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Annals of Surgical Oncology
Published in: Annals of Surgical Oncology 10/2017

01-10-2017 | Breast Oncology

A Validated Nomogram to Predict Upstaging of Ductal Carcinoma in Situ to Invasive Disease

Authors: James W. Jakub, MD, Brittany L. Murphy, MD, MS, Alexandra B. Gonzalez, MD, Amy L. Conners, MD, Tara L. Henrichsen, MD, Santo Maimone IV, MD, Michael G. Keeney, MD, Sarah A. McLaughlin, MD, Barbara A. Pockaj, MD, Beiyun Chen, MD, PhD, Tashinga Musonza, MD, William S. Harmsen, MS, Judy C. Boughey, MD, Tina J. Hieken, MD, Elizabeth B. Habermann, PhD, MPH, Harsh N. Shah, MPH, Amy C. Degnim, MD

Published in: Annals of Surgical Oncology | Issue 10/2017

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Abstract

Background

Approximately 8–56% of patients with a core needle biopsy (CNB) diagnosis of ductal carcinoma in situ (DCIS) will be upstaged to invasive disease at the time of excision. Patients with invasive disease are recommended to undergo axillary nodal staging, most often requiring a second operation. We developed and validated a nomogram to preoperatively predict percentage of risk for upstaging to invasive cancer.

Methods

We reviewed 834 cases of DCIS on CNB between January 2004 and October 2014. Multivariable analysis was used to evaluate CNB and imaging factors to develop a nomogram to predict the risk of upstaging from DCIS to invasive cancer. This nomogram was validated with an external dataset of 579 similar patients between November 1998 and September 2016. An area under the receiver operating characteristic curve was constructed to evaluate nomogram discrimination.

Results

The rate of upstaging to invasive disease was 118/834 (14.1%). On multivariable analysis, grade on CNB and imaging factors, including mass lesion, multicentric disease, and largest linear dimension, were associated with upstage to invasive disease, and was used to develop a nomogram (c-statistic 0.71). In the external validation dataset, 62/579 (10.7%) patients were upstaged to invasive disease. Our nomogram was validated in this dataset with a c-statistic of 0.71.

