Nomogram for predicting invasion in patients with a preoperative diagnosis of ductal carcinoma in situ of the breast

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

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.

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

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.

Surgical nodal assessment for endometrial hyperplasia - A meta-analysis and systematic review

OBJECTIVE

Endometrial intraepithelial neoplasia (EIN) and atypical hyperplasia (AH) are recognized precursors for endometrial cancer (EC). Most current guidelines do not recommend the routine surgical evaluation of lymph nodes (LN), although recent studies indicate increased use of sentinel lymph node (SLN) biopsy in patients with a preoperative diagnosis of EIN/AH. We aimed to evaluate the rates of positive LN and its effect on the incidence of upstaging of EIN/AH patients, complications, and adjuvant treatment administration.

METHODS

A systematic review and meta-analysis was conducted in the following databases: MEDLINE(R) using the OvidSP interface and PUBMED, Embase, Web of Science, Clinicaltrials.gov and Cochrane Library. Included were studies investigating lymph node evaluation in patients diagnosed with EIN/AH, presenting results of LN assessment and/or comparisons of hysterectomy results with and without lymph node assessment. This analysis was registered at PROSPERO International prospective register of systematic reviews (CRD42023443598).

RESULTS

A total of 447 studies were initially identified through database searching. The current analysis includes 7 studies comprising 1791 atypical endometrial hyperplasia patients who underwent hysterectomy with lymph node assessment. The incidence of positive lymph nodes among those who had undergone any LN evaluation was found to be 1.1% (95% CI 0.3%-2%). The rate of positive LNs was 1.4% (95% CI 0.2%-1.9%) among those who had undergone specifically SLN. 319 (44.3%, 95% CI 34%-54.7%) patients of the patients initially diagnosed with EIN/AH (n = 699), were finally upgraded to EC diagnosis. Fifteen percent of the final EC diagnosed patients were treated with adjuvant treatment. No significant difference regarding complication rates was noticed.

CONCLUSIONS

Our review indicates that the rate of metastatic LNs is <2% in patients undergoing surgical nodal evaluation for EIN/AH. However, the rate of complication for SLN mapping is low and may have an impact on postoperative therapy decisions in those diagnosed with malignancy.

Development of a Multi-Parametric ultrasonography nomogram for prediction of invasiveness in ductal carcinoma in situ

OBJECTIVE

To investigate the independent risk variables associated with the potential invasiveness of ductal carcinoma in situ (DCIS) on multi-parametric ultrasonography, and further construct a nomogram for risk assessment.

METHODS

Consecutive patients from January 2017 to December 2022 who were suspected of having ductal carcinoma in situ (DCIS) based on magnetic resonance imaging or mammography were prospectively enrolled. Histopathological findings after surgical resection served as the gold standard. Grayscale ultrasound, Doppler ultrasound, shear wave elastography (SWE), and contrast-enhanced ultrasound (CEUS) examinations were preoperative performed. Binary logistic regression was used for multifactorial analysis to identify independent risk factors from multi-parametric ultrasonography. The correlation between independent risk factors and pathological prognostic markers was analyzed. The predictive efficacy of DCIS associated with invasiveness was assessed by logistic analysis, and a nomogram was established.

RESULTS

A total of 250 DCIS lesions were enrolled from 249 patients, comprising 85 pure DCIS and 165 DCIS with invasion (DCIS-IDC), of which 41 exhibited micro-invasion. The multivariate analysis identified independent risk factors for DCIS with invasion on multi-parametric ultrasonography, including image size (>2cm), Doppler ultrasound RI (≥0.72), SWE's Emax (≥66.4 kPa), hyper-enhancement, centripetal enhancement, increased surrounding vessel, and no contrast agent retention on CEUS. These factors correlated with histological grade, Ki-67, and human epidermal growth factor receptor 2 (HER2) (P < 0.1). The multi-parametric ultrasound approach demonstrated good predictive performance (sensitivity 89.7 %, specificity 73.8 %, AUC 0.903), surpassing single US modality or combinations with SWE or CEUS modalities. Utilizing these factors, a predictive nomogram achieved a respectable performance (AUC of 0.889) for predicting DCIS with invasion. Additionally, a separate nomogram for predicting DCIS with micro-invasion, incorporating independent risk factors such as RI (≥0.72), SWE's Emax (≥65.2 kPa), and centripetal enhancement, demonstrated an AUC of 0.867.

CONCLUSION

Multi-parametric ultrasonography demonstrates good discriminatory ability in predicting both DCIS with invasion and micro-invasion through the analysis of lesion morphology, stiffness, neovascular architecture, and perfusion. The use of a nomogram based on ultrasonographic images offers an intuitive and effective method for assessing the risk of invasion in DCIS. Although the nomogram is not currently considered a clinically applicable diagnostic tool due to its AUC being below the threshold of 0.9, further research and development are anticipated to yield positive outcomes and enhance its viability for clinical utilization.

Validation and Clinical Utility of a Prediction Model for the Risk of Upstaging to Invasive Breast Cancer After a Biopsy Diagnosis Ductal Carcinoma In Situ

BACKGROUND

This study aimed to validate the DCIS-upstage model, a previously developed model to predict the risk of upstaging to invasive breast cancer in patients with biopsy-proven ductal carcinoma in situ (DCIS) in a more recent cohort and to assess the model's clinical utility.

METHODS

The model was validated in a registry cohort (n = 2269) and in an institution cohort (n = 302). A calibration plot was made, followed by a decision curve analysis (DCA). The model's area under the curve (AUC) was compared with the AUC of another published model and with the AUCs of new models using the risk factors of the DCIS-upstage model and additional risk factors.

RESULTS

The DCIS-upstage model had an AUC of 0.67 at development; in the validation, the AUC was 0.65 in the registry cohort and 0.73 in the institution cohort. The DCA showed that the model has clinical utility. The other published model had an AUC of 0.66 in the institution cohort. Adding risk factors to the DCIS-upstage model slightly increased the AUC.

CONCLUSIONS

The DCIS-upstage prediction model is valid in other cohorts. The model has clinical utility and may be used to select patients with biopsy-proven DCIS for sentinel lymph node biopsy.

A clinical radiomics nomogram preoperatively to predict ductal carcinoma in situ with microinvasion in women with biopsy-confirmed ductal carcinoma in situ: a preliminary study

PURPOSE

To predict ductal carcinoma in situ with microinvasion (DCISMI) based on clinicopathologic, conventional breast magnetic resonance imaging (MRI), and dynamic contrast enhanced MRI (DCE-MRI) radiomics signatures in women with biopsy-confirmed ductal carcinoma in situ (DCIS).

