the role of sentinel lymph node IN DCIS

1. The role of sentinel lymph node in microinvasive DCIS
Dr . Mutaz al makhamrah
Surgical oncology fellow
KHCC
Surgical oncology department

2. Background
 The status of the regional lymph nodes is the single most important predictor of disease-free
and overall survival in breast cancer patients
 DCIS is a disease devoid of invasive behaviour and thus without potential for spread to the
axillary lymph nodes.
 Current practice is to perform sentinel lymph node biopsy (SLNB) only in selected patients
with DCIS when there is
 substantial risk of upgrade of the lesion at final pathology,
 such as a mass lesion highly suggestive of invasive cancer at imaging and physical
examination,
 patients with a large area of DCIS at imaging (5 cm or greater), or
 when mastectomy is indicated

3.  Microinvasive breast cancer is an uncommon pathological entity, approximately 1 per
cent of all breast cancers.
 The definition:
 Extension of cancer cells beyond the basement membrane into the adjacent tissue with
no focus more than 1mm in greatest dimension, ( AJCC )
 As a result, the term ‘T1mic’ has now been added to the TNM staging system.
 According to the international treatment guidelines, MIBC falls into the group of T1
cancer subset, and it should be treated as such.
 This includes axillary staging via sentinel lymph node biopsy (SLNB).(NCCN2018)

5.  613 cases of DCIS and microinvasive carcinoma that were consecutively resected
from 2003 to 2014 and analysed
 clinicopathological variables, expression of standard biomarkers such as
 the estrogen receptor (ER), progesterone receptor (PR), human epidermal growth
factor receptor 2 (HER2), p53, and Ki-67, and tumor recurrence.

12. conclusion
 axillary staging is performed for patients with microinvasive carcinoma, lymph node metastasis is a
rare event for such patients.
 observed axillary nodal metastases in only four (3.7%) of 110 patients with microinvasive carcinoma
who underwent axillary staging surgery.
 microinvasive carcinoma is different from pure DCIS with respect to pathological features and
biomarker expressions but is similar to DCIS with respect to clinical outcomes.
 The triple-negative subtype is the only factor associated with tumor recurrence.
 These results suggest that microinvasive carcinomas can be treated and followed up as pure DCIS,
although axillary staging surgery is necessary.
 This study also indicates that patients with triple-negative DCIS or microinvasive carcinoma need
close follow-up because such cancers are associated with tumor recurrence, especially invasive
recurrence.

14.  Between July 1989 and December 2008,
 9635 patients had operation on invasive breast cancer in Asan Medical Center. Among these
patients,
 319 patients had MIC.
 The research conducted on the 293 patients (excluded were 26 who did not receive axillary
lymph node dissection or SLN biopsy).
 retrospectively checked clinical and pathologic variables.

17. Conclusion
 There were 22 cases of ALN metastases identified in this group of patients (7.5%).
 the incidence of ALN metastases is low in MIC patients;
 Lymphatic invasion (P<.001)
 positive estrogen receptor status (P =. 03) were independent significant predictors of axillary
metastases.
 studies of predictors of SLN metastases indicate that selective SLN node evaluation is
warranted in such patients, whereas routine SLNB is not indicated in all patients with MIC.

19.  From November 1997 to November 1999, all patients who underwent sentinel node biopsy for high-risk
DCIS (n 5 76) or DCISM (n 5 31) were enrolled prospectively in database.
 Patients with DCIS were considered high risk and were selected for sentinel lymph node biopsy if there
was concern that an invasive component would be identified in the specimen obtained during the
definitive surgery.
 Patients underwent intraoperative mapping that used both blue dye and radionuclide.
 Excised sentinel nodes were serially sectioned and were examined by hematoxylin and eosin and by
immunohistochemistry.

