Microinvasive Carcinoma of the Breast

Development and validation of a nomogram for predicting lymph node metastasis in ductal carcinoma in situ with microinvasion: A SEER population-based study

BACKGROUND

Ductal carcinoma in situ with microinvasion (DCIS-MI) is a special type of breast cancer. It is an invasive lesion less than 1.0 mm in size related to simple ductal carcinoma in situ (DCIS). Lymph node metastasis (LNM) in DCIS-MI often indicates a poor prognosis. Therefore, the management of lymph nodes plays a vital role in the treatment strategy of DCIS-MI. Since DCIS-MI is often diagnosed by postoperative paraffin section and immunohistochemical detection, to obtain the best clinical benefits for such patients, we aim to establish and verify a nomogram to predict the possibility of lymph node metastasis in DCIS-MI patients and help preoperative or intraoperative clinical decision-making.

METHODS

A retrospective analysis of patients with DCIS-MI in the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2019 was performed. The study cohort was randomly divided into a training cohort and a validation cohort at a ratio of 7:3. The risk factors were determined by univariate and multivariate logistic regression analyses in the training cohort, and a nomogram was constructed. The receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) were used to evaluate the nomogram in the training set and validation set. An independent data cohort was obtained from the Shanghai Jiao Tong University Breast Cancer Database (SJTU-BCDB) for external validation.

RESULTS

This study included 3951 female patients from SEER with DCIS-MI, including 244 patients with regional lymph node metastasis, accounting for 6.18% of the total. An independent test set of 323 patients from SJTU-BCDB was used for external validation. According to the multifactorial logistic regression analysis results, age at diagnosis, ethnicity, grade, and surgical modality were included in the prediction model. The areas under the ROC curves (AUCs) were 0.739 (95% CI: 0.702~0.775), 0.732 (95% CI: 0.675~0.788), and 0.707 (95%CI: 0.607-0.807) in the training, validation and external test groups, suggesting that the column line graphs had excellent differentiation. The calibration curves slope was close to 1, and the model's predicted values were in good agreement with the actual values. The DCA curves showed good clinical utility.

CONCLUSION

In this study, we constructed accurate and practical columnar maps with some clinical benefit to predict the likelihood of lymph node metastasis in patients with postoperatively diagnosed DCIS-MI and provide a reference value for specifying treatment strategies.

Prognostic Markers of Microinvasive Breast Carcinoma: A Systematic Review and Meta-Analysis

(1) Background: The prognostic factors of microinvasive (≤1 mm) breast carcinoma are not completely clear. The aim of this study was to perform a systematic review and meta-analysis to clarify these factors. (2) Methods: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was followed. Two databases were interrogated, PubMed and Embase, and papers in English were included to address this question. The selected studies were those that reported on female patients affected by microinvasive carcinoma, and on prognostic factors with a hazard ratio (HR) for disease-free survival (DFS) and overall survival (OS). (3) Results: In total, 618 records were identified. After removing duplicates (166), identification, and screening (336 by title and abstract alone, 116 by full text and eventual supplementary material), 5 papers were selected. Seven different meta-analyses were conducted in this study, all referring to DFS, analyzing the following prognostic factors: estrogen receptor, progesterone receptor, HER2 status, multifocality and grade of microinvasion, patient's age, and lymph node status. Only lymph node status was associated with prognosis and DFS (total number of cases: 1528; Z = 1.94; p = 0.05). The other factors examined did not significantly affect prognosis (p > 0.05). (4) Conclusions: Positive lymph node status significantly worsens prognosis in patients with microinvasive breast carcinoma.

Outcomes and imaging features of microinvasive carcinoma and ductal carcinoma in situ: Matched cohort study

INTRODUCTION

The purpose of this study is to investigate the differences in clinical outcomes between microinvasive carcinoma (mIC) and ductal carcinoma in situ (DCIS) and compare the imaging features of both using mammography, US and MRI.

MATERIALS AND METHODS

This retrospective study was approved by our institutional review board. Between January 2011 and December 2013, 516 women with mIC or DCIS confirmed by surgery were included. Patients were matched with propensity score matching to compare recurrence-free survival (RFS). RFS was compared using a Cox proportional hazards model. Imaging features were also compared between the two groups.

RESULTS

Among 516 women, 219 mIC and 297 DCIS tumors were identified. After matching, 132 women were allocated to each group. The mean follow-up duration was 80.2 months. In the matched cohort, no statistically significant association was observed between the DCIS and mIC groups in terms of total recurrence (hazard ratio [HR]: 1.7; 95% confidence interval [CI]: 0.8-4.0; P = 0.19), local-regional recurrence (HR: 3.4; 95% CI: 0.9-12.3, P = 0.07), or contralateral recurrence (HR: 0.9; 95% CI: 0.3-2.8, P = 0.89). Non-mass lesions at US (P = 0.004), moderate or marked background parenchymal enhancement (P = 0.04), and higher peak enhancement (P = 0.02) at MRI were more commonly seen in the mIC group than in the DCIS group.

CONCLUSION

Microinvasive carcinomas are distinct from DCIS in terms of imaging features, but no statistically significant association in recurrence survival.

Long-term outcomes and effects of hypofractionated radiotherapy in microinvasive breast cancer: Analysis from a randomized trial

PURPOSE

The natural history of microinvasive (T1mi) breast cancer is uncertain. The objective was to evaluate long-term local and distant recurrence rates following breast conserving surgery (BCS) in a prospective cohort of patients with T1mi compared to T1a-2 disease who received whole breast irradiation (WBI) in the context of a randomized trial of hypofractionation.

METHODS

1234 patients with T1-2 N0 breast cancer were randomized to receive adjuvant WBI of 42.5Gy in 16 daily fractions, or 50Gy in 25 daily fractions after BCS. An analysis of patients with T1mi tumors compared with T1a-2 disease was performed. Kaplan-Meier estimates of local recurrence (LR), distant recurrence, and overall survival (OS) were compared using the log-rank test.

RESULTS

Median follow-up was 12 years. T1mi was found in 3% (n = 38) of patients. The 10-year LR rate was 22.6% in T1mi vs. 6.9% in T1a-2 breast cancer [hazard ratio (HR) = 3.73; 95% confidence interval (CI): 1.93, 7.19; p < 0.001]. The 10-year risk of distant recurrence was 5.1% for T1mi, and 12.1% for T1a-2 disease (HR = 0.56; 95% CI: 0.19, 1.84; p = 0.36). Ten-year OS was 91.5% in T1mi and 84.4% in T1a-2 disease, (HR = 0.48; 95% CI: 0.18, 1.30; p = 0.14). Rates of LR did not differ whether treated by hypofractionation or conventional fractionation (HR = 1.21; 95% CI: 0.35, 4.18; p = 0.77).

CONCLUSIONS

The risk of LR was considerably higher in patients with T1mi compared to T1a-2 tumors, but OS remained very good. Future research should evaluate the utility of wider local excision and boost radiation to optimize local control for microinvasive breast cancer.

Clinicopathological characteristics, treatments, and prognosis of breast ductal carcinoma in situ with microinvasion: A narrative review

Background

Ductal carcinoma in situ with microinvasion (DCIS-MI) is defined as ductal carcinoma in situ (DCIS) with a microscopic invasive focus ≤1 mm in the longest diameter. The current literature is controversial concerning the clinical prognostic features and management of DCIS-MI. This narrative review described recently reported literature regarding the characteristics, treatment, and prognosis of it.

Methods

Searching PubMed for relevant articles covering the period of 1982 to 2021 using the following terms by MeSH and free-word: breast cancer, microinvasion, DCIS, DCIS-MI, and invasive ductal carcinoma (IDC).

Results

DCIS-MI tends to express more aggressive pathological features such as necrosis, HER2+, ER- or PR-, and high nuclear grade. The overall prognosis of DCIS-MI is typically good, however, some indicators such as young age, HR-, HER2+ and multimicroinvasive lesions, were associated with worse prognoses. And there are also conflicting results on the differences between the prognoses of DCIS-MI and DCIS or T1a-IDC. Postoperative chemotherapy and anti-HER2 therapy still have uncertain benefits and are more likely to be used to treat high-risk patients who are HR- orHER2+ to improve the prognosis.

Conclusion

DCIS-MI has more aggressive pathological features, which may suggest its biological behavior is worse than that of DCIS and similar to early IDC. Although the overall prognosis of DCIS-MI is good, when making decisions about adjuvant therapy clinicians need to give priority to the hormone receptor status, HER2 expression and axillary lymph node status of patients, because these may affect the prognosis and treatment response.

