Clinicopathologic characteristics and molecular subtypes of microinvasive carcinoma of the breast

Unveiling the Clinical Path of Microinvasive Breast Cancer: A Comparative Study With Tis-T1 Breast Cancer

PURPOSE

The prognosis of microinvasive breast cancer (MIBC) is controversial, with a high reported rate of local recurrence (LR). This study aimed to evaluate the characteristics, treatments, and prognosis of patients with MIBC compared to those with carcinoma in situ (CIS) or early invasive cancer.

METHODS

Patients who diagnosed with CIS or stage I breast cancer were retrospectively enrolled. Using the Kaplan-Meier method, local recurrence-free survival (LRFS), systemic recurrence-free survival (SRFS), and cancer-specific survival (CSS) were compared according to T stage. The prognostic factors associated with LRFS were identified using the Cox proportional hazards model.

RESULTS

According to T stage, 517 (21.6%), 200 (8.4%), 207 (8.7%), 363 (15.2%), and 1101 (46.1%) patients had Tis, T1mi, T1a, T1b, and T1c tumors, respectively. The proportion of human epidermal growth factor receptor 2-positive tumors was significantly higher in patients with MIBC (p < 0.0001). The administered adjuvant treatments also showed differences according to T stage (p < 0.0001). During the 73-month median follow-up period, patients with MIBC showed significantly worse LRFS than those with T1a or T1c tumors (p = 0.002). There was no significant difference in SRFS and CSS. In the Cox regression analysis, tumor multiplicity (p = 0.017), Ki-67 (p = 0.025), cancer subtype (p = 0.034), adjuvant endocrine therapy (p = 0.003), and adjuvant radiation therapy (p < 0.0001) were significant prognostic factors associated with LRFS.

CONCLUSION

The risk of LR was higher in patients with MIBC than in those with small invasive breast cancer. Therefore, if indicated, adjuvant endocrine and radiation therapies should be administered to prevent undertreatment in patients with MIBC.

A clinical radiomics nomogram preoperatively to predict ductal carcinoma in situ with microinvasion in women with biopsy-confirmed ductal carcinoma in situ: a preliminary study

PURPOSE

To predict ductal carcinoma in situ with microinvasion (DCISMI) based on clinicopathologic, conventional breast magnetic resonance imaging (MRI), and dynamic contrast enhanced MRI (DCE-MRI) radiomics signatures in women with biopsy-confirmed ductal carcinoma in situ (DCIS).

METHODS

Eighty-six women with eighty-seven biopsy-proven DCIS who underwent preoperative MRI and underwent surgery were retrospectively identified. Clinicopathologic, conventional MRI, DCE-MRI radiomics, combine (based on conventional MRI and DCE-MRI radiomics), traditional (based on clinicopathologic and conventional MRI) and mixed (based on clinicopathologic, conventional MRI and DCE-MRI radiomics) models were constructed by logistic regression (LR) with a 3-fold cross-validation, all evaluated using receiver operating characteristic (ROC) curve analysis. A clinical radiomics nomogram was then built by incorporating the Radiomics score, significant clinicopathologic and conventional MRI features of mixed model.

RESULTS

The area under the curves (AUCs) of clinicopathologic, conventional MRI, DCE-MRI radiomics, traditional, combine, and mixed model were 0.76 (95% confidence interval [CI] 0.59-0.94), 0.77 (95%CI 0.59-0.95), 0.74 (95%CI 0.55-0.93), 0.87 (95%CI 0.73-1), 0.8 (95%CI 0.63-0.96), and 0.93 (95%CI 0.84-1) in the validation cohort, respectively. The clinical radiomics nomogram based on mixed model showed higher AUCs than both clinicopathologic and DCE-MRI radiomics models in training/test (all P < 0.05) set and showed the greatest overall net benefit for upstaging according to decision curve analysis (DCA).

CONCLUSION

A nomogram constructed by combining clinicopathologic, conventional MRI features and DCE-MRI radiomics signatures may be useful in predicting DCISMI from DICS preoperatively.

Clinical significance of microinvasive breast cancer across the different subtypes and human epidermal growth factor receptor 2 expression levels

PURPOSE

The clinical behavior, prognosis, and management of microinvasive breast cancer (MiBC) is controversial. We aimed to clarify its significance across different subtypes and the role of human epidermal growth factor receptor 2 (HER2) expression in MiBC.

