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Meurs CJC, van Rosmalen J, Menke-Pluijmers MBE, Siesling S, Westenend PJ. Predicting Lymph Node Metastases in Patients with Biopsy-Proven Ductal Carcinoma In Situ of the Breast: Development and Validation of the DCIS-met Model. Ann Surg Oncol 2023; 30:2142-2151. [PMID: 36496490 PMCID: PMC10027636 DOI: 10.1245/s10434-022-12900-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/15/2022] [Indexed: 12/14/2022]
Abstract
PURPOSE In patients with a biopsy-proven ductal carcinoma in situ (DCIS), axillary staging is frequently performed, but in hindsight often turns out to be superfluous. The aim of this observational study was to develop a prediction model for risk of lymph node metastasis in patients with a biopsy-proven DCIS. METHODS Data were received from the Dutch Pathology Databank and the Netherlands Cancer Registry. The population-based cohort consisted of all biopsy-proven DCIS patients diagnosed in the Netherlands in 2011 and 2012. The prediction model was evaluated with the area under the curve (AUC) of the receiver operating characteristic, and a calibration plot and a decision curve analysis and was validated in a Dutch cohort of patients diagnosed in the period 2016-2019. RESULTS Of 2892 biopsy-proven DCIS patients, 127 had metastasis (4.4%). Risk factors were younger age (OR = 0.97, 95% CI 0.95-0.99), DCIS not detected by screening (OR = 1.55, 95% CI 1.01-2.38), suspected invasive component at biopsy (OR = 1.86, 95% CI 1.01-3.41), palpable tumour (OR = 2.06, 95% CI 1.34-3.18), BI-RADS score 5 (OR = 2.41, 95% CI 1.53-3.78), intermediate-grade DCIS (OR = 3.01, 95% CI 1.27-7.15) and high-grade DCIS (OR = 3.20, 95% CI 1.36-7.54). For 24% (n = 708) of the patients, the predicted risk of lymph node metastasis was above 5%. Based on the decision curve analysis, the model had a net benefit for a predicted risk below 25%. The AUC was 0.745. Of the 2269 patients in the validation cohort, 53 (2.2%) had metastasis and the AUC was 0.741. CONCLUSIONS This DCIS-met model can support clinical decisions on axillary staging in patients with biopsy-proven DCIS.
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Affiliation(s)
- Claudia J C Meurs
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
- CMAnalyzing, Zevenaar, The Netherlands
| | - Joost van Rosmalen
- Department of Biostatistics, Erasmus MC, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | | | - Sabine Siesling
- Department of Health Technology and Services Research, Technical Medical Centre, University of Twente, Enschede, The Netherlands
- Department of Research, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
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Chiu CW, Chang LC, Su CM, Shih SL, Tam KW. Precise application of sentinel lymph node biopsy in patients with ductal carcinoma in situ: A systematic review and meta-analysis of real-world data. Surg Oncol 2022; 45:101880. [DOI: 10.1016/j.suronc.2022.101880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Revised: 09/26/2022] [Accepted: 10/16/2022] [Indexed: 11/21/2022]
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Lai HW, Chang YL, Chen ST, Chang YJ, Wu WP, Chen DR, Kuo SJ, Liao CY, Wu HK. Revisit the practice of lymph node biopsy in patients diagnosed as ductal carcinoma in situ before operation: a retrospective analysis of 682 cases and evaluation of the role of breast MRI. World J Surg Oncol 2021; 19:263. [PMID: 34470633 PMCID: PMC8411510 DOI: 10.1186/s12957-021-02336-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 07/19/2021] [Indexed: 11/25/2022] Open
Abstract
Background The optimal axillary lymph node (ALN) management strategy in patients diagnosed with ductal carcinoma in situ (DCIS) preoperatively remains controversial. The value of breast magnetic resonance imaging (MRI) to predict ALN metastasis pre-operative DCIS patients was evaluated. Methods Patients with primary DCIS with or without pre-operative breast MRI evaluation and underwent breast surgery were recruited from single institution. The value of breast MRI for ALN evaluation, predictors of breast and ALN surgeries, upgrade from DCIS to invasive cancer, and ALN metastasis were analyzed. Results A total of 682 cases with pre-operative diagnosis of DCIS were enrolled in current study. The rate of upgrade to invasive cancer were found in 34.2% of specimen, and this upgrade rate is 23% for patients who received breast conserving surgery and 40.7% for mastectomy (p < 0.01). Large pre-operative imaging tumor size and post-operative invasive component were risk factors to ALN metastasis. Breast MRI had 53.8% sensitivity, 77.8% specificity, 14.9% positive predictive value, 95.9% negative predictive value (NPV), and 76.2% accuracy to predict ALN metastasis in pre-OP DCIS patients. In MRI node-negative breast cancer patients with MRI tumor size < 3 cm, the NPV was 96.4%, and all these false-negative cases were N1. Pre-OP diagnosed DCIS patients with MRI tumor size < 3 cm and node negative suitable for BCS could safely omit SLNB if whole breast radiotherapy is to be performed. Conclusion Breast MRI had high NPV to predict ALN metastasis in pre-OP DCIS patients, which is useful and could be provided as shared decision-making reference.
