Measuring extent of ductal carcinoma in situ in breast excision specimens: A comparison of 4 methods

Department of Laboratory Medicine and Pathobiology, University of Toronto, Ontario, Canada.
Archives of pathology & laboratory medicine (Impact Factor: 2.88). 02/2009; 133(1):31-7. DOI: 10.1043/1543-2165-133.1.31
Source: PubMed

ABSTRACT Measuring the extent of nonpalpable ductal carcinoma in situ (DCIS) in a breast specimen is challenging but important because it influences patient management. There is no standardized method for estimating the extent of DCIS, although serial sequential sampling with mammographic correlation is considered an accurate method.
To estimate the extent of DCIS using various methods and to compare these estimations with the extent as determined by the serial sequential sampling method.
A total of 78 primary breast excisions with DCIS were retrospectively reviewed. All specimens had been sampled using the serial sequential sampling method, which involved mapping the location of each block on the sliced specimen radiograph and calculating the extent through 3-dimensional reconstruction. The other measures for estimating extent included (1) calculating size based on areas of calcification, (2) recording the number of blocks involved by DCIS and multiplying that number by 0.3 cm, and (3) measuring the largest extent of DCIS on a single slide.
All 3 alternative methods tended to underestimate the DCIS. Discrepancies became more pronounced as size increased. The percentage of cases estimated to within 1 cm of the serial sequential sampling method were 81%, 72%, and 50%, respectively, for the calcification, blocks, and single-slide methods; differences of more than 2 cm were seen in 9%, 8%, and 30% of cases, respectively.
The single-slide method performed poorly and should be used only when DCIS is limited to a single slide. Although the calcification and the blocks methods gave better estimates, both produced substantial underestimates and/or overestimates that could affect clinical decision making.

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    ABSTRACT: RESUMEN El carcinoma ductal in situ incluye un grupo heterogéneo de lesiones con características, alteraciones genéticas, manifestación y com-portamiento clínico diversos. Debido al mayor uso de la mastografía de vigilancia, la detección del carcinoma ductal in situ puro se ha incrementado de manera importante. Los criterios diagnósticos del carcinoma ductal in situ dependen del grado de atipia citológica, pero en general incluyen características citonucleares y arquitecturales, la clonalidad de la población celular y la extensión de la lesión. Se han propuesto diversos sistemas de clasificación del carcinoma ductal in situ a fin de predecir la recurrencia de la enfermedad después de la resección quirúrgica, y la mayor parte de los sistemas se basa principalmente en el grado nuclear y, en segundo lugar, en la polarización celular y en la ausencia o presencia de necrosis. Debido a que el estándar de atención actual es la remoción quirúrgica de la lesión, la evolución natural del carcinoma ductal in situ no puede observarse directamente y, en la actualidad, es escasamente entendida. Sin embargo, varias líneas de evidencia apoyan el punto de vista de que el carcinoma ductal in situ sirve como un precursor no obligado de carcinoma invasivo. Debido a su naturaleza típicamente localizada, se ha demostrado que el carcinoma ductal in situ es tratable, en la mayoría de los casos, con escisión sola, generalmente en conjunto con radioterapia coadyuvante, con tasas bajas de recurrencia local. El riesgo de recurrencia depende de las características de la paciente –como el antecedente familiar de cáncer de mama y la edad al momento del diagnóstico– y de los factores del tumor, que incluyen extensión de la enfermedad, el tipo histológico, el grado nuclear, la presencia de comedonecrosis, el patrón arquitectural y el estado de los márgenes de resección. La baja morbilidad de la biopsia del ganglio linfático centinela impulsó el interés de usar esta biopsia en el manejo de pacientes con carcinoma ductal in situ; sin embargo, su uso rutinario en este marco es en la actualidad motivo de intenso debate. Nuestra capacidad de predecir el comportamiento biológico del carcinoma ductal in situ mejorará con el uso de nuevas técnicas moleculares para identificar los biomarcadores específicos, lo que permitirá el manejo óptimo de pacientes con carcinoma ductal in situ. Palabras clave: carcinoma ductal in situ. ABSTRACT Ductal carcinoma in situ (DCIS) includes a heterogeneous group of lesions with diverse morphologic features, genetic alterations, presenta-tion and clinical behavior. Following the increased use of screening mammography the detection of pure DCIS has dramatically increased. Diagnostic criteria for DCIS depend on the degree of cytologic atypia, but in general include cytonuclear and architectural features, clonality of the cell population and extent of the lesion. Numerous classification systems have been proposed for DCIS in order to predict disease recurrence after surgical resection, and most systems are based primarily on nuclear grade and secondarily on cell polarization and the absence or presence of necrosis. Since the current standard of care is surgical removal of the lesion, the natural history of DCIS cannot be directly observed and is currently poorly understood. However, several lines of evidence support the view that DCIS serves as a non-obligate precursor to invasive carcinoma. Due to its typically localized nature, DCIS was shown to be treatable in most cases with excision alone, usually in conjunction with adjuvant radiotherapy, with low rates of local recurrence. The risk of recurrence depends on both patient characteristics, such as family history of breast cancer and age at diagnosis, as well as on tumor factors including extent of disease, his-tological type, nuclear grade, presence of comedo-type necrosis, architectural pattern and the status of the resection margins. The advent of sentinel lymph node biopsy with its low morbidity prompted interest in its use in the management of patients with DCIS, however its routine use in this setting is currently a matter of intense debate. Our ability to predict the biologic behavior of DCIS will improve with the identification of specific biomarkers using new molecular techniques and will enable optimal management of patients with DCIS.
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