Initial Diagnosis Of Ductal Carcinoma Research Articles

High rate of postoperative upstaging of ductal carcinoma in situ when prioritizing ultrasound evaluation of mammography-detected lesions: a single-center retrospective cohort study

BackgroundThe initial diagnosis of ductal carcinoma in situ (DCIS) can be upstaged to invasive cancer after definitive surgery. This study aimed to identify risk factors for DCIS upstaging using routine breast ultrasonography and mammography (MG) and to propose a prediction model.MethodsIn this single-center retrospective study, patients initially diagnosed with DCIS (January 2016–December 2017) were enrolled (final sample size = 272 lesions). Diagnostic modalities included ultrasound-guided core needle biopsy (US-CNB), MG-guided vacuum-assisted breast biopsy, and wire-localized surgical biopsy. Breast ultrasonography was routinely performed for all patients. US-CNB was prioritized for lesions visible on ultrasound. Lesions initially diagnosed as DCIS on biopsy with a final diagnosis of invasive cancer at definitive surgery were defined as “upstaged.”ResultsThe postoperative upstaging rates were 70.5%, 9.7%, and 4.8% in the US-CNB, MG-guided vacuum-assisted breast biopsy, and wire-localized surgical biopsy groups, respectively. US-CNB, ultrasonographic lesion size, and high-grade DCIS were independent predictive factors for postoperative upstaging, which were used to construct a logistic regression model. Receiver operating characteristic analysis showed good internal validation (area under the curve = 0.88).ConclusionsSupplemental screening breast ultrasonography possibly contributes to lesion stratification. The low upstaging rate for ultrasound-invisible DCIS diagnosed by MG-guided procedures suggests that it is unnecessary to perform sentinel lymph node biopsy for lesions invisible on ultrasound. Case-by-case evaluation of DCIS detected by US-CNB can help surgeons determine if repeating biopsy with vacuum-assisted breast biopsy is necessary or if sentinel lymph node biopsy should accompany breast-preserving surgery.Trial registrationThis single-center retrospective cohort study was conducted with the approval of the institutional review board of our hospital (approval number 201610005RIND). As this was a retrospective review of clinical data, it was not registered prospectively.

Abstract PD6-02: The metastatic breast cancer project - Expanding the clinical, genomic, and transcriptomic landscape of metastatic breast cancer through patient-partnered research

