frozen section of sentinel lymph node for ductal carcinoma in situ (dcis)

Frozen Section ofSentinel lymph node for

Ductal Carcinoma in Situ (DCIS)

Dr Cheung Chi Ying Genevieve

Cox CE, Ann Surg. 1998

• SLNBx is well recognized in invasive breast cancer– avoid full axillary dissection – decrease the morbidity associated with

axillary dissection

• Surgical techniques were well described and were mastered by many surgeons

Introduction

SLNBx in DCIS

• Increasing interest of SLNBx in other applications in breast surgery– DCIS

• DCIS is the precursor of invasive cancer

• Incidence of DCIS is increasing in the screening era– From 3/100000 to 34/100000 in 50-69

y.o.

• Prognosis of pure DCIS is excellent– 5 years survival >95%

Van Steenbergen LN et al, breast cancer rest treat. 2009

Controversial issues• Pre op trucut biopsy of DCIS

– not 100% !– About 29.9% of these group had

upstaging of disease in final pathology

WK Hung et al, Breast cancer 2009

Controversial issues• Pure DCIS theoretically will not have

any LN metastasis

• Management of axilla– SLNBx for F.S.?– Axillary dissection or not?– If not -> miss the invasive disease that

need AD?

Veronesi P et al, Breast. 2005

Current recommendation

• Selective application in high risk DCIS– Extensive microcalcifications– Palpable mass– High nuclear grade– Requiring mastectomy

• SLNBx is not possible as a 2nd procedure

Schneider C et al, Am Surg. 2010 D’Eredita G et al, Tumori. 2009

KWH experience inSLNBx for DCIS

• In KWH, SLNBx technique was introduced for DCIS since year 2002

• Results of KWH experience of SLNBx in DCIS are being presented here

Patients

• Retrospective study

• Period: 3/2002 till 6/2010

• Total number of patients: 170

• Inclusion– Preop trucut Biopsy: DCIS

Patients

• Exclusion– Patient with microinvasive disease on

trucut bx– Patients with DCIS diagnosed after OT

• Mean age: 54.4 years old

Presentation

Presentations No. %

Mammographic abnormality

113 66%

Breast lump 48 29%

Nipple discharge 9 5%

Operation

Operation No. %

Mastectomy 122 72%

Mastectomy + immediate reconstruction

5 3%

Breast conservating treatment

43 25%

Methods of mapping

• Methods used for localization of SLN– Blue dye method

• Intra-op sub-dermal injection of Patent Blue

– Isotope method• Pre-op scintigraphy with 99m Tc Sulfur

colloid• Localization with intra-op hand-held gamma

probe

– Combined

Frozen section

• The sentinel LN would be sent to the laboratory immediately

• The pathologist would then give a verbal report– Whether the LN is positive for any

macrometastasis

Results

• SLNBx was successful in 162 (95%) of patients

• 5 patients (3%) had +ve SLN on frozen section intraoperatively– Axillary dissection was carried out

Results

• 12 patients (7%) had false –ve FS– Axillary dissection was carried out in 6 of

them

Pre-op core biopsy : DCIS170

SLN Failed8 (5%)

SLN Successful162 (95%)

F.S. +ve5 (3%)

F.S. –ve157 (92%)

3 A.D. –ve(2%)2 A.D. +ve(1%)

True –ve145 (85%)

False –ve12 (7%)

A.D. 6(3.5%)

No A.D.6 (3.5%)

Pre-op core biopsy : DCIS170

SLN Failed8 (5%)

SLN Successful162 (95%)

F.S. +ve5 (3%)

F.S. –ve157 (92%)

3 A.D. –ve(2%)2 A.D. +ve(1%)

True –ve145 (85%)

False –ve12 (7%)

A.D. 6(3.5%)

No A.D.6 (3.5%)

• 11 axillary dissections were done

• Only 3 of them were +ve in AD

• Final pathology– invasive ductal carcinoma

Discussion

Summary

SLN Successful rate 95%

F.S. +ve 3%

False –ve F.S. 7%

True LN +ve (ie F.S. + P.S.) 10%

For pure DCIS, SLN +ve 4%

Upstage to invasive disease 27%

SLN Successful162 (95%)

Negative145 (85%)

Positive17 (10%)

A.D. 11 (6%)

No A.D.6 (4%)

SLN for P.S.

Invasive ductal CA

8 (5%)

DCIS3 (2%)

All AD -veAD –ve 5 (3%)AD +ve 3 (2%)

SLN Successful162 (95%)

Negative145 (85%)

Positive17 (10%)

A.D. 11 (6%)

No A.D.6 (4%)

SLN for P.S.

Invasive ductal CA

8 (5%)

DCIS3 (2%)

All AD -veAD –ve 5 (3%)AD +ve 3 (2%)

SLN Successful162 (95%)

Negative145 (85%)

Positive17 (10%)

A.D. 11 (6%)

No A.D.6 (4%)

SLN for P.S.

Invasive ductal CA

8 (5%)

DCIS3 (2%)

All AD -veAD –ve 5 (3%)AD +ve 3 (2%)

• For pure DCIS with +ve sentinel lymph node– either in F.S. or paraffin section– SLN is the only LN that is +ve– rest of axilla is -ve

Discussion

• Axillary dissection and intraop frozen section for pure DCIS is unnecessary

Discussion

• For pure DCIS, taking out the SLN would be enough without the need of further axillary dissection

Discussion

• Hypothetically, if no F.S. was done for DCIS– Potentially save

• 162 frozen sections• 3 axillary dissections

Discussion

Thank you