Absence of Residual Microcalcifications in Atypical Ductal Hyperplasia Diagnosed via Stereotactic Vacuum-Assisted Breast Biopsy: Is Surgical Excision Obviated?

Purpose

The purpose of our study was to evaluate the underestimation rate of atypical ductal hyperplasia (ADH) on vacuum-assisted breast biopsy (VABB), and to examine the correlation between residual microcalcifications and the underestimation rate of ADH.

Methods

A retrospective study was performed on 27 women (mean age, 49.2±9.2 years) who underwent additional excision for ADH via VABB for microcalcifications observed by using mammography. The mammographic findings, histopathologic diagnosis of all VABB and surgical specimens, and association of malignancy with residual microcalcifications were evaluated. The underestimation rate of ADH was also calculated.

Results

Of the 27 women with microcalcifications, nine were upgraded to ductal carcinoma in situ (DCIS); thus, the underestimation rate was 33.3% (9/27). There was no difference in age (p=0.40) and extent of microcalcifications (p=0.10) when comparing benign and malignant cases. Six of 17 patients (35.3%) with remaining calcifications after VABB were upgraded to DCIS, and three of 10 patients (30%) with no residual calcifications after VABB were upgraded (p=1.00).

Conclusion

The underestimation rate of ADH on VABB was 33.3%. Furthermore, 30% of patients with no remaining calcifications were upgraded to DCIS. Therefore, we conclude that all ADH cases diagnosed via VABB should be excised regardless of the presence of residual microcalcifications.     

Possible Prognostic Role of HER2/Neu in Ductal Carcinoma In Situ and Atypical Ductal Proliferative Lesions of the Breast

HER2/neu is a well-established prognostic and predictive factor for invasive breast cancer. However, the role of HER2/neu in ductal breast carcinoma in situ (DCIS) is debated and recent data have suggested that it is mainly linked to in situ local recurrence. Although molecular data suggest that atypical ductal hyperplasia (ADH) and duct carcinoma in situ (DCIS) are related lesions, albeit with vastly different clinical implications, the role of HER2/neu expression in atypical ductal hyperplasia is not well de ned either. The aim of this study was to evaluate over expression of HER2/neu in DCIS and cases of ADH in comparison with invasive breast carcinoma. Archival primary breast carcinoma paraf n blocks (n15), DCIS only (n10) and ductal epithelial hyperplasia and other breast benign lesions (n25) were analyzed for HER2/neu immunoexpression. Follow up was available for 40% of the patients. HER2/neu was positive in 80%of both DCIS and invasive carcinoma, and 67% of atypical ductal hyperplasia (ADH) cases. Thus at least a subset of patients with preinvasive breast lesions were positive, which strongly suggests a role for Her2/neu in identifying high-risk patients for malignant transformation. Although these are preliminary data, which need further studies of gene ampli cation within these patients as well as a larger patient cohort with longer periods of follow up, they support the implementation of routine Her2/neu testing in patients diagnosed as pure DCIS and in orid ADH.     

Utility of Intraoperative Frozen Section Examination of Sentinel Lymph Nodes in Ductal Carcinoma In Situ of the Breast

BackgroundIntraoperative frozen section (IFS) examination of sentinel lymph nodes (SLN) is useful in selecting patients with invasive breast cancer for immediate axillary lymph node dissection. However, whether IFS evaluation of the SLNs in ductal carcinoma in situ (DCIS) of the breast has any value has not been previously assessed.MethodsClinicopathologic data from patients with DCIS who underwent resection with SLN biopsy (2004-2010) were collected to assess the sensitivity, specificity, and accuracy of IFS, and its impact on axillary management.ResultsA total of 267 patients with DCIS underwent resection with SLN biopsy and IFS evaluation. Preoperative pathology was DCIS (n = 231), DCIS with microinvasion (n = 24), and DCIS with other lesions (n = 12). Fifty-two (19.5%) patients had invasive breast cancer on final pathology. SLN metastases were identified in 13 (4.8%) patients; however, only 4 (1.5%) were IFS positive. IFS examination was negative in 263 (98.5%) patients. Among patients with SLN metastases, the most common pattern of metastases was either micrometastasis (n = 6) or immunohistochemistry-positive individual tumor cells (n = 4), whereas 3 patients had a macrometastasis. IFS examination was falsely negative in 9 of these 13 patients for a false-negative rate of 69.3%, and a sensitivity and specificity of 31% and 100% respectively. Nine of the 13 patients underwent axillary lymph node dissection and only 1 patient had further axillary metastasis.ConclusionsSLN metastases in DCIS is rare and most commonly involves SLN micrometastasis or immunohistochemistry-positive individual tumor cells. SLN IFS evaluation in DCIS has a low yield and sensitivity, and can be safely omitted to reduce operative duration and cost.     

