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Olaya W, Wong J, Morgan JW, Truong C, Roy-Chowdhury S, Kazanjian K, Lum S. Factors Associated with Variance in Compliance with a Sentinel Lymph Node Dissection Quality Measure in Early-Stage Breast Cancer. Ann Surg Oncol 2010; 17 Suppl 3:297-302. [DOI: 10.1245/s10434-010-1248-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Indexed: 11/18/2022]
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Fedko MG, Scow JS, Shah SS, Reynolds C, Degnim AC, Jakub JW, Boughey JC. Pure tubular carcinoma and axillary nodal metastases. Ann Surg Oncol 2010; 17 Suppl 3:338-42. [PMID: 20853056 DOI: 10.1245/s10434-010-1254-2] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2010] [Indexed: 11/18/2022]
Abstract
BACKGROUND Pure tubular carcinoma of the breast is a rare subtype with a low incidence of axillary lymph node metastases. The aim of this study was to determine the frequency of axillary lymph node metastasis in patients with pure tubular carcinoma. METHODS We identified patients diagnosed with tubular carcinoma from 1987 to 2009 from our institution's tumor registry. Pathology slides were reviewed, and pure tubular carcinoma was defined as ≥ 90% tubule formation, low nuclear grade, and rare to no mitoses. Medical records were reviewed for clinicopathologic data including tumor size, number of positive and negative axillary lymph nodes, treatment, and recurrence. RESULTS We identified 105 cases of pure tubular carcinoma of the breast in 103 patients. Median tumor size was 0.8 (range 0.1-1.8) cm. Nodal staging was performed in 93 cases (89%). Five patients (5.4%) had positive lymph nodes, and two patients (2.2%) had isolated tumor cells. All patients with lymph node metastases had tumors >0.8 cm in size. At 5.2 years' follow-up, no patients have developed recurrence or metastases, or have died from breast cancer. CONCLUSIONS Axillary lymph node metastases are not common in small pure tubular carcinomas. Nodal staging may be omitted in small pure tubular carcinomas.
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Affiliation(s)
- Martin G Fedko
- Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA
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Buckle T, van Leeuwen AC, Chin PTK, Janssen H, Muller SH, Jonkers J, van Leeuwen FWB. A self-assembled multimodal complex for combined pre- and intraoperative imaging of the sentinel lymph node. NANOTECHNOLOGY 2010; 21:355101. [PMID: 20689167 DOI: 10.1088/0957-4484/21/35/355101] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Specific removal of the sentinel lymph node (SLN) during breast cancer surgery presents physicians with the opportunity to detect early metastatic disease. To increase the accuracy of intraoperative SLN detection, new methods with higher sensitivity and specificity are required. We have quantitatively compared conventional preoperative lymphoscintigraphy with albumin radiocolloids ((99m)Tc-NanoColl) with optical intraoperative guidance using the near infrared dye indocyanine green (ICG) in an orthotopic mouse model for metastatic breast cancer. Furthermore, we have applied a self-assembled multimodal complex, in which ICG is non-covalently bound to the albumin radiocolloid, to attain identical dynamics of the radioactive and optical components. The SLN specificity of the multimodal complex is similar to conventional lymphoscintigraphy, while the fluorescent signal-to-noise ratio is improved by 86% compared to ICG alone. In addition, the multimodal complex permits scintigraphic validation of the fluorescent findings. The multimodal ICG-(99m)Tc-NanoColl complex can be used both for lymphoscintigraphy by preoperative single photon emission computed tomography/computed tomography and for surgical navigation by intraoperative fluorescence imaging.
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Affiliation(s)
- Tessa Buckle
- Department of Radiology, The Netherlands Cancer Institute-Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
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Cheng G, Kurita S, Torigian DA, Alavi A. Current status of sentinel lymph-node biopsy in patients with breast cancer. Eur J Nucl Med Mol Imaging 2010; 38:562-75. [PMID: 20700739 DOI: 10.1007/s00259-010-1577-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Accepted: 07/18/2010] [Indexed: 12/17/2022]
Abstract
Axillary node status is the most important prognostic indicator for patients with invasive breast cancer. Sentinel lymph-node biopsy (SLNB) is widely accepted and the preferred procedure for identifying lymph-node metastasis. SLNB allows focused excision and pathological examination of the most likely axillary lymph nodes to receive tumor metastases while avoiding morbidities associated with complete axillary nodal dissection. Since its introduction in the early 1990s, the process of SLNB has undergone continual modification and refinement; however, the procedure varies between institutions and controversies remain. In this review, we examine the technical issues that influence the success of lymph node mapping, discuss the controversies, and summarize the indications and contraindications for axillary node mapping and biopsy in clinical practice.
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Affiliation(s)
- Gang Cheng
- Division of Nuclear Medicine, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
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205
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Lindell G, Jonsson C, Ehrsson RJ, Jacobsson H, Danielsson KG, Källström BN, Larson B. Evaluation of preoperative lymphoscintigraphy and sentinel node procedure in vulvar cancer. Eur J Obstet Gynecol Reprod Biol 2010; 152:91-5. [PMID: 20579801 DOI: 10.1016/j.ejogrb.2010.05.011] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2009] [Revised: 04/19/2010] [Accepted: 05/23/2010] [Indexed: 11/20/2022]
Abstract
OBJECTIVE To assess the value of preoperative lymphoscintigraphy, and to evaluate the validity and feasibility of the sentinel node (SN) procedure in vulvar carcinoma. STUDY DESIGN Retrospective clinical and histopathological review of 77 patients with invasive squamous cell carcinoma in vulva who were treated at Karolinska University Hospital Stockholm, Sweden, from 2000 to 2007. The patients underwent SN mapping preoperatively with radioactive tracer and blue dye (n=60) or only blue dye (n=17). The SN was removed separately followed by complete inguinofemoral lymphadenectomy. RESULTS The relation between SNs detected on the scintigram and those found during surgery showed good agreement using weighted kappa. The detection rate of SN was 98% for radioisotope plus blue dye, and 94% for blue dye alone. Two cases of false negative SN (false negative rate 2.7%) were found, both with large midline tumors. CONCLUSION Preoperative scintigram is a valuable help to identify and localize the SNs and gives the best estimate of the accurate number but cannot determine if unilateral or bilateral groins should be explored in cases of midline tumors. Our results are in favor of using radioisotope and blue dye to identify the SNs. This study support previous reports that the method is not recommended for tumors larger than 40 mm to optimize detection of SN and minimize the false negative detection rate.
