Ductal carcinoma in situ of the breast

Outcomes of DCIS treated with breast conserving surgery without radiotherapy on recurrence, survival, and health-related quality of life

BACKGROUND

Sector resection for Ductal Carcinoma in Situ (DCIS) allows wide excision without compromising breast shape. There are concerns that radiotherapy for some DCIS after sector resection is unnecessary and reduces patient satisfaction and quality of life without affecting survival. This study aimed to investigate whether women with DCIS managed with sector resection without radiotherapy had acceptable rates of recurrence and health-related quality of life outcomes.

METHODS

Retrospective study of patients who underwent sector resection for DCIS without adjuvant radiotherapy from 1992 to 2021. Tumour size, grade, necrosis, margins, follow up and time to ipsilateral recurrence was recorded. Patients were posted a BREAST-Q to assess health-related quality of life.

RESULTS

One hundred and thirty-eight patients were treated for pure DCIS by two surgeons from 1992 to 2018. One hundred and sixteen patients underwent sector resection, 22 had mastectomy. Average age 61 years. Mean follow up 9.14 years. Recurrence rate after sector resection was 18.97%. 55% were DCIS. Annualized recurrence rate was 2.07%. There were no cancer-related deaths. BREAST-Q completion rate was 44%. Satisfaction with breasts, physical, psychosocial, and sexual well-being scores were significantly higher than normative Australian values and a mixed cohort of women who underwent breast conserving surgery with radiotherapy.

CONCLUSION

DCIS can be safely managed with sector resection without radiotherapy and regular long-term follow up. This approach results in low annualized recurrence rates, high levels patient satisfaction and health-related quality of life and should be considered a safe alternative for patients with DCIS to minimize morbidity without affecting cancer survival.

Apparent Diffusion Coefficient-Based Convolutional Neural Network Model Can Be Better Than Sole Diffusion-Weighted Magnetic Resonance Imaging to Improve the Differentiation of Invasive Breast Cancer From Breast Ductal Carcinoma In Situ

BACKGROUND AND PURPOSE

Breast ductal carcinoma in situ (DCIS) has no metastatic potential, and has better clinical outcomes compared with invasive breast cancer (IBC). Convolutional neural networks (CNNs) can adaptively extract features and may achieve higher efficiency in apparent diffusion coefficient (ADC)-based tumor invasion assessment. This study aimed to determine the feasibility of constructing an ADC-based CNN model to discriminate DCIS from IBC.

METHODS

The study retrospectively enrolled 700 patients with primary breast cancer between March 2006 and June 2019 from our hospital, and randomly selected 560 patients as the training and validation sets (ratio of 3 to 1), and 140 patients as the internal test set. An independent external test set of 102 patients during July 2019 and May 2021 from a different scanner of our hospital was selected as the primary cohort using the same criteria. In each set, the status of tumor invasion was confirmed by pathologic examination. The CNN model was constructed to discriminate DCIS from IBC using the training and validation sets. The CNN model was evaluated using the internal and external tests, and compared with the discriminating performance using the mean ADC. The area under the curve (AUC), sensitivity, specificity, and accuracy were calculated to evaluate the performance of the previous model.

RESULTS

The AUCs of the ADC-based CNN model using the internal and external test sets were larger than those of the mean ADC (AUC: 0.977 vs. 0.866, P = 0.001; and 0.926 vs. 0.845, P = 0.096, respectively). Regarding the internal test set and external test set, the ADC-based CNN model yielded sensitivities of 0.893 and 0.873, specificities of 0.929 and 0.894, and accuracies of 0.907 and 0.902, respectively. Regarding the two test sets, the mean ADC showed sensitivities of 0.845 and 0.818, specificities of 0.821 and 0.829, and accuracies of 0.836 and 0.824, respectively. Using the ADC-based CNN model, the prediction only takes approximately one second for a single lesion.

CONCLUSION

The ADC-based CNN model can improve the differentiation of IBC from DCIS with higher accuracy and less time.

Breast intraductal nanoformulations for treating ductal carcinoma in situ II: Dose de-escalation using a slow releasing/slow bioconverting prodrug strategy

Ductal carcinoma in situ (DCIS) represents approximately 20-25% of newly diagnosed breast cancers. DCIS is treated by surgery and possibly radiotherapy. Chemotherapy is only used as adjuvant or neoadjuvant therapy but not as primary therapy. The present study investigated the intraductal administration of Ciclopirox (CPX) formulated in nanosuspensions (NSs) or nanoparticles (NPs) to treat DCIS locally in a Fischer 344 rat model orthotopically implanted with 13762 Mat B III cells. Slow converting esterase responsive CPX prodrugs (CPDs) were successfully synthesized at high purity (> 95%) by directly acetylating the hydroxyl group or by appending a self-immolative linker between CPX and a phenolic ester. Direct esterification CPDs were not sufficiently stable so self-immolative CPDs were formulated in NSs and NPs. Prodrug release was evaluated from poly(lactic-co-glycolic acid) NPs, and CPD4 demonstrated the slowest release rate with the rank order of CPD2 (R = methyl) > CPD3 (R = t-butyl) > CPD4 (R = phenyl). Intraductally administered CPX NS, CPD4 NS, and an innovative mixture of CDP4 NS and NPs (at 1 mg CPX equivalent/duct) demonstrated significant (p < 0.05) in vivo anti-tumor efficacy compared with immediate release (IR) CPX NS and non-treated controls. CPX mammary persistence at 6 h and 48 h after CPD4 NS or NP administration was also greater than after the immediate release CPX NS. A strong correlation between CPX mammary persistence and efficacy is demonstrated. In conclusion, nanoformulations utilizing a slow releasing/slow bioconverting CPX prodrug delivery strategy resulted in significant dose de-escalation (~ five fold) while maintaining anti-tumor efficacy.

Discriminating low-grade ductal carcinoma in situ (DCIS) from non-low-grade DCIS or DCIS upgraded to invasive carcinoma: effective texture features on ultrafast dynamic contrast-enhanced magnetic resonance imaging

PURPOSE

To investigate effective model composed of features from ultrafast dynamic contrast-enhanced magnetic resonance imaging (UF-MRI) for distinguishing low- from non-low-grade ductal carcinoma in situ (DCIS) lesions or DCIS lesions upgraded to invasive carcinoma (upgrade DCIS lesions) among lesions diagnosed as DCIS on pre-operative biopsy.

