Excision alone for small size ductal carcinoma in situ of the breast

Outcomes from low-risk ductal carcinoma in situ: a systematic review and meta-analysis

PURPOSE

The current standard of treatment for ductal carcinoma in situ (DCIS) is surgery with or without adjuvant radiotherapy. With a growing debate about overdiagnosis and overtreatment of low-risk DCIS, active surveillance is being explored in several ongoing trials. We conducted a systematic review and meta-analysis to evaluate the recurrence of low-risk DCIS under various treatment approaches.

METHODS

PubMed, Embase, Web of Science, and Cochrane were searched for studies reporting ipsilateral breast tumour event (IBTE), contralateral breast cancer (CBC), and breast cancer-specific survival (BCSS) rates at 5 and 10 years in low-risk DCIS. The primary outcome was invasive IBTE (iIBTE) defined as invasive progression in the ipsilateral breast.

RESULTS

Thirty three eligible studies were identified, involving 47,696 women with low-risk DCIS. The pooled 5-year and 10-year iIBTE rates were 3.3% (95% confidence interval [CI]: 1.3, 8.1) and 5.9% (95% CI: 3.8, 9.0), respectively. The iIBTE rates were significantly lower in patients who underwent surgery compared to those who did not, at 5 years (3.5% vs. 9.0%, P = 0.003) and 10 years (6.4% vs. 22.7%, P = 0.008). Similarly, the 10-year BCSS rate was higher in the surgery group (96.0% vs. 99.6%, P = 0.010). In patients treated with breast-conserving surgery, additional radiotherapy significantly reduced IBTE risk, but not total-CBC risk.

CONCLUSION

This review showed a lower risk of progression and better survival in women who received surgery and additional RT for low-risk DCIS. However, our findings were primarily based on observational studies, and should be confirmed with the results from the ongoing trials.

Adjuvant radiation therapy in small ductal carcinoma in situ

BACKGROUND

The objective of this study was to evaluate ipsilateral breast tumor recurrence (IBTR) rates in patients with small (≤1 cm) ductal carcinoma in situ (DCIS) who were followed up for more than 15 years.

METHODS

We identified 209 patients with primary small (≤1 cm) DCIS without invasion who received curative excision with and without adjuvant radiation therapy (RT) from 1996 to 2009. IBTR rates and prognostic factors in all patients were estimated by univariate and multivariate analyses.

RESULTS

With a median follow-up of 104 months, eight (53.3%) had DCIS recurrence and seven (46.7%) had recurrence of invasive ductal carcinoma. IBTR rate of all patients was 7.5% at 10 years and 12.1% at 15 years. In univariate analysis, age and subtypes were significant factors for IBTR. In multivariate analysis, resection margin, adjuvant RT, and endocrine therapy were significant factors for IBTR.

CONCLUSIONS

IBTR rate of small (≤1 cm) DCIS following excision with or without adjuvant RT was 12.1% at 15 years. Adjuvant RT and endocrine therapy were associated with lower IBTR rate in small DCIS.

Recurrence outcomes after omission of postoperative radiotherapy following breast-conserving surgery for ductal carcinoma in situ of the breast: a multicenter, retrospective study in Korea (KROG 16-02)

PURPOSE

To evaluate the loco-regional recurrence (LRR) rate after breast-conserving surgery without postoperative radiotherapy (RT) for ductal carcinoma in situ (DCIS) of the breast.

METHODS

Between 2000 and 2010, 311 DCIS patients from 9 institutions were analyzed retrospectively. The median age was 47 (range, 20-82). The median tumor size was 7 mm (range, 0.01-76). Margin width was <1 cm in 85 patients (27.3%), and nuclear grade was high in 37 patients (11.9%). Two hundred and three patients (65.3%) received tamoxifen.

RESULTS

With a median follow-up of 74 months (range, 5-189), there were 11 local recurrences (invasive carcinoma in 6 and DCIS in 5) and 1 regional recurrence. The 7-year LRR rate was 3.8%. On univariate analysis, age and margin width were significant risk factors influencing LRR (p = 0.017 and 0.014, respectively). When age and margin width were combined among 211 patients whose margin width were available, the 7-year LRR rates were as follows (p < 0.001): (1) 0% in patients with age >50 years and any margin width status (n = 64), (2) 1.2% in age ≤50 years and margin width ≥1 cm (n = 93), (3) 13.1% in age ≤50 years and margin width <1 cm (n = 54).

CONCLUSIONS

The LRR rate was very low in selected DCIS patients treated with breast-conserving surgery without postoperative RT. However, adjuvant RT should be considered for those with age ≤50 years and margin width <1 cm.

The Association of Surgical Margins and Local Recurrence in Women with Ductal Carcinoma In Situ Treated with Breast-Conserving Therapy: A Meta-Analysis

PURPOSE

There is no consensus on adequate negative margins in breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS). We systematically reviewed the evidence on margins in BCS for DCIS.

