Results of conservative surgery and radiation for mammographically detected ductal carcinoma in situ (DCIS)

A Prospective Study of Weight Gain in Women Diagnosed with Early-Stage Invasive Breast Cancer, Ductal Carcinoma In Situ, and Women Without Breast Cancer

Background: Weight gain after breast cancer has been associated with recurrence and mortality. We therefore examined factors associated with ≥5% weight gain over 2-year follow-up of a cohort of newly diagnosed early-stage invasive breast cancer (EIBC) and ductal carcinoma in situ (DCIS) patients and age-matched controls without a breast cancer history. Materials and Methods: We interviewed participants 4-6 weeks after definitive surgical treatment (patients) or a negative/benign screening mammogram (controls). Multivariable logistic regression models were used to identify socioeconomic, psychosocial, and treatment factors associated with ≥5% weight gain over 2-year follow-up. Results: Overall, 88 (24%) of 362 EIBC patients, 31 (17%) of 178 DCIS patients, and 82 (15%) of 541 controls had ≥5% weight gain during follow-up. EIBC patients were more likely to experience ≥5% weight gain than DCIS patients (Odds ratio [OR] = 2.16; 95% confidence interval [95% CI] = 1.19-3.95) and controls (OR = 1.76; 95% CI = 1.23-2.51). Among EIBC patients, older patients (OR = 0.96; 95% CI = 0.93-0.99), patients who underwent endocrine therapy (OR = 0.43; 95% CI = 0.19-0.95), smokers (OR = 0.35; 95% CI = 0.14-0.86), and African Americans (OR = 0.23; 95% CI = 0.09-0.58) were less likely to have ≥5% weight gain than their respective counterparts. Among DCIS patients, older patients (OR = 0.94; 95% CI = 0.89-0.99) were less likely to have ≥5% weight gain. Among controls, smokers were more likely to have ≥5% weight gain (OR = 3.03; 95% CI = 1.49-6.17). Conclusions: EIBC patients were more likely than DCIS patients and controls to experience ≥5% weight gain over follow-up. Studies are necessary to elucidate mechanisms of weight gain in early-stage breast cancer survivors.

Subclinical Ductal Carcinoma in Situ of the Breast: Treatment with Conservative Surgery and Radiotherapy

Aims and Background

In spite of the fact that ductal carcinoma in situ (DCIS) of the breast is a frequently encountered clinical problem, there is no consensus about the optimal treatment of clinically occult (i.e., mammographic presentation only) DCIS. Interest in breast conservation therapy has recently increased. Few data are available in Italy on the conservative treatment with surgery and adjuvant postoperative radiotherapy.

Methods

A retrospective multi-institutional study was performed in 15 Radiation Oncology Departments in northern Italy involving 112 women with subclinical DCIS of the breast treated between 1982 and 1993. Age of the patients ranged between 32 and 72 years (median, 50 years). All of them underwent conservative surgery: quadrantectomy in 89, tumorectomy in 11, and wide excision in 12 cases. The most common histologic subtype was comedocarcinoma (37%). The median pathologic size was 10 mm (range 1 to 55 mm). Axillary dissection was performed in 83 cases: all the patients were node negative. All the patients received adjunctive radiation therapy with 60Co units (77%) or 6 MV linear accelerators (23%) for a median total dose to the entire breast of 50 Gy (mean, 49.48 Gy; range, 45-60 Gy). Seventy-six cases (68%) received a boost to the tumor bed at a dose of 8-20 Gy (median 10 Gy) for a minimum tumor dose of 58 Gy.

Results

At a median follow-up of 66 months, 8 local recurrences were observed, 4 intraductal and 4 invasive. All recurrent patients had a salvage mastectomy and are alive and free of disease at this writing. The 10-year actuarial overall, cause-specific, and recurrence-free survival was of 98.8%, 100%, and 91%, respectively.

Conclusions

The retrospective multicentric study, with a local control rate of more than 90% at 10 years with 100% cause-specific survival, showed that conservative surgery and adjuvant radiation therapy is a safe and efficacious treatment for patients with occult, non-palpable DCIS.

Characterization of the CD49f+/CD44+/CD24- single-cell derived stem cell population in basal-like DCIS cells

The molecular mechanisms responsible for the Ductal Carcinoma in Situ (DCIS)-Invasive Ductal Carcinoma (IDC) transition have yet to be elucidated. Due to the lack of molecularly targeted therapies, basal-like DCIS has a high risk of recurrence and progression to invasive and metastatic cancers. In this study, by applying a novel single-cell clonogenic approach with the CD49f+/CD44+/CD24- surface markers, we characterized the aggressive clones that have enhanced self-renewal, migratory and invasive capacities derived from a human DCIS model cell line MCF10DCIS. The aggressive clones had elevated ALDH1 activity, lower global DNA methylation and increased expression of stem cell related genes, especially concurrent activation of SOX2/OCT4. In addition, we showed that the aggressive clones have increased expression of lincRNA-RoR and miR-10b compared to non-aggressive clones, which enhance their self-renewal and invasive abilities. Finally, we confirmed our in vitro results in vivo, demonstrating that aggressive clones were capable of forming tumors in nude mice, whereas non-aggressive clones were not. Our data suggest that lincRNA-RoR and miR10b could be used to distinguish aggressive clones from non-aggressive clones within the heterogeneous CD49f+/CD44+/CD24- DCIS population. Our findings also provide the foundation to develop new chemoprevention agents for DCIS-IDC transition.

The Association of Surgical Margins and Local Recurrence in Women with Ductal Carcinoma In Situ Treated with Breast-Conserving Therapy: A Meta-Analysis

PURPOSE

There is no consensus on adequate negative margins in breast-conserving surgery (BCS) for ductal carcinoma in situ (DCIS). We systematically reviewed the evidence on margins in BCS for DCIS.

METHODS

A study-level meta-analysis of local recurrence (LR), microscopic margin status and threshold distance for negative margins. LR proportion was modeled using random-effects logistic meta-regression (frequentist) and network meta-analysis (Bayesian) that allows for multiple margin distances per study, adjusting for follow-up time.

RESULTS

Based on 20 studies (LR: 865 of 7883), odds of LR were associated with margin status [logistic: odds ratio (OR) 0.53 for negative vs. positive/close (p < 0.001); network: OR 0.45 for negative vs. positive]. In logistic meta-regression, relative to >0 or 1 mm, ORs for 2 mm (0.51), 3 or 5 mm (0.42) and 10 mm (0.60) showed comparable significant reductions in the odds of LR. In the network analysis, ORs relative to positive margins for 2 (0.32), 3 (0.30) and 10 mm (0.32) showed similar reductions in the odds of LR that were greater than for >0 or 1 mm (0.45). There was weak evidence of lower odds at 2 mm compared with >0 or 1 mm [relative OR (ROR) 0.72, 95 % credible interval (CrI) 0.47-1.08], and no evidence of a difference between 2 and 10 mm (ROR 0.99, 95 % CrI 0.61-1.64). Adjustment for covariates, and analyses based only on studies using whole-breast radiotherapy, did not change the findings.

CONCLUSION

Negative margins in BCS for DCIS reduce the odds of LR; however, minimum margin distances above 2 mm are not significantly associated with further reduced odds of LR in women receiving radiation.

Cancer stem cells and early stage basal-like breast cancer

Ductal carcinoma in situ (DCIS) is a category of early stage, non-invasive breast tumor defined by the intraductal proliferation of malignant breast epithelial cells. DCIS is a heterogeneous disease composed of multiple molecular subtypes including luminal, HER2 and basal-like types, which are characterized by immunohistochemical analyses and gene expression profiling. Following surgical and radiation therapies, patients with luminal-type, estrogen receptor-positive DCIS breast tumors can benefit from adjuvant endocrine-based treatment. However, there are no available targeted therapies for patients with basal-like DCIS (BL-DCIS) tumors due to their frequent lack of endocrine receptors and HER2 amplification, rendering them potentially susceptible to recurrence. Moreover, multiple lines of evidence suggest that DCIS is a non-obligate precursor of invasive breast carcinoma. This raises the possibility that targeting precursor BL-DCIS is a promising strategy to prevent BL-DCIS patients from the development of invasive basal-like breast cancer. An accumulating body of evidence demonstrates the existence of cancer stem-like cells (CSCs) in BL-DCIS, which potentially determine the features of BL-DCIS and their ability to progress into invasive cancer. This review encompasses the current knowledge in regard to the characteristics of BL-DCIS, identification of CSCs, and their biological properties in BL-DCIS. We summarize recently discovered relevant molecular signaling alterations that promote the generation of CSCs in BL-DCIS and the progression of BL-DCIS to invasive breast cancer, as well as the influence of the tissue microenvironment on CSCs and the invasive transition. Finally, we discuss the translational implications of these findings for the prognosis and prevention of BL-DCIS relapse and progression.

