Factors affecting failed localisation and false-negative rates of sentinel node biopsy in breast cancer--results of the ALMANAC validation phase

Transferring innovative freehand SPECT to the operating room: first experiences with sentinel lymph node biopsy in malignant melanoma

PURPOSE

The purpose of this study was to report on the first experiences with freehand single-photon emission-computed tomography (freehand SPECT) in sentinel lymph node biopsy (SLNB) in patients with malignant melanoma. Freehand SPECT is a novel imaging modality combining gamma probes, surgical navigation systems, and emission tomography algorithms, designed to overcome some of the limitations of conventional gamma probes.

METHODS

In this study 20 patients with malignant melanoma underwent conventional planar scintigraphy prior to surgery. In the operating room, the number and location of separable SLNs were detected first by a pre-incisional scan with freehand SPECT to render a 3D-image of the target site and afterwards by a scan with a conventional gamma probe. After SLNB another scan was performed to document the removal of all targeted SLNs.

RESULTS

Planar scintigraphy identified 40 SLNs in 26 nodal basins. Pre-incisional freehand SPECT mapped 38 of these nodes as well as one additional node in one patient (95.0% node based sensitivity). The results of freehand SPECT were identical to those of planar scintigraphy in 25 basins, while it missed one basin (96.2% basin based sensitivity). In comparison, the gamma probe failed to detect 7 nodes in 4 basins (82.5% node based sensitivity and 84.6% basin based sensitivity). After resection freehand SPECT detected 9 remaining radioactive spots, two of whichwere resected as they matched the position of SLNs detected on preoperative planar scintigraphy.

CONCLUSIONS

Freehand SPECT provides a real-time, intraoperative 3D-image of the radioactive labelled SLNs, facilitating their detection and resection.

Is sentinel lymph node dissection an appropriate standard of care for low-stage endometrial cancers? A review of the literature

BACKGROUND/AIMS

To review the literature and compare detection rates, false negative (FN) rates, and negative predictive values (NPVs) of sentinel lymph node (SLN) biopsy in endometrial cancer to those in breast and vulvar cancer. Secondary objectives were to evaluate techniques of SLN biopsy in endometrial cancer.

METHODS

The PubMed database was searched for applicable scientific articles. Detection rates, FN rates, and NPVs were calculated for all studies. Studies were stratified by techniques and compared.

RESULTS

Nineteen articles met criteria for this review. The overall detection rates ranged from 62 to 100%, the FN rate ranged from 0 to 50%, and the NPVs ranged from 95 to 100%. There is no technique that is definitively superior to any other with regard to surgical modality, injectant used, injection site, or pathologic techniques.

CONCLUSIONS

Studies on SLN biopsy in endometrial cancer have a large range of detection rates and FN rates, and larger studies including more patients with metastatic disease are needed for comparison with breast and vulvar cancers. While no techniques are definitively superior to others, minimally invasive surgery, cervical injection, and pathologic analysis utilizing HE staining, immunohistochemistry, and ultrastaging may be clinically advantageous.

Clinical trial of combined radio- and fluorescence-guided sentinel lymph node biopsy in breast cancer

BACKGROUND

Combining radioactive colloids and a near-infrared (NIR) fluorophore permits preoperative planning and intraoperative localization of deeply located sentinel lymph nodes (SLNs) with direct optical guidance by a single lymphatic tracer. The aim of this clinical trial was to evaluate and optimize a hybrid NIR fluorescence and radioactive tracer for SLN detection in patients with breast cancer.

METHODS

Patients with breast cancer undergoing SLN biopsy were enrolled. The day before surgery, a periareolar injection of indocyanine green (ICG)-99mTc-radiolabelled nanocolloid was administered and a lymphoscintigram acquired. Blue dye was injected immediately before surgery. Intraoperative SLN localization was performed using a γ probe and the Mini-FLARE™ NIR fluorescence imaging system. Patients were divided into two dose groups, with one group receiving twice the particle density of ICG and nanocolloid, but the same dose of radioactive 99mTc.

RESULTS

Thirty-two patients were enrolled in the trial. At least one SLN was identified before and during operation. All 48 axillary SLNs could be detected by γ tracing and NIR fluorescence imaging, but only 42 of them stained blue. NIR fluorescence imaging permitted detection of lymphatic vessels draining to the SLN up to 29 h after injection. Doubling the particle density did not yield a difference in fluorescence intensity (median 255 (range 98-542) versus 284 (90-921) arbitrary units; P = 0.590) or signal-to-background ratio (median 5·4 (range 3·0-15·4) versus 4·9 (3·5-16·3); P = 1·000) of the SLN.

CONCLUSION

The hybrid NIR fluorescence and radioactive tracer permitted accurate preoperative and intraoperative detection of the SLNs in patients with breast cancer.

REGISTRATION NUMBER

NTR3685 (Netherlands Trial Register; http://www.trialregister.nl).

[Evaluation of the efficacy of sentinel node detection in breast cancer: chronological course and influence of the incorporation of an intra-operative portable gamma camera]

AIM

To define the sentinel node identification rate in breast cancer, the chronological evolution of this parameter and the influence of the introduction of a portable gamma camera.

MATERIAL AND METHODS

A retrospective study was conducted using a prospective database of 754 patients who had undergone a sentinel lymph node biopsy between January 2003 and December 2011. The technique was mixed in the starting period and subsequently was performed with radiotracer intra-peritumorally administered the day before of the surgery. Until October 2009, excision of the sentinel node was guided by a probe. After that date, a portable gamma camera was introduced for intrasurgical detection.

