Role of sentinel lymph node biopsy in high-risk ductal carcinoma in situ patients

OUP accepted manuscript

Background

Axillary lymph node status remains the most powerful prognostic indicator in invasive breast cancer. Ductal carcinoma in situ (DCIS) is a non-invasive disease and does not spread to axillary lymph nodes. The presence of an invasive component to DCIS mandates nodal evaluation through sentinel lymph node biopsy (SLNB). Quantification of the necessity of upfront SLNB for DCIS requires investigation. The aim was to establish the likelihood of having a positive SLNB (SLNB+) for DCIS and to establish parameters predictive of SLNB+.

Methods

A systematic review was performed as per the PRISMA guidelines. Prospective studies only were included. Characteristics predictive of SLNB+ were expressed as dichotomous variables and pooled as odds ratios (o.r.) and associated 95 per cent confidence intervals (c.i.) using the Mantel–Haenszel method.

Results

Overall, 16 studies including 4388 patients were included (mean patient age 54.8 (range 24 to 92) years). Of these, 72.5 per cent of patients underwent SLNB (3156 of 4356 patients) and 4.9 per cent had SLNB+ (153 of 3153 patients). The likelihood of having SLNB+ for DCIS was less than 1 per cent (o.r. <0.01, 95 per cent c.i. 0.00 to 0.01; P < 0.001, I² = 93 per cent). Palpable DCIS (o.r. 2.01, 95 per cent c.i. 0.64 to 6.24; P = 0.230, I² = 0 per cent), tumour necrosis (o.r. 3.84, 95 per cent c.i. 0.85 to 17.44; P = 0.080, I² = 83 per cent), and grade 3 DCIS (o.r. 1.34, 95 per cent c.i. 0.80 to 2.23; P = 0.270, I² = 0 per cent) all trended towards significance in predicting SLNB+.

Conclusion

While aggressive clinicopathological parameters may guide SLNB for patients with DCIS, the absolute and relative risk of SLNB+ for DCIS is less than 5 per cent and 1 per cent, respectively. Well-designed randomized controlled trials are required to establish fully the necessity of SLNB for patients diagnosed with DCIS.

Registration number

CRD42021284194 (https://www.crd.york.ac.uk/prospero/)

Predictors of invasive disease in patients preoperatively diagnosed with ductal carcinoma without stromal invasion, with breast magnetic resonance imaging (MRI) and ultrasound (US)

BACKGROUND

A preoperative diagnosis of ductal carcinoma in situ (DCIS) is sometimes upstaged to invasive disease postoperatively. Our objective was to clarify the predictive factors of invasive disease using preoperative imaging and to investigate the positive ratio of sentinel lymph nodes (SLN) and the incidence of invasive disease.

METHODS

The subjects were 402 patients with preoperatively diagnosed ductal carcinoma without stromal invasion who underwent breast surgery with concomitant SLN surgery in January 2007 to December 2016. Of the 306 included patients, all 306 patients underwent preoperative MRI and US assessment. Outcomes were analyzed for significance using univariate and multivariate analyses.

RESULTS

Of the 306 patients, 115 (37.6%) had invasive disease and 191 (62.4%) had DCIS only. Of the 115 patients with invasive disease, 5 (4.4%) and 4 (3.5%) had macro- and micrometastases in SLN. On the other hand, of the 191 patients with DCIS, only 1 (0.5%) had a micrometastasis. Predictors of invasive disease in the univariate analysis included having a palpable mass, were varied by biopsy method, having a US hypoechoic mass, MRI enhancement, or MRI large enhanced lesion; the size of the mass enhancement ≥ 1.1 cm or a spread of non-mass enhancement ≥ 3.1 cm (P = 0.003). Predictors of invasive disease in the multivariate analysis included US hypoechoic mass and MRI large enhanced lesion.

CONCLUSION

We need to perform SLN biopsy for preoperatively diagnosed DCIS when patients have predictors of invasive disease, but SLN biopsy will no longer be essential for patients when they have no predictors of invasive disease.

Factors predictive of invasive ductal carcinoma in cases preoperatively diagnosed as ductal carcinoma in situ

Background

Invasion is often found during postoperative pathological examination of cases diagnosed as ductal carcinoma in situ (DCIS) by histological examinations such as core needle biopsy (CNB) or vacuum-assisted biopsy (VAB). A meta-analysis reported that 25.9% of invasive ductal carcinoma (IDC) cases are preoperatively diagnosed by CNB as DCIS. Risk factors for invasion have been studied by postoperative examination, but no factors have been found that could be obtained preoperatively from blood tests. In this study, we investigated factors predictive of invasion based on preoperative blood tests in patients diagnosed with DCIS by preoperative biopsy.

