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Solís O, Addae J, Sweeting R, Meszoely I, Grau A, Kauffmann R, Kelley M, McCaffrey R, Hewitt K. Cost containment analysis of superparamagnetic iron oxide (SPIO) injection in patients with ductal carcinoma in situ. Breast Cancer Res Treat 2024:10.1007/s10549-024-07451-2. [PMID: 39085674 DOI: 10.1007/s10549-024-07451-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2024] [Accepted: 07/27/2024] [Indexed: 08/02/2024]
Abstract
PURPOSE Recent studies have established the safety and efficacy of Superparamagnetic Iron Oxide (SPIO, Magtrace®) for delayed sentinel lymph node biopsy (SLNB) in patients with ductal carcinoma in situ (DCIS) who are undergoing mastectomy. The aim of our study was to measure cost containment with use of Magtrace® in comparison to upfront SLNB with traditional technetium-99 lymphatic tracer. METHODS A total of 41 patients at our institution underwent mastectomy with Magtrace® injection for DCIS and were included in our single-institution, retrospective analysis. For comparison, total charges data were obtained for an upfront SLNB at the time of mastectomy. Cost comparison analysis was then performed against charges for intraoperative Magtrace® injection with additional charges incorporated for those patients who required return to the operating room for delayed SLNB. Total cost containment for the cohort with use of Magtrace® was then measured. RESULTS Of the 41 patients who underwent Magtrace® injection, two patients required return to the operating room for a delayed SLNB for invasive disease. Including these charges for a second encounter into our cost analysis, the use of Magtrace® still yielded an overall cost containment of $205,793.55 in our cohort when comparing to patients who underwent upfront SLNB. For patients who underwent Magtrace® injection and did not require return to the operating room, charges were reduced by $6,768.52 per patient. CONCLUSION The use of Magtrace® for delayed SLNB in patients with DCIS undergoing mastectomy yielded a significant overall cost containment, further supporting its use in this patient population.
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Affiliation(s)
- Odette Solís
- Division of Surgical Oncology & Endocrine Surgery, Vanderbilt University Medical Center, Preston Research Building, 597, 2220 Pierce Avenue, Nashville, TN, 37232, USA.
| | - Jamin Addae
- Division of Surgical Oncology & Endocrine Surgery, Vanderbilt University Medical Center, Preston Research Building, 597, 2220 Pierce Avenue, Nashville, TN, 37232, USA
| | - Raeshell Sweeting
- Division of Surgical Oncology & Endocrine Surgery, Vanderbilt University Medical Center, Preston Research Building, 597, 2220 Pierce Avenue, Nashville, TN, 37232, USA
| | - Ingrid Meszoely
- Division of Surgical Oncology & Endocrine Surgery, Vanderbilt University Medical Center, Preston Research Building, 597, 2220 Pierce Avenue, Nashville, TN, 37232, USA
| | - Ana Grau
- Division of Surgical Oncology & Endocrine Surgery, Vanderbilt University Medical Center, Preston Research Building, 597, 2220 Pierce Avenue, Nashville, TN, 37232, USA
| | - Rondi Kauffmann
- Division of Surgical Oncology & Endocrine Surgery, Vanderbilt University Medical Center, Preston Research Building, 597, 2220 Pierce Avenue, Nashville, TN, 37232, USA
| | - Mark Kelley
- Division of Surgical Oncology & Endocrine Surgery, Vanderbilt University Medical Center, Preston Research Building, 597, 2220 Pierce Avenue, Nashville, TN, 37232, USA
| | - Rachel McCaffrey
- Division of Surgical Oncology & Endocrine Surgery, Vanderbilt University Medical Center, Preston Research Building, 597, 2220 Pierce Avenue, Nashville, TN, 37232, USA
| | - Kelly Hewitt
- Division of Surgical Oncology & Endocrine Surgery, Vanderbilt University Medical Center, Preston Research Building, 597, 2220 Pierce Avenue, Nashville, TN, 37232, USA
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Yoon J, Yang J, Lee HS, Kim MJ, Park VY, Rho M, Yoon JH. AI analytics can be used as imaging biomarkers for predicting invasive upgrade of ductal carcinoma in situ. Insights Imaging 2024; 15:100. [PMID: 38578585 PMCID: PMC10997564 DOI: 10.1186/s13244-024-01673-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 03/11/2024] [Indexed: 04/06/2024] Open
Abstract
OBJECTIVES To evaluate whether the quantitative abnormality scores provided by artificial intelligence (AI)-based computer-aided detection/diagnosis (CAD) for mammography interpretation can be used to predict invasive upgrade in ductal carcinoma in situ (DCIS) diagnosed on percutaneous biopsy. METHODS Four hundred forty DCIS in 420 women (mean age, 52.8 years) diagnosed via percutaneous biopsy from January 2015 to December 2019 were included. Mammographic characteristics were assessed based on imaging features (mammographically occult, mass/asymmetry/distortion, calcifications only, and combined mass/asymmetry/distortion with calcifications) and BI-RADS assessments. Routine pre-biopsy 4-view digital mammograms were analyzed using AI-CAD to obtain abnormality scores (AI-CAD score, ranging 0-100%). Multivariable logistic regression was performed to identify independent predictive mammographic variables after adjusting for clinicopathological variables. A subgroup analysis was performed with mammographically detected DCIS. RESULTS Of the 440 DCIS, 117 (26.6%) were upgraded to invasive cancer. Three hundred forty-one (77.5%) DCIS were detected on mammography. The multivariable analysis showed that combined features (odds ratio (OR): 2.225, p = 0.033), BI-RADS 4c or 5 assessments (OR: 2.473, p = 0.023 and OR: 5.190, p < 0.001, respectively), higher AI-CAD score (OR: 1.009, p = 0.007), AI-CAD score ≥ 50% (OR: 1.960, p = 0.017), and AI-CAD score ≥ 75% (OR: 2.306, p = 0.009) were independent predictors of invasive upgrade. In mammographically detected DCIS, combined features (OR: 2.194, p = 0.035), and higher AI-CAD score (OR: 1.008, p = 0.047) were significant predictors of invasive upgrade. CONCLUSION The AI-CAD score was an independent predictor of invasive upgrade for DCIS. Higher AI-CAD scores, especially in the highest quartile of ≥ 75%, can be used as an objective imaging biomarker to predict invasive upgrade in DCIS diagnosed with percutaneous biopsy. CRITICAL RELEVANCE STATEMENT Noninvasive imaging features including the quantitative results of AI-CAD for mammography interpretation were independent predictors of invasive upgrade in lesions initially diagnosed as ductal carcinoma in situ via percutaneous biopsy and therefore may help decide the direction of surgery before treatment. KEY POINTS • Predicting ductal carcinoma in situ upgrade is important, yet there is a lack of conclusive non-invasive biomarkers. • AI-CAD scores-raw numbers, ≥ 50%, and ≥ 75%-predicted ductal carcinoma in situ upgrade independently. • Quantitative AI-CAD results may help predict ductal carcinoma in situ upgrade and guide patient management.
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Affiliation(s)
- Jiyoung Yoon
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, 50-1 Yonsei-ro Seodaemun-gu, Seoul, 03722, South Korea
| | - Juyeon Yang
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, 50-1 Yonsei-ro Seodaemun-gu, Seoul, 03722, South Korea
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, 50-1 Yonsei-ro Seodaemun-gu, Seoul, 03722, South Korea
| | - Min Jung Kim
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, 50-1 Yonsei-ro Seodaemun-gu, Seoul, 03722, South Korea
| | - Vivian Youngjean Park
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, 50-1 Yonsei-ro Seodaemun-gu, Seoul, 03722, South Korea
| | - Miribi Rho
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, 50-1 Yonsei-ro Seodaemun-gu, Seoul, 03722, South Korea
| | - Jung Hyun Yoon
- Department of Radiology, Severance Hospital, Research Institute of Radiological Science, Yonsei University College of Medicine, 50-1 Yonsei-ro Seodaemun-gu, Seoul, 03722, South Korea.