Prognostic significance of microinvasion with ductal carcinoma in situ of the breast: a meta-analysis

PURPOSE

Ductal carcinoma in situ (DCIS) associated with invasive carcinoma ≤ 1 mm in size is defined as DCIS with microinvasion (DCIS/microinvasion) rather than as invasive breast carcinoma. The number of patients with microinvasion accounts for < 1% of all breast cancer in published studies. As the numbers are limited, the prognostic significance of DCIS/microinvasion has not been clearly elucidated. This meta-analysis aimed to investigate the survival differences between patients with DCIS/microinvasion and those with pure DCIS.

METHODS

A meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was performed. We searched three electronic databases (MEDLINE, Cochrane Library, and EMBASE) and included observational studies published in English that contained survival details of patients with either DCIS or DCIS/microinvasion.

RESULTS

This study identified 26 studies that described the clinicopathological characteristics of patients in both the DCIS and DCIS/microinvasion groups. Survival differences were evaluated in 10 of 26 studies. Disease-free survival and loco-regional recurrence-free survival were significantly shorter in patients with DCIS/microinvasion than in those with DCIS (Hazard ratio, 1.52; 95% confidence interval, 1.11-2.08; p = 0.01 and hazard ratio, 2.53; 95% confidence interval, 1.45-4.41; p = 0.001, respectively). Both overall survival and distant metastasis-free survival tended to be shorter in patients with DCIS/microinvasion than in patients with DCIS (Hazard ratio, 1.63; 95% CI, 0.63-4.23; p = 0.31 and hazard ratio, 1.85; 95% confidence interval, 0.74-4.66; p = 0.19, respectively) but the difference was not statistically significant.

CONCLUSION

Our meta-analysis suggests that DCIS/microinvasion may display more aggressive biological and clinical behavior than pure DCIS, highlighting the potential need for closer follow-up and consideration of adjuvant treatment strategies in DCIS patients with microinvasive disease.

Survival outcomes after breast-conserving surgery plus radiotherapy compared with mastectomy in breast ductal carcinoma in situ with microinvasion

Ductal carcinoma in situ with microinvasion (DCIS-MI) is a subtype of breast cancer with a good prognosis, for which both breast conserving surgery plus radiotherapy (BCS + RT) and mastectomy are feasible surgical methods, but no clear conclusion has been made on the choice of these treatments. We used the Surveillance, Epidemiology and End Results database to extract 5432 DCIS-MI patients. Participants were divided into the BCS + RT group and the mastectomy group. We compared the overall survival (OS) and breast cancer-specific survival (BCSS) of the two groups using the Kaplan-Meier method and Cox regressions before and after propensity score matching (PSM). Before PSM, both univariate and multivariate analyses showed that BCS + RT group had significantly higher OS and BCSS compared with patients in the mastectomy group (P < 0.001). After PSM, the multivariate analysis showed that compared with mastectomy, the BCS + RT showed significantly higher OS and BCSS (HR = 0.676, 95% CI = 0.540-0.847, P < 0.001; HR = 0.565,95% CI = 0.354-0.903, P = 0.017). In addition, the subgroup analysis showed that BCS + RT is at least equivalent to mastectomy with respect to OS and BCSS in any subgroup. For patients with DCIS-MI, the prognosis of BCS + RT was superior to mastectomy.

National Cancer Institute Experience in Micro-invasive Breast Carcinoma Treatment and Outcome

AbstractBackground: Significant relationship between breast cancer immunophenotype and risk of recurrence either local and/or distant may help determine which patients might benefit more from axillary staging and whether axillary staging is warranted in all cases or not. Patients with microinvasive carcinoma can present with axillary LN. metastasis, with incidence ranges from 0% to 20% . Thus, sentinel node biopsies are considered for patients with microinvasive carcinoma. The role of axillary staging in MIBC is not well defined, with the rate of axillary L.N. metastases ranging 0–11 %. Current studies focus on the clinical characteristics of MIBC. However, only a few studies have evaluated the survival and treatment, especially adjuvant chemotherapy after surgery, for patients with MIBC.Methods: This is a retrospective study of 139 cases diagnosed with microinvasive breast carcinoma from 2011 to 2015 who were identified in the National Cancer Institute, Cairo University. The pathologic database of our hospital was searched to identify patients with a pathologic diagnosis of MIBC on surgical specimens. The clinical features, sonographic and mammographic images and pathology records were reviewed.Results: There is increased incidence of MIBC over the past decade. Patients with MIBC were managed surgically with BCS. MIBC have the good prognosis. However, patients who are negative hormonal receptors have relatively substantial risk of relapse within the first 5 years after surgical operation. Adjuvant chemotherapy can only improve the outcomes of patients with negative hormonal receptors. Further studies with prolonged follow-up of large cohort are warranted to assess the prognostic significance and treatment of this lesion.Keywords: MIBC, CIS, DCIS, BC

Prognostic Factors and a Nomogram Predicting Survival in Patients with Breast Ductal Carcinoma in situ with Microinvasion: A Population-Based Study

Purpose

Ductal carcinoma in situ with microinvasion (DCISM) can be challenging to balance the risks of overtreatment versus undertreatment. We aim to identify prognostic factors in patients with DCISM and construct a nomogram to predict breast cancer-specific survival (BCSS).

Materials and Methods

A retrospective cohort study of women diagnosed with DCISM from 1988 to 2015 who were identified in the Surveillance, Epidemiology and End Results database. Clinical variables and tumor characteristics were evaluated, and Cox proportional-hazards regression was performed. A nomogram was constructed from the multivariate logistic regression to combine all the prognostic factors to predict the prognosis of DCISM patients at 5 years, 10 years, and 15 years.

Results

We identified 5438 total eligible breast cancer patients with a median and max survival time of 78 and 227 months, respectively. Here, patients with poorer survival outcomes were those diagnosed between 1988 and 2001, African-American race, under 40 years of age, higher tumor N stage, progesterone receptor-negative tumor, and received no surgery. The nomogram was constructed by the seven variables and passed the calibration and validation steps. The area under the receiver operating characteristic (ROC) curve (AUC) of both the training set and the validating set (5-year AUC: 0.77 and 0.88, 10-year AUC: 0.75 and 0.73, 15-year AUC: 0.72 and 0.65). Receiving chemotherapy was associated with a better BCSS (hazard ratio, HR=0.45, 95% confidence interval, 95% CI = 0.23–0.89), especially in patients with estrogen receptor (ER) negative, progesterone receptor (PR) negative (HR = 0.35, 95% CI = 0.13–0.97) and ER+PR-/ER-PR+ DCISM (HR = 0.07, 95% CI = 0.01–0.59).

Conclusion

Our current study is the first to construct nomograms of patients with DCISM which could help physicians identify breast cancer patients that more likely to benefit from more intensive treatment and follow-up. Chemotherapy might benefit patients with ER-PR- and ER+PR-/ER-PR+ DCISM.

Characteristics, prognosis, risk factors, and management of recently diagnosed ductal carcinoma in situ with microinvasion

Background

Ductal carcinoma in situ with microinvasion (DCISM) represents ~1% of all breast cancer cases and is arguably a more aggressive subtype of ductal carcinoma in situ (DCIS). Lacking studies with a large population, the survival outcomes of DCISM are still poorly understood and the treatment recommendations remain controversial. This study aims to investigate the long‐term outcome of patients with DCISM, potential risk factors for their prognosis, and the difference of survival between patients treated with breast‐conserving surgery plus radiotherapy (BCT + RT) and mastectomy only.

Methods

In total, 1299 patients from 2008 to 2019 with DCISM were retrospectively retrieved. Clinicopathological features were analyzed. Subgroup analysis was conducted between patients who underwent BCT + RT and mastectomy only. Univariate and multivariate analyses were performed to identify prognostic factors for survival. Differences of survival between two groups were compared using the log‐rank test.

Results

Totally, 1286 patients had follow‐up information, the median follow‐up is 54.57 months, the 5‐year local–regional‐free survival (LRFS), distant metastasis‐free survival (DMFS), and overall survival (OS) were 98.6%, 97.1%, and 99.4%, respectively, two deaths were due to breast cancer. Multivariate analysis identified age <40 (p = 0.028) and close margin (≤2 mm) as independent negative prognostic factors for LRFS. No prognostic factors were identified for DMFS and OS. The 5‐year LRFS, DMFS, and OS of patients who had DCIS component ≥5 cm and underwent mastectomy without adjuvant radiotherapy were 100%, 98.4%, and 98.4%, respectively. After propensity score matching (PSM), no survival difference was observed between patients treated with BCT + RT or mastectomy only.

Conclusions

DCISM patients had a good survival, even those with DCIS component ≥5 cm. Patients aged <40 or with close margin (≤2 mm) had a poorer LRFS, but not DMFS or OS. BCT + RT is a feasible choice for DCISM patients.