METHODS

Eighty-six women with eighty-seven biopsy-proven DCIS who underwent preoperative MRI and underwent surgery were retrospectively identified. Clinicopathologic, conventional MRI, DCE-MRI radiomics, combine (based on conventional MRI and DCE-MRI radiomics), traditional (based on clinicopathologic and conventional MRI) and mixed (based on clinicopathologic, conventional MRI and DCE-MRI radiomics) models were constructed by logistic regression (LR) with a 3-fold cross-validation, all evaluated using receiver operating characteristic (ROC) curve analysis. A clinical radiomics nomogram was then built by incorporating the Radiomics score, significant clinicopathologic and conventional MRI features of mixed model.

RESULTS

The area under the curves (AUCs) of clinicopathologic, conventional MRI, DCE-MRI radiomics, traditional, combine, and mixed model were 0.76 (95% confidence interval [CI] 0.59-0.94), 0.77 (95%CI 0.59-0.95), 0.74 (95%CI 0.55-0.93), 0.87 (95%CI 0.73-1), 0.8 (95%CI 0.63-0.96), and 0.93 (95%CI 0.84-1) in the validation cohort, respectively. The clinical radiomics nomogram based on mixed model showed higher AUCs than both clinicopathologic and DCE-MRI radiomics models in training/test (all P < 0.05) set and showed the greatest overall net benefit for upstaging according to decision curve analysis (DCA).

CONCLUSION

A nomogram constructed by combining clinicopathologic, conventional MRI features and DCE-MRI radiomics signatures may be useful in predicting DCISMI from DICS preoperatively.

Delayed Sentinel Lymph Node Dissection in Patients with a Preoperative Diagnosis of Ductal Cancer In Situ by Preoperative Injection with Superparamagnetic Iron Oxide (SPIO) Nanoparticles: The SentiNot Study

BACKGROUND

Difficulty in preoperatively assessing the risk for occult invasion or surgery that precludes future accurate axillary mapping in patients with ductal cancer in situ (DCIS) account for overutilization of SLND.

METHODS

Prospective, multicenter, cohort study, including women with any DCIS planned for mastectomy or DCIS grade 2 and > 20 mm, any DCIS grade 3, any mass-forming DCIS and any planned surgery. Patients received an interstitial SPIO injection during breast surgery, but no upfront SLND was performed. If invasion was identified on final pathology, delayed SLND (d-SLND) was performed separately with the coadministration of isotope ± blue dye (BD). Study outcomes were proportion of upfront SLNDs that were avoided, detection rates during d-SLND, and impact on healthcare costs.

RESULTS

In total, 78.7% of study participants (N = 254, mean age 60 years, mean DCIS size 37.8 mm) avoided upfront SLND. On d-SLND (median 28 days, range 9-46), SPIO outperformed Tc99 with (98.2% vs. 63.6%, p < 0.001) or without BD (92.7% vs. 50.9%, p < 0.001) and had higher nodal detection rate (86.9% vs. 32.3%, p < 0.001) and with BD (93.9% vs. 41.4%, p < 0.001). Only 27.9% of all SLNs retrieved were concordant for Tc99 and SPIO. Type of breast procedure (WLE vs. oncoplastic BCT vs. mastectomy) affected these outcomes and accounted for the low performance of Tc99 (p < 0.001). d-SLND resulted in a 28.1% total cost containment for women with pure DCIS on final pathology (4190 vs. 5828 USD, p < 0.001).

CONCLUSIONS

Marking the SLN with SPIO may avoid overtreatment and allow for accurate d-SLND in patients with DCIS.

Ductal carcinoma in situ: a risk prediction model for the underestimation of invasive breast cancer

Patients with a biopsy diagnosis of ductal carcinoma in situ (DCIS) may be diagnosed with invasive breast cancer after excision. We evaluated the preoperative clinical and imaging predictors of DCIS that were associated with an upgrade to invasive carcinoma on final pathology and also compared the diagnostic performance of various statistical models. We reviewed the medical records; including mammography, ultrasound (US), and magnetic resonance imaging (MRI) findings; of 644 patients who were preoperatively diagnosed with DCIS and who underwent surgery between January 2012 and September 2018. Logistic regression and three machine learning methods were applied to predict DCIS underestimation. Among 644 DCIS biopsies, 161 (25%) underestimated invasive breast cancers. In multivariable analysis, suspicious axillary lymph nodes (LNs) on US (odds ratio [OR], 12.16; 95% confidence interval [CI], 4.94-29.95; P < 0.001) and high nuclear grade (OR, 1.90; 95% CI, 1.24-2.91; P = 0.003) were associated with underestimation. Cases with biopsy performed using vacuum-assisted biopsy (VAB) (OR, 0.42; 95% CI, 0.27-0.65; P < 0.001) and lesion size <2 cm on mammography (OR, 0.45; 95% CI, 0.22-0.90; P = 0.021) and MRI (OR, 0.29; 95% CI, 0.09-0.94; P = 0.037) were less likely to be upgraded. No significant differences in performance were observed between logistic regression and machine learning models. Our results suggest that biopsy device, high nuclear grade, presence of suspicious axillary LN on US, and lesion size on mammography or MRI were independent predictors of DCIS underestimation.

Is Axillary Assessment of Ductal Carcinoma In Situ of the Breast Necessary in All Cases?

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.

COVID 19 pandemic: Effect on management of patients with breast cancer; single center retrospective cohort study

Background

(SARS-COV-2) infection, led to a pandemic affecting many countries, resulting in hospitals diverting most of their resources to fight the pandemic. Breast cancer, already a healthcare dilemma, is also affected in this scenario. Our aim was to find out the impact of COVID-19 on presentation of breast cancer stage and its effects on overall onco-surgical management.

Methods

This cohort single-centered retrospective review was carried out at our hospital, over a period of 18 months. Females with known breast cancer were included in the study. Data was collected on performas by a single researcher. Effect of COVID pandemic on presentation stage and its impact on overall management was studied. SPSS 23.0 used for data analysis. A 95% CI was used. Descriptive statistics were presented as range/means. Categorical data was analyzed by Fisher exact test, t-test was applied to numerical data, p value ≤ 0.05 was considered significant.

Results

Out of 87 patients presenting with suspicious lump, 69 who had malignancy on histo-pathology were included in study. Twelve out of 69 were COVID positive. Sixty patients presented with advanced stage (≥stage 2b) out of which 21 underwent upstaging of disease due to delay in presentation/management. We found that 9 out of 12 (majority) Covid positive patients had disease upstaging. Overall main reason for delay in presentation was found to be unawareness of disease.

