乳腺导管原位癌及其微浸润的临床病理研究

目的 探讨乳腺导管原位癌（DCIS）患者微浸润（MI）与其他临床病理参数的关系.方法 回顾性分析2006年10月至2012年10月本院收治的131例乳腺DCIS患者的临床资料,采用Spearman相关性分析检验DCIS-MI、淋巴结转移与其病理分级之间是否具有相关性,采用Fisher确切概率法分析DCIS-MI是否影响其淋巴结转移,比较DCIS手术方式、病理级别、微浸润、腋窝淋巴结清扫是否影响其复发.结果 （1）在131例DCIS的病理分级中,低级别60例（45.8%）,中级别60例（45.8%）,高级别11例（8.4%）,各组DCIS-MI分别有12例、31例、8例,与病理分级之间具有相关性（r=0.375,P=0.000）.（2）共计76例行前哨淋巴结活组织检查,3例转移;56例行腋窝淋巴结清扫,5例转移.腋窝淋巴结转移与微浸润有关（P=0.015）,与病理分级之间无相关性（r=0.154,P=0.107）.（3）本组DCIS患者随访3月至6年,1例中风死亡,3例局部复发,无乳腺癌死亡.DCIS复发与手术方式、病理分级、微浸润、腋窝淋巴结清扫均无关（P=0.359、1.000、1.000、0.260）.结论 DCIS病理分级高易发生DCIS-MI;DCIS-MI易发生腋窝淋巴结转移.     

乳腺导管原位癌的间质微浸润危险因素分析

目的:分析乳腺导管原位癌（ductal carcinoma in situ,DCIS）间质微浸润的危险因素,探讨导管原位癌伴微浸润（ductal carcinoma in situ with microinvasion,DCIS-MI）患者的腋窝淋巴结术式。方法:回顾性分析2013年2 月至2016年2 月南京大学医学院附属金陵医院经手术后病理证实为DCIS、DCIS-MI 共45例患者临床资料,依据是否伴微浸润分为DCIS与DCIS-MI 组,对患者年龄、就诊时是否绝经、肿瘤大小等因素行统计学分析。结果:就诊时未绝经（P = 0.006）、肿物直径≥ 3.15cm（P = 0.006）、有恶性肿瘤家族史（P = 0.002）的患者更易发生肿瘤间质微浸润。结论:具有可触及腋窝肿物、未绝经、乳腺巨大肿物、有恶性肿瘤家族史危险因素,同时术前行穿刺或术中冰冻提示DCIS、DCIS伴可疑微浸润的患者存在微浸润可能性大,应予前哨淋巴结活检。触及腋窝肿物为首要症状患者,腋窝淋巴结清扫术应作为首选方式。      

乳腺导管内癌及其微浸润癌病理和生物学指标表达差异的临床意义

目的比较乳腺导管内癌（DCIS）与微浸润癌（DCIS—MI）的病理及生物学指标表达差异,探讨DCIS发展为浸润癌的过程中可能存在的病理或生物学特性改变。方法回顾分析40例DCIS和30例DCIS-MI,采用Pearsonx。检验比较两者导管内癌成分的病理学指标,采用Wilcoxon秩和检验比较两者雌激素受体（ER）、孕激素受体（PR）、人表皮生长因子受体（HER-2）、P53及Ki67生物学指标的差异。结果DCIS的病理分型中,粉刺型和非粉刺型的病例分别占25．0％（10／40）和75．0％（30／40）,而DCIS。MI的导管内癌成分中粉刺型和非粉刺型分别占63．3％（19／30）和36．7％（11／30）,两者差异有统计学意义（0=10．38,P=0．001）;DCIS—MI的导管内癌成分中高级别的核分级和伴坏死的比例明显高于DCIS（x2=9．52,P=0．009,x2=8．57,P=0．003）。DCIS与DCIS—MI两组间ER、PR、HER-2和P53的表达差异均无统计学意义（P〉0．050）。DCIS—MI中Ki67增殖指数高表达（〉20％）比例明显高于DCIS（40．0％比17．5％;Z=-2．35,P=0．019）。结论Ki67增殖指数对评价DCIS发生浸润有一定的临床价值。     

