Disease recurrence in patients undergoing mastectomy for ductal carcinoma in situ.

PURPOSE: With DCIS incidence on the rise, up to 30% of patients undergo mastectomy for Ductal carcinoma in situ (DCIS) (Nash and Hwang, in: Ann Surg Oncol 30(6):3206-3214, 2023). Local recurrence rates after mastectomy for DCIS are reportedly low, but risk factors for recurrence are not known (Kim et al., in: J Cancer Res Ther 16(6):1197-1202, 2020). We aim to define risk factors associated with ipsilateral breast cancer recurrence in patients undergoing mastectomy for DCIS. METHODS: We aimed to identify risk factors that may contribute to recurrence of breast cancer following mastectomy for pure DCIS. We hypothesized that close or positive mastectomy margins, age at diagnosis, extent of breast disease and mutation carriers would be associated with increased risk of recurrence. We performed a retrospective chart review of patients who underwent unilateral or bilateral mastectomies for pure DCIS at a single academic tertiary referral center from 2013 to 2023. RESULTS: There were 165 patients who met inclusion criteria with an average length of follow-up of 39.9 months. On final surgical pathology, the average span of DCIS was 33.7 mm (± 24.6 mm). Hormone receptor positive disease was identified in 80.6% of the patient cohort. For margin status, 23 patients (14%) had < 1 mm margins on final pathology and of those, 1 received adjuvant radiation therapy and 4 returned to the OR for re-excision. Only 1 (0.6%) patient had ipsilateral disease recurrence during the study period. CONCLUSION: Recurrence after mastectomy for pure DCIS is a rare event and in our study sample, only one recurrence occurred. Risk factors for recurrence appear unrelated to margin status, age, extent of DCIS, or pathogenic mutation (ElSherif et al., in Am J Surg 226(5):646-651, 2023).

Development of diffuse cutaneous squamous cell carcinoma in situ after chemotherapy for ovarian carcinoma and remission with PD1-inhibitor.

This is a 74-year-old female, initially presenting with malignant pleural effusion, and evaluation revealed programmed cell death ligand 1 (PDL1)-positive stage IV high grade serous ovarian cancer. Following initiation of standard chemotherapy agents, carboplatin and paclitaxel, the patient developed a diffuse, itchy rash over her abdomen, back, and bilateral upper and lower extremities. Biopsy of the rash revealed a diffuse non-resectable cutaneous squamous cell skin carcinoma (cSCC) in situ. Consequently, a PD1-inhibitor was added to her neoadjuvant chemotherapy regimen, which resulted in complete response to both metastatic ovarian and diffuse cSCC in situ at time of surgery.

Spectrum of Ductal Carcinoma In Situ (DCIS) Lesions of the Breast: From Morphology to Molecular Characteristics.

Background Specific molecular characteristics of invasive breast cancer have been linked to an increased risk of early relapse. Similarly, ductal carcinoma in situ (DCIS) displays a comparable molecular profile, although their prevalence and implications are not yet fully understood. Aims and objectives The study design defined a multivariable statistical approach aimed at describing the interplay between the histopathological features of ductal carcinoma in situ (DCIS) and their molecular profile. The objective was to explore the correlations between the histopathological features of DCIS (tumor location, DCIS grade, DCIS type, and presence or absence of comedo necrosis) and various biomarkers like estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor (HER2/neu), androgen receptor (AR), and epidermal growth factor receptor (EGFR), in addition to the Ki-67 labeling index. Methods In this retrospective study, we selected and analyzed 100 diagnosed cases of ductal carcinoma in situ (DCIS) to represent various subtypes, grades, and morphological characteristics. A detailed histopathological review and immunohistopathological staining for ER, PR, HER2/neu, AR, EGFR, and Ki-67 were performed on formalin-fixed paraffin-embedded (FFPE) tumor tissue blocks. Molecular subtyping was done based on the biomarker analysis into luminal A, luminal B, luminal HER2/neu, HER2/neu enriched, and triple-negative subtypes. Statistical analysis was done to examine the correlation between tumor location, histopathological features of ductal carcinoma in situ (DCIS), and the expression of the immunohistochemical markers and the molecular subtypes. Results The majority of cases exhibited positivity for estrogen receptor (ER) and progesterone receptor (PR). A strong association was observed between histopathological features (DCIS grade, type, and comedo necrosis) of DCIS and ER/PR status. Additionally, a significant correlation was found between ductal carcinoma in situ (DCIS) grade and HER2/neu status. However, no association was identified between histopathological features and AR or EGFR status. Contrary to expectations, triple-negative DCIS did not show the most aggressive behavior, whereas HER2/neu-positive tumors, particularly high-grade ones, exhibited more aggressive features. No low-grade cases of luminal HER2/neu and HER2/neu-enriched tumors were found. A higher Ki-67 labeling index was found in cases with grade 3 and solid and comedo architectural types of DCIS, while low-grade tumors had a lower Ki-67 labeling index. Conclusion These findings suggest that hormone pathways play a crucial role in ductal carcinoma in situ (DCIS) progression, but the molecular interactions are complex and extend beyond simple binary associations. The complex relationship between the histopathological features of ductal carcinoma in situ (DCIS) and its hormone receptor status warrants further investigation with a larger sample size to fully understand the underlying mechanisms. The results challenge the expectation that triple-negative DCIS is the most aggressive subtype, highlighting the need for further research into the prognostic significance of different DCIS subtypes.