Vitamin D compounds reduce mammosphere formation and decrease expression of putative stem cell markers in breast cancer

Breast cancer stem cells (BCSCs) are a subset of tumor cells that are believed to be the cells responsible for the establishment and maintenance of tumors. Moreover, BCSCs are suggested to be the main cause of progression to metastasis and recurrence of cancer because of their tumor-initiating abilities and resistance to conventional therapies. Ductal carcinoma in situ (DCIS) is an early precursor in breast carcinogenesis which progresses to invasive ductal carcinoma (IDC). We have previously reported that a vitamin D compound, BXL0124, inhibits the progression of DCIS to IDC. In the present study we sought to determine whether this effect was mediated through an influence on BCSCs. In MCF10DCIS cells treated with vitamin D compounds (1α25(OH)2D3 or BXL0124), the breast cancer stem cell-like population, identified by the CD44(+)/CD24(-/low) and CD49f(+)/CD24(-/low) subpopulations, was reduced. To determine the effects of vitamin D compounds on cancer stem cell activity, the MCF10DCIS mammosphere cell culture system, which enriches for mammary progenitor cells and putative BCSCs, was utilized. Untreated MCF10DCIS mammospheres showed a disorganized and irregular shape. When MCF10DCIS cells were treated with 1α25(OH)2D3 or BXL0124, the mammospheres that formed exhibited a more organized, symmetrical and circular shape, similar to the appearance of spheres formed by the non-malignant, normal mammary epithelial cell line, MCF10A. The mammosphere forming efficiency (MFE) was significantly decreased upon treatment with 1α25(OH)2D3 or BXL0124, indicating that these compounds have an inhibitory effect on mammosphere development. Treatment with 1α25(OH)2D3 or BXL0124 repressed markers associated with the stem cell-like phenotype, such as CD44, CD49f, c-Notch1, and pNFκB. Furthermore, 1α25(OH)2D3 and BXL0124 reduced the expression of pluripotency markers, OCT4 and KLF-4 in mammospheres. This study suggests that vitamin D compounds repress the breast cancer stem cell-like population, potentially contributing to their inhibition of breast cancer. This article is part of a Special Issue entitled '17th Vitamin D Workshop'.

Targeting exosomes from preadipocytes inhibits preadipocyte to cancer stem cell signaling in early-stage breast cancer

The tumor microenvironment plays a critical role in regulating breast tumor progression. Signaling between preadipocytes and breast cancer cells has been found to promote breast tumor formation and metastasis. Exosomes secreted from preadipocytes are important components of the cancer stem cell niche. Mouse preadipocytes (3T3L1) are treated with the natural antitumor compound shikonin (SK) and exosomes derived from mouse preadipocytes are co-cultured with MCF10DCIS cells. We examine how preadipocyte-derived exosomes can regulate early-stage breast cancer via regulating stem cell renewal, cell migration, and tumor formation. We identify a critical miR-140/SOX2/SOX9 axis that regulates differentiation, stemness, and migration in the tumor microenvironment. Next, we find that the natural antitumor compound SK can inhibit preadipocyte signaling inhibiting nearby ductal carcinoma in situ (DCIS) cells. Through co-culture experiments, we find that SK-treated preadipocytes secrete exosomes with high levels of miR-140, which can impact nearby DCIS cells through targeting SOX9 signaling. Finally, we find that preadipocyte-derived exosomes promote tumorigenesis in vivo, providing strong support for the importance of exosomal signaling in the tumor microenvironment. Our data also show that targeting the tumor microenvironment may assist in blocking tumor progression.

Epigenetic Regulation of miRNAs and Breast Cancer Stem Cells

MicroRNAs have emerged as important targets of chemopreventive strategies in breast cancer. We have found that miRNAs are dysregulated at an early stage in breast cancer, in non-malignant Ductal Carcinoma In Situ. Many dietary chemoprevention agents can act by epigenetically activating miRNA-signaling pathways involved in tumor cell proliferation and invasive progression. In addition, many miRNAs activated via chemopreventive strategies target cancer stem cell signaling and prevent tumor progression or relapse. Specifically, we have found that miRNAs regulate DCIS stem cells, which may play important roles in breast cancer progression to invasive disease. We have shown that chemopreventive agents can directly inhibit DCIS stem cells and block tumor formation in vivo, via activation of tumor suppressor miRNAs.

Characterization of a stem-like subpopulation in basal-like ductal carcinoma in situ (DCIS) lesions

Previously, we found that basal-like ductal carcinoma in situ (DCIS) contains cancer stem-like cells. Here, we characterize stem-like subpopulations in a model of basal-like DCIS and identify subpopulations of CD49f+/CD24- stem-like cells that possess aldehyde dehydrogenase 1 activity. We found that these cells show enhanced migration potential compared with non-stem DCIS cells. We also found that the chemopreventive agent sulforaphane can target these DCIS stem-like cells, reduce aldehyde dehydrogenase 1 (ALDH1) expression, and decrease mammosphere and progenitor colony formation. Furthermore, we characterized exosomal trafficking of microRNAs in DCIS and found that several microRNAs (miRs) including miR-140, miR-29a, and miR-21 are differentially expressed in exosomes from DCIS stem-like cells. We found that SFN treatment could reprogram DCIS stem-like cells as evidenced by significant changes in exosomal secretion more closely resembling that of non-stem cancer cells. Finally, we demonstrated that exosomal secretion of miR-140 might impact signaling in nearby breast cancer cells.

Downregulation of miR-140 promotes cancer stem cell formation in basal-like early stage breast cancer

The major goal of breast cancer prevention is to reduce the incidence of ductal carcinoma in situ (DCIS), an early stage of breast cancer. However, the biology behind DCIS formation is not well understood. It is suspected that cancer stem cells (CSCs) are already programmed in pre-malignant DCIS lesions and that these tumor-initiating cells may determine the phenotype of DCIS. MicroRNA (miRNA) profiling of paired DCIS tumors revealed that loss of miR-140 is a hallmark of DCIS lesions. Previously, we have found that miR-140 regulates CSCs in luminal subtype invasive ductal carcinoma. Here, we find that miR-140 has a critical role in regulating stem cell signaling in normal breast epithelium and in DCIS. miRNA profiling of normal mammary stem cells and cancer stem-like cells from DCIS tumors revealed that miR-140 is significantly downregulated in cancer stem-like cells compared with normal stem cells, linking miR-140 and dysregulated stem cell circuitry. Furthermore, we found that SOX9 and ALDH1, the most significantly activated stem-cell factors in DCIS stem-like cells, are direct targets of miR-140. Currently, targeted therapies (tamoxifen) are only able to reduce DCIS risk in patients with estrogen receptor α (ERα)-positive disease. We examined a model of ERα-negative/basal-like DCIS and found that restoration of miR-140 via a genetic approach or with the dietary compound sulforaphane decreased SOX9 and ALDH1, and reduced tumor growth in vivo. These results support that a miR-140/ALDH1/SOX9 axis is critical to basal CSC self-renewal and tumor formation in vivo, suggesting that the miR-140 pathway may be a promising target for preventative strategies in patients with basal-like DCIS.

[Does molecular biology play any role in ductal carcinoma in situ?]

The natural history of ductal carcinoma in situ (DCIS) is not fully elucidated, but it is recognized that DCIS is the true precursor of invasive carcinoma. Studies could show that DCIS is as heterogeneous as invasive ductal carcinoma, yet, they were unable to predict which DCIS will progress to invasion. Several biomarkers were also demonstrated to have a certain prognostic value. However, except for estrogen receptors and HER2, biomarkers are not yet widely used in clinical practice since their predictive value has not proven to be better than the grade and the classical classifying systems of DCIS. Identifying biomarkers for risk of invasiveness in DCIS could be of great value to help high risk patients through the management of their disease and to avoid overtreatment in low risk patients.