MATERIALS AND METHODS

Eighty-six consecutive women with 86 DCIS lesions diagnosed by biopsy underwent UF-MRI including pre- and 18 post-contrast ultrafast scans (temporal resolution of 3 s/phase). The last phase of UF-MRI was used to perform 3D segmentation. The time point at 6 s after the aorta started to enhance was used to obtain subtracted images. From the 3D segmentation and subtracted images, enhancement, shape, and texture features were calculated and compared between low- and non-low-grade or upgrade DCIS lesions using univariate analysis. Feature selection by least absolute shrinkage and selection operator (LASSO) algorithm and k-fold cross-validation were performed to evaluate the diagnostic performance.

RESULTS

Surgical specimens revealed 16 low-grade DCIS lesions, 37 non-low-grade lesions and 33 upgrade DCIS lesions. In univariate analysis, five shape and seven texture features were significantly different between low- and non-low-grade lesions or upgrade DCIS lesions, whereas enhancement features were not. The six features including surface/volume ratio, irregularity, diff variance, uniformity, sum average, and variance were selected using LASSO algorism and the mean area under the receiver operating characteristic curve for training and validation folds were 0.88 and 0.88, respectively.

CONCLUSION

The model with shape and texture features of UF-MRI could effectively distinguish low- from non-low-grade or upgrade DCIS lesions.

Intraductal Therapy in Breast Cancer: Current Status and Future Prospective

With our improved understanding of the biological behavior of breast cancer, minimally invasive intervention is urgently needed for personalized treatment of early disease. Intraductal therapy is one such minimally invasive approach. With the help of appropriate tools, technologies using the intraductal means of entering the ducts may be used both to diagnose and treat lesions in the mammary duct system with less trauma and at the same time avoid systemic toxicity. Traditional agents such as those targeting pathways, endocrine therapy, immunotherapy, or gene therapy can be used alone or combined with other new technologies, such as nanomaterials, through the intraductal route. Additionally, relevant mammary tumor models in rodents which reflect changes in the tumor microenvironment will help deepen our understanding of their biological behavior and heterogeneity. This article reviews the current status and future prospects of intraductal therapy in breast cancer, with emphasis on ductal carcinoma in situ.

Breast intraductal nanoformulations for treating ductal carcinoma in situ I: Exploring metal-ion complexation to slow ciclopirox release, enhance mammary persistence and efficacy

INTRODUCTION

Ductal Carcinoma In Situ (DCIS) represents a significant fraction (~20-25%) of all newly diagnosed breast cancer cases and, if left untreated, a significant fraction of patients will progress to invasive disease. Surgery is the only treatment option. Ciclopirox (CPX), an FDA-approved antifungal drug, has exhibited promising antitumor activity by down-regulating the expression of vital antiapoptotic cellular proteins and inhibiting the genetic expression of several oncogenic pathways. In this study, the feasibility of using nanoscale delivery systems to control release and prolong mammary tissue persistence of a lipophilic metal complex of CPX and Zinc (CPXZn) after intraductal administration was investigated.

METHODS

CPX and CPX-Zn nanosuspensions (NSs) were prepared using an evaporative nanoprecipitation-ultra-sonication method. Flash nanoprecipitation was used to prepare PLGA nanoparticles (NPs) loaded with CPXZn. Our established orthotopic DCIS rat model was used to evaluate efficacy. Briefly, two days after 13762 Mat B III cell intraductal inoculation, rats were divided into treatment groups and a single intraductal injection of CPX NS, CPX-Zn NS or CPX-Zn NPs was administered. In the first study arm, the efficacy of CPX NS (1, 3, 5 mg/duct) was evaluated. In the second arm, the in vivo efficacy of CPX NS, CPX-Zn NS and CPX-Zn loaded NPs was evaluated and compared at equivalent CPX doses. The mammary persistence of CPX from CPX NS, CPX-Zn NS, and CPX-Zn PLGA NPs was also assessed.

RESULTS

CPX-Zn complex was successfully synthesized and characterized by several spectral analyses. CPX release was slowed from the CPX-Zn NS and further slowed by incorporating CPX-Zn into PLGA NPs as compared to the CPX NS with release half times following the order: CPX NS < CPX-Zn NS << CPX-Zn NP. Intraductal CPX NS administration was dose and time dependent in suppressing tumor initiation suggesting prolonged mammary exposure may improve efficacy. In the second arm, mammary tissue persistence of CPX followed the rank order CPX NS < CPX-Zn NS << CPX-Zn NP at 6 h and 48 h post-administration. Prolonged mammary CPX exposure was highly correlated to improved efficacy. Prolonged CPX tissue persistence, attributed to slower release from the zinc complex and the PLGA NPs, resulted in a 5-fold dose reduction compared to the CPX NS.

CONCLUSIONS

The current results demonstrate that slowing drug release in the mammary duct after intraductal administration overcomes the rapid ductal clearance of CPX, prolongs mammary tissue persistence, improves efficacy against DCIS lesions in vivo, and requires 5-fold less CPX to achieve equivalent efficacy. The studies also provide a strategic path forward for developing a locally administered drug delivery system for treating DCIS, for which no primary chemotherapy option is available.

Evaluation of intraductal delivery of poly(ethylene glycol)-doxorubicin conjugate nanocarriers for the treatment of ductal carcinoma in situ (DCIS)-like lesions in rats