Comparative long-term oncological outcomes of intraoperative radiotherapy vs. whole-breast irradiation in early breast cancer: a single institute study.

Background: Intraoperative radiation therapy (IORT) and whole breast irradiation (WBI) are both effective adjuvant radiotherapy methods for ductal carcinoma in situ (DCIS) or early-stage breast cancer (BC) patients undergoing breast-conserving surgery (BCS). We aim to evaluate the long-term oncological efficacy and refine patient selection criteria based on our findings. Methods: Female patients who underwent either IORT or WBI from January 2016 to December 2019, with a minimum follow-up of 12 months were collected. IORT was administered as a single fraction of 20 Gray (Gy) to the lumpectomy cavity using the Axxent electronic brachytherapy system, while WBI consisted of a standard fractionation of 50 Gy in 25 fractions, along with a reduced boost of 10 Gy. The clinicopathologic characteristics and oncological outcomes were retrospectively analyzed. Results: A total of 247 patients were enrolled, comprising 164 with BC and 83 with DCIS. Among them, 112 underwent IORT, and 135 received WBI after BCS. The median age was 62.2 years, with median tumor sizes of 1.5 cm for BC and 1.2 cm for DCIS. At a median follow-up of 64.6 months, IORT demonstrated 11 locoregional recurrences (LRR), 1 metastasis, and 1 death, compared to 4 LRR, 5 metastases, and 2 deaths in the WBI group. WBI yielded significantly higher locoregional control (97.0% vs. 90.2%, p = 0.033), although metastasis-free (96.3% vs. 99.1%, p = 0.166) and overall survival rates (98.4% vs. 99%, p = 0.688) did not differ. The LRR rate was significantly higher in the IORT group among the DCIS or BC patients (p = 0.043). The hazard ratio for locoregional recurrence significantly increased in estrogen-receptor-negative (ER-) patients in both univariate analysis (HR = 4.98, 95% CI = 1.76-14.09, p = 0.002) and multivariate analysis (HR = 40.88, 95% CI = 1.29-1297.84, p = 0.035). Additionally, IORT was associated with increased LRR in the multivariate analysis (HR = 4.71, 95% CI = 1.16-19.06, p = 0.030). Conclusion: At a long-term follow-up, the LRR rate was higher in the BCS followed by IORT, without significant differences in metastasis-free or overall survival rates. Our data confirmed the importance of exclusion ER- patients for IORT.

Ductal Carcinoma In Situ in Borderline Phyllodes Tumor: A Diagnostic and Treatment Dilemma.

The co-existence of breast carcinoma in the form of ductal carcinoma in situ (DCIS) in a case of Phyllodes tumor (PT) is extremely rare. We present a case of a pre-menopausal lady with a large breast lump diagnosed as benign PT on her initial biopsy. Wide local excision and breast conservation with round block oncoplasty were done. A post-operative diagnosis of borderline PT with sclerosing adenosis and high-grade DCIS were made. Adjuvant radiotherapy and hormonal therapy were given, and the patient had no recurrence after three years of follow-up. DCIS in PT is very rare, and hence no standard protocol for treating such cases exists. So proper histopathological diagnosis, treatment with multidisciplinary involvement, and regular follow-up can help us conserve the breast and prevent recurrence in such cases.

