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Amornsiripanitch N, Lam DL, Rahbar H. Advances in Breast MRI in the Setting of Ductal Carcinoma In Situ. Semin Roentgenol 2018; 53:261-269. [PMID: 30449344 DOI: 10.1053/j.ro.2018.08.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
| | - Diana L Lam
- University of Washington, Seattle Cancer Care Alliance, Seattle, WA.
| | - Habib Rahbar
- University of Washington, Seattle Cancer Care Alliance, Seattle, WA.
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102
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A review of statistical and machine learning methods for modeling cancer risk using structured clinical data. Artif Intell Med 2018; 90:1-14. [DOI: 10.1016/j.artmed.2018.06.002] [Citation(s) in RCA: 68] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2017] [Revised: 09/08/2017] [Accepted: 06/13/2018] [Indexed: 02/06/2023]
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103
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Prognostic significance of tumor-infiltrating lymphocytes in ductal carcinoma in situ of the breast. Mod Pathol 2018; 31:1226-1236. [PMID: 29559742 DOI: 10.1038/s41379-018-0040-8] [Citation(s) in RCA: 52] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Revised: 01/31/2018] [Accepted: 01/31/2018] [Indexed: 01/17/2023]
Abstract
Tumor-infiltrating lymphocytes (TILs) provide prognostic value in invasive breast cancer and guidelines for their assessment have been published. This study aims to evaluate: (a) methods of TILs assessment, and (b) their prognostic significance in breast ductal carcinoma in situ (DCIS). Hematoxylin and eosin sections from two clinically annotated DCIS cohorts; a training set (n = 150 pure DCIS) and a validation set (n = 666 comprising 534 pure DCIS and 132 cases wherein DCIS and invasive breast carcinoma were co-existent) were assessed. Seven different scoring methods were applied to the training set to identify the most optimal reproducible method associated with strongest prognostic value. Among different methods, TILs touching ducts' basement membrane or away from it by one lymphocyte cell thickness provided the strongest significant association with outcome and highest concordance rate [inter-cluster correlation coefficient = 0.95]. Assessment of periductal TILs at increasing distances from DCIS (0.2 , 0.5 , and 1 mm) as well as percent of stromal TILs were practically challenging and showed lower concordance rates than touching TILs. TILs hotspots and lymphoid follicles did not show prognostic significance. Within the pure DCIS validation set, dense TILs were associated with younger age, symptomatic presentation, larger size, higher nuclear grade, comedo necrosis and estrogen receptor negativity as well as shorter recurrence-free interval (p = 0.002). In multivariate survival analysis, dense TILs were independent predictor of shorter recurrence-free interval (p = 0.002) in patients treated with breast conservation. DCIS associated with invasive carcinoma showed denser TILs than pure DCIS (p = 9.0 × 10-13). Dense TILs is an independent prognostic variable in DCIS. Touching TILs provides a reproducible method for their assessment that can potentially be used to guide management.
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104
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Dubrovsky E, Nguyen P, Chun J, Schwartz S, Raymond S, Guth A, Schnabel F, Gerber NK. Ductal carcinoma in situ on core needle biopsy only with no residual disease at surgery. Breast J 2018; 24:971-975. [DOI: 10.1111/tbj.13095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2017] [Revised: 09/29/2017] [Accepted: 10/03/2017] [Indexed: 11/28/2022]
Affiliation(s)
| | | | | | | | | | - Amber Guth
- NYU Langone Medical Center; New York City New York
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105
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Bremer T, Whitworth PW, Patel R, Savala J, Barry T, Lyle S, Leesman G, Linke SP, Jirström K, Zhou W, Amini RM, Wärnberg F. A Biological Signature for Breast Ductal Carcinoma In Situ to Predict Radiotherapy Benefit and Assess Recurrence Risk. Clin Cancer Res 2018; 24:5895-5901. [PMID: 30054280 DOI: 10.1158/1078-0432.ccr-18-0842] [Citation(s) in RCA: 80] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 06/19/2018] [Accepted: 07/25/2018] [Indexed: 11/16/2022]
Abstract
PURPOSE Ductal carcinoma in situ (DCIS) patients and their physicians currently face challenging treatment decisions with limited information about the individual's subsequent breast cancer risk or treatment benefit. The DCISionRT biological signature developed in this study provides recurrence risk and predicts radiotherapy (RT) benefit for DCIS patients following breast-conserving surgery (BCS). EXPERIMENTAL DESIGN A biological signature that calculates an individualized Decision Score (DS) was developed and cross-validated in 526 DCIS patients treated with BCS ± RT. The relationship was assessed between DS and 10-year risk of invasive breast cancer (IBC) or any ipsilateral breast event (IBE), including IBC or DCIS. RT benefit was evaluated by risk group and as a function of DS. RESULTS The DS was significantly associated with IBC and IBE risk, HR (per 5 units) of 4.2 and 3.1, respectively. For patients treated without RT, DS identified a Low Group with 10-year IBC risk of 4% (7% IBE) and an Elevated Risk Group with IBC risk of 15% (23% IBE). In analysis of DS and RT by group, the Elevated Risk Group received significant RT benefit, HR of 0.3 for IBC and IBE. In a clinicopathologically low-risk subset, DS reclassified 42% of patients into the Elevated Risk Group. In an interaction analysis of DS and RT, patients with elevated DS had significant RT benefit over baseline. CONCLUSIONS The DS was prognostic for risk and predicted RT benefit for DCIS patients. DS identified a clinically meaningful low-risk group and a group with elevated 10-year risks that received substantial RT benefit over baseline.
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Affiliation(s)
| | | | - Rakesh Patel
- Good Samaritan Cancer Center, Los Gatos, California
| | | | - Todd Barry
- Spectrum Pathology, Inc., Mission Viejo, California
| | - Stephen Lyle
- University of Massachusetts Medical School, Worcester, Massachusetts
| | | | | | - Karin Jirström
- Division of Oncology and Pathology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Wenjing Zhou
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Rose-Marie Amini
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | - Fredrik Wärnberg
- Department of Surgical Sciences, Uppsala University, Department of Surgery, Uppsala Academic Hospital, Uppsala, Sweden.
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106
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Hong YK, McMasters KM, Egger ME, Ajkay N. Ductal carcinoma in situ current trends, controversies, and review of literature. Am J Surg 2018; 216:998-1003. [PMID: 30244816 DOI: 10.1016/j.amjsurg.2018.06.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 06/05/2018] [Accepted: 06/14/2018] [Indexed: 10/28/2022]
Abstract
Ductal carcinoma in situ (DCIS) is a non-obligate precursor, non-invasive malignancy confined within the basement membrane of the breast ductal system. There is a wide variation in the natural history of DCIS with an estimated incidence of progression to invasive ductal carcinoma being at least 13%-50% over a range of 10 or more years after initial diagnosis. Regardless of the treatment strategy, long-term survival is excellent. The controversy surrounding DCIS relates to preventing under-treatment, while also avoiding unnecessary treatments. In this article, we review the incidence, presentation, management options and surveillance of DCIS. Furthermore, we address several current controversies related to the management of DCIS, including margin status, sentinel node biopsy, hormonal therapy, the role of radiation in breast conservation surgery, and various risk stratification schemes.
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Affiliation(s)
- Young K Hong
- Division of Surgical Oncology, Department of Surgery, University of Louisville, USA
| | - Kelly M McMasters
- Division of Surgical Oncology, Department of Surgery, University of Louisville, USA
| | - Michael E Egger
- Division of Surgical Oncology, Department of Surgery, University of Louisville, USA
| | - Nicolas Ajkay
- Division of Surgical Oncology, Department of Surgery, University of Louisville, USA.
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107
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McCormick B. It is time to personalize local treatment options for women with "good risk" DCIS. Breast J 2018; 24:231-232. [PMID: 29870127 DOI: 10.1111/tbj.12890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2017] [Accepted: 06/29/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center and Weill Cornell Medical School, New York, NY, USA
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108
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Prise en charge des carcinomes mammaires in situ : surtraitement ? Peut-on faire moins ? IMAGERIE DE LA FEMME 2018. [DOI: 10.1016/j.femme.2018.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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109
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Abstract
Ductal carcinoma in situ has been stable in incidence for a decade and has an excellent prognosis. Breast conservation therapy is safe and effective for most patients. Adjuvant whole breast radiation therapy is recommended to reduce the risk of local recurrence. Accelerated partial breast irradiation is a promising alternative to decrease toxicity and improve cosmetic results. Adjuvant hormonal therapy can reduce local recurrence, but should be used cautiously. Future directions in management include developing predictive tools for guidance for use of adjuvant therapy and selecting low-risk patients with ductal carcinoma in situ in whom surgery may be safely omitted.
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Affiliation(s)
- FangMeng Fu
- Fujian Medical University Union Hospital, 29 Xinquan Rd, DongJieKou SangQuan, Gulou Qu, Fuzhou Shi, Fujian Sheng 350001, China
| | - Richard C Gilmore
- Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Lisa K Jacobs
- Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA.
