Incidence and prediction of invasive disease and nodal metastasis in preoperatively diagnosed ductal carcinoma in situ

Ductal carcinoma in situ: a risk prediction model for the underestimation of invasive breast cancer

Patients with a biopsy diagnosis of ductal carcinoma in situ (DCIS) may be diagnosed with invasive breast cancer after excision. We evaluated the preoperative clinical and imaging predictors of DCIS that were associated with an upgrade to invasive carcinoma on final pathology and also compared the diagnostic performance of various statistical models. We reviewed the medical records; including mammography, ultrasound (US), and magnetic resonance imaging (MRI) findings; of 644 patients who were preoperatively diagnosed with DCIS and who underwent surgery between January 2012 and September 2018. Logistic regression and three machine learning methods were applied to predict DCIS underestimation. Among 644 DCIS biopsies, 161 (25%) underestimated invasive breast cancers. In multivariable analysis, suspicious axillary lymph nodes (LNs) on US (odds ratio [OR], 12.16; 95% confidence interval [CI], 4.94-29.95; P < 0.001) and high nuclear grade (OR, 1.90; 95% CI, 1.24-2.91; P = 0.003) were associated with underestimation. Cases with biopsy performed using vacuum-assisted biopsy (VAB) (OR, 0.42; 95% CI, 0.27-0.65; P < 0.001) and lesion size <2 cm on mammography (OR, 0.45; 95% CI, 0.22-0.90; P = 0.021) and MRI (OR, 0.29; 95% CI, 0.09-0.94; P = 0.037) were less likely to be upgraded. No significant differences in performance were observed between logistic regression and machine learning models. Our results suggest that biopsy device, high nuclear grade, presence of suspicious axillary LN on US, and lesion size on mammography or MRI were independent predictors of DCIS underestimation.

Breast Lesions Diagnosed as Ductal Carcinoma In Situ by Ultrasound-Guided Core Needle Biopsy: Risk Predictors for Concomitant Invasive Carcinoma and Axillary Lymph Node Metastasis

Background

The major concern over preoperatively diagnosed ductal carcinoma in situ (DCIS) of breast via ultrasound-guided core needle biopsy (US-CNB) is the risk of missing concomitant invasive carcinoma. It is crucial to identify risk predictors for such a phenomenon and evaluate its impact on axillary conditions to help surgeons determine which patients should receive appropriate axillary lymph node management.

Methods

Medical records of 260 patients preoperatively diagnosed with DCIS via 14-gauge CNB were retrospectively analyzed. All of them underwent subsequent surgery at our institution and were successively divided into invasive and non-invasive groups, and metastatic and non-metastatic groups according to pathology of resected specimens and metastasis of axillary lymph nodes (ALNs). Predictive value of preoperative physical examinations, imaging findings, histopathological findings, and hematological indexes for pathological underestimation and metastasis of ALN was assessed by logistic regression analysis.

Results

The concomitant invasive carcinoma was overlooked in 75 out of 260 patients (29.3%). Multivariate analysis revealed that presence of microinvasion, presence of abnormal lymph node on ultrasound, and absent linear or segmental distributed calcification on mammography were independent risk predictors for invasive carcinoma. Fourteen patients had lymph node metastasis, and five of them were in the non-invasive group. The presence of abnormal lymph node on ultrasound and increased ratio of platelet distribution width to platelet crit (PDW/PCT) (>52.85) were identified as independent risk predictors for ALN metastasis.

Conclusion

For patients diagnosed with DCIS preoperatively, appropriate ALN management is necessary if they have risk predictors for concomitant invasive carcinoma and ALN metastasis.

Surgical upstaging rates in patients meeting the eligibility for active surveillance trials

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.