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Addae JK, Sweeting RS, Meszoely IM, McCaffrey RL, Kauffmann RM, Kelley MC, Grau AM, Hewitt K. Superparamagnetic iron oxide (SPIO) for axillary mapping in patients with ductal carcinoma in situ undergoing mastectomy: single-institution experience. Breast Cancer Res Treat 2024; 204:117-121. [PMID: 38087058 DOI: 10.1007/s10549-023-07193-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 11/19/2023] [Indexed: 01/24/2024]
Abstract
PURPOSE Unnecessary axillary surgery can potentially be avoided in patients with DCIS undergoing mastectomy. Current guidelines recommend upfront sentinel lymph node biopsy during the index operation due to the potential of upstaging to invasive cancer. This study reviews a single institution's experience with de-escalating axillary surgery using superparamagnetic iron oxide dye for axillary mapping in patients undergoing mastectomy for DCIS. METHODS This is a retrospective single-institution cross-sectional study. All medical records of patients who underwent mastectomy for a diagnosis of DCIS from August 2021 to January 2023 were reviewed and patients who had SPIO injected at the time of the index mastectomy were included in the study. Descriptive statistics of demographics, clinical information, pathology results, and interval sentinel lymph node biopsy were performed. RESULTS A total of 41 participants underwent 45 mastectomies for DCIS. The median age of the participants was 58 years (IQR = 17; range 25 to 76 years), and the majority of participants were female (97.8%). The most common indication for mastectomy was diffuse extent of disease (31.7%). On final pathology, 75.6% (34/45) of mastectomy specimens had DCIS without any type of invasion and 15.6% (7/45) had invasive cancer. Of the 7 cases with upgrade to invasive disease, 2 (28.6%) of them underwent interval sentinel lymph node biopsy. All sentinel lymph nodes biopsied were negative for cancer. CONCLUSION The use of superparamagnetic iron oxide dye can prevent unnecessary axillary surgery in patients with DCIS undergoing mastectomy.
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Affiliation(s)
- Jamin Kweku Addae
- Department of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Preston Research Building, 2220 Pierce Ave., Nashville, TN, 37232, USA.
| | - Raeshell Sharawn Sweeting
- Department of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Preston Research Building, 2220 Pierce Ave., Nashville, TN, 37232, USA
| | - Ingrid Marie Meszoely
- Department of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Preston Research Building, 2220 Pierce Ave., Nashville, TN, 37232, USA
| | - Rachel Louise McCaffrey
- Department of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Preston Research Building, 2220 Pierce Ave., Nashville, TN, 37232, USA
| | - Rondi Marie Kauffmann
- Department of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Preston Research Building, 2220 Pierce Ave., Nashville, TN, 37232, USA
| | - Mark Carlton Kelley
- Department of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Preston Research Building, 2220 Pierce Ave., Nashville, TN, 37232, USA
| | - Ana Magdalena Grau
- Department of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Preston Research Building, 2220 Pierce Ave., Nashville, TN, 37232, USA
| | - Kelly Hewitt
- Department of Surgical Oncology and Endocrine Surgery, Vanderbilt University Medical Center, Preston Research Building, 2220 Pierce Ave., Nashville, TN, 37232, USA
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Wu Z, Lin Q, Wang H, Wang G, Fu G, Bian T. An MRI-Based Radiomics Nomogram to Distinguish Ductal Carcinoma In Situ with Microinvasion From Ductal Carcinoma In Situ of Breast Cancer. Acad Radiol 2023; 30 Suppl 2:S71-S81. [PMID: 37211478 DOI: 10.1016/j.acra.2023.03.038] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/24/2023] [Accepted: 03/25/2023] [Indexed: 05/23/2023]
Abstract
RATIONALE AND OBJECTIVES Accurate preoperative differentiation between ductal carcinoma in situ with microinvasion (DCISM) and ductal carcinoma in situ (DCIS) could facilitate treatment optimization and individualized risk assessment. The present study aims to build and validate a radiomics nomogram based on dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) that could distinguish DCISM from pure DCIS breast cancer. MATERIALS AND METHODS MR images of 140 patients obtained between March 2019 and November 2022 at our institution were included. Patients were randomly divided into a training (n = 97) and a test set (n = 43). Patients in both sets were further split into DCIS and DCISM subgroups. The independent clinical risk factors were selected by multivariate logistic regression to establish the clinical model. The optimal radiomics features were chosen by the least absolute shrinkage and selection operator, and a radiomics signature was built. The nomogram model was constructed by integrating the radiomics signature and independent risk factors. The discrimination efficacy of our nomogram was assessed by using calibration and decision curves. RESULTS Six features were selected to construct the radiomics signature for distinguishing DCISM from DCIS. The radiomics signature and nomogram model exhibited better calibration and validation performance in the training (AUC 0.815, 0.911, 95% confidence interval [CI], 0.703-0.926, 0.848-0.974) and test (AUC 0.830, 0.882, 95% CI, 0.672-0.989, 0.764-0.999) sets than in the clinical factor model (AUC 0.672, 0.717, 95% CI, 0.544-0.801, 0.527-0.907). The decision curve also demonstrated that the nomogram model exhibited good clinical utility. CONCLUSION The proposed noninvasive MRI-based radiomics nomogram model showed good performance in distinguishing DCISM from DCIS.
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Affiliation(s)
- Zengjie Wu
- Department of Radiology, the Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong, China (Z.W.)
| | - Qing Lin
- Breast Disease Center, the Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong, China (Q.L., H.W., T.B.)
| | - Haibo Wang
- Breast Disease Center, the Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong, China (Q.L., H.W., T.B.)
| | - Guanqun Wang
- Department of Pathology, the Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong, China (G.W., G.F.)
| | - Guangming Fu
- Department of Pathology, the Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong, China (G.W., G.F.)
| | - Tiantian Bian
- Breast Disease Center, the Affiliated Hospital of Qingdao University, Qingdao 266000, Shandong, China (Q.L., H.W., T.B.).
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Davey MG, Lowery AJ, Kerin MJ. Oncological safety of active surveillance for low-risk ductal carcinoma in situ - a systematic review and meta-analysis. Ir J Med Sci 2023; 192:1595-1600. [PMID: 36112315 DOI: 10.1007/s11845-022-03157-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 09/06/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Current standard of care for patients diagnosed with "low-risk" ductal carcinoma in situ (DCIS) involves surgical resection. Ongoing phase III clinical trials are hoping to establish the oncological safety of active surveillance (AS) in managing "low-risk" DCIS. AIMS To evaluate the oncological safety of AS versus surgery for "low-risk" DCIS. METHODS A systematic review was performed in accordance with PRISMA guidelines. Survival outcomes were expressed as dichotomous variables and reported as odds ratios (OR) with 95% confidence intervals (95% CI) using the Mantel-Haenszel method. RESULTS Four studies including 9626 patients were included, 3.9% of which were managed using AS (374/9626) and 96.1% with surgery (9252/9626). The mean age of included patients was 50.3 years (range: 30-99 years) and mean follow-up was 6.1 years. Invasive cancer detection after surgery and AS were similar (OR: 0.93, 95% CI: 0.41-2.11, P = 0.860, heterogeneity (I2) = 0%). At 5 years, BCSS (surgery 99.5% vs. AS 98.7%, P = 0.116) and OS (surgery 95.8% vs. AS 95.7%, P = 0.876) were similar for both groups. At 10 years, BCSS (surgery 98.7% vs. AS 98.6%, P = 0.789) and OS (surgery 87.9% vs. AS 90.9%, P = 0.183) were similar for both groups. Overall, 10-year OS outcomes were similar for both management strategies (OR: 0.32, 95% CI: 0.02-6.42, P = 0.460, I2 = 69%). CONCLUSION This study outlines the provisional oncological safety of AS for cases of "low-risk" DCIS. While survival outcomes were comparable for both management strategies, ratification of these results in the ongoing phase III clinical trials is still required prior to changes to current management strategies. PROSPERO REGISTRATION CRD42022313241.
