Ductal Carcinoma in Situ: Current Concepts in Biology, Imaging, and Treatment

Improving the diagnosis of ductal carcinoma in situ with microinvasion without immunohistochemistry: An innovative method with H&E-stained and multiphoton microscopy images

Ductal carcinoma in situ with microinvasion (DCISM) is a challenging subtype of breast cancer with controversial invasiveness and prognosis. Accurate diagnosis of DCISM from ductal carcinoma in situ (DCIS) is crucial for optimal treatment and improved clinical outcomes. However, there are often some suspicious small cancer nests in DCIS, and it is difficult to diagnose the presence of intact myoepithelium by conventional hematoxylin and eosin (H&E) stained images. Although a variety of biomarkers are available for immunohistochemical (IHC) staining of myoepithelial cells, no single biomarker is consistently sensitive to all tumor lesions. Here, we introduced a new diagnostic method that provides rapid and accurate diagnosis of DCISM using multiphoton microscopy (MPM). Suspicious foci in H&E-stained images were labeled as regions of interest (ROIs), and the nuclei within these ROIs were segmented using a deep learning model. MPM was used to capture images of the ROIs in H&E-stained sections. The intensity of two-photon excitation fluorescence (TPEF) in the myoepithelium was significantly different from that in tumor parenchyma and tumor stroma. Through the use of MPM, the myoepithelium and basement membrane can be easily observed via TPEF and second-harmonic generation (SHG), respectively. By fusing the nuclei in H&E-stained images with MPM images, DCISM can be differentiated from suspicious small cancer clusters in DCIS. The proposed method demonstrated good consistency with the cytokeratin 5/6 (CK5/6) myoepithelial staining method (kappa coefficient = 0.818).

Prediction of Surgical Upstaging Risk of Ductal Carcinoma In Situ Using Machine Learning Models

Objective

The purpose of this study was to build machine learning models to predict surgical upstaging risk of ductal carcinoma in situ (DCIS) to invasive cancer and to compare model performance to eligibility criteria used by the Comparison of Operative versus Monitoring and Endocrine Therapy (COMET) active surveillance trial.

Methods

Medical records were retrospectively reviewed of all women with DCIS at core-needle biopsy who underwent surgery from 2007 to 2016 at an academic medical center. Multivariable regression and machine learning models were developed to evaluate upstaging-related features and their performance was compared with that achieved using the COMET trial eligibility criteria.

Results

Of 1387 women (mean age, 57 years; range, 27-89 years), the upstaging rate of DCIS was 17% (235/1387). On multivariable analysis, upstaging-associated features were presentation of DCIS as a palpable area of concern, imaging finding of a mass, and nuclear grades 2 or 3 at biopsy (P < 0.05). If COMET trial eligibility criteria were applied to our study cohort, then 496 women (42%, 496/1175) would have been eligible for the trial, with an upstaging rate of 12% (61/496). Of the machine learning models, none had a significantly lower upstaging rate than 12%. However, if using the models to determine eligibility, then a significantly larger proportion of women (56%-87%) would have been eligible for active surveillance.

Conclusion

Use of machine learning models to determine eligibility for the COMET trial identified a larger proportion of women eligible for surveillance compared with current eligibility criteria while maintaining similar upstaging rates.

Ipsilateral tumor recurrence risk in women with ductal carcinoma in situ: application of the Van Nuys Prognostic Index and the Memorial Sloan Kettering Cancer Center nomogram

PURPOSE

To apply the Van Nuys Prognostic Index (VNPI) and the Memorial Sloan Kettering Cancer Center (MSKCC) ductal carcinoma in situ (DCIS) nomogram to DCIS patients with known long-term outcomes.

METHODS

A retrospective review was performed of consecutive patients diagnosed with DCIS from 2007 to 2014. Included patients underwent breast-conserving surgery (BCS) and were followed with imaging for at least five years. For each patient, the VNPI and MSKCC nomogram risk estimates were determined. In addition, variables used in both models were compared between women with and without recurrences using the Wilcoxon signed-rank test and the Pearson's chi-squared test.

RESULTS

Over the eight-year period, 456 women (average age 57 years, range 30-87) underwent BCS for DCIS. Thirty-one (6.8%) experienced an ipsilateral recurrence. The average VNPI scores were 7 (range 5-9) and 7 (range 4-10) for women with and without a recurrence (p = 0.14), respectively, with 4-6, 7-9, and 10-12 being the low, moderate, and high-risk groups, respectively. Per the MSKCC nomogram, the average five-year recurrence risks were 5% (range 1-12%) and 4% (range 1-38%) for women with and without a recurrence (p = 0.09), respectively. The recurrence risk-related variables were younger patient age, need for one or more re-excision surgeries, and use of endocrine therapy for 0 to less than five years after surgery.

CONCLUSION

Ipsilateral tumor recurrence risk estimates based on the VNPI and MSKCC nomogram are similar between women with DCIS who did and did not have a recurrence, suggesting that more robust prognostic models are needed.

