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Zhu K, Sui Y, Zhu M, Gao Y, Yuan Y, Sun P, Meng L, Dai J, Li Z. Development and validation of a nomogram for predicting lymph node metastasis in ductal carcinoma in situ with microinvasion: A SEER population-based study. PLoS One 2024; 19:e0301057. [PMID: 38557552 PMCID: PMC10984531 DOI: 10.1371/journal.pone.0301057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 03/06/2024] [Indexed: 04/04/2024] Open
Abstract
BACKGROUND Ductal carcinoma in situ with microinvasion (DCIS-MI) is a special type of breast cancer. It is an invasive lesion less than 1.0 mm in size related to simple ductal carcinoma in situ (DCIS). Lymph node metastasis (LNM) in DCIS-MI often indicates a poor prognosis. Therefore, the management of lymph nodes plays a vital role in the treatment strategy of DCIS-MI. Since DCIS-MI is often diagnosed by postoperative paraffin section and immunohistochemical detection, to obtain the best clinical benefits for such patients, we aim to establish and verify a nomogram to predict the possibility of lymph node metastasis in DCIS-MI patients and help preoperative or intraoperative clinical decision-making. METHODS A retrospective analysis of patients with DCIS-MI in the Surveillance, Epidemiology, and End Results (SEER) database from 2010 to 2019 was performed. The study cohort was randomly divided into a training cohort and a validation cohort at a ratio of 7:3. The risk factors were determined by univariate and multivariate logistic regression analyses in the training cohort, and a nomogram was constructed. The receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) were used to evaluate the nomogram in the training set and validation set. An independent data cohort was obtained from the Shanghai Jiao Tong University Breast Cancer Database (SJTU-BCDB) for external validation. RESULTS This study included 3951 female patients from SEER with DCIS-MI, including 244 patients with regional lymph node metastasis, accounting for 6.18% of the total. An independent test set of 323 patients from SJTU-BCDB was used for external validation. According to the multifactorial logistic regression analysis results, age at diagnosis, ethnicity, grade, and surgical modality were included in the prediction model. The areas under the ROC curves (AUCs) were 0.739 (95% CI: 0.702~0.775), 0.732 (95% CI: 0.675~0.788), and 0.707 (95%CI: 0.607-0.807) in the training, validation and external test groups, suggesting that the column line graphs had excellent differentiation. The calibration curves slope was close to 1, and the model's predicted values were in good agreement with the actual values. The DCA curves showed good clinical utility. CONCLUSION In this study, we constructed accurate and practical columnar maps with some clinical benefit to predict the likelihood of lymph node metastasis in patients with postoperatively diagnosed DCIS-MI and provide a reference value for specifying treatment strategies.
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Affiliation(s)
- Kaijun Zhu
- School of Medicine, Shaoxing University, Shaoxing, Zhejiang, P. R. China
| | - Yuan Sui
- School of Medicine, Shaoxing University, Shaoxing, Zhejiang, P. R. China
| | - Mingliao Zhu
- School of Medicine, Shaoxing University, Shaoxing, Zhejiang, P. R. China
| | - Yuan Gao
- Department of Breast and Thyroid Surgery, Shaoxing People’s Hospital, The First Affiliated Hospital of Shaoxing University, Shaoxing, Zhejiang Province, People’s Republic of China
| | - Ying Yuan
- School of Medicine, Shaoxing University, Shaoxing, Zhejiang, P. R. China
| | - Pujian Sun
- School of Medicine, Shaoxing University, Shaoxing, Zhejiang, P. R. China
| | - Liwei Meng
- Department of Breast and Thyroid Surgery, Shaoxing People’s Hospital, The First Affiliated Hospital of Shaoxing University, Shaoxing, Zhejiang Province, People’s Republic of China
| | - Jiangfeng Dai
- Department of Oncological Surgery, Shaoxing Second Hospital, Shaoxing, Zhejiang, China
| | - Zhian Li
- Department of Oncological Surgery, Shaoxing Second Hospital, Shaoxing, Zhejiang, China
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Rodriguez-Tirado C, Sosa MS. How much do we know about the metastatic process? Clin Exp Metastasis 2024:10.1007/s10585-023-10248-0. [PMID: 38520475 DOI: 10.1007/s10585-023-10248-0] [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: 08/13/2023] [Accepted: 11/17/2023] [Indexed: 03/25/2024]
Abstract
Cancer cells can leave their primary sites and travel through the circulation to distant sites, where they lodge as disseminated cancer cells (DCCs), even during the early and asymptomatic stages of tumor progression. In experimental models and clinical samples, DCCs can be detected in a non-proliferative state, defined as cellular dormancy. This state can persist for extended periods until DCCs reawaken, usually in response to niche-derived reactivation signals. Therefore, their clinical detection in sites like lymph nodes and bone marrow is linked to poor survival. Current cancer therapy designs are based on the biology of the primary tumor and do not target the biology of the dormant DCC population and thus fail to eradicate the initial or subsequent waves of metastasis. In this brief review, we discuss the current methods for detecting DCCs and highlight new strategies that aim to target DCCs that constitute minimal residual disease to reduce or prevent metastasis formation. Furthermore, we present current evidence on the relevance of DCCs derived from early stages of tumor progression in metastatic disease and describe the animal models available for their study. We also discuss our current understanding of the dissemination mechanisms utilized by genetically less- and more-advanced cancer cells, which include the functional analysis of intermediate or hybrid states of epithelial-mesenchymal transition (EMT). Finally, we raise some intriguing questions regarding the clinical impact of studying the crosstalk between evolutionary waves of DCCs and the initiation of metastatic disease.
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Affiliation(s)
- Carolina Rodriguez-Tirado
- Department of Microbiology and Immunology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, 10461, USA.
- Department of Oncology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, 10461, USA.
- Montefiore Einstein Comprehensive Cancer Center, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, 10461, USA.
- Cancer Dormancy and Tumor Microenvironment Institute/Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10461, USA.
- Ruth L. and David S. Gottesman Institute for Stem Cell Research and Regenerative Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, 10461, USA.
| | - Maria Soledad Sosa
- Department of Microbiology and Immunology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, 10461, USA.
- Department of Oncology, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, 10461, USA.
- Montefiore Einstein Comprehensive Cancer Center, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, 10461, USA.
- Cancer Dormancy and Tumor Microenvironment Institute/Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, 10461, USA.
- Ruth L. and David S. Gottesman Institute for Stem Cell Research and Regenerative Medicine, Albert Einstein College of Medicine/Montefiore Medical Center, Bronx, NY, 10461, USA.
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Prognostic significance of microinvasion with ductal carcinoma in situ of the breast: a meta-analysis. Breast Cancer Res Treat 2023; 197:245-254. [PMID: 36427119 PMCID: PMC9823049 DOI: 10.1007/s10549-022-06800-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 11/03/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE Ductal carcinoma in situ (DCIS) associated with invasive carcinoma ≤ 1 mm in size is defined as DCIS with microinvasion (DCIS/microinvasion) rather than as invasive breast carcinoma. The number of patients with microinvasion accounts for < 1% of all breast cancer in published studies. As the numbers are limited, the prognostic significance of DCIS/microinvasion has not been clearly elucidated. This meta-analysis aimed to investigate the survival differences between patients with DCIS/microinvasion and those with pure DCIS. METHODS A meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) methodology was performed. We searched three electronic databases (MEDLINE, Cochrane Library, and EMBASE) and included observational studies published in English that contained survival details of patients with either DCIS or DCIS/microinvasion. RESULTS This study identified 26 studies that described the clinicopathological characteristics of patients in both the DCIS and DCIS/microinvasion groups. Survival differences were evaluated in 10 of 26 studies. Disease-free survival and loco-regional recurrence-free survival were significantly shorter in patients with DCIS/microinvasion than in those with DCIS (Hazard ratio, 1.52; 95% confidence interval, 1.11-2.08; p = 0.01 and hazard ratio, 2.53; 95% confidence interval, 1.45-4.41; p = 0.001, respectively). Both overall survival and distant metastasis-free survival tended to be shorter in patients with DCIS/microinvasion than in patients with DCIS (Hazard ratio, 1.63; 95% CI, 0.63-4.23; p = 0.31 and hazard ratio, 1.85; 95% confidence interval, 0.74-4.66; p = 0.19, respectively) but the difference was not statistically significant. CONCLUSION Our meta-analysis suggests that DCIS/microinvasion may display more aggressive biological and clinical behavior than pure DCIS, highlighting the potential need for closer follow-up and consideration of adjuvant treatment strategies in DCIS patients with microinvasive disease.
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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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Miles BL, He J, Nguyen QD. Intracystic Papillary Carcinoma: A Case Report. Cureus 2022; 14:e28504. [PMID: 36185853 PMCID: PMC9514804 DOI: 10.7759/cureus.28504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/28/2022] [Indexed: 11/21/2022] Open
Abstract
Intracystic papillary carcinoma (IPC) of the breast is a rare form of in-situ carcinoma, which is contained within a dilated duct. Mammography and ultrasound may provide clues to its presence, but formal diagnosis always requires histologic evidence. Although IPC is associated with an excellent prognosis, surgical resection is important in order to rule out the possibility of any invasive component, which would result in the need for more aggressive treatment. In this paper, we review the radiographic and histologic features of this interesting diagnosis, present a patient case, and explore the possible reason why IPC does not require the same treatment modalities as the more common ductal carcinoma in situ (DCIS).
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Li G, Zhao J, Zhang X, Ma X, Li H, Chen Y, Zhang L, Zhang X, Wu J, Wang X, Zhang Y, Xu S. Toward Exempting from Sentinel Lymph Node Biopsy in T1 Breast Cancer Patients: A Retrospective Study. Front Surg 2022; 9:890554. [PMID: 35836596 PMCID: PMC9273897 DOI: 10.3389/fsurg.2022.890554] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Accepted: 06/07/2022] [Indexed: 12/24/2022] Open
Abstract
Background and Objective Sentinel lymph node biopsy (SLNB) is used to assess the status of axillary lymph node (ALN), but it causes many adverse reactions. Considering the low rate of sentinel lymph node (SLN) metastasis in T1 breast cancer, this study aims to identify the characteristics of T1 breast cancer without SLN metastasis and to select T1 breast cancer patients who avoid SLNB through constructing a nomogram. Methods A total of 1,619 T1 breast cancer patients with SLNB in our hospital were enrolled in this study. Through univariate and multivariate logistic regression analysis, we analyzed the tumor anatomical and clinicopathological factors and constructed the Heilongjiang Medical University (HMU) nomogram. We selected the patients exempt from SLNB by using the nomogram. Results In the training cohort of 1,000 cases, the SLN metastasis rate was 23.8%. Tumor volume, swollen axillary lymph nodes, pathological types, and molecular subtypes were found to be independent predictors for SLN metastasis in multivariate regression analysis. Distance from nipple or surface and position of tumor have no effect on SLN metastasis. A regression model based on the results of the multivariate analysis was developed to predict the risk of SLN metastasis, indicating an AUC of 0.798. It showed excellent diagnostic performance (AUC = 0.773) in the validation cohort. Conclusion The HMU nomogram for predicting SLN metastasis incorporates four variables, including tumor volume, swollen axillary lymph nodes, pathological types, and molecular subtypes. The SLN metastasis rates of intraductal carcinoma and HER2 enriched are 2.05% and 6.67%. These patients could be included in trials investigating the SLNB exemption.