Mullerian adenosarcoma accidentally detected and coexisting with cervical carcinoma in situ: a rare case report.

Mullerian adenosarcoma is rare, usually found in the uterine corpus and rarely in the cervix. Adenosarcoma that grows diffusely in the uterine cavity and the cervical canal is even rarer without symptoms. Herein, we report a rare case of multiple primary malignant neoplasms of Mullerian adenosarcoma accidentally detected and coexisting with cervical carcinoma in situ. Fortunately, the tumor was in the early stage and the Mullerian adenosarcoma was treated together with the cervical carcinoma in situ by hysterectomy + bilateral adnexectomy. Histopathology and immunohistochemistry results confirmed this diagnosis, further confirmed by a pathology consultation at the University Hospital. The patient recovered well from the surgical treatment and was discharged with regular follow-up. The patient did not undergo pelvis-abdomen CT and diagnostic curettage preoperatively, and no malignancy was detected by cryo-pathology intraoperatively, which may be related to the rarity of the disease and the relative lack of awareness and experience of our clinicians and pathologists for this tumor. We hope that this rare case can provide some lessons for gynecologists and pathologists.

MRI-only breast cancers are less aggressive than cancers identifiable on conventional imaging.

BACKGROUND: Magnetic resonance imaging (MRI) has a superior sensitivity for the diagnosis of breast cancer, leading to lesions primarily detected by MRI. Some of these lesions cannot be identified by targeted second-look ultrasound (SLUS) examinations and are thus referred to as MRI-only lesions. We hypothesize that biologically more aggressive cancers lead to more distinct tissue damage improving visibility on SLUS. OBJECTIVE: To investigate whether there are differences in cancer subtypes between MRI-only and SLUS-detected malignant lesions. METHODS: This retrospective single-center observational study evaluated 435 patients who received breast MRI examinations between January 2017 and December 2022, with at least one lesion primarily detected on MRI and histologically confirmed as malignant. Demographic characteristics, lesion type (mass or non-mass), MRI-assessed lesion size (mm), histological diagnosis, stage, immunohistochemical analysis (ER, PR, HER-2, Ki-67), and lymph node status were assessed and compared between MRI-only and SLUS-detected. RESULTS: Among 435 patients (mean age of 57.4 ± 13.3), 34.02 % (n = 148) were in the MRI-only group, while the remaining 65.98 % (n = 287) were identified by SLUS. MRI-only cases were significantly smaller in size (10 mm vs 20 mm), mostly staged as T1 (66.9 %) and showed features associated with less biological aggressiveness (higher pure ductal carcinoma in situ rates: 30.4 % vs 5.2 %; lower Ki-67, median values: 10 vs 20) compared to SLUS-detected cases (P < 0.001). SLUS-detected cancers had higher ratios of microscopic (4.9 % vs 3.4 %) and macroscopic axillary metastasis (26.8 % vs 7.4 %) compared to MRI-only lesions (P < 0.001). CONCLUSION: MRI-only lesions presented histologically and immunohistochemically with less aggressive patterns compared to those detected via SLUS. Clinic Impact: Our data provide evidence that MRI-only lesions are biologically less aggressive and of lower stage, offering the potential of earlier treatment chance since they are visible on MRI before becoming more aggressive and destructive.

Prediction of Microinvasion in Breast Ductal Carcinoma in Situ Using Conventional Ultrasound Combined with Contrast-Enhanced Ultrasound Features: A Two-Center Study.

