Axillary lymph node metastases in patients with a final diagnosis of ductal carcinoma in situ

Core biopsy diagnosis of ductal carcinoma in situ: An indication for sentinel lymph node biopsy

BACKGROUND

Sentinel lymph node biopsy (SLNB) is a minimally invasive, accurate method of evaluating axillary lymph nodes in patients with invasive cancer. The technique has also been applied successfully in patients with ductal carcinoma in situ (DCIS). The purpose of this study was to review our experience performing SLNB in patients with a biopsy diagnosis of DCIS.

METHODS

A prospective study of consecutive patients seen at our institution from August 2001 to April 2004 with a biopsy diagnosis of DCIS was undertaken. Demographic data, biopsy method, final pathology, and surgical treatment were recorded. Patients undergoing SLNB were identified, and pathologic results were noted.

RESULTS

Eighty-five patients with a biopsy diagnosis of DCIS were treated. Fifty-five (64.7%) had their diagnosis made by excisional biopsy, and 30 (35.3%) by core biopsy. Forty-four (51.7%) patients underwent SLNB as part of their definitive surgical procedure, and an SLN was successfully identified in 41 (93.2%). Nine (22.0%) patients who underwent successful SLNB had a positive SLN, 2 by hematoxylin and eosin (H&E) staining and 7 by immunohistochemical (IHC) staining for cytokeratin. Both patients with H&E-positive SLN were ultimately found to have invasive disease in their primary lesion. Final pathologic assessment of all primary lesions revealed invasive carcinoma in 7, 6 of whom had their diagnosis made by core biopsy. Overall, 20.0% of patients with a core biopsy diagnosis of DCIS were upstaged to invasive disease. Whether the lesion was palpable, grade and the presence or absence of necrosis were not significantly different in patients ultimately found to have invasive disease versus those who did not.

DISCUSSION

Sentinel lymph node biopsy can be performed accurately in patients with a biopsy diagnosis of DCIS. The rate of axillary disease in patients with pure, completely resected DCIS is low; therefore, SLNB is not indicated in all patients with this biopsy diagnosis. Because of a high rate of invasive disease on the final pathology of patients with DCIS diagnosed by core biopsy, these patients should be offered SLNB.

Cancers canalaires in situ du sein avec micro-invasion

OBJECTIVE

Specify the role of axillary lymph node removal in micro-invasive in situ duct carcinomas (DCIS-MI) of the breast with a series of 107 consecutive cases.

METHODS

Single-centre, retrospective, anatomoclinical study with application of the European guidelines adopting as pathological definition the presence of areas of micro-invasion not exceeding 1mm. Axillary lymph node dissection was systematically complete and was preceded by the search for the sentinel node in 10 patients using the isotope method.

RESULTS

Lymph node invasion was revealed in 8 cases in the global population (7.5%). All the cases except one exhibited typical deleterious histological features: comedo architectural sub-type, high nuclear grade, and size of the lesion>3 cm. The lymph node invasion was of 18.5% in the sub-group of high-grade micro-invasive comedo-carcinomas measuring more than 3 cm.

CONCLUSION

Contrary to those exhibiting pure DCIS, DCIS-MI patients require surgical exploration of the armpit, the most appropriate modalities of which are currently debated: classical axillary lymph node dissection or search for the sentinel lymph node; the selective lymphadenectomy procedure is not yet a consensually validated technique.

Sentinel Lymph Node Mapping and Biopsy for Ductal Carcinoma in situ and Other Controversial Indications

This review discusses the currently available literature regarding three controversial indications for sentinel node mapping for breast cancer patients. For women with ductal carcinoma in situ (DCIS), the use of sentinel lymph node mapping (SLNM) should be limited to women having a mastectomy. For patients with multifocal breast carcinoma, SLNM is accurate when a retroareolar injection technique is employed in the procedure. When treatment plans for node-negative patients call for neoadjuvant chemotherapy, accurate sentinel node mapping can be performed prior to the administration of chemotherapy. The resolution of these and other controversies should result in the expansion of the number of patients evaluated with SLNM in the future.

The relevance of occult axillary micrometastasis in ductal carcinoma in situ: a clinicopathologic study with long-term follow-up

BACKGROUND

Ductal carcinoma in situ (DCIS) represents 20% of newly diagnosed breast carcinoma cases. Historically, the incidence of axillary metastasis in DCIS has been small (1-2%) and its significance has been debated. It is widely known that serial sections of lymph nodes coupled with keratin immunohistochemistry (IHC) increases identification of micrometastasis. The advent of sentinel lymph node evaluation underscores the need to reevaluate the significance of occult micrometastases in DCIS.

METHODS

Patients with DCIS and negative axillary lymph nodes from 1974 to 1992 were selected from the Saint Barnabas Medical Center Tumor Registry. All diagnoses were confirmed, and paraffin blocks were retrieved after acceptance into the study. Seven serial sections were obtained from each block and evaluated with two cytokeratin IHC stains. Clinical follow-up ranged from 10 to 28 years.

RESULTS

One hundred two patients were included in the study. Micrometastases were identified in 13 patients (13%), mostly on 1 level and composed of microscopic clusters in the subcapsular sinus. Seven of these lymph node-positive patients (58%) had high-grade comedo DCIS, 4 (33%) had intermediate grades of various types of DCIS, and one had a low-grade micropapillary DCIS. The overall disease recurrence rate was 12%, but micrometasis was not detected in any of the patients who developed disease recurrence.

CONCLUSIONS

Serial IHC evaluation of lymph nodes dramatically increased the identification of occult micrometastasis. However, IHC detected micrometastasis has no apparent clinical significance in DCIS, based on the current long-term clinicopathologic study. Therefore, the authors questioned the significance of occult micrometastasis, identified by IHC, in DCIS of any type and extent. Further evaluation and follow-up of lymph node micrometastases in patients with invasive tumors of various sizes are needed. The current findings would not support altering the stage of patients with DCIS and micrometastasis detected by IHC only.