Impact of hormonal status on outcome of ductal carcinoma in situ treated with breast-conserving surgery plus radiotherapy: Long-term experience from two large-institutional series

BackgroundDuctal carcinoma in situ (DCIS) is a heterogeneous disease, for which the best adjuvant treatment is still uncertain. Many attempts of risk-groups stratification have been made over time, developing prognostic scores to predict risk of local recurrence (LR) on the basis of features such as age, final surgical margins (FSM) status, grade, and tumor size. The aim of our analysis was to evaluate the patterns of recurrence from a two large-institutional retrospective series.Patients and methodsWe collected data on 457 patients treated with BCS and adjuvant RT between 1990 and 2012. Final analysis was performed on 278 patients, due to missing data about hormonal status (HS). Patients were treated at the Radiation Oncology Unit of the University of Florence (n = 195), and S. Maria Annunziata Hospital (n = 83) (Florence, Italy).ResultsAt a median follow up time of 10.8 years (range 3–25), we observed 20 LR (7.2%). The 5-year and 10-year LR rates were 4.9% and 10.2%, respectively. At Cox regression univariate analysis, estrogen receptor (ER) positive status (p = 0.001), HS positive (p = 0.003), and FSM <1 mm (p = 0.0001) significantly impacted on LR. At Cox regression multivariate analysis positive ER status maintained a protective role (p = 0.003), and FSM status <1 mm its negative impact (p = 0.0001) on LR rate.ConclusionsOur experience confirmed the wide heterogeneity of DCIS. Inadequate FSM and negative ER status negatively influenced LR rates. Tumor biology should be integrated in adjuvant treatment decision-making process.     

Patterns of care for ductal carcinoma in situ of the breast: Queensland's experience over a decade

ObjectivesTo review management of ductal carcinoma in situ (DCIS) of the breast in Queensland, with reference to breast conserving surgery (BCS) and adjuvant radiation therapy (RT). In addition, we examined the incidence of invasive breast cancer recurrence and factors predictive of invasive recurrence.Materials and methodsA retrospective review of the Queensland Oncology Repository identified women with resected DCIS (TisN0) ± adjuvant RT between 2003 and 2012. Time to invasive breast cancer recurrence was analysed using the Kaplan Meier method. Median follow-up was 4.9 years.Results3038 women had surgery. 940 (31%) had mastectomy and 2098 (69%) underwent BCS. Of 2098 women having BCS, 1100 (52%) received BCS alone and 998(48%) received adjuvant RT. The use of RT significantly increased over the decade from 25% to 62% (p=<0.001). Clinicopathological factors associated with RT use on multivariate analysis included age ≤70, higher socioeconomic status, larger tumour size, higher nuclear grade and surgical margins ≤5 mm. Invasive breast cancer recurrence at 5 years was 1.7% [95% CI 1.0–3.0] in RT group versus 2.8% [95% CI 2.1–3.8] in BCS alone group. Factors associated with increased risk of invasive recurrence on multivariate analysis were age <40 and surgical margins ≤2 mm.ConclusionThe use of adjuvant RT in Queensland significantly increased between 2003 and 2012. Selection of patients for RT was based on clinicopathological factors associated with higher recurrence risk. Although longer follow-up is required, the selective use of radiation therapy after BCS is associated with a low rate of invasive breast cancer recurrence at 5 years.     

Local treatment options for young women with ductal carcinoma in situ: A systematic review and meta-analysis comparing breast conserving surgery with or without adjuvant radiotherapy,and mastectomy