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Affiliation(s)
- Gunnel Lindell
- Department of Women's and Children's Health, Division for Obstetrics and Gynecology, Karolinska Institutet, 17176 Stockholm, Sweden.
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Goldberg JI, Wiechmann LI, Riedel ER, Morrow M, Van Zee KJ. Morbidity of Sentinel Node Biopsy in Breast Cancer: The Relationship Between the Number of Excised Lymph Nodes and Lymphedema. Ann Surg Oncol 2010; 17:3278-86. [DOI: 10.1245/s10434-010-1155-4] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Indexed: 11/18/2022]
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Krikanova M, Biggar M, Moss D, Poole G. Accuracy of sentinel node biopsy for breast cancer using blue dye alone. Breast J 2010; 16:384-8. [PMID: 20545938 DOI: 10.1111/j.1524-4741.2010.00942.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Blue dye alone (BDA), lymphoscintigraphy alone, or, a combination of the two techniques are used for sentinel node biopsy (SNB) in breast cancer. This study reviews the effectiveness of the SNB technique using BDA by measuring the node identification rate and comparing the cohort node positivity with expected rates from established nomograms. A consecutive case series was examined from the database. This included the learning experience of six surgeons. Patients with unifocal tumors estimated at less than 31 mm were eligible. The tumor and axillary nodal histology was recorded. Published data were then used to calculate and predict node positivity rates in the study according to the size and grade of the tumors. There were 332 SNB procedures from 2001 to 2008. BDA successfully identified nodes in 94.6% (314/332) of the cases. The identification rate improved with experience. In patients with invasive cancer, 28.4% (85/299) of SNB were found to be positive for metastases or micrometastases. The node identification rate and the node positivity rate were found to be within published predicted ranges for the size and grade of the study tumors. The SNB with BDA was found to be effective in identifying sentinel nodes (SLN) in breast cancer. Surgeon experience was a factor in the success of the technique. Rates of detecting metastases were consistent with internationally published data, suggesting that BDA may perform as well as other techniques in experienced hands.
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208
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Comparison of early and delayed lymphoscintigraphy images of early breast cancer patients undergoing sentinel node mapping. Nucl Med Commun 2010. [DOI: 10.1097/mnm.0b013e328337eea8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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209
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Keshtgar M, Aresti N, Macneil F. Establishing axillary Sentinel Lymph Node Biopsy (SLNB) for early breast cancer in the United Kingdom: a survey of the national training program. Eur J Surg Oncol 2010; 36:393-8. [PMID: 20227232 DOI: 10.1016/j.ejso.2009.10.012] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2009] [Revised: 10/11/2009] [Accepted: 10/19/2009] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION The UK National training programme (NEWSTART) for SLNB in breast cancer was established in 2004, aimed at providing structured, standardised training with a focus on multidisciplinary team (MDT) delivery. METHODOLOGY A questionnaire was devised and after approval by the Association of Breast Surgeons (ABS) executive committee they were sent to all full members of the ABS. RESULTS Most (97%) of breast surgeons are convinced by the evidence for SLNB as standard of care for early breast cancer. 64% use SLNB to stage clinically node negative patients, of whom 23% use it as a standalone procedure. 38% of surgeons were dissatisfied with the time it takes to complete the in house training, and 87% with the time it takes to complete the validation phase. Logistical and funding issues were the main problems cited. The majority of surgeons (86%) use the recommended combined technique, with 47% continuing to use the dual localisation method. 14% use either blue dye or isotope alone, without scintiscan. Only 10% offer intra operative diagnosis, of which the majority (6%) use touch imprint cytology. 31% included their results in their most recent surgical appraisal. CONCLUSIONS The majority of breast surgeons in the UK are convinced by the evidence for SLNB, and most use SLNB in their practice for staging. Reasons for not conducting SLNB are logistical rather than lack of belief in the procedure. The majority of respondents completed their training within the anticipated time line. The majority of centres do not perform intra-operative assessment.
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Affiliation(s)
- M Keshtgar
- The Royal Free and University College Medical School, UCL, London; The Raven Department of Education, Royal College of Surgeons of England.
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210
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Aitken E, Osman M. Factors Affecting Nodal Status in Invasive Breast Cancer: A Retrospective Analysis of 623 Patients. Breast J 2010; 16:271-8. [DOI: 10.1111/j.1524-4741.2009.00897.x] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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211
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Goyal A. Management of the axilla in patients with breast cancer. Indian J Surg 2010; 71:328-34. [PMID: 23133186 DOI: 10.1007/s12262-009-0089-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2009] [Accepted: 12/03/2009] [Indexed: 11/25/2022] Open
Abstract
This article reviews the changes in management of the axilla in patients with breast cancer in the last decade. It discusses the recent advances, existing controversies and provides evidence-based guidelines for use in clinical practice.Sentinel lymph node (SLN) biopsy has replaced the more morbid axillary lymph node dissection (ALND) and four node sampling for axillary nodal staging. Blue dye guided four node sampling is an acceptable alternative when radioisotope facilities are not available. ALND is reserved for patients with proven axillary lymph node involvement.Preoperative axillary ultrasound and fine-needle aspiration cytology or core biopsy of suspicious lymph nodes reliably identifies around 30% of node positive patients. Intraoperative assessment of the SLN using frozen section or real time molecular assays enables surgeons to perform one stage ALND in node positive patients. For those patients in whom intra-operative SLN assessment is negative, but whose final pathology reveals SLN metastasis, standard treatment has been to perform a completion ALND. Predictive models can be used to identify a lowrisk group of SLN-positive patients in whom routine ALND may not be necessary. In the future, completion ALND for microscopic disease will not be the standard of care but axillary radiotherapy may be an alternative with equal control and less morbidity.
