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Heller SL, Plaunova A, Gao Y. Ductal Carcinoma In Situ and Progression to Invasive Cancer: A Review of the Evidence. JOURNAL OF BREAST IMAGING 2021; 3:135-143. [PMID: 38424826 DOI: 10.1093/jbi/wbaa119] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Indexed: 03/02/2024]
Abstract
Ductal carcinoma in situ (DCIS), breast cancer confined to the milk ducts, is a heterogeneous entity. The question of how and when a case of DCIS will extend beyond the ducts to become invasive breast cancer has implications for both patient prognosis and optimal treatment approaches. The natural history of DCIS has been explored through a variety of methods, from mouse models to biopsy specimen reviews to population-based screening data to modeling studies. This article will review the available evidence regarding progression pathways and will also summarize current trials designed to assess DCIS progression.
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Affiliation(s)
- Samantha L Heller
- NYU Grossman School of Medicine, Department of Radiology, New York, NY
| | | | - Yiming Gao
- NYU Grossman School of Medicine, Department of Radiology, New York, NY
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2
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Abstract
The nonobligate precursor lesions columnar cell change/hyperplasia and flat epithelial atypia, atypical ductal hyperplasia and atypical lobular hyperplasia, lobular carcinoma in situ, and low-grade ductal carcinoma in situ share morphologic, immunophenotypic, and molecular features supporting the existence of a low-grade breast neoplasia pathway. The practical implication for pathologists is that the identification of one of these lesions should prompt careful search for others. From a clinical management perspective, however, their designation as "precursor lesions" should not be overemphasized, as the risk of progression among the earliest lesions is exceedingly low. Factors determining which lesions will progress remain unknown.
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Affiliation(s)
- Laura C Collins
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, 330 Brookline Avenue, Boston, MA 02215, USA.
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3
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Gorringe KL, Fox SB. Ductal Carcinoma In Situ Biology, Biomarkers, and Diagnosis. Front Oncol 2017; 7:248. [PMID: 29109942 PMCID: PMC5660056 DOI: 10.3389/fonc.2017.00248] [Citation(s) in RCA: 67] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2017] [Accepted: 10/02/2017] [Indexed: 12/21/2022] Open
Abstract
Ductal carcinoma in situ (DCIS) is an often-diagnosed breast disease and a known, non-obligate, precursor to invasive breast carcinoma. In this review, we explore the clinical and pathological features of DCIS, fundamental elements of DCIS biology including gene expression and genetic events, the relationship of DCIS with recurrence and invasive breast cancer, and the interaction of DCIS with the microenvironment. We also survey how these various elements are being used to solve the clinical conundrum of how to optimally treat a disease that has potential to progress, and yet is also likely over-treated in a significant proportion of cases.
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Affiliation(s)
- Kylie L. Gorringe
- Cancer Genomics Program, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
- The Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
| | - Stephen B. Fox
- The Sir Peter MacCallum Department of Oncology, University of Melbourne, Parkville, VIC, Australia
- Department of Pathology, Peter MacCallum Cancer Centre, Melbourne, VIC, Australia
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4
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Pang JMB, Gorringe KL, Fox SB. Ductal carcinoma in situ - update on risk assessment and management. Histopathology 2016; 68:96-109. [PMID: 26768032 DOI: 10.1111/his.12796] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 07/31/2015] [Indexed: 12/20/2022]
Abstract
Ductal carcinoma in situ (DCIS) accounts for ~20-25% of breast cancers. While DCIS is not life-threatening, it may progress to invasive carcinoma over time, and treatment intended to prevent invasive progression may itself cause significant morbidity. Accurate risk assessment is therefore necessary to avoid over- or undertreatment of an individual patient. In this review we will outline the evidence for current management of DCIS, discuss approaches to DCIS risk assessment and challenges facing identification of novel DCIS biomarkers.
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Affiliation(s)
- Jia-Min B Pang
- Department of Pathology, Peter MacCallum Cancer Centre, East Melbourne, Vic., Australia.,Department of Pathology, University of Melbourne, Melbourne, Vic., Australia
| | - Kylie L Gorringe
- Department of Pathology, University of Melbourne, Melbourne, Vic., Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Vic., Australia.,Cancer Genetics Laboratory, Peter MacCallum Cancer Centre, East Melbourne, Vic., Australia
| | - Stephen B Fox
- Department of Pathology, Peter MacCallum Cancer Centre, East Melbourne, Vic., Australia.,Department of Pathology, University of Melbourne, Melbourne, Vic., Australia.,Sir Peter MacCallum Department of Oncology, University of Melbourne, Melbourne, Vic., Australia
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5
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Bröckelmann PJ, Goergen H, Fuchs M, Kriz J, Semrau R, Baues C, Kobe C, Behringer K, Eichenauer DA, von Tresckow B, Klimm B, Halbsguth T, Wongso D, Plütschow A, Haverkamp H, Dietlein M, Eich HT, Stein H, Diehl V, Borchmann P, Engert A. Impact of centralized diagnostic review on quality of initial staging in Hodgkin lymphoma: experience of the German Hodgkin Study Group. Br J Haematol 2015; 171:547-56. [DOI: 10.1111/bjh.13646] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Accepted: 07/23/2015] [Indexed: 11/30/2022]
Affiliation(s)
- Paul J. Bröckelmann
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | | | - Michael Fuchs
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Jan Kriz
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Radiation Oncology; University Hospital Münster; Münster Germany
| | - Robert Semrau
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Radiation Oncology; University Hospital of Cologne; Cologne Germany
| | - Christian Baues
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Radiation Oncology; University Hospital of Cologne; Cologne Germany
| | - Carsten Kobe
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Nuclear Medicine; University Hospital of Cologne; Cologne Germany
| | - Karolin Behringer
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Dennis A. Eichenauer
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Bastian von Tresckow
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Beate Klimm
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department III of Internal Medicine; Krankenhaus Düren; Düren Germany
| | - Teresa Halbsguth
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department II of Internal Medicine; University Hospital of Frankfurt; Frankfurt Germany
| | - Diana Wongso
- German Hodgkin Study Group (GHSG); Cologne Germany
| | | | | | - Markus Dietlein
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Nuclear Medicine; University Hospital of Cologne; Cologne Germany
| | - Hans T. Eich
- German Hodgkin Study Group (GHSG); Cologne Germany
- Department of Radiation Oncology; University Hospital Münster; Münster Germany
| | - Harald Stein
- German Hodgkin Study Group (GHSG); Cologne Germany
- Pathodiagnostik Berlin; Berlin Germany
| | - Volker Diehl
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Peter Borchmann
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
| | - Andreas Engert
- Department I of Internal Medicine; University Hospital of Cologne; Cologne Germany
- German Hodgkin Study Group (GHSG); Cologne Germany