PurposeYoung age is associated with poor prognosis in ductal carcinoma in situ (DCIS) of female breast and controversy exists regarding the optimal treatment modality for young patients. We aimed to compare treatment outcomes among breast conserving surgery (BCS), BCS with adjuvant radiotherapy (BCS + RT), and total mastectomy (MT) for young DCIS women.MethodsPubMed, Cochrane, and Embase were searched for studies reporting comparative results among BCS, BCS + RT, or MT in ≤50 years old (y/o) DCIS females. Study quality was assessed and meta-analysis with subgroup analysis was performed to pool the effect sizes of the outcomes-of-interest.ResultsWe included 3 randomized control trials and 18 observational studies. For DCIS women ≤50 y/o, RT following BCS significantly reduced the risk for ipsilateral breast tumor recurrence (IBTR) (HR = 0.66, 95% CI 0.50–0.87). However, the benefit was less robust in extremely young patients and with long follow-ups. RT revealed no statistically significant preventive effect on ipsilateral invasive recurrence (HR = 1.38, 95% CI 0.98–1.94). On the other hand, MT yielded the lowest IBTR (BCS + RT vs MT: HR = 4.4, 95% CI 2.06–9.40), both in ipsilateral DCIS recurrence and ipsilateral invasive recurrence. There was great heterogeneity and could not reach an evident conclusion concerning survival outcomes.ConclusionThis study highlighted the varying effect of RT for young DCIS females. The local control benefit of MT was definite without survival differences observed. Our study provided a moderate certainty of evidence to guide the treatment for young DCIS women. Further age-specific prospective trial is warranted.     

Presence of Lobular Carcinoma In Situ Does Not Increase Local Recurrence in Patients Treated with Breast-Conserving Therapy

Background  Lobular carcinoma in situ (LCIS) is known to be a risk factor for the development of invasive breast cancer. Debate continues as to whether LCIS is also a precursor lesion. We hypothesized that, if LCIS were a precursor, its presence in the lumpectomy specimen, particularly at the margin, could increase local recurrence (LR) after breast-conserving therapy (BCT). Methods  2894 patients treated with BCT for ductal carcinoma in situ (DCIS), stage I or II breast cancer between 1/80 and 5/07 were identified. Patients with DCIS or invasive cancer at the margins or those receiving neoadjuvant therapy were excluded. Group A had 290 patients with LCIS in the lumpectomy; 84 had LCIS at the final margin. Group B included 2604 patients with no evidence of LCIS. Results  Median patient age in group A and B was 57 and 58 years, respectively (P = 0.05); 12% and 13%, respectively, of patients in group A and B had margins <2 mm (P = NS). The histologic distribution of tumor types in group A was lobular in 47.2%, ductal in 34.5%, DCIS in 11.4%, and other invasive histologies in 6.9%, compared with 4.1%, 76.3%,13.6%, and 6.0% for group B, respectively (P < 0.0001). There was no significant difference between the groups in tumor–node–metastasis (TNM) stage. The crude rate of LR was 4.5% in group A and 3.8% in group B (P = NS). Five- and 10-year actuarial LR rates for LCIS at the margin were 6% and 6%, 1% and 15% for LCIS present but not at the margin, and 2% and 6% for no LCIS (P = NS), for group A and B, respectively. In multivariate analysis, menopausal status and adjuvant therapy use were significant predictors of LR. LCIS, either in the specimen or at the margin, was not significantly associated with LR. Conclusion  Presence of LCIS, even at the margin, in BCT specimens does not have an impact on LR. Re-excision is not indicated if LCIS is present or close to margin surfaces. These findings do not support consideration of LCIS as a precursor to the development of invasive lesions. Abstract presentation at the Scientific Session of the 61st Annual Cancer Symposiumof the Society of Surgical Oncology, Chicago, IL, March 13–16, 2008.     

Treatment Selection for Patients with Ductal Carcinoma In Situ (DCIS) of the Breast Using the University of Southern California/Van Nuys (USC/VNPI) Prognostic Index

The University of Southern California/Van Nuys Prognostic Index (USC/VNPI) is an algorithm that quantifies five measurable prognostic factors known to be important in predicting local recurrence in conservatively treated patients with ductal carcinoma in situ (DCIS) (tumor size, margin width, nuclear grade, age, and comedonecrosis). With five times as many patients since originally developed, sufficient numbers now exist for analysis by individual scores rather than groups of scores. To achieve a local recurrence rate of less than 20% at 12 years, these data support excision alone for all patients scoring 4, 5, or 6 and patients who score 7 but have margin widths ≥3 mm. Excision plus RT achieves the less than 20% local recurrence threshold at 12 years for patients who score 7 and have margins <3 mm, patients who score 8 and have margins ≥3 mm, and for patients who score 9 and have margins ≥5 mm. Mastectomy is required for patients who score 8 and have margins <3 mm, who score 9 and have margins <5 mm and for all patients who score 10, 11, or 12 to keep the local recurrence rate less than 20% at 12 years. DCIS is a highly favorable disease. There is no difference in mortality rate regardless of which treatment is chosen. The USC/VNPI is a numeric tool that can be used to aid the treatment decision‐making process.     

