Advertisement

Annals of Surgical Oncology

, Volume 24, Issue 12, pp 3534–3540 | Cite as

Surgical Upstaging Rates for Vacuum Assisted Biopsy Proven DCIS: Implications for Active Surveillance Trials

  • Lars J. Grimm
  • Marc D. Ryser
  • Ann H. Partridge
  • Alastair M. Thompson
  • Jeremy S. Thomas
  • Jelle Wesseling
  • E. Shelley Hwang
Breast Oncology

Abstract

Purpose

This study was designed to determine invasive cancer upstaging rates at surgical excision following vacuum-assisted biopsy of ductal carcinoma in situ (DCIS) among women meeting eligibility for active surveillance trials.

Methods

Patients with vacuum-assisted, biopsy-proven DCIS at a single center from 2008 to 2015 were retrospectively reviewed. Imaging and pathology reports were interrogated for the imaging appearance, tumor grade, hormone receptor status, and presence of comedonecrosis. Subsequent surgical reports were reviewed for upstaging to invasive disease. Cases were classified by eligibility criteria for the COMET, LORIS, and LORD DCIS active surveillance trials.

Results

Of 307 DCIS diagnoses, 15 (5%) were low, 95 (31%) intermediate, and 197 (64%) high nuclear grade. The overall upstage rate to invasive disease was 17% (53/307). Eighty-one patients were eligible for the COMET Trial, 74 for the LORIS trial, and 10 for the LORD Trial, although LORIS trial eligibility also included real-time, multiple central pathology review, including elements not routinely reported. The upstaging rates to invasive disease were 6% (5/81), 7% (5/74), and 10% (1/10) for the COMET, LORIS, and LORD trials, respectively. Among upstaged cancers (n = 5), four tumors were Stage IA invasive ductal carcinoma and one was Stage IIA invasive lobular carcinoma; all were node-negative.

Conclusions

DCIS upstaging rates in women eligible for active surveillance trials are low (6–10%), and in this series, all those with invasive disease were early-stage, node-negative. The careful patient selection for DCIS active surveillance trials has a low risk of missing occult invasive cancer and additional studies will determine clinical outcomes.

Notes

Acknowledgments

The authors are grateful for the feedback from Adele Francis for the interpretation of results and manuscript editing. The authors have no financial conflicts of interest to disclose.

Disclosure

None.

Supplementary material

10434_2017_6018_MOESM1_ESM.docx (14 kb)
Supplementary material 1 (DOCX 14 kb)