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Goodwin A, Parker S, Ghersi D, Wilcken N. Post-operative radiotherapy for ductal carcinoma in situ of the breast. Cochrane Database Syst Rev 2013:CD000563. [PMID: 24259251 DOI: 10.1002/14651858.cd000563.pub7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The addition of radiotherapy (RT) following breast conserving surgery (BCS) was first shown to reduce the risk of ipsilateral recurrence in the treatment of invasive breast cancer. Ductal carcinoma in situ (DCIS) is a pre-invasive lesion. Recurrence of ipsilateral disease following BCS can be either DCIS or invasive breast cancer. Randomised controlled trials (RCTs) have shown that RT can reduce the risk of recurrence, but assessment of potential long-term complications from addition of RT following BSC for DCIS has not been reported for women participating in RCTs. OBJECTIVES To summarise the data from RCTs testing the addition of RT to BCS for treatment of DCIS to determine the balance between the benefits and harms. SEARCH METHODS We searched the Cochrane Breast Cancer Group Specialised Register (2 June 2011), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 1), MEDLINE (2 June 2011), EMBASE (2 June 2011) and the World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP; 2 June 2011). Reference lists of articles and handsearching of ASCO (2007), ESMO (2002 to 2007), and St Gallen (2005 to 2007) conferences were performed. SELECTION CRITERIA RCTs of breast conserving surgery with and without radiotherapy in women at first diagnosis of pure ductal carcinoma in situ (no invasive disease present). DATA COLLECTION AND ANALYSIS Two authors independently assessed each potentially eligible trial for inclusion and its quality. Two authors also independently extracted data from published Kaplan-Meier analysis (survival curves) and reported summary statistics. Data were extracted and pooled for four trials. Data for planned subgroups were extracted and pooled for analysis.There were insufficient data to pool for long-term toxicity from radiotherapy. MAIN RESULTS Four RCTs involving 3925 women were identified and included in this review. All were high quality with minimal risk of bias. Three trials compared the addition of RT to BCS. One trial was a two by two factorial design comparing the use of RT and tamoxifen, each separately or together, in which participants were randomised in at least one arm. Analysis confirmed a statistically significant benefit from the addition of radiotherapy on all ipsilateral breast events (hazards ratio (HR) 0.49; 95% CI 0.41 to 0.58, P < 0.00001), ipsilateral invasive recurrence (HR 0.50; 95% CI 0.32 to 0.76, p=0.001) and ipsilateral DCIS recurrence (HR 0.61; 95% CI 0.39 to 0.95, P = 0.03). All the subgroups analysed benefited from addition of radiotherapy. No significant long-term toxicity from radiotherapy was found. No information about short-term toxicity from radiotherapy or quality of life data were reported. AUTHORS' CONCLUSIONS This review confirms the benefit of adding radiotherapy to breast conserving surgery for the treatment of all women diagnosed with DCIS. No long-term toxicity from use of radiotherapy was identified.
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Affiliation(s)
- Annabel Goodwin
- Medical Oncology/Cancer Genetics, Concord Hospital, Hospital Rd, Concord, NSW, Australia, 2137
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7
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Variation among Spanish teaching hospitals in ductal carcinoma in situ treatment: results of a national survey. Eur J Obstet Gynecol Reprod Biol 2013; 171:128-31. [DOI: 10.1016/j.ejogrb.2013.08.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2012] [Revised: 04/07/2013] [Accepted: 08/06/2013] [Indexed: 11/21/2022]
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Bijker N, Donker M, Wesseling J, den Heeten GJ, Rutgers EJT. Is DCIS breast cancer, and how do I treat it? Curr Treat Options Oncol 2013; 14:75-87. [PMID: 23239193 DOI: 10.1007/s11864-012-0217-1] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Ductal carcinoma in situ (DCIS) is a pre-invasive stage of breast cancer with a heterogeneous clinical behaviour. Since the introduction of mammographic screening programmes, the incidence of DCIS has shown a dramatic increase. Treatment should focus on the prevention of progression to invasive disease. If progression occurs, poorly differentiated DCIS frequently gives rise to grade III invasive breast cancer, whereas well differentiated DCIS more often recurs as grade I invasive disease. However, at present, validated diagnostic test are lacking to predict progression accurately. The majority of women with DCIS are suitable for breast conserving therapy. Obtaining clear surgical margins is the most important goal of a local excision. Radiotherapy is effective in reducing the risk of local recurrence with about 50 % in all subgroups of patients with DCIS. (Breast cancer specific) survival of women with DCIS is excellent, and radiotherapy does not further improve this. Future research should be directed in enabling to select women who have a high risk of--invasive--recurrence, so in which radiotherapy should be standard part of the breast conserving approach, and those women with a more indolent lesion, in which after surgery a watchful waiting approach can be followed.
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Affiliation(s)
- N Bijker
- Department of Radiation Oncology, Academic Medical Center, P.O. Box 22700, 1100DE, Amsterdam, The Netherlands.
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9
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Wong P, Lambert C, Agnihotram RV, David M, Duclos M, Freeman CR. Ductal Carcinoma in Situ—The Influence of the Radiotherapy Boost on Local Control. Int J Radiat Oncol Biol Phys 2012; 82:e153-8. [DOI: 10.1016/j.ijrobp.2011.03.045] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2010] [Revised: 02/27/2011] [Accepted: 03/04/2011] [Indexed: 10/18/2022]
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11
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Ballehaninna UK, Chamberlain RS. Inclusion of Tumor Biology Molecular Markers to Improve the Ductal Carcinoma In Situ Ipsilateral Breast Tumor Recurrence Nomogram Predictability. J Clin Oncol 2011; 29:e97-8; author reply e99. [DOI: 10.1200/jco.2010.32.6850] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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12
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Low CD10 mRNA expression identifies high-risk ductal carcinoma in situ (DCIS). PLoS One 2010; 5. [PMID: 20856894 PMCID: PMC2938371 DOI: 10.1371/journal.pone.0012100] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Accepted: 07/12/2010] [Indexed: 11/23/2022] Open
Abstract
Purpose Optimal management of breast ductal carcinoma in situ (DCIS) is controversial, and many patients are still overtreated. The local death of myoepithelial cells (MECs) is believed to be a pre-requisite to tumor invasion. We thus hypothesized that loss of CD10 expression, a MEC surface peptidase, would signify basement membrane disruption and confer increased risk of relapse in DCIS. The aim of our study was to retrospectively evaluate the prognostic value of CD10 in DCIS. Experimental Design CD10 expression was evaluated by quantitative RT-PCR and immunohistochemistry using paraffin-embedded samples of normal breast tissue (n = 11); of morphologically normal ducts associated with DCIS (n = 10); and of DCIS without an invasive component (n = 154). Results CD10 immunostaining was only observed in MECs in normal tissue and in DCIS. Normal tissue showed high mRNA expression levels of CD10, whereas DCIS showed a variable range. After a median follow-up of 6 years, DCIS with CD10 expression below the levels observed in normal tissue (71%) demonstrated a higher risk of local relapse (HR = 1.88; [95CI:1.30–2.70], p = 0.001) in univariate analysis. No relapse was observed in patients expressing high CD10 mRNA levels (29%) similar to the ones observed in normal tissue. In multivariate analysis including known prognostic factors, low CD10 mRNA expression remained significant (HR = 2.25; [95%CI:1.24–4.09], p = 0.008), as did the recently revised Van Nuys Prognostic Index (VNPI) score (HR = 2.03; [95%CI:1.23–3.35], p = 0.006). Conclusion The decrease of CD10 expression in MECs is associated with a higher risk of relapse in DCIS; this knowledge has the potential to improve DCIS management.
