Ductal carcinoma in situ of the breast: progress and controversy

Mechanostimulation of breast myoepithelial cells induces functional changes associated with DCIS progression to invasion

Women with ductal carcinoma in situ (DCIS) have an increased risk of progression to invasive breast cancer. Although not all women with DCIS will progress to invasion, all are treated as such, emphasising the need to identify prognostic biomarkers. We have previously shown that altered myoepithelial cells in DCIS predict disease progression and recurrence. By analysing DCIS duct size in sections of human breast tumour samples, we identified an associated upregulation of integrin β6 and an increase in periductal fibronectin deposition with increased DCIS duct size that associated with the progression of DCIS to invasion. Our modelling of the mechanical stretching myoepithelial cells undergo during DCIS progression confirmed the upregulation of integrin β6 and fibronectin expression in isolated primary and cell line models of normal myoepithelial cells. Our studies reveal that this mechanostimulated DCIS myoepithelial cell phenotype enhances invasion in a TGFβ-mediated upregulation of MMP13. Immunohistochemical analysis identified that MMP13 was specifically upregulated in DCIS, and it was associated with progression to invasion. These findings implicate tissue mechanics in altering the myoepithelial cell phenotype in DCIS, and that these alterations may be used to stratify DCIS patients into low and high risk for invasive progression.

An insight into the invasion of breast ductal carcinoma in situ based on clinical, pathological and hematological data

Background

Ductal carcinoma in situ (DCIS) has become a non-negligible part of breast cancers owing to the greatly increased incidence. While its natural history was not fully elucidated, which is the reason for current controversies in clinical treatment. Exploration of this issue from a clinical perspective is meaningful.

Methods

Medical records of 389 patients diagnosed with DCIS or DCIS with invasive ductal carcinoma (IDC) were reviewed. All of them received appropriate medical care in our center. All 324 patients in training cohort were divided into invasion and non-invasion groups based on pathology. Differences in DCIS immunohistochemical markers and hematological indicators between them were analyzed. In the invasion group, differences between DCIS and matched IDC were compared to explore changes in the tumor heterogeneity during invasion. Conclusions are validated in the validation cohort of 65 patients.

Results

Patients in invasion and non-invasion groups were balanced in baseline characteristics and no statistically significant differences were noticed for DCIS immunohistochemical markers. For hematological indicators, high expression of platelet >291.50) (odds ratio, 2.46; CI [1.35-4.46]; p = 0.003) and SII (>347.20) (odds ratio, 2.54; CI [1.56-4.12]; p < 0.001) were established as independent predictors for invasion by logistic analysis and were validated in the validation cohort. Ki-67 of IDC was significantly higher than that of matched DCIS (p < 0.001). HER2 expression and histological grade of DCIS were separately linearly related to those of IDC.

Conclusion

The change in hematological indicators is an independent predictor for invasion and can be incorporated into the treatment decision-making process for DCIS. Invasion tumor cells exhibit a stronger proliferative capacity compared with the in-situ ones. There are linear relationships in HER2 expression and histological grades between DCIS and matched IDC. DCIS subclones with different histological grades will develop into invasive carcinomas separately.

Accounting for Preinvasive Conditions in Analysis of Invasive Cancer Risk: Application to Breast Cancer

BACKGROUND

Preinvasive cancer conditions are often actively treated to minimize progression to life-threatening invasive cancers, but this creates challenges for analysis of invasive cancer risk. Conventional methods of treating preinvasive conditions as censoring events or targeting at the composite outcome could both lead to bias.

METHODS

We propose two solutions: one that provides exact estimates of risk based on distributional assumptions about progression, and one that provides risk bounds corresponding to extreme cases of no or complete progression. We compare these approaches through simulations and an analysis of the Sister Study data in the context of ductal carcinoma in situ (DCIS) and invasive breast cancer.

RESULTS

Simulations suggested important biases with conventional approaches, whereas the proposed estimate is consistent when progression parameters are correctly specified, and the risk bounds are robust in all scenarios. With Sister Study, the estimated lifetime risks for invasive breast cancer are 0.220 and 0.269 with DCIS censored or combined. Without detailed progression information, a sensitivity analysis suggested lifetime risk falls between the bounds of 0.214 and 0.269 across assumptions of 10%-95% of DCIS patients progressing to invasive cancer in an average of 1-10 years.

CONCLUSIONS

When estimating invasive cancer risk while preinvasive conditions are actively treated, it is important to consider the implied assumptions and potential biases of conventional approaches. Although still not perfect, we proposed two practical solutions that provide improved understanding of the underlying mechanism of invasive cancer.