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Affiliation(s)
- Guozheng Li
- Department ofs Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Jiyun Zhao
- School of Life Science and Technology, Computational Biology Research Center, Harbin Institute of Technology, Harbin, China
| | - Xingda Zhang
- Department ofs Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xin Ma
- Department ofs Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Hui Li
- Department ofs Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yihai Chen
- Department ofs Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Lei Zhang
- Department ofs Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xin Zhang
- Department ofs Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Jiale Wu
- Department ofs Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Xinheng Wang
- Department ofs Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
| | - Yan Zhang
- School of Life Science and Technology, Computational Biology Research Center, Harbin Institute of Technology, Harbin, China
- Correspondence: Shouping Xu Yan Zhang
| | - Shouping Xu
- Department ofs Breast Surgery, Harbin Medical University Cancer Hospital, Harbin, China
- Correspondence: Shouping Xu Yan Zhang
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Zerdan MB, Nasr L, Kassab J, Saba L, Ghossein M, Yaghi M, Dominguez B, Chaulagain CP. Adhesion molecules in multiple myeloma oncogenesis and targeted therapy. Int J Hematol Oncol 2022; 11:IJH39. [PMID: 35663420 PMCID: PMC9136637 DOI: 10.2217/ijh-2021-0017] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 04/07/2022] [Indexed: 11/21/2022] Open
Abstract
Every day we march closer to finding the cure for multiple myeloma. The myeloma cells inflict their damage through specialized cellular meshwork and cytokines system. Implicit in these interactions are cellular adhesion molecules and their regulators which include but are not limited to integrins and syndecan-1/CD138, immunoglobulin superfamily cell adhesion molecules, such as CD44, cadherins such as N-cadherin, and selectins, such as E-selectin. Several adhesion molecules are respectively involved in myelomagenesis such as in the transition from the precursor disorder monoclonal gammopathy of undetermined significance to indolent asymptomatic multiple myeloma (smoldering myeloma) then to active multiple myeloma or primary plasma cell leukemia, and in the pathological manifestations of multiple myeloma.
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Affiliation(s)
- Maroun Bou Zerdan
- Department of Hematology-Oncology, Myeloma & Amyloidosis Program, Maroone Cancer Center, Cleveland Clinic Florida, Weston, FL 33331, USA
| | - Lewis Nasr
- Saint-Joseph University, Faculty of Medicine, Beirut, Lebanon
| | - Joseph Kassab
- Saint-Joseph University, Faculty of Medicine, Beirut, Lebanon
| | - Ludovic Saba
- Saint-Joseph University, Faculty of Medicine, Beirut, Lebanon
| | - Myriam Ghossein
- Department of Medicine & Medical Sciences, University of Balamand, Balamand, Lebanon
| | - Marita Yaghi
- Department of Hematology-Oncology, Myeloma & Amyloidosis Program, Maroone Cancer Center, Cleveland Clinic Florida, Weston, FL 33331, USA
| | - Barbara Dominguez
- Department of Hematology-Oncology, Myeloma & Amyloidosis Program, Maroone Cancer Center, Cleveland Clinic Florida, Weston, FL 33331, USA
| | - Chakra P Chaulagain
- Department of Hematology-Oncology, Myeloma & Amyloidosis Program, Maroone Cancer Center, Cleveland Clinic Florida, Weston, FL 33331, USA
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Davey MG, O’Flaherty C, Cleere EF, Nohilly A, Phelan J, Ronane E, Lowery AJ, Kerin MJ. OUP accepted manuscript. BJS Open 2022; 6:6563503. [PMID: 35380620 PMCID: PMC8982203 DOI: 10.1093/bjsopen/zrac022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Accepted: 01/28/2022] [Indexed: 11/17/2022] Open
Abstract
Background Axillary lymph node status remains the most powerful prognostic indicator in invasive breast cancer. Ductal carcinoma in situ (DCIS) is a non-invasive disease and does not spread to axillary lymph nodes. The presence of an invasive component to DCIS mandates nodal evaluation through sentinel lymph node biopsy (SLNB). Quantification of the necessity of upfront SLNB for DCIS requires investigation. The aim was to establish the likelihood of having a positive SLNB (SLNB+) for DCIS and to establish parameters predictive of SLNB+. Methods A systematic review was performed as per the PRISMA guidelines. Prospective studies only were included. Characteristics predictive of SLNB+ were expressed as dichotomous variables and pooled as odds ratios (o.r.) and associated 95 per cent confidence intervals (c.i.) using the Mantel–Haenszel method. Results Overall, 16 studies including 4388 patients were included (mean patient age 54.8 (range 24 to 92) years). Of these, 72.5 per cent of patients underwent SLNB (3156 of 4356 patients) and 4.9 per cent had SLNB+ (153 of 3153 patients). The likelihood of having SLNB+ for DCIS was less than 1 per cent (o.r. <0.01, 95 per cent c.i. 0.00 to 0.01; P < 0.001, I2 = 93 per cent). Palpable DCIS (o.r. 2.01, 95 per cent c.i. 0.64 to 6.24; P = 0.230, I2 = 0 per cent), tumour necrosis (o.r. 3.84, 95 per cent c.i. 0.85 to 17.44; P = 0.080, I2 = 83 per cent), and grade 3 DCIS (o.r. 1.34, 95 per cent c.i. 0.80 to 2.23; P = 0.270, I2 = 0 per cent) all trended towards significance in predicting SLNB+. Conclusion While aggressive clinicopathological parameters may guide SLNB for patients with DCIS, the absolute and relative risk of SLNB+ for DCIS is less than 5 per cent and 1 per cent, respectively. Well-designed randomized controlled trials are required to establish fully the necessity of SLNB for patients diagnosed with DCIS. Registration number CRD42021284194 (https://www.crd.york.ac.uk/prospero/)
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Affiliation(s)
- Matthew G. Davey
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
- Correspondence to: Matthew G. Davey, Department of Surgery, Galway University Hospitals, Galway H91YR71, Republic of Ireland (e-mail: )
| | - Colm O’Flaherty
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| | - Eoin F. Cleere
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| | - Aoife Nohilly
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| | - James Phelan
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| | - Evan Ronane
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| | - Aoife J. Lowery
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
| | - Michael J. Kerin
- Department of Surgery, The Lambe Institute for Translational Research, National University of Ireland, Galway, Ireland
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Choi B, Jegatheeswaran L, Nakhoul M, Haria P, Srivastava R, Karki S, Lupi M, Patel V, Chakravorty A, Babu E. Axillary staging in ductal carcinoma in situ with microinvasion: A meta-analysis. Surg Oncol 2021; 37:101557. [PMID: 33819852 DOI: 10.1016/j.suronc.2021.101557] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 03/26/2021] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Ductal carcinoma in situ with microinvasion (DCISM); arguably a more aggressive subtype of DCIS, currently has variable recommendations governing its staging and management in the UK. As a result, there is ongoing controversy surrounding the most appropriate management of DCISM, in particular the need of axillary staging. METHOD A search was conducted on the databases MEDLINE and Embase using the keywords: breast, DCISM, microinvasion, "ductal carcinoma in situ with microinvasion", sentinel lymph node biopsy, SLNB, axillary staging was performed. 23 studies were selected for analysis. Primary outcome was the positivity of metastasis of lymph node; secondary outcome looked at characteristics of DCISM that may affect node positivity. RESULTS A total of 2959 patients were included. Significant heterogeneity was observed amongst the studies with regards to metastases (I2 = 61%; P < 0.01). Lymph node macrometastases was estimated to be 2%. Significant subgroup difference was not observed between SLNB technique and lymph node macrometastases (Q = 0.74; p = 0.69). Statistical significance was observed between the focality of the DCISM and lymph node macrometastases (Q = 8.71; p = 0.033). CONCLUSION Although histologically more advanced than DCIS, DCISM is not linked with higher rates of clinically significant metastasis to axillary lymph nodes. Survival rates are very similar to those seen in cases of DCIS. Current evidence suggests that axillary staging in cases of DCISM will not change their overall management, thus may only be an unnecessary and inconvenient additional intervention considering the majority of DCISM diagnoses are made from post-operative pathology samples. A multidisciplinary team approach evaluating pre-operative clinical and histological information to tailor the management specific to individual cases of DCISM would be a preferred approach than routine axillary staging.
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Affiliation(s)
- Byung Choi
- Department of Breast Surgery, The Hillingdon Hospital NHS Foundation Trust, London, UK.
| | | | | | - Payal Haria
- Department of Breast Surgery, The Hillingdon Hospital NHS Foundation Trust, London, UK
| | | | - Smriti Karki
- Department of Breast Surgery, The Hillingdon Hospital NHS Foundation Trust, London, UK
| | - Micol Lupi
- Department of Breast Surgery, The Hillingdon Hospital NHS Foundation Trust, London, UK
| | - Vishal Patel
- Department of Breast Surgery, The Hillingdon Hospital NHS Foundation Trust, London, UK
| | - Arunmoy Chakravorty
- Department of Breast Surgery, The Hillingdon Hospital NHS Foundation Trust, London, UK; AHERF, New Delhi, India
| | - Ekambaram Babu
- Department of Breast Surgery, The Hillingdon Hospital NHS Foundation Trust, London, UK
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Cortadellas T, Argacha P, Acosta J, Jurado J, Peiró R, Gomez M, Gonzalez-Farré X, Martinez M, Luna M, Peg V, Gil-Moreno A, Xiberta M. When Is Sentinel Node Biopsy Indicated in High-Risk Ductal Carcinoma in situ? Four Hundred Sixty-Eight Cases from Three Institutions. Breast Care (Basel) 2021; 16:630-636. [DOI: 10.1159/000514849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 01/28/2021] [Indexed: 11/19/2022] Open
Abstract
<b><i>Introduction:</i></b> Sentinel lymph node biopsy (SLNB) in ductal carcinoma in situ (DCIS) is not indicated. However, in certain cases (size >3 cm, high grade, mass effect on mammography, or palpable mass), it may be possible to find incidental invasive carcinoma (IC) that requires an SLNB. We studied the correlation of the aforesaid factors with the probability of finding IC in the surgical specimen. <b><i>Methods:</i></b> Data was collected from 3 different institutions between 2010 and 2016, recording characteristics such as, but not limited to: high grade, size >3 cm, mass effect on mammography, and palpable mass. <b><i>Results:</i></b> On the whole, 468 “high-risk” DCIS cases were identified, 139 (29%) of which had IC. When the DCIS was high grade or the size was >3 cm, there was no significant difference in the probability of finding IC in the surgical specimen (OR = 1.13; 95% CI 0.84–1.51; OR = 1.2; 95% CI 0.85–1.40). Nevertheless, when a high grade and size (>3 cm) were combined, IC was more likely to exist (72.7 vs. 27.3%; <i>p</i> = 0.001). In addition, mass effect and palpation were independently associated with a significantly greater degree of IC (OR = 12.76; 95% CI 6.93–23.52). <b><i>Conclusions:</i></b> The results suggest that high-grade DCIS or DCIS with a size >3 cm, independently, does not require SLNB. Nonetheless, in the event that both factors are found in the same case, SLNB may be indicated. Additionally, SLNB is advisable for DCIS cases that are palpable or show a mass effect on mammography.