Conclusion

We concluded that COVID-19 pandemic had no impact on presentation delay, breast cancer management/treatment and disease upstaging as compared to figures available for our population before the pandemic. However, our study showed significant correlation between disease upstaging and COVID status. This led us to reconsider our preformed protocols for COVID positive breast cancer patients. Our results can be used by future researchers to investigate if COVID itself can contributes in patho-physiology of upstaging in breast cancer or not.

Surgical upstaging rates in patients meeting the eligibility for active surveillance trials

PURPOSE

Four clinical active surveillance trials including LORIS, COMET, LORD and LORETTA, are being conducted to assess whether women with low-risk ductal carcinoma in situ can safely avoid surgery. The present study aimed to determine the rate of upstaging to invasive cancer among patients with a preoperative diagnosis of ductal carcinoma in situ and to evaluate the incidence of upstaging in patients meeting the eligibility criteria for four active surveillance clinical trials.

METHODS

The present study initially enrolled 180 patients with 183 calcifications who received the diagnosis of ductal carcinoma in situ by biopsy. Patients were classified as eligible for four clinical trials according to the respective inclusion criteria.

RESULTS

In total, 152 patients with 155 calcifications were analyzed. Of these, 32 (21%) were upstaged to invasive disease based on the final pathological analysis of surgical specimens. Of the 152 patients, 53 (35%), 90 (59%), 24 (16%) and 34 (22%) met the eligibility criteria for the LORIS, COMET, LORD and LORETTA trial, respectively. Among patients with low-risk ductal carcinoma in situ, 10 (19%), 14 (16%), 6 (25%) and 4 (12%) patients were upstaged to invasive disease in LORIS, COMET, LORD and LORETTA, respectively. The upstaging to pT1b or higher rates were 2% (1/53), 3% (3/90), 0% (0/24) and 3% (1/34) in LORIS, COMET, LORD and LORETTA, respectively.

CONCLUSIONS

The upstaging rate in patients eligible for the clinical active surveillance trials was 12-25%. Although the rate of upstaging to pT1b or higher was low, further studies are required to determine the rates of upstaging to invasive cancer and the risk factors among patients with low-risk ductal carcinoma in situ.

Necessity of sentinel lymph node biopsy in ductal carcinoma in situ patients: a retrospective analysis

BACKGROUND

Sentinel lymph node biopsy (SLNB) is unnecessarily performed too often, owing to the high upstaging rates of ductal carcinoma in situ (DCIS). This study aimed to evaluate the upstaging rates of DCIS to invasive cancer, determine the prevalence of axillary lymph node metastasis, and identify the clinicopathological factors associated with upstaging and lymph node metastasis. We also examined surgical patterns among DCIS patients and determined whether SLNB guidelines were followed.

METHODS

We retrospectively analysed 307 consecutive DCIS patients diagnosed by preoperative biopsy in a single centre between 2014 and 2018. Data from clinical records, including imaging studies, axillary and breast surgery types, and pathology results from preoperative and postoperative biopsies, were extracted. Univariate analyses using Chi-square tests and multiple logistic regression analyses were used to analyse the data.

RESULTS

The rate of upstaging to invasive cancer was 19.2% (59/307). DCIS diagnosed by core-needle biopsy (odds ratio [OR]: 6.861, 95% confidence interval [CI]: 2.429-19.379), the presence of ultrasonic mass-forming lesions (OR: 2.782, 95% CI: 1.224-6.320), and progesterone receptor-negative status (OR: 3.156, 95% CI: 1.197-8.323) were found to be associated with upstaging. The rate of sentinel lymph node metastasis was only 1.9% (4/202), and all were total mastectomy patients diagnosed by core-needle biopsy. SLNB was performed in 37.2% of 145 breast-conserving surgery patients and 91.4% of 162 total mastectomy patients. Among the 202 patients who underwent SLNB, 145 (71.7%) without invasive cancer on final pathology had redundant SLNB. Two of 59 patients (3.4%) with disease upstaged to invasive cancer had inadequate primary staging of the axilla, as the rate seemed sufficiently small.

CONCLUSIONS

In patients with a preoperative diagnosis of DCIS, although an unavoidable possibility of upstaging to invasive cancer exists, axillary metastasis is unlikely. Only 2.7% of patients with DCIS undergoing total mastectomy were found to have sentinel lymph node metastases. SLNB should not be performed in breast-conserving surgery patients and should be reserved only for total mastectomy patients diagnosed by core-needle biopsy.

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

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.

Application of deep learning to predict underestimation in ductal carcinoma in situ of the breast with ultrasound

Background

To develop an ultrasound-based deep learning model to predict postoperative upgrading of pure ductal carcinoma in situ (DCIS) diagnosed by core needle biopsy (CNB) before surgery.

Methods

Of the 360 patients with DCIS diagnosed by CNB and identified retrospectively, 180 had lesions upstaged to ductal carcinoma in situ with microinvasion (DCISM) or invasive ductal carcinoma (IDC) postoperatively. Ultrasound images obtained from the hospital database were divided into a training set (n=240) and validation set (n=120), with a ratio of 2:1 in chronological order. Four deep learning models, based on the ResNet and VggNet structures, were established to classify the ultrasound images into postoperative upgrade and pure DCIS. We obtained the area under the receiver operating characteristic curve (AUROC), specificity, sensitivity, accuracy, positive predictive value (PPV), and negative predictive value (NPV) to estimate the performance of the predictive models. The robustness of the models was evaluated by a 3-fold cross-validation.

Results

Clinical features were not significantly different between the training set and the test set (P value >0.05). The area under the receiver operating characteristic curve of our models ranged from 0.724 to 0.804. The sensitivity, specificity, and accuracy of the optimal model were 0.733, 0.750, and 0.742, respectively. The three-fold cross-validation results showed that the model was very robust.

Conclusions

The ultrasound-based deep learning prediction model is effective in predicting DCIS that will be upgraded postoperatively.

Trends in Axillary Surgery for Treating Ductal Carcinoma In Situ: A Korean Population-based Study

Purpose

Ductal carcinoma in situ (DCIS) is common in South Korea. We evaluated the patterns of axillary surgery among patients with DCIS to highlight the need for compliance with the updated national guidelines. We also evaluated whether sentinel lymph node biopsy (SLNB) was performed in accordance with the national guidelines.

Methods

The Korean Health Insurance Review and Assessment Service-National Inpatient Sample database was searched for patients with DCIS (2009–2015) to identify axillary surgery patterns by breast surgery type, year of diagnosis, age at diagnosis, and the location and volume of surgeries for DCIS at the hospital. The rates of SLNB and axillary dissection were compared using descriptive statistics and univariate analyses. Analyses were also conducted using the chi-squared test and multiple logistic regression analysis.

