Sentinel Lymph Node Biopsy In Ductal Carcinoma In Situ Research Articles

O081 De-escalating axillary dissection in mastectomy cases for ductal carcinoma in-situ

Abstract Introduction Axillary surgery has been de-escalated in invasive breast carcinoma and may be omitted in certain age groups according to the Choosing Wisely initiative. Invasion can be found in 10-20% of patients with ductal carcinoma in-situ (DCIS). Therefore, Sentinel lymph node biopsy (SLNB) is indicated to rule out nodal metastasis. Our purpose was to study the risk factors and outcome of positive SLNB. Methods A retrospective analysis was performed on a series of 67 cases of patients who underwent mastectomy with SLNB for DCIS at Beaumont Hospital, Ireland, Royal College of Surgeons in Ireland, between 2015 and 2021. We evaluated their clinical, histopathological characteristics and regional recurrence. Results Only one invasive component was identified out of 67 cases (1.5%). Eight patients (11.9%) had positive SLN, six with isolated tumour cells, one micro-metastasis and one macro-metastasis. The three patients who proceeded for axillary lymph node dissection (ALND) presented with palpable lump, nipple discharge and through family history screening; however, all additional nodes retrieved were negative. All three patients had >5 cm high/intermediate grade disease. They were ER receptor positive and HER-2 negative. Regional recurrence was not reported in any. Conclusion This study identified a low rate of positive SLNB in DCIS and microinvasion on final histopathology. Factors which may increase the risk of positive SLNB are large tumours, palpable lump or nipple discharge. Our results indicate that ALND can be safely omitted in DCIS with positive SLNB but may be considered in high-risk patients.

Investigate the accuracy and economic value of the upstaging prediction model for ductal carcinoma in situ.

e12577 Background: The current study aims to define the “high-risk upstaging model” in ductal carcinoma in situ (DCIS) and investigate its accuracy in order to suggest the most precise application of sentinel lymph node biopsy (SLNB). Methods: PubMed, EMBASE, and Cochrane library databases were searched. Prospective and retrospective cohort studies that evaluated the pathological outcomes of SLNB and the upstaging rate in women with DCIS were included. We analyzed factors that potentially indicate nodal involvement risk and combine the significant ones into “high-risk upstaging model”. Consecutively, we conducted a retrospective study by applying our model and NCCN guideline model into DCIS patients extracted from hospital database. Both the excess treatment rate and incomplete treatment rate of SLNB were analyzed. The diagnostic performance of the model in predicting upstaging risk was evaluated with receiver operating characteristic (ROC) curve. Results: We retrieved 43 prospective and 69 retrospective studies including 44,001 DCIS patients. The upstaging rate was significantly higher in patients with estrogen receptor-negative status, palpable mass, tumor size > 2 cm on imaging, and high-nuclear grade and those who received a preoperative diagnosis through core needle biopsy. We then collected 168 DCIS patients who entered in Shuang-Ho hospital from February 2017 to August 2021. Ninety-six patients who didn’t upstage in final pathology have received extra SLNB and two patients who upstaged in final pathology did not receive SLNB in primary surgery. The areas under the ROC curve of the model developed by multivariable logistic regression for predicting upstaging risk in the NCCN guideline group and “high-risk upstaging model” group were 0.642 and 0.706, the sensitivity at 66.0% and 83.0%, and the specificities at 62.5% and 49.2%, respectively. Conclusions: “High-risk upstaging model” shows higher areas under the ROC curve and sensitivity as well compared with current NCCN guideline. Our prediction model can provide surgeons with a more accurate and specific indications of SLNB in DCIS.

Utilidad del estudio del ganglio centinela en carcinoma ductal in situ diagnosticado mediante biopsia con sistema de corte por vacío

