Upstaging to invasive ductal carcinoma after mastectomy for ductal carcinoma in situ: predictive factors and role of sentinel lymph node biopsy

Watanabe, Yusuke; Anan, Keisei; Saimura, Michiyo; Koga, Kenichiro; Fujino, Minoru; Mine, Mari; Tamiya, Sadafumi; Nishihara, Kazuyoshi; Nakano, Toru; Mitsuyama, Shoshu

doi:10.1007/s12282-018-0871-7

Cited by 21 publications

(25 citation statements)

References 24 publications

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“…We found the upstage rate to invasive carcinoma to be 29%. This is consistent with the reported 8%‐40% upstage rate and corresponds with Brennan et al's meta‐analysis which found 26% (95% CI: 23%‐30%) of patients with an initial diagnosis of DCIS on PCB had invasive disease on final pathology. In our study, the rate of SLN positivity among these upstaged patients was small but clinically significant (10%).…”

Section: Resultssupporting

confidence: 91%

“…Other studies have demonstrated the utility of these preoperative markers of upstage risk . Multicentricity, patient reported symptoms and the presence of necrosis have also been reported as predictive factors; our study did not corroborate the significance of these additional findings. However, even without additional markers, our model consisting of palpability, disease on imaging greater than 1.20 cm and mass on pre‐op imaging significantly predicted upstaging in our population, with an overall positive predictive value (PPV) of 81%.…”

Section: Resultscontrasting

confidence: 86%

“…However, there is a risk of underestimating invasion on PCB due to sampling error. DCIS diagnosed on PCB is upstaged to invasive disease on final surgical pathology at a rate of 8%‐40% . When DCIS is upstaged to invasive disease, the rate of SLN positivity is reported in the literature as 4%‐15% …”

Section: Introductionmentioning

confidence: 99%

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

et al. 2020

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Breast J. 2020;26:931-936. wileyonlinelibrary.com/journal/tbj | 931 Abstract 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). Clinicopathologic 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 withupstaging 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. K E Y W O R D S core biopsy, ductal carcinoma in situ, invasive carcinoma, sentinel lymph node biopsy, total mastectomy, upgrade rate

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Section: Resultssupporting

confidence: 91%

Section: Resultscontrasting

confidence: 86%

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

et al. 2020

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“…Notably, the proportion of SLN metastasis in DCIS patients undergoing SLN biopsy during breast surgery (breast conserving surgery or mastectomy) is reported to be 0.6-13.4% (6,8,(11)(12)(13)(14)(15)(16)(17). Given the low positivity and the potential harms the SLN procedure may cause, the role of SLN biopsy in most DCIS patients has been controversial in recent years (18).…”

Section: Introductionmentioning

confidence: 99%

Prediction of Sentinel Lymph Node Metastasis in Breast Ductal Carcinoma In Situ Diagnosed by Preoperative Core Needle Biopsy

et al. 2020

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Purpose The positivity of sentinel lymph node (SLN) metastasis is relatively low in ductal carcinoma in situ (DCIS) patients. The aim of this study was to investigate factors associated with SLN metastasis and build a model to predict the potential risk of SLN metastasis in patients with a preoperative diagnosis of DCIS. Patients and Methods Core needle biopsy-proved DCIS patients who underwent SLN biopsy and breast surgery were retrospectively reviewed and selected. Univariate analysis was used to identify the variables correlated with SLN metastasis. A model to predict SLN metastasis was developed using a multivariate logistic regression in the training set and then validated in an internal set. Results A total of 407 patients with a preoperative diagnosis of DCIS were included. Upstaging to invasive/microinvasive cancer occurred in 225 patients after surgery. SLN metastasis was found in 42 patients, including 32 patients upstaging to invasive disease, 8 to microinvasive disease, and 2 pure DCIS. Tumor size based on US examination, axillary ultrasound finding, multifocality, surgery, upstaging, and Ki-67 expression were significantly related to SLN metastasis. The model incorporating tumor size, axillary ultrasound finding and multifocality yielded an AUC of 0.805 (95% CI: 0.715–0.895, p <0.001) in the training set, and 0.729 (95% CI: 0.547–0.911, p =0.013) in the testing set. Conclusion A simple model was developed to predict SLN metastasis in patients with a preoperative diagnosis of DCIS. With good discriminatory power, this model should be helpful for surgeons to decide if SLN biopsy could be safely avoided in certain patients.

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“…To The Editor, I want to congratulate Dr. Watanabe et al for their study on the upstaging to invasive ductal carcinoma (IDC) after mastectomy for ductal carcinoma in situ (DCIS) [1]. They reported that 22.6% of 226 DCIS lesions were upgraded to IDC after mastectomy, and the prevalence of macrometastasis of sentinel lymph nodes (SLNs) was 0.9%.…”

mentioning

confidence: 99%

Could sentinel lymph node biopsy be exempted for ductal carcinoma in situ after mastectomy?

Yang

2018

Breast Cancer

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I want to congratulate Dr. Watanabe et al. for their study on the upstaging to invasive ductal carcinoma (IDC) after mastectomy for ductal carcinoma in situ (DCIS) [1]. They reported that 22.6% of 226 DCIS lesions were upgraded to IDC after mastectomy, and the prevalence of macrometastasis of sentinel lymph nodes (SLNs) was 0.9%. I would like to make two comments on this study. First, the authors believed SLN biopsy for patients undergoing mastectomy with a preoperative diagnosis of DCIS was overtreatment based on the fact that the prevalence of SLN metastasis was low and the long-term outcome was excellent. However, although the reported 5-year recurrence-free survival was as high as 99.5%, I noticed the median follow-up period was only 31 months. The survival might be biased with a large ratio of censored data. Moreover, three out of five patients with SLN metastasis were post-operatively pathologically diagnosed as DCIS, indicating that the micro-invasive component were likely to be missed in the pathological test in this study, not only for original lesions, but also for SLNs. As a result, the rate of upstaging and SLN metastasis could both be underestimated. Second, since the surgical procedures were decided by patients themselves, I wonder how many of the included lesions could alternatively be treated by breast-conserving surgery and how many were lesions with a wide range of micro-calcifications or suspected intraductal spreadings. It would be essential to know if there were any differences in rates of upstaging and/or SLN metastasis between these two types of patients.

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Upstaging to invasive ductal carcinoma after mastectomy for ductal carcinoma in situ: predictive factors and role of sentinel lymph node biopsy

Cited by 21 publications

References 24 publications

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

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

Prediction of Sentinel Lymph Node Metastasis in Breast Ductal Carcinoma In Situ Diagnosed by Preoperative Core Needle Biopsy

Could sentinel lymph node biopsy be exempted for ductal carcinoma in situ after mastectomy?

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