乳腺浸润性导管癌钼靶X线钙化与c-erbB-2表达的关系

目的探讨乳腺浸润性导管癌钼靶X线钙化特征与人表皮生长因子相关基因（c-erbB-2）表达的关系。方法回顾64例经术后病理证实的乳腺浸润性导管癌的钼靶X线钙化特征及采用免疫组织化学方法测定肿瘤细胞c-erbB-2的表达情况,分析乳腺癌钙化灶与c-erbB-2表达的相关性。结果 64例患者中,X线表现有钙化的c-erbB-2阳性表达率为64.5%,高于无钙化组的24.2%,差异有统计学意义（χ^2=10.54,P〈0.05）。结论乳腺浸润性导管癌钼靶X线钙化与C-erbB-2的表达具有一定的相关性,可在一定程度上反映肿瘤组织的c-erbB-2的表达情况及表达水平。     

Ductal carcinoma<Emphasis Type="Italic">in situ</Emphasis> and related lesions of the breast: Recent advances in pathology practice

The incidence of ductal carcinoma in situ (DCIS) of the breast has increased significantly in Japanese women. It comprises 14.1% (172/1216) of all primary breast cancers at our institute, and nowadays this histological type is familiar to the surgeons and pathologists of any institute. Several subclassifications have been published recently. Most based on nuclear atypia and the presence of comedonecrosis, and sometimes on the structures of the involved glands. These classifications are correlated with the biological behavior, tumor extent and the risk for local recurrences. The diagnostic accuracy of minimally invasive procedures (aspiration biopsy cytology/core needle biopsy) may differ between subclasses. Atypical ductal hyperplasia (ADH) and microinvasive ductal carcinomas are lesions which resemble but deviate from the DCIS spectrum. The incidence of ADH seems to be lower than in Western countries. Patients with ADH may have a risk for subsequent breast cancer, because ADH is frequently associated with contralateral breast carcinomas. Microinvasion should be treated with caution, but we could not find any metastatic foci in microinvasive ductal carcinomas (T1mic). Tentatively, ADH may be treated similarly to non-comedo (low-grade) DCIS cases, according to our limited clinical experience.     

Imaging for the diagnosis and management of ductal carcinoma in situ

Diagnosis of ductal carcinoma in situ (DCIS) has increased dramatically in parallel with the increased use of screening mammography. There are specific mammographic findings, most associated with shapes (amorphous, fine and coarse pleomorphic, and fine linear) and distributions (linear and segmental) of calcifications that permit a reasonable sensitivity for detection of DCIS without an unreasonable decrease in specificity, especially in view of the dramatic decrease in breast cancer mortality associated with early detection. While some DCIS may never progress to invasive disease, at this time, we cannot make that separation. This should be an active area for research.     