IntroductionAbout 24% of patients with ductal carcinoma in situ (DCIS) diagnosed with a core biopsy will also be found to have an invasive component when the lesion is completely excised. This underestimation is reduced when the biopsy is undertaken with a vacuum-assisted device (VAD). We evaluated our experience in the diagnosis of DCIS with a VAD and the final result of the sentinel lymph node biopsy (SLNB) in these patients. MethodsThis study included patients from the CECLINES database in Caracas (Venezuela) from 1998 to 2013. Out of 841 SLNB performed during that period, 64 corresponded to DCIS, diagnosed by a VAD under stereotactic or ultrasound guidance. Patients with microinvasion (pT1mic) or mixed lesions at the time of the pathological evaluation of the biopsy specimen, as well as those diagnosed by a core device, were excluded from this investigation. The methodology for the biopsy consisted of multiple samples from different parts of the lesion. The indications for SLNB in DCIS were: size >30mm (extensive DCIS) or a scheduled mastectomy. ResultsThe detection rate was 95.3% (61/64). Median lesion size was 40mm (SD 19.6). A total of 67.1% (43/64) had a diagnosis of extensive DCIS. In 87.5% (56/64), the mammographic findings were microcalcifications. Most of the lesions (92.1% [59/64]) were non-palpable. A median of 16 (SD 10.4) samples per lesion were obtained. Mastectomy was performed in 82.8% (53/64) of the patients. The distribution of histological grade was: G1 in 15.6% (10/64), G2 in 60.9% (39/64) and G3 in 23.5% (15/64). None of the patients had a positive SLNB. No positive lymph nodes were found in any of the patients who underwent axillary dissection. The underestimation rate for biopsy with a VAD was 6.2% (4/64). ConclusionsThe underestimation rate of DCIS was very low when the biopsy was performed with a VAD and when multiple samples were obtained in non-palpable lesions, regardless of the lesion size or the histological grade. We believe that SLNB can be omitted in selected patients with DCIS.

Is Sentinel Lymph Node Biopsy Indicated at Completion Mastectomy for Ductal Carcinoma In Situ?

Sentinel lymph node biopsy (SLNB) is recommended when mastectomy is performed for ductal carcinoma in situ (DCIS). The role of SLNB for women with DCIS who undergo mastectomy following one or more attempts at breast-conserving surgery (BCS) is uncertain. We examined the upgrade rate and SLNB yield in women who converted to mastectomy after one or more attempts at BCS for DCIS. All patients who underwent one or more attempts at BCS prior to conversion to mastectomy with SLNB for DCIS were identified. Margin status as the indication for mastectomy was confirmed, and comparisons were made between patients with/without upgrade on final pathology. From February 2006 to November 2012, a total of 233 patients underwent completion mastectomy following one or more attempts at BCS for positive/close margins (median age 50years; range 34-84). The median number of BCS attempts was 1 (range 1-4). Overall, 20 (9%) patients were upgraded on final pathology; 15 (6%) stage I, and 5 (3%) stage II (three micrometastasis, two macrometastasis). In two of five cases with a positive SLN, invasive carcinoma was not identified in the mastectomy specimen. The only factor associated with any upgrade was the presence of micropapillary DCIS (80 vs. 55%, with and without upgrade; p=0.03). In this cohort of patients with DCIS who converted to mastectomy for positive/close margins after one or more attempts at BCS, 18 (8%) would have required second-stage axillary surgery had an SLNB not been performed, and in two (1%) patients, the SLN provided the only evidence of invasion. These findings support the recommendation for SLNB at the time of completion mastectomy.

Predictors of Treatment with Mastectomy, Use of Sentinel Lymph Node Biopsy and Upstaging to Invasive Cancer in Patients Diagnosed with Breast Ductal Carcinoma In situ (DCIS) on Core Biopsy

There are few established indications for sentinel lymph node biopsy (SLNB) in breast ductal carcinoma in situ (DCIS). This study examines factors contributing to the high rate of SLNB in DCIS in Alberta, Canada. Patients who underwent definitive surgery from January 2009 to July 2011 for DCIS diagnosed on preoperative core-needle biopsy were identified using a provincial synoptic operative report database (WebSMR). The relationship between baseline patient and tumor characteristics and treatment with total mastectomy (TM), use of SLNB, and upstaging were examined. There were 394 patients identified in the study cohort. Mean age was 57 years, and average preoperative tumor size was 3 cm. Overall, 148 patients (37.6 %) underwent TM; predictors were preoperative tumor size [odds ratio (OR), 1.92 per 1-cm increase in size; 95 % CI 1.65-2.24] and surgeon. Upstaging to invasive cancer at surgery occurred in 23 %, predicted only by preoperative tumor size (OR 1.14 per 1 cm; 95 % CI 1.03-1.27). SLNB was performed in 306 patients overall (77 %) and 140 of those treated with BCS (61 %). Predictors of SLNB were larger preoperative tumor size (OR 1.55 per 1 cm; 95 % CI 1.18-2.04) and the surgeon. In patients treated with BCS, 3 patients who were upstaged had positive SLNs (>0.2 mm), and no patients with DCIS had a positive SLN. SLNB use is high in patients undergoing BCS for DCIS. Tumor size and the operating surgeon predicted SLNB use. Despite a 23 % upstaging rate, the rate of clinically significant positive SLNs in patients treated with BCS is low, supporting omission of upfront SLNB.