从原位癌到微小浸润：乳腺肿瘤的临床病理分析及对外科治疗的影响

背景对乳腺原位癌（CIS）是否应进行前哨淋巴结活检（SLNB）目前仍处于争议中。临床诊疗中常遇到：一些在术前穿刺或术中活检被诊断为原位癌且未进行SLNB的患者,术后却经病理确诊为乳腺微小浸润性癌（MIBC）。此时,是否二次手术进行腋窝淋巴结状态评估对外科医师来说是一个困难的选择。一方面,MIBC淋巴结转移风险尚不明确;另一方面,再次手术时SLNB的准确性及可操作性往往受到质疑,多数情况下腋窝淋巴结清扫成为唯一的选择。目的识别原位癌伴发微小浸润的危险因素;比较CIS和MIBC腋窝淋巴结的转移风险;探索选择合适的病例直接进行术中前哨淋巴结活检以避免二次手术的合理性。方法对接受手术且经病理确诊的乳腺原位癌（493例）及微小浸润癌（199例）患者的临床病历资料进行回顾性的统计分析;采用Pearson卡方检验和Fisher确切概率法进行组间比对;通过单因素分析和多因素Logistic回归识别原位癌伴发微小浸润的危险因素。结果原位癌组中出现4例小叶原位癌（LCIS）,其余均为导管原位癌（DCIS）,而MIBC所伴发的原位癌均以DCIS为主。单因素分析显示,X线片BI-RADS≥4级的钙化,肿瘤﹥2.5 cm,高级别DCIS,ER（－）,PR （－）,HER-2（+++）是原位癌伴微小浸润的危险因素（P均﹤0.05）;Ki-67≥20%也可能与发生微小浸润有关（P=0.057）。使用Logistic回归将重要协变量（年龄）与上述危险因素一起进行多因素分析显示,年龄﹥50岁（P=0.034）,肿瘤﹥2.5 cm（P=0.033）,高级别DCIS（P=0.011）等是原位癌伴微小浸润的独立危险因素。此外,相对于2.0%的原位癌淋巴结转移概率,MIBC的淋巴结转移概率为5.5%,二者比较差异具有统计学意义（P=0.029）。结论 MIBC淋巴结转移风险为5.5%,多伴发于患者年龄超过50岁的较大范围的高级别DCIS中。目前来说,对合并这些高风险因素的原位癌患者直接进行SLNB是一种合理和稳妥的诊治手段,可以有效避免二次手术的发生并为下一步治疗提供依据。     

乳腺导管原位癌和乳腺导管原位癌伴微浸润的分子分型差异性研究

背景与目的：乳腺导管原位癌伴微浸润（ductal carcinoma in situ with microinvasion,DCISMI）是乳腺导管原位癌（ductal carcinoma in situ,DCIS）发展到浸润性乳腺癌（invasive breast cancer,IDC）的中间阶段,该研究旨在分析乳腺DCIS和DCIS-MI这两类早期乳腺癌不同临床病理学特征和各个分子分型间的差异。方法：本回顾性研究纳入了317例DCIS患者,其中227例（71.6%）为纯DCIS患者,90例（28.4%）为DCIS-MI患者。所有患者根据其DCIS成分而非微浸润成分的免疫组织化学检查结果分成腔面A型［雌激素受体（estrogen receptor,ER）和（或）孕激素受体（progesterone receptor,PR）阳性,人类表皮生长因子受体2（human epidermal growth factor receptor 2,HER-2）阴性］、腔面B型［ER和（或）PR阳性,HER-2阳性］、HER-2过表达型（ER和PR阴性,HER-2阳性）和基底样型（ER和PR阴性,HER-2阴性）。结果：DCIS-MI患者的肿瘤大小倾向更大（P=0.059）,病理核分级显著更高（P=0.002）。和DCIS患者相比,乳腺DCIS-MI患者中腔面A型比例较低而基底样型比例较高（P=0.001）。结论：乳腺DCIS和DCIS-MI间分子分型分布不同,临床病理特征迥异,提示DCIS-MI是DCIS发展的新阶段,有了“质”的改变,本结论有待后续更大样本量的研究进行验证。     

