title: The influence of clinicopathological features on the predictive accuracy of conventional breast imaging in determining the extent of screen-detected high-grade pure ductal carcinoma in situ.
abstract: BACKGROUND
  The extent of calcified ductal carcinoma in situ (DCIS) detected by screening mammography is a determinant for treatment with breast conserving surgery (BCS). However, DCIS may be uncalcified and almost a quarter of patients with DCIS treated initially by BCS either require a second operation or are found to have unexpected invasive disease following surgery. Identification of these cases might guide selective implementation of additional diagnostic procedures.
  
  
  METHODS
  A retrospective review of patients with a preoperative diagnosis of pure high-grade DCIS at the Southampton and Salisbury Breast Screening Unit over a ten-year period was carried out. Mammograms were reviewed independently by a consultant radiologist and additional factors including the Breast Imaging Reporting and Data System (BI-RADS(®)) breast density score, DCIS extent and disease location within the breast recorded.
  
  
  RESULTS
  Unexpected invasive disease was found in 35 of 144 patients (24%). Within our unit the re-excision rate for all screen-detected DCIS is currently 23% but for patients included in this study with high-grade DCIS the re-excision rate was 39% (34/87). The extent of DCIS (p=0.008) and lack of expression of the oestrogen receptor (ER) predicted the requirement for re-excision in both univariate (p=0.004) and multivariate analysis (p=0.005).
  
  
  CONCLUSIONS
  High-grade DCIS may be focally uncalcified, leading to underestimation of disease extent, which might be related to ER status. Invasive foci associated with high-grade DCIS are often mammographically occult. Exploration of additional biomarkers and targeted use of further diagnostic techniques may improve the preoperative staging of DCIS.
authors.affiliation: Southampton Breast unit, Princess Anne Hospital, Southampton, UK.
authors.forename: L
authors.initials: L
authors.lastname: Hayward
authors.forename: R S
authors.initials: RS
authors.lastname: Oeppen
authors.forename: A V
authors.initials: AV
authors.lastname: Grima
authors.forename: G T
authors.initials: GT
authors.lastname: Royle
authors.forename: C M
authors.initials: CM
authors.lastname: Rubin
authors.forename: R I
authors.initials: RI
authors.lastname: Cutress
mesh_terms: D000368:Aged; D001943:Breast Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery; D002114:Calcinosis / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery; D018270:Carcinoma, Ductal, Breast / Q000000981:diagnostic imaging / Q000473:pathology / Q000601:surgery; D002285:Carcinoma, Intraductal, Noninfiltrating / Q000000981:diagnostic imaging / Q000473:pathology* / Q000601:surgery; D005260:Female; D006801:Humans; D033162:Incidental Findings; D008327:Mammography / Q000592:standards*; D008408:Mastectomy / Q000379:methods; D008875:Middle Aged; D011300:Preoperative Care; D012086:Reoperation; D012189:Retrospective Studies