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Miceli R, Mercado CL, Hernandez O, Chhor C. Active Surveillance for Atypical Ductal Hyperplasia and Ductal Carcinoma In Situ. JOURNAL OF BREAST IMAGING 2023; 5:396-415. [PMID: 38416903 DOI: 10.1093/jbi/wbad026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Indexed: 03/01/2024]
Abstract
Atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS) are relatively common breast lesions on the same spectrum of disease. Atypical ductal hyperblasia is a nonmalignant, high-risk lesion, and DCIS is a noninvasive malignancy. While a benefit of screening mammography is early cancer detection, it also leads to increased biopsy diagnosis of noninvasive lesions. Previously, treatment guidelines for both entities included surgical excision because of the risk of upgrade to invasive cancer after surgery and risk of progression to invasive cancer for DCIS. However, this universal management approach is not optimal for all patients because most lesions are not upgraded after surgery. Furthermore, some DCIS lesions do not progress to clinically significant invasive cancer. Overtreatment of high-risk lesions and DCIS is considered a burden on patients and clinicians and is a strain on the health care system. Extensive research has identified many potential histologic, clinical, and imaging factors that may predict ADH and DCIS upgrade and thereby help clinicians select which patients should undergo surgery and which may be appropriate for active surveillance (AS) with imaging. Additionally, multiple clinical trials are currently underway to evaluate whether AS for DCIS is feasible for a select group of patients. Recent advances in MRI, artificial intelligence, and molecular markers may also have an important role to play in stratifying patients and delineating best management guidelines. This review article discusses the available evidence regarding the feasibility and limitations of AS for ADH and DCIS, as well as recent advances in patient risk stratification.
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Affiliation(s)
- Rachel Miceli
- NYU Langone Health, Department of Radiology, New York, NY, USA
| | | | | | - Chloe Chhor
- NYU Langone Health, Department of Radiology, New York, NY, USA
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Karakatsanis A, Eriksson S, Pistiolis L, Olofsson Bagge R, Nagy G, Man V, Kwong A, Wärnberg F. Delayed Sentinel Lymph Node Dissection in Patients with a Preoperative Diagnosis of Ductal Cancer In Situ by Preoperative Injection with Superparamagnetic Iron Oxide (SPIO) Nanoparticles: The SentiNot Study. Ann Surg Oncol 2023; 30:4064-4072. [PMID: 36719570 PMCID: PMC10250503 DOI: 10.1245/s10434-022-13064-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 12/22/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Difficulty in preoperatively assessing the risk for occult invasion or surgery that precludes future accurate axillary mapping in patients with ductal cancer in situ (DCIS) account for overutilization of SLND. METHODS Prospective, multicenter, cohort study, including women with any DCIS planned for mastectomy or DCIS grade 2 and > 20 mm, any DCIS grade 3, any mass-forming DCIS and any planned surgery. Patients received an interstitial SPIO injection during breast surgery, but no upfront SLND was performed. If invasion was identified on final pathology, delayed SLND (d-SLND) was performed separately with the coadministration of isotope ± blue dye (BD). Study outcomes were proportion of upfront SLNDs that were avoided, detection rates during d-SLND, and impact on healthcare costs. RESULTS In total, 78.7% of study participants (N = 254, mean age 60 years, mean DCIS size 37.8 mm) avoided upfront SLND. On d-SLND (median 28 days, range 9-46), SPIO outperformed Tc99 with (98.2% vs. 63.6%, p < 0.001) or without BD (92.7% vs. 50.9%, p < 0.001) and had higher nodal detection rate (86.9% vs. 32.3%, p < 0.001) and with BD (93.9% vs. 41.4%, p < 0.001). Only 27.9% of all SLNs retrieved were concordant for Tc99 and SPIO. Type of breast procedure (WLE vs. oncoplastic BCT vs. mastectomy) affected these outcomes and accounted for the low performance of Tc99 (p < 0.001). d-SLND resulted in a 28.1% total cost containment for women with pure DCIS on final pathology (4190 vs. 5828 USD, p < 0.001). CONCLUSIONS Marking the SLN with SPIO may avoid overtreatment and allow for accurate d-SLND in patients with DCIS.
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Affiliation(s)
- Andreas Karakatsanis
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.
- Department of Surgery, Uppsala University Hospital, Uppsala, Sweden.
| | - Staffan Eriksson
- Centre for Clinical Research, Uppsala University, Västerås, Sweden
- Department of Surgery, Västmanland County Hospital, Västerås, Sweden
| | - Lida Pistiolis
- Department of Surgery, Sahlgrenska Center for Cancer Research, Institute of Clinical Sciences, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Roger Olofsson Bagge
- Department of Surgery, Sahlgrenska Center for Cancer Research, Institute of Clinical Sciences, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Gyula Nagy
- Breast Unit, Department of Surgery, Linköping University Hospital, Linköping, Sweden
| | - Vivian Man
- Department of Surgery, University of Hong Kong, Hong Kong, Hong Kong SAR, China
| | - Ava Kwong
- Department of Surgery, University of Hong Kong, Hong Kong, Hong Kong SAR, China
- Department of Surgery, The University of Hong, Kong-Shen Zhen Hospital, Shenzhen, China
- Department of Surgery, Hong Kong Sanatorium and Hospital, Hong Kong, Hong Kong SAR, China
| | - Fredrik Wärnberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
- Department of Surgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Surgery, Sahlgrenska Center for Cancer Research, Institute of Clinical Sciences, University of Gothenburg, Sahlgrenska Academy, Gothenburg, Sweden
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
- Wallenberg Centre for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
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Identification of patients with ductal carcinoma in situ at high risk of postoperative upstaging: A comprehensive review and an external (un)validation of predictive models developed. Eur J Obstet Gynecol Reprod Biol 2022; 271:7-14. [DOI: 10.1016/j.ejogrb.2022.01.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 12/30/2021] [Accepted: 01/27/2022] [Indexed: 12/17/2022]
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Preneoplastic Low-Risk Mammary Ductal Lesions (Atypical Ductal Hyperplasia and Ductal Carcinoma In Situ Spectrum): Current Status and Future Directions. Cancers (Basel) 2022; 14:cancers14030507. [PMID: 35158775 PMCID: PMC8833401 DOI: 10.3390/cancers14030507] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Revised: 01/12/2022] [Accepted: 01/17/2022] [Indexed: 02/04/2023] Open
Abstract
Intraepithelial mammary ductal neoplasia is a spectrum of disease that varies from atypical ductal hyperplasia (ADH), low-grade (LG), intermediate-grade (IG), to high-grade (HG) ductal carcinoma in situ (DCIS). While ADH has the lowest prognostic significance, HG-DCIS carries the highest risk. Due to widely used screening mammography, the number of intraepithelial mammary ductal neoplastic lesions has increased. The consequence of this practice is the increase in the number of patients who are overdiagnosed and, therefore, overtreated. The active surveillance (AS) trials are initiated to separate lesions that require active treatment from those that can be safely monitored and only be treated when they develop a change in the clinical/radiologic characteristics. At the same time, the natural history of these lesions can be evaluated. This review aims to evaluate ADH/DCIS as a spectrum of intraductal neoplastic disease (risk and histomorphology); examine the controversies of distinguishing ADH vs. DCIS and the grading of DCIS; review the upgrading for both ADH and DCIS with emphasis on the variation of methods of detection and the definitions of upgrading; and evaluate the impact of all these variables on the AS trials.
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5
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Low-risk DCIS. What is it? Observe or excise? Virchows Arch 2021; 480:21-32. [PMID: 34448893 PMCID: PMC8983540 DOI: 10.1007/s00428-021-03173-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 07/09/2021] [Accepted: 07/23/2021] [Indexed: 01/25/2023]
Abstract
The issue of overdiagnosis and overtreatment of lesions detected by breast screening mammography has been debated in both international media and the scientific literature. A proportion of cancers detected by breast screening would never have presented symptomatically or caused harm during the patient's lifetime. The most likely (but not the only) entity which may represent those overdiagnosed and overtreated is low-grade ductal carcinoma in situ (DCIS). In this article, we address what is understood regarding the natural history of DCIS and the diagnosis and prognosis of low-grade DCIS. However, low cytonuclear grade disease may not be the totality of DCIS that can be considered of low clinical risk and we outline the issues regarding active surveillance vs excision of low-risk DCIS and the clinical trials exploring this approach.
