The frequency of presentation and clinico-pathological characteristics of symptomatic versus screen detected ductal carcinoma in situ of the breast

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Abstract

Introduction

DCIS accounts for 20% of screen-detected breast cancers, but also presents symptomatically. Historically, approximately 5% of DCIS was thought to be symptomatic, but accurate evaluation of the presentation of symptomatic DCIS is needed to determine its incidence and tumour biology.

Methods

Clinico-pathological details of a consecutive series of patients presenting to a single breast-unit, with a pre-operative diagnosis of DCIS, were selected. Data included age, mode of presentation, pre-operative clinical and radiographical findings. The final tumour histology, operation, size, grade, ER status (and HER2 expression in invasive cases) were recorded.

Results

375 patients had a pre-operative histological diagnosis of DCIS. 308 (82%) screen-detected (median age 59), 67 (18%) presented via symptomatic clinics (median age 50). At final histology 286 (74%) were pure DCIS, and 67 (23%) had an invasive focus. 43% (29/67) of symptomatic cases had an invasive focus at final histology versus 19% (60/308) screen-detected (p ≤ 0.001). 31% (9/29) of symptomatic, versus 10% (6/60) of screen-detected cases with invasion were node positive (p = 0.05). 45% (28/62) intermediate/high-grade symptomatic cases had an invasive focus at final histology, compared to 19% (57/297) intermediate/high-grade screen-detected cases. 86% (212/248) screen-detected pure DCIS was ER positive compared to 68% (26/38) symptomatically presenting pure DCIS (p ≤ 0.001). Overall, 13% (38/248) pure DCIS presented symptomatically (p = 0.001).

Conclusions

Overall, thirteen percent of pure DCIS present symptomatically. Nearly half of symptomatically presenting DCIS at core biopsy has an occult invasive focus and is more frequently ER negative. Symptomatic DCIS with an invasive focus is more likely to have lymph node involvement.

Introduction

Ductal carcinoma in Situ (DCIS) accounts for 20% of all screen-detected breast cancers, but it has been estimated that only 5% of DCIS in the UK presents symptomatically.1 With recent debate as to the potential “overdiagnosis” and more importantly “overtreatment” of screen-detected DCIS, it is important to clarify the proportion of DCIS that presents symptomatically and determine whether the clinico-pathological features of symptomatic DCIS differs from that detected at breast screening assessment by mammography. In addition, it is important to understand whether there are differences in steroid receptor status, invasive foci or lymph node involvement at final histology.

Symptomatic invasive breast cancer often has a poorer overall prognosis than screen-detected, it is therefore important to identify whether symptomatic DCIS has a poorer prognosis than screen-detected DCIS or whether they are clinico-patholologically similar. Although a pre-operative diagnosis of invasive disease is ideal, sometimes, despite repeat biopsy, this is not always possible and the invasive focus only becomes apparent at final histology. Therefore identification of patients with a high chance of harbouring an occult invasive focus (and who could be counselled accordingly) is crucial. At meta-analysis, of (mainly screening-detected cases) of DCIS at pre-operative needle biopsy,2 factors associated with underestimation of associated invasive disease included high-grade disease, lesions larger than 20 mm on imaging, Breast Imaging Reporting and Data System (BI-RADS) score of 4 or 5, a mass seen on mammogram versus calcification alone, and the presence of a palpable lesion in the breast.2

When looking at screen-detected versus symptomatic DCIS, sonographic (USS) and mammographic differences have previously been demonstrated. At both USS and mammography the presence of a mass is more common in symptomatic compared to asymptomatic patients.3, 4 Whereas, microcalcifications and posterior shadowing are more frequently found in the screen-detected cases.3, 4

This study looks at a consecutive series of patients presenting to a single UK breast unit, with a pre-operative diagnosis of DCIS. This is important, as it would reflect cases seen in real practice. We compared the pre-operative findings both clinically and on imaging, to the final histology and tumour characteristics, highlighting differences between screen-detected and symptomatically presenting disease. We aimed to determine if the mode of presentation of DCIS or pre-operative clinico-pathological factors could predict the presence of invasion or lymph node involvement and whether steroid receptor status differed between the groups.

