Internal mammary chain sentinel lymph node identification in breast cancer

Predictors of internal mammary lymph nodes (IMLN) metastasis and disease-free survival comparison between IMLN-positive and IMLN-negative breast cancer patients: Results from Western China Clinical Cooperation Group (WCCCG) database (CONSORT)

Limited studies performed a comprehensive assessment of risk factors for internal mammary lymph nodes (IMLN) metastasis, and disease-free survival (DFS) difference between IMLN-positive and IMLN-negative breast cancer (BC) patients undergoing IMLN dissection and systemic therapies was not clear.A retrospective study included 1977 BC patients from Western China Clinical Cooperation Group between January 2005 and December 2012. The impact of clinicopathological factors on the occurrence of IMLN metastasis was assessed in univariate and multivariate logistic regression analyses, and a nomogram (model) was constructed to predict the IMLN status. DFS difference was evaluated in univariate and multivariate Cox regression analyses between IMLN-negative and IMLN-positive patients, and univariate analysis was performed to compare DFS between individuals with high and low IMLN metastasis risk defined by proposed nomogram.Of 1977 enrolled patients, 514 cases underwent IMLN dissection and 1463 cases did not undergo IMLN irradiation or dissection. We found that initial disease symptoms and signs, mammographic calcification, tumor site, number of positive axillary lymph nodes (ALNs), American Joint Committee on Cancer pT stage, and human epidermal growth factor receptor 2 status were associated with IMLN metastasis (all P < .05). Those variables were included in nomogram, whose predictive ability was better than that of ALN classification (area under the curve: 0.82 vs 0.76, P < .001). Univariate cox proportional hazards model indicated that better DFS was observed in IMLN-negative patients than IMLN-positive group (hazard ratio [HR] = 1.87, 95% confidence interval [CI] = 1.05-3.34; P = .04), whereas no significant differences in DFS (HR = 0.99, 95% CI = 0.49-2.00; P = .97) were found after adjusting patient-, disease-, and treatment-related factors.Nipple inversion, mammographic calcification, larger tumor size, medial tumor site, negative HER-2 status, and more positive ALNs are independent risk factors for IMLN metastasis, and the individualized nomogram is a feasible tool to predict the status of IMLN. Equivalent DFS was found between positive and negative IMLN patients who all accepted IMLN dissection and systemic therapies.

Sentinel Node Biopsy in the Evaluation of the Internal Mammary Node Chain in Patients with Breast Cancer

Aims and Background

In patients with breast cancer the presence of internal mammary chain (IMC) metastases changes tumor staging, and the occurrence of IMC drainage is quite common in breast cancer. Nevertheless, IMC dissection is not a routine procedure in modern surgical approaches towards breast cancer. We therefore need minimally invasive techniques for accurate assessment of the IMC nodal basin. The aim of this study was to investigate whether sentinel node biopsy (SLNB) could offer a solution.

Methods and Study Design

From November 1997 to June 2001 143 female patients who were eligible for breast cancer surgery were included in the study. All patients had T1 breast cancer and clinically negative axillae. Patients were submitted to preoperative lymphoscintigraphy with subsequent SLNB. We used a 99m-technetium nanocolloid tracer (Nanocoll®) that was injected peritumorally so as to have about 10 MBq of radioactivity at the time of surgery. Scintigraphy was performed about 17 hours after tracer administration. During surgery, lymphoscintigraphic imaging and a gamma ray detection probe were used to locate the sentinel node. Histological examination after embedding in paraffin was usually requested and multilevel sectioning of the sentinel node (SLN) was performed, with hematoxylin and eosin staining and immunohistochemistry.

Results

Preoperative lymphoscintigraphy localized SLNs in the IMC basin in 27 of 143 patients (18.9%). Harvesting of IMC-SLNs based on lymphoscintigraphy results was successful in 20 of 27 patients (74.1 %). Histological examination revealed micrometastases in four of the 20 harvested nodes. One of these patients showed no axillary drainage and no axillary lymph node dissection was therefore performed. In the remaining three patients also axillary SLNs were harvested, which turned out be free from metastatic involvement.