Lobular Breast Cancer: Histomorphology and Different Concepts of a Special Spectrum of Tumors

Simple Summary

Invasive lobular breast cancer (ILC) is a special type of breast cancer (BC) that was first described in 1941. The diagnosis of ILC is made by microscopy of tumor specimens, which reveals a distinct morphology. This review recapitulates the developments in the microscopic assessment of ILC from 1941 until today. We discuss different concepts of ILC, provide an overview on ILC variants, and highlight advances which have contributed to a better understanding of ILC as a special histologic spectrum of tumors.

Abstract

Invasive lobular breast cancer (ILC) is the most common special histological type of breast cancer (BC). This review recapitulates developments in the histomorphologic assessment of ILC from its beginnings with the seminal work of Foote and Stewart, which was published in 1941, until today. We discuss different concepts of ILC and their implications. These concepts include (i) BC arising from mammary lobules, (ii) BC growing in dissociated cells and single files, and (iii) BC defined as a morpho-molecular spectrum of tumors with distinct histological and molecular characteristics related to impaired cell adhesion. This review also provides a comprehensive overview of ILC variants, their histomorphology, and differential diagnosis. Furthermore, this review highlights recent advances which have contributed to a better understanding of the histomorphology of ILC, such as the role of the basal lamina component laminin, the molecular specificities of triple-negative ILC, and E-cadherin to P-cadherin expression switching as the molecular determinant of tubular elements in CDH1-deficient ILC. Last but not least, we provide a detailed account of the tumor microenvironment in ILC, including tumor infiltrating lymphocyte (TIL) levels, which are comparatively low in ILC compared to other BCs, but correlate with clinical outcome. The distinct histomorphology of ILC clearly reflects a special tumor biology. In the clinic, special treatment strategies have been established for triple-negative, HER2-positive, and ER-positive BC. Treatment specialization for patients diagnosed with ILC is just in its beginnings. Accordingly, ILC deserves greater attention as a special tumor entity in BC diagnostics, patient care, and cancer research.

Breast ductal carcinoma in situ with micro-invasion versus ductal carcinoma in situ: a comparative analysis of clinicopathological and mammographic findings

AIM

To determine the differences in clinicopathological and mammographic findings between ductal carcinoma in situ (DCIS) and ductal carcinoma in situ with micro-invasion (DCIS-MI) and explore clinicopathological and mammographic factors associated with DCIS-MI.

MATERIALS AND METHODS

All DCIS patients with or without micro-invasion who underwent preoperative mammography at The Affiliated Hospital of Qingdao University from January 2016 through June 2020 were identified retrospectively. The correlations of clinicopathological findings with DCIS-MI were evaluated using univariate and multivariate binary logistic regression analyses. Imaging findings were compared between the groups by using the Pearson chi-square test.

RESULTS

A total of 445 DCIS lesions and 151 DCIS-MI lesions were included in the final analysis. Large extent (≥2.7 cm), high nuclear grade, comedo-type, negative progesterone receptor (PR), negative oestrogen receptor (ER), high Ki-67 and axillary lymph node metastasis were more frequently found in DCIS-MI than in DCIS (all p<0.05), and the first four of these were found to be independent predictors of DCIS-MI in the multivariate analysis (all p<0.05). Regarding imaging findings, compared to DCIS, DCIS-MI showed fewer occult lesions and more lesions with calcifications in mass, asymmetry, and architectural distortion (p=0.004). Grouped calcifications were usually associated with DCIS, while regional calcifications were commonly found in DCIS-MI (p<0.05).

CONCLUSION

Large extent, high nuclear grade, comedo-type and negative PR were found to be independent predictors of DCIS-MI. Lesions with calcifications and regional calcifications were more likely associated with DCIS-MI on mammography.

Axillary staging in ductal carcinoma in situ with microinvasion: A meta-analysis

INTRODUCTION

Ductal carcinoma in situ with microinvasion (DCISM); arguably a more aggressive subtype of DCIS, currently has variable recommendations governing its staging and management in the UK. As a result, there is ongoing controversy surrounding the most appropriate management of DCISM, in particular the need of axillary staging.

METHOD

A search was conducted on the databases MEDLINE and Embase using the keywords: breast, DCISM, microinvasion, "ductal carcinoma in situ with microinvasion", sentinel lymph node biopsy, SLNB, axillary staging was performed. 23 studies were selected for analysis. Primary outcome was the positivity of metastasis of lymph node; secondary outcome looked at characteristics of DCISM that may affect node positivity.

RESULTS

A total of 2959 patients were included. Significant heterogeneity was observed amongst the studies with regards to metastases (I² = 61%; P < 0.01). Lymph node macrometastases was estimated to be 2%. Significant subgroup difference was not observed between SLNB technique and lymph node macrometastases (Q = 0.74; p = 0.69). Statistical significance was observed between the focality of the DCISM and lymph node macrometastases (Q = 8.71; p = 0.033).

CONCLUSION

Although histologically more advanced than DCIS, DCISM is not linked with higher rates of clinically significant metastasis to axillary lymph nodes. Survival rates are very similar to those seen in cases of DCIS. Current evidence suggests that axillary staging in cases of DCISM will not change their overall management, thus may only be an unnecessary and inconvenient additional intervention considering the majority of DCISM diagnoses are made from post-operative pathology samples. A multidisciplinary team approach evaluating pre-operative clinical and histological information to tailor the management specific to individual cases of DCISM would be a preferred approach than routine axillary staging.

Multiple Microinvasion Foci in Ductal Carcinoma In Situ Is Associated With an Increased Risk of Recurrence and Worse Survival Outcome

Background

Ductal carcinoma in situ with microinvasion (DCISM) was defined as one or more foci of invasion beyond the basement membrane within 1 mm. The size of primary lesion is associated with axillary status and prognosis in patients with invasive breast cancer; thus, it is of interest to determine whether multiple foci of microinvasion are associated with a higher risk of positive axillary status or worse long-term outcomes in patients with DCISM.

Methods

This study identified 359 patients with DCISM who had undergone axillary evaluation at our institute from January 2006 to December 2015. Patients were categorized as one focus or multiple foci (≥2 foci) according to the pathological results. Clinicopathological features, axillary status, and disease-free survival rate were obtained and analyzed.

Results

Of 359 patients, 233 (64.90%) had one focus of microinvasion and 126 (35.10%) had multiple foci. Overall, 242 (67.41%) and 117 (32.59%) patients underwent sentinel lymph nodes biopsy (SLNB) and axillary lymph nodes dissection (ALND), respectively. Isolated tumor cells were found in four (1.11%) patients and axillary metastasis rate was 2.51%. Neither axillary evaluation methods (P = 0.244) nor axillary metastasis rate (P = 0.559) was significantly different between patients with one focus and multiple foci. In univariate analysis, patients with multiple foci tended to have larger tumor size (P < 0.001), higher nuclear grade (P = 0.001), and higher rate of lymphatic vascular invasion (P = 0.034). Also, the proportion of positive HER2 (P = 0.027) and Ki67 level (P = 0.004) increased in patients with multiple foci, while in multivariate analysis, only tumor size showed significant difference (P = 0.009). Patients with multiple foci were more likely to receive chemotherapy (56.35 vs 40.77%; P = 0.028). At median 5.11 years follow-up, overall survival rate was 99.36%. Patients with multiple microinvasive foci had worse disease-free survival rate compared with one-focus patients (98.29 vs 93.01%, P = 0.032).

Conclusion

Even though the numbers of microinvasion were different and patients with multiple foci of microinvasion tended to have larger tumor size, there was no higher risk of axillary involvement compared with patients with one focus of microinvasion, while patients with multiple microinvasive foci had worse DFS rate. Thus, DCISM patients with multiple foci of microinvasion may be the criterion for more aggressive local–regional treatment. Optimization of adjuvant therapy in DCISM patients is required.

Pathological features of 11,337 patients with primary ductal carcinoma in situ (DCIS) and subsequent events: results from the UK Sloane Project

Background

The Sloane audit compares screen-detected ductal carcinoma in situ (DCIS) pathology with subsequent management and outcomes.

Methods

This was a national, prospective cohort study of DCIS diagnosed during 2003–2012.

Results

Among 11,337 patients, 7204 (64%) had high-grade DCIS. Over time, the proportion of high-grade disease increased (from 60 to 65%), low-grade DCIS decreased (from 10 to 6%) and mean size increased (from 21.4 to 24.1 mm). Mastectomy was more common for high-grade (36%) than for low-grade DCIS (15%). Few (6%) patients treated with breast-conserving surgery (BCS) had a surgical margin <1 mm. Of the 9191 women diagnosed in England (median follow-up 9.4 years), 7% developed DCIS or invasive malignancy in the ipsilateral and 5% in the contralateral breast. The commonest ipsilateral event was invasive carcinoma (n = 413), median time 62 months, followed by DCIS (n = 225), at median 37 months. Radiotherapy (RT) was most protective against recurrence for high-grade DCIS (3.2% for high-grade DCIS with RT compared to 6.9% without, compared with 2.3 and 3.0%, respectively, for low/intermediate-grade DCIS). Ipsilateral DCIS events lessened after 5 years, while the risk of ipsilateral invasive cancer remained consistent to beyond 10 years.

