Comedo Necrosis Research Articles

Abstract P5-17-03: The 12-gene DCIS score assay: Impact on radiation treatment (XRT) recommendations and clinical utility

Abstract Background: In the management of DCIS clinicians and patients (pts) must choose between the various options for breast conservation treatment based on an assessment of local recurrence (LR) risk. Traditional clinicopathologic (CP) factors such as age, size, grade, margin width or comedo necrosis, provide an average LR risk derived from clinical trials and population studies. The Oncotype DX® 12-gene assay for DCIS gives individual 10-yr LR risk estimates and has now been validated in two studies in a total of 893 pts. We report the 2nd study assessing the impact of the DCIS Score result on XRT recommendations. In addition, surveys assessing pt and physician confidence will provide insight into the overall clinical utility of the DCIS Score result. Baseline characteristics including the pre-assay LR risk and XRT recommendation are described here; final results on change in XRT recommendation from pre- to post-assay and distribution of the score across the CP factors will be presented. Methods: 13 U.S. sites enrolled pts with DCIS from 3/2014-5/2015. Pts with LCIS but no DCIS, invasive BC, or planned mastectomy were excluded. Data were prospectively collected on CP factors, physician estimates of LR risk, DCIS score, and pre/post XRT recommendation. Each pt had a surgeon and radiation oncologist complete study surveys. Pt surveys were also administered pre/post assay for decision conflict and the STAIT anxiety survey. The LR risk estimates and XRT recommendations were analyzed for all physicians as well as by specialty. Descriptive statistics summarized study variables. 95% Clopper-Pearson Exact CIs were calculated for percent change in XRT recommendation. McNemar's test was used to determine if the proportion of pts had a significant change in XRT recommendation post assay. Paired t-tests were used to compare physician estimates of recurrence risk pre/post assay. Results: Of the 121 pts enrolled, median age was 61y (34-83) and 80.2% were postmenopausal. Median size was 8mm and 40% were < 5mm; 22.3% were grade 1, 51.2% grade 2, and 26.4% grade 3. Comedo necrosis was noted in 55.4% and 19% had multiple foci. Median margin width was 3mm and 47.1% had margins 1-3mm. ER and PR by IHC were positive in 88.4% and 75.2% of pts. Among the 242 MD risk assessments, mean 10-yr LR risk was 14.8% (range 4-50%) for any LR; 14.2% for surgeons and 15.3% for radiation oncologists. The pre-assay XRT recommendation was 70.2%; 68.6% for surgeons and 71.9% for radiation oncologists. Conclusions: The role of new molecular tools such as the DCIS Score assay that provide individual risk estimates for LR on treatment decisions is evolving. The DCIS pts enrolled in the study reveal inclusion of baseline features like higher nuclear grade (26%), comedo necrosis (55%) and margin width of 1-3mm (47%) that have historically been associated with XRT use. This represents a continued broadening of the assay use from the predominantly lower risk DCIS cohort in the 1st validation study (E5194). The impact on XRT decisions is critical to establishing the clinical utility of the assay. The decision impact analysis, differences in use of the assay among surgeons and radiation oncologists and the impact on overall confidence with the treatment decision will be presented. Citation Format: Manders JB, Kuerer HM, Smith BD, McCluskey C, Farrar WB, Frazier TG, Li L, Leonard CE, Carter DL, Chawla S, Medeiros LE, Guenther JM, Castellini LE, Buchholz DJ, Mamounas EP, Wapnir IL, Horst KC, Chagpar A, Evans SB, Riker AI, Vali FS, Solin LJ, Jablon L, Recht A, Sharma R, Lu R, Sing AP, Hwang ES, White J. The 12-gene DCIS score assay: Impact on radiation treatment (XRT) recommendations and clinical utility. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P5-17-03.

Abstract P1-01-10: Pleomorphic lobular carcinoma in situ (PLCIS)-presentation, associated lesions and outcome