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Affiliation(s)
- Amit Goyal
- Department of Surgery, School of Medicine, Cardiff University, Cardiff, CF14 4XN UK
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212
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Sentinel lymph node biopsy in breast cancer: the node to recovery. Indian J Surg Oncol 2010; 1:10-3. [PMID: 22930612 DOI: 10.1007/s13193-010-0005-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2009] [Accepted: 08/17/2009] [Indexed: 10/19/2022] Open
Abstract
The widespread adoption of sentinel lymph node biopsy to stage the axilla has led to decrease in arm and shoulder morbidity. Sentinel lymph node biopsy is suitable for patients with clinically/radiologically node negative invasive breast cancer and selected patients with DCIS (those with clinical/radiological mass or extensive lesions requiring mastectomy). The combined isotope-blue dye injection technique gives the best results. We inject the isotope intra-dermally preoperatively and blue dye dye subdermally after anesthetic induction into the tumour quadrant peri-areolar tissue. Lymphoscintiscan is not necessary but is useful during the learning phase. Sentinel node biopsy can be performed through a small transverse or vertical axillary incision (∼3 cm) appropriately placed to allow axillary lymph node clearance if needed.
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213
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Problematic Aspects of Sentinel Lymph Node Biopsy and Its Relation to Previous Excisional Biopsy in Breast Cancer. Clin Nucl Med 2009; 34:854-8. [DOI: 10.1097/rlu.0b013e3181becec2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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214
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Barthelmes L, Goyal A, Newcombe RG, McNeill F, Mansel RE. Adverse reactions to patent blue V dye - The NEW START and ALMANAC experience. Eur J Surg Oncol 2009; 36:399-403. [PMID: 19939618 DOI: 10.1016/j.ejso.2009.10.007] [Citation(s) in RCA: 104] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2009] [Revised: 08/14/2009] [Accepted: 10/08/2009] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND Blue dye with or without isotope has been widely used to identify the sentinel lymph node(s) in breast cancer. Patent blue V is used in the UK while its isomer isosulfan blue is used in the US. The allergic potential of isosulfan blue is well documented (1.4% adverse reactions) but that of patent blue V is less clearly defined. METHODS In this paper we review the adverse reactions of patent blue V in 7,917 patients who participated in the NEW START training programme and the ALMANAC trial. All patients underwent sentinel lymph node biopsy for breast carcinoma using patent blue V in combination with (99m)Tc-albumin colloid. RESULTS In total, 72 of 7,917 (0.9%) patients experienced adverse reactions : non-allergic reactions were observed in 4 (0.05%) patients, 23 (0.3%) patients had minor grade I allergic skin reactions (urticaria, blue hives, pruritus, or generalised rash) and 16 (0.2%) had grade II reactions (transient hypotension/bronchospasm/laryngospasm). Severe Grade III reactions (severe hypotension requiring vasopressor support and/or change/abandoning of planned procedure and/or HDU/ITU admission) were noted in 5 (0.06%) patients. The type of adverse reaction was not specified in 24 (0.3%) patients. No mortality was recorded. CONCLUSION The allergic potential of patent blue V dye compares favourably with isosulfan blue however both the surgeon and anaesthetist need to be alert to the risk of allergic reactions.
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Affiliation(s)
- L Barthelmes
- Department of Surgery, School of Medicine, Cardiff University, Cardiff, UK
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215
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Scow JS, Degnim AC, Hoskin TL, Reynolds C, Boughey JC. Assessment of the performance of the Stanford Online Calculator for the prediction of nonsentinel lymph node metastasis in sentinel lymph node-positive breast cancer patients. Cancer 2009; 115:4064-70. [PMID: 19517477 DOI: 10.1002/cncr.24469] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Several models for the prediction of nonsentinel lymph node (NSLN) metastasis in sentinel lymph node (SLN)-positive breast cancer patients have been proposed. In this study, the authors evaluate the Stanford Online Calculator (SOC), which was designed to predict the likelihood of NSLN metastasis using only 3 variables: primary tumor size, SLN metastasis size, and angiolymphatic invasion status. They compared it with the Mayo and Memorial Sloan-Kettering Cancer Center (MSKCC) nomograms. METHODS The SOC was used to calculate the probability of NSLN metastasis in 464 breast cancer patients with SLN metastasis who underwent completion axillary lymph node dissection at the Mayo Clinic. The area under the receiver operating characteristic curve (AUC) was calculated for each model. Mean probabilities of patients with and without NSLN metastasis were compared. Patients with <or=5%, <or=10%, and 100% NSLN metastasis probabilities were examined. RESULTS The AUCs of the Stanford, MSKCC, and Mayo models were 0.72, 0.74, and 0.77, respectively (P=.13). The mean Stanford probabilities for patients with and without NSLN metastasis were 0.75 (range, 0.06-1.0) and 0.50 (range, 0.05-1.0), respectively (P<.0001). The false-negative rates for patients with a Stanford probability of <or=5% and <or=10% were 0% and 13%, respectively. Of the patients with a Stanford probability of 100%, 26% did not have NSLN metastasis. CONCLUSIONS Despite using only 3 variables, the Stanford nomogram appears to perform on a par with, but not better than, the MSKCC and Mayo nomograms. Further validation in other patient populations is needed.