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Maeda H, Hayashida T, Watanuki R, Kikuchi M, Nakashoji A, Yokoe T, Seki T, Takahashi M, Kitagawa Y. Predictors of invasive disease in patients preoperatively diagnosed with ductal carcinoma without stromal invasion, with breast magnetic resonance imaging (MRI) and ultrasound (US). Breast Cancer 2020; 28:398-404. [PMID: 33200381 DOI: 10.1007/s12282-020-01187-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 10/06/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND A preoperative diagnosis of ductal carcinoma in situ (DCIS) is sometimes upstaged to invasive disease postoperatively. Our objective was to clarify the predictive factors of invasive disease using preoperative imaging and to investigate the positive ratio of sentinel lymph nodes (SLN) and the incidence of invasive disease. METHODS The subjects were 402 patients with preoperatively diagnosed ductal carcinoma without stromal invasion who underwent breast surgery with concomitant SLN surgery in January 2007 to December 2016. Of the 306 included patients, all 306 patients underwent preoperative MRI and US assessment. Outcomes were analyzed for significance using univariate and multivariate analyses. RESULTS Of the 306 patients, 115 (37.6%) had invasive disease and 191 (62.4%) had DCIS only. Of the 115 patients with invasive disease, 5 (4.4%) and 4 (3.5%) had macro- and micrometastases in SLN. On the other hand, of the 191 patients with DCIS, only 1 (0.5%) had a micrometastasis. Predictors of invasive disease in the univariate analysis included having a palpable mass, were varied by biopsy method, having a US hypoechoic mass, MRI enhancement, or MRI large enhanced lesion; the size of the mass enhancement ≥ 1.1 cm or a spread of non-mass enhancement ≥ 3.1 cm (P = 0.003). Predictors of invasive disease in the multivariate analysis included US hypoechoic mass and MRI large enhanced lesion. CONCLUSION We need to perform SLN biopsy for preoperatively diagnosed DCIS when patients have predictors of invasive disease, but SLN biopsy will no longer be essential for patients when they have no predictors of invasive disease.
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Affiliation(s)
- Hinako Maeda
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku, Tokyo, 160-8582, Japan
| | - Tetsu Hayashida
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku, Tokyo, 160-8582, Japan.
| | - Rurina Watanuki
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku, Tokyo, 160-8582, Japan
| | - Masayuki Kikuchi
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku, Tokyo, 160-8582, Japan
| | - Ayako Nakashoji
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku, Tokyo, 160-8582, Japan
| | - Takamichi Yokoe
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku, Tokyo, 160-8582, Japan
| | - Tomoko Seki
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku, Tokyo, 160-8582, Japan
| | - Maiko Takahashi
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku, Tokyo, 160-8582, Japan
| | - Yuko Kitagawa
- Department of Surgery, Keio University School of Medicine, 35 Shinanomachi, Shinjyuku, Tokyo, 160-8582, Japan
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12
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Zheng J, Yu J, Zhou T. Clinical characteristics of breast ductal carcinoma in situ with microinvasion: a narrative review. J Int Med Res 2020; 48:300060520969304. [PMID: 33179556 PMCID: PMC7673047 DOI: 10.1177/0300060520969304] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Ductal carcinoma in situ (DCIS) with microinvasion (DCIS-MI) is defined as the extension of cancer cells beyond the basement membrane into adjacent tissue with no focus larger than 1 mm or a maximum diameter of less than 1 mm for multiple invasive foci. DCIS-MI constitutes approximately 1% of all breast cancer cases and 5% to 10% of cases of DCIS. The current literature is controversial concerning the clinical prognostic features and management of DCIS-MI. This narrative review described recently reported literature regarding the characteristics, diagnosis, treatment, and prognosis of DCIS-MI.
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Affiliation(s)
- Jie Zheng
- Department of Breast Cancer Center, the Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jingjing Yu
- Division of Gland Sugery, The Third Hospital of Xingtai, Xingtai, China
| | - Tao Zhou
- Department of Breast Cancer Center, the Fourth Hospital of Hebei Medical University, Shijiazhuang, China
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13
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Evaluating the role of sentinel lymph node biopsy in patients with DCIS treated with breast conserving surgery. Am J Surg 2020; 220:654-659. [PMID: 31964523 DOI: 10.1016/j.amjsurg.2020.01.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 01/08/2020] [Accepted: 01/10/2020] [Indexed: 11/23/2022]
Abstract
INTRODUCTION The role of sentinel lymph node biopsy (SLNB) for patients with ductal carcinoma in-situ (DCIS) is limited given the rarity of nodal metastasis in non-invasive disease. Although SLNB is typically a safe procedure, there are potential complications and associated costs. The purpose of this study is to assess national surgical practice patterns and clinical outcomes with respect to the use of SLNB for DCIS in patients undergoing breast conserving surgery (BCS). METHODS Case-level data from the National Cancer Data Base (NCDB) was assessed to identify adult patients ≥ 18 with DCIS, who underwent BCS and SLNB. Patient demographics and hospital characteristics were grouped for analytic purposes. A multivariate analysis was performed for patient and hospital characteristics. RESULTS We identified 15,422 patients with DCIS undergoing BCS in 2015, of which 2,698 (18%) underwent SLNB. A multivariate analysis demonstrated a significant association between greater frequency of SLNB in patients age range of 60-69, receipt of care at a community facility, and higher nuclear grade DCIS. Positive sentinel nodes metastasis was identified in 0.9% patients undergoing BCS and SLNB for DCIS. CONCLUSION The role of SLNB in patients with DCIS undergoing BCS is limited and does not routinely provide meaningful information or benefit to clinical management. Despite this, nearly one in five patients undergoing BCS for DCIS had lymph node sampling performed. Given the potential increased morbidity and financial implications, this finding represents an opportunity for further education and improvement in patient selection for SLNB.
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14
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Hotton J, Salleron J, Rauch P, Buhler J, Pierret M, Baumard F, Leufflen L, Marchal F. Predictive factors of axillary positive sentinel lymph node biopsy in extended ductal carcinoma in situ treated by simple mastectomy at once. J Gynecol Obstet Hum Reprod 2019; 49:101641. [PMID: 31562936 DOI: 10.1016/j.jogoh.2019.101641] [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: 06/03/2019] [Revised: 08/30/2019] [Accepted: 09/24/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND The incidence of positive sentinel lymph node biopsy (SLNB) in ductal carcinoma in situ (DCIS) ranged from 0 to 14%. The main hypothesis would be the presence of an invasive contingent on the final histology. The objective was to identify predictive factors of sentinel lymph node positivity in the management of extended ductal carcinoma in situ treated by simple mastectomy. METHODS This was a retrospective study carried out at the Lorraine Cancer Institute from January 2003 to December 2017. Women with DCIS on core-needle biopsy whose management consisted of simple mastectomy and SLNB procedure were included. RESULTS 188 patients were analyzed. Preoperatively, 18 patients (9.6%) had DCIS with microinvasion, while the others had pure DCIS. Eight patients (4.2%) had positive sentinel lymph node biopsy, the majority of which were single micrometastases. Predictive factor of node invasion was microinvasion on biopsy (p<0.01). Only in cases of pure DCIS, the percentage of positive SLNB was reduced to 2.9%. Invasive carcinoma was found in the majority of patients with positive axillary SLNB procedure (75%, n=6), compared to 16.7% (n=30) without SLNB involvement (p<0.01). CONCLUSIONS The low rate of positive sentinel node biopsy in pure ductal carcinoma in situ suggests that in the absence of microinvasion, the sentinel procedure would seem less appropriate. New techniques for identifying sentinel lymph node biopsy could report axillary staging after definitive histologic results.
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Affiliation(s)
- Judicael Hotton
- Institut de Cancérologie de Lorraine, Department of Surgical Oncology, Université de Lorraine, F-54519 Vandoeuvre-lès-Nancy, France.
| | - Julia Salleron
- Institut de Cancérologie de Lorraine, Biostatistics Unit, Université de Lorraine, F-54519 Vandoeuvre-lès-Nancy, France
| | - Philippe Rauch
- Institut de Cancérologie de Lorraine, Department of Surgical Oncology, Université de Lorraine, F-54519 Vandoeuvre-lès-Nancy, France
| | - Julie Buhler
- Institut de Cancérologie de Lorraine, Department of Surgical Oncology, Université de Lorraine, F-54519 Vandoeuvre-lès-Nancy, France
| | - Marion Pierret
- Institut de Cancérologie de Lorraine, Department of Surgical Oncology, Université de Lorraine, F-54519 Vandoeuvre-lès-Nancy, France
| | - Florian Baumard
- Institut de Cancérologie de Lorraine, Biostatistics Unit, Université de Lorraine, F-54519 Vandoeuvre-lès-Nancy, France
| | - Lea Leufflen
- Institut de Cancérologie de Lorraine, Department of Surgical Oncology, Université de Lorraine, F-54519 Vandoeuvre-lès-Nancy, France
| | - Frederic Marchal
- Institut de Cancérologie de Lorraine, Department of Surgical Oncology, Université de Lorraine, F-54519 Vandoeuvre-lès-Nancy, France; Université de Lorraine, CNRS UMR7039, CRAN, F-54000 Nancy, France
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15
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Gooch JC, Schnabel F, Chun J, Pirraglia E, Troxel AB, Guth A, Shapiro R, Axelrod D, Roses D. A Nomogram to Predict Factors Associated with Lymph Node Metastasis in Ductal Carcinoma In Situ with Microinvasion. Ann Surg Oncol 2019; 26:4302-4309. [PMID: 31529311 DOI: 10.1245/s10434-019-07750-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Ductal carcinoma in situ (DCIS) with foci of invasion measuring ≤ 1 mm (DCISM), represents < 1% of all invasive breast cancers. Sentinel lymph node biopsy (SLNB) has been a standard component of surgery for patients with invasive carcinoma or extensive DCIS. We hypothesize that selective performance of SLNB may be appropriate given the low incidence of sentinel node (SN) metastasis for DCISM. We investigated the clinicopathologic predictors for SN positivity in DCISM, to identify which patients might benefit from SLNB. METHODS A retrospective review of the National Cancer Database was performed for cases from 2012 to 2015. Clinical and tumor characteristics, including SN results, were evaluated, and Pearson's Chi square tests and logistic regression were performed. RESULTS Of 7803 patients with DCISM, 306 (4%) had at least one positive SN. Patients with positive SNs were younger, more often of Black race, had higher-grade histology and larger tumor size, and were more likely to have lymphovascular invasion (LVI; all p < 0.001). In an adjusted model, the presence of LVI was associated with the highest odds ratio (OR) for node positivity (OR 8.80, 95% confidence interval 4.56-16.96). CONCLUSIONS Among women with DCISM, only 4% had a positive SN. Node positivity was associated with more extensive and higher-grade DCIS, and the presence of LVI was strongly correlated with node positivity. Our data suggest that LVI is the most important factor in determining which patients with DCISM will benefit from SN biopsy.
