The influence of clinicopathological features on the predictive accuracy of conventional breast imaging in determining the extent of screen-detected high-grade pure ductal carcinoma in situ

Abstract

Since the introduction of mammographic breast screening there has been a significant increase in the rate of detection of ductal carcinoma in situ (DCIS) without an invasive component (pure DCIS). This now comprises approximately 20% of all screen-detected breast malignancies in the uK. 1 DCIS may progress to invasive breast cancer. Apparently, pure DCIS frequently coexists with concurrent invasive breast cancer, which in cases of widespread high-grade DCIS is found unexpectedly on final histology following surgery in up to 10-25% of cases and necessitates additional staging of the axilla if axillary surgery is not performed. 2Screening mammography is very sensitive at detecting calcified high-grade DCIS. Approximately 80-90% of DCIS lesions are calcified, 3,4 which enables accurate prediction of disease extent. This is a major determinant of the suitability to treatment by wide local excision (WLE) and therefore breast conservation. It is recognised, however, that the distribution of calcification seen mammographically as well as on specimen radiographs is not always representative of the full extent of disease, leading to an underestimation of extent, both preoperatively and in intraoperative specimen radiographs.5 For example, DCIS is often found at or within a few millimetres of the initial excision margins. Re-excision procedures are often required as DCIS present at the surgical margin leads to a greater incidence of local recurrence. [6][7][8] Annual returns to the NHS Breast Screening Programme (NHSBSP) indicate that our re-excision rates for all pure screen-detected DCIS were 23% between 2008 and 2009. This figure is within normal limits for a large breast screening unit and is given as an example. As an NHSBSP centre, our unit is audited on a yearly basis against national standards. These audits confirmed that the overall rates of reexcision for DCIS historically over the period of this study were also within acceptable levels. However, we suspected from anecdotal evidence that the re-excision rates for pure The extent of calcified ductal carcinoma in situ (DCIS) detected by screening mammography is a determinant for treatment with breast conserving surgery (BCS). However, DCIS may be uncalcified and almost a quarter of patients with DCIS treated initially by BCS either require a second operation or are found to have unexpected invasive disease following surgery. Identification of these cases might guide selective implementation of additional diagnostic procedures. METHODS A retrospective review of patients with a preoperative diagnosis of pure high-grade DCIS at the Southampton and Salisbury Breast Screening Unit over a ten-year period was carried out. Mammograms were reviewed independently by a consultant radiologist and additional factors including the Breast Imaging Reporting and Data System (BI-RADS

Radiopathological features predictive of involved margins in ductal carcinoma in situ

“…20 Our institution has previously identified ER status and extent as predictors of need for further breast surgery following attempted BCS for HG DCIS. 9 The current paper builds on this by including the wider spectrum of tumour grades as well as by establishing the relevance of grade in terms of risk of invasion and margin involvement.…”

“…Patients treated for biopsy proven DCIS without preoperative evidence of an invasive component over a ten-year period (1999)(2000)(2001)(2002)(2003)(2004)(2005)(2006)(2007)(2008)(2009) were identified from the Southampton and Salisbury breast screening unit database. All cases with available information were included; 144 patients with HG disease from previous analysis by our unit 9 were incorporated with data from an additional 104 patients with any grade of DCIS. Patients having surgery for a preoperative diagnosis other than DCIS and those found to have neither DCIS nor invasive breast carcinoma following surgical excision were excluded.…”

“…Our unit has previously described predictors of requirement of re-excision in patients treated for screen detected, high grade (HG) DCIS. 9 Negative oestrogen receptor (ER) status and disease extent were identified as positive predictors for requirement of re-excision. However, low/intermediate grade (LIG) tumours were not included in the study.…”

Clinicopathologic, mammographic, and sonographic features in 1,187 patients with pure ductal carcinoma in situ of the breast by estrogen receptor status

“…The ER expression rate in DCIS ranges from 49% to 97% (mean, 69%) [16]. Relationships have been described between ER status and disease recurrence [25–28], nuclear grade [17,18,20,23], indications for adjuvant hormonal therapy [35–38], and presurgical prediction of disease extent [7,39]. However, information is scarce regarding the influence of ER expression on clinicopathologic and imaging features of DCIS [29].…”

Reporting the greatest linear extent of ductal carcinoma in situ on needle core biopsy

“…[18] In addition to its utility in assessing a need for adjuvant radiation therapy, estimated extent of DCIS also influences surgical management. The extent of DCIS has been shown to be predictive of the need for re-excision [19] and the presence of residual disease after lumpectomy. [20,21] Because of these data, it is not surprising that the extent of DCIS has become a required element in the CAP tumor summary checklist [11,22] and is required by the Association of Directors of Anatomic and Surgical Pathology as one of many features "generally accepted as being of prognostic importance, required for therapy and/or traditionally expected.…”