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Dcis sentinel node biopsy9/11/2023 ![]() ![]() ![]() Understaging can present a problem for surgeons when nondiagnosed invasive cancer coexists with DCIS or if an undetected invasive tumor is present in other parts of the breast with potential axillary node involvement. ( 14) in patients with core biopsy–proven DCIS, underestimations for microinvasive or invasive disease were 1.9 times more likely with masses than with calcifications, 1.8 times greater with large core biopsy than with vacuum-assisted devices, and 1.5 times more frequent with 10 or fewer specimens per lesion than with more than 10 specimens. Upstaging from DCIS on the core biopsy to microinvasive or invasive disease in the final pathology review of the resected tissue can occur and therefore may eliminate the benefit of a one-stage surgical procedure ( 14– 17). Based on the 7th edition American Joint Committee on Cancer (AJCC) guidelines, microinvasive carcinoma is the extension of cancer cells beyond the basement membrane into adjacent tissues with no focus more than 1 mm in greatest dimension. As good as the diagnostic accuracy of large core needle biopsy may be, understaging of the extent of disease can range from 13% to 44% of cases. ![]() This minimally invasive biopsy technique has clear benefits for the patient: It is less invasive than is open surgical biopsy and can establish a diagnosis that permits patients to have definitive surgical treatment planning before they undergo surgery. Although some tumors are commonly detected by the evaluation of suspicious mammographic abnormalities such as calcifications, pathological tissue diagnosis is necessary and is routinely accomplished by image-guided percutaneous core biopsy. With the increased use of screening mammography, DCIS tumors are being detected at an earlier time, at a smaller size, as nonpalpable, and associated with a lower rate of nodal involvement, if any. Thus, the routine use of sentinel node biopsy (SNB) in patients with pure DCIS does not appear to be indicated because there are no survival data of any magnitude in patients treated by SNB who have an axillary recurrence. The very low recurrence rates found in these studies is less than the positive axillary metastasis rate associated with undiagnosed invasive breast cancer with DCIS present ( 6, 11– 13). A similar finding of very low axillary recurrence in the long-term follow-up of DCIS patients treated with lumpectomy and whole-breast irradiation was reported by City of Hope Cancer Center ( 10). In a review of the NSABP DCIS protocols B-17 (lumpectomy +/- whole-breast irradiation) and B-24 (lumpectomy plus whole-breast irradiation ± tamoxifen), the risk of axillary recurrence in patients was found to be less than 1% ( 9). Following Silverstein’s report, the routine use of ALND was made optional in the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-17 trial, in which patients with DCIS were randomly assigned to lumpectomy with or without whole-breast radiotherapy ( 8). After a 27 -month follow-up, two patients had recurrence, and no mortality was encountered ( 2). One hundred patients who were treated with either mastectomy (n = 49) or breast-conserving surgery and radiation therapy (n = 51) and ALND all had negative axillary lymph nodes (ALN). questioned the need for routine ALND in patients with DCIS and recommended that it be abandoned. ( 7) evaluated the treatment of DCIS using Surveillance, Epidemiology, and End Results data from 1973 to 1992 and found a decrease in the proportion of patients treated with mastectomy from 71% in 1983 to 44% in 1992. ![]() However, as the trend toward breast conservation for early-stage invasive breast cancers increased, the justification for mastectomy and ALND with only 1% positive nodal rate and a 1%–2% mortality rate for noninvasive cancer became a focus of attention ( 6). Cure rates of greater than 90% and very low mortality resulted ( 4, 5). Diagnosed pathologically by open surgical biopsy, surgical treatment recommendation consisted of mastectomy and axillary lymph node dissection (ALND). Historically, noninvasive breast cancer was detected by a palpable mass on physical examination. The diagnosis of DCIS increased from 2% of all breast cancers to as high as 30% ( 1) it can be detected on screening mammography in 15%–20% of cases and accounts now for 14%–30% of all diagnosed breast cancers ( 1– 3). The 1980s brought increased public awareness of breast cancer and improved mammography equipment and techniques that resulted in more frequent diagnoses of nonpalpable occult breast carcinoma. It is considered a local disease with no regional involvement. Noninvasive carcinoma of the breast or ductal carcinoma in situ (DCIS) is histologically defined as proliferating malignant ductal cells limited to the ducts themselves, without evidence of invasion through the basement membrane into the surrounding stroma. ![]()
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