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Iwamoto N, Nara M, Horiguchi SI, Aruga T. Surgical upstaging rates in patients meeting the eligibility for active surveillance trials. Jpn J Clin Oncol 2021; 51:1219-1224. [PMID: 34091677 DOI: 10.1093/jjco/hyab082] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2021] [Accepted: 05/22/2017] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Four clinical active surveillance trials including LORIS, COMET, LORD and LORETTA, are being conducted to assess whether women with low-risk ductal carcinoma in situ can safely avoid surgery. The present study aimed to determine the rate of upstaging to invasive cancer among patients with a preoperative diagnosis of ductal carcinoma in situ and to evaluate the incidence of upstaging in patients meeting the eligibility criteria for four active surveillance clinical trials. METHODS The present study initially enrolled 180 patients with 183 calcifications who received the diagnosis of ductal carcinoma in situ by biopsy. Patients were classified as eligible for four clinical trials according to the respective inclusion criteria. RESULTS In total, 152 patients with 155 calcifications were analyzed. Of these, 32 (21%) were upstaged to invasive disease based on the final pathological analysis of surgical specimens. Of the 152 patients, 53 (35%), 90 (59%), 24 (16%) and 34 (22%) met the eligibility criteria for the LORIS, COMET, LORD and LORETTA trial, respectively. Among patients with low-risk ductal carcinoma in situ, 10 (19%), 14 (16%), 6 (25%) and 4 (12%) patients were upstaged to invasive disease in LORIS, COMET, LORD and LORETTA, respectively. The upstaging to pT1b or higher rates were 2% (1/53), 3% (3/90), 0% (0/24) and 3% (1/34) in LORIS, COMET, LORD and LORETTA, respectively. CONCLUSIONS The upstaging rate in patients eligible for the clinical active surveillance trials was 12-25%. Although the rate of upstaging to pT1b or higher was low, further studies are required to determine the rates of upstaging to invasive cancer and the risk factors among patients with low-risk ductal carcinoma in situ.
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Affiliation(s)
- Naoko Iwamoto
- Department of Breast Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Miyako Nara
- Department of Breast Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Shin-Ichiro Horiguchi
- Department of Pathology, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
| | - Tomoyuki Aruga
- Department of Breast Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital, Bunkyo-ku, Tokyo, Japan
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Corradini AG, Cremonini A, Cattani MG, Cucchi MC, Saguatti G, Baldissera A, Mura A, Ciabatti S, Foschini MP. Which type of cancer is detected in breast screening programs? Review of the literature with focus on the most frequent histological features. Pathologica 2021; 113:85-94. [PMID: 34042090 PMCID: PMC8167395 DOI: 10.32074/1591-951x-123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/12/2020] [Indexed: 12/20/2022] Open
Abstract
Breast cancer is the most frequent type of cancer affecting female patients. The introduction of breast cancer screening programs led to a substantial reduction of mortality from breast cancer. Nevertheless, doubts are being raised on the real efficacy of breast screening programs. The aim of the present paper is to review the main pathological type of cancers detected in breast cancer screening programs. Specifically, attention will be given to: in situ carcinoma, invasive carcinoma histotypes and interval cancer.
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Affiliation(s)
- Angelo G Corradini
- Unit of Anatomic Pathology, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
| | - Anna Cremonini
- Unit of Anatomic Pathology, Department of Oncology, Bellaria Hospital, Bologna, Italy
| | - Maria G Cattani
- Unit of Anatomic Pathology, Department of Oncology, Bellaria Hospital, Bologna, Italy
| | - Maria C Cucchi
- Unit of Breast Surgery, Department of Oncology, Bellaria Hospital, Bologna Italy
| | - Gianni Saguatti
- Unit of Senology, Department of Oncology, Bellaria Hospital, Bologna, Italy
| | | | - Antonella Mura
- Department of Medical Oncology, Azienda USL, Bologna, Italy; IRCCS Institute of Neurological Sciences, Bologna, Italy
| | | | - Maria P Foschini
- Unit of Anatomic Pathology, Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy.,Unit of Anatomic Pathology, Department of Oncology, Bellaria Hospital, Bologna, Italy
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Complete Removal of the Lesion as a Guidance in the Management of Patients with Breast Ductal Carcinoma In Situ. Cancers (Basel) 2021; 13:cancers13040868. [PMID: 33670739 PMCID: PMC7923077 DOI: 10.3390/cancers13040868] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/29/2021] [Accepted: 02/11/2021] [Indexed: 12/27/2022] Open
Abstract
Simple Summary A diagnosis of ductal carcinoma in situ, made on biopsy, is often followed by surgery or radiotherapy because of the risk of an upgrading disease upon subsequent surgical specimens, finding invasive carcinoma. In order to select which patients can be spared overtreatments and alternatively followed with active surveillance, we retrospectively reviewed 2173 vacuum assisted breast biopsies. Our goal was to demonstrate if complete removal of the lesion by biopsy, documented by mammograms, can be a valid criterion to select the patients that can be spared further treatments. The results of our study demonstrate a significant lower upgrading rate of disease when the lesion is completely removed. Thus, performing a mammogram to document the absence of residual lesion following vacuum-assisted breast biopsy (VABB) allows us to reduce overtreatments and to select which patients can be followed with an active surveillance, sparing unjustified public health costs. Abstract Background: Considering highly selected patients with ductal carcinoma in situ (DCIS), active surveillance is a valid alternative to surgery. Our study aimed to show the reliability of post-biopsy complete lesion removal, documented by mammogram, as additional criterion to select these patients. Methods: A total of 2173 vacuum-assisted breast biopsies (VABBs) documented as DCIS were reviewed. Surgery was performed in all cases. We retrospectively collected the reports of post-VABB complete lesion removal and the histological results of the biopsy and surgery. We calculated the rate of upgrade of DCIS identified on VABB upon excision for patients with post-biopsy complete lesion removal and for those showing residual lesion. Results: We observed 2173 cases of DCIS: 408 classified as low-grade, 1262 as intermediate-grade, and 503 as high-grade. The overall upgrading rate to invasive carcinoma was 15.2% (330/2173). The upgrade rate was 8.2% in patients showing mammographically documented complete removal of the lesion and 19% in patients without complete removal. Conclusion: The absence of mammographically documented residual lesion following VABB was found to be associated with a lower upgrading rate of DCIS to invasive carcinoma on surgical excision and should be considered when deciding the proper management DCIS diagnosis.
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Takada K, Kashiwagi S, Asano Y, Goto W, Morisaki T, Takahashi K, Fujita H, Takashima T, Tomita S, Hirakawa K, Ohira M. Factors predictive of invasive ductal carcinoma in cases preoperatively diagnosed as ductal carcinoma in situ. BMC Cancer 2020; 20:513. [PMID: 32493410 PMCID: PMC7268513 DOI: 10.1186/s12885-020-07001-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2019] [Accepted: 05/25/2020] [Indexed: 12/24/2022] Open
Abstract
Background Invasion is often found during postoperative pathological examination of cases diagnosed as ductal carcinoma in situ (DCIS) by histological examinations such as core needle biopsy (CNB) or vacuum-assisted biopsy (VAB). A meta-analysis reported that 25.9% of invasive ductal carcinoma (IDC) cases are preoperatively diagnosed by CNB as DCIS. Risk factors for invasion have been studied by postoperative examination, but no factors have been found that could be obtained preoperatively from blood tests. In this study, we investigated factors predictive of invasion based on preoperative blood tests in patients diagnosed with DCIS by preoperative biopsy. Methods In this study, 118 patients who were diagnosed with DCIS by preoperative biopsy were included. Biopsies were performed with 16-gauge CNB or VAB. Peripheral blood was obtained at the time of diagnosis. This study evaluated absolute platelet count, absolute lymphocyte count, lactate dehydrogenase, carcinoembryonic antigen, and cancer antigen 15–3 (CA15–3). The platelet–lymphocyte ratio (PLR) was calculated by dividing the absolute platelet count by the absolute lymphocyte count, and patients were grouped into high PLR (≥160.0) and low PLR (< 160.0) groups. Results Invasion was found more frequently after surgery in pathologically high-grade cases than in pathologically not-high-grade cases (p = 0.015). The median PLR was 138.9 and 48 patients (40.7%) were classified into the high PLR group. The high PLR group was significantly more likely to have invasion detected by the postoperative pathology than the low PLR group (p = 0.018). In multivariate analysis of factors predictive of invasion in postoperative pathology, a high PLR (p = 0.006, odds ratio [OR] = 3.526) and biopsy method (VAB vs. CNB, p = 0.001, OR = 0.201) was an independent risk factor. Conclusions The PLR may be a predictor of invasion in the postoperative pathology for patients diagnosed with DCIS by preoperative biopsy.
