The optimal management of the axillae of patients with microinvasive breast cancer in the sentinel lymph node era

Department of General Surgery, Mayo Clinic Arizona, 5777 E. Mayo Blvd, Phoenix, AZ 85054, USA.
American journal of surgery (Impact Factor: 2.41). 01/2008; 194(6):845-8; discussion 848-9. DOI: 10.1016/j.amjsurg.2007.08.034
Source: PubMed

ABSTRACT For patients with microinvasive breast cancer, the value of intraoperative analysis of sentinel lymph nodes (SLNs) and complete axillary lymph node dissection (CALND) is not well known.
All patients staged T1mic from 2001 to 2005 were analyzed.
Among all 81 patients, 4 (5%) had SLN metastases detected with hematoxylin and eosin staining and 2 (2%) had metastases identified by immunohistochemistry staining only. Seventy-seven patients (95%) underwent SLN biopsy; 3 (4%) had hematoxylin and eosin SLN metastases and 2 (3%) had immunohistochemistry-detected metastases. One SLN metastasis was identified on frozen section analysis. No patient with a SLN metastasis had additional metastases on CALND. The patient charges for frozen section analyses were $39,578 for 77 patients. This prevented 1 reoperative CALND at a charge of $20,274.
Frozen section analysis should be used only in select patients with microinvasive breast cancer and CALND is of limited value for these patients.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Background. Ductal carcinoma in situ with microinvasion (DCISM) is a rare diagnosis with a good prognosis. Although nodal metastases are uncommon, sentinel lymph node biopsy (SLNB) remains standard care. Volume of disease in invasive breast cancer is associated with SLNB positivity, and, thus we hypothesized that in a large cohort of patients with DCISM, multiple foci of microinvasion might be associated with a higher risk of positive SLNB. Methods. Records from a prospective institutional database were reviewed to identify patients with DCISM who underwent SLNB between June 1997 and December 2010. Pathology reports were reviewed for number of microinvasive foci and categorized as 1 focus or >= 2 foci. Demographic, pathologic, treatment, and outcome data were obtained and analyzed. Results. Of 414 patients, 235 (57 %) had 1 focus of microinvasion and 179 (43 %) had >= 2 foci. SLNB macrometastases were found in 1.4 %, and micrometastases were found in 6.3 %; neither were significantly different between patients with 1 focus versus >= 2 foci (p = 1.0). Patients with positive SLNB or >= 2 foci of microinvasion were more likely to receive chemotherapy. At median 4.9 years (range 0-16.2 years) follow-up, 18 patients, all in the SLNB negative group, had recurred for an overall 5-year recurrence-free proportion of 95.9 %. Conclusions. Even with large numbers, there was no higher risk of nodal involvement with >= 2 foci of microinvasion compared with 1 focus. Number of microinvasive foci and results of SLNB appear to be used in decision making for systemic therapy. Prognosis is excellent.
    Annals of Surgical Oncology 08/2014; 21(10). DOI:10.1245/s10434-014-3920-2 · 3.94 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: The objective of this systematic review was to determine the impact of sentinel lymph node (SLN) biopsy and breast magnetic resonance imaging (MRI) on important outcomes for patients with ductal carcinoma in situ. We identified no study that directly evaluated important outcomes for SLN biopsy. So, we determined the incidence of SLN metastases among patients with ductal carcinoma in situ. Using American Joint Committee on Cancer criteria, the incidence of pN1 and pN1(mic) SLN metastases were 0.9% and 1.5%, respectively. Because the incidence of SLN metastasis is very low, SLN biopsy is not likely to affect important outcomes. We identified one study that directly evaluated important outcomes after breast MRI. In this study, the use of MRI did not affect local recurrence rates after breast-conserving surgery and radiation. Although MRI may identify occult multicentric or contralateral breast cancer in some patients, it may also lead to unnecessary biopsies and overtreatment.
    JNCI Monographs 10/2010; 2010(41):117-20. DOI:10.1093/jncimonographs/lgq023
  • Source
    [Show abstract] [Hide abstract]
    ABSTRACT: BACKGROUND Microinvasive breast carcinoma (MIC) has a good prognosis but specific definitions have varied in the past, making the clinical significance of MIC a subject of debate.METHODS Microscopic slides of 59 cases of breast carcinoma originally diagnosed as MIC were reviewed retrospectively. Histologic parameters were correlated with clinical findings and outcome to define diagnostic criteria better.RESULTSOn review, the 59 cases were recategorized as follows: pure DCIS (N = 16), DCIS with foci equivocal for microinvasion (N = 7), DCIS with ≥ 1 focus of microinvasion (N = 11), T1 invasive carcinomas with ≥ 90% DCIS (N = 18), and T1 tumors with < 90% DCIS (N = 7). The MIC cases in the current study averaged 3 separate foci of early infiltration outside the basement membrane, each one not > 1.0 mm. The mean follow-up was 95 months. Six patients (10%) had only local recurrence: 1 case each in patients with equivocal microinvasion, microinvasion, and T1 tumors with < 90% DCIS and 3 cases among the patients with T1 tumors with ≥ 90% DCIS. Four patients, all with T1 tumors with ≥ 90% DCIS, had distant failure (7%). In the MIC group, only one patient developed a local recurrence after breast conservation. No patient had axillary lymph node metastasis. For the entire series, factors associated with local recurrence were younger age, breast conservation versus mastectomy, and close surgical margins. The only factor associated with distant failure was the size of the DCIS component. Seven patients with T1 tumors with ≥ 90% DCIS experienced local or distant failure and 5 of these (71%) developed progressive disease or died of disease. All other patients who developed a recurrence were disease free at last follow-up. In a retrospective series, poorer outcome in carcinomas with ≥ 90% DCIS may be related to the greater likelihood of missed larger areas of invasive carcinoma. Therefore, meticulous and extensive sampling of these carcinomas is required.CONCLUSIONSMIC as defined has a good prognosis. It has a different biology than T1 invasive carcinoma with ≥ 90% DCIS, which may progress and cause death. Large tumors with multiple foci of microinvasion may have metastatic potential. Cancer 2000;88:1403–9. © 2000 American Cancer Society.
    Cancer 01/2000; 88(6):1403 - 1409. DOI:10.1002/(SICI)1097-0142(20000315)88:6<1403::AID-CNCR18>3.0.CO;2-S · 4.90 Impact Factor