Abstract Background: The Metastatic Breast Cancer Project (MBCproject) is an ongoing research study that directly engages patients (pts) through social media and advocacy groups, and empowers them to share their biospecimens, clinical history, and experiences. The goal is to create a publicly available dataset of linked clinicogenomic and pt-reported data to enable research. From 2015-10-20 to 2020-3-31, 3,245 MBC pts who received treatment at >1,700 institutions, consented to share medical records, pt-reported data, and tumor/saliva/blood samples and to have genomic analysis performed. Here, we describe an analysis of the clinical and genomic features in this initial MBCproject cohort. Methods: We performed whole exome sequencing (WES) on 379 tumors (with matched germline) from 301 pts, 377 germline samples and RNA sequencing (RNA-seq) from 200 tumors from 141 pts. In 14 pts, we characterized 2 or more serial tumor biopsies. WES data was analyzed for mutations and copy number variants. RNA-seq data was used to call fusions, research-grade PAM50, and gene set enrichment scores. Medical records and pt-reported data were abstracted to create detailed clinical record for each pt. Results: WES of 249 metastatic tumors identified 34 cancer genes (e.g., TP53, PIK3CA, CDH1, PTEN, AKT1, NF1, ESR1) that were significantly recurrently altered. Potential clinically actionable alterations were identified in 39% of metastatic tumors. 45 tumors (22.5%) had fusions with known functional effects and 24 (12%) had in-frame fusions in key cancer genes like FANCD2 (3), FGFR3 (2), ESR1 (1), BRAF (1), and NCOR1 (1). PAM50 classification suggested depletion of Luminal A subtype in this cohort compared to TCGA breast cancer cohort (p-value <0.05). Of 29 pts with paired RNA-seq biopsies, 10 pts showed a PAM50 subtype switch [LumB to Basal = 1, Her2 to Basal =1, Basal to LumA = 1, Her2 to LumA = 2, LumA/B to Her2 = 3, LumA to LumB = 2]. Germline analysis showed that 30.2% (114/377) of pts had at least one pathogenic variant in a cancer predisposition gene, including BRCA1/BRCA2 (5%), NF1 (5.8%), ATM (1.06%) and PALB2 (1.59%). In 10.9% pts (33/301), pathogenic variants in a cancer predisposition gene was accompanied by an apparent somatic loss of function event in the same gene. There was ~ 90% concordance between abstracted features (e.g., receptor status, histology, diagnosis dates, metastatic sites) and pt-reported data, enabling the use of both data types for integrated analyses. The utility of integrated analyses is illustrated by a case study of a pt who had an initial diagnosis of ductal carcinoma in situ and developed metastatic disease 5.5 yrs later. Analysis of 3 metastatic tumors (WES and RNA-seq) and a circulating tumor DNA sample (WES only) from this pt collected over the course of therapy revealed evidence of tumor evolution and multiple mechanisms of resistance to endocrine therapies and CDK4/6 inhibitors, including 2 distinct acquired ESR1 mutations, an activating BRAF fusion, and estrogen receptor (ER) loss by immunohistochemistry with concomitant development of ESR1-PLEKHG1 in-frame fusion. RNA-seq data also showed a PAM50 luminal phenotype and a persistent ER. signature throughout despite the apparent ER loss, suggesting compensation by the ESR1 fusion. Analyses of 13 additional pts with serial biopsies will be presented. Integrated analyses of several additional cohorts of interest, such as de novo MBC (91 pts), resistance to CDK4/6 inhibitors (39 pts), and pts diagnosed with breast cancer <40 yrs, will also be presented. Conclusion: This clinicogenomic dataset generated by partnering directly with pts was uniquely built with pt-reported data, medical record data, and multi-omic characterization, and serves as a powerful tool for researchers to harness to accelerate discoveries in MBC. Citation Format: Esha Jain, Dewey Kim, Jorge Gomez Tejeda Zanudo, Sara Balch, Mary McGillicuddy, Brett N. Tomson, Tania G. Hernandez, Beena S. Thomas, Daniel L. Abravanel, Shahrayz Shah, Rafael Ramos, Delia Sosa, Ilan Small, Lauren Sterlin, Sarah Winnicki, Colleen Nguyen, Micheal Dunphy, Elana Anastasio, Todd R. Golub, Corrie A. Painter, Nikhil Wagle. The metastatic breast cancer project - Expanding the clinical, genomic, and transcriptomic landscape of metastatic breast cancer through patient-partnered research [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr PD6-02.

Underestimation of invasive breast carcinoma in patients with initial diagnosis of ductal carcinoma in situ: Size matters

BackgroundThe aim of our study was to identify those patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) and high risk of upstaging to invasive breast carcinoma (IBC), in whom sentinel lymph node biopsy (SLNB) should be considered. Materials and methodsOne-hundred and five DCIS patients treated with breast-conserving surgery (BCS) or mastectomy were studied. Preoperative features of the tumours were analyzed to investigate its association with underestimation of IBC on final pathology. ResultsOverall, the underestimation rate of IBC was 16.2%. The underestimation rate was highest in lesions with initial size >2 cm compared with those with size ≤2 cm (26.8% vs. 4.1%, respectively; p < 0.003). Eighty-eight patients (83.8%) underwent concurrent SLNB and only one case had lymph node involvement (1.1%). ConclusionsSLNB should be considered in DCIS patients receiving BCS with lesions greater than 2 cm since approximately one in four will harbour an IBC.

