Surgical Nodal Staging for Ductal Carcinoma In Situ: When to Omit, When to Delay, and What Comes Next?

Abstract Purpose of Review Sentinel lymph node biopsy (SLNB) remains controversial in ductal carcinoma in situ (DCIS) management. Although pure DCIS lacks metastatic potential, SLNB is frequently performed during surgical resection of DCIS for concern of occult invasive disease. This review examines current evidence regarding SLNB omission, when it remains appropriate, and emerging strategies to further de-escalate axillary surgery for DCIS. Recent Findings Contemporary studies demonstrate low rates of nodal metastases with DCIS, even among patients undergoing mastectomy despite pathologic upstaging to invasive disease. These findings highlight that risk of invasion does not equate to risk of clinically meaningful nodal disease. Delayed SLNB using superparamagnetic iron oxide (SPIO) tracers offers a potential approach to preserve accurate nodal mapping while avoiding unnecessary upfront axillary surgery. Summary SLNB should be omitted during breast-conserving surgery for DCIS and selectively considered for mastectomy. Risk-adapted and delayed staging strategies may further reduce axillary overtreatment in DCIS.