Necessity of sentinel lymph node biopsy in ductal carcinoma in situ patients: a retrospective analysis

BACKGROUND

Sentinel lymph node biopsy (SLNB) is unnecessarily performed too often, owing to the high upstaging rates of ductal carcinoma in situ (DCIS). This study aimed to evaluate the upstaging rates of DCIS to invasive cancer, determine the prevalence of axillary lymph node metastasis, and identify the clinicopathological factors associated with upstaging and lymph node metastasis. We also examined surgical patterns among DCIS patients and determined whether SLNB guidelines were followed.

METHODS

We retrospectively analysed 307 consecutive DCIS patients diagnosed by preoperative biopsy in a single centre between 2014 and 2018. Data from clinical records, including imaging studies, axillary and breast surgery types, and pathology results from preoperative and postoperative biopsies, were extracted. Univariate analyses using Chi-square tests and multiple logistic regression analyses were used to analyse the data.

RESULTS

The rate of upstaging to invasive cancer was 19.2% (59/307). DCIS diagnosed by core-needle biopsy (odds ratio [OR]: 6.861, 95% confidence interval [CI]: 2.429-19.379), the presence of ultrasonic mass-forming lesions (OR: 2.782, 95% CI: 1.224-6.320), and progesterone receptor-negative status (OR: 3.156, 95% CI: 1.197-8.323) were found to be associated with upstaging. The rate of sentinel lymph node metastasis was only 1.9% (4/202), and all were total mastectomy patients diagnosed by core-needle biopsy. SLNB was performed in 37.2% of 145 breast-conserving surgery patients and 91.4% of 162 total mastectomy patients. Among the 202 patients who underwent SLNB, 145 (71.7%) without invasive cancer on final pathology had redundant SLNB. Two of 59 patients (3.4%) with disease upstaged to invasive cancer had inadequate primary staging of the axilla, as the rate seemed sufficiently small.

CONCLUSIONS

In patients with a preoperative diagnosis of DCIS, although an unavoidable possibility of upstaging to invasive cancer exists, axillary metastasis is unlikely. Only 2.7% of patients with DCIS undergoing total mastectomy were found to have sentinel lymph node metastases. SLNB should not be performed in breast-conserving surgery patients and should be reserved only for total mastectomy patients diagnosed by core-needle biopsy.

Predictors of invasive disease in patients preoperatively diagnosed with ductal carcinoma without stromal invasion, with breast magnetic resonance imaging (MRI) and ultrasound (US)

BACKGROUND

A preoperative diagnosis of ductal carcinoma in situ (DCIS) is sometimes upstaged to invasive disease postoperatively. Our objective was to clarify the predictive factors of invasive disease using preoperative imaging and to investigate the positive ratio of sentinel lymph nodes (SLN) and the incidence of invasive disease.

METHODS

The subjects were 402 patients with preoperatively diagnosed ductal carcinoma without stromal invasion who underwent breast surgery with concomitant SLN surgery in January 2007 to December 2016. Of the 306 included patients, all 306 patients underwent preoperative MRI and US assessment. Outcomes were analyzed for significance using univariate and multivariate analyses.

RESULTS

Of the 306 patients, 115 (37.6%) had invasive disease and 191 (62.4%) had DCIS only. Of the 115 patients with invasive disease, 5 (4.4%) and 4 (3.5%) had macro- and micrometastases in SLN. On the other hand, of the 191 patients with DCIS, only 1 (0.5%) had a micrometastasis. Predictors of invasive disease in the univariate analysis included having a palpable mass, were varied by biopsy method, having a US hypoechoic mass, MRI enhancement, or MRI large enhanced lesion; the size of the mass enhancement ≥ 1.1 cm or a spread of non-mass enhancement ≥ 3.1 cm (P = 0.003). Predictors of invasive disease in the multivariate analysis included US hypoechoic mass and MRI large enhanced lesion.

CONCLUSION

We need to perform SLN biopsy for preoperatively diagnosed DCIS when patients have predictors of invasive disease, but SLN biopsy will no longer be essential for patients when they have no predictors of invasive disease.

