Predictors of Residual Invasive Disease after Core Needle Biopsy Diagnosis of Ductal Carcinoma In Situ

Abstract

Core needle biopsy (CNB) is used to sample both mammographically and ultrasound detected breast lesions. A diagnosis of ductal carcinoma in situ (DCIS) by CNB does not ensure the absence of invasive cancer upon surgical excision and as a result an upstaged patient may need to undergo additional surgery for axillary nodal evaluation. This study evaluates the accuracy of CNB in excluding invasive disease and the preoperative features that predict upstaging of DCIS to invasive breast cancer. Two hundred fifty-four patients over an 8-year period from 1994 to 2002 with a diagnosis of DCIS alone by CNB were retrospectively reviewed. Underestimation of invasive cancer by CNB was determined. Radiographic, pathologic, and surgical features of the cohort were compared using univariate and multivariate analysis. The mean age was 55 years (range 27-84) and mean follow-up was 25 months with one patient unavailable for follow-up. There were a total of six patient deaths, all of which were not disease-specific. A total of 21 out of 254 patients (8%) with DCIS by CNB were upstaged to invasive cancer following surgical excision. There was a significant inverse relationship between the number of core biopsies and the incidence of upstaging (p < 0.006) in that patients with fewer core samples were more likely to be upstaged at surgical pathology. No relationship was noted between the size of the core samples and the likelihood of upstaging (p > 0.4). Of 21 patients with invasion, all but two had comedonecrosis by CNB. Comedonecrosis by CNB significantly increased the likelihood of upstaging (p < 0.001). Of the 21 patients who were upstaged, 12 required subsequent surgery for nodal evaluation while nine had sentinel node biopsy at initial operation. Finally, upstaged patients were significantly more likely to have a positive margin (p < 0.008). Ductal carcinoma in situ with comedonecrosis on CNB can help to predict the possibility of invasion. Increasing the number of core biopsies reduced the likelihood of sampling error.

Predictors of invasion in needle core biopsies of the breast with ductal carcinoma in situ

“…7,17,21 The advantage of assessing the percentage of positive cores over size estimation or the number of positive cores is that a positive ratio is independent of the core sizes and the total number of cores obtained. It has been previously reported that inadequate (or smaller number)cores was associated with a higher upgrading rate, 13,18 although the latter study 18 also showed that core size was not related to missed invasion in the final excision. Whereas the issue of number of cores has not been well documented in this context, it has also been reported to be unrelated to missed invasion.…”

“…Whether these factors are totally insignificant is still debatable, as all of these had been shown to be significant or insignificant in different series. For instance, some studies showed that age, 16 number of cores, 16,21 grade, [7][8][9]11,16,21 architecture, 7,16,21 necrosis, 9,11,16,21 periductal stromal fibrosis or desmoplasia [14][15][16]21 and calcification 16,18 were insignificant, whereas other studies showed the same factors, including number of cores, 13,18 grade, 10,14,15,20 comedo necrosis, 10,11,19 and periductal inflammatory cells infiltrate, 14 to be significant. It seems that prediction of eventual invasion in needle core biopsy showing only DCIS is still fraught with uncertainty.…”

“…However, some cases of needle core biopsy-diagnosed DCISs turned out to be invasive in the final excisions. This was not an uncommon occurrence, being reported in 8-44% [7][8][9][10][11][12][13][14][15][16][17][18] of multiple series of needle core biopsy-diagnosed DCISs of the breast. It is interesting to note that the upstaging rates of several series spanning over a period of time were similar, indicating that there has not been substantial progress in the histological evaluation of predictive factors of invasion in needle core biopsy showing DCIS only.…”

“…Many of these series evaluated various factors, but so far no single factor stood out to be a consistent predictor. The factors that had been evaluated could be categorized as radiological features (mass, density, radiologic extent as measured using mammography or sonography, and the extent and morphology of the calcifications), 8,10,13,14,16,19 histological features (size, grade, necrosis, calcifications, architecture, lobular extension, periductal inflammation and periductal stromal fibrosis), [7][8][9][10]12,[14][15][16][18][19][20][21] sampling adequacy as indicated by the number of cores sampled 16,18 and patient factor, such as age. 10,16 There were reports that either confirmed or refuted their roles as predictors for invasion in needle core biopsy showing DCIS only.…”

Not All Ductal Carcinomas In Situ Are Created IDLE (Indolent Lesions of Epithelial Origin)

“…Underestimation of invasive carcinoma in patients with a core biopsy diagnosis of DCIS ranges from 0% to 59%. [18][19][20][21][22][23][24][25][26][27] This prompted us to examine the predictive value of a core biopsy diagnosis of DCIS, particularly the upgrade rate to invasive carcinoma, and to identify any associated factors that meet criteria for inclusion in surveillance clinical trials.…”