Residual disease after radiologically complete vacuum-assisted breast excision in patients with ductal carcinoma in situ: A systematic review and meta-analysis

Background: Vacuum-assisted breast excision (VABE) permits radiologically complete percutaneous removal of ductal carcinoma in situ (DCIS); however, the rates of residual disease and upstaging to invasive carcinoma at subsequent surgery remain poorly defined. We performed a systematic review and meta-analysis to estimate these rates and identify clinicopathological predictors. Methods: PubMed/MEDLINE, Google Scholar, Scopus, SciSpace, Cochrane CENTRAL, and Web of Science were searched from January 2010 to December 2025 per PRISMA 2020 guidelines. Studies reporting residual disease or upstaging after radiologically complete VABE of DCIS were included. Risk of bias was assessed using the Newcastle–Ottawa Scale. Pooled proportions were estimated using Freeman–Tukey double-arcsine transformation with DerSimonian–Laird random effects; certainty of evidence was rated using GRADE. Results: Twelve studies (N = 5302 patients) were included. Eleven studies (N = 4995) contributed to the primary analysis: pooled residual disease rate 67.4% (95% CI 63.9–70.8%; I² = 18.7%; prediction interval 60.6–73.8%). All 12 studies (N = 4881) contributed to the upstaging analysis: pooled rate 16.4% (95% CI 12.8–20.4%; I² = 50.7%). These estimates are concordant with contemporary data reporting 18.2% upstaging in trial-eligible DCIS (Vila et al., EJSO 2025) and 8.5% eight-year invasive cancer incidence in conservatively managed low-risk DCIS (Ryser et al., BMJ 2025). Suspicious axillary lymph nodes (OR 12.16) and high nuclear grade (OR 1.90) independently predicted residual disease; lesion size ≤10 mm (OR 0.02) and low or intermediate nuclear grade (OR 0.08) were protective. Certainty of evidence was low for residual disease and very low for upstaging. Conclusions: Despite radiologically complete VABE, residual disease persists in approximately two-thirds of patients, supporting surgical excision as standard of care. Patients with small (≤10 mm), low- or intermediate-grade lesions represent the most promising candidates for future VABE-based active surveillance trials, anchored by emerging evidence from the COMET trial and concordant observational data.