Ductal carcinoma in situ - update on risk assessment and management

Clinicopathological characteristics and prognosis of triple-negative breast cancer invasive ductal carcinoma with ductal carcinoma in situ

PURPOSE

The purpose of this study is to compare and analyze the clinicopathological characteristics and prognosis of patients with invasive ductal carcinoma coexisting with ductal carcinoma in situ (IDC-DCIS) and invasive ductal carcinoma (IDC) in triple-negative breast cancer (TNBC), and to explore the factors affecting the prognosis, so as to provide new ideas for clinical diagnosis and treatment of these patients.

METHODS

The patients with TNBC underwent surgery in the Department of Breast Surgery of Harbin Medical University Cancer Hospital from October 2012 to December 2018 were retrospectively analyzed and divided into IDC-DCIS group and IDC group. The clinicopathological characteristics and prognosis of the two groups were compared. P < 0.05 was considered statistically significant.

RESULTS

A total of 358 patients were enrolled. There were significant differences in age (P = 0.002), family history (P = 0.016), menopausal status (P = 0.003), KI-67% (P < 0.001), lymphovascular invasion (P = 0.010), histologic grade of IDC (P < 0.001) and multifocal (P < 0.001) between the two groups. The disease-free survival (DFS) of the IDC-DCIS group was better than that of the IDC group (the 5-year DFS was 87.9% vs. 82.6%, P = 0.045), but the overall survival (OS) of the two groups was not statistically significant (the 5-year OS was 96.2% vs. 96.0%, P = 0.573). In addition, the coexistence of DCIS (P = 0.030), lymph node pathologic stage (P = 0.001), tumor location (P = 0.011), and adjuvant chemotherapy (P < 0.001) were independent prognostic factors for DFS.

CONCLUSION

In TNBC, the IDC-DCIS group had less invasive biological characteristics. The DFS of the IDC-DCIS group was better than that of the IDC group, but there was no statistical difference in OS between the two groups. In addition, the coexistence of DCIS, lymph node stage, tumor location and adjuvant chemotherapy may be independent prognostic factors for DFS.

A low risk of recurrence after breast-conserving surgery for DCIS: A single-institution experience

BACKGROUND

Previously published studies report up to 30% recurrence rates after DCIS, so it would be desirable to identify those women at risk for recurrence and adapt adjuvant management. This study aimed to identify the locoregional recurrence rate after breast conserving surgery (BCS) for DCIS, and to evaluate the possible role of immunohistochemical (IHC) staining in predicting the risk of recurrence.

PATIENTS AND METHODS

In a retrospective cohort study, patients who underwent BCS for pure DCIS were identified. Data on well-established clinical-pathological risk factors and development of locoregional recurrence was gathered from patient files. In addition, IHC stains of ER, PR, HER2, p53, and ki67 were performed on original tumor samples. Univariable Cox regression analyses were performed to identify possible risk factors for locoregional recurrence.

RESULTS

190 patients were included. At a median follow-up time of 12.8 years fifteen (8%) patients developed locoregional recurrence: 7 invasive cancer and 8 DCIS. These recurrences were diagnosed within a range of 1.7 to 19.6 years after the initial diagnosis. Univariable Cox regression analysis did only show a significant association between p53 and locoregional recurrence. Our re-excision rate to obtain free margins was 30.5%, and 90% received radiotherapy. Endocrine treatment was not used.

CONCLUSIONS

At 12.8 years follow-up, patients with DCIS treated with BCS have a very low locoregional recurrence of 8%. Although we could demonstrate that increased p53 expression is a risk factor for locoregional recurrence, we think this is of little clinical value in our population with such a low recurrence rate.

MICROABSTRACT

With a published recurrence rate up to 30% after DCIS, it would be desirable to identify those at risk to adapt treatment and follow-up. We aimed to evaluate the role of immunohistochemical staining to determine the risk of locoregional recurrence, in addition to established clinical and pathological risk factors. At a median follow-up of 12.8 years, we found a locoregional recurrence rate of 8%. Increased expression of p53 is associated with an increased risk of locoregional recurrence.