临床淋巴结阴性乳腺癌新辅助化疗与腋窝降阶梯处理的研究

背景与目的：前哨淋巴结活检（sentinel lymph node biopsy,SLNB）是临床淋巴结阴性（clinically nodenegative,cN₀）早期乳腺癌患者诊断的标准,但对于新辅助化疗（neoadjuvant chemotherapy,NAC）的cN₀患者行SLNB的时机仍存在争议。本研究旨在探讨cN₀患者接受NAC与SLNB的最佳时机,评估其NAC后选择性避免腋窝手术的可行性。方法：回顾性分析2010年10月—2018年4月山东大学附属山东省肿瘤医院乳腺病中心收治的809例行NAC患者的临床病理学资料,分析138例cN₀患者的不同临床病理学特征与NAC后腋窝淋巴结阴性（即ypN₀）的相关性。结果：cN₀患者NAC后81.9%（113/138）为ypN₀。激素受体（hormone receptor positive,HR）阳性（+）/人表皮生长因子受体2（human epidermal growth factor receptor-2,HER2）阴性（-）、HR⁺/HER2⁺、HR-/HER2⁺,以及三阴性乳腺癌（triple-negative breast cancer,TNBC）患者NAC后ypN₀率分别为75.4%（46/61）、81.0%（17/21）、79.2%（19/24）和96.9%（31/32）（P<0.001）。HER2⁺患者接受靶向治疗、TNBC患者接受NAC后,ypN₀率分别为94.1%（16/17）、96.9%（31/32）,较HR⁺/HER2^-患者显著增高（均P<0.05）。乳房肿瘤的分子分型、临床分期、影像学完全缓解及病理完全缓解（breast pathologic complete response,bpCR）与NAC（行全疗程化疗）后ypN₀显著相关（P均<0.05）,其中乳房肿瘤的分子分型（OR=0.454, P=0.049）、临床分期（OR=3.174,P=0.029）和bpCR（OR=0.337,P=0.016）是NAC后ypN₀的独立预测因素。结论：不同分子分型cN₀患者NAC与SLNB的最佳时机不同：HR⁺/HER2^-患者接受NAC前行SLNB可降低腋窝淋巴结清扫（axillary lymph node dissection,ALND）的风险,而HER2⁺患者接受靶向治疗和TNBC患者NAC后行SLNB能更好地避免ALND。鉴于cN₀患者NAC后的高ypN₀率,尤以HER2⁺行靶向治疗及TNBC患者为著,使其NAC后选择性避免腋窝手术成为可能。     

前哨淋巴结活检术在乳腺癌特殊临床状况下的应用

以往认为SLNB仅适用于单一病灶的早期乳腺癌,内乳淋巴结、多灶性/多中心乳腺癌、导管原位癌(DCIS)均不宜SLNB.本文主要对上述问题实行SLNB的可能性做一综述.内乳前哨淋巴结活检(IMSLNB)可提供腋窝外的淋巴结状态信息,尤其某些孤立IMLN受累患者可能改变术后辅助治疗策略.前哨淋巴结(SLN)是整个乳房组织的第一站引流的淋巴结而非针对于某一个病灶,这使多灶性/多中心乳腺癌患者行SLNB成为可能,可获得较满意成功率和准确率.SLNB不必用于所有DCIS患者,而对于伴浸润性癌高危因素如年轻、CNB诊断的DCIS、肿物较大(≥4cm)、高级别DCIS而且欲行乳房切除术的DCIS患者可考虑SLNB.     