Methods

In this study, 118 patients who were diagnosed with DCIS by preoperative biopsy were included. Biopsies were performed with 16-gauge CNB or VAB. Peripheral blood was obtained at the time of diagnosis. This study evaluated absolute platelet count, absolute lymphocyte count, lactate dehydrogenase, carcinoembryonic antigen, and cancer antigen 15–3 (CA15–3). The platelet–lymphocyte ratio (PLR) was calculated by dividing the absolute platelet count by the absolute lymphocyte count, and patients were grouped into high PLR (≥160.0) and low PLR (< 160.0) groups.

Results

Invasion was found more frequently after surgery in pathologically high-grade cases than in pathologically not-high-grade cases (p = 0.015). The median PLR was 138.9 and 48 patients (40.7%) were classified into the high PLR group. The high PLR group was significantly more likely to have invasion detected by the postoperative pathology than the low PLR group (p = 0.018). In multivariate analysis of factors predictive of invasion in postoperative pathology, a high PLR (p = 0.006, odds ratio [OR] = 3.526) and biopsy method (VAB vs. CNB, p = 0.001, OR = 0.201) was an independent risk factor.

Conclusions

The PLR may be a predictor of invasion in the postoperative pathology for patients diagnosed with DCIS by preoperative biopsy.

Predictors of Invasive Breast Cancer in Patients With Ductal Carcinoma In Situ in Ultrasound-Guided Core Needle Biopsy

OBJECTIVES

To determine predictors of invasiveness of lesions with US-guided biopsy-confirmed ductal carcinoma in situ (DCIS), focusing on US features, including shear wave elastography (SWE).

METHODS

From January 2015 to September 2016, a total of 80 lesions with US-guided biopsy-confirmed DCIS were detected in patients who underwent preoperative mammography, B-mode US, and SWE. Data were retrospectively reviewed from clinical records, pathologic reports, and imaging assessments. Imaging data included mammographic findings, B-mode US findings based on the American College of Radiology Breast Imaging Reporting and Data System (BI-RADS), and the mean and maximum elasticity values on SWE. The final BI-RADS assessment, including the degree of elasticity of the mass, was evaluated. Continuous variables were examined by an independent t test, and categorical variables were examined by the Fisher exact test. The independent factors for predicting a histologic upgrade were evaluated by a multivariate logistic regression analysis.

RESULTS

Among the 80 lesions, 27 (33.8%) showed an invasive component after surgical excision. None of the BI-RADS US descriptors, which include shape, orientation, margin, and echogenicity, showed a significant correlation with the rate of a histologic upgrade to invasive cancer. However, the BI-RADS assessment category (P = .015) and nuclear grade (P = .005) were significantly correlated with invasiveness of the mass. The maximum stiffness value was lower in the pure DCIS group (119.04 vs 85.33 kPa; P = .041).

CONCLUSIONS

The BI-RADS category based on US findings, maximum stiffness value on SWE, and nuclear grade of DCIS are predictive of invasive components in DCIS.

Upstaging to invasive ductal carcinoma after mastectomy for ductal carcinoma in situ: predictive factors and role of sentinel lymph node biopsy

BACKGROUND

The aim of this study was to investigate preoperative factors associated with ductal carcinoma in situ (DCIS) upstaged to invasive ductal carcinoma (IDC) and sentinel lymph node (SLN) status in patients who underwent mastectomy for a preoperative diagnosis of DCIS.

METHODS

The medical records of 220 patients who underwent mastectomy for a preoperative diagnosis of DCIS were retrospectively reviewed.

RESULTS

Fifty-one (22.6%) of 226 lesions were upgraded to IDC after mastectomy. Preoperative factors associated with upstaging to IDC included patient-reported signs and symptoms, a clinically palpable mass, ultrasound findings classified as category 4 or 5, the ultrasound appearance of a mass or widely distributed non-mass abnormality (NMA), and a high Ki67 index. The prevalence of SLN macrometastasis was 0.9%. IDC was diagnosed for 10.9% of lesions of a preoperative ultrasound category of 0-3, 13.0% of those with no mass or NMA detected by ultrasonography, and 14.1% of lesions preoperatively diagnosed by methods other than core needle biopsy (CNB). Of those lesions, none was associated with SLN metastasis.

CONCLUSIONS

Routinely performing SLN biopsy for patients undergoing mastectomy for a preoperative diagnosis of DCIS is overtreatment, because the prevalence of SLN metastasis was low. SLN biopsy can be omitted for most patients. In particular, we suggest omitting SLN biopsy for patients who have lesions of ultrasound category 0-3, who have neither a mass nor NMA detected by ultrasound, or whose initial diagnosis was made based on a specimen obtained by methods other than CNB.

