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Lorentzen EH, Chen YJ, Jin G, King TA, Mittendorf EA, Minami CA. Potential Overtreatment of DCIS in Patients with Limited Life Expectancy. Ann Surg Oncol 2024; 31:6812-6819. [PMID: 39031264 DOI: 10.1245/s10434-024-15894-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2024] [Accepted: 07/11/2024] [Indexed: 07/22/2024]
Abstract
INTRODUCTION As the benefits of intensive locoregional therapy for ductal carcinoma in situ (DCIS) are realized over time in older adults, life expectancy may help to guide treatment decisions. We examined whether life expectancy was associated with extent of locoregional therapy in this population. PATIENTS AND METHODS Women ≥ 70 years old with < 5 cm of DCIS diagnosed 2010-2015 were identified in the Surveillance, Epidemiology, and End Results (SEER)-Medicare dataset and categorized by a life expectancy ≤ 5 or > 5 years, defined by a validated claims-based measure. Differences in locoregional therapy (mastectomy + axillary surgery, mastectomy-only, lumpectomy + radiation therapy (RT) + axillary surgery, lumpectomy + RT, lumpectomy-only, and no treatment) by life expectancy were assessed using Pearson chi-squared tests. Generalized linear mixed models were used to identify factors associated with receipt of lumpectomy-only. RESULTS Of 5346 women (median age of 75 years, range 70-97 years), 927 (17.3%) had a life expectancy ≤ 5 years. Of the 4041 patients who underwent lumpectomy, 710 (13.3%) underwent axillary surgery. More patients with life expectancy ≤ 5 years underwent lumpectomy-only (39.4% versus 27%), mastectomy-only (8.1% versus 5.3%), or no treatment (5.8% versus 3.2%; p < 0.001). On multivariable analysis, women with life expectancy ≤ 5 years had a significantly greater likelihood of undergoing lumpectomy-only [OR 1.90, 95% CI (1.63-2.22)]. CONCLUSIONS Life expectancy is associated with lower-intensity locoregional therapy for older women with DCIS, yet a large proportion of patients with a life expectancy ≤ 5 years received RT and axillary surgery, highlighting potential overtreatment and opportunities to de-escalate locoregional therapy in older adults.
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MESH Headings
- Humans
- Female
- Aged
- Life Expectancy
- Carcinoma, Intraductal, Noninfiltrating/therapy
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/mortality
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Breast Neoplasms/therapy
- Breast Neoplasms/pathology
- Breast Neoplasms/mortality
- Breast Neoplasms/surgery
- Aged, 80 and over
- SEER Program
- Mastectomy, Segmental
- Medical Overuse/statistics & numerical data
- Follow-Up Studies
- Mastectomy/mortality
- Prognosis
- United States
- Survival Rate
- Axilla
- Combined Modality Therapy
- Medicare
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Affiliation(s)
- Eliza H Lorentzen
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Yu-Jen Chen
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Ginger Jin
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA
| | - Tari A King
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber/Brigham Cancer Center, Boston, MA, USA
| | - Elizabeth A Mittendorf
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
- Breast Oncology Program, Dana-Farber/Brigham Cancer Center, Boston, MA, USA
| | - Christina A Minami
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
- Center for Surgery and Public Health, Brigham and Women's Hospital, Boston, MA, USA.
- Breast Oncology Program, Dana-Farber/Brigham Cancer Center, Boston, MA, USA.
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Kanbayashi C, Iwata H. Update on the management of ductal carcinoma in situ of the breast: current approach and future perspectives. Jpn J Clin Oncol 2024:hyae122. [PMID: 39223698 DOI: 10.1093/jjco/hyae122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Accepted: 08/26/2024] [Indexed: 09/04/2024] Open
Abstract
The standard treatment for ductal carcinoma in situ became well established through the results of several valuable clinical trials, and its therapeutic benefits have now come to be taken for granted. Ductal carcinoma in situ has an extremely good prognosis with the current treatment approach, with a 10-year breast cancer-specific survival rate of 97-98%. According to one retrospective cohort study, the breast cancer-specific survival rate of patients with low-grade ductal carcinoma in situ does not differ significantly between patients undergoing and not undergoing surgery. Some patients with ductal carcinoma in situ are not at a risk of progression to invasive cancer, but the predictors of such progression have not yet been clearly identified. Therefore, the same therapeutic strategies have been used to treat ductal carcinoma in situ and under the assumption that they have risks of invasive breast cancer, and a well-balanced risk/benefit ratio in respect of treatment has not yet been achieved. Based on the results of several recent clinical trials aimed at ensuring provision of a well-balanced treatment for patients with ductal carcinoma in situ which carries a good prognosis, de-escalation of postoperative adjuvant therapy has now begun. Currently, not only is the optimization of postoperative adjuvant therapy accelerating, but also clinical trials to de-escalate basic surgical treatments are under way. There is a possibility of achieving individualized treatment for patients with ductal carcinoma in situ of the breast with reduced treatment intervention. In this review, we present an overview of the current treatment approaches and potential future management strategies for ductal carcinoma in situ of the breast.
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Affiliation(s)
- Chizuko Kanbayashi
- Department of Breast Oncology, Niigata Cancer Center Hospital, Niigata, Japan
| | - Hiroji Iwata
- Department of Medical Research and Developmental Strategy, Core Laboratory, Graduate School of Medical Sciences, Nagoya City University, Nagoya, Japan
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Bae SJ, Kook Y, Jang JS, Baek SH, Moon S, Kim JH, Lee SE, Kim MJ, Ahn SG, Jeong J. Selective omission of sentinel lymph node biopsy in mastectomy for ductal carcinoma in situ: identifying eligible candidates. Breast Cancer Res 2024; 26:65. [PMID: 38609935 PMCID: PMC11015583 DOI: 10.1186/s13058-024-01816-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2023] [Accepted: 03/26/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) is recommended for patients with ductal carcinoma in situ (DCIS) undergoing mastectomy, given the concerns regarding upstaging and technical difficulties of post-mastectomy SLNB. However, this may lead to potential overtreatment, considering favorable prognosis and de-escalation trends in DCIS. Data regarding upstaging and axillary lymph node metastasis among these patients remain limited. METHODS We retrospectively reviewed patients with DCIS who underwent mastectomy with SLNB or axillary lymph node dissection at Gangnam Severance Hospital between January 2010 and December 2021. To explore the feasibility of omitting SLNB, we assessed the rates of DCIS upgraded to invasive carcinoma and axillary lymph node metastasis. Binary Cox regression analysis was performed to identify clinicopathologic factors associated with upstaging and axillary lymph node metastasis. RESULTS Among 385 patients, 164 (42.6%) experienced an invasive carcinoma upgrade: microinvasion, pT1, and pT2 were confirmed in 53 (13.8%), 97 (25.2%), and 14 (3.6%) patients, respectively. Seventeen (4.4%) patients had axillary lymph node metastasis. Multivariable analysis identified age ≤ 50 years (adjusted odds ratio [OR], 12.73; 95% confidence interval [CI], 1.18-137.51; p = 0.036) and suspicious axillary lymph nodes on radiologic evaluation (adjusted OR, 9.31; 95% CI, 2.06-41.99; p = 0.004) as independent factors associated with axillary lymph node metastasis. Among patients aged > 50 years and/or no suspicious axillary lymph nodes, only 1.7-2.3%) experienced axillary lymph node metastasis. CONCLUSIONS Although underestimation of the invasive component was relatively high among patients with DCIS undergoing mastectomy, axillary lymph node metastasis was rare. Our findings suggest that omitting SLNB may be feasible for patients over 50 and/or without suspicious axillary lymph nodes on radiologic evaluation.
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Affiliation(s)
- Soong June Bae
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Yoonwon Kook
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Soo Jang
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Ho Baek
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sohyun Moon
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jung Hyun Kim
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Seung Eun Lee
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Min Ji Kim
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Sung Gwe Ahn
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
- Institute for Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon Jeong
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea.
- Institute for Breast Cancer Precision Medicine, Yonsei University College of Medicine, Seoul, Republic of Korea.
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4
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Wu H, Jiang Y, Tian H, Ye X, Cui C, Shi S, Chen M, Ding Z, Li S, Huang Z, Luo Y, Peng Q, Xu J, Dong F. Sonography-based multimodal information platform for identifying the surgical pathology of ductal carcinoma in situ. COMPUTER METHODS AND PROGRAMS IN BIOMEDICINE 2024; 245:108039. [PMID: 38266556 DOI: 10.1016/j.cmpb.2024.108039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Revised: 01/11/2024] [Accepted: 01/17/2024] [Indexed: 01/26/2024]
Abstract
BACKGROUND The risk of ductal carcinoma in situ (DCIS) identified by biopsy often increases during surgery. Therefore, confirming the DCIS grade preoperatively is necessary for clinical decision-making. PURPOSE To train a three-classification deep learning (DL) model based on ultrasound (US), combining clinical data, mammography (MG), US, and core needle biopsy (CNB) pathology to predict low-grade DCIS, intermediate-to-high-grade DCIS, and upstaged DCIS. MATERIALS AND METHODS Data of 733 patients with 754 DCIS cases confirmed by biopsy were retrospectively collected from May 2013 to June 2022 (N1), and other data (N2) were confirmed by biopsy as low-grade DCIS. The lesions were randomly divided into training (n=471), validation (n=142), and test (n = 141) sets to establish the DCIS-Net. Information on the DCIS-Net, clinical (age and sign), US (size, calcifications, type, breast imaging reporting and data system [BI-RADS]), MG (microcalcifications, BI-RADS), and CNB pathology (nuclear grade, architectural features, and immunohistochemistry) were collected. Logistic regression and random forest analyses were conducted to develop Multimodal DCIS-Net to calculate the specificity, sensitivity, accuracy, receiver operating characteristic curve, and area under the curve (AUC). RESULTS In the test set of N1, the accuracy and AUC of the multimodal DCIS-Net were 0.752-0.766 and 0.859-0.907 in the three-classification task, respectively. The accuracy and AUC for discriminating DCIS from upstaged DCIS were 0.751-0.780 and 0.829-0.861, respectively. In the test set of N2, the accuracy and AUC of discriminating low-grade DCIS from upstaged low-grade DCIS were 0.769-0.987 and 0.818-0.939, respectively. DL was ranked from one to five in the importance of features in the multimodal-DCIS-Net. CONCLUSION By developing the DCIS-Net and integrating it with multimodal information, diagnosing low-grade DCIS, intermediate-to high-grade DCIS, and upstaged DCIS is possible. It can also be used to distinguish DCIS from upstaged DCIS and low-grade DCIS from upstaged low-grade DCIS, which could pave the way for the DCIS clinical workflow.
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Affiliation(s)
- Huaiyu Wu
- Department of Ultrasound, The Second Clinical Medical College, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen People's Hospital, Jinan University, Shenzhen 518020, Guangdong, China
| | - Yitao Jiang
- Department of Ultrasound, The Second Clinical Medical College, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen People's Hospital, Jinan University, Shenzhen 518020, Guangdong, China; Research and Development Department, Microport Prophecy, Shanghai 201203, China
| | - Hongtian Tian
- Department of Ultrasound, The Second Clinical Medical College, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen People's Hospital, Jinan University, Shenzhen 518020, Guangdong, China
| | - Xiuqin Ye
- Department of Ultrasound, The Second Clinical Medical College, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen People's Hospital, Jinan University, Shenzhen 518020, Guangdong, China
| | - Chen Cui
- Research and Development Department, Illuminate, LLC, Shenzhen, Guangdong 518000, China
| | - Siyuan Shi
- Research and Development Department, Illuminate, LLC, Shenzhen, Guangdong 518000, China
| | - Ming Chen
- Department of Ultrasound, The Second Clinical Medical College, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen People's Hospital, Jinan University, Shenzhen 518020, Guangdong, China
| | - Zhimin Ding
- Department of Ultrasound, The Second Clinical Medical College, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen People's Hospital, Jinan University, Shenzhen 518020, Guangdong, China
| | - Shiyu Li
- Department of Ultrasound, The Second Clinical Medical College, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen People's Hospital, Jinan University, Shenzhen 518020, Guangdong, China
| | - Zhibin Huang
- Department of Ultrasound, The Second Clinical Medical College, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen People's Hospital, Jinan University, Shenzhen 518020, Guangdong, China
| | - Yuwei Luo
- Department of Breast Surgery, The Second Clinical Medical College, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen People's Hospital, Jinan University, Shenzhen 518020, Guangdong, China; Department of General Surgery, Shenzhen People's Hospital, Shenzhen 518020, Guangdong, China
| | - Quanzhou Peng
- Department of Pathology, The Second Clinical Medical College, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen People's Hospital, Jinan University, Shenzhen 518020, Guangdong, China
| | - Jinfeng Xu
- Department of Ultrasound, The Second Clinical Medical College, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen People's Hospital, Jinan University, Shenzhen 518020, Guangdong, China
| | - Fajin Dong
- Department of Ultrasound, The Second Clinical Medical College, The First Affiliated Hospital, Southern University of Science and Technology, Shenzhen People's Hospital, Jinan University, Shenzhen 518020, Guangdong, China.