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Affiliation(s)
- Jeffrey S Scow
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
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216
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Johnson MT, Guidroz JA, Smith BJ, Graham MM, Scott-Conner CE, Sugg SL, Weigel RJ. A single institutional experience of factors affecting successful identification of sentinel lymph node in breast cancer patients. Surgery 2009; 146:671-6; discussion 676-7. [DOI: 10.1016/j.surg.2009.06.025] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2009] [Accepted: 06/01/2009] [Indexed: 02/06/2023]
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217
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Bézu C, Coutant C, Antoine M, Moutafoff C, Guillo E, Daraï E, Rouzier R, Uzan S. Faisabilité du ganglion sentinelle dans le cancer invasif du sein en cas de découverte histologique de la multifocalité. ACTA ACUST UNITED AC 2009; 37:604-10. [DOI: 10.1016/j.gyobfe.2009.04.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2008] [Accepted: 04/16/2009] [Indexed: 11/28/2022]
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Sentinel lymph node biopsy in two Burgundy districts: prospective multicentric study on 528 breast cancers during the year 2005. Arch Gynecol Obstet 2009; 281:491-8. [PMID: 19554339 DOI: 10.1007/s00404-009-1163-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2009] [Accepted: 06/11/2009] [Indexed: 10/20/2022]
Abstract
OBJECTIVES Our purpose was to assess development of sentinel lymph node biopsy (SLNB) in two Burgundy districts during the year 2005. METHODS All women undergoing breast surgery as primary care between 1 January 2005 and 1 January 2006 were eligible for inclusion. Eleven surgeons from five different breast-treatment centres took part in this prospective multicentric study. As our objective was to evaluate practices, patients were not randomized and surgeons were free to choose treatment patterns. RESULTS The 528 enrolled cases account for 90% of all new breast cancers in 2005 in Cote d'Or and Saône et Loire. Half of these patients (286) fulfilled requirements for SLNB. The others (242) had primary full axillary clearance (AC). Four of our five centres offer double-detection of sentinel lymph nodes as well as intraoperative pathology examination. Most tumours were invasive ductal carcinomas, with an average size of 12 mm in the SLNB group (T1C) and 22 mm in the AC group (T2). Two or three lymph nodes were removed during each SLNB procedure. Whereas most SLNB studies report around 25% positive nodes, we barely recorded 18.5% (53 of our 256 patients). Moreover, 2/3 of these node-positive patients had optimal care since additional axillary clearance was done right away. CONCLUSION Sentinel lymph node biopsy has become routine practice in our Burgundy area. It is mainly dedicated to early stage breast cancer with limited metastatic risk. Our surgeons follow the most recent guidelines and indications are the same regardless of treatment centre.
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219
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Somasundaram SK, Chicken DW, Waddington WA, Bomanji J, Ell PJ, Keshtgar MRS. Sentinel node imaging in breast cancer using superficial injections: technical details and observations. Eur J Surg Oncol 2009; 35:1250-6. [PMID: 19540710 DOI: 10.1016/j.ejso.2009.05.006] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2008] [Revised: 05/12/2009] [Accepted: 05/18/2009] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Sentinel lymph node (SLN) biopsy is the evolving standard of care for the management of early breast cancer. Accurate identification of the SLN is paramount for success of this procedure. Various techniques are described for SLN identification, but the superficial injection techniques, advocated by the UK National Training Programme (NEW START), are validated, reproducible and rapid. Pre-operative lymphoscintigraphy provides a road map for the surgeon and requires a reporting template. METHODS As one of the NEW START training institutions in the UK practising this technique, we reviewed a mature series of 100 unselected, consecutive SLN lymphoscintigraphy procedures. We correlated the imaging, operative and pathology findings and have provided technical details of the technique and a template for reporting SLN lymphoscintigrams. RESULTS The SLN localisation rate was 99% with one failed imaging. Seven patients required delayed imaging. The mean activity of the radiocolloid injected was 14.4MBq (range 8.3-23 MBq). The SLNs were visualised in the ipsilateral axilla in 98 images, intramammary in 3, and internal mammary in 1. A mean of 1.35 nodes were classified as 'True' SLNs on imaging criteria. Intra-operatively, a mean of 1.91 SLNs were excised. 32 of 116 hot and blue nodes, 7 of 15 only blue nodes, 13 of 47 only hot and 7 of 13 parasentinel nodes harboured metastases. CONCLUSION The NEW START recommended, combined superficial injection techniques, have high localisation rates. Pre-operative sentinel node imaging is recommended and a template for reporting is provided.
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Affiliation(s)
- S K Somasundaram
- University Department of Surgery, Royal Free and University College Medical School, Pond Street, London NW3 2QG, UK
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220
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Taras AR, Hendrickson NA, Pugliese MS, Lowe KA, Atwood M, Beatty JD. Intraoperative evaluation of sentinel lymph nodes in invasive lobular carcinoma of the breast. Am J Surg 2009; 197:643-6; discussion 646-7. [DOI: 10.1016/j.amjsurg.2008.12.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2008] [Revised: 12/23/2008] [Accepted: 12/29/2008] [Indexed: 10/20/2022]
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Lee JH, Ryu KW, Nam BH, Kook MC, Cho SJ, Lee JY, Kim CG, Choi IJ, Park SR, Kim YW. Factors associated with detection failure and false-negative sentinel node biopsy findings in gastric cancer: results of prospective single center trials. J Surg Oncol 2009; 99:137-42. [PMID: 19117015 DOI: 10.1002/jso.21222] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND OBJECTIVES The factors associated with successful sentinel node biopsy (SNB) are limited in gastric cancer despite a wide range of sensitivities reported. This study was performed to identify the factors associated with detection failure and SNB false-negativity in gastric cancer. METHODS SNB was performed on 156 gastric cancer patients from May 2002 to April 2007 at the Korean National Cancer Center during three consecutive prospective trials. Indications for SNB were determined preoperatively in cT1-2N0 patients. Dissected SNs and non-SNs after D2 lymphadenectomy were pathologically evaluated for metastasis. Clinical, pathological, and technical factors were analyzed for detection failure and false-negativity. RESULTS SNs were detected in 147 patients (94.2%) and the median number of SNs detected per patient was 3 (1-12). Twenty-five of 37 with nodal metastasis were diagnosed by SNB (sensitivity, 67.6%). Surgeon's inexperience (<or=30 procedures) and a male patient gender were significantly associated with detection failure (P = 0.014 and 0.031, respectively). A small number of SNs (<or= 3) was found to be significantly associated with false-negativity (P = 0.027). CONCLUSIONS SNB requires experience for successful detection and should be performed cautiously in male patients. Harvesting of more than three SNs is warranted to reduce false-negatives when diagnosing nodal metastasis.