Role of combined clinical-radiomics model based on contrast-enhanced MRI in predicting the malignancy of breast non-mass enhancements without an additional diffusion-weighted imaging sequence

Background

In our previous study, we developed a combined diagnostic model based on time-intensity curve (TIC) types and radiomics signature on contrast-enhanced magnetic resonance imaging (CE-MRI) for non-mass enhancement (NME). The model had a high diagnostic ability for differentiation without the additional diffusion-weighted imaging (DWI) sequence. In this study, we aimed to compare the diagnostic performance of the combined clinical-radiomics model based on CE-MRI and DWI in discriminating Breast Imaging-Reporting and Data System (BI-RADS) 4 NME breast lesions, ductal carcinoma in situ (DCIS), and invasive carcinoma.

Methods

This retrospective study enrolled 364 NME lesions (343 patients). Of these, 183 malignant and 84 benign breast lesions classified as BI-RADS 4 NMEs by the initial diagnosis were reclassified based on the combined clinical-radiomics model and DWI, respectively. The nomogram score (NS) values for malignancy risk derived from the combined clinical-radiomics model and the minimal apparent diffusion coefficient (ADC) values from DWI were calculated and compared. The percentage of false positives were estimated in comparison with the original classification. Receiver operating characteristic (ROC) curve analysis was performed to determine the diagnostic value of the NS and minimal ADC values in distinguishing benign and malignant lesions, DCIS, and invasive breast carcinoma. An ablation experiment was used to test the value of the additional DWI sequence.

Results

The diagnostic value of the NS values [area under curve (AUC) =0.843; 95% CI: 0.789-0.896] for discriminating the 267 NME breast lesions categorized as BI-RADS 4 was significantly higher than the minimal ADC values (AUC =0.662; 95% CI: 0.590-0.735). The NS values showed higher sensitivity, specificity, and accuracy compared with the minimal ADC values (sensitivity: 80.3% vs. 65.6%; specificity: 79.8% vs. 65.5%; accuracy: 80.1% vs. 65.5%). The NS values and minimal ADC values did not achieve high diagnostic accuracy in discriminating between DCIS and invasive cancer. However, the diagnostic performance of the combined NS-ADC model (AUC =0.731; 95% CI: 0.655-0.806) was higher than that of the NS values alone (P=0.008) and comparable to that of the minimal ADC values (P=0.440).

Conclusions

The combined clinical-radiomics model based on CE-MRI could improve the diagnostic performance in discriminating the BI-RADS 4 NME lesions without an additional DWI sequence. However, DWI may improve the diagnostic performance in discriminating DCIS from invasive cancer.

The added value of apparent diffusion coefficient and microcalcifications to the Kaiser score in the evaluation of BI-RADS 4 lesions

PURPOSE

To explore the added value of combining microcalcifications or apparent diffusion coefficient (ADC) with the Kaiser score (KS) for diagnosing BI-RADS 4 lesions.

METHODS

This retrospective study included 194 consecutive patients with 201 histologically verified BI-RADS 4 lesions. Two radiologists assigned the KS value to each lesion. Adding microcalcifications, ADC, or both these criteria to the KS yielded KS1, KS2, and KS3, respectively. The potential of all four scores to avoid unnecessary biopsies was assessed using the sensitivity and specificity. Diagnostic performance was evaluated by the area under the curve (AUC) and compared between KS and KS1.

RESULTS

The sensitivity of KS, KS1, KS2, and KS3 ranged from 77.1% to 100.0%.KS1 yielded significantly higher sensitivity than other methods (P < 0.05), except for KS3 (P > 0.05), most of all, when assessing NME lesions. For mass lesions, the sensitivity of these four scores was comparable (p > 0.05). The specificity of KS, KS1, KS2, and KS3 ranged from 56.0% to 69.4%, with no statistically significant differences(P > 0.05), except between KS1 and KS2 (p < 0.05).The AUC of KS1 (0.877) was significantly higher than that of KS (0.837; P = 0.0005), particularly for assessing NME (0.847 vs 0.713; P < 0.0001).

CONCLUSION

KS can stratify BI-RADS 4 lesions to avoid unnecessary biopsies. Adding microcalcifications, but not adding ADC, as an adjunct to KS improves diagnostic performance, particularly for NME lesions. ADC provides no additional diagnostic benefit to KS. Thus, only combining microcalcifications with KS is most conducive to clinical practice.

Imaging findings for response evaluation of ductal carcinoma in situ in breast cancer patients treated with neoadjuvant systemic therapy: a systematic review and meta-analysis

OBJECTIVES

In approximately 45% of invasive breast cancer (IBC) patients treated with neoadjuvant systemic therapy (NST), ductal carcinoma in situ (DCIS) is present. Recent studies suggest response of DCIS to NST. The aim of this systematic review and meta-analysis was to summarise and examine the current literature on imaging findings for different imaging modalities evaluating DCIS response to NST. More specifically, imaging findings of DCIS pre- and post-NST, and the effect of different pathological complete response (pCR) definitions, will be evaluated on mammography, breast MRI, and contrast-enhanced mammography (CEM).