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Affiliation(s)
- Koji Takada
- Department of Breast and Endocrine Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Shinichiro Kashiwagi
- Department of Breast and Endocrine Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.
| | - Yuka Asano
- Department of Breast and Endocrine Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Wataru Goto
- Department of Breast and Endocrine Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Tamami Morisaki
- Department of Breast and Endocrine Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Katsuyuki Takahashi
- Department of Pharmacology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Hisakazu Fujita
- Department of Scientific and Linguistic Fundamentals of Nursing, Osaka City University Graduate School of Nursing, 1-5-17 Asahi-machi, Abeno-ku, Osaka, 545-0051, Japan
| | - Tsutomu Takashima
- Department of Breast and Endocrine Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Shuhei Tomita
- Department of Pharmacology, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Kosei Hirakawa
- Department of Breast and Endocrine Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.,Department of Gastrointestinal Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
| | - Masaichi Ohira
- Department of Breast and Endocrine Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan.,Department of Gastrointestinal Surgery, Osaka City University Graduate School of Medicine, 1-4-3 Asahi-machi, Abeno-ku, Osaka, 545-8585, Japan
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Oseni TO, Bahl M. ASO Author Reflections: Active Surveillance for Ductal Carcinoma In Situ (DCIS). Ann Surg Oncol 2020; 27:4466-4467. [PMID: 32440718 DOI: 10.1245/s10434-020-08637-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Indexed: 11/18/2022]
Affiliation(s)
- Tawakalitu O Oseni
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Manisha Bahl
- Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA.
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Oseni TO, Smith BL, Lehman CD, Vijapura CA, Pinnamaneni N, Bahl M. Do Eligibility Criteria for Ductal Carcinoma In Situ (DCIS) Active Surveillance Trials Identify Patients at Low Risk for Upgrade to Invasive Carcinoma? Ann Surg Oncol 2020; 27:4459-4465. [PMID: 32418079 DOI: 10.1245/s10434-020-08576-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Clinical trials are currently ongoing to determine the safety and efficacy of active surveillance (AS) versus usual care (surgical and radiation treatment) for women with ductal carcinoma in situ (DCIS). This study aimed to determine upgrade rates of DCIS at needle biopsy to invasive carcinoma at surgery among women who meet the eligibility criteria for AS trials. METHODS A retrospective review was performed of consecutive women at an academic medical center with a diagnosis of DCIS at needle biopsy from 2007 to 2016. Medical records were reviewed for mode of presentation, imaging findings, biopsy pathology results, and surgical outcomes. Each patient with DCIS was evaluated for AS trial eligibility based on published criteria for the COMET, LORD, and LORIS trials. RESULTS During a 10-year period, DCIS was diagnosed in 858 women (mean age 58 years; range 28-89 years). Of the 858 women, 498 (58%) were eligible for the COMET trial, 101 (11.8%) for the LORD trial, and 343 (40%) for the LORIS trial. The rates of upgrade to invasive carcinoma were 12% (60/498) for the COMET trial, 5% (5/101) for the LORD trial, and 11.1% (38/343) for the LORIS trial. The invasive carcinomas ranged from 0.2 to 20 mm, and all were node-negative. CONCLUSIONS Women who meet the eligibility criteria for DCIS AS trials remain at risk for occult invasive carcinoma at presentation, with upgrade rates ranging from 5 to 12%. These findings suggest that more precise criteria are needed to ensure that women with invasive carcinoma are excluded from AS trials.
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Affiliation(s)
- Tawakalitu O Oseni
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Barbara L Smith
- Division of Surgical Oncology, Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Constance D Lehman
- Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Charmi A Vijapura
- Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Niveditha Pinnamaneni
- Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA
| | - Manisha Bahl
- Division of Breast Imaging, Department of Radiology, Massachusetts General Hospital, Boston, MA, USA.
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12
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Ballantyne N, Chen YA, Rabhar H, Grimm LJ. Multimodality Imaging of Ductal Carcinoma In Situ. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-019-00349-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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13
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Cutuli B. [Ductal carcinoma in situ in 2019: Diagnosis, treatment, prognosis]. Presse Med 2019; 48:1112-1122. [PMID: 31653542 DOI: 10.1016/j.lpm.2019.08.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2019] [Accepted: 08/28/2019] [Indexed: 12/27/2022] Open
Abstract
Ductal carcinoma in situ (DCIS) currently represents up to 15% of the newly diagnosed breast cancers, and are almost always detected by microcalcifications. Global prognosis is good (3% of 15-year specific mortality) but invasive local recurrences (LR) can lead to metastasis in 12-15% of the cases. Breast conserving surgery with whole breast irradiation is the main treatment (reducing LR by 50%), but mastectomy (with or without reconstruction) is performed in about 30% of the cases due to wide lesion size and/or multicentricity. The role of tamoxifen remains unclear. Axillary dissection is needless but sentinel node biopsy is proposed in case of micro-invasion suspicion (large lesions with high grade). The main factors of LR are young age (≤40 years) incomplete excision, and high nuclear grade with comedonecrosis. Several studies on "therapeutic descalation" are still ongoing in order to identify the "low risk" DCIS (about 10% of the cases) in which radiotherapy could be safely omitted.
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MESH Headings
- Age Factors
- Antineoplastic Agents, Hormonal/therapeutic use
- Biopsy
- Breast/pathology
- Breast Neoplasms/diagnosis
- Breast Neoplasms/etiology
- Breast Neoplasms/pathology
- Breast Neoplasms/therapy
- Carcinoma, Intraductal, Noninfiltrating/diagnosis
- Carcinoma, Intraductal, Noninfiltrating/etiology
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/therapy
- Combined Modality Therapy/methods
- Conservative Treatment
- Diagnostic Imaging/methods
- Female
- Humans
- Lymph Node Excision/trends
- Mastectomy
- Neoplasm Recurrence, Local/diagnosis
- Prognosis
- Radiotherapy
- Risk Factors
- Tamoxifen/therapeutic use
- Time Factors
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Affiliation(s)
- Bruno Cutuli
- Institut du cancer Courlancy Reims, 38, rue du Courlancy, 51100 Reims, France.
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14
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Krischer B, Forte S, Singer G, Kubik-Huch RA, Leo C. Stereotactic Vacuum-Assisted Breast Biopsy in Ductal Carcinoma in situ: Residual Microcalcifications and Intraoperative Findings. Breast Care (Basel) 2019; 15:386-391. [PMID: 32982649 DOI: 10.1159/000502944] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2019] [Accepted: 08/27/2019] [Indexed: 11/19/2022] Open
Abstract
Purpose The question of overtreatment of ductal carcinoma in situ (DCIS) was raised because a significant proportion of especially low-grade DCIS lesions never progress to invasive cancer. The rationale for the present study was to analyze the value of stereotactic vacuum-assisted biopsy (VAB) for complete removal of DCIS, focusing on the relationship between the absence of residual microcalcifications after stereotactic VAB and the histopathological diagnosis of the definitive surgical specimen. Patients and Methods Data of 58 consecutive patients diagnosed with DCIS by stereotactic VAB in a single breast center between 2012 and 2017 were analyzed. Patient records from the hospital information system were retrieved, and mammogram reports and images as well as histopathology reports were evaluated. The extent of microcalcifications before and after biopsy as well as the occurrence of DCIS in biopsy and definitive surgical specimens were analyzed and correlated. Results There was no correlation between the absence of residual microcalcifications in the post-biopsy mammogram and the absence of residual DCIS in the final surgical specimen (p = 0.085). Upstaging to invasive cancer was recorded in 4 cases (13%) but occurred only in the group that had high-grade DCIS on biopsy. Low-grade DCIS was never upgraded to high-grade DCIS in the definitive specimen. Conclusions The radiological absence of microcalcifications after stereotactic biopsy does not rule out residual DCIS in the final surgical specimen. Since upstaging to invasive cancer is seen in a substantial proportion of high-grade DCIS, the surgical excision of high-grade DCIS should remain the treatment of choice.