Twenty-year outcomes after breast-conserving surgery and definitive radiotherapy for mammographically detected ductal carcinoma in situ

BACKGROUND

Management of mammographically detected ductal carcinoma in situ (DCIS) at a single institution was reviewed to determine long-term clinical outcomes after treatment with breast-conserving therapy (BCT).

METHODS

Data from all patient-cases with DCIS who received BCT between 1980 and 1993 were reviewed. Patient demographics and pathologic factors were analyzed for their effect on outcomes, including ipsilateral breast tumor recurrence (IBTR) and survival. BCT included breast-conserving surgery followed by external-beam radiotherapy to the whole breast, with 86 % of patients receiving a lumpectomy cavity boost. The median dose to the whole breast was 50 Gy and 60.4 Gy to the lumpectomy cavity.

RESULTS

A total of 129 cases were evaluated; the median follow-up was 19.3 years. Twenty-one patients developed an ipsilateral breast tumor recurrence (IBTR), 76.2 % of which were invasive (n = 16). Fourteen recurrences (66 %) were within the same breast quadrant (true recurrence), while an additional 7 cases developed an IBTR elsewhere in the breast. True recurrences were more prevalent in women <45 years of age (20 %/24 % vs. 5.1 %/8 %) at 10 and 20 years (p = 0.02). The 5-, 10-, 15-, and 20-year actuarial rates of IBTR for this cohort were 8.7, 10.4, 12.1, and 16.3 % (IBTR), while overall survival at 5, 10, and 20 years was 97.6, 96.8, and 96.8 %, respectively.

CONCLUSIONS

Mammographically detected DCIS remains a clinically distinct subset of noninvasive breast cancer. With 20 year follow-up, local control and overall survival are excellent after BCT.

Evaluation of a breast cancer nomogram for predicting risk of ipsilateral breast tumor recurrences in patients with ductal carcinoma in situ after local excision

PURPOSE

Prediction of patients at highest risk for ipsilateral breast tumor recurrence (IBTR) after local excision of ductal carcinoma in situ (DCIS) remains a clinical concern. The aim of our study was to evaluate a published nomogram from Memorial Sloan-Kettering Cancer Center to predict for risk of IBTR in patients with DCIS from our institution.

PATIENTS AND METHODS

We retrospectively identified 794 patients with a diagnosis of DCIS who had undergone local excision from 1990 through 2007 at the MD Anderson Cancer Center (MDACC). Clinicopathologic factors and the performance of the Memorial Sloan-Kettering Cancer Center nomogram for prediction of IBTR were assessed for 734 patients who had complete data.

RESULTS

There was a marked difference with respect to tumor grade, prevalence of necrosis, initial presentation, final margins, and receipt of endocrine therapy between the two cohorts. The biggest difference was that more patients received radiation in the MDACC cohort (75% at MDACC v 49% at MSKCC; P < .001). Follow-up time in the MDACC cohort was longer than in the MSKCC cohort (median 7.1 years v 5.6 years), and the recurrence rate was lower in the MDACC cohort (7.9% v 11%). The median 5-year probability of recurrence was 5%, and the median 10-year probability of recurrence was 7%. The nomogram for prediction of 5- and 10-year IBTR probabilities demonstrated imperfect calibration and discrimination, with a concordance index of 0.63.

CONCLUSION

Predictive models for IBTR in patients with DCIS who were treated with local excision are imperfect. Our current ability to accurately predict recurrence on the basis of clinical parameters alone is limited.

Local recurrence after breast-conserving surgery: multivariable analysis of risk factors and the impact of young age

BACKGROUND

Local recurrence (LR) after breast conservation surgery (BCS) varies with risk factors. This study was designed to evaluate the impact of young age on LR.

METHODS

All patients (excluding those who received neoadjuvant chemotherapy) who underwent BCS from 1988-2001 at our institution were identified and evaluated for risk factors of LR.

RESULTS

A total of 3,064 patients underwent 3,131 BCS. Mean age at surgery was 61 (range, 21-98) years: 175 (5.6%) patients were aged<40 years; 492 (15.7%) were 40-49 years; 761 (24.3%) were 50-59 years; 801 (25.6%) were 60-69 years; and 902 (28.8%) were age 70+years. A total of 212 patients (6.8%) developed LR at a mean of 4.5 (range, 0.1-14.4) years after BCS. Mean follow-up was 8.9 (range, 0-20.2) years. The 5-year LR-free survival rate was 94.9%. The frequencies of LR by age group were: <40 years--11.4%; 40-49 years--5.7%; 50-59 years--6.2%; 60-69 years--7.6%; 70 years and older--6.2%. The 5-year LR-free survival rates for these age groups were 90.5%, 95.4%, 95.5%, 95.4%, and 94.7%, respectively (P=0.09, log-rank test). On univariable analysis, patients aged<40 years were nearly twice as likely to experience LR (hazards ratio (HR), 1.81; P=0.012). Multivariable analysis of patients with complete data (n=2,122) demonstrated that age<40 years and node positivity were associated with increased risk of LR, whereas ER positivity and radiation therapy were associated with decreased risk.

CONCLUSIONS

Risk factors for LR after BCS include age<40 years, node positivity, ER negativity, and absence of adjuvant radiation therapy. Patients younger than age 40 years are at increased risk of LR after BCS.

Association between patient and tumor characteristics with clinical outcomes in women with ductal carcinoma in situ

We synthesized the evidence of the association between patient and tumor characteristics with clinical outcomes in women with ductal carcinoma in situ of the breast. We identified five randomized controlled clinical trials and 64 observational studies that were published in English from January 1970 to January 2009. Younger women with clinically presented ductal carcinoma in situ had higher risk of ipsilateral recurrent cancer. African Americans had higher mortality and greater rates of advanced recurrent cancer. Women with larger tumor size, comedo necrosis, worse pathological grading, positive surgical margins, and at a higher risk category, using a composite prognostic index, had worse outcomes. Inconsistent evidence suggested that positive HER2 receptor and negative estrogen receptor status were associated with worse outcomes. Synthesis of evidence was hampered by low statistical power to detect significant differences in predictor categories and inconsistent adjustment practices across the studies. Future research should address composite prediction indices among race groups for all outcomes.

Local control of ductal carcinoma in situ based on tumor and patient characteristics: the surgeon's perspective

Ductal carcinoma in situ (DCIS) is a disease whose manifestations are largely confined to in-breast pathology. Management strategies therefore focus on various combinations of local therapy: mastectomy, lumpectomy alone, and lumpectomy followed by breast irradiation. Although DCIS does not carry an inherent risk of distant organ metastasis, optimal local control is essential because any in-breast or chest wall recurrence may occur as an invasive lesion. Local recurrence has been reported following breast-conserving surgery as well as mastectomy. Breast radiation is therefore generally recommended following breast-conserving surgery, and in selected circumstances, mastectomy may be the preferred treatment strategy. This article reviews the surgical and associated clinicopathologic issues related to initial biopsy and perioperative planning that should be considered for all DCIS cases to optimize local control.

Ductal carcinoma in situ of the breast in younger women: a subgroup of patients at high risk

BACKGROUND

After breast conservative treatment (BCT), young age is a predictive factor for recurrence in patients with Ductal Carcinoma In Situ (DCIS) of the breast. The purpose of this study was to evaluate predictive factors for recurrence and outcomes in these younger women (under 40 years) treated for pure DCIS.

METHODS

From 1974 to 2003, 207 cases were collected in 12 French Cancer Centers. Median age was 36.3 years and median follow-up 160 months. Seventy four (35.8%) underwent mastectomy, 67 (32.4%) lumpectomy alone and 66 (31.9%) lumpectomy plus radiotherapy.

RESULTS

37 recurrences occurred (17.8%): 14 (38%) were in situ and 23 (62%) invasive. After BCT, the overall rate of recurrence was 27% (33% in the lumpectomy plus radiotherapy group vs. 21% in the lumpectomy alone group). Comedocarcinoma subtype (p = 0.004), histological size more than 10 mm (p = 0.011), necrosis (p = 0.022) and positive margin status (p = 0.019) were statistically significant predictive factors for recurrence. The actuarial 15-year rates of local recurrence were 29%, 42% and 37% in the lumpectomy alone, lumpectomy and whole breast radiotherapy and lumpectomy + whole breast radiotherapy with additional boost groups respectively. After recurrence, the 10-year overall survival rate was 67.2%.

CONCLUSION

High recurrence rates (mainly invasive) after BCT in young women with DCIS are confirmed. BCT in this subgroup of patients is possible if clear and large margins are obtained, tumor size is under 11 mm and necrosis- and/or comedocarcinoma-free.