Efficacy of radiation boost after breast-conserving surgery for breast cancer with focally positive, tumor-exposed margins

Many patients with positive margins following breast-conserving surgery (BCS) undergo re-excisions that aim to remove residual disease from the breast, which brings a tremendous emotional burden in addition to financial consequences. We sought to determine whether re-excisions could be safely avoided without compromising local control and survival by using whole-breast radiation therapy (WBRT) with a tumor bed boost in patients with early-stage breast cancer with focally positive, tumor-exposed margins after BCS. All patients with ductal carcinoma in situ (DCIS) and/or invasive breast cancer (IBC) who had pathologically tumor-exposed margins following BCS, without re-excision and treated with WBRT with tumor bed boost between March 2005 and December 2011, were included. The radiotherapy consisted of WBRT at a dose of 50 Gy in 25 fractions, followed by a tumor bed boost with an additional dose of 16 Gy in eight fractions. A total of 125 patients fulfilled the eligibility criteria; of the 125 patients, 1 had bilateral breast cancer, resulting in 126 cases. Invasive disease was found in 102 (81%) cases and purely ductal carcinoma in situ (DCIS) disease in 24 (19%) cases. The 10-year ipsilateral breast tumor recurrence (IBTR) -free survival, progression-free survival (PFS), and 10-year overall survival (OS) rates were 95%, 92.5% and 96%, respectively. Patients with early-stage breast cancer who receive BCS and have focally positive, tumor-exposed margins can avoid re-excision by undergoing WBRT followed by a sufficient dose of tumor bed boost, without negatively impacting local control and survival.

Analysis of Surgical Trends for Axillary Lymph Node Management in Patients with Ductal Carcinoma In Situ Using the NSQIP Database: Are We Following National Guidelines?

BACKGROUND

For patients with ductal carcinoma in situ (DCIS), multiple national cancer organizations recommend that sentinel lymph node biopsy (SLNB) be offered when treated with mastectomy, but not when treated with breast-conserving surgery (BCS). This study analyzes national surgical trends of SLNB and axillary lymph node dissection (ALND) in DCIS patients undergoing breast surgery with the aim to quantify deviations from national guidelines.

METHODS

A retrospective cohort analysis of the American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP) database from 2005 to 2017 identified patients with DCIS. Patients were categorized by their primary method of breast surgery, i.e. mastectomy or BCS, then further categorized by their axillary lymph node (ALN) management, i.e. no intervention, SLNB, or ALND. Data analysis was conducted via linear regression and a non-parametric Mann-Kendall test to assess a temporal trend and Sen's slope.

RESULTS

Overall, 43,448 patients with DCIS met the inclusion criteria: 20,504 underwent mastectomy and 22,944 underwent BCS. Analysis of DCIS patients from 2005 to 2017 revealed that ALND decreased and SLNB increased in every subgroup, regardless of surgical treatment modality. Evaluation in the mastectomy group increased overall: mastectomy alone increased from 57.1 to 65.8% (p < 0.01) and mastectomy with immediate reconstruction increased from 58.5 to 72.1% (p < 0.01). Increases also occurred in the total BCS population: partial mastectomy increased from 14.0 to 21.1% and oncoplastic surgery increased from 10.5 to 23.0% (both p < 0.01).

CONCLUSIONS

Despite national guideline recommendations for the management of ALN surgery in DCIS patients, approximately 20-30% of cases continue to not follow these guidelines. This warrants further education for surgeons and patients.

Multicentre study of the risk of invasive cancer and use of sentinel node biopsy in women with a preoperative diagnosis of ductal carcinoma in situ

Background

Ductal carcinoma in situ (DCIS) in the breast that is diagnosed by biopsy implies a risk of upstaging to invasive carcinoma (IC) on final pathology. These patients require a sentinel lymph node biopsy (SLNB) for axillary staging. A two-stage procedure is not always feasible and precise selection of patients who should be offered SLNB is crucial. The aims were: to determine the rate of upstaging, and use of redundant and required SLNB in women with a preoperative diagnosis of DCIS; and to identify patient and tumour characteristics that increase the risk of upstaging.