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110
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Wang W, Sun Z, Deng JY, Qi XL, Feng XY, Fang C, Ma XH, Wang ZN, Liang H, Xu HM, Zhou ZW. A novel nomogram individually predicting disease-specific survival after D2 gastrectomy for advanced gastric cancer. Cancer Commun (Lond) 2018; 38:23. [PMID: 29764518 PMCID: PMC5993138 DOI: 10.1186/s40880-018-0293-0] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 11/09/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Few studies have shown nomograms that may predict disease-specific survival (DSS) probability after curative D2 gastrectomy for advanced gastric cancer (AGC), particularly among Chinese patients. This study sought to develop an elaborative nomogram that predicts long-term DSS for AGC in Chinese patients. METHODS A retrospective study was conducted on 6753 AGC patients undergoing D2 gastrectomy between January 1, 2000 and December 31, 2012 from three large medical hospitals in China. We assigned patients from Sun Yat-sen University Cancer Center to the training set, and patients from the First Affiliated Hospital of China Medical University and Tianjin Medical University Cancer Hospital to two separate external validation sets. A multivariate survival analysis was performed using Cox proportional hazards regression model in a training set, and a nomogram was constructed. Harrell's C-index was used to evaluate discrimination and calibration plots were used to validate similarities between survival probabilities predicted by the nomogram model and actual survival rates in two validation sets. RESULTS The multivariate Cox regression model identified age, tumor size, location, Lauren classification, lymphatic/venous invasion, depth of invasion, and metastatic lymph node ratio as covariates associated with survival. In the training set, the nomogram exhibited superior discrimination power compared with the 8th American Joint Committee on Cancer TNM classification (Harrell's C-index, 0.82 vs. 0.74; P < 0.001). In two validation sets, the nomogram's discrimination power was also excellent relative to TNM classification (C-index, 0.83 vs. 0.75 and 0.81 vs. 0.74, respectively; P < 0.001 for both). After calibration, the nomogram produced survival predictions that corresponded closely with actual survival rate. CONCLUSIONS The established nomogram was able to predict 3-, 5-, and 10-year DSS probabilities for AGC patients. Validation revealed that this nomogram exhibited excellent discrimination and calibration capacity, suggesting its clinical utility.
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Affiliation(s)
- Wei Wang
- Department of Gastric Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, P. R. China
| | - Zhe Sun
- Department of Surgical Oncology, The First Affiliated Hospital of China Medical University, Shenyang, 110000, Liaoning, P. R. China
| | - Jing-Yu Deng
- Department of Gastric Cancer Surgery, Tianjin Medical University Cancer Hospital, Tianjin, 300000, P. R. China
| | - Xiao-Long Qi
- Department of General Surgery, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, P. R. China
| | - Xing-Yu Feng
- Department of Gastroenterology Surgery, Guangdong General Hospital, Guangzhou, 510030, Guangdong, P. R. China
| | - Cheng Fang
- Department of Gastric Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, P. R. China
| | - Xing-Hua Ma
- Department of Preventive Medicine, School of Public Health, Sun Yat-sen University, Guangzhou, 510275, Guangdong, P. R. China
| | - Zhen-Ning Wang
- Department of Surgical Oncology, The First Affiliated Hospital of China Medical University, Shenyang, 110000, Liaoning, P. R. China
| | - Han Liang
- Department of Gastric Cancer Surgery, Tianjin Medical University Cancer Hospital, Tianjin, 300000, P. R. China.
| | - Hui-Mian Xu
- Department of Surgical Oncology, The First Affiliated Hospital of China Medical University, Shenyang, 110000, Liaoning, P. R. China.
| | - Zhi-Wei Zhou
- Department of Gastric Surgery, Sun Yat-sen University Cancer Center, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, 651 Dongfeng East Road, Guangzhou, 510060, Guangdong, P. R. China.
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111
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Visser LL, Elshof LE, Schaapveld M, van de Vijver K, Groen EJ, Almekinders MM, Bierman C, van Leeuwen FE, Rutgers EJ, Schmidt MK, Lips EH, Wesseling J. Clinicopathological Risk Factors for an Invasive Breast Cancer Recurrence after Ductal Carcinoma In Situ-A Nested Case-Control Study. Clin Cancer Res 2018; 24:3593-3601. [PMID: 29685879 DOI: 10.1158/1078-0432.ccr-18-0201] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/30/2018] [Accepted: 04/17/2018] [Indexed: 11/16/2022]
Abstract
Purpose: Ductal carcinoma in situ (DCIS) is treated to prevent progression to invasive breast cancer. Yet, most lesions will never progress, implying that overtreatment exists. Therefore, we aimed to identify factors distinguishing harmless from potentially hazardous DCIS using a nested case-control study.Experimental Design: We conducted a case-control study nested in a population-based cohort of patients with DCIS treated with breast-conserving surgery (BCS) alone (N = 2,658) between 1989 and 2005. We compared clinical, pathologic, and IHC DCIS characteristics of 200 women who subsequently developed ipsilateral invasive breast cancer (iIBC; cases) and 474 women who did not (controls), in a matched setting. Median follow-up time was 12.0 years (interquartile range, 9.0-15.3). Conditional logistic regression models were used to assess associations of various factors with subsequent iIBC risk after primary DCIS.Results: High COX-2 protein expression showed the strongest association with subsequent iIBC [OR = 2.97; 95% confidence interval (95% CI), 1.72-5.10]. In addition, HER2 overexpression (OR = 1.56; 95% CI, 1.05-2.31) and presence of periductal fibrosis (OR = 1.44; 95% CI, 1.01-2.06) were associated with subsequent iIBC risk. Patients with HER2+/COX-2high DCIS had a 4-fold higher risk of subsequent iIBC (vs. HER2-/COX-2low DCIS), and an estimated 22.8% cumulative risk of developing subsequent iIBC at 15 years.Conclusions: With this unbiased study design and representative group of patients with DCIS treated by BCS alone, COX-2, HER2, and periductal fibrosis were revealed as promising markers predicting progression of DCIS into iIBC. Validation will be done in independent datasets. Ultimately, this will aid individual risk stratification of women with primary DCIS. Clin Cancer Res; 24(15); 3593-601. ©2018 AACR.
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Affiliation(s)
- Lindy L Visser
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Lotte E Elshof
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, the Netherlands.,Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, the Netherlands.,Department of Surgery, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Michael Schaapveld
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Koen van de Vijver
- Department of Pathology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Emma J Groen
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, the Netherlands.,Department of Pathology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Mathilde M Almekinders
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, the Netherlands.,Department of Pathology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Carolien Bierman
- Department of Pathology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Flora E van Leeuwen
- Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Emiel J Rutgers
- Department of Surgery, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Marjanka K Schmidt
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, the Netherlands.,Division of Psychosocial Research and Epidemiology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Esther H Lips
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Jelle Wesseling
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, the Netherlands. .,Department of Pathology, The Netherlands Cancer Institute, Amsterdam, the Netherlands
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112
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Lui SA, Oh HB, Wang S, Chan CW. Ductal carcinoma in-situ arising within benign phyllodes tumours. Ann R Coll Surg Engl 2018; 100:e97-e102. [PMID: 29484937 PMCID: PMC5958862 DOI: 10.1308/rcsann.2018.0024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/03/2017] [Indexed: 12/11/2022] Open
Abstract
Ductal carcinoma in situ arising within a benign phyllodes tumour is a rare neoplasm of the breast. We present a case of a 19-year-old woman who had a right breast lump for six months with the above diagnosis together with a mini-review of the literature. Ultrasound revealed a 5-cm breast lump and core biopsy revealed ductal carcinoma in situ. She underwent wide local excision of the breast lump with clear margins. Final histology confirmed ductal carcinoma in situ within a fibroepithelial lesion consistent with a benign phyllodes tumour. To our knowledge, this is the youngest case of ductal carcinoma in situ arising in a phyllodes tumour to have been reported so far.
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MESH Headings
- Adult
- Antineoplastic Agents, Hormonal/therapeutic use
- BRCA1 Protein/genetics
- BRCA2 Protein/genetics
- Biopsy, Large-Core Needle/methods
- Breast/pathology
- Breast/surgery
- Breast Neoplasms/diagnostic imaging
- Breast Neoplasms/genetics
- Breast Neoplasms/pathology
- Breast Neoplasms/therapy
- Carcinoma, Intraductal, Noninfiltrating/diagnostic imaging
- Carcinoma, Intraductal, Noninfiltrating/genetics
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/therapy
- Chemotherapy, Adjuvant
- Female
- Humans
- Mastectomy, Segmental
- Neoplasm Recurrence, Local/diagnostic imaging
- Neoplasms, Multiple Primary/diagnostic imaging
- Neoplasms, Multiple Primary/pathology
- Neoplasms, Multiple Primary/therapy
- PTEN Phosphohydrolase/genetics
- Phyllodes Tumor/diagnostic imaging
- Phyllodes Tumor/pathology
- Phyllodes Tumor/therapy
- Sentinel Lymph Node Biopsy/methods
- Tamoxifen/therapeutic use
- Ultrasonography, Interventional
- Ultrasonography, Mammary
- Young Adult
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Affiliation(s)
- S-A Lui
- Division of Breast Surgery, Department of Surgery, National University Health System, Singapore
| | - HB Oh
- Division of Breast Surgery, Department of Surgery, National University Health System, Singapore
| | - S Wang
- Department of Pathology, National University Hospital, National University Health System, Singapore
| | - CW Chan
- Division of Breast Surgery, Department of Surgery, National University Health System, Singapore
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113
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114
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Krug D, Baumann R. Radiotherapy for Ductal Cancer In Situ (DCIS) of the Breast. Radiat Oncol 2018. [DOI: 10.1007/978-3-319-52619-5_58-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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115
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Abstract
Ductal carcinoma in situ (DCIS), the noninvasive form of breast cancer (BC), comprises just over 20% of breast cancer cases diagnosed each year in the USA. Most patients are treated with local excision of the disease followed by whole breast radiation therapy. Total mastectomy is not an uncommon approach, and total mastectomy with a contralateral risk-reducing mastectomy has been on the rise in the past decade. In estrogen receptor-positive disease, patients are often offered endocrine ablative therapy with a selective estrogen receptor modulator or an aromatase inhibitor as both treatment and prevention. Local regional treatment options have no impact upon ultimate overall survival. Long-term survival rates are higher in patients with DCIS than with any other form of the disease. Are these strikingly high success rates a testament to effective treatment strategies or is there a significant subset of DCIS that was unlikely to ever progress to invasive ductal carcinoma? DCIS was not seen in the US prior to the advent of screening mammography. When compared to other countries, the USA has the highest utilization of screening mammography and the incidence rate of DCIS. Other lines of evidence include autopsy series examining the breast tissue of women who died of other causes, missed-diagnosis series and current retrospective reviews of DCIS, all align in support of the concept of DCIS as indolent in the majority of cases [3-14]. The evidence suggests that both patient and physician misconceptions about DCIS have led to overdiagnosis and over-treatment of DCIS. Recently, a gene expression profiling tool (12 gene assay, Oncotype DCIS) has emerged that shows considerable promise in predicting class in DCIS patients.