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Affiliation(s)
- Jun Ho Lee
- Gastric Cancer Branch, Research Institute and Hospital, National Cancer Center, Gyeonggi-do, Korea
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Dixon J, Mak C, Radhakrishna S, Kehoe T, Millar A, Wong D, Thomas J. Effectiveness of immediate preoperative injection of radiopharmaceutical and blue dye for sentinel node biopsy in patients with breast cancer. Eur J Cancer 2009; 45:795-9. [DOI: 10.1016/j.ejca.2008.11.011] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2008] [Revised: 11/04/2008] [Accepted: 11/07/2008] [Indexed: 11/25/2022]
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van la Parra RFD, Ernst MF, Bevilacqua JLB, Mol SJJ, Van Zee KJ, Broekman JM, Bosscha K. Validation of a Nomogram to Predict the Risk of Nonsentinel Lymph Node Metastases in Breast Cancer Patients with a Positive Sentinel Node Biopsy: Validation of the MSKCC Breast Nomogram. Ann Surg Oncol 2009; 16:1128-35. [DOI: 10.1245/s10434-009-0359-y] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2008] [Revised: 09/09/2008] [Accepted: 12/21/2008] [Indexed: 01/17/2023]
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Meretoja TJ, Leidenius MH, Heikkilä PS, Joensuu H. Sentinel node biopsy in breast cancer patients with large or multifocal tumors. Ann Surg Oncol 2009; 16:1148-55. [PMID: 19242761 DOI: 10.1245/s10434-009-0397-5] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2008] [Accepted: 02/08/2009] [Indexed: 12/29/2022]
Abstract
BACKGROUND The axillary recurrence (AR) rate after negative sentinel node biopsy (SNB) in patients with high risk of axillary metastases is largely unknown. The aim of this study was to analyze the risk factors for isolated AR after negative SNB with special interest in large or multifocal tumors. METHODS A prospective SNB registry was analyzed for 2,408 invasive breast cancer patients operated between 2001 and 2007. No axillary clearance was performed in 1,309 cases with a negative SNB, including 1,138 small unifocal tumors, 121 small multifocal tumors, 48 large unifocal tumors, and 2 large multifocal tumors. RESULTS Six (0.5%) isolated AR were observed during a median follow-up of 43 months. Four (0.4%) patients with small unifocal tumors and two (1.6%) with small multifocal tumors had isolated AR (p = 0.179). None of the patients with large unifocal or multifocal tumors had isolated AR. Instead of tumor size and multifocality, estrogen receptor negativity (p < 0.001), nuclear grade III (p < 0.001), Her-2 status (p = 0.002), no radiotherapy (p = 0.005), and mastectomy (p = 0.005) were found to be associated with AR. CONCLUSIONS A remarkable proportion of patients with large unifocal tumors and small multifocal tumors may avoid unnecessary AC due to tumor negative SNB, without an excessive risk of AR.
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Affiliation(s)
- Tuomo J Meretoja
- Department of Gastrointestinal and General Surgery, Breast Surgery Unit, Helsinki University Central Hospital, Helsinki, Finland.
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Ferreira P, Baía R, António A, Almeida J, Simões J, Amaro J, Quintana C, Branco L, Rigueira M, Gonçalves M, Pereira E, Ferreira L. Sentinel lymph node biopsy: technique validation at the Setúbal Medical Centre, Portugal. Ecancermedicalscience 2009; 3:124. [PMID: 22275996 PMCID: PMC3224010 DOI: 10.3332/ecancer.2008.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2008] [Indexed: 12/02/2022] Open
Abstract
Aims: To evaluate the accuracy of sentinel lymph node biopsy in breast cancer patients at this institution, using combined technetium-99m (99mTc) sulphur colloid and patent blue vital dye. Methods: From March 2007 to July 2008, 50 patients with a tumour of less than 3 cm and with clinically negative axillary lymph nodes underwent sentinel lymph node biopsy (SLNB), followed by axillary lymph node dissection (ALND). Sub-areolar 99mTc sulphur colloid injection was performed the day before surgery, and patent blue vital dye was also injected sub-areolarly at least 5 minutes before surgery. Sentinel lymph node was identified during the surgical procedure, using a gamma probe and direct vision. All sentinel nodes underwent frozen section analysis. Later haematoxylin and eosin staining and immunohistochemical analysis were performed. Finally, SLNB was compared with standard ALND for its ability to accurately reflect the final pathological status of the axillary nodes. Results: The sentinel lymph node (SLN) was identified in 48 of 50 patients (96%). The number of sentinel lymph nodes ranged from one to four (mean 1.48) and non-sentinel nodes ranged from seven to 27 (mean 14.33). Of the 48 patients with successfully identified SLNs, 29.17% (14/48) were histologically positive. Sensivity of the SLN to predict axilla was 93.75%; accuracy was 97.96%. The SLN was falsely negative in one patient—6.25% (1/16). Conclusions: The SLNB represents a major advance in the surgical treatment of breast cancer as a minimally invasive procedure predicting the axillary lymph node status. This validation study demonstrates the accuracy of the SLNB and its reasonable false negative rate when performed in our institute. It can now be used as the standard method of staging in patients with early breast cancer at this institution.
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Affiliation(s)
- P Ferreira
- Senology Unit, General Surgery Service, Setúbal Medical Centre, Portugal
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van Deurzen CHM, de Boer M, Monninkhof EM, Bult P, van der Wall E, Tjan-Heijnen VCG, van Diest PJ. Non-sentinel lymph node metastases associated with isolated breast cancer cells in the sentinel node. J Natl Cancer Inst 2008; 100:1574-80. [PMID: 19001602 DOI: 10.1093/jnci/djn343] [Citation(s) in RCA: 86] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
There are many reports on the frequency of non-sentinel lymph node involvement when isolated tumor cells are found in the sentinel node, but results and recommendations for the use of an axillary lymph node dissection differ among studies. This systematic review was conducted to give an overview of this issue and to provide recommendations for the use of an axillary lymph node dissection in these patients. We searched Medline, Embase, and Cochrane databases from January 1, 2002, through November 27, 2007, for articles on patients with invasive breast cancer who had isolated tumor cells in the sentinel lymph node (according to the sixth edition of the Cancer Staging Manual of the American Joint Committee on Cancer) and who also underwent axillary lymph node dissection. Of 411 selected articles, 29 (including 836 patients) were included in this review. These 29 studies were heterogeneous, reporting a wide range of non-sentinel lymph node involvement (defined as the presence of isolated tumor cells or micro- or macrometastases) associated with isolated tumor cells in the sentinel lymph node, with an overall pooled risk for such involvement of 12.3% (95% confidence interval = 9.5% to 15.7%). This pooled risk estimate was marginally higher than the risk of a false-negative sentinel lymph node biopsy examination (ie, 7%-8%) but marginally lower than the risk of non-sentinel lymph node metastases in patients with micrometastases (ie, approximately 20%) who are currently eligible for an axillary lymph node dissection. Because 36 (64%) of the 56 patients with isolated tumor cells in their sentinel lymph node also had non-sentinel lymph node macrometastases, those patients with isolated tumor cells in the sentinel lymph node without other indications for adjuvant systemic therapy might be candidates for axillary lymph node dissection.
