Preoperative Diagnosis Of Ductal Carcinoma Research Articles

Abstract PO5-20-01: SENTINOT2- Use of superparamagnetic iron oxide tracer to avoid unnecessary sentinel lymph node biopsies

Abstract Background/Purpose: The use of superparamagnetic nanoparticles of iron oxide tracers (Magtrace) and electromagnetometers (SentiMag) for the detection of sentinel lymph nodes (SLN) during breast cancer surgery has been demonstrated to be noninferior to traditional radioisotope (RI) and blue dye detection, with additional safety benefits. Previous work has shown that transcutaneous detection of SLN with Magtrace/Sentimag is possible for over 30 days. Because of the safety, efficacy, and long detection window of Magtrace, we aim to investigate the use of Magtrace to prevent unnecessary SLN biopsies (SLNB) in breast cancer surgery. SLNB are commonly performed during breast conserving surgeries (BCS) or mastectomy for patients with a preoperative diagnosis of ductal carcinoma in-situ (DCIS). Because metastasis is not expected in patients diagnosed with DCIS, SLNB may be unnecessary and potentially harmful. However, in 15-25% of cases, unexpected invasive carcinoma is found during the post-surgical histopathological analysis of the resected breast tissue. For these cases, if SLNB are forgone during the initial surgery, SLNB during a second (delayed) procedure is the usual standard of care to evaluate SLN for metastasis. However, potential changes to lymphatic drainage following the initial resection may affect tracer localization to SLN. Consequently, we aim to compare SLN detection rates during delayed SLNB with Magtrace administered prior to initial BCS or mastectomy and subsequent RI tracer administered prior to delayed SLNB. Methods: SENTINOT2 is an ongoing international trial with BCM as the sole US site. For eligible patients with a preoperative diagnosis of DCIS, Magtrace will be administered prior to BCS or mastectomy. If invasive carcinoma is found from the post-surgical histopathological analysis, patients will receive delayed SLNB within 4 weeks of their initial surgery. Prior to delayed SLNB, patients will be randomized into two groups differing in the order of modality used for SLN detection (Magtrace or RI). Subjects with the following conditions will be excluded from the study: hypersensitivity to Magtrace, iron overload disease, pregnancy, and lactation. The total expected accrual for this study is 538 subjects globally and 50 subjects at BCM. Results: Currently, 19 patients have been enrolled in SENTINOT2. The subject population is 11% Asian, 26% Black/African American, and 47% Caucasian with non-Hispanic ethnicity. 5% of subjects identified as Hispanic Caucasian and 11% of subjects declined to report their race or ethnicity. 79% of patients had mastectomies, while 21% had BCS. After post-surgical histopathological analysis, 21% (4/19) patients were determined to have invasive carcinoma and received delayed SLNB. 50% (2/4) of these patients were randomized to have Magtrace as their first SLN detection modality (Mag-RI) while the other 50% (2/4) had RI as their first SLN detection modality (RI-Mag). Table 1 shows comparable SLN detection rates between Magtrace and RI for patients who received delayed SLNB. Only 1/4 patients showed SLN metastasis. For this patient, the positive SLN was successfully detected by both modalities. Conclusion: Magtrace has shown potential in delayed SLN detection and the use of Magtrace has prevented 79% (15/19) of enrolled patients from receiving unnecessary SLNB. Table 1. Number of Lymph Nodes (LN) Detected by Magtrace/Radioisotope, Biopsied and Positive for Metastasis Citation Format: Mary Bajomo, Ivan Marin, Jessica Montalvan, Margarita Riojas-Barrett, Logan Healy, Elizabeth Bonefas, Stacey Carter, Alastair Thompson. SENTINOT2- Use of superparamagnetic iron oxide tracer to avoid unnecessary sentinel lymph node biopsies [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO5-20-01.

Role of contrast-enhanced mammography in the preoperative detection of ductal carcinoma in situ of the breasts: a comparison with low-energy image and magnetic resonance imaging.