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Affiliation(s)
- Hung-Wen Lai
- Endoscopic & Oncoplastic Breast Surgery Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan. .,Division of General Surgery, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan. .,Comprehensive Breast Cancer Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan. .,Minimal Invasive Surgery Research Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan. .,Tumor Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan. .,Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan. .,Division of Breast Surgery, Yuanlin Christian Hospital, Yuanlin, Taiwan. .,School of Medicine, Chung Shan Medical University, Taichung, Taiwan. .,Department of Biomedical Imaging and Radiological Sciences, Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan. .,Chang Gung University College of Medicine, Taoyuan City, Taiwan. .,Division of General Surgery, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung, Taiwan.
| | - Yi-Lin Chang
- Division of General Surgery, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan
| | - Shou-Tung Chen
- Division of General Surgery, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan.,Comprehensive Breast Cancer Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan
| | - Yu-Jun Chang
- Center for Research and Epidemiology, Big Data Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan
| | - Wen-Pei Wu
- Department of Surgery, Kaohsiung Medical University, Kaohsiung, Taiwan.,Department of Biomedical Imaging and Radiological Sciences, Department of Surgery, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan.,Department of Radiology, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan
| | - Dar-Ren Chen
- Endoscopic & Oncoplastic Breast Surgery Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan.,Division of General Surgery, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan.,Comprehensive Breast Cancer Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan.,School of Medicine, Chung Shan Medical University, Taichung, Taiwan
| | - Shou-Jen Kuo
- Division of General Surgery, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan.,Comprehensive Breast Cancer Center, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan
| | - Chiung-Ying Liao
- Department of Radiology, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan
| | - Hwa-Koon Wu
- Department of Radiology, Changhua Christian Hospital, 135 Nanxiao Street, Changhua, 500, Taiwan
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Predictors of Sentinel Lymph Node Metastasis in Postoperatively Upgraded Invasive Breast Carcinoma Patients. Cancers (Basel) 2021; 13:cancers13164099. [PMID: 34439252 PMCID: PMC8392104 DOI: 10.3390/cancers13164099] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 08/10/2021] [Accepted: 08/11/2021] [Indexed: 11/17/2022] Open
Abstract
Sentinel lymph node (SLN) biopsy (SLNB) usually need not be simultaneously performed with breast-conserving surgery (BCS) for patients diagnosed with ductal carcinoma in situ (DCIS) by preoperative core needle biopsy (CNB), but must be performed once there is invasive carcinoma (IC) found postoperatively. This study aimed to investigate the factors contributing to SLN metastasis in underestimated IC patients with an initial diagnosis of DCIS by CNB. We retrospectively reviewed 1240 consecutive cases of DCIS by image-guided CNB from January 2010 to December 2017 and identified 316 underestimated IC cases with SLNB. Data on clinical characteristics, radiologic features, and final pathological findings were examined. Twenty-three patients (7.3%) had SLN metastasis. Multivariate analysis indicated that an IC tumor size > 0.5 cm (odds ratio: 3.11, p = 0.033) and the presence of lymphovascular invasion (odds ratio: 32.85, p < 0.0001) were independent risk predictors of SLN metastasis. In the absence of any predictors, the incidence of positive SLNs was very low (2.6%) in the total population and extremely low (1.3%) in the BCS subgroup. Therefore, omitting SLNB may be an acceptable option for patients who initially underwent BCS without risk predictors on final pathological assessment. Further prospective studies are necessary before clinical application.
