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Zhu Y, Jia X, Zhan W, Zhou J. Adding contrast-enhanced ultrasound can improve the predictive ability of breast conventional ultrasound and mammography for pathological upgrade of biopsy-confirmed ductal carcinoma in situ. Eur J Radiol 2024; 180:111687. [PMID: 39213762 DOI: 10.1016/j.ejrad.2024.111687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 08/15/2024] [Accepted: 08/18/2024] [Indexed: 09/04/2024]
Abstract
OBJECTIVES To evaluate the added value of contrast-enhanced ultrasound (CEUS) on top of breast conventional imaging for predicting the upgrading of ductal carcinoma in situ (DCIS) to invasive cancer after surgery. METHODS This retrospective study enrolled 140 biopsy-proven DCIS lesions in 138 patients and divided them into two groups based on postoperative histopathology: non-upgrade and upgrade groups. Conventional ultrasound (US), mammography (MMG), CEUS and clinicopathological (CL) features were reviewed and compared between the two groups. The predictive performance of different models (with and without CEUS features) for histologic upgrade were compared to calculate the added value of CEUS. RESULTS Fifty-nine (42.1 %) lesions were histologically upgraded to invasive cancer after surgery. By logistic regression analyses, we found that high-grade DCIS at biopsy (P=0.004), ultrasonographic lesion size > 20 mm (P=0.007), mass-like lesion on US (P=0.030), the presence of suspicious calcification on MMG (P=0.014), the presence of perfusion defect (P=0.005) and the area under TIC>1021.34 ml (P<0.001) on CEUS were six independent factors predicting concomitant invasive components after surgery. The CL+US+MMG model made with the four predictors in the clinicopathologic, US and MMG categories yielded an area under the receiver operating curve (AUROC) value of 0.759 (95 % CI: 0.680-0.828) in predicting histological upgrade. The combination model built by adding the two CEUS predictors to the CL+US+MMG model showed higher predictive efficacy than the CL+US+MMG model (P=0.018), as the AUROC value was improved to 0.861 (95 % CI: 0.793-0.914). CONCLUSIONS The addition of contrast-enhanced ultrasound to breast conventional imaging could improve the preoperative prediction of an upgrade to invasive cancer from CNB -proven DCIS lesions.
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Affiliation(s)
- Ying Zhu
- Department of Ultrasound, Shanghai Ruijin Hospital Affiliated to Medical School of Shanghai Jiaotong University, Shanghai, China
| | - Xiaohong Jia
- Department of Ultrasound, Shanghai Ruijin Hospital Affiliated to Medical School of Shanghai Jiaotong University, Shanghai, China
| | - Weiwei Zhan
- Department of Ultrasound, Shanghai Ruijin Hospital Affiliated to Medical School of Shanghai Jiaotong University, Shanghai, China
| | - Jianqiao Zhou
- Department of Ultrasound, Shanghai Ruijin Hospital Affiliated to Medical School of Shanghai Jiaotong University, Shanghai, China.
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Vanni G, Pellicciaro M, Materazzo M, Berretta M, Meucci R, Perretta T, Portarena I, Pistolese CA, Buonomo OC. Radiological and pathological predictors of post-operative upstaging of breast ductal carcinoma in situ (DCIS) to invasive ductal carcinoma and lymph-nodes metastasis; a potential algorithm for node surgical de-escalation. Surg Oncol 2024; 56:102128. [PMID: 39241490 DOI: 10.1016/j.suronc.2024.102128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2023] [Revised: 07/12/2024] [Accepted: 08/29/2024] [Indexed: 09/09/2024]
Abstract
BACKGROUND/AIM Ductal carcinoma in situ is considered a local disease with no metastatic potential, thus sentinel lymph node biopsy (SLNB) may be deemed an overtreatment. SLNB should be reserved for patients with invasive cancer, even though the risk of upstaging rises to 25 %. We aimed to identify clinicopathological predictors of post-operative upstaging in invasive carcinoma. METHODS We retrospectively analyzed patients with a pre-operative diagnosis of DCIS subjected to breast surgery between January 2017 to December 2021, and evaluated at the Breast Unit of PTV (Policlinico Tor Vergata, Rome). RESULTS Out of 267 patients diagnosed with DCIS, 33(12.4 %) received a diagnosis upstaging and 9(3.37 %) patients presented with sentinel lymph node (SLN) metastasis. In multivariate analysis, grade 3 tumor (OR 1.9; 95 % CI 1.2-5.6), dense nodule at mammography (OR 1.3; 95 % CI 1.1-2.6) and presence of a solid nodule at ultrasonography (OR 1.5; 95 % CI 1.2-2.6) were independent upstaging predictors. Differently, the independent predictors for SLNB metastasis were: upstaging (OR 2.1.; 95 % CI 1.2-4.6; p = 0.0079) and age between 40 and 60yrs (OR 1.4; 95 % CI 1.4-2.7; p = 0.027). All 9 patients with SLN metastasis received a diagnosis upstaging and were aged between 40 and 60 years old. CONCLUSION We identified pre-operative independent predictors of upstaging to invasive ductal carcinoma. The combined use of different predictors in an algorithm for surgical treatments of DCIS could reduce the numbers of unnecessary SLNB.
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MESH Headings
- Humans
- Female
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Retrospective Studies
- Middle Aged
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/secondary
- Lymphatic Metastasis
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/secondary
- Algorithms
- Adult
- Aged
- Sentinel Lymph Node Biopsy/methods
- Prognosis
- Follow-Up Studies
- Mammography
- Mastectomy
- Neoplasm Staging
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Affiliation(s)
- Gianluca Vanni
- Breast Unit Policlinico Tor Vergata, Department of Surgical Science, Tor Vergata University, Viale Oxford 81, 00133, Rome, (RM), Italy
| | - Marco Pellicciaro
- Breast Unit Policlinico Tor Vergata, Department of Surgical Science, Tor Vergata University, Viale Oxford 81, 00133, Rome, (RM), Italy; Applied Medical-Surgical Sciences, Department of Surgical Science, Tor Vergata University, Rome, RM, Italy.
| | - Marco Materazzo
- Breast Unit Policlinico Tor Vergata, Department of Surgical Science, Tor Vergata University, Viale Oxford 81, 00133, Rome, (RM), Italy; Applied Medical-Surgical Sciences, Department of Surgical Science, Tor Vergata University, Rome, RM, Italy
| | - Massimiliano Berretta
- Department of Clinical and Experimental Medicine, University of Messina, 98100, Messina, (ME), Italy
| | - Rosaria Meucci
- Department of Diagnostic Imaging and Interventional Radiology, Molecular Imaging and Radiotherapy, Tor Vergata University, Viale Oxford 81, 00133, Rome, (RM), Italy
| | - Tommaso Perretta
- Department of Diagnostic Imaging and Interventional Radiology, Molecular Imaging and Radiotherapy, Tor Vergata University, Viale Oxford 81, 00133, Rome, (RM), Italy
| | - Ilaria Portarena
- Department of Oncology, Tor Vergata University, Viale Oxford 81, 00133, Rome, (RM), Italy
| | - Chiara Adriana Pistolese
- Department of Diagnostic Imaging and Interventional Radiology, Molecular Imaging and Radiotherapy, Tor Vergata University, Viale Oxford 81, 00133, Rome, (RM), Italy
| | - Oreste Claudio Buonomo
- Breast Unit Policlinico Tor Vergata, Department of Surgical Science, Tor Vergata University, Viale Oxford 81, 00133, Rome, (RM), Italy
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Li G, Zhao J, Zhang X, Ma X, Li H, Chen Y, Zhang L, Zhang X, Wu J, Wang X, Zhang Y, Xu S. Toward Exempting from Sentinel Lymph Node Biopsy in T1 Breast Cancer Patients: A Retrospective Study. Front Surg 2022; 9:890554. [PMID: 35836596 PMCID: PMC9273897 DOI: 10.3389/fsurg.2022.890554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 06/07/2022] [Indexed: 12/24/2022] Open
Abstract
Background and Objective Sentinel lymph node biopsy (SLNB) is used to assess the status of axillary lymph node (ALN), but it causes many adverse reactions. Considering the low rate of sentinel lymph node (SLN) metastasis in T1 breast cancer, this study aims to identify the characteristics of T1 breast cancer without SLN metastasis and to select T1 breast cancer patients who avoid SLNB through constructing a nomogram. Methods A total of 1,619 T1 breast cancer patients with SLNB in our hospital were enrolled in this study. Through univariate and multivariate logistic regression analysis, we analyzed the tumor anatomical and clinicopathological factors and constructed the Heilongjiang Medical University (HMU) nomogram. We selected the patients exempt from SLNB by using the nomogram. Results In the training cohort of 1,000 cases, the SLN metastasis rate was 23.8%. Tumor volume, swollen axillary lymph nodes, pathological types, and molecular subtypes were found to be independent predictors for SLN metastasis in multivariate regression analysis. Distance from nipple or surface and position of tumor have no effect on SLN metastasis. A regression model based on the results of the multivariate analysis was developed to predict the risk of SLN metastasis, indicating an AUC of 0.798. It showed excellent diagnostic performance (AUC = 0.773) in the validation cohort. Conclusion The HMU nomogram for predicting SLN metastasis incorporates four variables, including tumor volume, swollen axillary lymph nodes, pathological types, and molecular subtypes. The SLN metastasis rates of intraductal carcinoma and HER2 enriched are 2.05% and 6.67%. These patients could be included in trials investigating the SLNB exemption.
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Affiliation(s)
- Guozheng Li
- Department ofs Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Jiyun Zhao
- School of Life Science and Technology, Computational Biology Research Center, Harbin Institute of Technology, Harbin, China
| | - Xingda Zhang
- Department ofs Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xin Ma
- Department ofs Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Hui Li
- Department ofs Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yihai Chen
- Department ofs Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Lei Zhang
- Department ofs Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xin Zhang
- Department ofs Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Jiale Wu
- Department ofs Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xinheng Wang
- Department ofs Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yan Zhang
- School of Life Science and Technology, Computational Biology Research Center, Harbin Institute of Technology, Harbin, China
- Correspondence: Shouping Xu Yan Zhang
| | - Shouping Xu
- Department ofs Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
- Correspondence: Shouping Xu Yan Zhang
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Bellver G, Buch E, Ripoll F, Adrianzen M, Bermejo B, Burgues O, Julve A, Ortega J. Is Axillary Assessment of Ductal Carcinoma In Situ of the Breast Necessary in All Cases? J Surg Res 2021; 271:145-153. [PMID: 34902737 DOI: 10.1016/j.jss.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 09/29/2021] [Accepted: 10/10/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Staging of the axilla in women with ductal carcinoma in situ (DCIS) is a point of controversy. We aimed to assess whether there is a group of patients in whom axillary assessment can be avoided and whether the likelihood of underdiagnosis of infiltrating carcinoma is sufficient to justify this evaluation. MATERIALS AND METHODS This was a multicenter, prospective, observational study of patients who were operated on between 2008 and 2018 in three Spanish hospitals, with a diagnosis by radiological or excisional biopsy of DCIS and clinically and radiologically negative axilla. RESULTS A total of 530 patients with a preoperative diagnosis of DCIS were studied. An axillary assessment was performed in 77% of the patients. In 397 patients, selective sentinel lymph node biopsy was performed. Axillary involvement was found in 7.2% of all patients, which dropped to 2.15% if we only included DCIS diagnosed after a definitive anatomical pathology analysis. Underdiagnosis was correlated with the type of biopsy performed: the risk was 1.34 times as high if the biopsy was performed with a core needle. The risk of lymph node metastasis was higher when there was lymphovascular invasion and when mastectomy was performed. CONCLUSIONS We propose an axilla management algorithm in patients with a preoperative diagnosis of DCIS. The patients who would benefit from sentinel lymph node biopsy would be those who are not candidates for breast-conserving surgery, those with a BIRADS 5 lesion biopsied by core-needle biopsy, and those whose definitive diagnosis is lymphovascular invasion.