Identifying recurrences and metastasis after ductal carcinoma in situ (DCIS) of the breast

Ductal carcinoma in situ (DCIS) of the breast is a non-invasive tumour that has the potential to progress to invasive ductal carcinoma (IDC). Thus, it represents a treatment dilemma: alone it does not present a risk to life, however, left untreated it may progress to a life-threatening condition. Current clinico-pathological features cannot accurately predict which patients with DCIS have invasive potential, and therefore clinicians are unable to quantify the risk of progression for an individual patient. This leads to many women being over-treated, while others may not receive sufficient treatment to prevent invasive recurrence. A better understanding of the molecular features of DCIS, both tumour-intrinsic and the microenvironment, could offer the ability to better predict which women need aggressive treatment, and which can avoid therapies carrying significant side-effects and such as radiotherapy. In this review, we summarise the current knowledge of DCIS, and consider future research directions.

Pathological underestimation and biomarkers concordance rates in breast cancer patients diagnosed with ductal carcinoma in situ at preoperative biopsy

Ductal carcinoma in situ (DCIS) often upgrade to invasive breast cancer at surgery. The current study aimed to identify factors associated with pathological underestimation and evaluate concordance rates of biomarkers between biopsy and surgery. Patients diagnosed with DCIS at needle biopsy from 2009 to 2020 were retrospectively reviewed. Univariate and multivariate analyses were performed to identify factors associated with pathological underestimation. Concordance rates between paired biopsy samples and surgical specimens were evaluated. A total of 735 patients with pure DCIS at biopsy were included, and 392 patients (53.3%) underwent pathological underestimation at surgery. Multivariate analysis demonstrated that tumor size > 5.0 cm [odds ratio (OR) 1.79], MRI BI-RADS ≥ 5 categories (OR 2.03), and high nuclear grade (OR 2.01) were significantly associated with pathological underestimation. Concordance rates of ER, PR, HER2 status and Ki-67 between biopsy and surgery were 89.6%, 91.9%, 94.8%, and 76.4% in lesions without pathological underestimation, and were 86.4%, 93.2%, 98.2% and 76.3% for in situ components in lesions with pathological underestimation. Meanwhile, in situ components and invasive components at surgery had concordance rates of 92.9%, 93.8%, 97.4%, and 86.5% for those biomarkers, respectively. In conclusion, lesions diagnosed as DCIS at biopsy have a high rate of pathological underestimation, which was associated with larger tumor size, higher MRI BI-RADS category, and higher nuclear grade. High concordances were found in terms of ER, PR, and HER2 status evaluation between biopsy and surgery, regardless of the pathological underestimation.

National Variations in the Work-Up, Investigation, and Surgical Management of Ductal Carcinoma In Situ of the Breast across Canadian Surgeons

Variation in the management of Ductal Carcinoma In Situ (DCIS) of the breast occur at both national and international levels. The aim of this study is to determine the degree of, and reasons behind, this variation in the workup and treatment of DCIS among Canadian surgeons. We developed a 35-question survey involving the pre-, peri, and post-operative management of DCIS using SurveyMonkey^®. The survey was sent out via email and responses were analyzed using SurveyMonkey^® and Microsoft Excel. 51/119 (43%) of the Canadian General Surgeons contacted participated in this study. Some variation was observed in the utilization of pre-operative imaging with 29/48 (60%) surgeons routinely using ultrasound. Perceived contraindications to breast conserving therapy also varied with multicentricity (54%) and the presence of diffuse microcalcifications (13%). Nearly all respondent's (98%) patients had access to immediate breast reconstruction following a mastectomy but 14/48 (29%) of respondents' patients were required to travel a mean distance of 300 km to undergo the procedure. Substantial variation was also seen during follow-up with half (52%) of surgeons following up patients for >1 month in their surgical clinic. There is considerable variation in the management of DCIS among Canadian Surgeons. The present study indicates the need for pan-Canadian, evidence-based guidelines to ensure a standardized management strategy for patients with DCIS.

Early diagnosis of breast cancer from exhaled breath by gas chromatography-mass spectrometry (GC/MS) analysis: A prospective cohort study

BACKGROUND

It has proved that there is an association between cancer and volatile organic compounds (VOCs) of exhaled breath. This study targets on verifying the existence of specific VOCs in breathing in breast cancer patients, especially those with ductal carcinoma in situ (DCIS).

METHODS

There were a total of 203 participants included in the final analysis, which included 71 (35.0%) patients with histologically confirmed breast cancer (including 13 with DCIS, 31 with lymph node metastasis-negative status, and 27 with lymph node metastasis-positive status), 78 (38.4%) healthy volunteers, and 54 (26.6%) patients with histologically confirmed gastric cancer. Gas chromatography-mass spectrometry and solid-phase microextraction were used to analyze the breath samples for the presence of VOCs.