Results

We identified 16,315 Korean women who underwent surgery for DCIS, including 11,292 cases of SLNB (69.2%) and 131 cases of axillary lymph node dissection (0.8%). Breast-conserving surgery (BCS) was performed in 10,323 patients (63.3%) with an SLNB rate of 56.0%, while total mastectomy (TM) was performed in 5,992 patients (36.7%), with an SLNB rate of 92.0%. During 2009–2015, the SLNB rate during TM increased from 88.23% to 92.80%. SLNB was influenced by hospital region and surgical volume, and hospitals performing low volumes of surgeries were significantly more likely to perform SLNB regardless of the surgery type (odds ratio, 1.372; 95% confidence interval, 1.265–1.488).

Conclusion

Although the Korean guidelines recommend SLNB for all TM procedures and select BCS procedures for DCIS, relatively high rates of SLNB were performed for BCS, and there was inter-hospital variability in performing SLNB. Improved compliance with the guidelines by the surgeons is critical for Korean patients with DCIS.

Are Nomograms Useful in Predicting Upstage From Ductal Carcinoma In Situ to Invasive Carcinoma Requiring Sentinel Lymph Node Biopsy?

The upstage rate from ductal carcinoma in situ (DCIS) on core biopsy to invasive carcinoma at definitive excision ranges from 20 to 30%. Nomograms have been developed to aid in the prediction of upstaging so as to guide surgical planning with respect to performance of sentinel lymph node biopsy (SLNB). The aim of this study was to evaluate the ability of these nomograms to predict upstaging within our public hospital population. A retrospective review of patients with DCIS from 2013 to 2018 at a single institution was performed. Individualized probability of upstage was calculated using the Samsung Medical Center (SMC) and Annals of Surgical Oncology (ASO) nomograms. Areas under the receiver operating characteristic curves were calculated to assess the discriminative power of each. Of 105 patients with DCIS, 31 (29.5%) were upstaged to invasive disease. The SMC and ASO nomograms demonstrated area under the curves (AUCs) of .65 (OR = 1.023, 95% CI 1.004-1.042, P = .02) and .60 (OR = 1.035, 95% CI 1.003-1.068, P = .03), respectively. While SMC provided greater discrimination in our cohort, the performance of these nomograms as reliable clinical adjuncts to guide SLNB decision-making in this cohort was less than optimal and thus should not be the sole factor in determining individual upstage risk.

Breast Ductal Carcinoma in Situ: Precursor to Invasive Breast Cancer

This Editorial introduces this month's special Breast Ductal Carcinoma in Situ Theme Issue, a series of reviews intended to highlight the relationship of ductal carcinoma in situ as a precursor to breast cancer and emphasize the need for appropriate treatment in hopes of minimizing the progression to invasive disease.

Sentinel lymph node positivity in patients undergoing mastectomies for ductal carcinoma in situ (DCIS)

Current guidelines recommend sentinel lymph node biopsy (SLNB) for patients undergoing mastectomy for a preoperative diagnosis of ductal carcinoma in situ (DCIS). We examined the factors associated with sentinel lymph node positivity for patients undergoing mastectomy for a diagnosis of DCIS on preoperative core biopsy (PCB). The Institutional Breast Cancer Database was queried for patients with PCB demonstrating pure DCIS followed by mastectomy and SLNB from 2010 to 2018. Patients were divided according to final pathology (DCIS or invasive cancer). Clinico-pathologic variables were analyzed using Pearson's chi-squared, Wilcoxon Rank-Sum and logistic regression. Of 3145 patients, 168(5%) had pure DCIS on PCB and underwent mastectomy with SLNB. On final mastectomy pathology, 120(71%) patients had DCIS with 0 positive sentinel lymph nodes (PSLNs) and 48(29%) patients had invasive carcinoma with 5(10%) cases of ≥1 PSLNs. Factors positively associated with upstaging to invasive cancer in univariate analysis included age (P = .0289), palpability (P < .0001), extent of disease on imaging (P = .0121), mass on preoperative imaging (P = .0003), multifocality (P = .0231) and multicentricity (P = .0395). In multivariate analysis, palpability (P = .0080), extent of disease on imaging (P = .0074) and mass on preoperative imaging (P = .0245) remained significant (Table 2). In a subset of patients undergoing mastectomy for DCIS with limited disease on preoperative evaluation, SLNB may be omitted as the risk of upstaging is low. However, patients who present with clinical findings of palpability, large extent of disease on imaging and mass on preoperative imaging have a meaningful risk of upstaging to invasive cancer, and SLNB remains important for management.

An Updated Nomogram for Predicting Invasiveness in Preoperative Ductal Carcinoma In Situ of the Breast

PURPOSE

To validate and update a nomogram for predicting ductal carcinoma in situ (DCIS) upstaging in preoperative biopsy.

MATERIALS AND METHODS

Medical records of 444 preoperative DCIS patients were evaluated and used to validate a previous version of the Severance nomogram for predicting DCIS upstaging in preoperative biopsy. Patients were divided into two groups according to the final postoperative pathology. Univariate and multivariate analyses with the chi-square test, Student's t-test, and binary logistic regression method identified new significant variables. The updated nomogram was evaluated with the C-index and Hosmer-Lemeshow goodness of fit test.

RESULTS

The area under a receiver operating characteristic curve for comparison with the previous nomogram was 0.48. In postoperative pathology, the pure DCIS and invasive cancer groups comprised 345 and 99 cases, respectively. Approximately 22.3% of patients preoperatively diagnosed with DCIS were upstaged to invasive cancer. Significant variables in the univariate analysis were operation type, human epidermal growth factor receptor 2 overexpression, comedo necrosis, sonographic mass, mammographic mass, preoperative biopsy method, and suspicious microinvasion in preoperative biopsy. In multivariate analysis, operation type, sonographic mass, mammographic mass, and suspicious microinvasion were risk factors for upstaging. The updated model with these variables showed moderate discrimination and was appropriate in the calibration test.

CONCLUSION

The previous nomogram did not effectively discriminate upstaging of preoperative DCIS in an independent cohort. An updated version of the nomogram appears to provide more accurate information for predicting preoperative DCIS upstaging.

Axillary evaluation is not warranted in patients preoperatively diagnosed with ductal carcinoma in situ by core needle biopsy

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.