To compare contrast-enhanced mammography (CEM) with low-energy image (LEI) alone and with magnetic resonance imaging (MRI) in the preoperative diagnosis of ductal carcinoma in situ (DCIS). In this single-center retrospective study, we reviewed 98 pure DCIS lesions in 96 patients who underwent CEM and MRI within 2weeks preoperatively. The diagnostic performances of each imaging modality, lesion morphology, and extent were evaluated. The sensitivity of CEM to DCIS was similar to that of MRI (92.9% vs. 93.9%, p = 0.77) and was significantly higher than that of LEI alone (76.5%, p = 0.002). The sensitivity of CEM to calcified DCIS (92.4%) was not significantly different from LEI alone (92.4%) and from MRI (93.9%, p = 1.00). However, CEM contributed to the simultaneous comparison of calcifications with enhancements. CEM had considerably higher sensitivity compared with LEI alone (93.8% vs. 43.8%, p < 0.001) and performed similarly to MRI (93.8%, p = 1.00) for noncalcified DCIS. All DCIS lesions were enhanced in MRI, whereas 94.9% (93/98) were enhanced in CEM. Non-mass enhancement was the most common presentation (CEM 63.4% and MRI 66.3%). The difference between the lesion size on each imaging modality and the histopathological size was smallest in MRI, followed by CEM, and largest in LEI. CEM was more sensitive than LEI alone and comparable to MRI in DCIS diagnosis. The enhanced morphology of DCIS in CEM was consistent with that in MRI. CEM was superior to LEI alone in size measurement of DCIS. This study investigated the value of CEM in the diagnosis and evaluation of DCIS, aiming to offer a reference for the selection of examination methods for DCIS and contribute to the early diagnosis and precise treatment of DCIS. • DCIS is an important indication for breast surgery. Early and accurate diagnosis is crucial for DCIS treatment and prognosis. • CEM overcomes the deficiency of mammography in noncalcified DCIS diagnosis, exhibiting similar sensitivity to MRI; and CEM contributes to the comparison of calcification and enhancement of calcified DCIS, thereby outperforming MRI. • CEM is superior to LEI alone and slightly inferior to MRI in the size evaluation of DCIS.

Preoperative diagnosis of ductal carcinoma in situ of the breast over a 24-year period.

The method of diagnosis of ductal carcinoma in situ (DCIS) has changed since the 1980s. The aim of this audit was to assess changes in the preoperative diagnosis of DCIS since the introduction of needle core biopsy, particularly the proportion with a preoperative biopsy diagnosis of DCIS. The preoperative diagnoses of patients with a final diagnosis of DCIS in the surgical specimen were reviewed (i) in 809 patients who presented through breast screening from 1997 to 2021, and (ii) in all patients in 5 individual years at 5-year intervals from 2000 to 2020 (254 in total). For screening-detected DCIS the proportion with a preoperative diagnosis of DCIS increased from 75% to 98% over the study period. In a detailed analysis of all cases of DCIS in 5 separate years the proportion with a preoperative diagnosis of DCIS increased from 68% in 2000 to 96% in 2020. For high-grade DCIS the proportion increased from 87% to 97%, and for low- or intermediate-grade DCIS from 48% to 93%. The proportion of women who had vacuum-assisted biopsy increased from 7% in 2000 to 58% in 2015. There was a small increase in the number of biopsies that had basal cytokeratin and oestrogen receptor immunohistochemistry to aid diagnosis. There has been an increase in the preoperative diagnosis of DCIS, particularly of low- or intermediate-grade, over the last two decades. The increasing use of vacuum-assisted biopsy is likely to be a major contributory factor to this increase.

Abstract OT1-20-01: SentiNot 2.0: Avoid unnecessary Sentinel Lymph Node Biopsies in women with DCIS