Is there any utility to frozen section or immunohistochemistry examination of the sentinel lymph node (SLN) in patients with ductal carcinoma in situ (DCIS)?

1091 Background: Whether SLN biopsy (SLNB) should be performed in patients with DCIS is controversial. Many centers perform SLNB in DCIS believing it obviates the need for re-operation for axillary staging when invasive cancer (IC) is discovered. Given the low incidence of occult IC detected, whether intra-operative pathologic evaluation during SLNB in DCIS patients provides value has not been addressed. Methods: Demographic and clinico-pathologic data was collected and analyzed for all patients undergoing surgical resection for DCIS between 2004-2010 in order to determine the sensitivity, specificity and accuracy of frozen section (FS) and immuno-histochemistry (IHC) examination of the SLN, and its’ impact on axillary management. Results: 267 DCIS patients (median age 57 years) underwent lumpectomy (N=72) or mastectomy (N=195) with SLNB, intra-operative FS and IHC evaluation. Pre-operative pathology was DCIS (N=231), DCIS with micro-invasion (< 2 mm, N= 24) and DCIS associated with other lesions (N=12). SLN metastasis (SLNM) was identified in 13 patients (4%), of which only 4 were FS positive (1%). SLN micrometastasis (≤ 2 mm) and individual tumor cells (ITCs) were detected by IHC in 10 of 13 patients, while 3 patients had macro-metastasis. Overall, 50 patients (19%) had IC on final pathology. The FS was falsely negative in 9 patients (7%), and had sensitivity, specificity and accuracy of 31%, 100% and 98% respectively in identifying SLNM. 8 of 13 patients with SLNM underwent axillary lymph node dissection (ALND) of which only 1 patient (with macro-metastasis) had further axillary metastasis. On a need to treat basis, 30 and 91 patients would have to undergo FS and IHC exam respectively to identify 1 patient with a metastasis. Conclusions: SLN metastasis in DCIS is uncommon and the prognostic significance of micro-metastasis or ITCs in DCIS is unknown. Given the infrequent higher axillary nodal involvement and low sensitivity and yield of FS and IHC evaluation in DCIS particularly for identifying candidates for ALND, these procedures can be safely omitted thereby reducing operative time and cost. Additional studies are needed to validate these results.

Clinical Applications of Sentinel Lymph Node Biopsy in Ductal Carcinoma in situ of the Breast: A Dilemma

Breast cancer is the fifth most common cause of cancer deaths in the world, which often spreads first to the axillary lymph nodes (ALN) from the primary tumor. ALN helps clinician stage breast cancer. In addition, it is one of the key prognostic factors for patients with invasive breast cancer. The sentinel lymph node (SLN) is defined as the first regional lymph node to receive lymphatic fluid from a malignant tumor. As a result, it seems possible to assess the complete nodal status with sentinel lymph node biopsy (SLNB), which is attractive and reliable approach for identifying lymph node metastasis. Ductal carcinoma in situ (DCIS) is the most common type of non-invasive breast cancer. However, the role of SLNB in DCIS is controversial because DCIS does not cause invasion and metastasis theoretically. In this review, clinical applications of SLNB in DCIS will be discussed. The potential benefit of accurately upstaging patients with DCIS and the minimal invasiveness of SLNB justify use of SLNB in selected high-risk DCIS patients. At least DSIS with microinvasion, have DCIS of sufficient extent on mammography or MRI, or indicated invasive or microinvasive focus by final histological examination, are recommended for SLNB. Moreover, large randomized trials to evaluate the usefulness of SLNB in DCIS patients after long-term follow-up on local control and survival are required for further evaluation.