MUC1与HER2基因在乳腺癌中的表达及其与临床病理学指标的相关性研究

目的：检测粘蛋白1（mucinl，MUC1）和人类表皮生长因子2（Human epidermal growth factor receptor 2，HER2）在乳腺癌组织中的表达，研究其与临床、病理学因子的关系及MUC1与HER2的相关性。方法：应用免疫组化SP法检测111例乳腺癌组织，37例良性乳腺肿瘤和26例癌旁正常组织中MUC1和HER2的表达情况。结果：MUC1和HER2在乳腺癌中的表达率分别为83．78％、46．85％，与良性肿瘤及癌旁正常组织比较，均有显著性差异。乳腺癌组织中，MUC1表达与腋窝淋巴结转移、临床TNM分期有关，与年龄、肿瘤大小、组织学分级、病理类型无关。HER2表达与组织学分级、临床TNM分期有关，与年龄、肿瘤大小、淋巴结转移、病理类型无关。MUC1与HER2表达呈显著正相关，r=0．197，P=0．038。结论：MUC1与HER2基因的联合监测对判断乳腺癌的恶性程度，淋巴转移，预后及治疗有重要意义．     

乳腺导管内癌前哨淋巴结活检术的临床意义

  目的  探讨乳腺导管内癌(DCIS)患者接受前哨淋巴结活检术(SLNB)的临床意义。  方法  回顾性分析2002年1月至2011年5月来自全国13家医院的325例接受SLNB的乳腺癌患者的临床资料, 其中DCIS患者237例, 导管内癌伴微浸润(DCISM)患者88例, 分析前哨淋巴结(SLN)的阳性率及其影响因素等指标。  结果  325例患者的SLN阳性率为6.15%。237例DCIS患音的SLN阳性率为3.80%, 超声示肿瘤较大和高组织学分级的患者SLN阳性率较高。88例DCISM患者阳性率为12.5%, 年轻患者SLN阳性率较高。  结论  DCISM患者需要接受SLNB, 接受乳房切除术的DCIS患者需要同时接受SLNB, 接受保乳手术的DCIS患者可以不同时接受SLNB, 但高度怀疑存在浸润成分的DCIS患者建议接受SLNB      

乳腺导管内癌全乳腺切片病理组织学及免疫组化研究

目的：探索导管内癌（ductal carcinoma in situ,DCIS)的生物学特性,以期以脒导管内癌新的分型提供依据。方法：对导管内癌标本进行全乳腺次连续切片,c-erbB-2,p53和PCNA蛋白免疫组化检测并检测并结合形态学观察,探讨导管内癌的生物学特性。结果：1）核分级与小叶内末梢导管受累相关（P＜0．05,Ⅲ）级病变较Ⅰ级病变易累及小叶内末梢导管,2）对34例导管内癌全乳腺次连续切片观察发现：核分级Ⅰ级的DCIS70％（14／20）的病变范围小于5cm,而3例Ⅲ级的病变范围均大于5cm;2例（65）DCIS呈多中心性;3）免疫组化检测发现:c-erbB-2,PCNA的阳性表达率粉型DCIS比非粉刺型高（P＜0．05）;c-erbB-2,pcna,P53的表达率与核分级呈正相关（P＜0．05）,与小叶内末梢导管受累和坏死程度则无关（P＞0．05）。核分级高者c-erbB-2,p53,PCNA的表达率均较核分级低者高（P＜0．05－P＜001）。4）导管内癌腋淋巴结转移率较低为17％,转移是由于隐匿性浸润所致。结论：导管内癌无论在病理形态还是生的学行为方面都是异质性的群体,除传统的组织学亚型外,核分级及c-erbB-2,p53和PCNA的表达也可作为其恶性度的指标,其中,核分级更能全面真实反映DCIS的生物学特性,按核分级的高柢将DCIS分成生物学特性不同的三个亚型,具有临床实用价值。     