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Affiliation(s)
- Matthew G Davey
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, H91YR71, Ireland.
- Department of Surgery, Galway University Hospitals, Galway, H91YR71, Republic of Ireland.
| | - Aoife J Lowery
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, H91YR71, Ireland
| | - Michael J Kerin
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, H91YR71, Ireland
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Magnoni F, Bianchi B, Corso G, Alloggio EA, Di Silvestre S, Abruzzese G, Sacchini V, Galimberti V, Veronesi P. Ductal Carcinoma In Situ (DCIS) and Microinvasive DCIS: Role of Surgery in Early Diagnosis of Breast Cancer. Healthcare (Basel) 2023; 11:healthcare11091324. [PMID: 37174866 PMCID: PMC10177838 DOI: 10.3390/healthcare11091324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/20/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
Advances in treatments, screening, and awareness have led to continually decreasing breast cancer-related mortality rates in the past decades. This achievement is coupled with early breast cancer diagnosis. Ductal carcinoma in situ (DCIS) and microinvasive breast cancer have increasingly been diagnosed in the context of mammographic screening. Clinical management of DCIS is heterogenous, and the clinical significance of microinvasion in DCIS remains elusive, although microinvasive DCIS (DCIS-Mi) is distinct from "pure" DCIS. Upfront surgery has a fundamental role in the overall treatment of these breast diseases. The growing number of screen-detected DCIS diagnoses with clinicopathological features of low risk for local recurrence (LR) allows more conservative surgical options, followed by personalised adjuvant radiotherapy plans. Furthermore, studies are underway to evaluate the validity of surgery omission in selected low-risk categories. Nevertheless, the management, the priority of axillary surgical staging, and the prognosis of DCIS-Mi remain the subject of debate, demonstrating how the paucity of data still necessitates adequate studies to provide conclusive guidelines. The current scientific scenario for DCIS and DCIS-Mi surgical approach consists of highly controversial and diversified sources, which this narrative review will delineate and clarify.
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Affiliation(s)
- Francesca Magnoni
- Division of Breast Surgery, European Institute of Oncology (IEO), IRCCS, 20141 Milan, Italy
- European Cancer Prevention Organization (ECP), 20141 Milan, Italy
| | - Beatrice Bianchi
- Division of Breast Surgery, European Institute of Oncology (IEO), IRCCS, 20141 Milan, Italy
| | - Giovanni Corso
- Division of Breast Surgery, European Institute of Oncology (IEO), IRCCS, 20141 Milan, Italy
- European Cancer Prevention Organization (ECP), 20141 Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Erica Anna Alloggio
- Division of Breast Surgery, European Institute of Oncology (IEO), IRCCS, 20141 Milan, Italy
| | - Susanna Di Silvestre
- Division of Breast Surgery, European Institute of Oncology (IEO), IRCCS, 20141 Milan, Italy
| | - Giuliarianna Abruzzese
- Division of Breast Surgery, European Institute of Oncology (IEO), IRCCS, 20141 Milan, Italy
| | - Virgilio Sacchini
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Viviana Galimberti
- Division of Breast Surgery, European Institute of Oncology (IEO), IRCCS, 20141 Milan, Italy
| | - Paolo Veronesi
- Division of Breast Surgery, European Institute of Oncology (IEO), IRCCS, 20141 Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
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Weber GF. Crossroads: the role of biomarkers in the management of lumps in the breast. Oncotarget 2023; 14:358-362. [PMID: 37096988 DOI: 10.18632/oncotarget.28402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023] Open
Abstract
Premalignant lesions in the breast pose a difficult decision-making problem, whether to treat proactively and accept the side effects or to engage in watchful waiting and possibly encounter a later diagnosis of invasive cancer. A biomarker or set of biomarkers to inform on the individual progression risk would be beneficial to the patient and cost-effective for the healthcare system. The gene products of tumor progression may be expressed in early non-cancerous ("premalignant") lesions, where they are associated with a high probability for full transformation in breast cancers. One such molecule is the OPN splice variant-c. OPN-c is also present in a fraction of the premalignant lesions, where it reflects an elevated risk for progression to cancer within 5 years, regardless of the lesion's subtype. This marker has the properties needed to facilitate decisions to treat at the premalignant stage.
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Affiliation(s)
- Georg F Weber
- University of Cincinnati Academic Health Center, Cincinnati, OH 45267, USA
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Ben Khadra S, Hacking SM, Carpentier B, Singh K, Wang L, Yakirevich E, Wang Y. Mass-forming ductal carcinoma in situ: An ultrasonographic and histopathologic correlation study. Pathol Res Pract 2022; 237:154035. [PMID: 35878531 DOI: 10.1016/j.prp.2022.154035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 07/19/2022] [Indexed: 10/17/2022]
Abstract
Ultrasound (US) guided core needle biopsy (CNB) for mass lesions resulting in a diagnosis of ductal carcinoma in situ (DCIS) is often considered radiologically discordant and generates surgical planning difficulty. One hundred cases of US-guided CNB for mass lesions diagnosed as DCIS were collected from 2013 to 2021. Histological features were reviewed and correlated with radiology and surgical excision findings. Thirty (30%) were high-grade (HG), and seventy (70%) were low- to intermediate-grade. Seventy-one (71%) cases had a histological correlate of a mass-forming lesion, including 26 (26%) were associated with benign mass-forming lesions (category 1) such as papilloma, complex sclerosing lesion/radial scar, fibroadenoma, sclerosing adenosis, and ruptured cyst; 23 (23%) were HG with solid pattern, comedo necrosis, and stromal desmoplasia (category 2); and 22 (22%) had predominantly papillary architecture (category 3). Twenty-nine (29%) were discordant with no histologic correlate of a mass lesion (category 4). Follow-up excisions were available in 79 cases. Invasive carcinoma was identified in 14 cases (18%), of which 8 were from the radiologically discordant category (35%), 3 (17%) associated with HG DCIS with desmoplasia, 2 (10%) associated with benign mass lesion and 1(5%) was predominantly papillary architecture. US-guided CNB for mass-forming lesions with a DCIS diagnosis on CNB can be grouped into four categories. Radiology-pathology correlation is essential. This categorization emphasized rad-path correlation and had a clear difference in upgrade rate on follow-up excision. Rad-path discordant biopsy cases were more likely to be associated with a missed invasive carcinoma (p < 0.05).
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Affiliation(s)
- Shaza Ben Khadra
- Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Pathology and Laboratory Medicine, Women and Infant Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Sean M Hacking
- Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Pathology and Laboratory Medicine, Women and Infant Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Bianca Carpentier
- Department of Diagnostic Radiology, Rhode Island Hospital and Alpert Medical School of Brown University, Providence, RI, USA; Department of Pathology and Laboratory Medicine, Women and Infant Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Kamaljeet Singh
- Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Pathology and Laboratory Medicine, Women and Infant Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Lijuan Wang
- Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Pathology and Laboratory Medicine, Women and Infant Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Evgeny Yakirevich
- Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Pathology and Laboratory Medicine, Women and Infant Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Yihong Wang
- Department of Pathology and Laboratory Medicine, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA; Department of Pathology and Laboratory Medicine, Women and Infant Hospital, Warren Alpert Medical School of Brown University, Providence, RI, USA.
