Pathological

and

Biological

Differences

Between

Screen-Detected

and

Interval

Ductal

Carcinoma

in

situ

of

the

Breast

Background

The

incidence

of

ductal

carcinoma

in

situ

-LRB-

DCIS

-RRB-

has

risen

dramatically

with

the

introduction

of

screening

mammography

The

aim

was

to

evaluate

differences

in

pathological

and

biological

characteristics

between

patients

with

screen-detected

and

interval

DCIS

With

the

introduction

of

widespread

screening

mammography

the

incidence

rates

of

ductal

carcinoma

in

situ

-LRB-

DCIS

-RRB-

have

risen

dramatically

in

Western

Europe

and

North

America

DCIS

now

accounts

for

nearly

of

all

screen-detected

breast

malignancies

As

a

consequence

treating

physicians

are

confronted

with

a

cumulative

caseload

because

it

is

not

known

how

many

women

with

screen-detected

DCIS

will

develop

an

invasive

carcinoma

in

their

lifetimes

The

proportion

of

untreated

cases

of

DCIS

that

would

progress

to

invasive

malignancy

has

been

difficult

to

evaluate

because

DCIS

is

usually

excised

when

detected

Because

DCIS

is

a

nonobligatory

precursor

to

invasive

carcinoma

and

therefore

has

a

relatively

benign

nature

screen-detected

DCIS

has

been

argued

to

represent

an

overdiagnosis

This

argument

is

supported

by

autopsy

studies

in

which

the

median

prevalence

of

DCIS

was

suggesting

some

cases

do

not

progress

to

clinically

significant

lesions

in

a

patient

's

lifetime

On

the

contrary

patients

with

DCIS

treated

with

biopsy

alone

in

the

premammography

era

had

a

higher

rate

of

subsequent

occurrences

-LRB-

-RRB-

of

invasive

breast

cancer

than

expected

Large

clinical

trials

in

which

patients

had

been

treated

with

lumpectomy

alone

have

also

indicated

that

DCIS

can

recur

as

invasive

ductal

carcinoma

Screen-detected

DCIS

is

more

often

presented

as

linear

branching

microcalcifications

on

mammography

than

symptomatic

DCIS

The

screen-detected

group

in

the

previously

mentioned

study

had

a

larger

proportion

of

patients

with

comedocarcinoma

Therefore

it

was

suggested

that

linear

branching

microcalcifications

were

related

with

a

more

aggressive

type

of

DCIS

This

is

confirmed

in

other

reports

that

have

indicated

that

linear

branching

microcalcifications

on

mammography

are

associated

with

high

grade

DCIS

We

believe

that

screen-detected

DCIS

is

more

often

associated

with

suspicious

microcalcifications

representing

high-grade

DCIS

which

has

been

detected

before

it

has

had

the

chance

to

progress

to

invasive

cancer

Therefore

it

is

hypothesized

that

screen-detected

DCIS

is

biologically

more

aggressive

than

interval

DCIS

To

compare

screen-detected

DCIS

with

interval

DCIS

in

such

a

retrospective

study

the

clinicopathological

and

biological

characteristics

of

both

groups

were

evaluated

for

differences

Screen-detected

DCIS

was

classified

as

DCIS

detected

by

screening

mammography

when

the

examination

from

two

years

earlier

failed

to

reveal

an

abnormality

Interval

DCIS

was

classified

as

DCIS

detected

within

the

two-year

interval

between

two

subsequent

screening

rounds

when

the

earlier

examination

failed

to

reveal

an

abnormality

Age

tumor

size

and

pathological

grade

were

studied

for

their

known

relation

with

local

recurrence

Finally

the

expression

of

established

prognostic

biomarkers

in

breast

cancer

was

studied

by

immunohistochemistry

for

estrogen

receptor

-LRB-

ER

-RRB-

progesterone

receptor

-LRB-

PR

-RRB-

and

cyclin

PATIENTS

AND

METHODS

Patients

and

Tumors

The

Dutch

screening

program

for

breast

cancer

has

been

gradually

implemented

in

the

North

Netherlands

since

It

offered

biennial

mammography

to

women