Abstract Background Approximately 15-30% of women with a preoperative diagnosis of ductal carcinoma in situ (DCIS) will be diagnosed with invasive cancer (IBC) on specimen pathology. Risk of upgrade, and impairment of lymphatic outflow after breast surgery, mainly mastectomy, are drivers for upfront sentinel lymph node dissection (SLND). In the SentiNot feasibility study, marking the SLN by superparamagnetic iron oxide nanoparticles (SPIO) injection during primary surgery minimized unnecessary SLNDs, allowing for delayed SLND (d-SLND) only in those with IBC up to 50 days after primary surgery. This policy resulted in that 78.3% study participants avoided upfront SLND. In the d-SLND setting, SPIO detection outperformed the isotope (98.5 vs 60.6%), regardless of type of breast procedure. Incremental healthcare costs were reduced by 8.5% (485 USD per patient) for the entire trial population (ref 1). Prospective Clinical Trial Design SentiNot 2.0 (ClinicalTrials.gov Identifier: NCT04722692), is currently accruing data, powered to examine the detection rate of SPIO over isotope±blue dye during d-SLND. Trial candidates are: patients with a diagnosis of high-risk DCIS/pLCIS (mass-lesions, microinvasion, grade 3, grade 2 &amp;gt;20mm) regardless of type of breast surgery, and patients with planned breast surgery that precludes safe and accurate axillary mapping at a d-SLND (extensive oncoplastic breast conservation, tumors of the axillary tail and mastectomy). In d-SLND, study patients receive isotope±blue dye and within-patient-randomization is performed for which detection method to start with (SPIO-first vs. isotope-first). The trial is stratified for mastectomy and breast conservation. Secondary outcomes are nodal concordance (SPIO vs. isotope) at d-SLND, quality-of-life and health-economy outcomes. Present and Planned Accrual Total target accrual is 500 d-SLNDs. Insofar, 360 women have been included at six different sites in Sweden, Hong Kong, and the USA. Currently, data accrual and institution recruitment is active and expanding. For more information about the trial please refer to ClinicalTrials.gov Identifier: NCT04722692. For discussion regarding potential participation contact dr Andreas Karakatsanis (andreas.karakatsanis@surgsci.uu.se). Citation Format: Eirini Pantiora, Staffan Eriksson, Lida Pistiolis, Roger Olofsson Bagge, Gyula Nagy, Alastair M. Thompson, Vivian Man, Ava Kwong, Andreas Karakatsanis, Fredrik Wärnberg. SentiNot 2.0: Avoid unnecessary Sentinel Lymph Node Biopsies in women with DCIS [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr OT1-20-01.

Surgical upstaging rates in patients meeting the eligibility for active surveillance trials.

Four clinical active surveillance trials including LORIS, COMET, LORD and LORETTA, are being conducted to assess whether women with low-risk ductal carcinoma in situ can safely avoid surgery. The present study aimed to determine the rate of upstaging to invasive cancer among patients with a preoperative diagnosis of ductal carcinoma in situ and to evaluate the incidence of upstaging in patients meeting the eligibility criteria for four active surveillance clinical trials. The present study initially enrolled 180 patients with 183 calcifications who received the diagnosis of ductal carcinoma in situ by biopsy. Patients were classified as eligible for four clinical trials according to the respective inclusion criteria. In total, 152 patients with 155 calcifications were analyzed. Of these, 32 (21%) were upstaged to invasive disease based on the final pathological analysis of surgical specimens. Of the 152 patients, 53 (35%), 90 (59%), 24 (16%) and 34 (22%) met the eligibility criteria for the LORIS, COMET, LORD and LORETTA trial, respectively. Among patients with low-risk ductal carcinoma in situ, 10 (19%), 14 (16%), 6 (25%) and 4 (12%) patients were upstaged to invasive disease in LORIS, COMET, LORD and LORETTA, respectively. The upstaging to pT1b or higher rates were 2% (1/53), 3% (3/90), 0% (0/24) and 3% (1/34) in LORIS, COMET, LORD and LORETTA, respectively. The upstaging rate in patients eligible for the clinical active surveillance trials was 12-25%. Although the rate of upstaging to pT1b or higher was low, further studies are required to determine the rates of upstaging to invasive cancer and the risk factors among patients with low-risk ductal carcinoma in situ.

AI-based imaging biomarker in mammography for prediction of tumor invasiveness.