METHODS

A study-level meta-analysis of local recurrence (LR), microscopic margin status and threshold distance for negative margins. LR proportion was modeled using random-effects logistic meta-regression (frequentist) and network meta-analysis (Bayesian) that allows for multiple margin distances per study, adjusting for follow-up time.

RESULTS

Based on 20 studies (LR: 865 of 7883), odds of LR were associated with margin status [logistic: odds ratio (OR) 0.53 for negative vs. positive/close (p < 0.001); network: OR 0.45 for negative vs. positive]. In logistic meta-regression, relative to >0 or 1 mm, ORs for 2 mm (0.51), 3 or 5 mm (0.42) and 10 mm (0.60) showed comparable significant reductions in the odds of LR. In the network analysis, ORs relative to positive margins for 2 (0.32), 3 (0.30) and 10 mm (0.32) showed similar reductions in the odds of LR that were greater than for >0 or 1 mm (0.45). There was weak evidence of lower odds at 2 mm compared with >0 or 1 mm [relative OR (ROR) 0.72, 95 % credible interval (CrI) 0.47-1.08], and no evidence of a difference between 2 and 10 mm (ROR 0.99, 95 % CrI 0.61-1.64). Adjustment for covariates, and analyses based only on studies using whole-breast radiotherapy, did not change the findings.

CONCLUSION

Negative margins in BCS for DCIS reduce the odds of LR; however, minimum margin distances above 2 mm are not significantly associated with further reduced odds of LR in women receiving radiation.

Comparison of ipsilateral breast tumor recurrence after breast-conserving surgery between ductal carcinoma in situ and invasive breast cancer

Background

We aimed to evaluate the differences in the rates and predictive factors for ipsilateral breast tumor recurrence (IBTR) after breast-conserving surgery (BCS) between ductal carcinoma in situ (DCIS) and invasive breast cancer. And, we evaluated the impact of IBTR on overall survival and distant metastasis.

Methods

We retrospectively reviewed 322 consecutive patients with DCIS or invasive breast cancer who underwent BCS between 2004 and 2010. We evaluated the rates of IBTR of DCIS and invasive breast cancer. Univariate and multivariate analyses were performed to determine the predictive factors for IBTR, and survival rates were analyzed with Kaplan-Meier estimates.

Results

With a median follow-up period of 57 months, 5 (10 %) out of 50 DCIS patients and 14 (5.1 %) out of 272 invasive cancer patients had developed IBTR. Factors associated with IBTR on univariate and multivariate analyses were positive resection margin status in DCIS and omission of radiotherapy in invasive cancer, respectively. The hormone receptor negativity was strong independent predictive factors for IBTR in both DCIS and invasive breast cancer. Although the differences of survival curve did not reach statistical significance, the 5-year overall survival and distant metastasis-free survival of invasive cancer patients who suffered IBTR were inferior to those without (84 vs. 98 % and 63.3 vs. 96.5 %, respectively). Advanced initial stage, lymph node metastasis and experience of IBTR were associated with poor overall survival and distant metastasis on univariate and multivariate analyses.

Conclusions

The hormone receptor negativity was revealed as independent predictive factor for IBTR after BCS in both DCIS and invasive cancer. Experience of IBTR was independent prognostic factor for poor overall outcome in patients with invasive breast cancer. Aggressive local control and adjuvant therapy should be made in hormone receptor-negative patients who receive treatment with BCS.

Proportion and clinical outcomes of postoperative radiotherapy omission after breast-conserving surgery in women with breast cancer

PURPOSE

The present study was conducted to investigate the proportion and clinical outcomes of breast cancer patients who did not receive postoperative radiotherapy (PORT) after breast-conserving surgery (BCS).

METHODS

This retrospective study included all breast cancer patients received curative BCS without PORT between 2003 and 2013. In the PORT omission group, characteristics and local recurrence differences were compared between the recommended group and the refused group. To compare the local recurrence-free survival (LRFS) of the PORT omission group and the control group who received PORT, subjects were selected by using the pooled data of patients treated between 1994 and 2007.

RESULTS

During the study period, 96 patients did not receive PORT among a total of 6,680 patients who underwent BCS. Therefore, the overall rate of PORT omission was 1.4%. Among the 96 patients, 20 were recommended for PORT omission (recommended group) and 76 refused PORT (refused group). The median follow-up period of all study participants was 19.3 months (range, 0.3-115.1 months). Patients in the recommended group were older (p=0.004), were more likely to be postmenopausal (p=0.013), and had more number of positive prognostic factors compared with the refused group. Overall, 12 cases of disease recurrence, including 11 cases of local recurrence, developed in the PORT-refused group. The LRFS of the PORT-omission group was significantly inferior to that of patients who received PORT after BCS (p<0.001). In the PORT-omission group, significant favorable prognostic factors for LRFS were having histologic grade 1 or 2 disease (p=0.023), having no axillary lymph node metastasis (p=0.039), receiving adjuvant endocrine therapy (p=0.046), and being in the recommended group (p=0.026).

CONCLUSION

The rate of PORT omission in the present study is very low among women who underwent surgery compared to that of other studies worldwide. PORT omission is significantly related to a high local recurrence rate.