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Israel PZ, Vicini F, Robbins AB, Shroff P, McLaughlin M, Grier K, Lyden M. Ductal carcinoma in situ of the breast treated with accelerated partial breast irradiation using balloon-based brachytherapy. Ann Surg Oncol 2010; 17:2940-4. [PMID: 20443148 DOI: 10.1245/s10434-010-1044-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2009] [Indexed: 11/18/2022]
Abstract
BACKGROUND We reviewed our institution's experience treating patients with ductal carcinoma in situ (DCIS) of the breast with balloon-based accelerated partial breast irradiation (APBI) to determine the efficacy of this treatment approach in this group of patients. MATERIALS AND METHODS A total of 126 cases of DCIS seen and treated with APBI using balloon-based brachytherapy constitute the study population. The median age at diagnosis was 59 years (range, 37-82) with 21% younger than age 50. Nuclear grade distribution was 52.5, 41.4, and 6.1% high, intermediate and low, respectively. Of these patients, 86% had estrogen receptor positive DCIS. The median tumor size was 6 mm (range, 1-26). Margins of excision were negative in 98.4% of patients. All patients were treated with 34 Gy in 10 fractions using either the MammoSite™ or Contura™ breast brachytherapy catheter. A total of 87 patients (73.1%) were placed on adjuvant tamoxifen or arimedex. RESULTS With a median follow-up of 24 months (range, 0.7-73.9), three (2.4%) ipsilateral breast tumor recurrences (IBTRs) developed for a 2-year actuarial rate of 0.81%. Recurrences developed 4.8, 24.7, and 24.9 months after treatment. On univariate analysis, no variable was associated with IBTR. A subset analysis of the first 50 consecutive patients treated was also performed. With a median follow-up of 40 months (range, 15.6-73.9), one IBTR developed for a 3-year actuarial rate of 2.15%. CONCLUSIONS Early results in patients with DCIS treated with APBI using balloon-based brachytherapy produced results similar to those with invasive cancer treated with APBI or DCIS treated with whole breast irradiation.
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Gonzalez LO, Junquera S, del Casar JM, González L, Marín L, González-Reyes S, Andicoechea A, González-Fernández R, González JM, Pérez-Fernández R, Vizoso FJ. Immunohistochemical study of matrix metalloproteinases and their inhibitors in pure and mixed invasive and in situ ductal carcinomas of the breast. Hum Pathol 2010; 41:980-9. [PMID: 20236691 DOI: 10.1016/j.humpath.2009.08.027] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2009] [Revised: 07/27/2009] [Accepted: 08/21/2009] [Indexed: 12/24/2022]
Abstract
We assessed differences in the patterns of expression of matrix metalloproteases and their inhibitors (tissue inhibitors of metalloproteases) in ductal carcinoma in situ alone and admixed with invasive ductal carcinomas (n = 40), as well as in pure invasive ductal carcinomas (n = 40), immunohistochemically and using tissue arrays. The invasive ductal carcinoma components showed higher expression of matrix metalloprotease-9 and -13 than did the admixed ductal carcinoma in situ, whereas stromal fibroblasts of the invasive components showed higher expression of matrix metalloprotease-2, -7, -9, -13, and -14 and tissue inhibitor of metalloprotease-1 and -3 than did fibroblasts around the neoplastic ducts of the admixed ductal carcinoma in situ. Expression of matrix metalloprotease-14 and tissue inhibitor of metalloprotease-3 was significantly higher in the mononuclear inflammatory cells of the invasive components. By contrast, matrix metalloprotease-1 expression was significantly higher in stromal cells of the ductal carcinoma in situ admixed with invasive ductal carcinoma. The pure invasive ductal carcinomas had significantly higher expression of matrix metalloprotease-1, -9, -11, and -14 and tissue inhibitor of metalloprotease-1 and -3 than the invasive ductal carcinomas admixed with ductal carcinoma in situ. Our findings indicate a significant association of matrix metalloprotease expression by the periductal stromal cells of the ductal carcinoma in situ component of mixed tumors and the occurrence of distant metastasis. Our data suggest that the molecular matrix metalloprotease/tissue inhibitor of metalloprotease profile can contribute to better characterization of early breast carcinomas.
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Affiliation(s)
- Luis O Gonzalez
- Unidad de Investigación, Fundación Hospital de Jove, Gijón, Spain
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Goodwin A, Parker S, Ghersi D, Wilcken N. Post-operative radiotherapy for ductal carcinoma in situ of the breast. Cochrane Database Syst Rev 2009:CD000563. [PMID: 19821272 DOI: 10.1002/14651858.cd000563.pub6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
BACKGROUND The addition of radiotherapy (RT) following breast conserving surgery (BCS) was first shown to reduce the risk of ipsilateral recurrence in the treatment of invasive breast cancer. Ductal carcinoma in situ (DCIS) is a pre-invasive lesion. Recurrence of ipsilateral disease following BCS can be either DCIS or invasive breast cancer. Randomised controlled trials (RCTs) have shown that RT can reduce the risk of recurrence, but assessment of potential long-term complications from addition of RT following BSC for DCIS has not been reported for women participating in RCTs. OBJECTIVES To summarise the data from RCTs testing the addition of RT to BCS for treatment of DCIS to determine the balance between the benefits and harms. SEARCH STRATEGY We searched the Cochrane Breast Cancer Group Specialised Register (January 2008), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 1), MEDLINE (February 2008), and EMBASE (February 2008). Reference lists of articles and handsearching of ASCO (2007), ESMO (2002 to 2007), and St Gallen (2005 to 2007) conferences were performed. SELECTION CRITERIA RCTs of breast conserving surgery with and without radiotherapy in women at first diagnosis of pure ductal carcinoma in situ (no invasive disease present). DATA COLLECTION AND ANALYSIS Two authors independently assessed each potentially eligible trial for inclusion and its quality. Two authors also independently extracted data from published Kaplan-Meier analysis (survival curves) and reported summary statistics. Data were extracted and pooled for four trials. Data for planned subgroups were extracted and pooled for analysis.There were insufficient data to pool for long-term toxicity from radiotherapy. MAIN RESULTS Four RCTs involving 3925 women were identified and included in this review. All were high quality with minimal risk of bias. Three trials compared the addition of RT to BCS. One trial was a two by two factorial design comparing the use of RT and tamoxifen, each separately or together, in which participants were randomised in at least one arm. Analysis confirmed a statistically significant benefit from the addition of radiotherapy on all ipsilateral breast events (hazards ratio (HR) 0.49; 95% CI 0.41 to 0.58, P < 0.00001), ipsilateral invasive recurrence (HR 0.50; 95% CI 0.32 to 0.76, p=0.001) and ipsilateral DCIS recurrence (HR 0.61; 95% CI 0.39 to 0.95, P = 0.03). All the subgroups analysed benefited from addition of radiotherapy. No significant long-term toxicity from radiotherapy was found. No information about short-term toxicity from radiotherapy or quality of life data were reported. AUTHORS' CONCLUSIONS This review confirms the benefit of adding radiotherapy to breast conserving surgery for the treatment of all women diagnosed with DCIS. No long-term toxicity from use of radiotherapy was identified.