METHODS

PubMed and Embase databases were searched for studies investigating NST response of IBC, including information on DCIS. Imaging findings and response evaluation of DCIS were assessed for mammography, breast MRI, and CEM. A meta-analysis was conducted per imaging modality to calculate pooled sensitivity and specificity for detecting residual disease between pCR definition no residual invasive disease (ypT0/is) and no residual invasive or in situ disease (ypT0).

RESULTS

Thirty-one studies were included. Calcifications on mammography are related to DCIS, but can persist despite complete response of DCIS. In 20 breast MRI studies, an average of 57% of residual DCIS showed enhancement. A meta-analysis of 17 breast MRI studies confirmed higher pooled sensitivity (0.86 versus 0.82) and lower pooled specificity (0.61 versus 0.68) for detection of residual disease when DCIS is considered pCR (ypT0/is). Three CEM studies suggest the potential benefit of simultaneous evaluation of calcifications and enhancement.

CONCLUSIONS AND CLINICAL RELEVANCE

Calcifications on mammography can remain despite complete response of DCIS, and residual DCIS does not always show enhancement on breast MRI and CEM. Moreover, pCR definition effects diagnostic performance of breast MRI. Given the lack of evidence on imaging findings of response of the DCIS component to NST, further research is demanded.

KEY POINTS

• Ductal carcinoma in situ has shown to be responsive to neoadjuvant systemic therapy, but imaging studies mainly focus on response of the invasive tumour. • The 31 included studies demonstrate that after neoadjuvant systemic therapy, calcifications on mammography can remain despite complete response of DCIS and residual DCIS does not always show enhancement on MRI and contrast-enhanced mammography. • The definition of pCR has impact on the diagnostic performance of MRI in detecting residual disease, and when DCIS is considered pCR, pooled sensitivity was slightly higher and pooled specificity slightly lower.

Active Surveillance for Atypical Ductal Hyperplasia and Ductal Carcinoma In Situ

Atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS) are relatively common breast lesions on the same spectrum of disease. Atypical ductal hyperblasia is a nonmalignant, high-risk lesion, and DCIS is a noninvasive malignancy. While a benefit of screening mammography is early cancer detection, it also leads to increased biopsy diagnosis of noninvasive lesions. Previously, treatment guidelines for both entities included surgical excision because of the risk of upgrade to invasive cancer after surgery and risk of progression to invasive cancer for DCIS. However, this universal management approach is not optimal for all patients because most lesions are not upgraded after surgery. Furthermore, some DCIS lesions do not progress to clinically significant invasive cancer. Overtreatment of high-risk lesions and DCIS is considered a burden on patients and clinicians and is a strain on the health care system. Extensive research has identified many potential histologic, clinical, and imaging factors that may predict ADH and DCIS upgrade and thereby help clinicians select which patients should undergo surgery and which may be appropriate for active surveillance (AS) with imaging. Additionally, multiple clinical trials are currently underway to evaluate whether AS for DCIS is feasible for a select group of patients. Recent advances in MRI, artificial intelligence, and molecular markers may also have an important role to play in stratifying patients and delineating best management guidelines. This review article discusses the available evidence regarding the feasibility and limitations of AS for ADH and DCIS, as well as recent advances in patient risk stratification.

An untrained deep learning method for reconstructing dynamic MR images from accelerated model-based data

PURPOSE

To implement physics-based regularization as a stopping condition in tuning an untrained deep neural network for reconstructing MR images from accelerated data.

METHODS

The ConvDecoder (CD) neural network was trained with a physics-based regularization term incorporating the spoiled gradient echo equation that describes variable-flip angle data. Fully-sampled variable-flip angle k-space data were retrospectively accelerated by factors of R = {8, 12, 18, 36} and reconstructed with CD, CD with the proposed regularization (CD + r), locally low-rank (LR) reconstruction, and compressed sensing with L1-wavelet regularization (L1). Final images from CD + r training were evaluated at the "argmin" of the regularization loss; whereas the CD, LR, and L1 reconstructions were chosen optimally based on ground truth data. The performance measures used were the normalized RMS error, the concordance correlation coefficient, and the structural similarity index.

RESULTS

The CD + r reconstructions, chosen using the stopping condition, yielded structural similarity indexs that were similar to the CD (p = 0.47) and LR structural similarity indexs (p = 0.95) across R and that were significantly higher than the L1 structural similarity indexs (p = 0.04). The concordance correlation coefficient values for the CD + r T1 maps across all R and subjects were greater than those corresponding to the L1 (p = 0.15) and LR (p = 0.13) T1 maps, respectively. For R ≥ 12 (≤4.2 min scan time), L1 and LR T1 maps exhibit a loss of spatially refined details compared to CD + r.

CONCLUSION

The use of an untrained neural network together with a physics-based regularization loss shows promise as a measure for determining the optimal stopping point in training without relying on fully-sampled ground truth data.