1568 Background: The preoperative diagnosis of ductal carcinoma in situ (DCIS) by core needle biopsy (CNB) can be upstaged in the final pathology, and this possibility is linked to the controversy over whether axillary staging is necessary in primary operation. In this study, we developed an artificial intelligence (AI)-powered Imaging Biomarker in Mammography (IBM) that can predict tumor invasiveness in preoperative mammography and evaluated its performance in an external validation cohort. Methods: A total of 151,764 exams of 4-view mammograms were collected from five institutions of three countries to develop the AI algorithm for breast cancer detection, where 31,776 were cancer exams. In previous studies, the performance of this breast cancer detection algorithm has already been evaluated, and in this study, we further developed the AI-powered IBM for predicting tumor invasiveness on top of the AI algorithm for breast cancer detection. To develop the AI-powered IBM for predicting invasiveness, final diagnosis information was collected for 8,251 cancer exams (472 DCIS, 388 ductal carcinoma in situ (DCIS-MI), and 7,391 invasive ductal carcinoma (IDC)), and 886 cancer exams (44 DCIS, 51 DCIS-MI, 791 IDC) were additionally collected for internal validation. The AI-powered IBM was developed via two stages of training – 1) training with diagnosis labels (cancer vs non-cancer), followed by 2) fine-tuning with invasiveness labels (DCIS, DCIS-MI, IDC). The AI-powered IBM also tested in an external validation cohort of 699 cancer exams (68 DCIS, 19 DCIS-MI, 612 IDC) and all the exams were confirmed by surgical biopsy. Results: The AI-powered IBM showed an area under the curve (AUC) values of 0.968 for breast cancer detection and it successfully distinguished IDC from DCIS and DCIS-MI with AUC values of 0.898 and 0.851, respectively (Table). In addition, the AUC value in terms of discriminating between DCIS and DCIS-MI was 0.752. When the AI-powered IBM was tested in the external cohort, it could detect breast cancer with the AUC of 0.952 and, its performance in terms of invasiveness prediction was similar that of the internal validation (IDC vs DCIS, 0.810; IDC vs DCIS-MI, 0.846), which supports the AI-powered IBM is applicable to the unseen mammography exam. Conclusions: The AI-powered IBM can distinguish IDC from DCIS and DCIS-MI in mammography. The results support that the AI-powered IBM can be used as a biomarker to help determine the surgical plan that includes whether or not to perform the axillary dissection.[Table: see text]

82P Predicting invasive disease and lymph node involvement in patients with preoperative diagnosis of ductal carcinoma in situ

Eight to 56% patients undergoing a mastectomy with preoperative diagnosis of ductal carcinoma in situ (DCIS) upgrade to invasive disease on final histopathological evaluation. Sentinel node biopsy in this cohort of patients cannot be safely excluded due to the high probability of finding invasive disease on final histopathological evaluation. We were keen to identify factors predictive of invasiveness and therefore probable nodal involvement.

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.

Infraestimación de carcinoma infiltrante de mama en pacientes con diagnóstico inicial de carcinoma ductal in situ: el tamaño importa

IntroductionThe 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. MethodsOne-hundred and five DCIS patients treated with breast-conserving surgery (BCS) or mastectomy were studied. Preoperative features of the tumors 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 harbor an IBC.

Predictors of invasive disease in patients preoperatively diagnosed with ductal carcinoma without stromal invasion, with breast magnetic resonance imaging (MRI) and ultrasound (US).

A preoperative diagnosis of ductal carcinoma in situ (DCIS) is sometimes upstaged to invasive disease postoperatively. Our objective was to clarify the predictive factors of invasive disease using preoperative imaging and to investigate the positive ratio of sentinel lymph nodes (SLN) and the incidence of invasive disease. The subjects were 402 patients with preoperatively diagnosed ductal carcinoma without stromal invasion who underwent breast surgery with concomitant SLN surgery in January 2007 to December 2016. Of the 306 included patients, all 306 patients underwent preoperative MRI and US assessment. Outcomes were analyzed for significance using univariate and multivariate analyses. Of the 306 patients, 115 (37.6%) had invasive disease and 191 (62.4%) had DCIS only. Of the 115 patients with invasive disease, 5 (4.4%) and 4 (3.5%) had macro- and micrometastases in SLN. On the other hand, of the 191 patients with DCIS, only 1 (0.5%) had a micrometastasis. Predictors of invasive disease in the univariate analysis included having a palpable mass, were varied by biopsy method, having a US hypoechoic mass, MRI enhancement, or MRI large enhanced lesion; the size of the mass enhancement ≥ 1.1cm or a spread of non-mass enhancement ≥ 3.1cm (P = 0.003). Predictors of invasive disease in the multivariate analysis included US hypoechoic mass and MRI large enhanced lesion. We need to perform SLN biopsy for preoperatively diagnosed DCIS when patients have predictors of invasive disease, but SLN biopsy will no longer be essential for patients when they have no predictors of invasive disease.