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Affiliation(s)
- Joshua Feinberg
- Department of Surgery, Maimonides Breast Center, Maimonides Medical Center, Research Fellow, Oxford University, Oxford, England
| | - Rachel Wetstone
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Dana Greenstein
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA
| | - Patrick Borgen
- Department of Surgery, Maimonides Medical Center, Brooklyn, NY, USA.
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116
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Abstract
Ductal carcinoma in situ (DCIS) accounts for 20% of all newly diagnosed breast cancers. Mastectomy was once the gold standard for the treatment of DCIS; however, breast-conserving surgery (BCS) has been adopted as the treatment of choice for patients with small, screen-detected lesions. Both adjuvant radiation and hormonal therapy following BCS have been demonstrated in randomized trials to reduce the risk of both invasive and DCIS recurrence, but neither affects survival. With the variety of surgical and adjuvant treatment options available, there has been great interest in tailoring the treatment to the individual, with the goal of optimizing the balance of risks and benefits according to the values and priorities of the woman herself. Prospective studies of women with "low-risk" DCIS treated with BCS alone have successfully identified women at lower than average risk but have not achieved the goal of identifying a subset of women with DCIS at minimal risk of recurrence after surgical excision alone. No studies have evaluated the safety of medical management alone.
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Affiliation(s)
- Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065;
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065;
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117
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Moran MS. Advancements and Personalization of Breast Cancer Treatment Strategies in Radiation Therapy. Cancer Treat Res 2018; 173:89-119. [PMID: 29349760 DOI: 10.1007/978-3-319-70197-4_7] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Significant technologic advances in radiation treatment delivery now allow for more personalized delivery considerations which incorporate individual patient characteristics (such as tumor location and patient anatomy) and more precise delivery in the breast conservation or post-mastectomy setting. The combined advancements with other treatment modalities (i.e., systemic therapy, surgical management) have had direct effects on local-regional management and outcomes such that currently, local-regional relapses after definitive treatment for localized disease are now rarely experienced. Recent advances in the radiation therapy field have come from careful patient selection for a variety of three-dimensional treatment delivery techniques and alternatives to conventional tangential radiation. These advances have been demonstrated to diminished acute/long-term toxicity, minimized dose to surrounding normal tissue structures such as the heart and lung, and ultimately result in an improvement in the therapeutic ratio for radiation treatment. This chapter discusses recent radiation innovations and appropriate patient selection for their application, for a more personalized approach to radiation therapy for breast cancer patients.
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Affiliation(s)
- Meena S Moran
- Therapeutic Radiology, Yale Radiation Therapy Program, Yale University School of Medicine, New Haven, USA.
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118
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Pruneri G, Lazzeroni M, Bagnardi V, Tiburzio GB, Rotmensz N, DeCensi A, Guerrieri-Gonzaga A, Vingiani A, Curigliano G, Zurrida S, Bassi F, Salgado R, Van den Eynden G, Loi S, Denkert C, Bonanni B, Viale G. The prevalence and clinical relevance of tumor-infiltrating lymphocytes (TILs) in ductal carcinoma in situ of the breast. Ann Oncol 2017; 28:321-328. [PMID: 28426105 DOI: 10.1093/annonc/mdw623] [Citation(s) in RCA: 64] [Impact Index Per Article: 9.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Background Tumor-infiltrating lymphocytes (TILs) are a robust prognostic adjunct in invasive breast cancer, but their clinical role in ductal carcinoma in situ (DCIS) has not been ascertained. Patients and methods We evaluated the prevalence and clinical relevance of TILs in a well annotated series of 1488 consecutive DCIS women with a median follow-up of 8.2 years. Detailed criteria for TILs evaluation were pre-defined involving the International Immuno-Oncology Biomarker Working Group. TILs percentage was considered both as a continuous and categorical variable. Levels of TILs were examined for their associations with ipsilateral breast event (IBE), whether in situ or invasive. Results Of the 1488 patients with DCIS under study, 35.1% had <1%, 58.3% 1-49% and 6.5% ≥50% peri-ductal stromal lymphocytes. The interobserver agreement in TILs evaluation, measured by the intraclass correlation coefficient (ICC) was 0.96 (95% CI 0.95-0.97). At univariable analysis, clinical factors significantly associated with TILs (P ≤0.001) were intrinsic subtype, grade, necrosis, type of surgery. Her-2 positive DCIS were more frequently associated with TILs (24% of patients with TILs ≥50%), followed by the triple negative (11%), Luminal B/Her-2 positive (9%) and Luminal A/B subtypes (1%) (P < 0.0001). We did not find any association between TILs as a continuous variable and the risk of IBEs. Likewise, when patients were stratified by TILs percentage (<1%, between 1% and 49.9%, and ≥50%), no statistically significant association was observed (10-year cumulative incidence of IBEs: 19%, 17.3%, and 18.7% respectively, P = 0.767). Conclusion TILs occur more frequently in the Her-2 positive DCIS. Although we did not find a significant association between TILs and the 10-year risk of IBE, our data suggest that immunotherapies might be considered in subsets of DCIS patients.
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Affiliation(s)
- G Pruneri
- Department of Pathology, European Institute of Oncology, Milan.,School of Medicine, University of Milan, Milan
| | - M Lazzeroni
- Cancer Prevention and Genetics, European Institute of Oncology, Milan
| | - V Bagnardi
- Epidemiology and Biostatistics, European Institute of Oncology, Milan.,Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan
| | - G B Tiburzio
- Department of Pathology, European Institute of Oncology, Milan
| | - N Rotmensz
- Epidemiology and Biostatistics, European Institute of Oncology, Milan
| | - A DeCensi
- Cancer Prevention and Genetics, European Institute of Oncology, Milan.,Division of Medical Oncology, E.O. Ospedali Galliera, Genoa
| | | | - A Vingiani
- Department of Pathology, European Institute of Oncology, Milan
| | - G Curigliano
- Experimental Therapeutics European Institute of Oncology, Milan
| | - S Zurrida
- Division of Senology, European Institute of Oncology, Milan, Italy
| | - F Bassi
- Division of Senology, European Institute of Oncology, Milan, Italy
| | - R Salgado
- Department of Pathology, GZA, Breast Cancer Translational Research Group, Jules Bordet Institute, Brussels
| | - G Van den Eynden
- Molecular Immunology Lab, Institut Jules Bordet, Université Libre de Bruxelles, Brussels, Belgium
| | - S Loi
- Division of Research and Cancer Medicine, Peter MacCallum Cancer Centre University of Melbourne, East Melbourne, Victoria, Australia
| | - C Denkert
- Institute of Pathology Charité University Hospital, Berlin, Germany and German Cancer Consortium, Berlin, Germany
| | - B Bonanni
- Cancer Prevention and Genetics, European Institute of Oncology, Milan
| | - G Viale
- Department of Pathology, European Institute of Oncology, Milan.,School of Medicine, University of Milan, Milan
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Clinical risk score to predict likelihood of recurrence after ductal carcinoma in situ treated with breast-conserving surgery. Breast Cancer Res Treat 2017; 167:751-759. [PMID: 29079937 DOI: 10.1007/s10549-017-4553-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 10/24/2017] [Indexed: 10/18/2022]
Abstract
PURPOSE A majority of women with ductal carcinoma in situ (DCIS) receive breast-conserving surgery (BCS) but then face a risk of ipsilateral breast tumor recurrence (IBTR) which can be either recurrence of DCIS or invasive breast cancer. We developed a score to provide individualized information about IBTR risk to guide treatment decisions. METHODS Data from 2762 patients treated with BCS for DCIS at centers within the National Comprehensive Cancer Network (NCCN) were used to identify statistically significant non-treatment-related predictors for 5-year IBTR. Factors most associated with IBTR were estrogen-receptor status of the DCIS, presence of comedo necrosis, and patient age at diagnosis. These three parameters were used to create a point-based risk score. Discrimination of this score was assessed in a separate DCIS population of 301 women (100 with IBTR and 200 without) from Kaiser Permanente Northern California (KPNC). RESULTS Using NCCN data, the 5-year likelihood of IBTR without adjuvant therapy was 9% (95% CI 5-12%), 23% (95% CI 13-32%), and 51% (95% CI 26-75%) in the low, intermediate, and high-risk groups, respectively. Addition of the risk score to a model including only treatment improved the C-statistic from 0.69 to 0.74 (improvement of 0.05). Cross-validation of the score resulted in a C-statistic of 0.76. The score had a c-statistic of 0.67 using the KPNC data, revealing that it discriminated well. CONCLUSIONS This simple, no-cost risk score may be used by patients and physicians to facilitate preference-based decision-making about DCIS management informed by a more accurate understanding of risks.