Breast conservative surgery for well-differentiated ductal intraepithelial neoplasia: Risk factors for ipsilateral breast tumor recurrence

RationalWe retrospectively analyzed 232 patients affected by well differentiated ductal intraepithelial neoplasia (DIN1c or DCIS G1) treated with conservative surgery without adjuvant radiotherapy.Results25 invasive and 18 non-invasive local recurrences were observed (median follow-up 80 months; 5-year cumulative incidence: 12.2%). Seven of the 15 young patients (<40 y) developed local recurrence (2 in situ, 5 invasive). Age <50 (HR 1.89, 95% C.I. 1.01–3.45), multifocality (HR 3.21, 95% C.I. 1.46–7.06), Ki-67 > 7% (HR 2.33, 95% C.I. 1.20–4.55) and surgical margins <10 mm (HR 2.00, 95% C.I. 1.06–3.76) were significantly associated with an increased risk of local recurrence.ConclusionsYoung age, multifocality and small margins appeared as clear risk factors of local recurrence in DIN1c (DCIS G1) population. The presence of multiple poor prognostic features warrant a thorough discussion regarding local treatment.     

Prediction of pathological margin status using preoperative contrast‐enhanced MRI in patients with early breast cancer who underwent skin‐sparing mastectomy

Skin‐sparing mastectomy (SSM) with immediate reconstruction is standard surgical treatment for early breast cancer with widespread ductal carcinoma in situ (DCIS). The local recurrence rate after SSM is up to 7.0%. We investigated prediction of the pathological margin using contrast‐enhanced MRI, and evaluated the cut‐off point to obtain the safety margin. We performed SSM with immediate reconstruction in 216 early breast cancer patients with widespread DCIS and/or invasive cancer from January 2014 to December 2015. Forty cases were retrospectively reviewed after excluding those with >15 mm between skin and tumor, determined by preoperative contrast‐enhanced MRI, or involving reconstructive surgery for local recurrence, immeasurable lesion by preoperative contrast‐enhanced MRI, or neoadjuvant chemotherapy. We defined a positive pathological margin as <1 mm from the cancer nest. We reviewed the distance between skin and tumor by MRI and pathological examination. To identify the cut‐off for predicting a positive pathological margin, we performed sensitivity analysis using an ROC curve. The margin‐positive rate by pathological examination was 27.5% (n = 11/40), with a moderate correlation of MRI margin and pathological margin (r = 0.44). The best cut‐off point for margin positivity was 5 mm of MRI margin, with sensitivity and specificity of 54% and 86%, respectively (P = 0.009). This is the first prediction of pathological margin by preoperative contrast‐enhanced MRI in early breast cancer patients with SSM. Care is required for SSM if the MRI margin is less than 5 mm due to pathological margin positivity.     

Excision alone for small size ductal carcinoma in situ of the breast

This study was performed to determine the risk of tumor recurrence after local excision alone in patients with small size (≤1 cm) ductal carcinoma in situ (DCIS) of the breast. We have treated 107 patients who had DCIS measuring ≤1 cm with margin widths of ≥0.3 cm with excision alone per institutional protocol. With a median follow-up time of 58 months, 4 patients developed ipsilateral breast tumor recurrence (IBTR). Two of the 4 recurrences were invasive, whereas 2 were DCIS. The 5-year rate of IBTR was 6.1%. The patients with resection margin of <1.0 cm had significantly higher rate of IBTR than the patients with resection margin of ≥1.0 cm (23.1% vs. 1.5% at 5-year, p < 0.01). In conclusion, radiotherapy is necessary in the patients with resection margin of <1.0 cm after excision alone because of the substantial risk of IBTR.     