METHODS

We analyzed 1530 patients with T1mi (tumor size ≤ 0.1 cm), node-negative breast cancer who underwent breast conserving surgery or total mastectomy between 2001 and 2020 at the Asan Medical Center (AMC).

RESULTS

When divided into four subtypes, hormone receptor (HR)+/HER2-, HR+ /HER2+ , HR-/HER2+ , and HR-/HER2-, HR-/HER2+ had the highest prevalence rate of 38.5% in MiBC patients. In a median follow-up period of 74 months (0-271 months), 103 (6.7%) patients had recurrent tumor, and 95 (6.2%) had local recurrence. Disease-free survival (DFS) and local recurrence-free survival (LRFS) were worst in the HR-/HER2+ group. The five-year DFS for the HR-/HER2+ group was 92.2%, while it was 97.1% for the HR+/HER2- group (p = 0.024 The five-year LRFS for HER2- patients were better than that of HER2+ MiBC patients, which were 97.1 and 93.8%, respectively (p = 0.010). Univariate and multivariate Cox regression analyses showed that the HR-/HER2+ group had relatively higher risk of recurrence compared to the HR+/HER2- group (hazard ratio [HR] = 2.332, 95% confidence interval [CI] 1.412-3.852, p = 0.001 unadjusted; HR = 3.346, 95% CI 1.408-7.953, p = 0.006 adjusted).

CONCLUSION

HER2 overexpression was significantly associated with adverse clinicopathologic parameters and increased local recurrence risk in MiBC. Therefore, more understanding of the clinical behavior of HER2 in MiBC will enable tailoring of adjuvant therapy for these patients.

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.

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.

Microinvasive breast cancer and the role of sentinel lymph node biopsy

Whether sentinel lymph node biopsy (SLNB) should be performed in patients with microinvasive breast cancer (MIBC) has been a matter of debate over the last decade. MIBC has a favorable prognosis and while metastasis to the axilla is rare, it can impact treatment recommendations. In this study we evaluated clinical and histological features in both MIBC and background DCIS including ER, PR, and HER-2, number of foci of MIBC, the extent of the DCIS, nuclear grade, presence of comedo necrosis, as well as surgical procedures, adjuvant treatment and follow up to identify variables which predict disease free survival (DFS), as well as the factors which influence clinical decision making. Our study included 72 MIBC patients with a mean patient follow-up time of 55 months. Three patients with MIBC had recurrence, and two deceased, leaving five patients in total with poor long-term outcomes and a DFS rate of 93.1%. Performing mastectomy, high nuclear grade, and negativity for ER and HER-2 were found to be associated with the use of SLNB, although none of these variables were found to be associated with DFS. One positive lymph node case was discovered following SLNB in our study. This suggests the use of SLNB may provide diagnostic information to some patients, although these are the anomalies. When comparing patients who had undergone SLNB to those which had not there was no difference in DFS. Certainly, the use of SLNB in MIBC is quite the conundrum. It is important to acknowledge that surgical complications have been reported, and traditional metrics used for risk assessment in invasive breast cancer may not hold true in the setting of microinvasion.

Clinicopathological characteristics and prognosis of microinvasive breast cancer: A population-based analysis

OBJECTIVES

Microinvasive breast cancer (MIBC) is a special type of breast cancer with a relatively low prevalence, of which the understanding remains controversial. In this article, we aimed to clarify the clinicopathological characteristics and prognosis of MIBC in the setting of different molecular subtypes and give feasible suggestions on clinical practice in MIBC.

METHODS

This study utilized the data from Surveillance, Epidemiology, and End Results (SEER) database. Patients were divided into subgroups based on the molecular subtypes, of which the clinicopathological characteristics were further undergone comparative analyses. Kaplan-Meier method and Cox proportional hazard regression analysis were employed to determine the prognosis of the subtypes, and to explore the prognostic factors. Patients were randomly assigned in a 7:3 ratio to the training and validation cohorts. The independent risk variables were then adopted to generate a nomogram to predict the 3- and 5-year survival probability.