RESULTS

The SN was biopsied in 725 out of the 754 patients studied. The resulting technique global effectiveness was 96.2%. In accordance with the year of the surgical intervention, the identification percentage was 93.5% in 2003, 88.7% in 2004, 94.3% in 2005, 95.7% in 2006, 93.3% in 2007, 98.8% in 2008, 97.1% in 2009 and 99.1% in 2010 and 2011. There was a significant difference in the proportion of identification before and after the incorporation of the portable gamma camera of 4.6% (95% CI of the difference 2-7.2%, P = 0.0037).

CONCLUSIONS

The percentage of global identification exceeds the recommended level following the current guidelines. Chronologically, the improvement for this parameter during the study period has been observed. These data suggest that the incorporation of a portable gamma camera had an important role.

Diagnostic imaging in obesity

Magnetic resonance of the body offers different techniques for mapping fat deposits (MR Imaging) and analysis of organs with small amounts of lipids (MR Spectroscopy). Possible approaches for whole-body assessment of adipose tissue are presented and discussed and spectroscopic examinations in different organs are depicted. With magnetic resonance imaging (MRI) it has been shown that obesity per se is not a marker for metabolic failure, but depends on regional variations of body composition and ectopic lipid accumulation. In addition MRI of the brain is a powerful research tool to understand the brain's role in the development and maintenance of obesity and the overconsumption of foods in obese individuals. Sonography has a low accuracy in estimating hepatic steatosis until now. New sonographic methods have been evaluated to detect hepatic steatosis by physical properties of fatty tissue as tissue stiffness, sound absorption or sound speed. Nuclear medicine and in particular Positron Emission Tomography (PET) methods are used to explore central pathophysiology, brown adipose tissue activity and alterations in homeostatic feedback and gut-brain communication.

Comparison of the sentinel node procedure between patients with multifocal and unifocal breast cancer in the EORTC 10981-22023 AMAROS Trial: identification rate and nodal outcome

INTRODUCTION

Multifocal breast cancer is associated with a higher risk of nodal involvement compared to unifocal breast cancer and the drainage pattern from multifocal localisations may be different. For this reason, the value of the sentinel node biopsy (SNB) procedure for this indication is debated. The aim of the current analysis was to evaluate the sentinel node identification rate and nodal involvement in patients with a multifocal tumour in the EORTC 10981-22023 AMAROS trial.

PATIENTS AND METHODS

From the first 4000 registered patients, 342 were identified with a multifocal tumour on histological examination and compared to a randomly selected control group of 684 patients with a unifocal tumour. The outcome of the SNB was assessed.

RESULTS

The sentinel node was identified in 96% of the patients with a multifocal tumour and in 98% of those with unifocal disease. In the multifocal group, 51% had a metastasis in the sentinel node compared to 28% in the unifocal group; and further nodal involvement after a positive sentinel node was found in 40% (38/95) and 39% (39/101) respectively.

CONCLUSION

In this prospective international multicentre study, the 96% detection rate indicates that the SNB procedure can be highly effective in patients with a multifocal tumour. Though the tumour-positive rate of the sentinel node was twice as high in the multifocal group compared to the unifocal group, further nodal involvement after a positive sentinel node was similar in both groups. This suggests that the SNB procedure is safe in patients with multifocal breast cancer.

Preoperative lymphoscintigraphy and tumor histologic grade are associated with surgical detection of the sentinel lymph node

OBJECTIVE

To study which variables involved in the process of selective sentinel node biopsy (SSNB) influence the intraoperative detection of the sentinel lymph node.

MATERIAL AND METHODS

This was a prospective cross-sectional study in 210 patients (mean age, 54 years) diagnosed with breast cancer who underwent SSNB. We recorded clinical, radiological, radioisotope administration, surgical, and histological data as well as follow-up data. We did a descriptive analysis of the data and an associative analysis using multivariable regression.

RESULTS

Deep injection alone was the most common route of radioisotope administration (72.7%). Most lesions were palpable (57.1%), presented as nodules (67.1%), measured less than 2 cm in diameter (64.8%), were located in the upper outer quadrant (49.1%), were ductal carcinomas (85.7%), were accompanied by infiltration (66.2%), and had a histologic grade of differentiation of ii (44.8%). Preoperative scintigraphy detected the sentinel node in 97.6% of cases and 95.7% were detected during the operation. One axillary relapse was observed. In the associative study, the variables "preoperative lymphoscintigraphy" and "histologic grade of differentiation of the tumor" were significantly associated with the detection of the sentinel lymph node during the operation.

CONCLUSION

The probability of not detecting the sentinel lymph node during the surgical intervention is higher in patients with high histologic grade tumors or in patients in whom preoperative lymphoscintigraphy failed to detect the sentinel node.

Molecular mechanisms and imaging of lymphatic metastasis

In many types of cancer, tumors metastasize through the lymphatic system to draining lymph nodes. These sentinel lymph nodes have gained increased attention as a prognostic indicator for the severity of the disease, leading to the sentinel lymph node mapping and biopsy procedure to be accepted as standard-of-care for breast cancer and melanoma. However, many limitations exist with this procedure resulting in high false negative rates. In this review we highlight the new advances in the understanding of the molecular mechanisms of lymphangiogenesis and tumor metastasis that may lead to improved strategies in the detection of the sentinel lymph nodes and therapeutic interventions to prevent further tumor spread. In addition, advances in imaging technology are allowing new approaches for anatomical mapping of lymphatic drainage patterns and molecular imaging strategies that may improve detection of metastatic tumor cells within sentinel lymph nodes.