Ductal carcinoma in situ is the most commonly diagnosed early stage breast cancer. The efficacy of intraductally delivered poly(ethylene glycol)-doxorubicin (PEG-DOX) nanocarriers, composed of one or more DOX conjugated to various PEG polymers, was investigated in an orthotopic ductal carcinoma in situ-like rat model. In vitro cytotoxicity was evaluated against 13762 Mat B III cells using MTT assay. The orthotopic model was developed by inoculating cancer cells into mammary ducts of female Fischer 344 retired breeder rats. The ductal retention and in vivo antitumour efficacy of two of the six nanocarriers (5 kDa PEG-DOX and 40 kDa PEG-(DOX)4) were investigated based on in vitro results. Mammary retention of DOX and PEG-DOX nanocarriers was quantified using in vivo imaging. Histopathologic effects of DOX and PEG-DOX nanocarriers on mammary ductal structure were also investigated. Cytotoxicities of small linear PEG-DOX nanocarriers (5 and 10 kDa) were not different from DOX whereas larger PEG-DOX nanocarriers showed reduced potency. The order of mammary retention was 40 kDa PEG-(DOX)4 > 5 kDa PEG-DOX >> DOX, in normal and tumour-bearing rats. Intraductally administered PEG-DOX nanocarriers and DOX were effective in reducing tumour incidence and increasing survival rate, with no significant differences found among the three treatment groups. However, nanocarriers administered intravenously at the same doses were not effective, and intraductally administered free DOX caused severe local toxicity. Intraductal administration of PEG-DOX nanocarriers is effective and less toxic than that of free DOX, as well as IV DOX/PEG-DOX. Furthermore, PEG-DOX nanocarriers demonstrate the added benefit of prolonging DOX ductal retention, which would necessitate less frequent dosing.

Evaluating the efficacy of post-surgery adjuvant therapies used for ductal carcinoma in situ patients: a network meta-analysis

OBJECTIVE

Post-surgery adjuvant therapies are very important for patients suffering from ductal carcinoma in situ (DCIS). In this study we conducted a network meta-analysis (NMA) to evaluate the efficacy of different post-surgery adjuvant therapies including tamoxifen, anastrozole and radiation therapy (RT) and their combinations (RT+ tamoxifen and RT+ anastrozole).

METHODS

We searched several databases, including Embase, MEDLINE / PUBMED, Cochrane Library, and Science Citation Index, for relevant studies. We then extracted the data from eligible studies in order to perform our NMA. We measured the comparative efficacy of each treatment option based on the calculated odds ratios (ORs) and the corresponding 95% credibility interval (95%CrI) for each treatment option. We calculated the surfaces under the cumulative ranking curves (SUCRA) in order to rank the therapies according to their different outcomes.

RESULTS

In this study, local recurrence (LC) was chosen as the primary outcome. Metastasis, contralateral-breast cancer (CBC), ipsilateral-breast cancer (IBC) and death were secondary outcomes. Patients treated with RT and RT + tamoxifen exhibited a lower risk of LC compared with control group (OR=0.54, 95%CrI: 0.40-0.73; OR=0.41, 95%CrI: 0.19-0.90). Patients treated by RT and RT + tamoxifen also exhibited a significantly lower risk of IBC compared with control group (OR=0.55, 95%CrI: 0.37-0.82; OR=0.42, 95%CrI: 0.18-0.99). Results from the SUCRA indicated that RT + anastrozole and RT + tamoxifen were potentially the best adjuvant treatments for patients with DCIS.

CONCLUSIONS

In conclusion, the RT + anastrozole and RT + tamoxifen are recommended for their performance and effectiveness.

Intraductal Delivery to the Rabbit Mammary Gland

Localized intraductal treatments for breast cancer offer potential advantages, including efficient delivery to the tumor and reduced systemic toxicity and adverse effects^{1,2,3,4,5,6,7}. However, several challenges remain before these treatments can be applied more widely. The development and validation of intraductal therapeutics in an appropriate animal model facilitate the development of intraductal therapeutic strategies for patients. While the mouse mammary gland has been widely used as a model system of mammary development and tumorigenesis, the anatomy is distinct from the human gland. A larger animal model, such as the rabbit, may serve as a better model for mammary gland structure and intraductal therapeutic development. In contrast to mice, in which ten ductal trees are spatially distributed along the body axis, each terminating in a separate teat, the rabbit mammary gland more closely resembles the human gland, with multiple overlapping ductal systems that exit through separate openings in one teat. Here, we present minimally invasive methods for the delivery of reagents directly into the rabbit mammary duct and for visualization of the delivery itself with high-resolution ultrasound imaging.

Lattice-based model of ductal carcinoma in situ suggests rules for breast cancer progression to an invasive state

Ductal carcinoma in situ (DCIS) is a heterogeneous group of non-invasive lesions of the breast that result from abnormal proliferation of mammary epithelial cells. Pathologists characterize DCIS by four tissue morphologies (micropapillary, cribriform, solid, and comedo), but the underlying mechanisms that distinguish the development and progression of these morphologies are not well understood. Here we explored the conditions leading to the emergence of the different morphologies of DCIS using a two-dimensional multi-cell lattice-based model that incorporates cell proliferation, apoptosis, necrosis, adhesion, and contractility. We found that the relative rates of cell proliferation and apoptosis governed which of the four morphologies emerged. High proliferation and low apoptosis favored the emergence of solid and comedo morphologies. In contrast, low proliferation and high apoptosis led to the micropapillary morphology, whereas high proliferation and high apoptosis led to the cribriform morphology. The natural progression between morphologies cannot be investigated in vivo since lesions are usually surgically removed upon detection; however, our model suggests probable transitions between these morphologies during breast cancer progression. Importantly, cribriform and comedo appear to be the ultimate morphologies of DCIS. Motivated by previous experimental studies demonstrating that tumor cells behave differently depending on where they are located within the mammary duct in vivo or in engineered tissues, we examined the effects of tissue geometry on the progression of DCIS. In agreement with our previous experimental work, we found that cells are more likely to invade from the end of ducts and that this preferential invasion is regulated by cell adhesion and contractility. This model provides additional insight into tumor cell behavior and allows the exploration of phenotypic transitions not easily monitored in vivo.

Breast cancer is a complex disease that affects women worldwide. One heterogeneous group of lesions, ductal carcinoma in situ (DCIS), often begins as a nonmalignant disease but can readily progress if left untreated. The progression of this disease is not well understood because DCIS is typically removed upon detection. Therefore, computational models might help predict whether DCIS will remain nonmalignant or progress towards invasive ductal carcinoma. Here we used a multi-cell lattice-based model to explore the relative effects of cell proliferation, death, division axis, adhesion and contractility on the development and progression of DCIS. We also examined the emergence and progression of DCIS in physiologically relevant geometries of the mammary duct. Our model suggests several plausible progressions between morphologies of DCIS, and predicts that some regions of a duct are preferential for tumor cell invasion.