Conclusion

DCIS pathology informs patient management and highlights the need for prolonged follow-up of screen-detected DCIS.

Breast ductal Carcinoma in situ associated with microinvasion induces immunological response and predicts ipsilateral invasive recurrence

Although microinvasion (Mi) is often thought to be an interim stage between ductal carcinoma in situ (DCIS) and established invasive ductal carcinoma, survival outcomes and biological behaviour of DCIS-Mi are still poorly understood. This study investigated the potential influence of Mi on disease-free survival (DFS) and assessed its correlations with clinicopathological parameters, prognosis, molecular, and immune markers. CD4, CD8, forkhead box P3 (FOXP3), CD68, CD163, programmed cell death protein 1 (PD-1), and its ligand (PD-L1) expression in pure DCIS and DCIS-Mi, from a cohort of 198 patients, were determined by immunohistochemistry. DFS, clinicopathological parameters, immune markers, and biomarker expression were correlated with presence of Mi. Twelve out of 198 DCIS cases were associated with Mi. DCIS-Mi was significantly linked with ipsilateral invasive recurrence (p = 0.032). Kaplan-Meier analysis revealed that DCIS-Mi had worse DFS for ipsilateral invasive recurrence (p = 0.011) and this was affirmed by multivariate Cox regression analysis (95% CI 1.181-9.010, HR = 3.262, p = 0.023). DCIS-Mi was associated with higher densities of immune infiltrates positive for CD4 (p = 0.037), FOXP3 (p = 0.037), CD163 (p = 0.01), and PD-L1 (p = 0.015). This study demonstrated that DCIS-Mi was correlated with high densities of immune infiltrates and predicted ipsilateral invasive recurrence.

Clinical characteristics of breast ductal carcinoma in situ with microinvasion: a narrative review

Ductal carcinoma in situ (DCIS) with microinvasion (DCIS-MI) is defined as the extension of cancer cells beyond the basement membrane into adjacent tissue with no focus larger than 1 mm or a maximum diameter of less than 1 mm for multiple invasive foci. DCIS-MI constitutes approximately 1% of all breast cancer cases and 5% to 10% of cases of DCIS. The current literature is controversial concerning the clinical prognostic features and management of DCIS-MI. This narrative review described recently reported literature regarding the characteristics, diagnosis, treatment, and prognosis of DCIS-MI.

Is it ductal carcinoma in situ with microinvasion or "Ductogenesis"? The role of myoepithelial cell markers

Mammary myoepithelial cells have been under-recognized for many years since they were considered less important in breast cancer tumorigenesis compared to luminal epithelial cells. However, in recent years with advances in genomics, cell biology, and research in breast cancer microenvironment, more emphasis has been placed on better understanding of the role that myoepithelial cells play in breast cancer progression. As the result, it has been recognized that the presence or absence of myoepithelial cells play a critical role in the assessment of tumor invasion in diagnostic breast pathology. In addition, advances in screening mammography and breast imaging has resulted in increased detection of ductal carcinoma in situ and consequently more diagnosis of ductal carcinoma in situ with microinvasion. In the present review, we discuss the characteristics of myoepithelial cells, their genomic markers and their role in the accurate diagnosis of ductal carcinoma in situ with microinvasion. We also share our experience with reporting of various morphologic features of ductal carcinoma in situ that may mimic microinvasion and introduce the term of ductogenesis.

Repression of miR-135b-5p promotes metastasis of early-stage breast cancer by regulating downstream target SDCBP

Metastasis is an essential event for breast cancer (BC) progression even after initial surgery. The identification of patients with a high probability of metastasis at an early stage is particularly important in clinical practice and requires individualized treatment or early prevention. A retrospective study of 242 cases of ductal carcinoma in situ with microinvasion (DCIS-Mi), the first stage of invasive BC, was performed in this follow-up analysis. Of all patients, 8 developed metastases, and they were all included for further mechanistic studies with control group of 24 DCIS-Mi by matched-pair designing. By screening DCIS-Mi with different prognoses, we found that the DCIS-Mi that metastasized had significantly lower miR-135b-5p expression than the DCIS-Mi that did not. The function of miR-135b-5p was studied in vitro and in vivo invasion and metastasis assays. We also validated a novel target gene for miR-135b-5p, syndecan binding protein (SDCBP), and assessed the functional consequences of SDCBP by invasion assays. By checking different BC cell lines, a strong inverse correlation between miR-135b-5p and SDCBP expression was recorded. For the functional study, the inhibition of miR-135b-5p was accompanied by increased BC cell growth, epithelial-mesenchymal transition (EMT), migration and invasion in vitro. Interestingly, silencing SDCBP can reverse miR-135b-5p-dependent EMT and proliferation. In vivo studies demonstrated that the newly revealed miR-135b-5p/SDCBP axis increased cell proliferation, invasion and malignant transformation, as well as promoted metastasis in a xenograft tumor mouse model. Thus, our clinical patient cohort and functional data suggest that miR-135b-5p/SDCBP is a crucial determinant of BC metastasis at a very early stage. Our results may shed light on the importance of miR-135b-5p molecular diagnosis and prognosis, as well as the early prevention of BC for metastasis.

Multiple foci of microinvasion is associated with an increased risk of invasive local recurrence in women with ductal carcinoma in situ treated with breast-conserving surgery

PURPOSE

The impact of Ductal Carcinoma in Situ (DCIS) with multiple foci of microinvasion (MI) (≤ 1 mm) on the risks of local recurrence (LR) and invasive LR is unknown, leading to uncertainty if DCIS with multiple foci of MI requires more aggressive treatment. We report a population-based analysis of the impact of multiple foci of MI, confirmed by pathology review, on the 15-year risks of LR and invasive LR treated with breast-conserving surgery (BCS) ± radiotherapy (RT).

METHODS

Cohort includes all women diagnosed with DCIS ± MI from 1994 to 2003 treated with BCS ± RT. Cox proportional hazards model was used to evaluate the impact of multiple foci of MI on the risks of LR and invasive LR, adjusting for covariates. The 15-year local and invasive local recurrence-free survival rates were calculated using the Kaplan-Meier method with differences compared by log-rank test.

RESULTS

The cohort includes 2988 women treated by BCS; 2721 had pure DCIS (51% received RT), 267 had DCIS with one or more foci of MI (58% had RT). Median follow-up was 13 years. Median age at diagnosis was 58 years. On multivariable analyses, the presence of multiple foci of MI was associated with an increased risk of invasive LR (HR = 1.59, 95% CI 1.01-2.49, p = 0.04) but not DCIS LR (HR = 0.89, 95% CI 0.46, 1.76, p = 0.7). The 15-year invasive LRFS risks for cases with pure DCIS, with 1 focus or multiple foci of MI were 85.7%, 85.6%, 74.7% following treatment by BCS alone, 87.2%, 89.9%, and 77% for those treated with BCS + RT without boost and 89.2%, 91.3%, and 95% for women treated with BCS + RT and boost.

CONCLUSIONS

The presence of multiple foci of MI in DCIS is associated with higher 15-year risks of invasive LR after breast-conserving therapy compared to women with pure DCIS but treatment with whole breast and boost RT can mitigate this risk.

Molecular profiling of microinvasive breast cancer microenvironment progression

Background

Tumors develop by progression through a series of stages. Every cell of the tumor microenvironment is constantly changing in the flow of the cancer progression. It has become clear in recent years that stroma is essential for tumor maintenance and growth. Here, we aimed to give a chronological order of gene expression changes given in the dynamical framework of microinvasive breast cancer microenvironment.

Methods

RNA-seq was performed on seven microinvasive breast cancers. For each of them we microdissected seven different portions of the tumor, four related to the breast epithelium and three to the stroma. Breast epithelium was chronologically subdivided in normal breast epithelium (NBE), carcinoma in situ (CIS), emerging invasive fingers (EIF) and invasive breast cancer (IBC). For each of the breast epithelium subdivisions we collected the adjacent stroma (S): S-NBE, S-EIF and S-IBC.

Results

The overall differentially expressed genes (DEGs) in all the compartments were analysed and evaluated to understand the pathways involved in tumor progression. Then we analysed the DEGs of the epithelial and stromal portions in comparison with the normal portions. We observed that the stromal cells are necessary for the development and the maintenance of the tumor, especially in tumor progression. Moreover the most important genes involved in the main metabolic pathways were analysed and the communications within the different cell compartments were highlighted.