Causes of false-negative sentinel node biopsy in patients with breast cancer

Background

Sentinel lymph node (SLN) biopsy has replaced axillary lymph node dissection as the routine staging procedure in clinically node-negative breast cancer. False-negative SLN biopsy results in misclassification and may cause undertreatment of the disease. The aim of this study was to investigate whether serial sectioning of SLNs reveals metastases more frequently in patients with false-negative SLNs than in patients with true-negative SLNs.

Methods

This was a case–control study. Tissue blocks from patients with false-negative SLNs, defined as tumour-positive lymph nodes excised at completion axillary dissection or a subsequent axillary tumour recurrence, were reassessed by serial sectioning and immunohistochemical staining. For each false-negative node, two true-negative SLN biopsies were analysed. Tumour and node characteristics in patients with false-negative SLNs were compared with those in patients with a positive SLN by univariable and multivariable regression analysis.

Results

Undiagnosed SLN metastases were discovered in nine (18 per cent) of 50 patients in the false-negative group and in 12 (11.2 per cent) of 107 patients in the true-negative group (P = 0.245). The metastases were represented by isolated tumour cells in 14 of these 21 patients. The risk of a false-negative SLN was higher in patients with hormone receptor-negative (odds ratio (OR) 2.50, 95 per cent confidence interval 1.17 to 5.33) or multifocal tumours (OR 3.39, 1.71 to 6.71), or if only one SLN was identified (OR 3.57, 1.98 to 6.45).

Conclusion

SLN serial sectioning contributes to a higher rate of detection of SLN metastasis. The rate of upstaging of the tumour is similar in false- and true-negative groups of patients.

Results of a national training programme in sentinel lymph node biopsy for breast cancer

BACKGROUND

New Start, a structured, validated, multidisciplinary training programme in sentinel lymph node biopsy (SLNB), was established to allow the introduction and rapid transfer of appropriate knowledge and technical skills to ensure safe and competent practice across the UK.

METHODS

Multidisciplinary teams attended a theory/skills laboratory course, following which they performed 30 consecutive SLNBs, either concurrently with their standard axillary staging procedure (training model A) or as stand-alone SLNB (training model B). SLNB was performed according to a standard protocol using the combined technique of isotope ((99m) Tc-labelled albumin colloid) and blue dye. An accredited New Start trainer mentored the first five procedures in the participant's hospital, or all 30 if stand-alone. Validation standards for model A and B were a localization rate of at least 90 per cent. In addition, for model A only, in which a minimum of ten patients were required to be node-positive, a false-negative rate (FNR) of 10 per cent or less was required.

RESULTS

From October 2004 to December 2008, 210 SLNB-naive surgeons, in 103 centres, performed 6685 SLNB procedures. The overall sentinel lymph node (SLN) localization rate was 98·9 (95 per cent confidence interval 98·6 to 99·1) per cent (6610 of 6685) and the FNR 9·1 (7·9 to 10·5) per cent (160 of 1757). The FNR was related to nodal yield, ranging from 14·8 per cent for one node and declining to 9·7, 6·6, 4·7 and 4·1 per cent for two, three, four and more than four SLNs respectively. No learning curve was identified for localization or FNR.

CONCLUSION

The programme successfully trained a wide range of UK breast teams to perform safe SLNB and suggested that a standard injection protocol and structured multidisciplinary training can abolish learning curves.

Value of sentinel lymph node biopsy in breast cancer surgery with simple pathology facilities--an Iranian local experience with a review of potential causes of false negative results

INTRODUCTION

Sentinel lymph node biopsy (SLNB) is a precise procedure for lymphatic staging in early breast cancer. In a valid SLNB procedure, axillary lymph node dissection (ALND) can be omitted in node- negative cases without compromising patient safety. In this study, detection rate, accuracy and false negative rate of SLNB for breast cancer was evaluated in a setting with simple modified conventional pathology facilities without any serial sectioning or immunohistochemistry.

MATERIAL AND METHOD

Patients with confirmed breast cancer were enrolled in the study. SLNB and ALND were performed in all cases. Lymph node metastasis was evaluated in SLN and in nodes removed by ALND to determine the false negative rate. Pathologic assessment was carried out only by modified conventional technique with only 3 sections. Detection rate was determined either by lymphoscintigraphy or during surgery.

RESULTS

78 patients with 79 breast units were evaluated. SLN was detected in 75 of 79 cases (95%) in lymphoscintigraphy and 76 of 79 cases (96%) during surgery. SLN metastases was detected in 30 of 75 (40%) cases either in SLNB and ALND groups. Accuracy of SLNB method for detecting LN metastases was 92%. False negative rate was 3 of 30 of positive cases: 10%. In 7 of 10 cases with axillary lymphadenopathy, LN metastastates was detected.

CONCLUSION

SLNB is recommended for patients with various tumor sizes without palpable lymph nodes. In modified conventional pathologic examination of SLNs, at least macrometastases and some micrometastases could be detected similar to ALND. Consequently, ALND could be omitted in node-negative cases with removal of all palpable LNs. We conclude that SLNB, as one of the most important developments in breast cancer surgery, could be expanded even in areas without sophisticated pathology facilities.