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Preneoplastic Low-Risk Mammary Ductal Lesions (Atypical Ductal Hyperplasia and Ductal Carcinoma In Situ Spectrum): Current Status and Future Directions. Cancers (Basel) 2022; 14:cancers14030507. [PMID: 35158775 PMCID: PMC8833401 DOI: 10.3390/cancers14030507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/12/2022] [Accepted: 01/17/2022] [Indexed: 02/04/2023] Open
Abstract
Intraepithelial mammary ductal neoplasia is a spectrum of disease that varies from atypical ductal hyperplasia (ADH), low-grade (LG), intermediate-grade (IG), to high-grade (HG) ductal carcinoma in situ (DCIS). While ADH has the lowest prognostic significance, HG-DCIS carries the highest risk. Due to widely used screening mammography, the number of intraepithelial mammary ductal neoplastic lesions has increased. The consequence of this practice is the increase in the number of patients who are overdiagnosed and, therefore, overtreated. The active surveillance (AS) trials are initiated to separate lesions that require active treatment from those that can be safely monitored and only be treated when they develop a change in the clinical/radiologic characteristics. At the same time, the natural history of these lesions can be evaluated. This review aims to evaluate ADH/DCIS as a spectrum of intraductal neoplastic disease (risk and histomorphology); examine the controversies of distinguishing ADH vs. DCIS and the grading of DCIS; review the upgrading for both ADH and DCIS with emphasis on the variation of methods of detection and the definitions of upgrading; and evaluate the impact of all these variables on the AS trials.
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10
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Farante G, Toesca A, Magnoni F, Lissidini G, Vila J, Mastropasqua M, Viale G, Penco S, Cassano E, Lazzeroni M, Bonanni B, Leonardi MC, Ripoll-Orts F, Curigliano G, Orecchia R, Galimberti V, Veronesi P. Advances and controversies in management of breast ductal carcinoma in situ (DCIS). Eur J Surg Oncol 2021; 48:736-741. [PMID: 34772587 DOI: 10.1016/j.ejso.2021.10.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 10/25/2021] [Accepted: 10/29/2021] [Indexed: 01/03/2023] Open
Abstract
Ductal carcinoma in situ (DCIS) is a non-obligate precursor of invasive breast cancer. It accounts for 25% of all breast cancers diagnosed, as a result of the expansion of breast cancer screening and is associated with a high survival rate. DCIS is particularly clinically challenging, due to its heterogeneous pathological and biological traits and its management is continually evolving towards more personalized and less aggressive therapies. This article suggests evidence-based guidelines for proper DCIS clinical management, which should be discussed within a multidisciplinary team in order to propose the most suitable approach in clinical practice, taking into account recent scientific studies. Here we include updated multidisciplinary treatment protocols and techniques in accordance with the most recent contributions published on this topic in the peer-reviewed medical literature, and we outline future perspectives.
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Affiliation(s)
- Gabriel Farante
- Division of Breast Surgery, European Institute of Oncology (EIO), IRCCS, Milan, Italy.
| | - Antonio Toesca
- Division of Breast Surgery, European Institute of Oncology (EIO), IRCCS, Milan, Italy
| | - Francesca Magnoni
- Division of Breast Surgery, European Institute of Oncology (EIO), IRCCS, Milan, Italy
| | - Germana Lissidini
- Division of Breast Surgery, European Institute of Oncology (EIO), IRCCS, Milan, Italy
| | - José Vila
- Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | - Giuseppe Viale
- Division of Anatomo-Pathology, European Institute of Oncology (EIO), Milan, Italy; School of Medicine, University of Milan, Italy
| | - Silvia Penco
- Division of Breast Radiology, European Institute of Oncology (EIO), IRCCS, Milan, Italy
| | - Enrico Cassano
- Division of Breast Radiology, European Institute of Oncology (EIO), IRCCS, Milan, Italy
| | - Matteo Lazzeroni
- Division of Cancer Prevention and Genetics, European Institute of Oncology (EIO), IRCCS, Milan, Italy
| | - Bernardo Bonanni
- Division of Cancer Prevention and Genetics, European Institute of Oncology (EIO), IRCCS, Milan, Italy
| | | | | | - Giuseppe Curigliano
- School of Medicine, University of Milan, Italy; Division of Breast Radiology, European Institute of Oncology (EIO), IRCCS, Milan, Italy; Division of Cancer Prevention and Genetics, European Institute of Oncology (EIO), IRCCS, Milan, Italy; Division of Radiotherapy, European Institute of Oncology (EIO), IRCCS, Milan, Italy; Division of Early Drug Development for Innovative Therapy, European Institute of Oncology (EIO), IRCCS, Milan, Italy
| | - Roberto Orecchia
- School of Medicine, University of Milan, Italy; Division of Breast Radiology, European Institute of Oncology (EIO), IRCCS, Milan, Italy; Division of Cancer Prevention and Genetics, European Institute of Oncology (EIO), IRCCS, Milan, Italy; Division of Radiotherapy, European Institute of Oncology (EIO), IRCCS, Milan, Italy
| | - Viviana Galimberti
- Division of Breast Surgery, European Institute of Oncology (EIO), IRCCS, Milan, Italy
| | - Paolo Veronesi
- Division of Breast Surgery, European Institute of Oncology (EIO), IRCCS, Milan, Italy; Hospital Universitario y Politécnico La Fe, Valencia, Spain; School of Medicine University of Bari "Aldo Moro", Italy; Division of Anatomo-Pathology, European Institute of Oncology (EIO), Milan, Italy; School of Medicine, University of Milan, Italy
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11
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Sá RDS, Logullo AF, Elias S, Facina G, Sanvido VM, Nazário ACP. Ductal Carcinoma in situ: Underestimation of Percutaneous Biopsy and Positivity of Sentinel Lymph Node Biopsy in a Brazilian Public Hospital. BREAST CANCER-TARGETS AND THERAPY 2021; 13:409-417. [PMID: 34188536 PMCID: PMC8232838 DOI: 10.2147/bctt.s314447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/02/2021] [Indexed: 11/24/2022]
Abstract
Background Mammography screening has become widely spread and provided a marked increase in ductal carcinoma in situ (DCIS) diagnosis. In DCIS, the ductal epithelium proliferates without invasion through the basal cell membrane. However, histologic underestimation can happen in some cases. Objective To analyze the rate of histologic underestimation (histopathologic results upgraded to invasive carcinoma after surgery) and the rate of positive results of sentinel lymph node biopsy (SLNB) in patients diagnosed with DCIS in a Brazilian public hospital. Methods We reviewed medical records of all consecutive patients admitted between 2009 and 2013 whose initial diagnosis was DCIS through core needle biopsy. DCIS cases with a high risk of invasion underwent SLNB. We excluded cases with invasion or micro-invasion components in the first biopsy. Results A total of 86 women were included, most with microcalcifications as the primary radiological lesion (73.2%), and underwent preoperative biopsy, with an invasive component in 21 (24.4%) in the final pathology report. Most had invasive carcinoma of no special type (NST): 52.3% (n = 11) and microinvasive tumors (7 cases, 33.3%). The main factors associated with histologic underestimation were nodular lesion (61.9%, p<0.001) and an ultra-sonography-guided biopsy (71.4%, p=0.0005). The positivity rate of SLNB was 4.3%. All these patients underwent mastectomy, and the initial histologic pattern was solid DCIS. Conclusion The “histologic underestimation” rate among patients with DCIS was not low, and less than 5% of patients who underwent SLNB had axillary positivity. This result suggests that patients who have DCIS and a high risk of invasion and undergoing mastectomy should have SLNB. As to the patients who will undergo lumpectomy, SLNB could be omitted and could be performed if patients have upgraded to invasive breast cancer.