RESULTS

There were significant differences in the volatile organic metabolites between the DCIS, lymph node metastasis-negative breast cancer, and lymph node metastasis-positive breast cancer groups compared with the healthy controls as well as between the breast cancer and gastric cancer patients. An overlapping set of seven VOCs, including (S)-1,2-propanediol, cyclopentanone, ethylene carbonate, 3-methoxy-1,2-propanediol, 3-methylpyridine, phenol, and tetramethylsilane, was significantly different between the breast cancer patients and healthy individuals as well as between the breast cancer and gastric cancer patients. The combination of these seven compounds was considered as a biomarker for breast cancer. The sensitivity for predicting DCIS by this set of seven compounds was determined to be 80.77%, and the specificity was determined to be 100%.

CONCLUSIONS

This set of seven breast cancer-specific VOCs can be regarded as one particular expiratory marker for DCIS and will help to establish new screening methods for early breast cancer.

Comparison of Mammography and Ultrasonography for Tumor Size of DCIS of Breast Cancer

OBJECTIVE

Accurate assessment of breast tumor size preoperatively is important for the initial decision-making in surgical approach. Therefore, we aimed to compare efficacy of mammography and ultrasonography in ductal carcinoma in situ (DCIS) of breast cancer.

METHODS

Preoperative mammography and ultrasonography were performed on 104 women with DCIS of breast cancer. We compared the accuracy of each of the imaging modalities with pathological size by Pearson correlation. For each modality, it was considered concordant if the difference between imaging assessment and pathological measurement is less than 0.5cm.

RESULTS

At pathological examination tumor size ranged from 0.4cm to 7.2cm in largest diameter. For mammographically determined size versus pathological size, correlation coefficient of r was 0.786 and for ultrasonography it was 0.651. Grouped by breast composition, in almost entirely fatty and scattered areas of fibroglandular dense breast, correlation coefficient of r was 0.790 for mammography and 0.678 for ultrasonography; in heterogeneously dense and extremely dense breast, correlation coefficient of r was 0.770 for mammography and 0.548 for ultrasonography. In microcalcification positive group, coeffient of r was 0.772 for mammography and 0.570 for ultrasonography. In microcalcification negative group, coeffient of r was 0.806 for mammography and 0.783 for ultrasonography.

CONCLUSION

Mammography was more accurate than ultrasonography in measuring the largest cancer diameter in DCIS of breast cancer. The correlation coefficient improved in the group of almost entirely fatty/ scattered areas of fibroglandular dense breast or in microcalcification negative group.

Essential role of STAT5a in DCIS formation and invasion following estrogen treatment

Ductal carcinoma in situ (DCIS) is one of the earliest stages of breast cancer (BCa). The mechanisms by which DCIS lesions progress to an invasive state while others remain indolent are yet to be fully characterized and both diagnosis and treatment of this pre-invasive disease could benefit from better understanding the pathways involved. While a decreased expression of Caveolin-1 (Cav-1) in the tumor microenvironment of patients with DCIS breast cancer was linked to progression to invasive breast cancer (IBC), the downstream effector(s) contributing to this process remain elusive. The current report shows elevated expression of Signal Transducer and Activator of Transcription 5a (STAT5a) within the DCIS-like lesions in Cav-1 KO mice following estrogen treatment and inhibition of STAT5a expression prevented the formation of these mammary lesions. In addition, STAT5a overexpression in a human DCIS cell line (MCF10DCIS.com) promoted their invasion, a process accelerated by estrogen treatment and associated with increased levels of the matrix metalloproteinase-9 (MMP-9) precursor. In sum, our results demonstrate a novel regulatory axis (Cav-1♦STAT5a♦MMP-9) in DCIS that is fully activated by the presence of estrogen. Our sudies suggest to further study phosphorylated STAT5a (Y694) as a potential biomarker to guide and predict outcome of DCIS patient population.

Do Eligibility Criteria for Ductal Carcinoma In Situ (DCIS) Active Surveillance Trials Identify Patients at Low Risk for Upgrade to Invasive Carcinoma?

BACKGROUND

Clinical trials are currently ongoing to determine the safety and efficacy of active surveillance (AS) versus usual care (surgical and radiation treatment) for women with ductal carcinoma in situ (DCIS). This study aimed to determine upgrade rates of DCIS at needle biopsy to invasive carcinoma at surgery among women who meet the eligibility criteria for AS trials.