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MESH Headings
- Axilla/pathology
- Breast Neoplasms/diagnosis
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/diagnosis
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/diagnosis
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Female
- Humans
- Lymph Nodes/pathology
- Mastectomy
- Prospective Studies
- Retrospective Studies
- Sentinel Lymph Node Biopsy
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Affiliation(s)
- Gemma Bellver
- Department of General and Digestive Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Elvira Buch
- Department of General and Digestive Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Francisco Ripoll
- Department of General and Digestive Surgery, Hospital Universitario La Fe de Valencia, Valencia, Spain
| | - Marcos Adrianzen
- Department of General and Digestive Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain.
| | - Begoña Bermejo
- Department of Oncology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Octavio Burgues
- Department of Patology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Ana Julve
- Department of Radiology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Joaquin Ortega
- Department of General and Digestive Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain; University of Valencia, Spain
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Shin HJ, Choi WJ, Park SY, Ahn SH, Son BH, Chung IY, Lee JW, Ko BS, Kim JS, Chae EY, Cha JH, Kim HH. Prediction of Underestimation Using Contrast-Enhanced Spectral Mammography in Patients Diagnosed as Ductal Carcinoma In Situ on Preoperative Core Biopsy. Clin Breast Cancer 2021; 22:e374-e386. [PMID: 34776365 DOI: 10.1016/j.clbc.2021.10.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 10/01/2021] [Accepted: 10/04/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND To assess the performance of contrast-enhanced spectral mammography (CESM) for the prediction of DCIS underestimation in comparison with mammography, breast US, and breast MRI. PATIENTS AND METHODS We prospectively enrolled patients diagnosed with DCIS on preoperative core biopsy. Visibility, lesion type, and extent on each imaging modality, CESM gray values (CGV) were evaluated. Pathologic features of core biopsy and surgery were recorded. Chi-square or Fisher's exact test were used for univariate analysis. Multivariate logistic regression analysis was used to find independent predictors for DCIS underestimation and receiver operating characteristic (ROC) curve analysis was performed. RESULTS A total of 113 lesions in 108 patients were analyzed (50 pure DCIS; 63 underestimated DCIS). Visibility on mammography, breast US, CESM, and breast MRI were 44%, 76%, 58%, and 80% for pure DCIS, and 73%, 81%, 86%, and 92% for underestimated DCIS. Tumor extents on surgical pathology of pure and underestimated DCIS were 1.11 ± 1.35 cm and 2.61 ± 2.09 cm. On multivariate analysis, nuclear grade and suspected invasion on core biopsy, visibility on mammography, and extent on breast MRI were independent factors for the model 1, whereas nuclear grade on core biopsy, extent on CESM, and mean CGV on MLO-recombined image were independent factors for the model 2. Area under ROC curve (AUC) was 0.843 for model 1 including breast MRI, whereas AUC was 0.823 for model 2 including CESM, which didn't show a significant difference (P = .968). CONCLUSION For detecting underestimated DCIS, CESM was superior to mammography and breast US, and comparable to breast MRI.
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Affiliation(s)
- Hee Jung Shin
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, South Korea.
| | - Woo Jung Choi
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, South Korea
| | - Seo Young Park
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, South Korea
| | - Sei Hyun Ahn
- Department of Breast Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, South Korea
| | - Byung Ho Son
- Department of Breast Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, South Korea
| | - Il Yong Chung
- Department of Breast Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, South Korea
| | - Jong Won Lee
- Department of Breast Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, South Korea
| | - Beom Seok Ko
- Department of Breast Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, South Korea
| | - Ji Sun Kim
- Department of Breast Surgery, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, South Korea
| | - Eun Young Chae
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, South Korea
| | - Joo Hee Cha
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, South Korea
| | - Hak Hee Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Songpa-gu, Seoul, South Korea
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Clinicopathological predictors of postoperative upstaging to invasive ductal carcinoma (IDC) in patients preoperatively diagnosed with ductal carcinoma in situ (DCIS): a multi-institutional retrospective cohort study. Breast Cancer 2021; 28:896-903. [PMID: 33599914 PMCID: PMC8213581 DOI: 10.1007/s12282-021-01225-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 02/07/2021] [Indexed: 11/16/2022]
Abstract
Background We conducted a prospective study with the intention to omit surgery for patients with ductal carcinoma in situ (DCIS) of the breast. We aimed to identify clinicopathological predictors of postoperative upstaging to invasive ductal carcinoma (IDC) in patients preoperatively diagnosed with DCIS. Patients and methods We retrospectively analyzed patients with DCIS diagnosed through biopsy between April 1, 2010 and December 31, 2014, from 16 institutions. Clinical, radiological, and histological variables were collected from medical records. Results We identified 2,293 patients diagnosed with DCIS through biopsy, including 1,663 DCIS (72.5%) cases and 630 IDC (27.5%) cases. In multivariate analysis, the presence of a palpable mass (odds ratio [OR] 1.8; 95% confidence interval [CI] 1.2–2.6), mammography findings (≥ category 4; OR 1.8; 95% CI 1.2–2.6), mass formations on ultrasonography (OR 1.8; 95% CI 1.2–2.5), and tumor size on MRI (> 20 mm; OR 1.7; 95% CI 1.2–2.4) were independent predictors of IDC. Among patients with a tumor size on MRI of ≤ 20 mm, the possibility of postoperative upstaging to IDC was 22.1%. Among the 258 patients with non-palpable mass, nuclear grade 1/2, and positive for estrogen receptor, the possibility was 18.1%, even if the upper limit of the tumor size on MRI was raised to ≤ 40 mm. Conclusion We identified four independent predictive factors of upstaging to IDC after surgery among patients with DCIS diagnosed by biopsy. The combined use of various predictors of IDC reduces the possibility of postoperative upstaging to IDC, even if the tumor size on MRI is larger than 20 mm.
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Ahn HS, Kim SM, Kim MS, Jang M, Yun BL, Kang E, Kim EK, Park SY, Kim B. Application of magnetic resonance computer-aided diagnosis for preoperatively determining invasive disease in ultrasonography-guided core needle biopsy-proven ductal carcinoma in situ. Medicine (Baltimore) 2020; 99:e21257. [PMID: 32756104 PMCID: PMC7402737 DOI: 10.1097/md.0000000000021257] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
The aim of this study was to analyze kinetic and morphologic features using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) with computer-aided diagnosis (CAD) to predict occult invasive components in cases of biopsy-proven ductal carcinoma in situ (DCIS).We enrolled 138 patients with 141 breasts who underwent preoperative breast MRI and were diagnosed with DCIS via ultrasonography (US)-guided core needle biopsy performed at our institution during January 2009 to December 2012. Their clinical, mammographic, ultrasonographic, MRI, and final histologic findings were retrospectively reviewed. Their mammographic, ultrasonographic, and MRI findings were analyzed according to the American College of Radiology Breast Imaging Reporting and Data System. CAD findings of detectability, initial (fast, medium, and slow) and delay (persistent, plateau, and washout) phase enhancement kinetic descriptor, peak enhancement percentage, and lesion size were evaluated. Continuous and categorical variables were analyzed using independent t test and χ or Fisher exact test, respectively. Independent factors for predicting the presence of invasive component were evaluated by multivariate logistic regression analysis.Final histologic findings revealed that 55 breasts (39%) had DCIS with an invasive component. MRI-detected, CAD-detected, or pathologic lesion size (P = .002, P = .001, P < .001, respectively), delay washout kinetics and detectability on CAD (P < .001 and P = .004, respectively), presence of symptoms (P = .01), presence of comedonecrosis (P < .001), nuclear grade (P = .001), abnormality on mammography (P = .02), or US (P = .03) were significantly different between pure DCIS and the DCIS with an invasive component group on univariate analysis. Of those findings, multivariate analysis revealed that delay washout on CAD (odds ratio [OR], 4.36; 95% confidence interval [CI], 1.96-9.69; P = .0003) and pathologic size (OR, 1.29; 95% CI 1.05-1.57; P = .014) were independent predictive factors for the presence of an invasive component.Delay washout kinetic features measured by CAD and pathologic tumor size are potentially useful for predicting occult invasion in cases of biopsy-proven DCIS.Breast MRI including a CAD system would be helpful for predicting invasive components in cases of biopsy-proven DCIS and for selecting patients for sentinel lymph node biopsy.
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Affiliation(s)
- Hye Shin Ahn
- Department of Radiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul
| | - Sun Mi Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Gyeonggi
| | - Mi Sun Kim
- Department of Radiology, Joint Heal Hospital, Seoul
| | - Mijung Jang
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Gyeonggi
| | - Bo La Yun
- Department of Radiology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Gyeonggi
| | | | | | - So Yeon Park
- Department of Pathology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Gyeonggi
| | - Bohyoung Kim
- Division of Biomedical Engineering, Hankuk University of Foreign Studies, Gyeonggi-do, Republic of Korea
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8
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Ductal Carcinoma In Situ—Pathological Considerations. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00359-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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9
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Si J, Guo R, Huang N, Xiu B, Zhang Q, Chi W, Wu J. Axillary evaluation is not warranted in patients preoperatively diagnosed with ductal carcinoma in situ by core needle biopsy. Cancer Med 2019; 8:7586-7593. [PMID: 31660702 PMCID: PMC6912045 DOI: 10.1002/cam4.2623] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 08/14/2019] [Accepted: 09/29/2019] [Indexed: 12/18/2022] Open
Abstract
Background Patients diagnosed with ductal carcinoma in situ (DCIS) by core needle biopsy (CNB) have a great chance of upstaging to invasive cancer. Positive axillary status can be found in these patients. This study sought to identify clinicopathological factors associated with upstaging and axillary metastasis in patients preoperatively diagnosed with DCIS by CNB. Materials and Methods This study identified 604 patients (cT1‐3N0M0) with preoperative diagnosis of pure DCIS by CNB who had undergone axillary evaluation from August 2006 to December 2015 at Fudan University Shanghai Cancer Center (FUSCC). Predictors of upstaging and axillary lymph nodes metastasis were analyzed, respectively. Results Of all 604 patients, 121 (20.03%) and 193 (31.95%) patients were upstaged to DCIS with microinvasion (DCISM) and invasive breast cancer (IBC). Positive axillary lymph nodes were identified in 41 (6.79%) patients. Predictors of upstaging included tumor size on ultrasonography (>2 cm) (OR 1.786, P = .002) and ER+HER2+ status (OR 1.874, P = .022) in multivariate analysis. Factors associated with axillary lymph nodes metastasis included tumor size on pathology (OR 2.336, P = .038) and number of lesions (OR 3.354, P = .039) in multivariate analysis. In addition, upstaging on final pathology had a significant influence on axillary lymph nodes status (P < .001). Conclusion Axillary evaluation was recommended in patients with larger tumor size (>2 cm), multifocal lesions or ER+HER2+ status. Despite of a 51.98% upstaging rate, the rate of axillary metastasis in these patients was relatively low, supporting the omission of axillary evaluation in selected patients with low risk of upstaging or axillary metastasis.
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Affiliation(s)
- Jing Si
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Rong Guo
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Naisi Huang
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Bingqiu Xiu
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Qi Zhang
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Weiru Chi
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Jiong Wu
- Department of Breast Surgery, Fudan University Shanghai Cancer Center, Shanghai, China.,Collaborative Innovation Center for Cancer Medicine, Shanghai, China
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Abstract
OBJECTIVE Ductal carcinoma in situ (DCIS) has the potential to progress to invasive carcinoma. The optimal management of DCIS and methods for individualizing treatment of DCIS are still being determined. This evidence map depicts the robustness and topical span of research on DCIS management choice on patient-centered and clinical outcomes. METHODS We searched PubMed, EMBASE, PsycINFO, PubMed Health, PROSPERO, and clinical practice guideline sites to identify systematic reviews of DCIS management options and consulted with topic experts. A bubble plot visualizes the literature volume and research content for patient-centered outcomes. An online decision tree facilitates discussions with patients and guides through the available evidence. RESULTS In total, 40 systematic reviews met inclusion criteria. The research syntheses addressed DCIS management options, including the role of magnetic resonance imaging, axillary surgery/sentinel lymph node biopsy, and excisional biopsy. The map shows existing evidence for mutually exclusive treatment options including active surveillance, breast-conserving surgery, nipple sparing mastectomy, and simple mastectomy. Research findings for intraoperative radiation, adjuvant radiation therapy, adjuvant hormone therapy, hypofractionation radiotherapy, accelerated partial breast irradiation, radiation therapy plus boost, and combined radiation and hormone therapy, as well as for breast reconstruction after mastectomy and surveillance mammography postsurgery are also displayed. The evidence map highlights a scarcity of robust evidence on patient-centered outcomes. CONCLUSIONS The evidence map provides an overview of DCIS research showing the range of management options and remaining decisional dilemmas that follow a diagnosis of DCIS. It maps the evidence in accessible tools to guide practice and future research. : Video Summary:http://links.lww.com/MENO/A448.
