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A Validated Nomogram to Predict Upstaging of Ductal Carcinoma in Situ to Invasive Disease

  • Breast Oncology
  • Published:
Annals of Surgical Oncology Aims and scope Submit manuscript

Abstract

Background

Approximately 8–56% of patients with a core needle biopsy (CNB) diagnosis of ductal carcinoma in situ (DCIS) will be upstaged to invasive disease at the time of excision. Patients with invasive disease are recommended to undergo axillary nodal staging, most often requiring a second operation. We developed and validated a nomogram to preoperatively predict percentage of risk for upstaging to invasive cancer.

Methods

We reviewed 834 cases of DCIS on CNB between January 2004 and October 2014. Multivariable analysis was used to evaluate CNB and imaging factors to develop a nomogram to predict the risk of upstaging from DCIS to invasive cancer. This nomogram was validated with an external dataset of 579 similar patients between November 1998 and September 2016. An area under the receiver operating characteristic curve was constructed to evaluate nomogram discrimination.

Results

The rate of upstaging to invasive disease was 118/834 (14.1%). On multivariable analysis, grade on CNB and imaging factors, including mass lesion, multicentric disease, and largest linear dimension, were associated with upstage to invasive disease, and was used to develop a nomogram (c-statistic 0.71). In the external validation dataset, 62/579 (10.7%) patients were upstaged to invasive disease. Our nomogram was validated in this dataset with a c-statistic of 0.71.

Conclusion

For patients with a CNB diagnosis of DCIS, our validated nomogram using DCIS grade on biopsy, and imaging factors of mass lesion, multicentric disease, and largest linear dimension, may be used for preoperative assessment of risk of upstaging to invasive disease, allowing patient counseling regarding axillary staging at the time of definitive surgery.

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Acknowledgment

The authors would like to acknowledge the support of the Mayo Clinic Departments of Surgery (Rochester, Jacksonville, and Scottsdale), Anatomic Pathology (Rochester), and Diagnostic Radiology (Rochester and Jacksonville), and the Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery (Rochester) as substantial contributors of resources to the project. Additionally, we would like to thank Tanya Hoskin and Courtney Day of the Mayo Clinic Department of Health Science Research for creation of the calibration curve.

Funding

The Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery provides salary support for Drs. Habermann and Murphy. No external funding was used.

Disclosure

James W Jakub, Brittany L Murphy, Alexandra B, Gonzalez, Amy L. Conners, Tara L. Henrichsen, Santo Maimone IV, Michael G. Keeney, Sarah A. McLaughlin, Barbara A. Pockaj, Beiyun Chen, Tashinga Musonza, William S. Harmsen, Judy C. Boughey, Tina J. Hieken, Elizabeth B. Habermann, Harsh N. Shah, and Amy C. Degnim disclose no conflicts of interest.

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Correspondence to James W. Jakub MD.

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Jakub, J.W., Murphy, B.L., Gonzalez, A.B. et al. A Validated Nomogram to Predict Upstaging of Ductal Carcinoma in Situ to Invasive Disease. Ann Surg Oncol 24, 2915–2924 (2017). https://doi.org/10.1245/s10434-017-5927-y

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