Value of multimodal imaging in the diagnosis of breast sclerosing adenosis associated with malignant lesions

AIM

To explore the diagnostic value of multimodal imaging techniques, including automatic breast volume scanner (ABVS), mammography (MG), and magnetic resonance (MRI) in breast sclerosing adenosis (SA) associated with malignant lesions.

METHODS

From January 2018 to October 2020, 76 patients (88 lesions) with pathologically confirmed as SA associated with malignant or benign lesions were retrospective analyzed. All patients completed ABVS examination, 58 patients (67 lesions) with MG and 50 patients (62 lesions) with MRI were also completed before biopsy or surgical excision, of which, six patients (eight lesions) diagnosed as Breast Imaging Reporting and Data System (BI-RADS) category 3 by all imaging examinations underwent surgical excision without biopsy, other 70 patients (80 lesions) with BI-RADS category 4 or above by any imaging examination completed biopsy, including 65 patients (75 lesions) were further surgical excised and the other five patients (five lesions) were just followed up. All lesions were retrospectively described and classified, and were divided into benign group and malignant group according to their pathological results. Image features of different examination methods between the two groups were compared and analyzed. A ROC curve was established using the sensitivity of BI-RADS categories to predict malignant lesions in different imaging techniques as the ordinate and 1-specificity as the abscissa.

RESULTS

88 lesions including 26 purely SA and 45 SA associated with benign lesions were classified as benign group, and the remaining 17 SA associated with malignant lesions were classified as malignant group. On ABVS, 40 mass lesions, their heterogeneous echo, not circumscribed margin and coronal convergence signs were statistically significant for malignant lesions (p < .05), but the remain 48 nonmass lesions lack specific sonographic features. On MG, 12 showed negative results, 55 showed with microcalcification, mass, structural distortion, and asymmetric density shadow, of which 11 lesions had the above two signs at the same time, but only microcalcification had statistical difference between the two groups. 35 mass enhanced lesions and 27 nonmass enhanced lesions on MRI, but there were no significant difference between their pathological results. Time signal intensity curves showed no differences, but ADC value <1.10 × 10^-3  mm² /s is more significant in malignant lesions (p < .05). The area under the ROC curve (AUC) of BI-RADS classification of ABVS, MG, and MRI in the diagnosis of malignant lesions were 0.611, 0.474, and 0.751, respectively, and the AUC of the combined diagnosis of the three was 0.761.

CONCLUSION

Mass lesions with heterogeneous echo, not circumscribed margin and coronal convergence sign on ABVS, microcalcification on MG and the ADC value <1.10 × 10^-3  mm² /s on MRI are significant signs for SA associated with malignant lesions. The combined diagnosis of the three methods was the highest, and the following were MRI, ABVS, and MG. Therefore, be cognizant of significant characteristics in SA associated with malignancy showed in different imaging examinations can improve the preoperative evaluation of SA and better provide basis for subsequent clinical decision-making.

PSHG-TISS: A collection of polarization-resolved second harmonic generation microscopy images of fixed tissues

Second harmonic generation (SHG) microscopy is acknowledged as an established imaging technique capable to provide information on the collagen architecture in tissues that is highly valuable for the diagnostics of various pathologies. The polarization-resolved extension of SHG (PSHG) microscopy, together with associated image processing methods, retrieves extensive image sets under different input polarization settings, which are not fully exploited in clinical settings. To facilitate this, we introduce PSHG-TISS, a collection of PSHG images, accompanied by additional computationally generated images which can be used to complement the subjective qualitative analysis of SHG images. These latter have been calculated using the single-axis molecule model for collagen and provide 2D representations of different specific PSHG parameters known to account for the collagen structure and distribution. PSHG-TISS can aid refining existing PSHG image analysis methods, while also supporting the development of novel image processing and analysis methods capable to extract meaningful quantitative data from the raw PSHG image sets. PSHG-TISS can facilitate the breadth and widespread of PSHG applications in tissue analysis and diagnostics.

Measurement(s)	Type I Collagen
Technology Type(s)	multi-photon laser scanning microscopy
Factor Type(s)	second order susceptibility tensor elements
Sample Characteristic - Organism	Homo sapiens
Sample Characteristic - Environment	laboratory environment
Sample Characteristic - Location	Romania

Finite Element Modeling of Quantitative Ultrasound Analysis of the Surgical Margin of Breast Tumor

Ultrasound is commonly used as an imaging tool in the medical sector. Compared to standard ultrasound imaging, quantitative ultrasound analysis can provide more details about a material microstructure. In this study, quantitative ultrasound analysis was conducted through computational modeling to detect various breast duct pathologies in the surgical margin tissue. Both pulse-echo and pitch-catch methods were evaluated for a high-frequency (22–41 MHz) ultrasound analysis. The computational surgical margin modeling was based on various conditions of breast ducts, such as normal duct, ductal hyperplasia, DCIS, and calcification. In each model, ultrasound pressure magnitude variation in the frequency spectrum was analyzed through peak density and mean-peak-to-valley distance (MPVD) values. Furthermore, the spectral patterns of all the margin models were compared to extract more pathology-based information. For the pitch-catch mode, only peak density provided a trend in relation to different duct pathologies. For the pulse-echo mode, only the MPVD was able to do that. From the spectral comparison, it was found that overall pressure magnitude, spectral variation, peak pressure magnitude, and corresponding frequency level provided helpful information to differentiate various pathologies in the surgical margin.