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Gorringe KL, Fox SB. Ductal Carcinoma In Situ Biology, Biomarkers, and Diagnosis. Front Oncol 2017; 7:248. [PMID: 29109942 PMCID: PMC5660056 DOI: 10.3389/fonc.2017.00248] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 10/02/2017] [Indexed: 12/21/2022] Open
Abstract
Ductal carcinoma in situ (DCIS) is an often-diagnosed breast disease and a known, non-obligate, precursor to invasive breast carcinoma. In this review, we explore the clinical and pathological features of DCIS, fundamental elements of DCIS biology including gene expression and genetic events, the relationship of DCIS with recurrence and invasive breast cancer, and the interaction of DCIS with the microenvironment. We also survey how these various elements are being used to solve the clinical conundrum of how to optimally treat a disease that has potential to progress, and yet is also likely over-treated in a significant proportion of cases.
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Affiliation(s)
- Kylie L. Gorringe
- Cancer Genomics Program, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- The Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
| | - Stephen B. Fox
- The Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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Wang L, Xia Y, Liu D, Zeng Y, Chang L, Li L, Hou Y, Ge L, Li W, Liu Z. Evaluating the efficacy of post-surgery adjuvant therapies used for ductal carcinoma in situ patients: a network meta-analysis. Oncotarget 2017; 8:79257-79269. [PMID: 29108304 PMCID: PMC5668037 DOI: 10.18632/oncotarget.17366] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Accepted: 03/16/2017] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVE Post-surgery adjuvant therapies are very important for patients suffering from ductal carcinoma in situ (DCIS). In this study we conducted a network meta-analysis (NMA) to evaluate the efficacy of different post-surgery adjuvant therapies including tamoxifen, anastrozole and radiation therapy (RT) and their combinations (RT+ tamoxifen and RT+ anastrozole). METHODS We searched several databases, including Embase, MEDLINE / PUBMED, Cochrane Library, and Science Citation Index, for relevant studies. We then extracted the data from eligible studies in order to perform our NMA. We measured the comparative efficacy of each treatment option based on the calculated odds ratios (ORs) and the corresponding 95% credibility interval (95%CrI) for each treatment option. We calculated the surfaces under the cumulative ranking curves (SUCRA) in order to rank the therapies according to their different outcomes. RESULTS In this study, local recurrence (LC) was chosen as the primary outcome. Metastasis, contralateral-breast cancer (CBC), ipsilateral-breast cancer (IBC) and death were secondary outcomes. Patients treated with RT and RT + tamoxifen exhibited a lower risk of LC compared with control group (OR=0.54, 95%CrI: 0.40-0.73; OR=0.41, 95%CrI: 0.19-0.90). Patients treated by RT and RT + tamoxifen also exhibited a significantly lower risk of IBC compared with control group (OR=0.55, 95%CrI: 0.37-0.82; OR=0.42, 95%CrI: 0.18-0.99). Results from the SUCRA indicated that RT + anastrozole and RT + tamoxifen were potentially the best adjuvant treatments for patients with DCIS. CONCLUSIONS In conclusion, the RT + anastrozole and RT + tamoxifen are recommended for their performance and effectiveness.
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Affiliation(s)
- Li Wang
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
- The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Yaoxiong Xia
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
- The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Dequan Liu
- Department of Breast surgery, the Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
- The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Yueqin Zeng
- Department of Breast Surgery, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Li Chang
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
- The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Lan Li
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
- The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Yu Hou
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
- The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Lv Ge
- The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Wenhui Li
- Department of Radiation Oncology, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
- The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
| | - Zhijie Liu
- Department of Breast Surgery, The Third Affiliated Hospital of Kunming Medical University, Tumor Hospital of Yunnan Province, Kunming, Yunnan, China
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Barbour S, Moore J, Dunn N, Effeney R, Harden H, McCarthy A, Walpole E, Lehman M. Patterns of care for ductal carcinoma in situ of the breast: Queensland's experience over a decade. Breast 2017; 35:169-176. [DOI: 10.1016/j.breast.2017.07.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 06/20/2017] [Accepted: 07/05/2017] [Indexed: 12/20/2022] Open
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Shurell E, Olcese C, Patil S, McCormick B, Van Zee KJ, Pilewskie ML. Delay in radiotherapy is associated with an increased risk of disease recurrence in women with ductal carcinoma in situ. Cancer 2017; 124:46-54. [PMID: 28960259 DOI: 10.1002/cncr.30972] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Revised: 07/31/2017] [Accepted: 08/08/2017] [Indexed: 11/10/2022]
Abstract
BACKGROUND The current study was conducted to examine the association between ipsilateral breast tumor recurrence (IBTR) and the timing of radiotherapy (RT) in women with ductal carcinoma in situ (DCIS) undergoing breast-conserving surgery (BCS). METHODS Women with DCIS who were treated with BCS and RT from 1980 through 2010 were identified from a prospectively maintained database. IBTR rates, measured from the time of RT completion, were compared between those who initiated RT ≤8 weeks, >8 to 12 weeks, and >12 weeks after the completion of surgery. The association between RT timing and IBTR was evaluated by Kaplan-Meier and log-rank analyses; Cox modeling was used for multivariable analysis. RESULTS A total of 1323 women met the inclusion criteria. The median follow-up was 6.6 years, with 311 patients followed for ≥10 years. A total of 126 IBTR events occurred. Patients were categorized by RT timing: 806 patients (61%) with timing of ≤8 weeks, 386 patients (29%) with timing of >8 to 12 weeks, and 131 patients (10%) with timing >12 weeks. The 5-year and 10-year IBTR rates were 5.8% and 13.0%, respectively, for RT starting ≤8 weeks after surgery; 3.8% and 7.6%, respectively, for RT starting >8 to 12 weeks after surgery; and 8.8% and 23.0%, respectively, for an RT delay >12 weeks after surgery (P = .004). On multivariable analysis, menopause (hazard ratio [HR], 0.54; P = .0009) and endocrine therapy (HR, 0.45; P = .002) were found to be protective against IBTR, whereas a delay in RT >12 weeks compared with ≤8 weeks was associated with a higher risk of IBTR (HR, 1.92; P = .014). There was no difference in IBTR noted between RT initiation at ≤8 weeks and initiation at >8 to 12 weeks after BCS (P = .3). CONCLUSIONS A delay in RT >12 weeks is associated with a significantly higher risk of IBTR in women undergoing BCS for DCIS. Efforts should be made to avoid delays in starting RT to minimize the risk of disease recurrence. Cancer 2018;124:46-54. © 2017 American Cancer Society.
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Affiliation(s)
- Elizabeth Shurell
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Cristina Olcese
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Beryl McCormick
- Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
| | - Melissa L Pilewskie
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, New York
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Nomogram individually predicts the overall survival of patients with gastroenteropancreatic neuroendocrine neoplasms. Br J Cancer 2017; 117:1544-1550. [PMID: 28949958 PMCID: PMC5680463 DOI: 10.1038/bjc.2017.315] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Revised: 08/06/2017] [Accepted: 08/18/2017] [Indexed: 12/11/2022] Open
Abstract
Background: The current study aimed to establish a novel nomogram to predict the overall survival of individual Chinese patients with gastroenteropancreatic neuroendocrine neoplasms (GEP-NENs). Furthermore, this study sought to externally validate this nomogram using the Surveillance, Epidemiology, and End Results (SEER) database. Methods: The records of 1183 patients with GEP-NENs treated at five high-capacity institutions in China between 2005 and 2015 were retrospectively analysed. In addition, 10 236 GEP-NEN cases from the SEER database were included as an external validation set. Results: A multivariate analysis using Cox proportional hazards (PHs) regression was performed, and a nomogram was constructed. Discrimination, calibration, and external validation were performed using the SEER data set. The multivariate Cox model indicated that age, tumour size, differentiation, lymph node metastases, and distant metastases were independent covariates associated with survival. With respect to the training set, the nomogram exhibited better discrimination power than TNM classification (Harrell’s concordance index (C-index): 0.837 vs 0.784, P=0.006). Discrimination was also excellent and superior to that of TNM classification for the SEER-based validation set (C-index: 0.808 vs 0.717, P<0.001). The calibrated nomogram predicted a survival rate that closely corresponded to the actual survival rate. Conclusions: We developed a nomogram that predicted the 3- and 5-year overall survival rates of patients with GEP-NENs. Validation revealed excellent discrimination and calibration for this nomogram, suggesting that it exhibits satisfactory clinical utility that might improve individualised predictions of survival risks and lead to the creation of additional clinical therapies.
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125
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Best practices for multidisciplinary integration of a DCIS genomic assay into clinical practice. J Surg Oncol 2017; 116:1016-1020. [DOI: 10.1002/jso.24754] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2017] [Accepted: 06/15/2017] [Indexed: 01/07/2023]
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126
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Muhsen S, Barrio AV, Miller M, Olcese C, Patil S, Morrow M, Van Zee KJ. Outcomes for Women with Minimal-Volume Ductal Carcinoma In Situ Completely Excised at Core Biopsy. Ann Surg Oncol 2017; 24:3888-3895. [PMID: 28828599 DOI: 10.1245/s10434-017-6043-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Indexed: 12/21/2022]
Abstract
BACKGROUND Overdiagnosis and overtreatment of ductal carcinoma in situ (DCIS) are concerns, especially for women with low-volume, screen-detected DCIS. This study aimed to evaluate the outcomes for such patients. METHODS Women who had minimal-volume DCIS (mDCIS, defined as DCIS diagnosed by core biopsy but with no residual disease on the surgical excision) treated with breast-conserving surgery from 1990 to 2011 were identified. Ipsilateral and contralateral breast events (IBE and CBE) were compared by competing-risk (CR) analysis. Kaplan-Meier (KM) estimates and log-rank tests were used to evaluate covariates. RESULTS The study identified 290 cases of mDCIS. The median age of the patients was 53 years. Radiation therapy (RT) was performed for 27.6% and endocrine therapy for 16.2% of the patients. The median follow-up period was 6.8 years. Overall, the IBE rates were 4.3% at 5 years and 12.3% at 10 years. Among the women not receiving RT, the 5- and 10-year IBE rates (5.4 and 14.5%) were higher than the CBE rates (1.8 and 2.7%). Among those receiving RT, the IBE rates (1.5 and 6.0%) were lower than the CBE rates (4.1 and 15.6%). The women receiving RT trended toward significantly lower IBE rates (p = 0.07). Age, grade, and endocrine therapy were not significantly associated with IBE risk. CONCLUSIONS Among the patients with mDCIS who did not receive RT, the IBE risk was substantially higher than the CBE risk, demonstrating that even DCIS of very low volume is associated with clinically relevant disease. The finding that the IBE risk was greater than the CBE risk supports current strategies that treat DCIS as a precursor rather than a risk marker. Women with mDCIS are not at negligible risk for IBE in the absence of adjuvant therapy.