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Hotton J, Salleron J, Rauch P, Buhler J, Pierret M, Baumard F, Leufflen L, Marchal F. Predictive factors of axillary positive sentinel lymph node biopsy in extended ductal carcinoma in situ treated by simple mastectomy at once. J Gynecol Obstet Hum Reprod 2019; 49:101641. [PMID: 31562936 DOI: 10.1016/j.jogoh.2019.101641] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/30/2019] [Accepted: 09/24/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND The incidence of positive sentinel lymph node biopsy (SLNB) in ductal carcinoma in situ (DCIS) ranged from 0 to 14%. The main hypothesis would be the presence of an invasive contingent on the final histology. The objective was to identify predictive factors of sentinel lymph node positivity in the management of extended ductal carcinoma in situ treated by simple mastectomy. METHODS This was a retrospective study carried out at the Lorraine Cancer Institute from January 2003 to December 2017. Women with DCIS on core-needle biopsy whose management consisted of simple mastectomy and SLNB procedure were included. RESULTS 188 patients were analyzed. Preoperatively, 18 patients (9.6%) had DCIS with microinvasion, while the others had pure DCIS. Eight patients (4.2%) had positive sentinel lymph node biopsy, the majority of which were single micrometastases. Predictive factor of node invasion was microinvasion on biopsy (p<0.01). Only in cases of pure DCIS, the percentage of positive SLNB was reduced to 2.9%. Invasive carcinoma was found in the majority of patients with positive axillary SLNB procedure (75%, n=6), compared to 16.7% (n=30) without SLNB involvement (p<0.01). CONCLUSIONS The low rate of positive sentinel node biopsy in pure ductal carcinoma in situ suggests that in the absence of microinvasion, the sentinel procedure would seem less appropriate. New techniques for identifying sentinel lymph node biopsy could report axillary staging after definitive histologic results.
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Affiliation(s)
- Judicael Hotton
- Institut de Cancérologie de Lorraine, Department of Surgical Oncology, Université de Lorraine, F-54519 Vandoeuvre-lès-Nancy, France.
| | - Julia Salleron
- Institut de Cancérologie de Lorraine, Biostatistics Unit, Université de Lorraine, F-54519 Vandoeuvre-lès-Nancy, France
| | - Philippe Rauch
- Institut de Cancérologie de Lorraine, Department of Surgical Oncology, Université de Lorraine, F-54519 Vandoeuvre-lès-Nancy, France
| | - Julie Buhler
- Institut de Cancérologie de Lorraine, Department of Surgical Oncology, Université de Lorraine, F-54519 Vandoeuvre-lès-Nancy, France
| | - Marion Pierret
- Institut de Cancérologie de Lorraine, Department of Surgical Oncology, Université de Lorraine, F-54519 Vandoeuvre-lès-Nancy, France
| | - Florian Baumard
- Institut de Cancérologie de Lorraine, Biostatistics Unit, Université de Lorraine, F-54519 Vandoeuvre-lès-Nancy, France
| | - Lea Leufflen
- Institut de Cancérologie de Lorraine, Department of Surgical Oncology, Université de Lorraine, F-54519 Vandoeuvre-lès-Nancy, France
| | - Frederic Marchal
- Institut de Cancérologie de Lorraine, Department of Surgical Oncology, Université de Lorraine, F-54519 Vandoeuvre-lès-Nancy, France; Université de Lorraine, CNRS UMR7039, CRAN, F-54000 Nancy, France
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12
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van Seijen M, Lips EH, Thompson AM, Nik-Zainal S, Futreal A, Hwang ES, Verschuur E, Lane J, Jonkers J, Rea DW, Wesseling J. Ductal carcinoma in situ: to treat or not to treat, that is the question. Br J Cancer 2019; 121:285-292. [PMID: 31285590 PMCID: PMC6697179 DOI: 10.1038/s41416-019-0478-6] [Citation(s) in RCA: 156] [Impact Index Per Article: 31.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 03/19/2019] [Accepted: 03/22/2019] [Indexed: 12/27/2022] Open
Abstract
Ductal carcinoma in situ (DCIS) now represents 20-25% of all 'breast cancers' consequent upon detection by population-based breast cancer screening programmes. Currently, all DCIS lesions are treated, and treatment comprises either mastectomy or breast-conserving surgery supplemented with radiotherapy. However, most DCIS lesions remain indolent. Difficulty in discerning harmless lesions from potentially invasive ones can lead to overtreatment of this condition in many patients. To counter overtreatment and to transform clinical practice, a global, comprehensive and multidisciplinary collaboration is required. Here we review the incidence of DCIS, the perception of risk for developing invasive breast cancer, the current treatment options and the known molecular aspects of progression. Further research is needed to gain new insights for improved diagnosis and management of DCIS, and this is integrated in the PRECISION (PREvent ductal Carcinoma In Situ Invasive Overtreatment Now) initiative. This international effort will seek to determine which DCISs require treatment and prevent the consequences of overtreatment on the lives of many women affected by DCIS.
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Affiliation(s)
- Maartje van Seijen
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Esther H Lips
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
| | - Alastair M Thompson
- Dan L Duncan Comprehensive Cancer Center, Baylor College of Medicine, Houston, TX, USA
| | - Serena Nik-Zainal
- Department of Medical Genetics, University of Cambridge, Cambridge, UK
| | - Andrew Futreal
- Department of Surgery, University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - E Shelley Hwang
- Department of Surgery, Duke University Comprehensive Cancer Center, Durham, NC, USA
| | | | - Joanna Lane
- Health Cluster Net, Amsterdam, The Netherlands
| | - Jos Jonkers
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands
- Oncode Institute, Amsterdam, The Netherlands
| | - Daniel W Rea
- Department of Medical Oncology, University of Birmingham, Birmingham, UK
| | - Jelle Wesseling
- Division of Molecular Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
- Department of Pathology, The Netherlands Cancer Institute, Amsterdam, The Netherlands.
- Department of Pathology, Leiden University Medical Center, Leiden, The Netherlands.
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13
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Hanna WM, Parra-Herran C, Lu FI, Slodkowska E, Rakovitch E, Nofech-Mozes S. Ductal carcinoma in situ of the breast: an update for the pathologist in the era of individualized risk assessment and tailored therapies. Mod Pathol 2019; 32:896-915. [PMID: 30760859 DOI: 10.1038/s41379-019-0204-1] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 12/13/2018] [Accepted: 12/13/2018] [Indexed: 12/30/2022]
Abstract
Ductal carcinoma in situ (DCIS) is a neoplastic proliferation of mammary ductal epithelial cells confined to the ductal-lobular system, and a non-obligate precursor of invasive disease. While there has been a significant increase in the diagnosis of DCIS in recent years due to uptake of mammography screening, there has been little change in the rate of invasive recurrence, indicating that a large proportion of patients diagnosed with DCIS will never develop invasive disease. The main issue for clinicians is how to reliably predict the prognosis of DCIS in order to individualize patient treatment, especially as treatment ranges from surveillance only, breast-conserving surgery only, to breast-conserving surgery plus radiotherapy and/or hormonal therapy, and mastectomy with or without radiotherapy. We conducted a semi-structured literature review to address the above issues relating to "pure" DCIS. Here we discuss the pathology of DCIS, risk factors for recurrence, biomarkers and molecular signatures, and disease management. Potential mechanisms of progression from DCIS to invasive cancer and problems faced by clinicians and pathologists in diagnosing and treating this disease are also discussed. Despite the tremendous research efforts to identify accurate risk stratification predictors of invasive recurrence and response to radiotherapy and endocrine therapy, to date there is no simple, well-validated marker or group of variables for risk estimation, particularly in the setting of adjuvant treatment after breast-conserving surgery. Thus, the standard of care to date remains breast-conserving surgery plus radiotherapy, with or without hormonal therapy. Emerging tools, such as pathologic or biologic markers, may soon change such practice. Our review also includes recent advances towards innovative treatment strategies, including targeted therapies, immune modulators, and vaccines.
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Affiliation(s)
- Wedad M Hanna
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada.
| | - Carlos Parra-Herran
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Fang-I Lu
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Elzbieta Slodkowska
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Eileen Rakovitch
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
| | - Sharon Nofech-Mozes
- Department of Anatomic Pathology, Sunnybrook Health Sciences Centre, University of Toronto Faculty of Medicine, E432-2075 Bayview Avenue, Toronto, ON, M4N 3M5, Canada
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14
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15
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Doke K, Butler S, Mitchell MP. Current Therapeutic Approaches to DCIS. J Mammary Gland Biol Neoplasia 2018; 23:279-291. [PMID: 30267199 DOI: 10.1007/s10911-018-9415-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Accepted: 09/18/2018] [Indexed: 12/21/2022] Open
Abstract
Treatment for ductal carcinoma in-situ (DCIS) has historically been extrapolated from studies of invasive breast cancer. Accepted local therapy approaches range from small local excisions, with or without radiation, to bilateral mastectomies. Systemic treatment with endocrine therapy is often recommended for hormone positive patients. With improvements in imaging, pathologic review, and treatment techniques in the modern era, combined with new information regarding tumor biology, the management of DCIS is rapidly evolving. A multidisciplinary approach to treatment is now more important than ever, with a shift towards de-escalating therapy to reduce treatment related toxicity. This review focuses on nuances of clinical management of DCIS in the modern era, highlighting key differences between DCIS as compared to invasive breast cancer. The American Cancer Society (ACS) currently recommends beginning screening with annual mammograms for women age 45, with the option to start at age 40. As treatment of DCIS has not been shown to impact survival, the USPSTF has more conservative screening recommendations of biennial mammograms from age 50-74. Unlike invasive breast cancer, DCIS is almost exclusively diagnosed by mammographic detection, and lymph node evaluation is not recommended. Pathologic review of biopsy specimens should follow the guidelines of the College of American Pathologists. Surgical management options include breast conservation, mastectomy, or possibly nipple sparing mastectomy, with upfront sentinel lymph node evaluation in the case of mastectomy. Radiation therapy is generally recommended as a component of breast conserving therapy for patients with DCIS, though in some low risk patients, there is trial data to suggest that adjuvant radiation may be omitted. Techniques for minimizing radiation toxicity should always be emphasized. Endocrine therapy is offered to women with hormone positive DCIS who have undergone lumpectomy for risk reduction, and has the benefit of decreasing incidence of events in both the ipsilateral and contralateral breast. More recent studies have explored use of targeted treatments such as trastuzumab in DCIS for HER2 overexpression. Future directions include tailoring therapy based on patient characteristics and tumor biology. With so many different options for treatment, it is also critical to engage in a discussion with the patient to arrive at a treatment decision that balances patient preferences for disease control versus treatment toxicity, financial toxicity, cosmesis, and quality of life.
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Affiliation(s)
- Kaleigh Doke
- Department of Radiation Oncology, The Kansas University Medical Center, 3901 Rainbow Blvd., Mailstop 4033, Kansas City, KS, 66160, USA
| | - Shirley Butler
- Department of Radiation Oncology, The Kansas University Medical Center, 3901 Rainbow Blvd., Mailstop 4033, Kansas City, KS, 66160, USA
| | - Melissa P Mitchell
- Department of Radiation Oncology, The Kansas University Medical Center, 3901 Rainbow Blvd., Mailstop 4033, Kansas City, KS, 66160, USA.
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16
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Yonekura R, Osako T, Iwase T, Ogiya A, Ueno T, Kitagawa M, Ohno S, Akiyama F. Prognostic impact and possible pathogenesis of lymph node metastasis in ductal carcinoma in situ of the breast. Breast Cancer Res Treat 2018; 174:103-111. [PMID: 30474777 DOI: 10.1007/s10549-018-5068-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 11/21/2018] [Indexed: 10/27/2022]
Abstract
PURPOSE Ductal carcinoma in situ (DCIS)-preinvasive breast cancer-with lymph node metastasis can clinically be treated as different stages: occult invasive cancer with true metastasis (T1N1) or pure DCIS with iatrogenic dissemination (TisN0). In this retrospective cohort study, we aimed to elucidate the prognostic impact and possible pathogenesis of nodal metastasis in DCIS to improve clinical management. METHODS Subjects were comprised of 427 patients with routine postoperative diagnosis of DCIS who underwent sentinel node (SN) biopsy using molecular whole-lymph-node analysis. Clinicopathological characteristics and prognosis were compared between SN-positive and -negative patients. Primary tumour tissues of SN-positive patients were exhaustively step-sectioned to detect occult invasions, and predictive factors for occult invasion were investigated. Median follow-up time was 73.6 months. RESULTS Of the 427 patients, 19 (4.4%) were SN-positive and 408 (95.6%) were SN-negative. More SN-positive patients received adjuvant systemic therapy than SN-negative patients (84.2% vs. 5.4%). Seven-year distant disease-free survivals were favourable for both cohorts (SN-positive, 100%; SN-negative, 99.7%). By examining 1421 slides, occult invasion was identified in 9 (47.4%) of the 19 SN-positive patients. Tumour burdens in SN and incidence of non-SN metastasis were similar between patients with and without occult invasion, and no predictive factor for occult invasion was found. CONCLUSIONS Node-positive DCIS has favourable prognosis with adjuvant systemic therapy. Half of the cases may be occult invasive cancer with true metastasis. In practical settings, clinicians may have to treat these tumours as node-positive small invasive cancers because it is difficult to predict the pathogenesis without exhaustive primary tumour sectioning.