years

old

and

since

women

years

old

have

also

been

included

Women

received

mammography

in

the

cranio-caudal

and

medio-latero-oblique

direction

for

each

breast

Two

radiologists

evaluated

the

mammograms

by

a

double

independent

reading

From

January

to

December

consecutive

patients

were

treated

for

pure

DCIS

at

our

institution

To

identify

patients

for

inclusion

in

the

study

all

women

who

had

actually

attended

the

screening

program

at

least

two

subsequent

rounds

with

a

two-year

interval

at

the

time

of

diagnosis

were

considered

as

attenders

Patients

who

had

skipped

one

or

more

screening

rounds

previous

to

the

diagnosis

and

patients

who

had

not

been

attending

the

program

at

all

were

considered

nonattenders

Patients

records

were

checked

to

obtain

this

information

and

if

there

was

no

information

regarding

the

participation

of

the

screening

program

at

the

time

of

diagnosis

the

general

practitioner

was

consulted

Out

of

the

consecutive

patients

attenders

and

nonattenders

could

be

identified

For

immunohistochemistry

patients

were

selected

on

the

availability

of

sufficient

paraffin-embedded

tissue

Thirteen

out

of

the

nonattenders

and

out

of

the

attenders

remained

respectively

for

evaluation

of

overexpression

estrogen

receptor

-LRB-

ER

-RRB-

expression

progesterone

receptor

-LRB-

PR

-RRB-

expression

expression

and

cyclin

expression

using

tissue

microarray

analysis

as

part

of

a

project

protocol

that

had

been

approved

by

the

medical

ethics

committee

The

patients

in

the

study-group

-LRB-

n

-RRB-

were

divided

into

two

groups

Patients

with

DCIS

that

had

been

detected

by

screening

mammography

were

classified

as

screen-detected

patients

when

the

examination

two

years

earlier

failed

to

reveal

an

abnormality

-LRB-

n

-RRB-

Patients

with

DCIS

that

had

been

detected

within

the

two-year

interval

between

two

subsequent

screening

rounds

were

classified

as

interval

patients

when

the

earlier

examination

failed

to

reveal

an

abnormality

-LRB-

n

-RRB-

Mammography

and

Pathological

Assessment

Mammographic

and

pathological

characteristics

were

derived

from

mammography

and

pathological

reports

respectively

Data

were

delivered

and

evaluated

anonymously

If

data

were

missing

mammography

and

pathological

slides

were

reevaluated

Mammographic

appearances

were

scored

as

microcalcifications

a

mass

a

combination

of

the

two

or

as

occult

Microcalcifications

were

scored

as

fine

granular

coarse

granular

or

as

linear

branching

Pathological

size

had

been

estimated

and

the

grade

had

been

scored

according

to

the

European

Pathologists

Working

Group

-LRB-

-RRB-

and

according

to

the

Van

Nuys

classification

Tissue

Microarray

Construction

Slides

from

all

blocks

were

evaluated

for

representative

areas

with

DCIS

and

tissue

microarrays

were

prepared

as

described

earlier

In

brief

the

most

representative

area

of

DCIS

was

marked

on

the

original

hematoxylin

and

eosin

-LRB-

H&E

-RRB-

stained

section

With

this

marked

section

as

an

orientation

three

punches

were

taken

from

the

selected

area

in

the

donor

blocks

and

mounted

in

a

recipient

block

containing

approximately

biopsies

using

a

manual

tissue

microarray

device

-LRB-

Beecher

Instruments

Silver

Springs

MD

-RRB-

The

presence

of

DCIS

in

the

arrayed

samples

was

verified

on

hematoxylin

eosin

stained

sections

Immunohistochemistry

For

immunohistochemistry

μm

sections

of

the

paraffin-embedded

tissue

arrays

were

deparaffinized

in

changes

of

xylene

for

minutes

each

and

gradually

rehydrated

through

changes

of

graded

ethanol

from

to

distilled

water

Antigen

retrieval

methods

and

