Axillary staging in ductal carcinoma in situ with microinvasion: A meta-analysis.

INTRODUCTION: Ductal carcinoma in situ with microinvasion (DCISM); arguably a more aggressive subtype of DCIS, currently has variable recommendations governing its staging and management in the UK. As a result, there is ongoing controversy surrounding the most appropriate management of DCISM, in particular the need of axillary staging. METHOD: A search was conducted on the databases MEDLINE and Embase using the keywords: breast, DCISM, microinvasion, "ductal carcinoma in situ with microinvasion", sentinel lymph node biopsy, SLNB, axillary staging was performed. 23 studies were selected for analysis. Primary outcome was the positivity of metastasis of lymph node; secondary outcome looked at characteristics of DCISM that may affect node positivity. RESULTS: A total of 2959 patients were included. Significant heterogeneity was observed amongst the studies with regards to metastases (I2 = 61%; P < 0.01). Lymph node macrometastases was estimated to be 2%. Significant subgroup difference was not observed between SLNB technique and lymph node macrometastases (Q = 0.74; p = 0.69). Statistical significance was observed between the focality of the DCISM and lymph node macrometastases (Q = 8.71; p = 0.033). CONCLUSION: Although histologically more advanced than DCIS, DCISM is not linked with higher rates of clinically significant metastasis to axillary lymph nodes. Survival rates are very similar to those seen in cases of DCIS. Current evidence suggests that axillary staging in cases of DCISM will not change their overall management, thus may only be an unnecessary and inconvenient additional intervention considering the majority of DCISM diagnoses are made from post-operative pathology samples. A multidisciplinary team approach evaluating pre-operative clinical and histological information to tailor the management specific to individual cases of DCISM would be a preferred approach than routine axillary staging.

A rare cause of abdominal pain.

Pacemaker migration is a rare, but important, complication of pacemaker insertion mainly documented in children. We report the case of a 60-year-old woman who was admitted with right iliac fossa pain thought to be caused by appendicitis. She was noted to have both an epicardial and endocardial pacemaker in situ. Imaging and laparoscopy revealed migration of the epicardial pacemaker to the right iliac fossa. We describe the possible mechanisms of pacemaker migration.