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Karakatsanis A, Charalampoudis P, Pistioli L, Di Micco R, Foukakis T, Valachis A. Axillary evaluation in ductal cancer in situ of the breast: challenging the diagnostic accuracy of clinical practice guidelines. Br J Surg 2021; 108:1120-1125. [PMID: 34089583 DOI: 10.1093/bjs/znab149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Accepted: 04/09/2021] [Indexed: 11/13/2022]
Abstract
BACKGROUND Staging of the axilla is not routine in ductal cancer in situ (DCIS) although invasive cancer is observed in 20-25 per cent of patients at final pathology. Upfront sentinel lymph node dissection (SLND) is advocated in clinical practice guidelines in certain situations. These include expected challenges in subsequent SLN detection and when the risk for invasion is high. Clinical practice guidelines are, however, inconsistent and lead to considerable practice variability. METHODS Clinical practice guidelines for upfront SLND in DCIS were identified and applied to patients included in the prospective SentiNot study. These patients were evaluated by six independent, blinded raters. Agreement statistics were performed to assess agreement and concordance. Receiver operating characteristic curves were constructed, to assess guideline accuracy in identifying patients with underlying invasion. RESULTS Eight guidelines with relevant recommendations were identified. Interobserver agreement varied greatly (kappa: 0.23-0.9) and the interpretation as to whether SLND should be performed ranged from 40-90 per cent and with varying concordance (32-88 per cent). The diagnostic accuracy was low with area under the curve ranging from 0.45 to 0.55. Fifty to 90 per cent of patients with pure DCIS would undergo unnecessary SLNB, whereas 10-50 per cent of patients with invasion were not identified as 'high risk'. Agreement across guidelines was low (kappa = 0.24), meaning that different patients had a similar risk of being treated inaccurately. CONCLUSION Available guidelines are inaccurate in identifying patients with DCIS who would benefit from upfront SLNB. Guideline refinement with detailed preoperative work-up and novel techniques for SLND identification could address this challenge and avoid overtreatment.
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Affiliation(s)
- Andreas Karakatsanis
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden.,Breast Unit, Department of Surgery, Uppsala University Hospital, Uppsala, Sweden
| | | | - Lida Pistioli
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
| | - Rosa Di Micco
- Breast Unit, San Raffaele University Hospital, Milan, Italy
| | - Theodoros Foukakis
- Department of Oncology-Pathology, Karolinska Institute Stockholm, Stockholm, Sweden.,Breast Centre, Theme Cancer, Karolinska University Hospital, Stockholm, Sweden
| | - Antonios Valachis
- Department of Oncology, Faculty of Medicine & Health, Örebro University, Örebro, Sweden
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Luo J, Johnston BS, Kitsch AE, Hippe DS, Korde LA, Javid S, Lee JM, Peacock S, Lehman CD, Partridge SC, Rahbar H. Ductal Carcinoma in Situ: Quantitative Preoperative Breast MR Imaging Features Associated with Recurrence after Treatment. Radiology 2017; 285:788-797. [PMID: 28914599 DOI: 10.1148/radiol.2017170587] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Purpose To investigate whether specific imaging features on breast magnetic resonance (MR) images are associated with ductal carcinoma in situ (DCIS) recurrence risk after definitive treatment. Materials and Methods Patients with DCIS who underwent preoperative dynamic contrast material-enhanced (DCE) MR imaging between 2004 and 2014 with ipsilateral recurrence more than 6 months after definitive surgical treatment were retrospectively identified. For each patient, a control subject with DCIS that did not recur was identified and matched on the basis of clinical, histopathologic, and treatment features known to affect recurrence risk. On DCE MR images, lesion characteristics (longest diameter, functional tumor volume [FTV], peak percentage enhancement [PE], peak signal enhancement ratio [SER], and washout fraction) and normal tissue features (background parenchymal enhancement [BPE] volume, mean BPE) were quantitatively measured. MR imaging features were compared between patients and control subjects by using the Wilcoxon signed-rank test, with adjustment for multiple comparisons. Results Of 415 subjects with DCIS who underwent preoperative MR imaging, 14 experienced recurrence and 11 had an identifiable matching control subject (final cohort, 11 patients and 11 control subjects). Median time to recurrence was 14 months, and median follow-up for control subjects was 102 months. When compared with matched control subjects, patients with DCIS recurrence exhibited significantly greater FTV (median, 9.3 cm3 vs 1.3 cm3, P = .01), lesion peak SER (median, 1.7 vs 1.2; P = .03), and mean BPE (median, 58.3% vs 41.1%; P = .02). Conclusion Quantitative lesion and normal breast tissue characteristics at preoperative MR imaging in women with newly diagnosed DCIS show promise for association with breast cancer recurrence after treatment. © RSNA, 2017.