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Affiliation(s)
- Jessica C Gooch
- Division of Breast Surgery, Department of Surgery, Perlmutter Comprehensive Cancer Center, New York University Langone Health, 160 East 34th St, New York, NY, 10016, USA.,Division of Surgical Oncology, Department of Surgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Freya Schnabel
- Division of Breast Surgery, Department of Surgery, Perlmutter Comprehensive Cancer Center, New York University Langone Health, 160 East 34th St, New York, NY, 10016, USA
| | - Jennifer Chun
- Division of Breast Surgery, Department of Surgery, Perlmutter Comprehensive Cancer Center, New York University Langone Health, 160 East 34th St, New York, NY, 10016, USA
| | - Elizabeth Pirraglia
- Department of Population Health, Division of Biostatistics, New York University Langone Health, New York, NY, USA
| | - Andrea B Troxel
- Department of Population Health, Division of Biostatistics, New York University Langone Health, New York, NY, USA
| | - Amber Guth
- Division of Breast Surgery, Department of Surgery, Perlmutter Comprehensive Cancer Center, New York University Langone Health, 160 East 34th St, New York, NY, 10016, USA
| | - Richard Shapiro
- Division of Breast Surgery, Department of Surgery, Perlmutter Comprehensive Cancer Center, New York University Langone Health, 160 East 34th St, New York, NY, 10016, USA
| | - Deborah Axelrod
- Division of Breast Surgery, Department of Surgery, Perlmutter Comprehensive Cancer Center, New York University Langone Health, 160 East 34th St, New York, NY, 10016, USA
| | - Daniel Roses
- Division of Breast Surgery, Department of Surgery, Perlmutter Comprehensive Cancer Center, New York University Langone Health, 160 East 34th St, New York, NY, 10016, USA.
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16
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Hung P, Wang SY, Killelea BK, Mougalian SS, Evans SB, Sedghi T, Gross CP. Long-Term Outcomes of Sentinel Lymph Node Biopsy for Ductal Carcinoma in Situ. JNCI Cancer Spectr 2019; 3:pkz052. [PMID: 32337481 PMCID: PMC7049982 DOI: 10.1093/jncics/pkz052] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 06/21/2019] [Accepted: 07/22/2019] [Indexed: 12/18/2022] Open
Abstract
The use of sentinel lymph node biopsy (SLNB) for ductal carcinoma in situ (DCIS) is controversial. Using population-cohort data, we examined whether SLNB improves long-term outcomes among patients with DCIS who underwent breast-conserving surgery. We identified 12 776 women aged 67–94 years diagnosed during 2001–2013 with DCIS who underwent breast-conserving surgery from the US Surveillance, Epidemiology, and End Results-Medicare dataset, 1992 (15.6%) of whom underwent SLNB (median follow-up: 69 months). Tests of statistical significance are two-sided. Patients with and without SLNB did not differ statistically significantly regarding treated recurrence (3.9% vs 3.7%; P = .62), ipsilateral invasive occurrence (1.4% vs 1.7%, P = .33), or breast cancer mortality (1.0% vs 0.9%, P = .86). With Mahalanobis-matching and competing-risks survival analyses, SLNB was not statistically significantly associated with treated recurrence, ipsilateral invasive occurrence, or breast cancer mortality (P ≥ .27). Our findings do not support the routine performance of SLNB for older patients with DCIS amenable to breast conservation.
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Affiliation(s)
- Peiyin Hung
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia, SC.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Shi-Yi Wang
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, New Haven, CT.,Department of Chronic Disease Epidemiology, Yale School of Public Health, New Haven, CT
| | - Brigid K Killelea
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, New Haven, CT.,Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Sarah S Mougalian
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, New Haven, CT.,Section of Medical Oncology, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Suzanne B Evans
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, New Haven, CT.,Department of Therapeutic Radiology, Yale School of Medicine, New Haven, CT
| | - Tannaz Sedghi
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, New Haven, CT
| | - Cary P Gross
- Cancer Outcomes, Public Policy, and Effectiveness Research (COPPER) Center, Yale Cancer Center, New Haven, CT.,Section of General Internal Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
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17
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Phantana-angkool A, Voci AE, Warren YE, Livasy CA, Beasley LM, Robinson MM, Hadzikadic-Gusic L, Sarantou T, Forster MR, Sarma D, White RL. Ductal Carcinoma In Situ with Microinvasion on Core Biopsy: Evaluating Tumor Upstaging Rate, Lymph Node Metastasis Rate, and Associated Predictive Variables. Ann Surg Oncol 2019; 26:3874-3882. [DOI: 10.1245/s10434-019-07604-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Indexed: 12/30/2022]
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18
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Sheaffer WW, Gray RJ, Wasif N, Stucky CC, Cronin PA, Kosiorek HE, Basu A, Pizzitola VJ, Patel B, Giurescu ME, Lorans R, McCullough AE, Ocal IT, Pockaj BA. Predictive factors of upstaging DCIS to invasive carcinoma in BCT vs mastectomy. Am J Surg 2019; 217:1025-1029. [PMID: 30879795 DOI: 10.1016/j.amjsurg.2018.12.069] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2018] [Revised: 11/02/2018] [Accepted: 12/29/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Upstaging from DCIS to invasive ductal carcinoma varies widely from 0 to 59%. We aim to identify risk factors associated with upstaging in all DCIS patients and based on specific surgical intervention. METHODS Patients with a pre-operative diagnosis of DCIS undergoing BCT or mastectomy were reviewed. Multivariable analysis was performed to identify risk factors for upstaging. RESULTS In total, 623 patients had a preoperative diagnosis of DCIS. Upstaging occurred in 74 patients (12%) overall. There was no difference in upstaging rates between mastectomy and BCT (11% v 14% p = 0.27). Sentinel lymph node biopsy was positive in 4/212 patients (1%). Multivariable analysis revealed suspicion of microinvasion (OR 5.7 95%CI2.2-14.9), surgeon suspicion of invasive disease (OR 2.7, 95% CI 1.2-6.4) and larger size/multicentric/extensive tumor (OR 1.9 95% CI 1.1-3.4) increase risk of upstaging. CONCLUSIONS Suspicion of microinvasion, surgeon suspicion, and tumor size can be used to help guide the use of sentinel lymph node biopsy. For patients without these high risk characteristics, it is hard to justify the use of concurrent SLN biopsy for patients who undergo BCT.
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Affiliation(s)
- W W Sheaffer
- Department of General Surgery, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - R J Gray
- Department of General Surgery, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - N Wasif
- Department of General Surgery, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - C C Stucky
- Department of General Surgery, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - P A Cronin
- Department of General Surgery, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - H E Kosiorek
- Department of Biostatistics, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - A Basu
- Department of General Surgery, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - V J Pizzitola
- Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - B Patel
- Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - M E Giurescu
- Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - R Lorans
- Department of Radiology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - A E McCullough
- Department of Pathology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - I T Ocal
- Department of Pathology, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA
| | - B A Pockaj
- Department of General Surgery, Mayo Clinic Arizona, 5777 E Mayo Blvd, Phoenix, AZ, 85054, USA.
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19
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Magnoni F, Massari G, Santomauro G, Bagnardi V, Pagan E, Peruzzotti G, Galimberti V, Veronesi P, Sacchini VS. Sentinel lymph node biopsy in microinvasive ductal carcinoma in situ. Br J Surg 2019; 106:375-383. [PMID: 30791092 DOI: 10.1002/bjs.11079] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 07/25/2018] [Accepted: 11/12/2018] [Indexed: 11/12/2022]
Abstract
BACKGROUND Microinvasive breast cancer is an uncommon pathological entity. Owing to the rarity of this condition, its surgical axillary management and overall prognosis remain controversial. METHODS A database was analysed to identify patients with microinvasive ductal carcinoma in situ (DCIS) who had surgery for invasive breast cancer at the European Institute of Oncology, Milan, between 1998 and 2010. Women who had undergone axillary staging by sentinel lymph node biopsy were included in the study. RESULTS Of 257 women with microinvasive breast cancer who underwent sentinel lymph node biopsy (SLNB), 226 (87·9 per cent) had negative sentinel lymph nodes (SLNs) and 31 had metastatic SLNs. Twelve patients had isolated tumour cells (ITCs), 14 had micrometastases and five had macrometastases in sentinel nodes. Axillary lymph node dissection was performed in 16 of the 31 patients with positive SLNs. After a median follow-up of 11 years, only one regional first event was observed in the 15 patients with positive SLNs who did not undergo axillary lymph node dissection. There were no regional first events in the 16 patients with positive SLNs who had axillary dissection. CONCLUSION Good disease-free and overall survival were found in women with positive SLNs and microinvasive DCIS. This study is in line with studies showing that SLNB in microinvasive DCIS may not be useful, and supports the evidence that less surgery can provide the same level of overall survival with better quality of life.