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Affiliation(s)
- Benedict Krischer
- Department of Gynecology, Breast Center, Kantonsspital Baden, Baden, Switzerland
| | - Serafino Forte
- Department of Radiology, Kantonsspital Baden, Baden, Switzerland
| | - Gad Singer
- Department of Pathology, Kantonsspital Baden, Baden, Switzerland
| | | | - Cornelia Leo
- Department of Gynecology, Breast Center, Kantonsspital Baden, Baden, Switzerland
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15
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Shehata M, Grimm L, Ballantyne N, Lourenco A, Demello LR, Kilgore MR, Rahbar H. Ductal Carcinoma in Situ: Current Concepts in Biology, Imaging, and Treatment. JOURNAL OF BREAST IMAGING 2019; 1:166-176. [PMID: 31538141 DOI: 10.1093/jbi/wbz039] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Indexed: 12/27/2022]
Abstract
Ductal carcinoma in situ (DCIS) of the breast is a group of heterogeneous epithelial proliferations confined to the milk ducts that nearly always present in asymptomatic women on breast cancer screening. A stage 0, preinvasive breast cancer, increased detection of DCIS was initially hailed as a means to prevent invasive breast cancer through surgical treatment with adjuvant radiation and/or endocrine therapies. However, controversy in the medical community has emerged in the past two decades that a fraction of DCIS represents overdiagnosis, leading to unnecessary treatments and resulting morbidity. The imaging hallmarks of DCIS include linearly or segmentally distributed calcifications on mammography or nonmass enhancement on breast MRI. Imaging features have been shown to reflect the biological heterogeneity of DCIS lesions, with recent studies indicating MRI may identify a greater fraction of higher-grade lesions than mammography does. There is strong interest in the surgical, imaging, and oncology communities to better align DCIS management with biology, which has resulted in trials of active surveillance and therapy that is less aggressive. However, risk stratification of DCIS remains imperfect, which has limited the development of precision therapy approaches matched to DCIS aggressiveness. Accordingly, there are opportunities for breast imaging radiologists to assist the oncology community by leveraging advanced imaging techniques to identify appropriate patients for the less aggressive DCIS treatments.
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Affiliation(s)
- Mariam Shehata
- University of Washington School of Medicine, Department of Radiology, Seattle, WA
| | - Lars Grimm
- Duke University Medical School, Department of Radiology, Durham, NC
| | - Nancy Ballantyne
- Duke University Medical School, Department of Radiology, Durham, NC
| | - Ana Lourenco
- Brown University Medical School, Department of Radiology, Providence, RI
| | - Linda R Demello
- Brown University Medical School, Department of Radiology, Providence, RI
| | - Mark R Kilgore
- University of Washington School of Medicine, Department of Anatomic Pathology, Seattle, WA.,Seattle Cancer Care Alliance, Seattle, WA
| | - Habib Rahbar
- University of Washington School of Medicine, Department of Radiology, Seattle, WA.,Seattle Cancer Care Alliance, Seattle, WA
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16
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Ductal Carcinoma In Situ Management: All or Nothing, or Something in between? CURRENT BREAST CANCER REPORTS 2019. [DOI: 10.1007/s12609-019-0306-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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17
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Van Bockstal MR, Agahozo MC, Koppert LB, van Deurzen CHM. A retrospective alternative for active surveillance trials for ductal carcinoma in situ of the breast. Int J Cancer 2019; 146:1189-1197. [PMID: 31018242 PMCID: PMC7004157 DOI: 10.1002/ijc.32362] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Revised: 03/25/2019] [Accepted: 04/17/2019] [Indexed: 12/12/2022]
Abstract
Ductal carcinoma in situ (DCIS) of the breast is a nonobligate precursor of invasive breast cancer, accounting for 20 % of screen-detected breast cancers. Little is known about the natural progression of DCIS because most patients undergo surgery upon diagnosis. Many DCIS patients are likely being overtreated, as it is believed that only around 50 % of DCIS will progress to invasive carcinoma. Robust prognostic markers for progression to invasive carcinoma are lacking. In the past, studies have investigated women who developed a recurrence after breast-conserving surgery (BCS) and compared them with those who did not. However, where there is no recurrence, the patient has probably been adequately treated. The present narrative review advocates a new research strategy, wherein only those patients with a recurrence are studied. Approximately half of the recurrences are invasive cancers, and half are DCIS. So-called "recurrences" are probably most often the result of residual disease. The new approach allows us to ask: why did some residual DCIS evolve to invasive cancers and others not? This novel strategy compares the group of patients that developed in situ recurrence with the group of patients that developed invasive recurrence after BCS. The differences between these groups could then be used to develop a robust risk stratification tool. This tool should estimate the risk of synchronous and metachronous invasive carcinoma when DCIS is diagnosed in a biopsy. Identification of DCIS patients at low risk for developing invasive carcinoma will individualize future therapy and prevent overtreatment.
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Affiliation(s)
- Mieke R Van Bockstal
- Department of Pathology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Marie C Agahozo
- Department of Pathology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - Linetta B Koppert
- Department of Surgery, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
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18
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Visser LL, Groen EJ, van Leeuwen FE, Lips EH, Schmidt MK, Wesseling J. Predictors of an Invasive Breast Cancer Recurrence after DCIS: A Systematic Review and Meta-analyses. Cancer Epidemiol Biomarkers Prev 2019; 28:835-845. [PMID: 31023696 DOI: 10.1158/1055-9965.epi-18-0976] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 12/12/2018] [Accepted: 02/13/2019] [Indexed: 11/16/2022] Open
Abstract
We performed a systematic review with meta-analyses to summarize current knowledge on prognostic factors for invasive disease after a diagnosis of ductal carcinoma in situ (DCIS). Eligible studies assessed risk of invasive recurrence in women primarily diagnosed and treated for DCIS and included at least 10 ipsilateral-invasive breast cancer events and 1 year of follow-up. Quality in Prognosis Studies tool was used for risk of bias assessment. Meta-analyses were performed to estimate the average effect size of the prognostic factors. Of 1,781 articles reviewed, 40 articles met the inclusion criteria. Highest risk of bias was attributable to insufficient handling of confounders and poorly described study groups. Six prognostic factors were statistically significant in the meta-analyses: African-American race [pooled estimate (ES), 1.43; 95% confidence interval (CI), 1.15-1.79], premenopausal status (ES, 1.59; 95% CI, 1.20-2.11), detection by palpation (ES, 1.84; 95% CI, 1.47-2.29), involved margins (ES, 1.63; 95% CI, 1.14-2.32), high histologic grade (ES, 1.36; 95% CI, 1.04-1.77), and high p16 expression (ES, 1.51; 95% CI, 1.04-2.19). Six prognostic factors associated with invasive recurrence were identified, whereas many other factors need confirmation in well-designed studies on large patient numbers. Furthermore, we identified frequently occurring biases in studies on invasive recurrence after DCIS. Avoiding these common methodological pitfalls can improve future study designs.
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Affiliation(s)
- Lindy L Visser
- Division of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Emma J Groen
- Division of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, the Netherlands.,Department of Pathology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Flora E van Leeuwen
- Division of Psychosocial Research and Epidemiology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Esther H Lips
- Division of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Marjanka K Schmidt
- Division of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, the Netherlands.,Division of Psychosocial Research and Epidemiology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Jelle Wesseling
- Division of Molecular Pathology, the Netherlands Cancer Institute, Amsterdam, the Netherlands. .,Department of Pathology, the Netherlands Cancer Institute, Amsterdam, the Netherlands
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19
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Fuentes JAP, Martínez CEM, Casadiego AKR, Freites VFA, Marín VAA, Castellano ACR. Papillary breast lesions diagnosed by percutaneous needle biopsy: management approach. Ecancermedicalscience 2019; 13:902. [PMID: 30915160 PMCID: PMC6390833 DOI: 10.3332/ecancer.2019.902] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Indexed: 11/29/2022] Open
Abstract
Papillary breast lesions are a heterogeneous group of neoplasms of diverse imagenological, clinical and morphological presentation that display different behaviour, prognosis and, therefore, controversial diagnosis and management. The aim of this study is to propose an algorithm for the management of mammary lesions.
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20
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Hwang ES, Hyslop T, Lynch T, Frank E, Pinto D, Basila D, Collyar D, Bennett A, Kaplan C, Rosenberg S, Thompson A, Weiss A, Partridge A. The COMET (Comparison of Operative versus Monitoring and Endocrine Therapy) trial: a phase III randomised controlled clinical trial for low-risk ductal carcinoma in situ (DCIS). BMJ Open 2019; 9:e026797. [PMID: 30862637 PMCID: PMC6429899 DOI: 10.1136/bmjopen-2018-026797] [Citation(s) in RCA: 173] [Impact Index Per Article: 34.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Ductal carcinoma in situ (DCIS) is a non-invasive non-obligate precursor of invasive breast cancer. With guideline concordant care (GCC), DCIS outcomes are at least as favourable as some other early stage cancer types such as prostate cancer, for which active surveillance (AS) is a standard of care option. However, AS has not yet been tested in relation to DCIS. The goal of the COMET (Comparison of Operative versus Monitoring and Endocrine Therapy) trial for low-risk DCIS is to gather evidence to help future patients consider the range of treatment choices for low-risk DCIS, from standard therapies to AS. The trial will determine whether there may be some women who do not substantially benefit from current GCC and who could thus be safely managed with AS. This protocol is version 5 (11 July 2018). Any future protocol amendments will be submitted to Quorum Centralised Institutional Review Board/local institutional review boards for approval via the sponsor of the study (Alliance Foundation Trials). METHODS AND ANALYSIS COMET is a phase III, randomised controlled clinical trial for patients with low-risk DCIS. The primary outcome is ipsilateral invasive breast cancer rate in women undergoing GCC compared with AS. Secondary objectives will be to compare surgical, oncological and patient-reported outcomes. Patients randomised to the GCC group will undergo surgery as well as radiotherapy when appropriate; those in the AS group will be monitored closely with surgery only on identification of invasive breast cancer. Patients in both the GCC and AS groups will have the option of endocrine therapy. The total planned accrual goal is 1200 patients. ETHICS AND DISSEMINATION The COMET trial will be subject to biannual formal review at the Alliance Foundation Data Safety Monitoring Board meetings. Interim analyses for futility/safety will be completed annually, with reporting following Consolidated Standards of Reporting Trials (CONSORT) guidelines for non-inferiority trials. TRIAL REGISTRATION NUMBER NCT02926911; Pre-results.