Impact of concurrent proliferative high-risk lesions on the risk of ipsilateral breast carcinoma recurrence and contralateral breast carcinoma development in patients with ductal carcinoma in situ treated with breast-conserving therapy

BACKGROUND: The purpose of the study was to determine the risk of ipsilateral breast carcinoma recurrence (IBCR) and contralateral breast carcinoma (CBC) development in patients with a concurrent diagnosis of ductal carcinoma in situ (DCIS) with atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH), or lobular carcinoma in situ (LCIS). METHODS: Records of all 307 patients with DCIS treated with breast-conserving treatment (BCT) from 1968 to 1998 were analyzed. Initial pathology reports and all slides available were re-reviewed for evidence of ADH, ALH, or LCIS. Actuarial local recurrence rates were calculated. RESULTS: Fifty-five cases of DCIS were associated with ADH, 11 with ALH or LCIS, and 14 with both ADH and ALH or LCIS. Overall, IBCR occurred in 14% and no significant difference in the IBCR rate was identified for patients with proliferative lesions compared with patients without these lesions (P = 0.38). Development of CBC in patients with concurrent DCIS and ADH was 4.4 times (95% confidence interval [CI], 1.44-13.63) that in patients with DCIS alone (P < 0.01). The 15-year cumulative rate of CBC development was 22.7% in patients with ALH or LCIS compared with 6.5% in patients without these lesions (P = 0.30) and 19% in patients with ADH compared with 4.1% in patients with DCIS alone (P < 0.01). CONCLUSION: The risk of CBC development is higher with concurrent ADH than in patients with DCIS alone, and these patients may therefore be appropriate candidates for additional chemoprevention strategies. Concurrent ADH, ALH, or LCIS with DCIS is not a contraindication to BCT.     

Pure flat epithelial atypia identified on core needle biopsy does not require excision

BackgroundRoutine excision of flat epithelial atypia (FEA) of the breast found on core needle biopsy (CNB) is being questioned and a policy of selective excision of FEA was adopted in our area. The purpose of this study was to evaluate the upstage rate to malignancy across multiple diagnostic centers in our area following the policy of selective excision and to identify factors predictive of malignancy.MethodsPatients having excision of CNB FEA at our regional Hospital between 2013 and 2017 were identified. The primary endpoint was upstage to malignancy after excision. We also assessed for clinical, radiological, and pathological features associated with malignancy.ResultsWe identified 187 patients. Eighty-nine had pure FEA, 71 had concurrent ADH, and 18 had other pathological lesions. Following surgical excision, 9 patients were upstaged to malignancy (4. 8%) with 8 having concurrent ADH (2 invasive ductal carcinoma, 6 DCIS) and 1 with concurrent Complex Sclerosing Lesion (DCIS). None of the pure FEA cases upstaged. The presence of ADH or CSL in the CNB were the only factors found to be predictive of upstaging (p = 0.001, p = 0.0001 respectively).ConclusionsThe upstage rate to malignancy after excision of pure FEA at out center is 0%. Therefore, we recommend that pure FEA with radiology and pathology concordance does not require surgical excision and can instead be followed with serial imaging. However, patients with FEA in association with other high-risk lesions should be managed as per indicated for the other high-risk lesion and FEA with ADH should be excised.     

Magnetic Resonance Imaging-Guided Breast Biopsy in Korea: A 10-Year Follow-Up Experience

PurposeTo evaluate the accuracy of magnetic resonance imaging (MRI)-guided breast biopsy.MethodsWe retrospectively reviewed the clinical data of 111 consecutive patients referred for MRI-guided breast biopsy after mammography and breast ultrasound between May 2009 and April 2019. After excluding 37 patients without follow-up images (> 2 years), 74 patients (74 lesions) were finally included. We reviewed the histologic results of MRI-guided biopsy and subsequent surgery, post-biopsy management, and breast cancer development during follow-up. We investigated the false-negative rate, ductal carcinoma in situ (DCIS) underestimation, atypical ductal hyperplasia (ADH) underestimation rate, and technical failure rate of MRI-guided biopsy.ResultsAmong 74 scheduled MRI-guided biopsies, six were canceled because biopsy was deemed unnecessary, while three failed due to technical difficulties (technical failure rate: 3/68, 4.4%). MRI-guided biopsy was performed in 65 patients, of which 18 patients were diagnosed with malignant lesions, 46 with benign lesions, and one with ADH bordering on DCIS. Subsequent surgery (n = 27) showed DCIS underestimation in three cases (3/7, 43%), ADH underestimation in two cases (1/2, 50%), as well as seven concordant benign and 11 concordant malignant lesions. The overall false-negative rate was 4.3% (2/46). Thirty-eight out of 48 benign lesions were followed-up (median period, 5.8 years; interquartile range, 4.1 years) without subsequent surgery. Thirty-seven concordant benign lesions were stable (n = 27) or disappeared (n = 10); however, the size of one discordant benign lesion increased on follow-up MRI and it was diagnosed as DCIS after 1 year.ConclusionMRI-guided biopsy is an accurate method for exclusion of malignancy with a very low false-negative rate.     

