Is it time to de-escalate axillary surgery in patients with ductal carcinoma in-situ undergoing mastectomy?

Introduction

Axillary surgery has been de-escalated in invasive breast carcinoma and may be omitted in certain age groups. Up to 10–20 % of patients with ductal carcinoma in-situ (DCIS) will have an element of invasion. Therefore, SLNB is indicated to rule out nodal metastasis. Our purpose was to identify the rate and possible risk factors for lymph node metastasis in DCIS, and to measure oncological outcome of positive SLNB in this group.

Methods

A retrospective analysis was performed on 113 female patients with DCIS, who underwent mastectomy and SLNB. Their clinical and radiological features, as well as pre and post-operative histopathological characteristics were evaluated and data was reported over an average follow up period of 48 months.

Result

DCIS was upgraded to invasive cancer in 11 patients out of 113 (9.7 %). Five patients had positive SLNB (4.4 %), one micro-metastasis (0.8 %) and four macro-metastasis (3.5 %) All the five underwent axillary lymph node dissection (ALND) and all additional nodes retrieved were negative. High nuclear grade, Her2 neu overexpression, and palpable mass showed higher odds of association with metastasis to sentinel nodes. However, due to the low event rate, the association did not reach statistical significance. Seven patients (6.2 %) developed lymphedema, 4 of which after SLNB only. No regional recurrence was reported among our study sample.

Conclusion

This study confirms the very low rate of positive SLNB in patients with DCIS. It is time to de-escalate axillary surgery for patients with DCIS undergoing mastectomy and consider delayed SLNB for high risk group of patients.