antibodies

are

summarized

in

Table

The

endogenous

peroxidase

reaction

was

blocked

by

incubating

the

sections

in

perhydrol

for

minutes

Primary

antibodies

were

diluted

in

phosphate-buffered

saline

-LRB-

PBS

-RRB-

containing

bovine

serum

albumin

and

incubated

at

room

temperature

for

hour

Samples

were

then

washed

in

PBS

and

incubated

with

secondary

and

tertiary

antibodies

For

visualization

of

the

antibody-antigen

complex

the

diaminobenzidine

tetrahydrochloride/peroxidase

reaction

was

used

After

a

final

wash

with

distilled

water

sections

were

counterstained

with

hematoxylin

Sections

were

dehydrated

through

rising

concentrations

of

ethanol

and

mounted

Immunohistochemistry

was

successful

in

cases

for

staining

cases

for

ER

staining

for

PR

and

cyclin

staining

and

for

staining

TABLE

Antigen

retrieval

methods

and

antibodiesAntibodyCloneSupplierDilutionAntigen

retrievalSecondary

antibodySupplierTertiary

M

-LRB-

pH

-RRB-

°C

M

-LRB-

pH

-RRB-

°C

M

-LRB-

pH

-RRB-

°C

M

-LRB-

pH

-RRB-

°C

microwaveRAMBIODakoSARBIODakoCyclin

M

-LRB-

pH

-RRB-

°C

microwaveRAMBIODakoSARBIODakoa

Prediluted

by

supplier.ER

estrogen

receptor

PR

progesterone

receptor

RAMBIO

rabbit

anti-mouse

biotin

SARBIO

swine

anti-rabbit

biotin

Evaluation

of

Immunohistochemical

Staining

All

slides

stained

for

molecular

markers

were

read

by

two

authors

-LRB-

MdR

and

BvdV

-RRB-

The

slides

were

randomly

reviewed

by

a

third

author

-LRB-

JW

-RRB-

and

in

case

of

disagreement

between

the

other

two

authors

ER

PR

and

were

graded

based

on

the

percentage

of

cells

showing

positive

nuclear

staining

in

the

ducts

with

DCIS

ER

and

PR

were

considered

positive

if

nuclear

staining

was

present

in

of

the

cases

and

was

considered

positive

in

case

of

a

substantial

percentage

of

positively

stained

nuclei

-LRB-

-RRB-

expression

was

graded

as

recommended

by

the

HercepTestTM

scoring

guidelines

no

staining

at

all

or

membrane

staining

in

of

tumor

cells

a

faint/barely

perceptible

partial

membrane

staining

in

of

the

tumor

cells

weak

to

moderate

complete

membrane

staining

in

of

tumor

cells

strong

complete

membrane

staining

in

neu

was

considered

to

be

overexpressed

if

the

score

was

Cyclin

expression

was

scored

using

a

semiquantitative

system

as

described

by

Vos

et

al.

This

system

was

based

on

the

staining

intensity

scored

as

-LRB-

-RRB-

-LRB-

weak

-RRB-

-LRB-

moderate

-RRB-

and

-LRB-

strong

-RRB-

and

the

percentage

of

positive

tumor

cell

nuclei

scored

as

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

and

-LRB-

-RRB-

The

cyclin

staining

score

was

calculated

as

the

sum

of

the

intensity

and

the

percentage

of

positive

tumor

cells

Statistical

Analysis

Differences

in

clinicopathological

characteristics

between

screen-detected

and

interval

patients

with

DCIS

in

the

study

group

and

between

the

study

group

and

the

excluded

group

of

patients

were

analyzed

by

chi-square

analysis

Differences

in

clinicopathological

and

biological

characteristics

between

the

study

group

and

the

nonattenders

were

also

analyzed

by

chi-square

analysis

Differences

in

age

were

tested

by

using

the

Mann-Whitney

U

test

Univariate

analyses

investigating

differences

in

pathological

and

biological

features

was

performed

by

logistic

regression

using

screen

detection

as

a

dependent

variable

Multivariate

analyses

were

performed

with

a

logistic-regression

model

The

elimination

of

variables

in

a

stepwise

manner

identified

the

statistically

significant

pathological

and

biological

parameters

A

p

value

of

was

considered

as

significant

All

calculations

were

performed

with

SPSS

-LRB-

SPSS

inc.

