Is it really duct carcinoma in situ?

Memorial sloan-kettering cancer center: two decades of experience with ductal carcinoma in situ of the breast

Researchers at Memorial Sloan-Kettering Cancer Center have investigated many aspects of their experience with ductal carcinoma in situ of the breast over the past 20 years. This paper summarizes the most clinically relevant findings.

Indication for sentinel lymph node biopsy for breast cancer when core biopsy shows ductal carcinoma in situ

BACKGROUND

The use of sentinel lymph node biopsy (SLNB) for ductal carcinoma in situ (DCIS) is controversial.

METHODS

A total of 103 primary breast cancer patients who were diagnosed with DCIS by needle biopsy preoperatively and underwent initial SLNB were analyzed retrospectively.

RESULTS

No sentinel nodal metastasis was detected in 66 patients with the final diagnosis of DCIS. However, 2 (5.4%) of 37 patients with invasive ductal carcinoma at final diagnosis had positive sentinel nodes. Multivariate logistic regression analysis identified 2 independent significant predictors of existence of invasive components: presence of a palpable tumor (odds ratio, 4.091; 95% confidential interval, 1.399-11.959; P = .010) and tumor size of 2.0 cm or larger on magnetic resonance imaging (odds ratio, 4.506; 95% confidence interval, 1.322-15.358; P = .016).

CONCLUSIONS

Initial SLNB should be considered for patients diagnosed with DCIS by needle biopsy when they have a high risk for harboring invasive ductal cancer preoperatively.

Does blue dye contribute to success of sentinel node mapping for breast cancer?

BACKGROUND

We sought to evaluate the utilization of blue dye in addition to radioisotope and its relative contribution to sentinel lymph node (SLN) mapping at a high-volume institution.

METHODS

Using a prospectively maintained database, 3,402 breast cancer patients undergoing SLN mapping between 2002 and 2006 were identified. Trends in utilization of blue dye and results of SLN mapping were assessed through retrospective review. Statistical analysis was performed with Student t test and chi-square analysis.

RESULTS

2,049 (60.2%) patients underwent mapping with dual technique, and 1,353 (39.8%) with radioisotope only. Blue dye use decreased gradually over time (69.8% in 2002 to 48.3% in 2006, p < 0.0001). Blue dye was used significantly more frequently in patients with lower axillary counts, higher body mass index (BMI), African-American race, and higher T stage, and in patients not undergoing skin-sparing mastectomy. There was no difference in SLN identification rates between patients who had dual technique versus radiocolloid alone (both 98.4%). Four (0.8%) of 496 patients who had dual mapping and a positive SLN had a blue but not hot node as the only involved SLN. None of these four had significant counts detected in the axilla intraoperatively. Nine (0.4%) of 2,049 patients who had dual mapping had allergic reactions attributed to blue dye.

CONCLUSIONS

Blue dye use has decreased with increasing institutional experience with SLN mapping. In patients with adequate radioactive counts in the axilla, blue dye is unlikely to improve the success of sentinel node mapping.

Meta-analysis of sentinel node biopsy in ductal carcinoma in situ of the breast

BACKGROUND

The need for sentinel lymph node (SLN) biopsy in patients with a preoperative diagnosis of ductal carcinoma in situ (DCIS) is debated. Advocates recommend such biopsy based on a high incidence of SLN involvement in some series. Opponents discourage SLN biopsy based on a perceived low incidence of nodal involvement in this setting. These contradictory arguments are generally based on small studies. The present study is a meta-analysis of the reported data on the incidence of SLN metastasis in patients with DCIS.

METHODS

A search of electronic databases identified studies reporting the frequency of SLN metastases in DCIS. The random-effects method was used to combine data.

RESULTS

Twenty-two published series were included in the meta-analysis. The estimate for the incidence of SLN metastases in patients with a preoperative diagnosis of DCIS was 7.4 (95 per cent confidence interval (c.i.) 6.2 to 8.9) per cent compared with 3.7 (95 per cent c.i. 2.8 to 4.8) per cent in patients with a definitive (postoperative) diagnosis of DCIS alone. This was a significant difference with an odds ratio of 2.11 (95 per cent c.i. 1.15 to 2.93).

CONCLUSION

Patients with a preoperative diagnosis of DCIS should be considered for SLN biopsy.

Role of sentinel lymph node biopsy in high-risk ductal carcinoma in situ patients

BACKGROUND

The role of sentinel lymph node biopsy (SLNB) for ductal carcinoma in situ (DCIS) is poorly defined. However, up to 20% of patients with DCIS will have invasive carcinoma; these patients require staging for axillary metastasis. The aim of this study was to identify patients with a core biopsy diagnosis of DCIS who may benefit from SLNB.

METHODS

In a prospective study, we performed SLNB on patients with a preoperative diagnosis of >2.5 cm of high-grade DCIS or DCIS when mastectomy was indicated.

RESULTS

Sixty-two patients underwent surgery for high-grade DCIS, and 35 of these patients underwent SLNB. Postsurgical excision histology revealed invasive disease in 20 patients, 19 of whom had undergone SLNB. Before the adoption of SLNB in selected DCIS patients, all 20 with occult invasive disease would have required second surgery axillary staging (P < .01, chi-square test).

CONCLUSIONS

SLNB should not be performed routinely for all patients with an initial diagnosis of DCIS. However, selective lymphadenectomy may be a useful clinical adjuvant in selected high-risk DCIS patients.

Tumour-positive sentinel node findings in patients with ductal carcinoma in situ

BACKGROUND

Our aim was to evaluate the prevalence of and risk factors for tumour-positive sentinel node (SN) findings in patients with ductal carcinoma in situ (DCIS).