Is There Any Association Between Mammographic Features of Microcalcifications and Breast Cancer Subtypes in Ductal Carcinoma In Situ?

RATIONALE AND OBJECTIVES

To analyze the association between mammographic features of microcalcifications and histopathological prognostic factors based on estrogen receptor (ER) and human epidermal growth factor receptor 2 (HER2/neu) in ductal carcinoma in situ (DCIS).

MATERIALS AND METHODS

We retrospectively determined 66 patients with microcalcification-associated pure DCIS. Distribution and morphological features of the microcalcifications were described using Breast Imaging Reporting and Data System lexicon. All patients were divided into three subgroups: ER-positive, HER-2 positive, and triple-negative according to the immunohistochemical findings.

RESULTS

The morphological features of microcalcifications and receptor subtypes were significantly correlated (p = 0.026). Fine pleomorphic and fine linear branching microcalcifications were observed in 85.2% of HER-2 positive cases, whereas this ratio was 71.4 % in ER-positive and 25% in the triple-negative group. Fine linear branching microcalcifications with linear or segmental distribution were more frequently found with comedo necrosis (p < 0.05). Larger tumour sizes were also associated with microcalcification distribution (p < 0.001). Segmental microcalcifications more likely associated with larger tumour sizes.

CONCLUSION

Mammographic features in DCIS correlated with immunohistochemical and histopathological prognostic factors.

Role of Breast MRI in the Evaluation and Detection of DCIS: Opportunities and Challenges

Historically, breast magnetic resonance imaging (MRI) was not considered an effective modality in the evaluation of ductal carcinoma in situ (DCIS). Over the past decade this has changed, with studies demonstrating that MRI is the most sensitive imaging tool for detection of all grades of DCIS. It has been suggested that not only is breast MRI the most sensitive imaging tool for detection but it may also detect the most clinically relevant DCIS lesions. The role and outcomes of MRI in the preoperative setting for patients with DCIS remains controversial; however, several studies have shown benefit in the preoperative evaluation of extent of disease as well as predicting an underlying invasive component. The most common presentation of DCIS on MRI is nonmass enhancement (NME) in a linear or segmental distribution pattern. Maximizing breast MRI spatial resolution is therefore beneficial, given the frequent presentation of DCIS as NME on MRI. Emerging MRI techniques, such as diffusion-weighted imaging (DWI), have shown promising potential to discriminate DCIS from benign and invasive lesions. Future opportunities including advanced imaging visual techniques, radiomics/radiogenomics, and machine learning / artificial intelligence may also be applicable to the detection and treatment of DCIS. Level of Evidence: 3 Technical Efficacy Stage: 3 J. Magn. Reson. Imaging 2019. J. Magn. Reson. Imaging 2020;52:697-709.

Ductal Carcinoma In Situ

Ductal carcinoma in situ has been stable in incidence for a decade and has an excellent prognosis. Breast conservation therapy is safe and effective for most patients. Adjuvant whole breast radiation therapy is recommended to reduce the risk of local recurrence. Accelerated partial breast irradiation is a promising alternative to decrease toxicity and improve cosmetic results. Adjuvant hormonal therapy can reduce local recurrence, but should be used cautiously. Future directions in management include developing predictive tools for guidance for use of adjuvant therapy and selecting low-risk patients with ductal carcinoma in situ in whom surgery may be safely omitted.

Controversies in the Treatment of Ductal Carcinoma in Situ

Ductal carcinoma in situ (DCIS) accounts for 20% of all newly diagnosed breast cancers. Mastectomy was once the gold standard for the treatment of DCIS; however, breast-conserving surgery (BCS) has been adopted as the treatment of choice for patients with small, screen-detected lesions. Both adjuvant radiation and hormonal therapy following BCS have been demonstrated in randomized trials to reduce the risk of both invasive and DCIS recurrence, but neither affects survival. With the variety of surgical and adjuvant treatment options available, there has been great interest in tailoring the treatment to the individual, with the goal of optimizing the balance of risks and benefits according to the values and priorities of the woman herself. Prospective studies of women with "low-risk" DCIS treated with BCS alone have successfully identified women at lower than average risk but have not achieved the goal of identifying a subset of women with DCIS at minimal risk of recurrence after surgical excision alone. No studies have evaluated the safety of medical management alone.

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

RATIONALE AND OBJECTIVES

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

Role of community risk factors and resources on breast carcinoma stage at diagnosis

BACKGROUND

The current study investigated the individual and community determinants of breast carcinoma stage at diagnosis (BCSAD) using multiple data sources merged with cancer registry data. The literature review yielded 5 studies that analyzed cancer registry data merged with community-level variables (1995-2004).