Conclusion

For patients with a CNB diagnosis of DCIS, our validated nomogram using DCIS grade on biopsy, and imaging factors of mass lesion, multicentric disease, and largest linear dimension, may be used for preoperative assessment of risk of upstaging to invasive disease, allowing patient counseling regarding axillary staging at the time of definitive surgery.
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Literature
1.
Brinton LA, Sherman ME, Carreon JD, Anderson WF. Recent trends in breast cancer among younger women in the United States. J Natl Cancer Inst. 2008;100(22):1643–-48.CrossRefPubMedPubMedCentral
2.
Virnig BA, Tuttle TM, Shamliyan T, Kane RL. Ductal carcinoma in situ of the breast: a systematic review of incidence, treatment, and outcomes. J Natl Cancer Inst. 2010;102(3):170–78.CrossRefPubMed
3.
Lyman GH, Giuliano AE, Somerfield MR, et al. American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol. 2005;23(30):7703–20.CrossRefPubMed
4.
Lyman GH, Somerfield MR, Giuliano AE. Sentinel lymph node biopsy for patients with early-stage breast cancer: 2016 American Society of Clinical Oncology clinical practice guideline update summary. J Oncol Pract. 2017;13(3):196–98.CrossRefPubMed
5.
Lyman GH, Temin S, Edge SB, et al. Sentinel lymph node biopsy for patients with early-stage breast cancer: American Society of Clinical Oncology clinical practice guideline update. J Clin Oncol. 2014;32(13):1365-1383.CrossRefPubMed
6.
National Comprehensive Cancer Network. NCCN clinical practice guidelines in oncology: breast cancer version 1.2017. 14 Mar 2017.
7.
Al-Ameer AY, Al Nefaie S, Al Johani B, et al. Sentinel lymph node biopsy in clinically detected ductal carcinoma in situ. World J Clin Oncol. 2016;7(2):258–64.CrossRefPubMedPubMedCentral
8.
Bae JS, Chang JM, Lee SH, Shin SU, Moon WK. Prediction of invasive breast cancer using shear-wave elastography in patients with biopsy-confirmed ductal carcinoma in situ. Eur Radiol. 2017;27(1):7–15.CrossRefPubMed
9.
Brennan ME, Turner RM, Ciatto S, et al. Ductal carcinoma in situ at core-needle biopsy: meta-analysis of underestimation and predictors of invasive breast cancer. Radiology. 2011;260(1):119–28.CrossRefPubMed
10.
Caswell-Smith P, Wall M. Ductal carcinoma in situ: Is core needle biopsy ever enough? J Med Imaging Radiat Oncol. 2017;61(1):29–33.CrossRefPubMed
11.
Chan MY, Lim S. Predictors of invasive breast cancer in ductal carcinoma in situ initially diagnosed by core biopsy. Asian J. 2010;33(2):76–82.
12.
Chang WC, Hsu HH, Yu JC, et al. Underestimation of invasive lesions in patients with ductal carcinoma in situ of the breast diagnosed by ultrasound-guided biopsy: a comparison between patients with and without HER2/neu overexpression. Eur J Radiol. 2014;83(6):935–41.CrossRefPubMed
13.
Chin-Lenn L, Mack LA, Temple W, et al. Predictors of treatment with mastectomy, use of sentinel lymph node biopsy and upstaging to invasive cancer in patients diagnosed with breast ductal carcinoma in situ (DCIS) on core biopsy. Ann Surg Oncol. 2014;21(1):66–73.CrossRefPubMed
14.
Cho N, Moon WK, Chang JM, et al. Sonoelastographic lesion stiffness: preoperative predictor of the presence of an invasive focus in nonpalpable DCIS diagnosed at US-guided needle biopsy. Eur Radiol. 2011;21(8):1618–27.CrossRefPubMed
15.
Coufal O, Selingerova I, Vrtelova P, et al. A simple model to assess the probability of invasion in ductal carcinoma in situ of the breast diagnosed by needle biopsy. BioMed Res Int. 2014;2014:480840.CrossRefPubMedPubMedCentral
16.
Cox CE, Nguyen K, Gray RJ, et al. Importance of lymphatic mapping in ductal carcinoma in situ (DCIS): why map DCIS? Am Surg. 2001;67(6):513–19PubMed
17.
Diepstraten SC, van de Ven SM, Pijnappel RM, et al. Development and evaluation of a prediction model for underestimated invasive breast cancer in women with ductal carcinoma in situ at stereotactic large core needle biopsy. PloS ONE. 2013;8(10):e77826.CrossRefPubMedPubMedCentral
18.
Doebar SC, de Monye C, Stoop H, Rothbarth J, Willemsen SP, van Deurzen CH. Ductal carcinoma in situ diagnosed by breast needle biopsy: Predictors of invasion in the excision specimen. Breast. 2016;27:15–21.CrossRefPubMed
19.
Evans A, Purdie CA, Jordan L, Macaskill EJ, Flynn J, Vinnicombe S. Stiffness at shear-wave elastography and patient presentation predicts upgrade at surgery following an ultrasound-guided core biopsy diagnosis of ductal carcinoma in situ. Clin Radiol. 2016;71(11):1156–59.CrossRefPubMed
20.
Francis AM, Haugen CE, Grimes LM, et al. Is sentinel lymph node dissection warranted for patients with a diagnosis of ductal carcinoma in situ? Ann Surg Oncol. 2015;22(13):4270–79.CrossRefPubMedPubMedCentral
