Counterpoint: Sentinel Lymph Node Biopsy Is Not Indicated for Ductal Carcinoma In Situ

Authors: Stephen B. Edge MD1 and David G. Sheldon MD1
View More View Less
  • 1 Department of Breast and Soft Tissue Surgery, Roswell Park Cancer Institute, and the Department of Surgery, State University of New York at Buffalo, Buffalo, New York

The purpose of axillary surgery in breast cancer is to provide prognostic information to guide the choice of adjuvant systemic therapy. Axillary surgery for ductal carcinoma in situ (DCIS) was abandoned in the 1980s because of the extremely low risk of lymph node metastases and high survival rates. Most women with metastases probably harbored an unrecognized focus of invasion or had metastases subsequent to an invasive local recurrence. Increased use of the less morbid sentinel node biopsy (SNB) for axillary staging of invasive cancer and the recognition that many patients will harbor micrometastases in nodes only recognized by cytokeratin immunohistochemistry (IHC) led two groups to perform SNB with IHC in women with DCIS. One group included all subtypes of DCIS and found metastases in 13% (half of which were detected only on IHC). The other group studied only patients with “high-risk” DCIS. They found metastases in 12% (7 of 9 by IHC only). These groups recommend SNB for women with DCIS. However, the use of SNB in DCIS should be tempered by the uncertainty of the prognostic significance of IHC-detected metastases, the conflicting results of these 2 studies, and the real potential to cause more harm than good from the morbidity of the procedure, the application of unnecessary axillary dissection, and the use of unwarranted adjuvant systemic chemotherapy. These results should be used to generate hypotheses for clinical trials addressing these problems. However, SNB for DCIS remains investigational and should not be generally applied.

Correspondence: Stephen B. Edge, MD, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, New York 14263. E-mail: stephen.edge@roswellpark.org
  • 1

    Pendas S, Dauway E, Giuliano R et al.. Sentinel node biopsy in ductal carcinoma in situ patients. Ann Surg Oncol 2000;7:1520.

  • 2

    Cox CE, Nguyen K, Gray RJ et al.. Importance of lymphatic mapping in ductal carcinoma in situ (DCIS): Why map DCIS? Am Surg 2001;67:513519.

  • 3

    Klauber-DeMore N, Tan LK, Liberman L et al.. Sentinel lymph node biopsy: Is it indicated in patients with high-risk ductal carcinoma-in-situ and ductal carcinoma-in-situ with microinvasion? Ann Surg Oncol 2000;7:636642.

    • Search Google Scholar
    • Export Citation
  • 4

    McMasters KM, Chao C, Wong SL et al.. Sentinel lymph node biopsy in patients with ductal carcinoma in situ: A proposal. Cancer 2002;95:1520.

  • 5

    Temple LK, Baron R, Cody HS III et al.. Sensory morbidity after sentinel lymph node biopsy and axillary dissection: a prospective study of 233 women. Ann Surg Oncol 2002; 9:654662.

    • Search Google Scholar
    • Export Citation
  • 6

    Sener SF, Winchester DJ, Martz CH et al.. Lymphedema after sentinel lymphadenectomy for breast carcinoma. Cancer 2001;92:748752.

  • 7

    Fisher B, Jeong JH, Anderson S et al.. Twenty-five-year follow-up of a randomized trial comparing radical mastectomy, total mastectomy, and total mastectomy followed by irradiation. N Engl J Med 2002;347:567575.

    • Search Google Scholar
    • Export Citation
  • 8

    Silverstein MJ, Rosser RJ, Gierson ED et al.. Axillary lymph node dissection for intraductal breast carcinoma—Is it indicated? Cancer 1987;59:18191824.

    • Search Google Scholar
    • Export Citation
  • 9

    Schwartz GF, Feig SA, Patchefsky AS. Significance and staging of nonpalpable carcinomas of the breast. Surg Gynecol Obstet 1988;166:610.

  • 10

    Silverstein MJ, Gierson ED, Colburn WJ et al.. Axillary lymphadenectomy for intraductal carcinoma of the breast. Surg Gynecol Obstet 1991;172:211214.

    • Search Google Scholar
    • Export Citation
  • 11

    Fisher ER, Sass R, Fisher B, Wickerham L et al.. Pathologic findings from the National Surgical Adjuvant Breast Project (protocol 6). I. Intraductal carcinoma (DCIS). Cancer 1986;57:197208.

    • Search Google Scholar
    • Export Citation
  • 12

    Solin LJ, Kurtz J, Fourquet A et al.. Fifteen-year results of breast-conserving surgery and definitive breast irradiation for the treatment of ductal carcinoma in situ of the breast. J Clin Oncol 1996;14:754763.