METHODS

A retrospective review was performed of consecutive women at an academic medical center with a diagnosis of DCIS at needle biopsy from 2007 to 2016. Medical records were reviewed for mode of presentation, imaging findings, biopsy pathology results, and surgical outcomes. Each patient with DCIS was evaluated for AS trial eligibility based on published criteria for the COMET, LORD, and LORIS trials.

RESULTS

During a 10-year period, DCIS was diagnosed in 858 women (mean age 58 years; range 28-89 years). Of the 858 women, 498 (58%) were eligible for the COMET trial, 101 (11.8%) for the LORD trial, and 343 (40%) for the LORIS trial. The rates of upgrade to invasive carcinoma were 12% (60/498) for the COMET trial, 5% (5/101) for the LORD trial, and 11.1% (38/343) for the LORIS trial. The invasive carcinomas ranged from 0.2 to 20 mm, and all were node-negative.

CONCLUSIONS

Women who meet the eligibility criteria for DCIS AS trials remain at risk for occult invasive carcinoma at presentation, with upgrade rates ranging from 5 to 12%. These findings suggest that more precise criteria are needed to ensure that women with invasive carcinoma are excluded from AS trials.

Interobserver variability in upfront dichotomous histopathological assessment of ductal carcinoma in situ of the breast: the DCISion study

Histopathological assessment of ductal carcinoma in situ, a nonobligate precursor of invasive breast cancer, is characterized by considerable interobserver variability. Previously, post hoc dichotomization of multicategorical variables was used to determine the "ideal" cutoffs for dichotomous assessment. The present international multicenter study evaluated interobserver variability among 39 pathologists who performed upfront dichotomous evaluation of 149 consecutive ductal carcinomas in situ. All pathologists independently assessed nuclear atypia, necrosis, solid ductal carcinoma in situ architecture, calcifications, stromal architecture, and lobular cancerization in one digital slide per lesion. Stromal inflammation was assessed semiquantitatively. Tumor-infiltrating lymphocytes were quantified as percentages and dichotomously assessed with a cutoff at 50%. Krippendorff's alpha (KA), Cohen's kappa and intraclass correlation coefficient were calculated for the appropriate variables. Lobular cancerization (KA = 0.396), nuclear atypia (KA = 0.422), and stromal architecture (KA = 0.450) showed the highest interobserver variability. Stromal inflammation (KA = 0.564), dichotomously assessed tumor-infiltrating lymphocytes (KA = 0.520), and comedonecrosis (KA = 0.539) showed slightly lower interobserver disagreement. Solid ductal carcinoma in situ architecture (KA = 0.602) and calcifications (KA = 0.676) presented with the lowest interobserver variability. Semiquantitative assessment of stromal inflammation resulted in a slightly higher interobserver concordance than upfront dichotomous tumor-infiltrating lymphocytes assessment (KA = 0.564 versus KA = 0.520). High stromal inflammation corresponded best with dichotomously assessed tumor-infiltrating lymphocytes when the cutoff was set at 10% (kappa = 0.881). Nevertheless, a post hoc tumor-infiltrating lymphocytes cutoff set at 20% resulted in the highest interobserver agreement (KA = 0.669). Despite upfront dichotomous evaluation, the interobserver variability remains considerable and is at most acceptable, although it varies among the different histopathological features. Future studies should investigate its impact on ductal carcinoma in situ prognostication. Forthcoming machine learning algorithms may be useful to tackle this substantial diagnostic challenge.

A retrospective alternative for active surveillance trials for ductal carcinoma in situ of the breast

Ductal carcinoma in situ (DCIS) of the breast is a nonobligate precursor of invasive breast cancer, accounting for 20 % of screen-detected breast cancers. Little is known about the natural progression of DCIS because most patients undergo surgery upon diagnosis. Many DCIS patients are likely being overtreated, as it is believed that only around 50 % of DCIS will progress to invasive carcinoma. Robust prognostic markers for progression to invasive carcinoma are lacking. In the past, studies have investigated women who developed a recurrence after breast-conserving surgery (BCS) and compared them with those who did not. However, where there is no recurrence, the patient has probably been adequately treated. The present narrative review advocates a new research strategy, wherein only those patients with a recurrence are studied. Approximately half of the recurrences are invasive cancers, and half are DCIS. So-called "recurrences" are probably most often the result of residual disease. The new approach allows us to ask: why did some residual DCIS evolve to invasive cancers and others not? This novel strategy compares the group of patients that developed in situ recurrence with the group of patients that developed invasive recurrence after BCS. The differences between these groups could then be used to develop a robust risk stratification tool. This tool should estimate the risk of synchronous and metachronous invasive carcinoma when DCIS is diagnosed in a biopsy. Identification of DCIS patients at low risk for developing invasive carcinoma will individualize future therapy and prevent overtreatment.