Sentinel Lymph Node Biopsy in Patients with Pure and High-Risk Ductal Carcinoma in Situ of the Breast

Aims and Background

The role of sentinel lymph node biopsy in patients initially diagnosed with ductal carcinoma in situ resides in determining the predictors of invasive disease. The aim of the present study was to examine the incidence of sentinel lymph node metastases in a selected group of patients, with characteristics of high-risk ductal carcinoma in situ, in order to determine the clinical usefulness of sentinel lymph node biopsy.

Methods

A total of 90 patients with a biopsy diagnosis of ductal carcinoma in situ were treated. Fifty-two patients with high-risk ductal carcinoma in situ had sentinel lymph node biopsy. The following characteristics of the primary tumor were considered as indicative of a risk of invasive disease: presence of palpable mass, mammographic mass, multicentric disease that required mastectomy, and histologically high nuclear grade or non-high nuclear grade with necrosis. Subdermal injections of 99mTc-labeled human albumin and subareolar injection ofblue dye were used for sentinel lymph node identification. All sentinel nodes were sectioned serially and stained with hematoxylin and eosin. Immunohistochemical analysis was performed using a cytokeratin monoclonal antibody.

Results

A positive sentinel lymph node was found in only one patient (1.9%). The patient had a double lesion, and core-needle biopsy showed an atypical ductal hyperplasia and a intermediate degree of ductal carcinoma in situ. At pathologic review of the specimen, no invasive aspect was detected.

Conclusions

The results of our study indicate that sentinel lymph node metastasis in pure ductal carcinoma in situ is extremely uncommon. We therefore suggest that sentinel lymph node biopsy might be indicated for patients with ductal carcinoma in situ detected as a palpable mass or as large extensive microcalcifications, as well as for patients who are undergoing mastectomy, especially with immediate reconstruction.

Ductal carcinoma in situ: Is core needle biopsy ever enough?

INTRODUCTION

This study investigates the rate of histological underestimation of invasive breast carcinoma following diagnosis of ductal carcinoma in situ (DCIS) on a radiologically guided core needle biopsy, and factors that may influence this upgrade rate.

METHODS

A retrospective review of the results of breast core biopsies performed between 1st January, 2005 and 2nd July, 2014 was conducted, and those with a diagnosis of DCIS were identified. Data including final excision pathology, lesion size, performing radiologist, core biopsy system and guidance method used were collected and included in the analysis.

RESULTS

We report an overall upgrade rate to invasive cancer of 20.5% (95% CI = 16.1-24.9%). No statistically significant relationship was identified between biopsy systems used or clinicians performing the biopsies and the rate of upgrade to invasive cancer. Initially a statistically significant relationship was demonstrated between upgrade rates and lesion size, DCIS grade, as well as guidance method. Subsequent multivariable analysis showed no statistically significant relationship between guidance method and upgrade rates but a trend towards statistical significance (P < 0.1).

CONCLUSION

Our recommendation is to inform women diagnosed with DCIS preoperatively in our programme, that there is a one in five chance the diagnosis will prove to be invasive cancer on definitive surgery. This is particularly important for women contemplating whether or not to undergo surgery for DCIS. Additionally, as the most significant predictor of upgrade rate demonstrated in this study is increasing lesion size, consideration should be given to increasing the number of core samples taken of larger lesions.

Prediction of invasive breast cancer using shear-wave elastography in patients with biopsy-confirmed ductal carcinoma in situ

OBJECTIVES

To investigate whether mass stiffness measured by shear-wave elastography (SWE) can predict the histological upgrade of ductal carcinoma in situ (DCIS) confirmed through ultrasound (US)-guided core needle biopsy (CNB).

METHODS

The institutional review board approved this study and informed consent was waived. A database search revealed 120 biopsy-confirmed DCIS in patients who underwent B-mode US and SWE prior to surgery. Clinicopathologic results, B-mode findings, size on US, and mean and maximum elasticity values on SWE were recorded. Associations between upgrade to invasive cancer and B-mode US findings, SWE information, and clinical variables were assessed using univariate, multivariate logistic regression, and multiple linear regression analysis.

RESULTS

The overall upgrade rate was 41.7 % (50/120). Mean stiffness value (P = .014) and mass size (P = .001) were significantly correlated with histological upgrade. The optimal cut-off value of mean stiffness value, yielding the maximal sum of sensitivity and specificity, was 70.7 kPa showing sensitivity of 72 % and specificity of 65.7 % for detecting invasiveness. Qualitative elasticity colour scores were significantly correlated with the histological upgrade, mammographic density, and B-mode category (P < .04).

CONCLUSION

Mean stiffness values evaluated through SWE can be utilized as a preoperative predictor of histological upgrade to invasive cancer in DCIS confirmed at US-guided needle biopsy.