Ductal Carcinoma in Situ: State-of-the-Art Review

Ductal carcinoma in situ (DCIS) is a nonobligate precursor of invasive cancer, and its detection, diagnosis, and management are controversial. DCIS incidence grew with the expansion of screening mammography programs in the 1980s and 1990s, and DCIS is viewed as a major driver of overdiagnosis and overtreatment. For pathologists, the diagnosis and classification of DCIS is challenging due to undersampling and interobserver variability. Understanding the progression from normal breast tissue to DCIS and, ultimately, to invasive cancer is limited by a paucity of natural history data with multiple proposed evolutionary models of DCIS initiation and progression. Although radiologists are familiar with the classic presentation of DCIS as asymptomatic calcifications at mammography, the expanded pool of modalities, advanced imaging techniques, and image analytics have identified multiple potential biomarkers of histopathologic characteristics and prognosis. Finally, there is growing interest in the nonsurgical management of DCIS, including active surveillance, to reduce overtreatment and provide patients with more personalized management options. However, current biomarkers are not adept at enabling identification of occult invasive disease at biopsy or accurately predicting the risk of progression to invasive disease. Several active surveillance trials are ongoing and are expected to better identify women with low-risk DCIS who may avoid surgery.

Contralateral breast cancer after curative-intent treatment for ductal carcinoma in situ: Rate and associated clinicopathological and imaging risk factors

PURPOSE

Patients who have ductal carcinoma in situ (DCIS) are undergoing bilateral mastectomy at increasing rates. One of the reasons is to minimize contralateral breast cancer (CBC) risk. The purpose of this study is to determine the rate of and risk factors associated with CBC in women treated for DCIS.

METHODS

A retrospective study was performed of women with DCIS at surgery from 2007 to 2014 who had at least five-year follow-up. Patient attributes, imaging findings, histopathology results, and surgical and long-term outcomes were collected. Features associated with a CBC were assessed with multivariable logistic regression models.

RESULTS

613 women (mean 56 years, range 30-87) with DCIS underwent breast-conserving surgery (BCS) (n = 426), unilateral mastectomy (n = 101), or bilateral mastectomy (n = 86), with mean follow-up of 7.9 years. Of the 527 women who had BCS or unilateral mastectomy, 7.4% (n = 39) developed a CBC (DCIS in 12 and invasive cancer in 27). 4.1% (5/122) of women treated with adjuvant endocrine therapy developed a CBC, compared to 8.4% (34/405) who were not treated (p = .11). Features associated with CBC risk were younger age at menarche (adjusted odds ratio [aOR] of 0.76, p = .03) and low nuclear grade of DCIS (aOR of 5.43 for grade 1 versus 3, p = .01).

CONCLUSION

In women treated for DCIS, the overall rate of CBC was low at 7.4%. Younger age at menarche and low nuclear grade of DCIS had significant associations with higher CBC risk.

Imaging of Noncalcified Ductal Carcinoma In Situ

Ductal carcinoma in situ (DCIS) is a commonly encountered malignancy, accounting for approximately 20% of new breast cancer diagnoses in the United States. DCIS is characterized by a proliferation of tumor cells within the terminal duct lobular unit with preservation of the basement membrane. Typically nonpalpable and asymptomatic, DCIS is most often detected as calcifications on screening mammography. However, DCIS may also be noncalcified. When compared to calcified DCIS, noncalcified DCIS is more likely to be symptomatic, with patients most often presenting with nipple discharge or a palpable mass. Diagnosing noncalcified DCIS is challenging since it may be occult or subtle on mammography, and ultrasound findings can be nonspecific and may be interpreted as benign fibrocystic changes. In cases with a calcified component of DCIS, the extent of DCIS may be underestimated by mammography because not all involved areas may calcify. Breast magnetic resonance imaging (MRI), although less readily available than mammography and ultrasound, is advantageous in detecting noncalcified DCIS, especially high grade DCIS, which may not develop microcalcifications. MRI relies on abnormal contrast uptake due to tumor vascularity and changes in vessel density and permeability. This pictoral review presents the spectrum of imaging findings of noncalcified DCIS to assist radiologists in accurately detecting and describing its key imaging findings. Utilizing different modalities, we review the differential diagnoses for noncalcified DCIS, show illustrative cases of noncalcified DCIS, and discuss the importance of this entity.

Breast MRI in the setting of DCIS: quality trials are still needed to determine its value

KEY POINTS

• Existing evidence suggests that preoperative breast MRI does not improve treatment outcomes for DCIS. • The quality of the available data used to answer this question is poor. • Quality randomized controlled trials are needed to definitively assess the benefits and harms of preoperative MRI in the setting of DCIS.