Abstract P5-08-05: Risk of subsequent events after initial diagnosis of ductal carcinoma in situ - A large multi-center registry study

Abstract Introduction: Ductal carcinoma in situ (DCIS) is a pre-malignant lesion but 14-53% will not progress to an invasive cancer. Large, well characterized DCIS datasets with long term follow up are sparse, and there is uncertainty regarding the long term effects of various treatment modalities on subsequent breast events (SBE). Here, we analyze trends identified in the SBE rates from patients treated at two large academic breast care centers in California, UCSF and UCSD. Methods: Institutional Cancer Registries were used to collect demographic, clinical, imaging and pathologic data. Patients aged 18 years and older without any prior history of breast disease whose first diagnosed breast neoplasm was DCIS and who had at least 6 months of follow up were included. Only SBE beyond 6 months after initial diagnosis were included. All mastectomy types and associated adjuvant treatment were grouped. All patients not undergoing surgery were grouped. Differences between patients in the various treatment groups were assessed using χ2, Student’s t-test, and one-way ANOVA. Poisson regression was used to compare differences in SBE rates between treatment groups. For analysis, follow up times were divided into three 5 years periods (0-5, 6-10, 11-15 years) after initial DCIS diagnosis. Results: 2730 patients - 1575 (57.7%) at UCSF and 1155 (42.3%) at UCSD - were diagnosed between 1985 and 2017 and included in the study. 1910 (70.0%) underwent breast conserving surgery (BCS), 672 (24.6 %) had mastectomy, 144 (5.3%) did not have surgery, and 4 (0.1%) had missing surgery status. 623 (22.8%) received adjuvant endocrine therapy (ET), 2081 (76.2%) did not and 26 (1.0%) had missing adjuvant endocrine therapy status. 1092 (40.0%) received adjuvant radiation therapy (RT), 1619 (59.3%) did not and 19 (0.7%) had unknown radiation therapy status. Median follow up time for all patients was 7.9 years. 305 patients were diagnosed with SBE. Of these, 144 (47.2%) were in situ and 147 (48.2%) were invasive including 16 (5.2%) metastatic lesions, and 14 (4.6%) had missing invasiveness. Of the 289 patients who did not have a metastatic second lesion, 176 (60.9%) SBE were ipsilateral, 88 (30.4%) were contralateral, and 25 (8.7%) had missing SBE laterality. The overall incidence (i) for any SBE over the entire study period was 1.4%/yr. Compared to women who were treated with BCS alone (N=642, i=2.14%/yr, 95% CI 1.76-2.51), SBE rates were lower in women undergoing BCS with RT (N=719, i=1.13%/yr, 95% CI 0.87-1.40, p&amp;lt;0.001), BCS with RT and ET (N=356, i=0.63%/yr, 95% CI 0.30-0.97, P&amp;lt;0.001), and mastectomy (N=672, i=1.00%/yr, 95% CI 0.75-1.25, p&amp;lt;0.001) but were not significantly different for patients undergoing BCS with ET (N=159, i=2.25%/yr, 95% CI 1.35-3.15, p=0.813). Within the first 5 years of diagnosis, mastectomy, BCS with RT, and BCS with RT and ET all lowered the SBE rate of ipsilateral in situ and invasive SBE (p&amp;lt;0.05, in each case). In contrast, no treatment modalities impacted the rate of contralateral SBE rate during any of the time periods. Importantly, the majority of patients, even with BCS alone never had a subsequent event and only 147 had an invasive event overall. Conclusion: This large two-center registry study reveals that the rate of invasive and in situ SBE after an initial DCIS diagnosis are comparable. The effect of each treatment modality on SBE incidence rates are consistent with other published studies, with the notable exception of BCS and ET which requires deeper investigation. As expected, local treatment affects mostly ipsilateral events within the first 5 years after initial diagnosis, without impacting the rate of contralateral SBE. Complementary molecular and cellular profiling of selected specimens are underway to help build a more precise BSE risk model and prevent overtreatment. Citation Format: Thomas O'Keefe, Christina Yau, Eliza Jeong, Emma Iaconetti, Paul Kim, Ann Griffin, Joseph McGuire, Rita Mukhtar, Laura Esserman, Olivier Harismendy, Gillian L. Hirst. Risk of subsequent events after initial diagnosis of ductal carcinoma in situ - A large multi-center registry study [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr P5-08-05.