KEY POINTS

• Higher stiffness values were noted in invasive cancer than DCIS. • Qualitative SWE colour scores significantly correlated with the histological upgrade. • Qualitative SWE colour scores had excellent interobserver agreement.

Sentinel lymph node biopsy in patients with breast ductal carcinoma in situ: Chinese experiences

The axillary treatment of patients with ductal carcinoma in situ (DCIS) remains controversial. The aim of the present study was to evaluate the roles of sentinel lymph node biopsy (SLNB) in patients with breast DCIS. A database containing the data from 262 patients diagnosed with breast DCIS and 100 patients diagnosed with DCIS with microinvasion (DCISM) who received SLNB between January 2002 and July 2014 was retrospectively analyzed. Of the 262 patients with DCIS, 9 presented with SLN metastases (3 macrometastases and 6 micrometastases). Patients with large tumors diagnosed by ultrasound or with tumors of high histological grade had a higher positive rate of SLNs than those without (P=0.037 and P<0.0001, respectively). Of the 100 patients with DCISM, 11 presented with metastases. Younger patients had a higher positive rate of SLNs (P=0.028). According to the results of this study and the systematic review of recent studies, the indications of SLNB for patients with DCIS are as follows: SLNB should be performed in all DCISM patients and in those DCIS patients who received mastectomy, and could be avoided in those who received breast-conserving surgery. However, SLNB should be recommended to patients who have high risks of harboring invasive components. The risk factors include a large, palpable tumor, a mammographic mass or a high histological grade.

The Role of Sentinel Lymph Node Biopsy and Factors Associated with Invasion in Extensive DCIS of the Breast Treated by Mastectomy: The Cinnamome Prospective Multicenter Study

Background

When invasive components are discovered at mastectomy for vacuum-assisted biopsy (VAB)-diagnosed ductal carcinoma in situ (DCIS), the only option available is axillary lymph node dissection (ALND). The primary aim of this prospective multicenter trial was to determine the benefit of performing upfront sentinel lymph node (SLN) biopsy for these patients. The secondary aim was to determine DCIS factors associated with microinvasion or invasion.

Methods

The SLN procedure was performed during mastectomy, and for positive SLN an ALND was performed during the same intervention. A tissue microarray containing DCIS lesions from the mastectomy specimens was subsequently performed.

Results

From May 2008 to December 2010, 228 patients were enrolled from 14 French cancer centers, including 192 eligible patients with pure DCIS on VAB and successful SLN procedures. ALND was avoided for 51 [67 %; 95 % confidence interval (CI), 56–77 %] of all the patients who had microinvasive DCIS or DCIS associated with invasive carcinoma at mastectomy and a negative SLN. Of the 192 patients, 76 (39 %) with VAB-diagnosed DCIS were upgraded after mastectomy to micro (n = 20) or invasive disease (n = 56). The rate of positive SLN for patients with DCIS on VAB was 14 %. High nuclear grade of DCIS was associated with greater risk of microinvasion and invasion, and HER2-amplified DCIS was associated with greater risk of invasion.

Conclusions

Underestimation of invasive components is high when DCIS is diagnosed by VAB in patients undergoing mastectomy. Upfront SLN for patients with VAB-diagnosed extensive DCIS avoids unnecessary ALND for two-thirds of patients with micro or invasive disease on mastectomy.

Electronic supplementary material

The online version of this article (doi:10.1245/s10434-015-4476-5) contains supplementary material, which is available to authorized users.

Extensive pure ductal carcinoma in situ of the breast: identification of predictors of associated infiltrating carcinoma and lymph node metastasis before immediate reconstructive surgery

AIM

To identify predictors for infiltrating carcinoma and lymph node involvement, before immediate breast reconstructive surgery, in patients with an initial diagnosis of extensive pure ductal carcinoma in situ of the breast (DCIS).

PATIENTS AND METHODS

Between January 2000 and December 2009, 241 patients with pure extensive DCIS in preoperative biopsy had underwent mastectomy. Axillary staging (sentinel node and/or axillary dissection) was performed in 92% (n = 221) of patients. Patients with micro-invasive lesions at initial diagnosis, recurrence or contralateral breast cancer were excluded.

RESULTS

Respectively 14% and 21% of patients had a final diagnosis of micro-invasive carcinoma (MIC) and invasive ductal carcinoma (IDC). Univariate analysis showed that the following variables at diagnosis were significantly correlated with the presence of either MIC or IDC in the mastectomy specimen: palpable tumor (p = 0.002), high grade DCIS (p = 0.002) and detection of an opacity by mammography (p = 0.019). Axillary lymph node (ALN) involvement was reported in 9% of patients. Univariate analysis suggested that a body mass index higher than 25 (p = 0.007), a palpable tumor (p = 0.012) and the detection of an opacity by mammography (p = 0.044) were associated with an increased rate of ALN involvement.