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Affiliation(s)
- Shirin Muhsen
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Andrea V Barrio
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Megan Miller
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cristina Olcese
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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128
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Sakai T, Iwase T, Teruya N, Kataoka A, Kitagawa D, Nakashima E, Ogiya A, Miyagi Y, Iijima K, Morizono H, Makita M, Gomi N, Oguchi M, Ito Y, Horii R, Akiyama F, Ohno S. Surgical excision without whole breast irradiation for complete resection of ductal carcinoma in situ identified using strict, unified criteria. Am J Surg 2017; 214:111-116. [DOI: 10.1016/j.amjsurg.2016.10.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 10/08/2016] [Accepted: 10/24/2016] [Indexed: 10/20/2022]
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129
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Lubelski D, Alentado V, Nowacki AS, Shriver M, Abdullah KG, Steinmetz MP, Benzel EC, Mroz TE. Preoperative Nomograms Predict Patient-Specific Cervical Spine Surgery Clinical and Quality of Life Outcomes. Neurosurgery 2017; 83:104-113. [DOI: 10.1093/neuros/nyx343] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2016] [Accepted: 05/22/2017] [Indexed: 11/13/2022] Open
Abstract
Abstract
BACKGROUND
Clinical and quality of life (QOL) outcomes vary depending on the patient's demographics, comorbidities, presenting symptoms, pathology, and surgical treatment used. While there have been individual predictors identified, no comprehensive method incorporates a patient's complex clinical presentation to predict a specific individual postoperative outcome.
OBJECTIVE
To create tool that predicts patient-specific outcomes among those undergoing cervical spine surgery.
METHODS
A total of 952 patients at a single tertiary care institution who underwent anterior or posterior cervical decompression/fusion between 2007 and 2013 were retrospectively reviewed. Outcomes included postoperative emergency department visit or readmission within 30 d, reoperation within 90 d for infection, and changes in QOL outcomes. Nomograms were modeled based on patient demographics and surgical variables. Bootstrap was used for internal validation.
RESULTS
Bias-corrected c-index for emergency department visits, readmission, and reoperation were 0.63, 0.78, and 0.91, respectively. For the QOL metrics, the bias-corrected adjusted R-squared was EQ-5D (EuroQOL): 0.43, for PHQ-9 (Patient Health Questionnaire-9): 0.35, and for PDQ (Pain/Disability Questionnaire): 0.47. Variables predicting the clinical outcomes varied, but included race and median income, body mass index, comorbidities, presenting symptoms, indication for surgery, surgery type, and levels. For the QOL nomograms, the predictors included similar variables, but were significantly more affected by the preoperative QOL of the patient.
CONCLUSION
These prediction models enable referring physicians and spine surgeons to provide patients with personalized expectations regarding postoperative clinical and QOL outcomes following a cervical spine surgery. After appropriate validation, use of patient-specific prediction tools, such as nomograms, has the potential to lead to superior spine surgery outcomes and more cost effective care.
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Affiliation(s)
- Daniel Lubelski
- Department of Neurosurgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Vincent Alentado
- Department of Neurosurgery and the Cleveland Clinic Center for Spine Health, Cleveland Clinic, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Amy S Nowacki
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
- Department of Quantitative Health Science, Cleveland Clinic, Cleveland, Ohio
| | - Michael Shriver
- Department of Neurosurgery and the Cleveland Clinic Center for Spine Health, Cleveland Clinic, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Kalil G Abdullah
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael P Steinmetz
- Department of Neurosurgery and the Cleveland Clinic Center for Spine Health, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Edward C Benzel
- Department of Neurosurgery and the Cleveland Clinic Center for Spine Health, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
| | - Thomas E Mroz
- Department of Neurosurgery and the Cleveland Clinic Center for Spine Health, Cleveland Clinic, Cleveland, Ohio
- Cleveland Clinic Lerner College of Medicine, Cleveland, Ohio
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Shelley Hwang E, Thompson A. What Can Molecular Diagnostics Add to Locoregional Treatment Recommendations for DCIS? J Natl Cancer Inst 2017; 109:3064544. [PMID: 28376162 DOI: 10.1093/jnci/djw270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/10/2016] [Indexed: 11/12/2022] Open
Affiliation(s)
- E Shelley Hwang
- Duke University Medical Center, Department of Surgery, Division of Surgical Oncology, Durham, NC, USA
| | - Alastair Thompson
- Department of Breast Surgery, MD Anderson Cancer Center, Houston, TX, USA
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Current treatment trends and the need for better predictive tools in the management of ductal carcinoma in situ of the breast. Cancer Treat Rev 2017; 55:163-172. [PMID: 28402908 DOI: 10.1016/j.ctrv.2017.03.009] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/21/2017] [Accepted: 03/23/2017] [Indexed: 12/14/2022]
Abstract
Ductal carcinoma in situ (DCIS) of the breast represents a group of heterogeneous non-invasive lesions the incidence of which has risen dramatically since the advent of mammography screening. In this review we summarise current treatment trends and up-to-date results from clinical trials studying surgery and adjuvant therapy alternatives, including the recent consensus on excision margin width and its role in decision-making for post-excision radiotherapy. The main challenge in the clinical management of DCIS continues to be the tailoring of treatment to individual risk, in order to avoid the over-treatment of low-risk lesions or under-treatment of DCIS with higher risk of recurring or progressing into invasion. While studies estimate that only about 40% of DCIS would become invasive if untreated, heterogeneity and complex natural history have prevented adequate identification of these higher-risk lesions. Here we discuss attempts to develop prognostic tools for the risk stratification of DCIS lesions and their limitations. Early results of a UK-wide audit of DCIS management (the Sloane Project) have also demonstrated a lack of consistency in treatment. In this review we offer up-to-date perspectives on current treatment and prediction of DCIS, highlighting the pressing clinical need for better prognostic indices. Tools integrating both clinical and histopathological factors together with molecular biomarkers may hold potential for adequate stratification of DCIS according to risk. This could help develop standardised practices for optimal management of patients with DCIS, improving clinical outcomes while providing only the amount of therapy required for each individual patient.
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Wai ES, Lesperance M, Lu L, Alexander CS, Truong PT. Effect of Referral Patterns and Treatment Type on Oncologic Outcomes for Women with Ductal Carcinoma In Situ. Cureus 2017; 9:e1128. [PMID: 28465875 PMCID: PMC5409819 DOI: 10.7759/cureus.1128] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
Objective Management of ductal carcinoma in situ (DCIS) remains controversial. This study examined long-term outcomes in a population-based cohort of patients with pure DCIS treated with breast-conserving surgery (BCS) alone, BCS + radiotherapy (RT), and mastectomy. Outcomes were compared between patients referred versus not referred for oncologic assessment after definitive surgery. Materials and methods Subjects were 2575 women diagnosed between 1985 and 1999. Data from several electronic databases were linked and analyzed. Outcomes were invasive local recurrence-free survival (ILRFS), mastectomy-free survival (MFS), breast cancer-specific survival (BCSS), and overall survival (OS). Results Median follow-up time was 9.8 years. Overall, 56% (n = 1448) of subjects were referred to a cancer centre. Factors associated with non-referral were older age, comorbidities, and travel distance. Ten-year MFS, BCSS, and OS were higher among referred patients (all p ≤ 0.001). In cohorts treated with BCS alone (n = 1314) vs. BCS + RT (n = 510) vs. mastectomy (n = 751), 10-year ILRFS were 93.7% vs. 96.6% vs. 97.7%, (p < 0.001) and BCSS were 97.6% vs. 99.8% vs. 98.6%, (p = 0.01). Corresponding rates of ipsilateral invasive breast relapse at 10 years were 6.3% after BCS alone, 3.4% after BCS + RT, and 2.3% after mastectomy (p < 0.001). On multivariable analysis, factors associated with improved ILRFS were older age at diagnosis, low comorbidity score, absence of comedo histology, mastectomy, and post-BCS RT. Conclusion Patients with DCIS referred for oncologic assessment were more likely to undergo post-BCS RT, resulting in lower mastectomy and higher survival rates compared to non-referred patients. Patients with significant comorbidities were less likely to be referred and experienced lower ILRFS and BCSS. Referral for multidisciplinary oncologic assessment after surgery is warranted to individualize management and optimize outcomes for patients with DCIS.