Predictive factors for invasive cancer in surgical specimens following an initial diagnosis of ductal carcinoma in situ after stereotactic vacuum-assisted breast biopsy in microcalcification-only lesions.

The aim of this study was to determine the incidence of invasive breast carcinoma in patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) by stereotactic vacuum-assisted biopsy (SVAB) performed for microcalcification-only lesions, and to identify the predictive factors of invasion. From 2000 to 2010, the records of 353 DCIS patients presenting with microcalcification-only lesions who underwent SVAB were retrospectively reviewed. The mammographic size of microcalcification cluster, presence of microinvasion within the cores, the total number of calcium specks, and the number of calcium specks within the retrieved core biopsy specimen were recorded. Patients were grouped as those with or without invasion in the final pathologic report, and variables were compared between the two groups. The median age was 58 years (range, 34-88 years). At histopathologic examination of the surgical specimen, 63 of 353 patients (17.8%) were found to have an invasive component, although SVAB cores had only shown DCIS preoperatively. The rate of underestimation was significantly higher in patients with microcalcification covering an area of 40 mm or more, in the presence of microinvasion at biopsy, and in cases where less than 40% of the calcium specks were removed from the lesion. Invasion might be underestimated in DCIS cases diagnosed with SVAB performed for microcalcification-only lesions, especially when the mammographic size of calcification is equal to or more than 40 mm or if microinvasion is found within the biopsy specimen and less than 40% of the calcifications are removed. At least 40% of microcalcification specks should be removed from the lesion to decrease the rate of underestimation with SVAB.

Sentinel lymph node biopsy is not necessary in patients diagnosed with ductal carcinoma in situ of the breast by stereotactic vacuum-assisted biopsy.

This study evaluated the role and need of a sentinel lymph node biopsy (SLNB) in patients with an initial diagnosis of ductal carcinoma in situ (DCIS) made by stereotactic vacuum-assisted biopsy (VAB). A retrospective analysis was performed of 1,458 patients who underwent stereotactic VAB between January 1999 and December 2012 at Aichi Cancer Center Hospital. The rates of axillary node metastasis and the underestimation of invasive ductal carcinoma (IDC) were examined. Of the 1,458 patients who underwent stereotactic VAB, 199 had a preoperative diagnosis of DCIS and underwent surgery. In these patients, 20 % (39/199) were upstaged to IDC or at least microinvasion in final pathology. Axillary lymph node status was investigated in 81 % (161/199) of initially diagnosed DCIS patients, and resulted in finding lymph node metastasis in 0.62 % (1/161) patients. To assess the potential preoperative predictors of invasiveness, the value of DCIS histological grade on biopsy samples, the distribution of calcifications on mammograms, and the combination of these factors were studied. The underestimation rate was higher (30 %) in the combination of high DCIS histological grade and extensive calcification although there was no significant association (p = 0.23). The rate of lymph node metastasis was extremely low (0.62 %), even when invasive carcinoma was identified on excision in patients initially diagnosed with DCIS by stereotactic VAB. Because of the low prevalence of metastatic involvement, the cessation of SLNB is a reasonable consideration in patients initially diagnosed with DCIS by stereotactic VAB.