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Affiliation(s)
- Rafael da Silva Sá
- Department of Gynaecology, Breast Surgery Team, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil.,Universidade do Oeste Paulista (UNOESTE), Presidente Prudente, Brazil
| | - Angela Flávia Logullo
- Department of Pathology, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Simone Elias
- Department of Gynaecology, Breast Surgery Team, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Gil Facina
- Department of Gynaecology, Breast Surgery Team, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Vanessa Monteiro Sanvido
- Department of Gynaecology, Breast Surgery Team, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
| | - Afonso Celso Pinto Nazário
- Department of Gynaecology, Breast Surgery Team, Universidade Federal de São Paulo (UNIFESP), São Paulo, Brazil
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12
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Iwamoto N, Nara M, Horiguchi SI, Aruga T. Surgical upstaging rates in patients meeting the eligibility for active surveillance trials. Jpn J Clin Oncol 2021; 51:1219-1224. [PMID: 34091677 DOI: 10.1093/jjco/hyab082] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 05/22/2017] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Four clinical active surveillance trials including LORIS, COMET, LORD and LORETTA, are being conducted to assess whether women with low-risk ductal carcinoma in situ can safely avoid surgery. The present study aimed to determine the rate of upstaging to invasive cancer among patients with a preoperative diagnosis of ductal carcinoma in situ and to evaluate the incidence of upstaging in patients meeting the eligibility criteria for four active surveillance clinical trials. METHODS The present study initially enrolled 180 patients with 183 calcifications who received the diagnosis of ductal carcinoma in situ by biopsy. Patients were classified as eligible for four clinical trials according to the respective inclusion criteria. RESULTS In total, 152 patients with 155 calcifications were analyzed. Of these, 32 (21%) were upstaged to invasive disease based on the final pathological analysis of surgical specimens. Of the 152 patients, 53 (35%), 90 (59%), 24 (16%) and 34 (22%) met the eligibility criteria for the LORIS, COMET, LORD and LORETTA trial, respectively. Among patients with low-risk ductal carcinoma in situ, 10 (19%), 14 (16%), 6 (25%) and 4 (12%) patients were upstaged to invasive disease in LORIS, COMET, LORD and LORETTA, respectively. The upstaging to pT1b or higher rates were 2% (1/53), 3% (3/90), 0% (0/24) and 3% (1/34) in LORIS, COMET, LORD and LORETTA, respectively. CONCLUSIONS The upstaging rate in patients eligible for the clinical active surveillance trials was 12-25%. Although the rate of upstaging to pT1b or higher was low, further studies are required to determine the rates of upstaging to invasive cancer and the risk factors among patients with low-risk ductal carcinoma in situ.
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Affiliation(s)
- Naoko Iwamoto
- Department of Breast Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Miyako Nara
- Department of Breast Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Shin-Ichiro Horiguchi
- Department of Pathology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Tomoyuki Aruga
- Department of Breast Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
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13
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Yan M, Bomeisl P, Gilmore H, Harbhajanka A. Clinicopathological Follow-up of Breast DCIS Diagnosed on Biopsies: A Single Institutional Study of 575 Patients. Int J Surg Pathol 2021; 29:836-843. [PMID: 33890815 DOI: 10.1177/10668969211012088] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Stratifying ductal carcinoma in situ (DCIS) patients into different upgrading risk groups is important in exploiting more precise therapeutic options. Evaluation of estrogen receptor/progesterone receptor/human epidermal growth factor receptor 2 (ER/PR/HER2) status and axillary lymph node metastatic status for DCIS and their upgraded invasive counterparts can also provide diagnostic and therapeutic implications. We retrospectively studied 575 patients with first-time diagnosis of DCIS on biopsies, and followed up their final diagnosis, ER/PR/HER2 status, and axillary lymph node involvement on excisions. As a result, biopsy-diagnosed DCIS had an overall 19.1% risk to be upgraded on subsequent excisions, with 4.7% being upgraded to microinvasive carcinoma (pT1mi) and 14.4% to overt invasive carcinoma (⩾pT1a). Factors significantly associated with higher upgrading risk on multivariate analysis include biopsy guidance by ultrasound (P <.001), DCIS with suspicious microinvasion (P < .001), and DCIS diagnosed in left breast (P = .026). DCIS diagnosed in younger patients (⩽40 years old) or DCIS with high nuclear grade showed higher upgrading risk only on univariate analysis. About 80% ER + /PR + and ER-/PR- DCIS remained the same ER/PR status after being upgraded, and ER + /PR - DCIS had the highest risk (63.6%) of having HER2 amplification in upgraded invasive carcinoma. For upgraded DCIS, microinvasive carcinoma was more likely to have HER2 amplification (50%) than overt invasive carcinoma (29.5%). Besides, pure DCIS had a low risk of axillary lymph node macrometastasis (0.74%), while the risk increased in DCIS with microinvasion (4.4%) and was highest in overt invasive carcinoma (14.7%). The findings of this study are clinically relevant with respect to criteria that might be used in selecting patients for de-escalation trials.
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MESH Headings
- Adult
- Axilla
- Biomarkers, Tumor/analysis
- Biomarkers, Tumor/metabolism
- Biopsy
- Breast/pathology
- Breast Neoplasms/diagnosis
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Intraductal, Noninfiltrating/diagnosis
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Female
- Follow-Up Studies
- Humans
- Lymph Node Excision
- Lymph Nodes/pathology
- Mastectomy
- Neoplasm Invasiveness/pathology
- Receptor, ErbB-2/analysis
- Receptor, ErbB-2/metabolism
- Receptors, Estrogen/analysis
- Receptors, Estrogen/metabolism
- Receptors, Progesterone/analysis
- Receptors, Progesterone/metabolism
- Retrospective Studies
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Affiliation(s)
- Mingfei Yan
- 24575University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Phillip Bomeisl
- 24575University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Hannah Gilmore
- 24575University Hospitals Cleveland Medical Center, Cleveland, OH, USA
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14
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Digital Mammography Has Persistently Increased High-Grade and Overall DCIS Detection Without Altering Upgrade Rate. AJR Am J Roentgenol 2021; 216:912-918. [PMID: 33594910 DOI: 10.2214/ajr.20.23314] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE. The purpose of this article is to evaluate whether digital mammography (DM) is associated with persistent increased detection of ductal carcinoma in situ (DCIS) or has altered the upgrade rate of DCIS to invasive cancer. MATERIALS AND METHODS. An institutional review board-approved retrospective search identified DCIS diagnosed in women with mammographic calcifications between 2001 and 2014. Ipsilateral cancer within 2 years, masses, papillary DCIS, and patients with outside imaging were excluded, yielding 484 cases. Medical records were reviewed for mammographic calcifications, technique, and pathologic diagnosis. Mammograms were interpreted by radiologists certified by the Mammography Quality Standards Act. The institution transitioned from film-screen mammography (FSM) to exclusive DM by 2010. Statistical analyses were performed using chi-square test. RESULTS. Of 484 DCIS cases, 158 (33%) were detected by FSM and 326 (67%) were detected by DM. The detection rate was higher with DM than FSM (1.4 and 0.7 per 1000, respectively; p < .001). The detection rate of high-grade DCIS doubled with DM compared with FSM (0.8 and 0.4 per 1000, respectively; p < .001). The prevalent peak of DM-detected DCIS was 2.7 per 1000 in 2008. Incident DM detection remained double FSM (1.4 vs 0.7 per 1000). Similar proportions of high-grade versus low- to intermediate-grade DCIS were detected with both modalities. There was no significant difference in the upgrade rate of DCIS to invasive cancer between DM (10%; 34/326) and FSM (10%; 15/158) (p = .74). High-grade DCIS led to 71% (35/49) of the upgrades to invasive cancer. CONCLUSION. DM was associated with a significant doubling in DCIS and high-grade DCIS detection, which persisted after prevalent peak. The majority of upgrades to invasive cancer arose from high-grade DCIS. DM was not associated with decreased upgrade to invasive cancer.