P130: Does routine sentinel node biopsy in patients undergoing mastectomy for screening high-grade ductal carcinoma in-situ of the breast cause more harm than good?

Introduction: Sentinel Lymph Node Biopsy (SLNB) is not feasible following mastectomy thus has been the standard of care for patients, with a pre-operative diagnosis of ductal carcinoma in-situ (DCIS), undergoing mastectomy. Whether such an approach is safe depends on the complication rates of SLNB relative to axillary dissection and the upstaging rate. The upstaging rate that would justify routine SLNB ranges from 26% to 83% according to 4 major randomized trials. This study examines the incidence and predictors of upstaging in screen detected High-Grade DCIS (HGDCIS).

Sentinel lymph node positivity in patients undergoing mastectomies for ductal carcinoma in situ (DCIS).

Current guidelines recommend sentinel lymph node biopsy (SLNB) for patients undergoing mastectomy for a preoperative diagnosis of ductal carcinoma in situ (DCIS). We examined the factors associated with sentinel lymph node positivity for patients undergoing mastectomy for a diagnosis of DCIS on preoperative core biopsy (PCB). The Institutional Breast Cancer Database was queried for patients with PCB demonstrating pure DCIS followed by mastectomy and SLNB from 2010 to 2018. Patients were divided according to final pathology (DCIS or invasive cancer). Clinico-pathologic variables were analyzed using Pearson's chi-squared, Wilcoxon Rank-Sum and logistic regression. Of 3145 patients, 168(5%) had pure DCIS on PCB and underwent mastectomy with SLNB. On final mastectomy pathology, 120(71%) patients had DCIS with 0 positive sentinel lymph nodes (PSLNs) and 48(29%) patients had invasive carcinoma with 5(10%) cases of ≥1 PSLNs. Factors positively associated with upstaging to invasive cancer in univariate analysis included age (P=.0289), palpability (P<.0001), extent of disease on imaging (P=.0121), mass on preoperative imaging (P=.0003), multifocality (P=.0231) and multicentricity (P=.0395). In multivariate analysis, palpability (P=.0080), extent of disease on imaging (P=.0074) and mass on preoperative imaging (P=.0245) remained significant (Table 2). In a subset of patients undergoing mastectomy for DCIS with limited disease on preoperative evaluation, SLNB may be omitted as the risk of upstaging is low. However, patients who present with clinical findings of palpability, large extent of disease on imaging and mass on preoperative imaging have a meaningful risk of upstaging to invasive cancer, and SLNB remains important for management.

Multicentre study of the risk of invasive cancer and use of sentinel node biopsy in women with a preoperative diagnosis of ductal carcinoma in situ.

Ductal carcinoma in situ (DCIS) in the breast that is diagnosed by biopsy implies a risk of upstaging to invasive carcinoma (IC) on final pathology. These patients require a sentinel lymph node biopsy (SLNB) for axillary staging. A two-stage procedure is not always feasible and precise selection of patients who should be offered SLNB is crucial. The aims were: to determine the rate of upstaging, and use of redundant and required SLNB in women with a preoperative diagnosis of DCIS; and to identify patient and tumour characteristics that increase the risk of upstaging. Patients with DCIS treated between 2008 and 2016 were identified using Orbit operation planning system software, and those suitable for the study were selected based on review of the medical records. Upstaging rates and proportions of redundant and required SLNBs were calculated. Associations between clinicopathological characteristics and upstaging were analysed using univariable and multivariable logistic regression analyses. Of 1368 patients initially identified, 975 women with a preoperative diagnosis of DCIS were included in the study. Tumours in 246 of these patients (25·2 per cent) were upstaged to IC. Redundant SLNB was performed in 392 of 975 women (40·2 per cent). Forty-four patients (4·5 per cent) with a final diagnosis of IC were not offered SLNB and thus potentially undertreated. In adjusted analysis, DCIS size, palpability and mass formation identified by breast imaging were associated with increased risk of upstaging. The Van Nuys classification was not associated with upstaging. Most patients with IC on final pathology underwent SLNB, but a considerable number of patients with DCIS had a redundant SLNB. Lesion size, palpability and mass formation, but not Van Nuys classification group, are suggested risk factors for upstaging.