Ductal CarcinomaIn Situand Sentinel Lymph Node Biopsy

PurposeAxillary lymph node status is the strongest prognostic indicator of survival for women with breast cancer. The purpose of this study was to evaluate whether sentinel lymph node biopsy (SLNB) is required in patients with an initial diagnosis of ductal carcinoma in situ (DCIS).MethodsA retrospective analysis was performed of 78 patients with an initial diagnosis of DCIS between December 2002 and April 2010 and who proceeded to have either SLNB or axillary node dissection performed as part of their primary surgical procedure. The study focused on the rates of axillary node metastasis and the underestimation of invasive carcinoma at an initial diagnosis.ResultsForty-eight patients underwent SLNB and 18 patients underwent axillary node dissection. Only 1 of 66 patients (1.5%) had a positive sentinel lymph node. After definite surgery, the final diagnosis was changed to invasive ductal carcinoma (IDC) in 12 patients and DCIS with microinvasion in 2 patients; 14 of 78 patients (17.9%) were therefore underestimated at preoperative histological examinations. In 35 patients who were diagnosed DCIS by core needle biopsy (CNB), 13 patients (37.1%) were upstaged into IDC or DCIS with microinvasion in the final diagnosis. The statistically significant factors predictive of invasive breast cancer were a large tumor size and HER2 overexpression.ConclusionThe rates of SLNB positivity in pure DCIS are very low, and there is continuing uncertainty about its clinical importance. However in view of the high rate of underestimation of invasive carcinoma in patients with an initial diagnosis of DCIS, SLNB appears to be appropriate in these patients, especially in the case when DCIS is diagnosed by a core needle biopsy. In patients with an initial diagnosis of DCIS by CNB, SLNB should be considered as part of the primary surgical procedure, when preoperative variables show a tumor larger than 2.35 cm and with HER2 overexpression.

Diagnosis of second breast cancer events after initial diagnosis of early stage breast cancer

To examine whether there are any characteristics of women or their initial tumors that might be useful for tailoring surveillance recommendations to optimize outcomes. We followed 17,286 women for up to 5 years after an initial diagnosis of ductal carcinoma in situ (DCIS) or early stage (I/II) invasive breast cancer diagnosed between 1996 and 2006. We calculated rates per 1,000 women years of recurrences and second breast primaries relative to demographics, risk factors, and characteristics of initial diagnosis: stage, treatment, mode of initial diagnosis. Nearly 4% had a second breast cancer event (314 recurrences and 344 second breast primaries). Women who used adjuvant hormonal therapy or were ≥ 80 years had the lowest rates of second events. Factors associated with higher recurrence and second primary rates included: initial DCIS or stage IIB, estrogen/progesterone receptor-negative, younger women (<50 years). Women with a family history or greater breast density had higher second primary rates, and women who received breast conserving surgery without radiation had higher recurrence rates. Roughly one-third of recurrences (37.6%) and second primaries (36.3%) were not screen-detected. Initial mode of diagnosis was a predictor of second events after adjusting for age, stage, primary treatment, and breast density. A recent negative mammogram should not falsely reassure physicians or women with new breast symptoms or changes because one-third of second cancers were interval cancers. This study does not provide any evidence in support of changing surveillance intervals for different subgroups.

Using Lifetime Risk Estimates to Recommend Magnetic Resonance Imaging Screening for Breast Cancer Survivors