Abstract Pleomorphic lobular carcinoma in situ (PLCIS) is an uncommon lesion characterised by dyscohesive lobular cells showing high grade nuclei. It is commonly associated with comedo necrosis and luminal calcifications and hence diagnosed on mammographic screening. Data on the presentation, focality, associated lesions, optimal treatment and outcome of PLCIS is patchy. Methods Cases diagnosed as PLCIS between 2005 and 2015 were identified from the imaging and pathology databases of two UK large breast screening units. Cases diagnosed on diagnostic core biopsy/VAB or surgical excisions were included. Comprehensive data was collected on age, mode of presentation (screening vs symptomatic), imaging (mammography, ultrasound and MRI), surgical management, histological features on core biopsy and excision including type, grade and immunohistochemical profile of associated ductal carcinoma in situ (DCIS) and invasive carcinoma. Results 86 cases with the diagnosis of PLCIS (confirmed by review and e-cadherin negativity) were identified. The mean patient age at diagnosis was 61.04 years, range: 39-84 years. 32 cases were treated with wide local excision with/without axillary procedure. A total of 38 patients were screen detected & 36 cases were diagnosed in the symptomatic setting. Others presented as incidental calcifications on family history screening, incidental histological findings in breast reductions and risk reducing mastectomy. On mammography, 6 patients presented with an asymmetrical density, with or without calcifications, 25 with calcifications, 44 as a mass and 2 as stromal deformity. No mammographic abnormality was found in 9 cases. PLCIS was multifocal in 19.7% of cases, diffuse in 9.9%, focal in 69% and multi-centric in 1.4% on imaging. Histologically, PLCIS was the most advanced lesion on core biopsy without associated DCIS or invasive disease (pure PLCIS) in 23 patients. Of these, surgical excision revealed an invasive carcinoma in 7 cases (upgrade rate =30.4%). Six more patients presented as DCIS and PLCIS on core biopsy; three of whom (50%) had invasive disease on excision. Classical LCIS was associated with PLCIS in 27/86 cases (31.3%). The most common type of associated invasive carcinoma on surgical excision was invasive classical lobular carcinoma (ILC, 40 cases), followed by invasive pleomorphic lobular carcinoma (IPLC, 27 cases). Ductal no special type carcinoma, solid papillary and tubulo-lobular carcinoma were also identified. The size of PLCIS on excision ranged from 1-80mm. DCIS was associated in 26.7% of cases. The majority of invasive cancers were of grade 2 (53.5%) and 3 (19%). The tumors were ER positive (53 cases), PR positive (43 cases) and HER2 negative (52 cases). Conclusion PLCIS is an uncommon in situ carcinoma presenting via mammographic and also in the symptomatic setting. Unlike classical LCIS, PLCIS is a disease of postmenopausal women. It is multifocal in approximately one fifth of the cases. PLCIS is commonly associated with classical LCIS and both ILC and IPLC. When identified in core biopsy, the upgrade rate in this series was 30.4% which increased to 50% if the lesion co-existed with DCIS. The associated cancers are often ER positive, HER2 negative. These findings support managing those lesions surgically as per DCIS. Citation Format: Shaaban AM, Smith S, Bradley S, McMahon M, Sharma N. Pleomorphic lobular carcinoma in situ (PLCIS)-presentation, associated lesions and outcome. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P1-01-10.

Abstract P4-01-06: Microcalcifications as imaging biomarker in breast cancer: High-throughput radiogenomic analysis using microarrya data

Abstract Purpose: To investigate relationships between microcalcifications and gene expression pattern using microarray analysis in breast cancer. Materials and methods: The institutional review board approved this retrospective study and waived the informed consent. Clinicopathologic finding, mammographic features, and gene expression data were evaluated in 133 women (mean age, 50.1 years; range, 21-79 years) with stage I-III breast cancer. Women with microcalcifications (n=33) and without microcalcifications (n=100) were compared. Immunohistochemical analysis of estrogen receptor, progesterone receptor, HER-2, and Ki-67 expression was performed. Differentially expressed genes (DEGs) using Affymetrix GeneChip® Human Gene 2.0 ST arrays (53,427 probes) were identified in tissue with microcalcifications versus without microcalcifications. In addition, genes included in the prediction analysis of PAM50, MammaPrint® and OncotypeDX® were also compared between two groups (microcalcifications versus no calcification). To further investigate the functions and underlying biology of DEGs, we performed enrichment analysis using the Gene Ontology database and pathway anlyais using the Kyoto Encyclopedia of Genes and Genomes database and Ingenuity Pathway Analysis. Results: Among clinicopathologic varibales, HER2 positivity (p<0.001) and presence of comedo necrosis (p=0.024) are significantly higher in the calcification group. About 128 genes had differential expression (> 1.5 fold difference, adjusted p value<0.05). Among known gene signatures, GRB7 (fold change=2.26, p=0.006) and ERBB2 (fold change=2.13, p=0.001) which are known as associated with recurrence, cell invasion and poor survival were highly expressed. In contrast, ZNF385B which is associated with p53-mediated apoptosis and good prognosis was underexpressed (fold change=0.39, p=0.001) in calcification group. Significant gene ontology terms included response to wounding, coagulation, wound healing, and response to hypoxia. Network and canonical pathway analysis indicated that increased cellular movement, cellular growth and proliferation, cellular develoment, coagulation and atherosclerosis signaling in breast cancer with microcalcifications, suggesting biological aggressiveness. Conclusion: Gene expression patterns are different according to microcalcifications status in breast cancer. Breast cancers with mammographic microcalcifications are associated with metabolic aggressiveness and poor prognosis. Citation Format: Shin SU, Kim W, Song SE, Chu A, Han W, Moon WK. Microcalcifications as imaging biomarker in breast cancer: High-throughput radiogenomic analysis using microarrya data. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P4-01-06.

The role of specimen radiography in breast-conserving therapy of ductal carcinoma in situ

BackgroundTo assess the role of intraoperative specimen radiography (SR) and to define risk factors for positive margins in breast-conserving therapy (BCT) of ductal carcinoma in situ (DCIS). MethodsIn a retrospective study in calcification-associated DCIS treated with BCT between January 2009 and December 2011, digital mammographs and SR were reviewed and radiological margin width was determined. Clinical, radiological, and histological data were correlated with surgical histological data, and a histologically free margin of at least 2 mm was taken as evidence of successful BCT. Results47/91 patients (51.6%) fulfilling the inclusion criteria had histologically involved surgical margins. Univariate analyses revealed DCIS size, mammographic extension of calcification, presence of comedo necrosis, negative progesterone receptor status, and a small radiological margin on SR to be risk factors for unsuccessful BCT. Receiver Operating Characteristic (ROC) analysis showed a radiological margin width of 4 mm to be optimal, with a sensitivity of 72.3% and specificity of 52.3%. The likelihood of surgical free margins was increased 2.9-fold with a radiological margin width ≥4 mm. On multivariate logistic regression analysis, only histological DCIS size >20 mm clearly emerged as an independent predictive factor for surgically involved margins (p < 0.001), while an SR margin <4 mm trended toward significance (p = 0.066). ConclusionsSR is a reliable method for predicting free surgical margins in non-invasive breast cancer where a minimum radiological free margin of 4 Fmm is achieved. However, histological DCIS size remains the most important factor determining successful BCT.