Conclusions

In our experience lymphoscintigraphy with SLNB was an accurate method to detect IMC metastases in patients with breast cancer. We recommend peritumoral tracer injection and a reasonable interval between injection and scintigraphy. IMC-SLN biopsy did not result in any serious additional complications or morbidity. In our study this approach led to improved cancer staging: four of 20 harvested IMC-SLNs proved to be micrometastatic. None of these four patients had metastatic axillary SLNs. Exclusive drainage to the IMC is present in only a small number of breast cancer patients, and our results suggest that it is possible to avoid unnecessary axillary node dissection in such cases.

Report on a Case of Pure Cribriform Carcinoma of the Breast with Internal Mammary Node Metastasis: Description of the Case and Review of the Literature

Aims and background

Pure ductal invasive carcinoma of the breast is more frequently associated with lymphatic invasion, lymph node involvement and high malignant histological grade than combined forms of breast carcinoma. Internal mammary node metastases are not frequently detected when the axillary nodes are negative.

Patients and methods

We report our experience of a case of pure cribriform carcinoma, associated with an intraductal cribriform component, in which the sentinel axillary nodes were negative, while nodal and perinodal metastasis was detected in one internal mammary lymph node.

Conclusions

Data from the literature show that positive internal mammary nodes are an unusual finding when the axillary sentinel node is negative, especially in cases of cancer with a relatively good prognosis, such as cribriform cases.

Impact of internal mammary lymph node drainage identified by preoperative lymphoscintigraphy on outcomes in patients with stage I to III breast cancer

BACKGROUND

Involvement of internal mammary (IM) lymph nodes is associated with a poor prognosis for patients with breast cancer. This study examined the effect of drainage to IM nodes identified by lymphoscintigraphy on oncologic outcomes.

METHODS

A prospectively maintained breast cancer patient database at the University of Texas MD Anderson Cancer Center was used to identify patients with stage I to III breast cancer who underwent preoperative lymphoscintigraphy with peritumoral injection of colloid and intraoperative lymphatic mapping from 1996 to 2005. Medical records were reviewed of 1772 patients who had drainage to any lymph node basin on lymphoscintigraphy but who did not undergo IM nodal biopsy. Patients with IM drainage, with or without axillary drainage, were compared with patients without IM drainage. Local-regional recurrence, distant disease-free survival (DDFS), and overall survival were evaluated.

RESULTS

We identified IM drainage in 334 patients (18.8%). Patients with IM drainage were significantly younger, less likely to have upper outer quadrant tumors, and more likely to have smaller and medial tumors than patients without IM drainage. Rates of IM irradiation did not differ between the 2 groups. The median follow-up time was 7.4 years. On multivariate analysis, IM drainage was significantly associated with a worse DDFS (hazard ratio, 1.6; 95% confidence interval, 1.03-2.6; P = .04) but not local-regional recurrence or overall survival.

CONCLUSIONS

IM drainage on preoperative lymphoscintigraphy was found to be significantly associated with worse DDFS. Further study is needed to determine the role of lymphoscintigraphy in the personalization of breast cancer staging and therapy.

[Usefulness of imaging posture using anterior view of the half supine position for sentinel lymphscintigraphy in patients with breast cancer]

OBJECTIVES

Sentinel lymphoscintigraphy(SLSG) is focused on the visualization of an injection site and lymph nodes. Therefore, an anterior view is effective in identifying the location of a lymph node easily. For this reason, we devised a new imaging method of anterior view (Modified Anterior View; MAV), and the usefulness was assessed.

METHODS

SLSG was obtained in 166 patients with breast cancer. In MAV imaging, patients were laid in an oblique position on a triangular styrene foam elevating the target axillary side. The detector was also leaned. Just after the MAV were imaged, the patient was shifted to the supine position and the SAV imaging was also performed using the same acquisition times.

RESULTS

The detectability of MAV and SAV was 92.42% and 81.99%, respectively. However, the detectability of SAV showed the better value for the few cases which the lymph node detected by the inside of injection site.

CONCLUSION

MAV may improve detectability of SLN. However, SAV is still required for a few cases in which lymph node is detected by the inside of injection site.

Should internal mammary chain (IMC) sentinel node biopsy be performed?

INTRODUCTION

Although the status of the regional lymph nodes is an important determinant of prognosis in breast cancer, harvesting sentinel nodes (SN) detected in the internal mammary chain (IMC) is still controversial.