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Affiliation(s)
- E Shelley Hwang
- Department of Surgery, Division of Surgical Oncology, Duke University, Durham, North Carolina, USA
| | - Terry Hyslop
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Thomas Lynch
- Department of Surgery, Division of Surgical Oncology, Duke University, Durham, North Carolina, USA
| | | | | | | | | | - Antonia Bennett
- Department of Health Policy and Management, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Celia Kaplan
- Department of Medicine, University of California, San Francisco, California, USA
| | - Shoshana Rosenberg
- Department of Medicine, Brigham and Women’s Hospital, Dana Farber Cancer Institute, Boston, Massachusetts, USA
| | - Alastair Thompson
- Department of Breast Surgery, Division of Surgical Oncology, Baylor College of Medicine, Houston, Texas, USA
| | - Anna Weiss
- Alliance Foundation Trials, Boston, Massachusetts, USA
| | - Ann Partridge
- Department of Medicine, Brigham and Women’s Hospital, Dana Farber Cancer Institute, Boston, Massachusetts, USA
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21
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Leonardi MC, Corrao G, Frassoni S, Vingiani A, Dicuonzo S, Lazzeroni M, Fodor C, Morra A, Gerardi MA, Rojas DP, Dell'Acqua V, Marvaso G, Bassi FD, Galimberti VE, Veronesi P, Miglietta E, Cattani F, Zurrida S, Bagnardi V, Viale G, Orecchia R, Jereczek-Fossa BA. Ductal carcinoma in situ and intraoperative partial breast irradiation: Who are the best candidates? Long-term outcome of a single institution series. Radiother Oncol 2019; 133:68-76. [PMID: 30935584 DOI: 10.1016/j.radonc.2018.12.030] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 12/30/2018] [Accepted: 12/31/2018] [Indexed: 12/27/2022]
Abstract
AIMS To report the long-term outcome of a single institution series of pure ductal carcinoma in situ (DCIS) treated with accelerated partial irradiation using intraoperative electrons (IOERT). METHODS From 2000 to 2010, 180 DCIS patients, treated with quadrantectomy and 21 Gy IOERT, were analyzed in terms of ipsilateral breast recurrences (IBRs) and survival outcomes by stratification in two subgroups. The low-risk group included patients who fulfilled the suitable definition according to American Society of Radiation Oncology (ASTRO) Guidelines (size ≤2.5 cm, grade 1-2 and surgical margins ≥3 mm) (Suitable), while the remaining ones formed the high-risk group (Non-Suitable). RESULTS Eighty-four and 96 patients formed the Suitable and Non-Suitable groups, respectively. In the whole population, the cumulative incidence of IBR at 5, 7 and 10 years was 19%, 21%, and 25%, respectively. In the Suitable group, the cumulative incidence of IBR remained constant at 11% throughout the years, while in the Non-Suitable group increased from 26% at 5 years to 36% at 10 years (p < 0.0001). When hormonal positivity and HER2 absence of expression were added to the selection of the Suitable group, the cumulative incidence of IBR dropped and stabilized at 4% at 10 years. None died of breast cancer. In the whole population, 5-year and 10-year overall survival rate was 98% and 96.5%, respectively, without any difference between the two groups. CONCLUSIONS The overall and by group IBR rates were high and stricter criteria are required for acceptable local control for Suitable DCIS. Because of the concerns raised, IOERT should not be used in clinical practice.
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Affiliation(s)
| | - Giulia Corrao
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Italy
| | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Italy
| | - Andrea Vingiani
- Department of Pathology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Samantha Dicuonzo
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy.
| | - Matteo Lazzeroni
- Division of Cancer Prevention and Genetics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Cristiana Fodor
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Anna Morra
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Damaris Patricia Rojas
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Italy
| | - Veronica Dell'Acqua
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Giulia Marvaso
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Fabio Domenico Bassi
- Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | | | - Paolo Veronesi
- Department of Oncology and Hemato-oncology, University of Milan, Italy; Division of Breast Surgery, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Eleonora Miglietta
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Federica Cattani
- Unit of Medical Physics, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Stefano Zurrida
- Department of Oncology and Hemato-oncology, University of Milan, Italy
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milano-Bicocca, Italy
| | - Giuseppe Viale
- Department of Oncology and Hemato-oncology, University of Milan, Italy; Department of Pathology, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Roberto Orecchia
- Scientific Direction, IEO, European Institute of Oncology IRCCS, Milan, Italy
| | - Barbara Alicja Jereczek-Fossa
- Division of Radiation Oncology, IEO, European Institute of Oncology IRCCS, Milan, Italy; Department of Oncology and Hemato-oncology, University of Milan, Italy
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22
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Meurs CJC, van Rosmalen J, Menke-Pluijmers MBE, Ter Braak BPM, de Munck L, Siesling S, Westenend PJ. A prediction model for underestimation of invasive breast cancer after a biopsy diagnosis of ductal carcinoma in situ: based on 2892 biopsies and 589 invasive cancers. Br J Cancer 2018; 119:1155-1162. [PMID: 30327564 PMCID: PMC6219477 DOI: 10.1038/s41416-018-0276-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 09/04/2018] [Accepted: 09/06/2018] [Indexed: 02/08/2023] Open
Abstract
Background Patients with a biopsy diagnosis of ductal carcinoma in situ (DCIS)
might be diagnosed with invasive breast cancer at excision, a phenomenon known as
underestimation. Patients with DCIS are treated based on the risk of
underestimation or progression to invasive cancer. The aim of our study was to
expand the knowledge on underestimation and to develop a prediction model. Methods Population-based data were retrieved from the Dutch Pathology
Registry and the Netherlands Cancer Registry for DCIS between January 2011 and
June 2012. Results Of 2892 DCIS biopsies, 21% were underestimated invasive breast
cancers. In multivariable analysis, risk factors were high-grade DCIS (odds ratio
(OR) 1.43, 95% confidence interval (CI): 1.05–1.95), a palpable tumour (OR 2.22,
95% CI: 1.76–2.81), a BI-RADS (Breast Imaging Reporting and Data System) score 5
(OR 2.36, 95% CI: 1.80–3.09) and a suspected invasive component at biopsy (OR
3.84, 95% CI: 2.69–5.46). The predicted risk for underestimation ranged from 9.5
to 80.2%, with a median of 14.7%. Of the 596 invasive cancers, 39% had
unfavourable features. Conclusions The risk for an underestimated diagnosis of invasive breast cancer
after a biopsy diagnosis of DCIS is considerable. With our prediction model, the
individual risk of underestimation can be calculated based on routinely available
preoperatively known risk factors (https://www.evidencio.com/models/show/1074).
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Affiliation(s)
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, University Medical Center Rotterdam, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | | | - Bert P M Ter Braak
- Department of Radiology, Albert Schweitzer Hospital, PO Box 444, 3300 AK, Dordrecht, The Netherlands
| | - Linda de Munck
- Department of Research, Netherlands Comprehensive Cancer Organisation, PO Box 19079, 3501 DB, Utrecht, The Netherlands
| | - Sabine Siesling
- Department of Research, Netherlands Comprehensive Cancer Organisation, PO Box 19079, 3501 DB, Utrecht, The Netherlands
| | - Pieter J Westenend
- Laboratory of Pathology Dordrecht, Karel Lotsyweg 145, 3318 AL, Dordrecht, The Netherlands. .,Regional screening organization South West the Netherlands, Maasstadweg 12, 3079 DZ, Rotterdam, The Netherlands.