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Affiliation(s)
- Jing Luo
- From the Departments of Radiology (J.L., B.S.J., A.E.K., D.S.H., J.M.L., S.P., S.C.P., H.R.), Medicine, Division of Oncology (L.A.K.), and Surgery, Division of Surgical Oncology (S.J.), University of Washington School of Medicine, Seattle Cancer Care Alliance, 825 Eastlake Ave East, Seattle, WA 98109-1023; and Department of Radiology, Massachusetts General Hospital, Boston, Mass (C.D.L.)
| | - Brian S Johnston
- From the Departments of Radiology (J.L., B.S.J., A.E.K., D.S.H., J.M.L., S.P., S.C.P., H.R.), Medicine, Division of Oncology (L.A.K.), and Surgery, Division of Surgical Oncology (S.J.), University of Washington School of Medicine, Seattle Cancer Care Alliance, 825 Eastlake Ave East, Seattle, WA 98109-1023; and Department of Radiology, Massachusetts General Hospital, Boston, Mass (C.D.L.)
| | - Averi E Kitsch
- From the Departments of Radiology (J.L., B.S.J., A.E.K., D.S.H., J.M.L., S.P., S.C.P., H.R.), Medicine, Division of Oncology (L.A.K.), and Surgery, Division of Surgical Oncology (S.J.), University of Washington School of Medicine, Seattle Cancer Care Alliance, 825 Eastlake Ave East, Seattle, WA 98109-1023; and Department of Radiology, Massachusetts General Hospital, Boston, Mass (C.D.L.)
| | - Daniel S Hippe
- From the Departments of Radiology (J.L., B.S.J., A.E.K., D.S.H., J.M.L., S.P., S.C.P., H.R.), Medicine, Division of Oncology (L.A.K.), and Surgery, Division of Surgical Oncology (S.J.), University of Washington School of Medicine, Seattle Cancer Care Alliance, 825 Eastlake Ave East, Seattle, WA 98109-1023; and Department of Radiology, Massachusetts General Hospital, Boston, Mass (C.D.L.)
| | - Larissa A Korde
- From the Departments of Radiology (J.L., B.S.J., A.E.K., D.S.H., J.M.L., S.P., S.C.P., H.R.), Medicine, Division of Oncology (L.A.K.), and Surgery, Division of Surgical Oncology (S.J.), University of Washington School of Medicine, Seattle Cancer Care Alliance, 825 Eastlake Ave East, Seattle, WA 98109-1023; and Department of Radiology, Massachusetts General Hospital, Boston, Mass (C.D.L.)
| | - Sara Javid
- From the Departments of Radiology (J.L., B.S.J., A.E.K., D.S.H., J.M.L., S.P., S.C.P., H.R.), Medicine, Division of Oncology (L.A.K.), and Surgery, Division of Surgical Oncology (S.J.), University of Washington School of Medicine, Seattle Cancer Care Alliance, 825 Eastlake Ave East, Seattle, WA 98109-1023; and Department of Radiology, Massachusetts General Hospital, Boston, Mass (C.D.L.)
| | - Janie M Lee
- From the Departments of Radiology (J.L., B.S.J., A.E.K., D.S.H., J.M.L., S.P., S.C.P., H.R.), Medicine, Division of Oncology (L.A.K.), and Surgery, Division of Surgical Oncology (S.J.), University of Washington School of Medicine, Seattle Cancer Care Alliance, 825 Eastlake Ave East, Seattle, WA 98109-1023; and Department of Radiology, Massachusetts General Hospital, Boston, Mass (C.D.L.)
| | - Sue Peacock
- From the Departments of Radiology (J.L., B.S.J., A.E.K., D.S.H., J.M.L., S.P., S.C.P., H.R.), Medicine, Division of Oncology (L.A.K.), and Surgery, Division of Surgical Oncology (S.J.), University of Washington School of Medicine, Seattle Cancer Care Alliance, 825 Eastlake Ave East, Seattle, WA 98109-1023; and Department of Radiology, Massachusetts General Hospital, Boston, Mass (C.D.L.)
| | - Constance D Lehman
- From the Departments of Radiology (J.L., B.S.J., A.E.K., D.S.H., J.M.L., S.P., S.C.P., H.R.), Medicine, Division of Oncology (L.A.K.), and Surgery, Division of Surgical Oncology (S.J.), University of Washington School of Medicine, Seattle Cancer Care Alliance, 825 Eastlake Ave East, Seattle, WA 98109-1023; and Department of Radiology, Massachusetts General Hospital, Boston, Mass (C.D.L.)
| | - Savannah C Partridge
- From the Departments of Radiology (J.L., B.S.J., A.E.K., D.S.H., J.M.L., S.P., S.C.P., H.R.), Medicine, Division of Oncology (L.A.K.), and Surgery, Division of Surgical Oncology (S.J.), University of Washington School of Medicine, Seattle Cancer Care Alliance, 825 Eastlake Ave East, Seattle, WA 98109-1023; and Department of Radiology, Massachusetts General Hospital, Boston, Mass (C.D.L.)
| | - Habib Rahbar
- From the Departments of Radiology (J.L., B.S.J., A.E.K., D.S.H., J.M.L., S.P., S.C.P., H.R.), Medicine, Division of Oncology (L.A.K.), and Surgery, Division of Surgical Oncology (S.J.), University of Washington School of Medicine, Seattle Cancer Care Alliance, 825 Eastlake Ave East, Seattle, WA 98109-1023; and Department of Radiology, Massachusetts General Hospital, Boston, Mass (C.D.L.)
