Journal List > J Korean Surg Soc > v.80(2) > 1011274

Shin, Kim, Song, Yoon, Cho, Park, Yoon, and Jegal: Risk Factor of Invasive Breast Cancer in Patients with Preoperative Diagnosis of Ductal Carcinoma in Situ

Abstract

Purpose

Ductal carcinoma in situ (DCIS), unlike invasive ductal carcinoma, does not require sentinel lymph node biopsy or axillary lymph node dissection because the possibility of axillary lymph node metastasis is low. However, occasionally, despite preoperative diagnosis of DCIS, invasive ductal carcinoma can be diagnosed by postoperative biopsy. Therefore, a study of the associated risk factors is necessary.

Methods

198 patients with an initial diagnosis of DCIS, treated between February 2005 and December 2009, were retrospectively analyzed. Associations between clinical and pathologic factors were analyzed for significance using univariate and multivariate analyses.

Results

Of the 198 patients, 57 (28.8%) were found to have invasive disease on final pathology. Multivariate analysis revealed 4 independent predictors of invasive cancer upon final pathology: diagnosis by needle biopsy (OR, 3.165; P=0.008), positive p53 on preoperative biopsy (OR, 2.494; P=0.019) DCIS size (>2 cm) on microscopic finding (OR, 2.683; P=0.014), and relatively young age (OR, 0.958, P=0.046). Of the 13 patients with positive axillary lymph nodes, 11 (84.6%) were shown to have invasive cancer on final pathology (P<0.001).

Conclusion

In cases of preoperative diagnosis based on needle biopsy, positive p53, large tumor, and relatively young age, an SLNB procedure can be considered because in almost 30% of the patients an invasive carcinoma is found after surgery.