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23
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Breast cancer-related deaths according to grade in ductal carcinoma in situ: A Dutch population-based study on patients diagnosed between 1999 and 2012. Eur J Cancer 2018; 101:134-142. [PMID: 30059817 DOI: 10.1016/j.ejca.2018.07.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2018] [Revised: 07/02/2018] [Accepted: 07/03/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND The incidence of ductal carcinoma in situ (DCIS) has drastically increased over the past decades. Because DCIS is resected after diagnosis similar to invasive breast cancer, the natural cause and behaviour of DCIS is not well known. We aimed to determine breast cancer-specific survival (BCSS) and overall survival (OS) according to grade in DCIS patients after surgical treatment in the Netherlands. PATIENTS AND METHODS All DCIS patients diagnosed between 1999 and 2012 were selected from the Netherlands Cancer Registry. The cause of death was obtained from 'Statistics Netherlands'. BCSS and OS were estimated using multivariable Cox regression in the entire cohort and stratified for grades. RESULTS In total, 12,256 patients were included, of whom 1509 (12.3%) presented with grade I, 3675 (30.0%) with grade II, 6064 (49.5%) with grade III and 1008 (8.2%) with an unknown grade. During a median follow-up of 7.8 years, 1138 (9.3%) deaths were observed, and 179 (1.5%) were breast cancer-related. Of these, 10 patients had grade I; 46 grade II; 95 grade III and 28 an unknown grade. After adjustment for confounding, grade II and III were related to worse BCSS than grade I with hazard ratios of 1.92 (95% confidence interval [CI]: 0.97-3.81) and 2.14 (95% CI: 1.11-4.12), respectively. No association between grades and OS was observed. CONCLUSION BCSS and OS in DCIS patients were excellent. Because superior rates were observed for low-grade DCIS, it seems justified to investigate whether active surveillance may be a balanced alternative for conventional surgical treatment.
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24
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Hong YK, McMasters KM, Egger ME, Ajkay N. Ductal carcinoma in situ current trends, controversies, and review of literature. Am J Surg 2018; 216:998-1003. [PMID: 30244816 DOI: 10.1016/j.amjsurg.2018.06.013] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 06/05/2018] [Accepted: 06/14/2018] [Indexed: 10/28/2022]
Abstract
Ductal carcinoma in situ (DCIS) is a non-obligate precursor, non-invasive malignancy confined within the basement membrane of the breast ductal system. There is a wide variation in the natural history of DCIS with an estimated incidence of progression to invasive ductal carcinoma being at least 13%-50% over a range of 10 or more years after initial diagnosis. Regardless of the treatment strategy, long-term survival is excellent. The controversy surrounding DCIS relates to preventing under-treatment, while also avoiding unnecessary treatments. In this article, we review the incidence, presentation, management options and surveillance of DCIS. Furthermore, we address several current controversies related to the management of DCIS, including margin status, sentinel node biopsy, hormonal therapy, the role of radiation in breast conservation surgery, and various risk stratification schemes.
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Affiliation(s)
- Young K Hong
- Division of Surgical Oncology, Department of Surgery, University of Louisville, USA
| | - Kelly M McMasters
- Division of Surgical Oncology, Department of Surgery, University of Louisville, USA
| | - Michael E Egger
- Division of Surgical Oncology, Department of Surgery, University of Louisville, USA
| | - Nicolas Ajkay
- Division of Surgical Oncology, Department of Surgery, University of Louisville, USA.
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25
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Prise en charge des carcinomes mammaires in situ : surtraitement ? Peut-on faire moins ? IMAGERIE DE LA FEMME 2018. [DOI: 10.1016/j.femme.2018.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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26
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Podoll MB, Reisenbichler ES, Roland L, Bruner A, Mizuguchi S, Sanders MAG. Feasibility of the Less Is More Approach in Treating Low-Risk Ductal Carcinoma In Situ Diagnosed on Core Needle Biopsy: Ten-Year Review of Ductal Carcinoma In Situ Upgraded to Invasion at Surgery. Arch Pathol Lab Med 2018; 142:1120-1126. [PMID: 29582675 DOI: 10.5858/arpa.2017-0268-oa] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT - Ductal carcinoma in situ (DCIS) represents 20% of screen-detected breast cancers. The likelihood that certain types of DCIS are slow growing and may never progress to invasion suggests that our current standards of treating DCIS could result in overtreatment. The LORIS (LOw RISk DCIS) and LORD (LOw Risk DCIS) trials address these concerns by randomizing patients with low-risk DCIS to either active surveillance or conventional treatment. OBJECTIVE - To determine the upgrade rate of DCIS diagnosed on core needle biopsy to invasive carcinoma at surgery and to evaluate the safety of managing low-risk DCIS with surveillance alone, by characterizing the pathologic and clinical features of upgraded cases and applying criteria of the LORD and LORIS trials to these cases. DESIGN - A 10-year retrospective analysis of DCIS on core needle biopsy with subsequent surgery. RESULTS - We identified 1271 cases of DCIS on core needle biopsy: 200 (16%) low grade, 649 (51%) intermediate grade, and 422 (33%) high grade. Of the 1271 cases, we found an 8% upgrade rate to invasive carcinoma (n = 105). Nineteen of the 105 upgraded cases (18%) had positive lymph nodes. Low-grade DCIS was least likely to upgrade to invasion, comprising 10% (10 of 105) of upgraded cases. Three of the 105 upgraded cases (3%) met criteria for the LORD trial, and all were low-grade DCIS on core needle biopsy with favorable biology on follow-up. CONCLUSIONS - There is a clear risk of upgrade to invasion on follow-up excision; however, applying strict criteria of the LORD trial effectively decreases the likelihood of a missed invasive component or missed aggressive pathologic features.
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Affiliation(s)
| | | | | | | | | | - Mary Ann G Sanders
- From the Department of Pathology, Microbiology and Immunology, Vanderbilt University, Nashville, Tennessee (Drs Podoll and Reisenbichler); and the Departments of Radiology (Drs Roland, Bruner, and Mizuguchi) and Pathology and Laboratory Medicine (Dr Sanders), University of Louisville Hospital, Louisville, Kentucky
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Farshid G, Edwards S, Kollias J, Gill PG. Active surveillance of women diagnosed with atypical ductal hyperplasia on core needle biopsy may spare many women potentially unnecessary surgery, but at the risk of undertreatment for a minority: 10-year surgical outcomes of 114 consecutive cases from a single center. Mod Pathol 2018; 31:395-405. [PMID: 29099502 DOI: 10.1038/modpathol.2017.114] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 07/23/2017] [Accepted: 07/23/2017] [Indexed: 11/09/2022]
Abstract
A needle core biopsy diagnosis of atypical ductal hyperplasia is an indication for open biopsy. The launch of randomized clinical trials of active surveillance for low-risk ductal carcinoma in situ leads to the paradoxical situation of women with low-grade ductal carcinoma in situ being observed, whereas those with atypical ductal hyperplasia have surgery. If the malignancies diagnosed after surgery for atypical ductal hyperplasia are dominated by low-risk ductal carcinoma in situ, women with atypical ductal hyperplasia may also be considered for surveillance. This 10-year prospective observational study includes women diagnosed with atypical ductal hyperplasia on core biopsy after screening mammography. We retrieved their clinical, imaging and histologic data and carried out a blind review of core biopsy histology, sub-classifying the atypical ductal hyperplasia along a spectrum from hyperplasia to ductal carcinoma in situ. Using the final surgical pathology data, we calculated: (1) The proportion and grades of ductal carcinoma in situ and invasive cancers diagnosed at open biopsy. (2) The histologic extent of the malignancy at surgery. (3) The biomarker profile and nodal status of any invasive cancers. (4) Ascertained any independent predictors of (i) any malignancy, (ii) high-risk malignancy, defined in this study as invasive cancer, or high-grade ductal carcinoma in situ, or intermediate grade ductal carcinoma in situ with any necrosis. (5) Extrapolated the above to simulate active surveillance for women with screen-detected atypical ductal hyperplasia. Between January 2005 and December 2014, 114 women, mean age 59 years (range 40-79 years) were included. Surgical pathology, available in 110 (97%), confirmed malignancy in 46 (40%). All 46 malignant cases had ductal carcinoma in situ, accompanied by invasive carcinoma in 9 (8%) women. Together, 21 (19%) women had either invasive cancer (9%), high-grade ductal carcinoma in situ (6%), or necrotizing, intermediate grade ductal carcinoma in situ (6%). Only one of nine invasive breast cancers was grade 1, 3 were multifocal, all were ≤8 mm, node negative, and ER positive but two were HER2 amplified. The mean extent of the ductal carcinoma in situ in any one specimen was 19.8 mm, median 13 mm, range 2-110 mm. Overall 32 women, 29% of the whole cohort and 70% of those 46 with malignancy, required further surgery, including mastectomy in 12 (11%). A multivariable model for predicting the likelihood of any malignancy showed a statistically significant association only with the post review subtype of atypical ductal hyperplasia, adjusting for lesion size. Independent predictors of high-risk malignancy (invasive cancer or non-low-grade ductal carcinoma in situ) were not identified. If active surveillance is adopted for screen-detected atypical ductal hyperplasia diagnosed on core biopsy, 60% of women will avoid unnecessary surgery and a further 24% would meet eligibility criteria for ductal carcinoma in situ surveillance trials. However, 18% of women will have undiagnosed invasive breast cancer or non-low-risk ductal carcinoma in situ. These women with high-risk lesions are not reliably identified pre-operatively.