CONCLUSION

Skin-sparing mastectomy and immediate breast reconstruction (IBRS) has become increasingly popular, especially for patients with extended DCIS of the breast. This study confirmed that extended DCIS is associated with a substantial risk of finding MIC or IDC on the surgical specimen but also ALN involvement. Adjuvant systemic treatment and/or radiotherapy could be indicated for some of these patients after the surgery. Patients should be informed of the rate of 1) complications associated to IBRS that will potentially delay the introduction of systemic or local therapy 2) complications associated to radiotherapy after IBRS.

Nomogram for predicting invasion in patients with a preoperative diagnosis of ductal carcinoma in situ of the breast

Background

The aim of this study was to identify risk factors for invasive breast cancer in patients diagnosed with ductal carcinoma in situ (DCIS) on a preoperative biopsy. These factors were used to develop a nomogram for predicting the risk of invasion in the preoperative setting.

Methods

This was a retrospective analysis of patients who underwent surgical treatment for DCIS diagnosed before surgery between 1997 and 2009. Multivariable analysis was used to identify clinical, radiological and histopathological factors that may predict upstaging. A nomogram was developed to predict the probability of invasion using multiple logistic regression analysis. This nomogram was subsequently validated using another cohort of patients with a preoperative diagnosis of DCIS between 2010 and 2012.

Results

Upstaging to invasive cancer occurred in 123 (24.9 per cent) of 493 women treated between 1997 and 2009. A larger DCIS lesion (at least 15 mm), lack of hormone receptor expression, intermediate or high nuclear grade, diagnosis on core biopsy compared with vacuum-assisted biopsy, and non-cribriform subtype of DCIS were significantly associated with upstaging. A nomogram developed using these factors demonstrated good predictive performance (area under the receiver operating characteristic (ROC) curve (AUC) 0·823, 95 per cent confidence interval 0·787 to 0·860). The nomogram showed similar predictive performance in the validation data set, based on another 149 women (AUC 0·700, 0·613 to 0·786).

Conclusion

Upstaging to invasive cancer in women with a preoperative diagnosis of DCIS is common. A nomogram based on the five most significant factors related to upstaging accurately predicted invasive cancer. This nomogram may be useful when deciding whether to pursue axillary staging with sentinel lymph node biopsy in patients with DCIS.

MR features to suggest microinvasive ductal carcinoma of the breast: can it be differentiated from pure DCIS?

BACKGROUND

Morphologic and kinetic characteristics of breast lesions are regarded as a major criterion for their differential diagnosis in dynamic magnetic resonance imaging (MRI). However, there have not been well-reported MRI findings of microinvasive ductal carcinoma.

PURPOSE

To evaluate MRI characteristics of microinvasive ductal carcinoma of the breast and to compare MRI findings in patients with microinvasive ductal carcinoma and pure ductal carcinoma in situ (DCIS).

MATERIAL AND METHODS

Eighty-one patients with pathologically confirmed microinvasive ductal carcinomas (n = 37) or pure DCIS (n = 44) were included in this study. The MRI findings were analyzed without knowledge of the pathologic and conventional imaging findings. For all the lesions detected on MRI, morphologic and kinetic analyses were performed according to the Breast Imaging Reporting and Data System. For the non-mass lesions, the presence of clustered ring enhancement was also analyzed. Statistical analyses were performed using Student's t test, χ(2) test, and Fisher's exact test.

RESULTS

In total 35 cases of microinvasive ductal carcinoma and 39 cases of DCIS were detected on MRI. The most common and dominant MRI findings of microinvasive ductal carcinoma and DCIS were non-mass lesions with heterogeneous enhancement. However, the spiculated margin of the mass-type lesion (P = 0.022), the segmental distribution (P = 0.023), and clustered ring enhancement (P = 0.006) of the non-mass-type lesion, and the enhancement kinetics showing strong initial enhancement (P = 0.004) with subsequent wash-out (P = 0.001) were significantly more frequent in microinvasive ductal carcinoma than in DCIS.

CONCLUSION

Non-mass lesions with segmental distribution, heterogeneous enhancement, and strong initial enhancement with a wash-out curve were the dominant MRI findings of microinvasive ductal carcinoma. Compared with DCIS, microinvasive ductal carcinoma showed more suspicious imaging characteristics. For the non-mass lesions, clustered ring enhancement was also a characteristic finding of microinvasion on MRI.

Utility of intraoperative frozen section examination of sentinel lymph nodes in ductal carcinoma in situ of the breast

BACKGROUND

Intraoperative frozen section (IFS) examination of sentinel lymph nodes (SLN) is useful in selecting patients with invasive breast cancer for immediate axillary lymph node dissection. However, whether IFS evaluation of the SLNs in ductal carcinoma in situ (DCIS) of the breast has any value has not been previously assessed.