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Affiliation(s)
- Elaine S Wai
- Radiation Oncology, University of British Columbia, BC Cancer Agency
| | | | | | | | - Pauline T Truong
- Radiation Oncology, University of British Columbia, BC Cancer Agency
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Notake T, Kobayashi A, Shinkawa H, Kawahara T, Shimizu A, Yokoyama T, Hasegawa K, Kokudo N, Matsuyama Y, Makuuchi M, Miyagawa SI. Nomogram predicting long-term survival after the diagnosis of intrahepatic recurrence of hepatocellular carcinoma following an initial liver resection. Int J Clin Oncol 2017; 22:715-725. [PMID: 28303401 DOI: 10.1007/s10147-017-1114-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2017] [Accepted: 03/08/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND The aim of this study was to construct and validate a nomogram for predicting survival after the intrahepatic recurrence of hepatocellular carcinoma (HCC) following an initial hepatectomy. METHODS A primary cohort of 268 patients who underwent curative hepatectomy for HCC at Shinshu University Hospital between 1990 and 2010 was retrospectively studied. A nomogram was constructed based on independent prognostic factors for overall survival after recurrence. The predictive performance was evaluated using the concordance index (c-index) and a calibration curve. The nomogram was then externally validated in a cohort of patients from Tokyo University Hospital (n = 296). RESULTS In multivariate analysis, the following 5 variables were identified as independent predictors of overall survival and incorporated into the nomogram-Japan Integrated Stage score at initial liver resection, platelet count at initial liver resection, time until intrahepatic recurrence, vascular invasion at recurrence, and type of treatment used for intrahepatic recurrence. The nomogram had a c-index of 0.75 (95% confidence interval 0.60-0.85) for the Shinshu cohort and 0.71 (0.57-0.81) for the Tokyo cohort. The predicted 3- and 5-year survival probabilities corresponded well with the actual outcomes. CONCLUSIONS The established nomogram might be useful for estimating survival after the intrahepatic recurrence of HCC.
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Affiliation(s)
- Tsuyoshi Notake
- Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Akira Kobayashi
- Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan.
| | - Hiroji Shinkawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Takuya Kawahara
- Department of Biostatistics, School of Public Health, University of Tokyo, Tokyo, Japan
| | - Akira Shimizu
- Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Takahide Yokoyama
- Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
| | - Kiyoshi Hasegawa
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Norihiro Kokudo
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Graduate School of Medicine, University of Tokyo, Tokyo, Japan
| | - Yutaka Matsuyama
- Department of Biostatistics, School of Public Health, University of Tokyo, Tokyo, Japan
| | - Masatoshi Makuuchi
- Hepato-Biliary-Pancreatic Surgery Division, Department of Surgery, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Shin-Ichi Miyagawa
- Department of Surgery, Shinshu University School of Medicine, 3-1-1 Asahi, Matsumoto, 390-8621, Japan
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Wang EH, Park HS, Rutter CE, Gross CP, Soulos PR, Yu JB, Evans SB. Association between access to accelerated partial breast irradiation and use of adjuvant radiotherapy. Cancer 2017; 123:502-511. [PMID: 27657353 DOI: 10.1002/cncr.30356] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 08/16/2016] [Accepted: 09/01/2016] [Indexed: 11/09/2022]
Abstract
BACKGROUND The current study was performed to determine whether access to facilities performing accelerated partial breast irradiation (APBI) is associated with differences in the use of adjuvant radiotherapy (RT). METHODS Using the National Cancer Data Base, the authors performed a retrospective study of women aged ≥50 years who were diagnosed with early-stage breast cancer between 2004 and 2013 and treated with breast-conserving surgery (BCS). Facilities performing APBI in ≥10% of their eligible patients within a given year were defined as APBI facilities whereas those not performing APBI were defined as non-APBI facilities. All other facilities were excluded. The authors identified independent factors associated with RT use using multivariable logistic regression with clustering in the overall sample as well as in subsets of patients with standard-risk invasive cancer, low-risk invasive cancer, and ductal carcinoma in situ. RESULTS Among 222,544 patients, 76.6% underwent BCS plus RT and 23.4% underwent BCS alone. The likelihood of RT receipt in the overall sample did not appear to differ significantly between APBI and non-APBI facilities (adjusted odds ratio [AOR], 1.02; P = .61). Subgroup multivariable analysis demonstrated that among patients with standard-risk invasive cancer, there was no association between evaluation at an APBI facility and receipt of RT (AOR, 0.98; P = .69). However, patients with low-risk invasive cancer were found to be significantly more likely to receive RT (54.4% vs 59.5%; AOR, 1.22 [P<.001]), whereas patients with ductal carcinoma in situ were less likely to receive RT (56.9% vs 55.3%; AOR, 0.89 [P = .04]) at APBI facilities. CONCLUSIONS Patients who were eligible for observation were more likely to receive RT in APBI facilities but no difference was observed among patients with standard-risk invasive cancer who would most benefit from RT. Cancer 2017;123:502-511. © 2016 American Cancer Society.
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Affiliation(s)
- Elyn H Wang
- Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Henry S Park
- Yale School of Medicine, Yale University, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research Center at Yale, Yale University, New Haven, Connecticut.,Department of Therapeutic Radiology, Yale University, New Haven, Connecticut
| | - Charles E Rutter
- Yale School of Medicine, Yale University, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research Center at Yale, Yale University, New Haven, Connecticut.,Department of Therapeutic Radiology, Yale University, New Haven, Connecticut
| | - Cary P Gross
- Yale School of Medicine, Yale University, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research Center at Yale, Yale University, New Haven, Connecticut.,Department of Therapeutic Radiology, Yale University, New Haven, Connecticut
| | - Pamela R Soulos
- Yale School of Medicine, Yale University, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research Center at Yale, Yale University, New Haven, Connecticut
| | - James B Yu
- Yale School of Medicine, Yale University, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research Center at Yale, Yale University, New Haven, Connecticut.,Department of Therapeutic Radiology, Yale University, New Haven, Connecticut
| | - Suzanne B Evans
- Yale School of Medicine, Yale University, New Haven, Connecticut.,Cancer Outcomes, Public Policy, and Effectiveness Research Center at Yale, Yale University, New Haven, Connecticut.,Department of Therapeutic Radiology, Yale University, New Haven, Connecticut
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135
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Kim K, Jung SY, Shin KH, Kim JH, Han W, Lee HB, Huh SJ, Choi DH, Park W, Ahn SD, Kim SS, Kim JH, Suh CO, Kim YB, Kim IA, Kim S, Kim YJ. Recurrence outcomes after omission of postoperative radiotherapy following breast-conserving surgery for ductal carcinoma in situ of the breast: a multicenter, retrospective study in Korea (KROG 16-02). Breast Cancer Res Treat 2017; 162:77-83. [PMID: 28083820 DOI: 10.1007/s10549-017-4111-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2016] [Accepted: 01/09/2017] [Indexed: 01/03/2023]
Abstract
PURPOSE To evaluate the loco-regional recurrence (LRR) rate after breast-conserving surgery without postoperative radiotherapy (RT) for ductal carcinoma in situ (DCIS) of the breast. METHODS Between 2000 and 2010, 311 DCIS patients from 9 institutions were analyzed retrospectively. The median age was 47 (range, 20-82). The median tumor size was 7 mm (range, 0.01-76). Margin width was <1 cm in 85 patients (27.3%), and nuclear grade was high in 37 patients (11.9%). Two hundred and three patients (65.3%) received tamoxifen. RESULTS With a median follow-up of 74 months (range, 5-189), there were 11 local recurrences (invasive carcinoma in 6 and DCIS in 5) and 1 regional recurrence. The 7-year LRR rate was 3.8%. On univariate analysis, age and margin width were significant risk factors influencing LRR (p = 0.017 and 0.014, respectively). When age and margin width were combined among 211 patients whose margin width were available, the 7-year LRR rates were as follows (p < 0.001): (1) 0% in patients with age >50 years and any margin width status (n = 64), (2) 1.2% in age ≤50 years and margin width ≥1 cm (n = 93), (3) 13.1% in age ≤50 years and margin width <1 cm (n = 54). CONCLUSIONS The LRR rate was very low in selected DCIS patients treated with breast-conserving surgery without postoperative RT. However, adjuvant RT should be considered for those with age ≤50 years and margin width <1 cm.
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Affiliation(s)
- Kyubo Kim
- Department of Radiation Oncology, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - So-Youn Jung
- Center for Breast Cancer, National Cancer Center, Goyang, Gyeonggi, Republic of Korea
| | - Kyung Hwan Shin
- Department of Radiation Oncology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.