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Affiliation(s)
- Annabel Goodwin
- Cancer Genetics, Westmead Hospital, Hawksberry Road, Westmead, NSW, Australia, 2145
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16
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Bricou A, Delpech Y, Barranger E. [Atypical ductal and lobular hyperplasia of the breast]. ACTA ACUST UNITED AC 2009; 37:814-9. [PMID: 19766043 DOI: 10.1016/j.gyobfe.2009.06.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Accepted: 06/24/2009] [Indexed: 10/20/2022]
Abstract
Atypical hyperplasia represents 4% of all benign breast diseases. There are two different types: atypical ductal hyperplasia and atypical lobular hyperplasia. Aside columnar cell lesion. They represent an early stage of some forms of low grade carcinoma in situ and invasive carcinomas. Atypical hyperplasia is a benign lesion with intermediate carcinologic risk and the existence of a concomitant aggressive lesion should be suspected. When atypical lesion is found on a biopsy specimen, surgical excision is recommended especially in case of atypical ductal hyperplasia. A regular supervision is recommended.
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Affiliation(s)
- A Bricou
- Service de gynécologie-obstétrique, hôpital Lariboisière, AP-HP, 2, rue Ambroise-Paré, 75010 Paris, France
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17
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Goodwin A, Parker S, Ghersi D, Wilcken N. Post-operative radiotherapy for ductal carcinoma in situ of the breast. Cochrane Database Syst Rev 2009:CD000563. [PMID: 19588320 DOI: 10.1002/14651858.cd000563.pub5] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The addition of radiotherapy (RT) following breast conserving surgery (BCS) was first shown to reduce the risk of ipsilateral recurrence in the treatment of invasive breast cancer. Ductal carcinoma in situ (DCIS) is a pre-invasive lesion. Recurrence of ipsilateral disease following BCS can be either DCIS or invasive breast cancer. Randomised controlled trials (RCTs) have shown that RT can reduce the risk of recurrence, but assessment of potential long-term complications from addition of RT following BSC for DCIS has not been reported for women participating in RCTs. OBJECTIVES To summarise the data from RCTs testing the addition of RT to BCS for treatment of DCIS to determine the balance between the benefits and harms. SEARCH STRATEGY We searched the Cochrane Breast Cancer Group Specialised Register (January 2008), Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2008, Issue 1), MEDLINE (February 2008), and EMBASE (February 2008). Reference lists of articles and handsearching of ASCO (2007), ESMO (2002 to 2007), and St Gallen (2005 to 2007) conferences were performed. SELECTION CRITERIA RCTs of breast conserving surgery with and without radiotherapy in women at first diagnosis of pure ductal carcinoma in situ (no invasive disease present). DATA COLLECTION AND ANALYSIS Two authors independently assessed each potentially eligible trial for inclusion and its quality. Two authors also independently extracted data from published Kaplan-Meier analysis (survival curves) and reported summary statistics. Data were extracted and pooled for four trials. Data for planned subgroups were extracted and pooled for analysis.There were insufficient data to pool for long-term toxicity from radiotherapy. MAIN RESULTS Four RCTs involving 3925 women were identified and included in this review. All were high quality with minimal risk of bias. Three trials compared the addition of RT to BCS. One trial was a two by two factorial design comparing the use of RT and tamoxifen, each separately or together, in which participants were randomised in at least one arm. Analysis confirmed a statistically significant benefit from the addition of radiotherapy on all ipsilateral breast events (hazards ratio (HR) 0.49; 95% CI 0.41 to 0.59, P < 0.00001) and ipsilateral DCIS recurrence (HR 0.64; 95% CI 0.41 to 1.01, P = 0.05). Pooled analysis for invasive recurrence did not reach statistical significance. All the subgroups analysed benefited from addition of radiotherapy. No significant long-term toxicity from radiotherapy was found. No information about short-term toxicity from radiotherapy or quality of life data were reported. AUTHORS' CONCLUSIONS This review confirms the benefit of adding radiotherapy to breast conserving surgery for the treatment of all women diagnosed with DCIS. No long-term toxicity from use of radiotherapy was identified.
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Affiliation(s)
- Annabel Goodwin
- Cancer Genetics, Westmead Hospital, Hawksberry Road, Westmead, NSW, Australia, 2145
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Gonzalez LO, Corte MD, Vazquez J, Junquera S, Sanchez R, Viña A, Rodriguez JC, Lamelas ML, Vizoso F. Study of matrix metalloproteinases and their tissue inhibitors in ductal in situ carcinomas of the breast. Histopathology 2009; 53:403-15. [PMID: 18983606 DOI: 10.1111/j.1365-2559.2008.03136.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
AIMS To analyse the expression of metalloproteinases (MMPs) and their inhibitors (TIMPs) in ductal carcinoma in situ of the breast (DCIS). METHODS AND RESULTS An immunohistochemical study was performed in 56 patients with pure DCIS, in 39 with DCIS adjacent to invasive carcinoma (IDC) and 63 patients with T1 IDC, using tissue microarrays and specific antibodies against MMPs and TIMPs. Immunohistochemical results were categorized using a specific software program. The data were analysed by unsupervised hierarchical cluster analysis by each cellular type. IDC showed a higher expression rate of MMP-7 and TIMP-1 than pure DCIS, as well as a higher expression rate of MMP-9 and TIMP-3 than the DCIS component of mixed cases, whereas pure DCIS showed a higher rate of expression of MMP-9 and -11 and TIMP-3 than in the DCIS component of mixed cases. Pure DCIS with a periductal inflammatory infiltrate showed significantly higher MMP-2, -14 and TIMP-1. Dendograms identified two cluster groups with distinct MMP/TIMP expression profiles in neoplastic cells and fibroblastic or mononuclear inflammatory cells surrounding the neoplastic ducts of pure DCIS. CONCLUSIONS The results indicate the distinct variability in MMP/TIMP expression by DCIS, which may be of potential biological and clinical interest in breast cancer.
