Ductal carcinoma in situ DCIS

Patients with DCIS have a low (1%) incidence of lymph node metastasis using conventional hematoxylin-eosin (H&E) staining and have an excellent long-term prognosis (98% survival). Given this background, SLNB in all patients with DCIS cannot be justified. However, 10-38% of patients with DCIS will be found at definitive surgery to have an invasive cancer. SLNB following lumpectomy is associated with increased failed localisation and false-negative rates (31) and is impossible after a mastectomy. Therefore, if SLNB is not performed at the time of the definitive operative procedure, a significant number of patients found to have an invasive cancer will require a second operative procedure and, in all likelihood, axillary lymph node dissection. The combination of low morbidity and greater risk for invasive carcinoma at the time of definitive resection make SLNB an important consideration in high-risk patients with DCIS. Historically, risk factors reportedly associated with invasive disease have included large tumours, high-grade tumours, tumours with comedo-type necrosis, and presence of palpable mass or mass that is appreciated by imaging studies (45-49).

It is difficult to compare different series as biopsy techniques, grading system for DCIS, and patient populations have varied. Furthermore, most series numbers are not large enough to provide the power to detect significance. At the present time there is no consensus on the predictive factors and this issue remains controversial. In a large study reported recently, we found two independent predictors of invasive cancer in patients with an initial diagnosis of DCIS: clinically palpable mass and mammographic mass (50). Presence of a clinically palpable mass increased the risk of invasive carcinoma 5-fold (odds ratio 5.09, 95% CI 3.06-8.48); while a mammographic mass increased the risk of invasive disease 7-fold (odds ratio 7.37, 95% CI 3.27-16.64). SLNB should be performed at the time of the initial procedure in this subgroup of patients to avoid a second operative procedure for axillary nodal staging. In addition, SLNB should be performed in patients undergoing breast reconstruction or mastectomy because both preclude SLNB if invasive disease is subsequently discovered.

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