| | - Jin Ho Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea
| | - Wonshik Han
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Han-Byoel Lee
- Department of Surgery, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Seung Jae Huh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Doo Ho Choi
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Won Park
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | - Seung Do Ahn
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Su Ssan Kim
- Department of Radiation Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Jin Hee Kim
- Department of Radiation Oncology, Dongsan Medical Center, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Chang-Ok Suh
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yong Bae Kim
- Department of Radiation Oncology, Yonsei Cancer Center, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - In Ah Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.,Department of Radiation Oncology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi, Republic of Korea
| | - Suzy Kim
- Department of Radiation Oncology, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul, 110-744, Republic of Korea.,Department of Radiation Oncology, SMG-SNU Boramae Medical Center, Seoul, Republic of Korea
| | - Yi-Jun Kim
- Department of Radiation Oncology, Ewha Womans University School of Medicine, Seoul, Republic of Korea
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137
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Whole-Breast Radiation Following Breast-Conserving Surgery in Noninvasive Cancer. Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_52] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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138
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Toss MS, Pinder SE, Green AR, Thomas J, Morgan DAL, Robertson JFR, Ellis IO, Rakha EA. Breast conservation in ductal carcinomain situ(DCIS): what defines optimal margins? Histopathology 2016; 70:681-692. [DOI: 10.1111/his.13116] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Michael S Toss
- Department of Histopathology, Division of Cancer and Stem Cells, School of Medicine; The University of Nottingham, Nottingham City Hospital; Nottingham UK
| | - Sarah E Pinder
- Department of Research Oncology; King's College London, Guy's Hospital; London UK
| | - Andrew R Green
- Department of Histopathology, Division of Cancer and Stem Cells, School of Medicine; The University of Nottingham, Nottingham City Hospital; Nottingham UK
| | - Jeremy Thomas
- Department of Pathology; Western General Hospital; Edinburgh UK
| | - David A L Morgan
- Department of Oncology, Division of Cancer and Stem Cells, School of Medicine; The University of Nottingham, Nottingham City Hospital; Nottingham UK
| | - John F R Robertson
- Division of Breast Surgery, Graduate Entry Medicine and Health School (GEMS); University of Nottingham, Royal Derby Hospital; Derby UK
| | - Ian O Ellis
- Department of Histopathology, Division of Cancer and Stem Cells, School of Medicine; The University of Nottingham, Nottingham City Hospital; Nottingham UK
| | - Emad A Rakha
- Department of Histopathology, Division of Cancer and Stem Cells, School of Medicine; The University of Nottingham, Nottingham City Hospital; Nottingham UK
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139
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Leonard KL, Wazer DE. Genomic Assays and Individualized Treatment of Ductal Carcinoma In Situ in the Era of Value-Based Cancer Care. J Clin Oncol 2016; 34:3953-3955. [PMID: 29236596 DOI: 10.1200/jco.2016.69.8332] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Kara-Lynne Leonard
- Kara-Lynne Leonard and David E. Wazer, Alpert Medical School of Brown University, Providence, RI
| | - David E Wazer
- Kara-Lynne Leonard and David E. Wazer, Alpert Medical School of Brown University, Providence, RI
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140
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Pang JMB, Gorringe KL, Fox SB. Ductal carcinoma in situ - update on risk assessment and management. Histopathology 2016; 68:96-109. [PMID: 26768032 DOI: 10.1111/his.12796] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 07/31/2015] [Indexed: 12/20/2022]
Abstract
Ductal carcinoma in situ (DCIS) accounts for ~20-25% of breast cancers. While DCIS is not life-threatening, it may progress to invasive carcinoma over time, and treatment intended to prevent invasive progression may itself cause significant morbidity. Accurate risk assessment is therefore necessary to avoid over- or undertreatment of an individual patient. In this review we will outline the evidence for current management of DCIS, discuss approaches to DCIS risk assessment and challenges facing identification of novel DCIS biomarkers.
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Affiliation(s)
- Jia-Min B Pang
- Department of Pathology, Peter MacCallum Cancer Centre, East Melbourne, Vic., Australia.,Department of Pathology, University of Melbourne, Melbourne, Vic., Australia
| | - Kylie L Gorringe
- Department of Pathology, University of Melbourne, Melbourne, Vic., Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Vic., Australia.,Cancer Genetics Laboratory, Peter MacCallum Cancer Centre, East Melbourne, Vic., Australia
| | - Stephen B Fox
- Department of Pathology, Peter MacCallum Cancer Centre, East Melbourne, Vic., Australia.,Department of Pathology, University of Melbourne, Melbourne, Vic., Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Vic., Australia
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141
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Pilewskie M, Olcese C, Patil S, Van Zee KJ. Women with Low-Risk DCIS Eligible for the LORIS Trial After Complete Surgical Excision: How Low Is Their Risk After Standard Therapy? Ann Surg Oncol 2016; 23:4253-4261. [PMID: 27766556 DOI: 10.1245/s10434-016-5595-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Identifying DCIS patients at low risk for disease progression could obviate need for standard therapy. The LORIS (surgery versus active monitoring for low-risk DCIS) trial is studying the safety of monitoring low-risk DCIS, although ipsilateral breast tumor recurrence (IBTR) rates in patients meeting enrollment criteria after complete surgical excision are unknown. METHODS Women with pure DCIS treated with breast-conserving surgery (BCS) with/without radiation therapy (RT) from 1/1996-1/2011 were included from a prospectively maintained database. IBTR rates were compared between those who did and did not meet LORIS eligibility criteria (age ≥ 46 years, screen-detected calcifications, nipple discharge absence, minimal family history, non-high-grade DCIS) after complete surgical excision. RESULTS A total of 2394 women were identified; 401 met LORIS criteria. Median follow-up was 5.9 years; 431 had ≥10 years follow-up. LORIS cohort median age was 61 years (range 46-86 years); 207 (52 %) underwent RT, 79 (20 %) received endocrine therapy. Of 401 patients, 24 experienced an IBTR. Overall 10-year IBTR rates were 10.3 % (LORIS) versus 15.4 % (non-LORIS) (p = 0.08); without RT, 12.1 versus 21.4 %, respectively (p = 0.06). The 10-year invasive-IBTR rates for women meeting LORIS criteria were: 5.3 % BCS overall, 6.0 % without RT. CONCLUSIONS Women meeting LORIS criteria (after complete surgical excision) are at somewhat lower risk for IBTR. Among such women undergoing excision without RT, the 10-year invasive-IBTR rate was 6 %. Given that approximately 20 % of women with core biopsy-proven non-high-grade DCIS have invasive cancer at excision, women managed without excision would be expected to incur higher invasive cancer rates. Additional criteria are needed to identify women not requiring intervention for DCIS.
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Affiliation(s)
- Melissa Pilewskie
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Cristina Olcese
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Abstract
PURPOSE OF REVIEW Ductal carcinoma in situ (DCIS) accounts for approximately 20% of mammographically diagnosed breast cancers. Currently, there is a trend to consider DCIS as a lesion for which treatment deescalation is advocated to avoid overtreatment, that is, radiotherapy in addition to breast-conserving surgery or even surgery at all. RECENT FINDINGS The long-term follow-up updates of the four first-generation randomized trials comparing lumpectomy with and without radiation therapy have confirmed that radiation halves the local failure rates. However, radiotherapy is not associated with a survival benefit just as affirmed by the recently published evaluation of the Surveillance, Epidemiology, and End Results registries database, including 108,196 women with DCIS. Nevertheless, the risk of dying of breast cancer increases about factor 18 after experience of an invasive local recurrence. That means at least some DCIS have the potential to progress to a life threatening disease. At the same time, none of the recently updated prospective trials that tested the outcome after excision alone in low-risk DCIS achieved a 10-year local failure rate below 10%. SUMMARY DCIS is not a uniform disease. Its clinical behaviour is heterogeneous, but up to date no citeria are available that allow a precise identification of patients with low or very low progression risk who do not need irradiation. Therefore, excision followed by radiotherapy is still the standard of care in patients undergoing breast conservation. Promising new approaches for risk estimation have to be validated prospectively before their use in daily practice can be recommended.
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143
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Chae EY, Shin HJ, Kim S, Baek HM, Yoon D, Kim S, Shim YE, Kim HH, Cha JH, Choi WJ, Lee JH, Shin JH, Lee HJ, Gong G. The Role of High-Resolution Magic Angle Spinning 1H Nuclear Magnetic Resonance Spectroscopy for Predicting the Invasive Component in Patients with Ductal Carcinoma In Situ Diagnosed on Preoperative Biopsy. PLoS One 2016; 11:e0161038. [PMID: 27560937 PMCID: PMC4999265 DOI: 10.1371/journal.pone.0161038] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2016] [Accepted: 07/28/2016] [Indexed: 12/15/2022] Open
Abstract
The purpose of this study was to evaluate the role of high-resolution magic angle spinning (HR-MAS) 1H nuclear magnetic resonance (NMR) spectroscopy in patients with ductal carcinoma in situ (DCIS) diagnosed on preoperative biopsy. We investigated whether the metabolic profiling of tissue samples using HR-MAS 1H NMR spectroscopy could be used to distinguish between DCIS lesions with or without an invasive component. Our institutional review board approved this combined retrospective and prospective study. Tissue samples were collected from 30 patients with pure DCIS and from 30 with DCIS accompanying invasive carcinoma. All patients were diagnosed with DCIS by preoperative core-needle biopsy and underwent surgical resection. The metabolic profiling of tissue samples was performed by HR-MAS 1H NMR spectroscopy. All observable metabolite signals were identified and quantified in all tissue samples. Metabolite intensity normalized by total spectral intensities was compared according to the tumor type using the Mann-Whitney test. Multivariate analysis was performed with orthogonal projections to latent structure-discriminant analysis (OPLS-DA). By univariate analysis, the metabolite concentrations of choline-containing compounds obtained with HR-MAS 1H NMR spectroscopy did not differ significantly between the pure DCIS and DCIS accompanying invasive carcinoma groups. However, the GPC/PC ratio was higher in the pure DCIS group than in the DCIS accompanying invasive carcinoma group (p = 0.004, Bonferroni-corrected p = 0.064), as well as the concentration of myo-inositol and succinate. By multivariate analysis, the OPLS-DA models built with HR-MAS MR metabolic profiles could clearly discriminate between pure DCIS and DCIS accompanying invasive carcinoma. Our preliminary results suggest that HR-MAS MR metabolomics on breast tissue may be able to distinguish between DCIS lesions with or without an invasive component.