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Affiliation(s)
- L O Gonzalez
- Unidad de Investigación, Hospital de Jove, Gijón, Spain
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19
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Orr J, Kelley J, Dizon D, Escobar P, Fleming E, Gemignani M, Hetzel D, Hoskins W, Kieback D, Kilgore L, LaPolla J, Lewin S, Lucci J, Markman M, Pothuri B, Powell CB, Tejada-Berges T. Society of gynecologic oncologists position paper: breast cancer care. Gynecol Oncol 2008; 110:7-12. [PMID: 18589209 DOI: 10.1016/j.ygyno.2008.04.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2008] [Accepted: 04/04/2008] [Indexed: 10/21/2022]
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20
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Wiechmann L, Kuerer HM. The molecular journey from ductal carcinoma in situ to invasive breast cancer. Cancer 2008; 112:2130-42. [PMID: 18383519 DOI: 10.1002/cncr.23430] [Citation(s) in RCA: 96] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Affiliation(s)
- Lisa Wiechmann
- Breast Center, Baylor College of Medicine, Houston, Texas, USA
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Nofech-Mozes S, Spayne J, Rakovitch E, Kahn HJ, Seth A, Pignol JP, Lickley L, Paszat L, Hanna W. Biological Markers Predictive of Invasive Recurrence in DCIS. Clin Med Oncol 2008. [DOI: 10.1177/117955490800200202] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
DCIS is a heterogeneous group of non-invasive cancers of the breast characterized by various degrees of differentiation and unpredictable propensity for transformation into invasive carcinoma. We examined the expression and prognostic value of 9 biological markers with a potential role in tumor progression in 133 patients with pure DCIS treated with breast conserving surgery alone, between 1982–2000. Histology was reviewed and immunohistochemical staining was performed. Pearson correlation coefficient was used to determine the associations between markers and histopathological features. Univariate and multivariate analysis examined associations between time to recurrence and clinico-pathologic features and biological markers. Median age at diagnosis was 55 years (25–85). With a median follow up of 8.91 years, 41/133 patients recurred (21 as invasive recurrence). In this cohort 13.5% had low, 43% intermediate and 42% high nuclear grade. Comedo necrosis was found in 65% of cases. Expression of ER (62.4%), PR (55.6%), HER2/neu (31.6%), MIB1 (39.8%), p53 (22.6%), p21 (39.8%), Cyclin D1 (95.5%) calgranulin (20.5%), psoriasin (12%), was found in DCIS. HER2/neu was overexpressed in 45% that recurred as DCIS and 42.9% that recurred as invasive cancer, and only in 26.1% in cases that never recurred. On univariate analysis, HER2/neu overexpression was the only marker associated with an increased risk for any recurrence (p = 0.044). The hazard ratio for recurrence for HER2/neu positive DCIS was 1.927 (confidence interval 1.016–3.653) compared to HER2 negative DCIS. On multivariate analysis, HER2/neu overexpression remained the only independent variable significantly associated with any recurrence (p = 0.014) and with invasive recurrence (p = 0.044). This data suggest that HER2/neu testing may become an important parameter in the management of DCIS and the treatment of cases with positive HER2/neu status could be modified accordingly, similar to the current approach for HER2/neu positive invasive disease.
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Affiliation(s)
| | - Jacqueline Spayne
- Department of Radiation Oncology Toronto Sunnybrook Regional Cancer Centre
| | - Eileen Rakovitch
- Department of Radiation Oncology Toronto Sunnybrook Regional Cancer Centre
| | - Harriette J Kahn
- Department of Pathology, Sunnybrook Health Sciences Center (SHSC)
| | - Arun Seth
- Department of Molecular Biology, SHSC
- Research Institue, SHSC
| | | | | | - Lawrence Paszat
- Department of Radiation Oncology Toronto Sunnybrook Regional Cancer Centre
- The Institute for Clinical Evaluative Sciences
| | - Wedad Hanna
- Department of Pathology, Sunnybrook Health Sciences Center (SHSC)
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22
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Gonzalez LO, Corte MD, Junquera S, Bongera M, Rodriguez JC, Vizoso FJ. Expression of androgen receptor and two androgen-induced proteins (apolipoprotein D and pepsinogen C) in ductal carcinoma in situ of the breast. Histopathology 2007; 50:866-74. [PMID: 17543076 DOI: 10.1111/j.1365-2559.2007.02687.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIMS To evaluate the expression of androgen receptors (AR) and two androgen-induced proteins [apolipoprotein D (ApoD) and pepsinogen C (PepC)] in ductal carcinoma in situ (DCIS) of the breast. METHODS AND RESULTS AR, ApoD and PepC expression was examined in 28 cases of pure DCIS and in 31 cases of DCIS adjacent to invasive carcinoma of the breast using immunohistochemical methods and then correlated with the architectural subtype, the degree of differentiation and the ostrogen receptor (ER)/progesterone receptor (PgR)/HER-2 status. We found no significant differences between pure DCIS and DCIS adjacent to invasive breast cancer regarding the percentage of positive cases for ApoD (64.3% versus 54.8%), PepC (42.9% versus 48.4%), ER (64.3% versus 58.1%), PgR (60.7% versus 58.1%) and HER-2 (39.3% versus 67.7%). However, there was a significantly higher percentage of AR+ DCIS among those adjacent to invasive carcinomas of the breast than among pure DCIS lesions (93.5% versus 60.9%) (P = 0.009). AR expression did not correlate with architectural subtype, degree of differentiation, or ER/PgR/HER-2/ApoD/PepC status, in cases of pure DCIS, nor in DCIS adjacent to invasive carcinoma of the breast. CONCLUSIONS AR expression may represent an independent predictive factor in DCIS of the breast.
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MESH Headings
- Apolipoproteins D/metabolism
- Biomarkers, Tumor/metabolism
- Breast Neoplasms/metabolism
- Breast Neoplasms/pathology
- Carcinoma, Ductal, Breast/metabolism
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Intraductal, Noninfiltrating/metabolism
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Female
- Glycoproteins/metabolism
- Humans
- Immunohistochemistry
- Membrane Transport Proteins/metabolism
- Middle Aged
- Neoplasm Proteins/metabolism
- Pepsinogen C/metabolism
- Receptor, ErbB-2/metabolism
- Receptors, Androgen/metabolism
- Receptors, Estrogen/metabolism
- Receptors, Progesterone/metabolism
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Affiliation(s)
- L O Gonzalez
- Instituto Universitario de Oncologí,a del Principado de Asturias, Hospital de Jove, Gijón, Spain
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23
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André G, Tunon-de-Lara C, Macgrogan G, Laharie-Mineur H, Bussieres JE, Valentin F, Barreau B, Dilhuydy MH, Dilhuydy JM, Mauriac L, Debled M, Durand M, Mathoulin S, Avril A. [Bilateral ductal carcinoma in situ of the breast: independent events or bilateral disease?]. ACTA ACUST UNITED AC 2007; 36:260-6. [PMID: 17376610 DOI: 10.1016/j.jgyn.2007.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2006] [Revised: 01/08/2007] [Accepted: 02/06/2007] [Indexed: 11/19/2022]
Abstract
OBJECTIVES In a retrospective study of bilateral Ductal Carcinoma In Situ (DCIS), cases were analysed to determine the relationship between the two events. MATERIAL AND METHODS From 1971 to 2001, among 812 patients with DCIS in Bergonie Institute, 78 suffering from bilateral DCIS and only19 were treated entirely in our institute. It was either synchronous DCIS or asynchronous (before 6 months). We realised a comparative study between, clinical and pathological characteristics of each DCIS. RESULTS In case of asynchronous DCIS, contra lateral DCIS occurred after a median 75-months period and until 22 years after the first event. We found at least for one histological subtype an agreement in 53% of cases. In 31% of cases, the grade was the same. For low plus intermediary grade versus high grade, the agreement was 53%. There was a subtype and grade agreement of 32% and a subtype or grade agreement in 63% of cases. CONCLUSION Histological agreement between the two lesions indicated the possible existence of in situ bilateral disease in these women. The local relapse rate was 20% and all of them were invasive. The risk of relapse in controlateral breast is high and patient needs a long follow up even in case of mastectomy.
