Although DCIS has become a rather common diagnosis, the biology of the disease is not well understood. Adjuvant endocrine therapy with an aromatase inhibitorĭCIS (or stage 0 breast cancer) accounts for approximately 20% of mammographically detected breast cancers. Radiation treatment of the regional undissected lymph nodesĮ. Post-mastectomy radiation to the left chest wallĭ. Re-excision and axillary lymph node dissectionĬ. Which of the following represents the best next step in management for this patient?ī. Postoperative staging positron emission tomography (PET)/CT scans showed two suspicious foci in the left axilla (Figure 5). The cancer was estrogen receptor– and progesterone receptor–positive and human epidermal growth factor receptor 2/ neu–negative (stage IIA, rT1b, N1, M0). The two lymph nodes that were removed were both positive for metastatic carcinoma in one, the cancerous deposit measured 1.3 cm, and in the other, 1.6 cm (Figure 4). The lesion was associated with high–nuclear grade DCIS, and displayed solid and cribriform growth patterns with associated comedonecrosis and microcalcifications. The carcinoma was grade 2, with lymphovascular space invasion. The final pathology report showed a 0.9-cm invasive ductal carcinoma with marked lymphoplasmacytic response, and resection margins positive for invasive carcinoma. She had a left wire-guided lumpectomy and excision of two lymph nodes. Imaging and biopsy revealed invasive ductal carcinoma and high-grade DCIS (Figure 3). One year after her initial diagnosis, the patient noted a palpable abnormality in the left reconstructed breast, at the 2 o’clock position. Six months after her mastectomy, she underwent expander exchange and placement of silicone implants. Left sentinel lymph node excision was negative for carcinoma. Margins showed no DCIS involvement the closest margin was 1.4 mm. The two foci of disease demonstrated a predominantly solid pattern, with focal micropapillary and comedo patterns. The pathology report showed two foci of high-grade DCIS, with the larger of these approximately 20 mm in size (Figure 2). With the superior lesion as the only site of disease, she was an excellent candidate for lumpectomy however, she opted for bilateral mastectomy and left sentinel lymph node biopsy, followed by tissue expander placement. No known mutations were found, but four variants of uncertain significance were identified in the APC gene. ![]() The patient underwent genetic counseling and testing. The DCIS specimen stained positive for estrogen receptor (3+, 90%) and progesterone receptor (3+, 75%). The posterior site showed high–nuclear grade ductal carcinoma in situ (DCIS) with comedonecrosis. Three sites of calcifications were biopsied. The follow-up mammogram showed pleomorphic calcifications spanning 1.5 cm (Figure 1). A diagnostic mammogram showed several small punctate calcifications, and a 6-month interval follow-up was recommended. However, patients who present with clinical findings of palpability, large extent of disease on imaging and mass on preoperative imaging have a meaningful risk of upstaging to invasive cancer, and SLNB remains important for management.A 46-year-old woman had a routine screening mammogram that showed new calcifications in the posterior left breast. In a subset of patients undergoing mastectomy for DCIS with limited disease on preoperative evaluation, SLNB may be omitted as the risk of upstaging is low. 0074) and mass on preoperative imaging (P =. 0080), extent of disease on imaging (P =. In multivariate analysis, palpability (P =. 0121), mass on preoperative imaging (P =. 0001), extent of disease on imaging (P =. Factors positively associated with upstaging to invasive cancer in univariate analysis included age (P =. On final mastectomy pathology, 120(71%) patients had DCIS with 0 positive sentinel lymph nodes (PSLNs) and 48(29%) patients had invasive carcinoma with 5(10%) cases of ≥1 PSLNs. Of 3145 patients, 168(5%) had pure DCIS on PCB and underwent mastectomy with SLNB. Clinico-pathologic variables were analyzed using Pearson's chi-squared, Wilcoxon Rank-Sum and logistic regression. ![]() Patients were divided according to final pathology (DCIS or invasive cancer). The Institutional Breast Cancer Database was queried for patients with PCB demonstrating pure DCIS followed by mastectomy and SLNB from 2010 to 2018. We examined the factors associated with sentinel lymph node positivity for patients undergoing mastectomy for a diagnosis of DCIS on preoperative core biopsy (PCB). Sentinel lymph node positivity in patients undergoing mastectomies for ductal carcinoma in situ (DCIS).Ĭurrent guidelines recommend sentinel lymph node biopsy (SLNB) for patients undergoing mastectomy for a preoperative diagnosis of ductal carcinoma in situ (DCIS).
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