Conclusions

As a future perspective, a deeply study of the identified key genes, particularly in the stromal cells, will be crucial to develop an anticancer therapy that is undergoing a conversion from a cancer cell-centric strategy to a stroma-centric strategy, more genomically stable.

Electronic supplementary material

The online version of this article (10.1186/s12967-019-1936-x) contains supplementary material, which is available to authorized users.

Sentinel lymph node biopsy in microinvasive ductal carcinoma in situ

BACKGROUND

Microinvasive breast cancer is an uncommon pathological entity. Owing to the rarity of this condition, its surgical axillary management and overall prognosis remain controversial.

METHODS

A database was analysed to identify patients with microinvasive ductal carcinoma in situ (DCIS) who had surgery for invasive breast cancer at the European Institute of Oncology, Milan, between 1998 and 2010. Women who had undergone axillary staging by sentinel lymph node biopsy were included in the study.

RESULTS

Of 257 women with microinvasive breast cancer who underwent sentinel lymph node biopsy (SLNB), 226 (87·9 per cent) had negative sentinel lymph nodes (SLNs) and 31 had metastatic SLNs. Twelve patients had isolated tumour cells (ITCs), 14 had micrometastases and five had macrometastases in sentinel nodes. Axillary lymph node dissection was performed in 16 of the 31 patients with positive SLNs. After a median follow-up of 11 years, only one regional first event was observed in the 15 patients with positive SLNs who did not undergo axillary lymph node dissection. There were no regional first events in the 16 patients with positive SLNs who had axillary dissection.

CONCLUSION

Good disease-free and overall survival were found in women with positive SLNs and microinvasive DCIS. This study is in line with studies showing that SLNB in microinvasive DCIS may not be useful, and supports the evidence that less surgery can provide the same level of overall survival with better quality of life.

Risk factors for lymph node metastasis and the impact of adjuvant chemotherapy on ductal carcinoma in situ with microinvasion: a population-based study

BACKGROUND

Ductal carcinoma in situ with microinvasion (DCISM) represents ~1% of all breast cancer cases. Risk factors for lymph node (LN) metastasis and appropriate adjuvant therapy for DCISM are still widely debated.

METHODS

We retrieved DCISM data from the National Cancer Institute's Surveillance, Epidemiology, and End Results registry database (1998-2013). Chi-squared tests and logistic regression models were applied to investigate the potential risks of LN metastasis. Univariate and multivariate Cox proportional hazards regressions were performed to estimate the prognostic factors of DCISM. Survival outcomes were estimated using the Kaplan-Meier method. A 1:1 propensity score matching was used to minimize potential bias.

RESULTS

Overall, 6,219 patients with DCISM met our inclusion criteria. Younger age and higher grade disease were identified as risk factors for LN metastasis. In the multivariable analysis, LN metastasis and chemotherapy were prognostic factors for worse overall survival and breast cancer-specific survival. Furthermore, propensity score matching and subgroup analysis showed that chemotherapy may not be effective for DCISM patients.

CONCLUSION

Younger patients with high-grade disease tend to have LN involved in DCISM. Adjuvant chemotherapy might not be necessary for patients with DCISM.

Expression of estrogen receptor, progesterone receptor, human epidermal growth factor receptor 2, and Ki-67 in ductal carcinoma in situ (DCIS) and DCIS with microinvasion

Ductal carcinoma in situ (DCIS) represents a heterogeneous disease in its histologic appearance and biological potential. Some women treated for DCIS subsequently develop invasive breast cancer. DCIS with microinvasion is considered as the interim stage in the progression from DCIS to invasive breast cancer. Analysis of the differences between DCIS and DCIS with microinvasion may aid in understanding the characteristic of DCIS with microinvasion and identifying biological factors determining progression of DCIS to invasive disease.Retrospective analysis of 219 cases between 2012 and 2018 was performed in our institution. The pathological results and axillary lymph nodes status were collected. Analysis of the expression of estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER-2), and Ki-67 in pure DCIS (164 cases), and DCIS with microinvasion (55 cases) using immunohistochemistry.DCIS with microinvasion had a higher nuclear grade (P < .001) and was more likely to have sentinel lymph node biopsy (SLNB) positivity (P = .039) than DCIS. Expression of ER, PR were significantly higher in DCIS compared with DCIS with microinvasion (P < .001, P < .001). While the expression of HER-2 in DCIS with microinvasion (56.4%) was significantly higher than in DCIS (36.6%, P = .01). Furthermore, DCIS with microinvasion was significantly more likely to have aggressive subtype (Triple-negative and HER2-enriched tumors, P = .005).Our results indicated that DCIS with microinvasion was different from pure DCIS in clinicopathologic characteristics and molecular alterations. It displayed a more aggressive biological nature than pure DCIS. It may be a distinct entity.

Microinvasive Carcinoma versus Ductal Carcinoma In Situ: A Comparison of Clinicopathological Features and Clinical Outcomes

PURPOSE

Although microinvasive carcinoma is distinct from ductal carcinoma in situ (DCIS), the clinical significance of microinvasion in DCIS remains elusive. The purpose of this study is to evaluate the clinicopathological features and clinical outcomes of microinvasive carcinoma compared with pure DCIS.

METHODS

We assessed 613 cases of DCIS and microinvasive carcinoma that were consecutively resected from 2003 to 2014 and analyzed clinicopathological variables, expression of standard biomarkers such as the estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2), p53, and Ki-67, and tumor recurrence.

RESULTS

Among the 613 cases, 136 (22.2%) were classified as microinvasive carcinoma. Microinvasive carcinoma was significantly associated with DCIS with a large extent, high nuclear grade, necrosis, and comedotype architectural pattern. ER and PR expressions were dominantly observed in pure DCIS, whereas positive HER2 status, p53 overexpression, and high Ki-67 proliferation indices were more frequently observed in microinvasive carcinoma. Lymph node metastasis was found in only four cases of microinvasive carcinoma with multifocal microinvasion. In the multivariate analysis, DCIS with a large extent, comedo-type architectural pattern, and negative ER status were found to be independent predictors of microinvasion. During follow-up, 12 patients had ipsilateral breast recurrence, and no differences in recurrence rates were observed between patients with DCIS and those with microinvasive carcinoma. The triple-negative subtype was the only factor that was associated with tumor recurrence.

CONCLUSION

Microinvasive carcinomas are distinct from DCIS in terms of clinicopathological features and biomarker expressions but are similar to DCIS in terms of clinical outcomes. Our results suggest that microinvasive carcinoma can be treated and followed up as pure DCIS.

Biologic behavior and long-term outcomes of breast ductal carcinoma in situ with microinvasion

Background

Ductal carcinoma in situ with microinvasion (DCIS-Mi) generally has favorable prognosis, but the long-term outcomes of DCIS-Mi and the biologic evolution from ductal carcinoma in situ (DCIS), DCIS-Mi, to DCIS with T1a breast cancer (DCIS-T1a) has not been specified. The aim of our study was to explore the biological and prognostic features of DCIS-Mi, compared with pure DCIS and DCIS-T1a.

Results

After a median follow-up of 31 months, the 3-year estimated disease free survival(DFS) rate of DCIS-Mi patients was significantly lower than that of pure DCIS patients (89.5% vs 97.1%, P=0.009). Patients with DCIS-Mi or DCIS-T1a tumors had comparable 3-year estimated DFS rates (89.5% vs 94.3%, P=0.13). No significant difference in overall survival (OS) was found among different groups (99.6%, 100% and 99.1% for DCIS, DCIS-Mi and DCIS-T1a, P=0.797). In chemotherapy and trastuzumab-naive DCIS-Mi patients, human epidermal growth factor receptor2 (HER2) positivity (HR=21.8, 95%CI, 1.7-286.8, P=0.019) were independent predictor of worse DFS on multivariate analysis.

Methods

During September 2002 and December 2014, 602 breast cancer patients who underwent radical surgery were retrospectively reviewed. Three hundred and fifty-nine patients (59.6%) had pure DCIS, 84(14.0%) and 159(26.4%) were diagnosed as DCIS-Mi and DCIS-T1a. Clinico-pathological features were compared between different subgroups.

Conclusions

DCIS-Mi displayed a comparable survival to that of DCIS-T1a and a more aggressive biological nature than pure DCIS. Patients with HER2-positive DCIS-Mi had a worse survival and adjuvant chemotherapy plus target therapy needs to be further optimized in those patients.

