ReviewThe role of sentinel lymph node biopsy in ductal carcinoma in situ
Introduction
The optimal surgical management of ductal carcinoma in situ (DCIS) is unclear. DCIS is a pre-invasive form of breast cancer with a low incidence of axillary metastasis, which may be a contraindication to axillary surgery. However, some may be found to harbour occult invasive breast cancer following their surgical procedure. Axillary staging is an essential prognostic indicator for patients with invasive breast carcinoma. Sentinel lymph node biopsy (SLNB) represents is a minimally invasive approach to the surgical management of the axilla for patients with invasive breast cancer. Its role in the management of DCIS is less clear. Here we review the role of SLNB in the surgical management of patients with DCIS.
Section snippets
Ductal carcinoma in situ
DCIS is the pre-invasive stage of breast carcinoma.1, 2, 3 It is estimated that DCIS now accounts for greater than 10% of all newly diagnosed breast malignancies and approximately 20% of all breast carcinomas detected mammographically.4 The earlier diagnosis of breast malignancies has resulted from improved access to mammographic screening, increased public awareness and improved radiological techniques in recent years.
The idea of DCIS as a single disease has been dispersed. As our
Disease shift and axillary sampling
There is a low incidence of nodal metastases (<2%) on routine axillary dissection in individuals affected by DCIS. This data dates from the period when full axillary dissection was understood to be warranted in such patients.2, 3, 4 However, it has been suggested that some patients with DCIS should have an axillary procedure. This is based on the current recognition that at least some individuals with an initial diagnosis of pure-DCIS harbour additional foci of invasive disease, which may or
Sentinel lymph node biopsy
Much data on axillary lymph node status in patients affected by DCIS over the past decade preceded the development of the sentinel lymph node (SLN) concept.14, 15, 16, 17, 18, 19 Axillary staging via axillary lymphadenectomy is associated with morbidity. Many patients describe debilitating complications, including lymphoedema, parasthesias, pain and impaired range of movement. Even patients who have apparently uneventful recovery from standard axillary dissection often have chronic discomfort
Published experience of SLNB in DCIS
It has been suggested that patients with small unifocal DCIS lesions do not benefit from radiotherapy in addition to surgery.20, 21, 22, 23, 24 These findings followed the Van Nuys Prognostic Index (VNPI), which was established to aid the treatment selection process.23, 24 Nuclear grade, the presence of comedo-type necrosis, tumour size, and the width of the excision margin are all important factors capable of predicting local recurrence in patients with DCIS. By using a combination of these
Identification of high risk DCIS patients who may require SLNB
Many US based series are based on reliable pure DCIS from open-biopsy based studies while European screening programme guidelines mandate core-biopsy diagnosis. Therefore, when planning surgery in the era of core-biopsy pre-operative diagnosis of screen-detected anomalies we must try to identify the group at highest risk of harbouring invasive disease. Up to 20% of patients with a core biopsy diagnosis of DCIS will harbour invasive disease, consideration of predictors of disease shift, i.e.
SLN metastases and pathological analysis
Ultrastaging is a dilemma in relation to SLN biopsy and warrants consideration.36, 37, 38 The term ‘ultrastaging’ refers to the prognostic information that has become clinically available as a consequence of the molecular detection of previously occult malignant cells; though the significance of this information is often unknown. It is widely known that serial sections of lymph nodes coupled with keratin immunohistochemistry increases identification of occult metastases in breast cancer. The
Advantages of SLNB in DCIS to patient and system
Not all issues regarding DCIS and SLN analysis relate to biology. Multidisciplinary approach to the management of patients with breast cancer is commonplace in screening programmes; adequate consideration should be given to the various needs of the patient. From a patients' perspective, dealing with the diagnosis of breast disease and its immediate and long-term consequences is a major burden. Their distress need not be compounded by apparent confusion in relation to possible re-admission and
Conclusion
Ductal carcinoma in situ (DCIS) is thought to be a contraindication for sentinel lymph node biopsy (SLNB) by many clinicians.8, 40, 41, 47, 48, 49 However, we know now that up to 20% of patients with DCIS will have invasive carcinoma; these patients require staging for axillary metastasis. Axillary lymphadenectomy is clearly an overtreatment for this patient group. SLN biopsy is a minimally invasive technique, which may be used to evaluate the regional nodal status of DCIS patients. Performing
References (49)
- et al.
Axillary lymph node metastases in patients with a final diagnosis of ductal carcinoma in situ
Am J Surg
(2003) - et al.
Ductal carcinoma in situ with microinvasion
Am J Surg
(2003) - et al.
Sentinel node biopsy to avoid axillary dissection in breast cancer with clinically negative lymph nodes
Lancet
(1997) - et al.