Size does matter: High volume breast surgeons accept smaller excision margins for wide local excision – A national survey of the surgical management of wide local excision margins in UK breast cancer patients

IntroductionOptimal margins for wide local excision (WLE) have not been clearly established. Larger margins lead to lower recurrence rates but at the expense of cosmetic appearance. NICE guidelines recommend a 2 mm margin for ductal carcinoma in-situ (DCIS), whilst the British Association of Surgical Oncology (BASO) recommend units develop local guidelines. There are presently no specific guidelines for invasive cancer. We surveyed members of the Association of Breast Surgeons (ABS) in order to establish current practice nationally. We hypothesised that larger units may accept narrower excision margins to the benefit of better cosmesis.Materials and methodsA postal questionnaire was sent to all ABS members in October 2010. This consisted of questions about the current practice of the surgeon and their unit. 481 questionnaires were posted in total, all questionnaires returned by April 2011 were analysed.ResultsQuestionnaire response rate was 60% (281). Surgeons operating on over 50 cancers per year accepted smaller margins than those operating on less than 50 (p < 0.02). Acceptable adequate anterior and radial margins ranged from 0 to 10 mm for DCIS and 0 to 5 mm for invasive cancer. A variety of approaches to re-excising anterior margins were reported.ConclusionsThis survey suggests that substantial variations exist in current practice with regard to the approach to WLE. Operator workload appears to influence what is deemed to be an acceptable margin. There is a need for standardised national and international guidelines.     

Accompanying DCIS in breast cancer patients with invasive ductal carcinoma is predictive of improved local recurrence-free survival

BackgroundDuctal carcinoma in situ (DCIS) often accompanies invasive ductal carcinoma (IDC). The presence of co-existing DCIS is postulated to present as a less aggressive phenotype than IDC alone.Patients and methodsPatients diagnosed with hormone receptor-positive breast cancer receiving mastectomy were evaluated. Only patients without adjuvant radio- and chemotherapy were included to decrease treatment bias on local recurrence (LR).ResultsOf 2239 breast cancer patients, 198 fulfilled the inclusion criteria. The overall LR rate was 11.6%. Tumor stage (p = 0.002), nodal status (pN2 vs. pN0, p = 0.023) and pure IDC compared with IDC-DCIS (p = 0.029) were multivariate independent factors for increased LR risk. Patients with IDC-DCIS were significantly younger (p < 0.001), had smaller tumors (p = 0.001), less lymph node involvement (p = 0.012). The LR rate was significantly increased in patients with pure IDC (p = 0.012). The time to distant metastases was decreased in patients with pure IDC compared with that observed in patients with IDC-DCIS (log rank = 0.030).ConclusionInvasive ductal carcinoma accompanied by DCIS is associated with lower LR. The prognostic value of co-existing DCIS in the adjuvant decision-making process may be considered a new independent prognostic marker. This finding needs further studies to evaluate its usefulness in premenopausal women.     

Efficacy and Safety of Glandular Flap Techniques in Surgical Treatment of Large Ductal Carcinoma in situ

BackgroundIt is well known that full segmentary resection can be performed using oncoplastic surgery (OPS) techniques, and the anatomic resection of the ductal system is possible. Therefore, the efficacy and safety of OPS should be investigated in the treatment of ductal carcinoma in situ (DCIS).Patients and MethodsPatients who were diagnosed as pure DCIS and underwent surgical treatment and follow-up were retrospectively evaluated. Patients who underwent OPS and conventional breast-conserving surgery (BCS) were included in the study. The number of patients who required an intervention after the surgery and had a relapse during the follow-up period was determined in both groups.ResultsThere were 45 patients in the OPS group and 138 patients in the BCS group. The mean tumor size was larger in patients in the OPS group (36 ± 12 mm vs. 24 ± 8 mm, p = 0.02). Six (12.7%) patients were reoperated in the OPS group. Of these, 4 were re-excisions and 2 were mastectomies. In this group, breast conservation was possible in 45 (95.7%) patients. Thirty-nine (27%) patients were reoperated in the BCS group. Of these, 23 were re-excisions, and 16 were mastectomies. In this group, breast conservation was possible in 126 (88.7%) patients (p = 0.02). There was no significant difference between the groups in terms of 5-year cumulative local recurrence rates. While the 5-year local recurrence-free survival rate was 93.3% in the OPS group, it was 90.8% in the BCS group.ConclusionThis study provided evidence that OPS can be used safely in the surgical treatment of DCIS by reducing re-excision and completion mastectomy rates compared to BCS.     