20. n(38)
DCISM
n(385)
DCIS
n(76)SLNBX
21%
age :m(56y)
38y-81y
n(31)SLNBX
82%
age :m(51y)
31y-80y

21. • reviewed the 76 high-risk DCIS patients,
found that they each had at least one of the following
characteristics:
palpable mass (21%) presence
histology
suspicious but
not
diagnostic for
microinvasion
(24%) multicentric
disease
that required
mastectomy
(53%)
histologically high
nuclear grade or non-high
nuclear grade with necrosis
(72%).
mammograph
ic
mass
(34%) Axilla clinically (0%)
Type of
surgery :
Mastectomy+
SLNBX
(53%) BCS (47%)

25. conclusion
 This study documents a high incidence of lymph node micrometastases as
detected,by sentinel node biopsy in patients with high-risk DCIS and DCISM.
 Although the biological significance of breast cancer micrometastases remains
unclear at this time,
 these findings suggest that sentinel node biopsy should be considered in patients
with high-risk DCIS and DCISM.

27.  Institutional Review Board–approved chart review identified 322 patients with DCIS or DCISM on
final pathology who underwent SNB from 1997 to 2003.

28.  Positive SNBs in patients with DCIS or DCISM are not associated with higher risk of
local or distant recurrence.
 Other features of DCIS and DCISM may be important in predicting recurrence risk

34. Conclusion
 This study demonstrates a low incidence of SN macrometastase (< 4%) in patients with MIBC.
 The odds of SN metastases were almost a threefold higher in patients with a HER2+ status and nearly
a fivefold higher in patients under the age of 50.
 If SN macrometastases are detected, a considerable proportion (22%) has further metastatic spread
to non-SN and might need axillary treatment.
 to avoid overtreatment, advise against the routine use of axillary staging in MIBC patients above 50
years of age with a HER2− status.
 axillary staging should be confined to
 younger HER2+
 MIBC patients without staging at primary surgery.

36.  Retrospective review of our pathology database was performed (1994–2012).
 Of 7000 patients surgically treated for invasive breast carcinoma, 99 (1%) were classified as
microinvasive carcinoma.
 Axillary staging was performed in 81 patients (64, sentinel lymph node biopsy; 17, axillary
lymph node excision).

39.  results demonstrate a very low incidence of sentinel lymphe node metastases in microinvasive
carcinoma patients,
 exclusively limited to isolated tumor cells.
 This study highlights that many of the so-called ‘positive’ sentinel lymph nodes are falsely
positive
 secondary to iatrogenic transport of displaced epithelial cells.
 Careful pathologic evaluation of sentinel lymph nodes and the surgical breast specimen is
required to avoid false positives and subsequent unwarranted axillary surgery or adjuvant
treatment.
 recommend reassessment of the routine surgical practice of sentinel lymph node biopsy in
patients with microinvasive carcinoma.
 Alternative procedures to sentinel lymph node biopsy such as preoperative ultrasound and
ultrasound-guided fine-needle aspiration of axilla should be explored.

41.  A database was analysed to identify patients with microinvasive ductal carcinoma in situ
(DCIS) who had surgery for invasive breast cancer at the European Institute of Oncology,
Milan, between 1998 and 2010.
 Women who had undergone axillary staging by sentinel lymph node biopsy were included
in the study.
 257 women with microinvasive breast cancer who underwent sentinel lymph node biopsy
(SLNB),
 226 (87⋅9 per cent) had negative sentinel lymph nodes (SLNs) and 31 had metastatic SLNs.
 Twelve patients had isolated tumour cells (ITCs), 14 had micrometastases and five had
macrometastases in sentinel nodes.
 Axillary lymph node dissection was performed in 16 of the 31 patients with positive SLNs.
 median follow-up of 11 years.

46. conclusion
 The present findings, of low positive SLN rates in women with good DFS and OS, and the
lack of influence on selection of adjuvant treatment, are in line with other studies showing
that SLNB in microinvasive DCIS may not be useful.
 This study supports the evidence that less surgery, combined with adequate presurgical
clinical/histological information allowing the planning of a correct, personalized, clinical
pathway for each patient,
 may provide the same level of OS with better patient quality of life.

47. Discussion

48. Thank you