Thirty percent of ductal carcinoma in situ of the breast in Japan is extremely low-grade ER(+)/HER2(-) type without comedo necrosis.

Background Overdiagnosis in mammography (MMG) is a problem. Combination of MMG and ultrasonography for breast cancer screening may increase overdiagnosis. Most cases of overdiagnosis are low-grade ductal carcinoma in situ (LGD), but no reports have focused on them. Materials and methods We immunostained 169 ductal carcinoma in situ (DCIS) cases for ER, PgR, HER2 and Ki67 and classified them into 4 subtypes: ER(+)/HER2(-), ER(+)/HER2(+), ER(-)/HER2(-) and ER(-)/HER2(+). The Ki67 index was used to evaluate the grade of malignancy and examined for correlations with each ER/HER2 subtype and the nuclear grade (NG), with/without comedo necrosis. Results The Ki67 index correlated significantly with NG, both with/without comedo necrosis, and reliably evaluated the grade of malignancy. The index for ER(+)/HER2(-) (n=117, 69.2%) was 7.45±7.10, which was significantly lower than for each of the other types. The index was 5.71±6.94 for ER(+)/HER2(-) without comedo necrosis (n=52, 30.8%), which was significantly lower than with comedo necrosis. This was considered LGD, characterized by absence of microcalcification in MMG and either presence of a solid mass or cystic lesion or absence of hypoechoic areas in ultrasound. Conclusion In Japan, ER(+)/HER2(-) without comedo necrosis accounts for about 30% of DCIS and is LGD. This may be being overdiagnosed. J. Med. Invest. 63: 192-198, August, 2016.

Tumor characteristics of ductal carcinoma in situ of breast visualized on [F-18] fluorodeoxyglucose-positron emission tomography/computed tomography: Results from a retrospective study.

To clarify clinicopathological features of ductal carcinoma in situ (DCIS) visualized on [F-18] fluorodeoxyglucose-positron emission tomography/computed tomography (FDG-PET/CT). This study retrospectively reviewed 52 consecutive tumors in 50 patients with pathologically proven pure DCIS who underwent [F-18] FDG-PET/CT before surgery. [F-18] FDG-PET/CT was performed after biopsy in all patients. The mean interval from biopsy to [F-18] FDG-PET/CT was 29.2 d. [F-18] FDG uptake by visual analysis and maximum standardized uptake value (SUVmax) was compared with clinicopathological characteristics. [F-18] FDG uptake was visualized in 28 lesions (53.8%) and the mean and standard deviation of SUVmax was 1.63 and 0.90. On univariate analysis, visual analysis and the SUVmax were associated with symptomatic presentation (P = 0.012 and 0.002, respectively), palpability (P = 0.030 and 0.024, respectively), use of core-needle biopsy (CNB) (P = 0.023 and 0.012, respectively), ultrasound-guided biopsy (P = 0.040 and 0.006, respectively), enhancing lesion ≥ 20 mm on magnetic resonance imaging (MRI) (P = 0.001 and 0.010, respectively), tumor size ≥ 20 mm on histopathology (P = 0.002 and 0.008, respectively). However, [F-18] FDG uptake parameters were not significantly associated with age, presence of calcification on mammography, mass formation on MRI, presence of comedo necrosis, hormone status (estrogen receptor, progesterone receptor and human epidermal growth factor receptor-2), and nuclear grade. The factors significantly associated with visual analysis and SUVmax were symptomatic presentation (P = 0.019 and 0.001, respectively), use of CNB (P = 0.001 and 0.031, respectively), and enhancing lesion ≥ 20 mm on MRI (P = 0.001 and 0.049, respectively) on multivariate analysis. Although DCIS of breast is generally non-avid tumor, symptomatic and large tumors (≥ 20 mm) tend to be visualized on [F-18] FDG-PET/CT.

A model to predict upstaging to invasive carcinoma in patients preoperatively diagnosed with ductal carcinoma in situ of the breast

The aims of this study were to determine clinicopathological factors associated with postoperative upstaging to invasive carcinoma in patients preoperatively diagnosed with ductal carcinoma in situ (DCIS) and to develop a model to predict the risk of upstaging. Pre- and post-operative pathological diagnoses and radiological findings were assessed for 1,187 consecutive patients. Of the patients, 306 (25.8%) were upstaged on the surgical specimen. In multivariate analysis, the following four factors were significantly associated with upstaging: 1) the presence of sclerosing adenosis on the preoperative biopsy specimen (odds ratio [OR] 0.46, P = 0.013); 2) pleomorphic calcifications on the mammogram (OR 1.68, P = 0.009); 3) a mass suspicious for invasive carcinoma on ultrasonography and/or MRI (OR 2.13, P < 0.001); 4) tumor size ≥2 cm on ultrasonography (OR 1.80, P = 0.032). HER2-positive (OR 1.54, P = 0.062) and comedo necrosis (OR 1.42, P = 0.056) demonstrated a trend towards significance. A prediction model incorporating these variables demonstrated that the risk of upstaging was 5.1% with score 0-2 and was 58.1% with score 10. The prediction model incorporating clinicopathological features may be used to guide the selection of patients with DCIS for sentinel lymph node biopsy.