Use of indocyanine green for detecting the sentinel lymph node in breast cancer patients: from preclinical evaluation to clinical validation

Assessment of the sentinel lymph node (SLN) in patients with early stage breast cancer is vital in selecting the appropriate surgical approach. However, the existing methods, including methylene blue and nuclides, possess low efficiency and effectiveness in mapping SLNs, and to a certain extent exert side effects during application. Indocyanine green (ICG), as a fluorescent dye, has been proved reliable usage in SLN detection by several other groups. In this paper, we introduce a novel surgical navigation system to detect SLN with ICG. This system contains two charge-coupled devices (CCD) to simultaneously capture real-time color and fluorescent video images through two different bands. During surgery, surgeons only need to follow the fluorescence display. In addition, the system saves data automatically during surgery enabling surgeons to find the registration point easily according to image recognition algorithms. To test our system, 5 mice and 10 rabbits were used for the preclinical setting and 22 breast cancer patients were utilized for the clinical evaluation in our experiments. The detection rate was 100% and an average of 2.7 SLNs was found in 22 patients. Our results show that the usage of our surgical navigation system with ICG to detect SLNs in breast cancer patients is technically feasible.

Hypersensitivity reactions to Patent Blue V in breast cancer surgery: a prospective multicentre study

BACKGROUND

An increasing number of immediate hypersensitivity reactions (HSR) have been reported after the use of Patent Blue V (PBV) for breast cancer surgery. This is the first study to publish prospective data with systematic allergological assessment.

METHODS

We conducted a multicentre study in 10 French cancer centres for over 6 months. All patients scheduled for breast surgery with injection of PBV were included in the study. Patients were screened for past medical history, atopy, and known food and drug allergies. When suspected HSR or unexplained reactions occurred after injection of PBV, blood samples were taken, and plasma histamine and serum tryptase concentrations were measured. HSR to PBV was suggested if skin tests performed 6 weeks later were positive.

RESULTS

Nine suspected HSR to PBV were observed in 1742 patients. Skin tests were positive in six patients, giving an incidence of 0.34%. Four grade I and two grade III HSR were observed, both requiring intensive care unit treatment. Mean onset time of the reaction was 55 ± 37 min. Plasma histamine was elevated in four patients, while serum tryptase was normal. We found no risk factors associated with HSR to PBV.

CONCLUSION

An incidence rate of one in 300 HSR to PBV was observed for patients exposed to PBV during sentinel lymph node detection. This rate is higher than rates reported after the use of neuromuscular blocking agents, latex or antibiotics.

Sentinel node biopsy for breast cancer: past, present, and future

Sentinel node biopsy has replaced axillary lymph node dissection as the standard of care in early breast cancers. Sentinel node biopsy represents a highly accurate and less-morbid axillary staging, which allows most patients to avoid unnecessary axillary lymph node dissection and its morbidity. This review provides information including several issues which are still under debate, such as clinical significance of micrometastases, avoidance of axillary lymph node dissection for patients with positive sentinel nodes, accuracy and timing of sentinel node biopsy in patients undergoing neoadjuvant chemotherapy, and how many sentinel nodes are sufficient for removal. Finally, a new topic is introduced: superparamagnetic iron oxide (SPIO)-enhanced magnetic resonance (MR) imaging for the detection of metastases in sentinel nodes localized by computed tomography (CT)-lymphography (CT-LG) in patients with breast cancer. SPIO-enhanced MR imaging is a useful method of detecting metastases in sentinel nodes localized by CT-LG in patients with breast cancer. Patients with clinically negative nodes may be spared even sentinel node biopsy when the sentinel node is diagnosed as disease free using SPIO-enhanced MR imaging.

A novel finding of sentinel lymphatic channels in early stage breast cancer patients: which may influence detection rate and false-negative rate of sentinel lymph node biopsy

Background

The exact lymphatic drainage pattern of the breast hasn't been explained clearly. The aim of this study was to investigate the sentinel lymphatic channels (SLCs) in the cancerous breast. Whether the type of SLCs influenced the detection rate and false-negative rate of SLNB was also assessed.

Methodology and Principal Findings

Mimic SLNB was performed in 110 early-stage breast cancer patients with subareolar injection of blue methylene dye intraoperatively. Postoperatively, 110 specimens of modified radical mastectomy were examined for all blue SLCs after additional injection of methylene dye in peritumoral parenchyma. Interestingly, three types of SLCs, including superficial sentinel lymphatic channel (SSLC), deep sentinel lymphatic channel (DSLC), and penetrating sentinel lymphatic channel (PSLC) were found in 107 patients. Six lymphatic drainage patterns based on the three types of SLCs were observed in these 107 patients. The proportions of the drainage pattern SSLC, DSLC, PSLC, SSLC+DSLC, SSLC+PSLC, and DSLC+PSLC in the breast were 43%, 0.9%, 15.9%, 33.6%, 3.7% and 2.8%, respectively. The lymphatic drainage pattern in the breast was a significant risk factor for unsuccessful identification of sentinel lymph nodes (P<0.001) and false-negatives in SLNB (P = 0.034) with the subareolar injection technique.

Conclusions

Three kinds of SLCs are the basis of six lymphatic drainage patterns from the breast to the axilla. The type of SLCs is the factor influencing the detection rate and false-negative rate of SLNB. These findings suggest the optimal injection technique of the combination of superficial and deep injection in SLNB procedures. Future clinical studies are needed to confirm our novel findings.

Sentinel node mapping for breast cancer: current situation

Axillary node status is a major prognostic factor in early-stage disease. Traditional staging needs levels I and II axillary lymph node dissection. Axillary involvement is found in 10%–30% of patients with T1 (<2 cm) tumours. Sentinel lymph node biopsy is a minimal invasive method of checking the potential nodal involvement. It is based on the assumption of an orderly progression of lymph node invasion by metastatic cells from tumour site. Thus, when sentinel node is free of metastases the remaining nodes are free, too (with a false negative rate lesser than 5%). Moreover, Randomized trials demonstrated a marked reduction of complications associated with the sentinel lymph node biopsy when compared with axillary lymph node dissection. Currently, the sentinel node biopsy procedure is recognized as the standard treatment for stages I and II. In these stages, this approach has a positive node rate similar to those observed after lymphadenectomy, a significant decrease in morbidity and similar nodal relapse rates at 5 years. In this review, the indications and contraindications of the sentinel node biopsy are summarized and the methodological aspects discussed. Finally, the new technologic and histologic developments allow to develop a more accurate and refinate technique that can achieve virtually the identification of 100% of sentinel nodes and reduce the false negative rate.