METHODS

Clinicopathologic data from patients with DCIS who underwent resection with SLN biopsy (2004-2010) were collected to assess the sensitivity, specificity, and accuracy of IFS, and its impact on axillary management.

RESULTS

A total of 267 patients with DCIS underwent resection with SLN biopsy and IFS evaluation. Preoperative pathology was DCIS (n = 231), DCIS with microinvasion (n = 24), and DCIS with other lesions (n = 12). Fifty-two (19.5%) patients had invasive breast cancer on final pathology. SLN metastases were identified in 13 (4.8%) patients; however, only 4 (1.5%) were IFS positive. IFS examination was negative in 263 (98.5%) patients. Among patients with SLN metastases, the most common pattern of metastases was either micrometastasis (n = 6) or immunohistochemistry-positive individual tumor cells (n = 4), whereas 3 patients had a macrometastasis. IFS examination was falsely negative in 9 of these 13 patients for a false-negative rate of 69.3%, and a sensitivity and specificity of 31% and 100% respectively. Nine of the 13 patients underwent axillary lymph node dissection and only 1 patient had further axillary metastasis.

CONCLUSIONS

SLN metastases in DCIS is rare and most commonly involves SLN micrometastasis or immunohistochemistry-positive individual tumor cells. SLN IFS evaluation in DCIS has a low yield and sensitivity, and can be safely omitted to reduce operative duration and cost.

Predictors of invasive breast cancer and lymph node involvement in ductal carcinoma in situ initially diagnosed by vacuum-assisted breast biopsy: experience of 733 cases

OBJECTIVE

To predict presence of invasive component and nodal involvement in women diagnosed preoperatively with ductal carcinoma in situ (DCIS) by vacuum-assisted breast biopsy (VABB).

MATERIALS AND METHODS

We retrospectively analyzed 733 patients with preoperatively diagnosed DCIS, investigating the association of clinical-radiological variables with invasive component and nodal involvement.

RESULTS

Mammographic size >20 mm and residual lesion on post-VABB mammogram were related to invasive component (both p < 0.0001) and nodal involvement (p = 0.001, p = 0.03). Age <40 years was associated with presence of invasive component (p = 0.003). By multivariate analysis residual disease was associated with invasive component, and mammographic tumor size >20 mm with nodal involvement, both highly significant.

CONCLUSIONS

Older age, lesion <20 mm, and no residual lesion predict absence of invasion and no nodal involvement in VABB-diagnosed DCIS. However it would be imprudent to routinely forego sentinel node biopsy in such patients as non-negligible proportions of them have invasive disease.

ACR appropriateness criteria(®) ductal carcinoma in situ

Ductal carcinoma in situ (DCIS) describes a wide spectrum of non-invasive tumors which carry a significant risk of invasive relapse, thus prevention of local recurrence is vital. For appropriate patients with limited disease, management with breast conserving surgery (BCS) followed by whole-breast radiation (RT) is supported by multiple Phase III studies, but mastectomy may be appropriate in selected patients. Omission of RT may also be reasonable in some patients, though which criteria are to be utilized remain unclear, and the existing data are contradictory with limited follow-up. Various RT techniques such as boost to the tumor bed, partial breast radiation or hypofractionated, whole-breast RT are increasingly utilized but the data to support their use specifically in DCIS is limited. Tamoxifen also increases local control for ER + DCIS, adding to the complexity of the local treatment management. This article reviews the existing scientific evidence, the controversies surrounding local management, and clinical guidelines for DCIS based on the group consensus by the ACR Breast Expert Panel. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed every 2 years by a multidisciplinary expert panel. The guideline development and review include an extensive analysis of current medical literature from peer-reviewed journals and the application of a well established consensus methodology (modified Delphi) to rate the appropriateness of imaging and treatment procedures by the panel. In those instances where evidence is lacking or not definitive, expert opinion may be used to recommend imaging or treatment.

Clinical applications of sentinel lymph node biopsy in ductal carcinoma in situ of the breast: a dilemma

Breast cancer is the fifth most common cause of cancer deaths in the world, which often spreads first to the axillary lymph nodes (ALN) from the primary tumor. ALN helps clinician stage breast cancer. In addition, it is one of the key prognostic factors for patients with invasive breast cancer. The sentinel lymph node (SLN) is defined as the first regional lymph node to receive lymphatic fluid from a malignant tumor. As a result, it seems possible to assess the complete nodal status with sentinel lymph node biopsy (SLNB), which is attractive and reliable approach for identifying lymph node metastasis. Ductal carcinoma in situ (DCIS) is the most common type of non-invasive breast cancer. However, the role of SLNB in DCIS is controversial because DCIS does not cause invasion and metastasis theoretically. In this review, clinical applications of SLNB in DCIS will be discussed. The potential benefit of accurately upstaging patients with DCIS and the minimal invasiveness of SLNB justify use of SLNB in selected high-risk DCIS patients. At least DSIS with microinvasion, have DCIS of sufficient extent on mammography or MRI, or indicated invasive or microinvasive focus by final histological examination, are recommended for SLNB. Moreover, large randomized trials to evaluate the usefulness of SLNB in DCIS patients after long-term follow-up on local control and survival are required for further evaluation.