Mammotome core biopsy for mammary microcalcification: analysis of 160 biopsies from 142 women with surgical and radiologic followup

BACKGROUND: Although stereotaxic fine-needle aspiration biopsy or core biopsy (14-gauge) have proven to be accurate techniques for the evaluation of mammographically detected microcalcification, the development of the Mammotome Biopsy System (Biopsys Medical, Inc., Irvine, CA) has led many medical centers to use this vacuum-assisted device for the sampling of microcalcification. METHODS: One hundred forty-two women underwent 160 stereotaxic Mammotome core biopsies of mammographic calcification over a 1-year period. The stereotaxic procedure was performed by radiologists using the Mammotome Biopsy System. Microcalcification was evident on specimen radiographs and microscopic slides in 99% of the cases. Excisional biopsy was recommended for diagnoses of atypia or carcinoma. Patients with benign diagnoses underwent mammographic followup. RESULTS: One hundred thirty-two benign, 12 atypical, and 15 adenocarcinoma diagnoses (comprising 1 lobular adenocarcinoma in situ [LCIS], 1 invasive ductal adenocarcinoma [IDC], and 13 intraductal adenocarcinomas [DCIS]: 10 comedo, 1 cribriform, 2 mixed cribriform and micropapillary) were rendered. Surgical excision in eight patients with atypia on Mammotome biopsy (two refused surgery, two were lost to followup) showed ductal hyperplasia in three, atypical ductal hyperplasia (ADH) in three and DCIS (low grade, solid) in two patients. Surgical excisions in 14 patients diagnosed with carcinoma (1 patient lost to followup) showed ADH in 3, ADH and LCIS in 1, residual DCIS in 8, IDC in 1, and microinvasive carcinoma in 1 patient. CONCLUSIONS: A diagnosis of atypia on Mammotome biopsy warranted excision of the atypical area, yet the underestimation rate for the presence of carcinoma remained low. The likelihood of an invasive component at excision was low for microcalcification diagnosed as DCIS on Mammotome biopsy. Mammotome biopsy proved to be an accurate technique for the sampling and diagnosis of mammary microcalcification.     

乳腺钼靶片对术前预测浸润性乳腺癌局部复发的价值

乳腺浸润性导管癌有扩散性导管内成份的存在是保留乳腺的局部切除手术后，局部复发的一个重要因素。对187例乳腺浸润性导管癌钼靶片及病理切片进行对照研究发现，钼靶片上的某些特征与扩散性导管内成分有密切关系，即：浸润性导管癌在乳腺片上表现为钙化，特别是钙化范围较大，极可能存在扩散性导管内成份：没有钙化表现的浸润性导管癌，很少合并扩散性导管内成份。所以乳腺片特征可以作为筛选实施保留乳腺手术病人的客观指标。     

Spontaneous mammary intraepithelial lesions in dogs--a model of breast cancer.