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Affiliation(s)
- Rika Yonekura
- Division of Pathology, The Cancer Institute of the Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.,Breast Oncology Center, The Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.,Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Tomo Osako
- Division of Pathology, The Cancer Institute of the Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan. .,Department of Pathology, The Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, 135-8550, Tokyo, Japan.
| | - Takuji Iwase
- Breast Oncology Center, The Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Akiko Ogiya
- Breast Oncology Center, The Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Takayuki Ueno
- Breast Oncology Center, The Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Masanobu Kitagawa
- Department of Comprehensive Pathology, Graduate School of Medical and Dental Sciences, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo, 113-8510, Japan
| | - Shinji Ohno
- Breast Oncology Center, The Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan
| | - Futoshi Akiyama
- Division of Pathology, The Cancer Institute of the Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, Tokyo, 135-8550, Japan.,Department of Pathology, The Cancer Institute Hospital of the Japanese Foundation for Cancer Research, 3-8-31 Ariake, Koto-ku, 135-8550, Tokyo, Japan
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17
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Dória MT, Maesaka JY, Soares de Azevedo Neto R, de Barros N, Baracat EC, Filassi JR. Development of a Model to Predict Invasiveness in Ductal Carcinoma In Situ Diagnosed by Percutaneous Biopsy—Original Study and Critical Evaluation of the Literature. Clin Breast Cancer 2018; 18:e805-e812. [DOI: 10.1016/j.clbc.2018.04.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 04/13/2018] [Accepted: 04/23/2018] [Indexed: 12/12/2022]
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18
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Charalampoudis P, Markopoulos C, Kovacs T. Controversies and recommendations regarding sentinel lymph node biopsy in primary breast cancer: A comprehensive review of current data. Eur J Surg Oncol 2018; 44:5-14. [DOI: 10.1016/j.ejso.2017.10.215] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 09/21/2017] [Accepted: 10/10/2017] [Indexed: 11/29/2022] Open
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19
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Karakatsanis A, Olofsson H, Stålberg P, Bergkvist L, Abdsaleh S, Wärnberg F. Simplifying Logistics and Avoiding the Unnecessary in Patients With Breast Cancer Undergoing Sentinel Node Biopsy. A Prospective Feasibility Trial of the Preoperative Injection of Super Paramagnetic Iron Oxide Nanoparticles. Scand J Surg 2017; 107:130-137. [PMID: 29132268 DOI: 10.1177/1457496917738867] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
PURPOSE Sentinel node is routinely localized with the intraoperative use of a radioactive tracer, involving challenging logistics. Super paramagnetic iron oxide nanoparticle is a non-radioactive tracer with comparable performance that could allow for preoperative localization, would simplify the procedure, and possibly be of value in axillary mapping before neoadjuvant treatment. The current trial aimed to determine the a priori hypothesis that the injection of super paramagnetic iron oxide nanoparticles in the preoperative period for the localization of the sentinel node is feasible. METHODS This is a prospective feasibility trial, conducted from 9 September 2014 to 22 October 2014 at Uppsala University Hospital. In all, 12 consecutive patients with primary breast cancer planned for resection of the primary and sentinel node biopsy were recruited. Super paramagnetic iron oxide nanoparticles were injected in the preoperative visit in the outpatient clinic. The radioactive tracer (99mTc) and the blue dye were injected perioperatively in standard fashion. A volunteer was injected with super paramagnetic iron oxide nanoparticles to follow the decline in the magnetic signal in the sentinel node over time. The primary outcome was successful sentinel node detection. RESULTS Super paramagnetic iron oxide nanoparticles' detection after preoperative injection (3-15 days) was successful in all cases (100%). In the volunteer, axillary signal was presented for 4 weeks. No adverse effects were noted. Conclusion and relevance: Preoperative super paramagnetic iron oxide nanoparticles' injection is feasible and leads to successful detection of the sentinel node. That may lead to simplified logistics as well as the identification, sampling, and marking of the sentinel node in patients planned for neoadjuvant treatment.
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Affiliation(s)
- A Karakatsanis
- 1 Section for Endocrine and Breast Surgery, Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - H Olofsson
- 2 Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden.,3 Department of Pathology, Uppsala University Hospital, Uppsala, Sweden
| | - P Stålberg
- 1 Section for Endocrine and Breast Surgery, Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
| | - L Bergkvist
- 4 Center for Clinical Research, Uppsala University, Uppsala, Sweden
| | - S Abdsaleh
- 5 Department of Radiology, Oncology and Radiation Science, Uppsala University, Uppsala, Sweden
| | - F Wärnberg
- 1 Section for Endocrine and Breast Surgery, Department of Surgical Sciences, Uppsala University Hospital, Uppsala, Sweden
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Sorrentino L, Sartani A, Bossi D, Amadori R, Nebuloni M, Truffi M, Bonzini M, Riggio E, Foschi D, Corsi F. Sentinel node biopsy in ductal carcinoma in situ of the breast: Never justified? Breast J 2017; 24:325-333. [PMID: 29024241 DOI: 10.1111/tbj.12928] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2016] [Revised: 05/24/2016] [Accepted: 06/16/2016] [Indexed: 11/29/2022]
Abstract
Sentinel lymph node biopsy for ductal carcinoma in situ (DCIS) of the breast is not standard of care. However, nodal involvement for DCIS patients is reported. Aim of our study was to identify preoperative features predictive of nodal involvement in DCIS patients. We have retrospectively reviewed 175 patients with a preoperative diagnosis of DCIS following a vacuum-assisted breast biopsy, and undergoing surgery with sentinel node biopsy. Variables distribution was compared between patients upstaged to invasive cancer at final pathology and patients with a confirmed DCIS, and between positive vs negative sentinel node patients. Univariate and multivariate analyses were performed for risk of a positive node. Lymph node biopsy was positive in 13 (7.4%) patients, with 8 (61.5%) macrometastases and 5 (38.5%) micrometastases. In these patients, Breast Imaging Reporting and Data System (BI-RADS) index >4 (OR 4.69, 95% CI 1.282-17.224, P = .02), lesion extension ≥20 mm (OR 4.25, 95% CI 1.255-14.447, P = .02), multifocal disease (OR 4.12, 95% CI 0.987-17.174, P = .05), comedo type (OR 3.54, 95% CI 1.044-11.969, P = .04), and upstaging (OR 4.56, 95% CI 1.080-19.249, P = .04) were all predictive of nodal involvement, although upstaging could not be predicted preoperatively. By multivariate analysis, the only independent factor predictive for positive sentinel node was multifocal disease (OR 5.14, 95% CI 1.015-26.066, P < .05). A preoperative diagnosis of DCIS, also including advanced biopsy systems such as vacuum-assisted breast biopsy, may be not always sufficient to exclude patients from sentinel node biopsy. DCIS patients with associated BI-RADS >4, lesion extension ≥20 mm, comedo type, and above all multifocal disease should be considered for axillary evaluation.
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Affiliation(s)
- Luca Sorrentino
- Surgery Division, ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Milano, Italy
| | - Alessandra Sartani
- Surgery Division, ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Milano, Italy
| | - Daniela Bossi
- Surgery Department, Breast Unit, ICS Maugeri S.p.A. SB, Pavia, Italy
| | - Rosella Amadori
- Surgery Department, Breast Unit, ICS Maugeri S.p.A. SB, Pavia, Italy
| | - Manuela Nebuloni
- Service of Pathology, ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Milano, Italy.,Department of Biomedical and Clinical Sciences, "Luigi Sacco", University of Milan, Milano, Italy
| | - Marta Truffi
- Department of Biomedical and Clinical Sciences, "Luigi Sacco", University of Milan, Milano, Italy
| | - Matteo Bonzini
- Department of Clinical Sciences and Community Health, University of Milan, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Eliana Riggio
- Surgery Division, ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Milano, Italy
| | - Diego Foschi
- Surgery Division, ASST Fatebenefratelli-Sacco, Luigi Sacco University Hospital, Milano, Italy.,Department of Biomedical and Clinical Sciences, "Luigi Sacco", University of Milan, Milano, Italy
| | - Fabio Corsi
- Surgery Department, Breast Unit, ICS Maugeri S.p.A. SB, Pavia, Italy.,Department of Biomedical and Clinical Sciences, "Luigi Sacco", University of Milan, Milano, Italy
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21
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Zahoor S, Haji A, Battoo A, Qurieshi M, Mir W, Shah M. Sentinel Lymph Node Biopsy in Breast Cancer: A Clinical Review and Update. J Breast Cancer 2017; 20:217-227. [PMID: 28970846 PMCID: PMC5620435 DOI: 10.4048/jbc.2017.20.3.217] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 08/22/2017] [Indexed: 12/20/2022] Open
Abstract
Sentinel lymph node biopsy has become a standard staging tool in the surgical management of breast cancer. The positive impact of sentinel lymph node biopsy on postoperative negative outcomes in breast cancer patients, without compromising the oncological outcomes, is its major advantage. It has evolved over the last few decades and has proven its utility beyond early breast cancer. Its applicability and efficacy in patients with clinically positive axilla who have had a complete clinical response after neoadjuvant chemotherapy is being aggressively evaluated at present. This article discusses how sentinel lymph node biopsy has evolved and is becoming a useful tool in new clinical scenarios of breast cancer management.
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Affiliation(s)
- Sheikh Zahoor
- Department of Surgical Oncology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Altaf Haji
- Department of Surgical Oncology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Azhar Battoo
- Department of Surgical Oncology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Mariya Qurieshi
- Department of Community Medicine, Government Medical College, Srinagar, India
| | - Wahid Mir
- Department of Surgical Oncology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Mudasir Shah
- Department of Surgical Oncology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
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22
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Karakatsanis A, Daskalakis K, Stålberg P, Olofsson H, Andersson Y, Eriksson S, Bergkvist L, Wärnberg F. Superparamagnetic iron oxide nanoparticles as the sole method for sentinel node biopsy detection in patients with breast cancer. Br J Surg 2017; 104:1675-1685. [PMID: 28877348 DOI: 10.1002/bjs.10606] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 12/27/2016] [Accepted: 04/12/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Sentinel node biopsy (SNB) using superparamagnetic iron oxide (SPIO) nanoparticles is a novel method in breast cancer. Several studies have verified the non-inferiority of SPIO compared with the standard use of radioisotope 99m Tc with or without blue dye. The aim of the MONOS study presented here was to evaluate the use of SPIO as a sole tracer and the efficacy of tracer injection in the preoperative setting. METHODS This prospective cohort study was carried out in two hospitals, one using 99m Tc and the other SPIO. 99m Tc was injected in the morning of the day of surgery or the day before. SPIO was either injected before surgery in the outpatient clinic or 1 h before the operation. RESULTS A total of 338 consecutive patients with breast cancer underwent 343 procedures; SPIO nanoparticles were used in 184 procedures and 99m Tc-labelled tracer in 159. Detection rates for SPIO and 99m Tc were 95·6 and 96·9 per cent respectively (P = 0·537). All nodes with SPIO uptake were coloured brown. Fewer nodes were retrieved with SPIO (mean 1·35 versus 1·89), regardless of whether blue dye was used (P < 0·001). Preoperative SPIO injection (58·7 per cent of procedures), a median of 16 (range 2-27) days before the procedure, was associated with a better tracer-specific detection rate (95·3 versus 86 per cent; P = 0·031) and retrieval of more nodes (mean 1·43 versus 1·03; P < 0·001) than perioperative administration. Skin staining was present in 39·9 per cent of patients, and was related to breast-conserving surgery and periareolar injection. CONCLUSION The use of SPIO alone is a safe alternative, with results comparable to those of the standard dual technique using 99m Tc and blue dye. The efficacy of injection in the preoperative setting simplifies logistics and improves performance. Skin staining can be prevented by a deeper peritumoral injection.
