An Immunohistochemistry-based Decision Flowchart to De-escalate Axillary Surgery for Biopsy-Diagnosed Pure…

Cohort studyModern pathology : an official journal of the United States and Canadian Academy of Pathology, Inc· Jul 2026

An Immunohistochemistry-based Decision Flowchart to De-escalate Axillary Surgery for Biopsy-Diagnosed Pure Ductal Carcinoma In Situ (DCIS) of the Breast.

Julia A M Riggi, Christine Galant, Caroline Bouzin … Mieke R Van Bockstal

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Breast & Gynecologic PathologyCohort studyTreatmentQ1IF 6.6

Model identified 55% of ductal carcinoma in situ patients as low-risk for upstaging.

An Immunohistochemistry-based Decision Flowchart to De-escalate Axillary Surgery for Biopsy-Diagnosed Pure Ductal Carcinoma In Situ (DCIS) of the Breast.

Julia A M Riggi … Mieke R Van Bockstal

Modern pathology · Jul 2026 · Q1 in Pathology

Background

The treatment of ductal carcinoma in situ (ductal carcinoma in situ) of the breast and invasive breast carcinoma (invasive breast carcinoma) is considerably similar, despite their different biology.

Purpose

We aimed to identify markers to predict the upstaging risk after a biopsy-diagnosis of pure ductal carcinoma in situ, and to provide data to justify de-escalation of axillary surgery for ductal carcinoma in situ patients.

Methods

Axillary surgery is increasingly de-escalated by omitting sentinel lymph node biopsies (sentinel lymph node biopsies) for hormone receptor-positive, HER2-negative (HER2-) early-stage IBCs, supported by recent clinical trial data.

n = 32 patients

Results

55% of these patients could potentially skip sentinel lymph node biopsy safely.

Model 1

17%

Model 2

55%

More results

Solid architecture (p=0.001) and radiological size (>20 mm) (p=0.025) were independently associated with upstaging risk.

Two algorithms were created, based on surgery type, estrogen receptor/HER2 status, and upstaging risk.

More results

Each model identified a single patient with upstaging to estrogen receptor+/HER2- invasive breast carcinoma, without positive sentinel lymph node biopsies.

Both models show that sentinel lymph node biopsies may be safely omitted in low-risk estrogen receptor+/HER2- ductal carcinoma in situ, even when treated with mastectomy.

“

Conclusion

Routine implementation of this decision flowchart requires retrospective validation before moving to prospective clinical trials but could substantially de-escalate axillary surgery for future ductal carcinoma in situ patients.

An Immunohistochemistry-based Decision Flowchart to De-escalate Axillary Surgery for Biopsy-Diagnosed Pure Ductal Carcinoma In Situ (DCIS) of the Breast.

An Immunohistochemistry-based Decision Flowchart to De-escalate Axillary Surgery for Biopsy-Diagnosed Pure Ductal Carcinoma In Situ (DCIS) of the Breast.

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