21.
Go EM, Chan SK, Vong JS, et al. Predictors of invasion in needle core biopsies of the breast with ductal carcinoma in situ. Mod Pathol.2010;23(5):737–42.CrossRefPubMed
22.
Han JS, Molberg KH, Sarode V. Predictors of invasion and axillary lymph node metastasis in patients with a core biopsy diagnosis of ductal carcinoma in situ: an analysis of 255 cases. Breast J. 2011;17(3):223–29.CrossRefPubMed
23.
Harowicz MR, Saha A, Grimm LJ, et al. Can algorithmically assessed MRI features predict which patients with a preoperative diagnosis of ductal carcinoma in situ are upstaged to invasive breast cancer? J Magn Reson Imaging. 2017;09:09.
24.
Heymans C, van Bastelaar J, Visschers RG, Vissers YL. Sentinel node procedure obsolete in lumpectomy for ductal carcinoma in situ. Clin Breast Cancer.2017;17(3):e87–e93.CrossRefPubMed
25.
Hogue JC, Morais L, Provencher L, et al. Characteristics associated with upgrading to invasiveness after surgery of a DCIS diagnosed using percutaneous biopsy. Anticancer Res. 2014;34(3):1183–91.PubMed
26.
Houssami N, Ambrogetti D, Marinovich ML, et al. Accuracy of a preoperative model for predicting invasive breast cancer in women with ductal carcinoma-in situ on vacuum-assisted core needle biopsy. Ann Surg Oncol. 2011;18(5):1364–71.CrossRefPubMed
27.
Huang ML, Hess K, Candelaria RP, et al. Comparison of the accuracy of US-guided biopsy of breast masses performed with 14-gauge, 16-gauge and 18-gauge automated cutting needle biopsy devices, and review of the literature. Eur Radiol. 2016;14:14.
28.
Huang YT, Cheung YC, Lo YF, Ueng SH, Kuo WL, Chen SC. MRI findings of cancers preoperatively diagnosed as pure DCIS at core needle biopsy. Acta Radiol. 2011;52(10):1064–68.CrossRefPubMed
29.
Huo L, Sneige N, Hunt KK, Albarracin CT, Lopez A, Resetkova E. Predictors of invasion in patients with core-needle 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(8):1760–68.CrossRefPubMed
30.
Kim J, Han W, Lee JW, et al. Factors associated with upstaging from ductal carcinoma in situ following core needle biopsy to invasive cancer in subsequent surgical excision. Breast. 2012;21(5):641–45.CrossRefPubMed
31.
Kondo T, Hayashi N, Ohde S, et al. A model to predict upstaging to invasive carcinoma in patients preoperatively diagnosed with ductal carcinoma in situ of the breast. J Surg Oncol. 2015;112(5):476–80.CrossRefPubMed
32.
Kurniawan ED, Rose A, Mou A, et al. Risk factors for invasive breast cancer when core needle biopsy shows ductal carcinoma in situ. Arch Surg. 2010;145(11):1098–04.CrossRefPubMed
33.
Lee JW, Han W, Ko E, et al. Sonographic lesion size of ductal carcinoma in situ as a preoperative predictor for the presence of an invasive focus. J Surg Oncol. 2008;98(1):15–20.CrossRefPubMed
34.
Lee SK, Yang JH, Woo SY, Lee JE, Nam SJ. Nomogram for predicting invasion in patients with a preoperative diagnosis of ductal carcinoma in situ of the breast. Br J Surg. 2013;100(13):1756–63.CrossRefPubMed
35.
Miller ME, Kyrillos A, Yao K, et al. Utilization of axillary surgery for patients with ductal carcinoma in situ: a report from the National Cancer Data Base. Ann Surg Oncol. 2016;23(10):3337–46.CrossRefPubMed
36.
Mittendorf EA, 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(2):253–57.CrossRefPubMed
37.
O’Flynn EA, Morel JC, Gonzalez J, et al. Prediction of the presence of invasive disease from the measurement of extent of malignant microcalcification on mammography and ductal carcinoma in situ grade at core biopsy. Clin Radiol. 2009;64(2):178–83.CrossRefPubMed
38.
Osako T, Iwase T, Ushijima M, et al. Incidence and prediction of invasive disease and nodal metastasis in preoperatively diagnosed ductal carcinoma in situ. Cancer Sci. 2014;105(5):576–82.CrossRefPubMedPubMedCentral
39.
Pandelidis S, Heiland D, Jones D, Stough K, Trapeni J, Suliman Y. Accuracy of 11-gauge vacuum-assisted core biopsy of mammographic breast lesions [published erratum appears in Ann Surg Oncol. 2003;10(3):330 Note: Heilman, D [corrected to Heiland, David]]. Ann Surg Oncol. 2003;10(1):43–47.CrossRefPubMed
40.
Park AY, Gweon HM, Son EJ, Yoo M, Kim JA, Youk JH. Ductal carcinoma in situ diagnosed at US-guided 14-gauge core-needle biopsy for breast mass: preoperative predictors of invasive breast cancer. Eur J Radiol. 2014;83(4):654–59.CrossRefPubMed
41.
Pilewskie M, Stempel M, Rosenfeld H, Eaton A, Van Zee KJ, Morrow M. Do LORIS trial eligibility criteria identify a ductal carcinoma in situ patient population at low risk of upgrade to invasive carcinoma? Ann Surg Oncol. 2016;23(11):3487–93.CrossRefPubMed
42.