AIMS

To determine in how many patients a positive IMC-SN might change the systemic or locoregional adjuvant therapy, with a possible benefit in outcome.

PATIENTS AND METHODS

During 6 1/2 years data of T1-2 breast cancer patients, having an SN procedure, were prospectively collected. Our policy was not to explore the IMC even if it was the only localization of an SN.

RESULTS

In 86 of 571 patients lymphoscintigraphy showed an IMC-SN. In 64 of these, the axillary SN was negative and only 25 of these patients did not have an indication for adjuvant systemic treatment based on their tumor characteristics. In the literature, IMC metastases are found in 0-10% of axillary negative patients. Routine IMC-SN biopsies would have resulted in an indication for adjuvant systemic therapy in 2-3 of our patients. Four parasternal recurrences were found during a median follow-up of 51 months.

CONCLUSIONS

Harvesting IMC-SNs is a procedure of which only a limited number of patients have therapeutical benefit. Even with a thorough selection of patients, the extra morbidity of the procedure should be weighed against the potential benefit for the patient.

Breast conservation: Current results and future perspectives at the European Institute of Oncology

In the recent 10 years breast cancer treatments' scenario is radically changed. Extraordinary new surgical approaches give more and more conservative solutions both for the breast and especially for the axilla avoiding dissection in more than 80% of early cases. Instrumental early diagnosis and clinical prediction are now able to identify very initial cases often in premalignant stage. Technology arrived in the operating theatre for the intraoperative radiotherapy treatments giving to the patients the better quality of life with the help also of the plastic surgeons. There are still near horizons to reach: modern neo-adjuvant and adjuvant treatments are going quickly from the laboratory to patient's bed.

President’s Address

In breast cancer surgery, there has been a major shift toward less invasive local treatment: from extended or radical mastectomy to modified radical mastectomy, from modified radical mastectomy to breast conserving therapy, and from routine axillary lymph node dissection to sentinel lymph node biopsy. Many breast surgeons have experienced an evolutionary progression of surgical management of breast cancer. However, there is an increasing demand for minimally invasive and non-surgical treatment methods for patients with small breast cancer. Radiofrequency (RF) ablation is the most promising among non-surgical ablation techniques in the treatment of breast cancer, although it is still in the investigative stage. Nevertheless, surgery still plays an integral role in the treatment of breast cancer, because local therapy is important for enhancing survival in the presence of systemic therapy. In clinical practice, surgical oncologists must individualize treatments, selecting a surgical or non-surgical procedure that provides the best local control, does not compromise the chances of cure, and achieves the best cosmetic results.

Clinical and Therapeutic Importance of Sentinel Node Biopsy of the Internal Mammary Chain in Patients with Breast Cancer: A Single-Center Study with Long-Term Follow-Up

BACKGROUND

We evaluated the incidence of sentinel lymph nodes (SLNs) in the internal mammary chain, calculated the lymphoscintigraphy and surgical detection rates, and evaluated the clinical effect on staging and the therapeutic approach in patients with breast cancer.

METHODS

The study involved 741 women diagnosed with breast cancer eligible for the SLN technique. Lymphoscintigraphy was performed on the day before the operation by peritumoral injection of (99m)Tc-labeled nanocolloid. During the operation, a gamma probe was used to detect the SLN, which was then removed.

RESULTS

A total of 719 SLNs were found in the axillary chain and 72 in the internal mammary chain. Preoperative lymphoscintigraphy showed 107 hot spots in the internal mammary chain, but only 72 SLNs in 65 patients were identified by the gamma probe and then removed with no complications. Of these 65 patients, 10 had a positive internal mammary chain SLN on final pathologic examination, whereas 55 patients had >or=1 negative SLNs on final pathologic analysis. Thirty-five (53%) of 65 patients had also an axillary SLN, but only 5 patients (8%) had a positive SLN on pathologic analysis.

CONCLUSIONS

Evaluation of the SLNs in the internal mammary chain may provide more accurate staging in breast cancer patients. If an internal mammary sampling is not performed, patients may be understaged. This technique may allow better selection of those patients who will be submitted to adjuvant locoregional radiotherapy.