Screening mammography-detected ductal carcinoma in situ: mammographic features based on breast cancer subtypes

We evaluated the mammographic and histopathologic features of screening mammography-detected ductal carcinoma in situ (DCIS) based on the breast cancer subtypes determined by immunohistochemistry. A total of 94 patients with 94 screening mammography-detected DCIS were included in this study. Mammographically, human epidermal growth factor receptor 2 (HER2)-positive DCIS was more commonly associated with calcifications than estrogen receptor (ER)-positive and triple-negative DCIS (P=.003). Histopathologically, HER2-positive DCIS and triple-negative DCIS were associated with high nuclear grade (P≤.001) and comedo necrosis (P≤.001) than ER-positive DCIS.

Multidisciplinary Shared Decision Making in the Management of Ductal Carcinoma In Situ of the Breast.

Controversy continues regarding the use of adjuvant radiation therapy (RT) and hormonal therapy (HT) for patients undergoing breast-conserving therapy (BCT) for ductal carcinoma in situ (DCIS). A prospective database was queried to identify women 18 years of age or older treated for DCIS from 2002 to 2013. BCT was completed for 300 patients with a median age of 66 years. The median DCIS size was 0.7 cm (range 0.1-6.0 cm). The DCIS grades were high (44 %), intermediate (37 %), and low (19 %). The closest margin was wider than 3 mm in 80 % and wider than 5 mm in 63 % of the cases. Adjuvant RT was administered to 183 patients (61 %), and the RT status of 9 patients (3 %) was unknown. RT was associated with age, DCIS size, comedo necrosis, grade, and treatment in 2002-2007 versus 2008-2013. Adjuvant HT was administered to 86 estrogen receptor-positive patients (39 %), and the HT status of 4 patients (2 %) was unknown. The median follow-up period was 63 months (range 4-151 months). The 5-year overall local recurrence (LR) rate was 4 % (95 % confidence interval [CI] 2.1-7.4 %). The 5-year LR rate was 3.9 % (95 % CI 1.8-8.6 %) for the RT patients and 4.1 % (95 % CI 1.6-10.7 %) for the patients not receiving RT. Of 13 LRs, 10 (77 %) were DCIS, and 3 (23 %) were invasive including one node-positive recurrence. Multidisciplinary and joint decision making in the treatment of DCIS results in a substantial and increasing number of patients forgoing adjuvant RT, adjuvant HT, or both. Reasonable 5-year LR rates suggest that such decision making can appropriately allocate patients to adjuvant therapies.

Abstract PD1-5: Characterizing the Tumor Immune MicroEnvironment (TIME) in high-risk ductal carcinoma in situ

Abstract Background: Ductal carcinoma in situ (DCIS) of the breast is a premalignant condition. Although DCIS is treated as an obligate precursor of invasive ductal carcinoma, the rate and latency of progression from DCIS to invasive breast cancer (IBC) in the absence of treatment are unknown. DCIS is not one condition, but rather a spectrum of disease and although DCIS itself is not a lethal condition, women with DCIS are at higher risk of developing subsequent IBC over a time period of 1-20 years depending on DCIS subtype. Features of DCIS that are associated with high risk of recurrence include large size (&amp;gt; 5cm), high grade, comedo necrosis, palpable mass, hormone receptor (HR) negativity, and HER2 positivity. The objective of this study was to characterize the tumor immune microenvironment (TIME) of these high-risk DCIS lesions. Methods: Forty-eight cases of high grade DCIS, enriched for large, confluent lesions and history of recurrence were age matched with 64 cases of non-high grade DCIS. IHC analyses were performed as single or two-color stains for the following antigens: CD68, CD8, CD4, CD20, HLA-DR, CD115, FoxP3, PCNA, Mac387, MRC1, ALDH, CD24, CD44, Ki-67, and HER2. HR status was determined from ER and PR staining results in pathology reports. A Nuance multispectral imaging system was used to image and spectrally unmix each stain. Protocols for automated image analysis were developed using CellProfiler software. Associations between immune cell populations and clinical parameters (tumor palpability, recurrence, HR status, HER2 status, and Van Nuys score [12-point scale: margins, age, size, grade]) were identified with non-parametric Spearman correlation tests. Results: We found a high macrophage infiltrate associated with a high Van Nuys score, palpability, and high Ki-67. High CD115 (CSF-1 receptor) was associated with HER2+, high Ki-67, and recurrence. Mac387+ cells and FoxP3+ regulatory T cells (Treg) were associated with high Van Nuys score, comedo necrosis, high Ki-67, HR- and HER2+. Interestingly, both Mac387 and CD115 were expressed on tumor cells as well as macrophages and high CD115 staining on tumor cells was associated with recurrence. The presence of CD8+HLA-DR-negative T cells throughout a section was associated with high Van Nuys score, HR-, HER2+, and recurrence. In contrast, CD8+ T cells within the nests of tumor cells were negatively associated with Van Nuys score, palpability, and comedo necrosis. A tumor immune microenvironment score (TIME score) was developed based on the proportions of various immune cell populations. A high TIME score was significantly associated with high Van Nuys scores as well as with recurrence. Summary: These results demonstrate that high risk DCIS features (palpability, high Van Nuys score, high proliferation, HR-, HER2+, and increased recurrence) are associated with a suppressed tumor immune micro-environment (high FoxP3+ cells, CD68+Mac387+ cells, CD8+HLA-DR-neg T cells, and upregulated CD115). These high risk lesions truly represent an opportunity to prevent cancer. Identifying these high risk lesions with the help of tumor immune microenvironment markers and manipulating the DCIS TIME via local or systemic immunotherapeutic strategies may represent an ideal preventative intervention. Citation Format: Michael J Campbell, Rita Mukhtar, Ekene Obi-Okoye, Booyeon Han, Vickram Tandon, Sarah Zheng, Zelos Zhu, Max Endicott, Max Wicha, Linda Lindstrom, Alfred Au, Frederick Baehner, Joe Gray, Laura Esserman. Characterizing the Tumor Immune MicroEnvironment (TIME) in high-risk ductal carcinoma in situ [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr PD1-5.