Virtual tissue microarrays: a novel and viable approach to optimizing tissue microarrays for biomarker research applied to ductal carcinoma in situ

AIMS

Tissue microarrays (TMAs) are effective tools for performing high-throughput standardization analyses of biomarkers, but evidence indicating the core number required to be representative of the whole tumour is lacking. Ductal carcinoma in situ (DCIS) is a non-obligate precursor of invasive breast cancer. The number and size of cores that can best represent a DCIS lesion are unknown. Rather than performing extensive experiments using several variants of physical TMAs, the aim of this study was to develop a 'virtual TMA' approach that is effective at optimizing biomarker discovery and validation.

METHODS AND RESULTS

Whole DCIS sections from 95 patients were evaluated by immunohistochemistry for oestrogen receptor (ER), progesterone receptor (PgR), HER2, and Ki67. Histoscores were generated manually for ER, PgR, and HER2, as well as percentage positivity for Ki67. Slides were scanned using the FDA-approved Ariol SL50 Image Analysis system, and the virtual array (V-Array) module was used. Virtual cores created virtual TMAs, and our validated scoring classifiers were applied. Automated histoscores and percentage positivity were determined, and compared against increasing numbers of cores. The optimal number of cores was based on concordant results between virtual TMAs and corresponding whole sections.

CONCLUSIONS

We have shown that virtual arrays constitute an important tool in digital pathology in both research and clinical settings.

Influence of molecular size on the retention of polymeric nanocarrier diagnostic agents in breast ducts

PURPOSE

To investigate the influence of nanocarrier molecular size and shape on breast duct retention in normal rats using a non-invasive optical imaging method.

METHODS

Fluorescein-labeled PEG nanocarriers of different molecular weights and shapes (linear, two-arm, four-arm, and eight-arm) were intraductally administered (50 nmol) to female Sprague-Dawley rats. Whole body images were obtained non-invasively. Fluorescence intensities (i.e., amount remaining in duct) were plotted against time to estimate the nanocarrier ductal retention half-lives (t(1/2)). Plasma samples were taken and the pharmacokinetics (Tmax, Cmax) of absorbed nanocarriers was also assessed.

RESULTS

The t(1/2) of linear 12, 20, 30, 40, and two-arm 60 kDa nanocarriers were 6.7 ± 0.9, 16.1 ± 4.1, 16.6 ± 3.4, 21.5 ± 2.7, and 19.5 ± 6.1 h, whereas the four-arm 20, 40, and eight-arm 20 kDa had t(1/2) of 9.0 ± 0.5, 11.5 ± 1.9, and 12.6 ± 3.0 h. The t(1/2) of unconjugated fluorescein was significantly lower (14.5 ± 1.4 min). The Tmax for 12, 40, 60 kDa nanocarriers were 1, 24, and 32 h, respectively, and only 30 min for fluorescein.

CONCLUSIONS

Since normal breast ducts are highly permeable, the use of nanocarriers may be helpful in prolonging ductal retention of diagnostic and/or therapeutic agents.

Adjuvant tamoxifen reduces subsequent breast cancer in women with estrogen receptor-positive ductal carcinoma in situ: a study based on NSABP protocol B-24

PURPOSE

The NSABP (National Surgical Adjuvant Breast and Bowel Project) B-24 study demonstrated significant benefit with adjuvant tamoxifen in patients with ductal carcinoma in situ (DCIS) after lumpectomy and radiation. Patients were enrolled without knowledge of hormone receptor status. The current study retrospectively evaluated the relationship between receptors and response to tamoxifen.

PATIENTS AND METHODS

Estrogen (ER) and progesterone receptors (PgR) were evaluated in 732 patients with DCIS (41% of original study population). An experienced central laboratory determined receptor status in all patient cases with available paraffin blocks (n = 449) by immunohistochemistry (IHC) using comprehensively validated assays. Results for additional patients (n = 283) determined by various methods (primarily IHC) were available from enrolling institutions. Combined results were evaluated for benefit of tamoxifen by receptor status at 10 years and overall follow-up (median, 14.5 years).

RESULTS

ER was positive in 76% of patients. Patients with ER-positive DCIS treated with tamoxifen (v placebo) showed significant decreases in subsequent breast cancer at 10 years (hazard ratio [HR], 0.49; P < .001) and overall follow-up (HR, 0.60; P = .003), which remained significant in multivariable analysis (overall HR, 0.64; P = .003). Results were similar, but less significant, when subsequent ipsilateral and contralateral, invasive and noninvasive, breast cancers were considered separately. No significant benefit was observed in ER-negative DCIS. PgR and either receptor were positive in 66% and 79% of patients, respectively, and in general, neither was more predictive than ER alone.

CONCLUSION

Patients in NSABP B-24 with ER-positive DCIS receiving adjuvant tamoxifen after standard therapy showed significant reductions in subsequent breast cancer. The use of adjuvant tamoxifen should be considered for patients with DCIS.

Characterization of ductal carcinoma in situ on diffusion weighted breast MRI

OBJECTIVES

To characterize ductal carcinoma in situ (DCIS) and its subtypes on diffusion-weighted imaging (DWI).

METHODS

We retrospectively reviewed 74 pure DCIS lesions in 69 women who underwent DWI at 1.5 T (b = 0 and 600 s/mm(2)). Each lesion was characterized by qualitative DWI intensity, quantitative DWI lesion-to-normal contrast-to-noise ratio (CNR), and quantitative apparent diffusion coefficient (ADC). The detection rate was calculated with predetermined thresholds for each parameter. The effects of lesion size, grade, morphology, and necrosis were assessed.

RESULTS

Ninety-six percent (71/74) of DCIS lesions demonstrated greater qualitative DWI intensity than normal breast tissue. Quantitatively, DCIS lesions demonstrated on average 56% greater signal than normal tissue (mean CNR = 1.83  ±  2.7) and lower ADC values (1.50 ± 0.28 × 10(-3) mm(2)/s) than normal tissue (2.01 ± 0.37 × 10(-3) mm(2)/s, p < 0.0001). A 91% detection rate was achieved utilizing an ADC threshold (<1.81 × 10(-3) mm(2)/s ). Non-high-grade DCIS exhibited greater qualitative DWI intensity (p = 0.02) and quantitative CNR (p = 0.01) than high-grade DCIS but no difference in ADC (p = 0.40). Lesion size, morphology, and necrosis did not affect qualitative or quantitative DWI parameters of DCIS lesions (p > 0.05).