Rates of second malignancies after definitive local treatment for ductal carcinoma in situ of the breast

PURPOSE

We analyzed the risk of second malignancies developing in patients with ductal carcinoma in situ (DCIS) undergoing surgery and radiotherapy (S+RT) vs. surgery alone.

METHODS AND MATERIALS

The S+RT cohort consisted of 256 women treated with breast-conserving therapy at William Beaumont Hospital. The surgery alone cohort consisted of 2,788 women with DCIS in the regional Surveillance, Epidemiology, and End Results database treated during the same time period. A matched-pair analysis was performed in which each S+RT patient was randomly matched with 8 surgery alone patients (total of 2,048 patients). Matching criteria included age±2 years. The rates of second malignancies were analyzed overall and as contralateral breast vs. non-breast cancers and by organ system.

RESULTS

Median follow-up was 13.7 years for the S+RT cohort and 13.3 years for the surgery alone cohort. The overall 10-/15-year rates of second malignancies among the S+RT and surgery alone cohorts were 14.2%/24.2% and 16.4%/22.6%, respectively (p=0.668). The 15-year second contralateral breast cancer rate was 14.2% in the S+RT cohort and 10.3% in the surgery alone cohort (p=0.439). The 15-year risk of a second non-breast malignancy was 14.2% for the S+RT cohort and 13.4% for the surgery alone cohort (p=0.660). When analyzed by organ system, the 10- and 15-year rates of second malignancies did not differ between the S+RT and surgery alone cohorts for pulmonary, gastrointestinal, central nervous system, gynecologic, genitourinary, lymphoid, sarcomatoid, head and neck, or unknown primary tumors.

CONCLUSIONS

Compared with surgery alone, S+RT is not associated with an overall increased risk of second malignancies in women with DCIS.

Young age is not associated with increased local recurrence for DCIS treated by breast-conserving surgery and radiation

BACKGROUND

We report local recurrence (LR) after breast-conserving surgery and radiation (BCS + RT) for ductal carcinoma in situ (DCIS) to determine outcomes for patients aged <or=40 years compared with older women.

METHODS

The study included 440 women with DCIS treated from 1978 to 2007. All patients received whole-breast radiotherapy with a boost in 95% of cases. Demographics, characteristics, surgical, and adjuvant treatments were analyzed for an effect on LR.

RESULTS

Median age was 56.5 years with 24 patients aged <or=40. Median DCIS size was 0.8 cm. Re-excision was required in 62% of patients, and in 75% of those aged <or=40. Tamoxifen was used in 22%, but only one patient aged <or=40. Median follow-up was 6.8 years. Actuarial LR was 7% (95% confidence interval of 4-11%) at 10 years and 8% (5-14%) at 15 years. There was no difference in LR by age (P = 0.76).

CONCLUSIONS

The long-term risk of LR after BCS + RT for DCIS is low, even in patients <or=40 years. This may be due to patient selection for small size, high utilization of re-excision, and radiation boost. Young age may be a smaller contributor to LR risk in DCIS than previously suggested.

Effect of Margin Status on Local Recurrence After Breast Conservation and Radiation Therapy for Ductal Carcinoma In Situ

Purpose

There is no consensus on what constitutes an adequate surgical margin in patients receiving breast-conserving surgery (BCS) and postoperative radiation therapy (RT) for ductal carcinoma in situ (DCIS). Inadequate margins may result in high local recurrence, and excessively large resections may lead to poor cosmetic outcome without oncologic benefit.

Methods

A comprehensive search for published trials that examined outcomes after adjuvant RT after BCS for DCIS was performed using MEDLINE and cross referencing available data. Reviews of each study were conducted, and data were extracted. Primary outcome was ipsilateral breast tumor recurrence (IBTR) related to surgical margins.

Results

A total of 4,660 patients were identified from trials examining BCS and RT for DCIS. Patients with negative margins were significantly less likely to experience recurrence than patients with positive margins after RT (odds ratio [OR] = 0.36; 95% CI, 0.27 to 0.47). A negative margin significantly reduced the risk of IBTR when compared with a close (OR = 0.59; 95% CI, 0.42 to 0.83) or unknown margin (OR = 0.56; 95% CI, 0.36 to 0.87). When specific margin thresholds were examined, a 2-mm margin was superior to a margin less than 2 mm (OR = 0.53; 95% CI, 0.26 to 0.96); however, we saw no significant difference in the rate of IBTR with margins between 2 mm and more than 5 mm (OR = 1.51; 95% CI, 0.51 to 5.0; P > .05).

Conclusion

Surgical margins negative for DCIS should be obtained after BCS for DCIS. A margin threshold of 2 mm seems to be as good as a larger margin when BCS for DCIS is combined with RT.

[Ductal carcinoma in situ of the breast (DCIS) under 40: a specific management?]

Ductal carcinoma in situ of the breast (DCIS) is rare in younger women, accounting for about 4% of all cases of DCIS in France, and tends to be diagnosed by clinical findings or casually, after plastic surgery. After breast conserving treatment, young age ( less than 40) is a predictive factor of relapses in patients with DCIS. Age may serve as one more parameter that should be considered in the complex decision-making process necessary to create a treatment plan for a woman with DCIS. Breast conservative treatment (BCT) could be used if: margins are free and more than 10 mm; if DCIS size is less than 11 mm and DCIS is free of necrosis and comedocarcinoma. Mastectomy ought to be proposed in case of: multifocal DCIS, or DCIS size more than 30 mm; invaded margins after re-excision; radiotherapy contraindicated; small breasts and patient choice. Immediate breast reconstruction should be proposed for patients with all the poor predictive factors. In other cases, treatment procedure will be explained to the patient and the treatment will be chosen by the patient in consultation with the medical team (radiologist, surgeon, pathologist and oncologist). Radiotherapy with boost or hormonotherapy with tamoxifen should not be used routinely but may be proposed individually.

259 Patients with DCIS of the breast applying USC/Van Nuys prognostic index: a retrospective review with long term follow up

BACKGROUND

The Van Nuys Prognostic Index (VNPI) is a simple score for predicting the risk of local recurrence (LR) in patients with Ductal Carcinoma In Situ (DCIS) conservatively treated. This score combines three independent predictors of Local Recurrence. The VNPI has recently been updated with the addition of age as a fourth parameter into the scoring system (University of Southern California/ VNPI).

PATIENTS AND METHODS

Our database consisted of 408 women with DCIS. Applying the USC/VNPI we reviewed retrospectively 259 patients who were treated with breast conserving surgery with or without radiotherapy (RT). Of these patients 63.5% had a low VNPI score, 32% intermediate and 4.5% a high score. In the low score group, the majority of the patients underwent Conservative Surgery (CS) without RT while in the intermediate group, almost half of the patients received RT. Eighty-three percent (83%) of the patients with high VNPI were treated with Conservative Surgery plus RT. Nodal assessment by Sentinel Lymph Node Biopsy was obtained in 32 patients since 2002.

RESULTS

Twenty-one Local Recurrences were observed (8%) with a mean follow up of 130 months: sixteen were invasive. No statistically significant differences in Disease Free Survival were reached in all groups of VNPI score between patients treated with Conservative Surgery or Conservative Surgery plus RT. However it was noted that the higher the VNPI score, the lower was the risk of local recurrence in the group treated additionally with RT, even though it was not statistically significant. Further analysis included those patients treated with Conservative Surgery alone and followed up. Disease-free survival (DFS) at 10 years was 94% with low VNPI and 83% in both intermediate and high score (P < 0.05). No significant differences were observed in the subgroups of VNPI. The Local Relapse rate after Conservative Surgery alone, increased with tumor size, margin width, and pathology classification (P < 0,05), while age was not found to be a significant factor. Lesions with only mammographic appearances are associated with lower DFS but it did not reach significance (P = ns), while assumption of estrogenic hormones and familial history of breast cancer are significant factors associated with a higher risk of local recurrence. After multivariate analysis including seven clinical and pathological factors, the only significant predictors of local recurrence remained margin width of surgical excision, previous therapy with estrogens (contraceptives or Hormone Replacement Therapy) and the Van Nuys pathologic classification. The overall survival breast cancer specific was 99% and no differences were observed between groups (P = ns). The comparison of patients treated with a total mastectomy and those conservatively treated showed a significantly better local relapse free survival rate obtained with mastectomy (98.2% vs. 89.7% at 10 years P = 0.02). However, the overall cause-specific survival did not prove any better outcome (98.7% in both groups). Of the 32 patients who underwent a Sentinel Lymph Node Biopsy, four were found to have micrometastases and all of them had a previous Directional Vacuum Assisted Biopsy.