Abstract P6-13-01: Local excision without radiation for ductal carcinoma in situ: 12-year results from the ECOG E5194 study

Abstract Background: The ECOG E5194 study was a prospective trial designed to evaluate surgical excision (lumpectomy) without radiation for selected women with ductal carcinoma in situ (DCIS) of the breast with low risk clinical and pathologic features. Methods: Eligible patients were enrolled on two study cohorts (not randomized): (1) low or intermediate grade DCIS, tumor size &amp;lt; 2.5 cm; or (2) high grade DCIS, tumor size &amp;lt; 1.0 cm. Cohort assignment was based on pathology assessment from the treating institution. Protocol specifications included surgical excision of the DCIS tumor with a minimum negative margin width of at least 3 mm or no tumor on re-excision. Radiation treatment was not allowed. From April 1997 to October 2002, 665 evaluable patients were enrolled through ECOG or NCCTG (561 in Cohort 1; 104 in Cohort 2). Tamoxifen was optional (not randomized) beginning in May 2000, and was given to 30% of the patients. The primary study endpoint was the rate of developing an ipsilateral breast event (IBE), defined as local recurrence of DCIS or invasive carcinoma in the treated breast. The median follow-up was 12.3 years. We have previously reported 7-year results (L. Hughes, J Clin Oncol 27:5319, 2009; median follow-up 6.3 years; 66 IBE’s), and we herein provide 12-year results. Results: Median patient age was 60 years and 58 years for Cohort 1 and Cohort 2, respectively. Tumor size was &amp;lt; 10 mm for 79% and 80% of patients, respectively. The minimum negative margin width was &amp;gt; 5 mm for 64% and 69% of patients, respectively. There were 99 IBE’s, of which 51 (52%) were an invasive IBE. The IBE and invasive IBE rates increased over time in both cohorts (see Table). The 12-year rates of an IBE were 14.4% for Cohort 1 and 24.6% for Cohort 2 (p = 0.003), and for an invasive IBE, 7.5% and 13.4%, respectively (p = 0.08). No difference was seen for the 12-year rates of overall survival (84.0% vs 82.8%; p = .96) or contralateral breast events (6.7% vs 12.0%; p = 0.16). On multivariate analysis, study cohort (hazard ratio = 1.81; p = 0.01) and tumor size (p = 0.01) were statistically significant for an IBE, and study cohort was borderline statistically significant for an invasive IBE (p = 0.08). On central pathology review (75% of cases), neither grade nor comedo necrosis was associated with the risk of an IBE or invasive IBE (all p &amp;gt; 0.15). Salvage treatment at the time of an IBE included mastectomy for 42% (31/74) and 64% (16/25) of the patients, respectively. Conclusions: For these selected patients with favorable DCIS based on clinical and pathologic characteristics treated with surgical excision without radiation, the rates of an IBE and an invasive IBE continued to increase through at least 12 years of follow-up. IBE Rates According To Study Cohort. Cohort 1 (Low or Intermediate Grade)Cohort 2 (High Grade)TimeIBEInvasive IBEIBEInvasive IBEAt 5 years6.0% (4.0%, 8.1%)2.7% (1.3%, 4.1%)15.0% (7.7%, 21.7%)5.3% (0.8%, 9.7%)At 7 years9.5% (7.0%, 12.0%)4.8% (2.9%, 6.6%)18.2% (10.6%, 25.8%)7.6% (2.2%, 13.0%)At 10 years12.5% (9.5%, 15.4%)6.4% (4.2%, 8.6%)24.6% (15.7%, 33.4%)13.4% (5.9%, 20.9%)At 12 years14.4% (11.2%, 17.6%)7.5% (5.1%, 10.0%)24.6% (15.7%, 33.4%)13.4% (5.9%, 20.9%) Citation Format: Lawrence J Solin, Robert Gray, Lorie L Hughes, William C Wood, Mary Ann Lowen, Sunil Badve, Frederick L Baehner, James N Ingle, Edith A Perez, Abram Recht, Joseph Sparano, Kathy Miller, Nancy E Davidson. Local excision without radiation for ductal carcinoma in situ: 12-year results from the ECOG E5194 study [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P6-13-01.

Methylation profiling of ductal carcinoma in situ and its relationship to histopathological features.

