OUP accepted manuscript

Evaluating the utility of robotic axillary lymph node dissection in patients with invasive breast cancer: a systematic review

Robot-assisted axillary lymph node dissection (RALND) has been proposed to improve surgical and oncological outcomes for patients with breast cancer. To perform a systematic review of current literature evaluating RALND in patients with invasive breast cancer. A systematic search was performed in accordance with the PRISMA guidelines. Studies outlining outcomes following RALND were included. Two studies involving 92 patients were included in this review. Of these, 41 underwent RALND using the da Vinci© robotic system (44.57%), and 51 underwent conventional axillary lymph node dissection (CALND) (55.43%). There was no significant difference observed with respect to intra-operative blood loss or duration of procedure in those undergoing CALND and RALND (P > 0.050). One study reported a significant difference in lymphoedema rates in support of RALND (6.67% vs 26.67%, P = 0.038). Overall, data in relation to postoperative fat necrosis (10.00% vs 33.33%, P = 0.028), wound infection rates (3.33% vs. 20.00%, P = 0.044), and wound ≤ 40 mm in length (63.63% vs. 19.05%, P = 0.020) supported RALND. Oncological outcomes were only reported in one of the studies, which concluded that there was no local or metastatic recurrence in either group at 3-month follow-up. These provisional results support RALND as a safe alternative to CALND. Notwithstanding, the paucity of data limits the robustness of conclusions which may be drawn surrounding the adoption of RALND as the standard of care. Further high-quality studies are required to ratify these findings.

Ductal Carcinoma Arising in a Squamous Epithelial Inclusion Cyst within an Axillary Lymph Node: A Challenging Nodal Metastasis

Introduction. Assessment of axillary lymph nodes in breast carcinoma is an important part of staging to guide appropriate clinical management. Lymph node inclusions of different types, including nevoid, squamous, and glandular, are rare but have been reported in multiple different anatomic locations including the axilla. These can result in diagnostic challenges and pose risks of misdiagnoses. Rarely, malignancies may arise intrinsic to otherwise incidental benign nodal inclusions. Case Presentation. We report a case of ductal carcinoma diagnosed within a squamous epithelial inclusion cyst within an axillary lymph node in a patient with pure ductal carcinoma in situ (DCIS) of the ipsilateral right breast. To our knowledge, this is the fifth report in the literature of breast carcinoma confirmed within an axillary inclusion in a patient with pure DCIS. Evaluation of the primary DCIS and lymph node inclusions, by routine and immunohistochemical stains, was performed for assessment. Discussion. The presence of lymph node inclusions can pose a challenge in assessment of benignity and malignancy, on frozen and permanent histologic sections. Pathologists should carefully evaluate lymph node inclusions to ensure that intrinsic malignancies are not missed within rare otherwise benign appearing incidental epithelial rests.

Oncological safety of active surveillance for low-risk ductal carcinoma in situ - a systematic review and meta-analysis

INTRODUCTION

Current standard of care for patients diagnosed with "low-risk" ductal carcinoma in situ (DCIS) involves surgical resection. Ongoing phase III clinical trials are hoping to establish the oncological safety of active surveillance (AS) in managing "low-risk" DCIS.

AIMS

To evaluate the oncological safety of AS versus surgery for "low-risk" DCIS.

METHODS

A systematic review was performed in accordance with PRISMA guidelines. Survival outcomes were expressed as dichotomous variables and reported as odds ratios (OR) with 95% confidence intervals (95% CI) using the Mantel-Haenszel method.

RESULTS

Four studies including 9626 patients were included, 3.9% of which were managed using AS (374/9626) and 96.1% with surgery (9252/9626). The mean age of included patients was 50.3 years (range: 30-99 years) and mean follow-up was 6.1 years. Invasive cancer detection after surgery and AS were similar (OR: 0.93, 95% CI: 0.41-2.11, P = 0.860, heterogeneity (I2) = 0%). At 5 years, BCSS (surgery 99.5% vs. AS 98.7%, P = 0.116) and OS (surgery 95.8% vs. AS 95.7%, P = 0.876) were similar for both groups. At 10 years, BCSS (surgery 98.7% vs. AS 98.6%, P = 0.789) and OS (surgery 87.9% vs. AS 90.9%, P = 0.183) were similar for both groups. Overall, 10-year OS outcomes were similar for both management strategies (OR: 0.32, 95% CI: 0.02-6.42, P = 0.460, I2 = 69%).