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Affiliation(s)
- F Magnoni
- European Institute of Oncology, University of Milan-Bicocca, Milan, Italy
| | - G Massari
- European Institute of Oncology, University of Milan-Bicocca, Milan, Italy
| | - G Santomauro
- European Institute of Oncology, University of Milan-Bicocca, Milan, Italy
| | - V Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - E Pagan
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, Milan, Italy
| | - G Peruzzotti
- European Institute of Oncology, University of Milan-Bicocca, Milan, Italy
| | - V Galimberti
- European Institute of Oncology, University of Milan-Bicocca, Milan, Italy
| | - P Veronesi
- European Institute of Oncology, University of Milan-Bicocca, Milan, Italy
| | - V S Sacchini
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
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20
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Costarelli L, Cianchetti E, Corsi F, Friedman D, Ghilli M, Lacaria M, Menghini L, Murgo R, Ponti A, Rinaldi S, del Turco MR, Taffurelli M, Tinterri C, Tomatis M, Fortunato L. Microinvasive breast carcinoma: An analysis from ten Senonetwork Italia breast centres. Eur J Surg Oncol 2019; 45:147-152. [DOI: 10.1016/j.ejso.2018.09.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Revised: 09/20/2018] [Accepted: 09/26/2018] [Indexed: 11/25/2022] Open
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21
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Guvenc I, Whitman GJ, Liu P, Yalniz C, Ma J, Dogan BE. Diffusion‐weighted MR imaging increases diagnostic accuracy of breast MR imaging for predicting axillary metastases in breast cancer patients. Breast J 2019; 25:47-55. [DOI: 10.1111/tbj.13151] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Revised: 11/29/2017] [Accepted: 12/12/2017] [Indexed: 11/28/2022]
Affiliation(s)
- Inanc Guvenc
- Department of Radiology Medical Park Ankara Ankara Turkey
- Departments of Radiology and Breast Imaging The University of Texas M. D. Anderson Cancer Center Houston Texas
| | - Gary J. Whitman
- Departments of Radiology and Breast Imaging The University of Texas M. D. Anderson Cancer Center Houston Texas
| | - Ping Liu
- Department of Biostatistics The University of Texas M. D. Anderson Cancer Center Houston Texas
| | - Ceren Yalniz
- Departments of Radiology and Breast Imaging The University of Texas M. D. Anderson Cancer Center Houston Texas
| | - Jingfei Ma
- Department of Imaging Physics The University of Texas M. D. Anderson Cancer Center Houston Texas
| | - Basak E. Dogan
- Departments of Radiology and Breast Imaging The University of Texas M. D. Anderson Cancer Center Houston Texas
- Departments of Radiology and Breast Imaging The University of Texas Southwestern Medical Center Dallas Texas
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22
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Wan ZB, Gao HY, Wei L, Zhang AQ, Zhang JY, Wang Y, Wang DD, Zhang Y. Expression of estrogen receptor, progesterone receptor, human epidermal growth factor receptor 2, and Ki-67 in ductal carcinoma in situ (DCIS) and DCIS with microinvasion. Medicine (Baltimore) 2018; 97:e13055. [PMID: 30383678 PMCID: PMC6221707 DOI: 10.1097/md.0000000000013055] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Ductal carcinoma in situ (DCIS) represents a heterogeneous disease in its histologic appearance and biological potential. Some women treated for DCIS subsequently develop invasive breast cancer. DCIS with microinvasion is considered as the interim stage in the progression from DCIS to invasive breast cancer. Analysis of the differences between DCIS and DCIS with microinvasion may aid in understanding the characteristic of DCIS with microinvasion and identifying biological factors determining progression of DCIS to invasive disease.Retrospective analysis of 219 cases between 2012 and 2018 was performed in our institution. The pathological results and axillary lymph nodes status were collected. Analysis of the expression of estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER-2), and Ki-67 in pure DCIS (164 cases), and DCIS with microinvasion (55 cases) using immunohistochemistry.DCIS with microinvasion had a higher nuclear grade (P < .001) and was more likely to have sentinel lymph node biopsy (SLNB) positivity (P = .039) than DCIS. Expression of ER, PR were significantly higher in DCIS compared with DCIS with microinvasion (P < .001, P < .001). While the expression of HER-2 in DCIS with microinvasion (56.4%) was significantly higher than in DCIS (36.6%, P = .01). Furthermore, DCIS with microinvasion was significantly more likely to have aggressive subtype (Triple-negative and HER2-enriched tumors, P = .005).Our results indicated that DCIS with microinvasion was different from pure DCIS in clinicopathologic characteristics and molecular alterations. It displayed a more aggressive biological nature than pure DCIS. It may be a distinct entity.
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Affiliation(s)
- Zhi-Bin Wan
- Department of Pathology, Guangdong Women and Children Hospital of Guangzhou Medical University
| | - Hong-Yi Gao
- Department of Pathology, Guangdong Women and Children Hospital
| | - Lian Wei
- School of Public Health, Guangzhou Medical University
| | - An-Qin Zhang
- Breast Disease Center, Guangdong Women and Children Hospital, Guangzhou, Guangdong, China
| | - Jiang-Yu Zhang
- Department of Pathology, Guangdong Women and Children Hospital
| | - Yi Wang
- Department of Pathology, Guangdong Women and Children Hospital
| | - Dong-Dong Wang
- Department of Pathology, Guangdong Women and Children Hospital
| | - Yan Zhang
- Department of Pathology, Guangdong Women and Children Hospital
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Dória MT, Maesaka JY, Soares de Azevedo Neto R, de Barros N, Baracat EC, Filassi JR. Development of a Model to Predict Invasiveness in Ductal Carcinoma In Situ Diagnosed by Percutaneous Biopsy—Original Study and Critical Evaluation of the Literature. Clin Breast Cancer 2018; 18:e805-e812. [DOI: 10.1016/j.clbc.2018.04.011] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2018] [Revised: 04/13/2018] [Accepted: 04/23/2018] [Indexed: 12/12/2022]
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24
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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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Zahoor S, Haji A, Battoo A, Qurieshi M, Mir W, Shah M. Sentinel Lymph Node Biopsy in Breast Cancer: A Clinical Review and Update. J Breast Cancer 2017; 20:217-227. [PMID: 28970846 PMCID: PMC5620435 DOI: 10.4048/jbc.2017.20.3.217] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 08/22/2017] [Indexed: 12/20/2022] Open
Abstract
Sentinel lymph node biopsy has become a standard staging tool in the surgical management of breast cancer. The positive impact of sentinel lymph node biopsy on postoperative negative outcomes in breast cancer patients, without compromising the oncological outcomes, is its major advantage. It has evolved over the last few decades and has proven its utility beyond early breast cancer. Its applicability and efficacy in patients with clinically positive axilla who have had a complete clinical response after neoadjuvant chemotherapy is being aggressively evaluated at present. This article discusses how sentinel lymph node biopsy has evolved and is becoming a useful tool in new clinical scenarios of breast cancer management.
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Affiliation(s)
- Sheikh Zahoor
- Department of Surgical Oncology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Altaf Haji
- Department of Surgical Oncology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Azhar Battoo
- Department of Surgical Oncology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Mariya Qurieshi
- Department of Community Medicine, Government Medical College, Srinagar, India
| | - Wahid Mir
- Department of Surgical Oncology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
| | - Mudasir Shah
- Department of Surgical Oncology, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, India
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Pendas S, Jakub J, Giuliano R, Gardner M, Swor GB, Reintgen DS. The Role of Sentinel Lymph Node Biopsy in Patients with Ductal Carcinoma in Situ or with Locally Advanced Breast Cancer Receiving Neoadjuvant Chemotherapy. Cancer Control 2017; 11:231-5. [PMID: 15284714 DOI: 10.1177/107327480401100404] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background A significant number of patients who are initially diagnosed with pure DCIS will harbor missed or occult invasive disease at their definitive surgery. To provide more accurate staging information and to avoid a second operation, some investigators believe that SLN mapping should be performed in DCIS patients. The role of SLN biopsy after neoadjuvant chemotherapy in patients with advanced breast cancer is controversial. Methods A review of the literature was performed to determine the role of SLN biopsy in patients with DCIS or advanced breast cancer receiving neoadjuvant chemotherapy. The success rate of SLN biopsy after neoadjuvant chemotherapy was investigated as well as the percentage of positive SLNs in patients with DCIS. Results Two consecutive studies revealed metastatic disease to the regional lymph nodes in up to 13% of DCIS patients. In addition, 10% of DCIS patients were upstaged to infiltrating ductal carcinoma at their definitive therapy. The ability of the SLN to predict the status of the remaining non-SLNs after neoadjuvant chemotherapy is unknown. False-negative rates range from 0% to 33%. The success rate for SLN identification for the combined series varies from 84% to 97%. Conclusions SLN biopsy is a minimally invasive technique that can be used to evaluate the regional nodal status of DCIS patients. Performing a SLN biopsy during the initial surgical procedure may avoid a second operation in some DCIS patients who are diagnosed with invasive disease at their definitive operation. The success rate of sentinel node identification does not seem to be altered after neoadjuvant therapy. However, the ability of the SLN to predict the pathologic status of the adjacent non-SLNs remains unknown. Therefore, until further prospective randomized trials are conducted, it cannot be assumed that all the regional nodes have the same biologic response to chemotherapy as the SLN.
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Affiliation(s)
- Solange Pendas
- Surgical Oncology, Lakeland Regional Cancer Center, FL 33804, USA.
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The Demographic Features, Clinicopathological Characteristics and Cancer-specific Outcomes for Patients with Microinvasive Breast Cancer: A SEER Database Analysis. Sci Rep 2017; 7:42045. [PMID: 28165014 PMCID: PMC5292735 DOI: 10.1038/srep42045] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 12/15/2016] [Indexed: 11/08/2022] Open
Abstract
To investigate the clinicopathological characteristics and survival outcomes of microinvasive breast cancer, we conducted an observational study of female diagnosed with DCIS or DCIS with microinvasion (DCISM) from 1990 to 2012 using the Surveillance, Epidemiology, and End Results (SEER) database. There were 87695 DCIS and 8863 DCISM identified. In DCISM group, patients appeared to be younger and more black patients were identified in comparison with DCIS group. Furthermore, DCISM was associated with more aggressive tumor characteristics like higher rates of oestrogen receptor (ER) and progesterone receptor (PR) negativity, HER2 positivity, and lymph node metastasis. With a median follow-up of 91 months, patients with DCISM had worse cancer-specific survival (CSS) (hazard ratio [HR], 2.475; P < 0.001) and overall survival (OS) (HR, 1.263; P < 0.001). In the multivariable analysis, microinvasion was an independent prognostic factor for worse CSS (HR, 1.919; P < 0.001) and OS (HR, 1.184; P < 0.001). The 10-year cancer-specific mortality rate was 1.49% in DCIS and 4.08% in DCISM (HR, 2.771; P < 0.001). The 20-year cancer-specific mortality rate was 4.00% in DCIS and 9.65% in DCISM (HR, 2.482; P < 0.001). Deepening understanding of the nature of microinvasive breast cancer will be valuable for clinical treatment recommendations.