There are millions of breast cancer survivors in the United States currently, and expectations are that the number will continue to increase in the years to come. Survivors of early-stage breast cancer are at increased risk for developing second primary breast cancers. Data regarding the effectiveness of surveillance mammography among survivors of early-stage breast cancer are limited, but suggest that mammography may reduce breast cancer mortality for this cohort as it does when used to screen the general population. Although national guidelines recommend annual mammographic surveillance for survivors of early-stage breast cancer, studies suggest surveillance mammography is underutilized. Mammography is not a perfect test. In fact, it may be particularly insensitive at detecting breast cancer among selected high-risk populations, such as BRCA carriers, young women, and women with dense breast tissue. Magnetic resonance imaging (MRI) has consistently demonstratedgreatersensitivityversusmammographyinthesepopulations. However, MRI screening is more costly and time consuming, requires the injection of intravenous contrast, generates more false-positive results, and has not been shown to impact breast cancer mortality. Debate regarding the role of MRI as a screening test led the American Cancer Society to convene an expert panel to develop guidelines in 2007. The panel recommended breast MRI screening as an adjunct to mammography for: BRCA mutation carriers and their first-degree relatives; women with a lifetime breast cancer risk 20% to 25%; women with a history of chest radiation between ages of 10 and 30 years; and women with predisposing genetic syndromes (eg, Li-Fraumeni, Cowden). The group felt there was insufficient evidence to recommend for or against MRI screening among women with a personal history of invasive breast cancer or ductal carcinoma in situ. On one hand, MRI surveillance may seem appropriate for breast cancer survivors. Compared to women with a higher than 20% lifetime risk of primary breast cancer as defined by BRCAPRO or other family history–based models, many survivors of early-stage breast cancer could experience an even greater risk of second primary breast cancer. In addition, the sensitivity of mammography among survivors could be impaired by changes in the breast caused by previous treatments. In contrast, no studies have explored the utility of surveillance MRI among survivors. Moreover, this cohort also faces a competing risk of mortality from the primary breast cancer diagnosis. Based on personal observations, use of surveillance MRI among women with a personal history of early-stage breast cancer appears to be increasing. These issues raise serious questions regarding the appropriate use of surveillance breast MRI among survivors of early-stage breast cancer. To explore the implications of applying the American Cancer Society risk threshold to women with a personal history of breast cancer who are not BRCA carriers, we constructed an analytic model to calculate lifetime risk of developing a second breast cancer after diagnosis of an initial breast cancer. Specifically, we sought to determine which subsets of breast cancer survivors met a 20% or 25% lifetime risk threshold of having a new cancer, taking into account the competing risk of cancer mortality from the first diagnosis and agedependent noncancer mortality. The model was designed to provide customized values for lifetime risk of developing breast cancer for each year after diagnosis, as a function of the initial cancer (hormone receptor–positive v –negative, mortality risk), its treatment (breastconserving surgery v mastectomy, and tamoxifen v not for hormone receptor–positive cancers), and age at initial diagnosis. Our model assumed the risk of developing a second breast cancer was constant over time, not related to a patient’s age, and the same for the ipsilateral versus contralateral breast—as demonstrated in multiple prospective and retrospective studies. Adjuvant tamoxifen therapy was associated with a 47% reduction in the risk of developing a new breast cancer over the 10-year period after the primary cancer diagnosis. Therefore, the risk of developing a second breast cancer was only a function of the number of intact breasts and use of tamoxifen. No assumptions were made regarding the sensitivity or specificity of MRI screening in women with a personal history of breast cancer. Mortality risk from the initial diagnosis was assumed to be constant and completed within 7 years for hormone receptor–negative cancers and 15 years for hormone receptor–positive cancers. Patients with an initial diagnosis of ductal carcinoma in situ were assumed to have no mortality risk associated with their primary breast cancer diagnosis. Nonbreast cancer mortality was determined using 2004 United States female life-tables. The annual likelihood of a survivor developing a second breast cancer was determined by multiplying the per year probability of developing a new breast cancer with the per year probability of being alive (ie, not dying from the primary breast cancer or a nonbreast cancer cause). The lifetime risk of developing a JOURNAL OF CLINICAL ONCOLOGY COMMENTS AND CONTROVERSIES VOLUME 28 NUMBER 27 SEPTEMBER 2

The Predictors of Tumor Invasion for Patients with an Initial Diagnosis of Ductal Carcinoma in situ and the Indications for Performing Sentinel Lymph Node Biopsy