Utility of Additional Tissue Sections in Surgical Pathology

Background. To avoid diagnostic errors such as missed diagnosis and errors in staging tumors due to inadequate tissue sampling, pathologists submit additional sections (AS). Objective. This study assessed frequency, diagnostic yield, distribution, and cost of AS. Method. Among 1542 AS cases, we calculated mean AS per case; fraction of AS that altered diagnosis or stage; AS variation by tissue, malignant versus benign lesions, presence or absence of neoadjuvant therapy, mass, margin, lymph nodes, or other source, resident versus pathologist assistant (PA) dissector; and AS cost per case. Results. Overall 9.2 ± 8.8 AS were collected per case. In only 3.8% (58/1542) of cases AS altered diagnosis or stage. Urinary bladder cases provoked the most AS: 19.5 ± 15.1 per case. Significantly more AS came from malignant versus benign lesions (10.8 ± 9.7 vs 7.6 ± 7.5, P = <.0001) and from specimens treated with neoadjuvant therapy versus malignant lesions not so treated (12.3 ± 9.4 vs 10.3 ± 9.8, P = .02). Lymph nodes were sampled more heavily compared with mass, margin, and other sites combined (11.8 ± 11.4 vs 8.9 ± 8.4, P = .003), but in 78.4% (1209/1542) of cases, AS were from mass. Of diagnosis or stage altering AS cases, two thirds (38/58) were from masses, one fifth (11/58) from lymph nodes, a 10th (6/58) from margins, and a 20th (3/58) from other specimen sites. Resident versus pathologist assistant dissection caused no significant AS difference. AS contributed 40% cost per case. Conclusions. AS per case ranged widely; their diagnostic yield was low; they were highest in urinary bladder specimens, in malignant and particularly neoadjuvant-treated lesions. Although lymph nodes were most heavily sampled, most AS were from masses. Resident dissection did not increase AS and cost of AS was high.

Impact of microinvasion on breast cancer mortality in women with ductal carcinoma in situ

BACKGROUND

Ductal carcinoma in situ (DCIS) is a neoplastic proliferation of epithelial cells which is confined within the basement membrane of the mammary ductal-lobular system. It is of interest to determine to what extent the potential to metastasize increases for DCIS patients when the basement membrane is breached (i.e. microinvasion is present).

METHODS

We retrieved the records of 525,395 women who had either first primary DCIS or small (≤ 2.0 cm) node-negative invasive breast cancer in the Surveillance, Epidemiology and End Results (SEER) registries database (1990-2013). For each patient, we extracted information on year of diagnosis, age at diagnosis, tumour size, tumour grade, oestrogen receptor status, use of radiotherapy, type of surgery, cause of death and follow-up time. We classified patients into four groups, according to the size of the invasive component of the primary tumour. We estimated the actuarial rate of breast cancer-specific mortality at ten and 20 years for women in each size category.

RESULTS

We identified 161,394 women with pure DCIS, 13,489 women with microinvasive carcinoma (≤ 0.1 cm of invasion), 153,856 women with invasive cancer 0.2-1.0 cm in size and 196,656 women with invasive cancer 1.1-2.0 cm in size. The 20-year actuarial breast cancer-specific mortality rate was 3.8% for women with pure DCIS, was 6.9% for women with microinvasive carcinoma, was 6.8% for women with invasive cancer 0.2-1.0 cm in size and was 12.1% for women with invasive cancer 1.1-2.0 cm in size. The adjusted hazard ratio for death associated with microinvasive carcinoma (vs. pure DCIS) was 2.00 (95% CI 1.76-2.26; p < 0.0001).

CONCLUSIONS

In terms of prognosis, microinvasive cancer more closely resembles small invasive cancer 0.2-1.0 cm) than pure DCIS. For invasive cancers under 1.0 cm, size has little impact on mortality.

Incidence, characteristics, and management of recently diagnosed, microscopically invasive breast cancer by receptor status: Iowa SEER 2000 to 2013

BACKGROUND

Recent incidence, treatment patterns, and outcomes for node negative microscopically invasive breast cancer (MIBC) have not been reported.

METHODS

State Health Registry of Iowa data identified women with ductal carcinoma in situ (DCIS), MIBC, and stage I breast cancer excluding MIBC (stage 1BC).

RESULTS

From 2000 to 2013, 1,706, 193, and 4,514 women were diagnosed with DCIS, MIBC, and stage 1BC, respectively. MIBC increased at an annual percentage change of 2.1 (P = .041). MIBC was more frequently human epidermal growth factor receptor 2 positive than stage 1BC (39.7% vs 9.6%, P < .001). Mastectomy was performed more frequently in MIBC than DCIS (40.9% vs 30.6%, P = .014) or stage 1BC (40.9% vs 33.8%, P = .119). Chemotherapy was given to 4.1% of women with MIBC. Survival for women with MIBC was intermediate between DCIS and stage 1BC.

CONCLUSIONS

Management of MIBC is an increasingly frequent clinical scenario. Women with MIBC receive more aggressive local and systemic therapy than women with DCIS.

The Demographic Features, Clinicopathological Characteristics and Cancer-specific Outcomes for Patients with Microinvasive Breast Cancer: A SEER Database Analysis

To investigate the clinicopathological characteristics and survival outcomes of microinvasive breast cancer, we conducted an observational study of female diagnosed with DCIS or DCIS with microinvasion (DCISM) from 1990 to 2012 using the Surveillance, Epidemiology, and End Results (SEER) database. There were 87695 DCIS and 8863 DCISM identified. In DCISM group, patients appeared to be younger and more black patients were identified in comparison with DCIS group. Furthermore, DCISM was associated with more aggressive tumor characteristics like higher rates of oestrogen receptor (ER) and progesterone receptor (PR) negativity, HER2 positivity, and lymph node metastasis. With a median follow-up of 91 months, patients with DCISM had worse cancer-specific survival (CSS) (hazard ratio [HR], 2.475; P < 0.001) and overall survival (OS) (HR, 1.263; P < 0.001). In the multivariable analysis, microinvasion was an independent prognostic factor for worse CSS (HR, 1.919; P < 0.001) and OS (HR, 1.184; P < 0.001). The 10-year cancer-specific mortality rate was 1.49% in DCIS and 4.08% in DCISM (HR, 2.771; P < 0.001). The 20-year cancer-specific mortality rate was 4.00% in DCIS and 9.65% in DCISM (HR, 2.482; P < 0.001). Deepening understanding of the nature of microinvasive breast cancer will be valuable for clinical treatment recommendations.

Characterizing the immune microenvironment in high-risk ductal carcinoma in situ of the breast

PURPOSE

The recent increase in the incidence of ductal carcinoma in situ (DCIS) has sparked debate over the classification and treatment of this disease. Although DCIS is considered a precursor lesion to invasive breast cancer, some DCIS may have more or less risk than is realized. In this study, we characterized the immune microenvironment in DCIS to determine if immune infiltrates are predictive of recurrence.

METHODS

Fifty-two cases of high-grade DCIS (HG-DCIS), enriched for large lesions and a history of recurrence, were age matched with 65 cases of non-high-grade DCIS (nHG-DCIS). Immune infiltrates were characterized by single- or dual-color staining of FFPE sections for the following antigens: CD4, CD8, CD20, FoxP3, CD68, CD115, Mac387, MRC1, HLA-DR, and PCNA. Nuance multispectral imaging software was used for image acquisition. Protocols for automated image analysis were developed using CellProfiler. Immune cell populations associated with risk of recurrence were identified using classification and regression tree analysis.

RESULTS

HG-DCIS had significantly higher percentages of FoxP3⁺ cells, CD68⁺ and CD68⁺PCNA⁺ macrophages, HLA-DR⁺ cells, CD4⁺ T cells, CD20⁺ B cells, and total tumor infiltrating lymphocytes compared to nHG-DCIS. A classification tree, generated from 16 immune cell populations and 8 clinical parameters, identified three immune cell populations associated with risk of recurrence: CD8⁺HLADR⁺ T cells, CD8⁺HLADR^- T cells, and CD115⁺ cells.

CONCLUSION

These findings suggest that the tumor immune microenvironment is an important factor in identifying DCIS cases with the highest risk for recurrence and that manipulating the immune microenvironment may be an efficacious strategy to alter or prevent disease progression.

Is adjuvant chemotherapy necessary for patients with microinvasive breast cancer after surgery?

