Clinical applications of breast pathology: management of in situ breast carcinomas and sentinel node biopsy issues

Abstract

The purpose of this article is to review the current clinical management of in situ breast carcinomas, including how specific aspects of a pathology report are used in clinical decision-making, and to discuss the current role of sentinel node biopsy in management of invasive breast carcinomas and ductal carcinoma in situ of the breast. Sentinel node biopsy: reducing the morbidity of axillary stagingThe pathological status of axillary lymph nodes remains one of the most important prognostic factors in patients with breast cancer. Identification of metastatic tumor deposits in the axillary nodes indicates a poorer prognosis and often prompts a recommendation for more aggressive systemic and local therapies. Surgical staging of the axilla is a routine component of breast cancer treatment for the majority of the 200 000 patients diagnosed with invasive breast cancer in the United States each year.Unfortunately, axillary dissection is often the main source of morbidity in patients with earlystage breast cancer. Immediate problems include acute pain, the need for hospital stay, reduced range of motion, and the need for a drain in the surgical bed for a week or more. Long-term problems resulting from axillary dissection include permanent lymphedema in up to 35% of patients, numbness in 35%, chronic pain in 10%, and reduced range of motion in 5-10%.2-13 An assessment of patients' subjective symptoms of arm problems shows even higher rates of persistent arm symptoms, with 25-50% of patients reporting arm swelling, pain, numbness, and/or decreased mobility.10,14-16 Studies of quality of life in patients treated for breast cancer have shown prolonged decreases in quality of life for those with lymphedema and other chronic arm symptoms resulting from axillary dissection. [7][8][9]17 At present, there are no effective therapies to reverse established lymphedema.2 As lymphedema after axillary dissection cannot be 'cured', or even reliably prevented, identification of alternatives to standard axillary dissection have been sought.The technique of sentinel node biopsy was developed with the aim of reducing the morbidity of surgical staging of the axilla. Identification of the first or 'sentinel' nodes draining the affected breast using radioactive particles 18 or blue dye 19 has allowed selective and minimally traumatic excision of only the most informative axillary nodes. Morbidity rates are substantially lower with sentinel node biopsy compared with axillary dissection.6,17-23 Acutely, sentinel node biopsy is an

The Role of Sentinel Lymph Node Biopsy and Factors Associated with Invasion in Extensive DCIS of the Breast Treated by Mastectomy: The Cinnamome Prospective Multicenter Study

“…We present a prospective study on the relevance of the SLN procedure for patients who have extensive DCIS with microcalcifications on mammography diagnosed by VAB and treated by mastectomy. We selected three major predictive factors of disease upgrading as patient inclusion criteria: 14 extensive microcalcifications, 15 , 16 mastectomy, 4 , 5 , 17 and VAB diagnosis. 18 – 20 …”

“…The SLN biopsy is a minimally invasive procedure, and when results are negative, axillary lymph node dissection (ALND), 4 , 5 associated with higher morbidity rates, 6 , 7 can be avoided. When results are positive, ALND remains the standard of care, but its use often has been called into question.…”

Basal cytokeratin as a potential marker of low risk of invasion in ductal carcinoma in situ

“…Another source of debate concerns the appropriate indications for sentinel lymph node biopsy in patients with pure DCIS (32–34). Most studies agree that sentinel lymph node biopsy should be considered only in cases of DCIS with a risk of invasive disease (32).…”

“…The challenge is to identify this subset of patients after a biopsy results in a DCIS diagnosis. The features generally considered to indicate lymph node biopsy are extensive DCIS, areas of suspected microinvasion, irregular mass lesions and planned mastectomy (34,35). Immunohistochemical markers have been correlated with the risk of recurrence, but there has been minimal research analyzing these markers as indicators of the risk of invasion.…”

Isolated tumour cells and micrometastases in intraductal breast cancer: a simple mechanical question in some cases

“…Related to the sentinel node biopsy, the classical concept of intradutal carcinoma contrasts with the following two findings: (a) ∼9% of the cases of all published series involve infiltrated lymph nodes when sentinel node analysis is used as the staging method (Smith, 2010); and (b) in 1–2% of the cases the patient presents with specific mortality related to breast cancer in the follow-up period in spite of appropriate treatment (Ernster et al , 2000). …”