breast Imaging Center;
Jefferson Medical College, Philadelphia, Pa. - Dr. Daniel B. Kopans
Massachusetts General Hospital, Boston, Mass.
Radiation Oncologist:
- Dr. Beryl McCormick
Memorial Sloan-Kettering Cancer Center, New York, N.Y.
Surgeons:
- Dr. Edward M. Copeland, III
University of Florida College of Medicine, Gainesville, Fla. - Dr. Armando E. Giuliano
John Wayne Center Institute, Santa Monica, Calif. - Dr. Gordon Schwartz, professor of Surgery, Jefferson Medical College, Philadelphia, Pa.
- Dr. Melvin J. Silverstein
The Breast Center, Van Nuys, Calif. - Dr. Joop A. van Dongen
The Netherlands Cancer Institute, Amsterdam, The Netherlands
Biostatistician:
- Dr. Carol Bodian
The Mount Sinai Medical Center, New York, N.Y.
The report's significance in determining the recommended approach for DCIS is confirmed by the fact that three journals have agreed to publish the paper at the same time.
"It's rarely been done," said Dr. Schwartz of the multiple journal publishings. "By chance, not by design, three of the physicians who were here are also the editors-in-chief of the three journals. They thought it was important enough to reach all three journal audiences."
DCIS can be described as looking like a cluster of salt granules on a mammogram. Although a majority of patients with DCIS will not develop a more threatening cancer, in some patients, the DCIS can progress to become an invasive, life-threatening malignancy, Dr. Schwartz said.
"Until now, the greatest challenge for physicians who treat DCIS has been to discriminate between the less aggressive and more aggressive cases," he said.
As a result, the treatment of DCIS has ranged from mastectomy to a combination of lumpectomy and radiation treatment to lumpectomy alone, depending on the physician's judgement. In the late 1970s, mastectomy was the standard treatment for DCIS, Dr. Schwartz noted.
"If you can't define it, you can't treat it properly," he said. "The subtleties of classification are such that the treatments may be different based upon how the subtleties of DCIS are perceived. So what we tried to do was to get these experts to agree upon an uniform system of classification."
The consensus of these international specialists was to identify a set of factors in descending order of importance:
How the cancer cells appear on the miscroscope (Nuclear Grade) : The cells can have one of three appearances: biologically aggressive; biologically non-aggressive; in a state between between these two. The conference determined that the more aggressive the cells are, the greater the chance of subsequent recurrance.
Amount of tissue death (Necrosis): The conferees concluded that the more cellular death found, the greater the chance the cancer might recur.
Cell formation (Polarization): The specialists determined that cells that are well organized or in good formation are more likely to be less threatening than cells in a loose formation.
Physical shape (Architecture): Cell patterns have been categorized by the conference into five types:
- Comedo (previously considered the type most likely to recur)
- Cribriform
- Papillary
- Micropapillary
- Solid
The conferees also concluded that the size and distribution of the DCIS should also be taken into account in classifying the cancer.
As part of their report, the breast cancer specialists recommended a process for removing and evaluating breast tissue for DCIS, and that a radiologist, surgeon and pathologist work as a unified team in this effort. The conferees suggested that the traditional surgical procedure involving a needle-guided localization be employed in removal of the tissue sample. It is also recommended that metallic clips be placed on the tissue specimen near the site of the DCIS if the flakes shown on the mammogram are faint or within a very small area of the specimen.
It was also recommended by the conferees that biologic markers such as estrogen and proestrogen receptors or nuclear proliferation antigen Ki-67, for example, be determined in each case, although these markers are not currently used to determine treatment. Dr. Schwartz noted that Jefferson is in the forefront in the use of these biologic markers.
Now that the conference has determined a means for better identifying DCIS, the next step is to determine a universally acceptable clinical use for the classification system, the conference report states. The conferees said they hope to meet again in the near future to map out that strategy.
The conference was funded through the annual "Give the Shirt Off Your Back! Fight Breast Cancer" gala dinner dance and silent auction sponsored by the Breast Health Institute and the Fashion Group International-Philadelphia.
The Breast Health Institute (BHI) was founded in response to an ever-increasing incidence of breast cancer and a corresponding decrease in the availability of public funds for basic and clinical research in this specialty. BHI is a non-profit organization dedicated to raising funds for clinical research, education and public awareness of breast cancer. BHI funds many early detection programs for the underserved women of the Delaware Valley.
Fashion Group International (FGI) is a nonprofit association promoting the advancement of women in the fashion industry. Members include professionals in design, marketing, manufacturing, retailing, advertising and publishing, and those who provide research, financial and educational services to the fashion industry. FGI members create events nationwide and join with other organizations to support causes that benefit entire communities.
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