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5
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Kim S, Lee K, Alshahrani MA, Ahn JH, Lee J, Park HS. Frozen Sections in Decision-Making Regarding the Axillary Procedures in Breast Conserving Surgery for Intraductal Carcinoma at Preoperative Diagnosis. J Korean Med Sci 2023; 38:e224. [PMID: 37527907 PMCID: PMC10396433 DOI: 10.3346/jkms.2023.38.e224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 03/30/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND Axillary evaluation is unnecessary for pure ductal carcinoma in situ (DCIS); however, it is performed because of the risk of upstaging to invasive cancer. We assessed the role of intraoperative frozen section (IOF) biopsy in reducing invasive cancer upstaging and axillary evaluation in preoperative DCIS patients. METHODS We reviewed patients with preoperative DCIS who underwent breast-conserving surgery (BCS) with IOF biopsy. Positive IOF biopsy findings were defined as the presence of invasive or micro-invasive cancer. The IOF biopsy and permanent pathology findings were compared. RESULTS Seventy-eight patients underwent BCS with IOF biopsy. Six patients showed positive IOF biopsy findings; five of these patients showed concordant permanent pathology findings. Sentinel lymph node biopsy (SLNB) was positive in one patient. Thirteen patients with invasive breast cancer were missed by IOF biopsy; they underwent SLNB during the second surgery. None of them had metastatic lymph nodes. The sensitivity and specificity of IOF biopsy were 27.7% and 98.3%, respectively, with 82.1% accuracy. None of the other factors showed statistically significant relationships with the permanent pathology findings, except for the IOF biopsy findings. CONCLUSION IOF evaluation can aid in detecting the invasiveness of tumors in patients with preoperative DCIS.
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Affiliation(s)
- Sanghwa Kim
- Department of Breast and Endocrine Surgery, Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Kwanbum Lee
- Departement of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | | | - Jee Hyun Ahn
- Departement of Surgery, Yonsei University College of Medicine, Seoul, Korea
| | - Jeea Lee
- Department of Surgery, Graduate School of Medicine, Yonsei University College of, Medicine, Seoul, Korea
| | - Hyung Seok Park
- Departement of Surgery, Yonsei University College of Medicine, Seoul, Korea.
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Magnoni F, Bianchi B, Corso G, Alloggio EA, Di Silvestre S, Abruzzese G, Sacchini V, Galimberti V, Veronesi P. Ductal Carcinoma In Situ (DCIS) and Microinvasive DCIS: Role of Surgery in Early Diagnosis of Breast Cancer. Healthcare (Basel) 2023; 11:healthcare11091324. [PMID: 37174866 PMCID: PMC10177838 DOI: 10.3390/healthcare11091324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/20/2023] [Accepted: 05/03/2023] [Indexed: 05/15/2023] Open
Abstract
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.
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Affiliation(s)
- Francesca Magnoni
- Division of Breast Surgery, European Institute of Oncology (IEO), IRCCS, 20141 Milan, Italy
- European Cancer Prevention Organization (ECP), 20141 Milan, Italy
| | - Beatrice Bianchi
- Division of Breast Surgery, European Institute of Oncology (IEO), IRCCS, 20141 Milan, Italy
| | - Giovanni Corso
- Division of Breast Surgery, European Institute of Oncology (IEO), IRCCS, 20141 Milan, Italy
- European Cancer Prevention Organization (ECP), 20141 Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
| | - Erica Anna Alloggio
- Division of Breast Surgery, European Institute of Oncology (IEO), IRCCS, 20141 Milan, Italy
| | - Susanna Di Silvestre
- Division of Breast Surgery, European Institute of Oncology (IEO), IRCCS, 20141 Milan, Italy
| | - Giuliarianna Abruzzese
- Division of Breast Surgery, European Institute of Oncology (IEO), IRCCS, 20141 Milan, Italy
| | - Virgilio Sacchini
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY 10065, USA
| | - Viviana Galimberti
- Division of Breast Surgery, European Institute of Oncology (IEO), IRCCS, 20141 Milan, Italy
| | - Paolo Veronesi
- Division of Breast Surgery, European Institute of Oncology (IEO), IRCCS, 20141 Milan, Italy
- Department of Oncology and Hemato-Oncology, University of Milan, 20122 Milan, Italy
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Abdulla HA, Khalaf Y. De-escalation of Sentinel Lymph Node Biopsy in Patients With Ductal Carcinoma In Situ. Cureus 2023; 15:e37383. [PMID: 37182081 PMCID: PMC10171883 DOI: 10.7759/cureus.37383] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/10/2023] [Indexed: 05/16/2023] Open
Abstract
Introduction Current guidelines recommend that sentinel lymph node biopsy (SLNB) be performed in patients with ductal carcinoma in situ (DCIS) undergoing mastectomy, in patients for whom the location of excision may compromise future SLNB, or if there is a high suspicion or risk of upstaging to invasive cancer on final pathology. Whether axillary surgery should be performed in patients with DCIS remains controversial. Our study aimed to examine the factors associated with the upgrade of DCIS to invasive cancer on final pathology and sentinel lymph node (SLN) metastases to evaluate whether axillary surgery may be safely omitted in DCIS. Methods Patients with a diagnosis of DCIS on core biopsy who underwent surgery with axillary staging between 2016 and 2022 were identified from our pathology database and retrospectively reviewed. Patients who underwent surgical management of DCIS without axillary staging and those treated for local recurrence were excluded. Results Out of 65 patients, 35.3% of patients were upstaged to the invasive disease on final pathology. 9.23% of cases had a positive SLNB. Predictive factors associated with upstaging to invasive cancer included palpable mass on clinical examination (P = 0.013), presence of a mass on preoperative imaging (P = 0.040), and estrogen receptor status (P = 0.036). Conclusion Our results support ongoing opportunities for the de-escalation of axillary surgery in patients with DCIS. In a subset of patients undergoing surgery for DCIS, SLNB may be omitted as the risk of upstaging to invasive cancer is low. Patients with a mass on clinical examination or imaging and negative estrogen receptor (ER) lesions have a higher risk of upstaging to invasive cancer, where a sentinel lymph node biopsy should be performed.
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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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9
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Harrison B. Update on sentinel node pathology in breast cancer. Semin Diagn Pathol 2022; 39:355-366. [PMID: 35803776 DOI: 10.1053/j.semdp.2022.06.016] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/14/2022] [Accepted: 06/27/2022] [Indexed: 11/11/2022]
Abstract
Pathologic examination of the sentinel lymph nodes (SLNs) in patients with breast cancer has been impacted by the publication of practicing changing trials over the last decade. With evidence from the ACOSOG Z0011 trial to suggest that there is no significant benefit to axillary lymph node dissection (ALND) in early-stage breast cancer patients with up to 2 positive SLNs, the rate of ALND, and in turn, intraoperative evaluation of SLNs has significantly decreased. It is of limited clinical significance to pursue multiple levels and cytokeratin immunohistochemistry to detect occult small metastases, such as isolated tumor cells and micrometastases, in this setting. Patients treated with neoadjuvant therapy, who represent a population with more extensive disease and aggressive tumor biology, were not included in Z0011 and similar trials, and thus, the evidence cannot be extrapolated to them. Recent trials have supported the safety and accuracy of sentinel lymph node biopsy (SLNB) in these patients when clinically node negative at the time of surgery. ALND remains the standard of care for any amount of residual disease in the SLNs and intraoperative evaluation of SLNs is still of value for real time surgical decision making. Given the potential prognostic significance of residual small metastases in treated lymph nodes, as well as the decreased false negative rate with the use of cytokeratin immunohistochemistry (IHC), it may be reasonable to maintain a low threshold for the use of cytokeratin IHC in post-neoadjuvant cases. Further recommendations for patients treated with neoadjuvant therapy await outcomes data from ongoing clinical trials. This review will provide an evidence-based discussion of best practices in SLN evaluation.
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Affiliation(s)
- Beth Harrison
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, United States.
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10
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Identification of patients with ductal carcinoma in situ at high risk of postoperative upstaging: A comprehensive review and an external (un)validation of predictive models developed. Eur J Obstet Gynecol Reprod Biol 2022; 271:7-14. [DOI: 10.1016/j.ejogrb.2022.01.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2021] [Revised: 12/30/2021] [Accepted: 01/27/2022] [Indexed: 12/17/2022]
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Giammarile F, Vidal-Sicart S, Paez D, Pellet O, Enrique EL, Mikhail-Lette M, Morozova O, Maria Camila NM, Diana Ivonne RS, Delgado Bolton RC, Valdés Olmos RA, Mariani G. Sentinel Lymph Node Methods in Breast Cancer. Semin Nucl Med 2022; 52:551-560. [PMID: 35241267 DOI: 10.1053/j.semnuclmed.2022.01.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 01/27/2022] [Accepted: 01/27/2022] [Indexed: 12/21/2022]
Abstract
Breast cancer is the most frequent cancer diagnosed in women worldwide. Accurate lymph node staging is essential for both prognosis (of early-stage disease) and treatment (for regional control of disease) in patients with breast cancer. The sentinel lymph nodes are the regional nodes that directly drain lymph from the primary tumor. No imaging modality is accurate enough to detect lymph node metastases when a primary breast cancer is at an early stage (I or II), but sentinel lymph node biopsy is a highly reliable method for screening axillary nodes and for identifying metastatic (including micro-metastatic) disease in regional lymph nodes. Despite the widespread use of sentinel lymph node biopsy for early-stage breast cancer, relevant variations have been described regarding practical aspects of the procedure, and some variability has initially been reported regarding the rates of intraoperative sentinel lymph node identification and of false-negative findings, most likely because of differences in the size of the populations being investigated and in lymphatic mapping techniques. Nevertheless, using adequate learning curves and once a multidisciplinary team is experienced with the procedure, improved levels of accuracy are achieved.