Ductal Carcinoma In Situ and Progression to Invasive Cancer: A Review of the Evidence

Ductal carcinoma in situ (DCIS), breast cancer confined to the milk ducts, is a heterogeneous entity. The question of how and when a case of DCIS will extend beyond the ducts to become invasive breast cancer has implications for both patient prognosis and optimal treatment approaches. The natural history of DCIS has been explored through a variety of methods, from mouse models to biopsy specimen reviews to population-based screening data to modeling studies. This article will review the available evidence regarding progression pathways and will also summarize current trials designed to assess DCIS progression.

Noncalcified Ductal Carcinoma In Situ (DCIS): Rate and Predictors of Upgrade to Invasive Carcinoma

RATIONALE AND OBJECTIVES

To determine the upgrade rate of noncalcified ductal carcinoma in situ (DCIS) and features that are associated with risk of upgrade to invasive disease at surgery.

MATERIALS AND METHODS

A retrospective review was conducted of consecutive women who were diagnosed with noncalcified DCIS from January 2007 to December 2016. Patient demographics, imaging findings, biopsy pathology results, and surgical outcomes were reviewed. The unpaired t test, chi-square test, and Fisher's exact test were used to compare features between the cases of DCIS that did and did not upgrade to invasive carcinoma at surgery.

RESULTS

Over a 10-year period, 78 women (mean age 62 years, range 30-88 years) were diagnosed with noncalcified DCIS. Two-thirds (67.9%, 53/78) of cases were detected on screening mammography, and 15.4% (12/78) of diagnoses were made after presentation with an area of palpable concern. The most common mammographic presentations of noncalcified DCIS were mass (51.3%, 40/78) and asymmetry (30.8%, 24/78). Seventeen cases (21.8%, 17/78) were upgraded to invasive ductal carcinoma (IDC) at surgery. Features associated with upgrade risk included older patient age (68.1 versus 60.3 years, OR 1.08, p < 0.01) and family history of breast cancer in a first-degree relative (41.2% [7/17] versus 16.4% [10/61], OR 3.57, p = 0.03).

CONCLUSION

In our study cohort, the upgrade rate of noncalcified DCIS to IDC at surgery is 21.8%. Upgrade risk is associated with older patient age and family history of breast cancer in a first-degree relative.

Abbreviated MR Imaging for Breast Cancer

Breast MR imaging is the most sensitive imaging method for the detection of breast cancer and detects more aggressive malignancies than mammography and ultrasound examination. Despite these advantages, breast MR imaging has low use rates for breast cancer screening. Abbreviated breast MR imaging, in which a limited number of breast imaging sequences are obtained, has been proposed as a way to solve cost and patient tolerance issues while preserving the high cancer detection rate of breast MR imaging. This review discusses abbreviated breast MR imaging, including protocols, multicenter clinical trial results, clinical workflow implementation challenges, and future directions.

Symptomatic ductal carcinoma in situ (DCIS): Upstaging risk and predictors

PURPOSE

To estimate the upstaging risk of symptomatic ductal carcinoma in situ (DCIS) to invasive disease and to identify features related to upstaging risk.

MATERIALS AND METHODS

This retrospective investigation includes symptomatic women with DCIS at core needle biopsy from January 2007 to December 2016 at a large academic institution. Patient characteristics, findings at imaging, core needle biopsy histopathology results, and final surgical histopathology results were retrieved from the medical records. Using standard statistical tests, patient, imaging, and pathology features were compared between DCIS cases that were upstaged to invasive disease at surgery versus cases that were not upstaged.

RESULTS

From 2007 to 2016, fewer than 5% (63/1399) of women diagnosed with DCIS presented with symptoms. Therefore, 63 women (mean age, 51; range, 27-88 years) comprised the study cohort. 84.1% (n = 53) presented with an area of clinical concern, and 15.9% (n = 10) presented with pathologic nipple discharge. The most common finding at mammography was calcifications with or without an associated asymmetry or mass (74.1%, 40/54). The upstaging rate of symptomatic DCIS to invasive disease was 34.9% (22/63). Imaging modality used for biopsy was associated with higher upstaging risk, with cases that were biopsied under MRI guidance accounting for 22.7% of upstaged cases versus 4.9% of non-upstaged cases (p = 0.03).

CONCLUSIONS

Women with DCIS uncommonly present with symptoms, and the upstaging rate of symptomatic DCIS is high at nearly 35%. Biopsy modality type of MRI is associated with higher upstaging risk.

Imaging of Breast Cancers With Predilection for Nonmass Pattern of Growth: Invasive Lobular Carcinoma and DCIS-Does Imaging Capture It All?

OBJECTIVE. Invasive lobular carcinoma (ILC) and ductal carcinoma in situ (DCIS) are distinct histopathologic entities with several commonalities: both have subtle clinical and imaging presentation, have been linked with controversy regarding optimal imaging techniques and management, and exemplify the codependence of adequate imaging evaluation and optimal treatment strategies in breast care. CONCLUSION. We review molecular mechanisms and histopathologic patterns that define the biologic behavior of both ILC and DCIS and discuss how these mechanisms translate into distinct clinical and imaging presentations that affect the staging workup and patient management algorithm.