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Affiliation(s)
- Gelareh Farshid
- Surgical Pathology, BreastScreen SA, Discipline of Medicine, Adelaide University and South Australian Pathology, Frome Road Adelaide University and Directorate of Surgical Pathology, Adelaide, SA, Australia
| | - Suzanne Edwards
- Adelaide Health Technology Assessment, School of Public Health, Adelaide University, Adelaide, SA, Australia
| | - James Kollias
- BreastScreen SA and The Department of Surgery, University of Adelaide, Adelaide, SA, Australia
| | - Peter Grantley Gill
- BreastScreen SA and The Department of Surgery, University of Adelaide, Adelaide, SA, Australia
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Imaging Features of Patients Undergoing Active Surveillance for Ductal Carcinoma in Situ. Acad Radiol 2017; 24:1364-1371. [PMID: 28705686 DOI: 10.1016/j.acra.2017.05.017] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2017] [Revised: 05/21/2017] [Accepted: 05/24/2017] [Indexed: 11/21/2022]
Abstract
RATIONALE AND OBJECTIVES The aim of this study was to describe the imaging appearance of patients undergoing active surveillance for ductal carcinoma in situ (DCIS). MATERIALS AND METHODS We retrospectively identified 29 patients undergoing active surveillance for DCIS from 2009 to 2014. Twenty-two patients (group 1) refused surgery or were not surgical candidates. Seven patients (group 2) enrolled in a trial of letrozole and deferred surgical excision for 6-12 months. Pathology and imaging results at the initial biopsy and follow-up were recorded. RESULTS In group 1, the median follow-up was 2.7 years (range: 0.6-13.9 years). Fifteen patients (68%) remained stable. Seven patients (32%) underwent additional biopsies with invasive ductal carcinoma diagnosed in two patients after 3.9 and 3.6 years who developed increasing calcifications and new masses. In group 2, one patient (14%) was upstaged to microinvasive ductal carcinoma at surgery. Among the patients in both groups with calcifications (n = 26), there was no progression to invasive disease among those with stable (50%, 13/26) or decreased (19%, 5/26) calcifications. CONCLUSIONS Among a DCIS active surveillance cohort, invasive disease progression presented as increasing calcifications and a new mass following more than 3.5 years of stable imaging. In contrast, there was no progression to invasive disease among cases of DCIS with stable or decreasing calcifications. Close imaging is a key follow-up component in active surveillance.
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Toss M, Miligy I, Thompson A, Khout H, Green A, Ellis I, Rakha E. Current trials to reduce surgical intervention in ductal carcinoma in situ of the breast: Critical review. Breast 2017; 35:151-156. [DOI: 10.1016/j.breast.2017.07.012] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Accepted: 07/13/2017] [Indexed: 12/12/2022] Open
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Grimm LJ, Ryser MD, Partridge AH, Thompson AM, Thomas JS, Wesseling J, Hwang ES. Surgical Upstaging Rates for Vacuum Assisted Biopsy Proven DCIS: Implications for Active Surveillance Trials. Ann Surg Oncol 2017; 24:3534-3540. [PMID: 28795370 DOI: 10.1245/s10434-017-6018-9] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Indexed: 11/18/2022]
Abstract
PURPOSE This study was designed to determine invasive cancer upstaging rates at surgical excision following vacuum-assisted biopsy of ductal carcinoma in situ (DCIS) among women meeting eligibility for active surveillance trials. METHODS Patients with vacuum-assisted, biopsy-proven DCIS at a single center from 2008 to 2015 were retrospectively reviewed. Imaging and pathology reports were interrogated for the imaging appearance, tumor grade, hormone receptor status, and presence of comedonecrosis. Subsequent surgical reports were reviewed for upstaging to invasive disease. Cases were classified by eligibility criteria for the COMET, LORIS, and LORD DCIS active surveillance trials. RESULTS Of 307 DCIS diagnoses, 15 (5%) were low, 95 (31%) intermediate, and 197 (64%) high nuclear grade. The overall upstage rate to invasive disease was 17% (53/307). Eighty-one patients were eligible for the COMET Trial, 74 for the LORIS trial, and 10 for the LORD Trial, although LORIS trial eligibility also included real-time, multiple central pathology review, including elements not routinely reported. The upstaging rates to invasive disease were 6% (5/81), 7% (5/74), and 10% (1/10) for the COMET, LORIS, and LORD trials, respectively. Among upstaged cancers (n = 5), four tumors were Stage IA invasive ductal carcinoma and one was Stage IIA invasive lobular carcinoma; all were node-negative. CONCLUSIONS DCIS upstaging rates in women eligible for active surveillance trials are low (6-10%), and in this series, all those with invasive disease were early-stage, node-negative. The careful patient selection for DCIS active surveillance trials has a low risk of missing occult invasive cancer and additional studies will determine clinical outcomes.
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Affiliation(s)
- Lars J Grimm
- Department of Radiology, Duke University, Durham, NC, USA
| | - Marc D Ryser
- Department of Mathematics, Duke University, Durham, NC, USA
| | - Ann H Partridge
- Division of Oncology, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Alastair M Thompson
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jeremy S Thomas
- Department of Pathology, Western General Hospital, Edinburgh, UK
| | - Jelle Wesseling
- Department of Pathology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - E Shelley Hwang
- Department of Surgery, Duke University Comprehensive Cancer Center, Durham, NC, USA.
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Choo WG, Jeon CW, Ryu DW. Clinicopathological Factors Associated with Remnant or Regrowth of Benign Breast Tumor after Previous Vacuum-Assisted Core Biopsy. ACTA ACUST UNITED AC 2017. [DOI: 10.14449/jbd.2017.5.1.23] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Benson JR, Jatoi I, Toi M. Treatment of low-risk ductal carcinoma in situ: is nothing better than something? Lancet Oncol 2017; 17:e442-e451. [PMID: 27733270 DOI: 10.1016/s1470-2045(16)30367-9] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Revised: 07/08/2016] [Accepted: 07/13/2016] [Indexed: 10/20/2022]
Abstract
The heterogeneous nature of ductal carcinoma in situ has been emphasised by data for breast-cancer screening that show substantial increases in the detection of early-stage non-invasive breast cancer but no noteworthy change in the incidence of invasive and distant metastatic disease. Indolent non-progressive forms of ductal carcinoma in situ are managed according to similar surgical strategies as high-risk disease, with extent of resection dictated by radiological and pathological estimates of tumour dimensions. Although adjuvant treatments might be withheld for low-risk lesions, surgical treatments incur potential morbidity, especially when mastectomy and breast reconstruction are done for widespread low-grade or intermediate-grade ductal carcinoma in situ. Low rates of deaths from breast cancer coupled with overdiagnosis within screening programmes have prompted a fundamental rethink of approaches to the management of both low-risk and high-risk ductal carcinoma in situ. Changes include active surveillance for low-risk lesions and a watchful waiting policy with intervention when invasive local recurrence after breast-conserving surgery is detected. Prediction of ipsilateral invasive recurrence is likely to be improved by integration of molecular biomarkers with conventional histopathological parameters. Moreover, further genetic interrogation of ductal carcinoma in situ might lead to a reclassification of some low-grade lesions as non-cancerous entities.