METHODS

Altogether 1,470 patients underwent sentinel node biopsy (SNB) between April 2001 and March 2005 in our unit. According to a histopathological review, 11 of them had microinvasive and 74 pure DCIS and were included in the study.

RESULTS

Five patients (7%) with pure DCIS had SN metastases. Three of them had isolated tumour cells (ITC) only. Axillary clearance without further metastatic findings was performed in three patients. The median histological size of DCIS was larger, 50 (45-60) mm in patients with metastatic SN findings than the median of 18 (2-110) mm in those with tumour-negative SN, P=0.0103. All five patients with metastatic SN findings underwent mastectomy. Metastatic SN findings were detected in one (9%) patient with microinvasive DCIS.

CONCLUSIONS

Metastatic SN findings in patients with pure DCIS may be a sign of missed invasion.

The role of sentinel lymph node biopsy in ductal carcinoma in situ

AIM

To review the role of sentinel lymph node (SLN) biopsy in the surgical management of patients with ductal carcinoma in situ (DCIS).

METHODS

A search was conducted of Medline and the National Library of Medicine to identify key articles concerning DCIS, SLN biopsy (SLNB) and axillary dissection. Further relevant articles were obtained from the references cited in the literature.

RESULTS

Up to 20% of patients with a core biopsy diagnosis of DCIS will be later up-staged based on an invasive component identified on the excision specimen. Quality assurance in breast screening programmes requires minimally invasive pre-operative diagnosis and also axillary sampling in the case of documented invasive disease. As an effective and validated procedure, SLNB represents a paradigm shift in the surgical management of the axilla for patients with invasive breast cancer. It remains undefined which, if any, subgroups of patients with DCIS should undergo SLNB.

CONCLUSION

Axillary lymphadenectomy is an overtreatment for patients with DCIS. Performing a SLNB during the initial procedure may avoid a second operation in some DCIS patients who are diagnosed with occult invasive disease at their definitive operation. When predictors of hidden invasive disease are clarified by further study, SLNB may be used in the management of selected high-risk DCIS patients.

EXPERIENCE OF SENTINEL NODE BIOPSY ALONE IN EARLY BREAST CANCER WITHOUT FURTHER AXILLARY DISSECTION IN PATIENTS WITH NEGATIVE SENTINEL NODE

AIMS

The aims of surgical therapy of breast cancer are loco-regional tumour control and staging. Axillary staging is still considered the single most important prognostic indicator in breast cancer. Surgical removal of axillary nodes remains the standard way to assess their involvement in most centres. The morbidity associated with axillary dissection (AD) is well recognized. In recent years sentinel node biopsy (SNB) has evolved. Multiple studies suggest it has the same accuracy as AD in axillary staging and less morbidity in early breast cancer (EBC). SNB has become the standard of practice in EBC in many parts of the world. In Australia, the preference has been to wait for the results of the Sentinel Node versus Axillary Clearance (SNAC) trial as well as other international trials before accepting SNB as a standard of care. The experience of a single surgeon with SNB alone in EBC without further completion axillary dissection (CAD) in negative sentinel node (SLN) is described in the present paper.

METHODS

An audit was done of the senior author's prospective data from the Royal Australasian College of Surgeons database. Other information was added retrospectively from case notes.

RESULTS

Between December 2000 and December 2003, 154 EBC cases (153 patients) underwent SNB alone. An average of four SLN was removed. Of these cases, 31.8% had positive SLNs (excluding 2.6% cases that had isolated tumour cells), of these, 93.9% had metastases (39.1% micro- and 60.9% macro-metastases) in axillary-SLN (ASLN) and almost all of these had CAD. ASLNs were the only positive nodes in 73.9%. Extra-ASLN retrieved in 68.8% of 34% demonstrated on lymphoscintigraphy. Of these, 12.1% were positive (6.1% micro- and macro-metastases each), all internal mammary. Mean follow up was 22.1 months. There was one local-regional-systemic and one systemic recurrence over this time.

CONCLUSION

SNB has a valid role in staging of the axilla particularly in low-risk patients. After adequate self audit, SNB offers a minimal morbidity and reliable method of axillary staging. Patients choosing SNB alone must understand that the long-term results of the randomized controlled trial are still pending for level I evidence of long-term efficacy.

Do not contemplate invasive surgery for ductal carcinoma in situ

BACKGROUND

Ductal carcinoma in-situ (DCIS), by definition, has no metastatic potential. The routine examination of axillary lymph nodes in these patients may expose them to unnecessary operative morbidity and is the subject of continuing controversy. This study evaluates the lymph node status of patients with DCIS.

METHODS

A retrospective review of all tumor registry patients diagnosed with DCIS between January 1996 and December 2000 was performed. Data obtained included (1) patient demographics, (2) the surgical procedure performed, (3) the histologic grade of the tumor, and (4) the lymph node status, if obtained. All analysis was by hematoxylin and eosin (H&E) stain only.

RESULTS

In all, 380 patients were diagnosed with DCIS. Surgical therapy for these patients varied from lumpectomy (with negative margins) to modified radical mastectomy. Ninety-seven (25.5%) had their axillary lymph nodes (average 9, range 1 to 33) analyzed by H&E stain and are the subject of this study. One patient (1%) was found to have a lymph node micrometastasis.

CONCLUSIONS

This study demonstrates that axillary lymph node examination is a low-yield endeavor for patients diagnosed with DCIS, regardless of the histologic grade of the tumor. Routine sampling of lymph nodes in these patients is not warranted.