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.     

Role of sentinel lymph node biopsy in patients with ductal carcinoma in situ and microinvasion

Aim: Ductal carcinoma in situ with microinvasion (DCISMI) is characterized by one or more areas of focal invasion, 1 mm or less in diameter. While pure ductal carcinoma in situ (DCIS) does not have the potential to metastasize to regional nodes, the presence of microinvasion makes lymph node metastasis possible, leading to current guidelines recommending staging of the axilla with sentinel lymph node biopsy (SLNB). However, there are few studies looking at the risk of lymphatic spread in patients with DCISMI, and indications for axillary staging in such cases is controversial. The aim of the present study was to assess the prevalence of nodal metastasis in patients with DCISMI in order to help ascertain whether SLNB can be safely avoided in DCISMI. Patients and Methods: A retrospective analysis was performed of patients undergoing surgery for DCIS over a 2‐year period (April 2006–08). Data were collected from the National Health Service Breast Screening Programme database and patient case notes. Patients having a SLNB had injection of radioisotope and blue dye. All SLNB were evaluated with serial sectioning and haematoxylin–eosin staining. Results: Over the 2‐year period, 399 screen‐detected breast cancers were treated, of which 310 (77 per cent) were invasive, 17 (4 per cent) had DCISMI and 72 (19 per cent) pure DCIS. The group with DCISMI was studied in more detail. Twelve out of the 17 patients had a wide local excision and five had a mastectomy. All 17 patients with DCISMI had a SLNB. No positive lymph nodes were found in this group. Conclusion: Our data suggest that the risk of nodal metastasis in DCISMI might be low, and question the role of SLNB in DCISMI. We highlight the lack of data on DCISMI and risk of nodal metastasis, and the need for further investigation.     

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.     

Value of sentinel lymph node biopsy in breast ductal carcinoma in situ upstaged to invasive carcinoma

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

Sentinel lymph node biopsy in breast cancer: technical aspects and results

Sentinel lymph node biopsy for breast cancer has been introduced in the mid-1990s and it has now been performed on thousands of patients. Although this procedure has not been validated by randomised clinical trials, it has been rapidly adopted around the world by surgical specialists in clinical practice as a diagnostic procedure instead of the axillary lymph node dissection. The critical issue in sentinel lymph node biopsy is the false negative results which could expose the patients to axillary recurrence and lead to understaging and incorrect adjuvant therapy decisions. The current problem is to perfect the procedure for an optimal use in routine reducing this risk of false negative results. This false negative rate declines sharply when the technique is performed in selected patients by experienced surgeons using a combined detection. In this article, we review the technical aspects and results of the sentinel lymph node biopsy in breast cancer and discuss the recommendations for the optimal clinical practice.     

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

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

Core biopsy diagnosis of ductal carcinoma in situ: an indication for sentinel lymph node biopsy

BACKGROUND: Sentinel lymph node biopsy (SLNB) is a minimally invasive, accurate method of evaluating axillary lymph nodes in patients with invasive cancer. The technique has also been applied successfully in patients with ductal carcinoma in situ (DCIS). The purpose of this study was to review our experience performing SLNB in patients with a biopsy diagnosis of DCIS. METHODS: A prospective study of consecutive patients seen at our institution from August 2001 to April 2004 with a biopsy diagnosis of DCIS was undertaken. Demographic data, biopsy method, final pathology, and surgical treatment were recorded. Patients undergoing SLNB were identified, and pathologic results were noted. RESULTS: Eighty-five patients with a biopsy diagnosis of DCIS were treated. Fifty-five (64.7%) had their diagnosis made by excisional biopsy, and 30 (35.3%) by core biopsy. Forty-four (51.7%) patients underwent SLNB as part of their definitive surgical procedure, and an SLN was successfully identified in 41 (93.2%). Nine (22.0%) patients who underwent successful SLNB had a positive SLN, 2 by hematoxylin and eosin (H&E) staining and 7 by immunohistochemical (IHC) staining for cytokeratin. Both patients with H&E-positive SLN were ultimately found to have invasive disease in their primary lesion. Final pathologic assessment of all primary lesions revealed invasive carcinoma in 7, 6 of whom had their diagnosis made by core biopsy. Overall, 20.0% of patients with a core biopsy diagnosis of DCIS were upstaged to invasive disease. Whether the lesion was palpable, grade and the presence or absence of necrosis were not significantly different in patients ultimately found to have invasive disease versus those who did not. DISCUSSION: Sentinel lymph node biopsy can be performed accurately in patients with a biopsy diagnosis of DCIS. The rate of axillary disease in patients with pure, completely resected DCIS is low; therefore, SLNB is not indicated in all patients with this biopsy diagnosis. Because of a high rate of invasive disease on the final pathology of patients with DCIS diagnosed by core biopsy, these patients should be offered SLNB.     