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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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Axillary evaluation and lymphedema in women with ductal carcinoma in situ. Breast Cancer Res Treat 2016; 158:373-84. [PMID: 27365080 DOI: 10.1007/s10549-016-3890-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 06/25/2016] [Indexed: 10/21/2022]
Abstract
Axillary evaluation in women with ductal carcinoma in situ (DCIS) is increasing; however, this may introduce additional morbidity with unclear benefit. Our objective was to examine the morbidity and mortality associated with axillary evaluation in DCIS. We conducted a retrospective cohort study of 10,504 women aged 65-90 years with DCIS who underwent breast conserving surgery between 2002 and 2012 using SEER-Medicare database. Patients were categorized by receipt of axillary evaluation with either sentinel lymph node biopsy (SLNB) or axillary node dissection (ALND). We determined the incidence of lymphedema treatment as defined by diagnostic and procedural codes, as well as 10-year breast cancer-specific and all-cause mortality. 18.3 % of those treated with BCS and 69.4 % of those treated with mastectomy had an axillary evaluation. One year after treatment, 8.2 % of women who had an axillary evaluation developed lymphedema, compared to 5.9 % of those who did not. In a multivariable Cox proportional hazard model, the incidence of lymphedema was higher among those who underwent axillary evaluation (HR 1.22, 95 % CI 1.04-1.45). Overall 10-year breast cancer-specific survival was similar between both groups (HR 0.83, 95 % CI 0.40-1.74). Only 44 (0.40 %) women died of breast cancer; receipt of axillary evaluation did not alter overall survival. Axillary evaluation is commonly performed in women with DCIS, especially those undergoing mastectomy. However, women who receive an axillary evaluation have higher rates of lymphedema, without breast cancer-specific or overall survival benefit. Efforts should be made to determine the population of women with DCIS who benefit from this procedure.
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Miller ME, Kyrillos A, Yao K, Kantor O, Tseng J, Winchester DJ, Shulman LN. Utilization of Axillary Surgery for Patients With Ductal Carcinoma In Situ: A Report From the National Cancer Data Base. Ann Surg Oncol 2016; 23:3337-46. [PMID: 27334212 DOI: 10.1245/s10434-016-5322-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2016] [Indexed: 11/18/2022]
Abstract
BACKGROUND This study evaluated the use of axillary surgery (AS), including sentinel lymph node biopsy (SLNB), for patients with ductal carcinoma in situ (DCIS) and the factors associated with its use. To determine whether utilization of SLNB is appropriate, predictors of SLNB performance were compared with factors predictive of tumor upstaging. METHODS The National Cancer Data Base was utilized to identify patients with American Joint Committee on Cancer (AJCC) clinical stage 0 breast cancer treated from 2004 to 2013. DCIS with microinvasion was excluded. Chi square tests and logistic regression were used to examine patient, tumor, and facility features associated with SLNB and tumor upstaging. RESULTS Of the 218,945 total patients, 155,093 (70.8 %) underwent lumpectomy, and 63,852 (29.2 %) underwent mastectomy. SLNB was performed for 19.0 % of lumpectomy patients and 63.5 % of mastectomy patients. Multivariate analysis for 2012-2013 demonstrated that estrogen receptor (ER)-negative and grade 3 tumors were more likely to be treated with SLNB in both groups. Tumor size was significant only for the lumpectomy patients who underwent one operation. Further, 22.8 % of lumpectomy patients and 18.7 % of mastectomy patients who underwent AS were upstaged compared with 1.8 % of lumpectomy and 3.6 % of mastectomy patients who did not undergo AS. Tumor upstaging was predicted by ER-negative status (odds ratio [OR] 2.99; 95 % confidence interval [CI] 2.76-3.24) but not by higher grade or larger tumor size. CONCLUSIONS Use of SLNB for DCIS is high with mastectomy, and nearly one fifth of the lumpectomy patients underwent SLNB. However, the performance of AS was strongly associated with the likelihood of upstaging in both groups, suggesting that surgical judgment plays an important role in this decision.
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Affiliation(s)
- Megan E Miller
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Alexandra Kyrillos
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Katharine Yao
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA.
| | - Olga Kantor
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - Jennifer Tseng
- Department of Surgery, The University of Chicago Medicine, Chicago, IL, USA
| | - David J Winchester
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Lawrence N Shulman
- Abramson Cancer Center, University of Pennsylvania, Philadelphia, PA, USA
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van Roozendaal LM, Goorts B, Klinkert M, Keymeulen KBMI, De Vries B, Strobbe LJA, Wauters CAP, van Riet YE, Degreef E, Rutgers EJT, Wesseling J, Smidt ML. Sentinel lymph node biopsy can be omitted in DCIS patients treated with breast conserving therapy. Breast Cancer Res Treat 2016; 156:517-525. [PMID: 27083179 PMCID: PMC4837213 DOI: 10.1007/s10549-016-3783-2] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 04/05/2016] [Indexed: 10/29/2022]
Abstract
Breast cancer guidelines advise sentinel lymph node biopsy (SLNB) in patients with ductal carcinoma in situ (DCIS) on core biopsy at high risk of invasive cancer or in case of mastectomy. This study investigates the incidence of SLNB and SLN metastases and the relevance of indications in guidelines and literature to perform SLNB in order to validate whether SLNB is justified in patients with DCIS on core biopsy in current era. Clinically node negative patients diagnosed from 2004 to 2013 with only DCIS on core needle biopsy were selected from a national database. Incidence of SLN biopsy and metastases was calculated. With Fisher exact tests correlation between SLNB indications and actual presence of SLN metastases was studied. Further, underestimation rate for invasive cancer and correlation with SLN metastases was analysed. 910 patients were included. SLNB was performed in 471 patients (51.8 %): 94.5 % had pN0, 3.0 % pN1mi and 2.5 % pN1. Patients undergoing mastectomy had 7 % SLN metastases versus 3.5 % for breast conserving surgery (BCS) (p = 0.107). The only factors correlating to SLN metastases were smaller core needle size (p = 0.01) and invasive cancer (p < 0.001). Invasive cancer was detected in 16.7 % by histopathology with 15.6 % SLN metastases versus only 2 % in pure DCIS. SLNB showed metastases in 5.5 % of patients; 3.5 % in case of BCS (any histopathology) and 2 % when pure DCIS was found at definitive histopathology (BCS and mastectomy). Consequently, SLNB should no longer be performed in patients diagnosed with DCIS on core biopsy undergoing BCS. If definitive histopathology shows invasive cancer, SLNB can still be considered after initial surgery.
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Affiliation(s)
- L M van Roozendaal
- Department of Surgical Oncology, Maastricht University Medical Centre, P.O. Box 5800, 6202, Maastricht, The Netherlands.,Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands.,GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Amsterdam, The Netherlands
| | - B Goorts
- Department of Surgical Oncology, Maastricht University Medical Centre, P.O. Box 5800, 6202, Maastricht, The Netherlands. .,Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands. .,GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Amsterdam, The Netherlands.
| | - M Klinkert
- Department of Surgical Oncology, Maastricht University Medical Centre, P.O. Box 5800, 6202, Maastricht, The Netherlands
| | - K B M I Keymeulen
- Department of Surgical Oncology, Maastricht University Medical Centre, P.O. Box 5800, 6202, Maastricht, The Netherlands
| | - B De Vries
- Department of Pathology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - L J A Strobbe
- Department of Surgical Oncology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - C A P Wauters
- Department of Pathology, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Y E van Riet
- Department of Surgical Oncology, Catharina Hospital, Eindhoven, The Netherlands
| | - E Degreef
- Department of Pathology, Laboratory for Pathology and Medical Microbiology (PAMM), Eindhoven, The Netherlands
| | - E J T Rutgers
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - J Wesseling
- Department of Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
| | - M L Smidt
- Department of Surgical Oncology, Maastricht University Medical Centre, P.O. Box 5800, 6202, Maastricht, The Netherlands.,GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre, Amsterdam, The Netherlands
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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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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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Hanna MG, Jaffer S, Bleiweiss IJ, Nayak A. Re-evaluating the role of sentinel lymph node biopsy in microinvasive breast carcinoma. Mod Pathol 2014; 27:1489-98. [PMID: 24743214 DOI: 10.1038/modpathol.2014.54] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2013] [Revised: 02/13/2014] [Accepted: 02/18/2014] [Indexed: 11/09/2022]
Abstract
The role of sentinel lymph node biopsy in microinvasive breast carcinoma is unclear. We examined the incidence of lymph node metastasis in patients with microinvasive carcinoma who underwent surgery at our institution. Retrospective review of our pathology database was performed (1994-2012). Of 7000 patients surgically treated for invasive breast carcinoma, 99 (1%) were classified as microinvasive carcinoma. Axillary staging was performed in 81 patients (64, sentinel lymph node biopsy; 17, axillary lymph node excision). Seven cases (9%) showed isolated tumor/epithelial cells in sentinel nodes. Three of these seven cases showed reactive changes in lymph nodes, papillary lesions in the breast with or without displaced epithelial cells within biopsy site tract, or immunohistochemical (estrogen receptor, progesterone receptor, and HER2) discordance between the primary tumor in the breast and epithelial cells in the lymph node, consistent with iatrogenically transported epithelial cells rather than true metastasis. The remaining four cases included two cases, each with a single cytokeratin-positive cell in the subcapsular sinus detected by immunohistochemistry only, and two cases with isolated tumor cells singly and in small clusters (<20 cells per cross-section) by hematoxylin and eosin and immunohistochemistry. The exact nature of cytokeratin-positive cells in the former two cases could not be determined and might still have represented iatrogenically displaced cells. In the final analysis, only two cases (3%) had isolated tumor cells. Three of these four cases had additional axillary lymph nodes excised, which were all negative for tumor cells. At a median follow-up of 37 months (range 6-199 months), none of these patients had axillary recurrences. Our results show very low incidence of sentinel lymph node involvement (3%), only as isolated tumor cells, in microinvasive carcinoma patients. None of our cases showed micrometastases or macrometastasis. We recommend reassessment of the routine practice of sentinel lymph node biopsy in patients with microinvasive carcinoma.
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Affiliation(s)
- Matthew G Hanna
- Department of Pathology and Laboratory Medicine, The Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Shabnam Jaffer
- Department of Pathology and Laboratory Medicine, The Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Ira J Bleiweiss
- Department of Pathology and Laboratory Medicine, The Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Anupma Nayak
- Department of Pathology and Laboratory Medicine, The Mount Sinai Hospital and Icahn School of Medicine at Mount Sinai, New York, NY, USA
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Teng Z, Sun C, Liu S, Wang H, Zhang S. Functional characterization of chitinase-3 reveals involvement of chitinases in early embryo immunity in zebrafish. DEVELOPMENTAL AND COMPARATIVE IMMUNOLOGY 2014; 46:489-498. [PMID: 24968080 DOI: 10.1016/j.dci.2014.06.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Revised: 06/14/2014] [Accepted: 06/16/2014] [Indexed: 06/03/2023]
Abstract
The function and mechanism of chitinases in early embryonic development remain largely unknown. We show here that recombinant chitinase-3 (rChi3) is able to hydrolyze the artificial chitin substrate, 4-methylumbelliferyl-β-D-N,N',N″-triacetylchitotrioside, and to bind to and inhibit the growth of the fungus Candida albicans, implicating that Chi3 plays a dual function in innate immunity and chitin-bearing food digestion in zebrafish. This is further corroborated by the expression profile of Chi3 in the liver and gut, which are both immune- and digestion-relevant organs. Compared with rChi3, rChi3-CD lacking CBD still retains partial capacity to bind to C. albicans, but its enzymatic and antifungal activities are significantly reduced. By contrast, rChi3-E140N with the putative catalytic residue E140 mutated shows little affinity to chitin, and its enzymatic and antifungal activities are nearly completely lost. These suggest that both enzymatic and antifungal activities of Chi3 are dependent on the presence of CBD and E140. We also clearly demonstrate that in zebrafish, both the embryo extract and the developing embryo display antifungal activity against C. albicans, and all the findings point to chitinase-3 (Chi3) being a newly-identified factor involved in the antifungal activity. Taken together, a dual function in both innate immunity and food digestion in embryo is proposed for zebrafish Chi3. It also provides a new angle to understand the immune role of chitinases in early embryonic development of animals.