Predictors of Reexcision following Breast-Conserving Surgery for Ductal Carcinoma In Situ

BACKGROUND

Reexcision following breast-conserving surgery (BCS) in women with ductal carcinoma in situ (DCIS) results in adjuvant treatment delays, higher health care costs, and undesirable cosmetic outcomes. The purpose of this study is to determine patient, imaging, pathological, and surgical predictors of reexcision following BCS for DCIS.

PATIENTS AND METHODS

A retrospective review of women with DCIS who had BCS from 2007 to 2016 was conducted. Patient, imaging, pathological, and surgical features, in addition to surgical outcomes, were collected from medical records. Standard statistical tests were used to compare features between patients who did and did not undergo at least one reexcision. A multivariable logistic regression model was fit to assess features associated with reexcision.

RESULTS

A total of 547 women (mean age 59 years; range 30-88 years) diagnosed with DCIS at core needle biopsy underwent BCS. Of all women, 31.6% (173/547) had at least one reexcision. With multivariable analysis, features associated with reexcision included younger patient age (adjusted odds ratio [aOR] 0.98, 95% confidence interval [CI] 0.97-1.0, p = 0.049), African-American race (aOR 2.66, 95% CI 1.13-6.26, p = 0.03), biopsy modality of ultrasound (aOR 2.35, 95% CI 1.22-4.53, p = 0.01), and earlier year of surgery (aOR 0.92, 95% CI 0.86-0.98, p = 0.01). No pathological features of DCIS were associated with reexcision risk.

CONCLUSIONS

In our cohort of nearly 550 women with DCIS who underwent BCS, 31.6% had at least one reexcision. Features associated with reexcision include younger patient age, African-American race, biopsy modality of ultrasound, and earlier year of surgery.

Could ultrasound-guided cryoablation be used to manage "low-risk" DCIS?: a feasibility case report

Management of ductal carcinoma in-situ (DCIS) is controversial as there is concern that the majority of diagnoses will never become life threatening such that a subset of patients may be overtreated with surgery. Active surveillance is an alternative proposed management strategy; however, we cannot accurately predict which DCIS will never progress to invasive disease potentially undertreating a large proportion of women. We present a case of a 58-year-old female with DCIS successfully treated with only ultrasound-guided cryoablation without resection. A follow-up needle biopsy of the ablation zone was benign and imaging follow-up has demonstrated no evidence of disease at 14-months. Cryoablation of DCIS is feasible with appropriate patient selection and warrants further investigation as an alternative to surgical resection or active surveillance.

Ductal carcinoma in situ on digital mammography versus digital breast tomosynthesis: rates and predictors of pathologic upgrade

OBJECTIVES

To compare upgrade rates of ductal carcinoma in situ (DCIS) on digital mammography (DM) versus digital breast tomosynthesis (DBT) and identify patient, imaging, and pathological features associated with upgrade risk.

METHODS

A retrospective review was performed of 318 women (mean 59 years, range 37-89) with screening-detected DCIS from 2007 to 2011 (DM group) and from 2013 to 2016 (DBT group). Comparisons made between DM and DBT groups using the unpaired t test and chi-square test include detection rates of DCIS, upgrade rates to invasive cancer, and pathological features of DCIS and upgraded cases. Patient, imaging, and pathological features associated with upgrade were also determined. P values < 0.05 were considered significant.

RESULTS

There was no significant difference in detection rates of DCIS between DM and DBT groups (0.9 versus 1.0 per 1000 examinations, p = 0.45). Upgrade rates of DCIS to invasive cancer in DM and DBT groups were similar (17.3% versus 16.8%, p = 0.90), despite significant differences in pathological features of DCIS between DM and DBT groups (including nuclear grade, comedonecrosis, and progesterone receptor status [p ≤ 0.01]). Among upgraded cases, a higher proportion were high-grade invasive cancers with DBT (36.7% versus 9.5%, p = 0.03). In both groups, ultrasound-guided (versus stereotactic) biopsy was associated with higher upgrade risk (p ≤ 0.03).

CONCLUSIONS

There was no significant difference in detection rates or upgrade rates of DCIS on DM versus DBT; however, upgraded cases were more likely to be high grade with DBT, suggesting possible differences in tumor biology between cancers with DM and DBT. In both DM and DBT groups, biopsy modality was associated with upgrade risk.

KEY POINTS

• Detection rates and upgrade rates of ductal carcinoma in situ (DCIS) on digital mammography (DM) versus digital breast tomosynthesis (DBT) are similar. • A higher proportion of upgraded cases were high-grade invasive cancers with DBT than DM, suggesting possible differences in tumor biology between cancers that are detected with DM and DBT. • With both DM and DBT, ultrasound-guided biopsy (versus stereotactic biopsy) was associated with a higher risk of upgrade.

Pre-operative MRI in patients with ductal carcinoma in situ: Is MRI useful for identifying additional disease?