Subdermal re-injection: a method to increase surgical detection of the sentinel node in breast cancer without increasing the false-negative rate

PURPOSE

The aim of this study was to evaluate in breast cancer whether subdermal (SB) re-injection improves surgical detection (SD) of the sentinel node (SN) in patients with negative lymphoscintigraphy on peritumoral (PT) injection, without increasing the false-negative (FN) rate.

METHODS

Group I comprised 261 patients with invasive breast cancer >3 cm and clinically negative axilla treated with primary chemotherapy. Axillary lymphadenectomy was performed in all of these patients. Group IA comprised 201 patients with PT injection, while group IB comprised 60 patients with SB injection in the tumour quadrant. Group II comprised 652 patients with breast cancer <3 cm; in 73 of these patients with negative lymphoscintigraphy, SB re-injection was performed. For lymphoscintigraphy, 37-55 MBq (99m)Tc-albumin nanocolloid in 1 ml was used for PT injection, and 18 MBq in 0.2 ml for SB injection. Five-minute images were obtained 2 h p.i. for PT injection and 20-30 min p.i. for SB injection. SD was performed 4 or 24 h p.i. Lymphoscintigraphic (LD), surgical and internal mammary (IM) detection rates were calculated. In group I, FN, negative predictive value (NPV) and accuracy (A) were calculated. Statistical analysis was performed using the chi-square test.

RESULTS

In percentages, results were as follows: Group IA: SD: 84.1, FN: 13.6, NPV: 88.9, A: 78.6, IM: 14.5*. Group IB: SD: 90, FN: 0, NPV: 100, A: 90, IM: 1.7* (*p<0.025). Group II: PT injection only: LD: 82.4, SD: 94; PT injection+SB re-injection: LD: 90, SD: 98.5. SD was 97.8** in patients with positive lymphoscintigraphy and 58.5** when lymphoscintigraphy was negative (**p<0.001).

CONCLUSION

For correct staging, including extra-axillary drainage, peritumoural injection should first be performed. When the SN is not visualised, and only in those cases, SB re-injection should be performed, which increases the SD rate without increasing the FN rate.

Breast Cancer With Isolated Internal Mammary Lymph Node Metastasis

Internal mammary (IM) lymph nodes can be seen on sonograms. It is important to recognize the sonographic features that make IM nodes worrisome for metastatic disease. Breast cancer, especially when located in the medial breast, can have IM node involvement without axillary lymphadenopathy. Prognosis, staging, and treatment will be altered based on lymph node involvement found with breast cancer. Breast sonography has been warranted following mammographically detectable densities and/or palpable abnormalities.

Lymphatic mapping and sentinel node biopsy in women with an ipsilateral second breast carcinoma and a history of breast and axillary surgery

BACKGROUND

Women with a history of breast and axillary surgery may demonstrate aberrant lymphatic drainage caused by disrupted lymphatic channels. Lymphoscintigraphy may be valuable in evaluation and staging of an ipsilateral second breast carcinoma.

METHODS

We conducted a retrospective review of 16 women treated for a second ipsilateral breast carcinoma who underwent breast lymphoscintigraphy and intraoperative lymphatic mapping. Drainage patterns were compared with pathologic and operative findings.

RESULTS

Lymphoscintigraphy succeeded in 69% of patients and demonstrated widely varied drainage patterns including ipsilateral axillary and supraclavicular as well as contralateral axillary and supraclavicular basins. No trend between successful lymphatic mapping and multiple clinical and pathologic measures was seen.

CONCLUSIONS

In women with a second ipsilateral breast carcinoma and history of previous breast and axillary surgery, lymphoscintigraphy is feasible. Drainage patterns vary widely including across the midline of the thorax. Preoperative lymphoscintigraphy may be useful to ensure inclusion of potential sentinel nodes within the operative field.

Clinical relevance of sentinel lymph nodes in the internal mammary chain in breast cancer patients

PURPOSE

Despite the widespread use of sentinel lymph node (SLN) biopsy in breast cancer patients, some controversy exists about the correct management of extra-axillary nodes, especially those located in the internal mammary chain. The aim of this study was to evaluate the incidence of SLNs in this region, calculate the lymphoscintigraphic and surgical detection rates and evaluate the clinical impact on staging and therapeutic decisions.