References

1. The Korean Breast Cancer Society. Nationwide Korean breast cancer data of 2002. J Korean Breast Cancer Soc. 2004; 7:72–83.
2. Pendas S, Dauway E, Giuliano R, Ku N, Cox CE, Reintgen DS. Sentinel node biopsy in ductal carcinoma in situ patients. Ann Surg Oncol. 2000; 7:15–20.
crossref
3. Zelis JJ, Sickle-Santanello BJ, Liang WC, Nims TA. Do not contemplate invasive surgery for ductal carcinoma in situ. Am J Surg. 2002; 184:348–9.
crossref
4. Leonard GD, Swain SM. Ductal carcinoma in situ, complex-ities and challenges. J Natl Cancer Inst. 2004; 96:906–20.
crossref
5. Morrow M, Venta L, Stinson T, Bennett C. Prospective comparison of stereotactic core biopsy and surgical excision as diagnostic procedures for breast cancer patients. Ann Surg. 2001; 233:537–41.
crossref
6. Ham HW. Incidence of axillary lymph node metastases in T1 breast cancer. J Korean Breast Cancer Soc. 2002; 5:142–6.
crossref
7. Leidenius M, Salmenkivi K, von Smitten K, Heikkila P. Tumour positive sentinel node findings in patients with ductal carcinoma in situ. J Surg Oncol. 2006; 94:380–4.
8. Swain SM. Ductal carcinoma in situ. Cancer Invest. 1992; 10:443–54.
crossref
9. Yen TW, Hunt KK, Ross MI, Mirza NQ, Babiera GV, mer-ic-Bernstam F, et al. Predictors of invasive breast cancer in patients with an initial diagnosis of ductal carcinoma in situ. J Am Coll Surg. 2005; 200:516–26.
10. Hoorntje LE, Schipper ME, Peeters PH, Bellot F, Storm RK, Borel Rinkes IH. The finding of invasive cancer after a pre-operative diagnosis of ductal carcinoma-in-situ: causes of ductal carcinoma-in-situ underestimated with stereotactic 14-gauge needle biopsy. Ann Surg Oncol. 2003; 10:748–53.
11. Leifland K, Lagerstedt U, Svane G. Comparison of stereotactic fine needle aspiration cytology and core needle biopsy in 522 nonpalpable breast lesions. Acta Radiol. 2003; 44:387–91.
crossref
12. Crowe JP, Rim A, Patrick RJ, Rybicki LA, Grundfest- Broniatowski SF, Kim JA, et al. Does core needle breast biopsy accurately reflect breast pathology? Surgery. 2003; 134:523–8.
13. Wahedna Y, Evans AJ, Pinder SE, Ellis IO, Blamey RW, Geraghty JG. Mammographic size of ductal carcinoma in situ does not predict the presence of an invasive focus. Eur J Cancer. 2001; 37:459–62.
crossref
14. Jackman RJ, Burbank F, Parker SH, Evans WP 3rd, Lechner MC, Richardson TR, et al. Stereotactic breast biopsy of nonpalpable lesions: determinants of ductal carcinoma in situ un-derestimation rates. Radiology. 2001; 218:497–502.
crossref
15. Hung WK, Lam HS, Lau Y, Chan CM, Yip AW. Diagnostic accuracy of vacuum-assisted biopsy device for image-detected breast lesions. ANZ J Surg. 2001; 71:457–60.
crossref
16. Mittendorf ME, Arciero CA, Gutchell V, Hooke J, Shriver CD. Core biopsy diagnosis of ductal carcinoma in situ: An indication for sentinel lymph node biopsy. Curr Surg. 2005; 62:253–7.
crossref
17. Renshaw AA. Predicting invasion in the excision specimen from breast core needle biopsy specimens with only ductal carcinoma in situ. Arch Path Lab Med. 2002; 126:39–41.
crossref
18. Kang SS, Ko SS, Jo BH, Hur MH, Lee HK, Lee SK, et al. Ductal carcinoma in situ (DCIS) of the breast; Clinicopathological analysis, expression of molecular marker, and correlation between known prognostic factors. J Korean Surg Soc. 2003; 64:289–95.
19. Liberman L, Abramson AF, Squires FB, Glassman JR, Morris EA, Dershaw DD. The breast imagine reporting and data system: positive predictive value of mammographic features and final assessment categories. AJR Am J Roentgenol. 1998; 171:35–40.
20. Schwartz GF, Patchefsky AS, Finklestein SD, Sohn SH, Prestipino A, Feig SA, et al. Nonpalpable in situ ductal carcinoma of the breast: Predictors of multicentricity and microinvasion and implications for teatment. Arch Surg. 1989; 124:29–32.
21. Fisher ER, Costantino J, Fisher B, Palekar AS, Redmond C, Mamounas E. Pathologic findings from the National Surgical Adjuvant Breast Project (NSABP) Protocol B-17. Intraductal carcinoma (ductal carcinoma in situ). The National Surgical Adjuvant Breast and Bowel Project Collaborating Investigators. Cancer. 1995; 75:1310–9.
22. Huo L, Sneige N, Hunt KK, Albarracin CT, Lopez A, Resetkova E. Predictors of invasion in patients with core-nee-dle biopsy-diagnosed ductal carcinoma in situ and recommendations for a selective approach to sentinel lymph node biopsy in ductal carcinoma in situ. Cancer. 2006; 107:1760–8.
crossref
23. Vicini FA, Kestin LL, Goldstein NS, Chen PY, Pettinga J, Frazier RC, et al. Impact of young age on outcome in patients with ductal carcinoma-in-situ treated with breast-conserving therapy. J Clin Oncol. 2000; 18:296–306.
crossref
24. Lee HD, Kim DY, Choi JW, Park BW, Jung WH, Oh KK. Clinicopatholotical analysis of ductal carcinoma in situ and ductal carcinoma in situ with microinvasion. J Korean Surg Soc. 2001; 60:495–500.
25. Kang HS, Roh DY, Yoon YG, Oh SG, Choi GJ. A clinicopatholotical analysis of microinvasive carcinoma. J Korean Surg Soc. 2000; 58:182–9.
26. Poller DN, Roberts EC, Bell JA, Elston CW, Blamey RW, Ellis IO. p53 protein expression in mammary ductal carcinoma in situ: relationship to immunohistochemical expression of estrogen receptor and c-erbB-2 protein. Hum Pathol. 1993; 24:463–8.
crossref
27. O'Malley FP, Vnencak JC, Dupont WD, Parl F, Manning S, Page DL. p53 mutations are confined to the comedo type ductal carcinoma in-situ of the breast. Immunohistochemical and sequencing data. Lab Invest. 1994; 71:67–72.

Table 1.
The relation of invasiveness with age distribution, clinical presentations and operation methods
  DICS* Invasive carcinoma P-value
Age      
  Mean age 51.7 (±10.7) 48.2 (±8.9) 0.021
Symptoms      
  Screening 97 (68.8%) 27 (47.4%) 0.004
  Palpable mass 30 (21.3%) 21 (36.8%) 0.020
  Mastalgia 3 (2.1%) 5 (8.8%) 0.046
  Nipple discharge 11 (7.8%) 4 (7.0%) 0.557
  Palpation by clinician 62 (44.0%) 36 (63.2%) 0.011
Operation method     0.450
  BCS 76 (53.9%) 32 (56.1%)  
  Mastectomy 65 (46.1%) 25 (43.9%)  
Total 141 57  

* DCIS = ductal carcinoma in situ; surgery.