Section snippets

Methods

Clinico-pathological details of all patients presenting to a single NHS breast unit (both NHS breast screening and symptomatic patients) with a pre-operative histological diagnosis of DCIS were collected. Data included age at presentation, mode of presentation, and both pre-operative clinical and radiographical findings. The final, post-operative, histology was also documented. This detailed the type of operation, whether there was invasion or microinvasion present, the size, grade and

Results

Three hundred and seventy-five patients with a pre-operative histological diagnosis of DCIS presented to our unit between July 2007 and December 2011. Three hundred and eight patients (82%) presented via the NHS breast-screening programme and sixty-seven patients (18%) presented via symptomatic clinics. The diagnosis of DCIS was made at pre-operative core biopsy in 327 patients (87%), twenty-one patients (5%) had a Vacuum Assisted biopsy, 26 patients (7%) had an excision-biopsy or total duct

Discussion

This study of a consecutive series of patients from a large screening unit has shown that 18% of cases with a pre-operative histological diagnosis of DCIS present symptomatically. Thirteen percent of pure DCIS at final histology presents symptomatically, a higher percentage than has previously been suggested.1 Nearly half (43%) of all symptomatically presenting women had an invasive focus identified at final histology. Therefore the pre-operative diagnosis of DCIS in a patient presenting

Summary

Symptomatic DCIS is now more common than previously thought, accounting for 13% of all cases. A pre-operative diagnosis of DCIS in a patient who presents symptomatically with either a mass lesion, nipple discharge, or changes in the nipple should have a pre-operative ultrasound scan of the breast and axilla, and in addition, even if the axillary USS shows no abnormal nodes, it is these symptomatically presenting women that should be considered for a sentinel node biopsy at the time of

References (12)

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    The upgrade rate to invasive cancer in the setting of pDCIS is variable in the literature. Invasive disease was noted at time of surgical pathology in 15 % (n = 6) of pDCIS cases by Rajan et al., 54 % (n = 25) of pDCIS patients by Barnes et al., and 59 % (n = 19) of pDCIS patients by Yen et al. [9,16,18] These studies document an upgrade rate to invasive disease in the setting of pDCIS that is higher than the 7.7 % (n = 2) noted in our study. We found no statistically significant difference in upgrade rate to invasive disease between pDCIS and screen-detected DCIS.

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    Given this uncommon presentation, the few published studies of symptomatic DCIS include relatively small numbers of patients and report variable upstaging rates.4,12,13 Upstaging rates of symptomatic DCIS range from 17.6% to 46.1% but in general are thought to exceed upstaging rates of screening-detected or incidental DCIS, which are on the order of 25%.4,12,13 In one study of 74 cases of symptomatic DCIS, the rate of upstaging to invasive disease was 17.6% (13/74).13

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    Furthermore, there were relatively few younger women with screen-detected DCIS. Given that DCIS is most commonly diagnosed through screening [35,36], the disproportionate number of women in this study with DCIS diagnosed through other routes (either symptomatic or incidentally detected on mammography performed for investigation of unrelated symptoms) is probably because screening mammography in the UK is targeted at women aged 70 years of age or younger who are more likely to be suitable for, and to be willing to undergo, primary surgical resection of DCIS than older women who were diagnosed outside the screening service. Although endocrine treatment was recorded on the initial assessment form it was not recorded on the subsequent forms and it is possible that some women stopped treatment, or conversely that others commenced treatment.

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    Typically, approximately 20% of lesions identified by a population based mammographic screening program will be pre-invasive which is consistent with the current study [30–32]. Conversely, symptomatic DCIS accounts for approximately 10–15% of all women presenting with breast cancer and interestingly this study demonstrates that DCIS accounts for an even smaller proportion of interval cancers [33]. Despite concerns regarding over-diagnosis, DCIS that is detected and treated early has an excellent prognosis [34].

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