Value of Sentinel Lymph Node Biopsy in Breast Ductal Carcinoma in Situ Upstaged to Invasive Carcinoma

The role of sentinel lymph node (SLN) biopsy in patients with initial diagnosis of ductal carcinoma in situ (DCIS) is still a dilemma. Different studies are trying to define predicting factors of invasive cancer in DCIS. The aim of this study was to confirm the value of SLN biopsy in DCIS because of the invasive upstaging risk on final histology. Patients with initial diagnosis of DCIS and with axillary SLN biopsy were selected. All diagnoses were confirmed by biopsy of mammographic lesions. Surgical treatment was lumpectomy or mastectomy associated with SLN biopsy. Imprint stains were performed, and then serial sections were stained with hematoxylin and eosin (H&E) and with immunohistochemistry (IHC). A complete axillary lymph node dissection (ALND) was performed during the same surgery when a node metastasis was found. Eighty patients were enrolled in the study. Of the 61 patients who were initially diagnosed with DCIS, 12 (20%) were upstaged to microinvasive or invasive carcinoma and 9 (15%) had a metastatic SLN. Patients upstaged to invasive carcinoma had macrometastatic SLN immediately fed by a complete ALND. SLN micrometastases and isolated cells were detected by IHC and secondary complete ALND found an additional metastatic lymph node in one patient. Tumor size larger than 30 mm and mastectomy were the only significative predicting factors of upstaged disease (p < 0.0001) in our study. In patients with initial diagnosis of large DCIS programmed for mastectomy, SLN biopsy should be discussed in order to detect underlying invasive disease and to spare patients a second operating time.

The value of sentinel lymph node biopsy in ductal carcinoma in situ (DCIS) and DCIS with microinvasion of the breast

Aim Ductal carcinoma in situ (DCIS) refers to the preinvasive stage of breast carcinoma and should not give axillary metastases. Its diagnosis, however, is subject to sampling errors. The role of sentinel lymph node biopsy (SLNB) in management of DCIS or DCISM (with microinvasion) remains unclear. The purpose of this study was to review our experience with SLNB in DCIS and DCISM. Methods A review of 51 patients with a diagnosis of DCIS ( n = 45) or DCISM ( n = 6), who underwent SLNB and a definitive breast operation between January 1999 and December 2006, was performed. Results In 10 patients (19.6%) definitive histology revealed an invasive carcinoma. SLN (micro)metastases were detected in 5 out of 51 patients, of whom 2 had a preoperative diagnosis of grade III DCIS and 3 of DCISM. Three patients (75%) had micrometastases (<2 mm) only. In 2 patients, histopathology demonstrated a macrometastasis (>2 mm). All 5 patients underwent axillary dissection. No additional positive axillary lymph nodes were found. Conclusions In case of a preoperative diagnosis of grade III DCIS or a grade II DCIS with comedo necrosis and DCIS with microinvasion, an SLNB procedure has to be considered because in almost 20% of the patients an invasive carcinoma is found after surgery. In this case the SLNB procedure becomes less reliable after a lumpectomy or ablation has been performed. SLN (micro)metastases were detected in nearly 10% of the patients. The prognostic significance of individual tumour cells remains unclear.

Sentinel Lymph Node Biopsy for Ductal Carcinoma in Situ: An Evolving Approach at the University of Florida

While sentinel lymph node biopsy (SLNB) has virtually replaced axillary dissection as the initial diagnostic procedure for invasive breast cancer, the role of SLNB in ductal carcinoma in situ (DCIS) remains controversial. The purpose of this study was to review our experience with SLNB in DCIS. All patients with DCIS or DCIS with microinvasion (DCISM) who underwent SLNB from June 1997 to April 2002 at the University of Florida were included for analysis. The indications for SLNB were at the discretion of the treating surgeon. Lymphatic mapping involved a sequential dermal-peritumoral radiocolloid injection and dynamic lymphoscintigraphy followed by an intraoperative assessment of radioactivity with a handheld gamma probe. All sentinel lymph nodes (SLNs) with radioactive counts>or=10% of the ex vivo counts of the most radioactive SLN were removed. Pathologic analysis consisted of slicing the SLN at 2 mm intervals for permanent section. All paraffin blocks of the SLNs were step sectioned in 4 microm sections (92 microm spacing) through the entire lymph node. Slides were then stained with an immunohistochemical stain for cytokeratin (AE1/AE3) and evaluated by microscopy. Nodal metastases were classified using the 6th edition of the American Joint Committee on Cancer (AJCC) staging manual. From April 1998 to April 2002, 43 patients with DCIS underwent SLNB at the University of Florida. Seven patients (16%) with multifocal or extensive DCIS (five patients) or DCISM (two patients) who underwent SLNB had a positive sentinel node. Two of the three patients considered positive by immunohistochemistry alone had either DCISM or invasive disease. Four (80%) of the five patients with extensive DCIS and a positive sentinel node were ultimately determined to have invasive or microinvasive disease. While SLNB remains controversial in DCIS, our data suggest that patients with extensive DCIS should undergo SLNB at the initial procedure to avoid the need for a second operation. Data from clinical trials are needed to determine the impact of SLNB results on overall survival in patients with DCIS.