Mammary intraepithelial lesions (IEL) are nowadays frequently diagnosed as a result of the success of mammographic screening, education programs, and awareness by women. Establishment of an animal model for these lesions to test treatment or preventive modalities is a prerequisite for human clinical trials. A model for spontaneous IELs, especially for estrogen receptor (ER)-negative lesions, does not exist. This study describes the histologic and immunohistochemical similarity between human and canine mammary IELs. Mammary tumors from 200 dogs were classified and histologic sections of the excisional specimens were evaluated for IELs. IELs, found in specimens from 60 dogs, were categorized as adenosis, sclerosing adenosis, intraductal papilloma, sclerosing papilloma, ductal hyperplasia, atypical ductal hyperplasia (ADH), and ductal carcinoma in situ (DCIS; high, intermediate, and low grade). Most proliferative IELs without atypia were associated with benign tumors, whereas IELs with atypia (ADH and DCIS) were generally associated with mammary cancer. ER-alpha expression was significantly low or absent in most ADH and DCIS lesions as well as in their associated tumors. Ki67 expression was significantly higher in high-grade DCIS than in hyperplasia or low-grade DCIS. Two thirds of high-grade DCIS lesions were positive for HER-2. Canine mammary IELs were strikingly similar to those of the human breast. The frequency of IELs in the dog, their association with spontaneous mammary cancer, their pattern of ER-alpha and HER-2 expression, and their histologic resemblance to human IELs may make the dog an ideal model to study human ER-negative (both HER-2 positive and negative) breast cancer progression as well as prevention and treatment.     

Multicenter evaluation of the breast lesion excision system, a percutaneous, vacuum-assisted, intact-specimen breast biopsy device

BACKGROUND: Percutaneous, vacuum-assisted, large-gauge core needle biopsy (VACNB) provides an alternative to open surgical biopsy as an initial diagnostic tool for breast lesions, yet rates of underestimating malignant diagnoses remain sufficiently high to warrant surgical biopsy in some cases. The current study was performed to determine if the Breast Lesion Excision System (BLES) provides a feasible alternative to VACNB. METHODS: A retrospective review was conducted of 742 consecutive mammographic lesions with microcalcifications classified as Breast Imaging Reporting and Data System (BIRADS) IV or V that had stereotactic percutaneous biopsy using BLES. Initial diagnoses obtained from the histopathologic examination of tissues retrieved at biopsy were compared with the histopathologic examination of tissues received from surgical excision or lumpectomy. Underestimation rates for atypical ductal hyperplasia (ADH) and ductal carcinoma in situ (DCIS) were recorded if open surgical biopsy revealed DCIS or invasive cancer, and invasive cancer, respectively. RESULTS: Of the 742 breast lesions, 34 displayed ADH upon biopsy with the BLES device. Two patients did not receive open surgical biopsy. Of the 32 patients who had open surgical excision, 3 (9.4%) had DCIS or invasive cancer. There were 119 diagnoses of DCIS upon biopsy with the BLES device. Four patients did not receive open surgical biopsy. Of the 115 patients who had open surgical excision, 6 (5.2%) had invasive cancer. CONCLUSIONS: Breast biopsy can be performed accurately using the BLES device. Compared with VACNB, it does not alter the need for surgical excision in women diagnosed with ADH or DCIS at core biopsy.     

Ductal carcinoma in situ of the breast, a population-based study of epidemiology and pathology

In a population-based series of 2109 women with ductal carcinoma in situ (DCIS) diagnosed in 1995-2000 in New South Wales, Australia, incidence increased by an average of 5.5% a year, mostly between 1995 and 1996 and in women 50-69 years of age. This increase paralleled the increases in mammographic screening. BreastScreen NSW, an organised mammographic screening programme, detected 65% of all DCIS. High-grade lesions were 54% of all lesions and were more likely to be 2+ cm in diameter (OR=2.12, 95%CI 1.46-3.14) than low-grade lesions. In all, 40% of DCIS in women younger than 40 years was 2+ cm in diameter compared with 21% in women 40 years and older. Young age, high grade, mixed architecture and multifocality were significant and independent predictors of 2+ cm DCIS.     

Ductal carcinoma in situ of the breast -- among factors predicting for recurrence, distance from the nipple is important.

