1. Dr Cheung Chi Ying Genevieve
Frozen Section of Sentinel lymph node for Ductal Carcinoma in Situ (DCIS)
Dr Cheung Chi Ying Genevieve

2. Introduction 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
Cox CE, Ann Surg. 1998

3. SLNBx in DCIS
Increasing interest of SLNBx in other applications in breast surgery
DCIS
DCIS is the precursor of invasive cancer

4. Van Steenbergen LN et al, breast cancer rest treat. 2009
Incidence of DCIS is increasing in the screening era
From 3/ to 34/ in y.o.
Prognosis of pure DCIS is excellent
5 years survival >95%
Van Steenbergen LN et al, breast cancer rest treat. 2009

5. WK Hung et al, Breast cancer 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
Lymph node metastasis do occur
3-13%
Associated with missed invasive cancer in most cases 5

6. 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
Lymph node metastasis do occur
3-13%
Associated with missed invasive cancer in most cases 6

7. 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 D’Eredita G et al, Tumori. 2009

8. KWH experience in SLNBx 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

9. Patients Retrospective study Period: 3/2002 till 6/2010
Total number of patients: 170
Inclusion
Preop trucut Biopsy: DCIS

10. Patients Exclusion Mean age: 54.4 years old
Patient with microinvasive disease on trucut bx
Patients with DCIS diagnosed after OT
Mean age: 54.4 years old

11. Presentation Presentations No. % Mammographic abnormality 113 66%
Breast lump 48
29%
Nipple discharge 9 5%

12. Operation Operation No. % Mastectomy
122
72%
Mastectomy + immediate reconstruction 5 3%
Breast conservating treatment 43
25%

13. 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
Pre-op scintigraphy with 99m Tc Sulfur colloid, sub-dermal injection over tumour
Localization with intra-op hand-held gamma probe
Intra-op sub-dermal injection of Patent Blue
SLN, and any enlarged, non-SLN excised for frozen section examination

14. 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
Pre-op scintigraphy with 99m Tc Sulfur colloid, sub-dermal injection over tumour
Localization with intra-op hand-held gamma probe
Intra-op sub-dermal injection of Patent Blue
SLN, and any enlarged, non-SLN excised for frozen section examination 14

15. Results SLNBx was successful in 162 (95%) of patients
5 patients (3%) had +ve SLN on frozen section intraoperatively
Axillary dissection was carried out
Final pathology
3 of them had SLN as the only +ve LN ( 2 DCIS and 1 CA)
2 of them had LN +ve in axillary dissection (2/9 LN and 7/9 LN)
Final pathology of these 2 were invasive ductal CA

16. Results 12 patients (7%) had false –ve FS
Axillary dissection was carried out in 6 of them
Final pathology
1 DCIS, AD –ve
5 CA, AD –ve x 4, 3/12 LN x 1
No AD group
DCIS x 3
CA x 3

17. Pre-op core biopsy : DCIS 170
SLN Failed 8 (5%)
SLN Successful 162 (95%)
F.S. +ve 5 (3%)
F.S. –ve 157 (92%)
True –ve 145 (85%)
False –ve 12 (7%)
3 A.D. –ve(2%) 2 A.D. +ve(1%)
SLN failed
All are DCIS
3 have AD, all -ve
A.D. 6(3.5%)
No A.D. 6 (3.5%)

18. Pre-op core biopsy : DCIS 170
SLN Failed 8 (5%)
SLN Successful 162 (95%)
F.S. +ve 5 (3%)
F.S. –ve 157 (92%)
True –ve 145 (85%)
False –ve 12 (7%)
3 A.D. –ve(2%) 2 A.D. +ve(1%)
A.D. 6(3.5%)
No A.D. 6 (3.5%)

19. Discussion 11 axillary dissections were done
Only 3 of them were +ve in AD
Final pathology
invasive ductal carcinoma
AD: 7/9 LN +ve, 2/9 LN +ve, 3/12 LN +ve

20. 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%
AD: 7/9 LN +ve, 2/9 LN +ve, 3/12 LN +ve

21. SLN Successful 162 (95%)
SLN for P.S.
Positive 17 (10%)
Negative 145 (85%)
No A.D. 6 (4%)
A.D (6%)
DCIS 3 (2%)
Invasive ductal CA 8 (5%)
All AD -ve
AD –ve 5 (3%) AD +ve 3 (2%)

22. SLN Successful 162 (95%) SLN for P.S. Positive 17 (10%)
Negative 145 (85%)
No A.D. 6 (4%)
A.D (6%)
DCIS 3 (2%)
For pure DCIS, no further treatment needed even if we didn’t send any F.S, as all AD was negative
Invasive ductal CA 8 (5%)
All AD -ve
AD –ve 5 (3%) AD +ve 3 (2%)

23. SLN Successful 162 (95%) SLN for P.S. Positive 17 (10%)
Negative 145 (85%)
No A.D. 6 (4%)
A.D (6%)
DCIS 3 (2%)
For invasive ductal CA group, only 3 had +ve LN in AD, and we can always do it as a second operation
Invasive ductal CA 8 (5%)
All AD -ve
AD –ve 5 (3%) AD +ve 3 (2%)

24. Discussion 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

25. Discussion
Axillary dissection and intraop frozen section for pure DCIS is unnecessary

26. Discussion
For pure DCIS, taking out the SLN would be enough without the need of further axillary dissection

27. Discussion Hypothetically, if no F.S. was done for DCIS
Potentially save
162 frozen sections
3 axillary dissections

28. Thank you