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Affiliation(s)
- Francesco Giammarile
- Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria; Service de Médecine Nucléaire, Centre Léon Berard, Lyon, France.
| | - Sergi Vidal-Sicart
- Nuclear Medicine Department, Hospital Clinic Barcelona and Institut d'Investigació Biomèdica August Pi I Sunyer (IDIBAPS), Barcelona, Spain
| | - Diana Paez
- Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Olivier Pellet
- Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Estrada-Lobato Enrique
- Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Miriam Mikhail-Lette
- Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Olga Morozova
- Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Navarro Marulanda Maria Camila
- Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Rodríguez Sanchez Diana Ivonne
- Nuclear Medicine and Diagnostic Imaging Section, Division of Human Health, Department of Nuclear Sciences and Applications, International Atomic Energy Agency, Vienna, Austria
| | - Roberto C Delgado Bolton
- Department of Diagnostic Imaging (Radiology) and Nuclear Medicine, University Hospital San Pedro and Centre for Biomedical Research of La Rioja (CIBIR), Logroño, La Rioja, Spain
| | - Renato A Valdés Olmos
- Department of Radiology, Section of Nuclear Medicine & Interventional Molecular Imaging Laboratory, Leiden University Medical Center, ZA, Leiden, The Netherlands
| | - Giuliano Mariani
- Regional Center of Nuclear Medicine, University of Pisa, Pisa, Italy
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Hersh EH, King TA. De-escalating axillary surgery in early-stage breast cancer. Breast 2021; 62 Suppl 1:S43-S49. [PMID: 34949533 PMCID: PMC9097808 DOI: 10.1016/j.breast.2021.11.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/23/2021] [Accepted: 11/25/2021] [Indexed: 02/06/2023] Open
Abstract
The role of axillary surgery has evolved over the last three decades from routine axillary lymph node dissection (ALND) to sentinel lymph node biopsy to omission of axillary surgery altogether in select patients. This evolution has been achieved through the design and conduct of multiple clinical trials demonstrating that ALND does not impact survival and is not necessary for local control in patients with early-stage breast cancer and limited nodal involvement. Importantly, this practice-changing shift mirrored the trend towards earlier stage at diagnosis and the recognition of the interplay between local and systemic therapies in maintaining local control. There are numerous clinical scenarios today in which axillary staging can be safely avoided, including (1) DCIS treated with lumpectomy, (2) at the time of contralateral prophylactic mastectomy, and (3) in elderly patients with early-stage, HR+/HER2-clinically node-negative (cN0) disease. Ongoing clinical trials seek to expand the cohorts in which surgical nodal staging can be omitted. These populations include a broader range of early-stage, cN0 patients undergoing upfront surgery, as seen in the SOUND, INSEMA, BOOG 2013-08, SOAPET and NAUTILUS trials. Omission of axillary surgery in cN0 patients with HER2+ or triple-negative disease treated with neoadjuvant chemotherapy is also being tested in the ASICS and EUBREAST-01 trials. Continued advances in imaging and the growing role of genomic assays in selecting patients for systemic therapy are likely to further minimize the need for axillary surgery; thereby further reducing the morbidity of local therapy for women with breast cancer.
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Affiliation(s)
- Eliza H Hersh
- Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Tari A King
- Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA; Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.
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Bellver G, Buch E, Ripoll F, Adrianzen M, Bermejo B, Burgues O, Julve A, Ortega J. Is Axillary Assessment of Ductal Carcinoma In Situ of the Breast Necessary in All Cases? J Surg Res 2021; 271:145-153. [PMID: 34902737 DOI: 10.1016/j.jss.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 09/29/2021] [Accepted: 10/10/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Staging of the axilla in women with ductal carcinoma in situ (DCIS) is a point of controversy. We aimed to assess whether there is a group of patients in whom axillary assessment can be avoided and whether the likelihood of underdiagnosis of infiltrating carcinoma is sufficient to justify this evaluation. MATERIALS AND METHODS This was a multicenter, prospective, observational study of patients who were operated on between 2008 and 2018 in three Spanish hospitals, with a diagnosis by radiological or excisional biopsy of DCIS and clinically and radiologically negative axilla. RESULTS A total of 530 patients with a preoperative diagnosis of DCIS were studied. An axillary assessment was performed in 77% of the patients. In 397 patients, selective sentinel lymph node biopsy was performed. Axillary involvement was found in 7.2% of all patients, which dropped to 2.15% if we only included DCIS diagnosed after a definitive anatomical pathology analysis. Underdiagnosis was correlated with the type of biopsy performed: the risk was 1.34 times as high if the biopsy was performed with a core needle. The risk of lymph node metastasis was higher when there was lymphovascular invasion and when mastectomy was performed. CONCLUSIONS We propose an axilla management algorithm in patients with a preoperative diagnosis of DCIS. The patients who would benefit from sentinel lymph node biopsy would be those who are not candidates for breast-conserving surgery, those with a BIRADS 5 lesion biopsied by core-needle biopsy, and those whose definitive diagnosis is lymphovascular invasion.
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MESH Headings
- Axilla/pathology
- Breast Neoplasms/diagnosis
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/diagnosis
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/diagnosis
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Female
- Humans
- Lymph Nodes/pathology
- Mastectomy
- Prospective Studies
- Retrospective Studies
- Sentinel Lymph Node Biopsy
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Affiliation(s)
- Gemma Bellver
- Department of General and Digestive Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Elvira Buch
- Department of General and Digestive Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Francisco Ripoll
- Department of General and Digestive Surgery, Hospital Universitario La Fe de Valencia, Valencia, Spain
| | - Marcos Adrianzen
- Department of General and Digestive Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain.
| | - Begoña Bermejo
- Department of Oncology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Octavio Burgues
- Department of Patology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Ana Julve
- Department of Radiology, Hospital Clínico Universitario de Valencia, Valencia, Spain
| | - Joaquin Ortega
- Department of General and Digestive Surgery, Hospital Clínico Universitario de Valencia, Valencia, Spain; University of Valencia, Spain
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Underestimation of invasive breast carcinoma in patients with initial diagnosis of ductal carcinoma in situ: Size matters. Cir Esp 2021; 99:655-659. [PMID: 34749924 DOI: 10.1016/j.cireng.2021.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Accepted: 10/26/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The aim of our study was to identify those patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) and high risk of upstaging to invasive breast carcinoma (IBC), in whom sentinel lymph node biopsy (SLNB) should be considered. MATERIALS AND METHODS One-hundred and five DCIS patients treated with breast-conserving surgery (BCS) or mastectomy were studied. Preoperative features of the tumours were analyzed to investigate its association with underestimation of IBC on final pathology. RESULTS Overall, the underestimation rate of IBC was 16.2%. The underestimation rate was highest in lesions with initial size >2 cm compared with those with size ≤2 cm (26.8% vs. 4.1%, respectively; p < 0.003). Eighty-eight patients (83.8%) underwent concurrent SLNB and only one case had lymph node involvement (1.1%). CONCLUSIONS SLNB should be considered in DCIS patients receiving BCS with lesions greater than 2 cm since approximately one in four will harbour an IBC.
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Farante G, Toesca A, Magnoni F, Lissidini G, Vila J, Mastropasqua M, Viale G, Penco S, Cassano E, Lazzeroni M, Bonanni B, Leonardi MC, Ripoll-Orts F, Curigliano G, Orecchia R, Galimberti V, Veronesi P. Advances and controversies in management of breast ductal carcinoma in situ (DCIS). Eur J Surg Oncol 2021; 48:736-741. [PMID: 34772587 DOI: 10.1016/j.ejso.2021.10.030] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 10/25/2021] [Accepted: 10/29/2021] [Indexed: 01/03/2023] Open
Abstract
Ductal carcinoma in situ (DCIS) is a non-obligate precursor of invasive breast cancer. It accounts for 25% of all breast cancers diagnosed, as a result of the expansion of breast cancer screening and is associated with a high survival rate. DCIS is particularly clinically challenging, due to its heterogeneous pathological and biological traits and its management is continually evolving towards more personalized and less aggressive therapies. This article suggests evidence-based guidelines for proper DCIS clinical management, which should be discussed within a multidisciplinary team in order to propose the most suitable approach in clinical practice, taking into account recent scientific studies. Here we include updated multidisciplinary treatment protocols and techniques in accordance with the most recent contributions published on this topic in the peer-reviewed medical literature, and we outline future perspectives.
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Affiliation(s)
- Gabriel Farante
- Division of Breast Surgery, European Institute of Oncology (EIO), IRCCS, Milan, Italy.
| | - Antonio Toesca
- Division of Breast Surgery, European Institute of Oncology (EIO), IRCCS, Milan, Italy
| | - Francesca Magnoni
- Division of Breast Surgery, European Institute of Oncology (EIO), IRCCS, Milan, Italy
| | - Germana Lissidini
- Division of Breast Surgery, European Institute of Oncology (EIO), IRCCS, Milan, Italy
| | - José Vila
- Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | | | - Giuseppe Viale
- Division of Anatomo-Pathology, European Institute of Oncology (EIO), Milan, Italy; School of Medicine, University of Milan, Italy
| | - Silvia Penco
- Division of Breast Radiology, European Institute of Oncology (EIO), IRCCS, Milan, Italy
| | - Enrico Cassano
- Division of Breast Radiology, European Institute of Oncology (EIO), IRCCS, Milan, Italy
| | - Matteo Lazzeroni
- Division of Cancer Prevention and Genetics, European Institute of Oncology (EIO), IRCCS, Milan, Italy
| | - Bernardo Bonanni
- Division of Cancer Prevention and Genetics, European Institute of Oncology (EIO), IRCCS, Milan, Italy
| | | | | | - Giuseppe Curigliano
- School of Medicine, University of Milan, Italy; Division of Breast Radiology, European Institute of Oncology (EIO), IRCCS, Milan, Italy; Division of Cancer Prevention and Genetics, European Institute of Oncology (EIO), IRCCS, Milan, Italy; Division of Radiotherapy, European Institute of Oncology (EIO), IRCCS, Milan, Italy; Division of Early Drug Development for Innovative Therapy, European Institute of Oncology (EIO), IRCCS, Milan, Italy
| | - Roberto Orecchia
- School of Medicine, University of Milan, Italy; Division of Breast Radiology, European Institute of Oncology (EIO), IRCCS, Milan, Italy; Division of Cancer Prevention and Genetics, European Institute of Oncology (EIO), IRCCS, Milan, Italy; Division of Radiotherapy, European Institute of Oncology (EIO), IRCCS, Milan, Italy
| | - Viviana Galimberti
- Division of Breast Surgery, European Institute of Oncology (EIO), IRCCS, Milan, Italy
| | - Paolo Veronesi
- Division of Breast Surgery, European Institute of Oncology (EIO), IRCCS, Milan, Italy; Hospital Universitario y Politécnico La Fe, Valencia, Spain; School of Medicine University of Bari "Aldo Moro", Italy; Division of Anatomo-Pathology, European Institute of Oncology (EIO), Milan, Italy; School of Medicine, University of Milan, Italy
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16
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Shin YD, Lee HM, Choi YJ. Necessity of sentinel lymph node biopsy in ductal carcinoma in situ patients: a retrospective analysis. BMC Surg 2021; 21:159. [PMID: 33752671 PMCID: PMC7986566 DOI: 10.1186/s12893-021-01170-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 03/17/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) is unnecessarily performed too often, owing to the high upstaging rates of ductal carcinoma in situ (DCIS). This study aimed to evaluate the upstaging rates of DCIS to invasive cancer, determine the prevalence of axillary lymph node metastasis, and identify the clinicopathological factors associated with upstaging and lymph node metastasis. We also examined surgical patterns among DCIS patients and determined whether SLNB guidelines were followed. METHODS We retrospectively analysed 307 consecutive DCIS patients diagnosed by preoperative biopsy in a single centre between 2014 and 2018. Data from clinical records, including imaging studies, axillary and breast surgery types, and pathology results from preoperative and postoperative biopsies, were extracted. Univariate analyses using Chi-square tests and multiple logistic regression analyses were used to analyse the data. RESULTS The rate of upstaging to invasive cancer was 19.2% (59/307). DCIS diagnosed by core-needle biopsy (odds ratio [OR]: 6.861, 95% confidence interval [CI]: 2.429-19.379), the presence of ultrasonic mass-forming lesions (OR: 2.782, 95% CI: 1.224-6.320), and progesterone receptor-negative status (OR: 3.156, 95% CI: 1.197-8.323) were found to be associated with upstaging. The rate of sentinel lymph node metastasis was only 1.9% (4/202), and all were total mastectomy patients diagnosed by core-needle biopsy. SLNB was performed in 37.2% of 145 breast-conserving surgery patients and 91.4% of 162 total mastectomy patients. Among the 202 patients who underwent SLNB, 145 (71.7%) without invasive cancer on final pathology had redundant SLNB. Two of 59 patients (3.4%) with disease upstaged to invasive cancer had inadequate primary staging of the axilla, as the rate seemed sufficiently small. CONCLUSIONS In patients with a preoperative diagnosis of DCIS, although an unavoidable possibility of upstaging to invasive cancer exists, axillary metastasis is unlikely. Only 2.7% of patients with DCIS undergoing total mastectomy were found to have sentinel lymph node metastases. SLNB should not be performed in breast-conserving surgery patients and should be reserved only for total mastectomy patients diagnosed by core-needle biopsy.