Breast-conserving therapy for primary Ductal Carcinoma in Situ in The Netherlands: A multi-center study and population-based analysis

ObjectiveThe aim of this study was to analyse the efficacy of breast-conserving therapy (BCT) for women with primary DCIS in a population-based setting.MethodsData were used from five Radiotherapy centres in The Netherlands from 2000 to 2010, all treated with BCT. Of all the cases, 59.2% received a boost of radiotherapy after their whole breast irradiation (WBI), irrespective of margin status.ResultsA total of 1248 cases with primary DCIS were analysed. The 10-years LRFS was 92.9%. Age ≤50 years and a positive margin were significantly related to local relapse free survival (LRFS). Having a boost had no impact on LRFS, showing a nearly equal recurrence pattern in patients with and without a boost. Separate analyses were done on patients who had received and not received a boost of radiotherapy after WBI. We noted 9.1% contra-lateral breast tumours. The 10-years disease specific survival (DSS) rate was 99.0%.ConclusionsDCIS of the breast and treated with BCT results in excellent LRFS and DSS. Primary surgical lumpectomy with negative margins followed by WBI seems to be the treatment of choice in DCIS treated with BCS with respect to IBTR.     

Predictors of Surgical Margin Status in Breast-Conserving Surgery Within a Breast Screening Program

Background  Breast-conserving surgery (BCS) requires clear surgical margins to minimize local recurrence. We sought to identify groups of patients at higher risk of involved margins who might benefit from preoperative counselling and/or more generous excision at the first operation. Methods  We reviewed demographic, clinical, radiological and pathological records of all women diagnosed with ductal carcinoma in situ (DCIS) or invasive cancer (IC) through a population-based breast screening program in Melbourne, Australia between 1994 and 2005. Results  A total of 2,160 women were diagnosed with DCIS or IC. We excluded 199 who had mastectomy (TM) as initial procedure or had missing data. Three hundred and thirteen had a diagnostic biopsy. Of 1,648 women who had BCS after a preoperative diagnosis of DCIS or IC, 13.5% had involved margins, 16.6% had close (≤1 mm), and 69.8% clear (>1 mm) margins. Of the patients, 281/1,648 (17.1%) underwent re-excision, of whom 93 (33.1%) had residual disease identified. Mammographic microcalcifications (P < 0.0001), absence of a mammographic mass (P = 0.002), presence of DCIS (P < 0.0001), high tumour grade (P < 0.0001), large size (P < 0.0001), multifocal disease (P < 0.0001) and lobular histology (P = 0.005) were associated with involved margins. Microcalcifications (odds ratio [OR] 1.97), large size (OR 4.22) and multifocal disease (OR 2.85) were independently associated with involved margins. Residual disease was associated with involved margins (P < 0.0001), presence of DCIS (P = 0.05) and large tumour size (P = 0.01). Conclusion  After BCS, patients with mammographic microcalcifications, larger tumour size and multifocal tumours are more likely to have involved margins. Patients with involved margins, large tumour size and/or a DCIS component are more likely to have residual disease on re-excision.     

What should be the width of radiological margin to optimize resection of non-palpable invasive or in situ ductal carcinoma?

Purposethe aim of our study was to investigate whether there is radiological margin that optimize resection of non-palpable invasive or in situ ductal carcinoma.Materials and methodsData were collected for all patients undergoing wire localization prior to therapeutic surgical excision between January 2010 and December 2013 at our institution. A 5 and 10-mm radiological margins were considered adequate for invasive ductal carcinoma (IDC) and in situ ductal carcinoma (DCIS) respectively. Clear histological margins were defined as no ink on the tumor for IDC and ≥2 mm for DCIS. Data were analyzed both in order to assess accuracy of the technique and in order to determine what radiological threshold should be taken.ResultsThree hundred seventy seven women were included to the study. The radiological thresholds permitted negative histological margins in 94.7%, 60.9% and 80.9% in the pure invasive ductal carcinoma group (IDC, n = 133), the pure ductal carcinoma in situ group (DCIS, n = 92) and the mixed group (both IDC and DCIS, n = 152) respectively. In an ROC analysis evaluating the ability of radiological thresholds to obtain free pathological margins: the AUC was 0.79 (0.71–0.87, 95% confident interval, p = .0007) for Pure IDC group, 0.67 (0.57–0.87, 95% confident interval, p = .0005) for pure DCIS group, and 0.72 (0.62–0.80, 95% confident interval, p < .0001) for the mixed group.ConclusionWe found that a radiological margin of 10 mm is needed in presence of an in situ component and 5-mm radiological margin seems enough in case of pure IDC tumors.     