RESULTS

A total of 4301 MIBC patients between 2010 and 2016 were obtained from the SEER database, which were subsequently separated into HR+/HER2- (n = 2598), HR+/HER2+ (n = 723), HR-/HER2+ (n = 633), and HR-/HER2- (n = 347) groups. The HR+/HER2+ group showed the best overall survival (OS) (81.28 months, 95% CI 80.45-82.11) compared with other groups (p = 0.0089). The application of radiotherapy in HR+/HER2- and HR+/HER2+ MIBC patients brought out additional survival benefit compared with those without radiotherapy (p < 0.0001 and p = 0.024, respectively). The prognosis among four subgroups with or without chemotherapy showed no statistical difference. Based on the curated nomogram, the high-score group exhibited a better OS compared with patients from the low-score group.

CONCLUSIONS

Profound heterogeneity was detected among different molecular subtypes in MIBC patients, of which HR+/HER2+ subtype presented the best prognosis. For HR-positive MIBC patients, increasing survival benefits could be retrieved from radiotherapy. Chemotherapy was not recommended for patients with MIBC. Individual-based protocols were introduced based on the nomogram which warranted further validation.

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

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.

Significance of HER2 in Microinvasive Breast Carcinoma

OBJECTIVES

We compared the clinicopathologic features, clinical management, and outcomes of human epidermal growth factor receptor 2 (HER2)-expressing and nonexpressing microinvasive breast carcinomas (MiBC) to explore the significance of HER2 in MiBC.

METHODS

Clinicopathologic and follow-up information of cases with final diagnosis of MiBC with known HER2 status between 2007 and 2019 were analyzed.

RESULTS

Nineteen (41.3%) HER2-positive (HER2+) and 27 (58.7%) HER2-negative (HER2-) MiBCs were identified. HER2 positivity was likely to be associated with high nuclear grade, presence of tumor-infiltrating lymphocytes, hormonal receptor negativity, and increased Ki-67 in both microinvasive and associated in situ carcinomas. Nodal metastases were found in 2 ER+/HER2- cases (5.3%). One HER2+ case was found to have isolated tumor cells in the axillary node. The majority of patients with HER2+ MiBCs (76.5%) did not receive HER2-targeted therapy. All patients with available follow-up were alive without recurrence or distant metastasis, with a median follow-up of 38 months.

CONCLUSIONS

Similar to the larger size of invasive breast carcinomas, HER2 positivity is associated with high-grade morphologic features in MiBCs. However, HER2 overexpression in MiBCs does not appear to be associated with nodal metastasis or worse outcome in our study cohort. The role of HER2-targeted therapy in this clinical setting merits additional study.

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.

Comparison of the ductal carcinoma in situ between White Americans and Chinese Americans

Currently, the wide-spread use of screening mammography has led to dramatic increases in ductal carcinoma in situ (DCIS). However, DCIS of Chinese Americans, the largest Asian subgroup in American, has rarely been comprehensively studied over the past decade. This work compared the DCIS characteristics and prognosis of Chinese American patients with White Americans in the USA to determine the characteristics and prognosis of DCIS patients of Chinese Americans.The data were obtained using the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) data. The diagnosis and treatment variables between the two groups were compared by means of Chi-square tests. Survival was determined with the use of the Kaplan-Meier method and the multivariable Cox proportional hazard regression model.From 1975 to 2016, 81,745 White Americans and 2069 Chinese Americans were diagnosed with ductal carcinoma in situ. Compared with the white patients, the Chinese Americans were younger (P < .001) with smaller tumors (P < .001) and higher family income (P < .001). DCIS patients of Chinese American group accounted for a higher percentage of all breast cancers than the whites (P < .001). In the multivariable Cox proportional hazard regression analysis, Chinese American was an independent favorable prognostic factor in terms of overall survival (OS) (HR, 0.684; 95% CI, 0.593-0.789; P < .001) compared with the white group.In conclusion, DCIS characteristics of the Chinese group, which exhibited a higher proportion of younger age, a higher DCIS ratio, and a better prognosis, were distinct from those of the White Americans.

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.

Characteristics of Microinvasive Ductal Carcinoma In Situ Versus Noninvasive and Invasive Breast Cancer

BACKGROUND

The present literature is conflicting regarding the management of microinvasive ductal carcinoma in situ (miDCIS) as to following recommendations for DCIS (margin status, surgical axillary staging, and possible observation) versus invasive breast cancer. We hypothesize that miDCIS represents more aggressive disease than pure DCIS.