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Affiliation(s)
- Young Duck Shin
- Department of Anesthesiology and Pain Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Hyung-Min Lee
- Department of Anesthesiology and Pain Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Republic of Korea
| | - Young Jin Choi
- Department of Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, 1 Chungdae-ro, Seowon-gu, Cheongju-si, Chungcheongbuk-do, 28644, Republic of Korea.
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17
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Bouzón Alejandro A, Iglesias López Á, Acea Nebril B, García Jiménez ML, Díaz Carballada CC, Varela Romero JR. Underestimation of invasive breast carcinoma in patients with initial diagnosis of ductal carcinoma in situ: Size matters. Cir Esp 2021; 99:S0009-739X(20)30350-X. [PMID: 33541705 DOI: 10.1016/j.ciresp.2020.10.020] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2020] [Revised: 10/23/2020] [Accepted: 10/26/2020] [Indexed: 11/20/2022]
Abstract
INTRODUCTION The aim of our study was to identify those patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) and high risk of upstaging to invasive breast carcinoma (IBC), in whom sentinel lymph node biopsy (SLNB) should be considered. METHODS One-hundred and five DCIS patients treated with breast-conserving surgery (BCS) or mastectomy were studied. Preoperative features of the tumors were analyzed to investigate its association with underestimation of IBC on final pathology. RESULTS Overall, the underestimation rate of IBC was 16.2%. The underestimation rate was highest in lesions with initial size >2 cm compared with those with size ≤2 cm (26.8% vs. 4.1%, respectively; p < 0.003). Eighty-eight patients (83.8%) underwent concurrent SLNB and only one case had lymph node involvement (1.1%). CONCLUSIONS SLNB should be considered in DCIS patients receiving BCS with lesions greater than 2 cm since approximately one in four will harbor an IBC.
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Affiliation(s)
- Alberto Bouzón Alejandro
- Unidad de Mama, Servicio de Cirugía General, Complejo Hospitalario Universitario A Coruña, España.
| | - Ángela Iglesias López
- Unidad de Mama, Servicio de Radiología, Complejo Hospitalario Universitario A Coruña, España
| | - Benigno Acea Nebril
- Unidad de Mama, Servicio de Cirugía General, Complejo Hospitalario Universitario A Coruña, España
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18
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Shin YD, Kang G, Jang H, Choi YJ. Trends in Axillary Surgery for Treating Ductal Carcinoma In Situ: A Korean Population-based Study. J Breast Cancer 2021; 24:49-62. [PMID: 33634620 PMCID: PMC7920862 DOI: 10.4048/jbc.2021.24.e10] [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: 09/06/2020] [Revised: 01/25/2021] [Accepted: 01/25/2021] [Indexed: 11/30/2022] Open
Abstract
Purpose Ductal carcinoma in situ (DCIS) is common in South Korea. We evaluated the patterns of axillary surgery among patients with DCIS to highlight the need for compliance with the updated national guidelines. We also evaluated whether sentinel lymph node biopsy (SLNB) was performed in accordance with the national guidelines. Methods The Korean Health Insurance Review and Assessment Service-National Inpatient Sample database was searched for patients with DCIS (2009–2015) to identify axillary surgery patterns by breast surgery type, year of diagnosis, age at diagnosis, and the location and volume of surgeries for DCIS at the hospital. The rates of SLNB and axillary dissection were compared using descriptive statistics and univariate analyses. Analyses were also conducted using the chi-squared test and multiple logistic regression analysis. Results We identified 16,315 Korean women who underwent surgery for DCIS, including 11,292 cases of SLNB (69.2%) and 131 cases of axillary lymph node dissection (0.8%). Breast-conserving surgery (BCS) was performed in 10,323 patients (63.3%) with an SLNB rate of 56.0%, while total mastectomy (TM) was performed in 5,992 patients (36.7%), with an SLNB rate of 92.0%. During 2009–2015, the SLNB rate during TM increased from 88.23% to 92.80%. SLNB was influenced by hospital region and surgical volume, and hospitals performing low volumes of surgeries were significantly more likely to perform SLNB regardless of the surgery type (odds ratio, 1.372; 95% confidence interval, 1.265–1.488). Conclusion Although the Korean guidelines recommend SLNB for all TM procedures and select BCS procedures for DCIS, relatively high rates of SLNB were performed for BCS, and there was inter-hospital variability in performing SLNB. Improved compliance with the guidelines by the surgeons is critical for Korean patients with DCIS.
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Affiliation(s)
- Young Duck Shin
- Department of Anesthesiology and Pain Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Gilwon Kang
- Department of Health Informatics and Management, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Hoyeon Jang
- Department of Health Informatics and Management, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Young Jin Choi
- Department of Surgery, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea.
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Magnoni F, Galimberti V, Corso G, Intra M, Sacchini V, Veronesi P. Axillary surgery in breast cancer: An updated historical perspective. Semin Oncol 2020; 47:341-352. [PMID: 33131896 DOI: 10.1053/j.seminoncol.2020.09.001] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 09/28/2020] [Accepted: 09/28/2020] [Indexed: 12/11/2022]
Abstract
This historical surgical retrospection focuses on the temporal de-escalation axillary surgery, focusing on the unceasing efforts of researchers toward new challenges, as documented by extensive studies and trials. Axillary surgery has evolved, aiming to offer the best oncologic treatment and improve the quality of life of women. Axillary lymph-node dissection (ALND) has been replaced by sentinel lymph-node biopsy (SLNB) in women with early clinically node-negative breast cancer, providing adequate axillary nodal staging information with minimal morbidity, and becoming the standard of care in the management of breast cancer. However, this is only the beginning. Strategies in defining systemic and radiotherapeutic treatments have gradually been optimized, offering increasingly refined and targeted breast cancer treatment tools. In recent years, the paradigm of completion ALND after a positive SLNB has been questioned, and several studies have led to revolutionary changes in clinical practice. Moreover, the increasingly pivotal role played by neoadjuvant chemotherapy (NAC) has had a profound effect on the extent of axillary surgery, paving the way to a more finite "targeted" procedure in women with node-positive breast cancer who convert to negative nodes clinically after NAC. The utility of SLNB itself and its subsequent omission in women with negative nodes clinically and breast conservative surgery is also under scientific evaluation. The changes over time in the surgical approach to breast cancer have been numerous and significant. The novel emerging perspective characterized by recent advances in biology and genetics, in dedicated axillary ultrasound imaging and chemotherapy regimens, is the present reality that points to the future of axillary node treatment in breast cancer.
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Affiliation(s)
- Francesca Magnoni
- Division of Breast Cancer Surgery, IEO, European Institute of Oncology, IRCCS, Milan, Italy.
| | - Viviana Galimberti
- Division of Breast Cancer Surgery, IEO, European Institute of Oncology, IRCCS, Milan, Italy
| | - Giovanni Corso
- Division of Breast Cancer Surgery, IEO, European Institute of Oncology, IRCCS, Milan, Italy; Faculty of Medicine, University of Milan, Milan, Italy
| | - Mattia Intra
- Division of Breast Cancer Surgery, IEO, European Institute of Oncology, IRCCS, Milan, Italy
| | - Virgilio Sacchini
- Division of Breast Cancer Surgery, IEO, European Institute of Oncology, IRCCS, Milan, Italy; Faculty of Medicine, University of Milan, Milan, Italy
| | - Paolo Veronesi
- Division of Breast Cancer Surgery, IEO, European Institute of Oncology, IRCCS, Milan, Italy; Faculty of Medicine, University of Milan, Milan, Italy
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20
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Özkurt E, Wong S, Rhei E, Golshan M, Brock J, Barbie TU. Omission of Surgical Axillary Lymph Node Staging in Patients with Tubular Breast Cancer. Ann Surg Oncol 2020; 28:2589-2598. [PMID: 33078312 DOI: 10.1245/s10434-020-09223-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 09/15/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND With more effective screening and treatment strategies, there is debate over whether surgical axillary staging should be deescalated for patients with small favorable breast cancers, such as tubular carcinoma (TC). PATIENTS AND METHODS We identified patients with TC [defined as > 90% tubular tubules (angulated, not multilayered)] and known surgical axillary staging from our institutional database (2000-2018). Using the National Cancer Database (NCDB) (2004-2015), we identified patients with TC, ductal carcinoma in situ (DCIS), and pT1 estrogen receptor (ER)-positive invasive ductal carcinoma (IDC). We determined the rates of lymph node (LN) metastases, and the 5- and 10-year overall survival (OS) for patients with LN-negative versus LN-positive disease using the Kaplan-Meier method and propensity match analysis. RESULTS In our institutional cohort, we identified 112 patients with T1 TC; only one (0.9%) patient had nodal involvement. In the NCDB cohort, we identified 6938 patients with T1 TC; 323 (4.7%) patients had axillary LN disease. The rate of axillary LN involvement for TC was comparable to that identified for patients with DCIS (4.2%), and much lower than that found for patients with grade I-III, T1, ER-positive IDC (20.5%), and patients with grade I, T1, ER-positive IDC (14.4%). There was no difference in 5-year (94.6% versus 95.4%, p = 0.67) and 10-year (83.9% versus 85.2%, p = 0.98) OS between TC patients with or without LN involvement. Kaplan-Meier survival curves even after propensity score matching suggest that tubular histology is independently associated with improved survival. CONCLUSIONS T1 TC is an excellent starting point for deescalation of surgical axillary staging.
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Affiliation(s)
- Enver Özkurt
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Breast Unit, Department of General Surgery, Istanbul Faculty of Medicine, Istanbul University, Topkapi, Istanbul, Turkey
| | - Stephanie Wong
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Esther Rhei
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Mehra Golshan
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA.,Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.,Department of Surgery, Yale University School of Medicine, New Haven, CT, USA
| | - Jane Brock
- Department of Pathology, Brigham and Women's Hospital, Boston, MA, USA
| | - Thanh U Barbie
- Breast Oncology Program, Dana-Farber/Brigham and Women's Cancer Center, Boston, MA, USA. .,Division of Breast Surgery, Department of Surgery, Brigham and Women's Hospital, Boston, MA, USA.
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Does sentinel lymph node biopsy for screening high-grade ductal carcinoma in situ of the breast cause more harm than good? Breast Cancer Res Treat 2020; 182:47-54. [PMID: 32430678 DOI: 10.1007/s10549-020-05690-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2020] [Accepted: 05/11/2020] [Indexed: 10/24/2022]
Abstract
PURPOSE Ductal carcinoma in situ (DCIS) of the breast does not metastasize to axillary lymph nodes. Yet high-grade DCIS (HgDCIS) is often subjected to Sentinel Lymph Node Biopsy (SLNB) concomitant with definitive surgery. This is to avoid further axillary surgery in the event of upstaging to invasive carcinoma, which often entails Axillary Lymph Node Dissection (ALND). We wished to examine the validity of this approach. METHODS This study includes a retrospective analysis of consecutive pre-operatively diagnosed HgDCIS patients from a single screening unit between December/2014 and August/2016. The main outcomes were the overall incidence of upstaging and the independent predictors of upstaging on multivariable analysis. The rates of various complications of SLNB vs ALND in four RCTs were used to calculate the upstaging rate below which SLNB could be safely omitted. RESULTS There were 224 eligible patients of whom 26 (11.6%) were upstaged. Axillary metastasis (pN1) occurred in two patients (0.9%). On Univariable analysis, upstaged patients were significantly younger (median (IQR) = 56.0 (51.0-63) vs 60.0 (54.0-65.0); p = 0.019). Radiological size, pathological size, type of biopsy, type of operation, and comedo-necrosis were not significant (p > 0.05). On multivariable analysis, age as a continuous variable (OR 0.93; p = 0.031) and core biopsy (OR 2.62; p = 0.036) were the only independent predictors of upstaging. Chi-square test showed that patients < 55 years whose pre-operative diagnosis was made on core biopsy were at significantly higher risk of upstaging than the others (31.8% vs 9.4%; p = 0.002). CONCLUSION Upstaging of HgDCIS is infrequent. According to the known rates of complications of SLNB relative to ALND, routine SLNB concomitant with surgery seems to be more harmful than its routine omission. A selective approach based on age and type of biopsy could be considered.
