Importance of lymphatic mapping in ductal carcinoma in situ (DCIS): why map DCIS?
Cox CE, Nguyen K, Gray RJ, et al
The appropriateness of sentinel lymph node biopsy in the management of patients with biopsy diagnoses of ductal carcinoma in situ (DCIS) or DCIS with microinvasion (DCISM) has not been established.
Three hundred forty-one patients presented with a biopsy diagnosis of DCIS or DCISM. Two hundred forty (70%) underwent sentinel node biopsy at their definitive procedure. All clinical and pathologic data were collected prospectively. Of 224 patients with a biopsy diagnosis of DCIS 23 (10%) were upstaged to infiltrating ductal carcinoma (IDC) at their definitive therapy and of 16 patients with a biopsy diagnosis of DCISM seven (44%) were upstaged to IDC.
Excisional biopsies were no more sensitive for detecting IDC than was core biopsy. Lymph node metastases were detected in 26 of 195 (13%) patients with a definitive diagnosis of DCIS, in three of 15 (20%) with a definitive diagnosis of DCISM, and in eight of 30 (27%) with a definitive diagnosis of IDC.
Sentinel lymph node biopsy is a valuable tool in the treatment of patients with DCIS and DCISM and is particularly needed in those undergoing mastectomy. No "high-risk" group of patients can be identified for selective sentinel lymph node biopsy.
Am Surg. 2001 Jun 1;67 (6):513-519. PMID: 11409797
EDITOR'S COMMENT This paper from the University of South Florida in Tampa is the largest reported experience with doing sentinel node biopsies in patients with DCIS.
They found a 13% incidence of positive sentinel nodes in these patients (half visible on H&E, the other half on immunohistochemisty).
These findings (reported previously in abstract form and in other papers from their group) have created great controversy. The available data show that very few patients with DCIS treated with mastectomy or breast-conserving therapy with or without radiotherapy (without specific treatment or surgery to the axillary nodes) develop regional nodal or systemic relapse in the absence of local failure.
Hence, the biologic significance of their findings is not clear. There are no clinical follow-up data on the patients included in this prospective study.
However, in the discussion following the paper (which was presented at a meeting in New Orleans in February 2001), Dr Cox noted that his group has performed a retrospective study of 90 patients with DCIS or microinvasive disease undergoing axillary dissection.
Of these 90 patients, 7% of those with DCIS and 11% of those with microinvasive disease had cytokeratin-positive axillary nodes when the blocks were recut. (The exact number of patients with DCIS or microinvasion was not given. None of these patients appear to have had H&E positive axillary nodes, although this was not explicitly stated.)
None of the 90 patients had relapsed by 10 years after treatment, despite the lack of systemic therapy. My own belief is that, until the implications of such findings are clarified by prospective studies, sentinel node biopsy should not be routinely performed in patients with DCIS (with an exception for those individuals with extensive lesions that will be treated with mastectomy, in whom there is a significant risk that invasive disease may be found in the mastectomy specimen).
If sentinel node biopsy is performed, then I do not believe that the nodal findings should be used to justify giving patients systemic therapy.
ABRAM RECHT, M.D. - 05/1/2002
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