PURPOSE

To determine if pre-operative MRI is useful for identifying additional disease that would impact surgical management in women with ductal carcinoma in situ (DCIS).

METHODS

We conducted a retrospective review of consecutive women with calcifications at mammography yielding DCIS at core biopsy from 2007 to 2016 who subsequently underwent MRI examinations. Patient characteristics, imaging findings, and pathology outcomes were collected from the medical records. Standard statistical tests were used to compare the patients who underwent MRI examinations (MRI group) and those who did not (no MRI group).

RESULTS

963 women (age 58 years, range 28-89 years) presented with calcifications that yielded DCIS at biopsy, of whom 236 (24.5 %) underwent MRI examinations. The MRI group was younger, less likely to have a prior breast cancer, and more likely to have dense breasts than the no MRI group (all p < 0.001). 66 women (28.0 %) had 80 MRI findings that were recommended for work-up and/or biopsy. 21 patients had 23 MRI findings that were not pursued pre-operatively, and 45 patients with 57 MRI findings underwent biopsy. The positive predictive value of biopsies performed (PPV3) was 45.6 % (26/57). 26 cancers were detected in 24 women; thus, MRI detected additional sites of cancer in 11.2 % (24/215) of patients. Of the 26 cancers, 13 (50.0 %) were DCIS and 13 (50.0 %) were invasive.

CONCLUSIONS

MRI in selected women with DCIS identified additional sites of disease in 11.2 % and thus could be considered in the pre-operative evaluation of this specific patient cohort.

Ductal Carcinoma In Situ Biology, Language, and Active Surveillance: A Survey of Breast Radiologists' Knowledge and Opinions

PURPOSE

To understand how breast radiologists perceive ductal carcinoma in situ (DCIS).

MATERIALS AND METHODS

A 19-item survey was developed by the Society of Breast Imaging Patient Care and Delivery Committee and distributed to all Society of Breast Imaging members. The survey queried respondents' demographics, knowledge of DCIS biology, language used to discuss a new diagnosis of DCIS, and perspectives on active surveillance for DCIS. Five-point Likert scales (1 = strongly disagree, 3 = neutral, 5 = strongly agree) were used.

RESULTS

There were 536 responses for a response rate of 41%. There was agreement that DCIS is the primary driver of overdiagnosis in breast cancer screening (median 4), and respondents provided mean and median overdiagnosis estimates of 29.7% and 25% for low-grade DCIS as well as 4.2% and 0% for high-grade DCIS, respectively. Responses varied in how to describe DCIS but most often used the word "cancer" with a qualifier such as "early" (32%) or "pre-invasive" (25%). Respondents disagreed (median 2) with removing the word "carcinoma" from DCIS. Finally, there was agreement that current standard of care therapy for some forms of DCIS is overtreatment (median 4) and that active surveillance as an alternative management strategy should be studied (mean 4), but felt that ultrasound (median 4) and MRI (median 4) should be used to exclude women with occult invasive disease before active surveillance.

CONCLUSIONS

Breast radiologists' opinions about DCIS biology, language, and active surveillance are not homogenous, but general trends exist that can be used to guide research, education, and advocacy efforts.

FAP-a and GOLPH3 Are Hallmarks of DCIS Progression to Invasive Breast Cancer

Biological markers that could predict the progression of ductal carcinoma in-situ (DCIS) to invasive breast cancer (IDC) are required urgently for personalized therapy for patients diagnosed with DCIS. As stroma was invaded by malignant cells, perturbed stromal-epithelial interactions would bring about tissue remodeling. With the specific expression of the fibroblast activation protein-alpha (FAP-a), Carcinoma-associated fibroblasts (CAFs) are the main cell populations in the remodeled tumor stroma. Golgi phosphoprotein 3 (GOLPH3), a documented oncogene possessing potent transforming capacity, is not only up-regulated in many tumors but also an efficient indicator of poor prognosis and more malignant tumors. The present study aimed to retrospectively evaluate the pathological value of FAP-a and GOLPH3 in predicting the recurrence or progression of DCIS to invasive breast cancer. Immunohistochemical techniques were applied to investigate the expression of FAP-a GOLPH3 in 449 cases of DCIS patients received extensive resection and with close follow-up, but not being treated with any form of chemo- or radio-therapy. The combination of FAP-a and GOLPH3 in predicating the recurrence or progression of DCIS into invasive breast cancer was specifically examined. The study demonstrated that the overexpression of FAP-a in stromal fibroblasts and GOLPH3 in carcinoma cells are highly predictive of DCIS recurrence and progression into invasive breast cancer. Both FAP-a and GOLPH3 have high specificity and sensitivity to predict the recurrence of DCIS. Moreover, the combination of FAP-a and GOLPH3 tends to further improve the specificity and sensitivity of DCIS recurrence by 9.72–10.31 and 2.72–3.63%, respectively. FAP-a and GOLPH3 serve as novel markers in predicting the recurrence or progression of DCIS into invasive breast cancer.