METHODS

The study involved 383 consecutive women diagnosed with early breast cancer with T1 or T2 tumours. Eight patients had a bilateral tumour, which brought the total to 391 lesions. Lymphoscintigraphy was performed on the day before surgery by injection of (99m)Tc-labelled nanocolloid. The injection site was subdermal (68 patients), peritumoural (107 patients) or intratumoural (216 patients). During surgery a gamma probe was used to guide the surgeon and the SLNs were removed. SLNs were analysed by a conventional pathological study and processed for H&E examination and immunohistochemistry.

RESULTS

Lymphoscintigraphy detected at least one SLN in 369 out of the 391 procedures (94.4%). SLNs were found in the axillary chain in 367 cases and in the internal mammary chain in 55. In two of these 55 cases (3.6%), the SLN was the only one detected. There was no drainage to the internal mammary chain in any case of subdermal injection but such drainage was found in 15.9% of cases with peritumoural injection and 17.6% of those with intratumoural injection. Compared with tumours located in the outer quadrants, a higher percentage of tumours located in the inner quadrants showed drainage to the internal mammary chain (p<0.001). A total of 42 SLNs in the internal mammary chain could be removed in 32 patients without appreciable morbidity. In 20 cases both axillary and internal mammary SLNs were negative, in four both were positive, and in five axillary SLNs were positive and internal mammary SLNs were negative. More interestingly, in the remaining patient with both axillary and internal mammary SLNs, the axillary SLN was negative while malignant cells were found in the internal mammary region. In the evaluation of the clinical impact of internal mammary SLN biopsy, we found that staging was modified from pN1a to pN1c in four patients and, more importantly, from pN0 to pN0(i+) in one patient. The change in stage led to a modification of the postoperative treatment plan with respect to radiotherapy and systemic therapy.

CONCLUSION

Evaluation of the SLNs in the internal mammary chain provides more accurate staging of breast cancer patients. If internal mammary sampling is not performed, patients can be understaged. This technique can offer a better indication of those patients who will benefit from selective treatment options like radiotherapy to this region or systemic therapy.

Lower and central tumor location correlates with lymphoscintigraphy drainage to the internal mammary lymph nodes in breast carcinoma

BACKGROUND

Radiation to the internal mammary chain (IMC) may be indicated for breast carcinoma patients with positive axillary sentinel lymph nodes (SLNs) and lymphoscintigraphic evidence of drainage to the IMC. The purpose of this study was to identify predictors of IMC drainage in patients with positive axillary SLNs.

METHODS

The records of 297 breast carcinoma patients with positive axillary SLNs and preoperative lymphoscintigraphy were reviewed between 1995 and 2002. Radiolabeled colloid was injected peritumorally with lymphoscintigraphy performed 30-60 minutes later. Drainage to the regional nodes of 279 patients was seen on lymphoscintigraphy. Associations among patient and tumor-related factors and drainage to the IMC were examined.

RESULTS

Drainage to the IMC on lymphoscintigraphy was seen in 63 patients (21%). IMC drainage only occurred in 4 patients, and 59 patients had both axillary and IMC drainage. The only variable that correlated with IMC drainage was tumor location (P = 0.017). Rates of drainage to the IMC were 14.1% for upper outer quadrant (n = 128), 16.7% for upper inner quadrant (n = 30), 31.6% for lower outer quadrant (n = 19), 42.9% for lower inner quadrant (n = 14), and 28.4% for central tumors (n = 88). IMC drainage rates differed significantly between upper and lower tumors (lower 36.4% vs. central 28.4% vs. upper 14.6%, P = 0.003) but not between medial and lateral tumors (medial 25.0% vs. central 28.4% vs. lateral 16.3%, P = 0.077).

CONCLUSIONS

Patients with tumors in the lower or central breast and positive axillary SLNs have increased incidence of drainage to the IMC. Preoperative lymphoscintigraphy can help to define the nodal basins at risk for harboring disease.