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Diaz Casas SE, Serrano Muñoz WA, Buelvas Gómez NA, Osorio Ruiz AM, Ángel Aristizábal J, Guzmán Abisaab LH, Garcia Mora M, Lehmann Mosquera C, Cervera-Bonilla S, Sanchez Pedraza R. When is Sentinel Lymph Node Biopsy Useful in Ductal Carcinoma In Situ? The Experience at a Latin American Cancer Center. Cureus 2021; 13:e16134. [PMID: 34354880 PMCID: PMC8327396 DOI: 10.7759/cureus.16134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/21/2021] [Indexed: 11/10/2022] Open
Abstract
Introduction Ductal carcinoma in situ (DCIS) accounts for 15% of breast cancers. Surgery is the main treatment, and the use of sentinel node biopsy (SLNB) is restricted to patients at risk of infiltration, which is estimated to be around 26%. Materials and methods Aimed at evaluating the benefit of SLNB in patients with DCIS at the Breast and Soft Tissue Functional Unit of the National Cancer Institute (INC for its initials in Spanish), a descriptive observational study of a retrospective cases series was conducted between August 1, 2013, and September 30, 2018. Results A total of 40 patients with a median age of 57 years were included in the study; 62.5% of them underwent mastectomy with SLNB, and the remaining 37.5% underwent conservative surgery with SLNB. 100% of sentinel nodes were identified, by using lymphoscintigraphy in 95%. Sentinel node was positive in four patients (10%), three of whom had infiltration in the surgical specimen reported. With a follow-up of 49 months, only one patient had a local relapse. None of the patients had axillary or distant recurrence. Conclusions SLNB in DCIS should be limited to patients with risk factors for infiltration (tumor size greater than 3 cm, comedo-type histology, and high-grade DCIS), and patients with an indication for mastectomy. Its percentage of complications is low, and a high identification percentage in surgical groups with adequate training.
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Affiliation(s)
- Sandra E Diaz Casas
- Breast and Soft Tissue Surgery, Instituto Nacional de Cancerología, Bogotá D.C, COL
| | | | | | | | | | | | - Mauricio Garcia Mora
- Breast and Soft Tissue Surgery, Instituto Nacional de Cancerología, Bogotá D.C, COL
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Pure Ductal Carcinoma In Situ of the Breast: Analysis of 270 Consecutive Patients Treated in a 9-Year Period. Cancers (Basel) 2021; 13:cancers13030431. [PMID: 33498737 PMCID: PMC7865419 DOI: 10.3390/cancers13030431] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Accepted: 01/19/2021] [Indexed: 11/27/2022] Open
Abstract
Simple Summary Ductal carcinoma in situ (DCIS) accounts for 20 to 25% of all breast cancers and its incidence of progression to invasive ductal carcinoma is at least 13 to 50%. The aim of our retrospective observational analysis is to review the issues of this histological type of cancer. We confirmed in a wide population of 270 consecutive patients who underwent surgery in a single institute that the management of DCIS can be difficult and particularly complex. There are many variables to be taken into consideration such as the choice of the diagnostic and bioptical technique. This delicate management must be carried out in specialized centres such as Breast Units involving multiple professional figures to define and guarantee the best possible treatment for each patient. Abstract Introduction: Ductal carcinoma in situ (DCIS) is an intraductal neoplastic proliferation of epithelial cells that are confined within the basement membrane of the breast ductal system. This retrospective observational analysis aims at reviewing the issues of this histological type of cancer. Materials and methods: Patients treated for DCIS between 1 January 2009 and 31 December 2018 were identified from a retrospective database. The patients were divided into two groups of 5 years each, the first group including patients treated from 2009 to 2013, and the second group including patients treated from 2014 to 2018. Once the database was completed, we performed a statistical analysis to see if there were significant differences among the 2 periods. Statistical analyses were performed using GraphPad Prism software for Windows, and the level of significance was set at p < 0.05. Results: 3586 female patients were treated for breast cancer over the 9-year study period (1469 patients from 2009 to 2013 and 2117 from 2014 to 2018), of which 270 (7.53%) had pure DCIS in the final pathology. The median age of diagnosis was 59-year-old (range 36–86). In the first period, 81 (5.5%) women out of 1469 had DCIS in the final pathology, in the second, 189 (8.9%) out of 2117 had DCIS in the final pathology with a statistically significant