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