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15
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Stanciu-Pop C, Nollevaux MC, Berlière M, Duhoux FP, Fellah L, Galant C, Van Bockstal MR. Morphological intratumor heterogeneity in ductal carcinoma in situ of the breast. Virchows Arch 2021; 479:33-43. [PMID: 33502600 DOI: 10.1007/s00428-021-03040-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 01/08/2021] [Accepted: 01/20/2021] [Indexed: 11/28/2022]
Abstract
Ductal carcinoma in situ (DCIS) of the breast is a heterogeneous disease in terms of morphological characteristics, protein expression profiles, genetic abnormalities, and potential for progression. Molecular heterogeneity has been extensively studied in DCIS. Yet morphological heterogeneity remains relatively undefined. This study investigated morphological intratumor heterogeneity in a series of 51 large DCIS. Nuclear atypia, DCIS architecture, necrosis, calcifications, stromal architecture, and stromal inflammation were assessed in one biopsy slide and three representative slides from each corresponding resection. For each histopathological feature, a histo-score was determined per slide and compared between the biopsy and the resection, as well as within a single resection. Statistical analysis comprised of Friedman tests, post hoc Wilcoxon tests with Bonferroni corrections, Mann-Whitney U tests, and chi-square tests. Despite substantial morphological heterogeneity in around 50% of DCIS, the histopathological assessment of the biopsy did not statistically significantly differ from the resection. Morphological heterogeneity was not significantly associated with patient age, DCIS size, or type of surgery, except for a weak association between heterogeneous stromal inflammation and smaller DCIS size. At the group level, the degree of heterogeneity did not significantly affect the representativity of a biopsy. At the individual patient level, however, the presence of necrosis, intraductal calcifications, myxoid stromal changes, and high-grade nuclear atypia was underestimated in a minority of DCIS patients. This study confirms the presence of morphological heterogeneity in DCIS for all six evaluated histopathological features. This should be kept in mind when taking biopsy-based treatment decisions for DCIS patients.
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Affiliation(s)
- Claudia Stanciu-Pop
- Department of Pathology, CHU UCL Namur, Site Godinne, Avenue Docteur G. Thérasse 1, 5530, Yvoir, Belgium
| | - Marie-Cécile Nollevaux
- Department of Pathology, CHU UCL Namur, Site Godinne, Avenue Docteur G. Thérasse 1, 5530, Yvoir, Belgium
| | - Martine Berlière
- Breast Clinic, King Albert II Cancer Institute, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Francois P Duhoux
- Breast Clinic, King Albert II Cancer Institute, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Avenue Hippocrate 10, 1200, Brussels, Belgium.,Department of Medical Oncology, King Albert II Cancer Institute, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Latifa Fellah
- Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Avenue Hippocrate 10, 1200, Brussels, Belgium.,Department of Radiology, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Christine Galant
- Breast Clinic, King Albert II Cancer Institute, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.,Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Avenue Hippocrate 10, 1200, Brussels, Belgium.,Department of Pathology, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium
| | - Mieke R Van Bockstal
- Breast Clinic, King Albert II Cancer Institute, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium. .,Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Avenue Hippocrate 10, 1200, Brussels, Belgium. .,Department of Pathology, Cliniques universitaires Saint-Luc, Avenue Hippocrate 10, 1200, Brussels, Belgium.
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16
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Nickel B, McCaffery K, Houssami N, Jansen J, Saunders C, Spillane A, Rutherford C, Dixon A, Barratt A, Stuart K, Robertson G, Hersch J. Views of healthcare professionals about the role of active monitoring in the management of ductal carcinoma in situ (DCIS): Qualitative interview study. Breast 2020; 54:99-105. [PMID: 32971350 PMCID: PMC7509786 DOI: 10.1016/j.breast.2020.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2020] [Revised: 08/28/2020] [Accepted: 09/07/2020] [Indexed: 01/27/2023] Open
Abstract
BACKGROUND Ductal carcinoma in situ (DCIS) is an in-situ (pre-cancerous) breast malignancy whereby malignant cells are contained within the basement membrane of the breast ducts. Increasing awareness that some low-risk forms of DCIS might remain indolent for many years has led to concern about overtreatment, with at least 3 clinical trials underway internationally assessing the safety of active monitoring for low-risk DCIS. This study aimed to understand healthcare professionals' (HCPs) views on the management options for patients with DCIS. METHODS Qualitative study using semi-structured interviews with HCPs involved in the diagnosis and management of DCIS in Australia and New Zealand. Interviews were audio-recorded, transcribed and analysed thematically using Framework Analysis method. RESULTS Twenty-six HCPs including 10 breast surgeons, 3 breast physicians, 6 radiation oncologists, and 7 breast care nurses participated. There was a strong overall consensus that DCIS requires active treatment. HCPs generally felt uncomfortable recommending active monitoring as a management option for low-risk DCIS as they viewed this as outside current standard care. Overall, HCPs felt that active monitoring was an unproven strategy in need of an evidence base; however, many acknowledged that active monitoring for low-risk DCIS could be appropriate for patients with significant co-morbidities or limited life expectancy. They believed that most patients would opt for surgery wherever possible. CONCLUSIONS This study highlights the important need for robust randomised controlled trial data about active monitoring for women with low-risk DCIS, to provide HCPs with confidence in their management recommendations and decision-making.
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Affiliation(s)
- Brooke Nickel
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia; Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Kirsten McCaffery
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia; Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Nehmat Houssami
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Jesse Jansen
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia; Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia; Department of Family Medicine, Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, the Netherlands
| | | | - Andrew Spillane
- The University of Sydney, Northern Clinical School, St Leonards, NSW, Australia; Mater Hospital, Wollstonecraft, NSW, Australia; Royal North Shore Hospital, St Leonards, NSW, Australia
| | - Claudia Rutherford
- The University of Sydney, Faculty of Science, School of Psychology, Sydney, NSW, Australia; The University of Sydney, Faculty Medicine and Health, Sydney Nursing School, Sydney, NSW, Australia
| | - Ann Dixon
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Alexandra Barratt
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia
| | - Kirsty Stuart
- Department of Radiation Oncology, Crown Princess Mary Cancer Centre, Westmead, NSW, Australia; Westmead Breast Cancer Institute, Westmead, NSW, Australia; Western Clinical School, The University of Sydney, NSW, Australia
| | | | - Jolyn Hersch
- Wiser Healthcare, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia; Sydney Health Literacy Lab, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, NSW, Australia.
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17
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Genco IS, Ozgultekin B, Hosseini H, Hackman K, Ferreira L, Santagada E, Wahl S, Hajiyeva S. High EZH2 expression in ductal carcinoma in situ diagnosed on breast core needle biopsy is an independent predictive factor for upgrade on surgical excision. Pathol Res Pract 2020; 216:153283. [PMID: 33197837 DOI: 10.1016/j.prp.2020.153283] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Revised: 11/02/2020] [Accepted: 11/03/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE Approximately 25 % of DCIS diagnosed on breast core needle biopsy (CNB) is upgraded to invasive carcinoma on surgical excision. Risk factors to predict the upgrade on excision are not well established, leading many patients to be over or under-treated. EZH2 was shown to be associated with aggressive behavior of cancer from many sites, including breast cancer. We aimed to analyze EZH2 expression and tumor infiltrating lymphocytes (TILs) in DCIS as predictive factors for an upgrade on excision. METHODS We assessed EZH2 expression in 34 DCIS cases diagnosed on CNB and upgraded to invasive carcinoma on excision. Then, we compared these cases with 60 control cases that were not upgraded on excision. A staining score for DCIS (0-12) was obtained by multiplying the staining intensity (0-3) and the percentage of positive cells (1-4). The nuclear staining score ≥6 was considered as 'high' expression. RESULTS 46 of 94 (49 %) DCIS on CNB showed high EZH2 expression. EZH2 expression was directly correlated with TILs density, nuclear grade, HER2 expression, Ki-67 index and negative ER status. On univariate analysis, upgrade on excision was associated with high EZH2 expression, high TILs density, negative ER status and high Ki-67 index. Multivariate analysis revealed the high EZH2 expression as the only independent predictive factor for upgrade on excision. CONCLUSIONS Our study revealed the high EZH2 expression as the only independent predictive factor for an upgrade on excision. Future studies should focus on the evaluation of EZH2 expression in tumor-microenvironment interaction in terms of diagnostic, treatment and prognostic purposes.
