frozen section of sentinel lymph node for ductal carcinoma in situ (dcis)
DESCRIPTION
Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS). Dr Cheung Chi Ying Genevieve. Cox CE, Ann Surg. 1998. Introduction. SLNBx is well recognized in invasive breast cancer avoid full axillary dissection decrease the morbidity associated with axillary dissection - PowerPoint PPT PresentationTRANSCRIPT
![Page 1: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/1.jpg)
Frozen Section ofSentinel lymph node for
Ductal Carcinoma in Situ (DCIS)
Dr Cheung Chi Ying Genevieve
![Page 2: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/2.jpg)
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
![Page 3: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/3.jpg)
SLNBx in DCIS
• Increasing interest of SLNBx in other applications in breast surgery– DCIS
• DCIS is the precursor of invasive cancer
![Page 4: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/4.jpg)
• 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
![Page 5: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/5.jpg)
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
![Page 6: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/6.jpg)
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
![Page 7: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/7.jpg)
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
![Page 8: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/8.jpg)
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
![Page 9: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/9.jpg)
Patients
• Retrospective study
• Period: 3/2002 till 6/2010
• Total number of patients: 170
• Inclusion– Preop trucut Biopsy: DCIS
![Page 10: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/10.jpg)
Patients
• Exclusion– Patient with microinvasive disease on
trucut bx– Patients with DCIS diagnosed after OT
• Mean age: 54.4 years old
![Page 11: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/11.jpg)
Presentation
Presentations No. %
Mammographic abnormality
113 66%
Breast lump 48 29%
Nipple discharge 9 5%
![Page 12: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/12.jpg)
Operation
Operation No. %
Mastectomy 122 72%
Mastectomy + immediate reconstruction
5 3%
Breast conservating treatment
43 25%
![Page 13: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/13.jpg)
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
![Page 14: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/14.jpg)
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
![Page 15: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/15.jpg)
Results
• SLNBx was successful in 162 (95%) of patients
• 5 patients (3%) had +ve SLN on frozen section intraoperatively– Axillary dissection was carried out
![Page 16: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/16.jpg)
Results
• 12 patients (7%) had false –ve FS– Axillary dissection was carried out in 6 of
them
![Page 17: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/17.jpg)
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%)
![Page 18: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/18.jpg)
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%)
![Page 19: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/19.jpg)
• 11 axillary dissections were done
• Only 3 of them were +ve in AD
• Final pathology– invasive ductal carcinoma
Discussion
![Page 20: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/20.jpg)
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%
![Page 21: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/21.jpg)
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%)
![Page 22: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/22.jpg)
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%)
![Page 23: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/23.jpg)
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%)
![Page 24: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/24.jpg)
• 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
![Page 25: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/25.jpg)
• Axillary dissection and intraop frozen section for pure DCIS is unnecessary
Discussion
![Page 26: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/26.jpg)
• For pure DCIS, taking out the SLN would be enough without the need of further axillary dissection
Discussion
![Page 27: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/27.jpg)
• Hypothetically, if no F.S. was done for DCIS– Potentially save
• 162 frozen sections• 3 axillary dissections
Discussion
![Page 28: Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)](https://reader036.vdocuments.site/reader036/viewer/2022062308/56812c22550346895d908950/html5/thumbnails/28.jpg)
Thank you