Chicago

IL

-RRB-

RESULTS

Table

shows

the

clinicopathological

characteristics

of

the

patients

in

the

study

group

-LRB-

n

-RRB-

Screen-detected

DCIS

was

less

often

symptomatic

than

interval

DCIS

-LRB-

p

-RRB-

Five

patients

-LRB-

-RRB-

in

the

interval

group

had

no

objective

signs

on

presentation

all

patients

had

felt

a

lump

in

the

breast

that

could

not

be

verified

on

clinical

examination

On

mammography

microcalcifications

were

more

often

seen

in

screen-detected

DCIS

-LRB-

p

-RRB-

Screen-detected

DCIS

was

more

often

presented

as

linear

branching

-LRB-

-RRB-

and

coarse

granular

-LRB-

-RRB-

microcalcifications

than

interval

DCIS

-LRB-

p

-RRB-

High-grade

DCIS

-LRB-

Van

Nuys

p

-RRB-

was

also

more

often

observed

in

screen-detected

DCIS

TABLE

Clinicopathological

characteristics

of

the

patients

in

the

study

group

and

differences

between

screen-detected

and

interval

patientsClinicopathological

characteristicsScreen-detected

n

n

-LRB-

mean

-RRB-

Family

history

of

breast

cancer

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Signs

Palpable

-LRB-

-RRB-

-LRB-

-RRB-

Nipple

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

No

objective

-LRB-

-RRB-

-LRB-

-RRB-

Mammography

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Combination

mc

's

and

-LRB-

-RRB-

-LRB-

-RRB-

Microcalcifications

Linear

-LRB-

-RRB-

-LRB-

-RRB-

Coarse

-LRB-

-RRB-

-LRB-

-RRB-

Fine

-LRB-

-RRB-

-LRB-

-RRB-

Mammographic

size

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Tumor

size

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Grade

-LRB-

EPWG

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Grade

-LRB-

Van

Nuys

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Mann-Whitney

U

test.Values

between

parentheses

are

percentages.BCS

breast

conserving

surgery

EPWG

European

Pathologist

Working

Group.a

Chi-square

analyses

Differences

in

clinicopathological

characteristics

between

the

study-group

-LRB-

n

-RRB-

and

the

group

of

patients

that

had

been

excluded

-LRB-

n

-RRB-

because

of

insufficient

paraffin

embedded

tissue

are

outlined

in

Table

There

was

no

marked

difference

in

age

microcalcifications

tumor

size

and

pathological

grade

according

to

the

EPWG

classification

between

both

groups

The

excluded

group

of

patients

represented

a

relatively

large

proportion

of

low-grade

DCIS

according

to

the

Van

Nuys

classification

-LRB-

p

-RRB-

in

comparison

with

the

TMA

group

TABLE

Comparison

of

clinicopathological

characteristics

between

the

study

group

and

the

group

of

patients

that

were

excluded

because

of

insufficient

paraffin-embedded

tissueClinicopathological

characteristicsStudy

group

n

n

-LRB-

mean

-RRB-

Microcalcifications

-LRB-

n

-RRB-

Linear

-LRB-

-RRB-

-LRB-

-RRB-

Coarse

-LRB-

-RRB-

-LRB-

-RRB-

Fine

-LRB-

-RRB-

-LRB-

-RRB-

Tumor

size

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Grade

-LRB-

EPWG

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Grade

-LRB-

Van

Nuys

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Mann-Whitney

U

test.Values

between

parentheses

are