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Ward WH, DeMora L, Handorf E, Sigurdson ER, Ross EA, Daly JM, Aggon AA, Bleicher RJ. Preoperative Delays in the Treatment of DCIS and the Associated Incidence of Invasive Breast Cancer. Ann Surg Oncol 2019; 27:386-396. [PMID: 31562602 PMCID: PMC6949196 DOI: 10.1245/s10434-019-07844-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Indexed: 12/17/2022]
Abstract
Background Although treatment delays have been associated with survival impairment for invasive breast cancer, this has not been thoroughly investigated for ductal carcinoma in situ (DCIS). With trials underway to assess whether DCIS can remain unresected, this study was performed to determine whether longer times to surgery are associated with survival impairment or increased invasion. Methods A population-based study of prospectively collected national data derived from women with a clinical diagnosis of DCIS between 2004 and 2014 was conducted using the National Cancer Database. Overall survival (OS) and presence of invasion were assessed as functions of time by evaluating five intervals (≤ 30, 31–60, 61–90, 91–120, 121–365 days) between diagnosis and surgery. Subset analyses assessed those having pathologic DCIS versus invasive cancer on final pathology. Results Among 140,615 clinical DCIS patients, 123,947 had pathologic diagnosis of DCIS and 16,668 had invasive ductal carcinoma. For all patients, 5-year OS was 95.8% and unadjusted median delay from diagnosis to surgery was 38 days. With each delay interval increase, added relative risk of death was 7.4% (HR 1.07; 95% CI 1.05–1.10; P < 0.001). On final pathology, 5-year OS for noninvasive patients was 96.0% (95% CI 95.9–96.1%) versus 94.9% (95% CI 94.6–95.3%) for invasive patients. Increasing delay to surgery was an independent predictor of invasion (OR 1.13; 95% CI 1.11–1.15; P < 0.001). Conclusions Despite excellent OS for invasive and noninvasive cohorts, invasion was seen more frequently as delay increased. This suggests that DCIS trials evaluating nonoperative management, which represents infinite delay, require long term follow up to ensure outcomes are not compromised. Electronic supplementary material The online version of this article (10.1245/s10434-019-07844-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- William H Ward
- Department of Surgery, Naval Medical Center, Portsmouth, VA, USA
| | - Lyudmila DeMora
- Biostatistics and Bioinformatics Facility, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Elizabeth Handorf
- Biostatistics and Bioinformatics Facility, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Elin R Sigurdson
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Eric A Ross
- Biostatistics and Bioinformatics Facility, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - John M Daly
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Allison A Aggon
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
| | - Richard J Bleicher
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA.
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van Leeuwen RJH, Kortmann B, Rijna H. Ductal Carcinoma in situ after Core Needle Biopsy: In Which Cases Is a Sentinel Node Biopsy Necessary? Breast Care (Basel) 2019; 15:260-264. [PMID: 32774220 DOI: 10.1159/000502277] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Accepted: 07/22/2019] [Indexed: 11/19/2022] Open
Abstract
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.
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Affiliation(s)
| | | | - Herman Rijna
- Department of Surgery, Spaarne Gasthuis, Haarlem, The Netherlands
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24
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Wang J, Tang H, Li X, Song C, Xiong Z, Wang X, Xie X, Tang J. Is surgical axillary staging necessary in women with T1 breast cancer who are treated with breast-conserving therapy? Cancer Commun (Lond) 2019; 39:25. [PMID: 31068224 PMCID: PMC6505128 DOI: 10.1186/s40880-019-0371-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 04/25/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND In the post-Z0011 trial era, the need to perform surgical axillary staging for early-stage breast cancer patients, who are treated with breast-conserving therapy (BCT), is being questioned. We conducted a retrospective cohort study using the Surveillance, Epidemiology, and End Results (SEER) database to evaluate the safety of waiving surgical axillary staging in patients with T1 breast cancer treated with BCT. METHODS A total of 166,615 eligible patients diagnosed between 2000 and 2012 were divided into staging (sentinel lymph node biopsy or axillary lymph node dissection) and non-staging (no lymph node examined or only needle aspiration biopsy of lymph nodes) groups. Propensity score matching (PSM) was performed to balance disparities between the two groups. Multivariate analysis with the Cox proportional hazards model was used to assess factors related to breast cancer-specific survival (BCSS). RESULTS Although the tumor size at time of presentation was decreasing over years, the rate of surgical axillary staging increased from 93.3% to 96.9%. The 5-year BCSS rates of the whole cohort (before PSM) and matched cohort (after PSM) were 98.0% and 97.5%. Within the matched cohort, the BCSS was significantly longer in the staging group than in the non-staging group (P < 0.001). However, surgical axillary staging did not benefit patients who were 50-79 years old, had tumor size < 1 cm, histological grade I disease, or favorable histological types (tubular/mucinous/papillary) in stratified analyses (P > 0.05). Race, marital status, hormone receptors, and chemotherapy were not associated with the favorable impact of surgical axillary staging on BCSS (P > 0.05). CONCLUSION Although surgical axillary staging remains important for T1 breast cancer patients treated with BCT, it might be unnecessary for patients with old age, small tumor, grade I disease, or favorable histological types.
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Affiliation(s)
- Jin Wang
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, No. 651 Dongfeng East Road, Yuexiu District, Guangzhou, 510060, Guangdong, P.R. China.
| | - Hailin Tang
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, No. 651 Dongfeng East Road, Yuexiu District, Guangzhou, 510060, Guangdong, P.R. China
| | - Xing Li
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, No. 651 Dongfeng East Road, Yuexiu District, Guangzhou, 510060, Guangdong, P.R. China
| | - Cailu Song
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, No. 651 Dongfeng East Road, Yuexiu District, Guangzhou, 510060, Guangdong, P.R. China
| | - Zhenchong Xiong
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, No. 651 Dongfeng East Road, Yuexiu District, Guangzhou, 510060, Guangdong, P.R. China
| | - Xi Wang
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, No. 651 Dongfeng East Road, Yuexiu District, Guangzhou, 510060, Guangdong, P.R. China
| | - Xiaoming Xie
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, No. 651 Dongfeng East Road, Yuexiu District, Guangzhou, 510060, Guangdong, P.R. China
| | - Jun Tang
- Department of Breast Oncology, State Key Laboratory of Oncology in South China, Collaborative Innovation Center for Cancer Medicine, Sun Yat-sen University Cancer Center, No. 651 Dongfeng East Road, Yuexiu District, Guangzhou, 510060, Guangdong, P.R. China.
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25
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Pollock SE, Pollock J, Nestor S, Hardin R, Ghaphery D. Sentinel node mapping and ductal carcinoma in situ. Breast Cancer 2019; 26:612-617. [PMID: 30903404 DOI: 10.1007/s12282-019-00960-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 03/11/2019] [Indexed: 11/25/2022]
Abstract
BACKGROUND Pure ductal carcinoma in situ (DCIS) is typically unassociated with a risk of regional lymph node involvement. Retrospective series maintain that larger tumors or high-grade histopathology may harbor a risk of lymph node involvement. PURPOSE Our community hospital retrospectively reviewed a series wherein women with DCIS were subjected to sentinel lymph node biopsy based on large tumor size and/or high-grade histopathology. MATERIALS AND METHODS 232 consecutive women with a diagnosis of pure DCIS were evaluated independently by two breast surgeons, one who typically offers sentinel node mapping to patients with tumors larger than 10 mm and the other who offers sentinel node mapping to women with grade 3 tumors. 60 women (26%) underwent sentinel node mapping along with appropriate surgery directed to the breast. Women were offered risk-adjusted adjuvant radiotherapy and anti-endocrine therapy. RESULTS At a median follow-up of 18 months (range 6-132 months), 9 women (15%) were identified with regional axillary nodal disease. A statistical analysis was conducted between women who did or did not undergo sentinel node mapping because there was overlap in large tumor size and high grade between the two groups. A univariate logistic regression statistic showed a trend toward a significant relationship between grade 3 tumors and a risk of occult nodal involvement. This was not confirmed by multivariate analysis. CONCLUSIONS In our moderate-sized surgical experience evaluating women with pure DCIS who underwent a sentinel node mapping due to large tumor size or high grade histology, we were unable to confirm that either is predictive of occult node involvement.
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Affiliation(s)
| | - Jondavid Pollock
- Division of Radiation Oncology, Schiffler Cancer Center, Wheeling, WV, USA.
| | - Scott Nestor
- Department of Pathology, Wheeling Hospital, Wheeling, WV, USA
| | - Rosemarie Hardin
- Department of Breast Surgery, Wheeling Hospital, Wheeling, WV, USA
| | - David Ghaphery
- Department of Breast Surgery, Wheeling Hospital, Wheeling, WV, USA
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Karakatsanis A, Hersi AF, Pistiolis L, Olofsson Bagge R, Lykoudis PM, Eriksson S, Wärnberg F, Nagy G, Mohammed I, Sundqvist M, Bergkvist L, Kwong A, Olofsson H, Stålberg P. Effect of preoperative injection of superparamagnetic iron oxide particles on rates of sentinel lymph node dissection in women undergoing surgery for ductal carcinoma in situ (SentiNot study). Br J Surg 2019; 106:720-728. [DOI: 10.1002/bjs.11110] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2018] [Revised: 10/31/2018] [Accepted: 12/11/2018] [Indexed: 01/07/2023]
Abstract
Abstract
Background
One-fifth of patients with a preoperative diagnosis of ductal carcinoma in situ (DCIS) have invasive breast cancer (IBC) on definitive histology. Sentinel lymph node dissection (SLND) is performed in almost half of women having surgery for DCIS in Sweden. The aim of the present study was to try to minimize unnecessary SLND by injecting superparamagnetic iron oxide (SPIO) nanoparticles at the time of primary breast surgery, enabling SLND to be performed later, if IBC is found in the primary specimen.
Methods
Women with DCIS at high risk for the presence of invasion undergoing breast conservation, and patients with DCIS undergoing mastectomy were included. The primary outcome was whether this technique could reduce SLND. Secondary outcomes were number of SLNDs avoided, detection rate and procedure-related costs.
Results
This was a preplanned interim analysis of 189 procedures. IBC was found in 47 and a secondary SLND was performed in 41 women. Thus, 78·3 per cent of patients avoided SLND (P < 0·001). At reoperation, SPIO plus blue dye outperformed isotope and blue dye in detection of the sentinel node (40 of 40 versus 26 of 40 women; P < 0·001). Costs were reduced by a mean of 24·5 per cent in women without IBC (€3990 versus 5286; P < 0·001).
Conclusion
Marking the sentinel node with SPIO in women having surgery for DCIS was effective at avoiding unnecessary SLND in this study. Registration number: ISRCTN18430240 (http://www.isrctn.com).