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Affiliation(s)
- Zinan Teng
- Laboratory for Evolution & Development, Institute of Evolution & Marine Biodiversity, Department of Marine Biology, Ocean University of China, Qingdao 266003, China
| | - Chen Sun
- Laboratory for Evolution & Development, Institute of Evolution & Marine Biodiversity, Department of Marine Biology, Ocean University of China, Qingdao 266003, China
| | - Shousheng Liu
- Laboratory for Evolution & Development, Institute of Evolution & Marine Biodiversity, Department of Marine Biology, Ocean University of China, Qingdao 266003, China
| | - Hongmiao Wang
- Laboratory for Evolution & Development, Institute of Evolution & Marine Biodiversity, Department of Marine Biology, Ocean University of China, Qingdao 266003, China
| | - Shicui Zhang
- Laboratory for Evolution & Development, Institute of Evolution & Marine Biodiversity, Department of Marine Biology, Ocean University of China, Qingdao 266003, China.
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Matsen CB, Hirsch A, Eaton A, Stempel M, Heerdt A, Van Zee KJ, Cody HS, Morrow M, Plitas G. Extent of microinvasion in ductal carcinoma in situ is not associated with sentinel lymph node metastases. Ann Surg Oncol 2014; 21:3330-5. [PMID: 25092160 DOI: 10.1245/s10434-014-3920-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2014] [Indexed: 02/03/2023]
Abstract
BACKGROUND Ductal carcinoma in situ with microinvasion (DCISM) is a rare diagnosis with a good prognosis. Although nodal metastases are uncommon, sentinel lymph node biopsy (SLNB) remains standard care. Volume of disease in invasive breast cancer is associated with SLNB positivity, and, thus we hypothesized that in a large cohort of patients with DCISM, multiple foci of microinvasion might be associated with a higher risk of positive SLNB. METHODS Records from a prospective institutional database were reviewed to identify patients with DCISM who underwent SLNB between June 1997 and December 2010. Pathology reports were reviewed for number of microinvasive foci and categorized as 1 focus or ≥2 foci. Demographic, pathologic, treatment, and outcome data were obtained and analyzed. RESULTS Of 414 patients, 235 (57 %) had 1 focus of microinvasion and 179 (43 %) had ≥2 foci. SLNB macrometastases were found in 1.4 %, and micrometastases were found in 6.3 %; neither were significantly different between patients with 1 focus versus ≥2 foci (p = 1.0). Patients with positive SLNB or ≥2 foci of microinvasion were more likely to receive chemotherapy. At median 4.9 years (range 0-16.2 years) follow-up, 18 patients, all in the SLNB negative group, had recurred for an overall 5-year recurrence-free proportion of 95.9 %. CONCLUSIONS Even with large numbers, there was no higher risk of nodal involvement with ≥2 foci of microinvasion compared with 1 focus. Number of microinvasive foci and results of SLNB appear to be used in decision making for systemic therapy. Prognosis is excellent.
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Affiliation(s)
- Cindy B Matsen
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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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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Chagpar AB, McMasters KM. Sentinel lymph node biopsy for breast cancer: from investigational procedure to standard practice. Expert Rev Anticancer Ther 2014; 4:903-12. [PMID: 15485323 DOI: 10.1586/14737140.4.5.903] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Sentinel lymph node biopsy, popularized in melanoma, has revolutionized the management of breast cancer. While the morbidity associated with axillary node dissection was once thought to be a requisite risk in order to appropriately stage the axilla, large validation studies have demonstrated that sentinel lymph node biopsy is a minimally invasive technique that can accurately predict nodal status. This technique has become an accepted practice in many centers, but there remain many controversies surrounding the technique itself, the pathologic evaluation of the sentinel node and the optimal management of patients with minimal nodal disease. The historic roots of this technique are discussed, along with the controversial issues surrounding the technique and the clinical trials that are currently ongoing.
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Affiliation(s)
- Anees B Chagpar
- Division of Surgical Oncology, University of Louisville, KY 40202, USA.
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Goodman S, O'Connor A, Kandil D, Khan A. The Ever-Changing Role of Sentinel Lymph Node Biopsy in the Management of Breast Cancer. Arch Pathol Lab Med 2014; 138:57-64. [DOI: 10.5858/arpa.2012-0441-ra] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Context.—Axillary nodal status remains one of the most important prognostic indicators in the management of breast cancer. Axillary node metastases are seen in fewer than half of breast cancer cases, and axillary lymph node dissection is associated with significant morbidity. Sentinel lymph node biopsy (SLNB) has become the gold standard for axillary staging of breast cancer.
Objective.—To present a detailed review of the existing studies on SLNB in relation to the various techniques, the pathologic evaluation of the sentinel node, and special situations that can involve SLNB. We discuss recent trials that have already had an influence on surgical and pathologic management of breast cancer. In this article, we also discuss our practice and experience at UMass Memorial Medical Center, Worcester, Massachusetts, from a pathologic and surgical perspective.
Data Sources.—Published articles from peer-reviewed journals in PubMed (US National Library of Medicine).
Conclusions.—Sentinel node biopsy has become standard of care in the surgical management of breast cancer, and emerging data show that the survival benefits of axillary lymph node dissection may not be greater than sentinel node biopsy alone in patients with up to 2 positive sentinel nodes. Therefore, there have been recent changes to the role of intraoperative sentinel node evaluation, and an impact on overall breast cancer management.
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Affiliation(s)
- Steven Goodman
- From the Departments of Pathology (Drs Goodman, Kandil, and Khan) and Surgery (Dr O'Connor), University of Massachusetts Medical School and UMass Memorial Medical Center, Worcester
| | - Ashling O'Connor
- From the Departments of Pathology (Drs Goodman, Kandil, and Khan) and Surgery (Dr O'Connor), University of Massachusetts Medical School and UMass Memorial Medical Center, Worcester
| | - Dina Kandil
- From the Departments of Pathology (Drs Goodman, Kandil, and Khan) and Surgery (Dr O'Connor), University of Massachusetts Medical School and UMass Memorial Medical Center, Worcester
| | - Ashraf Khan
- From the Departments of Pathology (Drs Goodman, Kandil, and Khan) and Surgery (Dr O'Connor), University of Massachusetts Medical School and UMass Memorial Medical Center, Worcester
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Sentinel Lymph Node Biopsy Should Be Included with the Initial Surgery for High-Risk Ductal Carcinoma-In-Situ. INTERNATIONAL SCHOLARLY RESEARCH NOTICES 2014; 2014:624185. [PMID: 27379334 PMCID: PMC4897395 DOI: 10.1155/2014/624185] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 04/23/2014] [Revised: 08/30/2014] [Accepted: 09/02/2014] [Indexed: 12/02/2022]
Abstract
Background. A proportion of those diagnosed preoperatively with ductal carcinoma-in-situ (DCIS) will be histologically upgraded to invasive carcinoma. Repeat surgery for sentinel lymph node (SLN) biopsy will be required if it had not been included with the initial surgery. We reviewed the outcome of SLN biopsy performed with the initial surgery based on a preoperative diagnosis of DCIS and aimed to identify patients at risk of histological upgrade. Methods. Retrospective review of 294 consecutive female patients diagnosed with DCIS was performed at our institute from January 1, 2001, to December 31, 2008. Results. Of the 294 patients, 132 (44.9%) underwent SLN biopsy together with the initial surgery. The SLN was positive for metastases in 5 patients, all of whom had tumours that were histologically upgraded. Histological upgrade also occurred in 43 of the 127 patients (33.9%) in whom the SLN was negative for metastases. On multivariate analysis, histological upgrade was more likely if a mass was detected on mammogram, if the preoperative diagnosis was obtained with core biopsy and if microinvasion was reported in the biopsy. Conclusion. Patients in whom a preoperative diagnosis of DCIS is likely to be upgraded to invasive carcinoma will benefit from SLN biopsy being performed with the initial surgery.
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Sentinel lymph node biopsy in patients with microinvasive breast cancer: A systematic review and meta-analysis. Eur J Surg Oncol 2014; 40:5-11. [DOI: 10.1016/j.ejso.2013.10.020] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Revised: 10/26/2013] [Accepted: 10/28/2013] [Indexed: 11/20/2022] Open
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Shatat L, Gloyeske N, Madan R, O'Neil M, Tawfik O, Fan F. Microinvasive breast carcinoma carries an excellent prognosis regardless of the tumor characteristics. Hum Pathol 2013; 44:2684-9. [DOI: 10.1016/j.humpath.2013.07.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2013] [Revised: 06/21/2013] [Accepted: 07/05/2013] [Indexed: 10/26/2022]
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Hahn SY, Han BK, Ko EY, Shin JH, Hwang JY, Nam M. MR features to suggest microinvasive ductal carcinoma of the breast: can it be differentiated from pure DCIS? Acta Radiol 2013; 54:742-8. [PMID: 23588154 DOI: 10.1177/0284185113484640] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Morphologic and kinetic characteristics of breast lesions are regarded as a major criterion for their differential diagnosis in dynamic magnetic resonance imaging (MRI). However, there have not been well-reported MRI findings of microinvasive ductal carcinoma. PURPOSE To evaluate MRI characteristics of microinvasive ductal carcinoma of the breast and to compare MRI findings in patients with microinvasive ductal carcinoma and pure ductal carcinoma in situ (DCIS). MATERIAL AND METHODS Eighty-one patients with pathologically confirmed microinvasive ductal carcinomas (n = 37) or pure DCIS (n = 44) were included in this study. The MRI findings were analyzed without knowledge of the pathologic and conventional imaging findings. For all the lesions detected on MRI, morphologic and kinetic analyses were performed according to the Breast Imaging Reporting and Data System. For the non-mass lesions, the presence of clustered ring enhancement was also analyzed. Statistical analyses were performed using Student's t test, χ(2) test, and Fisher's exact test. RESULTS In total 35 cases of microinvasive ductal carcinoma and 39 cases of DCIS were detected on MRI. The most common and dominant MRI findings of microinvasive ductal carcinoma and DCIS were non-mass lesions with heterogeneous enhancement. However, the spiculated margin of the mass-type lesion (P = 0.022), the segmental distribution (P = 0.023), and clustered ring enhancement (P = 0.006) of the non-mass-type lesion, and the enhancement kinetics showing strong initial enhancement (P = 0.004) with subsequent wash-out (P = 0.001) were significantly more frequent in microinvasive ductal carcinoma than in DCIS. CONCLUSION Non-mass lesions with segmental distribution, heterogeneous enhancement, and strong initial enhancement with a wash-out curve were the dominant MRI findings of microinvasive ductal carcinoma. Compared with DCIS, microinvasive ductal carcinoma showed more suspicious imaging characteristics. For the non-mass lesions, clustered ring enhancement was also a characteristic finding of microinvasion on MRI.