BCS = breast conserving

Table 2.
The relation of invasiveness with tumor characteristics
  DCIS* Invasive carcinoma P-value
Tumor location     0.211
  Right 71 (50.4%) 33 (57.9%)  
  Left 70 (49.6%) 24 (42.1%)  
Tumor location      
  Central 13 (9.2%) 1 (1.8%) 0.051
  UOQ 58 (41.1%) 30 (52.6%) 0.094
  UIQ 36 (25.5%) 13 (22.8%) 0.418
  LOQ§ 22 (15.6%) 8 (14.0%) 0.485
  LIQ 12 (8.5%) 5 (8.8%) 0.574
Number of tumor      
  1 127 (90.1%) 51 (89.5%) 0.541
  2 4 (2.8%) 1 (1.8%) 0.552
  ≥3 8 (5.7%) 4 (7.0%) 0.471
Size      
  Mean size (mm) 17.1 (±13.5) 27.3 (±17.9) 0.009
  <2 cm 103 (73.0%) 23 (40.4%) <0.001
  ≥2 cm 38 (27.0%) 34 (59.6%)  
Total 141 57  

* DCIS = ductal carcinoma in situ;

UOQ = upper outer quadrant;

UIQ = upper inner quadrant;

§ LOQ = lower outer quadran;

LIQ = lower inner quadrant.

Table 3.
The relation of invasiveness with pathological subtype and molecular marker
  DCIS* Invasive carcinoma P-value
Microscopic finding      
  Comedo type 65 (46.1%) 29 (50.9%) 0.325
  Cribriform type 61 (34.3%) 10 (18.2%) 0.001
  Papillary type 25 (17.9%) 6 (10.5%) 0.142
  Solid type 52 (36.9%) 17 (29.8%) 0.219
  Microcalcification 100 (70.9%) 35 (61.4%) 0.129
  Necrosis 81 (57.4%) 41 (71.9%) 0.040
ER     0.073
  Positive 94 (66.7%) 31 (54.4%)  
  Negative 47 (33.3%) 26 (45.6%)  
PR     0.002
  Positive 93 (66.0%) 24 (42.1%)  
  Negative 48 (34.0%) 33 (57.9%)  
p53§     0.001
  Positive 34 (27.6%) 30 (54.5%)  
  Negative 89 (72.4%) 25 (45.5%)  
C-erb2 (3+) 39 (27.9%) 19 (33.3%) 0.275
Nuclear grade      
  1 (low) 25 (19.2%) 7 (12.5%) 0.343
  2(intermediate) 75 (57.7%) 34 (60.7%) 0.468
  3 (high) 30 (13.1%) 15 (26.8%) 0.316
Total 141 57  

* DCIS = ductal carcinoma in situ;

ER = estrogen receptor;

PR = progesterone receptor;

§ p53 = tumor protein 53.

Table 4.
The relation of invasiveness with biopsy methods
  DCIS* Invasive carcinoma P-value
Core needle biopsy 64 (45.4%) 45 (78.9%) <0.001
Excision biopsy 77 (54.6%) 12 (21.1%)  
  MGB 39 (27.7%) 3 (5.3%)  
  Excision biopsy 24 (17.0%) 7 (12.3%)  
  Mammotome 14 (9.9%) 2 (3.5%)  
Total 141 57  

* DCIS = ductal carcinoma in situ;

MGB = mammography guided excision biopsy.

Table 5.
Univariate and multivariate analysis of predictors of in vasive breast cancer in patients with initial diagnosis o ductal carcinoma in situ
  P-value Odd ratio
Univariate analysis Multivariate analysis
Age 0.021 0.046 0.958
Not detect by screening 0.004 0.368 1.457
Palpation by clinician 0.011 0.569 1.281
Tumor size >2 cm <0.001 0.014 2.683
Cribroform type 0.001 0.098 2.063
Necrosis 0.040 0.393 1.422
PR(−)* 0.002 0.396 1.414
p53(+) 0.001 0.019 2.494
Needle biopsy <0.001 0.008 3.165

* PR = progesterone receptor;

p53 = tumor protein 53.

TOOLS
Similar articles