Revisit the practice of lymph node biopsy in patients diagnosed as ductal carcinoma in situ before operation: a retrospective analysis of 682 cases and evaluation of the role of breast MRI

Hung-Wen Lai,Chiung-Ying Liao,Dar-Ren Chen,Shou-Tung Chen,Hwa-Koon Wu,Yi-Lin Chang,Wen-Pei Wu,Shou-Jen Kuo,Yu-Jun Chang

doi:10.1186/s12957-021-02336-w

Abstract

BackgroundThe optimal axillary lymph node (ALN) management strategy in patients diagnosed with ductal carcinoma in situ (DCIS) preoperatively remains controversial. The value of breast magnetic resonance imaging (MRI) to predict ALN metastasis pre-operative DCIS patients was evaluated.MethodsPatients with primary DCIS with or without pre-operative breast MRI evaluation and underwent breast surgery were recruited from single institution. The value of breast MRI for ALN evaluation, predictors of breast and ALN surgeries, upgrade from DCIS to invasive cancer, and ALN metastasis were analyzed.ResultsA total of 682 cases with pre-operative diagnosis of DCIS were enrolled in current study. The rate of upgrade to invasive cancer were found in 34.2% of specimen, and this upgrade rate is 23% for patients who received breast conserving surgery and 40.7% for mastectomy (p < 0.01). Large pre-operative imaging tumor size and post-operative invasive component were risk factors to ALN metastasis. Breast MRI had 53.8% sensitivity, 77.8% specificity, 14.9% positive predictive value, 95.9% negative predictive value (NPV), and 76.2% accuracy to predict ALN metastasis in pre-OP DCIS patients. In MRI node-negative breast cancer patients with MRI tumor size < 3 cm, the NPV was 96.4%, and all these false-negative cases were N1. Pre-OP diagnosed DCIS patients with MRI tumor size < 3 cm and node negative suitable for BCS could safely omit SLNB if whole breast radiotherapy is to be performed.ConclusionBreast MRI had high NPV to predict ALN metastasis in pre-OP DCIS patients, which is useful and could be provided as shared decision-making reference.

Highlights

Lymph node evaluation plays important role of breast cancer staging and management, and had been evolved from axillary lymph node dissection (ALND) to sentinel lymph node biopsy (SLNB)
According to inclusion and exclusion criteria, a total of 682 cases with pre-OP biopsy diagnosed ductal car‐ cinoma in situ (DCIS) were enrolled in current study
The clinicopathologic characteristics and management flow chart of pre-OP DCIS patients were shown in Table 1 and Fig. 1

Summary

Introduction

Lymph node evaluation plays important role of breast cancer staging and management, and had been evolved from axillary lymph node dissection (ALND) to sentinel lymph node biopsy (SLNB). Indication and adequacy of application of SLNB in lymph node evaluation of patients with pre-operative (pre-OP) DCIS diagnosed by biopsy remained a debated issue as SLNB remains an invasive procedure and not morbidity free [18,19,20]. SLNB was not routinely suggested for patients with pre-OP DCIS planned to receive breast conserving surgery (BCS) as the rate of upgrade to DCIS-IC is not so high in lesion suitable for local excision, and even if invasive component found a secondary SLNB could still be performed [21]. In patients with pre-OP DCIS and indicated for mastectomy, SLNB remained recommended as the upgrade rate is increased and there would be rare chance for secondary lymph node surgical biopsy. The optimal axillary lymph node (ALN) management strategy in patients diagnosed with ductal car‐ cinoma in situ (DCIS) preoperatively remains controversial. The value of breast magnetic resonance imaging (MRI) to predict ALN metastasis pre-operative DCIS patients was evaluated

Methods

Results

Conclusion