Sentinel Node Procedure is Warranted in Ductal Carcinoma In Situ with High Risk of Occult Invasive Carcinoma and Microinvasive Carcinoma Treated by Mastectomy

Abstract

Axillary lymph node dissection in patients with ductal carcinoma in situ (DCIS) of the breast is not warranted because DCIS has no metastatic potential. However, the risk of microinvasive carcinoma (MIC) exists in large DCIS treated by mastectomy. The aim of this series is to evaluate the incidence of lymph node metastases in DCIS and DCIS-MIC. We analyzed retrospectively patients treated in six French cancer centers for pure DCIS or DCIS-MIC. Surgical procedures were lumpectomy or mastectomy associated with an axillary sentinel node (SN) procedure. We included 161 patients suffering from pure DCIS (116/161, 72%) or DCIS-MIC (45/161, 28%). Mean age was 56 years (32-78). We observed underestimation between core biopsy and histological result in 43/142 cases (30%). These data show an association between lesion size, solid subtype, high-grade DCIS, and underestimation. Forty-eight breast conservative procedures were performed and 113 mastectomies (70%). SN procedure was performed using blue dye, technetium, or both. In our series, we selected patients with a high risk of occult invasive carcinoma: high grade (55%), mean size (27 mm), and mastectomy (112). Six SN were found positive (3.7%). In the five patients treated with complete axillary dissection, the SN was the only positive node. SN in DCIS is an interesting procedure but not necessary for all patients. We need to focus on the subgroup with or a high risk of occult MIC: extensive calcifications or palpable mass, DCIS diagnosed by core biopsy and underestimation, multifocality, high grade, large tumor size, MIC, and mastectomy.

Breast-conserving surgery with or without radiotherapy vs mastectomy for ductal carcinoma in situ: French Survey experience

“…In theory, there is no axillary lymph node involvement in DCIS, although a recent review has reported 1.4% involvement in 1621 patients with pure DCIS (Morrow et al, 2002;Leonard and Swain, 2004). There may, however, be a risk of associated microinvasive foci, especially when the lesion is extensive (McMasters et al, 2002;Moran et al, 2005;Tunon de Lara et al, 2008). This may be a reason why, even though axilla management is pointless, 10.4% of our patients underwent AD and 21.3% underwent SNB.…”

“…In our study, SNB rate was 12.3% after CS vs 41.7% after mastectomy (Po0.001). Finally, a recent French multicentric study (Tunon de Lara et al, 2008) including 116 large DCIS found 4 positive sentinel nodes (3.4%). Thus, SNB could be proposed in patients treated by mastectomy.…”

Sentinel lymph node biopsy in clinically detected ductal carcinomain situ

“…Although SLNB is a less invasive procedure compared with axillary lymph node dissection (ALND), it is associated with a certain degree of morbidity and may lead to overdiagnosis and overtreatment [6] . Paresthesias, lymphedemas, and seromas have also been reported [7,8] . Therefore, the role of SLNB in DCIS is controversial and the indications for its use are not clear.…”

“…Second, a SLNB will be unnecessary in the majority of patients with a preoperative image-guided CNB diagnosis of DCIS because the final postoperative histology will only contain pure DCIS and will not contain any invasive disease [2,19] . Third, although SLNB is a less morbid surgical procedure compared with ALND, it is also associated with complications [7,8] . Fourth, SLNB can also lead to excessive and unnecessary treatment by providing misleading information about the axillary status.…”

The management of ductal intraepithelial neoplasia (DIN): open controversies and guidelines of the Istituto Europeo di Oncologia (IEO), Milan, Italy

“…In the few cases published in the literature [63,[68][69][70][78][79][80][81], in which AD was performed after an positive SLNB, in all cases but one (67/68, 98,5%) all the non-SLNs were negative and the SLN already biopsied was the only positive LN. That is why we conclude that in cases of DIN patients with a positive SLNB, AD should not be immediately performed except for only those cases that present mammary invasion on final pathologic evaluation.…”