Objective: Survival and treatment of patients with microinvasive breast cancer (MIBC) remain controversial. In this paper, we evaluated whether adjuvant chemotherapy is necessary for patients with MIBC to identify risk factors influencing its prognosis and decide the indication for adjuvant chemotherapy. Methods: In this retrospective study, 108 patients with MIBC were recruited according to seventh edition of the staging manual of the American Joint Committee on Cancer (AJCC). The subjects were divided into chemotherapy and non-chemotherapy groups. We compared the 5-year disease-free survival (DFS) and overall survival (OS) rates between groups. Furthermore, we analyzed the factors related to prognosis for patients with MIBC using univariate and multivariate analyses. We also evaluated the impact of adjuvant chemotherapy on the prognostic factors by subgroup analysis after median follow-up time of 33 months (13-104 months). Results: The 5-year DFS and OS rates for the chemotherapy group were 93.7% and 97.5%, whereas those for the non-chemotherapy group were 89.7% and 100%. Results indicate that 5-year DFS was superior, but OS was inferior, in the former group compared with the latter group. However, no statistical significance was observed in the 5-year DFS (P=0.223) or OS (P=0.530) rate of the two groups. Most relevant poor-prognostic factors were Ki-67 overexpression and negative hormonal receptors. Cumulative survival was 98.2% vs. 86.5% between low Ki-67 (≤20%) and high Ki-67 (>20%). The hazard ratio of patients with high Ki-67 was 16.585 [95% confidence interval (CI), 1.969-139.724; P=0.010]. Meanwhile, ER(-)/PR(-) patients with MIBC had cumulative survival of 79.3% compared with 97.5% for ER(+) or PR(+) patients with MIBC. The hazard ratio for ER(-)/PR(-) patients with MIBC was 19.149 (95% CI, 3.702-99.057; P<0.001). Subgroup analysis showed that chemotherapy could improve the outcomes of ER(-)/PR(-) patients (P=0.014), but not those who overexpress Ki-67 (P=0.105). Conclusions: Patients with MIBC who overexpress Ki-67 and with negative hormonal receptors have relatively substantial risk of relapse within the first five years after surgery. However, adjuvant chemotherapy can only improve the outcomes of ER(-)/PR(-) patients, but not those who overexpress Ki-67. Further studies with prolonged follow-up of large cohorts are recommended to assess the prognostic significance and treatment of this lesion.

The clinical features and management of women with ductal carcinoma in situ with microinvasion: A retrospective Cohort study

OBJECTIVE

The purpose of our study is to demonstrate the clinical features and management of patients with Ductal Carcinoma in situ with microinvasion (DCISM) in a single Chinese cancer center.

METHODS

Retrospectively analysis of cases between 2003 and 2009 was performed in our institution. The type of treatments, pathological results, and axillary lymph nodes status, hormonal receptor statues (estrogen receptor (ER), progesterone receptor (PR) and Her2) were collected. The disease-free survival rate was calculated from the date of initial diagnosis using the Kaplan-Meier method.

RESULTS

Five hundred and sixty-seven cases were enrolled in our study, 474 pure Ductal Carcinoma in situ (DCIS) and 93 DCISM were included. Among these, 168 (35.4%) was diagnosed with the grade I and 26(5.5%) with grade III in pure DCIS group, compared with 3 (3.2%) and 11(11.8%) with grade I and III in DCISM (p < .0001). We also found that DCISM was associated with comadonecrosis histologic subtype (p < .0001) and presence of luminal B type (ER/PR positive and Her-2 positive) (p < .0032). There were more positive axillary lymph nodes involvement in patients with DCISM than those with DCIS after performing ALND(p = .0284). Patients with DCISM underwent more axillary lymph node dissection (ALND) in Chinese cancer center than those did in US centers (1.1% VS 47.8-68% and 86.1% VS 3.6-6.9%, respectively). No significantly difference was found in the overall survival rate between patients with DCIS and DCISM during median 100 months follow-up.

CONCLUSIONS

In a Chinese cancer hospital, the majority of cases underwent mastectomy and ALDN after the diagnosis of DCISM.The optimal treatments of patients with DCISM should be further investigated.

Diagnostic evaluation of ductal carcinoma in situ of the breast: ultrasonographic, mammographic and histopathologic correlations

The aims of the study described here were to illustrate the spectrum of ultrasonographic features of ductal carcinoma in situ (DCIS) and to evaluate the ability of ultrasonography (US) to predict the grade and recurrence of DCIS on the basis of mammographic and histopathologic findings. We retrospectively evaluated the ultrasonographic features of 129 DCIS lesions from 127 consecutive women and compared these with their mammographic and histopathologic features. The mean size of DCISs on ultrasonography and mammography (MMG) was 3.67 ± 1.40 and 4.00 ± 1.74 cm, respectively, which do not differ statistically (p = 0.09). Despite the statistical difference in Breast Imaging Reporting and Data System (BI-RADS) classification on US and MMG (p = 0.000), the median BI-RADS classification is category 4c on both US and MMG (p = 0.01). There was no statistically significant difference in the distribution of microcalcification on MMG and US. Clusters <5 mm in greatest diameter are easily seen on MMG. At US, a scattered/linear distribution on MMG had a higher level of visibility than clustered distribution on MMG. The correlation between tumor size and DCIS with micro-invasion evaluated using US is higher than that obtained using MMG (p = 0.001 and 0.024, respectively). When US was used for the detection of DCIS, diagnostic accuracy was significantly associated with higher Van Nuys groups, the presence of micro-invasion and comedo carcinoma (p = 0.000, 0.022 and 0.011, respectively). However, mammographic diagnostic accuracy was found not to associate with higher Van Nuys groups, the presence of micro-invasion and comedo carcinoma (p = 0.054, 0.093 and 0.256, respectively). Ultrasonography may play an important role both in detecting DCIS and in evaluating its histopathologic features. Detection of DCIS using MMG alone may be suboptimal for patients with dense breasts, especially among Chinese women.

Vav2 protein overexpression marks and may predict the aggressive subtype of ductal carcinoma in situ

Background

A subset of patients with ductal carcinoma in situ (DCIS) will develop invasive breast cancer (IBC). To date, there are no effective predictive biomarkers for identifying this subset with worse prognosis whose lesions are essentially indistinguishable histologically from those with favorable outcomes. We hypothesized that measurable parameters that discriminate DCIS from DCIS with concurrent invasion may serve as diagnostic biomarkers (BM) of progressive cancer in situ (CIS).

Results

Using a novel imaging-based method of tissue testing, we measured the relative expression levels of three candidate BM proteins specifically implicated in IBC progression - the insulin-like growth factor I receptor (IGF-IR), Ras-related protein 1 (Rap1), and Vav2 oncoprotein. Protein profiles were compared in 42 histologically normal mammary epithelial samples, 71 CIS (35 without/36 with invasion either on diagnostic biopsy or final surgical excision), and 98 IBC of known estrogen receptor (ER), progesterone receptor (PR) and human epidermal growth factor receptor 2 (HER2) status. The levels of the IGF-IR and Rap1 protein expression were significantly elevated in ER-positive (ER+/PR+/-/HER2 –) DCIS relative to normal epithelium (P <0.0001). The IGF-IR protein expression was also significantly up regulated in HER2-positive (ER+/-/PR+/-/HER2+) DCIS relative to normal epithelium (P = 0.0002). IGF-IR and Rap1 protein expression levels were similar among DCIS patients without or with concurrent invasion. Vav2 upregulation in DCIS relative to normal group was not associated with steroid hormone receptor and HER2 status, but was associated with the presence of concurrent invasion, including microinvasion (invasive foci of less than 1 mm). DCIS with high Vav2 were more than twice as likely to progress to invasive cancers as DCIS with low Vav2 (odds ratio, 2.42; 95% CI, 1.26-4-65; P =0.008). Furthermore, a receiver operating characteristic curve analysis revealed moderate ability of Vav2 protein expression measurements in DCIS to predict the existence of invasion concurrent with DCIS (area under the curve, 0.71; 95% CI, 0.59- 0.84).

Conclusions

Our novel findings hold promise for utilizing Vav2 protein as a predictive BM for differentiating progressive from non-progressive DCIS.

Electronic supplementary material

The online version of this article (doi:10.1186/2050-7771-2-22) contains supplementary material, which is available to authorized users.

Re-evaluating the role of sentinel lymph node biopsy in microinvasive breast carcinoma

The role of sentinel lymph node biopsy in microinvasive breast carcinoma is unclear. We examined the incidence of lymph node metastasis in patients with microinvasive carcinoma who underwent surgery at our institution. Retrospective review of our pathology database was performed (1994-2012). Of 7000 patients surgically treated for invasive breast carcinoma, 99 (1%) were classified as microinvasive carcinoma. Axillary staging was performed in 81 patients (64, sentinel lymph node biopsy; 17, axillary lymph node excision). Seven cases (9%) showed isolated tumor/epithelial cells in sentinel nodes. Three of these seven cases showed reactive changes in lymph nodes, papillary lesions in the breast with or without displaced epithelial cells within biopsy site tract, or immunohistochemical (estrogen receptor, progesterone receptor, and HER2) discordance between the primary tumor in the breast and epithelial cells in the lymph node, consistent with iatrogenically transported epithelial cells rather than true metastasis. The remaining four cases included two cases, each with a single cytokeratin-positive cell in the subcapsular sinus detected by immunohistochemistry only, and two cases with isolated tumor cells singly and in small clusters (<20 cells per cross-section) by hematoxylin and eosin and immunohistochemistry. The exact nature of cytokeratin-positive cells in the former two cases could not be determined and might still have represented iatrogenically displaced cells. In the final analysis, only two cases (3%) had isolated tumor cells. Three of these four cases had additional axillary lymph nodes excised, which were all negative for tumor cells. At a median follow-up of 37 months (range 6-199 months), none of these patients had axillary recurrences. Our results show very low incidence of sentinel lymph node involvement (3%), only as isolated tumor cells, in microinvasive carcinoma patients. None of our cases showed micrometastases or macrometastasis. We recommend reassessment of the routine practice of sentinel lymph node biopsy in patients with microinvasive carcinoma.

