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

Kondo, Takafumi; Hayashi, Naoki; Ohde, Sachiko; Suzuki, Koyu; Yoshida, Atsushi; Yagata, Hiroshi; Niikura, Naoki; Inomata, Takayuki; Kida, Kumiko; Murai, Michiko; Takahashi, Yuko; Tsunoda, Hiroko; Nakamura, Seigo; Yamauchi, Hideko

doi:10.1002/jso.24037

Cited by 35 publications

(24 citation statements)

References 31 publications

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“…18 In numerous previous studies, large tumor size, palpable lump, and number of lesions were associated with the risk of upstaging. 2,8,15,[18][19][20][21] Other factors, such as nuclear grade, comedo necrosis, sclerosing adenosis, and CNB method, were also correlated with upstaging. 2,8,[18][19][20] Studies on molecular subtype as a predictor of upstaging are rare.…”

Section: Discussionmentioning

confidence: 96%

“…Other factors, such as nuclear grade, comedo necrosis, sclerosing adenosis, and CNB method, were also correlated with upstaging . Studies on molecular subtype as a predictor of upstaging are rare . Some studies showed a correlation between negative hormone receptor (HR) and invasion of DCIS, and others showed that positive HER2 status was associated with upstaging .…”

Section: Discussionmentioning

confidence: 99%

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Axillary evaluation is not warranted in patients preoperatively diagnosed with ductal carcinoma in situ by core needle biopsy

Guo

Huang

et al. 2019

Cancer Medicine

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BackgroundPatients diagnosed with ductal carcinoma in situ (DCIS) by core needle biopsy (CNB) have a great chance of upstaging to invasive cancer. Positive axillary status can be found in these patients. This study sought to identify clinicopathological factors associated with upstaging and axillary metastasis in patients preoperatively diagnosed with DCIS by CNB.Materials and MethodsThis study identified 604 patients (cT1‐3N0M0) with preoperative diagnosis of pure DCIS by CNB who had undergone axillary evaluation from August 2006 to December 2015 at Fudan University Shanghai Cancer Center (FUSCC). Predictors of upstaging and axillary lymph nodes metastasis were analyzed, respectively.ResultsOf all 604 patients, 121 (20.03%) and 193 (31.95%) patients were upstaged to DCIS with microinvasion (DCISM) and invasive breast cancer (IBC). Positive axillary lymph nodes were identified in 41 (6.79%) patients. Predictors of upstaging included tumor size on ultrasonography (>2 cm) (OR 1.786, P = .002) and ER+HER2+ status (OR 1.874, P = .022) in multivariate analysis. Factors associated with axillary lymph nodes metastasis included tumor size on pathology (OR 2.336, P = .038) and number of lesions (OR 3.354, P = .039) in multivariate analysis. In addition, upstaging on final pathology had a significant influence on axillary lymph nodes status (P < .001).ConclusionAxillary evaluation was recommended in patients with larger tumor size (>2 cm), multifocal lesions or ER+HER2+ status. Despite of a 51.98% upstaging rate, the rate of axillary metastasis in these patients was relatively low, supporting the omission of axillary evaluation in selected patients with low risk of upstaging or axillary metastasis.

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Section: Discussionmentioning

confidence: 96%

Section: Discussionmentioning

confidence: 99%

Axillary evaluation is not warranted in patients preoperatively diagnosed with ductal carcinoma in situ by core needle biopsy

Guo

Huang

et al. 2019

Cancer Medicine

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“…An overview of the found risk factors for underestimation is given in Table 1. Based on risk factors, several studies developed prediction models with the purpose to select patients for SLN biopsy 14,17,24,[28][29][30] .…”

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confidence: 99%

A prediction model for underestimation of invasive breast cancer after a biopsy diagnosis of ductal carcinoma in situ: based on 2892 biopsies and 589 invasive cancers