Methods

Patients with DCIS treated between 2008 and 2016 were identified using Orbit operation planning system software, and those suitable for the study were selected based on review of the medical records. Upstaging rates and proportions of redundant and required SLNBs were calculated. Associations between clinicopathological characteristics and upstaging were analysed using univariable and multivariable logistic regression analyses.

Results

Of 1368 patients initially identified, 975 women with a preoperative diagnosis of DCIS were included in the study. Tumours in 246 of these patients (25·2 per cent) were upstaged to IC. Redundant SLNB was performed in 392 of 975 women (40·2 per cent). Forty-four patients (4·5 per cent) with a final diagnosis of IC were not offered SLNB and thus potentially undertreated. In adjusted analysis, DCIS size, palpability and mass formation identified by breast imaging were associated with increased risk of upstaging. The Van Nuys classification was not associated with upstaging.

Conclusion

Most patients with IC on final pathology underwent SLNB, but a considerable number of patients with DCIS had a redundant SLNB. Lesion size, palpability and mass formation, but not Van Nuys classification group, are suggested risk factors for upstaging.

Prognostic impact and possible pathogenesis of lymph node metastasis in ductal carcinoma in situ of the breast

PURPOSE

Ductal carcinoma in situ (DCIS)-preinvasive breast cancer-with lymph node metastasis can clinically be treated as different stages: occult invasive cancer with true metastasis (T1N1) or pure DCIS with iatrogenic dissemination (TisN0). In this retrospective cohort study, we aimed to elucidate the prognostic impact and possible pathogenesis of nodal metastasis in DCIS to improve clinical management.

METHODS

Subjects were comprised of 427 patients with routine postoperative diagnosis of DCIS who underwent sentinel node (SN) biopsy using molecular whole-lymph-node analysis. Clinicopathological characteristics and prognosis were compared between SN-positive and -negative patients. Primary tumour tissues of SN-positive patients were exhaustively step-sectioned to detect occult invasions, and predictive factors for occult invasion were investigated. Median follow-up time was 73.6 months.

RESULTS

Of the 427 patients, 19 (4.4%) were SN-positive and 408 (95.6%) were SN-negative. More SN-positive patients received adjuvant systemic therapy than SN-negative patients (84.2% vs. 5.4%). Seven-year distant disease-free survivals were favourable for both cohorts (SN-positive, 100%; SN-negative, 99.7%). By examining 1421 slides, occult invasion was identified in 9 (47.4%) of the 19 SN-positive patients. Tumour burdens in SN and incidence of non-SN metastasis were similar between patients with and without occult invasion, and no predictive factor for occult invasion was found.

CONCLUSIONS

Node-positive DCIS has favourable prognosis with adjuvant systemic therapy. Half of the cases may be occult invasive cancer with true metastasis. In practical settings, clinicians may have to treat these tumours as node-positive small invasive cancers because it is difficult to predict the pathogenesis without exhaustive primary tumour sectioning.

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

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).

Exosome-encapsulated microRNA-223-3p as a minimally invasive biomarker for the early detection of invasive breast cancer