METHODS

Community variables constructed for the current study reflected social and economic risk factors, physician supply, and health maintenance organization penetration. Multivariate logistic regression was used to identify the significant predictors of increasingly progressive BCSAD.

RESULTS

Disparities remained for black and Hispanic females in California, who were least likely to be diagnosed early compared with their white counterparts. Younger (< 40 years) and middle-aged (40-64 years) females were less likely to be diagnosed with early BCSAD, compared with older females (> or = 65 years). Utilizing services at hospitals serving a lower volume of patients with breast carcinoma was associated with later BCSAD. After controlling for individual-level factors, community-level variables constructed at the census block group and county level were tested. If a woman resided in a neighborhood with greater percentages of female-headed households, persons living below the poverty level, less educated people, and more recent immigrants, then her chances of being diagnosed at an earlier stage were diminished. If, conversely, she resided in a neighborhood with greater percentages of females > or = 65 years (a proxy for Medicare coverage), her access to medical care and the probability of earlier BCSAD increased. County-level insurance rates and residing in counties where greater percentages of women ever had a mammogram were associated with in situ and early-stage diagnosis. Similarly, the supply of primary care physicians and radiologists was associated positively with earlier BCSAD.

CONCLUSIONS

Results confirmed community-level predictors of socioeconomic and delivery system context matter, although the individual-level predictors showed a stronger effect. Nevertheless, analysis of community variables is promising for guiding and evaluating the effects of health policy and developing community and delivery system interventions for earlier detection and treatment of breast carcinoma.

Autoantibodies to Annexin XI-A and Other Autoantigens in the Diagnosis of Breast Cancer

We report on the identification of autoantigens commonly recognized by sera from patients with breast cancer. We selected ten sera from patients with invasive ductal carcinoma (IDC) of the breast with high titer IgG autoantibodies for biopanning of a T7 phage breast cancer cDNA display library. A high throughput method involved the assembly of 938 T7 phages encoding potential breast cancer autoantigens. Microarrays of positive phages were probed with sera from 90 patients with breast cancer [15 patients with ductal carcinoma in situ (DCIS) and 75 patients with IDC of the breast], with 51 non-cancer control sera and with sera from 21 patients with systemic autoimmune diseases. A 12-phage breast cancer predictor group was constructed with phage inserts recognized by sera from patients with breast cancer and not by non-cancer or autoimmune control sera (P < 0.0001). Several autoantigens including annexin XI-A, the p80 subunit of the Ku antigen, ribosomal protein S6, and other unknown autoantigens could significantly discriminate between breast cancer and non-cancer control sera. Biopanning with three different sera led to the cloning of partial cDNA sequences identical to annexin XI-A. IgG autoantibodies reacting with the amino acid 41-74 sequence of annexin XI-A were found in 19% of all women with breast cancer but in 60% of sera from women with DCIS of the breast. In addition, partial sequences identical to annexin XI-A, nucleolar protein interacting with the forkhead-associated (FHA) domain of pKi-67, the KIAA1671 gene product, ribosomal protein S6, cyclin K, elongation factor-2, Grb2-associated protein 2, and other unknown proteins could distinguish DCIS from IDC of the breast and appear to be potential biomarkers for the diagnosis of breast cancer.

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

PURPOSE

To assess the long-term outcome for women with ductal carcinoma in situ of the breast treated in current clinical practice by conservative surgery with or without definitive breast irradiation.

METHODS AND MATERIALS

We analyzed 705 cases of ductal carcinoma in situ treated between 1985 and 1995 in nine French regional cancer centers; 515 underwent conservative surgery and radiotherapy (CS+RT) and 190 CS alone. The median follow-up was 7 years.