CONCLUSION

This study outlines the provisional oncological safety of AS for cases of "low-risk" DCIS. While survival outcomes were comparable for both management strategies, ratification of these results in the ongoing phase III clinical trials is still required prior to changes to current management strategies.

PROSPERO REGISTRATION

CRD42022313241.

Ductal Carcinoma In Situ (DCIS) and Microinvasive DCIS: Role of Surgery in Early Diagnosis of Breast Cancer

Advances in treatments, screening, and awareness have led to continually decreasing breast cancer-related mortality rates in the past decades. This achievement is coupled with early breast cancer diagnosis. Ductal carcinoma in situ (DCIS) and microinvasive breast cancer have increasingly been diagnosed in the context of mammographic screening. Clinical management of DCIS is heterogenous, and the clinical significance of microinvasion in DCIS remains elusive, although microinvasive DCIS (DCIS-Mi) is distinct from "pure" DCIS. Upfront surgery has a fundamental role in the overall treatment of these breast diseases. The growing number of screen-detected DCIS diagnoses with clinicopathological features of low risk for local recurrence (LR) allows more conservative surgical options, followed by personalised adjuvant radiotherapy plans. Furthermore, studies are underway to evaluate the validity of surgery omission in selected low-risk categories. Nevertheless, the management, the priority of axillary surgical staging, and the prognosis of DCIS-Mi remain the subject of debate, demonstrating how the paucity of data still necessitates adequate studies to provide conclusive guidelines. The current scientific scenario for DCIS and DCIS-Mi surgical approach consists of highly controversial and diversified sources, which this narrative review will delineate and clarify.

Upgrade Rate of Ductal Carcinoma In Situ to Invasive Carcinoma and the Clinicopathological Factors Predicting the Upgrade Following a Mastectomy: A Retrospective Study

Background The rate of upgrading ductal carcinoma in situ (DCIS) to invasive cancer varies widely in the literature with no consensus regarding sentinel lymph node biopsy (SLNB) for DCIS; however, some guidelines do recommend it in the event of a mastectomy. The primary aim of this study was to determine the upgrade rate of DCIS to invasive carcinoma (IC) in patients undergoing mastectomy for DCIS and identify the clinicopathological predicting factors for the upgrade. The secondary aim was to determine the SLNB positivity rate. Methodology We retrospectively analysed consecutive patients with DCIS diagnosed through a biopsy who then underwent mastectomy over a 10-year period (2010 to 2020). Clinical, radiological, and histological variables were collected from medical records. Results We studied 143 women (mean age = 57.4 years, range = 26-85 years) who underwent mastectomy for DCIS identified on biopsy. Almost two-thirds (62.9%, 90/143) of the patients were detected on screening mammography, while 35.6% (51/143) were diagnosed following presentation with either an area of palpable concern or nipple discharge. The most common mammographic presentation of DCIS was calcification (83.9%, 120/143), and, in 85.9% of the patients, the mammographic lesion was more than 20 mm. High-grade DCIS was noted in 76.9% of preoperative biopsy results, while the rest was either low or intermediate-grade DCIS. Overall, 24.5% (35/143) were upgraded to IC (upgraded group) on postoperative histology, whereas 108/143 remained DCIS postoperatively (pure DCIS group). The positivity rate of SLNB was 4.8%. Multifocality was the only significant predictor of IC on multivariate analyses of clinicopathological predictors (odds ratio = 3.0, 95% confidence interval = 1.0-8.7). The presence of comedonecrosis was higher in the upgraded group compared to the pure DCIS group (42.9% vs. 27.8%), but this was not statistically significant. Conclusions In our study cohort, nearly one in four (24.5%) patients were upgraded from DCIS to IC on postoperative histology, with an SLNB positivity rate of 4.8%. This is important when counselling patients regarding the risk of coincident occult IC and the importance of SLNB at the time of mastectomy. Multifocality on preoperative imaging was the only significant predictive factor. Based on this result, we recommend that SLNB should also be considered if patients have multifocal DCIS and planned for oncoplastic breast-conserving surgery. However, further studies are required to investigate the association between multifocal DCIS and the risk of upgrading to IC.