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Affiliation(s)
- A Karakatsanis
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - A-F Hersi
- Centre for Clinical Research, Uppsala University, Västerås, Sweden
- Department of Surgery, Västmanland County Hospital, Västerås, Sweden
| | - L Pistiolis
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - R Olofsson Bagge
- Department of Surgery, Institute of Clinical Sciences, Sahlgrenska Academy at University of Gothenburg, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - P M Lykoudis
- Division of Surgery and Interventional Science, University College London, London, UK
| | - S Eriksson
- Centre for Clinical Research, Uppsala University, Västerås, Sweden
- Department of Surgery, Västmanland County Hospital, Västerås, Sweden
| | - F Wärnberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - G Nagy
- Breast Unit, Department of Surgery, Linköping University Hospital, Linköping, Sweden
| | - I Mohammed
- Department of Surgery, Kalmar County Hospital, Kalmar, Sweden
| | - M Sundqvist
- Department of Surgery, Kalmar County Hospital, Kalmar, Sweden
| | - L Bergkvist
- Centre for Clinical Research, Uppsala University, Västerås, Sweden
| | - A Kwong
- Department of Surgery, University of Hong Kong, Hong Kong, University of Hong Kong-Shenzhen Hospital, Shenzhen, China, and Hong Kong Sanatorium and Hospital, Hong Kong
| | - H Olofsson
- Department of Clinical Pathology, Uppsala University Hospital, Uppsala, Sweden
| | - P Stålberg
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
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27
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Risk factors of sentinel and non-sentinel lymph node metastases in patients with ductal carcinoma in situ of the breast: A nationwide study. Breast 2018; 42:128-132. [PMID: 30257226 DOI: 10.1016/j.breast.2018.09.004] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2018] [Revised: 09/12/2018] [Accepted: 09/15/2018] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Unexplained axillary metastases have been detected in some patients with ductal carcinoma in situ (DCIS), possibly because of occult invasion or iatrogenic tumor cell displacement. The significance of these metastases is unknown and brings into questions the need for upstaging and axillary surgery. What are the risk factors for sentinel lymph node (SN) and non-SN metastases, including the risk of iatrogenic displacement of tumor cells in relation to an excisional biopsy, in patients diagnosed with DCIS? METHODS Nationwide data on 1787 women diagnosed with DCIS between 2001 and 2015 were retrieved from the Danish Breast Cancer Group database. The association of clinicopathological variables with a positive SN (isolated tumor cells (ITCs), micro- or macrometastases) was evaluated using univariate and multivariate analyses. RESULTS Of the 1787 patients, 71 (4.0%) had a positive SN: 15 (0.8%) had macrometastases, 42 (2.4%) had micrometastases, and 14 (0.8%) had ITCs. Five patients with a positive SN also had a positive non-SN. In adjusted analysis, a positive SN was associated with younger age (P = 0.036), increased size (P = 0.002), palpability (P = 0.0004) and surgical excisional biopsy (P < 0.001). CONCLUSIONS The overall risk of a positive SN in patients with DCIS on final pathology is low and less than 9% of these patients had positive non-SNs. This argues against using axillary lymph node dissection in this group. The odds of positive SN after surgical excisional biopsies showed more than a four-fold increase, indicating iatrogenic tumor cell displacement. It is questioned whether these patients should be upstaged and classified as having invasive carcinoma.
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Yoo J, Kim BS, Yoon HJ. Predictive significance of breast-specific gamma imaging for upstaging core-needle biopsy-detected ductal carcinoma in situ to invasive cancer. Ann Nucl Med 2018; 32:328-336. [DOI: 10.1007/s12149-018-1251-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Accepted: 03/15/2018] [Indexed: 12/21/2022]
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Fancellu A, Cottu P, Feo CF, Bertulu D, Giuliani G, Mulas S, Sanna V, Mura S, Madeddu G, Spanu A. Sentinel Node Biopsy in Early Breast Cancer: Lessons Learned from More than 1000 Cases at a Single Institution. TUMORI JOURNAL 2018; 98:413-20. [PMID: 23052155 DOI: 10.1177/030089161209800403] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Aims The aims of this paper are to report the development of sentinel node biopsy (SNB) in breast cancer at a single institution and to discuss the relevant issues on SNB still to be elucidated. Patients and methods From 1998 to 2010, 1021 SNBs with frozen section examination were carried out in patients with breast cancer. In the early period (1998–2002) SNB was always combined with axillary lymph node dissection (ALND). From 2002 onwards, only patients with a positive SNB result underwent ALND (late period). The characteristics of patients with infiltrating carcinoma (IC) and ductal carcinoma in situ (DCIS) and the histological status of the sentinel nodes were examined. The survival outcomes of node-negative patients were compared between patients submitted to SNB and ALND (ALND group) during the early period and patients who underwent only SNB during the late period (SNB group). Results The sentinel node was identified intraoperatively in 98.3% of cases. During the early period the overall accuracy of SNB was 97.0%. During the late period, 700 patients with IC and 140 with DCIS underwent SNB. In the IC group, 149 patients (21.3%) had sentinel node macrometastases and 36 (5.1%) micrometastases; of that subgroup, 21 underwent ALND and no other metastatic lymph nodes were found, and 15 underwent SNB only. Axillary recurrences were observed in 4 patients (0.77%) with negative SNB; none of these were among the patients with micrometastatic SNB. Two patients (1.4%) with DCIS had a positive SNB. In node-negative patients the 5-year overall survival was 96.7% in the ALND group and 96.5% in the SNB group (P = 0.63). The 5-year disease-free survival was 93.8% and 93.2% in the ALND and SNB groups, respectively (P = 0.77). Conclusions Overall and disease-free survival in patients with a negative SNB result and no further axillary surgery were equal to those in patients with negative ALND. Intraoperative assessment of the sentinel node in expert hands has a low false-negative rate and allows immediate ALND in patients with sentinel node metastases, avoiding the need for a second operation. ALND for sentinel node micrometastases may be safely omitted in most patients with early stage breast cancer.
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Affiliation(s)
| | | | | | | | | | | | | | - Silvia Mura
- Oncology Unit, University of Sassari, Sassari, Italy
| | | | - Angela Spanu
- Nuclear Medicine Unit, University of Sassari, Sassari, Italy
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30
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D'eredità G, Giardina C, Napoli A, Ingravallo G, Leopoldo Troilo V, Fischetti F, Berardi T. Sentinel Lymph Node Biopsy in Patients with Pure and High-Risk Ductal Carcinoma in Situ of the Breast. TUMORI JOURNAL 2018; 95:706-11. [DOI: 10.1177/030089160909500612] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
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.
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Affiliation(s)
| | | | - Anna Napoli
- Department of Pathology, University of Bari, Bari, Italy
| | | | | | | | - Tommaso Berardi
- Department of Clinical Methodology and Medical-Surgical Technologies
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31
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Holm-Rasmussen EV, Jensen MB, Balslev E, Kroman N, Tvedskov TF. The use of sentinel lymph node biopsy in the treatment of breast ductal carcinoma in situ: A Danish population-based study. Eur J Cancer 2017; 87:1-9. [DOI: 10.1016/j.ejca.2017.09.037] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2017] [Revised: 09/05/2017] [Accepted: 09/27/2017] [Indexed: 10/18/2022]
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Tasoulis MK, Hughes T, Babiera G, Chagpar AB. Sentinel lymph node biopsy in low risk settings. Am J Surg 2017; 214:489-494. [PMID: 28335989 DOI: 10.1016/j.amjsurg.2017.03.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2016] [Revised: 02/24/2017] [Accepted: 03/12/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) should be performed in patients with ductal carcinoma in situ (DCIS) undergoing mastectomy. Yet, the same logic is controversial in the setting of prophylactic mastectomy. METHODS Surgeons were surveyed as to their practices. Statistical analyses were performed to identify associated factors. RESULTS 238 surgeons responded to the survey. 73.1% of respondents stated they would always perform SLNB in the setting of mastectomy for DCIS, but only 6.6% would always do so in the prophylactic setting. While generally perceived that the rate of SLN positivity in the setting of pure DCIS and prophylactic mastectomy was <5% (96.9% and 99.5%, respectively), 61.8% of surgeons who reported "always" performing SLNB in the setting of DCIS treated with mastectomy stated they "never" performed a SLNB for prophylactic mastectomy. CONCLUSION SLNB practice patterns for these low risk settings are disparate. Consensus is required to rationalize practice.
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Affiliation(s)
| | - Tyler Hughes
- McPherson Medical and Surgical Associates, McPherson, KS, USA
| | - Gildy Babiera
- Department of Surgical Oncology and Radiology, University of Texas MD Anderson Cancer Center, Houston, USA
| | - Anees B Chagpar
- Department of Surgery, Yale University School of Medicine, New Haven, CT, USA.
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33
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Paganelli G, Matteucci F, Gilardi L. Nuclear Medicine in the Clinical Management (ROLL, SNB, and PET). Breast Cancer 2017. [DOI: 10.1007/978-3-319-48848-6_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Heymans C, van Bastelaar J, Visschers RGJ, Vissers YLJ. Sentinel Node Procedure Obsolete in Lumpectomy for Ductal Carcinoma In Situ. Clin Breast Cancer 2016; 17:e87-e93. [PMID: 28162949 DOI: 10.1016/j.clbc.2016.10.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Revised: 09/08/2016] [Accepted: 10/12/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Patients with a preoperative needle-biopsy diagnosis of ductal carcinoma in situ (DCIS) may have an indication for a sentinel lymph node biopsy if invasive carcinoma is found. We investigated how often a positive sentinel node and invasive carcinoma occurred in patients with a preoperative diagnosis of DCIS and whether this influenced the adjuvant regime. MATERIALS AND METHODS From 2005 to 2014, the records of 240 patients with needle-biopsy diagnosis of DCIS were retrospectively reviewed for postoperative pathology outcomes of the sentinel node and breast, and decisions on adjuvant treatment. Descriptive statistics and univariable and multivariable analysis were used. RESULTS A total of 160 of 240 patients underwent a sentinel node biopsy. Sixteen of 85 patients undergoing lumpectomy had occult invasive cancer. One patient had a micrometastasis. In patients undergoing mastectomy, 30 of 155 patients had occult invasive cancer. One patient had a micrometastasis, and 3 had a macrometastases. Eleven patients received adjuvant treatment as a result of invasive cancer. Three patients received adjuvant treatment (radiotherapy of the axilla or axillary dissection) because of node positivity. These patients underwent a primary mastectomy. CONCLUSION A positive sentinel lymph node biopsy in patients with needle-biopsy diagnosis of ductal DCIS is rare and rarely changes adjuvant regimes. Current Dutch guidelines should be updated.
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Affiliation(s)
- Cathelijne Heymans
- Department of Surgery, Zuyderland Medical Center, Sittard, The Netherlands
| | | | | | - Yvonne L J Vissers
- Department of Surgery, Zuyderland Medical Center, Sittard, The Netherlands.
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El Hage Chehade H, Headon H, Wazir U, Abtar H, Kasem A, Mokbel K. Is sentinel lymph node biopsy indicated in patients with a diagnosis of ductal carcinoma in situ? A systematic literature review and meta-analysis. Am J Surg 2016; 213:171-180. [PMID: 27773373 DOI: 10.1016/j.amjsurg.2016.04.019] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 04/19/2016] [Accepted: 04/29/2016] [Indexed: 02/08/2023]
Abstract
BACKGROUND Recent discussion has suggested that some cases of ductal carcinoma in situ (DCIS) with high risk of invasive disease may require sentinel lymph node biopsy (SLNB). METHODS Systematic literature review identified 48 studies (9,803 DCIS patients who underwent SLNB). Separate analyses for patients diagnosed preoperatively by core sampling and patients diagnosed postoperatively by specimen pathology were conducted to determine the percentage of patients with axillary nodal involvement. Patient factors were analyzed for associations with risk of nodal involvement. RESULTS The mean percentage of positive SLNBs was higher in the preoperative group (5.95% vs 3.02%; P = .0201). Meta-regression analysis showed a direct association with tumor size (P = .0333) and grade (P = .00839) but not median age nor tumor upstage rate. CONCLUSIONS The SLNB should be routinely considered in patients with large (>2 cm) high-grade DCIS after a careful multidisciplinary discussion. In the context of breast conserving surgery, the SLNB is not routinely indicated for low- and intermediate-grade DCIS, high-grade DCIS smaller than 2 cm, or pure DCIS diagnosed by definitive surgical excision.
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Affiliation(s)
- Hiba El Hage Chehade
- The London Breast Institute, Princess Grace Hospital, 42-52 Nottingham Place, London W1U 5NY, UK.
| | - Hannah Headon
- The London Breast Institute, Princess Grace Hospital, 42-52 Nottingham Place, London W1U 5NY, UK
| | - Umar Wazir
- The London Breast Institute, Princess Grace Hospital, 42-52 Nottingham Place, London W1U 5NY, UK
| | - Houssam Abtar
- The London Breast Institute, Princess Grace Hospital, 42-52 Nottingham Place, London W1U 5NY, UK
| | - Abdul Kasem
- The London Breast Institute, Princess Grace Hospital, 42-52 Nottingham Place, London W1U 5NY, UK
| | - Kefah Mokbel
- The London Breast Institute, Princess Grace Hospital, 42-52 Nottingham Place, London W1U 5NY, UK
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Al-Ameer AY, Al Nefaie S, Al Johani B, Anwar I, Al Tweigeri T, Tulbah A, Alshabanah M, Al Malik O. Sentinel lymph node biopsy in clinically detected ductal carcinoma in situ. World J Clin Oncol 2016; 7:258-264. [PMID: 27081649 PMCID: PMC4826972 DOI: 10.5306/wjco.v7.i2.258] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 08/15/2015] [Accepted: 01/29/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the indications for sentinel lymph node biopsy (SLNB) in clinically-detected ductal carcinoma in situ (CD-DCIS).