BACKGROUND: To develop and validate a model based on conventional ultrasound (CUS) and contrast-enhanced ultrasound (CEUS) features to preoperatively predict microinvasion in breast ductal carcinoma in situ (DCIS). PATIENTS AND METHODS: Data from 163 patients with DCIS who underwent CUS and CEUS from the internal hospital was retrospectively collected and randomly apportioned into training and internal validation sets in a ratio of 7:3. External validation set included 56 patients with DCIS from the external hospital. Univariate and multivariate logistic regression analysis were performed to determine the independent risk factors associated with microinvasion. These factors were used to develop predictive models. The performance was evaluated through calibration, discrimination, and clinical utility. RESULTS: Multivariate analysis indicated that centripetal enhancement direction (odds ratio [OR], 13.268; 95% confidence interval [CI], 3.687-47.746) and enhancement range enlarged on CEUS (OR, 4.876; 95% CI, 1.470-16.181), lesion size of ≥20 mm (OR, 3.265; 95% CI, 1.230-8.669) and calcification detected on CUS (OR, 5.174; 95% CI, 1.903-14.066) were independent risk factors associated with microinvasion. The nomogram incorporated the CUS and CEUS features achieved favorable discrimination (AUCs of 0.850, 0.848, and 0.879 for the training, internal and external validation datasets), with good calibration. The nomogram outperformed the CUS model and CEUS model (all P < .05). Decision curve analysis confirmed that the predictive nomogram was clinically useful. CONCLUSION: The nomogram based on CUS and CEUS features showed promising predictive value for the preoperative identification of microinvasion in patients with DCIS.

Exploring the interaction mechanisms between cervical carcinoma in situ and antibody-mediated immune responses through Mendelian randomization analysis.

OBJECTIVE: This study aims to investigate the causal relationship between cervical carcinoma in situ and antibody-mediated immune responses, providing a scientific basis for the prevention and treatment of cervical carcinoma in situ. METHODS: A bidirectional Mendelian Randomization (MR) approach was utilized, leveraging two Genome-Wide Association Studies (GWAS) related to cervical carcinoma in situ and antibody-mediated immune responses to collect Single Nucleotide Polymorphism (SNP) data. Multiple statistical methods, including the inverse-variance weighted (IVW) method, MR-Egger regression, weighted median, and weighted mode, were utilized. Antibody-mediated immune response-related SNPs were used as instrumental variables (IVs) for a forward MR analysis of cervical carcinoma in situ, while cervical carcinoma in situ-related SNPs served as IVs for a reverse MR analysis of antibody-mediated immune responses. RESULTS: The forward MR analysis revealed significant causal associations between two SNPs, GCST90006901 (P = 0.012, OR (95%CI) = 1.167(1.034-1.317)) and GCST90006909 (P < 0.001, OR (95%CI) = 1.805(1.320-2.467)), within antibody-mediated immune responses and the occurrence of cervical carcinoma in situ. The reverse MR analysis demonstrated that cervical carcinoma in situ exerts influence on multiple SNPs associated with antibody-mediated immune responses. Specifically, GCST90006891 (P = 0.018, OR (95%CI) = 1.164(1.027-1.319)) and GCST90006894 (P = 0.048, OR (95%CI) = 1.074 (1.001-1.153)) showed positive effects, while GCST90006899 (P = 0.022, OR (95%CI) = 0.935(0.882-0.990)) and GCST90006911 (P = 0.0193, OR (95%CI) = 1.226(1.034-1.454)) exhibited distinct trends of influence. CONCLUSION: The Mendelian Randomization analysis indicates a clear causal relationship between antibody-mediated immune responses and the prevalence of cervical carcinoma in situ, with cervical carcinoma in situ also exerting a certain degree of influence on antibody-mediated immune responses. This finding provides important insights into the interaction mechanism between the two and suggests avenues for developing effective prevention and control strategies.

Quality of life issues in patients with ductal carcinoma in situ: a systematic review.

PURPOSE: Ductal carcinoma in situ (DCIS) of the breast is one of the most common pre-invasive cancers diagnosed in women. Quality of life (QoL) is extremely important to assess in studies including these patients due to the favorable prognosis of the disease. The primary objective of this systematic review was to compile a comprehensive list of QoL issues, all existing QoL assessment tools, and patient-reported outcome measures used to assess DCIS. METHODS: A search was conducted on Ovid MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials databases from inception to August 2023, using keywords such as "ductal carcinoma in-situ", "quality of life", and "patient-reported outcomes." QoL issues and QoL tools in primary research studies were extracted. RESULTS: A total of 67 articles identified issues pertaining to patients with DCIS spanning physical, functional, and psychosocial QoL domains. Physical and functional issues observed in patients included pain, fatigue, and impaired sexual functioning. Psychosocial issues such as anxiety, depression, and confusion about one's disease were also common. QoL tools included those that assessed general QoL, breast cancer-specific tools, and issue-specific questionnaires. CONCLUSION: The current instruments available to assess QoL in patients with DCIS do not comprehensively capture the issues that are pertinent to patients. Thus, the modification of existing tools or the creation of a DCIS-specific QoL tool is recommended to ensure that future research will be sensitive towards challenges faced by patients with DCIS.

