Dr Cheung Chi Ying Genevieve Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS) Dr Cheung Chi Ying Genevieve

Introduction 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 Cox CE, Ann Surg. 1998

SLNBx in DCIS Increasing interest of SLNBx in other applications in breast surgery DCIS DCIS is the precursor of invasive cancer

Van Steenbergen LN et al, breast cancer rest treat. 2009 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

WK Hung et al, Breast cancer 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 Lymph node metastasis do occur 3-13% Associated with missed invasive cancer in most cases 5

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 Lymph node metastasis do occur 3-13% Associated with missed invasive cancer in most cases 6

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 in SLNBx 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 Mean age: 54.4 years old 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 Pre-op scintigraphy with 99m Tc Sulfur colloid, sub-dermal injection over tumour Localization with intra-op hand-held gamma probe Intra-op sub-dermal injection of Patent Blue SLN, and any enlarged, non-SLN excised for frozen section examination

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 Pre-op scintigraphy with 99m Tc Sulfur colloid, sub-dermal injection over tumour Localization with intra-op hand-held gamma probe Intra-op sub-dermal injection of Patent Blue SLN, and any enlarged, non-SLN excised for frozen section examination 14

Results SLNBx was successful in 162 (95%) of patients 5 patients (3%) had +ve SLN on frozen section intraoperatively Axillary dissection was carried out Final pathology 3 of them had SLN as the only +ve LN ( 2 DCIS and 1 CA) 2 of them had LN +ve in axillary dissection (2/9 LN and 7/9 LN) Final pathology of these 2 were invasive ductal CA

Results 12 patients (7%) had false –ve FS Axillary dissection was carried out in 6 of them Final pathology 1 DCIS, AD –ve 5 CA, AD –ve x 4, 3/12 LN x 1 No AD group DCIS x 3 CA x 3

Pre-op core biopsy : DCIS 170 SLN Failed 8 (5%) SLN Successful 162 (95%) F.S. +ve 5 (3%) F.S. –ve 157 (92%) True –ve 145 (85%) False –ve 12 (7%) 3 A.D. –ve(2%) 2 A.D. +ve(1%) SLN failed All are DCIS 3 have AD, all -ve A.D. 6(3.5%) No A.D. 6 (3.5%)

Pre-op core biopsy : DCIS 170 SLN Failed 8 (5%) SLN Successful 162 (95%) F.S. +ve 5 (3%) F.S. –ve 157 (92%) True –ve 145 (85%) False –ve 12 (7%) 3 A.D. –ve(2%) 2 A.D. +ve(1%) A.D. 6(3.5%) No A.D. 6 (3.5%)

Discussion 11 axillary dissections were done Only 3 of them were +ve in AD Final pathology invasive ductal carcinoma AD: 7/9 LN +ve, 2/9 LN +ve, 3/12 LN +ve

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% AD: 7/9 LN +ve, 2/9 LN +ve, 3/12 LN +ve

SLN Successful 162 (95%) SLN for P.S. Positive 17 (10%) Negative 145 (85%) No A.D. 6 (4%) A.D. 11 (6%) DCIS 3 (2%) Invasive ductal CA 8 (5%) All AD -ve AD –ve 5 (3%) AD +ve 3 (2%)

SLN Successful 162 (95%) SLN for P.S. Positive 17 (10%) Negative 145 (85%) No A.D. 6 (4%) A.D. 11 (6%) DCIS 3 (2%) For pure DCIS, no further treatment needed even if we didn’t send any F.S, as all AD was negative Invasive ductal CA 8 (5%) All AD -ve AD –ve 5 (3%) AD +ve 3 (2%)

SLN Successful 162 (95%) SLN for P.S. Positive 17 (10%) Negative 145 (85%) No A.D. 6 (4%) A.D. 11 (6%) DCIS 3 (2%) For invasive ductal CA group, only 3 had +ve LN in AD, and we can always do it as a second operation Invasive ductal CA 8 (5%) All AD -ve AD –ve 5 (3%) AD +ve 3 (2%)

Discussion 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

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