CONCLUSIONS

DCIS lesions have higher DWI signal intensity and lower ADC values than normal breast tissue. DWI warrants further investigation as a potential non-contrast MRI tool for early breast cancer detection.

A 2D mechanistic model of breast ductal carcinoma in situ (DCIS) morphology and progression

Ductal carcinoma in situ (DCIS) of the breast is a non-invasive tumor in which cells proliferate abnormally, but remain confined within a duct. Although four distinguishable DCIS morphologies are recognized, the mechanisms that generate these different morphological classes remain unclear, and consequently the prognostic strength of DCIS classification is not strong. To improve the understanding of the relation between morphology and time course, we have developed a 2D in silico particle model of the growth of DCIS within a single breast duct. This model considers mechanical effects such as cellular adhesion and intra-ductal pressure, and biological features including proliferation, apoptosis, necrosis, and cell polarity. Using this model, we find that different regions of parameter space generate distinct morphological subtypes of DCIS, so elucidating the relation between morphology and time course. Furthermore, we find that tumors with similar architectures may in fact be produced through different mechanisms, and we propose future work to further disentangle the mechanisms involved in DCIS progression.

An improved process for breast cancer margin identification and orientation

Breast conservation surgery has improved treatment for women faced with a diagnosis of breast cancer. A key factor in breast cancer surgery is the assurance of clear surgical margins. Inadequate or unclear margins prompt the need for re-excision, which can be physically and emotionally stressful for patients. A variety of techniques have been used to indicate margins intraoperatively, but the use of arbitrary methods can contribute to miscommunication between the OR and the radiology and pathology departments. A standardized process to identify surgical margins using radiopaque charms has improved communication and outcomes for patients undergoing breast cancer surgery at one facility.

Predicting invasion in patients with DCIS in the preoperative percutaneous biopsy

When ductal carcinoma in situ (DCIS) is suspected in mammography, core needle biopsy or vacuum assisted biopsy is recommended. However, invasion remains undetected with percutaneous biopsy techniques in 10-20% of the patients. Our aim was to evaluate the prevalence of and predictive factors for invasion in the surgical specimen in patients with DCIS in the preoperative biopsy. Sixty-seven consecutive participants of the Helsinki City Mammography Screening program with DCIS in the preoperative percutaneous biopsy were included. The palpability, the mammographical size and appearance and the visibility of the lesion in breast ultrasound were evaluate as factors predictive for invasion, as well as the histopathological features of DCIS in the preoperative biopsy. Twenty patients had invasion in the surgical specimen. The only predictive factor for invasion was the visibility of the lesion in ultrasound, but even this finding failed to reach statistical significance. Thirteen of the 26 patients with lesions visible in US had invasion in their surgical specimens, while only seven of the 41 patients without such a lesion had invasive or microinvasive cancer, Pc = 0.0686. In conclusion, the visibility of the lesion in US may predict detecting invasion in the surgical specimen in patients with DCIS in the preoperative biopsy.

Effect of quantitative nuclear image features on recurrence of Ductal Carcinoma In Situ (DCIS) of the breast

Background

Nuclear grade has been associated with breast DCIS recurrence and progression to invasive carcinoma; however, our previous study of a cohort of patients with breast DCIS did not find such an association with outcome. Fifty percent of patients had heterogeneous DCIS with more than one nuclear grade. The aim of the current study was to investigate the effect of quantitative nuclear features assessed with digital image analysis on ipsilateral DCIS recurrence.

Methods

Hematoxylin and eosin stained slides for a cohort of 80 patients with primary breast DCIS were reviewed and two fields with representative grade (or grades) were identified by a Pathologist and simultaneously used for acquisition of digital images for each field. Van Nuys worst nuclear grade was assigned, as was predominant grade, and heterogeneous grading when present. Patients were grouped by heterogeneity of their nuclear grade: Group A: nuclear grade 1 only, nuclear grades 1 and 2, or nuclear grade 2 only (32 patients), Group B: nuclear grades 1, 2 and 3, or nuclear grades 2 and 3 (31 patients), Group 3: nuclear grade 3 only (17 patients). Nuclear fine structure was assessed by software which captured thirty-nine nuclear feature values describing nuclear morphometry, densitometry, and texture. Step-wise forward Cox regressions were performed with previous clinical and pathologic factors, and the new image analysis features.

Results

Duplicate measurements were similar for 89.7% to 97.4% of assessed image features. The rate of correct classification of nuclear grading with digital image analysis features was similar in the two fields, and pooled assessment across both fields. In the pooled assessment, a discriminant function with one nuclear morphometric and one texture feature was significantly (p = 0.001) associated with nuclear grading, and provided correct jackknifed classification of a patient’s nuclear grade for Group A (78.1%), Group B (48.4%), and Group C (70.6%). The factors significantly associated with DCIS recurrence were those previously found, type of initial presentation (p = 0.03) and amount of parenchymal involvement (p = 0.05), along with the morphometry image feature of ellipticity (p = 0.04).

Conclusion

Analysis of nuclear features measured by image cytometry may contribute to the classification and prognosis of breast DCIS patients with more than one nuclear grade.

Contraindications of sentinel lymph node biopsy: are there any really?

BACKGROUND

One of the most exciting and talked about new surgical techniques in breast cancer surgery is the sentinel lymph node biopsy. It is an alternative procedure to standard axillary lymph node dissection, which makes possible less invasive surgery and side effects for patients with early breast cancer that wouldn't benefit further from axillary lymph node clearance. Sentinel lymph node biopsy helps to accurately evaluate the status of the axilla and the extent of disease, but also determines appropriate adjuvant treatment and long-term follow-up. However, like all surgical procedures, the sentinel lymph node biopsy is not appropriate for each and every patient.

METHODS

In this article we review the absolute and relative contraindications of the procedure in respect to clinically positive axilla, neoadjuvant therapy, tumor size, multicentric and multifocal disease, in situ carcinoma, pregnancy, age, body-mass index, allergies to dye and/or radio colloid and prior breast and/or axillary surgery.

