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