Kurniawan Emil D, Rose Allison, Mou Arlene, Buchanan Malcolm, Collins John P, Wong Matthew H, Miller Julie A, Mann G Bruce
Department of Surgery, The Royal Melbourne Hospital, University of Melbourne, Victoria, Australia.
Arch Surg. 2010 Nov;145(11):1098-104. doi: 10.1001/archsurg.2010.243.
A core needle biopsy (CNB) diagnosis of ductal carcinoma in situ (DCIS) may be associated with a final diagnosis of invasive cancer. Preoperative radiologic, clinical, and pathological features may identify patients at high risk of diagnostic upstaging, who may be appropriate candidates for sentinel node biopsy at initial surgery.
Review of prospectively collected database.
Tertiary teaching referral hospital and a population-based breast screening center.
Consecutive patients from January 1, 1994, to December 31, 2006, whose CNB findings showed DCIS or DCIS with microinvasion.
Upstaging to invasive cancer.
Eleven of 15 cases of DCIS with microinvasion (73.3%) and 65 of 375 cases of DCIS (17.3%) were upstaged to invasive cancer. Ten of 21 palpable lesions (47.6%) were found to have microinvasion. For impalpable DCIS, multivariate analysis showed that noncalcific mammographic features (mass, architectural distortion, or nonspecific density) (odds ratio [95% confidence interval], 2.00 [1.02-3.94]), mammographic size of 20 mm or greater (2.80 [1.46-5.38]), and prolonged screening interval of 3 years or longer (4.41 [1.60-12.13]) were associated with upstaging. The DCIS grade on CNB was significant on univariate analysis (P = .04). The rate of upstaging increased with the number of significant factors present in a patient: 8.3% in patients with no risk factors, 20.8% in those with 1 risk factor, 39.6% in those with 2 risk factors, and 57.1% in those with 3 risk factors.
The risk of upstaging can be estimated by using preoperative features in patients with DCIS on CNB. We propose a management algorithm that includes sentinel node biopsy for patients with DCIS who have microinvasion on CNB, palpable DCIS, 2 or more predictive factors, and planned total mastectomy.
导管原位癌（DCIS）的粗针活检（CNB）诊断可能与浸润性癌的最终诊断相关。术前影像学、临床和病理特征可能识别出诊断升级风险高的患者，这些患者可能是初始手术时前哨淋巴结活检的合适人选。
回顾前瞻性收集的数据库。
三级教学转诊医院和基于人群的乳腺筛查中心。
1994年1月1日至2006年12月31日连续纳入的患者，其CNB结果显示为DCIS或伴有微浸润的DCIS。
升级为浸润性癌。
15例伴有微浸润的DCIS中有11例（73.3%）以及375例DCIS中有65例（17.3%）升级为浸润性癌。21例可触及病变中有10例（47.6%）发现有微浸润。对于不可触及的DCIS，多因素分析显示，非钙化乳腺X线特征（肿块、结构扭曲或非特异性密度）（比值比[95%置信区间]，2.00[1.02 - 3.94]）、乳腺X线大小为20 mm或更大（2.80[1.46 - 5.38]）以及筛查间隔延长3年或更长时间（4.41[1.60 - 12.13]）与诊断升级相关。CNB上的DCIS分级在单因素分析中具有显著性（P = 0.04）。诊断升级率随患者存在的显著因素数量增加而升高：无风险因素的患者为8.3%，有1个风险因素的患者为20.8%，有2个风险因素的患者为39.6%，有3个风险因素的患者为57.1%。
对于CNB诊断为DCIS的患者，可通过术前特征来估计诊断升级的风险。我们提出一种管理算法，包括对CNB有微浸润、可触及DCIS、有2个或更多预测因素且计划行全乳切除术的DCIS患者进行前哨淋巴结活检。
