What are the Sedlis criteria for evaluating suitability of breast-conserving surgery in patients with ductal carcinoma in situ (DCIS)?

Sedlis Criteria for DCIS Breast-Conserving Surgery

For patients with ductal carcinoma in situ (DCIS), the Sedlis criteria do not exist specifically for DCIS - they are actually criteria used for invasive breast cancer to determine the need for post-mastectomy radiation therapy. 1 The confusion arises because there are specific guidelines for determining suitability for breast-conserving surgery in DCIS patients, but these are not called "Sedlis criteria."

Actual Criteria for DCIS Breast-Conserving Surgery Suitability

Patient Selection Criteria

The following criteria determine if a patient with DCIS is suitable for breast-conserving surgery:

1. Extent of Disease:

   • DCIS should be localized without evidence of gross multicentricity or diffuse malignant calcifications 1
   • The extent of DCIS should be ≤4 cm, as there is limited data supporting breast conservation for larger lesions 1

2. Margin Status:

   • Negative margins are essential to minimize ipsilateral breast tumor recurrence 1
   • A 2 mm margin width is the standard recommendation for DCIS treated with breast-conserving surgery and whole-breast irradiation 1
   • Wider margins (>2 mm) do not significantly improve outcomes when radiation therapy is used 1

3. Complete Removal of Microcalcifications:

   • For mammographically detected DCIS presenting as microcalcifications, all malignant calcifications must be removed prior to radiation therapy 1
   • Post-excision mammography should confirm complete removal of suspicious calcifications 1

4. Contraindications:

   • Multiple primary tumors in the breast
   • Diffuse malignant-appearing microcalcifications
   • Persistent positive margins after reasonable surgical attempts 1
   • History of collagen vascular disease (especially scleroderma and lupus)
   • Prior therapeutic radiation to the breast/chest
   • Pregnancy 1

Risk Factors for Compromised Margins and Residual Disease

Several factors predict higher risk of compromised margins and residual disease:

• Pathological size >3 cm (84% risk of residual disease vs. 29% for lesions ≤3 cm) 2
• DCIS-margin distances ≤2 mm (62-64% risk of residual disease vs. 17% for 2-5 mm margins) 2
• Lack of preoperative diagnosis by core biopsy 2
• Multifocal disease (particularly without radiation therapy) 3
• High nuclear grade 1, 4
• Younger age (<40 years) 4

Treatment Recommendations

1. Breast-Conserving Surgery + Radiation Therapy:

   • Standard approach for most DCIS patients 1
   • Radiation therapy reduces ipsilateral breast tumor recurrence rates by 50-70% 1
   • Particularly important for patients with multifocal disease, as radiation eliminates the detrimental effect of multifocality on recurrence 3

2. Breast-Conserving Surgery Alone:

   • May be considered for small, low-grade lesions with clear margins 1
   • However, even in these selected cases, radiation therapy still provides benefit 1

3. Mastectomy:

   • Indicated when lesions are so large or diffuse that complete removal would cause unacceptable cosmesis
   • Appropriate for persistent positive margins, especially with high-grade lesions 1

Important Considerations

• Age Impact: Younger patients (<40 years) have significantly higher recurrence rates (47.2% at 6 years) compared to patients 40-69 years (14.0%) and ≥70 years (10.8%) 4

• Multifocality: While multifocality increases recurrence risk with surgery alone (59% vs. 80% 10-year recurrence-free survival), this difference disappears with radiation therapy (80% vs. 87%) 3

• Margin Width: For DCIS with microinvasion (no invasive focus >1 mm), the same margin recommendations apply as for pure DCIS 1

• Upstaging Risk: Approximately 25.9% of DCIS diagnosed on core needle biopsy will be upstaged to invasive cancer at surgical excision 1

Proper patient selection and careful attention to margin status are critical for successful breast-conserving therapy in DCIS. Radiation therapy significantly reduces recurrence risk and should be strongly considered for most patients undergoing breast-conserving surgery.