AIMS: To assess local and systemic recurrence rates and factors predicting for recurrence in patients treated for ductal carcinoma of the breast (DCIS). METHODS: Patients with DCIS treated between January 1986 and January 1997 were identified. All pathology specimens were reviewed. DCIS type, lesion size, nuclear grade and margin clearance were assessed. Mammograms were reviewed and mammographic patterns, size, type of lesion and distance from the nipple were measured. Treatments and subsequent outcomes were established by case note review. Factors predicting for recurrence were analysed by both univariant and multivariant analysis. RESULTS: Of the 220 patients, 153 (70%) had breast-conserving surgery. Sixty-seven (30%) had a mastectomy. Ninety-seven patients had adjuvant therapy of which 22 had radiotherapy alone, 54 had tamoxifen alone and 21 had radiotherapy and tamoxifen. Following mastectomy, two patients developed axillary recurrences. Following breast-conserving surgery 20 (13%) patients developed local recurrences, of which one developed systemic disease and died from breast cancer. CONCLUSIONS: Mammographic nipple to lesion distance of <40 mm and high/intermediate nuclear grade were the only factors found to increase the likelihood of recurrence. Copyright Harcourt Publishers Limited.     

Fourteen-gauge needle core biopsy of mammographically evident radial scars: is excision necessary?

BACKGROUND: Radial scars are benign lesions that may mimic breast carcinoma on mammography and usually are managed by excision biopsy. The authors report their experience with stereotactic needle core biopsy (SNCB) in sampling these lesions. METHODS: A prospective study examined a consecutive series of 75 mammographically detected radial scars from a population-based screening program. In patients who were sampled by SNCB followed by surgical biopsy, the histologic findings of core biopsy and the gold standard of excision biopsy were compared. RESULTS: Sixty-three patients were sampled by core biopsy: SNCB was used in 55 patients (87.0%), and ultrasound-guided needle core biopsy (UNCB) was used in 8 patients (13%). One patient who underwent SNCB did not undergo a follow-up excision biopsy. Radial scars were diagnosed preoperatively by core biopsy in 51 of 62 patients who underwent excision (82%; 95% confidence interval [95%CI], 70-91%). The sensitivity for SNCB was 85% (95%CI, 73-94%), and the sensitivity for UNCB was 63% (95%CI, 24-91%). Of 54 patients who underwent SNCB and excision, 4 patients had coexistent ductal carcinoma in situ (DCIS) at the time they underwent surgical excision: SNCB identified DCIS in 1 patient and identified atypical ductal hyperplasia (ADH) in 3 patients. In the entire group of 75 radial scars, 5 scars were associated with DCIS (7%), and there were no invasive carcinomas. ADH was present in association with 42 of 74 radial scars that were excised surgically (57%). Twenty-nine of those radial scars were sampled preoperatively by SNCB. ADH was found in 21 patients (72%; 95CI, 53-87%). CONCLUSIONS: The sensitivity of SNCB in the identification of radial scars was 85%. In four patients with associated DCIS, SNCB revealed either ADH or DCIS, both of which required excision. These findings suggest that patients with SNCB-proven radial scars among a screened population can be managed safely by mammographic follow-up, provided there is no associated DCIS, ADH, or lobular carcinoma in situ. Spiculated abnormalities with discordant SNCB results require surgical biopsy.     

Grade of Ductal Carcinoma In Situ Accompanying Infiltrating Ductal Carcinoma As an Independent Prognostic Factor

BackgroundSeveral studies about the relationship between IDC and DCIS have been reported, but no consensus has been reached regarding clinical characteristics and prognostic value.Patients and MethodsWe reviewed the medical records of patients who underwent surgery for IDC between 2006 and 2008. DCIS adjacent to IDC was pathologically classified as either high-grade DCIS or non–high-grade DCIS.ResultsAmong 1751 IDC patients within the study period, 1384 patients (79.0%) had concomitant DCIS. There was no survival difference between patients with pure IDC and those with IDC and concomitant DCIS. However, patients with high-grade DCIS had worse survival than did patients with non–high-grade DCIS or pure IDC (5-year recurrence-free survival rates for IDC with non–high-grade DCIS, pure IDC without DCIS, and IDC with high-grade DCIS were 97%, 93%, and 86%, respectively; P = .001). This tendency was maintained regardless of estrogen receptor status or histologic grade of IDC. In a Cox regression model, patients with IDC and accompanying high-grade DCIS had a 2.5-fold higher probability of local or distant relapse than did those with IDC and low-grade DCIS (hazard ratio, 2.51; 95% confidence interval, 1.12–5.64).ConclusionsThe prognosis of patients with invasive breast cancer differed according to the grade of concomitant adjacent DCIS. Accordingly, the grade of adjacent DCIS should be considered as a prognostic factor in the clinical management of patients with breast cancer. However, in our study, the follow-up periods were short to confirm prognostic effect. Further studies are needed.     