References

  1. 1.
    Virnig BA, Tuttle TM, Shamliyan T, Kane RL. Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes. J Natl Cancer Inst. 2010;102(3):170–8.CrossRefPubMedGoogle Scholar
  2. 2.
    Sorum R, Hofvind S, Skaane P, Haldorsen T. Trends in incidence of ductal carcinoma in situ: the effect of a population-based screening programme. Breast. 2010;19(6):499–505.CrossRefPubMedGoogle Scholar
  3. 3.
    Hall FM. Screening mammography guidelines: an alternative proactive approach. Radiology. 2014;273(3):646–51.CrossRefPubMedGoogle Scholar
  4. 4.
    Lopez-Garcia MA, Geyer FC, Lacroix-Triki M, Marchio C, Reis-Filho JS. Breast cancer precursors revisited: molecular features and progression pathways. Histopathology. 2010;57(2):171–92.CrossRefPubMedGoogle Scholar
  5. 5.
    Erbas B, Provenzano E, Armes J, Gertig D. The natural history of ductal carcinoma in situ of the breast: a review. Breast Cancer Res Treat. 2006;97(2):135–44.CrossRefPubMedGoogle Scholar
  6. 6.
    Alvarado M, Ozanne E, Esserman L. Overdiagnosis and overtreatment of breast cancer. American Society of Clinical Oncology Meeting. American Society of Clinical Oncology educational book/ASCO. 2012:e40–45.Google Scholar
  7. 7.
    Meyerson AF, Lessing JN, Itakura K, et al. Outcome of long-term active surveillance for estrogen receptor-positive ductal carcinoma in situ. Breast. 2011;20(6):529–33.PubMedPubMedCentralGoogle Scholar
  8. 8.
    Welch HG, Prorok PC, O’Malley AJ, Kramer BS. Breast cancer tumor size, overdiagnosis, and mammography screening effectiveness. N Engl J Med. 2016;375(15):1438–47.CrossRefPubMedGoogle Scholar
  9. 9.
    Benson JR, Jatoi I, Toi M. Treatment of low-risk ductal carcinoma in situ: is nothing better than something? Lancet Oncol. 2016;17(10):e442–51.CrossRefPubMedGoogle Scholar
  10. 10.
    Francis A, Thomas J, Fallowfield L, et al. Addressing overtreatment of screen detected DCIS; the LORIS trial. Eur J Cancer. 2015;51(16):2296–303.CrossRefPubMedGoogle Scholar
  11. 11.
    Elshof LE, Tryfonidis K, Slaets L, et al. Feasibility of a prospective, randomised, open-label, international multicentre, phase III, non-inferiority trial to assess the safety of active surveillance for low risk ductal carcinoma in situ - The LORD study. Eur J Cancer. 2015;51(12):1497–510.CrossRefPubMedGoogle Scholar
  12. 12.
    Comparison of operative versus medical endocrine therapy for low risk DCIS: the COMET Trial. http://www.pcori.org/research-results/2016/comparison-operative-versus-medical-endocrine-therapy-low-risk-dcis-comet. Accessed 8 Aug 2016.
  13. 13.
    LORIS A phase III trial of surgery versus active monitoring for low-risk ductal carcinoma in situ (DCIS). http://www.birmingham.ac.uk/research/activity/mds/trials/crctu/trials/loris/index.aspx. Accessed 19 Nov 2016.
  14. 14.
    Management of low-risk DCIS (LORD). https://clinicaltrials.gov/ct2/show/NCT02492607. Accessed 19 Nov 2016.
  15. 15.
    Ryser MD, Worni M, Turner EL, Marks JR, Durrett R, Hwang ES. Outcomes of active surveillance for ductal carcinoma in situ: a computational risk analysis. J Natl Cancer Inst. 2016;108(5).Google Scholar
  16. 16.
    Soumian S, Verghese ET, Booth M, et al. Concordance between vacuum assisted biopsy and postoperative histology: implications for the proposed Low Risk DCIS Trial (LORIS). Eur J Surg Oncol. 2013;39(12):1337–40.CrossRefPubMedGoogle Scholar
  17. 17.
    Brennan ME, Turner RM, Ciatto S, et al. Ductal carcinoma in situ at core-needle biopsy: meta-analysis of underestimation and predictors of invasive breast cancer. Radiology. 2011;260(1):119-28.CrossRefPubMedGoogle Scholar
  18. 18.
    Burak WE, Jr., Owens KE, Tighe MB, et al. Vacuum-assisted stereotactic breast biopsy: histologic underestimation of malignant lesions. Arch Surg. 2000;135(6):700–3.CrossRefPubMedGoogle Scholar
  19. 19.
    Pilewskie M, Stempel M, Rosenfeld H, Eaton A, Van Zee KJ, Morrow M. Do LORIS trial eligibility criteria identify a ductal carcinoma in situ patient population at low risk of upgrade to invasive carcinoma? Ann Surg Oncol. 2016.Google Scholar
  20. 20.
    Elmore JG, Longton GM, Carney PA, et al. Diagnostic concordance among pathologists interpreting breast biopsy specimens. JAMA. 2015;313(11):1122–32.CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Sagara Y, Mallory MA, Wong S, et al. Survival benefit of breast surgery for low-grade ductal carcinoma in situ: a population-based cohort study. JAMA Surg. 2015;150(8):739–45.CrossRefPubMedGoogle Scholar
  22. 22.
    Doebar SC, van den Broek EC, Koppert LB, et al. Extent of ductal carcinoma in situ according to breast cancer subtypes: a population-based cohort study. Breast Cancer Res Treat. 2016;158(1):179–87.CrossRefPubMedPubMedCentralGoogle Scholar
  23. 23.
    Familial breast cancer: classification, care and managing breast cancer and related risks in people with a family history of breast cancer. https://www.nice.org.uk/guidance/cg164. Accessed 19 Nov 2016.

Copyright information

© Society of Surgical Oncology 2017

Authors and Affiliations

  • Lars J. Grimm
    • 1
  • Marc D. Ryser
    • 2
  • Ann H. Partridge
    • 3
  • Alastair M. Thompson
    • 4
  • Jeremy S. Thomas
    • 5
  • Jelle Wesseling
    • 6
  • E. Shelley Hwang
    • 7
  1. 1.Department of RadiologyDuke UniversityDurhamUSA
  2. 2.Department of MathematicsDuke UniversityDurhamUSA
  3. 3.Division of Oncology, Department of MedicineHarvard Medical SchoolBostonUSA
  4. 4.Department of PathologyThe University of Texas MD Anderson Cancer CenterHoustonUSA
  5. 5.Department of PathologyWestern General HospitalEdinburghUK
  6. 6.Department of PathologyThe Netherlands Cancer Institute - Antoni van Leeuwenhoek HospitalAmsterdamThe Netherlands
  7. 7.Department of SurgeryDuke University Comprehensive Cancer CenterDurhamUSA

Personalised recommendations