Extent of microinvasion in ductal carcinoma in situ is not associated with sentinel lymph node metastases

BACKGROUND

Ductal carcinoma in situ with microinvasion (DCISM) is a rare diagnosis with a good prognosis. Although nodal metastases are uncommon, sentinel lymph node biopsy (SLNB) remains standard care. Volume of disease in invasive breast cancer is associated with SLNB positivity, and, thus we hypothesized that in a large cohort of patients with DCISM, multiple foci of microinvasion might be associated with a higher risk of positive SLNB.

METHODS

Records from a prospective institutional database were reviewed to identify patients with DCISM who underwent SLNB between June 1997 and December 2010. Pathology reports were reviewed for number of microinvasive foci and categorized as 1 focus or ≥2 foci. Demographic, pathologic, treatment, and outcome data were obtained and analyzed.

RESULTS

Of 414 patients, 235 (57 %) had 1 focus of microinvasion and 179 (43 %) had ≥2 foci. SLNB macrometastases were found in 1.4 %, and micrometastases were found in 6.3 %; neither were significantly different between patients with 1 focus versus ≥2 foci (p = 1.0). Patients with positive SLNB or ≥2 foci of microinvasion were more likely to receive chemotherapy. At median 4.9 years (range 0-16.2 years) follow-up, 18 patients, all in the SLNB negative group, had recurred for an overall 5-year recurrence-free proportion of 95.9 %.

CONCLUSIONS

Even with large numbers, there was no higher risk of nodal involvement with ≥2 foci of microinvasion compared with 1 focus. Number of microinvasive foci and results of SLNB appear to be used in decision making for systemic therapy. Prognosis is excellent.

Which breast cancer decisions remain non-compliant with guidelines despite the use of computerised decision support?

BACKGROUND

Despite multidisciplinary tumour boards (MTBs), non-compliance with clinical practice guidelines is still observed for breast cancer patients. Computerised clinical decision support systems (CDSSs) may improve the implementation of guidelines, but cases of non-compliance persist.

METHODS

OncoDoc2, a guideline-based decision support system, has been routinely used to remind MTB physicians of patient-specific recommended care plans. Non-compliant MTB decisions were analysed using a multivariate adjusted logistic regression model.

RESULTS

Between 2007 and 2009, 1624 decisions for invasive breast cancers with a global non-compliance rate of 8.3% were analysed. Patient factors associated with non-compliance were age>80 years (odds ratio (OR): 7.7; 95% confidence interval (CI): 3.7-15.7) in pre-surgical decisions; microinvasive tumour (OR: 5.2; 95% CI: 1.5-17.5), surgical discovery of microinvasion in addition to a unique invasive tumour (OR: 4.2; 95% CI: 1.4-12.5), and prior neoadjuvant treatment (OR: 4.2; 95% CI: 1.1-15.1) in decisions with recommendation of re-excision; age<35 years (OR: 4.7; 95% CI: 1.9-11.4), positive hormonal receptors with human epidermal growth factor receptor 2 overexpression (OR: 15.7; 95% CI: 3.1-78.7), and the absence of prior axillary surgery (OR: 17.2; 95% CI: 5.1-58.1) in adjuvant decisions.

CONCLUSION

Residual non-compliance despite the use of OncoDoc2 illustrates the need to question the clinical profiles where evidence is missing. These findings challenge the weaknesses of guideline content rather than the use of CDSSs.

Second harmonic generation reveals matrix alterations during breast tumor progression

Alteration of the extracellular matrix in tumor stroma influences efficiency of cell locomotion away from the primary tumor into surrounding tissues and vasculature, thereby affecting metastatic potential. We study matrix changes in breast cancer through the use of second harmonic generation (SHG) of collagen in order to improve the current understanding of breast tumor stromal development. Specifically, we utilize a quantitative analysis of the ratio of forward to backward propagating SHG signal (F/B ratio) to monitor collagen throughout ductal and lobular carcinoma development. After detection of a significant decrease in the F/B ratio of invasive but not in situ ductal carcinoma compared with healthy tissue, the collagen F/B ratio is investigated to determine the evolution of fibrillar collagen changes throughout tumor progression. Results are compared with the progression of lobular carcinoma, whose F/B signature also underwent significant evolution during progression, albeit in a different manner, which offers insight into varying methods of tissue penetration and collagen manipulation between the carcinomas. This research provides insights into trends of stromal reorganization throughout breast tumor development.

Different distribution of breast ductal carcinoma in situ, ductal carcinoma in situ with microinvasion, and invasion breast cancer

Background

Breast ductal cancer in situ (DCIS) can recur or progress to invasive ductal cancer (IDC), and the interim stage include DCIS with microinvasion (DCIS-Mi). In this article, we attempt to study the study the differences of clinicopathological features, imaging data, and immunohistochemical-based subtypes among DCIS, DCIS-Mi, and IDC.

Methods

In this retrospective study, we attempt to compare the clinicopathological features, immunohistochemical results and imaging data of 866 patients (included 73 DCIS, 72 DCIS-Mi, and 721 IDC).

Results

Patients with DCIS and DCIS-Mi were younger than those with IDC (P = 0.007). DCIS and DCIS-Mi often happened in premenopausal women while IDC was opposite (P <0.001). The incidence of IDC with node-positive was significantly higher than it in DCIS and DCIS-Mi (P <0.001). We also observed that the Her2-positive was more often found in patients with pure DCIS compared to those with DCIS-Mi and DCIS-I (P <0.001). There was a significant difference between the four subgroups (Luminal-A, Luminal-B, ERBB2+, Basal-like) from DCIS, DCIS-Mi, and IDC (P <0.001). Basal-like patients were fewer than other subgroups in DCIS, DCIS-Mi, and IDC. The incidence of the first performance of ultrasound (catheter winded and nodular mass) and mammography (nodular mass) had significantly difference among patients with DCIS, DCIS-Mi, and IDC (P <0.001).

Conclusions

Different clinicopathological, immunohistochemical, and imaging features among DCIS, DCIS-Mi, and IDC indicate that they are distinct entities. A larger sample size is needed for further study.

Expression and role of fibroblast activation protein-alpha in microinvasive breast carcinoma

BACKGROUND

Diagnosis of ductal carcinoma in situ (DCIS) in breast cancer cases is challenging for pathologist due to a variety of in situ patterns and artefacts, which could be misinterpreted as stromal invasion. Microinvasion is detected by the presence of cytologically malignant cells outside the confines of the basement membrane and myoepithelium. When malignant cells invade the stroma, there is tissue remodeling induced by perturbed stromal-epithelial interactions. Carcinoma-associated fibroblasts (CAFs) are main cells in the microenvironment of the remodeled tumor-host interface. They are characterized by the expression of the specific fibroblast activation protein-alpha (FAP-α), and differ from that of normal fibroblasts exhibiting an immunophenotype of CD34. We hypothesized that staining for FAP-α may be helpful in determining whether DCIS has microinvasion.

METHODS

349 excised breast specimens were immunostained for smooth muscle actin SMA, CD34, FAP-α, and Calponin. Study material was divided into 5 groups: group 1: normal mammary tissues of healthy women after plastic surgery; group 2: usual ductal hyperplasia (UDH); group 3: DCIS without microinvasion on H & E stain; group 4: DCIS with microinvasion on H & E stain (DCIS-MI), and group 5: invasive ductal carcinoma (IDC). A comparative evaluation of the four immunostains was conducted.

RESULTS

Our results demonstrated that using FAP-α and Calponin adjunctively improved the sensitivity of pathological diagnosis of DCIS-MI by 11.29%, whereas the adjunctive use of FAP-α and Calponin improved the sensitivity of pathological diagnosis of DCIS by 13.6%.

CONCLUSIONS

This study provides the first evidence that immunostaining with FAP-α and Calponin can serve as a novel marker for pathologically diagnosing whether DCIS has microinvasion.