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Affiliation(s)
- John R Benson
- Cambridge Breast Unit, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust Cambridge, UK.
| | - Ismail Jatoi
- Division of Surgical Oncology, University of Texas Health Science Center, San Antonio, TX, USA
| | - Masakazu Toi
- Breast Cancer Unit, Kyoto University Hospital, Kyoto University Graduate School of Medicine, Kyoto, Japan
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Groen EJ, Elshof LE, Visser LL, Rutgers EJT, Winter-Warnars HA, Lips EH, Wesseling J. Finding the balance between over- and under-treatment of ductal carcinoma in situ (DCIS). Breast 2017; 31:274-283. [DOI: 10.1016/j.breast.2016.09.001] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 08/19/2016] [Accepted: 09/01/2016] [Indexed: 12/21/2022] Open
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Pilewskie M, Olcese C, Patil S, Van Zee KJ. Women with Low-Risk DCIS Eligible for the LORIS Trial After Complete Surgical Excision: How Low Is Their Risk After Standard Therapy? Ann Surg Oncol 2016; 23:4253-4261. [PMID: 27766556 DOI: 10.1245/s10434-016-5595-3] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Identifying DCIS patients at low risk for disease progression could obviate need for standard therapy. The LORIS (surgery versus active monitoring for low-risk DCIS) trial is studying the safety of monitoring low-risk DCIS, although ipsilateral breast tumor recurrence (IBTR) rates in patients meeting enrollment criteria after complete surgical excision are unknown. METHODS Women with pure DCIS treated with breast-conserving surgery (BCS) with/without radiation therapy (RT) from 1/1996-1/2011 were included from a prospectively maintained database. IBTR rates were compared between those who did and did not meet LORIS eligibility criteria (age ≥ 46 years, screen-detected calcifications, nipple discharge absence, minimal family history, non-high-grade DCIS) after complete surgical excision. RESULTS A total of 2394 women were identified; 401 met LORIS criteria. Median follow-up was 5.9 years; 431 had ≥10 years follow-up. LORIS cohort median age was 61 years (range 46-86 years); 207 (52 %) underwent RT, 79 (20 %) received endocrine therapy. Of 401 patients, 24 experienced an IBTR. Overall 10-year IBTR rates were 10.3 % (LORIS) versus 15.4 % (non-LORIS) (p = 0.08); without RT, 12.1 versus 21.4 %, respectively (p = 0.06). The 10-year invasive-IBTR rates for women meeting LORIS criteria were: 5.3 % BCS overall, 6.0 % without RT. CONCLUSIONS Women meeting LORIS criteria (after complete surgical excision) are at somewhat lower risk for IBTR. Among such women undergoing excision without RT, the 10-year invasive-IBTR rate was 6 %. Given that approximately 20 % of women with core biopsy-proven non-high-grade DCIS have invasive cancer at excision, women managed without excision would be expected to incur higher invasive cancer rates. Additional criteria are needed to identify women not requiring intervention for DCIS.
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Affiliation(s)
- Melissa Pilewskie
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Cristina Olcese
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Sujata Patil
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Pilewskie M, Stempel M, Rosenfeld H, Eaton A, Van Zee KJ, Morrow M. Do LORIS Trial Eligibility Criteria Identify a Ductal Carcinoma In Situ Patient Population at Low Risk of Upgrade to Invasive Carcinoma? Ann Surg Oncol 2016; 23:3487-3493. [PMID: 27172775 DOI: 10.1245/s10434-016-5268-2] [Citation(s) in RCA: 60] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND The Surgery Versus Active Monitoring for Low-Risk DCIS (LORIS) trial is studying the safety of monitoring core-biopsy diagnosed low-risk ductal carcinoma in situ (DCIS) without excision. We sought to determine the incidence and characteristics of synchronous invasive carcinoma found in LORIS-eligible women who underwent excision, as this knowledge is essential in assessing the safety of observation alone. METHODS Women meeting LORIS eligibility criteria (age ≥46 years, screen-detected calcifications, non-high-grade DCIS diagnosed by core biopsy, absence of nipple discharge, or strong family history of breast cancer) who underwent surgical excision from 2009 to 2012 were identified. Histologic findings of excision specimens were reviewed. RESULTS Overall, 296 LORIS-eligible cases were identified; 58 (20 %) had invasive carcinoma on final pathology (90 % invasive ductal, 78 % >1 mm in size, 21 % high grade, 3 % triple negative, 9 % HER2 amplified). Of these, 18 (31 %) were pT1b or larger and 3 (5 %) were pN1. Among eligible upgraded cases, 90 % received radiation, 89 % received endocrine therapy, and 18 % were recommended chemotherapy. Women upgraded to invasive carcinoma were more likely to have intermediate-grade DCIS on core biopsy and to have undergone mastectomy. CONCLUSIONS Among LORIS-eligible women, 20 % had invasive carcinoma at surgical excision that was heterogeneous in grade, size, and receptor status. Information gained from surgical excision influenced receipt of adjuvant radiation and endocrine therapy in most patients, and indicated benefit from chemotherapy in 18 % of patients. Surgical excision is warranted until additional risk stratification is available to identify a cohort of DCIS patients at lower risk for clinically significant synchronous invasive carcinoma.
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Affiliation(s)
- Melissa Pilewskie
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Michelle Stempel
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Hope Rosenfeld
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Anne Eaton
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Kimberly J Van Zee
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Monica Morrow
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Booth ME, Nash CE, Roberts NP, Magee DR, Treanor D, Hanby AM, Speirs V. 3-D Tissue Modelling and Virtual Pathology as New Approaches to Study Ductal Carcinoma In Situ. Altern Lab Anim 2015; 43:377-83. [DOI: 10.1177/026119291504300605] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Widespread screening mammography programmes mean that ductal carcinoma in situ (DCIS), a pre-invasive breast lesion, is now more frequently diagnosed. However, not all diagnosed DCIS lesions progress to invasive breast cancer, which presents a dilemma for clinicians. As such, there is much interest in studying DCIS in the laboratory, in order to help understand more about its biology and determine the characteristics of those that progress to invasion. Greater knowledge would lead to targeted and better DCIS treatment. Here, we outline some of the models available to study DCIS, with a particular focus on animal-free systems.
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Affiliation(s)
- Mary E. Booth
- Leeds Institute of Cancer and Pathology, Leeds, UK
- Joint first authors
| | - Claire E. Nash
- Leeds Institute of Cancer and Pathology, Leeds, UK
- Joint first authors
- Current address: The Research Institute of the McGill University Health Centre, 1001 Decarie Boulevard, Montreal, Quebec H4A 3J1, Canada
| | | | | | - Darren Treanor
- Leeds Institute of Cancer and Pathology, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
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Nicholson S, Hanby A, Clements K, Kearins O, Lawrence G, Dodwell D, Bishop H, Thompson A. Variations in the management of the axilla in screen-detected Ductal Carcinoma In Situ: Evidence from the UK NHS Breast Screening Programme audit of screen detected DCIS. Eur J Surg Oncol 2015; 41:86-93. [DOI: 10.1016/j.ejso.2014.09.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 08/29/2014] [Accepted: 09/02/2014] [Indexed: 10/24/2022] Open
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Radiotherapy in DCIS, an underestimated benefit? Radiother Oncol 2014; 112:1-8. [DOI: 10.1016/j.radonc.2014.06.011] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2014] [Revised: 05/18/2014] [Accepted: 06/15/2014] [Indexed: 12/28/2022]
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Narod SA, Rakovitch E. A comparison of the risks of in-breast recurrence after a diagnosis of dcis or early invasive breast cancer. ACTA ACUST UNITED AC 2014; 21:119-24. [PMID: 24940092 DOI: 10.3747/co.21.1892] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND It is controversial whether ductal carcinoma in situ (dcis) is a preinvasive marker of breast cancer or if it is part of a spectrum of small cancers with malignant potential. Comparing clinical outcomes in women with invasive and noninvasive breast lesions might help to resolve the issue. METHODS From a database of 2641 patients with breast cancer, we selected women who had been treated with breast-conserving surgery for a cancer that was 2.0 cm or less in size, node-negative, and nonpalpable. No subject received chemotherapy. Cancers were categorized as noninvasive (stage 0, n = 172) or invasive (stage 1, n = 401) based on a review of the pathology records. We compared the actuarial risks of in-breast recurrence after invasive and noninvasive breast lesions before and after adjusting for tamoxifen and radiotherapy. RESULTS The 18-year cumulative risk of in-breast recurrence was 35.2% for patients with dcis and 12.8% for patients with small invasive cancers (hazard ratio: 2.4; 95% confidence interval: 1.5 to 3.8; p < 0.0003). After adjustment for radiotherapy and tamoxifen treatment, the difference was small and nonsignificant (hazard ratio: 1.4; 95% confidence interval: 0.9 to 2.4; p = 0.22). CONCLUSIONS For women with small, nonpalpable, node-negative breast cancers, the likelihood of experiencing an in-breast recurrence was associated with radiotherapy and with tamoxifen, but not with the presence of cancer cells invading beyond the basement membrane.
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Affiliation(s)
- S A Narod
- Women's College Research Institute, Women's College Hospital, and the Dalla Lana School of Public Health University of Toronto, Toronto, ON
| | - E Rakovitch
- Department of Radiation Oncology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON
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