Who should have or not have an axillary node dissection with breast cancer?

There have been dramatic changes in the approach to the axilla in women with breast cancer over the last 100 years, reflecting the evolution in our understanding of the underlying tumor biology, reduced disease burden because of early detection, and advances in all breast cancer treatment modalities. The approach to the axilla needs to be individualized, much like the extent of surgery for the primary tumor. Axillary dissection remains an important intervention for patients with more locally advanced disease. However, in patients with early-stage breast cancer, in whom regional recurrence is extremely low, the added benefit of an ALND has yet to be confirmed.

Randomized comparison of near-infrared fluorescence imaging using indocyanine green and 99(m) technetium with or without patent blue for the sentinel lymph node procedure in breast cancer patients

Background

Near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) has the potential to improve sentinel lymph node (SLN) mapping of breast cancer. We performed a randomized clinical trial to assess the value of blue dyes when used in combination with NIR fluorescence. We also preliminarily examined the possibility of performing SLN mapping without radiotracers.

Methods

Clinical trial subjects were 24 consecutive breast cancer patients scheduled to undergo SLN biopsy. All patients received standard of care using 99^m technetium-nanocolloid and received 1.6 mL of 500 μM ICG injected periareolarly. Patients were randomly assigned to undergo SLN biopsy with or without patent blue. To assess the need for radiocolloids to localize the SLN or SLNs, the surgeon did not use the handheld gamma probe during the first 15 min after the axillary skin incision.

Results

SLN mapping was successful in 23 of the 24 patients. No significant difference was found in signal-to-background ratio between the groups with and without patent blue (8.3 ± 3.8 vs. 10.3 ± 5.7, respectively, P = 0.32). In both groups, 100 % of SLNs were radioactive and fluorescent, and in the patent blue group, only 84 % of SLNs were stained blue. In 25 % of patients, the use of the gamma probe was necessary to localize the SLN within the first 15 min.

Conclusions

This study shows that there is no benefit of using patent blue for SLN mapping in breast cancer patients when using NIR fluorescence and 99^m technetium-nanocolloid. NIR fluorescence imaging outperformed patent blue in all patients.

[Adjuvant treatments in breast cancer: interest of completion of axillary dissection in case of micrometastases or isolated tumor cells in sentinel lymph node]

Prognostic signification of micrometastases ou isolated tumor cells (ITC) has not yet been clearly precised. Management of the axilla in case of micrometastases or ITC depends on the local pratices: no surgical completion or axillary lymph node dissection (ALND). Axillary lymph node status is the most important prognostic factor in patients with breast cancer; morbidity of ALND is now well known whereas its therapeutic benefit has not been demonstrated. This study is based on a retrospective database of 1375 patients who underwent sentinel node (SN) biopsy for breast cancer. In case of micrometastase or ITC in SN with completion axillary dissection, we examined if non-sentinel lymph node status has changed the indications of adjuvant treatments (chimiotherapy or radiotherapy). The results of our study show that non-sentinel lymph node status modify systemic therapy for a very few patients (less than 4% concerning chimiotherapy and less than 15% concerning radiotherapy).

Analysis of sentinel lymph node biopsy results in colon cancer in regard of the anthropometric features of the population and body composition assessment formulas

Purpose

The aim of the study was to assess sentinel lymph node biopsy (SLNB) results in colon cancer (CC) regarding basic anthropometric features of the studied population and their derivatives calculated using mathematical formulas.

Methods

One hundred three SLNBs in CC have been analysed. Various indicators were calculated for every patient using mathematical formulas: BMI, Roher’s index, lean body weight, body fat percentage and body weight/ideal body weight for a given height ratios using the following formulas: Broca’s, Broca’s ideal weight, Broca–Brugsch, Lorenz’s, Potton’s, Devine’s, Robinson’s, Miller’s and Hamwi. The results were compared with accuracy, sensitivity and false negative results percentage by means of ROC curves and the test for structure indicators (for determined cut-off points).

Results

No statistically significant relationship between the results and patients' sex or age were found. ROC curve analysis did not reveal statistically significant relationships between the obtained results and indicators calculated on the basis of growth and weigh (all p > 0.05). The analyses of sensitivity and accuracy with determined cut-off point, in spite of differences amounting to 19 % (analysis of lean body weight/weight ratio), showed no statistical significance for any of the relationships (all p > 0.05).

Conclusions

No indicator with high diagnostic and prognostic value has been found. The problem of qualifying patients for SLNB in CC in regard of the anthropometric features of the population and body composition assessment formulas remains open and requires further analysis on larger populations.

