Reliability of preoperative breast biopsies showing ductal carcinoma in situ and implications for non-operative treatment: a cohort study
Reliability of preoperative breast biopsies showing ductal carcinoma in situ and implications for non-operative treatment: a cohort study
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DOI：
10.1007/s10549-019-05362-1
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发表时间：
2019-11-01
影响因子：
3.8
通讯作者：
Wesseling, Jelle
中科院分区：
文献类型：
--
作者：
Mannu, Gurdeep S.;Groen, Emma J.;Wesseling, Jelle
目的：DCIS非手术治疗的未来依赖于区分需要治疗的病变和仅需要积极监测的病变。准确的术前分期和分级将有助于DCIS的诊断。我们确定了术前乳腺活检显示导管原位癌（DCIS）到浸润性乳腺癌（IBC）的决定因素，或在检查手术切除的标本后将其升级为更高级别的DCIS。方法我们研究了2000-2014年期间在大型专科癌症中心进行术前活检的所有DCIS女性。从临床记录、乳腺X线摄影和术前活检和切除标本的病理学标本中提取信息。活检期间怀疑患有IBC的女性被排除在外。结果在606例术前活检显示DCIS的患者中，15.0%（95%可信区间12.3-18.1）的患者升级为IBC，14.6%（11.3-18.4）的患者升级为更高级别的DCIS。可触及肿块的存在增加了提前分期的风险（21.1% vs 13.0%，p（差异）= 0.04），而升级的风险随着活检坏死的存在而增加（33.0% vs 9.5%，p（差异）< 0.001）和使用14 G空心针而非9 G真空辅助活检（22.8% vs 7.0%，p（差异）< 0.001）。较大的乳房X线摄影尺寸增加了升级（p（异质性）= 0.01）和升级（p（异质性）= 0.004）的风险。结论：术前活检中DCIS分期升高的风险低于先前的估计，并证明了进行随机临床试验以测试主动监测低级别DCIS的安全性的合理性。通过考虑本研究中确定的其他因素，可以改善选择低级别DCIS女性进行此类试验或进行主动监测的情况。
Purpose The future of non-operative management of DCIS relies on distinguishing lesions requiring treatment from those needing only active surveillance. More accurate preoperative staging and grading of DCIS would be helpful. We identified determinants of upstaging preoperative breast biopsies showing ductal carcinoma in situ (DCIS) to invasive breast cancer (IBC), or of upgrading them to higher-grade DCIS, following examination of the surgically excised specimen. Methods We studied all women with DCIS at preoperative biopsy in a large specialist cancer centre during 2000-2014. Information from clinical records, mammography, and pathology specimens from both preoperative biopsy and excised specimen were abstracted. Women suspected of having IBC during biopsy were excluded. Results Among 606 preoperative biopsies showing DCIS, 15.0% (95% confidence interval 12.3-18.1) were upstaged to IBC and a further 14.6% (11.3-18.4) upgraded to higher-grade DCIS. The risk of upstaging increased with presence of a palpable lump (21.1% vs 13.0%, p(difference) = 0.04), while the risk of upgrading increased with presence of necrosis on biopsy (33.0% vs 9.5%, p(difference) < 0.001) and with use of 14G core-needle rather than 9G vacuum-assisted biopsy (22.8% vs 7.0%, p(difference) < 0.001). Larger mammographic size increased the risk of both upgrading (p(heterogeneity) = 0.01) and upstaging (p(heterogeneity) = 0.004). Conclusions The risk of upstaging of DCIS in preoperative biopsies is lower than previously estimated and justifies conducting randomized clinical trials testing the safety of active surveillance for lower grade DCIS. Selection of women with low grade DCIS for such trials, or for active surveillance, may be improved by consideration of the additional factors identified in this study.