    • Search Google Scholar
    • Export Citation
  • 13

    Zelis JJ, Sickle-Santanello BJ, Liang WC et al.. Do not contemplate invasive surgery for ductal carcinoma in situ. Am J Surg 2002;184:348349.

  • 14

    de Mascarel I, MacGrogan G, Mathoulin-Pelissier S et al.. Breast ductal carcinoma in situ with microinvasion: a definition supported by a long-term study of 1248 serially sectioned ductal carcinomas. Cancer 2002;94:21342142.

    • Search Google Scholar
    • Export Citation
  • 15

    Winchester DP, Menck HR, Osteen RT et al.. Treatment trends for ductal carcinoma in situ of the breast. Ann Surg Oncol 1995;2:207213.

  • 16

    Lagios MD, Westdahl PR, Margolin FR et al.. Duct carcinoma in situ. Relationship of extent of noninvasive disease to the frequency of occult invasion, multicentricity, lymph node metastases, and short-term treatment failures. Cancer 1982;50:13091314.

    • Search Google Scholar
    • Export Citation
  • 17

    Silverstein MJ, Lagios MD, Martino S et al.. Outcome after invasive local recurrence in patients with ductal carcinoma in situ of the breast. J Clin Oncol 1998;16:13671373.

    • Search Google Scholar
    • Export Citation
  • 18

    Fisher B, Costantino J, Redmond C et al.. Lumpectomy compared with lumpectomy and radiation therapy for the treatment of intraductal breast cancer. N Engl J Med 1993; 328:15811586.

    • Search Google Scholar
    • Export Citation
  • 19

    Sakorafas GH, Tsiotou AG. Ductal carcinoma in situ (DCIS) of the breast: Evolving perspectives. Cancer Treat Rev 2000;26:103125.

  • 20

    The management of ductal carcinoma in situ (DCIS). The Steering Committee on Clinical Practice Guidelines for the Care and Treatment of Breast Cancer. Canadian Association of Radiation Oncologists. CMAJ 1998;158(Suppl 3):S27S34.

    • Search Google Scholar
    • Export Citation
  • 21

    Carlson RW, Anderson BO, Bensinger W et al.. NCCN Practice Guidelines for Breast Cancer. Oncology (Huntingt) 2000;14:3349.

  • 22

    Morrow M, Strom EA, Bassett LW et al.. Standard for the management of ductal carcinoma in situ of the breast (DCIS). CA Cancer J Clin 2002;52:256276.

    • Search Google Scholar
    • Export Citation
  • 23

    Erickson VS, Pearson ML, Ganz PA et al.. Arm edema in breast cancer patients. J Natl Cancer Inst 2001;93:96111.

  • 24

    Petrek JA, Senie RT, Peters M et al.. Lymphedema in a cohort of breast carcinoma survivors 20 years after diagnosis. Cancer 2001;92:13681377.

  • 25

    Kelemen PR, Lowe V, Phillips N. Positron emission tomography and sentinel lymph node dissection in breast cancer. Clin Breast Cancer 2002;3:7377.

    • Search Google Scholar
    • Export Citation
  • 26

    van der Hoeven JJ, Hoekstra OS, Comans EF et al.. Determinants of diagnostic performance of [F-18]fluorodeoxyglucose positron emission tomography for axillary staging in breast cancer. Ann Surg 2002;236:619624.

    • Search Google Scholar
    • Export Citation
  • 27

    Wong SL, Abell TD, Chao C et al.. Optimal use of sentinel lymph node biopsy versus axillary lymph node dissection in patients with breast carcinoma: A decision analysis. Cancer 2002;95:478487.

    • Search Google Scholar
    • Export Citation
  • 28

    Edge SB, Pass H, Niland J et al.. Rapid implementation of sentinel node biopsy for breast cancer at cancer centers (Abstr. #153). Proc Am Soc Clin Oncol 2001;20:39a.

    • Search Google Scholar
    • Export Citation
  • 29

    Pendas S, Dauway E, Cox CE et al.. Sentinel node biopsy and cytokeratin staining for the accurate staging of 478 breast cancer patients. Am Surg 1999;65:500505.

    • Search Google Scholar
    • Export Citation
  • 30

    Sabel MS, Zhang P, Barnwell JM et al.. Accuracy of sentinel node biopsy in predicting nodal status in patients with breast carcinoma. J Surg Oncol 2001;77:243246.

    • Search Google Scholar
    • Export Citation
  • 31

    Weaver DL, Krag DN, Ashikaga T et al.. Pathologic analysis of sentinel and nonsentinel lymph nodes in breast carcinoma: A multicenter study. Cancer 2000;88:10991107.

    • Search Google Scholar
    • Export Citation
  • 32

    Wong SL, Chao C, Edwards MJ et al.. The use of cytokeratin staining in sentinel lymph node biopsy for breast cancer. Am J Surg 2001;182:330334.