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Affiliation(s)
- Iskender Sinan Genco
- Northwell Health Lenox Hill Hospital, Department of Pathology and Laboratory Medicine, 100 E 77th Street, New York, NY, 10075, United States.
| | | | - Hossein Hosseini
- Northwell Health Lenox Hill Hospital, Department of Pathology and Laboratory Medicine, 100 E 77th Street, New York, NY, 10075, United States
| | - Kayla Hackman
- Northwell Health Lenox Hill Hospital, Department of Pathology and Laboratory Medicine, 100 E 77th Street, New York, NY, 10075, United States
| | - Lisa Ferreira
- Northwell Health Lenox Hill Hospital, Department of Pathology and Laboratory Medicine, 100 E 77th Street, New York, NY, 10075, United States
| | - Eugene Santagada
- Northwell Health Lenox Hill Hospital, Department of Pathology and Laboratory Medicine, 100 E 77th Street, New York, NY, 10075, United States
| | - Samuel Wahl
- Northwell Health Lenox Hill Hospital, Department of Pathology and Laboratory Medicine, 100 E 77th Street, New York, NY, 10075, United States
| | - Sabina Hajiyeva
- Northwell Health Lenox Hill Hospital, Department of Pathology and Laboratory Medicine, 100 E 77th Street, New York, NY, 10075, United States.
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18
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Lamb LR, Lehman CD, Oseni TO, Bahl M. Ductal Carcinoma In Situ (DCIS) at Breast MRI: Predictors of Upgrade to Invasive Carcinoma. Acad Radiol 2020; 27:1394-1399. [PMID: 31699638 DOI: 10.1016/j.acra.2019.09.025] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 09/17/2019] [Accepted: 09/19/2019] [Indexed: 01/24/2023]
Abstract
RATIONALE AND OBJECTIVES To determine the upgrade rate of magnetic resonance imaging (MRI)-detected ductal carcinoma in situ (DCIS) and to identify patient, imaging, and pathologic features that may predict the risk of upgrade. MATERIALS AND METHODS Medical chart review from January 2007 to December 2016 identified 60 patients with 61 cases of MRI-detected DCIS and negative mammographic evaluations within 1 year prior to the MRI. Imaging and pathology reports were reviewed. Standard statistical tests, including Student's t-tests and chi-square tests, were used to compare patient, imaging, and pathologic features between the cases of DCIS that did and did not upgrade to invasive carcinoma at surgery. RESULTS Over a 10-year period, 60 patients (mean age 52 years, range 30-76 years) were diagnosed with 61 cases of MRI-detected DCIS. Two-thirds of DCIS cases were detected on MRI examinations that were performed for purposes of high-risk screening (67.2%, 41/61). MRI features that led to the DCIS diagnosis were nonmass enhancement in 78.7% (48/61), enhancing mass in 16.4% (10/61), nonmass enhancement and enhancing mass in 3.3% (2/61), and enhancing focus in 1.6% (1/61). Thirteen cases (21.3%, 13/61) were upgraded to invasive ductal carcinoma at surgery. DCIS cases that upgraded were larger on MRI (40 mm vs 17 mm, p < 0.01) and more likely to be associated with comedonecrosis at biopsy (38.5% [5/13] vs 6.3% [3/48], p < 0.01). CONCLUSION The upgrade rate of MRI-detected DCIS to invasive ductal carcinoma at surgery is 21.3%. Features that are associated with upgrade include large size on MRI and the presence of comedonecrosis at biopsy.
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Affiliation(s)
- Leslie R Lamb
- Massachusetts General Hospital, Department of Radiology, 55 Fruit Street, WAC 240, Boston, MA 02114
| | - Constance D Lehman
- Massachusetts General Hospital, Department of Radiology, 55 Fruit Street, WAC 240, Boston, MA 02114
| | - Tawakalitu O Oseni
- Massachusetts General Hospital, Department of Surgery, Boston, Massachusetts
| | - Manisha Bahl
- Massachusetts General Hospital, Department of Radiology, 55 Fruit Street, WAC 240, Boston, MA 02114.
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19
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Cutuli B. [Ductal carcinoma in situ in 2019: Diagnosis, treatment, prognosis]. Presse Med 2019; 48:1112-1122. [PMID: 31653542 DOI: 10.1016/j.lpm.2019.08.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 08/28/2019] [Indexed: 12/27/2022] Open
Abstract
Ductal carcinoma in situ (DCIS) currently represents up to 15% of the newly diagnosed breast cancers, and are almost always detected by microcalcifications. Global prognosis is good (3% of 15-year specific mortality) but invasive local recurrences (LR) can lead to metastasis in 12-15% of the cases. Breast conserving surgery with whole breast irradiation is the main treatment (reducing LR by 50%), but mastectomy (with or without reconstruction) is performed in about 30% of the cases due to wide lesion size and/or multicentricity. The role of tamoxifen remains unclear. Axillary dissection is needless but sentinel node biopsy is proposed in case of micro-invasion suspicion (large lesions with high grade). The main factors of LR are young age (≤40 years) incomplete excision, and high nuclear grade with comedonecrosis. Several studies on "therapeutic descalation" are still ongoing in order to identify the "low risk" DCIS (about 10% of the cases) in which radiotherapy could be safely omitted.
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MESH Headings
- Age Factors
- Antineoplastic Agents, Hormonal/therapeutic use
- Biopsy
- Breast/pathology
- Breast Neoplasms/diagnosis
- Breast Neoplasms/etiology
- Breast Neoplasms/pathology
- Breast Neoplasms/therapy
- Carcinoma, Intraductal, Noninfiltrating/diagnosis
- Carcinoma, Intraductal, Noninfiltrating/etiology
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/therapy
- Combined Modality Therapy/methods
- Conservative Treatment
- Diagnostic Imaging/methods
- Female
- Humans
- Lymph Node Excision/trends
- Mastectomy
- Neoplasm Recurrence, Local/diagnosis
- Prognosis
- Radiotherapy
- Risk Factors
- Tamoxifen/therapeutic use
- Time Factors
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Affiliation(s)
- Bruno Cutuli
- Institut du cancer Courlancy Reims, 38, rue du Courlancy, 51100 Reims, France.
