The Diagnosis and Treatment of Ductal Carcinoma In Situ of the Breast

Genetic Polymorphism and Expression of CXCR4 in Breast Cancer

CXCR4 genetic polymorphisms, as well as their expression level, have been associated with cancer development and prognosis. The present study aimed to investigate the influence of CXCR4 rs2228014 polymorphism on its mRNA and protein expression in breast cancer samples. It was observed that patients presented higher CXCR4 mRNA relative expression (5.7-fold) than normal mammary gland, but this expression was not correlated with patients clinicopathological features (nuclear grade, nodal status, ER status, PR status, p53 staining, Ki67 index, and HER-2 status). Moreover, CXCR4 mRNA relative expression also did not differ regarding the presence or absence of T allele (p = 0.301). In the immunohistochemical assay, no difference was observed for CXCR4 cytoplasmic protein staining in relation to different genotypes (p = 0.757); however, high cytoplasmic CXCR4 staining was verified in invasive breast carcinoma (p < 0.01). All in all, the results from present study indicated that rs2228014 genetic variant does not alter CXCR4 mRNA or protein expression. However, this receptor was more expressed in tumor compared to normal tissue, in both RNA and protein levels, suggesting its promising applicability in the general context of mammary carcinogenesis.

The management of preinvasive breast cancer

SUMMARY Ductal carcinoma in situ (DCIS) is a preinvasive breast cancer in which the proliferations of malignant ductal epithelial cells have not breached the ductal basement membrane. Currently there is controversy over the optimum management of DCIS, with suggestions that there may be an element of ‘overdiagnosis’ of some low-risk cases that may never progress to invasive cancer within a patient’s lifetime. This review discusses the biology and natural history of DCIS and current management strategies, addresses the risk factors for recurrence and how these can be minimized, highlights areas of controversy and suggest the possible direction of future research.

Ductal carcinoma in situ with microinvasion: Clinicopathologic study and biopathologic profile

Data regarding the biologic behavior and surgical management, in particular the axillary lymph node excision, of ductal carcinoma in situ with microinvasion (DCIS-MI) are controversial. Therefore, we decided to study the histopathologic characteristics, the biopathologic profile, as well as the follow-up of a group of patients with DCIS-MI. Thirty-one cases of DCIS-MI, 21 of whom were treated with axillary lymph node dissection, were studied. All cases were classified according to the Van Nuys classification, and the extension of DCIS was quantified. The biopathologic profile (ER, PR, MIB 1, p53, c-erbB-2) as well as the follow-up was also investigated. The results did not reveal any statistically significant differences between the two groups, and there was no statistically significant relationship between the extension of DCIS and the number of microinvasion (MI) foci or maximum MI diameter, or between Van Nuys classification of DCIS and again the number of MI foci or maximum MI diameter. DCIS-MI seems associated with good prognosis. None of the patients had relapses or metastases. Our data seem to suggest that the natural history of DCIS-MI resembles DCIS, and we, therefore, suggest that all the surgically removed area should be examined histologically to avoid missing foci of infiltrating breast cancer larger than 1mm.

Outcome of patients with ductal carcinoma in situ untreated after diagnostic biopsy

BACKGROUND

Studies of patients with ductal carcinoma in situ (DCIS) "treated" by diagnostic biopsy alone have been rare, but provide important opportunities to gain insights into the natural history of these lesions.

METHODS

During a review of 1877 breast biopsy specimens in a nested case-control study of benign breast disease and breast carcinoma risk, the authors identified 13 biopsy specimens with DCIS that were originally diagnosed as benign. Because each of these women was initially given a benign diagnosis, they received no treatment beyond the diagnostic biopsy.

RESULTS

When compared with women with nonproliferative lesions, the odds ratio (OR) for the development of invasive breast carcinoma among those with retrospectively identified DCIS (n = 6) was 13.5 (95% confidence interval [CI], 3.7-49.7). The OR for the development of any subsequent invasive or in situ breast carcinoma event (n = 10) was 20.1 (95% CI, 6.1-66. 5). A retrospective review of these DCIS biopsy specimens revealed that the nuclear grade was low in four lesions, intermediate in six, and high in three. None showed comedo-type necrosis. Invasive carcinomas developed among women with DCIS of all nuclear grades. All 10 breast carcinoma events (100%) were in the ipsilateral breast.

CONCLUSIONS

These results provided further evidence that patients with DCIS who received no treatment beyond a diagnostic biopsy were at substantially increased risk for developing ipsilateral invasive breast carcinoma, and that the increased risk in this setting was seen in DCIS of low, intermediate, and high nuclear grades.

Histological markers that predict clinical recurrence in ductal carcinoma in situ of the breast: an Australian population-based study

AIMS

The incidence of ductal carcinoma in situ (DCIS) has increased substantially since the advent of widespread screening mammography. Identification of histological markers that predict recurrent disease is essential for optimal treatment management. To assist the clinico-pathological stratification of DCIS, we sought to determine histological markers of recurrence in DCIS in an Australian population-based series.