METHODS

We performed a retrospective review of female miDCIS patients compared with age-matched cohorts of DCIS and T1b/c patients with invasive breast cancer. We collected demographic, clinicopathologic, treatment, and outcome information. Analysis of variance or Kruskal-Wallis tests were used to analyze continuous variables and chi-square or Fisher's exact tests for categorical variables. Survival outcomes were analyzed using Kaplan-Meier curves.

RESULTS

We included 375 patients (125 in each group) with median age 59 y (range 33-91 y). miDCIS tumors were more likely to be hormone receptor negative and human epidermal growth factor receptor 2 positive compared with DCIS or invasive ductal carcinoma (IDC; all P < 0.001). Subgroup analysis by miDCIS focality demonstrated no significant differences. The number of involved lymph nodes was not significantly different from DCIS patients but was significantly fewer than invasive cancer patients. Of 115 miDCIS patients (88%) staged with sentinel lymph node biopsy, eight (7%) had nodal metastases. Six miDCIS patients (5%) were treated with adjuvant chemotherapy. Over a median follow-up of 23.3 mo, there were no significant differences in local or distant recurrence.

CONCLUSIONS

Based on our results, miDCIS has more aggressive pathologic features compared with DCIS and warrants surgical treatment and nodal staging similar to the management of IDC. In addition, similar to IDC, nodal and receptor status may influence medical management.

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.

Clinic-Pathological Features of Breast Ductal Carcinoma in Situ with Micro-Invasion

Background: To investigate the differences of clinic-pathological features among ductal carcinoma in situ (DCIS), ductal carcinoma in situ with micro-invasion (DCIS-MI) and early invasive carcinoma (IDC) in stage T1.Methods: From January 2014 to December 2018, 308 cases DCIS, DCIS-MI 92 cases and 111 cases of T1a, 343 cases of T1b, and 1032 cases of T1c were investigated in a retrospective analysis. The population and clinic-pathological characteristics including age, menstrual status, surgical mode, lymph node status and molecular markers were compared in each group. Survival rate of all patients were followed-up for 5 years.Results: Compared with DCIS-MI group, the higher breast-conserving rate and lower lymph node metastasis rate in the DCIS group were shown in the DCIS-MI group (p < .05). There were no significant differences in tumor diameter, number of tumors, ER, PR, HER2 and Ki67 expression, molecular typing, (p > .05). The expression of Ki67 in T1a, T1b and T1c groups increased gradually with elevated grades (p < .05). The proportion of HER2-positive patients in DCIS-MI group was significantly higher than that in T1a-b-c (p < .05). There were no significant differences in DFS and OS between the 3 groups (p > .05).Conclusions: The clinic-pathological features of DCIS-MI are similar to those of DCIS and T1a, but significantly different from T1c.

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.

[Decision making factors of the management of ductal carcinoma in situ of the breast with microinvasion]

INTRODUCTION

Microinvasive in situ ductal carcinomas of the breast are rare and of good prognosis. They are grouped with early stage invasive carcinomas in the TNM 2017 classification. This study assessed practitioners' treatment decisions and their justifications in comparison to the literature.

MATERIALS AND METHODS

Three clinical cases were evaluated by anonymous forms regarding sentinel node decisions, tumour bed boost irradiation and hormone therapy.

RESULTS

Sentinel lymph node was performed by 93.1%, 100% and 44.4% of the practitioners respectively. Radiation boost was a treatment option chosen by 62.1% and 61.1% of practitioners in both clinical cases. Hormone therapy was advocated for 65.5%, 94.7% and 50.0% patients depending on the clinical case.

CONCLUSION

The therapeutic attitude proposed in microinvasive breast carcinomas was heterogeneous in this study, reflecting the absence of specific recommendations. In view of the existing literature, it is not currently possible to propose recommendations for these three therapeutic options. Prospective cohorts and meta-analyses of the microinvasive subgroup could provide answers.

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.

Analysis of tumour-infiltrating lymphocytes reveals two new biologically different subgroups of breast ductal carcinoma in situ

Background

Tumour-infiltrating lymphocytes (TILs) have been demonstrated to significantly influence prognosis and response to therapy of invasive breast cancer (IBC). Thus, it has been suggested that TIL density or/and immunophenotype could serve as biomarkers for selection of IBC patients for immunotherapy. However, much less is known about significance of TILs in breast ductal carcinoma in situ (DCIS).