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Abstract
Biopsy of the sentinel lymph node now forms part of routine management in many centres dealing with early stage breast cancer. This article seeks to discuss developments over the past number of years and to summarise current practice.
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Use of ultrasound-guided axillary node core biopsy in staging of early breast cancer. Eur Radiol 2008; 19:561-9. [DOI: 10.1007/s00330-008-1177-5] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2008] [Revised: 08/05/2008] [Accepted: 08/24/2008] [Indexed: 02/05/2023]
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230
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Chung A, Yu J, Stempel M, Patil S, Cody H, Montgomery L. Is the "10% rule" equally valid for all subsets of sentinel-node-positive breast cancer patients? Ann Surg Oncol 2008; 15:2728-33. [PMID: 18688679 DOI: 10.1245/s10434-008-0050-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2008] [Revised: 06/11/2008] [Accepted: 06/15/2008] [Indexed: 11/18/2022]
Abstract
BACKGROUND In breast cancer, a combination of radioisotope and blue dye mapping maximizes the success and accuracy of sentinel node (SLN) biopsy. When multiple radioactive nodes are present, there is no single definition of isotope success, but the popular "10% rule" dictates removal of all SLN with counts >10% of the most radioactive node. Here we determine how frequently a positive SLN would be missed by the 10% rule. METHODS Between 9/96 and 12/04, we performed 6,369 successful SLN biopsies using (99m)Tc sulfur colloid and isosulfan blue dye, removing as SLN all radioactive and/or blue nodes, and taking counts from each node ex vivo. Standard processing of all SLNs with a benign frozen section included hematoxylin and eosin (H&E) staining, serial sectioning, and immunohistochemistry (IHC). RESULTS 33% of patients (2,130/6,369) had positive SLNs. Of these patients, 1,387/2,130 (65%) had >1 SLN identified. The most radioactive SLN was benign in 29% (398/1,387), and 107/1,387 (8%) had a positive SLN that was neither blue nor the hottest. From this group 1.7% (24/1387) of patients had positive SLN with counts <10% radioactive counts of the hottest node. The 10% rule captured 98.3% of positive nodes in patients with multiple SLNs. No patient characteristics were predictive of failure of the 10% rule. CONCLUSION With combined isotope and blue dye mapping, the 10% rule is a robust guideline and fails to identify only 1.7% (24/1387) of all SLN-positive patients with multiple SLNs. This guideline appears to be equally valid for all subsets of patients.
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Affiliation(s)
- Alice Chung
- Department of Surgery, Breast Service, Memorial Sloan-Kettering Cancer Center, 1275 York Avenue, MRI-1026, New York, NY 10065, USA.
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Multiparametric analysis of preoperative lymphatic mapping with the use of combined deep plus superficial radiotracer injection technique in early breast cancer. Nucl Med Commun 2008; 29:546-52. [DOI: 10.1097/mnm.0b013e3282f63965] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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232
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Zavagno G, Del Bianco P, Koussis H, Artioli G, Carraro P, De Salvo GL, Mencarelli R, Belardinelli V, Marconato G, Nitti D. Clinical impact of false-negative sentinel lymph nodes in breast cancer. Eur J Surg Oncol 2008; 34:620-5. [PMID: 17764888 DOI: 10.1016/j.ejso.2007.07.003] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2007] [Accepted: 07/02/2007] [Indexed: 02/06/2023] Open
Abstract
AIMS To evaluate the incidence of false-negative (FN) sentinel lymph node (SLN) cases, their correlation with a series of clinico-pathologic parameters and their impact on adjuvant treatment indications and on clinical axillary relapse in the setting of a multicentric clinical trial comparing SLN biopsy with axillary lymph node dissection (ALND). METHODS A series of 697 patients with primary breast cancer < or = 3 cm were randomized to SLN biopsy associated with ALND (ALND arm) or to SLN biopsy followed by ALND only if the SLN was metastatic (SLN arm). The FN SLN rate was assessed in the ALND arm. A series of 11 clinico-pathological parameters were tested for a possible association with FN results. The indications for adjuvant treatments were evaluated by considering both the FN nodal stages, as indicated by the SLN, and the true positive axillary status, as indicated by completion ALND. The occurrence of clinically evident axillary recurrences was evaluated in the two arms. RESULTS The FN rate was 16.7%. Of the clinico-pathologic parameters tested, only a tumour size < or = 2 cm and the presence of a single metastatic axillary node was significantly associated with a risk of FN (p = 0.033 and p = 0.018, respectively). The FN SLN would have led to different adjuvant therapy indications in 12/18 cases. At 56 months, no clinically evident axillary nodal recurrences were present in the ALND arm patients, whereas one case of axillary recurrence was detected in the SLN arm patients. CONCLUSIONS FN SLN biopsy is not uncommon, especially in the presence of a small primary tumour with a single nodal metastasis. An FN finding can lead to less than optimal adjuvant treatment. However, the clinical impact of FN in terms of axillary recurrence at 56 months was minimal.
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Affiliation(s)
- G Zavagno
- Clinica Chirurgica II, University of Padova, Via Giustiniani 2, 35128 Padova, Italy.
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233
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Choi YJ, Kim JH, Nam SJ, Ko YH, Yang JH. Intraoperative identification of suspicious palpable lymph nodes as an integral part of sentinel node biopsy in patients with breast cancer. Surg Today 2008; 38:390-4. [PMID: 18560959 DOI: 10.1007/s00595-007-3653-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2007] [Accepted: 04/08/2007] [Indexed: 10/22/2022]
Abstract
PURPOSE Despite the sensitivity and accuracy of sentinel lymph node biopsy (SLNB), the number of false negative (FN) results is still relatively high, which has prompted much investigation. We studied the effectiveness of the biopsy of suspicious palpable lymph nodes (LNs) in reducing the number of FN results. METHODS We reviewed the medical records of 865 breast cancer patients who underwent successful SLNB at a single institution. After excising the blue-stained or radioactive nodes, all suspicious palpable LNs that were not either blue-stained or radioactive were also excised. RESULTS Sampling of a suspicious palpable LN was done in 342 (39.5%) of the 865 patients. The average number of suspicious palpable nodes was 1.9. The suspicious nodes harbored metastasis in 19 of the 342 patients. Both blue-stained and radioactive metastatic SLNs were found in 8 patients, whereas the palpable nodes were the only ones involved in the other 11. LN involvement was identified solely by biopsy of a suspicious palpable LN in 11 (6.5%) of 170 patients with SLN metastasis (6.5%). CONCLUSION Biopsy of a suspicious palpable LN should be done as part of SLNB to reduce the number of FN results of SLNs in breast cancer patients.