IntroductionDNA methylation is a well-studied biomarker in invasive breast cancer, but its role in ductal carcinoma in situ (DCIS) is less well characterized. The aims of this study are to assess the methylation profile in DCIS for a panel of well-characterized genes that are frequently methylated in breast cancer, to investigate the relationship of methylation with pathological features, and to perform a proof-of-principle study to evaluate the practicality of methylation as a biomarker in diagnostic DCIS material.MethodsPromoter CpG island methylation for a panel of 11 breast cancer-related genes was performed by methylation-sensitive high resolution melting (MS-HRM). Formalin-fixed, paraffin-embedded (FFPE) biopsies from 72 samples of pure DCIS (DCIS occurring in the absence of synchronous invasive carcinoma), 10 samples of mixed DCIS (DCIS adjacent to invasive carcinoma), and 18 samples of normal breast epithelium adjacent to a DCIS lesion were micro-dissected prior to DNA extraction.ResultsMethylation was seen for all the tested genes except BRCA1. RASSF1A was the most frequently methylated gene (90% of DCIS samples) and its methylation was associated with comedo necrosis (p = 0.018). Cluster analysis based on the methylation profile revealed four groups, the highly methylated cluster being significantly associated with high nuclear grade, HER2 amplification, negative estrogen receptor (ER) α status, and negative progesterone receptor (PgR) status, (p = 0.038, p = 0.018, p <0.001, p = 0.001, respectively). Methylation of APC (p = 0.017), CDH13 (p = 0.017), and RARβ (p <0.001) was associated with negative ERα status. Methylation of CDH13 (p <0.001), and RARβ (p = 0.001) was associated with negative PgR status. Methylation of APC (p = 0.013) and CDH13 (p = 0.026) was associated with high nuclear grade. Methylation of CDH13 (p = 0.009), and RARβ (p = 0.042) was associated with HER2-amplification.ConclusionsDNA methylation can be assessed in FFPE-derived samples using suitable methodologies. Methylation of a panel of genes that are known to be methylated in invasive breast cancer was able to classify DCIS into distinct groups and was differentially associated with phenotypic features in DCIS.Electronic supplementary materialThe online version of this article (doi:10.1186/s13058-014-0423-9) contains supplementary material, which is available to authorized users.

Abstract 165: Suppressed immunity and macrophages characterize high risk high grade DCIS

Abstract Background: High grade in situ (DCIS) features associated with high recurrence include large size (&amp;gt;5cm), comedo necrosis, palpable mass, hormone receptor (HR) negativity, and HER2 positivity. Given that high grade, HR-neg invasive breast cancers have an inflammatory component (significant macrophage infiltration) we sought to characterize the immune microenvironment of DCIS to assess patterns of immune cell infiltrates associated with high risk lesions. Methods: 48 cases of high grade DCIS were age matched with 64 cases of non-high grade DCIS. Immunohistochemical analyses were performed as single color stains for the following antigens: CD115, FoxP3, ALDH, Ki-67, HER2. Two color IHC was performed for the following antigen pairs: CD68/PCNA; CD68/Mac 387; CD8/HLA-DR; CD68/MRC1, and CD24/CD44. HR status was determined from ER and PR staining results in pathology reports. For each case, 3 hot spots were identified and marked on 10 consecutive sections. Nuance multispectral imaging software was used to image each hot spot. Protocols for automated image analysis were developed using CellProfiler software. Clinical parameters of interest included tumor palpability, recurrence, and Van Nuys score, (12 point scale-margins, age, size, grade). Associations were identified with non-parametric Spearman correlation test. Results: High numbers of macrophages were associated with high Van Nuys score, palpability, and high Ki-67. High CD115 (CSF-1 receptor/c-fms) was associated with HER2+, high Ki-67, and recurrence. Mac387+ cells and FoxP3+ regulatory T cells (Treg) were significantly associated with high Van Nuys score, comedo necrosis, high Ki-67, HR- and HER2+. Interestingly, both Mac387 and CD115 were expressed on tumor cells as well as macrophages and high CD115 staining on tumor cells was associated with recurrence. The presence of CD8+HLA-DR negative T cells throughout a section was associated with high Van Nuys score, HR-, HER2+, and recurrence. In contrast, CD8+ T cells within the nests of tumor cells were negatively associated with Van Nuys score, palpability, and comedo necrosis. Conclusions: Suppressed immunity (high Treg and CD8+HLA-DR neg T cells) and upregulated CD115 and Mac387 expression on both tumor cells and macrophages were strongly correlated with high risk DCIS features (increased recurrence, palpability, high Van Nuys scores, high proliferation, HR- and HER2+). These results suggest that manipulation of the immune microenvironment in DCIS, via local stimulation of the immune system, depletion of Treg, and/or manipulation of macrophages could potentially alter disease progression. Targeted agents are in trials and could be tested in preoperative window trials using these biomarkers to monitor the impact of presurgical immunotherapy. Citation Format: Michael J. Campbell, Rita Mukhtar, Ekene Obi-Okoye, Booyeon Han, Vick Tandon, Sarah Zheng, Zelos Zhu, Max Endicott, Max Wicha, Linda Lindstrom, Alfred Au, Frederick Baehner, Joe Gray, Laura Esserman. Suppressed immunity and macrophages characterize high risk high grade DCIS. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 165. doi:10.1158/1538-7445.AM2014-165

259PD - The 12-Gene Dcis Score Assay and Quantitative Er, Pr, and Her2 Across Histologic Subtypes: Experience in the First 2 Years