Recent development of sentinel lymph node biopsy for breast cancer in Japan

The number of breast cancer cases undergoing sentinel lymph node biopsy (SLNB) has been increasing with the number of articles published in Japan. SLNB using the dye method alone is performed in about one-third of patients. Analysis of questionnaire responses from 40 institutions in Japan revealed an identification rate by the dye method alone of 87%, compared with 96% using the combined method; the combined method is now recognized in Japan as superior to the dye method alone. No dyes have been specifically approved by the government for use in SLNB, and physicians have been using several inappropriate dyes as tracers for SLNB, such as indocyanine green, patent blue, indigo carmine, and isosulfan blue. The colloidal radiotracers used in Japan include tin colloid, stannous phytate, rhenium sulfate and human serum albumin. Albumin colloid and sulfur colloid are not commercially available in Japan. Small-size tin colloids, stannous phytate and rhenium sulfate all yield good results in terms of detection and false-negative rates. Provided that the surgeon has adequate experience in SLNB, a negative sentinel node can serve as a substitute for negative results from axillary lymph node dissection. Although many institutions have introduced SLNB, few reports have focused on the results of SLNB without axillary dissection because of short follow-up times and small number of patients. The final decision as to whether SLNB is an adequate substitute for axillary dissection awaits the results of prospective randomized trials.

Current Controversies Concerning Sentinel Lymph Node Biopsy for Breast Cancer

BACKGROUND AND METHODS

The objectives of this article are to review existing controversies regarding sentinel lymph node (SLN) biopsy and to identify potential areas of consensus in order to eliminate routine axillary lymph node dissection (ALND).

RESULTS

A combination of peritumoral injection with radioisotopes and subdermal or subareolar injection with blue dye may result in enhanced success rates of SLN identification. Preoperative lymphoscintigraphy is most useful for detecting an internal mammary SLN, but the practicability of internal mammary SLN biopsy is still in the investigative stage. Intraoperative diagnosis of SLN is useful because patients with SLN metastases may be treated immediately with ALND, but it is unreasonable to expect that either examination of frozen sections or imprint cytology will detect every metastatic disease. SLN micrometastases may be of prognostic importance and these can be identified with H and E staining on permanent sections of 200 micro m intervals. While ALND is preferable for patients even with a small tumor (T1) and SLN micrometastases, radiation therapy is an acceptable alternative. SLN biopsy may be indicated for patients with DCIS detected as a palpable mass or those with large calcification areas in the breast. The accuracy of SLN biopsy after neoadjuvant chemotherapy is considered to be unproven.

CONCLUSION

Since SLN biopsy has been adopted by surgeons around the world, consistency of technique and case selection has attained great significance.

Lymphatic drainage patterns from the breast

OBJECTIVES

The aim of this study was to describe the lymphatic drainage patterns from the 5 "quadrants" of the breast.

SUMMARY BACKGROUND DATA

Lymphatic mapping has provided techniques to visualize and harvest sentinel nodes in various locations and has generated renewed interest in nodes outside the axilla.

METHODS

Between January 1997 and June 2002, 700 sentinel node procedures were performed in patients with cN0 breast cancer. Preoperative lymphoscintigraphy was performed after injection of 99mTc-nanocolloid into the tumor in a volume of 0.2 mL and a mean dose of 107.7 MBq (2.8 mCi). Intraoperatively, the sentinel node was pursued with the aid of a gamma-ray detection probe and patent blue dye (1.0 mL, into the lesion). The patients were divided into 5 groups according to the location of the primary breast cancer. In each group, a distinction was made between palpable and nonpalpable lesions of the breast.

RESULTS

Drainage to either an axillary or an extra-axillary basin was observed in 678 patients. Both palpable and nonpalpable lesions may drain toward the internal mammary chain, although the latter more frequently, regardless of the quadrant. Drainage was also observed to supraclavicular, infraclavicular, interpectoral, and intramammary sentinel nodes.

CONCLUSION

In each quadrant, a breast cancer may drain to sentinel nodes in various locations. There is a distinct difference in drainage patterns between palpable and nonpalpable lesions. These findings may improve the assessment of lymphatic dissemination in invasive breast cancer.

Malignant Pleural and Pericardial Effusion in Invasive Breast Cancer: Impact of the Site of the Primary Tumor

BACKGROUND

Malignant effusion in invasive breast cancer, either pleural or pericardial, is associated with a poor survival rate. We investigated the role of the location of invasive breast cancer in developing malignant pleural or pericardial effusion.