Significance of Microcalcifications on Mammography in the Surgical Treatment of Breast Cancer Patients with a Preoperative Diagnosis of Ductal Carcinoma in Situ by Core Needle Biopsy.

To clarify the surgical outcomes of breast cancer patients with a preoperative diagnosis of ductal carcinoma in situ (DCIS) by core needle biopsy (CNB) (abbreviated as CNBDCIS), we retrospectively analyzed the cases of 131 patients with CNBDCIS who underwent surgery at Oomoto Hospital (32 total mastectomies, 99 conservative mastectomies). Our analysis of underestimation and predictors of invasive breast cancer of CNBDCIS revealed that the underestimation rate of CNBDCIS was 40.5% (53/131). A logistic regression analysis revealed that palpable tumors (yes to no, odds ratio [OR] 3.25), mammography (MMG) category group (category 4 or 5 to categories 1 , 2, or 3, OR 4.69) and MMG microcalcifications (no to yes, OR 0.24) were significant predictive factors for CNBDCIS invasion. In our analysis of the predictors of positive margins during CNBDCIS surgery, 36 (27.5%) of the 131 patients had positive margins after postoperative pathological examination. A logistic regression analysis revealed that the operative procedure (conservative surgery to total mastectomy, OR 21.4) and MMG microcalcifications (yes to no, OR 3.35) were significant factors related to positive margins during CNBDCIS surgery. Thus, MMG microcalcifications are a negative predictor of upgrading of CNBDCIS and a positive predictor of positive surgical margins for CNBDCIS.

Can algorithmically assessed MRI features predict which patients with a preoperative diagnosis of ductal carcinoma in situ are upstaged to invasive breast cancer?

To assess the ability of algorithmically assessed magnetic resonance imaging (MRI) features to predict the likelihood of upstaging to invasive cancer in newly diagnosed ductal carcinoma in situ (DCIS). We identified 131 patients at our institution from 2000-2014 with a core needle biopsy-confirmed diagnosis of pure DCIS, a 1.5 or 3T preoperative bilateral breast MRI with nonfat-saturated T1 -weighted MRI sequences, no preoperative therapy before breast MRI, and no prior history of breast cancer. A fellowship-trained radiologist identified the lesion on each breast MRI using a bounding box. Twenty-nine imaging features were then computed automatically using computer algorithms based on the radiologist's annotation. The rate of upstaging of DCIS to invasive cancer in our study was 26.7% (35/131). Out of all imaging variables tested, the information measure of correlation 1, which quantifies spatial dependency in neighboring voxels of the tumor, showed the highest predictive value of upstaging with an area under the curve (AUC) = 0.719 (95% confidence interval [CI]: 0.609-0.829). This feature was statistically significant after adjusting for tumor size (P < 0.001). Automatically assessed MRI features may have a role in triaging which patients with a preoperative diagnosis of DCIS are at highest risk for occult invasive disease. 4 Technical Efficacy: Stage 3 J. Magn. Reson. Imaging 2017;46:1332-1340.

Added Value of Breast MRI for Preoperative Diagnosis of Ductal Carcinoma In Situ: Diagnostic Performance on 362 Patients

IntroductionThe purpose of this study was to evaluate the added value of breast magnetic resonance imaging (MRI) in preoperative diagnosis of ductal carcinoma in situ (DCIS). We reviewed our institution database of 3499 consecutive patients treated for breast cancer. Patients and MethodsA total of 362 patients with histologically proven DCIS were selected from the institutional database. Of these, 245 (67.7%) preoperatively underwent conventional imaging (CI) (mammography/ultrasonography) (CI group), and 117 (32.3%) underwent CI and dynamic MRI (CI + MRI group). The pathology of surgical specimens served as a reference standard. The Mann-Whitney U, χ2 test, and Spearman correlation coefficient were performed. ResultsThe CI + MRI group showed a sensitivity of 98.5% with an increase of 10.1% compared with the CI group to detect pure DCIS. Dynamic MRI identified 19.7% (n = 13) additional pure DCIS compared with CI. In the CI + MRI group, a single (1.5%) false negative was reported, whereas in the CI group, 11 (11.6%) false negatives were reported. Moreover, the CI + MRI group showed a sensitivity of 98.0% to detect DCIS + small invasive component. In this group, dynamic MRI identified 21.6% (n = 11) additional DCIS and a single (2.0%) false negative compared with the CI group, whereas in the CI group, 7 (4.7%) false negatives were reported. MRI and histopathologically measured lesion sizes, Breast Imaging Reporting and Data System MRI assessment categories, and enhancement signal intensity curve types showed a significant correlation. The MRI detection rate of DCIS increased significantly with increasing nuclear grade. ConclusionsPreoperative breast MRI showed a better accuracy then CI in preoperative diagnosis for both pure DCIS and DCIS + small invasive component with a precise assessment of lesion size. This can provide a more appropriate management of DCIS patients.