[Ductal carcinoma in situ in 2019: Diagnosis, treatment, prognosis]

Ductal carcinoma in situ (DCIS) currently represents up to 15% of the newly diagnosed breast cancers, and are almost always detected by microcalcifications. Global prognosis is good (3% of 15-year specific mortality) but invasive local recurrences (LR) can lead to metastasis in 12-15% of the cases. Breast conserving surgery with whole breast irradiation is the main treatment (reducing LR by 50%), but mastectomy (with or without reconstruction) is performed in about 30% of the cases due to wide lesion size and/or multicentricity. The role of tamoxifen remains unclear. Axillary dissection is needless but sentinel node biopsy is proposed in case of micro-invasion suspicion (large lesions with high grade). The main factors of LR are young age (≤40 years) incomplete excision, and high nuclear grade with comedonecrosis. Several studies on "therapeutic descalation" are still ongoing in order to identify the "low risk" DCIS (about 10% of the cases) in which radiotherapy could be safely omitted.

Collagen (XI) alpha-1 chain is an independent prognostic factor in breast ductal carcinoma in situ

Collagen11A1 (COL11A1) is a fibrillary type collagen constituting a minor component of the extracellular matrix and plays role in tissue tensile strength. Overexpression of COL11A1 expression is associated with aggressive behavior and poor outcome in several human malignancies. In this study, we evaluated the association between COL11A1 expression and clinicopathological parameters of the breast ductal carcinoma in situ (DCIS) and its prognostic value. COL11A1 protein expression was assessed immunohistochemically in a large well-characterized cohort of DCIS including pure (n = 776) and DCIS associated with invasive carcinoma (DCIS-mixed, n = 239). COL11A1 expression was assessed in tumor cells and surrounding stromal cells, and correlated with clinicopathological parameters, immunoprofile and disease outcome. In pure DCIS, high COL11A1 expression was observed in tumor cells and surrounding stromal cells in 25 and 13% of cases, respectively. Higher COL11A1 expression within the stromal cells was associated with hormone receptor negative, HER2 enriched and triple negative molecular subtypes and showed a positive linear correlation with proliferation index, dense tumor infiltrating lymphocytes and hypoxia-inducible factor 1 alpha. COL11A1 expression in tumor and stromal cells was significantly higher in DCIS associated with invasive carcinoma than in pure DCIS, and within the DCIS-mixed cohort, the invasive component showed higher COL11A1 expression than the DCIS component (all, p < 0.0001). Overexpression of stromal COL11A1 was an independent predictor of shorter local recurrence-free interval for all recurrences (HR = 13.2, 95% CI = 6.9-25.4, p < 0.0001) and for invasive recurrences (HR = 11.2, 95% CI = 4.9-25.8, p < 0.0001). When incorporated with other risk factors, stromal COL11A1 provided better patient risk stratification. DCIS with higher stromal COL11A1 expression showed poor outcome even with adjuvant radiotherapy management. In conclusion, overexpression of stromal COL11A1 is associated with invasive recurrence in DCIS and is a potential marker to predict the response to radiotherapy.

Geometric characteristics of collagen have independent prognostic significance in breast ductal carcinoma in situ: an image analysis study

Collagen plays a key role in normal and malignant tissue homeostasis. While the prognostic significance of collagen fiber remodeling in invasive breast cancer has been studied, its role in ductal carcinoma in situ (DCIS) remains poorly defined. Using image analysis, we aimed to evaluate the prognostic significance of the geometric characteristics of collagen surrounding DCIS. A large well-characterized cohort of DCIS comprising pure DCIS (n = 610) and DCIS coexisting with invasive carcinoma (n = 180) were histochemically stained for collagen using picrosirius red. ImageJ software was used to assess collagen density, degree of collagen fiber dispersion and directionality in relation to DCIS ducts' boundary. We developed a collagen prognostic index and evaluated its prognostic significance. A poor index was observed in 24% of the pure DCIS and was associated with determinants of high-risk DCIS including higher nuclear grade, comedo type necrosis, hormonal receptor negativity, HER2 positivity and high proliferation index. High collagen prognostic index was associated with the collagen remodeling protein prolyl-4-hydroxlase alpha subunit 2 and the hypoxia-related protein hypoxia inducible factor 1α. DCIS coexisting with invasive breast cancer had a higher collagen prognostic index than pure DCIS ( p < 0.0001). High index was an independent poor prognostic factor for DCIS recurrence for all recurrences (HR = 2.3, p = 0.005) and just invasive recurrences (HR = 3.4, p = 0.003). Interaction between collagen prognostic index and radiotherapy showed that the index was associated with poor outcome even with adjuvant radiotherapy ( p = 0.0001). Collagen reorganization around DCIS is associated with poor outcome and provides a potential predictor for disease progression and resistance to radiotherapy. Mechanistic studies are warranted to decipher the underlying mechanisms.

Breast cancer survival prediction using seven prognostic biomarker genes

Breast cancer (BC) is one of the most prevalent forms of cancer globally. However, the practical relevance of the RNA expression-based prediction of BC is not clearly understood and requires further study. Using gene expression data downloaded from The Cancer Genome Atlas (TCGA), a risk score staging classification was created using Cox's multiple regression and was used to predict the clinical outcomes of patients with BC. In total, 7 genes, including AC123595.1, leukocyte immunoglobulin-like receptor B5, CD209 molecule, AL049749.1, lymphatic vessel endothelial hyaluronan receptor 1, transmembrane protein 190 and tubulin α 3D chain were identified in association with patient survival. The patients with lower risk scores had considerably improved survival rates than those with higher risk scores. Compared with other clinical factors, the risk score more accurately predicted the clinical outcome of patients with BC. In summary, 7 genes were identified using the Cox regression model, and subsequently used to develop a risk staging model for BC, which may be of use for the medical management of patients.

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

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

Effect of preoperative injection of superparamagnetic iron oxide particles on rates of sentinel lymph node dissection in women undergoing surgery for ductal carcinoma in situ (SentiNot study)

Background

One-fifth of patients with a preoperative diagnosis of ductal carcinoma in situ (DCIS) have invasive breast cancer (IBC) on definitive histology. Sentinel lymph node dissection (SLND) is performed in almost half of women having surgery for DCIS in Sweden. The aim of the present study was to try to minimize unnecessary SLND by injecting superparamagnetic iron oxide (SPIO) nanoparticles at the time of primary breast surgery, enabling SLND to be performed later, if IBC is found in the primary specimen.

Methods

Women with DCIS at high risk for the presence of invasion undergoing breast conservation, and patients with DCIS undergoing mastectomy were included. The primary outcome was whether this technique could reduce SLND. Secondary outcomes were number of SLNDs avoided, detection rate and procedure-related costs.

Results

This was a preplanned interim analysis of 189 procedures. IBC was found in 47 and a secondary SLND was performed in 41 women. Thus, 78·3 per cent of patients avoided SLND (P &lt; 0·001). At reoperation, SPIO plus blue dye outperformed isotope and blue dye in detection of the sentinel node (40 of 40 versus 26 of 40 women; P &lt; 0·001). Costs were reduced by a mean of 24·5 per cent in women without IBC (€3990 versus 5286; P &lt; 0·001).