Severe fatigue after treatment of ductal carcinoma in situ: A comparison with age-matched breast cancer survivors and healthy controls

PurposeSevere fatigue after treatment of ductal carcinoma in situ (DCIS) has not been studied before. The current study examined (i) the prevalence of severe fatigue in DCIS patients versus breast cancer survivors (BCS) and healthy controls (HC), (ii) quality of life and functioning of severely versus non-severely fatigued DCIS patients and BCS, and (iii) the association of fatigue with psychosocial and behavioral factors in DCIS patients.Methods89 patients treated for DCIS were matched on age and gender to 67 BCS and 178 HC (ratio 1:1:2). Fatigue was measured with the Fatigue Severity subscale of the Checklist Individual Strength.Results23% of DCIS patients, 25% of BCS, and 6% of HC were severely fatigued (DCIS versus HC: p < 0.001). Severely fatigued DCIS patients had a lower quality of life and were more impaired in all domains of functioning than non-severely fatigued DCIS patients. Sleep problems, dysfunctional cognitions regarding fatigue, avoidance of activities, all-or-nothing behavior, perceived lack of social support, DCIS-related coping problems, and fear of future cancer occurrence were related to fatigue.ConclusionsThe prevalence of severe fatigue in DCIS patients was similar to BCS, but higher than in HC. Severely fatigued DCIS patients had a lower quality of life and more functional impairments. The psychosocial and behavioral fatigue-related factors in DCIS patients are known to perpetuate fatigue in BCS. These factors can be targeted in interventions for cancer-related fatigue. Our findings suggest that the same treatment elements might be applicable to severely fatigued DCIS patients.     

Is the systematic circumferential tumor cavity shaving a representative sample for the remaining mammary gland? About 75 cases

IntroductionThe conservative surgery is more and more indicated for breast cancer. However, we still fear local recurrence which is mostly due to residual tumors?. Several techniques have been used to minimize theses residual tumors; one of them is the systematic circumferential tumor cavity shaving (SCTCS).MethodsWe sampled 75 female patients who had conservative surgery with positive shaved margins in the anatomopathology examination and to whom a complementary treatment with mastectomy have been decided.ResultsThe median age was 48 years old. The median tumor size was 23 mm. In the histological examination of the tumors, 93% were invasive ductal carcinoma associated in 50% of the cases to the presence of ductal carcinoma in situ (DCIS) where all the lumpectomies had clear margin. For the SCTCS, 62,2% were DCIS and in 17,6% of the cases were invasive ductal carcinoma. A complementary treatment with mastectomy was indicated to all the patients. A residual tumor was detected in the remaining mammary gland in 47,7% of the cases out of which 50% were DCIS. Local recurrence happened in three patients (4,6%) after a median of follow up of 36 months. The overall survival and the disease free survival at five years were respectively 83,6% and 75,5%.ConclusionStandardized lumpectomy cavity shaving provides a backup to lumpectomy margins in conservative breast surgery but it can also be used as a sample for the remaining breast, helping to detect the residual tumor, and decreasing the rates of local recurrence after BCT.     