RESULTS

The 7-year crude local recurrence (LR) rate was 12.6% (95% confidence interval [CI] 9.4-15.8) and 32.4% (95% CI 25-39.7) for the CS+RT and CS groups, respectively (p <0.0001). The respective 10-year results were 18.2% (95% CI 13.3-23) and 43.8% (95% CI 30-57.7). A total of 125 LRs occurred, 66 and 59 in the CS+RT and CS groups, respectively. Invasive or microinvasive LRs occurred in 60.6% and 52% of the cases in the same respective groups. The median time to LR development was 55 and 41 months. Nine (1.7%) and 6 (3.1%) nodal recurrences occurred in the CS+RT and CS groups, respectively. Distant metastases occurred in 1.4% and 3% of the respective groups. Patient age and excision quality (final margin status) were both significantly associated with LR risk in the CS+RT group: the LR rate was 29%, 13%, and 8% among women aged < or =40, 41-60, and > or =61 years (p <0.001). Even in the case of complete excision, we observed a 24% rate of LR (6 of 25) in women <40 years. Patients with negative, positive, or uncertain margins had a 7-year crude LR rate of 9.7%, 25.2%, and 12.2%, respectively (p = 0.008). RT reduced the LR rate in all subgroups, especially in those with comedocarcinoma (17% vs. 59% in the CS+RT and CS groups, respectively, p <0.0001) and mixed cribriform/papillary tumors (9% vs. 31%, p <0.0001). In the multivariate Cox regression model, young age and positive margins remained significant in the CS+RT group (p = 0.00012 and p = 0.016). Finally, the relative LR risk in the CS+RT group compared with the CS group was 0.35 (95% CI 0.25-0.51, p = 0.0001). Subsequent contralateral breast cancer occurred in 7.1% and 7.5% of the patients in the CS+RT and CS groups, respectively.

CONCLUSION

Despite the absence of randomization, our results are extremely consistent with the updated National Surgical Adjuvant Breast Project B17 and European Organization for Research and Treatment of Cancer 10853 trials. We also noted that the LR risk was very high in women <40 years and/or in the case of incomplete excision.

Urokinase Plasminogen Activator Receptor (uPAR): A Potential Indicator of Invasion for In Situ Breast Cancer

Urokinase plasminogen activator (uPA) and its cellular receptor (uPAR) are important mediators in the cellular process of cancer invasion and metastasis. Ductal carcinoma in situ (DCIS) is classified by lack of invasion into the adjacent stroma, yet definitive histologic features have not been identified to indicate the propensity for cellular invasion. Therapy for DCIS remains controversial because of the probability for recurrence. We hypothesized that uPA and uPAR may represent new predictors for recurrence of DCIS. Tissue specimens were obtained from 10 normal, 10 hyperplasia, and 70 patients with DCIS. Representative sections of the regions were mounted and stained by immunohistologic techniques using mouse anti-human uPA and uPAR antibodies. Stain intensities were assessed by densitometry image analysis. Gray scale values for in situ patients were compared to normal averages to determine whether staining intensities were normal or significantly higher (p < 0.05) than normal. DCIS tissues were heterogeneous for stain intensities of uPA and uPAR. Patients with high stain intensities for uPAR (28/70 = 40%) correlated with a higher recurrence rate (15/28 = 54%) than with patients having high stains for uPA (19/70 = 28% with 17/50 = 34% recurrence). In addition, patients with combined high stains for uPA and uPAR (11/19 = 60%) showed a recurrence rate of 55% compared to high uPA/normal uPAR with 0% recurrence. Immunohistologic evaluation of DCIS for uPAR, alone and in combination with uPA, significantly correlates with recurrence of invasive breast carcinoma. Evaluation of uPAR among DCIS lesions may provide a new prognostic indicator for recurrence of breast carcinoma.

Volume of resection in patients treated with breast conservation for ductal carcinoma in situ

BACKGROUND

The optimal treatment of ductal carcinoma in situ (DCIS) is one of the most controversial issues in the management of breast cancer. Identification of factors that affect the risk of local recurrence is very important as the incidence of DCIS increases and the use of breast conservation becomes more widespread. Because the extent of resection may affect the relapse rate, we hypothesized that larger volumes of resection (VR) may account for the lower local recurrence rates we have previously found in elderly patients.

METHODS

Between 1978 and 1990, 173 cases of histologically confirmed DCIS were treated at MSKCC with breast conservation therapy. Of these, complete VR data were available for 126 cases. The VRs thus obtained were divided into two groups, <60 cm3 and > or =60 cm3, and were evaluated for correlating factors. The patients were divided into three groups by age at diagnosis: younger than 40 years, 40 to 69 years, and 70 years or older.

RESULTS

The eldest group had a significantly greater proportion of large VRs (30%) as compared to the middle group (11%) and the youngest group (9%) (P=.03, chi2). Although not statistically significant, the large VR group had a lower 6-year actuarial local recurrence rate (5.6%) than did the small VR group (21.3%) (P=.16, log-rank test). This trend was observed even though adjuvant radiotherapy was used less often in patients who had large VRs.

CONCLUSION

Breast conservation surgery for DCIS in elderly patients is more likely to employ a large VR. This may explain, at least in part, the observation that elderly patients have a lower local recurrence rate.