Jacky Luiten

134 | Chapter 9 2. Biopsy and surgery Currently, it is not yet clear to which degree histologic features of DCIS can be estimated by the mammographic patterns of microcalcifications alone. Therefore, a SCNB is still considered mandatory in the workup of these lesions to date. 31 We have shown that when a diagnostic surgical excision of high ‐ risk lesions after a negative SCNB was obtained, approximately 85% of all excisions did not reveal a clinically significant lesion (71% benign pathology). Moreover, in 14.2% of the surgical excision biopsies a low grade DCIS was found. For low grade DCIS a wait and see strategy may be favored over surgical intervention. Also, for lesion classifies as flat epithelial atypia, papillary lesions, radial scar or lobular carcinoma in situ; so ‐ called high ‐ risk lesions optimal management of is controversial 11, 19, 60, 61 . Serious inconsistencies in the management of these lesions are reported, with surgical excision rates ranging from 39% to 95% between centers. 19 In addition, our study shows that in almost 5% of all surgically treated women, no residual DCIS was found in the surgical specimen, suggesting that all DCIS was removed by SCNB. Vacuum assisted excision biopsy devices can remove even more tissue than SCNB and may be the future therapy of choice for the removal of DCIS characterized by small groups of clustered microcalcifications. 62,63 In order to decrease the number of potentially unnecessary surgical excisions, one may opt for vacuum ‐ assisted excision of high ‐ risk lesions as an alternative to surgical excision. 62 ‐ 64 In the future larger studies are needed to define evidence ‐ based practice recommendations of the management of pre ‐ malignant lesions detected at SCNB. 3. Surveillance follow ‐ up It is postulated that if low grade DCIS deteriorates it will more likely progress to low grade invasive carcinoma over a long time period, whereas high grade DCIS might develop into high grade invasive carcinoma over a shorter time period. 6,7 Therefore, the question has been raised whether surgical treatment for low ‐ and maybe even intermediate grade DCIS might be considered as overtreatment. It is reasonable to assume that active surveillance is nearly as safe as surgical treatment of screen ‐ detected low grade DCIS. The result of active surveillance is subject of several ongoing clinical trials. 22,23,65 . If these trials show favorable results, uniform histologic grading of DCIS might become of great clinical importance in the near future.