Axillary sentinel lymph node biopsy in patients with pure ductal carcinoma in situ of the breast

HYPOTHESIS: A sentinel lymph node (SLN) biopsy should not be considered a standard procedure in the treatment of all patients with ductal carcinoma in situ (DCIS) of the breast if the lesion is completely excised by radical surgery and there are free margins of resection. DESIGN: Prospective case series. SETTING: Department of breast surgery of a comprehensive cancer center. PATIENTS: From January 1, 1998, to December 1, 2001, 223 unselected consecutive patients affected by pure DCIS of the breast underwent an SLN biopsy. RESULTS: Metastases in the SLN were detected in 7 (3.1%) of the 223 patients, and complete axillary dissection was subsequently performed in all these patients but 1. Of these 7 patients, 5 had only micrometastases in the SLNs; and in the 6 patients treated with complete axillary dissection, the SLN was the only positive node. CONCLUSIONS: Because of the low prevalence of metastases, an SLN biopsy should not be considered a standard procedure in all patients with DCIS. In patients with pure DCIS in whom the lesion is completely excised by radical surgery, an SLN biopsy could be avoided. It could be considered in patients with DCIS undergoing mastectomy, in whom there exists a higher risk of harboring an invasive component using definitive histologic features, like large solid tumors or diffuse or multicentric microcalcifications; in these patients, an SLN biopsy cannot be performed at a later operation. Complete axillary dissection may not be mandatory if the SLN is micrometastatic.     

Sentinel lymph node positivity of patients with ductal carcinoma in situ or microinvasive breast cancer

PURPOSE: The purpose of this study was to determine the rates of sentinel lymph node (SLN) positivity in patients with a final diagnosis of ductal carcinoma in situ (DCIS) or microinvasive breast cancer (MIC). METHODS: One hundred thirty patients underwent SLN mapping from 1998 to 2003 for DCIS or MIC. RESULTS: One hundred nine patients with DCIS and 21 with MIC underwent SLN mapping. One patient with bilateral DCIS underwent 2 SLN procedures; therefore, the results of 131 SLN procedures are included. On hematoxylin and eosin (H&E) staining, 4 of 110 patients (3.6%) with DCIS had positive SLNs. Four additional patients had positive SLNs by IHC staining only (3.6%). Two of 8 patients underwent completion axillary dissection, and neither had additional involved nodes on completion axillary dissection. One of the 21 patients with MIC had positive SLNs by hematoxylin and eosin (H&E) (4.8%), and another had an involved SLN by IHC staining (4.8%). The patient with the positive SLN by H&E had 1 additional node on completion axillary dissection. CONCLUSION: Rates of SLN positivity for patients with DCIS are modest, even in a high-risk population, and there is continuing uncertainty about its clinical importance.     