[Sentinel node procedure and endometrial cancer: senti-endo results]

Based on two randomized trials and a meta-analysis, the recommendations of the National Cancer Institute (INCa) have validated the absence of systematic pelvic lymphadenectomy for patients with endometrial cancer at low risk (type 1 histology stage IA grade 1-2) and intermediate (type 1 histology stage IA grade 3 and IB grade 1-2) but without taking into account the contribution of the sentinel node (SN) procedure. The senti-endo trial assessing the role of the SN procedure in patients with early stages endometrial cancer showed that the detection rate by hemi-pelvis right and left were 77 and 76%, respectively. The detection rate per patient was 89%. Among patients with at least a SN detected, the detection was unilateral in 34 cases (31%) and bilateral in 77 cases (69%). Of the 111 patients with at least a SN detected, 19 had lymph node metastases (17%). Considering the hemi-pelvis right and left as a unit, no false negative case was observed, hence the sensitivity and NPV was 100%. Considering the NPV per patient, three false negative cases were observed. Among the 57 patients at low risk, six (11%) had lymph node metastases on SN with negative non sentinel nodes. Of the 33 patients at intermediate risk, five (15%) had lymph node metastases on SN with negative non sentinel nodes. Senti-endo results emphasize the contribution of the SN procedure to assess the nodal status in patients with low or intermediate risk group raising the issue on new definition of the recommendations of INCa.

Should a sentinel node biopsy be performed in patients with high-risk breast cancer?

A negative sentinel lymph node (SLN) biopsy spares many breast cancer patients the complications associated with lymph node irradiation or additional surgery. However, patients at high risk for nodal involvement based on clinical characteristics may remain at unacceptably high risk of axillary disease even after a negative SLN biopsy result. A Bayesian nomogram was designed to combine the probability of axillary disease prior to nodal biopsy with customized test characteristics for an SLN biopsy and provides the probability of axillary disease despite a negative SLN biopsy. Users may individualize the sensitivity of an SLN biopsy based on factors known to modify the sensitivity of the procedure. This tool may be useful in identifying patients who should have expanded upfront exploration of the axilla or comprehensive axillary irradiation.

Clinical and histopathological factors affecting failed sentinel node localization in axillary staging for breast cancer

BACKGROUND

Sentinel lymph node biopsy (SLNB) has become the standard of care in axillary staging of clinically node-negative breast cancer patients.

AIMS

To analyze reasons for failure of SLN localization by means of a multivariate analysis of clinical and histopathological factors.

METHODS

We performed a review of 164 consecutive breast cancer patients who underwent SLNB. A superficial injection technique was used.

RESULTS

9/164 patients failed to show nodes. In 7/9 patients no evidence of radioactivity or blue dye was observed. Age and nodal status were the only statistically significant factors (p < 0.05). For every unit increase in age there was a 9% reduced chance of failed SLN localization. Patients with negative nodal status have 90% reduced risk of failed sentinel node localization than patients with macro or extra capsular nodal invasion.

DISCUSSION

The results suggest that altered lymphatic dynamics secondary to tumour burden may play a role in failed sentinel node localization. We showed that in all failed localizations the radiocolloid persisted around the injection site, showing limited local diffusion only. While clinical and histopathological data may provide some clues as to why sentinel node localization fails, we further hypothesize that integrity of peri-areolar lymphatics is important for successful localization.

Sentinel lymph node biopsy after previous axillary surgery: A review

BACKGROUND

The utility of axillary lymph node dissection (ALND) in the management of breast cancer is currently under close scrutiny. At primary diagnosis the use of sentinel lymph node biopsy (SLNB) has restricted ALND for proven nodal disease, however the management of the axilla at local (in-breast) relapse is less clearly defined with many undergoing routine ALND. This review examines the role of SLNB in the re-operative setting with the objective of developing an axillary management algorithm for use at in-breast local relapse, and restricting ALND to node-positive recurrent cancers.

METHODS

We reviewed published reports of SLNB at local relapse in women who had previously undergone axillary surgery either as lymph node biopsy, SLNB, axillary sampling (AS) or axillary lymph node dissection (ALND).

RESULTS

There have been no randomised trials. Six reports with 327 cases were identified; of which 61% (199/327) had previous SLNB or ALND with <9 nodes removed. There was an overall successful sentinel lymph node (SLN) localisation at re-operation of 69% (227/327), range of 51-100%. In patients who have previously had limited axillary surgery (<9 nodes removed), the rate of successful SLN localisation was 83% (165/199), range of 68-100% and 142/165 (86%, range 80-100%) were node negative. In these highly selected patients no axillary recurrences were noted in those who had a negative SLN at re-operation after 26-46 months follow up.

CONCLUSION

SLNB at in-breast relapse is feasible and safe with successful localisation related to the extent of previous axillary surgery.

Local and regional control in breast cancer: role of sentinel node biopsy

The development and acceptance of the SLND has profoundly affected the management of breast cancer. SLND has supplanted ALND as a highly accurate and less-morbid axillary staging procedure in patients with clinically node-negative early-stage breast cancer. SLND alone is associated with less than 1% isolated axillary recurrence in patients with node-negative disease and provides excellent regional nodal control. Historically, ALND has been the recommended treatment for patients with SLN metastases. ALND was thought to offer prognostic information, prevent axillary local recurrence, and possibly render a small survival benefit. However, resection of nonsentinel nodes with metastases may not affect survival, and not all axillary metastases progress to become clinically evident. Furthermore, with increased understanding of tumor biology, nodal status and number of involved lymph nodes are no longer the only determinants of systemic therapy. As improved breast cancer screening allows identification of early-stage disease localized to the breast, and because treatment plans are more often made on the basis of tumor biology, the role of completion ALND may be less critical. The low LRR rates seen in the ACOSOG Z0011 trial, several other randomized trials, and retrospective reviews suggest that SLND alone may provide adequate locoregional control and provide adequate information to guide adjuvant systemic therapy in selected women with clinically node-negative early-stage breast cancer.

Factors influencing the time of sentinel node visualization in breast cancer patients using intradermal injection of the radiotracer

BACKGROUND

The objective of our study was to determine the important factors that have influence on the time of sentinel node visualization using intradermal injection of (99m)Tc-antimony sulfide colloid.