Patients diagnosed preoperatively with ductal carcinoma in situ (DCIS) breast cancer have the potential to develop invasive ductal carcinoma (IDC). The present study investigated the usefulness of exosome-encapsulated microRNA-223-3p (miR-223-3p) as a biomarker for detecting IDC in patients initially diagnosed with DCIS by biopsy. The potential association between miR-223-3p and clinicopathological characteristics was examined in patients with breast cancer. Exosomes of 185 patients with breast cancer were separated from plasma by ultracentrifugation. Initially a microRNA (miRNA) microarray was examined to reveal the invasion specific miRNAs using exosomes collected from 6 patients with breast cancer, including 3 DCIS patients, 3 IDC patients and 3 healthy controls. In the miR microarray analysis the miR-223-3p levels of IDC patients demonstrated the highest fold-change compared with those in the DCIS patients and healthy controls. The potential of miR-223-3p for cell proliferation and cell invasion were examined in vitro using MCF7 cells transfected with the miR-223-3p gene. MCF7 cells transfected with the miR-223-3p gene significantly promoted cell proliferation and cell invasive ability (P<0.05). The plasma exosomal miR-223-3p levels of the other 179 patients with breast cancer and 20 healthy controls were measured using TaqMan miR assays. The exosomal miR-223-3p levels of the patients with breast cancer were significantly increased compared with the healthy controls (P<0.01). A statistically significant association was observed between the exosomal miR-223-3p levels and histological type, pT stage, pN stage, pathological stage, lymphatic invasion and nuclear grade (P<0.05). The exosomal miR-223-3p levels of IDC patients (stage I) and upstaged IDC patients (stage I) were significantly higher compared with the DCIS patients (P<0.05). These results suggest that exosomal miR-223-3p may be a useful preoperative biomarker to identify the invasive lesions of DCIS patients diagnosed by biopsy. In addition, plasma exosome-encapsulated miR-223-3p level was significantly associated with the malignancy of breast cancer.

Sentinel node biopsy in ductal carcinoma in situ of the breast: Never justified?

Sentinel lymph node biopsy for ductal carcinoma in situ (DCIS) of the breast is not standard of care. However, nodal involvement for DCIS patients is reported. Aim of our study was to identify preoperative features predictive of nodal involvement in DCIS patients. We have retrospectively reviewed 175 patients with a preoperative diagnosis of DCIS following a vacuum-assisted breast biopsy, and undergoing surgery with sentinel node biopsy. Variables distribution was compared between patients upstaged to invasive cancer at final pathology and patients with a confirmed DCIS, and between positive vs negative sentinel node patients. Univariate and multivariate analyses were performed for risk of a positive node. Lymph node biopsy was positive in 13 (7.4%) patients, with 8 (61.5%) macrometastases and 5 (38.5%) micrometastases. In these patients, Breast Imaging Reporting and Data System (BI-RADS) index >4 (OR 4.69, 95% CI 1.282-17.224, P = .02), lesion extension ≥20 mm (OR 4.25, 95% CI 1.255-14.447, P = .02), multifocal disease (OR 4.12, 95% CI 0.987-17.174, P = .05), comedo type (OR 3.54, 95% CI 1.044-11.969, P = .04), and upstaging (OR 4.56, 95% CI 1.080-19.249, P = .04) were all predictive of nodal involvement, although upstaging could not be predicted preoperatively. By multivariate analysis, the only independent factor predictive for positive sentinel node was multifocal disease (OR 5.14, 95% CI 1.015-26.066, P < .05). A preoperative diagnosis of DCIS, also including advanced biopsy systems such as vacuum-assisted breast biopsy, may be not always sufficient to exclude patients from sentinel node biopsy. DCIS patients with associated BI-RADS >4, lesion extension ≥20 mm, comedo type, and above all multifocal disease should be considered for axillary evaluation.

Is sentinel lymph node biopsy indicated in patients with a diagnosis of ductal carcinoma in situ? A systematic literature review and meta-analysis

BACKGROUND

Recent discussion has suggested that some cases of ductal carcinoma in situ (DCIS) with high risk of invasive disease may require sentinel lymph node biopsy (SLNB).

METHODS

Systematic literature review identified 48 studies (9,803 DCIS patients who underwent SLNB). Separate analyses for patients diagnosed preoperatively by core sampling and patients diagnosed postoperatively by specimen pathology were conducted to determine the percentage of patients with axillary nodal involvement. Patient factors were analyzed for associations with risk of nodal involvement.

RESULTS

The mean percentage of positive SLNBs was higher in the preoperative group (5.95% vs 3.02%; P = .0201). Meta-regression analysis showed a direct association with tumor size (P = .0333) and grade (P = .00839) but not median age nor tumor upstage rate.