CONCLUSIONS

Although in our series there is not a significant difference in LR rates by the parameter of age, the new USC/VNPI is still a simple and reliable scoring system for therapeutic management of DCIS. We did not find any statistically significant advantage in groups treated with the addition of RT. Obtaining wide surgical margins appears to be the strongest prognostic factor for local recurrence, regardless of other pathological factors or the addition of adjuvant radiation therapy. However, only prospective randomized studies can precisely predict the risk of LR of conservatively treated DCIS. The clinical significance of Sentinel Lymph Nodes micrometastases Immuno-Histo-Chemistry-detected found in DCIS patients remains uncertain. However, we hypothesize that the anatomical disruption after preoperative biopsy procedures increases the likelihood of epithelial cell displacement and the frequency of IHC-positive Sentinel Lymph Nodes, both of which are directly proportional to the degree of manipulation.

Long-Term Results of Conservative Surgery and Radiotherapy for Ductal Carcinoma In Situ Using Lung Density Correction: The University of Michigan Experience

The purpose of the study was to review the treatment outcomes of 198 patients treated with breast-conserving surgery (BCS) and whole breast radiation therapy using lung density correction for ductal carcinoma in situ (DCIS). Between April 1985 and December 2002, 198 patients with 200 lesions diagnosed as DCIS (AJCC stage 0) were treated at the University of Michigan. All underwent BCS and whole breast radiotherapy. Median total follow-up was 6.2 years (range: 0.8-18.2). The 5- and 10-year cumulative rates of in-breast only failure were 5.9% (95% CI: 2.6-9.3%) and 9.8% (95% CI: 5.2-14.4%), respectively. Factors that significantly predicted for an increased risk of local failure were family history of breast cancer, positive or close surgical margins and age </= 50 years at diagnosis. Cosmetic outcome was scored as "excellent" or "good" in 94% of the assessed patients. On multivariate analysis, only patient separation significantly predicted cosmetic outcome (p = 0.04). BCS and radiotherapy using lung density correction resulted in high rates of local control at 5 and 10 years with excellent cosmetic results. To the best of our knowledge, this is the first study to report outcome in a series of patients with DCIS treated with lung density correction and results compare favorably with other series in which plans were calculated using unit density.

CIH-Tokyo Experience with Breast-Conserving Surgery without Radiotherapy: 6.5 Year Follow-Up Results of 1462 Patients

When breast-conserving therapy was introduced at the Cancer Institute Hospital (CIH) in Tokyo in 1986, we instituted our own strategy as follows: 1) every effort is to be made for complete tumor resection while avoiding deformity of the breast, and 2) radiotherapy (RT) is applied only to the patients with positive surgical margins. This is, in turn, to clarify the group of patients in whom postoperative RT can be safely spared. Among 9670 patients operated on for primary breast cancer during the 16.5 year period from 1986 to 2002 at CIH, there were 2449 patients who underwent breast-conserving surgery (BCS). During the 6.5 years mean follow-up period, ipsilateral intrabreast tumor recurrence (IBTR) developed in 99 of the 2449 patients, with an overall rate of 4.0% and an annual rate of 0.62%. These 2449 patients were categorized into four subgroups according to either negative or positive margins and with or without radiotherapy. The IBTR rates and the number of patients in each subgroup were 5.5% in 1351 margin(-)RT(-) patients, 1.0% in 307 margin(-)RT(+) patients, 2.4% in 680 margin(+)RT(+) patients, and 4.5% in 111 margin(+)RT(-) patients. These results either with or without RT seem to be quite comparable to or even better than the results of BCS with RT reported from Western countries, where less emphasis seems to be placed on completeness of the local tumor resection with BCS, while RT is administered to basically all patients following BCS. IBTR was categorized into true recurrence (TR) and second primary lesion (SP) according to the margin status at the time of BCS, the former being lesions developed in patients with positive margins and the latter being those in patients with negative margins. It was demonstrated that in patients with positive margins, TR was much more common than SP, whereas in patients with negative margins, these incidences were just the opposite (i.e., TR was 60% less common than SP) and postoperative RT was effective in preventing both TR and SP, the effect on the latter being much more striking. With RT, the incidence of developing TR in patients who had positive margins was reduced to almost equal to that in margin(-) patients treated with no RT. Our method of IBTR categorization is based on biological consideration and detailed histopathologic examination, and appears to be the only biologically reasonable means so far that has been proposed for distinction between these two biologically different entities. TR and SP can be further reduced to exceptionally low levels in patients who received RT despite negative margins, though it would not seem reasonable to administer RT to all of these patients because the actual number of patients who would benefit is comparatively small. From these observations, it seems that our imaging, pathologic examination, and surgical approaches for patients who are candidates for BCS have been highly valid, and our criteria for sparing postoperative RT as well as categorization of IBTR into TR and SP are quite appropriate. Although our results with BCS seem to deserve wide recognition, they are not from randomized clinical trials, so the findings must be confirmed by a study in order to investigate whether the results at CIH can be applied generally at other institutions.

[Retrospective analysis of 108 ductal carcinomas in situ of the breast treated by radiosurgery association]

PURPOSE

To evaluate survival and prognostic factors of 108 patients with clinically or mammographically detected ductal carcinoma in situ (DCIS), treated from 1980 to 1996 by complete local excision followed by external irradiation.

PATIENTS AND METHODS

The median age was 51 (range 37-80). All the patients underwent surgery consisting of a wide resection of the mammary gland harbouring the tumour. The surgical specimens were sent to the pathologists to get information on histology and margin clearance; all the slides were reviewed by one of us to assess the tumoral diameter. External beam therapy was delivered within 8 weeks after surgery. The prescribed irradiation dose was 50 Gy in 25 fractions to be given in 5 weeks. The median duration of follow-up was 93 months (range 40-173).

RESULTS

There were nine patients with local recurrence (8.3%); three patients had local recurrence of DCIS and six patients developed invasive breast cancer. The treatment of local recurrence consisted of mastectomy with or without axillary dissection (eight cases) and quadrantectomy (one case). The 5-year and 10-year ipsilateral recurrence-free rate was respectively 92 and 89%. The 10-year cause specific survival was 100%. In univariate analysis, size>or=10 mm, age<45 years old and margin status were significant P=0,02, P=0,03, P=0,005; margin status was significant in multivariate analysis (P<0,02).

CONCLUSION

These results are in keeping with those of the literature. They could be improved by the mass screening campaign, which is going on since January 1990 among women aged 50-74 years.

Long-Term Outcome for Mammographically Detected Ductal Carcinoma In Situ Managed with Breast Conservation Treatment

BACKGROUND

The importance of negative final resection margins for optimal local control has been established for women with ductal carcinoma in situ (intraductal carcinoma) undergoing breast conservation treatment. This study evaluated long-term outcome after breast conservation treatment and whether reexcision or the presence of residual tumor in the reexcision specimen predicted for local recurrence in patients with ductal carcinoma in situ with negative margins.

METHODS

The study cohort consisted of 192 women with ductal carcinoma in situ treated with breast conservation treatment at the University of Pennsylvania from 1978 to 2000. Analysis was performed for unilateral, mammographically detected, intraductal breast carcinomas. Study endpoints of interest included rates of local recurrence, overall survival, and cause-specific survival. The median follow-up was 6.2 years (mean, 7 years; range, 0.1-21.4 years).

RESULTS

The 10-year overall survival and 10-year cause-specific survival rates were 87% and 99%, respectively. There were 11 local failures (6%) in the treated breast, with a 10-year actuarial local failure rate of 10% and a median time to local failure of 7.4 years (mean, 6.6 years; range, 1.6-10.2 years). Among the subset of 124 patients with negative final resection margins, there was no statistically significant difference in the 8-year actuarial local recurrence rates among patients who underwent single excision (7%), reexcision with residual tumor (8%), or reexcision with no residual tumor (0%).

DISCUSSION

The use of breast conservation treatment in patients with ductal carcinoma in situ remains an effective and durable treatment approach. The need for reexcision to achieve negative margins and the presence of residual ductal carcinoma in situ in the reexcision specimen do not negatively impact local recurrence rates in the current study. These findings suggest that requiring more than one surgery to obtain clear resection margins is not an adverse prognostic factor for local failure.