increase (p = 0.0001). From 2009 to 2013, only 38 (46.9%) were in stage 0 (correct DCIS diagnosis) while in the second period, 125 (66.1%) were included in this stage. The number of patients included in clinical stage 0 increased significantly (p = 0.004). In the first period, 48 (59.3%) specimen margins were at a greater or equal distance than 2 mm (negative margins), between 2014 and 2018; 137 (72.5%) had negative margins. Between 2014 and 2018 the number of DCIS patients with positive margins decreased significantly (p = 0.02) compared to the first period examined. The mastectomies number increased significantly (p = 0.008) between the 2 periods, while the sentinel lymph node biopsy (SLNB) numbers had no differences (p = 0.29). For both periods analysed all the 253 patients who underwent the follow up are currently living and free of disease. We have conventionally excluded the 17 patients whose data were lost. Conclusion: The choice of the newest imaging techniques and the most suitable biopsy method allows a better pre-operative diagnosis of the DCIS. Surgical treatment must be targeted to the patient and a multidisciplinary approach discussed in the Breast Unit centres.
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Zhang K, Qian L, Zhu Q, Chang C. Prediction of Sentinel Lymph Node Metastasis in Breast Ductal Carcinoma In Situ Diagnosed by Preoperative Core Needle Biopsy. Front Oncol 2020; 10:590686. [PMID: 33304849 PMCID: PMC7693536 DOI: 10.3389/fonc.2020.590686] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 10/14/2020] [Indexed: 12/15/2022] Open
Abstract
Purpose The positivity of sentinel lymph node (SLN) metastasis is relatively low in ductal carcinoma in situ (DCIS) patients. The aim of this study was to investigate factors associated with SLN metastasis and build a model to predict the potential risk of SLN metastasis in patients with a preoperative diagnosis of DCIS. Patients and Methods Core needle biopsy-proved DCIS patients who underwent SLN biopsy and breast surgery were retrospectively reviewed and selected. Univariate analysis was used to identify the variables correlated with SLN metastasis. A model to predict SLN metastasis was developed using a multivariate logistic regression in the training set and then validated in an internal set. Results A total of 407 patients with a preoperative diagnosis of DCIS were included. Upstaging to invasive/microinvasive cancer occurred in 225 patients after surgery. SLN metastasis was found in 42 patients, including 32 patients upstaging to invasive disease, 8 to microinvasive disease, and 2 pure DCIS. Tumor size based on US examination, axillary ultrasound finding, multifocality, surgery, upstaging, and Ki-67 expression were significantly related to SLN metastasis. The model incorporating tumor size, axillary ultrasound finding and multifocality yielded an AUC of 0.805 (95% CI: 0.715–0.895, p<0.001) in the training set, and 0.729 (95% CI: 0.547–0.911, p=0.013) in the testing set. Conclusion A simple model was developed to predict SLN metastasis in patients with a preoperative diagnosis of DCIS. With good discriminatory power, this model should be helpful for surgeons to decide if SLN biopsy could be safely avoided in certain patients.
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Affiliation(s)
- Kai Zhang
- Department of Medical Ultrasound, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Lang Qian
- Department of Medical Ultrasound, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Qian Zhu
- Department of Medical Ultrasound, Fudan University Shanghai Cancer Center, Shanghai, China
| | - Cai Chang
- Department of Medical Ultrasound, Fudan University Shanghai Cancer Center, Shanghai, China
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Munck F, Clausen EW, Balslev E, Kroman N, Tvedskov TF, Holm-Rasmussen EV. Multicentre study of the risk of invasive cancer and use of sentinel node biopsy in women with a preoperative diagnosis of ductal carcinoma in situ. Br J Surg 2019; 107:96-102. [DOI: 10.1002/bjs.11377] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Revised: 06/27/2019] [Accepted: 08/30/2019] [Indexed: 01/05/2023]
Abstract
Abstract
Background
Ductal carcinoma in situ (DCIS) in the breast that is diagnosed by biopsy implies a risk of upstaging to invasive carcinoma (IC) on final pathology. These patients require a sentinel lymph node biopsy (SLNB) for axillary staging. A two-stage procedure is not always feasible and precise selection of patients who should be offered SLNB is crucial. The aims were: to determine the rate of upstaging, and use of redundant and required SLNB in women with a preoperative diagnosis of DCIS; and to identify patient and tumour characteristics that increase the risk of upstaging.