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Affiliation(s)
- G André
- Service de Chirurgie, Institut Bergonié, 229, Cours de l'Argonne, Bordeaux, France
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24
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Dillon MF, Mc Dermott EW, O'Doherty A, Quinn CM, Hill AD, O'Higgins N. Factors Affecting Successful Breast Conservation for Ductal Carcinoma in Situ. Ann Surg Oncol 2007; 14:1618-28. [PMID: 17443388 DOI: 10.1245/s10434-006-9246-y] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2006] [Revised: 09/02/2006] [Accepted: 09/05/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND Successful breast-conserving therapy in DCIS is restricted by high rates of residual disease resulting in the need for radiotherapy and/or re-excision. This study identifies patients with DCIS who are most at risk of compromised margins and of residual disease. METHODS All patients undergoing breast-conserving surgery for DCIS over a 6-year period were included. Method of diagnosis, mammographic size, pathological size, DCIS-margin distance and residual disease on re-excision were analysed. RESULTS One hundred and thirty-five patients underwent initial breast-conserving surgery for DCIS. The compromised margin rate was 72%, and the rate of residual disease on re-operation was 54%. On univariate analysis, underestimation of pathological size by mammography by >1 cm occurred in 40% of those with compromised margins undergoing a therapeutic operation compared to only 14% of those with clear margins (P = 0.02). However, on multivariate analysis only pathological size (P < 0.0001, OR = 1.0,95% CI 1.037-1.128) and lack of a preoperative diagnosis by core biopsy (P < 0.0001, OR = 5.3,95% CI 1.859-15.08) were predictive of compromised margins. The presence of residual disease on re-excision was associated with increasing pathological size (P < 0.0001, OR = 1.085,95% CI 1.038-1.134) and decreasing DCIS-margin distance (P = 0.03, OR = 6.694,95% CI 1.84-37.855). Twenty-nine percent (n = 13/45) of lesions < or =3 cm compared to 84% (n = 27/32) of lesions >3 cm had residual disease on re-operation (P < 0.0001). Residual disease was present in 62% (n = 34/55), 64% (n = 7/11) and 17% (n = 2/12) of patients with DCIS-margin distances < or =1, 1-2 and 2-5 mm, respectively. CONCLUSION Considerable underestimation of DCIS extent by mammography occurs in a high proportion of patients with compromised margins in breast conservation. Patients at particularly high risk of residual disease on re-excision are those with lesions >3 cm and those with DCIS-margin distances of < or = 2mm.
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Affiliation(s)
- Mary F Dillon
- Department of Surgery, St Vincent's University Hospital, Dublin, Ireland.
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25
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Bijker N, Meijnen P, Peterse JL, Bogaerts J, Van Hoorebeeck I, Julien JP, Gennaro M, Rouanet P, Avril A, Fentiman IS, Bartelink H, Rutgers EJT. Breast-conserving treatment with or without radiotherapy in ductal carcinoma-in-situ: ten-year results of European Organisation for Research and Treatment of Cancer randomized phase III trial 10853--a study by the EORTC Breast Cancer Cooperative Group and EORTC Radiotherapy Group. J Clin Oncol 2006; 24:3381-7. [PMID: 16801628 DOI: 10.1200/jco.2006.06.1366] [Citation(s) in RCA: 547] [Impact Index Per Article: 30.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The European Organisation for Research and Treatment of Cancer conducted a randomized trial investigating the role of radiotherapy (RT) after local excision (LE) of ductal carcinoma-in-situ (DCIS) of the breast. We analyzed the efficacy of RT with 10 years follow-up on both the overall risk of local recurrence (LR) and related to clinical, histologic, and treatment factors. PATIENTS AND METHODS After complete LE, women with DCIS were randomly assigned to no further treatment or RT (50 Gy). One thousand ten women with mostly (71%) mammographically detected DCIS were included. The median follow-up was 10.5 years. RESULTS The 10-year LR-free rate was 74% in the group treated with LE alone compared with 85% in the women treated by LE plus RT (log-rank P < .0001; hazard ratio [HR] = 0.53). The risk of DCIS and invasive LR was reduced by 48% (P = .0011) and 42% (P = .0065) respectively. Both groups had similar low risks of metastases and death. At multivariate analysis, factors significantly associated with an increased LR risk were young age (< or = 40 years; HR = 1.89), symptomatic detection (HR = 1.55), intermediately or poorly differentiated DCIS (as opposed to well-differentiated DCIS; HR = 1.85 and HR = 1.61 respectively), cribriform or solid growth pattern (as opposed to clinging/micropapillary subtypes; HR = 2.39 and HR = 2.25 respectively), doubtful margins (HR = 1.84), and treatment by LE alone (HR = 1.82). The effect of RT was homogeneous across all assessed risk factors. CONCLUSION With long-term follow-up, RT after LE for DCIS continued to reduce the risk of LR, with a 47% reduction at 10 years. All patient subgroups benefited from RT.
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26
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Poortmans PM, Davis JB, Ataman F, Bernier J, Horiot JC. The quality assurance programme of the Radiotherapy Group of the European Organisation for Research and Treatment of Cancer: past, present and future. Eur J Surg Oncol 2005; 31:667-74. [PMID: 16100781 DOI: 10.1016/j.ejso.2005.02.014] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
As early as in 1982, the European Organisation for Research and Treatment of Cancer Radiotherapy Group established a quality assurance programme. In the course of 20 years, quality assurance procedures have become a vast and important part of the activities of the group. Today, the membership committee uses standard procedures based on minimal requirements to evaluate current members and new membership applications. Moreover, for every new trial, specific quality assurance procedures are an integral part of the preparation of the protocol and executed under the responsibility of the study coordinator. With the growing complexity of the radiotherapy techniques used in the framework of the more recent trials, quality assurance procedures have also become more complex including trial specific phantom based measurements. Future ways to evaluate all steps of the radiotherapy process using a common platform connecting all users with the internet are currently under development.
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Affiliation(s)
- P M Poortmans
- Department of Radiotherapy, Dr Bernard Verbeeten Instituut, Tilburg, The Netherlands.
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27
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Nofech-Mozes S, Spayne J, Rakovitch E, Hanna W. Prognostic and predictive molecular markers in DCIS: a review. Adv Anat Pathol 2005; 12:256-64. [PMID: 16210921 DOI: 10.1097/01.pap.0000184177.65919.5e] [Citation(s) in RCA: 57] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Eighteen percent of all new breast cancers detected on screening mammography are ductal carcinoma in situ (DCIS), a preinvasive lesion that is highly curable. However, some women with DCIS will develop life-threatening invasive breast cancer. Because the determinants of invasive recurrence are unknown, all women with DCIS require the same treatment (usually with surgery and radiation). Therefore, there is a need to identify biologic markers and create a profile that will provide prognostic information that is more accurate than the currently used van Nuys Index to predict invasive recurrence. In the present review, we examined the many biologic markers studied in breast cancer, describe their main biologic role and their expression in DCIS, and review the various studies regarding their ability to serve as prognostic factors in breast cancer with an emphasis on predicting invasive recurrence in patients with DCIS. This review covers established markers, namely, ER, PR and HER2/neu, that are used routinely to make treatment decisions as well as investigative biologic factors involved in cell proliferation, cell cycle regulation, extracellular molecules, factors involved in extracellular matrix degradation, and angiogenesis. However, controversies exist regarding the value of these prognostic factors, their interrelationship, and their advantages over morphologic evaluation.
