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Is Sentinel Lymph Node Biopsy Indicated in Patients with a Diagnosis of Ductal Carcinoma in Situ? a Systematic Literature Review and Meta-Analysis

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The American Journal of Surgery (2017) 213, 171-180 Review Is sentinel lymph node biopsy indicated in patients with a diagnosis of ductal carcinoma in situ? A systematic literature review and meta-analysis Hiba El Hage Chehade, M.D., M.R.C.S.*, Hannah Headon, M.B.B.S., B.Sc., Umar Wazir, M.B.B.S., M.R.C.S., M.Sc., Houssam Abtar, M.D., Abdul Kasem, M.D., F.R.C.S., Kefah Mokbel, M.S., F.R.C.S. The London Breast Institute, Princess Grace Hospital, 42-52 Nottingham Place, London W1U 5NY, UK KEYWORDS: Abstract Sentinel lymph node BACKGROUND: Recent discussion has suggested that some cases of ductal carcinoma in situ (DCIS) biopsy; with high risk of invasive disease may require sentinel lymph node biopsy (SLNB). Ductal carcinoma in METHODS: Systematic literature review identified 48 studies (9,803 DCIS patients who underwent situ; SLNB). Separate analyses for patients diagnosed preoperatively by core sampling and patients diagnosed Breast cancer postoperatively by specimen pathology were conducted to determine the percentage of patients with axillary nodal involvement. Patient factors were analyzed for associations with risk of nodal involvement. RESULTS: The mean percentage of positive SLNBs was higher in the preoperative group (5.95% vs 3.02%; P 5 .0201). Meta-regression analysis showed a direct association with tumor size (P 5 .0333) and grade (P 5 .00839) but not median age nor tumor upstage rate. CONCLUSIONS: The SLNB should be routinely considered in patients with large (.2 cm) high- grade DCIS after a careful multidisciplinary discussion. In the context of breast conserving surgery, the SLNB is not routinely indicated for low- and intermediate-grade DCIS, high-grade DCIS smaller than 2 cm, or pure DCIS diagnosed by definitive surgical excision. Crown Copyright Ó 2016 Published by Elsevier Inc. All rights reserved. Ductal carcinoma in situ (DCIS) is the predominant At present, the treatment of DCIS comprises wide local noninvasive breast neoplasia in the United Kingdom, excision or mastectomy to achieve local control of the dis- comprising 83% of all in situ breast cancers diagnosed.1 ease. In patients treated with breast conserving surgery, radiotherapy may be considered to reduce the risk of local recurrence. This review was funded by grants from the Breast Cancer Hope Foun- In breast cancer, the status of the regional lymph nodes has dation (London, UK). been found to be the most important prognostic factor and The authors declare no conflicts of interest. predictor of survival and therefore has important implica- * Corresponding author. Tel.: 144 207 908 2101; fax: 144 207 908 tions for future treatment decisions.2 As DCIS is noninvasive 2275. E-mail address: [email protected] by definition, this implies that there should be no spread to the Manuscript received February 24, 2016; revised manuscript April 19, axillary lymph nodes. Subsequently, omission of axillary 2016 dissection is now the standard of treatment since previous 0002-9610/$ - see front matter Crown Copyright Ó 2016 Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.amjsurg.2016.04.019 172 The American Journal of Surgery, Vol 213, No 1, January 2017 Table 1 Characteristics of studies included in the preoperative sample Positive results Upstage Number of Median rate Study Design cases age Total (%) ITC (%) Micrometastases (%) Macrometastases (%) (%) Francis et al, 20155 Retrospective 1,234 54 132 (10.7) 66 (5.4) 36 (2.9) 30 (2.4) NR Tunon-de-Lara et al, Prospective 196 54.3 27 (14.1) 8 (4.1) 8 (4.1) 11 (5.6) NR 201539 Nowikiewicz et al, Retrospective 111 55 4 (3.6) NR NR NR NR 201528 Ruvalcaba-Limon Retrospective 50 51.6 5 (10) 0 (0) 3 (6) 2 (4) NR et al, 201435 Walters et al, 201543 Retrospective 84 57.7 1 (1.2) 0 (0) 1 (1.2) 0 (0) 17.2 Banys et al, 20149 Retrospective 316 55 3 (.9) 1 (.3) NR NR 0 Namm et al, 201527 Retrospective 52 54.8 3 (6) 0 (0) 2 (3.8) 1 (1.9) 32 Osako et al, 201430 Retrospective 336 NR 23 (6.8) 0 (0) 6 (1.8) 17 (5) 33.6 Ozkan-Gurdal et al, Prospective 33 51 1 (3.3) NR NR NR 0 201431 