Methods

We retrospectively investigated TIL density and immunophenotype in 96 pure DCIS and 35 microinvasive carcinomas (miCa). TIL density was assessed on H&E-stained breast biopsy sections as the percentage of tumour stromal area occupied by TILs, and classified into 4 grades: 0 (0%–9%), 1 (10–29%), 2 (30–49%) and 3 (50%–100%). TIL immunophenotype was assessed by immunohistochemistry for CD8, CD4, FoxP3, CD38 or CD20.

Results

Compared to pure DCIS, miCa contained significantly more cases with TIL density grade 3 (p = 0.028). Concordantly, CD8+, CD4+ and CD38+ cells were more numerous in miCa than in pure DCIS. In the pure DCIS subgroup with TIL density grades 2 and 3, all TIL subpopulations were more numerous than in the pure DCIS with TIL density grades 0 and 1, however the ratio between T-lymphocytes (CD8+ and CD4+) and B-lymphocytes (CD20+) was significantly lower (p = 0.029). On the other side, this ratio was significantly higher in miCa, in comparison with pure DCIS having TIL density grades 2 and 3 (p = 0.017). By cluster analysis of tumour cell pathobiological features we demonstrated similarity between miCa and the pure DCIS with TIL density grades 2 and 3. The only significant difference between those two categories was in the ratio of T- to B-TILs, higher in miCa.

Conclusion

Results indicate that TIL density level can distinguish 2 biologically different DCIS subgroups, one of which (DCIS with ≥30% TILs, the TIL-rich DCIS) is like miCa. Similarity of TIL-rich pure DCIS and miCa as well as the role of B-lymphocytes in DCIS invasiveness are worth further investigating with regards to the potential development of immunotherapy-based prevention of DCIS progression.

Electronic supplementary material

The online version of this article (10.1186/s12885-018-4013-6) contains supplementary material, which is available to authorized users.

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.

Clinical-pathological features and treatment modalities associated with recurrence in DCIS and micro-invasive carcinoma: Who to treat more and who to treat less

The primary aim in the management of DCIS is the prevention of recurrence and contralateral tumor. Risk factors for DCIS recurrence and appropriate treatments are still widely debated. Adjuvant therapies after surgical resection reduce recurrences and contralateral disease, but these treatments have significant financial costs, side effects and there is a group of low-risk patients who would not gain additional benefit. The aim of our analysis was to identify clinical-pathological features and treatment modalities associated with recurrence in DCIS and microinvasive carcinoma. In the Thomas Jefferson University Cancer Registry of Philadelphia, we identified 865 patients with DCIS or micro-invasive carcinoma treated between 2003 and 2013. Associations between recurrence and demographic factors (age at diagnosis, ethnicity), biological features (ER, PR and HER2) and treatment modalities (surgery, radiotherapy and endocrine treatment) were assessed. Our single institution register-based study showed that distribution of age at diagnosis and biological features did not significantly differ among ethnic groups. Younger women and micro-invasive carcinoma patients were more likely to undergo mastectomy, while African Americans were more likely to take endocrine therapy and undergo radiotherapy. In our sample only ER/PR negative DCIS were associated with significantly higher recurrence rate. Moreover, we reported a high rate of HER2 positive recurrences, suggesting that expression of this oncogene may represent a potential biomarker for DCIS at high risk of recurrence. To better define the molecular profile of the subgroup at worse prognosis might help to identify biomarkers predictive of recurrence or second tumors, identifying patients candidates for more appropriate treatments.

An Examination of the Local Cellular Immune Response to Examples of Both Ductal Carcinoma In Situ (DCIS) of the Breast and DCIS With Microinvasion, With Emphasis on Tertiary Lymphoid Structures and Tumor Infiltrating Lymphoctytes

OBJECTIVES

We tried to describe cellular immune response (tertiary lymphoid structures (TLSs), lymphoid aggregates, tumor infiltrating lymphocytes (TILs)) in neoplastic microenvironment of ductal carcinoma in situ (DCIS) with or without associated microinvasion.