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Affiliation(s)
- Sharon Nofech-Mozes
- Department of Pathology, Sunnybrook and Women's College Health Sciences Center, Toronto, Ontario, Canada
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28
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Abstract
The incidence of ductal carcinoma in situ (DCIS), a noninvasive form of breast cancer, has increased markedly in recent decades, and DCIS now accounts for approximately 20% of breast cancers diagnosed by mammography. Laboratory and patient data suggest that DCIS is a precursor lesion for invasive cancer. The appropriate classification of DCIS has provoked much debate; a number of classification systems have been developed, but there is a lack of uniformity in the diagnosis and prognostication of this disease. Further investigation of molecular markers should improve the classification of DCIS and our understanding of its relationship to invasive disease. Controversy also exists with regard to the optimal management of DCIS patients. In the past, mastectomy was the primary treatment for patients with DCIS, but as with invasive cancer, breast-conserving surgery has become the standard approach. Three randomized trials have reported a statistically significant decrease in the risk of recurrence with radiation therapy in combination with lumpectomy compared with lumpectomy alone, but there was no survival advantage with the addition of radiotherapy. Two randomized trials have suggested an additional benefit, in terms of recurrence, with the addition of adjuvant tamoxifen therapy, although in one trial the benefit was not statistically significant. Current data suggest that tamoxifen use should be restricted to patients with estrogen receptor-positive DCIS. Neither trial demonstrated a survival benefit with adjuvant tamoxifen. Ongoing and recently completed studies should provide information on outcomes in patients treated with lumpectomy alone and on the effectiveness of aromatase inhibitors as an alternative to tamoxifen.
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MESH Headings
- Antineoplastic Agents, Hormonal/administration & dosage
- Aromatase Inhibitors
- Biomarkers, Tumor/analysis
- Breast Neoplasms/diagnosis
- Breast Neoplasms/drug therapy
- Breast Neoplasms/epidemiology
- Breast Neoplasms/pathology
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Breast Neoplasms/therapy
- Carcinoma, Intraductal, Noninfiltrating/diagnosis
- Carcinoma, Intraductal, Noninfiltrating/drug therapy
- Carcinoma, Intraductal, Noninfiltrating/epidemiology
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/radiotherapy
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Intraductal, Noninfiltrating/therapy
- Chemotherapy, Adjuvant
- Clinical Trials as Topic
- Enzyme Inhibitors/pharmacology
- Estrogen Receptor Modulators/administration & dosage
- Female
- Humans
- Lymph Node Excision
- Lymphatic Metastasis
- Magnetic Resonance Imaging
- Mammography
- Mastectomy, Segmental
- Neoplasm Recurrence, Local/prevention & control
- Radiotherapy, Adjuvant
- Receptors, Estrogen/analysis
- Risk Factors
- SEER Program
- Tamoxifen/administration & dosage
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Affiliation(s)
- Gregory D Leonard
- Cancer Therapeutics Branch, National Cancer Institute, Bethesda, MD 20889-5105, USA
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29
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Barillot I, Cutuli B, Arnould L. [Ductal in situ carcinoma: is it ethical to consider the breast conserving therapy as a standard?]. Cancer Radiother 2004; 8:9-20. [PMID: 15093196 DOI: 10.1016/j.canrad.2003.09.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
The increasing incidence of DCIS during the past 20 years needs a continuous evaluation of the treatment strategies and a multidisciplinary decision process. The management of the DCIS remains a challenging issue in 2003. Mastectomy should still be considered as the reference treatment which is able to guarantee cure in almost all cases, whereas breast conserving surgery followed by radiation therapy is associated with 7-10% of local recurrence. However, the increasing knowledge of the predictive factors of the local recurrence allows to propose a conservative treatment strategy to a large amount of patients, without negative impact on their prognosis. This review presents the arguments that permit to justify the reasoned choice of the different therapeutic options according to the clinico-pathological situations.
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MESH Headings
- Adult
- Age Factors
- Analysis of Variance
- Antineoplastic Agents, Hormonal/administration & dosage
- Antineoplastic Agents, Hormonal/therapeutic use
- Breast Neoplasms/diagnostic imaging
- Breast Neoplasms/drug therapy
- Breast Neoplasms/mortality
- Breast Neoplasms/radiotherapy
- Breast Neoplasms/surgery
- Carcinoma in Situ/diagnostic imaging
- Carcinoma in Situ/drug therapy
- Carcinoma in Situ/mortality
- Carcinoma in Situ/radiotherapy
- Carcinoma in Situ/surgery
- Carcinoma, Ductal, Breast/diagnostic imaging
- Carcinoma, Ductal, Breast/mortality
- Carcinoma, Ductal, Breast/radiotherapy
- Carcinoma, Ductal, Breast/surgery
- Combined Modality Therapy
- Female
- Follow-Up Studies
- Humans
- Lymphatic Metastasis
- Mammography
- Mastectomy
- Middle Aged
- Multicenter Studies as Topic
- Neoplasm Recurrence, Local
- Prognosis
- Radiotherapy Dosage
- Randomized Controlled Trials as Topic
- Retrospective Studies
- Risk Factors
- Tamoxifen/administration & dosage
- Tamoxifen/therapeutic use
- Time Factors
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Affiliation(s)
- I Barillot
- Département de radiothérapie, centre de lutte contre le cancer Georges-François-Leclerc, 1, rue du Professeur-Marion, 21079 Dijon, France.
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30
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Peeters KCMJ, van de Velde CJH. Surgical quality assurance in breast, gastric and rectal cancer. J Surg Oncol 2003; 84:107-12. [PMID: 14598352 DOI: 10.1002/jso.10312] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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31
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Ottevanger PB, Therasse P, van de Velde C, Bernier J, van Krieken H, Grol R, De Mulder P. Quality assurance in clinical trials. Crit Rev Oncol Hematol 2003; 47:213-35. [PMID: 12962897 DOI: 10.1016/s1040-8428(03)00028-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
From the literature that was initially searched by electronic databases using the keywords quality, quality control and quality assurance in combination with clinical trials, surgery, pathology, radiotherapy, chemotherapy and data management, a comprehensive review is given on what quality assurance means, the various methods used for quality assurance in different aspects of clinical trials and the impact of this quality assurance on outcome and every day practice.
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Affiliation(s)
- P B Ottevanger
- Department of Internal Medicine, Division of Medical Oncology, 550, University Hospital Nijmegen, Geert Grooteplein 8, PO 9101, 6500HB Nijmegen, The Netherlands.