Purpose: The diagnostic methods for examining suspicious lesions in the breast are becoming less invasive, like core-needle biopsy. Yet, the risk of invasion has been reported to be up to 47% for patients with ductal carcinoma in situ (DCIS) initially diagnosed by core-needle biopsy. The value of sentinel lymph node biopsy (SLNB) for DCIS has not been clearly proved. We searched for the factors associated with invasiveness of preoperatively diagnosed DCIS, and we determined the indications for performing SLNB for patients with preoperatively diagnosed DCIS. Methods: Between October 1997 and December 2008, we retrospectively reviewed 135 patients with DCIS that was initially diagnosed by core-needle biopsy or other biopsy methods. We compared the invasive breast cancer group, which was finally diagnosed with the pure DCIS group in regards to clinical, radiological, and pathological factors. Results: 21.5% of the patients with initial diagnosis of DCIS were finally diagnosed with invasive breast cancer. On univariate analysis, the statistically meaningful factors for invasiveness were palpable lesion (P＜0.0001), core-needle diagnosis (P=0.007), large tumor size (P=0.028), high nuclear grade (P=0.002), and negative estrogen receptor (P=0.005). On multivariate analysis, a palpable lesion was the only independent risk factor (odds ratio 3.9 (1.1 to 13.8); P=0.035). Axillar lymph node metastases were found in three patients in the invasive cancer group. There was no lymph node metastasis in the DCIS group. Conclusion: We recommend that SLNB be considered in initially diagnosed DCIS with palpable lesion or high nuclear grade due to the high risk of invasiveness.

Value of Sentinel Lymph Node Biopsy in Breast Ductal Carcinoma in Situ Upstaged to Invasive Carcinoma

The role of sentinel lymph node (SLN) biopsy in patients with initial diagnosis of ductal carcinoma in situ (DCIS) is still a dilemma. Different studies are trying to define predicting factors of invasive cancer in DCIS. The aim of this study was to confirm the value of SLN biopsy in DCIS because of the invasive upstaging risk on final histology. Patients with initial diagnosis of DCIS and with axillary SLN biopsy were selected. All diagnoses were confirmed by biopsy of mammographic lesions. Surgical treatment was lumpectomy or mastectomy associated with SLN biopsy. Imprint stains were performed, and then serial sections were stained with hematoxylin and eosin (H&E) and with immunohistochemistry (IHC). A complete axillary lymph node dissection (ALND) was performed during the same surgery when a node metastasis was found. Eighty patients were enrolled in the study. Of the 61 patients who were initially diagnosed with DCIS, 12 (20%) were upstaged to microinvasive or invasive carcinoma and 9 (15%) had a metastatic SLN. Patients upstaged to invasive carcinoma had macrometastatic SLN immediately fed by a complete ALND. SLN micrometastases and isolated cells were detected by IHC and secondary complete ALND found an additional metastatic lymph node in one patient. Tumor size larger than 30 mm and mastectomy were the only significative predicting factors of upstaged disease (p < 0.0001) in our study. In patients with initial diagnosis of large DCIS programmed for mastectomy, SLN biopsy should be discussed in order to detect underlying invasive disease and to spare patients a second operating time.

4–29 Predictors of Invasive Breast Cancer in Patients With an Initial Diagnosis of Ductal Carcinoma In Situ: A Guide to Selective Use of Sentinel Lymph Node Biopsy in Management of Ductal Carcinoma In Situ

4–29 Predictors of Invasive Breast Cancer in Patients With an Initial Diagnosis of Ductal Carcinoma In Situ: A Guide to Selective Use of Sentinel Lymph Node Biopsy in Management of Ductal Carcinoma In Situ

Predictors of invasive breast cancer in patients with an initial diagnosis of ductal carcinoma in situ: A guide to selective use of sentinel lymph node biopsy in management of ductal carcinoma in situ