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Affiliation(s)
- Young Jin Choi
- Department of Surgery, Sungkyunkwan University School of Medicine, Seoul, South Korea
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234
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Straalman K, Kristoffersen US, Galatius H, Lanng C. Factors influencing sentinel lymph node identification failure in breast cancer surgery. Breast 2008; 17:167-71. [DOI: 10.1016/j.breast.2007.08.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2007] [Revised: 06/07/2007] [Accepted: 08/17/2007] [Indexed: 10/22/2022] Open
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Samphao S, Eremin JM, El-Sheemy M, Eremin O. Management of the axilla in women with breast cancer: current clinical practice and a new selective targeted approach. Ann Surg Oncol 2008; 15:1282-96. [PMID: 18330650 DOI: 10.1245/s10434-008-9863-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2008] [Revised: 01/31/2008] [Accepted: 02/07/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND Axillary nodal status is the most important prognostic factor for patients with breast cancer. Clinical assessment and imaging modalities are not always reliable. Surgical removal and histopathological examination of axillary lymph nodes remain essential methods of staging the axilla. However, the optimal management of the axilla remains uncertain. METHODS We performed Medline searches to identify relevant systematic reviews, meta-analysis, and nonrandomized and randomized controlled trials for the past 5 years (up to December 2007), as well as important historical articles and clinical guidelines relating to management of the axilla in women with breast cancer. RESULTS Axillary lymph node dissection (ALND) has been the standard surgical approach for many years. It is, however, associated with marked morbidity; survival benefit remains uncertain. Axillary node sampling, widely practiced in the United Kingdom, is a reliable alternative procedure in staging the axilla, with less morbidity. Sentinel lymph node biopsy (SLNB) has become an accurate method for staging the axilla in women with operable, clinically node-negative breast cancer. SLNB alone appears to be a safe and acceptable procedure for patients with uninvolved SLNs. Completion ALND or axillary radiotherapy remains the standard treatment for patients with tumor-involved SLNs. SLNB is associated with less morbidity than ALND. However, long-term follow-up and therapeutic outcomes are being awaited from randomized controlled trials. CONCLUSIONS Several procedures are available for staging and treating the axilla. A tailored surgical approach, with careful assessment of risk-benefit and patient preference, is guiding the evolving modern management of the axilla for women with breast cancer.
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Affiliation(s)
- Srila Samphao
- Research and Development Department, Lincoln County Hospital, Greetwell Road, Lincoln, LN2 5QY, UK.
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A Randomized Clinical Trial on Sentinel Lymph Node Dissection Versus Axillary Dissection: A Matter of Technique. Ann Surg 2008; 247:214-6. [DOI: 10.1097/sla.0b013e318163ff11] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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237
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Mathelin C, Salvador S, Croce S, Andriamisandratsoa N, Huss D, Guyonnet JL. Optimization of sentinel lymph node biopsy in breast cancer using an operative gamma camera. World J Surg Oncol 2007; 5:132. [PMID: 18021418 PMCID: PMC2203998 DOI: 10.1186/1477-7819-5-132] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2007] [Accepted: 11/17/2007] [Indexed: 12/02/2022] Open
Abstract
Background Sentinel lymph node (SLN) procedure is now a widely accepted method of LN staging in selected invasive breast cancers (unifocal, size ≤ 2 cm, clinically N0, without previous treatment). Complete axillary clearance is no longer needed if the SLN is negative. However, the oncological safety of this procedure remains to be addressed in randomized clinical trials. One main pitfall is the failure to visualize SLN, resulting in incorrect tumor staging, leading to suboptimal treatment or axillary recurrence. Operative gamma cameras have therefore been developed to optimize the SLN visualization and the quality control of surgery. Case presentation A 44-year-old female patient with a 14-mm infiltrative ductal carcinoma underwent the SLN procedure. An operative gamma camera was used during and after the surgery. The conventional lymphoscintigraphy showed only one SLN, which was also detected by the operative gamma camera, then removed and measured (9.6 kBq). It was analyzed by frozen sections, showing no cancer cells. During this analysis, the exploration of the axillary area with the operative gamma camera enabled the identification of a second SLN with low activity (0.5 kBq) that conventional lymphoscintigraphy, surgical probe and blue staining had failed to visualize. Histological examination revealed a macrometastasis. Axillary clearance was then performed, followed by a postoperative image proving that no SLN remained. Therefore, the use of the operative gamma camera prevented an under-estimation of staging which would have resulted in a suboptimal treatment for this patient. Conclusion This case report illustrates that an efficient operative gamma camera may be able to decrease the risk of false negative rate of the SLN procedure, and could be an additional tool to control the quality of the surgery. Trial Registration ClinicalTrials.gov Identifier: NCT00357487
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Affiliation(s)
- Carole Mathelin
- Service de Gynécologie-Obstétrique, Hôpital Civil, 1 place de l'Hôpital, F-67091 Strasbourg Cedex, France.