Guillot et al, 201418 Prospective 109 51 11 (9) 8 (7.3) 2 (1.8) 1 (.9) NR Rajan et al, 201338 Retrospective 25 56.9 0 (0) 0 (0) 0 (0) 0 (0) NR Chin-Lenn et al, Retrospective 306 57 3 (2.1) NR NR NR 17 201410 Zapardiel et al, Retrospective 84 NR 6 (6.9) NR NR NR NR 201344 Ballehaninna et al, Retrospective 267 57 13 (4.8) 4 (1.5) 6 (2.2) 3 (1.1) 15.4 20138 Fancellu et al, Prospective 140 56 2 (1.4) NR NR NR 1.4 201217 Park et al, 201332 Prospective 238 48.5 10 (4.2) NR NR NR 42.6 Ansari et al, 20127 Retrospective 61 NR 3 (4.9) 1 (1.6) 0 (0) 2 (3.3) NR Osako et al, 201229 Prospective 623 50 13 (2.1) NR NR NR NR Meretoja et al, Prospective 280 58 21 (7.5) 16 (5.7) 3 (1.1) 2 (.7) NR 201225 Chvalny et al, 201111 Retrospective 44 NR 4 (9) NR NR NR NR Usmani et al, 201141 Prospective 23 48 1 (4) NR NR NR 30 Miyake et al, 201126 Prospective 103 49 2 (5.4) NR NR NR 35.9 Han et al, 201119 Retrospective 131 55 18 (13.7) NR NR NR 36.6 Prendeville et al, Retrospective 181 NR 7 (4) 6 (3.3) 0 (0) 1 (.6) 30 201534 Matsen et al, 201424 Retrospective 414 54 32 (7.7) 0 (0) 26 (6.3) 6 (1.4) NR Kotani et al, 201623 Retrospective 161 NR 1 (.62) NR NR NR 20 Son et al, 201137 Retrospective 48 50.6 1 (2.08) NR NR NR NR Collado et al, 201012 Prospective 65 NR 11 (16.9) NR NR NR 33.8 D’Eredita et al, Prospective 52 56 1 (1.9) 0 (0) 1 (1.9) 0 (0) NR 200914 Hung et al, 201020 Retrospective 103 54 12 (11.6) 3 (2.9) 5 (4.9) 4 (3.9) 29.9 Doyle et al, 200916 Retrospective 145 NR 11 (7.6) 4 (2.8) 3 (2.1) 4 (2.8) 37.9 Polom et al, 200933 Retrospective 183 57 10 (5.5) NR NR NR 4 Tunon-de-Lara et al, Prospective 161 56 6 (3.73) 0 (0) 4 (2.5) 2 (1.2) 30 200840 Intra et al, 200821 Prospective 854 NR 16 (1.9) 4 (.47) 7 (.8) 5 (.6) NR Dominguez et al, Retrospective 179 48 20 (11.3) 18 (10.1) 2 (1.1) 0 (0) 11.2 2008 15 Cserni et al, 200213 Prospective 10 NR 1 (10) 0 (0) 1 (10) 0 (0) NR Veronesi et al, Prospective 508 NR 9 (1.8) 0 (0) 5 (1.0) 4 (.8) NR 200542 Katz et al, 200622 Retrospective 110 55 8 (7.34) 0 (0) 8 (7.3) 0 (0) NR Sakr et al, 200636 Prospective 39 54 4 (10) 0 (0) 4 (10.3) 0 (0) 25.7 This table outlines the studies included in the preoperative sample (n 5 39). ITC 5 isolated tumor cells; NR 5 not reported. H. El Hage Chehade et al. SLNB in DCIS patients 173 Table 2 Characteristics of studies included in the postoperative sample Positive results Number of Median Micrometastases Macrometastases Study Design cases age Total (%) ITC (%) (%) (%) Zetterlund et al, Retrospective 753 60 11 (1.5) 6 (.8) 3 (.4) 2 (.3) 201452 Tada et al, 201050 Retrospective 225 51.2 1 (.39) 0 (0) 0 (0) 1 (.4) Sakr et al, 200849 Retrospective 110 NR 7 (6) 4 (3.6) 0 (0) 3 (2.7) Takacs et al, Retrospective 48 55.8 0 (0) 0 (0) 0 (0) 0 (0) 200951 Kelly et al, 200346 Retrospective 41 55.4 1 (2.44) NR NR NR Intra et al, 200345 Prospective 223 50.1 7 (3.14) 0 (0) 5 (2.2) 2 (.9) Zavagno et al, Prospective 102 59.4 1 (.98) 0 (0) 1 (.98) 0 (0) 200553 Mabry et al, 200648 Prospective 171 50 10 (5.8) 10 (5.8) 0 (0) 0 (0) Leidenius et al, Retrospective 71 56 5 (7) 3 (4.2) 1 (1.4) 1 (1.4) 200647 This table outlines the studies include in the postoperative sample (n 5 9). ITC 5 isolated tumor cells; NR 5 not reported. reports have established that this practice had no adverse and add to previous reviews such as that by Francis et al5 by effect on overall survival or disease recurrence in those including the latest research and examining any factors that with pure in situ disease.3 Despite this, recent studies have may predispose toward a greater risk of having a positive suggested that some DCIS cases do in fact harbor an invasive SLNB result. From this, we hope to be able to identify a sub- component, meaning that leaving the lymph nodes intact may set of patients with a diagnosis of DCIS who would benefit increase the risk of local recurrence.4 from undergoing an SLNB as part of their management plan. It has been proposed that select patients diagnosed with DCIS determined to be at high risk of harboring an invasive Methods component should undergo sentinel lymph node biopsy (SLNB). If positive, a complete axillary dissection may be Literature search considered, weighing the risk of recurrence disease and the morbidities of the procedure.
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