Pleomorphic Lobular Carcinoma In Situ Composed of Signet-Ring Cells Mimicking Ductal Carcinoma In Situ with A Papillary Pattern: A Case Report.

While some forms of invasive or in situ carcinoma of the breast may be partly composed of signet-ring cells, signet-ring cells rarely become a prominent feature of pleomorphic lobular carcinoma in situ (LCIS). We report a rare example of pleomorphic LCIS composed predominantly of signet-ring cells with a papillary pattern mimicking ductal carcinoma in situ (DCIS). A 58-year-old woman presented with a mass in the left breast detected by ultrasonography. Fourteen years previously, the patient underwent right breast-conserving surgery for invasive breast carcinoma of no special type. Ultrasonography revealed an irregular parallel, angular hypoechoic mass measuring 1.5 cm in the left breast. An ultrasound-guided core needle core biopsy was conducted. Microscopically, the lesion was composed of epithelial cells supported by a fibrovascular stroma. The majority (> 70%) of the lesional cells between the fibrovascular stalks showed signet-ring cell features. Some of the nuclei of the signet-ring cells showed intermediate-grade atypia. A mucicarmine stain showed intracytoplasmic mucin in the signet-ring cells. Immunohistochemistry for E-cadherin was negative in the tumor cells. After surgical excision, the final diagnosis was a pleomorphic LCIS. To our knowledge, there have been no previous reports of pleomorphic LCIS consisting primarily of signet-ring cells with a papillary pattern.

Subsequent percutaneous breast biopsies after initial atypia diagnosis: The patient burden of long-term follow up.

BACKGROUND: Breast atypia increases overall breast cancer risk, potentially necessitating future interventions. This study examines the frequency and outcomes of additional percutaneous biopsies after an atypia diagnosis. METHODS: Adult patients with breast atypia (atypical ductal hyperplasia, atypical lobular hyperplasia, lobular carcinoma in situ) at a single institution were reviewed for subsequent core needle biopsies (CNBs) and corresponding malignant outcomes. RESULTS: Among 432 patients, median age at diagnosis was 54.8 â€‹y. Seventy-one (71/432, 16.4 â€‹%) patients developed a breast malignancy. During a median follow-up of 7.4 â€‹y, 113 patients underwent 149 additional CNBs. Twenty-six patients (26/113, 23.0 â€‹%) had >2 additional CNBs. Approximately half (79/149, 53.0 â€‹%) of all additional CNBs occurred within 5 years after breast atypia diagnosis. CONCLUSION: A considerable number of patients with breast atypia undergo additional percutaneous biopsies, especially within 5 years post-atypia diagnosis. Our study highlights the significant burden of surveillance and the need for tailored follow-up strategies.

Differences in Clinical Outcomes and Survival Among Primary, Secondary, and Concomitant Carcinoma In Situ of the Bladder.

PURPOSE: Carcinoma in situ (CIS) is a flat, high-grade, and aggressive form of urothelial carcinoma with a high risk of progression to muscle-invasive disease and metastasis. This study aimed to investigate differences in clinical outcomes and survival among patients with primary, secondary, and concomitant CIS of the bladder. METHODS: A total of 209 patients diagnosed with CIS between 2010 and 2022 in our department with a minimum follow-up of 12 months were retrospectively analyzed. Patients with muscle-invasive cancer at diagnosis, those with recurrence within one month after diagnosis, and those with primary malignant melanoma were excluded. The recurrence, progression, and cancer-specific mortality rates of patients receiving Bacillus Calmette-Guérin therapy for CIS were analyzed. RESULTS: A total of 96 patients with primary (n = 18), secondary (n = 29), and concomitant CIS (n = 49) were included in the analysis. The median follow-up was 52.2 months. Patients with secondary CIS had a significantly higher recurrence rate than those with concomitant CIS (58.6% vs. 32.7%, p = 0.016). However, no significant difference in progression rates was observed among the three groups. Furthermore, no significant association was observed between CIS subtypes and recurrence-free survival (RFS) (HR = 1.45, 95% CI 0.96-2.46, p = 0.16) or progression-free survival (PFS) (HR = 2.20, 95% CI 0.99-4.87, p = 0.054). CONCLUSION: Secondary CIS had a significantly higher recurrence rate than concomitant CIS. However, no statistically significant association was observed between CIS subtypes and RFS or PFS.