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32
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Kouloulias VE, Poortmans PM, Bernier J, Horiot JC, Johansson KA, Davis B, Godson F, Garavaglia G, Pierart M, van der Schueren E. The Quality Assurance programme of the Radiotherapy Group of the European Organization for Research and Treatment of Cancer (EORTC): a critical appraisal of 20 years of continuous efforts. Eur J Cancer 2003; 39:430-7. [PMID: 12751372 DOI: 10.1016/s0959-8049(02)00113-2] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
In 1982, the European Organization for Research and Treatment of Cancer (EORTC) Radiotherapy Group established the Quality Assurance (QA) programme. During the past 20 years, QA procedures have become a major part of the activities of the group. The methodology and steps of the QA programme over the past 20 years are briefly described. Problems and conclusions arising from the results of the long-lasting QA programme in the EORTC radiotherapy group are discussed and emphasised. The EORTC radiotherapy group continues to lead QA in the European radiotherapy community. Future challenges and perspectives are proposed.
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Affiliation(s)
- V E Kouloulias
- European Organization for Research and Treatment of Cancer (EORTC), Radiotherapy Group, Data Center, Av. Mounier 83, B-1200, Brussels, Belgium.
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33
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Cutuli B, Cohen-Solal-le Nir C, de Lafontan B, Mignotte H, Fichet V, Fay R, Servent V, Giard S, Charra-Brunaud C, Lemanski C, Auvray H, Jacquot S, Charpentier JC. Breast-conserving therapy for ductal carcinoma in situ of the breast: the French Cancer Centers' experience. Int J Radiat Oncol Biol Phys 2002; 53:868-79. [PMID: 12095552 DOI: 10.1016/s0360-3016(02)02834-1] [Citation(s) in RCA: 105] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
PURPOSE To assess the long-term outcome for women with ductal carcinoma in situ of the breast treated in current clinical practice by conservative surgery with or without definitive breast irradiation. METHODS AND MATERIALS We analyzed 705 cases of ductal carcinoma in situ treated between 1985 and 1995 in nine French regional cancer centers; 515 underwent conservative surgery and radiotherapy (CS+RT) and 190 CS alone. The median follow-up was 7 years. RESULTS The 7-year crude local recurrence (LR) rate was 12.6% (95% confidence interval [CI] 9.4-15.8) and 32.4% (95% CI 25-39.7) for the CS+RT and CS groups, respectively (p <0.0001). The respective 10-year results were 18.2% (95% CI 13.3-23) and 43.8% (95% CI 30-57.7). A total of 125 LRs occurred, 66 and 59 in the CS+RT and CS groups, respectively. Invasive or microinvasive LRs occurred in 60.6% and 52% of the cases in the same respective groups. The median time to LR development was 55 and 41 months. Nine (1.7%) and 6 (3.1%) nodal recurrences occurred in the CS+RT and CS groups, respectively. Distant metastases occurred in 1.4% and 3% of the respective groups. Patient age and excision quality (final margin status) were both significantly associated with LR risk in the CS+RT group: the LR rate was 29%, 13%, and 8% among women aged < or =40, 41-60, and > or =61 years (p <0.001). Even in the case of complete excision, we observed a 24% rate of LR (6 of 25) in women <40 years. Patients with negative, positive, or uncertain margins had a 7-year crude LR rate of 9.7%, 25.2%, and 12.2%, respectively (p = 0.008). RT reduced the LR rate in all subgroups, especially in those with comedocarcinoma (17% vs. 59% in the CS+RT and CS groups, respectively, p <0.0001) and mixed cribriform/papillary tumors (9% vs. 31%, p <0.0001). In the multivariate Cox regression model, young age and positive margins remained significant in the CS+RT group (p = 0.00012 and p = 0.016). Finally, the relative LR risk in the CS+RT group compared with the CS group was 0.35 (95% CI 0.25-0.51, p = 0.0001). Subsequent contralateral breast cancer occurred in 7.1% and 7.5% of the patients in the CS+RT and CS groups, respectively. CONCLUSION Despite the absence of randomization, our results are extremely consistent with the updated National Surgical Adjuvant Breast Project B17 and European Organization for Research and Treatment of Cancer 10853 trials. We also noted that the LR risk was very high in women <40 years and/or in the case of incomplete excision.
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Affiliation(s)
- Bruno Cutuli
- Department of Radiation Oncology, Paul Strauss Center Strasbourg and Polyclinique de Courlancy, Reims, France.
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Spatz A, Ruiter DJ, Busch C, Theodorovic I, Oosterhuis JW. The role of the EORTC pathologist in clinical trials: achievements and perspectives. European Organisation for Research and Treatment of Cancer. Eur J Cancer 2002; 38 Suppl 4:S120-4. [PMID: 11858977 DOI: 10.1016/s0959-8049(01)00445-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
The role of the pathologist in clinical trials (CT) is focused on three activities: pathology review, translational research, and participation in scientific committees. The primary goal of pathology review in CT is the quality control (QC) of the diagnosis and prognostic parameters. Important contributions have been achieved in the context of QC for CT such as new classifications of diseases or identification of new prognostic markers that are now widely used. Telematics implemented in some EORTC groups markedly facilitate the pathology review. The pathologist has a key-role in translational research for the identification of new targets in tissue specimens that may eventually lead to new therapeutics and for the understanding of the mechanisms involved in tumour progression. The gap between individualised prognosis and therapeutical possibilities has been considerably reduced by the development of drugs targeted on specific molecular defects. The paradigm of this is the treatment of stromal tumours by STI-571. For proper selection of patients to be treated, information on the expression of the molecules involved is needed, which is well suited for pathologists. The access to tissue resources from patients included in CT is a major goal to enhance translational research, both for brand institution and CT organisations. Active involvement of pathologists in scientific committees and interactions with the pharmaceutical industry is mandatory for an optimal design of CT protocols. In addition, translational research is a resource-consuming activity that necessitates an adequate financial flow to create a proper infrastructure at least for sponsored trials to the participating pathology departments and committees.
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Affiliation(s)
- Alain Spatz
- Department of Pathology, Institut Gustave-Roussy, Villejuif, France.
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Abstract
We review recent reports on breast cancer and its predictors, emphasizing the clinical utility of tissue samples from patients. We highlight indicators of increased cancer risk and lesions without metastatic capacity at time of detection, but of sufficient risk of attaining metastatic capacity that treatment is mandated ( ie, ductal carcinoma in situ ). Emphasized are histologic features of importance in stratification of ductal carcinoma in situ. We also review invasive lesions with little capacity for metastatic behavior and indicators of low malignant potential. Included are several papers reviewing the usefulness of histologic grading, emphasizing mitotic counts. Also, the continuing utility of recognizing some special and unusual types of breast cancer is detailed. Sentinel lymph node evaluation by histology is included because some minimal or artifactual findings in lymph nodes can mimic true metastases.
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Affiliation(s)
- J F Simpson
- Division of Anatomic Pathology, Vanderbilt University Medical Center, Nashville, Tennessee 37232, USA
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Bourez RL, Rutgers EJ. The European Organization for Research on Treatment of Cancer (eortc) Breast Cancer Group. Surg Oncol Clin N Am 2001. [DOI: 10.1016/s1055-3207(18)30033-4] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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