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20
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Champion CD, Ren Y, Thomas SM, Fayanju OM, Rosenberger LH, Greenup RA, Menendez CS, Hwang ES, Plichta JK. DCIS with Microinvasion: Is It In Situ or Invasive Disease? Ann Surg Oncol 2019; 26:3124-3132. [PMID: 31342393 DOI: 10.1245/s10434-019-07556-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Ductal carcinoma in situ (DCIS) with microinvasion (DCISM) can be challenging in balancing the risks of overtreatment versus undertreatment. We compared DCISM, pure DCIS, and small volume (T1a) invasive ductal carcinoma (IDC) as related to histopathology, treatment patterns, and survival outcomes. METHODS Women ages 18-90 years who underwent breast surgery for DCIS, DCISM, or T1a IDC were selected from the SEER Database (2004-2015). Multivariate logistic regression and Cox proportional hazards models were used to estimate the association of diagnosis with treatment and survival, respectively. RESULTS A total of 134,569 women were identified: 3.2% DCISM, 70.9% DCIS, and 25.9% with T1a IDC. Compared with invasive disease, DCISM was less likely to be ER+ or PR+ and more likely to be HER2+. After adjustment, DCIS and invasive patients were less likely to undergo mastectomy than DCISM patients (DCIS: OR 0.53, 95% CI 0.49-0.56; invasive: OR 0.86, CI 0.81-0.92). For those undergoing lumpectomy, the likelihood of receiving radiation was similar for DCISM and invasive patients but lower for DCIS patients (OR 0.57, CI 0.52-0.63). After adjustment, breast-cancer-specific survival was significantly different between DCISM and the other two groups (DCIS: HR 0.59, CI 0.43-0.8; invasive: HR 1.43, CI 1.04-1.96). However, overall survival was not significantly different between DCISM and invasive disease, whereas patients with DCIS had improved OS (HR 0.83, CI 0.75-0.93). CONCLUSIONS Although DCISM is a distinct entity, current treatment patterns and prognosis are comparable to those with small volume IDC. These findings may help providers counsel patients and determine appropriate treatment plans.
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Affiliation(s)
- Cosette D Champion
- Department of Surgery, Duke University Medical Center, DUMC, Durham, NC, USA.,Duke Cancer Institute, Durham, NC, USA
| | - Yi Ren
- Duke Cancer Institute, Durham, NC, USA.,Duke Cancer Institute, Biostatistics Shared Resources, Durham, NC, USA
| | - Samantha M Thomas
- Duke Cancer Institute, Durham, NC, USA.,Duke Cancer Institute, Biostatistics Shared Resources, Durham, NC, USA
| | - Oluwadamilola M Fayanju
- Department of Surgery, Duke University Medical Center, DUMC, Durham, NC, USA.,Duke Cancer Institute, Durham, NC, USA
| | - Laura H Rosenberger
- Department of Surgery, Duke University Medical Center, DUMC, Durham, NC, USA.,Duke Cancer Institute, Durham, NC, USA
| | - Rachel A Greenup
- Department of Surgery, Duke University Medical Center, DUMC, Durham, NC, USA.,Duke Cancer Institute, Durham, NC, USA
| | - Carolyn S Menendez
- Department of Surgery, Duke University Medical Center, DUMC, Durham, NC, USA.,Duke Cancer Institute, Durham, NC, USA
| | - E Shelley Hwang
- Department of Surgery, Duke University Medical Center, DUMC, Durham, NC, USA.,Duke Cancer Institute, Durham, NC, USA
| | - Jennifer K Plichta
- Department of Surgery, Duke University Medical Center, DUMC, Durham, NC, USA. .,Duke Cancer Institute, Durham, NC, USA.
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21
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Hanna WM, Parra-Herran C, Lu FI, Slodkowska E, Rakovitch E, Nofech-Mozes S. Ductal carcinoma in situ of the breast: an update for the pathologist in the era of individualized risk assessment and tailored therapies. Mod Pathol 2019; 32:896-915. [PMID: 30760859 DOI: 10.1038/s41379-019-0204-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/13/2018] [Accepted: 12/13/2018] [Indexed: 12/30/2022]
Abstract
Ductal carcinoma in situ (DCIS) is a neoplastic proliferation of mammary ductal epithelial cells confined to the ductal-lobular system, and a non-obligate precursor of invasive disease. While there has been a significant increase in the diagnosis of DCIS in recent years due to uptake of mammography screening, there has been little change in the rate of invasive recurrence, indicating that a large proportion of patients diagnosed with DCIS will never develop invasive disease. The main issue for clinicians is how to reliably predict the prognosis of DCIS in order to individualize patient treatment, especially as treatment ranges from surveillance only, breast-conserving surgery only, to breast-conserving surgery plus radiotherapy and/or hormonal therapy, and mastectomy with or without radiotherapy. We conducted a semi-structured literature review to address the above issues relating to "pure" DCIS. Here we discuss the pathology of DCIS, risk factors for recurrence, biomarkers and molecular signatures, and disease management. Potential mechanisms of progression from DCIS to invasive cancer and problems faced by clinicians and pathologists in diagnosing and treating this disease are also discussed. Despite the tremendous research efforts to identify accurate risk stratification predictors of invasive recurrence and response to radiotherapy and endocrine therapy, to date there is no simple, well-validated marker or group of variables for risk estimation, particularly in the setting of adjuvant treatment after breast-conserving surgery. Thus, the standard of care to date remains breast-conserving surgery plus radiotherapy, with or without hormonal therapy. Emerging tools, such as pathologic or biologic markers, may soon change such practice. Our review also includes recent advances towards innovative treatment strategies, including targeted therapies, immune modulators, and vaccines.
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Affiliation(s)
- Wedad M Hanna
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
| | - Carlos Parra-Herran
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Fang-I Lu
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Elzbieta Slodkowska
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Eileen Rakovitch
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Sharon Nofech-Mozes
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
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22
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Van Bockstal MR, Agahozo MC, Koppert LB, van Deurzen CHM. A retrospective alternative for active surveillance trials for ductal carcinoma in situ of the breast. Int J Cancer 2019; 146:1189-1197. [PMID: 31018242 PMCID: PMC7004157 DOI: 10.1002/ijc.32362] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/25/2019] [Accepted: 04/17/2019] [Indexed: 12/12/2022]
Abstract
Ductal carcinoma in situ (DCIS) of the breast is a nonobligate precursor of invasive breast cancer, accounting for 20 % of screen-detected breast cancers. Little is known about the natural progression of DCIS because most patients undergo surgery upon diagnosis. Many DCIS patients are likely being overtreated, as it is believed that only around 50 % of DCIS will progress to invasive carcinoma. Robust prognostic markers for progression to invasive carcinoma are lacking. In the past, studies have investigated women who developed a recurrence after breast-conserving surgery (BCS) and compared them with those who did not. However, where there is no recurrence, the patient has probably been adequately treated. The present narrative review advocates a new research strategy, wherein only those patients with a recurrence are studied. Approximately half of the recurrences are invasive cancers, and half are DCIS. So-called "recurrences" are probably most often the result of residual disease. The new approach allows us to ask: why did some residual DCIS evolve to invasive cancers and others not? This novel strategy compares the group of patients that developed in situ recurrence with the group of patients that developed invasive recurrence after BCS. The differences between these groups could then be used to develop a robust risk stratification tool. This tool should estimate the risk of synchronous and metachronous invasive carcinoma when DCIS is diagnosed in a biopsy. Identification of DCIS patients at low risk for developing invasive carcinoma will individualize future therapy and prevent overtreatment.
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Affiliation(s)
- Mieke R Van Bockstal
- Department of Pathology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Marie C Agahozo
- Department of Pathology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Linetta B Koppert
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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23
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Sardanelli F, Trimboli RM, Tot T. Expert Review of Breast Pathology in Borderline Lesions. JAMA Oncol 2018; 4:1325-1326. [DOI: 10.1001/jamaoncol.2018.1953] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Francesco Sardanelli
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
- Unit of Radiology, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Rubina M. Trimboli
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Milan, Italy
- PhD Program in Integrative Biomedical Research, Università degli Studi di Milano, Milan, Italy
| | - Tibor Tot
- Pathology & Cytology Dalarna, Falun, Sweden
- Uppsala University, Uppsala, Sweden
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