METHODS

Three thousand eight hundred and fifty six women with a history of invasive breast cancer between 1960 and 1994 were analyzed in a retrospective study. Two hundred and six patients (5.34%; group A) developed malignant pleural and/or pericardial fluid as the first visible clinical sign of distant metastasis. A control group of 206 patients (group B) without malignant effusions were matched in terms of clinical and pathological characteristics. The two groups were compared in respect of the location of the primary tumor. Fifty patients in group A (n = 50; 24.2%) had tumors in the inner quadrants, 83 patients (n = 83; 40.3%) in the outer quadrants, and 13 patients (n = 13; 6.3%) in a central location. No data were available for 60 patients (n = 60; 29.1%). In group B, 12 patients (n = 12; 5.9%) had tumors in the inner quadrants, 140 patients (n = 140; 68.0%) in the outer quadrants, 14 patients (n = 14; 6.8%) had centrally located tumors, while no data were available for 40 patients (n = 40; 19.4%). Invasive ductal carcinomas (IDC) located in the inner quadrants were highly significantly associated with increased pleural or pericardial effusion as the first site of distant metastasis (p <or= 0.0001; chi-square tests).

CONCLUSION

IDC in the inner quadrants were associated with a 4-fold higher rate of malignant pleural or pericardial effusions. Further studies will have to determine whether tumor location is a criterion for more aggressive adjuvant therapy.

Clinical relevance of parasternal uptake in sentinel node procedure for breast cancer

BACKGROUND AND OBJECTIVES

Preoperative lymphoscintigraphy contributes highly to the accuracy of the sentinel node procedure. Besides routing towards the axilla, in a number of patients additional parasternal focal accumulation may be observed. So far the clinical consequences of this parasternal uptake remains unclarified, i.e., whether any internal mammary lymph node uptake should be surgically biopsied. An analysis of all sentinel node procedures with parasternal uptake was performed.

METHODS

Sixty-nine patients with scintigraphic parasternal uptake and with a minimal follow-up of 24 months, were selected from a prospective database. Tumor characteristics, treatment strategies, and recurrences of these patients were analyzed and subsequently matched against the present day indications for adjuvant treatment.

RESULTS

During follow-up (median 41 months) only four (6%) patients developed systemic disease. Initially, three of these patients did not receive adjuvant chemotherapy. Two are alive without evidence of disease after treatment of these recurrences. Currently these patients would, initially, all have been eligible for chemotherapy based on tumor characteristics and age according to international guidelines.

CONCLUSIONS

For the indication of adjuvant treatment, the status of the internal mammary lymph nodes was not relevant in our patients. Parasternal uptake is not an indication to extend the surgical procedure.

Relevance and practicability of internal mammary sentinel node biopsy for breast cancer

OBJECTIVES AND METHOD

Recent observations in breast cancer patients undergoing sentinel lymph node (SLN) mapping, in which drainage can be traced to the internal mammary node (IMN) chain, have renewed interest in the staging and treatment of the disease. This paper discusses the relevance of internal mammary SLN biopsy and suggests an optimal procedure for the identification of the SLN in the IMN chain.

RESULTS

Axillary lymph node (AX) and IMN status have similar predictive relevance for survival, while the involvement of IMNs has prognostic value for AX-negative as well as AX-positive patients. Although parasternal recurrence is fortunately rare after modified radical mastectomy or breast conserving surgery, if left untreated it not infrequently develops as clinically evident disease in patients with histologic involvement of IMNs. "Hot" internal mammary SLNs can be identified by means of lymphoscintigraphy and gamma-detection probe after peritumoral injection of radioisotopes. A positive internal mammary SLN biopsy would be an indication for internal mammary radiotherapy as well as adjuvant systemic treatment. However, the reported incidence of positive internal mammary SLNs is still lower than expected because the spread of radioactivity does not necessarily coincide with nodal involvement.

CONCLUSION

Internal mammary SLN biopsy has proven to be relevant but not yet fully practical because more data are needed on the collection of a "Hot" internal mammary SLN and on pathologic involvement. This means that internal mammary SLN biopsy should be regarded as still investigative.

Stage migration after biopsy of internal mammary chain lymph nodes in breast cancer patients

BACKGROUND

Involvement of the internal mammary chain lymph nodes (IMNs) is associated with worsened prognosis in breast cancer. Use of lymphoscintigraphy to visualize sentinel nodes reveals that IMNs often receive lymph from the area containing the tumor.