Local recurrence of ductal carcinoma in situ after skin-sparing mastectomy

BACKGROUND: The incidence of local recurrence (LR) after conventional total mastectomy for ductal carcinoma in situ (DCIS) ranges from 1% to 3%. Skin-sparing mastectomy (SSM) preserves the native skin envelope to facilitate immediate breast reconstruction. Because DCIS is generally not clinically apparent, there is a potential for inadequate excision when SSM is performed. Risk factors for local recurrence after SSM for DCIS are examined. STUDY DESIGN: A retrospective review of 223 consecutive patients with DCIS treated by SSM and immediate reconstruction was performed. Age younger than 50 years, tumor size > 40 mm, high tumor grade, tumor necrosis, surgical margins < 1 mm, type of biopsy (excisional versus core), and SSM type were examined as risk factors for recurrence. RESULTS: Mean followup was 82.3 months (range 4.9 to 123.2 months). Recurrences developed in 11 patients (5.1%), including: local (n = 7; 3.3%), regional (n = 2; 0.9%), and distant (n = 2; 0.9%). All seven local recurrences were detected by physical examination. No patients received adjuvant radiation therapy. Two of 19 patients with surgical margins < 1 mm developed LR (10.5%). Univariate analysis showed high tumor grade (p = .019) to influence LR. CONCLUSIONS: The incidence of local recurrence of DCIS after SSM is similar to conventional total mastectomy. Reexcision of close margins should be performed if possible and adjuvant radiation therapy should be considered.     

Impact of hormonal status on ductal carcinoma in situ of the breast: Outcome and prognostic factors

Ductal carcinoma in situ (DCIS) of the breast is a heterogeneous disease which is increasingly diagnosed through improved screening measures. Multiple prognostic scores have been devised to predict the risk of local recurrence (LR), and the optimal adjuvant management for DCIS is still debated. Hence, the aim of this analysis is to investigate the factors contributing to the prognosis of DCIS, in particular the role of its hormonal status. From 2005 to 2016, a total of 1221 female patients diagnosed with DCIS at the National Cancer Centre Singapore and Singapore General Hospital were studied. The mean age of diagnosis was 54 years of age (sd = 11.0), with estrogen receptor (ER)–positive DCIS tumors presenting earlier (mean age 54 vs 57 years of age; P < .001). DCIS with negative hormonal status (HS) correlates significantly with a larger size (mean 23.5mm vs 13.0 mm, P < .001) and higher grade of tumor (P < .001). Patients with positive HS were more likely to undergo breast conservation surgery over a mastectomy, in contrast to patients with negative HS (P < .001). Patients with negative HS had a poorer prognosis, with a shorter time of overall survival time (HR = 26.3, P = .020). In conclusion, our study shows that the hormonal status, age of diagnosis, and positive margins are important prognostic factors for DCIS, at least in our Asian population.     

Macrophage density is an adverse prognosticator for ipsilateral recurrence in ductal carcinoma in situ

IntroductionThere is evidence that supports the association of dense tumor infiltrating lymphocyte (TILs) with an increased risk of ipsilateral recurrence in ductal carcinoma in situ (DCIS). However, the association of cellular composition of DCIS immune microenvironment with the histopathologic parameters and outcome is not well understood.MethodsWe queried our institutional database for patients with pure DCIS diagnosed between 2010 and 2019. Immunohistochemical studies for CD8, CD4, CD68, CD163, and FOXP3 were performed and evaluated in the DCIS microenvironment using tissue microarrays. Statistical methods included Fisher's exact test for categorical variables and the two-sample t-test or the Wilcoxon Rank-Sum test for continuous variables.ResultsThe analytic sample included 67 patients. Median age was 62 years (range = 53 to 66) and median follow up was 6.7 years (range = 5.3 to 7.8). Thirteen patients had ipsilateral recurrence. Of all the clinicopathologic variables, only the DCIS size and TIL density were significantly associated with recurrence (p = 0.023 and 0.006, respectively). After adjusting for age and TIL density, only high CD68 (>50) and high CD68/CD163 ratio (>0.46) correlated with ipsilateral recurrence (p = 0.026 and 0.013, respectively) and shorter time to recurrence [hazard ratio 4.87 (95% CI: 1.24–19, p = 0.023) and 10.32 (95% CI: 1.34–80, p = 0.025), respectively].ConclusionsIn addition to DCIS size and TIL density, high CD68⁺ tumor-associated macrophages predict ipsilateral recurrence in DCIS. High CD68⁺ macrophage density and CD68/CD163 ratio also predict a shorter time to recurrence.