CONCLUSIONS

The SLNB should be routinely considered in patients with large (>2 cm) high-grade DCIS after a careful multidisciplinary discussion. In the context of breast conserving surgery, the SLNB is not routinely indicated for low- and intermediate-grade DCIS, high-grade DCIS smaller than 2 cm, or pure DCIS diagnosed by definitive surgical excision.

Sentinel Lymph Node Biopsy in Breast Cancer: Indications, Contraindications, and Controversies

Axillary lymph node status, a major prognostic factor in early-stage breast cancer, provides information important for individualized surgical treatment. Because imaging techniques have limited sensitivity to detect metastasis in axillary lymph nodes, the axilla must be explored surgically. The histology of all resected nodes at the time of axillary lymph node dissection (ALND) has traditionally been regarded as the most accurate method for assessing metastatic spread of disease to the locoregional lymph nodes. However, ALND may result in lymphedema, nerve injury, shoulder dysfunction, and other short-term and long-term complications limiting functionality and reducing quality of life. Sentinel lymph node biopsy (SLNB) is a less invasive method of assessing nodal involvement. The concept of SLNB is based on the notion that tumors drain in an orderly manner through the lymphatic system. Therefore, the SLN is the first to be affected by metastasis if the tumor has spread, and a tumor-free SLN makes it highly unlikely for other nodes to be affected. Sentinel lymph node biopsy has become the standard of care for primary treatment of early breast cancer and has replaced ALND to stage clinically node-negative patients, thus reducing ALND-associated morbidity. More than 20 years after its introduction, there are still aspects concerning SLNB and ALND that are currently debated. Moreover, SLNB remains an unstandardized procedure surrounded by many unresolved controversies concerning the technique itself. In this article, we review the main indications, contraindications, and controversies of SLNB in breast cancer in the light of the most recent publications.

Ductal carcinoma in situ diagnosed by breast needle biopsy: Predictors of invasion in the excision specimen

BACKGROUND

A substantial proportion of women with a pre-operative diagnosis of pure ductal carcinoma in situ (DCIS) has a final diagnosis of invasive breast cancer (IBC) after surgical excision and, consequently, a potential indication for lymph node staging. The aim of our study was to identify novel predictors of invasion in patients with a needle-biopsy diagnosis of DCIS that would help us to select patients that may benefit from a sentinel node biopsy (SNB).

PATIENTS AND METHODS

We included 153 patients with a needle-biopsy diagnosis of DCIS between 2000 and 2014, which was followed by surgical excision. Several pre-operative clinical, radiological and pathological features were assessed and correlated with the presence of invasion in the excision specimen. Features that were significantly associated with upstaging in the univariable analysis were combined to calculate upstaging risks.

RESULTS

Overall, 22% (34/155) of the patients were upstaged to IBC. The following risk factors were significantly associated with upstaging: palpability, age ≤40 years, mammographic mass lesion, moderate to severe periductal inflammation and periductal loss of decorin expression. The upstaging-risk correlated with the number of risk factors present: e.g. 9% for patients without risk factors, 29% for patients with 1 risk factor, 37% for patients with 2 risk factors and 54% for patients with ≥3 risk factors.

CONCLUSION

The identified risk factors may be helpful to predict the upstaging-risk for patients with a needle-biopsy diagnosis of pure DCIS, which facilitates the performance of a selective SNB for high-risk patients and avoid this procedure in low-risk patients.

Is Sentinel Lymph Node Biopsy Indicated at Completion Mastectomy for Ductal Carcinoma In Situ?

BACKGROUND

Sentinel lymph node biopsy (SLNB) is recommended when mastectomy is performed for ductal carcinoma in situ (DCIS). The role of SLNB for women with DCIS who undergo mastectomy following one or more attempts at breast-conserving surgery (BCS) is uncertain. We examined the upgrade rate and SLNB yield in women who converted to mastectomy after one or more attempts at BCS for DCIS.

METHODS

All patients who underwent one or more attempts at BCS prior to conversion to mastectomy with SLNB for DCIS were identified. Margin status as the indication for mastectomy was confirmed, and comparisons were made between patients with/without upgrade on final pathology.