The role of sentinel lymph node biopsy (SLNB) in patients with an initial diagnosis of ductal carcinoma in situ (DCIS) has not been well defined. The purpose of our study was to determine when the risk of finding invasive disease on final pathology in patients with an initial diagnosis of DCIS was sufficiently high to justify use of SLNB. The records of 398 consecutive patients from our prospective database with an initial diagnosis of DCIS, treated between July 1999 and December 2002, were analyzed. Associations between clinical and pathologic factors and patient selection for SLNB and outcomes were analyzed for significance using univariate and multivariate analyses. Of the 398 patients, 80 (20%) were found to have invasive disease on final pathology. Multivariate analysis revealed 4 independent predictors of invasive cancer on final pathology: 55 years of age or younger (odds ratio [OR], 2.19; p = 0.024), diagnosis by core-needle biopsy (OR, 3.76; p = 0.006), mammographic DCIS size of at least 4 cm (OR, 2.92; p = 0.001), and high-grade DCIS (OR, 3.06; p = 0.002). A total of 141 patients (35%) underwent SLNB as a component of their initial operation. Multivariate analysis revealed that the presence of comedonecrosis (OR, 2.69; p = 0.007) and larger mammographic DCIS size (OR, 1.18; p = 0.0002) were independent predictors of patients' undergoing SLNB. Of these 141 patients, 103 (73%) were diagnosed by core-needle biopsy, 42 (30%) had invasive disease on final pathology, and 14 (10%) had a positive sentinel lymph node: 12 (86%) by hematoxylin and eosin staining and 2 by immunohistochemistry. The only independent predictor of a positive SLN was the presence of a palpable tumor (OR, 4.28, p = 0.042). Of these 14 patients with a positive sentinel node, only 11 (79%) had invasive cancer on final pathology. SLNB should not be performed routinely for all patients with an initial diagnosis of DCIS. Risks and benefits of SLNB should be discussed with patients who are younger, are diagnosed by core-needle biopsy, or have large or high-grade DCIS.

Predictors of invasive breast cancer in patients with an initial diagnosis of ductal carcinoma in situ: A guide to the selective carcinoma in situ

Predictors of invasive breast cancer in patients with an initial diagnosis of ductal carcinoma in situ: A guide to the selective carcinoma in situ

Relationship of family history and outcome after breast conservation therapy in women with ductal carcinoma in situ of the breast

Purpose: The purpose of this study was to evaluate the relationship between a family history of breast or ovarian cancer and outcome after breast-conserving surgery and radiation in women presenting with an initial diagnosis of ductal carcinoma in situ (DCIS) of the breast. Methods and Materials: A total of 146 consecutive women with a pathologic diagnosis of ductal carcinoma in situ as their first diagnosis of any breast cancer were identified; 28 (19%) had a positive family history of breast or ovarian cancer in a first-degree relative, 27 (19%) had a positive family history in a second-degree relative, and 91 (62%) had no family history. Pathologic, clinical, and treatment factors, and clinical outcomes for each family history group were compared. Cosmesis and complications were recorded at each follow-up. Patients were treated between 1978 and 1995, and the median follow-up was 7.1 years. Results: Patients with a positive family history in a first- or second-degree relative each had an 8% incidence of local failure at 10 years, while the negative family history group demonstrated a 16% local failure rate ( p = 0.33). Overall survival at 10 years for patients with a positive family history in a first- or second-degree relative was 100% and for those with a negative family history was 91% ( p = 0.08). The negative family history group had a higher median age that may account for the difference in overall survival. Cause-specific survival (CSS) was 97%, 100%, and 99%, respectively, at 10 years ( p = 0.25). There were no differences in the cosmetic results or complication rates between women with a positive or negative family history. Conclusion: We have shown that a family history of breast and/or ovarian cancer is not associated with an adverse outcome for women treated with breast conservation therapy for DCIS. Local recurrence, cause-specific survival, overall survival, cosmesis, and complication rates were comparable to that of similarly treated women with negative family histories. Therefore, a positive family history is not a contraindication for breast conservation therapy in women with DCIS.