Sentinel lymph node biopsy in clinically detected ductal carcinoma in situ

AIM: To study the indications for sentinel lymph node biopsy (SLNB) in clinically-detected ductal carcinoma in situ (CD-DCIS). METHODS: A retrospective analysis of 20 patients with an initial diagnosis of pure DCIS by an image-guided core needle biopsy (CNB) between June 2006 and June 2012 was conducted at King Faisal Specialist Hospital. The accuracy of performing SLNB in CD-DCIS, the rate of sentinel and non-sentinel nodal metastasis, and the histologic underestimation rate of invasive cancer at initial diagnosis were analyzed. The inclusion criteria were a preoperative diagnosis of pure DCIS with no evidence of invasion. We excluded any patient with evidence of microinvasion or invasion. There were two cases of mammographically detected DCIS and 18 cases of CD-DCIS. All our patients were diagnosed by an image-guided CNB except two patients who were diagnosed by fine needle aspiration (FNA). All patients underwent breast surgery, SLNB, and axillary lymph node dissection (ALND) if the SLN was positive. RESULTS: Twenty patients with an initial diagnosis of pure DCIS underwent SLNB, 2 of whom had an ALND. The mean age of the patients was 49.7 years (range, 35-70). Twelve patients (60%) were premenopausal and 8 (40%) were postmenopausal. CNB was the diagnostic procedure for 18 patients, and 2 who were diagnosed by FNA were excluded from the calculation of the underestimation rate. Two out of 20 had a positive SLNB and underwent an ALND and neither had additional non sentinel lymph node metastasis. Both the sentinel visualization rate and the intraoperative sentinel identification rate were 100%. The false negative rate was 0%. Only 2 patients had a positive SLNB (10%) and neither had additional metastasis following an ALND. After definitive surgery, 3 patients were upstaged to invasive ductal carcinoma (3/18 = 16.6%) and 3 other patients were upstaged to DCIS with microinvasion (3/18 = 16.6%). Therefore the histologic underestimation rate of invasive disease was 33%. CONCLUSION: SLNB in CD-DCIS is technically feasible and highly accurate. We recommend limiting SLNB to patients undergoing a mastectomy.     

Factors Predicting Microinvasion in Ductal Carcinoma in situ

Background: Whether sentinel lymph node biopsy (SLNB) should be performed in patients with pure ductalcarcinoma in situ (DCIS) of the breast has been a question of debate over the last decade. The aim of this studywas to identify factors associated with microinvasive disease and determine the criteria for performing SLNB inpatients with DCIS. Materials and Methods: 125 patients with DCIS who underwent surgery between January2000 and December 2008 were reviewed to identify factors associated with DCIS and DCIS with microinvasion(DCISM). Results: 88 patients (70.4%) had pure DCIS and 37 (29.6%) had DCISM. Among 33 DCIS patientswho underwent SLNB, one patient (3.3%) was found to have isolated tumor cells in her biopsy, whereas 1 of 14(37.8%) patients with DCISM had micrometastasis (7.1%). Similarly, of 16 patients (18.2%) with pure DCISand axillary lymph node dissection (ALND) without SLNB, none had lymph node metastasis. Furthermore, of 20patients with DCISM and ALND, only one (5%) had metastasis. In multivariate analysis, the presence of comedonecrosis [relative risk (RR)=4.1, 95% confidence interval (CI)=1.6-10.6, P=0.004], and hormone receptor (ER orPR) negativity (RR=4.0, 95%CI=1.5-11, P=0.007), were found to be significantly associated with microinvasion.Conclusions: Our findings suggest patients presenting with a preoperative diagnosis of DCIS associated withcomedo necrosis or hormone receptor negativity are more likely to have a microinvasive component in definitivepathology following surgery, and should be considered for SLNB procedure along with patients who will undergomastectomy due to DCIS.     