RESULTS

From February 2006 to November 2012, a total of 233 patients underwent completion mastectomy following one or more attempts at BCS for positive/close margins (median age 50 years; range 34-84). The median number of BCS attempts was 1 (range 1-4). Overall, 20 (9 %) patients were upgraded on final pathology; 15 (6 %) stage I, and 5 (3 %) stage II (three micrometastasis, two macrometastasis). In two of five cases with a positive SLN, invasive carcinoma was not identified in the mastectomy specimen. The only factor associated with any upgrade was the presence of micropapillary DCIS (80 vs. 55 %, with and without upgrade; p = 0.03).

CONCLUSION

In this cohort of patients with DCIS who converted to mastectomy for positive/close margins after one or more attempts at BCS, 18 (8 %) would have required second-stage axillary surgery had an SLNB not been performed, and in two (1 %) patients, the SLN provided the only evidence of invasion. These findings support the recommendation for SLNB at the time of completion mastectomy.

Trends in Treatment Patterns and Outcomes for Ductal Carcinoma In Situ

BACKGROUND

Impact of contemporary treatment of pre-invasive breast cancer (ductal carcinoma in situ [DCIS]) on long-term outcomes remains poorly defined. We aimed to evaluate national treatment trends for DCIS and to determine their impact on disease-specific (DSS) and overall survival (OS).

METHODS

The Surveillance, Epidemiology, and End Results (SEER) registry was queried for patients diagnosed with DCIS from 1991 to 2010. Treatment pattern trends were analyzed using Cochran-Armitage trend test. Survival analyses were performed using inverse probability weights (IPW)-adjusted competing risk analyses for DSS and Cox proportional hazard regression for OS. All tests performed were two-sided.

RESULTS

One hundred twenty-one thousand and eighty DCIS patients were identified. The greatest proportion of patients was treated with lumpectomy and radiation therapy (43.0%), followed by lumpectomy alone (26.5%) and unilateral (23.8%) or bilateral mastectomy (4.5%) with significant shifts over time. The rate of sentinel lymph node biopsy increased from 9.7% to 67.1% for mastectomy and from 1.4% to 17.8% for lumpectomy. Compared with mastectomy, OS was higher for lumpectomy with radiation (hazard ratio [HR] = 0.79, 95% confidence interval [CI] = 0.76 to 0.83, P < .001) and lower for lumpectomy alone (HR = 1.17, 95% CI = 1.13 to 1.23, P < .001). IPW-adjusted ten-year DSS was highest in lumpectomy with XRT (98.9%), followed by mastectomy (98.5%), and lumpectomy alone (98.4%).

CONCLUSIONS

We identified substantial shifts in treatment patterns for DCIS from 1991 to 2010. When outcomes between locoregional treatment options were compared, we observed greater differences in OS than DSS, likely reflecting both a prevailing patient selection bias as well as clinically negligible differences in breast cancer outcomes between groups.

Trends in Treatment Patterns and Outcomes for Ductal Carcinoma In Situ

BACKGROUND

Impact of contemporary treatment of pre-invasive breast cancer (ductal carcinoma in situ [DCIS]) on long-term outcomes remains poorly defined. We aimed to evaluate national treatment trends for DCIS and to determine their impact on disease-specific (DSS) and overall survival (OS).

METHODS

The Surveillance, Epidemiology, and End Results (SEER) registry was queried for patients diagnosed with DCIS from 1991 to 2010. Treatment pattern trends were analyzed using Cochran-Armitage trend test. Survival analyses were performed using inverse probability weights (IPW)-adjusted competing risk analyses for DSS and Cox proportional hazard regression for OS. All tests performed were two-sided.

