Abstract P2-03-10: Risk factors for upgrading and upstaging of pre-operative biopsies in ductal carcinoma in situ

Background: Ductal carcinoma in situ (DCIS), accounts for one fifth of all screen-detected neoplastic breast lesions. Contemporary research in DCIS focuses on separating lesions that need active treatment from those that can be safely left under surveillance. This, in turn, relies on accurate determination of invasive status and DCIS grade at time of initial biopsy. Most previous studies have examined factors associated with upstaging the diagnosis from DCIS to invasive breast cancer (IBC) following surgery, and few have evaluated factors associated with upgrading the diagnosis to a higher grade of DCIS. This is because upgrading has not traditionally influenced clinical management in the way that upstaging has done. However, recent interest in non-operative treatment for low-risk DCIS has meant that accurate determination of grade at time of initial biopsy has become more important. We aimed to compare risk factors for upgrading and upstaging of biopsies in DCIS.

Method: We undertook a cohort study of all women diagnosed with DCIS at a large specialist cancer centre between 2000–2014. Information from the clinical records was abstracted, including the pre-operative mammography (MMG) and pathology information from the initial biopsy. We also abstracted pathology information regarding the excised specimen in order to identify women whose diagnosis was subsequently upgraded or upstaged. We looked for factors that were predictive for upgrading or upstaging.

Result: A total of 641 women were diagnosed with DCIS at initial biopsy. Of these, 72 (11%) were upgraded: 26 (4%) from grade 1 to grade 2, 2 (0.3%) from grade 1 to grade 3 and 44 (7%) from grade 2 to grade 3. A further 115 (18%) were upstaged to IBC: 20 of these (3%) had grade 1 DCIS on initial biopsy, 47 (7%) had grade 2, 43 (7%) grade 3, and for 5 (1%) biopsy grade was not available. Necrosis on biopsy increased the risk of upgrading (with necrosis: 14% upgraded, without: 10% upgraded, p for difference 0.02) and also of upstaging (with necrosis: 23% upstaged, without: 15% upstaged, p for difference <0.01). Lesions measuring ≥50 mm on MMG were more likely to be upgraded than smaller lesions (0-19 mm: 9% upgraded, 20-50 mm: 9% upgraded, ≥50 mm: 19% upgraded, p for heterogeneity <0.01), while lesions measuring 20-50 mm and ≥50 mm were both more likely to be upstaged than lesions measuring 0-19 mm (0-19 mm: 9% upstaged, 20-50 mm: 23% upstaged and ≥50 mm: 21% upstaged, p for heterogeneity <0.01). Fewer 9G vacuum-assisted biopsies than 14G core biopsies were upgraded (9G vacuum-assisted: 7% upgraded, 14G core: 15% upgraded, p for difference 0.01), while the effect of biopsy method on upstaging was not significant (9G vacuum-assisted: 12% upstaged, 14G core: 16% upstaged, p for difference 0.15). Presence of a palpable lump was not significantly associated with upgrading (palpable lump: 13% upgraded, no palpable lump: 10% upgraded, p for difference 0.19) but increased the risk of upstaging (palpable lump: 23% upstaged, no palpable lump: 16% upstaged, p for difference 0.02).

Conclusion: Our findings suggest that consideration of MMG lesion size and necrosis on biopsy may be helpful in selecting low-risk women for non-operative management of DCIS, as may use of the 9G vacuum-assisted method of biopsy.

Citation Format: Mannu GS, Groen E, Wang Z, Schaapveld M, Lips E, Chung M, Joore I, Leeuwen Fv, Teerstra J, Winter-Warnars GAO, Darby SC, Wesseling J. Risk factors for upgrading and upstaging of pre-operative biopsies in ductal carcinoma in situ [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-03-10.