Ductal carcinoma in situ at core-needle biopsy: meta-analysis of underestimation and predictors of invasive breast cancer

PURPOSE

To perform a meta-analysis to report pooled estimates for underestimation of invasive breast cancer (where core-needle biopsy [CNB] shows ductal carcinoma in situ [DCIS] and excision histologic examination shows invasive breast cancer) and to identify preoperative variables that predict invasive breast cancer.

MATERIALS AND METHODS

Studies were identified by searching MEDLINE and were included if they provided data on DCIS underestimates (overall and according to preoperative variables). Study-specific and pooled percentages for DCIS underestimates were calculated. By using meta-regression (random effects logistic modeling) the association between each study-level preoperative variable and understaged invasive breast cancer was investigated.

RESULTS

Fifty-two studies that included 7350 cases of DCIS with findings at excision histologic examination as the reference standard met the eligibility criteria and were included. There were 1736 underestimates (invasive breast cancer at excision); the random-effects pooled estimate was 25.9% (95% confidence interval: 22.5%, 29.5%). Preoperative variables that showed significant univariate association with higher underestimation included the use of a 14-gauge automated device (vs 11-gauge vacuum-assisted biopsy, P = .006), high-grade lesion at CNB (vs non-high grade lesion, P < .001), lesion size larger than 20 mm at imaging (vs lesions ≤ 20 mm, P < .001), Breast Imaging Reporting and Data System (BI-RADS) score of 4 or 5 (vs BI-RADS score of 3, P for trend = .005), mammographic mass (vs calcification only, P < .001), and palpability (P < .001).

CONCLUSION

About one in four DCIS diagnoses at CNB represent understaged invasive breast cancer. Preoperative variables significantly associated with understaging include biopsy device and guidance method, size, grade, mammographic features, and palpability.

The impact of sentinel lymph node biopsy and magnetic resonance imaging on important outcomes among patients with ductal carcinoma in situ

The objective of this systematic review was to determine the impact of sentinel lymph node (SLN) biopsy and breast magnetic resonance imaging (MRI) on important outcomes for patients with ductal carcinoma in situ. We identified no study that directly evaluated important outcomes for SLN biopsy. So, we determined the incidence of SLN metastases among patients with ductal carcinoma in situ. Using American Joint Committee on Cancer criteria, the incidence of pN1 and pN1(mic) SLN metastases were 0.9% and 1.5%, respectively. Because the incidence of SLN metastasis is very low, SLN biopsy is not likely to affect important outcomes. We identified one study that directly evaluated important outcomes after breast MRI. In this study, the use of MRI did not affect local recurrence rates after breast-conserving surgery and radiation. Although MRI may identify occult multicentric or contralateral breast cancer in some patients, it may also lead to unnecessary biopsies and overtreatment.

Recurrence after Mastectomy for Ductal Carcinoma in Situ

Mastectomy has long been a standard option for patients with ductal carcinoma in situ (DCIS). It is preferentially chosen by some women and may be suggested for individuals with recurrent, multifocal, or multicentric disease. We chose to evaluate our recent experience with mastectomy for DCIS. A retrospective review was conducted of 83 patients (87 breasts) from 1995 to 2006 who underwent mastectomy for DCIS. Mastectomy for DCIS was performed in 49 postmenopausal, 33 premenopausal, and one male patient. The average age was 53 years and the mean follow up was 4.5 years. Sentinel lymph node (SLN) biopsy was performed on 44 cases; positive nodes were identified in two. Intraoperative analyses of SLN were all negative. Only one patient had ipsilateral recurrence of the skin (1.1%). DCIS with microinvasion was noted in 32 per cent of the patients; none of these patients had ipsilateral recurrence. Three patients had positive microscopic margins; none have recurred to date. These results confirm the usefulness of mastectomy for patients with DCIS. We recommend SLN biopsy without intraoperative touch prep analysis. Additional treatment may not be required in patients with microinvasion, positive or close margins because our series shows no local recurrence in these patients.

Accuracy of sentinel node biopsy in breast cancer patients with a high prevalence of axillary metastases

BACKGROUND

Sentinel lymph node biopsy (SLNB) has become a standard diagnostic tool for axillary staging of breast cancer and has many advantages in comparison with axillary dissection. The goal of our study was to determine accuracy and predictive value of SLNB for assessing the axillary lymph nodes involvement in breast cancer.