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Affiliation(s)
- A Karakatsanis
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala Academic Hospital, Uppsala, Sweden
| | - K Daskalakis
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala Academic Hospital, Uppsala, Sweden
| | - P Stålberg
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala Academic Hospital, Uppsala, Sweden
| | - H Olofsson
- Department of Clinical Pathology, Uppsala University Hospital, Uppsala Academic Hospital, Uppsala, Sweden
| | - Y Andersson
- Department of Surgery, Västmanlands County Hospital, Västerås, Sweden
| | - S Eriksson
- Department of Surgery, Västmanlands County Hospital, Västerås, Sweden
| | - L Bergkvist
- Centre for Clinical Research, Uppsala University, Uppsala, Sweden.,Department of Surgery, Västmanlands County Hospital, Västerås, Sweden
| | - F Wärnberg
- Department of Surgical Sciences, Uppsala University Hospital, Uppsala Academic Hospital, Uppsala, Sweden
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Hong KY, Lee HB, Yim S, Lee J, Kim TY, Han W, Jin US. Opportunistic Biopsy of Internal Mammary Lymph Nodes During Immediate Breast Reconstruction After Mastectomy for Breast Malignancies. Ann Surg Oncol 2017; 24:1881-1888. [DOI: 10.1245/s10434-017-5837-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Indexed: 01/19/2023]
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24
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Heymans C, van Bastelaar J, Visschers RGJ, Vissers YLJ. Sentinel Node Procedure Obsolete in Lumpectomy for Ductal Carcinoma In Situ. Clin Breast Cancer 2016; 17:e87-e93. [PMID: 28162949 DOI: 10.1016/j.clbc.2016.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 09/08/2016] [Accepted: 10/12/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with a preoperative needle-biopsy diagnosis of ductal carcinoma in situ (DCIS) may have an indication for a sentinel lymph node biopsy if invasive carcinoma is found. We investigated how often a positive sentinel node and invasive carcinoma occurred in patients with a preoperative diagnosis of DCIS and whether this influenced the adjuvant regime. MATERIALS AND METHODS From 2005 to 2014, the records of 240 patients with needle-biopsy diagnosis of DCIS were retrospectively reviewed for postoperative pathology outcomes of the sentinel node and breast, and decisions on adjuvant treatment. Descriptive statistics and univariable and multivariable analysis were used. RESULTS A total of 160 of 240 patients underwent a sentinel node biopsy. Sixteen of 85 patients undergoing lumpectomy had occult invasive cancer. One patient had a micrometastasis. In patients undergoing mastectomy, 30 of 155 patients had occult invasive cancer. One patient had a micrometastasis, and 3 had a macrometastases. Eleven patients received adjuvant treatment as a result of invasive cancer. Three patients received adjuvant treatment (radiotherapy of the axilla or axillary dissection) because of node positivity. These patients underwent a primary mastectomy. CONCLUSION A positive sentinel lymph node biopsy in patients with needle-biopsy diagnosis of ductal DCIS is rare and rarely changes adjuvant regimes. Current Dutch guidelines should be updated.
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Affiliation(s)
- Cathelijne Heymans
- Department of Surgery, Zuyderland Medical Center, Sittard, The Netherlands
| | | | | | - Yvonne L J Vissers
- Department of Surgery, Zuyderland Medical Center, Sittard, The Netherlands.
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25
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Miller ME, Kyrillos A, Yao K, Kantor O, Tseng J, Winchester DJ, Shulman LN. Utilization of Axillary Surgery for Patients With Ductal Carcinoma In Situ: A Report From the National Cancer Data Base. Ann Surg Oncol 2016; 23:3337-46. [PMID: 27334212 DOI: 10.1245/s10434-016-5322-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study evaluated the use of axillary surgery (AS), including sentinel lymph node biopsy (SLNB), for patients with ductal carcinoma in situ (DCIS) and the factors associated with its use. To determine whether utilization of SLNB is appropriate, predictors of SLNB performance were compared with factors predictive of tumor upstaging. METHODS The National Cancer Data Base was utilized to identify patients with American Joint Committee on Cancer (AJCC) clinical stage 0 breast cancer treated from 2004 to 2013. DCIS with microinvasion was excluded. Chi square tests and logistic regression were used to examine patient, tumor, and facility features associated with SLNB and tumor upstaging. RESULTS Of the 218,945 total patients, 155,093 (70.8 %) underwent lumpectomy, and 63,852 (29.2 %) underwent mastectomy. SLNB was performed for 19.0 % of lumpectomy patients and 63.5 % of mastectomy patients. Multivariate analysis for 2012-2013 demonstrated that estrogen receptor (ER)-negative and grade 3 tumors were more likely to be treated with SLNB in both groups. Tumor size was significant only for the lumpectomy patients who underwent one operation. Further, 22.8 % of lumpectomy patients and 18.7 % of mastectomy patients who underwent AS were upstaged compared with 1.8 % of lumpectomy and 3.6 % of mastectomy patients who did not undergo AS. Tumor upstaging was predicted by ER-negative status (odds ratio [OR] 2.99; 95 % confidence interval [CI] 2.76-3.24) but not by higher grade or larger tumor size. CONCLUSIONS Use of SLNB for DCIS is high with mastectomy, and nearly one fifth of the lumpectomy patients underwent SLNB. However, the performance of AS was strongly associated with the likelihood of upstaging in both groups, suggesting that surgical judgment plays an important role in this decision.
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Affiliation(s)
- Megan E Miller
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Alexandra Kyrillos
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Katharine Yao
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA.
| | - Olga Kantor
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Jennifer Tseng
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - David J Winchester
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Lawrence N Shulman
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
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Al-Ameer AY, Al Nefaie S, Al Johani B, Anwar I, Al Tweigeri T, Tulbah A, Alshabanah M, Al Malik O. Sentinel lymph node biopsy in clinically detected ductal carcinoma in situ. World J Clin Oncol 2016; 7:258-264. [PMID: 27081649 PMCID: PMC4826972 DOI: 10.5306/wjco.v7.i2.258] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/15/2015] [Accepted: 01/29/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the indications for sentinel lymph node biopsy (SLNB) in clinically-detected ductal carcinoma in situ (CD-DCIS).
METHODS: A retrospective analysis of 20 patients with an initial diagnosis of pure DCIS by an image-guided core needle biopsy (CNB) between June 2006 and June 2012 was conducted at King Faisal Specialist Hospital. The accuracy of performing SLNB in CD-DCIS, the rate of sentinel and non-sentinel nodal metastasis, and the histologic underestimation rate of invasive cancer at initial diagnosis were analyzed. The inclusion criteria were a preoperative diagnosis of pure DCIS with no evidence of invasion. We excluded any patient with evidence of microinvasion or invasion. There were two cases of mammographically detected DCIS and 18 cases of CD-DCIS. All our patients were diagnosed by an image-guided CNB except two patients who were diagnosed by fine needle aspiration (FNA). All patients underwent breast surgery, SLNB, and axillary lymph node dissection (ALND) if the SLN was positive.
RESULTS: Twenty patients with an initial diagnosis of pure DCIS underwent SLNB, 2 of whom had an ALND. The mean age of the patients was 49.7 years (range, 35-70). Twelve patients (60%) were premenopausal and 8 (40%) were postmenopausal. CNB was the diagnostic procedure for 18 patients, and 2 who were diagnosed by FNA were excluded from the calculation of the underestimation rate. Two out of 20 had a positive SLNB and underwent an ALND and neither had additional non sentinel lymph node metastasis. Both the sentinel visualization rate and the intraoperative sentinel identification rate were 100%. The false negative rate was 0%. Only 2 patients had a positive SLNB (10%) and neither had additional metastasis following an ALND. After definitive surgery, 3 patients were upstaged to invasive ductal carcinoma (3/18 = 16.6%) and 3 other patients were upstaged to DCIS with microinvasion (3/18 = 16.6%). Therefore the histologic underestimation rate of invasive disease was 33%.
CONCLUSION: SLNB in CD-DCIS is technically feasible and highly accurate. We recommend limiting SLNB to patients undergoing a mastectomy.
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Pilewskie M, Karsten M, Radosa J, Eaton A, King TA. Is Sentinel Lymph Node Biopsy Indicated at Completion Mastectomy for Ductal Carcinoma In Situ? Ann Surg Oncol 2016; 23:2229-34. [PMID: 26960927 DOI: 10.1245/s10434-016-5145-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2015] [Indexed: 12/21/2022]
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) is recommended when mastectomy is performed for ductal carcinoma in situ (DCIS). The role of SLNB for women with DCIS who undergo mastectomy following one or more attempts at breast-conserving surgery (BCS) is uncertain. We examined the upgrade rate and SLNB yield in women who converted to mastectomy after one or more attempts at BCS for DCIS. METHODS All patients who underwent one or more attempts at BCS prior to conversion to mastectomy with SLNB for DCIS were identified. Margin status as the indication for mastectomy was confirmed, and comparisons were made between patients with/without upgrade on final pathology. RESULTS From February 2006 to November 2012, a total of 233 patients underwent completion mastectomy following one or more attempts at BCS for positive/close margins (median age 50 years; range 34-84). The median number of BCS attempts was 1 (range 1-4). Overall, 20 (9 %) patients were upgraded on final pathology; 15 (6 %) stage I, and 5 (3 %) stage II (three micrometastasis, two macrometastasis). In two of five cases with a positive SLN, invasive carcinoma was not identified in the mastectomy specimen. The only factor associated with any upgrade was the presence of micropapillary DCIS (80 vs. 55 %, with and without upgrade; p = 0.03). CONCLUSION In this cohort of patients with DCIS who converted to mastectomy for positive/close margins after one or more attempts at BCS, 18 (8 %) would have required second-stage axillary surgery had an SLNB not been performed, and in two (1 %) patients, the SLN provided the only evidence of invasion. These findings support the recommendation for SLNB at the time of completion mastectomy.
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Affiliation(s)
- Melissa Pilewskie
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.