Methods
Patients with DCIS treated between 2008 and 2016 were identified using Orbit operation planning system software, and those suitable for the study were selected based on review of the medical records. Upstaging rates and proportions of redundant and required SLNBs were calculated. Associations between clinicopathological characteristics and upstaging were analysed using univariable and multivariable logistic regression analyses.
Results
Of 1368 patients initially identified, 975 women with a preoperative diagnosis of DCIS were included in the study. Tumours in 246 of these patients (25·2 per cent) were upstaged to IC. Redundant SLNB was performed in 392 of 975 women (40·2 per cent). Forty-four patients (4·5 per cent) with a final diagnosis of IC were not offered SLNB and thus potentially undertreated. In adjusted analysis, DCIS size, palpability and mass formation identified by breast imaging were associated with increased risk of upstaging. The Van Nuys classification was not associated with upstaging.
Conclusion
Most patients with IC on final pathology underwent SLNB, but a considerable number of patients with DCIS had a redundant SLNB. Lesion size, palpability and mass formation, but not Van Nuys classification group, are suggested risk factors for upstaging.
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Affiliation(s)
- F Munck
- Department of Breast Surgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - E W Clausen
- Department of Diagnostic Radiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - E Balslev
- Department of Pathology, Herlev Hospital, Herlev, Denmark
| | - N Kroman
- Department of Breast Surgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - T F Tvedskov
- Department of Breast Surgery, Copenhagen University Hospital, Copenhagen, Denmark
| | - E V Holm-Rasmussen
- Department of Breast Surgery, Copenhagen University Hospital, Copenhagen, Denmark
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Abstract
Ductal carcinoma in situ has been stable in incidence for a decade and has an excellent prognosis. Breast conservation therapy is safe and effective for most patients. Adjuvant whole breast radiation therapy is recommended to reduce the risk of local recurrence. Accelerated partial breast irradiation is a promising alternative to decrease toxicity and improve cosmetic results. Adjuvant hormonal therapy can reduce local recurrence, but should be used cautiously. Future directions in management include developing predictive tools for guidance for use of adjuvant therapy and selecting low-risk patients with ductal carcinoma in situ in whom surgery may be safely omitted.
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Affiliation(s)
- FangMeng Fu
- Fujian Medical University Union Hospital, 29 Xinquan Rd, DongJieKou SangQuan, Gulou Qu, Fuzhou Shi, Fujian Sheng 350001, China
| | - Richard C Gilmore
- Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA
| | - Lisa K Jacobs
- Johns Hopkins Hospital, The Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, USA.
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Charalampoudis P, Markopoulos C, Kovacs T. Controversies and recommendations regarding sentinel lymph node biopsy in primary breast cancer: A comprehensive review of current data. Eur J Surg Oncol 2018; 44:5-14. [DOI: 10.1016/j.ejso.2017.10.215] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2017] [Revised: 09/21/2017] [Accepted: 10/10/2017] [Indexed: 11/29/2022] Open
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Rosso KJ, Weiss A, Thompson AM. Are There Alternative Strategies for the Local Management of Ductal Carcinoma in Situ? Surg Oncol Clin N Am 2018; 27:69-80. [DOI: 10.1016/j.soc.2017.08.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Jakub JW, Murphy BL, Gonzalez AB, Conners AL, Henrichsen TL, Maimone S, Keeney MG, McLaughlin SA, Pockaj BA, Chen B, Musonza T, Harmsen WS, Boughey JC, Hieken TJ, Habermann EB, Shah HN, Degnim AC. A Validated Nomogram to Predict Upstaging of Ductal Carcinoma in Situ to Invasive Disease. Ann Surg Oncol 2017; 24:2915-2924. [DOI: 10.1245/s10434-017-5927-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Indexed: 12/20/2022]
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