Clinical impact of intraoperative pancreatic transection margin analysis and additional resection during pancreaticoduodenectomy for pancreatic ductal adenocarcinoma.

BACKGROUND: The prognostic impact of additional resection based on intraoperative frozen section analysis (FSA) of the pancreatic transection margin in patients with pancreatic ductal adenocarcinoma (PDAC) is controversial. The purpose of this study was to evaluate the prognosis based on the results of the first FSA of the pancreatic transection margin (1st FSA) and the clinical significance of additional resection. METHODS: Patients who underwent pancreaticoduodenectomy for PDAC from 2000 to 2020 at a single center were included. Patients were divided into 3 groups based on the 1stFSA. Survival and prognostic factors were analyzed according to the 1stFSA. RESULTS: A total of 311 patients were included in this study. The 1stFSA was negative in 272 patients (1stFSA-R0) and positive in 39 patients [carcinoma in situ (1stFSA-CIS), 21 patients; invasive carcinoma (1stFSA-IC), 18 patients]. Additional resections were performed on 37 patients [1stFSA-CIS, 20 patients; 1stFSA-IC, 17 patients], and R0 resection was achieved in 34 patients intraoperatively. Comparing median survival time to 1stFSA-R0 (36.4 months), 1stFSA-CIS was comparable (27.8 months, p = 0.276), although 1stFSA-IC was significantly worse (18.8 months, p = 0.001). On multivariate analysis, 1stFSA-IC was an independent prognostic factor (hazard ratio 2.68, 95 % confidence interval 1.16-6.17, p = 0.020). CONCLUSIONS: 1stFSA-CIS and 1stFSA-R0 had similar OS, implying that additional resection may be acceptable for 1stFSA-CIS. 1stFSA-IC was still an independent prognostic factor based on additional resection, and the prognostic significance of additional resection is uncertain for 1stFSA-IC.

Unveiling the Clinical Path of Microinvasive Breast Cancer: A Comparative Study With Tis-T1 Breast Cancer.

PURPOSE: The prognosis of microinvasive breast cancer (MIBC) is controversial, with a high reported rate of local recurrence (LR). This study aimed to evaluate the characteristics, treatments, and prognosis of patients with MIBC compared to those with carcinoma in situ (CIS) or early invasive cancer. METHODS: Patients who diagnosed with CIS or stage I breast cancer were retrospectively enrolled. Using the Kaplan-Meier method, local recurrence-free survival (LRFS), systemic recurrence-free survival (SRFS), and cancer-specific survival (CSS) were compared according to T stage. The prognostic factors associated with LRFS were identified using the Cox proportional hazards model. RESULTS: According to T stage, 517 (21.6%), 200 (8.4%), 207 (8.7%), 363 (15.2%), and 1101 (46.1%) patients had Tis, T1mi, T1a, T1b, and T1c tumors, respectively. The proportion of human epidermal growth factor receptor 2-positive tumors was significantly higher in patients with MIBC (p < 0.0001). The administered adjuvant treatments also showed differences according to T stage (p < 0.0001). During the 73-month median follow-up period, patients with MIBC showed significantly worse LRFS than those with T1a or T1c tumors (p = 0.002). There was no significant difference in SRFS and CSS. In the Cox regression analysis, tumor multiplicity (p = 0.017), Ki-67 (p = 0.025), cancer subtype (p = 0.034), adjuvant endocrine therapy (p = 0.003), and adjuvant radiation therapy (p < 0.0001) were significant prognostic factors associated with LRFS. CONCLUSION: The risk of LR was higher in patients with MIBC than in those with small invasive breast cancer. Therefore, if indicated, adjuvant endocrine and radiation therapies should be administered to prevent undertreatment in patients with MIBC.