Legumain is an independent predictor for invasive recurrence in breast ductal carcinoma in situ

Legumain is a proteolytic enzyme that plays a role in the regulation of cell proliferation in invasive breast cancer. Studies evaluating its role in ductal carcinoma in situ (DCIS) are lacking. Here, we aimed to characterize legumain protein expression in DCIS and evaluate its prognostic significance. Legumain was assessed immunohistochemically in a tissue microarray of a well-characterized cohort of DCIS (n = 776 pure DCIS and n = 239 DCIS associated with invasive breast cancer (DCIS-mixed)). Legumain immunoreactivity was scored in tumor cells and surrounding stroma and related to clinicopathological parameters and patient outcome. High legumain expression was observed in 23% of pure DCIS and was associated with features of high-risk DCIS including higher nuclear grade, comedo necrosis, hormone receptor negativity, HER2 positivity, and higher proliferation index. Legumain expression was higher in DCIS associated with invasive breast cancer than in pure DCIS (p < 0.0001). In the DCIS-mixed cohort, the invasive component showed higher legumain expression than the DCIS component (p < 0.0001). Legumain was an independent predictor of shorter local recurrencefree interval for all recurrences (p = 0.0003) and for invasive recurrences (p = 0.002). When incorporated with other risk factors, legumain provided better patient risk stratification. High legumain expression is associated with poor prognosis in DCIS and could be a potential marker to predict DCIS progression to invasive disease.

Ectopic expression of PLC-β2 in non-invasive breast tumor cells plays a protective role against malignant progression and is correlated with the deregulation of miR-146a

Cells in non‐invasive breast lesions are widely believed to possess molecular alterations that render them either susceptible or refractory to the acquisition of invasive capability. One such alteration could be the ectopic expression of the β2 isoform of phosphoinositide‐dependent phospholipase C (PLC‐β2), known to counteract the effects of hypoxia in low‐invasive breast tumor‐derived cells. Here, we studied the correlation between PLC‐β2 levels and the propensity of non‐invasive breast tumor cells to acquire malignant features. Using archival FFPE samples and DCIS‐derived cells, we demonstrate that PLC‐β2 is up‐regulated in DCIS and that its forced down‐modulation induces an epithelial‐to‐mesenchymal shift, expression of the cancer stem cell marker CD133, and the acquisition of invasive properties. The ectopic expression of PLC‐β2 in non‐transformed and DCIS‐derived cells is, to some extent, dependent on the de‐regulation of miR‐146a, a tumor suppressor miRNA in invasive breast cancer. Interestingly, an inverse relationship between the two molecules, indicative of a role of miR‐146a in targeting PLC‐β2, was not detected in primary DCIS from patients who developed a second invasive breast neoplasia. This suggests that alterations of the PLC‐β2/miR‐146a relationship in DCIS may constitute a molecular risk factor for the appearance of new breast lesions. Since neither traditional classification systems nor molecular characterizations are able to predict the malignant potential of DCIS, as is possible for invasive ductal carcinoma (IDC), we propose that the assessment of the PLC‐β2/miR‐146a levels at diagnosis could be beneficial for identifying whether DCIS patients may have either a low or high propensity for invasive recurrence.

Stromal characteristics are adequate prognosticators for recurrence risk in ductal carcinoma in situ of the breast

BACKGROUND

Ductal carcinoma in situ (DCIS) of the breast constitutes a heterogeneous group of non-obligate precursors for invasive breast cancer. To date, adequate risk stratification is lacking, which is presumed to result in overtreatment. We previously identified myxoid stromal architecture as a potential prognosticator for loco-regional recurrence. In the present study, we investigated the prognostic potential of stromal characteristics.

