Is it possible to refine the indication for sentinel node biopsy in high-risk ductal carcinoma in situ?

Ductal Carcinoma in situ after Core Needle Biopsy: In Which Cases Is a Sentinel Node Biopsy Necessary?

Introduction

In some hospitals it is still common practice to carry out a sentinel node biopsy (SNB) if ductal carcinoma in situ (DCIS) is determined in preoperative staging, although this is against international guidelines. The reason for this is because an infiltrative component can be demonstrated frequently in the final pathohistological examination. In this study, we wanted to investigate possible predictors for infiltrative growth, to select patients to do an SNB or to omit it.

Material and Methods

All patients with DCIS in the core needle biopsy (CNB), who were treated with surgery including an SNB, were included in a prospective data registry. Patient characteristics were collected through physical examination, mammography and ultrasonography. All characteristics of the DCIS were noted. After surgery, the pathological results were collected.

Results

From the 287 patients, 39 (13.6%) had an infiltrative component in the definitive pathological examination despite only DCIS in preoperative CNB. In total, there were only 14 (4.9%) positive SNBs, of which 11 patients had infiltrative growth in the breast tumor and 3 (1.2% of patients with DCIS alone in the final pathology) did not. In addition, characteristics of the CNB, including microcalcifications and comedonecrosis, did not show a statistically significant higher risk for infiltration.

Discussion

Considering the low rates of positive SNBs in our population, we think that an SNB should not be performed in advance when DCIS is diagnosed, because if infiltrative growth is found in the final biopsy, an SNB could always be performed afterwards. Only if an SNB cannot be performed afterwards is an SNB indicated.

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.

Palpable ductal carcinoma in situ: analysis of radiological and histological features of a large series with 5-year follow-up

BACKGROUND

Palpable pure DCIS is a rare entity that presents differently than screen-detected DCIS. The aim of this study was to evaluate the clinical, radiological, and pathological characteristics and management of pDCIS in a retrospective cohort of patients.

PATIENTS AND METHODS

Patients diagnosed with pDCIS from January 1999 to December 2011 were identified from an electronic patient database and were included in this study.

RESULTS

During this period, 669 cases of DCIS were diagnosed and 62 (9.3%) were pDCIS (mean age, 56.9 ± 15.1 years). The most common finding on ultrasound was mass in 43 patients (75%) and only 18 (33%) cases had calcification on mammography. The lesion was mammographically occult in 20 patients (37%). Ultrasound was more sensitive and delineated the pDCIS in 45 (80%) cases. Mean size of the pDCIS was 36.9 ± 30.4 mm and most were high grade (n = 42; 68%) and associated with comedo necrosis in 36 (59%). Most were oestrogen receptor (ER)-positive (n = 34; 62%), however 21 patients (38%) were ER-negative. Breast conservation was attempted in 30 patients (48%), however, because of involved margins further therapeutic surgery was needed in 10 patients (33%). Axillary surgery (sentinel lymph node biopsy or axillary nodal sampling) was performed in 34 patients (55%) and no lymph node metastasis was identified. During a medial follow-up of 60 months, 1 patient has developed a mastectomy scar recurrence and the rest remain disease-free.

CONCLUSION

Palpable DCIS is often occult on conventional radiological imaging and is generally associated with aggressive pathological features. Hence, careful individualized surgical planning through a multidisciplinary meeting is necessary for their management.

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.

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.

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.

Sentinel node biopsy is not a standard procedure in ductal carcinoma in situ of the breast: the experience of the European institute of oncology on 854 patients in 10 years

OBJECTIVE

The aim of this study is to assess the role of sentinel lymph node (SLN) biopsy in patients with pure ductal carcinoma in situ of the breast (DCIS) as a rationale for recommending the best managing option for the treatment of such patients in daily practice.

SUMMARY BACKGROUND DATA

DCIS cannot give rise to axillary metastases by definition. Axillary dissection is therefore not indicated. The role of SLN biopsy in the management of DCIS has not yet been established.

METHODS

From March 1996 to September 2006, 854 patients with pure DCIS underwent SLN biopsy at the European Institute of Oncology. Clinical and pathologic data were prospectively collected. When previous surgery or stereotactic biopsy had been performed elsewhere, all the histopathological preparations were reviewed. Patients with microinvasion were excluded from this investigation. Lymphatic mapping was performed using a radiocolloid technique.

RESULTS

SLN metastases were detected in 12 (1.4%) DCIS patients. In 7 cases, only micrometastases (<2 mm) were diagnosed and in 5 cases macrometastases. In addition, isolated tumoral cells (ITC) (<0.2 mm) were identified in 4 additional patients. Eleven patients underwent complete axillary dissection. None of these patients had additional positive axillary lymph nodes.

CONCLUSIONS

Because of the low prevalence of metastatic involvement, SLN biopsy should not be considered a standard procedure in the treatment of all patients with DCIS. The sole criteria for proposing SLN biopsy in DCIS should be when there exists any uncertainty regarding the presence of invasive foci at definitive histology.

Is there an indication for sentinel node biopsy in patients with ductal carcinoma in situ of the breast? A review

Ductal carcinoma in situ (DCIS) of the breast is defined as a proliferation of malignant epithelial cells within breast ducts without evidence of invasion through the basement membrane. The detection rate of DCIS of the breast has dramatically increased since the mid-1980s as the result of the widespread use of screening mammography. DCIS currently represents about 15-25% of all breast cancers detected in population screening programmes. Although inherently a non-invasive disease, occult invasion with the potential of lymph node metastases may occur. Where performing an axillary lymph node dissection-or-not for DCIS used to be an important dilemma, the same now holds for the sentinel node biopsy. This article reviews the potential role of the sentinel node biopsy (SNB) in patients with DCIS. We conclude that based on the current literature, there is in general no role for a SNB in DCIS. A SNB should only be considered in patients with an excisional biopsy diagnosis of high risk DCIS (grade III with palpable mass or large tumour area by imaging) as well as in patients undergoing mastectomy after a core or excisional biopsy diagnosis of DCIS, although SNB may be contraindicated in many of the latter patients because of lesion size and/or multifocality. Even in these patients the value of a positive SN, containing mostly isolated tumour cells, is questionable.