MATERIALS AND METHODS

Thirty three patients with breast cancer at Mehr and Taleghani hospitals in Tehran between July 2005 and 2006 were randomly selected. All women underwent presurgical lymphoscintigraphic mapping followed by sentinel node biopsy guided by intraoperative gamma probe and blue dye. Sentinel nodes were examined by standard hematoxylin and eosin (H&E) staining. Among studied patients, T1 stage accounted for 3%% of the patients, T2 for 6%, T3 for 66.7% and T4 for 24.3%. Statistical analyses were performed by evaluating of sensitivity, specificity, accuracy, and positive and negative predictive values of SLNB in comparison to axillary lymph node dissection (ALND).

RESULTS

The sentinel lymph nodes in 30.3% of patients were well imaged by lymphoscintigraphy. A mean of 4.8 sentinel lymph nodes were removed per patient. Sensitivity and specificity of SLNB were 92% and 87.5%, respectively. Totally, in comparison to ALND, the accuracy of SLNB was 90.9% and false negative rate of this method was also 8%.

CONCLUSION

Our experience shows SLNB to be reliable and accurate for axillary staging in breast cancer patients with a high prevalence of axillary metastases and can be replaced diagnostic ALND in our breast cancer centers.

Meta-analysis of sentinel node biopsy in ductal carcinoma in situ of the breast

BACKGROUND

The need for sentinel lymph node (SLN) biopsy in patients with a preoperative diagnosis of ductal carcinoma in situ (DCIS) is debated. Advocates recommend such biopsy based on a high incidence of SLN involvement in some series. Opponents discourage SLN biopsy based on a perceived low incidence of nodal involvement in this setting. These contradictory arguments are generally based on small studies. The present study is a meta-analysis of the reported data on the incidence of SLN metastasis in patients with DCIS.

METHODS

A search of electronic databases identified studies reporting the frequency of SLN metastases in DCIS. The random-effects method was used to combine data.

RESULTS

Twenty-two published series were included in the meta-analysis. The estimate for the incidence of SLN metastases in patients with a preoperative diagnosis of DCIS was 7.4 (95 per cent confidence interval (c.i.) 6.2 to 8.9) per cent compared with 3.7 (95 per cent c.i. 2.8 to 4.8) per cent in patients with a definitive (postoperative) diagnosis of DCIS alone. This was a significant difference with an odds ratio of 2.11 (95 per cent c.i. 1.15 to 2.93).

CONCLUSION

Patients with a preoperative diagnosis of DCIS should be considered for SLN biopsy.

[Ductal carcinoma in situ of the breast (DCIS) under 40: a specific management?]

Ductal carcinoma in situ of the breast (DCIS) is rare in younger women, accounting for about 4% of all cases of DCIS in France, and tends to be diagnosed by clinical findings or casually, after plastic surgery. After breast conserving treatment, young age ( less than 40) is a predictive factor of relapses in patients with DCIS. Age may serve as one more parameter that should be considered in the complex decision-making process necessary to create a treatment plan for a woman with DCIS. Breast conservative treatment (BCT) could be used if: margins are free and more than 10 mm; if DCIS size is less than 11 mm and DCIS is free of necrosis and comedocarcinoma. Mastectomy ought to be proposed in case of: multifocal DCIS, or DCIS size more than 30 mm; invaded margins after re-excision; radiotherapy contraindicated; small breasts and patient choice. Immediate breast reconstruction should be proposed for patients with all the poor predictive factors. In other cases, treatment procedure will be explained to the patient and the treatment will be chosen by the patient in consultation with the medical team (radiologist, surgeon, pathologist and oncologist). Radiotherapy with boost or hormonotherapy with tamoxifen should not be used routinely but may be proposed individually.

Modern concepts of ductal carcinoma in situ (DCIS) and its diagnosis through percutaneous biopsy

The incidence of ductal breast carcinoma in situ (DCIS) is increasing and currently lies at about 15% of all breast cancers. Detection of DCIS reduces the subsequent incidence of invasive ductal carcinoma. Patients with Breast Imaging Reporting and Data System (BI-RADS) category 4 lesions are best served by minimally invasive biopsies to improve the precision of diagnosing DCIS lesions. Vacuum-assisted biopsies have the greatest sensitivity and specificity of the biopsy techniques and reduce tumor upgrading of DCIS lesions at operation by at least half compared with core-needle biopsy. Moreover, vacuum-assisted biopsies have proved to be safe and reduce health care costs. Since they provide a maximum of preoperative information, vacuum-assisted biopsies could improve outcomes in patients with DCIS.