![]() When IC present, SLNB could be viewed as “adequate-treatment” while no axillary surgery seemed likely to “under-treatment”. Indication and threshold for surgical lymph biopsy in patients with pre-OP DCIS patients remained a controversial issue. In patients whom SLNB was indicated, methylene blue and/or radioisotope (Tc99m) were used. The rate and predictors of upgrade from pre-OP DCIS to DCIS-IC, ALN metastasis, and potential of breast MRI to replace SLNB in pre-OP biopsy diagnosed DCIS patients would be analyzed and discussed.įull size image Defining the adequacy of sentinel lymph node biopsy (SLNB) The aim of current study is to evaluate the role of ALN surgery in pre-OP biopsy diagnosed DCIS patients, and investigate the accuracy of breast MRI to predict ALN metastasis. We hypothesized that pre-OP MRI could have potential role for ALN evaluation and prevent unnecessary SLNB in some conditions. DCIS-IC was found to be the most important predictor of ALN metastasis in SLNB in patients with pre-OP DCIS. Certain characteristics of breast MRI, like MRI evidence of nipple areolar complex invasion, mass-like lesions, and measurable apparent diffusion coefficient area were significant predictors of DCIS-IC. In our previous study, we had showed pre-OP breast magnetic resonance image (MRI) had clinical benefit in predict DCIS with invasive component (DCIS-IC). In recent studies, the rate of positive SLNB following mastectomy of patients with pre-OP biopsied DCIS was low (around 10–20%), which raising the question of the need and value of routine SLNB in this particular group of patients in modern era of breast imaging. In patients with pre-OP DCIS and indicated for mastectomy, however, SLNB remained recommended as the upgrade rate is increased and there would be rare chance for secondary lymph node surgical biopsy. Furthermore, according to ACOSZ0011, even 1–2 positive SLNB could be managed with whole breast radiotherapy in T1–T2 tumor received BCS without ALND. In current practice guideline, SLNB was not routinely suggested for patients with pre-OP DCIS planned to receive breast conserving surgery (BCS) as the rate of upgrade to DCIS-IC is not so high in lesion suitable for local excision, and even if invasive component found a secondary SLNB could still be performed. Indication and adequacy of application of SLNB in lymph node evaluation of patients with pre-operative (pre-OP) DCIS diagnosed by biopsy remained a debated issue as SLNB remains an invasive procedure and not morbidity free. DCIS as determined by pathologic analysis of biopsy specimens, however, does not preclude invasive disease in excised specimens, and up to 50% (range, 3.5–56%) of core needle biopsy (CNB) or vacuum-assisted core biopsy (VACB) diagnosed DCIS would upgrade to have an invasive component (IC). In theory, ductal carcinoma in situ (DCIS) does not metastasize to adjacent lymph nodes, and axillary lymph node evaluation or surgery had limited role. Lymph node evaluation plays important role of breast cancer staging and management, and had been evolved from axillary lymph node dissection (ALND) to sentinel lymph node biopsy (SLNB). Conclusionīreast MRI had high NPV to predict ALN metastasis in pre-OP DCIS patients, which is useful and could be provided as shared decision-making reference. Pre-OP diagnosed DCIS patients with MRI tumor size < 3 cm and node negative suitable for BCS could safely omit SLNB if whole breast radiotherapy is to be performed. ![]() In MRI node-negative breast cancer patients with MRI tumor size < 3 cm, the NPV was 96.4%, and all these false-negative cases were N1. Breast MRI had 53.8% sensitivity, 77.8% specificity, 14.9% positive predictive value, 95.9% negative predictive value (NPV), and 76.2% accuracy to predict ALN metastasis in pre-OP DCIS patients. Large pre-operative imaging tumor size and post-operative invasive component were risk factors to ALN metastasis. ![]() The rate of upgrade to invasive cancer were found in 34.2% of specimen, and this upgrade rate is 23% for patients who received breast conserving surgery and 40.7% for mastectomy ( p < 0.01). ResultsĪ total of 682 cases with pre-operative diagnosis of DCIS were enrolled in current study. The value of breast MRI for ALN evaluation, predictors of breast and ALN surgeries, upgrade from DCIS to invasive cancer, and ALN metastasis were analyzed. Patients with primary DCIS with or without pre-operative breast MRI evaluation and underwent breast surgery were recruited from single institution. The value of breast magnetic resonance imaging (MRI) to predict ALN metastasis pre-operative DCIS patients was evaluated. The optimal axillary lymph node (ALN) management strategy in patients diagnosed with ductal carcinoma in situ (DCIS) preoperatively remains controversial. ![]()
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