Meurs¹,

Rosmalen

Menke-Pluijmers

et al. 2018

Br J Cancer

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BACKGROUND: Patients with a biopsy diagnosis of ductal carcinoma in situ (DCIS) might be diagnosed with invasive breast cancer at excision, a phenomenon known as underestimation. Patients with DCIS are treated based on the risk of underestimation or progression to invasive cancer. The aim of our study was to expand the knowledge on underestimation and to develop a prediction model. METHODS: Population-based data were retrieved from the Dutch Pathology Registry and the Netherlands Cancer Registry for DCIS between January 2011 and June 2012. RESULTS: Of 2892 DCIS biopsies, 21% were underestimated invasive breast cancers. In multivariable analysis, risk factors were highgrade DCIS (odds ratio (OR) 1.43, 95% confidence interval (CI): 1.05-1.95), a palpable tumour (OR 2.22, 95% CI: 1.76-2.81), a BI-RADS (Breast Imaging Reporting and Data System) score 5 (OR 2.36, 95% CI: 1.80-3.09) and a suspected invasive component at biopsy (OR 3.84, 95% CI: 2.69-5.46). The predicted risk for underestimation ranged from 9.5 to 80.2%, with a median of 14.7%. Of the 596 invasive cancers, 39% had unfavourable features. CONCLUSIONS: The risk for an underestimated diagnosis of invasive breast cancer after a biopsy diagnosis of DCIS is considerable. With our prediction model, the individual risk of underestimation can be calculated based on routinely available preoperatively known risk factors (https://www.evidencio.com/models/show/1074). BACKGROUNDPatients with ductal carcinoma in situ (DCIS) are treated based on the risk of underestimation or progression to invasive cancer. The standard treatment for patients with a biopsy diagnosis of DCIS is wide local excision with radiation or mastectomy. Often a sentinel lymph node (SLN) biopsy is advised for axillary staging. 1,2 Both the standard treatment and the use of the SLN biopsy can constitute overtreatment. The standard treatment might be disproportionate for screen-detected DCIS patients who have a high chance that the DCIS would not even have been detected during their lifetime. 3 It has been estimated that between 14 and 53% of DCIS progress into invasive breast cancer. 4,5 To address overtreatment, phase III trials investigate the safety of active surveillance of DCIS patients at low risk for developing or having invasive breast cancer. 6-11 Active surveillance is based on the result of the biopsy. By modelling of active surveillance of DCIS patients, the disease-specific cumulative mortality was related to underestimation. 12,13 Underestimation is the phenomenon that the invasive breast cancer is undetected at preoperative biopsy and only becomes evident after pathological examination of the excision material. The use of the SLN biopsy can also constitute overtreatment. The SLN biopsy is done if a mastectomy is chosen, and also for patients undergoing wide local excision who are at high risk of having an underestimated invasive breast cancer. 1,2 The reported risk of underestimation varies from 14 to 43% 14,15 , and in a meta-analysis it was estimated to be 25.9% (95% confidence inte...

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“…This could be due to the fact that HER2‐positive invasive carcinomas have an extensive HER2‐positive in situ component, which is a risk factor for sampling error. However, further investigations are necessary as this upstage risk was not confirmed by others . Of note, increased stromal inflammation is strongly correlated with HER2‐positivity in pure DCIS, and stromal inflammation is more frequently observed in DCIS admixed with invasive carcinoma than in pure DCIS .…”

Section: Introductionmentioning

confidence: 86%

“…However, further investigations are necessary as this upstage risk was not confirmed by others. 63,68 Of note, increased stromal inflammation is strongly correlated with HER2-positivity in pure DCIS, 69,70 and stromal inflammation is more frequently observed in DCIS admixed with invasive carcinoma than in pure DCIS. 65 It is currently unclear which feature is the most decisive factor in the progression of in situ to invasive carcinoma.…”

Section: Risk Assessment For Synchronous Invasion At the Biopsy Levelmentioning

confidence: 94%

A retrospective alternative for active surveillance trials for ductal carcinoma in situ of the breast

Bockstal

Agahozo

Koppert

et al. 2019

Intl Journal of Cancer

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Ductal carcinoma in situ (DCIS) of the breast is a nonobligate precursor of invasive breast cancer, accounting for 20 % of screen‐detected breast cancers. Little is known about the natural progression of DCIS because most patients undergo surgery upon diagnosis. Many DCIS patients are likely being overtreated, as it is believed that only around 50 % of DCIS will progress to invasive carcinoma. Robust prognostic markers for progression to invasive carcinoma are lacking. In the past, studies have investigated women who developed a recurrence after breast‐conserving surgery (BCS) and compared them with those who did not. However, where there is no recurrence, the patient has probably been adequately treated. The present narrative review advocates a new research strategy, wherein only those patients with a recurrence are studied. Approximately half of the recurrences are invasive cancers, and half are DCIS. So‐called “recurrences” are probably most often the result of residual disease. The new approach allows us to ask: why did some residual DCIS evolve to invasive cancers and others not? This novel strategy compares the group of patients that developed in situ recurrence with the group of patients that developed invasive recurrence after BCS. The differences between these groups could then be used to develop a robust risk stratification tool. This tool should estimate the risk of synchronous and metachronous invasive carcinoma when DCIS is diagnosed in a biopsy. Identification of DCIS patients at low risk for developing invasive carcinoma will individualize future therapy and prevent overtreatment.

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

Abstract: The prediction model incorporating clinicopathological features may be used to guide the selection of patients with DCIS for sentinel lymph node biopsy.

Cited by 35 publications

References 31 publications

Axillary evaluation is not warranted in patients preoperatively diagnosed with ductal carcinoma in situ by core needle biopsy

Axillary evaluation is not warranted in patients preoperatively diagnosed with ductal carcinoma in situ by core needle biopsy

A prediction model for underestimation of invasive breast cancer after a biopsy diagnosis of ductal carcinoma in situ: based on 2892 biopsies and 589 invasive cancers

A retrospective alternative for active surveillance trials for ductal carcinoma in situ of the breast

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