Conclusion

Marking the sentinel node with SPIO in women having surgery for DCIS was effective at avoiding unnecessary SLND in this study. Registration number: ISRCTN18430240 (http://www.isrctn.com).

Predictive factors of upstaging DCIS to invasive carcinoma in BCT vs mastectomy

BACKGROUND

Upstaging from DCIS to invasive ductal carcinoma varies widely from 0 to 59%. We aim to identify risk factors associated with upstaging in all DCIS patients and based on specific surgical intervention.

METHODS

Patients with a pre-operative diagnosis of DCIS undergoing BCT or mastectomy were reviewed. Multivariable analysis was performed to identify risk factors for upstaging.

RESULTS

In total, 623 patients had a preoperative diagnosis of DCIS. Upstaging occurred in 74 patients (12%) overall. There was no difference in upstaging rates between mastectomy and BCT (11% v 14% p = 0.27). Sentinel lymph node biopsy was positive in 4/212 patients (1%). Multivariable analysis revealed suspicion of microinvasion (OR 5.7 95%CI2.2-14.9), surgeon suspicion of invasive disease (OR 2.7, 95% CI 1.2-6.4) and larger size/multicentric/extensive tumor (OR 1.9 95% CI 1.1-3.4) increase risk of upstaging.

CONCLUSIONS

Suspicion of microinvasion, surgeon suspicion, and tumor size can be used to help guide the use of sentinel lymph node biopsy. For patients without these high risk characteristics, it is hard to justify the use of concurrent SLN biopsy for patients who undergo BCT.

Factors associated with upstaging in patients preoperatively diagnosed with ductal carcinoma in situ by core needle biopsy

Objective

Patients preoperatively diagnosed with ductal carcinoma in situ (DCIS) by core needle biopsy (CNB) exhibit a significant risk for upstaging on final pathology, which leads to major concerns of whether axillary staging is required at the primary operation. The present study aimed to identify clinicopathological factors associated with upstaging in patients preoperatively diagnosed with DCIS by CNB.

Methods

The present study enrolled 604 patients (cN0M0) with a preoperative diagnosis of pure DCIS by CNB, who underwent axillary staging between August 2006 and December 2015, at Fudan University Shanghai Cancer Center (Shanghai, China). Predictive factors of upstaging were analyzed retrospectively.

Results

Of the 604 patients, 20.03% (n = 121) and 31.95% (n = 193) were upstaged to DCIS with microinvasion (DCISM) and invasive breast cancer (IBC) on final pathology, respectively. Larger tumor size on ultrasonography (> 2 cm) was independently associated with upstaging [odds ratio (OR) 1.558,P = 0.014]. Additionally, patients in lower breast imaging reporting and data system (BI-RADS) categories were less likely to be upstaged (4B vs. 5: OR 0.435, P = 0.002; 4C vs. 5: OR 0.502, P = 0.001). Overall, axillary metastasis occurred in 6.79% (n = 41) of patients. Among patients with axillary metastasis, 1.38% (4/290), 3.31% (4/121) and 17.10% (33/193) were in the DCIS, DCISM, and IBC groups, respectively.

Conclusions

For patients initially diagnosed with DCIS by CNB, larger tumor size on ultrasonography (> 2 cm) and higher BI-RADS category were independent predictive factors of upstaging on final pathology. Thus, axillary staging in patients with smaller tumor sizes and lower BI-RADS category may be omitted, with little downstream risk for upstaging.

Sentinel lymph node biopsy in patients affected by breast ductal carcinoma in situ with and without microinvasion: Retrospective observational study

With the introduction of an organized mammographic screening, the incidence of ductal carcinoma in situ (DCIS) has experienced an important increase. Our experience with sentinel lymph node biopsy (SLNB) among patients with DCIS is reviewed.We collected retrospective data on patients operated on their breasts for DCIS (pTis), DCIS with microinvasion (DCISM) (pT1mi) and invasive ductal carcinoma (IDC) sized ≤2 cm (pT1) between January 2002 and June 2016, focusing on the result of SLNB.543 DCIS, 84 DCISM, and 2111 IDC were included. In cases of DCIS and DCISM, SLNB resulted micrometastatic respectively in 1.7% and 6.0% of cases and macrometastatic respectively in 0.9% and 3.6% of cases. 5-year disease-free survival and overall survival in DCISM and IDC were similar, while significantly longer in DCIS. 5-year local recurrence rate of DCIS and DCISM were respectively 2.5% and 7.9%, and their 5-year distant recurrence rate respectively 0% and 4%. IDC, tumor grading ≥2 and lymph node (LN) macrometastasis were significant predictors for decreased overall survival. Significant predictors for distant metastases were DCISM, IDC, macroscopic nodal metastasis, and tumor grading ≥2. Predictors for the microinvasive component in DCIS were tumor multifocality/multicentricity, grading ≥2, ITCs and micrometastases.Our study suggests that despite its rarity, sentinel node metastasis may also occur in case of DCIS, which in most cases are micrometastases. Even in the absence of an evident invasive component, microinvasion should always be suspected in these cases, and their management should be the same as for IDC.

A prediction model for underestimation of invasive breast cancer after a biopsy diagnosis of ductal carcinoma in situ: based on 2892 biopsies and 589 invasive cancers

Background

Patients with a biopsy diagnosis of ductal carcinoma in situ (DCIS) might be diagnosed with invasive breast cancer at excision, a phenomenon known as underestimation. Patients with DCIS are treated based on the risk of underestimation or progression to invasive cancer. The aim of our study was to expand the knowledge on underestimation and to develop a prediction model.

Methods

Population-based data were retrieved from the Dutch Pathology Registry and the Netherlands Cancer Registry for DCIS between January 2011 and June 2012.

Results

Of 2892 DCIS biopsies, 21% were underestimated invasive breast cancers. In multivariable analysis, risk factors were high-grade DCIS (odds ratio (OR) 1.43, 95% confidence interval (CI): 1.05–1.95), a palpable tumour (OR 2.22, 95% CI: 1.76–2.81), a BI-RADS (Breast Imaging Reporting and Data System) score 5 (OR 2.36, 95% CI: 1.80–3.09) and a suspected invasive component at biopsy (OR 3.84, 95% CI: 2.69–5.46). The predicted risk for underestimation ranged from 9.5 to 80.2%, with a median of 14.7%. Of the 596 invasive cancers, 39% had unfavourable features.

Conclusions

The risk for an underestimated diagnosis of invasive breast cancer after a biopsy diagnosis of DCIS is considerable. With our prediction model, the individual risk of underestimation can be calculated based on routinely available preoperatively known risk factors (https://www.evidencio.com/models/show/1074).