| | - Maria Karsten
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Julia Radosa
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA.,Department of Gynaecology and Obstetrics, Saarland University Hospital, Homburg, Germany
| | - Anne Eaton
- Department of Epidemiology and Biostatistics, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Tari A King
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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Kondo T, Hayashi N, Ohde S, Suzuki K, Yoshida A, Yagata H, Niikura N, Iwamoto T, Kida K, Murai M, Takahashi Y, Tsunoda H, Nakamura S, Yamauchi H. A model to predict upstaging to invasive carcinoma in patients preoperatively diagnosed with ductal carcinoma in situ of the breast. J Surg Oncol 2015; 112:476-80. [DOI: 10.1002/jso.24037] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 08/22/2015] [Indexed: 11/08/2022]
Affiliation(s)
- Takafumi Kondo
- Departments of Breast Surgical Oncology; St. Luke's International Hospital; Tokyo Japan
| | - Naoki Hayashi
- Departments of Breast Surgical Oncology; St. Luke's International Hospital; Tokyo Japan
| | - Sachiko Ohde
- St. Luke's Life Science Institute Center for Clinical Epidemiology; Tokyo Japan
| | - Koyu Suzuki
- Departments of Pathology; St. Luke's International Hospital; Tokyo Japan
| | - Atsushi Yoshida
- Departments of Breast Surgical Oncology; St. Luke's International Hospital; Tokyo Japan
| | - Hiroshi Yagata
- Departments of Breast Surgical Oncology; St. Luke's International Hospital; Tokyo Japan
| | - Naoki Niikura
- Departments of Breast and Endocrine Surgery; Tokai University School of Medicine; Kanagawa Japan
| | - Takayuki Iwamoto
- Department of Gastroenterological Surgery and Surgical Oncology; Okayama University; Okayama Japan
| | - Kumiko Kida
- Departments of Breast Surgical Oncology; St. Luke's International Hospital; Tokyo Japan
| | - Michiko Murai
- Departments of Breast Surgical Oncology; St. Luke's International Hospital; Tokyo Japan
| | - Yuko Takahashi
- Departments of Breast Surgical Oncology; St. Luke's International Hospital; Tokyo Japan
| | - Hiroko Tsunoda
- Departments of Radiology; St. Luke's International Hospital; Tokyo Japan
| | - Seigo Nakamura
- Department of Surgery; Division of Breast Surgical Oncology; Showa University School of Medicine; Tokyo Japan
| | - Hideko Yamauchi
- Departments of Breast Surgical Oncology; St. Luke's International Hospital; Tokyo Japan
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Yoon HJ, Kim Y, Kim BS. Intratumoral metabolic heterogeneity predicts invasive components in breast ductal carcinoma in situ. Eur Radiol 2015; 25:3648-58. [PMID: 26063655 DOI: 10.1007/s00330-015-3761-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 03/15/2015] [Accepted: 04/01/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVES This study investigated whether texture-based imaging parameters could identify invasive components of ductal carcinoma in situ (DCIS). METHODS We enrolled 65 biopsy-confirmed DCIS patients (62 unilateral, 3 bilateral) who underwent (18) F-FDG PET, diffusion-weighted imaging (DWI), or breast-specific gamma imaging (BSGI). We measured SUV max and intratumoral metabolic heterogeneity by the area under the curve (AUC) of cumulative SUV histograms (CSH) on PET, tumour-to-normal ratio (TNR) and coefficient of variation (COV) as an index of heterogeneity on BSGI, minimum ADC (ADC min ) and ADC difference (ADC diff ) as an index of heterogeneity on DWI. After surgery, final pathology was categorized as pure-DCIS (DCIS-P), DCIS with microinvasion (DCIS-MI), or invasive ductal carcinoma (IDC). Clinicopathologic features of DCIS were correlated with final classification. RESULTS Final pathology confirmed 44 DCIS-P, 14 DCIS-MI, and 10 IDC. The invasive component of DCIS was significantly correlated with higher SUV max (p = 0.017) and lower AUC-CSH (p < 0.001) on PET, higher TNR (p = 0.008) and COV (p = 0.035) on BSGI, lower ADC min (p = 0.016) and higher ADC diff (p = 0.009) on DWI, and larger pathologic size (p = 0.018). On multiple regression analysis, AUC-CSH was the only significant predictor of invasive components (p = 0.044). CONCLUSIONS The intratumoral metabolic heterogeneity of (18) F-FDG PET was the most important predictor of invasive components of DCIS. KEY POINTS • Preoperative identification of invasion in DCIS is important for axillary nodal management • Higher SUV max and lower AUC-CSH from FDG PET may indicate invasive components of DCIS • Higher TNR and COV from BSGI may indicate invasive components of DCIS • Lower ADC min and higher ADC diff from DWI may indicate invasive components of DCIS • AUC-CSH, an index of metabolic heterogeneity, is an independent predictor for invasive components.
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Affiliation(s)
- Hai-Jeon Yoon
- Department of Nuclear Medicine, Ewha Womans University School of Medicine, 911-1 Mok-Dong, Yangchun-Ku, Seoul, 158-710, Republic of Korea
| | - Yemi Kim
- Clinical Research Institute, Ewha Womans University, Seoul, Republic of Korea
| | - Bom Sahn Kim
- Department of Nuclear Medicine, Ewha Womans University School of Medicine, 911-1 Mok-Dong, Yangchun-Ku, Seoul, 158-710, Republic of Korea. .,Clinical Research Institute, Ewha Womans University, Seoul, Republic of Korea.
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Long-term prospective cohort study of patients undergoing pancreatectomy for intraductal papillary mucinous neoplasm of the pancreas: implications for postoperative surveillance. Ann Surg 2015; 260:356-63. [PMID: 24378847 DOI: 10.1097/sla.0000000000000470] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To evaluate long-term follow-up results after surgical treatment of intraductal papillary mucinous neoplasm (IPMN) to optimize postoperative surveillance strategies. BACKGROUND Little is known about the postoperative natural history of IPMN, especially about long-term follow-up results in patients with benign or noninvasive IPMN. METHODS Long-term follow-up was undertaken in a prospective cohort of 403 consecutive patients who underwent surgical treatment of IPMN at Seoul National University Hospital. Of these, 37 patients with ductal adenocarcinoma arising in IPMN were excluded from the analysis. RESULTS Of the 366 patients, 82 had low-grade dysplasia, 171 had intermediate-grade dysplasia, 45 had high-grade dysplasia, and 68 had IPMN with associated invasive carcinoma. During a median follow-up of 44.4 months, the overall recurrence rate was 10.7%. Pathologic grade of dysplasia was associated with recurrence rate (P < 0.001). IPMNs involving main duct had higher rate of recurrence (P = 0.021). Of the 298 patients with benign or noninvasive IPMN, 16 (5.4%) had recurrences including distant metastasis. Multivariate analysis revealed that the degree of dysplasia was the most important predictor of recurrence (P < 0.001). The overall 5-year disease-free survival rate was 78.9% and was significantly lower in patients with high-grade dysplasia than in those with low- or intermediate-grade dysplasia (P = 0.045). CONCLUSIONS Pancreatic IPMNs recur in 10.7% of patients. Recurrence is correlated with the degree of dysplasia, and 5.4% of patients with benign or noninvasive IPMN have recurrences including distant metastasis. Thorough postoperative surveillance is needed not only for patients with invasive IPMN but also for those with benign or noninvasive IPMN, especially for patients with high-grade dysplasia.
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Nicholson S, Hanby A, Clements K, Kearins O, Lawrence G, Dodwell D, Bishop H, Thompson A. Variations in the management of the axilla in screen-detected Ductal Carcinoma In Situ: Evidence from the UK NHS Breast Screening Programme audit of screen detected DCIS. Eur J Surg Oncol 2015; 41:86-93. [DOI: 10.1016/j.ejso.2014.09.003] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Revised: 08/29/2014] [Accepted: 09/02/2014] [Indexed: 10/24/2022] Open
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A simple model to assess the probability of invasion in ductal carcinoma in situ of the breast diagnosed by needle biopsy. BIOMED RESEARCH INTERNATIONAL 2014; 2014:480840. [PMID: 25114904 PMCID: PMC4119639 DOI: 10.1155/2014/480840] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/13/2014] [Revised: 06/21/2014] [Accepted: 06/25/2014] [Indexed: 11/21/2022]
Abstract
Objectives. The aim of the study was to develop a clinical prediction model for assessing the probability of having invasive cancer in the definitive surgical resection specimen in patients with biopsy diagnosis of ductal carcinoma in situ (DCIS) of the breast, to facilitate decision making regarding axillary surgery. Methods. In 349 women with DCIS, predictors of invasion in the definitive resection specimen were identified. A model to predict the probability of invasion was developed and subsequently simplified to divide patients into two risk categories. The model's performance was validated on another patient population. Results. Multivariate logistic regression revealed four independent predictors of invasion: (i) suspicious (micro)invasion in the biopsy specimen; (ii) visibility of the lesion on ultrasonography; (iii) size of the lesion on mammography >30 mm; (iv) clinical palpability of the lesion. The actual frequency of invasion in the high-risk patient group in the test and validation population was 52.6% and 48.3%, respectively; in the low-risk group it was 16.8% and 7.1%, respectively. Conclusion. The model proved to have good performance. In patients with a low probability of invasion, an axillary procedure can be omitted without a substantial risk of additional surgery.
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Osako T, Iwase T, Ushijima M, Horii R, Fukami Y, Kimura K, Matsuura M, Akiyama F. Incidence and prediction of invasive disease and nodal metastasis in preoperatively diagnosed ductal carcinoma in situ. Cancer Sci 2014; 105:576-82. [PMID: 24533797 PMCID: PMC4317837 DOI: 10.1111/cas.12381] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Revised: 02/08/2014] [Accepted: 02/12/2014] [Indexed: 11/29/2022] Open
Abstract
For breast cancer patients with a preoperative diagnosis of ductal carcinoma in situ (DCIS), sentinel lymph node (SN) biopsy has been proposed as an axillary staging procedure in selected patients with a higher likelihood of having occult invasive lesions. With detailed histological examination of primary tumors and molecular whole-node analysis of SNs, we aimed to validate whether this selective application accurately identifies patients with SN metastasis. The subjects were 336 patients with a preoperative needle-biopsy diagnosis of DCIS who underwent SN biopsy using the one-step nucleic acid amplification assay in the period 2009–2011. The incidence and preoperative predictors of upstaging to invasive disease on final pathology and SN metastasis, and their correlation, were investigated. Of the 336 patients, 113 (33.6%) had invasive disease, and 6 (1.8%) and 17 (5.0%) had macro- and micrometastasis in axillary nodes respectively. Of the 113 patients with invasive disease, 4 (3.5%) and 9 (8.0%) had macro- and micrometastasis. Predictors of invasive disease included palpability, mammographic mass, and calcifications (spread >20 mm), and intraductal solid structure, but no predictor was found for SN metastasis. Therefore, even though occult invasive disease was found at final pathology, most of the patients had no metastasis or only micrometastasis in axillary nodes. Predictors of invasive disease and SN metastasis were not completely consistent, so the selective SN biopsy for patients with a higher risk of invasive disease may not accurately identify those with SN metastasis. More accurate application of SN biopsy is required for patients with a preoperative diagnosis of DCIS.
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Affiliation(s)
- Tomo Osako
- Division of Pathology, The Cancer Institute of the Japanese Foundation for Cancer Research, Tokyo, Japan; Department of Pathology, The Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
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Detection and clinical relevance of hematogenous tumor cell dissemination in patients with ductal carcinoma in situ. Breast Cancer Res Treat 2014; 144:531-8. [DOI: 10.1007/s10549-014-2898-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 02/21/2014] [Indexed: 10/25/2022]
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Tamaoki M, Nio Y, Tsuboi K, Nio M, Tamaoki M, Maruyama R. A rare case of non-invasive ductal carcinoma of the breast coexisting with follicular lymphoma: A case report with a review of the literature. Oncol Lett 2014; 7:1001-1006. [PMID: 24944658 PMCID: PMC3961434 DOI: 10.3892/ol.2014.1885] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Accepted: 01/15/2014] [Indexed: 11/18/2022] Open
Abstract
The double presentation of breast cancer and follicular lymphoma is extremely rare, and only six cases have previously been reported in the literature. In the present study, a case of synchronous ductal carcinoma in situ (DCIS) of the breast and follicular lymphoma is reported. During an annual breast screening procedure, a 49-year-old female presented with a hard induration under the nipple of the right breast and swelling of a soft lymph node (LN) in the right axilla. Mammography and ultrasonography revealed two lesions in the right breast: One was a tumor with microcalcification, 1.0 cm in diameter, and the other was a large, crude calcification, 2.5 cm in diameter. In addition, computed tomography and positron emission tomography revealed swellings of the bilateral axillary (Ax) LN and intra-abdominal para-aortic LN. The patient underwent excisions of the large calcified mass, a micro-calcified tumor and the right AxLN. The pathological and immunohistochemical studies revealed fat necrosis and DCIS of the breast, which was positive for the estrogen receptor and the progesterone receptor, while human epidermal growth factor receptor II protein expression was evaluated as 2+ and stage was classified as pTis pN0 M0, stage 0. Furthermore, the Ax node was diagnosed as follicular lymphoma, which was positive for cluster of differentiation (CD)20, CD79a, CD10 and B-cell lymphoma (Bcl)-2 protein, but negative for Bcl-6 protein. The clinical stage was classified as stage III. The patient was administered chemotherapy followed by radiotherapy to the conserved breast. Two years have passed since the surgery, and the patient is disease-free.
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Affiliation(s)
| | | | | | | | | | - Riruke Maruyama
- Department of Pathology, Faculty of Medicine, Shimane University, Izumo, Japan
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Zetterlund L, Stemme S, Arnrup H, de Boniface J. Incidence of and risk factors for sentinel lymph node metastasis in patients with a postoperative diagnosis of ductal carcinoma in situ. Br J Surg 2014; 101:488-94. [DOI: 10.1002/bjs.9404] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2013] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Positive sentinel lymph nodes (SLNs) are found in up to 13 per cent of women with a preoperative diagnosis of ductal carcinoma in situ (DCIS) of the breast and in up to 4 per cent of those with a postoperative diagnosis. This retrospective national register study investigated the incidence of positive SLNs in women with a postoperative diagnosis of DCIS, and the value of additional tumour sectioning to identify occult tumour invasion.
Methods
All surgical patients with a final histopathological diagnosis of pure DCIS registered in the Swedish national breast cancer register in 2008 and 2009 were eligible. Additional sectioning was performed on archived primary tumour tissue from women with SLN metastasis (including cases of isolated tumour cells) and matched SLN-negative control patients with the aim of detecting occult invasion.