Clinical experience of patients with ductal carcinoma in situ of the breast treated with breast-conserving surgery plus radiotherapy: a preliminary report

PURPOSE

Breast-conserving therapy (BCT) is a practical alternative to mastectomy for treating ductal carcinoma in situ (DCIS). We reviewed our experience for treating patients with DCIS of the breast to evaluate the outcome after performing breast-conserving surgery plus radiotherapy (BCS-RT).

MATERIALS AND METHODS

Between January 1983 and December 2002, 25 patients with clinically or mammographically detected DCIS were treated by BCS-RT. One patient was diagnosed with bilateral DCIS. Thirteen cases (50%) had symptomatic lesions at presentation. All 26 cases of 25 patients underwent BCS such as lumpectomy, partial mastectomy or quadrantectomy. All of them received whole breast irradiation to a median dose of 50.4 Gy. Twenty-four cases (92.3%) received a boost to the tumor bed for a median total dose of 59.4 Gy. The median follow up period was 67 months (range: 38 to 149 months).

RESULTS

Two cases (7.7%) experienced ipsilateral breast tumor recurrence (IBTR) after BCS-RT. The histology results at the time of IBTR showed invasive ductal carcinoma (IDC), and the median time to IBTR was 25.5 months. On the univariate analysis, there were no significant factors associated with IBTR in the DCIS patients. The three-year local recurrence free survival rate was 96.0% and the overall survival rate was 96.3%.

CONCLUSION

After the treatment for DCIS, the IBTR rate in our study was similar to other previous studies. Considering that we included patients who had many symptomatic lesions, close or positive margins and less that complete early data, our result is comparable to the previous studies. We could not find the prognostic significant factors associated with IBTR after BCS-RT. A longer follow up period with more patients would be required to evaluate the role of any predictive factors and to confirm these short-term results.

Defining Negative Margins in DCIS Patients Treated with Breast Conservation Therapy: The University of Chicago Experience

Management of ductal carcinoma in situ (DCIS) has been evolving and the majority of women are now being treated with breast-conserving surgery and radiation therapy (i.e. breast conservation therapy [BCT]). Controversies still exist regarding the histologic features and margin status that are associated with local recurrence. The goal of this study was to review our institution's experience in patients diagnosed with DCIS and treated with BCT to determine pathologic features that can predict local recurrence, with particular emphasis on the final surgical margin status. We analyzed 103 consecutive patients with DCIS who were treated with BCT between 1986 and 2000. The slides were reviewed to determine the final margin status, type of DCIS, size of DCIS, nuclear grade, presence of necrosis and calcification, and volume of excised specimen. Margins were considered positive when DCIS touched or was transected at an inked margin. Negative margins were further categorized as close (less than 1 mm), 1--5 mm, and more than 5 mm. The size of the DCIS was determined based on either the maximal dimension on a slide or from the number of consecutive slides containing DCIS. Morphology and immunohistochemical profiles of the recurrent DCIS cases were compared with original DCIS. All patients were treated uniformly with external beam radiation therapy to the entire breast (median dose 46 Gy) with a boost to the tumor bed (median dose 14 Gy). The median follow-up was 63 months (range 7--191 months). The actuarial 5-year local control rate was 89%. The median time to local recurrence was 55 months. There were 13 local recurrences, of which 9 recurred as pure DCIS and 4 as invasive ductal carcinomas. Univariate analysis showed a significant association with local recurrence for positive margin (p=0.008), high nuclear grade (p=0.02), and young age at diagnosis (p=0.03). If margins were negative, the 5-year local control was 93%, as compared to 69% if margins were positive. A multivariate analysis showed that early age at diagnosis, positive margin status, and high nuclear grade were independently associated with local recurrence. The morphology and immunohistochemical stains of all nine recurrent DCIS were similar to those of the original DCIS. Breast conservation can be achieved with excellent local control by obtaining microscopically negative margins as strictly defined by DCIS not touching the inked surgical margins, and postoperative radiation that includes boost therapy to the tumor bed.

Predictors of local recurrence after breast-conservation therapy

Breast-conserving therapy (BCT) is a proven local treatment option for select patients with early-stage breast cancer. This paper reviews pathologic, clinical, and treatment-related features that have been identified as known or potential predictors for ipsilateral breast tumor recurrence in patients treated with BCT. Pathologic risk factors such as the final pathologic margin status of the excised specimen after BCT, the extent of margin involvement, the interaction of margin status with other adverse features, the role of biomarkers, and the presence of an extensive intraductal component or lobular carcinoma in situ all impact the likelihood of ipsilateral breast tumor recurrence. Predictors of positive repeat excision findings after conservative surgery include young age, presence of an extensive intraductal component, and close or positive margins in prior excision. Finally, treatment-related factors predicting ipsilateral breast tumor recurrence include extent of breast radiation therapy, use of a boost to the lumpectomy cavity, use of tamoxifen or chemotherapeutic agents, and timing of systemic therapy with irradiation. The ability to predict for an increased risk of ipsilateral breast tumor recurrence enhances the ability to select optimal local treatment strategies for women considering BCT.

[Ductal in situ carcinoma: is it ethical to consider the breast conserving therapy as a standard?]

The increasing incidence of DCIS during the past 20 years needs a continuous evaluation of the treatment strategies and a multidisciplinary decision process. The management of the DCIS remains a challenging issue in 2003. Mastectomy should still be considered as the reference treatment which is able to guarantee cure in almost all cases, whereas breast conserving surgery followed by radiation therapy is associated with 7-10% of local recurrence. However, the increasing knowledge of the predictive factors of the local recurrence allows to propose a conservative treatment strategy to a large amount of patients, without negative impact on their prognosis. This review presents the arguments that permit to justify the reasoned choice of the different therapeutic options according to the clinico-pathological situations.

Diagnosis and management of ductal carcinoma in situ

Ductal carcinoma in situ (DCIS) is a preinvasive form of breast cancer that has increased in incidence over the past 25 years, primarily as a result of mammographically detected microcalcifications. Inadequately treated DCIS carries a risk for evolving into the malignant phenotype; however, the magnitude and timeline for this risk are poorly defined. Treatment options include lumpectomy with or without breast irradiation and mastectomy. The overall survival rate is 96% to 98% with any of these strategies, but the risk of local recurrence (LR) is highest after lumpectomy alone. Breast irradiation can reduce this risk from levels in excess of 40% to 10% over a 10-year follow-up period. Approximately 50% of all LR from DCIS are invasive lesions. Therefore, the occurrence of a LR after breast-conserving therapy is a potentially greater threat to the patient with DCIS compared to the patient diagnosed with invasive cancer. In patients diagnosed with invasive cancer, the risk of micrometastatic disease is present from the time of initial diagnosis. In patients with DCIS, the expectation is that a potentially 100% cure rate should be achieved with local therapy alone. Although most DCIS cases complicated by LR will be successfully salvaged with prolonged overall survival, it is critically important to take every precaution that will minimize the risk of locally recurrent disease. Therefore, radiation therapy as an adjunct to lumpectomy is essential. A subset of patients with DCIS with low-volume low-grade disease who can be safely treated by lumpectomy alone has not yet been clearly defined. Prospective studies designed to identify this category are ongoing. Inadequate margin control is the most consistent risk factor for LR that has been reported thus far, but there is no universally accepted definition for what constitutes an optimal negative margin distance. Young age at diagnosis, high nuclear grade, and comedonecrosis are other factors that have been implicated as increasing the risk for LR. Tamoxifen can further decrease the rate of new in-breast events on the affected side and in the contralateral breast. Ongoing trials will also define the role of aromatase inhibitors as a risk-reducing strategy.

Carcinome canalaire in situ du sein

OBJECTIVE

This study assesses the results of "current clinical practice" among 882 women treated in nine French Cancer Centers from 1985 to 1995 for pure ductal carcinoma in situ (DCIS) of the breast.

METHOD

Median age was 53 years (range 21-87); 177 (20%) patients underwent mastectomy (M), 190 (22%) conservative surgery alone (CS) and 515 (58%) conservative surgery with radiotherapy (CS + RT).