Ten-year results comparing mastectomy to excision and radiation therapy for ductal carcinoma of the breast
Eur J Cancer
(1995) - et al.
A novel method for prediction of long term outcome of women with T1a, T1b and 10–14 mm of invasive breast cancer: A prospective study
Lancet
(2000) - et al.
Contemporary management of breast cancer
Obstet Gynecol Clin North Am
(2002) - et al.
Controversial topics in breast lymphatic mapping
Semin Oncol
(2004) - et al.
Role of immunohistochemical detection of lymph node metastases in management of breast cancer. International Breast Cancer Study Group
Lancet
(1999) - et al.
Secondary operations are frequently required to complete the surgical phase of therapy in the era of breast conservation and sentinel lymph node biopsy
Am J Surg
(2004) Patients and surgeons perspectives on axillary surgery for breast cancer
Eur J Surg Oncol
(2004)
Sentinel node procedure in breast carcinoma: A valid tool to omit unnecessary axillary treatment or even more?
Eur J Cancer
Duct carcinoma in situ: Biological implications for clinical practice
Semin Oncol
Ductal carcinoma in situ of the breast: A surgeons disease
Ann Surg Oncol
Ductal carcinoma in situ, complexities and challenges
J Natl Cancer Inst
Cancer statistics, 2000
CA Cancer J Clin
Ductal carcinoma in situ: A proposal for a new classification
Semin Diagn Pathol
Current controversies concerning sentinel lymph node biopsy for breast cancer
Breast Cancer Res Treat
Importance of lymphatic mapping in ductal carcinoma in situ (DCIS): Why map DCIS ?
Am Surg
Ductal carcinoma of the breast
BMJ
Sentinel node biopsy in ductal carcinoma in situ patients
Ann Surg Oncol
Sentinel lymph node biopsy as a tool for the staging of ductal carcinoma in situ in patients with breast carcinoma
Surg Today
Guidelines for sentinel node biopsy and lymphatic mapping of breast cancer patients
Ann Surg
Histopathological validation of the sentinel lymph node hypothesis for breast carcinoma
Ann Surg
Lymphatic mapping and sentinel node biopsy in the patient with breast cancer
JAMA
Cited by (22)
Variations in the management of the axilla in screendetected Ductal Carcinoma In Situ: Evidence from the UK NHS breast screening programme audit of screen detected DCIS
2015, European Journal of Surgical OncologyCitation Excerpt :The use of serial lymph node sectioning and immunohistochemistry has revealed significant rates of axillary nodal disease in patients with an apparent diagnosis of pure DCIS leading to the suggestion that this technique should be introduced as a routine in patients with DCIS.14 More recent studies, however, have reported much lower rates of nodal involvement, raising questions about a policy of routine axillary staging in patients with DCIS alone.15 Consequently, routine axillary staging is not recommended in patients with a pre-surgical (non-operative) diagnosis of DCIS treated by breast conserving surgery by either the National Institute of Clinical Excellence (NICE) or the UK Association of Breast Surgery (ABS), but they do acknowledge that in large lesions, requiring mastectomy, it is reasonable to perform SLNB.
Palpable ductal carcinoma in situ: Analysis of radiological and histological features of a large series with 5-year follow-Up
2013, Clinical Breast CancerCitation Excerpt :The evidence within the literature supports sentinel lymph node biopsy in patients undergoing mastectomy for DCIS29-31 and is not recommended for patients treated with breast conservation. However, evidence within the literature supports exception in patients with a tumour of > 5 cm in size,29,30,32 core biopsy-proven microinvasion,29-32 symptomatic presentation with a palpable mass,20,33 and high-grade DCIS.20 In our cohort, 34 patients (55%) underwent some form of axillary surgery and no lymph node metastases were detected.
The Management of Ductal Carcinoma in Situ: Current Controversies and Future Directions
2013, Clinical OncologyUtilization of lymph node assessment in patients with ductal carcinoma in situ treated with lumpectomy
2012, Journal of Surgical ResearchCitation Excerpt :Lymph node assessment (LNA), including sentinel lymph node biopsy (SLNB), is controversial among patients undergoing lumpectomy for the treatment of ductal carcinoma in situ (DCIS). Whereas opponents argue that DCIS has no potential to metastasize to regional lymph nodes, proponents of LNA counter that sampling error and missed underlying invasion may necessitate additional surgery for lymph node staging; at definitive surgery, DCIS may be upstaged to invasive carcinoma in 10% to 38% of cases [1–5]. Even among patients with pure DCIS without evidence of invasion, sentinel node metastases may be found in 1% to 7%, although their oncologic significance is unknown [6,7].
Current perspectives of treatment of ductal carcinoma in situ
2010, Cancer Treatment Reviews