Results
SLN tumour deposits were reported in 11 of 753 women who had SLN biopsy (macrometastases, 2; micrometastases, 3; isolated tumour cells, 6), resulting in a SLN positivity rate of 0·7 per cent (5 of 753). Occult invasion was found in one (9 per cent) of these 11 patients and in two (10 per cent) of 21 control patients. No risk factors for SLN metastasis were identified.
Conclusion
SLN positivity is rare in women with a histopathological diagnosis of pure DCIS. Additional primary tumour assessment may reveal occult invasion in both SLN metastasis-positive and -negative patients. The value of performing SLN biopsy in the setting of a preoperative diagnosis of DCIS was limited, and current Swedish practice should therefore be questioned.
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Affiliation(s)
- L Zetterlund
- Department of Surgery, Stockholm South General Hospital, Stockholm, Sweden
- Department of Clinical Science and Education, Karolinska Institute, Stockholm, Sweden
| | - S Stemme
- Department of Pathology, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology–Pathology, Karolinska Institute, Stockholm, Sweden
| | - H Arnrup
- Department of Acute Internal Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - J de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Breast and Endocrine Surgery, Karolinska University Hospital, Stockholm, Sweden
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Cserni G. Sentinel lymph node status and axillary lymph node dissection in the surgical treatment of breast cancer. Orv Hetil 2014; 155:203-15. [DOI: 10.1556/oh.2014.29816] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
Axillary lymph node dissection has been traditionally perceived as a therapeutic and a staging procedure and unselectively removes all axillary lymph nodes. There still remains some controversy as concerns the survival benefit associated with axillary clearance. Sentinel lymph node biopsy removes the most likely sites of regional metastases, the lymph nodes directly connected with the primary tumour. It allows a more accurate staging and a selective indication for clearing the axilla, restricting this to patients who may benefit of it. Axillary dissection was performed in all patients during the learning phase of sentinel lymphadenectomy, but later only patients with metastasis to a sentinel node underwent this operation. Currently, even some patients with minimal sentinel node involvement, including some with macrometastasis may skip axillary clearance. This review summarizes the changes that have occurred in the surgical management of the axilla, the evidences and controversies behind these changes, along with current recommendations. Orv. Hetil., 2014, 155(6), 203–215.
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Affiliation(s)
- Gábor Cserni
- Bács-Kiskun Megyei Kórház Patológiai Osztály Kecskemét Nyíri út 49. 6000
- Szegedi Tudományegyetem, Általános Orvostudományi Kar Patológiai Intézet Szeged Állomás u. 2. 6725
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Souchon R, Sautter-Bihl ML, Sedlmayer F, Budach W, Dunst J, Feyer P, Fietkau R, Haase W, Harms W, Wenz F, Sauer R. DEGRO practical guidelines: radiotherapy of breast cancer II. Strahlenther Onkol 2013; 190:8-16. [DOI: 10.1007/s00066-013-0502-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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van Steenbergen LN, Voogd AC, Roukema JA, Louwman WJ, Duijm LEM, Coebergh JWW, van de Poll-Franse LV. Time trends and inter-hospital variation in treatment and axillary staging of patients with ductal carcinoma in situ of the breast in the era of screening in Southern Netherlands. Breast 2013; 23:63-8. [PMID: 24291376 DOI: 10.1016/j.breast.2013.11.001] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2013] [Revised: 09/04/2013] [Accepted: 11/03/2013] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND To examine variation in time and place in axillary staging and treatment of patients with ductal carcinoma in situ (DCIS) of the breast. METHODS Trends in patients with DCIS recorded in the Eindhoven Cancer Registry diagnosed in 1991-2010 (n = 2449) were examined. RESULTS The use of breast conserving surgery (BCS) went from 17% to 67% in 1991-2010 and administration of radiotherapy after BCS increased to 89%. Axillary lymph node dissection decreased to almost 0%, while sentinel node biopsy was performed in 65% of patients in 2010. The proportion who underwent BCS varied between hospitals from 49% to 80%; the proportion without axillary staging ranged from 21% to 60%. Patients with screen-detected DCIS were more likely to receive BCS. CONCLUSION There was considerable variation in the use of BCS, radiotherapy, and axillary staging of DCIS over time and between hospitals. Patients with DCIS were more likely to be treated with BCS if their disease was detected by screening.
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Affiliation(s)
- L N van Steenbergen
- Eindhoven Cancer Registry, Comprehensive Cancer Centre South, PO Box 231, 5600 AE Eindhoven, The Netherlands.
| | - A C Voogd
- Eindhoven Cancer Registry, Comprehensive Cancer Centre South, PO Box 231, 5600 AE Eindhoven, The Netherlands; Department of Epidemiology, Maastricht University, PO Box 616, 6200 MD Maastricht, The Netherlands
| | - J A Roukema
- Department of Surgery, St. Elisabeth Hospital Tilburg, PO Box 90151, 5000 LC Tilburg, The Netherlands; Center of Research on Psychology in Somatic Diseases (CoRPS), Tilburg University, 5000 LE Tilburg, The Netherlands
| | - W J Louwman
- Eindhoven Cancer Registry, Comprehensive Cancer Centre South, PO Box 231, 5600 AE Eindhoven, The Netherlands
| | - L E M Duijm
- Department of Radiology, Canisius Wilhelmina Hospital, PO Box 9015, 6500 GS Nijmegen, The Netherlands
| | - J W W Coebergh
- Eindhoven Cancer Registry, Comprehensive Cancer Centre South, PO Box 231, 5600 AE Eindhoven, The Netherlands; Department of Public Health, Erasmus University Medical Centre, PO Box 2040, 3000 CA Rotterdam, The Netherlands
| | - L V van de Poll-Franse
- Eindhoven Cancer Registry, Comprehensive Cancer Centre South, PO Box 231, 5600 AE Eindhoven, The Netherlands; Center of Research on Psychology in Somatic Diseases (CoRPS), Tilburg University, 5000 LE Tilburg, The Netherlands
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A differential intra-operative molecular biological test for the detection of sentinel lymph node metastases in breast carcinoma. An extended experience from the first U.K. centre routinely offering the service in clinical practice. Eur J Surg Oncol 2013; 40:282-8. [PMID: 24331309 DOI: 10.1016/j.ejso.2013.10.030] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Revised: 10/30/2013] [Accepted: 10/31/2013] [Indexed: 01/22/2023] Open
Abstract
INTRODUCTION One-Step Nucleic acid Amplification (OSNA) is a molecular biological assay of cytokeratin-19 (a breast epithelial marker) mRNA. It can be employed intra-operatively for detection of lymph node metastases in breast carcinoma. Patients with positive sentinel nodes may proceed to axillary lymph node dissection (ALND) level I or higher dependent upon the OSNA quantitative result, during the same surgical procedure, avoiding a second operation and eliminating the technical difficulties possibly associated with delayed ALND. AIMS Our Breast Unit was the first in the UK to implement this novel technique in routine practice. This study reviews our first 44-month data following introduction of OSNA "live" on whole sentinel nodes following an extensive validation study (Snook et al.).(9) METHODS: Data was collected prospectively from the period of introduction 01/12/2008 to 30/08/2012. All patients eligible for sentinel node biopsy were offered OSNA and operations were performed by five consultant breast surgeons. On detection of macro-metastasis a level II/III and for a micro-metastasis a level I ALND was performed. RESULTS A total of 859 patients (1709 sentinel lymph nodes) were analysed. All except one were females. The majority underwent wide local excision (73.4%, n = 631) or mastectomy 25% (n = 215) and 1.6% (13) underwent SLN biopsy alone. IDC was seen in 79% (n = 680) of the patients and 53.5% (n = 460) had grade II tumours. One-third (30.8%, n = 265) had positive sentinel nodes and had further axillary surgery at the time of SLN biopsy. Of these, 47% (n = 125/265) had macro-metastases, 38% (n = 101/265) had micro-metastases and 14.7% (n = 39/265) had "positive but inhibited" results. Positive non-sentinel lymph nodes (NSLN) were seen in 35% (44/125) of those with macro-metastases; 17.8% (18/101) of the patients with micro-metastases and 10.2% (4/39) of the "positive but inhibited" group. CONCLUSION In our series over a third of our patients had positive lymph nodes detected with OSNA allowing them to proceed directly to axillary surgery at the same operation. This technique eliminates the need for a second operation in sentinel lymph node positive patients and avoids the anxiety waiting for histological results.
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Ballehaninna UK, Chamberlain RS. Utility of intraoperative frozen section examination of sentinel lymph nodes in ductal carcinoma in situ of the breast. Clin Breast Cancer 2013; 13:350-8. [PMID: 23791128 DOI: 10.1016/j.clbc.2013.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 01/31/2013] [Accepted: 02/04/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Intraoperative frozen section (IFS) examination of sentinel lymph nodes (SLN) is useful in selecting patients with invasive breast cancer for immediate axillary lymph node dissection. However, whether IFS evaluation of the SLNs in ductal carcinoma in situ (DCIS) of the breast has any value has not been previously assessed. METHODS Clinicopathologic data from patients with DCIS who underwent resection with SLN biopsy (2004-2010) were collected to assess the sensitivity, specificity, and accuracy of IFS, and its impact on axillary management. RESULTS A total of 267 patients with DCIS underwent resection with SLN biopsy and IFS evaluation. Preoperative pathology was DCIS (n = 231), DCIS with microinvasion (n = 24), and DCIS with other lesions (n = 12). Fifty-two (19.5%) patients had invasive breast cancer on final pathology. SLN metastases were identified in 13 (4.8%) patients; however, only 4 (1.5%) were IFS positive. IFS examination was negative in 263 (98.5%) patients. Among patients with SLN metastases, the most common pattern of metastases was either micrometastasis (n = 6) or immunohistochemistry-positive individual tumor cells (n = 4), whereas 3 patients had a macrometastasis. IFS examination was falsely negative in 9 of these 13 patients for a false-negative rate of 69.3%, and a sensitivity and specificity of 31% and 100% respectively. Nine of the 13 patients underwent axillary lymph node dissection and only 1 patient had further axillary metastasis. CONCLUSIONS SLN metastases in DCIS is rare and most commonly involves SLN micrometastasis or immunohistochemistry-positive individual tumor cells. SLN IFS evaluation in DCIS has a low yield and sensitivity, and can be safely omitted to reduce operative duration and cost.
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Affiliation(s)
- Umashankar K Ballehaninna
- Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ; Department of Surgery, Maimonides Medical Center, Brooklyn, NY
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Bayraktar S, Arun B, Glück S. Ductal carcinoma in situ: how should we treat it? BREAST CANCER MANAGEMENT 2013. [DOI: 10.2217/bmt.13.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY The observed incidence of ductal carcinoma in situ (DCIS) has increased because of the increasing use of sensitive imaging modalities. While the clinical course of DCIS is quite variable, it is considered a precursor lesion to invasive breast cancer. The current focus of DCIS treatment is on the prevention of progression to invasive disease. However, at present, validated diagnostic tests to predict progression accurately are lacking. Additionally, important clinical questions arise during DCIS management. For example, optimal margins of excision or axillary lymph node sampling have not been addressed in randomized clinical trials. May whole-breast radiation after lumpectomy be omitted in selected patients? What is the role of adjuvant tamoxifen if it does not impact overall survival rates? This review aims to describe the natural history of DCIS and highlights the current therapeutic options and challenges in patient management.
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Affiliation(s)
- Soley Bayraktar
- Department of Medical Oncology, Mercy Cancer Center, Ardmore, OK, USA
| | - Banu Arun
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stefan Glück
- Department of Medicine, Division of Hematology/Medical Oncology, University of Miami & Sylvester Comprehensive Cancer Center, Miami, FL, USA
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Osako T, Iwase T, Kimura K, Horii R, Akiyama F. Detection of occult invasion in ductal carcinoma in situ of the breast with sentinel node metastasis. Cancer Sci 2013; 104:453-7. [PMID: 23281914 DOI: 10.1111/cas.12095] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 12/19/2012] [Accepted: 01/03/2013] [Indexed: 12/21/2022] Open
Abstract
By definition, ductal carcinoma in situ (DCIS) - pre-invasive breast cancer - does not metastasize to the lymph nodes. However, since the introduction of molecular whole-node analysis using the one-step nucleic acid amplification assay for sentinel node (SN) biopsies, the number of patients with DCIS and SN metastasis has increased. The pathogenesis and clinical management of DCIS with SN metastasis remain controversial. In this case-control study, in order to elucidate the pathogenesis of SN metastasis in DCIS, we compared occult invasions between the SN-positive and SN-negative DCIS and investigated predictive factors of occult invasion. The subjects were 24 patients selected from 285 patients with a routine postoperative diagnosis of DCIS who had undergone SN biopsy using the one-step nucleic acid amplification whole-node assay between 2009 and 2011. Of these 24 patients, 12 were SN-positive, and 12 were SN-negative. The 12 SN-negative patients make up the control group and were selected from the 273 SN-negative patients based on patient characteristics. All paraffin blocks of the primary tumor from each patient were step-sectioned with 500-μm intervals until the block was exhausted and histopathologically examined. We analyzed 1830 step-sectioned slides and found occult invasions were more frequent in the SN-positive group (7/12, 58.3%) than in the SN-negative group (3/12, 25.0%). All occult invasions were <5 mm. There was no correlation between occult invasion and SN tumor burden, non-SN metastasis, or patient characteristics. Our results suggest true metastasis from occult invasion may be a potent pathogenesis indicating nodal metastasis in postoperatively diagnosed DCIS. Patient follow-up is required to elucidate the prognostic impact of nodal metastasis and occult invasion.