percentages.EPWG

European

Pathologist

Working

Group.a

Chi-square

analyses

There

were

no

differences

in

clinicopathological

and

biological

characteristics

between

the

study

group

and

the

nonattenders

-LRB-

n

-RRB-

except

the

fact

that

nonattenders

were

younger

than

the

patients

in

the

study

group

-LRB-

years

versus

years

p

-RRB-

Table

displays

the

relation

among

pathological

characteristics

biological

marker

expression

and

mode

of

detection

in

the

study

group

Univariate

logistic

regression

analysis

indicated

that

in

screen-detected

DCIS

is

more

often

overexpressed

-LRB-

odds

ratio

-LSB-

OR

-RSB-

confidence

interval

-LSB-

CI

-RSB-

p

-RRB-

Interval

DCIS

is

more

frequently

positive

for

PR

staining

-LRB-

OR

CI

p

-RRB-

and

is

related

to

low

pathological

grade

according

to

the

Van

Nuys

classification

-LRB-

OR

CI

p

-RRB-

In

multivariate

logistic

regression

including

pathological

grade

according

to

the

EPWG

and

Van

Nuys

classification

overexpression

and

PR

expression

in

the

model

overexpression

was

the

only

independent

indicator

for

screen-detected

DCIS

-LRB-

OR

CI

p

-RRB-

TABLE

Univariate

analysis

of

pathological

and

biological

characteristics

in

screen-detected

versus

interval

DCIS

in

the

study

groupPathological

and

biological

featuresScreen-detected

n

n

by

CIp-valueTumor

size

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

EPWG

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

Van

Nuys

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

n

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

n

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

PR

-LRB-

n

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

n

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Cyclin

-LRB-

n

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

analysis

using

logistic

regression.Figures

in

parentheses

are

percentages.OR

odds

ratio

EPWG

European

Pathologist

Working

Group

ER

estrogen

receptor

PR

progesterone

receptor

CI

confidence

interval

DISCUSSION

Approximately

in

every

screening

mammography

examinations

leads

to

a

diagnosis

of

DCIS

Data

from

a

large

trial

and

service

screening

programs

in

the

United

Kingdom

the

Netherlands

Australia

and

the

United

States

have

demonstrated

that

a

woman

attending

prevalence

screen

has

a

times

greater

chance

of

having

a

progressive

DCIS

or

an

invasive

tumor

diagnosed

than

of

having

a

nonprogressive

DCIS

diagnosed

It

is

questioned

what

to

do

with

the

high

detection

rate

of

screen-detected

DCIS

It

was

hypothesized

that

screen-detected

DCIS

is

biologically

more

aggressive

than

interval

DCIS

because

suspicious

microcalcifications

detected

by

the

screening

program

will

probably

more

frequently

represent

high-grade

DCIS

Therefore

screen-detected

DCIS

was

characterized

pathologically

and

biologically

to

determine

whether

screen-detected

DCIS

differed

from

interval

DCIS

The

results

of

this

study

indicate

that

screen-detected

DCIS

is

pathologically

-LRB-

OR

CI

p

-RRB-

and

biologically

-LRB-

OR

CI

p

-RRB-

more

aggressive