RESULTS

One hundred twenty-one thousand and eighty DCIS patients were identified. The greatest proportion of patients was treated with lumpectomy and radiation therapy (43.0%), followed by lumpectomy alone (26.5%) and unilateral (23.8%) or bilateral mastectomy (4.5%) with significant shifts over time. The rate of sentinel lymph node biopsy increased from 9.7% to 67.1% for mastectomy and from 1.4% to 17.8% for lumpectomy. Compared with mastectomy, OS was higher for lumpectomy with radiation (hazard ratio [HR] = 0.79, 95% confidence interval [CI] = 0.76 to 0.83, P < .001) and lower for lumpectomy alone (HR = 1.17, 95% CI = 1.13 to 1.23, P < .001). IPW-adjusted ten-year DSS was highest in lumpectomy with XRT (98.9%), followed by mastectomy (98.5%), and lumpectomy alone (98.4%).

CONCLUSIONS

We identified substantial shifts in treatment patterns for DCIS from 1991 to 2010. When outcomes between locoregional treatment options were compared, we observed greater differences in OS than DSS, likely reflecting both a prevailing patient selection bias as well as clinically negligible differences in breast cancer outcomes between groups.

Preoperatively diagnosed ductal cancers in situ of the breast presenting as even small masses are of high risk for the invasive cancer foci in postoperative specimen

Background

In ductal carcinoma in situ of the breast (DCIS), histologic diagnosis obtained before the definitive treatment is related to the risk of underestimation if the presence of invasive cancer is found postoperatively. These patients need a second operation to assess the nodal status. We evaluated the upstaging rate in patients with mass-forming DCIS.

Methods

Sixty-three women with pure DCIS presenting as sonographic mass lesion underwent vacuum-assisted or core-needle biopsy and subsequent surgery. Rates of postoperative upstaging to invasive cancer were calculated and compared with clinical character and size of DCIS.

Results

Median age of patients (range) was 63 years (27–88) while median diameter of DCIS was 11 mm (6–60). Fifty-six percent of DCIS were upstaged. Patient age did not differ significantly between groups with and without final invasion (median, mean, SD): 63, 61.4, 12.5 vs 62, 61.2, 10.6 years, respectively (P = 0.659). The difference of DCIS size between these groups was statistically important (median, mean, SD): 13, 17.3, 11.4 vs 9.5, 9.8, 3.2 mm, respectively (P = 0.0003). Mass size and palpability were significant risk factors (P < 0.001 and P < 0.01, respectively). Rate of underestimation for mass with diameter ≤10 mm, 10–20 mm and >20 mm was 37, 64 and 91 %, respectively.

Conclusions

DCIS diagnosed on minimal-invasive biopsy of even small sonographic mass is of high risk for the upstaging to invasive cancer after final surgical excision. In these patients, subsequent intervention is needed for nodal status assessment. They are good candidates for the sentinel node biopsy during the breast operation to avoid multi-step surgery.

Sentinel lymph node biopsy in patients with breast ductal carcinoma in situ: Chinese experiences

The axillary treatment of patients with ductal carcinoma in situ (DCIS) remains controversial. The aim of the present study was to evaluate the roles of sentinel lymph node biopsy (SLNB) in patients with breast DCIS. A database containing the data from 262 patients diagnosed with breast DCIS and 100 patients diagnosed with DCIS with microinvasion (DCISM) who received SLNB between January 2002 and July 2014 was retrospectively analyzed. Of the 262 patients with DCIS, 9 presented with SLN metastases (3 macrometastases and 6 micrometastases). Patients with large tumors diagnosed by ultrasound or with tumors of high histological grade had a higher positive rate of SLNs than those without (P=0.037 and P<0.0001, respectively). Of the 100 patients with DCISM, 11 presented with metastases. Younger patients had a higher positive rate of SLNs (P=0.028). According to the results of this study and the systematic review of recent studies, the indications of SLNB for patients with DCIS are as follows: SLNB should be performed in all DCISM patients and in those DCIS patients who received mastectomy, and could be avoided in those who received breast-conserving surgery. However, SLNB should be recommended to patients who have high risks of harboring invasive components. The risk factors include a large, palpable tumor, a mammographic mass or a high histological grade.