METHODS: A retrospective analysis of 20 patients with an initial diagnosis of pure DCIS by an image-guided core needle biopsy (CNB) between June 2006 and June 2012 was conducted at King Faisal Specialist Hospital. The accuracy of performing SLNB in CD-DCIS, the rate of sentinel and non-sentinel nodal metastasis, and the histologic underestimation rate of invasive cancer at initial diagnosis were analyzed. The inclusion criteria were a preoperative diagnosis of pure DCIS with no evidence of invasion. We excluded any patient with evidence of microinvasion or invasion. There were two cases of mammographically detected DCIS and 18 cases of CD-DCIS. All our patients were diagnosed by an image-guided CNB except two patients who were diagnosed by fine needle aspiration (FNA). All patients underwent breast surgery, SLNB, and axillary lymph node dissection (ALND) if the SLN was positive.
RESULTS: Twenty patients with an initial diagnosis of pure DCIS underwent SLNB, 2 of whom had an ALND. The mean age of the patients was 49.7 years (range, 35-70). Twelve patients (60%) were premenopausal and 8 (40%) were postmenopausal. CNB was the diagnostic procedure for 18 patients, and 2 who were diagnosed by FNA were excluded from the calculation of the underestimation rate. Two out of 20 had a positive SLNB and underwent an ALND and neither had additional non sentinel lymph node metastasis. Both the sentinel visualization rate and the intraoperative sentinel identification rate were 100%. The false negative rate was 0%. Only 2 patients had a positive SLNB (10%) and neither had additional metastasis following an ALND. After definitive surgery, 3 patients were upstaged to invasive ductal carcinoma (3/18 = 16.6%) and 3 other patients were upstaged to DCIS with microinvasion (3/18 = 16.6%). Therefore the histologic underestimation rate of invasive disease was 33%.
CONCLUSION: SLNB in CD-DCIS is technically feasible and highly accurate. We recommend limiting SLNB to patients undergoing a mastectomy.
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Nolan RM, Adie SG, Marjanovic M, Chaney EJ, South FA, Monroy GL, Shemonski ND, Erickson-Bhatt SJ, Shelton RL, Bower AJ, Simpson DG, Cradock KA, Liu ZG, Ray PS, Boppart SA. Intraoperative optical coherence tomography for assessing human lymph nodes for metastatic cancer. BMC Cancer 2016; 16:144. [PMID: 26907742 PMCID: PMC4763478 DOI: 10.1186/s12885-016-2194-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2015] [Accepted: 02/17/2016] [Indexed: 12/21/2022] Open
Abstract
Background Evaluation of lymph node (LN) status is an important factor for detecting metastasis and thereby staging breast cancer. Currently utilized clinical techniques involve the surgical disruption and resection of lymphatic structure, whether nodes or axillary contents, for histological examination. While reasonably effective at detection of macrometastasis, the majority of the resected lymph nodes are histologically negative. Improvements need to be made to better detect micrometastasis, minimize or eliminate lymphatic disruption complications, and provide immediate and accurate intraoperative feedback for in vivo cancer staging to better guide surgery. Methods We evaluated the use of optical coherence tomography (OCT), a high-resolution, real-time, label-free imaging modality for the intraoperative assessment of human LNs for metastatic disease in patients with breast cancer. We assessed the sensitivity and specificity of double-blinded trained readers who analyzed intraoperative OCT LN images for presence of metastatic disease, using co-registered post-operative histopathology as the gold standard. Results Our results suggest that intraoperative OCT examination of LNs is an appropriate real-time, label-free, non-destructive alternative to frozen-section analysis, potentially offering faster interpretation and results to empower superior intraoperative decision-making. Conclusions Intraoperative OCT has strong potential to supplement current post-operative histopathology with real-time in situ assessment of LNs to preserve both non-cancerous nodes and their lymphatic vessels, and thus reduce the associated risks and complications from surgical disruption of lymphoid structures following biopsy.
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Affiliation(s)
- Ryan M Nolan
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign (UIUC), 405 N. Mathews Ave., Urbana, IL, 61801, USA. .,PhotoniCare, Inc., Champaign, IL, USA.
| | - Steven G Adie
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign (UIUC), 405 N. Mathews Ave., Urbana, IL, 61801, USA. .,Department of Biomedical Engineering, Cornell University, Ithaca, NY, USA.
| | - Marina Marjanovic
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign (UIUC), 405 N. Mathews Ave., Urbana, IL, 61801, USA.
| | - Eric J Chaney
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign (UIUC), 405 N. Mathews Ave., Urbana, IL, 61801, USA.
| | - Fredrick A South
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign (UIUC), 405 N. Mathews Ave., Urbana, IL, 61801, USA. .,Department of Electrical and Computer Engineering, UIUC, Illinois, USA.
| | - Guillermo L Monroy
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign (UIUC), 405 N. Mathews Ave., Urbana, IL, 61801, USA. .,Department of Bioengineering, UIUC, Illinois, USA.
| | - Nathan D Shemonski
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign (UIUC), 405 N. Mathews Ave., Urbana, IL, 61801, USA. .,Department of Electrical and Computer Engineering, UIUC, Illinois, USA. .,Carl Zeiss Meditec, Inc., Dublin, CA, USA.
| | - Sarah J Erickson-Bhatt
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign (UIUC), 405 N. Mathews Ave., Urbana, IL, 61801, USA.
| | - Ryan L Shelton
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign (UIUC), 405 N. Mathews Ave., Urbana, IL, 61801, USA. .,PhotoniCare, Inc., Champaign, IL, USA.
| | - Andrew J Bower
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign (UIUC), 405 N. Mathews Ave., Urbana, IL, 61801, USA. .,Department of Electrical and Computer Engineering, UIUC, Illinois, USA.
| | - Douglas G Simpson
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign (UIUC), 405 N. Mathews Ave., Urbana, IL, 61801, USA. .,Department of Statistics, UIUC, Illinois, USA.
| | | | | | - Partha S Ray
- Carle Foundation Hospital, Urbana, IL, USA. .,Department of Surgery, University of Illinois College of Medicine at Urbana-Champaign and Carle Cancer Center, Urbana, IL, USA.
| | - Stephen A Boppart
- Beckman Institute for Advanced Science and Technology, University of Illinois at Urbana-Champaign (UIUC), 405 N. Mathews Ave., Urbana, IL, 61801, USA. .,Department of Electrical and Computer Engineering, UIUC, Illinois, USA. .,Department of Bioengineering, UIUC, Illinois, USA. .,Department of Internal Medicine, UIUC, Illinois, USA.
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Francis AM, Haugen CE, Grimes LM, Crow JR, Yi M, Mittendorf EA, Bedrosian I, Caudle AS, Babiera GV, Krishnamurthy S, Kuerer HM, Hunt KK. Is Sentinel Lymph Node Dissection Warranted for Patients with a Diagnosis of Ductal Carcinoma In Situ? Ann Surg Oncol 2015; 22:4270-9. [PMID: 25905585 PMCID: PMC5271669 DOI: 10.1245/s10434-015-4547-7] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND Positive sentinel lymph node (SLN) findings in ductal carcinoma in situ (DCIS) range from 1 to 22 % but have unknown biologic significance. This study sought to identify predictors of positive SLNs and to assess their clinical significance for patients with an initial diagnosis of DCIS. METHODS The study identified 1234 patients with an initial diagnosis of DCIS who underwent SLN dissection (SLND) at our institution from 1997 through 2011. Positive SLN findings were categorized as isolated tumor cells (ITCs) (≤0.2 mm), micrometastases (>0.2-2 mm), or macrometastases (>2 mm). Predictors of positive SLNs were analyzed, and survival outcomes were examined. RESULTS Positive SLN findings were identified in 132 patients (10.7 %): 66 patients with ITCs (5.4 %), 36 patients with micrometastases (2.9 %), and 30 patients with macrometastases (2.4 %). Upstaging to microinvasive (n = 68, 5.5 %) or invasive (n = 259, 21.0 %) cancer occurred for 327 patients (26.5 %). Factors predicting positive SLNs included diagnosis by excisional biopsy (odds ratio [OR] 1.90; P = 0.007), papillary histology (OR 1.77; P = 0.006), DCIS larger than 2 cm (OR 1.55; P = 0.030), more than three interventions before SLND (4 interventions: OR 2.04; P = 0.022; ≥5 interventions: OR 3.87; P < 0.001), and occult invasion (microinvasive: OR 3.44; P = 0.001; invasive: OR 6.21; P < 0.001). The median follow-up period was 61.7 months. Patients who had pure DCIS with and without positive SLNs had equivalent survival rates (100.0 vs 99.7 %; P = 0.679). Patients with occult invasion and positive SLNs had the worst survival rate (91.7 %; P < 0.001). CONCLUSIONS Occult invasion and more than three total interventions were the strongest predictors of positive SLN findings in patients with an initial diagnosis of DCIS. This supports the theory of benign mechanical transport of breast epithelial cells. Except for patients at high risk for invasive disease, routine use of SLND in DCIS is not warranted.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Breast Neoplasms/mortality
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/mortality
- Carcinoma, Ductal, Breast/secondary
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/mortality
- Carcinoma, Intraductal, Noninfiltrating/secondary
- Carcinoma, Intraductal, Noninfiltrating/surgery
- Female
- Follow-Up Studies
- Humans
- Lymph Node Excision
- Lymphatic Metastasis
- Middle Aged
- Neoplasm Invasiveness
- Neoplasm Micrometastasis
- Neoplasm Staging
- Prognosis
- Sentinel Lymph Node Biopsy
- Survival Rate
- Young Adult
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Affiliation(s)
- Ashleigh M Francis
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Christine E Haugen
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lynn M Grimes
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Jaime R Crow
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Min Yi
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Elizabeth A Mittendorf
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Isabelle Bedrosian
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Abigail S Caudle
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Gildy V Babiera
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Savitri Krishnamurthy
- Department of Pathology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Henry M Kuerer
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Kelly K Hunt
- Department of Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
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Abstract
OBJECTIVES To report our experience in sentinel lymph node biopsy (SLNB) in early breast cancer. METHODS This is a retrospective study conducted at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia between January 2005 and December 2014. There were 120 patients who underwent SLNB with frozen section examination. Data collected included the characteristics of patients, index tumor, and sentinel node (SN), SLNB results, axillary recurrence rate and SLNB morbidity. RESULTS There were 120 patients who had 123 cancers. Sentinel node was identified in 117 patients having 120 tumors (97.6% success rate). No SN was found intraoperatively in 3 patients. Frozen section results showed that 95 patients were SN negative, those patients had no immediate axillary lymph node dissection (ALND), whereas 25 patients were SN positive and subsequently had immediate ALND. Upon further examination of the 95 negative SN's by hematoxylin and eosin (H and E) and immunohistochemical staining for doubtful H and E cases, 10 turned out to have micrometastases (6 had delayed ALND and 4 had no further axillary surgery). Median follow up of patients was 35.5 months and the mean was 38.8 months. There was one axillary recurrence observed in the SN negative group. The morbidity of SLNB was minimal. CONCLUSION The obtainable results from our local experience in SLNB in breast cancer, concur with that seen in published similar literature in particular the axillary failure rate. Sentinel lymph node biopsy resulted in minimal morbidity.
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Affiliation(s)
- Abdulaziz A Alsaif
- Department of Surgery, Faculty of Medicine, King Khalid University Hospital, King Saud University, Riyadh, Kingdom of Saudi Arabia. E-mail.