  • 33

    Dowlatshahi K, Fan M, Anderson JM et al.. Occult metastases in sentinel nodes of 200 patients with operable breast cancer. Ann Surg Oncol 2001;8:675681.

    • Search Google Scholar
    • Export Citation
  • 34

    Cody HS, Klauber-DeMore N, Borgen P et al.. Is it really ductal carcinoma in situ? Ann Surg Oncol 2001;8:617619.

  • 35

    Colpaert C, Vermeulen P, Jeuris W et al.. Early distant relapse in “node-negative” breast cancer patients is not predicted by occult axillary lymph node metastases, but by the features of the primary tumour. J Pathol 2001;193:442449.

    • Search Google Scholar
    • Export Citation
  • 36

    Braun S, Cevatli BS, Assemi C et al.. Comparative analysis of micrometastasis to the bone marrow and lymph nodes of node-negative breast cancer patients receiving no adjuvant therapy. J Clin Oncol 2001;19:14681475.

    • Search Google Scholar
    • Export Citation
  • 37

    Gray RJ, Cox CE, Reintgen DS. Importance of missed axillary micrometastases in breast cancer patients. Breast J 2001;7:303307.

  • 38

    Gebauer G., Fehm T, Merkle E et al.. Epithelial cells in lymph nodes or bone marrow do not predict long term outcome in lymph node negative breast cancer patients (Abstr. #147). Proc Am Soc Clin Oncol 2002;21:38a.

    • Search Google Scholar
    • Export Citation
  • 39

    Cote RJ, Peterson HF, Chaiwun B et al.. Role of immunohistochemical detection of lymph-node metastases in management of breast cancer. International Breast Cancer Study Group. Lancet 1999;354:896900.

    • Search Google Scholar
    • Export Citation
  • 40

    Tan LK, Giri D, Panageas K et al.. Occult/micrometastases in axillary lymph nodes of breast cancer patients are significant: A retrospective study with long-term follow-up (Abstr. #146). Proc Am Soc Clin Oncol 2002;21:37a.

    • Search Google Scholar
    • Export Citation
  • 41

    Fitzgibbons PL, Page DL, Weaver D et al.. Prognostic factors in breast cancer. College of American Pathologists Consensus Statement 1999. Arch Pathol Lab Med 2000;124:966978.

    • Search Google Scholar
    • Export Citation
  • 42

    Edge SB, Hurd TC. Sentinel node update: Breast cancer. Oncology (Huntingt) 1999;13:21318.

  • 43

    Singletary SE, Allred C, Ashley P et al.. Revision of the American Joint Committee on Cancer staging system for breast cancer. J Clin Oncol 2002;20:36283636.

    • Search Google Scholar
    • Export Citation
  • 44

    Albo D, Wayne JD, Hunt KK et al.. Anaphylactic reactions to isosulfan blue dye during sentinel lymph node biopsy for breast cancer. Am J Surg 2001;182:393398.

    • Search Google Scholar
    • Export Citation
  • 45

    Cimmino VM, Brown AC, Szocik JF et al.. Allergic reactions to isosulfan blue during sentinel node biopsy—A common event. Surgery 2001;130:439442.

    • Search Google Scholar
    • Export Citation
  • 46

    Lagios MD, Silverstein MJ. Sentinel node biopsy for patients with DCIS: A dangerous and unwarranted direction. Ann Surg Oncol 2001;8:275277.

    • Search Google Scholar
    • Export Citation
  • 47

    Burbank F. Stereotactic breast biopsy of atypical ductal hyperplasia and ductal carcinoma in situ lesions: Improved accuracy with directional, vacuum-assisted biopsy. Radiology 1997;202:843847.

    • Search Google Scholar
    • Export Citation
  • 48

    Wong SL, Edwards MJ, Chao C et al.. The effect of prior breast biopsy method and concurrent definitive breast procedure on success and accuracy of sentinel lymph node biopsy. Ann Surg Oncol 2002;9:272277.

    • Search Google Scholar
    • Export Citation
  • 49

    Carter BA, Jensen RA, Simpson JF et al.. Benign transport of breast epithelium into axillary lymph nodes after biopsy. Am J Clin Pathol 2000;113:259265.

    • Search Google Scholar
    • Export Citation
  • 50

    Tamhane R, Dahlstrom JE, McCallum DD et al.. The clinical significance of cytokeratin-positive cells in lymph nodes at the time of mastectomy from patients with ductal carcinoma-in-situ. Ann Surg Oncol 2002;9:9991003.

    • Search Google Scholar
    • Export Citation
All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 126 28 1
PDF Downloads 73 26 1
EPUB Downloads 0 0 0