Discussion Of The Indications That Ductal Carcinoma In Situ Patients Should Undergo Sentinel Lymph Node Biopsy

Objectives To analyze the characteristics of the ductal carcinoma in situ patients who underwent sentinel lymph node biopsy. Discuss the indications that ductal carcinoma in situ patients should undergo sentinel lymph node biopsy.Details Ductal carcinoma is so called intraductal carcinoma, it refers the malignant ductal epithelial cells remains in the duct. Theoretically this type of carcinoma does not have the characteristic of migrate, nor lymph metastasis. Recently the ductal carcinoma in situ has got a larger proportion,around 10-25%, in the newly diagnosed breast cancer,under the use of mammography. DCIS has different types of biological behavior, which leads various degree of malignance under the use of histologic classification and immunohistochemical methods. DCIS can develop into invasive cancer, some of which is detected initially with micrometastasis. Different pathological physicians my have different understandings of severe atypical hyperplasia and DCIS, thus, they may make different diagnoses. Some doctors prefer to treat the severe atypical hyperplasia in the DCIS way, that is, extended local excision and check the margins of the tumor. SLN was firstly used in the carcinoma of the penis, referring to the fist few lymph nodes drainaging the area. In the year of 1991, Giuliano firstly used this concept of SLN in breast cancer, they use isosulfan blue as the tracer. The status of the lymph node of the axillary area is very important to the assessment of the breast cancer, as well as the prognostic and recurrence risk. ALND may course upper limb lymphedema,dysfunction, and movement restrictions, comparing with SLNB. More patients with breast cancer choose SLNB rather than ALND. However, SLNB for DCIS remains arguing for long term.Methods We retrospectively analyze the status of sentinel lymph node and their clinical and pathological characteristics of the ductal carcinoma in situ patients who underwent sentinel lymph node biopsy between October 2002 and November 2010 in our hospital.Results Forty-sixfemale patients are chosen, with the age between twenty-eight to seventy-one years old. Forty-one of them are younger than sixty years old(89.1 %). The median age is forty-five years old. The course of the disease is between three days to ten years, the median of which is forty days. They were preoperatively and(or)postoperatively diagnosed pure ductal carcinoma in situ or ductal carcinoma in situ with microinvasion, invasion, lobular carcinoma or page’s disease. All the patients underwent sentinel lymph node biopsy preoperatively or intraoperatively. The result of multiple logistic regression analysis shows no statistic significance of these factors, including age, tumor size, number of SLN excised, tumor grade, margin status, type of DCIS or accompanied with necrosis(p>0.05). However, Some factors might correlate to the node positive of DCIS patients, which are age between 41-69, size of tumor1.1cm-5.0cm, unknown status of the margin, with necrosis or unknown, tumor grade ⅡⅢ or unknown. It is commonly known that SLNB should be performed while mastectomy or immediate reconstruction of the breast, as well as SLN negative by core-needle biopsy under contract-enhanced type-B untrasonic. Tomohiro Miyake suggest that SLNB should be performed if the mass is larger than 2cm. Other reports show that high risk factors are: DICS diagnosed by core-needle biopsy, widely calcified,size of the tumor, nuclear grading, margin distance, accompanied by lobular carcinoma,status of the hormone receptor, the characteristic of the DCE and DW screening on MR,BRCA gene test. The distance of the free margin is greatly argued. Some studies show that the metastasis risk of the chest wall is low, even with margin positive, and PMRT is not always necessary. A reasonabletreatment should remedial measures when the primary treatment fails. Patients can benefit from the following breast radiotherapy,endocrine therapy.All these therapy provide us a better chance to perform the SLNB in DCIS patients. In our study, All node positive patients appear in the 41-69 years age group, tumor size 1.1cm-5.0cm group, margin status unknown group, accompanied with tumor necrosis or unknown group, tumor stage Ⅰ and upper group. These may provide us a hint that the longer the endocrine continues, the more activethe tumor cell metabolizes. Tumor size lager than 5 cm or smaller than 1 cm may predict better outcome. The following factors might correlate to the node positive of DCIS patients,which are age between 41-69, size of tumor 1.1cm-5.0cm, unknown status of the margin,with necrosis or unknown, tumor grade ⅡⅢ or unknown.Conclusion The following factors may help to predict DCIS patients undergo positive SLN and we should make careful decision in the treatment of these patients, including age between 41-69, size of tumor 1.1cm-5.0cm, unknown status of the margin, with necrosis or unknown, tumor grade Ⅱ Ⅲ or unknown. DCIS was sometime defined as preinvasive or non-invasive cancer. Clinically or technically, single cell can not be detected, however, it can breakthrough the duct and goes into the lymph or blood circulation. Thus, SLN positive strongly suggest that the DCIS be treated as invasive cancer.