METHODS

Two hundred fifty consecutive patients with the diagnosis of early-stage breast cancer were evaluated. Anterior and lateral views were acquired in various intervals after intradermal injection of the tracer until 180 minutes or visualization of the sentinel node. The effect of several variables on the time of sentinel node visualization was evaluated by univariate and multivariate analyses.

RESULTS

The time of sentinel node visualization was significantly correlated with age, body mass index (BMI), and interval between biopsy and sentinel node mapping. Standardized beta values for these variables were .1, .3, -.55 respectively.

CONCLUSIONS

Older age and higher BMI can result in slow sentinel node visualization. Longer interval between biopsy and sentinel node mapping can be associated with rapid sentinel node detection.

Sentinel lymph node micrometastasis in human breast cancer: an update

INTRODUCTION

The advent of sentinel lymph node biopsy (SLNB) and advances in histopathological and molecular analysis techniques have been associated with an increase in micrometastasis (MM) detection rate. However, the clinical significance of sentinel lymph node micrometastasis (SLN MM) continues to be a subject of much debate. In this article we review the literature concerning SLN MM, with particular emphasis on the prognostic significance of SLN MM. The controversies regarding histopathological assessment, clinical relevance and management implications are also discussed.

METHODS

Literature review facilitated by Medline and PubMed databases. Cross referencing of the obtained articles was used to identify other relevant studies.

RESULTS

Published studies have reported divergent and rather conflicting results regarding the clinical significance and implications of axillary lymph node (ALN) MM in general and SLN MM in particular. Some earlier studies demonstrated no associations, however most recent studies have found SLN MM to be an indicator of poorer prognosis and to be associated with non-SLN involvement. The use of adjuvant chemotherapy and/or hormonal manipulation therapy is associated with an improved survival in patients with SLN MM. Complete ALND may be safely omitted provided that adjuvant systemic therapy recommendations are equal to patients with node-positive disease. However, optimal management of SLN MM is yet to conclude. Furthermore, the identification of MM remains largely dependent on the analytical technique employed and the use of immunohistochemistry (IHC) increases the detection rate of SLN MM. Discrepancies in the histopathological interpretation of TNM classification of SLN tumour burden do exist. Published studies were non-randomized and have significant limitations including a small sample size, limited follow-up period, and lack of standardization and reproducibility of pathological examination of the SLN.

CONCLUSION

Patients with SLN MM have a poorer prognosis than those who are SLN negative. Therapeutic recommendations regarding patients with SLN MM should be taken in the context of multidisciplinary team setting and in selected cases of SLN MM, complete ALND may be safely omitted. A better reproducibility of pathological interpretation of the TNM classification is required so that future therapeutic guidelines can be applied without confusion.

Randomized, double-blind comparison of indocyanine green with or without albumin premixing for near-infrared fluorescence imaging of sentinel lymph nodes in breast cancer patients

Near-infrared (NIR) fluorescence imaging has the potential to improve sentinel lymph node (SLN) mapping in breast cancer. Indocyanine green (ICG) is currently the only clinically available fluorophore that can be used for SLN mapping. Preclinically, ICG adsorbed to human serum albumin (ICG:HSA) improves its performance as a lymphatic tracer in some anatomical sites. The benefit of ICG:HSA for SLN mapping of breast cancer has not yet been assessed in a clinical trial. We performed a double-blind, randomized study to determine if ICG:HSA has advantages over ICG alone. The primary endpoint was the fluorescence brightness, defined as the signal-to-background ratio (SBR), of identified SLNs. Clinical trial subjects were 18 consecutive breast cancer patients scheduled to undergo SLN biopsy. All patients received standard of care using (99m)Technetium-nanocolloid and patent blue. Patients were randomly assigned to receive 1.6 ml of 500 μM ICG:HSA or ICG that was injected periareolarly directly after patent blue. The Mini-Fluorescence-Assisted Resection and Exploration (Mini-FLARE) imaging system was used for NIR fluorescence detection and quantitation. SLN mapping was successful in all patients. Patient, tumor, and treatment characteristics were equally distributed over the treatment groups. No significant difference was found in SBR between the ICG:HSA group and the ICG alone group (8.4 vs. 11.3, respectively, P = 0.18). In both groups, the average number of detected SLNs was 1.4 ± 0.5 SLNs per patient (P = 0.74). This study shows that there is no direct benefit of premixing ICG with HSA prior to injection for SLN mapping in breast cancer patients, thereby reducing the cost and complexity of the procedure. With these optimized parameters that eliminate the necessity of HSA, larger trials can now be performed to determine patient benefit.

Breast imaging and intervention in the overweight and obese patient

OBJECTIVE

This article comments on the challenges and coping mechanisms for evaluating overweight and obese patients with breast imaging and diagnostic techniques. With the prevalence of obesity in society, the obstacles that arise regarding patients' adherence to screening guidelines are important to address.

CONCLUSION

This article discusses social factors and physical limitations that influence these patients' desires and ability to seek health care, specifically breast care and the problems that arise during imaging and interventional procedures.

Toward optimization of imaging system and lymphatic tracer for near-infrared fluorescent sentinel lymph node mapping in breast cancer

Background

Near-infrared (NIR) fluorescent sentinel lymph node (SLN) mapping in breast cancer requires optimized imaging systems and lymphatic tracers.