Ability of Intraoperative Pathologic Analysis of Ductal Carcinoma In Situ to Guide Selective Use of Sentinel Lymph Node Surgery

For patients with ductal carcinoma in situ (DCIS), sentinel lymph node (SLN) surgery is generally reserved for patients at high risk of being upstaged to invasive disease. The use of frozen section (FS) pathologic analysis of the primary tumor may allow for selective surgical nodal staging within one procedure. We sought to define the reliability of FS for detection of upstaging. Eight hundred and twenty-seven patients were identified with DCIS on core needle biopsy that underwent 834 operations at our institution between January 2004 and October 2014. We calculated the rate of upstage from DCIS to invasive cancer on both intraoperative FS and final pathology to determine the performance of FS. Upstage rate on final pathology was 118/834 (14.1%) 95 per cent confidence interval 11.8 to 16.7 per cent. FS identified 88/118 (74.6%) of the upstages. Specificity was 99.3 per cent (711/716). Overall accuracy was 95.8 per cent (799/834) and the positive predictive value was 96.0 per cent (711/741 patients). Mean size of invasive cancers identifiedon FS was 5.6 mm, versus 3.5 mm for those identified only on permanent section, P = 0.11. Intraoperative FS analysis of DCIS is useful for identification of upstage to invasive disease. This may facilitate a selective approach to SLN surgery that both decreases unnecessary SLN surgery and the need for a second operation.

Fine-needle versus core-needle biopsy - which one to choose in preoperative assessment of focal lesions in the breasts? Literature review

Aim

The aim of the study was to review two techniques that can be used to verify focal lesions in the breasts: fine-needle aspiration biopsy and core-needle biopsy.

Material and methods

Fifty-five articles (original papers and reviews), half of them published within the past 5 years, were included in the analysis. The authors also took their own experience into account.

Results

Pre-operative assessment of focal lesions in the breasts is crucial in the planning of further therapeutic management. The role of fine-needle aspiration biopsy has been reduced lately due to its low sensitivity and specificity as well as a high rate of non-diagnostic, suspicious and false negative results. This method does not enable one to differentiate between in situ and invasive disease. Currently, fine-needle biopsy is recommended for cystic lesions, suspected of being recurrences in the chest wall, and lymph node metastases. Core-needle biopsy is the basic diagnostic method of breast lesions. According to the recommendations of the Polish Ultrasound Society and American College of Radiology, BIRADS 4 and 5 lesions should be evaluated histopathologically. Core-needle biopsy makes it possible to establish a final diagnosis more frequently than fine-needle biopsy, both in the case of benign and malignant lesions. It delivers more information about the nature of a tumor (mutation of HER-2, estrogen and progesterone receptors and Ki-67 index). Its limitations include: underestimation of invasion and failure to recognize the components of ductal carcinoma in situ in papillary and atypical lesions. Single fine-needle aspiration biopsy is inexpensive, but when considering the cost of further diagnosis due to non-diagnostic, suspicious and atypical results, this method generates high additional costs.

Conclusions

Microscopic verification of focal breast lesions is crucial for further therapeutic decisions. It has been proven that histopathological verification is more accurate and has more advantages than cytological assessment.

Tumor thickness and histological features as predictors of invasive foci within preoperatively diagnosed ductal carcinoma in situ

Small invasion into ductal carcinoma in situ (DCIS) can easily be overlooked in resected breast specimens. To disclose useful markers predictive of invasive foci within preoperatively diagnosed DCIS lesions, a retrospective histopathological comparison was made between postoperatively diagnosed invasive ductal carcinoma with a predominant intraductal component (IDCPIC) (n=43) and pure DCIS (n=82). Through a multivariate logistic regression analysis model, 5 variables (DCIS grade, "tumor thickness," extent of retraction cleft, presence of lymph node metastasis, and HER2 score) were found to be significantly associated with the presence of invasive foci within DCIS; with a cutoff point of 0.315, sensitivity, specificity, positive predictive value, and negative predictive value were 0.93, 0.77, 0.68, and 0.95, respectively. No statistically significant difference was observed in recurrence-free survival between IDCPIC and pure DCIS, whereas the IDCPIC curve showed a slightly earlier decline than the DCIS one. In general, preoperative detection of lymph node metastasis in DCIS patients is elusive because of the extremely tiny metastatic size in most cases; thus, a 4-variable model, without lymph node metastasis, would be the actual working model. Furthermore, tumor "thickness" was found to be the most significant parameter predictive of invasive foci within DCIS. Although IDCPIC and pure DCIS showed similar recurrence-free survival curves, prediction of invasive foci within DCIS necessitates postoperative pathological analysis of surgically resected lesions.

Stiffness at shear-wave elastography and patient presentation predicts upgrade at surgery following an ultrasound-guided core biopsy diagnosis of ductal carcinoma in situ

AIM

The aim of this study is to establish predictors of invasion in lesions yielding an ultrasound-guided biopsy diagnosis of ductal carcinoma in situ (DCIS).

MATERIALS AND METHODS

Patients subjected to ultrasound-guided core biopsy yielding DCIS were studied. At shear-wave elastography (SWE) a threshold of 50 kPa was used for mean elasticity (Emean) to dichotomise the elasticity data between invasive and non-invasive masses. Data recorded included the mammographic and ultrasound features, the referral source, and grade of DCIS in the biopsy. The chi-square test was used to detect statistical significance.

RESULTS

Of 57 lesions, 24 (42%) had invasion at excision. Symptomatic patients and patients with stiff lesions were more likely to have invasion than patients presenting through screening and with soft lesions (58% [14 of 24] versus 30% [10 of 33], p=0.03) and (51% [20 of 39] versus 22% [4 of 18], p=0.04). No other factors showed a relationship with invasion. Combining the two predictors of invasion improved risk stratification with symptomatic and stiff lesions having a risk of invasion of 67% (12 of 18) and soft lesions presenting at screening having only a 17% (2 of 12) risk of invasion (p=0.02).

CONCLUSION

Stiffness on SWE and the referral source of the patient are predictors of occult invasion in women with an ultrasound-guided core biopsy diagnosis of DCIS.

Utilization of Axillary Surgery for Patients With Ductal Carcinoma In Situ: A Report From the National Cancer Data Base

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.

Ductal carcinoma in situ diagnosed by breast needle biopsy: Predictors of invasion in the excision specimen

BACKGROUND

A substantial proportion of women with a pre-operative diagnosis of pure ductal carcinoma in situ (DCIS) has a final diagnosis of invasive breast cancer (IBC) after surgical excision and, consequently, a potential indication for lymph node staging. The aim of our study was to identify novel predictors of invasion in patients with a needle-biopsy diagnosis of DCIS that would help us to select patients that may benefit from a sentinel node biopsy (SNB).