than

interval

DCIS

Indeed

screen-detected

DCIS

was

related

with

more

suspicious

microcalcifications

-LRB-

p

-RRB-

DCIS

detected

by

a

prevalence

screen

was

pathologically

and

biologically

comparable

to

DCIS

detected

in

later

rounds

-LRB-

data

not

shown

-RRB-

suggesting

prevalence

and

incident

cases

to

both

be

of

clinical

relevance

The

relative

incidence

of

high-grade

DCIS

in

our

series

of

screen-detected

patients

was

which

is

comparable

to

the

incidence

of

high-grade

DCIS

in

a

screening

population

from

the

Netherlands

Cancer

Institute

-LRB-

-RRB-

Much

data

point

out

that

poorly

differentiated

or

high-grade

DCIS

lesions

have

a

greater

potential

to

progress

to

invasive

disease

than

low-grade

DCIS

High

grade

is

also

an

independent

risk

factor

of

local

recurrence

after

lumpectomy

for

DCIS

and

approximately

of

these

recurrences

are

invasive

cancers

There

are

no

studies

available

comparing

screen-detected

with

interval

DCIS

in

a

group

of

patients

that

had

all

been

attending

the

screening

program

Reports

on

screen-detected

DCIS

regarding

histopathological

grade

vary

markedly

describing

a

higher

incidence

of

low

grade

no

difference

or

a

higher

incidence

of

high

in

screen-detected

DCIS

In

these

reports

screen-detected

DCIS

is

compared

to

symptomatic

DCIS

or

to

DCIS

detected

in

a

period

before

the

screening

program

was

introduced

In

the

present

study

a

higher

incidence

of

high-grade

lesions

which

were

classified

according

Van

Nuys

-LRB-

OR

CI

p

-RRB-

classification

was

found

in

screen-detected

DCIS

indicating

a

higher

malignant

potential

in

screen-detected

DCIS

These

results

are

consistent

with

the

results

from

the

studies

of

Evans

et

al.

and

Kessar

et

al.

DCIS

lesions

from

patients

in

the

study

group

were

compared

to

DCIS

lesions

from

patients

who

had

not

attended

the

screening

program

Out

of

the

nonattenders

there

were

only

patients

from

whom

sufficient

paraffin-embedded

tissue

was

available

Using

chi-square

analysis

there

were

no

differences

in

pathological

and

biological

characteristics

between

the

two

groups

The

difference

in

age

could

be

explained

by

the

fact

that

the

nonattenders

group

also

contained

patients

under

of

age

From

these

analyses

it

seems

that

DCIS

in

nonattenders

is

not

pathologically

and

biologically

more

aggressive

than

DCIS

in

attenders

of

the

screening

program

However

because

of

the

very

small

number

of

patients

in

the

nonattenders

group

no

hard

conclusions

can

be

drawn

overexpression

has

been

found

to

correlate

with

various

pathologic

and

biological

factors

believed

to

be

associated

with

more

aggressive

behavior

high

grade

presence

of

necrosis

ER

and

PR

negativity

and

overexpression

of

-LRB-

indicating

an

increased

proliferation

rate

-RRB-

are

features

that

are

strongly

related

with

neu

overexpression

The

report

of

Walker

et

al.

displayed

a

neu

expression

of

in

symptomatic

DCIS

and

of

in

mammographically

detected

DCIS

Another

study

by

Idvall

et

al.