METHODS

Hematoxylin and eosin stained slides from 211 DCIS patients were reviewed. The following histological features were dichotomously assessed: nuclear grade, DCIS architecture, presence of necrosis, intraductal calcifications, stromal inflammation and myxoid stromal architecture. Loco-regional recurrences constituted the primary endpoint.

RESULTS

Cox regression analysis showed that high nuclear grade, myxoid stromal architecture and moderate to extensive stromal inflammation were significantly associated with decreased recurrence-free survival, independent of radiotherapy. Based on these features, a combined risk score (CRS) was calculated, ranging from zero to three. A high CRS of three was associated with significantly shorter recurrence-free survival. Nineteen patients had a CRS of three, of which three relapsed (15.7%), whereas only one out of 113 patients with a CRS of zero relapsed (0.9%).

CONCLUSIONS

We were able to validate our previously reported findings regarding the prognostic potential of myxoid periductal stroma in an independent DCIS patient cohort. A CRS based on nuclear grade, myxoid stromal architecture and stromal inflammation might facilitate discrimination of low risk from high risk patients. Consequently, the CRS may tailor adjuvant therapy. Future research should investigate whether radiotherapy can be safely omitted in patients with a low CRS.

Dichotomous histopathological assessment of ductal carcinoma in situ of the breast results in substantial interobserver concordance

AIMS

Robust prognostic markers for ductal carcinoma in situ (DCIS) of the breast require high reproducibility and thus low interobserver variability. The aim of this study was to compare interobserver variability among 13 pathologists, in order to enable the identification of robust histopathological characteristics.

METHODS AND RESULTS

One representative haematoxylin and eosin-stained slide was selected for 153 DCIS cases. All pathologists independently assessed nuclear grade, intraductal calcifications, necrosis, solid growth, stromal changes, stromal inflammation, and apocrine differentiation. All characteristics were assessed categorically. Krippendorff's alpha was calculated to assess overall interobserver concordance. Cohen's kappa was calculated for every observer duo to further explore interobserver variability. The highest concordance was observed for necrosis, calcifications, and stromal inflammation. Assessment of solid growth, nuclear grade and stromal changes resulted in lower concordance. Poor concordance was observed for apocrine differentiation. Kappa values for each observer duo identified the 'ideal' cut-off for dichotomisation of multicategory variables. For instance, concordance was higher for 'non-high versus high' nuclear grade than for 'low versus non-low' nuclear grade. 'Absent/mild' versus 'moderate/extensive' stromal inflammation resulted in substantially higher concordance than other dichotomous cut-offs.

CONCLUSIONS

Dichotomous assessment of the histopathological features of DCIS resulted in moderate to substantial agreement among pathologists. Future studies on prognostic markers in DCIS should take into account this degree of interobserver variability to define cut-offs for categorically assessed histopathological features, as reproducibility is paramount for robust prognostic markers in daily clinical practice. A new prognostic index for DCIS might be considered, based on two-tier grading of histopathological features. Future research should explore the prognostic potential of such two-tier assessment.

Ductal Carcinoma In Situ

Ductal carcinoma in situ has been stable in incidence for a decade and has an excellent prognosis. Breast conservation therapy is safe and effective for most patients. Adjuvant whole breast radiation therapy is recommended to reduce the risk of local recurrence. Accelerated partial breast irradiation is a promising alternative to decrease toxicity and improve cosmetic results. Adjuvant hormonal therapy can reduce local recurrence, but should be used cautiously. Future directions in management include developing predictive tools for guidance for use of adjuvant therapy and selecting low-risk patients with ductal carcinoma in situ in whom surgery may be safely omitted.

Atypical ductal hyperplasia: update on diagnosis, management, and molecular landscape

BACKGROUND

Atypical ductal hyperplasia (ADH) is a common diagnosis in the mammographic era and a significant clinical problem with wide variation in diagnosis and treatment. After a diagnosis of ADH on biopsy a proportion are upgraded to carcinoma upon excision; however, the remainder of patients are overtreated. While ADH is considered a non-obligate precursor of invasive carcinoma, the molecular taxonomy remains unknown.

MAIN TEXT

Although a few studies have revealed some of the key genomic characteristics of ADH, a clear understanding of the molecular changes associated with breast cancer progression has been limited by inadequately powered studies and low resolution methodology. Complicating factors such as family history, and whether the ADH present in a biopsy is an isolated lesion or part of a greater neoplastic process beyond the limited biopsy material, make accurate interpretation of genomic features and their impact on progression to malignancy a challenging task. This article will review the definitions and variable management of the patients diagnosed with ADH as well as the current knowledge of the molecular landscape of ADH and its clonal relationship with ductal carcinoma in situ and invasive carcinoma.