The diagnosis and management of ductal carcinoma in-situ of the breast

The widespread utilization of screening mammography has produced a shift in the stage of breast cancer at diagnosis in the US: Currently, 12% to 15% of newly diagnosed breast cancer cases annually are ductal carcinoma in-situ (DCIS). The diagnosis is made, in at least 90% of patients, with mammography. Only about 10% of patients will have a palpable mass. The accurate characterization and visualization of calcifications typically requires magnification of mammographic imaging. The morphology of the calcifications is generally considered to be the most important factor in differentiating benign from malignant formations. Round and uniform shapes are more likely to be benign, while linear and heterogeneous morphologies are associated with DCIS. Following a complete mammographic work-up, most suspicious lesions are potential candidates for a stereotactic core needle biopsy. Ten percent to 50% of patients initially diagnosed with atypical ductal hyperplasia by needle biopsy have subsequently been surgically diagnosed with cancer near the biopsy site. Due to this relatively high incidence of co-existent carcinoma, a needle biopsy diagnosis of atypical ductal hyperplasia necessitates subsequent surgical excision. The most important change in our thinking about DCIS was from a monolithic view, conceiving of DCIS as a single disease highly likely to invade if left untreated, to the realization that DCIS represents a non-obligate precursor with a variable risk of progression, depending on a combination of factors, such as histology, lesion, size, and margin status. In discussing treatment options, patients should understand that local recurrence following total mastectomy is rare and that this is the procedure of choice for disease that cannot be adequately encompassed with a breast-conserving approach. If the patient and her surgeon are in agreement about proceeding with a breast-conserving approach, there needs to be a clear understanding of the incidence and implications of local recurrence. In all such discussions with newly diagnosed patients, however, it is essential to emphasize the excellent prognosis with this disease, irrespective of the surgical approach.     

Ductal Carcinoma In Situ That Involves Sclerosing Adenosis: High Frequency of Bilateral Breast Cancer Occurrence

BackgroundThe radiologic and pathologic characteristics of ductal carcinoma in situ (DCIS) that involves sclerosing adenosis (SA) (SA DCIS) resemble those of invasive carcinoma. However, differences in the clinical features of these conditions remain unclear. This study was designed to clarify the clinicopathologic characteristics of SA DCIS compared with those of DCIS not involving SA (non,-SA DCIS).MethodsWe retrospectively studied 1309 patients who underwent breast surgery at our hospital between January 2007 and December 2008. A total of 205 cases of DCIS were diagnosed in 198 patients, and 28 (13.7%) cases of breast SA DCIS were diagnosed in 24 patients. We compared clinical characteristics as well as radiologic and pathologic findings between SA DCIS and non-SA DCIS.ResultsSynchronous and metachronous bilateral breast cancer was detected at a significantly higher rate in SA DCIS (9 [38%] of 24 patients) than in non-SA DCIS (22 [13%] of 174 patients; P < .01). As for radiologic findings, architectural distortion was more frequent in patients with SA DCIS than in those with non-SA DCIS (15 [54%] of 28 cases vs. 5 [2%] of 177 cases on mammography; P < .01; and 14 [50%] of 28 cases vs. 4 [2%] of 177 cases on ultrasound; P < .01). The rate of negativity for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor 2 was significantly higher in SA DCIS than in non-SA DCIS (5 [18%] of 28 cases vs. 5 [3%] of 177 cases, P = .005) with immunohistochemical studies.ConclusionsThe rate of bilateral breast cancer and of architectural distortion on radiologic studies was higher in patients with SA DCIS than in those with non-SA DCIS. Our findings suggest that patients with SA DCIS should be closely monitored by radiologic and pathologic examinations to detect the presence of contralateral lesions.