Re: Trends in the Treatment of Ductal Carcinoma In Situ of the Breast

Extract

The treatment of ductal carcinoma in situ (DCIS) of the breast still represents a hotly debated issue, and wide variations in surgical management of DCIS have been recently reported ( 1 ). In particular, although the appropriateness of sentinel lymph node biopsy (SLNB) in the management of pure DCIS seems well established today because of the very low rate of axillary metastases and because its routine use is discouraged elsewhere ( 2 , 3 ) , we were surprised that several authors continue to routinely perform SLNBs in all DCIS patients, without any distinction between different subhistotypes, tumor size, or tumor grade, reporting an overall high rate of metastatic lymph nodes in a small series of DCIS patients. We present our SLNB policy to try to resolve the open debate.

Between March 1, 1996, and June 30, 2003, 482 patients (between ages 30 and 80 years, average = 50.1 years) with pure DCIS (cases of DCIS with microinvasion were excluded) were subjected to SLNB, as described elsewhere ( 4 , 5 ). SLN metastases were detected in eight (1.7%) of these patients. The SLNs were the only affected nodes in the seven of these eight patients who subsequently underwent complete axillary lymph node dissections. Five of the eight SLN-positive patients had only micrometastases (<2 mm in diameter). Unfortunately, the low number of SLN-positive patients and the subsequent imbalance in the two groups make any kind of comparison between the two groups impossible. In particular, the risk of lymph node metastases does not seem to be associated with clinical presentation, grade, sex hormone receptor status, proliferative index (Ki-67), or type of surgery (Table 1 ). Only tumor size and a comedocarcinoma subhistotype appear to be relevant in predicting the risk of SLN metastases.