Sentinel lymph node biopsy in patients with ductal carcinomain situ: systematic review and meta-analysis

Abstract

Background Axillary lymph node status remains the most powerful prognostic indicator in invasive breast cancer. Ductal carcinoma in situ (DCIS) is a non-invasive disease and does not spread to axillary lymph nodes. The presence of an invasive component to DCIS mandates nodal evaluation through sentinel lymph node biopsy (SLNB). Quantification of the necessity of upfront SLNB for DCIS requires investigation. The aim was to establish the likelihood of having a positive SLNB (SLNB+) for DCIS and to establish parameters predictive of SLNB+. Methods A systematic review was performed as per the PRISMA guidelines. Prospective studies only were included. Characteristics predictive of SLNB+ were expressed as dichotomous variables and pooled as odds ratios (o.r.) and associated 95 per cent confidence intervals (c.i.) using the Mantel–Haenszel method. Results Overall, 16 studies including 4388 patients were included (mean patient age 54.8 (range 24 to 92) years). Of these, 72.5 per cent of patients underwent SLNB (3156 of 4356 patients) and 4.9 per cent had SLNB+ (153 of 3153 patients). The likelihood of having SLNB+ for DCIS was less than 1 per cent (o.r. <0.01, 95 per cent c.i. 0.00 to 0.01; P < 0.001, I 2 = 93 per cent). Palpable DCIS (o.r. 2.01, 95 per cent c.i. 0.64 to 6.24; P = 0.230, I 2 = 0 per cent), tumour necrosis (o.r. 3.84, 95 per cent c.i. 0.85 to 17.44; P = 0.080, I 2 = 83 per cent), and grade 3 DCIS (o.r. 1.34, 95 per cent c.i. 0.80 to 2.23; P = 0.270, I 2 = 0 per cent) all trended towards significance in predicting SLNB+. Conclusion While aggressive clinicopathological parameters may guide SLNB for patients with DCIS, the absolute and relative risk of SLNB+ for DCIS is less than 5 per cent and 1 per cent, respectively. Well-designed randomized controlled trials are required to establish fully the necessity of SLNB for patients diagnosed with DCIS. Registration number CRD42021284194 ( https://www.crd.york.ac.uk/prospero/ )

Upgrade Rate of Ductal Carcinoma In Situ to Invasive Carcinoma and the Clinicopathological Factors Predicting the Upgrade Following a Mastectomy: A Retrospective Study

“…The SLNB positivity rate in our study was 4.8% (6/123 patients) which is in agreement with other studies [11,12,17], and a recent meta-analysis by Davey et al analysed the data from 4,388 patients in 16 studies and found a rate of 4.9% and recommended further well-designed randomised control trials to fully establish the necessity of SLNB for patients diagnosed with DCIS [14].…”

“…Due to the consequent risk of axillary lymph node involvement [ 14 ], upgrading DCIS to IC carries a significant impact on patients and surgeons.…”

Surgical Treatments for Ductal CarcinomaIn Situ(DCIS) in Elderly Patients

“…No differences were reported in terms of BMI between the groups (p=0.786). Charlson comorbidity index and ASA score were significantly higher in the elderly: 5 (3)(4)(5)(6)(7)(8)(9)(10)(11) vs. 1 (0-4), (p<0.001 for both); the score of anesthetic risk (ASA) and the median of CCI are summarized in Table I.…”

“…Lymph node evaluation for stage 0 breast cancer is controversial, and sentinel lymph node biopsy (SNLB) should be reserved for invasive cancer (4). Due to the risk of upstaging to invasive breast cancer and in order to avoid a potential second surgical procedure, a large proportion of women with a DCIS diagnosis undergo unnecessary SLNB (7). Despite DCIS often receiving similar treatments as ductal invasive cancer, all these measures have not been shown to reduce overall mortality in large observational studies (8).…”

The SOUND Randomized Clinical Trial Results

“…In patients with DCIS, a meta-analysis of 16 studies reported an SLN metastasis rate of 4.9% (153 of 3153). Subsequent large studies have reported rates between 1.9% (23 of 1240) and 7.6% (49 of 649), through 4.4% (127 of 2892) in the largest of such studies.…”