ABSTRACT Aim: The 12-gene DCIS Score has been validated to predict 10yr risk of local recurrence (DCIS or invasive) (Solin et al, JNCI, 2013). Here we report the Clinical Laboratory experience in the first 2 yrs of assay availability for the score results, quantitative gene expression and results of the assay across histologic subtypes. Methods: 3045 patient (pt) samples from 12/11 to 1/14 were processed for DCIS score. The DCIS score is based on the validated algorithm using 7 of 16 cancer-related genes from the 21-gene assay. Low, intermediate, and high risk groups are defined as scores of Results: Of 3045 samples, 2264 (74%) were excisions and 781 (26%) were cores; median age was 60y (21-94). The mean DCIS Score was 29 (0-97) with a mean score result of 29 for excisions and 29 for cores. 2064 (68%) were low, 495 (16%) were intermediate, and 486 (16%) were high. Mean ER, PR, and HER2 levels were 9.6, 7.5, and 9.9, respectively, and similar between excisions and cores. A range of DCIS Score results were observed for each histologic subtype with the highest mean values observed in samples with >50% comedo necrosis (mean = 47) and solid (mean = 34) subtypes, although none of the scores were in the high risk category. Table: 259PD . Tumor type Distribution (%) Mean DCIS Score (range) Mean ER Mean PR Mean HER2 Cribriform 1202 (39) 22 (0-90) 9.9 7.8 9.7 Solid 1053 (35) 34 (0-96) 9.4 7.2 9.9 DCIS with ≥50% comedo necrosis 345 (11) 47 (0-97) 8.4 6.3 10.2 Papillary 281 (9) 17 (0-90) 10.9 8.6 9.6 Micropapillary 146 (5) 26 (0-88) 9.4 7.3 10.0 Apocrine 11 (0.4) 26 (4-53) 7.6 6.0 9.7 Conclusions: In the first 2 yrs, there were > 3000 samples submitted for the 12-gene DCIS score assay. The proportion of score results that were low, intermediate and high was similar to the validation study. The mean DCIS score result between core bx and excision was also similar supporting assay use on cores. The overall experience shows that the score results reflect underlying biology differently than histology and are informative for guiding treatment decisions. Disclosure: All authors have declared: Genomic Health, Inc. - employee and stock ownership

Ductal carcinoma in situ (DCIS): Ethnicity, clinical-pathologic features, and outcome.

e11503 Background: The main goal in treating DCIS remains the prevention of ipsilateral recurrence and contralateral tumors. Known risk factors for recurrence include multifocal disease, tumor size, nuclear grade, presence of comedo necrosis, hormone receptor (HR) and HER-2 status and young age. Despite the similar distribution of molecular characteristics and treatments among ethnic groups, previous research reported that African Americans (AA) have worse outcomes. Methods: We identified 446 patients with DCIS (395) or microinvasive carcinoma (51), treated between 2008 and 2013, in the Thomas Jefferson University Tumor Registry. Associations between recurrence and demographic factors, histology, and treatment were assessed. Student’s t-test was used to compare age between recurrent and non-recurrent patients, Pearson’s Chi-squared test to test associations between recurrence variables with more than two categories, and Fisher’s Exact test for testing associations between recurrence and two-level categori...

Factors Predicting Microinvasion in Ductal Carcinoma in situ

Whether sentinel lymph node biopsy (SLNB) should be performed in patients with pure ductal carcinoma in situ (DCIS) of the breast has been a question of debate over the last decade. The aim of this study was to identify factors associated with microinvasive disease and determine the criteria for performing SLNB in patients with DCIS. 125 patients with DCIS who underwent surgery between January 2000 and December 2008 were reviewed to identify factors associated with DCIS and DCIS with microinvasion (DCISM). 88 patients (70.4%) had pure DCIS and 37 (29.6%) had DCISM. Among 33 DCIS patients who underwent SLNB, one patient (3.3%) was found to have isolated tumor cells in her biopsy, whereas 1 of 14 (37.8%) patients with DCISM had micrometastasis (7.1%). Similarly, of 16 patients (18.2%) with pure DCIS and axillary lymph node dissection (ALND) without SLNB, none had lymph node metastasis. Furthermore, of 20 patients with DCISM and ALND, only one (5%) had metastasis. In multivariate analysis, the presence of comedo necrosis [relative risk (RR)=4.1, 95% confidence interval (CI)=1.6-10.6, P=0.004], and hormone receptor (ER or PR) negativity (RR=4.0, 95%CI=1.5-11, P=0.007), were found to be significantly associated with microinvasion. Our findings suggest patients presenting with a preoperative diagnosis of DCIS associated with comedo necrosis or hormone receptor negativity are more likely to have a microinvasive component in definitive pathology following surgery, and should be considered for SLNB procedure along with patients who will undergo mastectomy due to DCIS.

Candidate methylation profiling of ductal carcinoma in situ and its relationship to phenotype

Background and Aim Ductal carcinoma in situ (DCIS) accounts for ~25% of breast cancer. Clinical and histopathological parameters cannot identify cases which will recur or progress. DNA methylation was assessed as a potential biomarker in DCIS. Methods DNA meťhylation was assessed by methylation sensitive high resolution melting on DNAs isolated from formalin fixed, paraffin embedded (FFPE) samples from 82 DCIS and 18 normal samples. Nuclear grade, architectural pattern, and comedo necrosis were evaluated and phenotype determined by immunohistochemical staining for ER, PgR, CK5, Ki-67, and HER2 SISH. Results The median age was 54 years (29-82 years); 47.6% of samples were high, 45.1%, intermediate and 7.3% low grade. There were significant associations between APC, CDH13 , and FOXC1 methylation and grade, and between RASSF1A methylation and comedo necrosis. There was a significant negative relationship between ER and APC , and RARβ methylation, and between PgR status and CDH1, CDH13 , and RARβ methylation. HER2 amplification and CDH13 methylation were significantly associated. There was no significant relationship between methylation and architectural pattern or presence of invasion. Conclusions DNA methylation status is associated with DCIS phenotypic features of known prognostic significance. This, combined with the ability to assess DNA methylation in FFPE material, indicates potential diagnostic utility in clinical risk stratification.