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Rahbar H, Parsian S, Lam DL, Dontchos BN, Andeen NK, Rendi MH, Lehman CD, Partridge SC. Can MRI biomarkers at 3 T identify low-risk ductal carcinoma in situ? Clin Imaging 2015; 40:125-9. [PMID: 26365872 DOI: 10.1016/j.clinimag.2015.07.026] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 07/21/2015] [Indexed: 11/28/2022]
Abstract
OBJECTIVE The objective was to explore whether 3-T magnetic resonance imaging (MRI) can identify low-risk ductal carcinoma in situ (DCIS). METHODS Dynamic contrast-enhanced and diffusion-weighted (DWI) MRI features of 36 DCIS lesions [8 low risk, Van Nuys Pathologic Classification (VNPC) 1; 28 high risk, VNPC 2/3] were reviewed. An MRI model that best identified low-risk DCIS was determined using multivariate logistic regression. RESULTS Low-risk DCIS exhibited different DWI properties [i.e., higher contrast-to-noise ratio (P=.02) and lower normalized apparent diffusion coefficients (P=.04)] than high-risk DCIS. A model combining these DWI features provided best performance (area under receiver operating characteristic curve =0.86). CONCLUSIONS DWI may help identify DCIS lesions requiring less therapy.
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Affiliation(s)
- Habib Rahbar
- University of Washington, Seattle Cancer Care Alliance, Department of Radiology, Breast Imaging Section, 825 Eastlake Avenue East, P.O. Box 19023, Seattle, WA 98109-1023, USA.
| | - Sana Parsian
- University of Washington, Seattle Cancer Care Alliance, Department of Radiology, Breast Imaging Section, 825 Eastlake Avenue East, P.O. Box 19023, Seattle, WA 98109-1023, USA
| | - Diana L Lam
- University of Washington, Seattle Cancer Care Alliance, Department of Radiology, Breast Imaging Section, 825 Eastlake Avenue East, P.O. Box 19023, Seattle, WA 98109-1023, USA
| | - Brian N Dontchos
- University of Washington, Seattle Cancer Care Alliance, Department of Radiology, Breast Imaging Section, 825 Eastlake Avenue East, P.O. Box 19023, Seattle, WA 98109-1023, USA
| | - Nicole K Andeen
- University of Washington Department of Anatomic Pathology, 1959 NE Pacific St., Box 357470, Seattle, WA 98195, USA
| | - Mara H Rendi
- University of Washington Department of Anatomic Pathology, 1959 NE Pacific St., Box 357470, Seattle, WA 98195, USA
| | - Constance D Lehman
- University of Washington, Seattle Cancer Care Alliance, Department of Radiology, Breast Imaging Section, 825 Eastlake Avenue East, P.O. Box 19023, Seattle, WA 98109-1023, USA
| | - Savannah C Partridge
- University of Washington, Seattle Cancer Care Alliance, Department of Radiology, Breast Imaging Section, 825 Eastlake Avenue East, P.O. Box 19023, Seattle, WA 98109-1023, USA
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Kim H, Noh JM, Choi DH, Lee J, Nam SJ, Lee JE, Park W, Huh SJ. Excision alone for small size ductal carcinoma in situ of the breast. Breast 2014; 23:586-90. [PMID: 24969239 DOI: 10.1016/j.breast.2014.05.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2013] [Revised: 03/31/2014] [Accepted: 05/24/2014] [Indexed: 10/25/2022] Open
Abstract
This study was performed to determine the risk of tumor recurrence after local excision alone in patients with small size (≤1 cm) ductal carcinoma in situ (DCIS) of the breast. We have treated 107 patients who had DCIS measuring ≤1 cm with margin widths of ≥0.3 cm with excision alone per institutional protocol. With a median follow-up time of 58 months, 4 patients developed ipsilateral breast tumor recurrence (IBTR). Two of the 4 recurrences were invasive, whereas 2 were DCIS. The 5-year rate of IBTR was 6.1%. The patients with resection margin of <1.0 cm had significantly higher rate of IBTR than the patients with resection margin of ≥1.0 cm (23.1% vs. 1.5% at 5-year, p < 0.01). In conclusion, radiotherapy is necessary in the patients with resection margin of <1.0 cm after excision alone because of the substantial risk of IBTR.
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Affiliation(s)
- Haeyoung Kim
- Department of Radiation Oncology, Hallym University Dongtan Sacred Heart Hospital, South Korea
| | - Jae Myoung Noh
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, South Korea
| | - Doo Ho Choi
- Department of Radiation Oncology, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Irwon-dong, Gangnam-gu, Seoul 135-710, South Korea.
| | - Jihye Lee
- Department of Radiation Oncology, Ewha Womans University Medical Center, South Korea
| | - Seok Jin Nam
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
| | - Jeong Eon Lee
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, South Korea
| | - Won Park
- Department of Radiation Oncology, Ewha Womans University Medical Center, South Korea
| | - Seung Jae Huh
- Department of Radiation Oncology, Ewha Womans University Medical Center, South Korea
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