METHODS

In a study of all DCIS reported in Victoria between 1988 and 1992, managed by breast conserving therapy (wide local excision or subtotal mastectomy) with or without adjuvant radiotherapy and/or hormonal therapy, the histological features of DCIS lesions with subsequent ipsilateral recurrence as in situ or invasive breast cancer were compared with a similarly managed control group of DCIS without recurrence.

RESULTS

Large lesion size, presence of nuclear pleomorphism, absence of cellular polarisation and extensive necrosis were all significant predictors of recurrence (P<0.05). Primary and recurrent DCIS lesions had similar morphological features, and invasive recurrence was characterised by ductal type with high nuclear grade.

CONCLUSION

This study identifies histological markers in DCIS associated with recurrence in an Australian population, and demonstrates similar histological appearances between primary and secondary lesions. These histological characteristics may be used to stratify DCIS subtypes and facilitate the future optimisation of disease management.

Oestrogen receptor negativity as a marker for high-grade ductal carcinoma in situ of the breast

AIMS

To compare the morphological and immunohistochemical characteristics of oestrogen receptor (ER)-negative and ER-positive ductal carcinoma in situ (DCIS) of the breast, in an attempt to establish more objective criteria for the classification of DCIS.

METHODS AND RESULTS

Sections of 64 cases of in-situ carcinoma of the breast were stained for ER, progesterone receptors (PgR), androgen receptors (AR), c-erbB-2 and p53, using the immunoperoxidase technique. The cases included 60 DCIS and four lobular carcinoma in situ (LCIS). Four DCIS lesions were associated with foci of microinvasion. The 60 DCIS cases included 31 high grade, 23 intermediate grade and six low grade. Twenty-four DCIS cases (40%) were ER-negative and 36 were positive. ER negativity was significantly associated with high nuclear grade (88% versus 27% for ER-positive cases, P < 0.001), PgR negativity (100% versus 25%, P < 0.001), c-erbB-2 positivity (79% versus 14%, P < 0.001) and p53 positivity (58% versus 6%, P < 0.001). There was no difference between ER-negative and -positive DCIS as regards AR expression, with 91% of cases in each group being AR-positive. Of the four cases of DCIS with microinvasion, three were ER- and PgR-negative, all four were c-erbB-2-positive and AR-positive and one was p53-positive. None of the four LCIS was ER, PgR or AR-negative and none was c-erbB-2- or p53-positive.

CONCLUSIONS

There is a highly significant direct relationship between ER negativity in DCIS and high nuclear grade, PgR negativity and c-erbB-2 and p53 positivity. We suggest that immunohistological assessment of ER status may help in providing a more objective way of classifying DCIS.

Biological markers that predict clinical recurrence in ductal carcinoma in situ of the breast

The optimal management of ductal carcinoma in situ (DCIS) is controversial, due in part to our poor understanding of its natural history. We undertook to identify subgroups of DCIS based on the expression of biomarkers, which were related to the likelihood of clinical recurrence. Biomarker expression of a total of 95 DCIS lesions in a nested case-control study within a population-based cohort with up to 135 months follow-up data (median 101 months) was analysed using immunohistochemistry. ERBB2-positivity and bcl-2-, oestrogen receptor (ER)- and progesterone receptor (PR)-negativity were individually associated with the risk of clinical recurrence. The predictive value of these biomarkers was independent of cytonuclear grade. ERBB2, bcl-2, ER and PR expression were conserved in the recurrent lesions, including subsequent invasive cancers. p21-positive DCIS was also associated with clinical recurrence, independently of the associations with ERBB2/bcl-2/ER/PR expression. These data identify clinically and biologically relevant subcategories of DCIS lesions, an essential basis for improving management.

Management of women with ductal carcinoma in situ of the breast: a population-based study

BACKGROUND

Increasing incidence of ductal carcinoma in situ (DCIS) confronts patients and clinicians with optimal treatment decisions. This multidisciplinary study investigates therapeutic modalities of DCIS in daily practice and provides recommendations on how to increase quality of care.

PATIENTS AND METHODS

All women (n = 116) with unilateral DCIS recorded in the Geneva Cancer Registry from 1995 to 1999 were considered. Information concerned patient and tumor characteristics, treatment and outcome. Factors linked to therapy were determined using a case-control approach. Cases were women with treatment of interest and controls other women on the study.

RESULTS

Most DCIS cases (62%) were discovered by mammography screening. Ninety (78%) women had breast-conserving surgery (BCS), 18 (16%) mastectomy and seven (6%) bilateral mastectomy. Eight (7%) patients had tumor-positive margins, 18 (16%) lymph node dissection and two (1.7%) chemotherapy. Twenty-five per cent of women with BCS had no radiotherapy, three had radiotherapy after mastectomy. Less than 50% underwent breast reconstruction after mastectomy. Method of discovery, multifocality, tumor localization, size and differentiation were linked to the use of BCS or lymph node dissection.

CONCLUSIONS

Because of important disparities in DCIS management, recommendations are made to increase quality of care, in particular to prevent axillary dissection or bilateral mastectomy and to increase the use of radiotherapy after BCS.