RESULTS

The crude 7-year local relapse (LR) rates were 2%, 31% and 13% among the M, CS and CS+RT subgroups (p<0.0001). All four LR after M were invasive as well as 31 (52%) out of 59 and 40 (61%) out of 66 in the CS and CS+RT groups. Distant metastases occurred in 1%, 3% and 1% of the three treatment groups. No LR factors were found in the M group. Among women treated with CS, the 7-year LR rates were 36%, 31% and 30% among women aged 40 or less, 41 to 60 and 61 or more (NS). For women treated by CS+RT, the LR rates in these age subgroups were 33%, 13% and 8%, respectively (p<0.0001). Patients with negative, positive or uncertain margins had 7-year LR rates of 26%, 56% and 29% respectively if treated with CS (p=0.02) and 11%, 23% and 9% if treated with CS+RT (p=0.0008). RT reduced LR rates by 65% in all histological subgroups, but more particularly in comedocarcinoma and mixed cribriform/papillary subgroups. The 7-year rate of contralateral breast cancer was 7%, identical in all subgroups.

CONCLUSION

Mastectomy remains the safest treatment for women with DCIS, with a 98% 7-year control rate. After conservative surgery, RT reduces very significantly LR rates, according to the NSABP B-17 and EORTC 10853 randomized trial results. The RT benefit is present in all clinical/histological subgroups, but its magnitude varies. Young age (<40 years) and incomplete excision are the most important LR risk factors.

Optimal management of ductal carcinoma in situ of the breast

Ductal carcinoma in situ (DCIS) represents a breast lesion that is diagnosed with increasing frequency, mainly due to the wide use of screening mammography. Today, DCIS comprises 15-25% of all breast cancers detected at population screening programs. Consequently, the concepts of properly managing such patients assume a greater importance in everyday practice. Mammographically detected microcalcifications are the most common presentation of DCIS. Despite recent technological advances (including Stereotactic-guided directional vacuum-assisted biopsy), mammographically guided wire biopsy remains the "gold-standard" for obtaining a histological diagnosis in patients with non-palpable, mammographically detected DCIS. Management options include mastectomy, local excision combined with radiation therapy, and local excision alone. Given that DCIS is a heterogeneous group of lesions rather than a single entity, and because patients have a wide variety of personal needs that must be addressed during treatment selection, it is obvious that no single approach will be appropriate for all forms of DCIS or for all patients. Careful patient selection is of key importance in order to achieve the best results in the management of the individual patient with DCIS. Axillary lymph node dissection is unnecessary in the treatment of pure DCIS, but it is indicated when microinvasion is present. In these cases, sentinel lymph node biopsy may be an excellent alternative. In the NSABP B-24 trial, tamoxifen reduced both the invasive and non-invasive breast cancer events in either breast by 37%. Nearly all patients who develop a non-invasive recurrence following breast-sparing surgery are cured with mastectomy, and approximately 75% of those with an invasive recurrence are salvaged. Selected patients initially treated by lumpectomy alone may also undergo breast-conservation therapy at the time of relapse according to the same strict guidelines of tumor margin clearance required for the primary lesion; radiation therapy should be given following local excision. The use of systemic therapy in patients with invasive recurrence should be based on standard criteria for invasive breast cancer.

Ductal carcinoma in situ

DCIS is a heterogeneous disease whose natural history is poorly defined. Screening mammography has increased the detection rate of DCIS, but we remain unable to identify cases of DCIS that will not progress to invasive carcinoma during an individual's lifetime. Genomics holds great promise in this regard, but prospective studies with long-term follow-up will be needed before concluding that a subset of DCIS is clinically insignificant. The varying intensity of treatment options for DCIS, ranging from mastectomy to excision, RT, and tamoxifen to excision alone, reflects the uncertainty about the natural history of DCIS as well as differing physician values regarding the impact of local recurrence. The extent of DCIS within the breast is the major determinant of whether the patient is a candidate for a breast-conserving approach, and contraindications to the use of breast conservation treatment and to the use of irradiation have been defined. The clinical decision-making process in DCIS would benefit greatly from improvements in our ability to convey information about the long-term risks and benefits of therapy, as well as the tradeoffs in health-related quality of life, to patients, and to incorporate their preferences into the decision-making process.

Conservative management of Paget disease of the breast with radiotherapy: 10- and 15-year results

BACKGROUND

At 5-year follow-up, patients with Paget disease of the breast who were treated with breast-conserving surgery (BCS) and radiotherapy (RT) had excellent results. The current report provides 10- and 15-year rates of tumor control in the breast, as well as disease-free and overall survival rates following BCS and RT in a cohort of patients with Paget disease presenting without a palpable mass or mammographic density.

METHODS

Through a collaborative review of patients treated with BCS and RT from seven institutions, 38 cases of Paget disease of the breast presenting without a palpable mass or mammographic density were identified. All patients had pathologic confirmation of typical Paget cells at time of diagnosis. Thirty-six of 38 patients had a minimum follow-up greater than 12 months and constitute the study cohort. Ninety-four percent of patients underwent complete or partial excision of the nipple-areola complex and all patients received a median external beam irradiation dose of 50 Gy (range, 45-54 Gy) to the whole breast. Ninety-seven percent of patients also received a boost to the remaining nipple or tumor bed, a median total dose of 61.5 Gy (range, 50.4-70 Gy).

RESULTS

With median follow-up of 113 months (range, 18-257 months), 4 of 36 patients (11%) developed a first recurrence of disease in the treated breast only. Two of the four recurrences in the breast were ductal carcinoma in situ (DCIS) only and two were invasive with DCIS. Two additional patients had a recurrence in the breast as a component of first failure. Actuarial local control rates for the breast as the only site of first recurrence were 91% at 5 years (95% confidence interval [CI], 80-100%) and 87% (95% CI, 75-99%) at both 10 and 15 years. Actuarial local control rates for breast recurrence, as a component of first failure, were 91% (95% CI, 80-100%), 83% (95% CI, 69-97%), and 76% (95% CI, 58-94%) at 5, 10, and 15 years, respectively. No clinical factors were identified as significant predictors for breast recurrence. Five-, 10- and 15-year actuarial rates for survival without disease of 97% (95% CI, 90-100%) and 5-, 10-, and 15-year actuarial rates of overall survival of 93% (95% CI, 84-100%) at 5 years and 90% (95% CI, 78-100%) at 10 and 15 years were reported.

CONCLUSIONS

These data confirm excellent rates of local control, disease-free survival, and overall survival at 10 and 15 years following BCS and RT for Paget disease of the breast. This study continues to support the recommendation of local excision and definitive breast irradiation as an alternative to mastectomy in the treatment of patients with Paget disease presenting without a palpable mass or mammographic density.

Differences in the pathologic and molecular features of intraductal breast carcinoma between younger and older women

BACKGROUND

Patients diagnosed with ductal carcinoma in situ (DCIS) at a young age appear to have a different natural history and biology, including a higher local relapse rate, than patients diagnosed later in life. The current study compared various pathologic and molecular features of DCIS arising in a cohort of young women with those of DCIS arising in a cohort of older women to identify potential biologic differences between these two populations of patients.

METHODS

The study population consisted of 20 patients age < 42 years and 34 patients age > 60 years who were treated at Yale University School of Medicine with breast-conserving therapy (BCT) and whose archival paraffin blocks were available and had sufficient tumor for staining. The original slides from each case were reviewed and the most representative specimen block from each case was processed for immunohistochemical staining. Pathologic characteristics evaluated for each case included histology, grade, and presence of necrosis. Paraffin-embedded sections were immunohistochemically evaluated for expression of HER-2/neu, estrogen receptor (ER), progesterone receptor (PR), bcl-2, cyclin D1, Ki-67, and p53.

RESULTS

Although there was no difference in pathologic features of the tumors between the two groups, HER-2/neu was found to be overexpressed in a greater percentage of the younger population (P = 0.06). There was no apparent difference in expression of the other markers. Of note, HER-2/neu expression was correlated with high nuclear grade (P = 0.004), necrosis (P = 0.06), and ER and PR negativity (P = 0.01 and P = 0.03, respectively) in the combined population.

CONCLUSIONS

The current study data suggested that HER-2/neu overexpression in younger patients may characterize a biologic difference in their tumor and may partially contribute to their higher risk of recurrence. Further studies are needed to assess whether this difference holds independent of grade and to evaluate the prognostic significance of HER-2/neu overexpression in DCIS.