RESULTS

Certain conditions involving host factors and tumor biologic characteristics may have a negative impact on the success rate and accuracy of the procedure. The overall fraction of patients unsuitable or with multiple risk factors that may compromise the success of the sentinel lymph node biopsy, is very small. Nevertheless, these patients need to be successfully identified, appropriately advised and cautioned, and so do the surgeons that perform the procedure.

CONCLUSION

When performed by an experienced multi-disciplinary team, the SLNB is a highly effective and accurate alternative to standard level I and II axillary clearance in the vast majority of patients with early breast cancer.

Does the insertion of more than one wire allow successful excision of large clusters of malignant calcification?

AIM

To determine whether the insertion of more than one localization wire for larger areas of malignant microcalcification reduces the need for re-excision.

METHOD

This is a retrospective study of 101 cases of malignant calcifications preoperatively marked by one or more wires. Surgical and histopathology data were obtained from hospital records. Mammograms and specimen radiographs were evaluated without knowledge of the eventual outcome, i.e., whether further surgery was required or not. All cases had a preoperative diagnosis of malignancy.

RESULT

In this study the group of patients in which two or more wires were inserted had mammographically larger lesions (p<0.000001) but did not have a greater chance of needing re-excision (p=0.822). Mammograms that demonstrated flecks of microcalcification outlying the main cluster were also more likely to require further surgery (p<0.01). Calcifications associated with high-grade ductal carcinoma in situ (DCIS) had three times the risk of requiring further surgery (p<0.01). However, as reported in other studies re-excision was not related to breast size (p=0.63) [Kollias J, Gill PG, Beamond B, Rossi H, Langlois S, Vernon-Roberts E. Clinical and radiological predictors of complete excision in breast-conserving surgery for primary breast cancer. Aust N Z J Surg 1998;68:702-6].

CONCLUSION

It was previously suggested that the risk of re-excision for DCIS is related to the size of the initial lesion [Cheng L, Al-Kaisi NK, Gordon NH, Liu AY, Gebrail F, Shenk RR. Relationship between the size and margins of ductal carcinoma in situ of the breast and residual disease. J Nat Cancer Inst 1997;89:1356-60]. However, in the present study larger clusters of microcalcification that have been 'bracketed' by two or more wires do not appear to have a greater requirement for re-excision. Grading of the malignant microcalcifications preoperatively may encourage the surgeon to take a wider margin. Careful examination of the mammograms at localization to include outlying flecks could help to reduce the need for further surgery.

Consensus review: A method of assessment of calcifications that appropriately undergo a six-month follow-up

RATIONALE AND OBJECTIVES

Breast calcifications seen on mammography may be associated with benign conditions or malignancies. Accurate characterization of these calcifications is crucial to providing optimal care that may spare women unnecessary biopsies and appropriately allow interval mammography. The purpose of this study is to determine if consensus characterization of calcifications by two breast imaging experts using standardized criteria can establish that follow-up is a safe option.

MATERIALS AND METHODS

For this retrospective study, our breast imaging database was reviewed and the cases imaged between the years 1999 and 2001 were used to identify patients with calcifications who were recommended for a six-month follow-up or biopsy. All cases had been prospectively assessed by at least two expert breast imagers using standardized features to assess the findings before a recommendation for follow-up or a biopsy was made. A retrospective chart review examining the radiology reports was done to determine the percentage of women from each of the two groups who developed malignancies.

RESULTS

Of 744 patients who had mammographically identified clusters of calcifications, 490 clusters (409 single and 81 multiple) were diagnosed as probably-benign, and a short-interval 6-month follow-up was recommended. Of these calcifications followed for three years, only two (0.5%) of the single clusters proved to be malignant, and malignancy was diagnosed at the 12-month follow-up examination. In both cases, the women were diagnosed with ductal carcinoma in situ (DCIS). Of 254 clusters recommended for biopsy, 242 (215 single and 27 multiple) underwent biopsy. A total of 70 cancers were diagnosed: 54 (77.1%) were DCIS and 16 (22.9%) were primary invasive mammary carcinoma (10 cases of invasive ductal carcinoma, 3 cases of invasive lobular carcinoma, 2 cases of invasive ductal carcinoma with DCIS, and one case of invasive mucinous carcinoma with DCIS). Twenty-nine percent of women who had a biopsy performed had calcifications associated with malignancy. In contrast, in the women whose calcifications were followed by mammography, only 0.5% went on to develop malignancies.

CONCLUSION

Consensus review of calcifications by two breast imagers using standardized criteria is a safe follow-up option.

Tumour-positive sentinel node findings in patients with ductal carcinoma in situ

BACKGROUND

Our aim was to evaluate the prevalence of and risk factors for tumour-positive sentinel node (SN) findings in patients with ductal carcinoma in situ (DCIS).

METHODS

Altogether 1,470 patients underwent sentinel node biopsy (SNB) between April 2001 and March 2005 in our unit. According to a histopathological review, 11 of them had microinvasive and 74 pure DCIS and were included in the study.

RESULTS

Five patients (7%) with pure DCIS had SN metastases. Three of them had isolated tumour cells (ITC) only. Axillary clearance without further metastatic findings was performed in three patients. The median histological size of DCIS was larger, 50 (45-60) mm in patients with metastatic SN findings than the median of 18 (2-110) mm in those with tumour-negative SN, P=0.0103. All five patients with metastatic SN findings underwent mastectomy. Metastatic SN findings were detected in one (9%) patient with microinvasive DCIS.

CONCLUSIONS

Metastatic SN findings in patients with pure DCIS may be a sign of missed invasion.

Rates of reexcision for breast cancer after magnetic resonance imaging-guided bracket wire localization

BACKGROUND

We performed this study to determine rates of close or transected cancer margins after magnetic resonance imaging-guided bracket wire localization for nonpalpable breast lesions.

STUDY DESIGN

Of 243 women undergoing MRI-guided wire localizations, 26 had MRI bracket wire localization to excise either a known cancer (n = 19) or a suspicious MRI-detected lesion (n = 7). We reviewed patient age, preoperative diagnosis, operative intent, mammographic breast density, MRI lesion size, MRI enhancement curve and morphology, MRI Breast Imaging Reporting and Data System (BI-RADS) assessment code, number of bracket wires, and pathology size. We analyzed these findings for their relationship to obtaining clear margins at first operative excision.