Materials and Methods

A small, portable version of the FLARE imaging system, termed Mini-FLARE, was developed for capturing color video and two semi-independent channels of NIR fluorescence (700 and 800 nm) in real time. Initial optimization of lymphatic tracer dose was performed using 35-kg Yorkshire pigs and a 6-patient pilot clinical trial. More refined optimization was performed in 24 consecutive breast cancer patients. All patients received the standard of care using ^99mTechnetium-nanocolloid and patent blue. In addition, 1.6 ml of indocyanine green adsorbed to human serum albumin (ICG:HSA) was injected directly after patent blue at the same location. Patients were allocated to 1 of 8 escalating ICG:HSA concentration groups from 50 to 1000 μM.

Results

The Mini-FLARE system was positioned easily in the operating room and could be used up to 13 in. from the patient. Mini-FLARE enabled visualization of lymphatic channels and SLNs in all patients. A total of 35 SLNs (mean = 1.45, range 1–3) were detected: 35 radioactive (100%), 30 blue (86%), and 35 NIR fluorescent (100%). Contrast agent quenching at the injection site and dilution within lymphatic channels were major contributors to signal strength of the SLN. Optimal injection dose of ICG:HSA ranged between 400 and 800 μM. No adverse reactions were observed.

Conclusions

We describe the clinical translation of a new NIR fluorescence imaging system and define the optimal ICG:HSA dose range for SLN mapping in breast cancer.

Electronic supplementary material

The online version of this article (doi:10.1245/s10434-011-1566-x) contains supplementary material, which is available to authorized users.

Factors influencing the identification rate of the sentinel node in breast cancer

Sentinel node biopsy is a widely accepted alternative to primary axillary lymph node dissection for ipsilateral nodal assessment in breast cancer. We have performed a retrospective chart review in 713 consecutive patients with primary, operable breast cancer who underwent sentinel node biopsy in order to identify factors that determine the sentinel node identification rate. Chi-squared test, univariate and multivariate analyses were used to evaluate the influence of different factors on the sentinel identification rate. Among the factors investigated, tumour size was correlated with sentinel lymph nodes detection rates (multiple logistic regression, P= 0.002). In addition, the patient's age showed to be a significant influencing factor (multiple logistic regression, P= 0.006). Body mass index and grade only exhibited a significant correlation with the identification rate in the univariate (P= 0.041, P= 0.025), but not in the multivariate analysis (P= not significant). All associations were found to be independent of the site of injection. Interestingly, surgeons with intermediate expertise (11-20 prior dissections) had the highest detection rates (P= 0.004). We conclude that sentinel identification rates are higher in larger tumours and in younger patients, independent of the injection site. Surgical experience in sentinel node dissection is not linearly correlated with higher identification rates.

The sentinel node procedure in breast cancer: nuclear medicine as the starting point

Axillary node status is a major prognostic factor in early breast cancer. Staging with sentinel node biopsy (SNB) leads to a substantial reduction in surgical morbidity. Recent multiinstitutional studies revealed SNB false-negative rates ranging from 5.5% to 16.7%, higher than the target (<5%) set by the 2005 guidelines of the American Society of Clinical Oncology. These alarming data point to the necessity of optimization. Dual mapping with radiotracer and blue dye, combining 2 different injection sites, and routinely using lymphoscintigraphy may improve accuracy. Factors associated with decreased sensitivity, such as prior excisional biopsy or neoadjuvant chemotherapy, should be recognized. The use of SNB in situations with a high prevalence of node positivity (large tumor, multifocality) is controversial. The risk of missed disease after negative SNB ranges from 1% to 4% in patients with T1 tumor and up to 15% in patients with T3. With peritumoral injection, internal mammary drainage is seen in about 20% of cases. Patients combining internal mammary drainage with a positive axillary sentinel node have close to a 50% probability of internal mammary involvement. Lymphoscintigraphy might thus be helpful in selecting patients for whom internal mammary radiation has a high benefit-to-risk ratio.

Sentinel lymph node biopsy in early breast cancer surgery--working with the risks of vital blue dye to reap the benefits

AIMS

Sentinel lymph node biopsy (SLNB) is an important method of staging early breast cancer because of the inherent benefits it confers on patients in terms of arm function and quality of life. Its success depends on a high level of accuracy in detecting the sentinel node. This is achieved by a dual mapping technique that employs a radio-labelled nanocolloid and a vital blue dye. The vital dyes however carry the risk of anaphylaxis, and as more surgeons employ SLNB in their daily practice, a proportionate rise in the number of anaphylactic reactions can be expected. A comprehensive review of risks and benefits associated with using vital blues dyes has not been published and therefore a retrospective review was undertaken of the different levels of anaphylaxis associated with vital dyes as well as their benefits in SLNB.

METHODS

An OVID MEDLINE search was performed of the English published literature using appropriate search terms to find published trial data and case series that focused on adverse reactions to vital blue dyes.

RESULTS

The risk of severe anaphylaxis (grade 3) can be as low as 0.06%, and up to 0.4% for patients undergoing SLNB when data is analysed from large trials. Furthermore, adverse reactions associated with blue dyes are reversible with appropriate management.

CONCLUSIONS

Surgeons should continue to use vital dyes to ensure that SLNB remains a highly sensitive procedure.

[Surgery for invasive breast cancer]

As most solid tumors, surgery is often the first step of the multidisciplinary management for breast cancers. Although mastectomy and axillar lymphadenectomy still have indications, conservative treatment and sentinel node detection are commonly used. Thanks to induction chemotherapy and oncoplastic techniques, surgery is conservative in most cases, even for important tumors without overall survival prejudice. There is no consensus about resection margins status but a limit of 2 to 3 mm seems to be reasonable while oncoplastic surgery allows large resection and good cosmetic outcomes. In this overview, we present the state of the art for breast cancer surgery including conservative and radical treatments, axillar lymphadenectomy and sentinel lymph node detection, margins status, oncoplastic techniques.