Reliability of sentinel lymph node biopsy for staging melanoma

BACKGROUND: The aim of this study was to evaluate the reliability of sentinel lymph node biopsy for staging melanoma. METHODS: Two hundred consecutive patients with a cutaneous melanoma of at least 1. 0 mm Breslow thickness, without palpable regional lymph nodes, were included from 1993 in a prospective cohort study in a single tertiary care hospital. One day after lymphoscintigraphy, sentinel node biopsy was performed, guided by a gamma probe and patent blue dye. Lymph node dissection was performed only if metastasis was found in a sentinel node. Median follow-up was 32 (range 3-61) months. No patient was lost to follow-up. RESULTS: A sentinel node was removed in 199 of 200 patients (mean 2.2 nodes per patient). Forty-eight patients (24 per cent) had metastasis in a sentinel node. Fifteen patients developed recurrence after removal of a tumour-negative sentinel node; six relapsed in the previously mapped basin (false-negative rate 11 per cent (six of 54)). The overall survival at 3 years was 93 per cent if the sentinel node was negative and 67 per cent if it was positive. Sentinel node status and Breslow thickness were strong predictors of recurrence and survival. Minor complications were seen in 18 patients. CONCLUSION: The sentinel node status was a strong prognostic factor, even with a false-negative rate of 11 per cent. Published in abstract form as Eur J Nucl Med 1999; 26(Suppl): S57     

Sentinel lymph node positivity in patients undergoing mastectomies for ductal carcinoma in situ (DCIS)

Current guidelines recommend sentinel lymph node biopsy (SLNB) for patients undergoing mastectomy for a preoperative diagnosis of ductal carcinoma in situ (DCIS). We examined the factors associated with sentinel lymph node positivity for patients undergoing mastectomy for a diagnosis of DCIS on preoperative core biopsy (PCB). The Institutional Breast Cancer Database was queried for patients with PCB demonstrating pure DCIS followed by mastectomy and SLNB from 2010 to 2018. Patients were divided according to final pathology (DCIS or invasive cancer). Clinico‐pathologic variables were analyzed using Pearson's chi‐squared, Wilcoxon Rank‐Sum and logistic regression. Of 3145 patients, 168(5%) had pure DCIS on PCB and underwent mastectomy with SLNB. On final mastectomy pathology, 120(71%) patients had DCIS with 0 positive sentinel lymph nodes (PSLNs) and 48(29%) patients had invasive carcinoma with 5(10%) cases of ≥1 PSLNs. Factors positively associated with upstaging to invasive cancer in univariate analysis included age (P = .0289), palpability (P < .0001), extent of disease on imaging (P = .0121), mass on preoperative imaging (P = .0003), multifocality (P = .0231) and multicentricity (P = .0395). In multivariate analysis, palpability (P = .0080), extent of disease on imaging (P = .0074) and mass on preoperative imaging (P = .0245) remained significant (Table 2). In a subset of patients undergoing mastectomy for DCIS with limited disease on preoperative evaluation, SLNB may be omitted as the risk of upstaging is low. However, patients who present with clinical findings of palpability, large extent of disease on imaging and mass on preoperative imaging have a meaningful risk of upstaging to invasive cancer, and SLNB remains important for management.     

Ductal carcinoma in situ (DCIS) and biopsy of the sentinel lymph node

INTRODUCTION: Ductal carcinoma in situ (DCIS) is the disease with increasing incidence. Nowadays, approximately 80% DCIS are diagnosed via mammography and represent more than 20% of all types of breast cancer. The acceptance of surgical procedures with this type of breast carcinoma is controversial as primary diagnosis of non-invasive carcinoma is often underestimated and in the end, histopathological examination reveals invasive carcinoma with biological potential to metastasize. In cases of "risk" patient groups with DCIS, several studies report lymph node metastases. The aim of the study has been to assess the incidence of sentinel lymph node metastatic involvement in high-risk patient group with DCIS and in ductal carcinoma in situ with microinvasion (DCISMI), to note the incidence of invasive carcinoma in definitive histopathology in patients with pre-operative diagnosis of DCIS and to analyze some predictors of invasivity. STUDY TYPE AND PATIENT GROUP: In retrospective analysis, we evaluated the setting of 119 patients who have been operated on at our Clinic from January, 1st 2008 until December, 31th 2010 for the diagnosis of DCIS. Prospectively, we have created the setting of 44 patients with high-risk DCIS with sentinel lymph node biopsy (SLNB) performed. METHODS AND RESULTS. Metastatic involvement of sentinel lymph node in high-risk DCIS has been found in 4 cases (9.0%)--in 1 patient (2.2%) with correct diagnosis of DCIS and in 3 patients (6.8%) with invasive carcinoma according to final histopathology. In the patient with DCIS, a micrometastasis of 0.4 mm was found in one sentinel lymph node. After complete axillary dissection, non-sentinel axillary lymph nodes metastatic involvement was not demonstrated (14/0). In 6 cases (5.0%), we identified DCISMI and did not find metastasis in sentinel lymph node. In the high-risk DCIS group, in 4 patients (9.0%) DCISMI and in 12 patients (27.2%) invasive carcinoma was found after definitive histopathologic examination. In this group, the overall ratio of invasive lesions was 36.2%. As for predictors of invasivity, high-grade carcinoma (OR 4.2; 95% CI 1,40-12,58) has more than 4-fold higher influence and lesion size     