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Affiliation(s)
- Eun Young Chae
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hee Jung Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Suhkmann Kim
- Department of Chemistry and Chemistry Institute for Functional Materials, Pusan National University, Busan, South Korea
| | - Hyeon-Man Baek
- Center for Magnetic Resonance Research, Korea Basic Science Institute, Chungbuk, South Korea.,Department of Bio-Analytical Science, Korea University of Science and Technology, Daejeon, South Korea
| | - Dahye Yoon
- Department of Chemistry and Chemistry Institute for Functional Materials, Pusan National University, Busan, South Korea
| | - Siwon Kim
- Department of Chemistry and Chemistry Institute for Functional Materials, Pusan National University, Busan, South Korea
| | - Ye Eun Shim
- University of Ulsan, College of Medicine, Seoul, South Korea
| | - Hak Hee Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Joo Hee Cha
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Woo Jung Choi
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Jeong Hyun Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Hee Jin Lee
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | - Gyungyub Gong
- Department of Pathology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
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144
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Mastropasqua MG, Viale G. Clinical and pathological assessment of high-risk ductal and lobular breast lesions: What surgeons must know. Eur J Surg Oncol 2016; 43:278-284. [PMID: 27544280 DOI: 10.1016/j.ejso.2016.07.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Revised: 06/16/2016] [Accepted: 07/06/2016] [Indexed: 12/13/2022] Open
Abstract
Terminology in pathology is sometimes over-complicated and may be misinterpreted by clinicians facing patients and having difficulty answering questions posed by them. This may especially be true for some breast lesions with an increased risk of malignant transformation, the complex terminology of which reflects attempts to stratify them according to potential risk. On the basis of morphological and molecular features, both ductal and lobular proliferations have been classified and named in different ways by pathologists, and this often makes it difficult for the treating physicians and the patients to fully understand the nature of the lesions and their associated risks. In order to clarify pathology reports, unambiguous and simple terms are needed.
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Affiliation(s)
- M G Mastropasqua
- Division of Pathology and Laboratory Medicine, European Institute of Oncology, Milan, Italy.
| | - G Viale
- Division of Pathology and Laboratory Medicine, European Institute of Oncology, Milan, Italy; Division of Pathology and Laboratory Medicine, European Institute of Oncology and University of Milan, School of Medicine, Milan, Italy
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145
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Rahbar H, McDonald ES, Lee JM, Partridge SC, Lee CI. How Can Advanced Imaging Be Used to Mitigate Potential Breast Cancer Overdiagnosis? Acad Radiol 2016; 23:768-73. [PMID: 27017136 DOI: 10.1016/j.acra.2016.02.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 02/22/2016] [Accepted: 02/24/2016] [Indexed: 02/08/2023]
Abstract
Radiologists, as administrators and interpreters of screening mammography, are considered by some to be major contributors to the potential harms of screening, including overdiagnosis and overtreatment. In this article, we outline current efforts within the breast imaging community toward mitigating screening harms, including the widespread adoption of tomosynthesis and potentially adjusting screening frequency and thresholds for image-guided breast biopsy. However, the emerging field of breast radiomics may offer the greatest promise for reducing overdiagnosis by identifying imaging-based biomarkers strongly associated with tumor biology, and therefore helping prevent the harms of unnecessary treatment for indolent cancers.
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146
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Cronin PA, Olcese C, Patil S, Morrow M, Van Zee KJ. Impact of Age on Risk of Recurrence of Ductal Carcinoma In Situ: Outcomes of 2996 Women Treated with Breast-Conserving Surgery Over 30 Years. Ann Surg Oncol 2016; 23:2816-24. [PMID: 27198513 DOI: 10.1245/s10434-016-5249-5] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Age is a known risk factor for recurrence in women with ductal carcinoma in situ (DCIS) treated with breast-conserving surgery (BCS). We explored the relationship between age, other risk factors, and recurrence. METHODS Using a prospectively maintained database of DCIS patients undergoing BCS from 1978 to 2010, the association of age and recurrence risk was analyzed using Kaplan-Meier estimates, multivariable analysis, and competing risk multivariable analysis. RESULTS Overall, 2996 cases were identified. Median follow-up for those without recurrence was 75 months; 732 were followed for ≥10 years, and 363 (12 %) had recurrence [192 (53 %) DCIS, 160 (44 %) invasive, 11 (3 %) unknown]. Risk of recurrence decreased with age, even after adjustment for eight clinicopathologic variables on multivariable analysis [hazard ratios (HR), with <40 years of age as the reference: 40-49 years, 0.82 (p = 0.36), 50-59 years, 0.46 (p = 0.0005), 60-69 years, 0.50 (p = 0.003), 70-79 years, 0.56 (p = 0.02), ≥80 years, 0.21 (p = 0.0015)]. This association persisted for cohorts with and without radiation therapy. Using competing risk multivariable analysis, the effect of age on invasive recurrence was empirically stronger than for DCIS recurrence. Ten-year invasive recurrence was 16 and 6.5 % in women <40 years of age and women ≥40 years of age, respectively. Only 0.6 % of the population ultimately developed distant disease; those <40 years of age constituted 4.7 % (141/2996) of the population, but 21 % (4/19) of those developed distant disease. CONCLUSIONS The risk of recurrence of DCIS decreases with age. This effect is particularly strong at the extremes of age and is independent of other clinicopathologic factors. The oldest women are at low risk of recurrence, while the youngest women have a higher overall, and especially invasive, recurrence rate, although mortality remains low. These findings should be incorporated into risk/benefit discussions of treatment options.
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Affiliation(s)
- Patricia A Cronin
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Cristina Olcese
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
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147
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Merlino G, Miodini P, Paolini B, Carcangiu ML, Gennaro M, Dugo M, Daidone MG, Cappelletti V. Stromal Activation by Tumor Cells: An in Vitro Study in Breast Cancer. MICROARRAYS 2016; 5:microarrays5020010. [PMID: 27600076 PMCID: PMC5003486 DOI: 10.3390/microarrays5020010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Revised: 05/06/2016] [Accepted: 05/10/2016] [Indexed: 12/16/2022]
Abstract
Background: The tumor microenvironment participates in the regulation of tumor progression and influences treatment sensitivity. In breast cancer, it also may play a role in determining the fate of non-invasive lesions such as ductal carcinoma in situ (DCIS), a non-obligate precursor of invasive diseases, which is aggressively treated despite its indolent nature in many patients since no biomarkers are available to predict the progression of DCIS to invasive disease. In vitro models of stromal activation by breast tumor cells might provide clues as to specific stromal genes crucial for the transition from DCIS to invasive disease. Methods: normal human dermal fibroblasts (NHDF) were treated under serum-free conditions with cell culture media conditioned by breast cancer cell lines (SkBr3, MDA-MB-468, T47D) for 72 h and subjected to gene expression profiling with Illumina platform. Results: TGM2, coding for a tissue transglutaminase, was identified as candidate gene for stromal activation. In public transcriptomic datasets of invasive breast tumors TGM2 expression proved to provide prognostic information. Conversely, its role as an early biosensor of tumor invasiveness needs to be further investigated by in situ analyses. Conclusion: Stromal TGM2 might probably be associated with precancerous evolution at earlier stages compared to DCIS.
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Affiliation(s)
- Giuseppe Merlino
- Department of Experimental Oncology and Molecular Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Amadeo 42, 20133 Milan , Italy.
| | - Patrizia Miodini
- Department of Experimental Oncology and Molecular Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Amadeo 42, 20133 Milan , Italy.
| | - Biagio Paolini
- Department of Pathology, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan , Italy.
| | - Maria Luisa Carcangiu
- Department of Pathology, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan , Italy.
| | - Massimiliano Gennaro
- Department of Surgery, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Venezian 1, 20133 Milan , Italy.
| | - Matteo Dugo
- Functional Genomics Core Facility, Department of Experimental Oncology and Molecular Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Amadeo 42, 20133Milan, Italy.
| | - Maria Grazia Daidone
- Department of Experimental Oncology and Molecular Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Amadeo 42, 20133 Milan , Italy.
| | - Vera Cappelletti
- Department of Experimental Oncology and Molecular Medicine, Fondazione IRCCS Istituto Nazionale dei Tumori, Via Amadeo 42, 20133 Milan , Italy.
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148
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Abstract
Internet tools have become a great aid in the daily practice of physicians who treat breast cancer patients. In cancer care there are frequent and important intersections where major decisions need to be made; these include (1) whether or not to give chemotherapy; (2) how much toxicity to expect, and (3) the life expectancy of the patient, considering non-breast cancer comorbidities. These decisions can be made more accurately using calculators based on data sets of thousands of patients as opposed to physician intuition. Such tools also help patients and caregivers in optimal decision making, as they estimate the absolute benefits and risks of treatment. In this perspective we describe selected internet sites that are useful across several domains of care, including the potential benefits of different adjuvant regimens for early breast cancer, prognosis after neoadjuvant therapy, prognosis for ductal carcinoma in situ, and toxicity and life expectancy estimates. We review the variables required to use the tools, the results obtained, the methods of validation, and the advantages and disadvantages of each tool.
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149
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Wood WC. Ductal Carcinoma In Situ of the Breast: Should Breast Irradiation Be Routinely Added to Surgical Excision? J Oncol Pract 2016; 12:309-11. [PMID: 27072386 DOI: 10.1200/jop.2015.010488] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Confusion exists among women with a new diagnosis of ductal carcinoma in situ and their physicians regarding choice of treatment. The press has accused the medical community of overtreatment and found many physicians eager to support or deny the charge. Improvements in treatment delivery have been matched with better definitions of risk on the basis of biology as defined by genomic analysis rather than only lesion size, margins, receptor status, and patient age. Understanding both the risk of a specific ductal carcinoma in situ progressing to invasive breast cancer and the risks of the treatment options allows tailored recommendations.
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150
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Margins in Breast-Conserving Surgery for Early Breast Cancer: How Much is Good Enough? CURRENT BREAST CANCER REPORTS 2016. [DOI: 10.1007/s12609-016-0204-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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