Tumor size as predictor of microinvasion, invasion, and axillary metastasis in ductal carcinoma in situ

Ductal carcinoma in situ (DCIS) represents a small number of cases in countries with inadequate breast cancer screening programs, and in the majority of cases is diagnosed as a palpable lump. It has been proposed that DCIS with palpable lump > or = 2.5 cm can be associated with microinvasion or invasive carcinoma and risk of axillary metastasis. The purpose of the present study is to evaluate incidence of microinvasion, invasion, and the role of lymphatic mapping and sentinel lymph node biopsy in DCIS > or = 2.5 cm.We conducted a retrospective analysis of patients with histologically proven incisional, excisional, or core biopsy of DCIS lump > or = 2.5 cm at a tertiary-care hospital. All patients underwent lymphatic mapping with sentinel lymph node biopsy.A total of 24 patients were included with average tumor size of 4 cm (range, 2.5-6 cm); 29% had microinvasive and 12.5% had invasive disease, three patients (12.5%) had positive sentinel lymph node, all had micrometastasis, and no metastasis were found in non-sentinel lymph nodes. Incidence of microinvasion and invasion were directly related with tumor size (10% for DCIS tumor size of 2.5-3.5 cm, 57% for 3.6-4.5 cm, and 71% for tumors between 4.5 and 6 cm). In addition, axillary metastasis incidence had a direct relationship with tumor size. (0% in 2.5-3.5-cm tumor size, 14% for 3.6-4.5 cm, and 28% in DCIS between 4.6 and 6.0 cm).The present study shows high incidence of microinvasion and invasion in DCIS diagnosed in tumors > or = 2.5 cm and supports the importance of axillary evaluation in patients with tumors >3.5 cm by means of lymphatic mapping and sentinel lymph node biopsy.     

US-guided 14G Core Needle Biopsy: Comparison Between Underestimated and Correctly Diagnosed Breast Cancers

Background: The purpose of study was to evaluate radiologic or clinical features of breast cancer undergoingultrasound (US)-guided 14G core needle biopsy (CNB) and analyze the differences between underestimated andaccurately diagnosed groups. Materials and Methods: Of 1,898 cases of US-guided 14G CNB in our institute,233 cases were proven to be cancer by surgical pathology. The pathologic results from CNB were invasive ductalcarcinoma (IDC) (n=157), ductal carcinoma in situ (DCIS) (n=40), high-risk lesions in 22 cases, and benign in14 cases. Among high-risk lesions, 7 cases of atypical ductal hyperplasia (ADH) were reported as cancer and 11cases of DCIS were proven IDC in surgical pathology. Some 29 DCIS cases and 157 cases of IDC were correctlydiagnosed with CNB. The clinical and imaging features between underestimated and accurately diagnosed breastcancers were compared. Results: Of 233 cancer cases, underestimation occurred in 18 lesions (7.7%). Amongunderestimated cancers, CNB proven ADH (n=2) and DCIS (n=11) were diagnosed as IDC and CNB provenADH (n=5) were diagnosed at DCIS finally. Among the 186 accurately diagnosed group, the CNB results wereIDC (n=157) and DCIS (n=29). Comparison of underestimated and accurately diagnosed groups for BI-RADScategory, margin of mass on mammography and US and orientation of lesion on US revealed statistically significantdifferences. Conclusions: Underestimation of US-guided 14G CNB occurred in 7.7% of breast cancers. Betweenunderestimated and correctly diagnosed groups, BI-RADS category, margin of the mass on mammography andmargin and orientation of the lesions on US were different.     