RESULTS

Twenty-one of 26 (81%) patients had cancer. Of 21 patients with cancer, 12 (57%) had negative margins at first excision and 9 (43%) had close/transected margins. MRI size > or = 4 cm was associated with a higher reexcision rate (7 of 9, 78%) than those < 4 cm (2 of 12, 17%) (p = 0.009). MRI BI-RADS score, enhancement curve, morphology, and preoperative core biopsy demonstrating ductal carcinoma in situ (DCIS) were not predictive of reexcision. The average number of wires used for bracketing increased with lesion size, but was not associated with improved outcomes. On pathology, cancer size was smaller in patients with negative margins (12 patients, 1.2 cm) than in those with close/transected margins (9 patients, 4.6 cm) (p < 0.001). Reexcision was based on close/transected margins involving DCIS alone (6, 67%), infiltrating ductal carcinoma and DCIS (2, 22%), or infiltrating ductal carcinoma alone (1, 11%). Reexcision pathology demonstrated DCIS (3, 33%), no residual cancer (5, 55%), and 1 patient was lost to followup (1, 11%). Interestingly, cancer patients who required reexcision were younger (p = 0.022), but breast density was not associated with reexcision.

CONCLUSIONS

To our knowledge, this is the first report of MRI-guided bracket wire localization. Patients with MRI-detected lesions less than 4 cm had clear margins at first excision; larger MRI-detected lesions were more likely to have close/transected margins. Reexcision was often because of DCIS and was the only pathology found at reexcision, perhaps because MRI is more sensitive for detecting invasive carcinoma than DCIS.

Ductal carcinoma in situ of the breast and heparanase-1 expression: A molecular explanation for more aggressive subtypes

BACKGROUND

Ductal carcinoma in situ of the breast (DCIS) forms a heterogeneous group of lesions with varying invasive potential. This study tested whether heparanase-1 (HPR1), an endoglycosidase that specifically degrades the heparan sulfate (HS) proteoglycans in the breast extracellular matrix, was associated with the most aggressive DCIS subtypes.

STUDY DESIGN

Fifty-seven DCIS specimens and 10 normal breast specimens were examined for HPR1 expression using immunohistochemical staining. Twenty-seven arbitrarily selected specimens were also examined for HS deposition by immunofluorescence staining, confirming HPR1 activity. Patient medical records were obtained to explore a possible association between biologic potential using Van Nuys Prognostic Index (VNPI) and HPR1 expression.

RESULTS

Twenty-one (75%) of 28 comedo and microinvasive DCIS specimens stained HPR1 positive; 4 (14%) of 29 other subtypes (papillary, cribriform, and solid subtypes) stained HPR1 positive on immunohistochemistry (p = 0.003). Among 27 DCIS stained for HS, we found that 8 (67%) of 12 HPR1-negative DCIS had intact HS deposition in the extracellular basement membrane; none of the 15 HPR1-positive DCIS stained HS positive. Six (86%) of seven DCIS with VNPI scores 8 to 9 and 14 (50%) of 28 DCIS with VNPI scores 5 to 7 were HPR1 positive; only 3 (17%) of 18 DCIS with VNPI scores 3 to 4 were HPR1 positive. Median VNPI score in patients with HPR1-positive DCIS was 7 (range 3 to 9), compared with 4.5 (range 3 to 7) in patients with HPR1-negative DCIS (p < 0.001).

CONCLUSIONS

HPR1 was expressed at a significantly higher frequency in the invasive comedo and DCIS with microinvasion subtypes than in the noninvasive subtypes. HPR1 expression was inversely associated with HS deposition in the extracellular basement membrane of the DCIS. HPR1 expression was associated with a higher VNPI score. These observations suggest that HPR1 expression in DCIS can play an important role in development of DCIS into an invasive breast cancer.

Evaluation of pathways for progression of heterogeneous breast tumors

To better understand the progression of heterogeneous breast cancers, four models of progession pathways have been evaluated. The models describe the progression through the grades of ductal carcinoma in situ (DCIS) 1, 2, and 3, and through the grades of invasive ductal carcinoma (IDC) 1, 2, and 3. The first three pathways, termed linear, nonlinear, and branched, describe DCIS as a progenitor of IDC, and grades of DCIS progressing into grades of IDC. The fourth pathway, termed parallel, describes DCIS and IDC as diverging from a common progenitor and progressing through grades in parallel. The best transition rates for the linear, nonlinear, and branched pathways were sought using a random search in combination with a directed search based on the Nelder-Mead simplex method. Parameter values for the parallel pathway were determined with heuristic graphs. Results of computer simulation were compared with clinically observed frequencies of grades of DCIS and grades of IDC that were reported to occur together in heterogeneous tumors. Each of the four pathways could simulate frequencies that resembled, to varying degrees, the clinical observations. The parallel pathway produced the best correspondence with clinical observations. These results quantify the traditional descriptions in which grades of DCIS are the progenitors of grades of IDC. The results also raise the alternative possibility that, in some tumors with both components, DCIS and IDC may have diverged from a common progenitor.

[Ductal in situ carcinoma: is it ethical to consider the breast conserving therapy as a standard?]

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.

Novel techniques in sentinel lymph node mapping and localization of nonpalpable breast lesions: the Moffitt experience

The concept of lymphatic mapping has helped to redefine the clinical significance of lymph nodes with respect to breast cancer. The combination technique using both blue dye and radiocolloid is the most effective method of lymphatic mapping. The data in the literature support the concept that all patients undergoing lumpectomy or especially mastectomy should undergo lymphatic mapping if a diagnosis of invasive cancer is remotely possible. The low morbidity, high sensitivity, and specificity of mapping indicate its use for increasing numbers of patients thought initially not to be candidates for the procedure.

Carcinome canalaire in situ du sein

OBJECTIVE

This study assesses the results of "current clinical practice" among 882 women treated in nine French Cancer Centers from 1985 to 1995 for pure ductal carcinoma in situ (DCIS) of the breast.

METHOD

Median age was 53 years (range 21-87); 177 (20%) patients underwent mastectomy (M), 190 (22%) conservative surgery alone (CS) and 515 (58%) conservative surgery with radiotherapy (CS + RT).