reported

no

difference

in

neu

expression

between

DCIS

before

and

after

introduction

of

mammographic

screening

In

this

present

study

overexpression

was

the

only

independent

feature

to

be

related

with

screen-detected

DCIS

in

multivariate

analysis

-LRB-

OR

CI

p

-RRB-

which

indicates

a

more

aggressive

profile

of

screen-detected

DCIS

when

compared

to

interval

DCIS

Although

the

statistical

methods

used

were

univariate

and

multivariate

analysis

the

numbers

in

both

groups

are

small

which

explains

the

broad

CI

The

small

numbers

are

due

to

the

selection

of

patients

in

this

study

for

study

period

attendance

of

screening

rounds

and

availability

of

sufficient

paraffin-embedded

tissue

Clearly

further

studies

with

larger

populations

are

needed

to

elucidate

the

relative

significance

of

the

overexpression

in

women

with

screen-detected

DCIS

Although

out

of

patients

were

excluded

because

of

lack

of

sufficient

paraffin-embedded

tissue

there

is

no

reason

to

assume

that

this

exclusion

results

in

a

significant

selection

bias

Apart

from

pathological

grade

according

to

Van

Nuys

there

were

no

differences

in

clinicopathological

characteristics

between

the

study

group

and

the

group

of

excluded

patients

The

group

of

excluded

patients

displayed

a

relatively

large

amount

of

low-grade

DCIS

according

to

Van

Nuys

-LRB-

p

-RRB-

which

is

mainly

derived

from

the

interval

group

-LRB-

n

data

not

shown

-RRB-

If

all

patients

would

have

been

included

the

relation

of

pathological

grade

and

probably

expression

with

screen-detected

patients

would

be

even

more

significant

The

inclusion

of

patients

that

actually

took

part

in

the

screening

program

was

necessary

to

analyze

differences

between

screen-detected

and

interval

DCIS

which

to

our

knowledge

has

not

been

performed

previously

Expression

of

ER

and

cyclin

was

not

related

to

screen-detected

or

interval

DCIS

There

was

however

a

relation

between

screen-detected

DCIS

and

PR

negativity

in

univariate

analysis

-LRB-

OR

CI

p

-RRB-

Other

studies

could

not

demonstrate

a

relation

of

screen-detected

DCIS

with

the

expression

of

the

aforementioned

markers

In

a

review

by

Boland

et

al.

ER

and

PR

positivity

are

related

to

low-grade

DCIS

whereas

and

cyclin

expression

are

associated

with

high

grade

The

fact

that

screen-detected

DCIS

is

associated

with

PR

negativity

provides

indirect

evidence

for

the

presence

of

a

more

aggressive

tumor

biology

Obviously

PR

expression

is

related

to

expression

because

PR

expression

was

not

significant

in

multivariate

analysis

Ultimately

the

question

is

how

we

should

interpret

these

findings

The

authors

think

the

results

from

this

study

represent

no

evidence

to

alter

patient

management

and

screening

recommendations

Instead

they

should

rather

be

regarded

as

support

of

current

clinical

practice

in

DCIS

of

the

breast

They

confirm

that

every

DCIS

should

be

treated

until

we

are

able

to

identify

DCIS

that

will

progress

to

invasive

cancer

if

left

untreated

In

conclusion

since

the

advent

of

screening

the

increased

incidence

of

DCIS

has

raised

concerns

about

the

possibility

of

overdiagnosis

of

DCIS

This

study

has

shown

that

screen-detected

DCIS

has

a

more

aggressive

tumor

profile

than

interval

DCIS

Therefore

screen-detected

DCIS

should

not

be

regarded

as

an

overdiagnosis

per

se

and

every

woman

diagnosed

with

DCIS

by

mammographic

screening

should

be

treated

properly

according

to

existing

guidelines

or

standards

of

care

O O O O O O O O B I I I O O O O O O O B I I I O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O B I I I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O