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Affiliation(s)
- Tomo Osako
- Division of Pathology, The Cancer Institute of the Japanese Foundation for Cancer Research, Tokyo, Japan
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Park HS, Park S, Cho J, Park JM, Kim SI, Park BW. Risk predictors of underestimation and the need for sentinel node biopsy in patients diagnosed with ductal carcinoma in situ by preoperative needle biopsy. J Surg Oncol 2012; 107:388-92. [PMID: 23007901 DOI: 10.1002/jso.23273] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Accepted: 09/06/2012] [Indexed: 11/11/2022]
Abstract
BACKGROUND Diagnosis of ductal carcinoma in situ (DCIS) by core needle biopsy showed a high rate of underestimation of invasiveness, and performing sentinel lymph node biopsy (SLNB) in DCIS patients was controversial. METHODS We analyzed 340 DCIS patients who were diagnosed by needle biopsies. Final pathology and clinicopathological features were reviewed. Predictors were accessed using the Chi-square test and a binary logistic regression model. RESULTS The overall DCIS underestimation rate was 42.6%. The underestimation was significantly related to the palpability, mass or calcification by ultrasonography, grade, suspicious microinvasion, and biopsy method in univariate analysis. In multivariate analysis, palpability, ultrasonographic calcification or mass, suspicious microinvasion, and core needle biopsy were independent predictors of underestimation of invasive cancer. In cases with one or no risk predictors, the underestimation rate was 14.3%, whereas, in those with five predictors, it increased to 90.9%. Among 144 invasive cancer patients who underwent axillary staging, 15.4% had node metastasis. CONCLUSIONS DCIS diagnosed by preoperative needle biopsy has a high probability of underestimation, and 15% of invasive cancer patients have node metastasis. SLNB may be justified in DCIS patients undergoing needle biopsies, and caution should be exercised in omitting SLNB in patients with one or no risk predictors.
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Affiliation(s)
- Hyung Seok Park
- Department of Surgery, Yonsei University College of Medicine, Seoul, Republic of Korea
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Kósa C, Garami Z, Dinya T, Fülöp B. [Predictive factors of invasion with initial diagnosis of ductal carcinoma in situ based on core biopsy]. Magy Seb 2012; 65:218-21. [PMID: 22940391 DOI: 10.1556/maseb.65.2012.4.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Previous studies suggest that sentinel lymph node biopsy (SLNB) should not be performed in case of pure ductal carcinoma in situ (DCIS) routinely. In order to avoid a second operation for invasive cancer detected postoperatively the chance of invasion need to be determined preoperatively. The purpose of our retrospective study was to evaluate the sensitivity of core biopsy and determine the predictive value of clinical and histological factors of invasion in cases when DCIS diagnosed preoperatively. MATERIAL AND METHODS Between January 2006 and December 2011, 1311 patients were treated for breast cancer in our institute, of whom preoperative core biopsy showed DCIS in 50 cases. Wide excision or quadrantectomy was performed in 41 cases, re-excision was necessary in 6 cases for positive surgical margins and mastectomy was carried out in four patients for multicentricity. In further 9 cases extensive tumour size indicated mastectomy straight away. SLNB was carried out in 31 patients, axillary block dissection (ABD) in 8 patients, while ABD for positive sentinel nodes in another two cases. Pathology showed invasion in 17 (34,7 %) cases. RESULTS Multivariate analysis showed that tumour grade, symptomatic disease, patients' age were significant predictors of invasion. Although preoperative tumour size also showed correlation with invasiveness, this was statistically not significant. CONCLUSION Evaluation of a larger patient population might be helpful to identify women who should undergo tumour excision and SLNB as a single step operation due to increased risk of invasive disease despite the preoperative diagnosis of DCIS.
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Affiliation(s)
- Csaba Kósa
- Debreceni Egyetem Orvos- és Egészségtudományi Centrum Sebészeti Intézet 4012 Debrecen Móricz Zsigmond krt. 22.
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Osako T, Iwase T, Kimura K, Masumura K, Horii R, Akiyama F. Incidence and possible pathogenesis of sentinel node micrometastases in ductal carcinoma in situ of the breast detected using molecular whole lymph node assay. Br J Cancer 2012; 106:1675-81. [PMID: 22531630 PMCID: PMC3349186 DOI: 10.1038/bjc.2012.168] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: The pathogenesis of lymph node metastases in preinvasive breast cancer – ductal carcinoma in situ (DCIS) – remains controversial. The one-step nucleic acid amplification (OSNA) assay is a novel molecular method that can assess a whole node and detect clinically relevant metastases. In this retrospective cohort study, we determined the performance of the OSNA assay in DCIS and the pathogenesis of node-positive DCIS. Methods: The subjects consisted of 623 patients with DCIS who underwent sentinel lymph node (SN) biopsy. Of these, 2-mm-sectioned nodes were examined using frozen-section (FS) histology in 338 patients between 2007 and 2009, while 285 underwent OSNA whole node assays between 2009 and 2011. The SN-positivity rate was compared between cohorts, and the characteristics of OSNA-positive DCIS were investigated. Results: The OSNA detected more cases of SN metastases than FS histology (12 out of 285, 4.2% vs 1 out of 338, 0.3%). Most of the metastases were micrometastases. The characteristics of high-risk DCIS (i.e., mass formation, size, grade, and comedo) and preoperative breast biopsy (i.e., methods or time to surgery) were not valid for OSNA assay–positive DCIS. Conclusion: The OSNA detects more SN metastases in DCIS than FS histology. Further examination of the primary tumours and follow-up of node-positive DCIS are needed to elucidate the pathogenesis.
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Affiliation(s)
- T Osako
- Division of Pathology, the Cancer Institute of the Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto-ku, Tokyo 135-8550, Japan.
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Ansari B, Boughey JC, Adamczyk DL, Degnim AC, Jakub JW, Morton MJ. Should axillary ultrasound be used in patients with a preoperative diagnosis of ductal carcinoma in situ? Am J Surg 2012; 204:290-3. [PMID: 22749764 DOI: 10.1016/j.amjsurg.2011.11.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Revised: 11/02/2011] [Accepted: 11/02/2011] [Indexed: 10/28/2022]
Abstract
BACKGROUND We evaluated the usefulness of axillary ultrasound (US) in patients with core biopsy-proven ductal carcinoma in situ (DCIS). METHODS Preoperative axillary US, fine-needle aspiration (FNA), and sentinel lymph node (SLN) data from women with DCIS were reviewed. RESULTS Eighty-two women with DCIS underwent axillary US. In 16 women (19.5%) US was abnormal; however, FNA was negative in all cases. Sixty-one women (74%) underwent SLN surgery; 2 were positive for macrometastasis (3%) and 1 had isolated tumor cells. None of them had an abnormal US. Axillary US did not change the management in any of the cases. CONCLUSIONS Axillary US and FNA did not change the management in any of the 82 cases. In women with a core biopsy diagnosis of DCIS, positive nodes are uncommon and unlikely to be detected by axillary US. Routine preoperative axillary US is not recommended for pure DCIS on core biopsy.
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Affiliation(s)
- Bijan Ansari
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
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Deurloo EE, Sriram JD, Teertstra HJ, Loo CE, Wesseling J, Rutgers EJT, Gilhuijs KGA. MRI of the breast in patients with DCIS to exclude the presence of invasive disease. Eur Radiol 2012; 22:1504-11. [PMID: 22367470 DOI: 10.1007/s00330-012-2394-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2011] [Revised: 12/12/2011] [Accepted: 01/09/2012] [Indexed: 12/31/2022]
Abstract
OBJECTIVES Core biopsy underestimates invasion in more than 20% of patients with preoperatively diagnosed ductal carcinoma in situ (DCIS) without evidence of invasion (pure DCIS). The aim of the current study was to evaluate the efficacy of preoperative magnetic resonance imaging (MRI) to discriminate between patients with DCIS who are at high risk of invasive breast cancer and patients at low risk. METHODS One hundred and twenty-five patients, preoperatively diagnosed with pure DCIS (128 lesions; 3 bilateral) by core-needle biopsy, were prospectively included. Clinical, mammographic, histological (core biopsy) and MRI features were assessed. All patients underwent breast surgery. Analyses were performed to identify features associated with presence of invasion. RESULTS Eighteen lesions (14.1%) showed invasion on final histology. Seventy-three lesions (57%) showed suspicious enhancement on MRI with a type 1 (n = 12, 16.4%), type 2 (n = 19, 26.0%) or type 3 curve, respectively (n = 42, 57.5%). At multivariate analysis, the most predictive features for excluding presence of invasive disease were absence of enhancement or a type 1 curve on MRI (negative predictive value 98.5%; A(Z) 0.80, P = 0.00006). CONCLUSION Contrast medium uptake kinetics at MRI provide high negative predictive value to exclude presence of invasion and may be useful in primary surgical planning in patients with a preoperative diagnosis of pure DCIS. KEY POINTS It is important to determine invasion in breast DCIS. • MRI contrast medium uptake kinetics can help exclude the presence of invasion. • However, the positive predictive value for the presence of invasion is limited. • MRI features were more accurate at predicting invasion than mammographic features alone.
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Affiliation(s)
- Eline E Deurloo
- Department of Radiology, Academic Medical Center, Amsterdam, The Netherlands.
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Tamaki Y, Sato N, Homma K, Takabatake D, Nishimura R, Tsujimoto M, Yoshidome K, Tsuda H, Kinoshita T, Kato H, Taniyama K, Kamio T, Nakamura S, Akiyama F, Noguchi S. Routine clinical use of the one-step nucleic acid amplification assay for detection of sentinel lymph node metastases in breast cancer patients: results of a multicenter study in Japan. Cancer 2012; 118:3477-83. [PMID: 22252672 DOI: 10.1002/cncr.26683] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2011] [Revised: 09/28/2011] [Accepted: 09/29/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND The objective of this study was to confirm, by means of a multicenter study conducted in Japan, the reliability and usefulness of the one-step nucleic acid amplification (OSNA) assay in routine clinical use for sentinel lymph node biopsy (SLNB) of breast cancer patients. METHODS Patients with Tis-T2N0M0 breast cancer who underwent SLNB before systemic chemotherapy comprised the study cohort. A whole sentinel lymph node (SLN) was examined intraoperatively with the OSNA assay except for a 1-mm-thick, central slice of the lymph node, which underwent pathologic examination after the operation. For patients who underwent axillary dissection, non-SLNs were examined with routine pathologic examination. RESULTS In total, 417 SLNBs from 413 patients were analyzed. SLN metastases were detected with greater sensitivity by the OSNA assay than by pathologic examination (22.5% vs 15.8%; P < .001), as expected from the difference in size of the specimens examined. Patients who had SLN metastases assessed with the OSNA assay proved to harbor non-SLN metastases with an overall risk ratio of 33.7%. The risk of non-SLN metastasis was significantly lower for patients who had positive SLNs assessed as OSNA+ than for those who had SLNs assessed as OSNA++ (17.6% vs 44%; P = .012). CONCLUSIONS The OSNA assay can be used for routine clinical SLNB, and its assessment for volume of metastasis may be a powerful predictive factor for non-SLN metastasis. Further studies with more patients are needed to confirm the usefulness of this assay for selection in the clinical setting of patients who do not need axillary dissection.
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Affiliation(s)
- Yasuhiro Tamaki
- Department of Breast and Endocrine Surgery, Osaka University Graduate School of Medicine, Suita, Japan
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