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.

A nomogram associated with high probability of invasive carcinoma on the surgical specimen in patients with preoperative diagnosis of ductal carcinoma in situ of the breast.

1595 Background: Sentinel node biopsy is frequently performed for patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) by needle biopsy because of a possibility of postoperative ...

Incidence and prediction of invasive disease and nodal metastasis in preoperatively diagnosed ductal carcinoma in situ

For breast cancer patients with a preoperative diagnosis of ductal carcinoma in situ (DCIS), sentinel lymph node (SN) biopsy has been proposed as an axillary staging procedure in selected patients with a higher likelihood of having occult invasive lesions. With detailed histological examination of primary tumors and molecular whole-node analysis of SNs, we aimed to validate whether this selective application accurately identifies patients with SN metastasis. The subjects were 336 patients with a preoperative needle-biopsy diagnosis of DCIS who underwent SN biopsy using the one-step nucleic acid amplification assay in the period 2009–2011. The incidence and preoperative predictors of upstaging to invasive disease on final pathology and SN metastasis, and their correlation, were investigated. Of the 336 patients, 113 (33.6%) had invasive disease, and 6 (1.8%) and 17 (5.0%) had macro- and micrometastasis in axillary nodes respectively. Of the 113 patients with invasive disease, 4 (3.5%) and 9 (8.0%) had macro- and micrometastasis. Predictors of invasive disease included palpability, mammographic mass, and calcifications (spread >20 mm), and intraductal solid structure, but no predictor was found for SN metastasis. Therefore, even though occult invasive disease was found at final pathology, most of the patients had no metastasis or only micrometastasis in axillary nodes. Predictors of invasive disease and SN metastasis were not completely consistent, so the selective SN biopsy for patients with a higher risk of invasive disease may not accurately identify those with SN metastasis. More accurate application of SN biopsy is required for patients with a preoperative diagnosis of DCIS.

Incidence of and risk factors for sentinel lymph node metastasis in patients with a postoperative diagnosis of ductal carcinomain situ

Positive sentinel lymph nodes (SLNs) are found in up to 13 per cent of women with a preoperative diagnosis of ductal carcinoma in situ (DCIS) of the breast and in up to 4 per cent of those with a postoperative diagnosis. This retrospective national register study investigated the incidence of positive SLNs in women with a postoperative diagnosis of DCIS, and the value of additional tumour sectioning to identify occult tumour invasion. All surgical patients with a final histopathological diagnosis of pure DCIS registered in the Swedish national breast cancer register in 2008 and 2009 were eligible. Additional sectioning was performed on archived primary tumour tissue from women with SLN metastasis (including cases of isolated tumour cells) and matched SLN-negative control patients with the aim of detecting occult invasion. SLN tumour deposits were reported in 11 of 753 women who had SLN biopsy (macrometastases, 2; micrometastases, 3; isolated tumour cells, 6), resulting in a SLN positivity rate of 0·7 per cent (5 of 753). Occult invasion was found in one (9 per cent) of these 11 patients and in two (10 per cent) of 21 control patients. No risk factors for SLN metastasis were identified. SLN positivity is rare in women with a histopathological diagnosis of pure DCIS. Additional primary tumour assessment may reveal occult invasion in both SLN metastasis-positive and -negative patients. The value of performing SLN biopsy in the setting of a preoperative diagnosis of DCIS was limited, and current Swedish practice should therefore be questioned.