METHODS

The histopathologic parameters of 177 DCIS and 27 DCIS with microinvasion were evaluated. We determined number of ducts involved by DCIS, and calculated percentage of these ducts surrounded by TLSs. TILs were quantitated in 27 microinvasive cases.

RESULTS

Tumors having higher percentage of DCIS ducts associated with TLSs had higher incidence of microinvasion (P < .001). Percentage of DCIS ducts involved by TLSs was also higher in hormone receptor (HR)-/human epidermal growth factor receptor 2 (HER2)+ and TNBC subtypes of DCIS than in HR+/HER2- and HR+/HER2+ subtypes (38.04 ± 25.8%, 32.6 ± 32.4%, 2.5 ± 7.3% and 17.4 ± 23.3%, respectively, P < .001). In DCIS without microinvasion, HR+/HER2- subtype predominated (P < .001). In microinvasive cases, HR-/HER2+ subtype was most common. TNBC was more common in microinvasive carcinoma than DCIS (P < .001). Among 27 microinvasive ductal carcinomas, increased TLS amount was associated with increased TILs (P = .013).

CONCLUSIONS

TLS abundance around DCIS was associated with HER2+ and TNBC subtypes and microinvasion. Pathologists should be aware of microinvasion when diagnosing DCIS lesions with abundant TLSs.

An Anthropometric-Based Subject-Specific Finite Element Model of the Human Breast for Predicting Large Deformations

The large deformation of the human breast threatens proper nodules tracking when the subject mammograms are used as pre-planning data for biopsy. However, techniques capable of accurately supporting the surgeons during biopsy are missing. Finite element (FE) models are at the basis of currently investigated methodologies to track nodules displacement. Nonetheless, the impact of breast material modeling on the mechanical response of its tissues (e.g., tumors) is not clear. This study proposes a subject-specific FE model of the breast, obtained by anthropometric measurements, to predict breast large deformation. A healthy breast subject-specific FE parametric model was developed and validated by Cranio-caudal (CC) and Medio-Lateral Oblique (MLO) mammograms. The model was successively modified, including nodules, and utilized to investigate the effect of nodules size, typology, and material modeling on nodules shift under the effect of CC, MLO, and gravity loads. Results show that a Mooney–Rivlin material model can estimate healthy breast large deformation. For a pathological breast, under CC compression, the nodules displacement is very close to zero when a linear elastic material model is used. Finally, when nodules are modeled, including tumor material properties, under CC, or MLO or gravity loads, nodules shift shows ~15% average relative difference.

Heat shock protein 27 and gross cystic disease fluid protein 15 play critical roles in molecular apocrine breast cancer

Molecular apocrine breast cancer (MABC) has a distinct hormonal profile, being estrogen receptor (ER) and progesterone receptor (PR) negative but androgen receptor (AR) positive. The clinical significance of MABC and its relative variables have not been absolutely clarified and remain to be determined. Five hundred cases of invasive breast carcinoma were randomly selected in this study, including 158 MABC cases and 342 nonMABC cases. Expression of ER, PR, epidermal growth factor receptor 2 (HER2), Ki67, AR, gross cystic disease fluid protein 15 (GCDFP15), and heat shock protein 27 (HSP27) were analyzed by immunohistochemistry. Differences of continuous variables between MABC and nonMABC subgroups were evaluated by the chi-square test. The Kaplan-Meier method was performed to evaluate disease-free survival (DFS) and overall survival (OS). The MABC subgroup had higher histological grade, bigger tumor size, more lymph node metastasis, and higher pTNM stage than the nonMABC subgroup (P < 0.05), and patients with MABC had poorer prognosis than those of the nonMABC subgroup (P < 0.05). Both GCDFP15 and HSP27 were expressed differently in the MABC and nonMABC subgroups (P < 0.05). Furthermore, in the MABC subgroup, positive HSP27 expression indicated higher risk of recurrence (P < 0.05) and positive GCDFP15 expression was also a poor marker for patient outcome (P < 0.05). MABC patients with HSP27 and GCDFP15 co-expression had worse outcome (P < 0.05). Our data suggested that MABC had a high risk of recurrence. Positive expression of both GCDFP15 and HSP27 were correlated with MABC malignancy. Targeting AR and HSP27 at the same time might offer a useful strategy to MABC.