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Amaral BB, Meurer L, Whitman GJ, Leung JW. Lymph Node Status in the Breast Cancer Patient: Sampling Techniques and Prognostic Significance. Semin Roentgenol 2007; 42:253-64. [DOI: 10.1053/j.ro.2007.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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Konstantiniuk P, Schrenk P, Reitsamer R, Koeberle-Wuehrer R, Tausch C, Roka S, Riedl O, Poestlberger S, Hecke D, Janauer M, Haid A. A nonrandomized follow-up comparison between standard axillary node dissection and sentinel node biopsy in breast cancer. Breast 2007; 16:520-6. [PMID: 17566737 DOI: 10.1016/j.breast.2007.04.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2007] [Accepted: 04/02/2007] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION In many countries sentinel node biopsy (SNB) has become the standard of care in breast cancer based on a large number of observational studies but without results from prospective randomized trials. The goal of our study was to evaluate the oncological safety of the SNB in breast cancer in a multicenter, nonrandomized setting with comparable groups. PATIENTS AND METHODS Between 1996/05 and 2004/11, 2942 patients from 14 departments in Austria with unicentric, unilateral, invasive disease without neoadjuvant therapy were collected in a database. The recommendations of the Austrian Sentinel Node Study Group were to complete a training period (phase I) with 50 cases of SNB followed by axillary lymph node dissection (ALND) to prove a detection rate of > or = 90% and a false-negative rate of < or = 5%. In the executing period (phase II), SNB was followed by ALND only if the sentinel node (SN) contained metastases. We compared the results on disease-free survival, local recurrence rates, distant recurrence rates and overall survival of both groups. Cases from phases I and II generated groups I (n=671) and 2 (n=2271 cases), respectively. RESULTS Overall mean follow-up time: 34.41 months. CONCLUSION SNB followed by ALND only in cases with metastases in the SN is a safe procedure and at least equal to ALND in all cases.
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Dauphine C, Vargas HI. Outcomes following sentinel lymph node biopsy for breast cancer. Expert Rev Pharmacoecon Outcomes Res 2007; 7:469-77. [PMID: 20528392 DOI: 10.1586/14737167.7.5.469] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Evaluation of axillary lymph nodes for metastatic involvement is the most significant factor in gauging prognosis in breast cancer patients. Complete axillary dissection can be associated with significant morbidity. Therefore, sentinel node biopsy was developed to sample nodes and avoid dissection in patients without clinical evidence of nodal involvement. While most surgeons currently perform the procedure, the technique remains unstandardized. Sentinel node identification rates, false-negative rates and procedural complication rates are the main outcomes measured and can depend significantly on variations in technique. Future studies on sentinel lymph node biopsy will probably focus on clarifying accuracy of the procedure in different clinical settings, delineating standard technical practice guidelines and further achieving improved outcomes.
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Affiliation(s)
- Christine Dauphine
- Harbor-UCLA Medical Center, 1000 West Carson St Box #25, Torrance, CA 90509, USA.
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Zakaria S, Degnim AC, Kleer CG, Diehl KA, Cimmino VM, Chang AE, Newman LA, Sabel MS. Sentinel lymph node biopsy for breast cancer: How many nodes are enough? J Surg Oncol 2007; 96:554-9. [PMID: 17685432 DOI: 10.1002/jso.20878] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Sentinel lymph node (SLN) biopsy using blue dye and radioisotope often results in the removal of multiple SLNs. We sought to determine whether there is a point where the surgeon can terminate the procedure without sacrificing accuracy. METHODS One thousand one hundred ninety-seven patients from University of Michigan and the Mayo Clinic undergoing SLN biopsy formed the study population. Surgeons removed all SLNs until counts within the axilla were less than 10% of the highest node ex vivo and recorded the order in which they were removed. RESULTS The mean number of SLNs removed per patient was 2.5 (range 1-9). Approximately 42% of patients had three or more lymph nodes removed, while 19% had four or more lymph nodes removed. Eighteen percent of patients (132/725) at University of Michigan and 22% (103/472) at Mayo Clinic had a positive SLN. Ninety-eight percent (231/235) of patients with lymph node metastases were identified by the 3rd SLN while 100% were identified by the 4th SLN. CONCLUSION Among patients undergoing SLN biopsy for breast cancer, the only positive SLN is rarely identified in the 4th or higher node. Terminating the procedure at the 4th node may lower the cost of the procedure and reduce morbidity.
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Affiliation(s)
- Shaheen Zakaria
- Department of Surgery, Mayo Clinic, Rochester, Minnesota, USA
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Mansel RE, Fallowfield L, Kissin M, Goyal A, Newcombe RG, Dixon JM, Yiangou C, Horgan K, Bundred N, Monypenny I, England D, Sibbering M, Abdullah TI, Barr L, Chetty U, Sinnett DH, Fleissig A, Clarke D, Ell PJ. Randomized multicenter trial of sentinel node biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC Trial. J Natl Cancer Inst 2006; 98:599-609. [PMID: 16670385 DOI: 10.1093/jnci/djj158] [Citation(s) in RCA: 1133] [Impact Index Per Article: 62.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Sentinel lymph node biopsy in women with operable breast cancer is routinely used in some countries for staging the axilla despite limited data from randomized trials on morbidity and mortality outcomes. We conducted a multicenter randomized trial to compare quality-of-life outcomes between patients with clinically node-negative invasive breast cancer who received sentinel lymph node biopsy and patients who received standard axillary treatment. METHODS The primary outcome measures were arm and shoulder morbidity and quality of life. From November 1999 to October 2003, 1031 patients were randomly assigned to undergo sentinel lymph node biopsy (n = 515) or standard axillary surgery (n = 516). Patients with sentinel lymph node metastases proceeded to delayed axillary clearance or received axillary radiotherapy (depending on the protocol at the treating institution). Intention-to-treat analyses of data at 1, 3, 6, and 12 months after surgery are presented. All statistical tests were two-sided. RESULTS The relative risks of any lymphedema and sensory loss for the sentinel lymph node biopsy group compared with the standard axillary treatment group at 12 months were 0.37 (95% confidence interval [CI] = 0.23 to 0.60; absolute rates: 5% versus 13%) and 0.37 (95% CI = 0.27 to 0.50; absolute rates: 11% versus 31%), respectively. Drain usage, length of hospital stay, and time to resumption of normal day-to-day activities after surgery were statistically significantly lower in the sentinel lymph node biopsy group (all P < .001), and axillary operative time was reduced (P = .055). Overall patient-recorded quality of life and arm functioning scores were statistically significantly better in the sentinel lymph node biopsy group throughout (all P < or = .003). These benefits were seen with no increase in anxiety levels in the sentinel lymph node biopsy group (P > .05). CONCLUSION Sentinel lymph node biopsy is associated with reduced arm morbidity and better quality of life than standard axillary treatment and should be the treatment of choice for patients who have early-stage breast cancer with clinically negative nodes.
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