Palpable Ductal Carcinoma in Situ: Analysis of Radiological and Histological Features of a Large Series With 5-Year Follow-Up

BackgroundPalpable pure DCIS is a rare entity that presents differently than screen-detected DCIS. The aim of this study was to evaluate the clinical, radiological, and pathological characteristics and management of pDCIS in a retrospective cohort of patients. Patients and MethodsPatients diagnosed with pDCIS from January 1999 to December 2011 were identified from an electronic patient database and were included in this study. ResultsDuring this period, 669 cases of DCIS were diagnosed and 62 (9.3%) were pDCIS (mean age, 56.9 ± 15.1 years). The most common finding on ultrasound was mass in 43 patients (75%) and only 18 (33%) cases had calcification on mammography. The lesion was mammographically occult in 20 patients (37%). Ultrasound was more sensitive and delineated the pDCIS in 45 (80%) cases. Mean size of the pDCIS was 36.9 ± 30.4 mm and most were high grade (n = 42; 68%) and associated with comedo necrosis in 36 (59%). Most were oestrogen receptor (ER)-positive (n = 34; 62%), however 21 patients (38%) were ER-negative. Breast conservation was attempted in 30 patients (48%), however, because of involved margins further therapeutic surgery was needed in 10 patients (33%). Axillary surgery (sentinel lymph node biopsy or axillary nodal sampling) was performed in 34 patients (55%) and no lymph node metastasis was identified. During a medial follow-up of 60 months, 1 patient has developed a mastectomy scar recurrence and the rest remain disease-free. ConclusionPalpable DCIS is often occult on conventional radiological imaging and is generally associated with aggressive pathological features. Hence, careful individualized surgical planning through a multidisciplinary meeting is necessary for their management.

Significance of HER2/neu overexpression in pure ductal carcinoma in situ: A clinicopathologic study with long-term follow-up.

85 Background: The prognostic value of HER2 (c-ERB2) overexpression in invasive breast cancer is well known, and correlates with aggressivene behavior. HER2 overexpression was reported in 13-56% of ductal carcinoma in-situ (DCIS). The significance of HER2 overexpression in DCIS has yet to be elucidated. The aim of this study was to correlate HER2 status with known prognostic indicators of DCIS and to evaluate whether the HER2 overexpression correlates with disease recurrence. Methods: All cases of DCIS diagnosed at our institution between 2000 and 2005 were retrieved. Cases without follow-up, those treated with mastectomy or those with concurrent invasive component were excluded. Clinicopathologic data were collected, including age at time of diagnosis, size of the lesion, nuclear grade, presence of comedo necrosis, margin status, estrogen (ER) and progesterone receptor (PR) status, type of adjuvant treatment received and length of follow-up. A representative block from each case was immunostained using the Hercept test. Slides were reviewed by 2 pathologists and interpreted in accordance with ASCO/CAP guidelines. Equivocal cases were reflexed for FISH testing. Results: A total of 152 cases were examined. Mean follow-up period was 77 months (range 12 to 138 months). HER2 was overexpressed in 49 cases (33%), and was significantly associated with high nuclear grade and presence of comedo necrosis. HER2-positive patients were more likely to be ER and PR negative. HER2 positive and negative patients did not differ significantly with respect to age at presentation or size of DCIS. On univariate analysis, HER2-type DCIS showed a higher risk of recurrence (P=0.037), however, this trend did not reach statistical signifance on multivariate analysis. Conclusions: HER2 overexpression was found to be associated with high nuclear grade, comedo necrosis as well as negativity for ER and PR but not with age or the size of DCIS. Patients with HER2-type DCIS (ER/PR-, HER2+) had a higher risk of disease recurrence than other types. However, after adjusting for all the other clinical variables, the molecular phenotype did not withhold its statistical significance as an independent predictor for recurrence.

A mucin-rich variant of salivary duct carcinoma with a prominent mucinous component, a tumor that mimics mucinous adenocarcinoma

The mucin-rich variant of salivary duct carcinoma (mSDC) is a rare type of salivary duct carcinoma. mSDC usually has both conventional SDC and mucinous adenocarcinoma-like areas. This article describes a first case of mSDC in which 95% of the tumor consisted of a mucinous area without no solid conventional SDC, so that the tumor mimicked mucinous adenocarcinoma. A 55-year-old man was evaluated for a 14 mm mass in the left submandibular gland. The tumor showed that floating tumor nests in a prominent mucinous lake. Some floating tumor nests had focal cribriform pattern with comedo necrosis, and all tumor cells had immunoreactivity for androgen receptor, gross cystic disease fluid protein 15, and Her-2/neu. A diagnosis of mSDC was rendered. mSDC with prominent mucinous component sometimes resembles mucinous adenocarcinoma. Identifying specific histological and immunohistochemical features of floating tumor nests in the mucinous area are important for the diagnosis.