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40
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Sun X, Li H, Liu YB, Zhou ZB, Chen P, Zhao T, Wang CJ, Zhang ZP, Qiu PF, Wang YS. Sentinel lymph node biopsy in patients with breast ductal carcinoma in situ: Chinese experiences. Oncol Lett 2015; 10:1932-1938. [PMID: 26622778 DOI: 10.3892/ol.2015.3480] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2014] [Accepted: 06/11/2015] [Indexed: 12/29/2022] Open
Abstract
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.
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Affiliation(s)
- Xiao Sun
- The Breast Cancer Center, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Hao Li
- The Breast Cancer Center, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Yan-Bing Liu
- The Breast Cancer Center, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Zheng-Bo Zhou
- The Breast Cancer Center, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Peng Chen
- The Breast Cancer Center, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Tong Zhao
- The Breast Cancer Center, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Chun-Jian Wang
- The Breast Cancer Center, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Zhao-Peng Zhang
- The Breast Cancer Center, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Peng-Fei Qiu
- The Breast Cancer Center, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
| | - Yong-Sheng Wang
- The Breast Cancer Center, Shandong Cancer Hospital, Jinan, Shandong 250117, P.R. China
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Yoon HJ, Kim Y, Kim BS. Intratumoral metabolic heterogeneity predicts invasive components in breast ductal carcinoma in situ. Eur Radiol 2015; 25:3648-58. [PMID: 26063655 DOI: 10.1007/s00330-015-3761-9] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2014] [Revised: 03/15/2015] [Accepted: 04/01/2015] [Indexed: 12/21/2022]
Abstract
OBJECTIVES This study investigated whether texture-based imaging parameters could identify invasive components of ductal carcinoma in situ (DCIS). METHODS We enrolled 65 biopsy-confirmed DCIS patients (62 unilateral, 3 bilateral) who underwent (18) F-FDG PET, diffusion-weighted imaging (DWI), or breast-specific gamma imaging (BSGI). We measured SUV max and intratumoral metabolic heterogeneity by the area under the curve (AUC) of cumulative SUV histograms (CSH) on PET, tumour-to-normal ratio (TNR) and coefficient of variation (COV) as an index of heterogeneity on BSGI, minimum ADC (ADC min ) and ADC difference (ADC diff ) as an index of heterogeneity on DWI. After surgery, final pathology was categorized as pure-DCIS (DCIS-P), DCIS with microinvasion (DCIS-MI), or invasive ductal carcinoma (IDC). Clinicopathologic features of DCIS were correlated with final classification. RESULTS Final pathology confirmed 44 DCIS-P, 14 DCIS-MI, and 10 IDC. The invasive component of DCIS was significantly correlated with higher SUV max (p = 0.017) and lower AUC-CSH (p < 0.001) on PET, higher TNR (p = 0.008) and COV (p = 0.035) on BSGI, lower ADC min (p = 0.016) and higher ADC diff (p = 0.009) on DWI, and larger pathologic size (p = 0.018). On multiple regression analysis, AUC-CSH was the only significant predictor of invasive components (p = 0.044). CONCLUSIONS The intratumoral metabolic heterogeneity of (18) F-FDG PET was the most important predictor of invasive components of DCIS. KEY POINTS • Preoperative identification of invasion in DCIS is important for axillary nodal management • Higher SUV max and lower AUC-CSH from FDG PET may indicate invasive components of DCIS • Higher TNR and COV from BSGI may indicate invasive components of DCIS • Lower ADC min and higher ADC diff from DWI may indicate invasive components of DCIS • AUC-CSH, an index of metabolic heterogeneity, is an independent predictor for invasive components.
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Affiliation(s)
- Hai-Jeon Yoon
- Department of Nuclear Medicine, Ewha Womans University School of Medicine, 911-1 Mok-Dong, Yangchun-Ku, Seoul, 158-710, Republic of Korea
| | - Yemi Kim
- Clinical Research Institute, Ewha Womans University, Seoul, Republic of Korea
| | - Bom Sahn Kim
- Department of Nuclear Medicine, Ewha Womans University School of Medicine, 911-1 Mok-Dong, Yangchun-Ku, Seoul, 158-710, Republic of Korea. .,Clinical Research Institute, Ewha Womans University, Seoul, Republic of Korea.
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Moncayo VM, Aarsvold JN, Alazraki NP. Lymphoscintigraphy and Sentinel Nodes. J Nucl Med 2015; 56:901-7. [DOI: 10.2967/jnumed.114.141432] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Accepted: 04/23/2015] [Indexed: 12/29/2022] Open
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44
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Sentinel lymph node biopsy is not warranted following a core needle biopsy diagnosis of ductal carcinoma in situ (DCIS) of the breast. Breast 2015; 24:197-200. [PMID: 25681861 DOI: 10.1016/j.breast.2015.01.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 01/11/2015] [Indexed: 12/19/2022] Open
Abstract
INTRODUCTION The role of sentinel lymph node biopsy (SLNB) in ductal carcinoma in situ (DCIS) is controversial. This study evaluates the risk of clinically relevant SLN metastasis following a core needle biopsy (CNB) diagnosis of pure DCIS. MATERIALS AND METHODS Cases that underwent SLNB following a CNB diagnosis of pure DCIS at our institution over a 4.5 year period were evaluated. Parameters including the DCIS characteristics on CNB, the rate of upstaging to invasive carcinoma at excision and the SLNB result were recorded. RESULTS Of 296 patients with a CNB diagnosis DCIS, 181 had SLNB (62%). The rate of invasion at excision in those undergoing SLNB was 30% (54/181). SLN metastasis was detected in 7/181 cases (4%), including 6 cases with isolated tumour cells only (3.5%) and only 1 case with a macro-metastatic deposit (0.5%). CONCLUSION The risk of clinically significant SLN metastasis following a CNB diagnosis of DCIS is extremely low, despite a relatively high rate of upstaging to invasive carcinoma at excision. Our findings support the opinion that SLNB is not warranted following a CNB diagnosis of DCIS, particularly for those patients undergoing breast conservation surgery.
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45
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Namm JP, Mueller J, Kocherginsky M, Kulkarni S. The Utility of Sentinel Lymph Node Biopsy in Patients with Ductal Carcinoma In Situ Suspicious for Microinvasion on Core Biopsy. Ann Surg Oncol 2014; 22:59-65. [DOI: 10.1245/s10434-014-3943-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2014] [Indexed: 01/16/2023]
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Wisner DJ, Hwang ES, Chang CB, Tso HH, Joe BN, Lessing JN, Lu Y, Hylton NM. Features of occult invasion in biopsy-proven DCIS at breast MRI. Breast J 2014; 19:650-8. [PMID: 24165314 DOI: 10.1111/tbj.12201] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
The purpose of this study is to determine if MRI BI-RADS criteria or radiologist perception correlate with presence of invasive cancer after initial core biopsy of ductal carcinoma in situ (DCIS). Retrospective search spanning 2000-2007 identified all core-biopsy diagnoses of pure DCIS that coincided with preoperative MRI. Two radiologists fellowship-trained in breast imaging categorized lesions according to ACR MRI BI-RADS lexicon and estimated likelihood of occult invasion. Semiquantitative signal enhancement ratio (SER) kinetic analysis was also performed. Results were compared with histopathology. 51 consecutive patients with primary core biopsy-proven DCIS and concurrent MRI were identified. Of these, 13 patients (25%) had invasion at excision. Invasion correlated significantly with presence of a mass for both readers (p = 0.012 and 0.001), rapid initial enhancement for Reader 1 (p = 0.001), and washout kinetics for Reader 2 (p = 0.012). Significant correlation between washout and invasion was confirmed by SER (p = 0.006) when threshold percent enhancement was sufficiently high (130%), corresponding to rapidly enhancing portions of the lesion. Radiologist perception of occult invasion was strongly correlated with true presence of invasion. These results provide evidence that certain BI-RADS MRI criteria, as well as radiologist perception, correlate with occult invasion after an initial core biopsy of DCIS.
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Affiliation(s)
- Dorota Jakubowski Wisner
- Department of Radiology & Biomedical Imaging, University of California, San Francisco, San Francisco, California
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47
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Detection and clinical relevance of hematogenous tumor cell dissemination in patients with ductal carcinoma in situ. Breast Cancer Res Treat 2014; 144:531-8. [DOI: 10.1007/s10549-014-2898-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2013] [Accepted: 02/21/2014] [Indexed: 10/25/2022]
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48
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Microbiopsie mammaire : fiabilité en fonction du BIRADS. IMAGERIE DE LA FEMME 2014. [DOI: 10.1016/j.femme.2014.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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49
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Omair M, Al-Azawi D, Mann GB. Sentinel node biopsy in breast cancer revisited. Surgeon 2014; 12:158-65. [PMID: 24548701 DOI: 10.1016/j.surge.2013.12.007] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Revised: 11/23/2013] [Accepted: 12/23/2013] [Indexed: 01/17/2023]
Abstract
The axilla has long been a focus of clinicians' attention in the management of breast cancer. The approach to the axilla has undergone dramatic changes over the last century, from radical and extended radical excisions, through the introduction of sentinel node biopsy for node negative patients to the current situation where selective management of those with nodal involvement is being introduced. The introduction of lymphatic mapping and sentinel node biopsy in the 1990's has been key to the major changes that have occurred. In less than 20 years it has moved from a hypothesis to a situation where it is the default approach to almost all clinically node negative patients and is being considered in other situations where axillary clearance was previously considered standard. This article reviews the development and introduction of sentinel node biopsy, its current uncertainties and limitations, and possible future developments.
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Affiliation(s)
- Mohammad Omair
- Department of Surgery, Royal Melbourne Hospital, University of Melbourne, Australia
| | - Dhafir Al-Azawi
- The Breast Service, Royal Melbourne and Royal Women's Hospital, Melbourne, Australia; St James's Hospital, Trinity College, Dublin, Ireland
| | - Gregory Bruce Mann
- Department of Surgery, Royal Melbourne Hospital, University of Melbourne, Australia; The Breast Service, Royal Melbourne and Royal Women's Hospital, Melbourne, Australia.
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Zetterlund L, Stemme S, Arnrup H, de Boniface J. Incidence of and risk factors for sentinel lymph node metastasis in patients with a postoperative diagnosis of ductal carcinoma in situ. Br J Surg 2014; 101:488-94. [DOI: 10.1002/bjs.9404] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/14/2013] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Positive sentinel lymph nodes (SLNs) are found in up to 13 per cent of women with a preoperative diagnosis of ductal carcinoma in situ (DCIS) of the breast and in up to 4 per cent of those with a postoperative diagnosis. This retrospective national register study investigated the incidence of positive SLNs in women with a postoperative diagnosis of DCIS, and the value of additional tumour sectioning to identify occult tumour invasion.
Methods
All surgical patients with a final histopathological diagnosis of pure DCIS registered in the Swedish national breast cancer register in 2008 and 2009 were eligible. Additional sectioning was performed on archived primary tumour tissue from women with SLN metastasis (including cases of isolated tumour cells) and matched SLN-negative control patients with the aim of detecting occult invasion.
Results
SLN tumour deposits were reported in 11 of 753 women who had SLN biopsy (macrometastases, 2; micrometastases, 3; isolated tumour cells, 6), resulting in a SLN positivity rate of 0·7 per cent (5 of 753). Occult invasion was found in one (9 per cent) of these 11 patients and in two (10 per cent) of 21 control patients. No risk factors for SLN metastasis were identified.
Conclusion
SLN positivity is rare in women with a histopathological diagnosis of pure DCIS. Additional primary tumour assessment may reveal occult invasion in both SLN metastasis-positive and -negative patients. The value of performing SLN biopsy in the setting of a preoperative diagnosis of DCIS was limited, and current Swedish practice should therefore be questioned.
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Affiliation(s)
- L Zetterlund
- Department of Surgery, Stockholm South General Hospital, Stockholm, Sweden
- Department of Clinical Science and Education, Karolinska Institute, Stockholm, Sweden
| | - S Stemme
- Department of Pathology, Karolinska University Hospital, Stockholm, Sweden
- Department of Oncology–Pathology, Karolinska Institute, Stockholm, Sweden
| | - H Arnrup
- Department of Acute Internal Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - J de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institute, Stockholm, Sweden
- Department of Breast and Endocrine Surgery, Karolinska University Hospital, Stockholm, Sweden
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