Predictors of invasive disease in breast cancer when core biopsy demonstrates DCIS only

BACKGROUND AND OBJECTIVES: Ductal carcinoma in-situ on core biopsy does not preclude invasive disease within the excision specimen, resulting in the need for further axillary surgery. We sought to identify predictors of invasion when DCIS is present on core biopsy. METHODS: From a database of 895 breast cancer patients, patients with DCIS on core biopsy who had subsequent surgical excision were identified. Their excision pathology and preoperative mammography were correlated with risk of invasion. RESULTS: Patients (93) with a preoperative diagnosis of DCIS on core biopsy were identified. On excision, 31 patients (33%) had invasive carcinoma and 13 patients (14%) had microinvasion. A preoperative finding of calcification only on mammogram was associated with DCIS on excision (P = 0.014), whereas the presence of other mammographic features increased the risk of invasion. Size > or =5 cm on excision pathology was associated with increased risk of invasion (P = 0.002). Forty-eight percent (n = 11/23) of those diagnosed by ultrasound-guided core biopsy had frank invasion on excision compared to 21% (n = 12/57) diagnosed by stereotactic techniques (P = 0.017). CONCLUSION: Mammographic features and tumor size can help predict invasion in patients who have DCIS on core biopsy. Patients who have features other than calcification on mammography or have tumor size > or =5 cm should be considered for a sentinel node biopsy.     

Sentinel lymph node biopsy in the management of ductal carcinoma in situ

Sentinel lymph node biopsy (SLNB) has been adopted by some physicians in the evaluation of ductal carcinoma in situ (DCIS). In a review of the current literature, we found no convincing data that SLNB is warranted as standard of care in newly diagnosed DCIS. Although lymph node invasion is present in 2% of women with traditional axillary lymph node dissection (ALND), as a result of the excellent prognosis of DCIS, it is not recommended. However, the detailed evaluation of the lymph node(s) with SLNB raises the issue that perhaps patients at risk for recurrence can be identified early and be treated aggressively without the morbidity associated with ALND. Limited data suggest that, with the use of more sensitive methods for detection of cytokeratin-positive cells, the prevalence of positive lymph nodes in pure DCIS is approximately 2%-13%. In high-risk DCIS or DCIS with microinvasion, the prevalence is 8%-20%. Several limited retrospective studies with long-term follow-up have not demonstrated an adverse relapse-free or overall survival effect for women with immunohistochemically (IHC) positive cells in the lymph nodes compared with those with negative IHC results in the lymph nodes. Sentinel lymph node biopsy in DCIS is associated with known risks, and health care benefits, if any, have not been demonstrated. Sentinel lymph node biopsy is not recommended in patients with DCIS.     

Underestimation of malignancy of breast core-needle biopsy: concepts and precise overall and category-specific estimates

BACKGROUND: A review of the literature indicated variable underestimation rates for breast core-needle biopsy (CNB) based on generally small series. In this article, the authors present precise estimates for overall underestimation and for categories of histologic underestimates (including categories that reflect contemporary classification) and examine the effect of lesion and sampling variables. METHODS: Among 4035 consecutive CNBs, the authors examined women whose CNB outcome represented a potential underestimate of malignancy (benign but of uncertain biologic or malignant potential or B3 and ductal carcinoma in situ [DCIS]). From 889 eligible women, all 758 women who had excision histology available were included. RESULTS: Overall underestimation of CNB was 27.7% (95% confidence interval [95% CI], 24.5-30.9%). The following category-specific rates were used: B3 underestimates, 36.2% (95% CI, 30.6-41.8%); B3 underestimates (excluding atypical proliferations), 17.9% (95% CI, 10.8-24.9%); atypical ductal hyperplasia underestimates, 29.0% (95% CI, 21.4-36.6%; upgraded to DCIS) and 44.2% (95% CI, 36.0-52.5%; upgraded to DCIS or invasive cancer); and DCIS underestimates, 22.8% (95% CI, 19.0-26.5%). There was a significant trend toward greater underestimation of malignancy with increasing lesion size on imaging studies for overall underestimates (P = .00008), B3 underestimates (P = .009), and DCIS underestimates (P = .0007). Underestimation rates did not differ between masses (27.9%) and microcalcifications (27.6%; chi-square statistic with 1 degree of freedom = 3.02; P = .98) and were significantly lower for vacuum-assisted CNB (11-gauge) than for automated CNB (14-gauge; P = .001). Underestimation rates, when sampling microcalcifications, decreased with increasing number of cores collected, but this was mainly for DCIS underestimates. CONCLUSIONS: CNB results that were not definitely negative or were not positive for invasive cancer were associated with high rates of underestimation of disease and with target lesion size. Identifying imaging or sampling factors that affect underestimation rates of CNB may assist in reducing their occurrence and better predicting excision histology outcomes.     