Primary nipple melanoma in a patient with breast cancer: A diagnosis to consider.

Melanoma in situ of the nipple is an uncommon diagnosis, with only a few reports in the literature. Due to the variety of pathologies that can affect the nipple-areola complex, the diagnosis can be challenging. In this case report we describe a patient with cosmetic bilateral breast implants who presented with eczema of the left nipple-areola complex and suspicious microcalcifications in the lower inner quadrant of the ipsilateral breast on mammography, subsequently diagnosed with nipple melanoma and concomitant ductal carcinoma in situ.

Adherence to First-Line Intravesical Bacillus Calmette-Guérin Therapy in the Context of Guideline Recommendations for US Patients With High-Risk Non-muscle Invasive Bladder Cancer.

Background: Bacillus Calmette-Guérin (BCG) can reduce recurrence and delay progression among patients with high-risk non-muscle invasive bladder cancer (NMIBC), but is associated with a substantial emotional, physical, and social burden. Objectives: This study evaluated the adequacy of first-line intravesical BCG treatment among high-risk NMIBC patients in the United States, including the subgroup with carcinoma in situ (CIS) of the bladder. Methods: Adults with high-risk NMIBC treated with BCG were selected from de-identified MarketScan® Commercial, Medicare, and Medicaid Databases (1/1/2010-2/28/2021). Adequacy of BCG induction and maintenance was evaluated from the first BCG claim until the end of the patient's observation, using a previously published claims-based algorithm (induction: ≥5 instillations within 70 days; induction and maintenance: ≥7 instillations within 274 days of first instillation) and a definition based on the landmark Southwest Oncology Group (SWOG) trial (induction: ≥5 instillations without gaps >7 days; followed by ≥2 instillations at month 3, 6, and every 6 months thereafter). Proportions of patients with adequate BCG induction and maintenance were reported overall and compared between those with and without CIS. Results: Of 5803 high-risk NMIBC patients treated with first-line BCG (mean age, 67.3 years; 20.6% female), 930 (16.0%) had CIS. After first-line BCG, 56.6% received another treatment. Although 86.9% had adequate BCG induction based on the claims-based algorithm (SWOG, 73.6%), only 41.5% had adequate BCG induction and maintenance (SWOG, 1.6%). Similar trends were observed for patients with and without CIS, with higher adherence to guidelines for patients with CIS (adequate induction using claims-based algorithm: 90.3% vs 86.2%; adequate induction and maintenance: 50.8% vs 39.7%, all P < .001). A greater proportion of CIS patients than non-CIS patients had cystectomy (CIS, 14.4%, non-CIS, 8.5%; P < .001) after first-line BCG. Discussion: Among patients with NMIBC treated with first-line intravesical BCG, most received adequate BCG induction but less than half had adequate BCG maintenance. BCG treatment was also inadequate for patients with CIS, with only half of patients receiving adequate BCG maintenance and a higher proportion undergoing cystectomy following first-line BCG. Conclusions: Results emphasize the need for additional treatment options for patients with NMIBC.

Exploring non-surgical alternatives for low to intermediate-grade in situ ductal carcinoma of the breast using vacuum-assisted excision: the VACIS protocol.

