AIM:To study the indications for sentinel lymph node biopsy (SLNB) in clinically-detected ductal carcinoma in situ (CD-DCIS). METHODS:A retrospective analysis of 20 patients with an initial diagnosis of pure DCIS by an image-guided core needle biopsy (CNB) Al-Ameer AY et al . SNLB in clinically detected DCIS of sentinel and non-sentinel nodal metastasis, and the histologic underestimation rate of invasive cancer at initial diagnosis were analyzed. The inclusion criteria were a preoperative diagnosis of pure DCIS with no evidence of invasion. We excluded any patient with evidence of microinvasion or invasion. There were two cases of mammographically detected DCIS and 18 cases of CD-DCIS. All our patients were diagnosed by an imageguided CNB except two patients who were diagnosed by fine needle aspiration (FNA). All patients underwent breast surgery, SLNB, and axillary lymph node dissection (ALND) if the SLN was positive. RESULTS:Twenty patients with an initial diagnosis of pure DCIS underwent SLNB, 2 of whom had an ALND. The mean age of the patients was 49.7 years (range, 35-70). Twelve patients (60%) were premenopausal and 8 (40%) were postmenopausal. CNB was the diagnostic procedure for 18 patients, and 2 who were diagnosed by FNA were excluded from the calculation of the underestimation rate. Two out of 20 had a positive SLNB and underwent an ALND and neither had additional non sentinel lymph node metastasis. Both the sentinel visualization rate and the intraoperative sentinel identification rate were 100%. The false negative rate was 0%. Only 2 patients had a positive SLNB (10%) and neither had additional metastasis following an ALND. After definitive surgery, 3 patients were upstaged to invasive ductal carcinoma (3/18 = 16.6%) and 3 other patients were upstaged to DCIS with microinvasion (3/18 = 16.6%). Therefore the histologic underestimation rate of invasive disease was 33%.CONCLUSION: SLNB in CD-DCIS is technically feasible and highly accurate. We recommend limiting SLNB to patients undergoing a mastectomy. Core tip: While most ductal carcinoma in situ (DCIS) cases present with a radiologically detected abnormality, our sample represented a rare group of ductal carcinoma which was detected clinically. This study had a specific objective to determine the indications for sentinel lymph node in clinically detected DCIS. There are very few studies worldwide tracking this specific group, and there is no screening program in our community for breast cancer. This study will help communities who have no screening program to put protocols in place for such a specific group of patients.

Objectives: To assess the benefits associated with radioactive seed localization (RSL) in comparison to conventional wire localization (WL) for nonpalpable breast lesions. Methods: Radioactive seed localization was initiated at our institution in July 2013. Retrospective review of all WL performed between June 2012 and July 2013 (2013) and all RSL performed during June 2015 and July 2016 (2016). Patients who received neoadjuvant therapy or did not undergo their planned surgeries and WL performed in 2016 were excluded. The following data were collected: final pathology, resection margins for malignant lesions, time to surgery, seed migration, and number of localized lumpectomies performed by each surgeon. Results: A total of 292 WL procedures (288 women) in 2013 and 194 RSL procedures (186 women) in 2016 were eligible for the study. All WLs were inserted the day of surgery. Mean time from RSL insertion to surgery was 4.0 ± 2.8 days (range: 1-17 days). There was no difference in specimen size for malignant lesions (6.8 ± 2.8 cm for WL and 6.9 ± 2.9 cm for RSL; P = .5). Specimen radiographs were obtained in 233 (80%) of 292 WL compared to 194 (100%) of 194 RSL ( P < .001). For malignant lesions, positive margins were present in 34 (17.2%) of 198 with WL compared to 15 (10.3%) of 146 with RSL ( P < .001). Close margins (≤1 mm) were present in 31 (15.6%) of 198 with WL compared to 1 (0.6%) of 146 with RSL ( P < .001). The seed fell out of the specimen during surgery in 6 (3.1%) of 194. No seed loss was recorded. The surgeons (n = 4) who transitioned to RSL increased the number of surgeries per month from a mean of 4.4 ± 2.6 in 2013 to 6.9 ± 3.5 in 2016, equivalent to a 41% increase ( P = .003). Conclusions: The use of RSL, as compared to conventional WL, resulted in a reduction in the number of pathologically involved surgical margins and was associated with an increased number of surgeries. Furthermore, RSL can be performed up to 14 days prior to surgery, which may improve scheduling flexibility in the radiology department.

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