Sentinel lymph node mapping and biopsy for ductal carcinoma in situ and other controversial indications

This review discusses the currently available literature regarding three controversial indications for sentinel node mapping for breast cancer patients. For women with ductal carcinoma in situ (DCIS), the use of sentinel lymph node mapping (SLNM) should be limited to women having a mastectomy. For patients with multifocal breast carcinoma, SLNM is accurate when a retroareolar injection technique is employed in the procedure. When treatment plans for node-negative patients call for neoadjuvant chemotherapy, accurate sentinel node mapping can be performed prior to the administration of chemotherapy. The resolution of these and other controversies should result in the expansion of the number of patients evaluated with SLNM in the future.     

Predictors of invasion and axillary lymph node metastasis in patients with a core biopsy diagnosis of ductal carcinoma in situ: an analysis of 255 cases

The diagnosis of ductal carcinoma in situ (DCIS) using core biopsy does not ensure the absence of invasion on final excision. We performed a retrospective analysis of 255 patients with DCIS who had subsequent excision. Clinical, radiologic, and pathologic findings were correlated with risk of invasion and sentinel lymph node (SLN) metastasis. Of 255 patients with DCIS, 199 had definitive surgery and 52 (26%) had invasive ductal carcinoma (IDC) on final excision. Extent of abnormal microcalcification on mammography, and presence of a radiologic/palpable mass and solid type of DCIS were significantly associated with invasion on final excision. Sentinel lymph node biopsy was performed in 131 (65.8%) patients of whom 18 (13.4%) had metastasis. Size of IDC and extent of DCIS on final pathology were significantly associated with positive SLN. Micrometastasis and isolated tumor cells comprised majority (71.4%) of the metastases in DCIS. SLN biopsy should be considered in those with high risk DCIS.     

Optimal histopathologic examination of the sentinel lymph node for breast carcinoma staging

Sentinel lymph node dissection is a minimally invasive surgical technique for staging of breast carcinoma. The optimal pathologic examination of the sentinel node (SN) has not yet been determined. Our standard protocol for evaluation of the SN in patients with breast cancer included frozen section at one level, plus paraffin sections at two levels, separated by 40 microm, and stained with hematoxylin and eosin and cytokeratin immunohistochemistry (IHC) at each paraffin section level. In the current study, we evaluated the use of step sections and cytokeratin IHC in 60 SNs (42 consecutive patients) that were tumor-negative on frozen section and hematoxylin and eosin staining at permanent section levels 1 and 2. The SN were reexamined with cytokeratin IHC at eight additional levels (levels 3-10) of the paraffin block, each separated by 40 microm. Previous IHC sections from levels 1 and 2 had shown micrometastases in nine SNs (eight patients) and no tumor cells in the remaining 51 SNs (34 patients). Of the 51 previously negative SNs, only two (4%) SNs from one (3%) patient had metastatic carcinoma cells in levels 3-10. Thus, the additional step sections with cytokeratin IHC did not significantly increase the number of patients with tumor-positive SNs. We currently recommend that the SN be examined with cytokeratin IHC at two levels of the paraffin block. This should optimize sentinel lymph node dissection as a staging technique and minimize the labor and financial burden associated with multiple step sections and IHC stains.