Background: Surgery is still the standard treatment for breast lesions such as in situ ductal carcinoma (DCIS); however, its survival benefit is minimal, particularly for low-grade DCIS. Surgical complications and related depression status can adversely affect patients' quality of life. Approximately 25% of breast cancer (BC) cases are in situ forms, with DCIS making up 90% of these. Low and intermediate-grade DCIS often grow slowly and do not always progress clinically significant diseases. Identifying non-invasive lesions could help prevent overtreatment. In this context, new diagnostic tools like vacuum-assisted excision (VAE) could enhance the management of these conditions. Methods: The prospective VACIS study explores the role of VAE in ensuring the absence of pathology at subsequent surgery and reducing the diagnostic underestimation of breast biopsies for microcalcifications. Patients with suspicious breast microcalcifications up to 15 mm, who are candidates for stereotactic biopsy, will be enrolled and randomised into two groups. The control group will complete the biopsy with typical sampling, aiming to collect some microcalcifications from the target, while the experimental group will focus on the complete removal of the biopsy target (confirmed by mammography on the biopsy table), followed by a second sequence of cleaning samples. Radiograms will confirm lesion removal. Pathologic outcomes at surgery will be compared between the groups, and the percentage of underestimation will be assessed. The sample size is calculated to be 70 patients per group, using statistical tests and multivariate logistic models to detect a significant difference in the absence of pathology. Data collected will include patient age, lesion characteristics, and details of the biopsy, pathology and surgery. Discussion: Current surgical treatments for low-and sometimes intermediate-grade DCIS offer limited survival benefits and may hurt patients' quality of life due to surgery-related complications and associated depression. These lesions often grow slowly and might not become clinically significant, suggesting a need to avoid overtreatment. Improved diagnostics procedures, such as VAE, could help distinguish non-invasive from potentially invasive lesions, reduce biopsy underestimation, enable personalised management and optimise treatment strategies. This study hypothesises that VAE could be a viable alternative to surgery, capable of removing pathology during the biopsy procedure. Clinical trial registration: Clinicaltrials.gov, identifier NCT05932758.

Magnetic lymphatic tracing for omission of sentinel lymph node biopsies in mastectomy patients: a community cancer center experience.

BACKGROUND: Patients with ductal carcinoma in situ (DCIS) and patients undergoing risk reduction mastectomy may undergo sentinel lymph node biopsy (SLNB) at the time of mastectomy to complete axillary staging were an underlying invasive malignancy to be found on final pathology. Among patients with DCIS undergoing mastectomy, 15-29% of patients will have invasive disease on final pathology; therefore, approximately 70-85% of patients may benefit from avoiding SLNB. Superparamagnetic tracers (SPMT) have been proven to be non-inferior to the standard radioisotope and blue dye combination. SPMT remains active for several weeks, allowing a large proportion of DCIS and genetic carrier patients to potentially avoid SLNB in the setting of mastectomy. We hypothesize the use of SPMT will reduce the number of SLNB performed in patients undergoing mastectomy for DCIS and risk reduction, ultimately reducing the number of complications associated with axillary surgery. We seek to report our community cancer center's experience with SPMT and omission of SLNB in the DCIS and prophylactic mastectomy patient population. METHODS: We performed a retrospective review of 52 female patients with DCIS or known genetic predisposition undergoing mastectomy. SPMT (Magtrace®, Endomag Ltd, Cambridge, UK) was injected ipsilateral to DCIS and bilaterally for prophylactic mastectomy patients. Our primary outcome was rate of return to the operating room (OR) for delayed SLNB. Secondary outcomes included post-operative complications within 30 days of surgery and operative time. We compared outcomes to a control group of 28 women undergoing mastectomy for DCIS or for risk reduction who underwent SLNB at their index operation in traditional fashion. Continuous variables were reported using median and interquartile ranges (IQR) and were compared using the Mann-Whitney U test. Categorical data were reported using frequency and percent and were compared using Pearson's Chi-Square or Fisher's Exact test, as appropriate. Alpha was set to 0.05 to determine statistical significance. RESULTS: There was a total of 80 patients (52 SPMT, 28 control). Median age of SPMT patients was 49.5 (IQR 40-60.75) vs. 54.5 (48 - 65) in the traditional tracer group. vs. control group. 57.7% of SPMT patients underwent mastectomy for DCIS vs. 89.3% in the control group. Eight SPMT patients (15.4%) had invasive ductal carcinoma (IDC) on final pathology and seven of those patients underwent delayed SLNB (87.5%). None of the delayed SLNB were positive for metastatic disease. Rates of post-operative complications were similar between the two groups, including hematoma, seroma, and surgical site infection. OR times were also similar with median OR time 202 min (min) for the SPMT group vs. 195 min for the control group. CONCLUSION: Use of SPMT avoided SLNB in 84.6% of our patients. We found no difference in rates of post-operative complications or operative times in patients using SPMT for omission of SLNB at time of mastectomy compared to the control group. Our findings suggest SLNB can be avoided in a majority of patients undergoing mastectomy for DCIS or risk reduction in the setting of genetic predisposition.