An update of sentinel lymph node mapping in patients with ductal carcinoma in situ

Objective The purpose of our study is to further clarify the incidence of ductal carcinoma in situ (DCIS) patients that are upstaged upon final pathology and/or have metastatic disease in the axilla. Methods All patients were diagnosed with DCIS or DCIS with microinvasion (DCISm) on their diagnostic biopsy and received a sentinel lymph node (SLN) biopsy between 1994 and 2004. Six hundred seventy-five patients were divided into 613 patients with DCIS and 62 patients with DCISm. Results Sixty-six of 675 (10%) were upstaged to invasive cancer. Fifty-five of 613 (9%) patients with DCIS were upstaged, whereas 11 of 62 (18%) patients with DCISm were upstaged. Forty-nine of 675 (7%) patients had +SLN. Twenty-two of 49 (45%) patients with +SLN had invasive carcinoma or DCISm on final histology. Conclusions After review of histology, grade, type of biopsy, and mammographic findings, the combined findings of high grade, mass by mammography, and microinvasion predict patients at higher risk for invasive carcinoma. Selective utilization of SLN biopsy in DCIS is recommended.

Prélèvement de ganglions sentinelles dans les carcinomes intracanalaires du sein (± micro-invasion)

Purpose. – The aim of this study was to define the interest of sentinel lymph node biopsy (SLNB) for the staging of ductal carcinoma in situ (DCIS) and DCIS with micro-invasion (DCISM) in patients with breast carcinoma. Material and methods. – From June 1999 to December 2002 we listed, in a retrospective study, 52 patients treated surgically for a DCIS or a DCISM. All except one had an histology before surgery, and all had SLNB. Intraoperative imprint cytology of the sentinel lymph node (SLN) was performed then there were analysed by staining with hematoxylin-eosin. Patients with positive SLN underwent complete axillary dissection. Results. – It was removed an average of three SLNs by patient (extreme 1 to 6). Metastases in the SLN were detected in four (7,7%) of the 52 patients, including three cases had only micrometastases in the SLN. In the four patients treated with complete axillary dissection, the SLN were the only positives nodes. Conclusion. – The SLNB for DCIS and DCISM increases the involvement rate of lymph node. Because of the widespread for early detection of breast cancer, it is noted a regular increase in the rate of DCIS. Even if the attitude to be had towards the lymph node metastases in these cases is not yet well defined, and so only 2% of the patients approximately die of this pathology, it is interesting because of increase in absolute value of mortality, to try to improve the prognosis criteria to modify the treatment of this pathology.

Point: Sentinel Lymph Node Biopsy Is Indicated for Patients With DCIS

Sentinel lymph node (SLN) biopsy, a new standard of care for staging invasive breast cancer, remains controversial for ductal carcinoma in situ (DCIS). Although DCIS has a natural history in which long-term distant disease-free survival (DDFS) is 98% to 99% and axillary node metastases are historically rare, three recent DCIS series have found SLN metastases in a surprising 6% to 13% of patients. The strongest argument for SLN biopsy in DCIS is the diagnostic uncertainty and inherent sampling error of conventional pathologic techniques. Definitive surgery (excision or mastectomy) reveals invasive cancer in 10% to 21% of patients with a preoperative core needle or surgical biopsy diagnosis of DCIS, all of whom become conventional candidates for SLN biopsy. In the absence of proven invasion, most positive SLN in DCIS are micrometastases detected by hematoxylin and eosin- and immunohistochemical-stained serial sections. An increasing body of evidence suggests that these are prognostically significant, not artifactual. We propose that DCIS patients with positive SLN have occult invasive cancers, and that the same may have been true for the 1% to 2% of DCIS patients who go on to develop distant metastasis, either after an invasive local recurrence or as a first event. We further suggest that the diagnosis of DCIS encompasses two patient populations: 1) a majority (perhaps 90%) with true in situ disease (or prognostically insignificant invasion), negative SLNs, and an expected DDFS of 100%; and 2) a minority (perhaps 10%) with occult invasion, positive SLNs, and an expected DDFS of perhaps 90%. Pending the development of predictive models for preoperative identification of this SLN-positive minority of DCIS patients, SLN biopsy is indicated in any DCIS patient who may have an underlying invasive cancer, especially those who require mastectomy. In DCIS, SLN biopsy may ultimately prove to be a more sensitive screening test for occult invasion than examination of the breast itself.