RESULTS

The crude 7-year local relapse (LR) rates were 2%, 31% and 13% among the M, CS and CS+RT subgroups (p<0.0001). All four LR after M were invasive as well as 31 (52%) out of 59 and 40 (61%) out of 66 in the CS and CS+RT groups. Distant metastases occurred in 1%, 3% and 1% of the three treatment groups. No LR factors were found in the M group. Among women treated with CS, the 7-year LR rates were 36%, 31% and 30% among women aged 40 or less, 41 to 60 and 61 or more (NS). For women treated by CS+RT, the LR rates in these age subgroups were 33%, 13% and 8%, respectively (p<0.0001). Patients with negative, positive or uncertain margins had 7-year LR rates of 26%, 56% and 29% respectively if treated with CS (p=0.02) and 11%, 23% and 9% if treated with CS+RT (p=0.0008). RT reduced LR rates by 65% in all histological subgroups, but more particularly in comedocarcinoma and mixed cribriform/papillary subgroups. The 7-year rate of contralateral breast cancer was 7%, identical in all subgroups.

CONCLUSION

Mastectomy remains the safest treatment for women with DCIS, with a 98% 7-year control rate. After conservative surgery, RT reduces very significantly LR rates, according to the NSABP B-17 and EORTC 10853 randomized trial results. The RT benefit is present in all clinical/histological subgroups, but its magnitude varies. Young age (<40 years) and incomplete excision are the most important LR risk factors.

Gauging the impact of breast carcinoma screening in terms of tumor size and death rate

BACKGROUND

While the question of whether the trials of breast cancer screening have resulted in a reduction in breast cancer death has been the subject of much scrutiny, there has been less attention to the reduction in tumor size achieved by screening.

METHODS

Size data for invasive breast tumors were assembled from a variety of sources. The health consequences that can be expected from finding tumors of various sizes were determined using a recently developed mathematical method for relating tumor size to death rate.

RESULTS

First, in both the Swedish two-country trial and at the MGH Breast Imaging Division, the sizes of the invasive breast cancers in the screening population (those masses seen at screening together with those found as palpable masses after screening examinations) were sufficiently smaller than the cancers found among women who had not used screening to have lead to considerable reductions in death. Second, the lack of reduction in death rates detected in both Canadian National Breast Screening Studies could be ascribed to the small reductions in tumor size achieved in these studies. Third, radiographic density had a small effect, whereas age had a negligible effect, on the capacity of mammographic screening to find breast carcinomas at smaller, and thus less lethal, sizes.

CONCLUSIONS

Prompt attendance at annual mammographic screening offers the potential to reduce tumor size and, presumably, breast carcinoma death, in women of all ages and density groups.

Breast-conserving therapy for ductal carcinoma in situ of the breast: the French Cancer Centers' experience

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.

Ductal carcinoma in situ of the breast results of conservative and radical treatments in 716 patients

Until now, less than 5% of the patients with breast ductal carcinoma in situ (DCIS) have been enrolled in clinical trials. Consequently, we have analysed the results of "current practice" among 716 women treated in eight French Cancer Centres from 1985 to 1992: 441 cases (61.6%) corresponded to impalpable lesions, 92 had a clinical size of less than or equal to 2 cm and 70 from 2 to 5 cm; in 113 cases, the size was unspecified. Median age was 53.2 years (range: 21-87 years). 145 patients underwent mastectomy (RS) and 571 conservative surgery (CS) without (136) or with (435) radiotherapy (CS+RT). The mean histological tumour sizes in these three groups were 25.6, 8.2, 14.8 mm, respectively (P<0.0001). After a 91-month median follow-up, local recurrence (LR) rates were 2.1, 30.1 and 13.8% in the RS, CS and CS +RT groups, respectively (P=0.001); LR were invasive in 59 and 60% in the CS and CS+RT groups, respectively. In these groups, the 8-year LR rates were 31.3 and 13.9%, respectively (P=0.0001). Nodal recurrence occurred in 3.7 and 1.8% in the CS and CS+RT groups. Metastases rates were 1.4, 4.4 and 1.4% in the RS, CS and CS+RT groups. Among the 60 cases of invasive LR, in CS and CS+RT groups 19% developed metastases. After multivariate analysis, we did not identify any significant LR risk factor in the CS group, whereas young age (<40 years) and incomplete excision were significant in the CS+RT group (P=0.012 and P=0.02, respectively).

Bracketing wires for preoperative breast needle localization

OBJECTIVE

The purpose of this study was to evaluate the outcomes of bracketing wire placement during preoperative breast needle localization.

SUBJECTS AND METHODS

We prospectively examined mammograms of 1057 consecutive lesions that had preoperative needle localization and surgical excision and classified the lesions according to Breast Imaging Reporting and Data System (BI-RADS) final assessment categories. Bracketing wires, defined as multiple wires placed to delineate the boundaries of a single lesion, were used in 103 (9.7%) of 1057 lesions. Medical records, imaging studies, and histologic findings in these 103 lesions were reviewed.

RESULTS

Of 103 bracketed lesions, median lesion size was 3.5 cm (range, 1.5-9.5 cm). Ninety-three lesions (90.3%) contained calcifications; 65 lesions (63.1%) were BI-RADS category 5 (highly suggestive of malignancy); and 33 lesions (32.0%) were percutaneously proven cancers. The median number of wires placed was two (range, 2-5). Surgical histologic findings were carcinoma in 75 lesions (72.8%), atypical hyperplasia in eight lesions (7.8%), and benign in 20 lesions (19.4%). Of 42 calcific lesions that were bracketed and had postoperative mammograms available for review, complete removal of suspicious calcifications was accomplished in 34 (81.0%). Of 75 cancers that were bracketed, clear histologic margins of resection were obtained in 33 (44.0%).

CONCLUSION

Bracketing wires were used during preoperative needle localization primarily for larger calcific lesions that were proven cancers or were highly suggestive of malignancy (BI-RADS category 5). Bracketing wires may assist the surgeon in achieving complete excision of calcifications, but bracketing wires do not ensure clear histologic margins of resection.

Pathology of preinvasive and excellent-prognosis breast cancer

Our review of recent developments in breast cancer emphasizes 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). This review also includes invasive lesions with little capacity for metastatic behavior and indicators of low malignant potential. Histologic criteria for their recognition, as well as biologic and clinical characterization, are discussed. Several papers reviewing the usefulness of histologic grading, emphasizing mitotic counts and definitions of microinvasion, are included.