A comparison of risk perception and psychological morbidity in women with ductal carcinoma in situ and early invasive breast cancer

PURPOSE

To assess how women with ductal carcinoma in situ (DCIS) perceive their risks of recurrence, dying from breast cancer, and psychological distress compared to women with early stage invasive breast cancer (EIBC).

PATIENTS AND METHODS

Eligible patients included those with DCIS or EIBC (T1 or T2, N0) referred to one cancer center between November 1998 and June 1999. Participants completed a self-administered survey regarding their views of their risks of developing recurrent cancer, of dying of breast cancer and the presence of psychological symptoms of distress. Responses were scored and compared between the two groups.

RESULTS

In total, 495 patients were screened, 240 found ineligible, 228 patients who agreed to participate. No significant difference between the two groups was observed in perceptions of risk related to the likelihood of developing local recurrence (DCIS: 53%, EIBC 45%, P = 0.14), distant recurrence (DCIS: 36%; EIBC: 39%, P = 0.35) or dying of breast cancer (DCIS: 27%, EIBC 27%, P = 0.5). Both groups expressed similar levels of psychological distress (anxiety, DCIS: 56%, EIBC 54%, P = 0.38; depression, DCIS: 41%, EIBC, 48%, P = 0.17).

CONCLUSIONS

Despite the excellent prognosis, women with DCIS express serious concerns and report similar psychological morbidity as women with invasive cancer.

Factors associated with residual disease on re-excision in patients with ductal carcinoma in situ of the breast

PURPOSE

This study examines the factors associated with the presence of residual disease at re-excision in patients with ductal carcinoma in situ of the breast.

METHODS

Of 143 consecutive patients undergoing breast conservation treatment from 1990 to 1999, 90 patients (63%) underwent re-excision of the tumor bed. Grade was recorded in 70% (N = 63), size in 78% (N = 70), margin status in 96% (N = 86), volume of excision in 90% (N = 81), and extent of residual disease in 99% (N = 89).

RESULTS

There was no significant correlation between extent of residual disease on re-excision and method of detection, tumor size, histology, grade, or first margin status. Of patients undergoing re-excision, 56% (N = 50) had no residual disease, 38% (N = 34) had minimal microscopic residual disease, and only 6% (N = 5) had either extensive microscopic or gross residual disease. For these five patients, the median volume of first excision was similar to that of the other patients (26 vs 36 cc), but the median volume of second excision was smaller (33 vs 63 cc). The median age for these five patients was 41 years, compared with 55 years for the remaining patients. All five patients had comedo (N = 4) or solid tumor (N = 1) histology, with grade 3 (N = 3) or unknown grade (N = 2).

DISCUSSION

Patients with extensive microscopic disease or gross residual at the time of re-excision would be at increased risk for local recurrence after conventional radiation treatment if re-excision had not been performed. Only 6% of patients in this study had such pathology findings. No factor predicted for these adverse pathology findings, although these patients tended to be younger, with high-grade or comedo histology.

Surgical margins in patients with early-stage breast cancer treated with breast conservation therapy

BACKGROUND

Patients receiving breast conservation therapy have a lifelong risk of local recurrence. To minimize this risk, surgeons have explored various approaches to examining the surgical margins of the resection specimen. If tumor cells are found at the margin, there is a high probability that residual tumor remains in the surgical cavity. This review examines published reports about standard and innovative approaches to assessing surgical margins, the clinical significance of margin size, and risk factors for positive margins.

METHODS

Published literature abstracted in Medline was reviewed using the Gateway site from the National Library of Medicine.

CONCLUSIONS

It is still not clear whether obtaining a radical margin will decrease the rate of local recurrence after breast conserving surgery. What is clear is that it is absolutely unacceptable to have tumor cells directly at the cut edge of the excised specimen, regardless of the type of post-surgical adjuvant therapy.

Age as a predictor of outcome for women with DCIS treated with breast-conserving surgery and radiation: The University of Texas M. D. Anderson Cancer Center experience

PURPOSE

To analyze the long-term outcome of breast conservation therapy in patients with ductal carcinoma in situ (DCIS) in a single institution and to analyze the prognostic importance, if any, of young patient age.

METHODS AND MATERIALS

The hospital records of 150 patients with DCIS treated with surgical excision and radiotherapy at our institution between 1980 and 1997 were retrospectively reviewed. For most of the patients, intraoperative specimen radiographs or postoperative mammograms were available for use in assessing that an adequate surgical resection had been performed. The median patient age was 53 years (range 32-81), with 13% of patients <or=40 years old.

RESULTS

At a median follow-up of 63 months, 12 patients had local disease recurrence. The actuarial rate of local recurrence-free survival at 5 and 10 years was 96% and 88%, respectively. Local recurrence correlated with nuclear grade (p = 0.002) but was not associated with patient age at diagnosis (<40 years vs. >or=40 years, p = 0.39). In all cases of local recurrence, patients underwent surgery with or without chemotherapy, and disease control was achieved.

CONCLUSION

The results of this study demonstrate high rates of long-term overall survival, disease-specific survival, and local control in patients with DCIS of the breast treated conservatively with segmental mastectomy and radiotherapy. On the basis of the excellent long-term local control and 100% disease-specific survival rates, we found that patient age does not affect the outcome if the margins are clear. Continued studies in young patients treated with breast conservative therapy for DCIS are needed.

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.

Age at diagnosis and outcome for women with ductal carcinoma-in-situ of the breast: a critical review of the literature

PURPOSE

Patients younger than 35 to 45 years old at the time of diagnosis of invasive breast cancer have been found to have a worse prognosis than older patients in many studies. However, the impact of patient age at diagnosis on the outcome of treatment with either lumpectomy and radiation therapy (RT) or mastectomy for patients with ductal carcinoma-in-situ (DCIS) of the breast has not been extensively analyzed.

MATERIALS AND METHODS

Articles addressing the effect of patient age at diagnosis on the outcome of treatment of DCIS with lumpectomy and RT or mastectomy were identified through the MEDLINE and CancerLit databases and reference lists of relevant articles. Studies were reviewed to determine the impact of patient age at diagnosis on clinical and pathologic features of DCIS, the influence of age on outcome after lumpectomy and RT, and the impact of age on outcome after mastectomy.

RESULTS

DCIS in younger patients more frequently contains adverse prognostic pathologic factors and extends over a greater distance in the breast than in older patients. In series with adequate follow-up, younger patients treated with lumpectomy and RT had a significantly higher rate of local recurrence than older patients, especially for invasive local recurrences. Some studies have suggested that careful attention to margin status and excising larger volumes of tissue can reduce this difference substantially. No available data show that younger patients have better long-term cancer-free survival rates if treated by mastectomy rather than lumpectomy and RT.

CONCLUSION

Successful treatment of younger patients with DCIS with lumpectomy and RT requires careful attention to patient evaluation, selection, and surgical technique. When this is done, age at diagnosis should not be a contraindication to breast-conserving therapy.

Ductal carcinoma in situ of the breast results of conservative and radical treatments in 716 patients

Until now, less than 5% of the patients with breast ductal carcinoma in situ (DCIS) have been enrolled in clinical trials. Consequently, we have analysed the results of "current practice" among 716 women treated in eight French Cancer Centres from 1985 to 1992: 441 cases (61.6%) corresponded to impalpable lesions, 92 had a clinical size of less than or equal to 2 cm and 70 from 2 to 5 cm; in 113 cases, the size was unspecified. Median age was 53.2 years (range: 21-87 years). 145 patients underwent mastectomy (RS) and 571 conservative surgery (CS) without (136) or with (435) radiotherapy (CS+RT). The mean histological tumour sizes in these three groups were 25.6, 8.2, 14.8 mm, respectively (P<0.0001). After a 91-month median follow-up, local recurrence (LR) rates were 2.1, 30.1 and 13.8% in the RS, CS and CS +RT groups, respectively (P=0.001); LR were invasive in 59 and 60% in the CS and CS+RT groups, respectively. In these groups, the 8-year LR rates were 31.3 and 13.9%, respectively (P=0.0001). Nodal recurrence occurred in 3.7 and 1.8% in the CS and CS+RT groups. Metastases rates were 1.4, 4.4 and 1.4% in the RS, CS and CS+RT groups. Among the 60 cases of invasive LR, in CS and CS+RT groups 19% developed metastases. After multivariate analysis, we did not identify any significant LR risk factor in the CS group, whereas young age (<40 years) and incomplete excision were significant in the CS+RT group (P=0.012 and P=0.02, respectively).