PATIENTS AND METHODS

We included 153 patients with a needle-biopsy diagnosis of DCIS between 2000 and 2014, which was followed by surgical excision. Several pre-operative clinical, radiological and pathological features were assessed and correlated with the presence of invasion in the excision specimen. Features that were significantly associated with upstaging in the univariable analysis were combined to calculate upstaging risks.

RESULTS

Overall, 22% (34/155) of the patients were upstaged to IBC. The following risk factors were significantly associated with upstaging: palpability, age ≤40 years, mammographic mass lesion, moderate to severe periductal inflammation and periductal loss of decorin expression. The upstaging-risk correlated with the number of risk factors present: e.g. 9% for patients without risk factors, 29% for patients with 1 risk factor, 37% for patients with 2 risk factors and 54% for patients with ≥3 risk factors.

CONCLUSION

The identified risk factors may be helpful to predict the upstaging-risk for patients with a needle-biopsy diagnosis of pure DCIS, which facilitates the performance of a selective SNB for high-risk patients and avoid this procedure in low-risk patients.

Cancer statistics: Breast cancer in situ

An estimated 60,290 new cases of breast carcinoma in situ are expected to be diagnosed in 2015, and approximately 1 in 33 women is likely to receive an in situ breast cancer diagnosis in her lifetime. Although in situ breast cancers are relatively common, their clinical significance and optimal treatment are topics of uncertainty and concern for both patients and clinicians. In this article, the American Cancer Society provides information about occurrence and treatment patterns for the 2 major subtypes of in situ breast cancer in the United States-ductal carcinoma in situ and lobular carcinoma in situ-using data from the North American Association of Central Cancer Registries and the 13 oldest Surveillance, Epidemiology, and End Results registries. The authors also present an overview of in situ breast cancer detection, treatment, risk factors, and prevention and discuss research needs and initiatives.

Preoperatively diagnosed ductal carcinoma in situ: risk prediction of invasion and effects on axillary management

BACKGROUND

Preoperatively diagnosed ductal carcinoma in situ (DCIS) has the potential to have occult invasion. The predictors of invasive carcinoma underestimation in patients with DCIS diagnosed by preoperative percutaneous biopsy were identified and the effects of underestimation on axillary management were evaluated.

METHODS

Medical records of 280 patients preoperatively diagnosed as DCIS who underwent surgery were retrospectively analyzed. The patients were divided into non-invasive and invasive carcinoma groups according to the final pathological diagnosis. Risk predictors of invasive carcinoma underestimation and axillary lymph node (ALN) metastasis were analyzed. The axillary status estimated by pathological diagnosis and one-step nucleic acid amplification (OSNA) assay was evaluated.

RESULTS

The presence of an invasive carcinoma was overlooked in 104 (37.1 %) patients. A clinically palpable mass was an independent risk predictor of invasive carcinoma underestimation by multivariate analysis. There was no risk predictor of ALN metastasis. No ALN metastasis was seen in non-invasive carcinoma group. Six (6.2 %) patients in invasive carcinoma group had macro- or micrometastasis in sentinel lymph nodes (SLNs). Non-SLN metastasis was observed in 3 patients of them. Fourteen patients with only isolated tumor cells (ITCs) or only OSNA-positive SLNs had no metastasis in non-SLNs.

CONCLUSIONS

SLN biopsy and, if necessary, subsequent ALN dissection (ALND) should be performed in patients with DCIS who have a risk predictor of underestimation. ALND can be avoided in patients who have histologically negative or ITC-positive SLNs, regardless of the presence of invasion on final pathological diagnosis.

Preoperatively diagnosed ductal cancers in situ of the breast presenting as even small masses are of high risk for the invasive cancer foci in postoperative specimen

Background

In ductal carcinoma in situ of the breast (DCIS), histologic diagnosis obtained before the definitive treatment is related to the risk of underestimation if the presence of invasive cancer is found postoperatively. These patients need a second operation to assess the nodal status. We evaluated the upstaging rate in patients with mass-forming DCIS.

Methods

Sixty-three women with pure DCIS presenting as sonographic mass lesion underwent vacuum-assisted or core-needle biopsy and subsequent surgery. Rates of postoperative upstaging to invasive cancer were calculated and compared with clinical character and size of DCIS.

Results

Median age of patients (range) was 63 years (27–88) while median diameter of DCIS was 11 mm (6–60). Fifty-six percent of DCIS were upstaged. Patient age did not differ significantly between groups with and without final invasion (median, mean, SD): 63, 61.4, 12.5 vs 62, 61.2, 10.6 years, respectively (P = 0.659). The difference of DCIS size between these groups was statistically important (median, mean, SD): 13, 17.3, 11.4 vs 9.5, 9.8, 3.2 mm, respectively (P = 0.0003). Mass size and palpability were significant risk factors (P < 0.001 and P < 0.01, respectively). Rate of underestimation for mass with diameter ≤10 mm, 10–20 mm and >20 mm was 37, 64 and 91 %, respectively.

Conclusions

DCIS diagnosed on minimal-invasive biopsy of even small sonographic mass is of high risk for the upstaging to invasive cancer after final surgical excision. In these patients, subsequent intervention is needed for nodal status assessment. They are good candidates for the sentinel node biopsy during the breast operation to avoid multi-step surgery.

Sentinel lymph node biopsy in patients with breast ductal carcinoma in situ: Chinese experiences

The axillary treatment of patients with ductal carcinoma in situ (DCIS) remains controversial. The aim of the present study was to evaluate the roles of sentinel lymph node biopsy (SLNB) in patients with breast DCIS. A database containing the data from 262 patients diagnosed with breast DCIS and 100 patients diagnosed with DCIS with microinvasion (DCISM) who received SLNB between January 2002 and July 2014 was retrospectively analyzed. Of the 262 patients with DCIS, 9 presented with SLN metastases (3 macrometastases and 6 micrometastases). Patients with large tumors diagnosed by ultrasound or with tumors of high histological grade had a higher positive rate of SLNs than those without (P=0.037 and P<0.0001, respectively). Of the 100 patients with DCISM, 11 presented with metastases. Younger patients had a higher positive rate of SLNs (P=0.028). According to the results of this study and the systematic review of recent studies, the indications of SLNB for patients with DCIS are as follows: SLNB should be performed in all DCISM patients and in those DCIS patients who received mastectomy, and could be avoided in those who received breast-conserving surgery. However, SLNB should be recommended to patients who have high risks of harboring invasive components. The risk factors include a large, palpable tumor, a mammographic mass or a high histological grade.