Prendeville S, Ryan C, Feeley L, et al. Sentinel lymph node biopsy is not warranted following a core needle biopsy diagnosis of ductal carcinoma in situ (DCIS) of the breast. Breast. 2015;24(3):197–200.CrossRefPubMed
43.
Renshaw AA. Predicting invasion in the excision specimen from breast core needle biopsy specimens with only ductal carcinoma in situ. Arch Pathol Lab Med. 2002;126(1):39–41.PubMed
44.
45.
Szynglarewicz B, Kasprzak P, Halon A, Matkowski R. Preoperatively diagnosed ductal cancers in situ of the breast presenting as even small masses are of high risk for the invasive cancer foci in postoperative specimen. World J Surg Oncol. 2015;13:218.CrossRefPubMedPubMedCentral
46.
van Roozendaal LM, Goorts B, Klinkert M, et al. Sentinel lymph node biopsy can be omitted in DCIS patients treated with breast conserving therapy. Breast Cancer Res Treat. 2016;156(3):517–25.CrossRefPubMedPubMedCentral
47.
Walters LL, Pang JC, Zhao L, Jorns JM. Ductal carcinoma in situ with distorting sclerosis on core biopsy may be predictive of upstaging on excision. Histopathology. 2015;66(4):577–86.CrossRefPubMed
48.
Wiratkapun C, Patanajareet P, Wibulpholprasert B, Lertsithichai P. Factors associated with upstaging of ductal carcinoma in situ diagnosed by core needle biopsy using imaging guidance. Jpn J Radiol. 2011;29(8):547–53.CrossRefPubMed
49.
Yen TW, Hunt KK, Ross MI, et al. Predictors of invasive breast cancer in patients with an initial diagnosis of ductal carcinoma in situ: a guide to selective use of sentinel lymph node biopsy in management of ductal carcinoma in situ. Journal of the American College of Surgeons. 2005;200(4):516–26.CrossRefPubMed
50.
Rutstein LA, Johnson RR, Poller WR, et al. Predictors of residual invasive disease after core needle biopsy diagnosis of ductal carcinoma in situ. Breast J. May-Jun 2007;13(3):251–57.CrossRef
51.
Schulz S, Sinn P, Golatta M, et al. Prediction of underestimated invasiveness in patients with ductal carcinoma in situ of the breast on percutaneous biopsy as rationale for recommending concurrent sentinel lymph node biopsy. Breast. 2013;22(4):537–42.CrossRefPubMed
52.
El Hage Chehade H, Headon H, Wazir U, Abtar H, Kasem A, Mokbel K. Is sentinel lymph node biopsy indicated in patients with a diagnosis of ductal carcinoma in situ? A systematic literature review and meta-analysis. Am J Surg. 2017;213(1):171–80.CrossRef
53.
Miyake T, Shimazu K, Ohashi H, et al. Indication for sentinel lymph node biopsy for breast cancer when core biopsy shows ductal carcinoma in situ. Am J Surg. 2011;202(1):59–65.CrossRefPubMed
54.
Park HS, Kim HY, Park S, Kim EK, Kim SI, Park BW. A nomogram for predicting underestimation of invasiveness in ductal carcinoma in situ diagnosed by preoperative needle biopsy. Breast. 2013;22(5):869–73.CrossRefPubMed
55.
Trentin C, Dominelli V, Maisonneuve P, et al. Predictors of invasive breast cancer and lymph node involvement in ductal carcinoma in situ initially diagnosed by vacuum-assisted breast biopsy: experience of 733 cases. Breast. 2012;21(5):635–40.CrossRefPubMed
56.
D’Orsi CJ SE, Mendelson EB, Morris EA, et al. ACR BI-RADS® Atlas: Breast Imaging Reporting and Data System. Reston, VA: American College of Radiology; 2013.
57.
Van Calster B, Nieboer D, Vergouwe Y, De Cock B, Pencina MJ, Steyerberg EW. A calibration hierarchy for risk models was defined: from utopia to empirical data. J Clin Epidemiol. 2016;74:167–76.CrossRefPubMed
58.
Francis A, Thomas J, Fallowfield L, et al. Addressing overtreatment of screen detected DCIS; the LORIS trial. Eur J Cancer. 2015;51(16):2296–2303.CrossRefPubMed
59.
Intra M, Veronesi P, Mazzarol G, et al. Axillary sentinel lymph node biopsy in patients with pure ductal carcinoma in situ of the breast. Arch Surg. 2003;138(3):309–13.CrossRefPubMed
60.
Capdet J, Martel P, Charitansky H, et al. Factors predicting the sentinel node metastases in T1 breast cancer tumor: an analysis of 1416 cases. Eur J Surg Oncol. 2009;35(12):1245–49.CrossRefPubMed
Metadata
Title
A Validated Nomogram to Predict Upstaging of Ductal Carcinoma in Situ to Invasive Disease
Authors
James W. Jakub, MD
Brittany L. Murphy, MD, MS
Alexandra B. Gonzalez, MD
Amy L. Conners, MD
Tara L. Henrichsen, MD
Santo Maimone IV, MD
Michael G. Keeney, MD
Sarah A. McLaughlin, MD
Barbara A. Pockaj, MD
Beiyun Chen, MD, PhD
Tashinga Musonza, MD
William S. Harmsen, MS
Judy C. Boughey, MD
Tina J. Hieken, MD
Elizabeth B. Habermann, PhD, MPH
Harsh N. Shah, MPH
Amy C. Degnim, MD
Publication date
01-10-2017
Publisher
Springer International Publishing
Published in
Annals of Surgical Oncology / Issue 10/2017
Print ISSN: 1068-9265
Electronic ISSN: 1534-4681
DOI
https://doi.org/10.1245/s10434-017-5927-y

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