CONCLUSIONS

Molecular data of ADH remain sparse. Large prospective cohorts of pure ADH with clinical follow-up need to be evaluated at DNA, RNA, and protein levels in order to develop biomarkers of progression to carcinoma to guide management decisions.

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

Background

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

Methods

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

Results

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

Conclusion

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

Electronic supplementary material

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

Article Commentary: Controversies Regarding the Diagnosis and Management of Ductal Carcinoma in Situ

Ductal carcinoma in situ (DCIS) is a premalignant condition, whose incidence is increasing in the current era of widespread screening mammography. While eminently treatable, there are innumerable controversies that surround this disease in terms of its diagnosis and treatment. We discuss these issues and review the data to date regarding this condition which affects roughly 20 per cent of all patients presenting with breast cancer.

Implementation of shared decision-making in oncology: development and pilot study of a nurse-led decision-coaching programme for women with ductal carcinoma in situ

Background

To implement informed shared decision-making (ISDM) in breast care centres, we developed and piloted an inter-professional complex intervention.

Methods

We developed an intervention consisting of three components: an evidence-based patient decision aid (DA) for women with ductal carcinoma in situ, a decision-coaching led by specialised nurses (breast care nurses and oncology nurses) and structured physician encounters.

In order to enable professionals to gain ISDM competencies, we developed and tested a curriculum-based training programme for specialised nurses and a workshop for physicians. After successful testing of the components, we conducted a pilot study to test the feasibility of the entire revised intervention in two breast care centres. Here the acceptance of the intervention by women and professionals, the applicability to the breast care centres’ procedures, women’s knowledge, patient involvement in treatment decision-making assessed with the MAPPIN’SDM-observer instrument MAPPIN’O_dyad, and barriers to and facilitators of the implementation were taken into consideration. We used questionnaires, structured verbal and written feedback and video recordings. Qualitative data were analysed descriptively, and mean values and ranges of quantitative data were calculated.

Results

To test the DA, focus groups and individual interviews were conducted with 27 women. Six expert reviews were obtained. The components of the nurse training were tested with 18 specialised nurses and 19 health science students. The development and piloting of the components were successful. The pilot test of the entire intervention included seven patients. In general, the intervention is applicable. Patients attained adequate knowledge (range of correct answers: 9–11 of 11). On average, a basic level of patient involvement in treatment decision-making was observed for nurses and patient–nurse dyads (M(MAPPIN-O_dyad): 2.15 and M(MAPPIN-O_nurse): 1.90). Relevant barriers were identified; physicians barely tolerated women’s preferences that were not in line with the medical recommendation. Classifying women as inappropriate for ISDM due to age or education led physicians to neglect eligible women during the recruitment phase.

Conclusion

Decision-coaching is feasible. Nevertheless, there are some indications that structural changes are needed for long-term implementation. We are currently evaluating the intervention in a cluster randomised controlled trial in 16 breast care centres.

Electronic supplementary material

The online version of this article (10.1186/s12911-017-0548-8) contains supplementary material, which is available to authorized users.

Chemokine Signaling Facilitates Early-Stage Breast Cancer Survival and Invasion through Fibroblast-Dependent Mechanisms

Ductal carcinoma in situ (DCIS) is the most common form of breast cancer, with 50,000 cases diagnosed every year in the United States. Overtreatment and undertreatment remain significant clinical challenges in patient care. Identifying key mechanisms associated with DCIS progression could uncover new biomarkers to better predict patient prognosis and improve guided treatment. Chemokines are small soluble molecules that regulate cellular homing through molecular gradients. CCL2-mediated recruitment of CCR2⁺ macrophages are a well-established mechanism for metastatic progression. Although the CCL2/CCR2 pathway is a therapeutic target of interest, little is known about the role of CCR2 expression in breast cancer. Here, using a mammary intraductal injection (MIND) model to mimic DCIS formation, the role of CCR2 was explored in minimally invasive SUM225 and highly invasive DCIS.com breast cancer cells. CCR2 overexpression increased SUM225 breast cancer survival and invasion associated with accumulation of CCL2 expressing fibroblasts. CCR2-deficient DCIS.com breast cancer cells formed fewer invasive lesions with fewer CCL2⁺ fibroblasts. Cografting CCL2-deficient fibroblasts with DCIS.com breast cancer cells in the subrenal capsule model inhibited tumor invasion and survival associated with decreased expression of aldehyde dehydrogenase (ALDH1), a proinvasive factor, and decreased expression of HTRA2, a proapoptotic serine protease. Through data mining analysis, high expression of CCR2 and ALDH1 and low HTRA2 expression were correlated with poor prognosis of breast cancer patients.Implications: This study demonstrates that CCR2 overexpression in breast cancer drives early-stage breast cancer progression through stromal-dependent expression of CCL2 with important insight into prognosis and treatment of DCIS. Mol Cancer Res; 16(2); 296-308. ©2017 AACR.

