Ductal Carcinoma In Situ (DCIS) and Axillary Staging

Rodrigo Arrangoiz MS, MD, FACS, FSSO
  • Pure ductal carcinoma in situ (DCIS):
    • Is by definition non-invasive:
      • Thus lacks the ability to metastasize to axillary nodes and distant sites:
      • For this reason, surgical axillary staging is not recommended in the management of most patients with DCIS undergoing breast conserving surgery
  • Approximately 20% of patients with DCIS on core needle biopsy:
    • Will upstage to invasive cancer:
      • And may ultimately require surgical axillary staging
  • Factors associated with upstaging to invasive disease include:
    • A palpable mass at the time of diagnosis
    • Intermediate- or high-grade lesions
    • Comedonecrosis
    • ER negative (-) subtype
    • A large span of disease:
      • Typically cited as > 5cm
  • The location of the lesion (eg. upper outer quadrant):
    • Is not predictive of upgrade or spread to regional / distant sites
  • While some authors cite multifocality as a risk factor for upstaging:
    • It is more predictive of recurrence than upstage
  • One exception to the recommendation of omission of SLNB is:
    • For DCIS patients undergoing mastectomy:
      • First, most patients undergoing mastectomy for DCIS have a larger burden of disease:
        • Therefore have a higher likelihood of upstaging to invasive cancer:
          • For which surgical axillary staging is warranted
      • Second, while axillary mapping and sentinel lymphadenectomy may be feasible after mastectomy (with injection of radiocolloid and / or blue dye into the remaining skin):
        • The accuracy of this strategy has not been fully evaluated and is therefore not the recommended approach
      • However, since the rate of nodal positivity is low in these patients, newer strategies (such as injection of superparamagnetic iron oxide nanoparticles at time of mastectomy as a tracer for delayed sentinel lymph node dissection):
        • Are under investigation and may serve to decrease the number of patients with DCIS undergoing surgical axillary staging
  • References:
  • Due to the non-invasive nature of ductal carcinoma in situ (DCIS):
    • Assessment of the axilla is not indicated regardless of receptor status or grade with pure DCIS in the setting of breast conserving surgery
  • It may be considered if the patient is undergoing a mastectomy or the tumor is located in a position where excision may compromise future performance of a sentinel lymph node biopsy
  • Microinvasive DCIS:
    • Comprises 5% to 10% of all cases of DCIS
    • In a review of the literature, the reported incidence of axillary metastases in microinvasive DCIS:
      • Has ranged from 0% to 28%
    • Axillary staging is appropriate and sentinel node biopsy should be performed in the setting of microinvasive DCIS
  • References
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Published by Rodrigo Arrangoiz MS, MD, FACS, FSSO

My name is Rodrigo Arrangoiz I am a breast surgeon/ thyroid surgeon / parathyroid surgeon / head and neck surgeon / surgical oncologist that works at Center for Advanced Surgical Oncology in Miami, Florida. I was trained as a surgeon at Michigan State University from (2005 to 2010) where I was a chief resident in 2010. My surgical oncology and head and neck training was performed at the Fox Chase Cancer Center in Philadelphia from 2010 to 2012. At the same time I underwent a masters in science (Clinical research for health professionals) at the University of Drexel. Through the International Federation of Head and Neck Societies / Memorial Sloan Kettering Cancer Center I performed a two year head and neck surgery and oncology / endocrine fellowship that ended in 2016. Mi nombre es Rodrigo Arrangoiz, soy cirujano oncólogo / cirujano de tumores de cabeza y cuello / cirujano endocrino que trabaja Center for Advanced Surgical Oncology en Miami, Florida. Fui entrenado como cirujano en Michigan State University (2005 a 2010 ) donde fui jefe de residentes en 2010. Mi formación en oncología quirúrgica y e n tumores de cabeza y cuello se realizó en el Fox Chase Cancer Center en Filadelfia de 2010 a 2012. Al mismo tiempo, me sometí a una maestría en ciencias (investigación clínica para profesionales de la salud) en la Universidad de Drexel. A través de la Federación Internacional de Sociedades de Cabeza y Cuello / Memorial Sloan Kettering Cancer Center realicé una sub especialidad en cirugía de cabeza y cuello / cirugia endocrina de dos años que terminó en 2016.

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