BREAST CANCER: SENTINEL LYMPH NODE BIOPSY LIST SERV
SCENARIO 3:
PATIENT WITH DCIS
LEARNING OBJECTIVES
CASE PRESENTATION
1. Discuss the role of SLNB in DCIS
2. Identify appropriate surgical technique for
SLNB
3. Identify appropriate pathological technique
for SLNB
4. Discuss indications for completion ALND
5. Discuss the role of MCCs
● A 40 year old female with a family history of breast cancer
presents with extensive microcalcifications on her first
mammogram.
● Her mother was diagnosed with a peri-menopausal breast
cancer and did well with a modified radical mastectomy 20
years ago.
● Clinical exam is unremarkable.
INVESTIGATIONS
QUESTIONS FOR DISCUSSION
Ultrasound
● Shows no mass lesion.
Mammogram
● Confirms an area of 4 cm of powdery
micro-calcifications in the upper outer
quadrant of her left breast.
1. Would you perform a SLNB on the patient at the time of
lumpectomy?
2. Is it adequate to just use blue dye or should you use blue
dye and radioisotope?
3. Where would you perform the injection?
4. What pathological technique is recommended?
Sterotactic Core Biopsy
● High grade DCIS with comedo necrosis.
FOLLOW-UP
TECHNIQUE & PATHOLOGY
Technique
● The patient’s preference is for a mastectomy
and you perform a SNLB at the same time.
Pathology
● Pathology reports a single 0.4mm nodal
metastases and confirms a T Ia cancer in a
background of extensive DCIS. The primary
tumour is 5mm, grade III, has lymphovascular invasion (LVI) and is ER/PR positive.
QUESTIONS FOR DISCUSSION
1. What is the risk of additional disease in the axillary basin
for this patient?
2. What if the metastases was 0.1 mm (ITC)?
3. Should an ALND be performed now?
4. Should this case be presented at a Multi-disciplinary
Cancer Conference (MCC)?
GUIDELINE INFORMATION
● “Sentinel Lymph Node Biopsy in Early-stage Breast Cancer: Guideline Recommendations”:
http://www.cancercare.on.ca/common/pages/UserFile.aspx?fileId=45870
● For key evidence, see pages 20-30 of the Evidentiary Base (Section 2) of the guideline.
● “Multidisciplinary Cancer Conference Standards”: http://www.cancercare.on.ca/cms/one.aspx?pageId=10473).
BREAST CANCER: SENTINEL LYMPH NODE BIOPSY LIST SERV
SCENARIO 3:
PATIENT WITH DCIS
FOLLOW-UP
KEY LEARNING POINTS
SLNB
● At initial surgery, the patient would be offered a wire localized lumpectomy. There is no indication for
SLNB at the time of lumpectomy.
● It was suggested that with a 4 cm lesion, risk of microinvasion or invasion is quite high.
● If there are indications for mastectomy, a SLNB should be performed at the same time.
Mapping Technique
○ A combination of blue dye and radioisotope are recommended for SLNB.
○ It is recommended that the tracer be injected intradermally at the edge of the areola and that the blue dye be
injected into the subareolar area or the breast parenchyma around the tumor.
○ If mapping after a previous upper outer quadrant incision, modification may be required to include some
dermal injection lateral to the incision or in the peri tumoural cavity.
Assessment of DCIS - Pathology
● Fixed and consecutively sliced specimens are sent to radiology to help map out calcifications. Radiological
correlation is important to correlate what is being seen histologically to what is identified radiologically.
The areas of interest are blocked out so that the location of each block can be determined, and the extent of
the DCIS can be calculated by using a diagram of the specimen, the thickness of the slices, and the location
of the involved blocks.
● Further blocks after review of the x-rays may be necessary if they suggest larger size or number of
microcalcifications.
● Keeping a gross diagram is important to estimate the extent of DCIS.
MRI
● There were mixed responses regarding the value of MRI.
● Some participants indicated that they would obtain a MRI and review findings with radiology to assess
extent of disease, likelihood of invasive disease and need for further evaluation/biopsy.
● It was suggested that MRI is very sensitive and not specific, so patients may have an increased number of
tests and biopsies. It might also lead to a delay in surgery.
● CCO does not have a guideline. Attached for information is the American Cancer Society Guidelines for
Breast Screening with MRI as an Adjunct to Mammography (Reference: CA Cancer J Clin 2007;57(2):7589)
ALND
● There was agreement that the patient’s risk of residual axillary disease with a micrometasteses (0.4mm)
found on SLNB is sufficiently high to warrant completion ALND.
MCC
● If the metasteses was 0.1mm (ITC), discussion at an MCC may be beneficial, as well as consideration of
other patient and tumour characteristics.
● The main issues would concern local control of disease in the axilla and guidance for adjuvant therapy.
Radioactive Exposure – Precautions
● There is agreement that the dose of radioactivity exposure is low during surgery or handling of the specimen
in pathology.