Sentinel lymph node biopsy is not necessary in patients diagnosed with ductal carcinoma in situ of the breast by stereotactic vacuum-assisted biopsy

Background

This study evaluated the role and need of a sentinel lymph node biopsy (SLNB) in patients with an initial diagnosis of ductal carcinoma in situ (DCIS) made by stereotactic vacuum-assisted biopsy (VAB).

Materials and methods

A retrospective analysis was performed of 1,458 patients who underwent stereotactic VAB between January 1999 and December 2012 at Aichi Cancer Center Hospital. The rates of axillary node metastasis and the underestimation of invasive ductal carcinoma (IDC) were examined.

Results

Of the 1,458 patients who underwent stereotactic VAB, 199 had a preoperative diagnosis of DCIS and underwent surgery. In these patients, 20 % (39/199) were upstaged to IDC or at least microinvasion in final pathology. Axillary lymph node status was investigated in 81 % (161/199) of initially diagnosed DCIS patients, and resulted in finding lymph node metastasis in 0.62 % (1/161) patients. To assess the potential preoperative predictors of invasiveness, the value of DCIS histological grade on biopsy samples, the distribution of calcifications on mammograms, and the combination of these factors were studied. The underestimation rate was higher (30 %) in the combination of high DCIS histological grade and extensive calcification although there was no significant association (p = 0.23).

Conclusion

The rate of lymph node metastasis was extremely low (0.62 %), even when invasive carcinoma was identified on excision in patients initially diagnosed with DCIS by stereotactic VAB. Because of the low prevalence of metastatic involvement, the cessation of SLNB is a reasonable consideration in patients initially diagnosed with DCIS by stereotactic VAB.

     

The value of sentinel lymph node biopsy in ductal carcinoma in situ (DCIS) and DCIS with microinvasion of the breast

Aim

Ductal carcinoma in situ (DCIS) refers to the preinvasive stage of breast carcinoma and should not give axillary metastases. Its diagnosis, however, is subject to sampling errors. The role of sentinel lymph node biopsy (SLNB) in management of DCIS or DCISM (with microinvasion) remains unclear. The purpose of this study was to review our experience with SLNB in DCIS and DCISM.

Methods

A review of 51 patients with a diagnosis of DCIS (n = 45) or DCISM (n = 6), who underwent SLNB and a definitive breast operation between January 1999 and December 2006, was performed.

Results

In 10 patients (19.6%) definitive histology revealed an invasive carcinoma. SLN (micro)metastases were detected in 5 out of 51 patients, of whom 2 had a preoperative diagnosis of grade III DCIS and 3 of DCISM. Three patients (75%) had micrometastases (<2 mm) only. In 2 patients, histopathology demonstrated a macrometastasis (>2 mm). All 5 patients underwent axillary dissection. No additional positive axillary lymph nodes were found.

Conclusions

In case of a preoperative diagnosis of grade III DCIS or a grade II DCIS with comedo necrosis and DCIS with microinvasion, an SLNB procedure has to be considered because in almost 20% of the patients an invasive carcinoma is found after surgery. In this case the SLNB procedure becomes less reliable after a lumpectomy or ablation has been performed. SLN (micro)metastases were detected in nearly 10% of the patients. The prognostic significance of individual tumour cells remains unclear.