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Affiliation(s)
- Soo Yeon Hahn
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - Boo-Kyung Han
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - Eun Young Ko
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - Jung Hee Shin
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
| | - Ji-Young Hwang
- Department of Radiology, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Meeyoung Nam
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul
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Kapoor NS, Shamonki J, Sim MS, Chung CT, Giuliano AE. Impact of Multifocality and Lymph Node Metastasis on the Prognosis and Management of Microinvasive Breast Cancer. Ann Surg Oncol 2013; 20:2576-2581. [DOI: 10.1245/s10434-013-2924-7] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
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Ballehaninna UK, Chamberlain RS. Utility of intraoperative frozen section examination of sentinel lymph nodes in ductal carcinoma in situ of the breast. Clin Breast Cancer 2013; 13:350-8. [PMID: 23791128 DOI: 10.1016/j.clbc.2013.02.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2012] [Revised: 01/31/2013] [Accepted: 02/04/2013] [Indexed: 10/26/2022]
Abstract
BACKGROUND Intraoperative frozen section (IFS) examination of sentinel lymph nodes (SLN) is useful in selecting patients with invasive breast cancer for immediate axillary lymph node dissection. However, whether IFS evaluation of the SLNs in ductal carcinoma in situ (DCIS) of the breast has any value has not been previously assessed. METHODS Clinicopathologic data from patients with DCIS who underwent resection with SLN biopsy (2004-2010) were collected to assess the sensitivity, specificity, and accuracy of IFS, and its impact on axillary management. RESULTS A total of 267 patients with DCIS underwent resection with SLN biopsy and IFS evaluation. Preoperative pathology was DCIS (n = 231), DCIS with microinvasion (n = 24), and DCIS with other lesions (n = 12). Fifty-two (19.5%) patients had invasive breast cancer on final pathology. SLN metastases were identified in 13 (4.8%) patients; however, only 4 (1.5%) were IFS positive. IFS examination was negative in 263 (98.5%) patients. Among patients with SLN metastases, the most common pattern of metastases was either micrometastasis (n = 6) or immunohistochemistry-positive individual tumor cells (n = 4), whereas 3 patients had a macrometastasis. IFS examination was falsely negative in 9 of these 13 patients for a false-negative rate of 69.3%, and a sensitivity and specificity of 31% and 100% respectively. Nine of the 13 patients underwent axillary lymph node dissection and only 1 patient had further axillary metastasis. CONCLUSIONS SLN metastases in DCIS is rare and most commonly involves SLN micrometastasis or immunohistochemistry-positive individual tumor cells. SLN IFS evaluation in DCIS has a low yield and sensitivity, and can be safely omitted to reduce operative duration and cost.
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Affiliation(s)
- Umashankar K Ballehaninna
- Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ; Department of Surgery, Maimonides Medical Center, Brooklyn, NY
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Bayraktar S, Arun B, Glück S. Ductal carcinoma in situ: how should we treat it? BREAST CANCER MANAGEMENT 2013. [DOI: 10.2217/bmt.13.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
SUMMARY The observed incidence of ductal carcinoma in situ (DCIS) has increased because of the increasing use of sensitive imaging modalities. While the clinical course of DCIS is quite variable, it is considered a precursor lesion to invasive breast cancer. The current focus of DCIS treatment is on the prevention of progression to invasive disease. However, at present, validated diagnostic tests to predict progression accurately are lacking. Additionally, important clinical questions arise during DCIS management. For example, optimal margins of excision or axillary lymph node sampling have not been addressed in randomized clinical trials. May whole-breast radiation after lumpectomy be omitted in selected patients? What is the role of adjuvant tamoxifen if it does not impact overall survival rates? This review aims to describe the natural history of DCIS and highlights the current therapeutic options and challenges in patient management.
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Affiliation(s)
- Soley Bayraktar
- Department of Medical Oncology, Mercy Cancer Center, Ardmore, OK, USA
| | - Banu Arun
- Department of Breast Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Stefan Glück
- Department of Medicine, Division of Hematology/Medical Oncology, University of Miami & Sylvester Comprehensive Cancer Center, Miami, FL, USA
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Murthy V, Chamberlain RS. Prophylactic mastectomy in patients at high risk: is there a role for sentinel lymph node biopsy? Clin Breast Cancer 2013; 13:180-7. [PMID: 23357305 DOI: 10.1016/j.clbc.2012.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2012] [Revised: 11/20/2012] [Accepted: 12/08/2012] [Indexed: 01/06/2023]
Abstract
INTRODUCTION Prophylactic mastectomy (PM) rates in the United States are rising due to determination of increased Gail risk, moderate-high risk lesions, a strong family history, and gene mutation carriers. The role of sentinel lymph node biopsy (SLNB) in PM remains controversial. This report sought to examine clinical utility of SLNB in PM. METHODS A total of 292 patients underwent bilateral or contralateral PM (1999-2011). SLNB was performed on the PM side in 195 (66.7%) patients with standard techniques. Clinicopathologic data were analyzed for the incidence of occult cancer in prophylactic breast and/or axilla. Univariate analysis was used to determine factors that predict SLN positivity. RESULTS The median patient age was 49 years (range, 19-79 years). Contralateral invasive breast cancer (64.7%) was the most common indication for PM. A total of 209 (71.5%) invasive breast cancer and 49 (16.7%) in situ cancers (n = 38 ductal carcinoma in situ, n = 10 lobular carcinoma in situ) were identified on the therapeutic mastectomy side, with a median tumor size of 1.5 cm. 58.6% were estrogen receptor positive and 4.7% were multicentric. Three (1%) ductal carcinoma in situ, 4 (1.3%) lobular carcinoma in situ, and 5 (1.7%) atypical ductal, and 1 (0.3%) lobular hyperplasia were identified in PM breast. No invasive breast cancer or positive SLN was identified in PM breast and/or axilla. CONCLUSION Although a minimally invasive procedure, the utility of SLNB in patients with absent or contralateral early disease is limited. Advanced T stage, multicentricity, or receptor status on the therapeutic side or a finding of in situ or atypical hyperplasia in prophylactic breast specimen yielded no positive SLN. Routine SLNB in pure bilateral PM can safely be omitted, which reduces axillary morbidity and operative time and/or cost. Selective use of SLNB for contralateral recurrent and/or locally advanced cancers warrants further investigation.
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Affiliation(s)
- Vijayashree Murthy
- Department of Surgery, Saint Barnabas Medical Center, Livingston, NJ 07039, USA
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Dhebri AR, Ahmad A, Shah N, Arora PK. Intracystic papillary carcinoma of breast: report of three cases and review of the literature. BMJ Case Rep 2012. [PMID: 23188855 DOI: 10.1136/bcr-2012-007237] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Intracystic papillary carcinoma (IPC) of the breast is a rare malignant tumour, found mainly but not exclusively in elderly women. IPC may be asymptomatic or presents with a palpable mass or blood-stained nipple discharge. The tumour is encysted within a dilated duct with arborisation of the fibrovascular stroma and contains nodules of papillary carcinoma surrounded by a thick fibrous capsule. Frequently excisional biopsy is required for diagnosis. The mainstay of treatment is breast-conserving surgery or mastectomy. Sentinel node biopsy could be considered in invasive cases. Adjuvant radiotherapy (XRT) and/or endocrine therapy is considered in appropriate cases. Prognosis is excellent. We report three such cases of IPC, in elderly women, which were successfully treated.
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Affiliation(s)
- Alhad R Dhebri
- Department of Surgery, Tameside General Hospital, Ashton-under-lyne, UK.
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Shah DR, Canter RJ, Khatri VP, Bold RJ, Yang AD, Martinez SR. Utilization of sentinel lymph node biopsy in patients with ductal carcinoma in situ undergoing mastectomy. Ann Surg Oncol 2012; 20:24-30. [PMID: 23054103 DOI: 10.1245/s10434-012-2539-4] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2012] [Indexed: 11/18/2022]
Abstract
BACKGROUND Current guidelines suggest consideration of sentinel lymph node biopsy (SLNB) for patients with ductal carcinoma in situ (DCIS) undergoing mastectomy. Our objective was to identify factors influencing the utilization of SLNB in this population. METHODS We used the Surveillance Epidemiology and End Results database to identify all women with breast DCIS treated with mastectomy from 2000 to 2008. We excluded patients without histologic confirmation, those diagnosed at autopsy, those who had axillary lymph node dissections performed without a preceding SLNB, and those for whom the status of SLNB was unknown. We used multivariate logistic regression reporting odds ratios (OR) and 95% confidence intervals (CI) to evaluate the relationship of patient- and tumor-related factors to the likelihood of undergoing SLNB. RESULTS Of 20,177 patients, 51% did not receive SLNB. Factors associated with a decreased likelihood of receiving a SLNB included advancing age (OR 0.66; 95% CI 0.62-0.71), Asian (OR 0.75; CI 0.68-0.83) or Hispanic (OR 0.84; 95% CI 0.74-0.96) race/ethnicity, and history of prior non-breast (OR 0.57; 95% CI 0.53-0.61). Factors associated with an increased likelihood of receiving a SLNB included treatment in the east (OR 1.28; 95% CI 1.17-1.4), intermediate (OR 1.25; 95% CI 1.11-1.41), high (OR 1.84; 95% CI 1.62-2.08) grade tumors, treatment after the year 2000, and DCIS size 2-5 cm (OR 1.54; 95% CI 1.42-1.68) and >5 cm (OR 2.43; 95% CI 2.16-2.75). CONCLUSIONS SLNB is increasingly utilized in patients undergoing mastectomy for DCIS, but disparities in usage remain. Efforts at improving rates of SLNB in this population are warranted.
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Affiliation(s)
- Dhruvil R Shah
- Division of Surgical Oncology, Department of Surgery, University of California Davis, Sacramento, CA, USA
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