Assessing Tumor-infiltrating Lymphocytes in Solid Tumors: A Practical Review for Pathologists and Proposal for a Standardized Method From the International Immunooncology Biomarkers Working Group: Part 1: Assessing the Host Immune Response, TILs in Invasive Breast Carcinoma and Ductal Carcinoma In Situ, Metastatic Tumor Deposits and Areas for Further Research

Assessment of tumor-infiltrating lymphocytes (TILs) in histopathologic specimens can provide important prognostic information in diverse solid tumor types, and may also be of value in predicting response to treatments. However, implementation as a routine clinical biomarker has not yet been achieved. As successful use of immune checkpoint inhibitors and other forms of immunotherapy become a clinical reality, the need for widely applicable, accessible, and reliable immunooncology biomarkers is clear. In part 1 of this review we briefly discuss the host immune response to tumors and different approaches to TIL assessment. We propose a standardized methodology to assess TILs in solid tumors on hematoxylin and eosin sections, in both primary and metastatic settings, based on the International Immuno-Oncology Biomarker Working Group guidelines for TIL assessment in invasive breast carcinoma. A review of the literature regarding the value of TIL assessment in different solid tumor types follows in part 2. The method we propose is reproducible, affordable, easily applied, and has demonstrated prognostic and predictive significance in invasive breast carcinoma. This standardized methodology may be used as a reference against which other methods are compared, and should be evaluated for clinical validity and utility. Standardization of TIL assessment will help to improve consistency and reproducibility in this field, enrich both the quality and quantity of comparable evidence, and help to thoroughly evaluate the utility of TILs assessment in this era of immunotherapy.

Current treatment trends and the need for better predictive tools in the management of ductal carcinoma in situ of the breast

Ductal carcinoma in situ (DCIS) of the breast represents a group of heterogeneous non-invasive lesions the incidence of which has risen dramatically since the advent of mammography screening. In this review we summarise current treatment trends and up-to-date results from clinical trials studying surgery and adjuvant therapy alternatives, including the recent consensus on excision margin width and its role in decision-making for post-excision radiotherapy. The main challenge in the clinical management of DCIS continues to be the tailoring of treatment to individual risk, in order to avoid the over-treatment of low-risk lesions or under-treatment of DCIS with higher risk of recurring or progressing into invasion. While studies estimate that only about 40% of DCIS would become invasive if untreated, heterogeneity and complex natural history have prevented adequate identification of these higher-risk lesions. Here we discuss attempts to develop prognostic tools for the risk stratification of DCIS lesions and their limitations. Early results of a UK-wide audit of DCIS management (the Sloane Project) have also demonstrated a lack of consistency in treatment. In this review we offer up-to-date perspectives on current treatment and prediction of DCIS, highlighting the pressing clinical need for better prognostic indices. Tools integrating both clinical and histopathological factors together with molecular biomarkers may hold potential for adequate stratification of DCIS according to risk. This could help develop standardised practices for optimal management of patients with DCIS, improving clinical outcomes while providing only the amount of therapy required for each individual patient.

Importance of cost-effectiveness and value in cancer care and healthcare policy

The cost of cancer care has increased by five fold over the last three decades. As our healthcare system shifts from volume to value, greater scrutiny of interventions with clinical equipoise is required. Traditionally, QALYs and ICER have served as surrogate markers for value. However, this approach fails to incorporate all stakeholders' viewpoints. Prostate cancer, low risk DCIS, and thyroid cancer are used as a framework to discuss value and cost-effectiveness. J. Surg. Oncol. 2016;114:275-280. © 2016 Wiley Periodicals, Inc.