ductal carcinoma in situ
screening
immunohistochemistry


Database of cell signaling enzymes This paper describes a database for cell signaling enzymes . Our web database offers methods to study , interpret and compare cell-signaling enzymes . Searching and retrieving data from this database has been made easy and user friendly and it is well integrated with other related databases . We believe the end user will be benefited from this database . Background A cell communicates with its neighbors and environment by sending and receiving information in the form of chemical signals . These signals are converted into intracellular second messenger signals that ultimately make the cells respond appropriately by dividing , moving or even dying . The external signals may enter the cell through enzymes , G-protein coupled receptors , hydrophobic molecules and ion channels . When the receptor sensing the signal is a catalyst such as enzyme , the response is amplified . Thus cell signaling governs the basic cellular activities and coordinates the cell action . Errors in cell signaling is the cause for many serious diseases/disorders including cancer , autoimmune diseases , diabetes etc. . By understanding cell signaling we can treat these diseases effectively and potentially . -LSB- 1 -RSB- However , no attempts have been made so far to curate and catalog the enzymes involved in cell signaling . DCSE , the Database of Cell Signaling Enzymes covers a gamut of cell signaling enzymes , which includes kinases , phosphatases , adenylyl cyclases , caspases , phosphodiesterases , phospholipases , prenyltransferases etc. . As mentioned above the defect in cell signaling mechanism is the major cause for diseases and hence the cell signaling enzymes are considered to be potential target in rational drug design approach . Methodology DCSE was developed using MySQL -LSB- 2 -RSB- , a relational database management system , at the back-end for storing data . The database can be regularly updated . The data for the database were collected from SwissProt -LSB- 3 -RSB- , the repository of protein sequence information . PHP -LSB- 4 -RSB- , a widely used general purpose scripting language that is especially suited for web development , was used to design the database interface . The database can be accessed over the Internet . A screenshot of the home page is shown in Figure 1 . The database can be searched by specifying keywords such as name , Enzyme Commission Number and species . For each enzyme in the database a unique identifier called DCSE ID has been assigned . The ID consists of two parts . The first part tells about the enzyme class and the second part indicates the number of that enzyme in that class . The two fields are separated by an underscore -LRB- _ -RRB- . Each enzyme has been defined with its name , Enzyme commission number , and the species from which it has been sequenced . Crossreference details to other databases are also provided . The functional and other sequence related informations are provided by SwissProt , the domain classification and function is provided by InterPro -LSB- 5 -RSB- , the protein family classification is provided by Pfam -LSB- 6 -RSB- and the structural details are provided by PDB . -LSB- 7 -RSB- A hyperlink has been provided to corresponding entry page in the abovementioned databases . The sequence is also displayed in raw-text format . One can retrieve the sequence in FASTA format using the ` Retrieve in Fasta format ' option available with each entry . An advanced search can also be performed by filling an advanced query form that takes input as DCSE id , name , EC number , Species , other database id such as SwissProt , InterPro , Pfam and PDB . The fields in the search form are joined together by AND operator . BLAST -LRB- Basic Local Alignment Search Tool -RRB- -LSB- 8 -RSB- is an algorithm for comparing biological sequences . Given a library or database of sequences , a BLAST search enables a researcher to look for sequences that resemble a given sequence of interest . A standalone BLAST has been installed and it can be used for similarity search purpose . BLAST can be done against SwissProt , DCSE or PD . Usability/Accessibility There are three ways in which a user can query the database . The first is the ` keyword search ' that can be done by specifying exact or likely keywords such as name , Enzyme Commission Number and species . The second search option is the ` Advanced Search ' wherein the user can fill a form by specifying the details for various fields such as DCSE id , Enzyme name , Enzyme commission number , SwissProt accession number , InterPro domain ID , Pfam id or PDB id . The fields are joined together by AND operator . Alternatively the users can also browse the database by the 21 different categories of cell signaling enzymes . Whenever the database is searched the search returns the result with number of hits found for that query along with a summary of details for each entry with its id , name and species . The user can then select the appropriate hit by following the link on it . This displays a page with all the available details of the enzyme in the database such as name , EC number , sequence information and cross-reference to already existing databases as shown in Figure 2 . A hyperlink has been provided to corresponding entry page in the cross-referenced databases for easy access . The sequence is displayed in raw-text format . One can retrieve the sequence in FASTA format using the ` Retrieve in Fasta format ' option available with each entry . A BLAST search can also be done to search for similar sequences within the database or in general . A link has been provided in the tools page . The BLAST input page and result page are shown in figure 3 and 4 . Utility to the biological community Since DCSE gather together all the information on biological molecules , sequences , structures , functions , and biological reactions , which transfer the cellular signals , this database has the potential of becoming a major hub of resource for the biological community . This database provides a mechanism by which researchers and students can transform information about interactions between biomolecules into knowledge about a cellular process . Caveats The database needs to be updated from time to time as the data has been obtained from other sources . Despite our efforts to collect information from various sources and check them for consistency , the quality of the information depends heavily on the original source . Future development The coiled-coil structure is important for protein interaction . Since the cell signaling also involves protein interaction , a tool to predict coiled-coil structure is of importance . There are few tools for this purpose like MultiCoil . The Multicoil program just gives the probability for a residue to be in coiled-coil region . We intend to develop a coiled-coil prediction tool based on artificial neural networks that could tell whether a residue is in coiled-coil region if it crosses a threshold computed from a training set consisting of proteins with known coiled-coil structure .

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