METHODS

We biopsied IMNs in 182 patients because there was radiouptake to the IMNs or because the tumor was located in the medial portion of the breast. After tumor removal, pectoralis major fibers were divided to expose intercostal muscle. A portion of intercostal muscle adjacent to the sternum was removed. Lymph nodes and surrounding fatty tissue in the intercostal space were freed, removed, and analyzed histologically. The pleural cavity was breached in four cases (2.2%), with spontaneous resolution.

RESULTS

IMNs were found in 160 (88%) of 182 patients; 146 (94.4%) were negative and 14 (8.8%) were positive. The latter received internal mammary chain radiotherapy. The axilla was negative in 4 of 14 cases and positive in 10.

CONCLUSIONS

IMNs can be quickly and easily removed via the breast incision with insignificant risk and no increase in postoperative hospitalization. The patients with a positive IMN migrated from N0 (4 cases) or N1 (10 cases) to N3, prompting modification of both local (radiotherapy to internal mammary chain) and systemic treatment; without IMN sampling, they would have been understaged.

Will early detection of non-axillary sentinel nodes affect treatment decisions?

Axillary lymph node involvement is the best prognostic factor for breast cancer survival. Staging breast cancers by axillary dissection remains standard management and is part of the UK national guidelines for breast cancer treatment. In the presence of involved axillary lymph nodes best treatment has been shown to be axillary clearance (Fentiman and Mansell, 1991), but clearly for women whose nodes are uninvolved avoidance of morbidity is optimal and this will be achieved by minimal dissection of the axilla. Thus, for node-negative women the introduction of the sentinel node biopsy technique may revolutionise the approach to the axilla. These will be women with mammographic screen detected small well and moderately differentiated tumours (Hadjiloucas and Bundred, 2000). The impact of sentinel node biopsy in women who have symptomatic large tumours is unproven, and around half of these women will require a second procedure to clear their axilla or radiotherapy as treatment. Even for those women found to have involved sentinel lymph nodes the ability to use early systemic chemotherapy followed by axillary clearance or radiotherapy may provide long-term survival gains. Sentinel node biopsy should not, however, become routine practice until randomised controlled trials have proven its benefit and safety in reducing morbidity. Several randomised controlled trials (including ALMANAC) are currently underway.

A selection algorithm for internal mammary sentinel lymph node biopsy in breast cancer

Internal mammary lymph-node (IMN) metastases in breast carcinomas have a major influence on survival, comparable with the influence of axillary lymph-node metastases (ALNM). Prospective, randomized trials have demonstrated that complete IMN dissection as part of extended radical mastectomy does not improve overall or disease-free survival. In the subset of patients with tumours 1cm or less in size and no ALNM, information on IMN status would provide important information. In these cases, the presence of IMN metastases would change the staging from stage I to stage IIIB, according to the current tumour, node and metastasis classification. More importantly, it would influence these patients' adjuvant treatment. Lymphatic mapping for sentinel lymph-node (SLN) biopsy has demonstrated extra-axillary drainage in up to 35% of patients. Recent reports have demonstrated the feasibility of internal mammary sentinel lymph-node (IM-SLN) biopsy. Here we review the general prognostic and clinical significance of tumor location and lymph-node metastases in breast cancer and discuss the specific factors associated with IMN identification, metastases and treatment in the pre-SLN and SLN eras. Based on our review, we propose an algorithm for a selective approach to IM-SLN in breast cancer.

Sentinel lymph node biopsy in breast cancer: an overview of the Japanese experience

This paper reviews the Japanese literature regarding sentinel lymph node (SLN) biopsy in an attempt to provide an overview of existing controversies and to suggest a method for the identification of the SLN and the detection of micrometastases in the SLN to eliminate unnecessary axillary lymph node dissection (ALND). The combined dye- and gamma probe-guided method resulted in the accurate identification of the SLN in 96% of patients, compared with 80% when the dye-guided method alone was used. Although neither 99m-Tc sulfur colloid nor 99m-Tc colloidal albumin is commercially available in Japan, 99m-Tc stannous phytate and 99m-Tc rhenium colloid appear to be ideal tracers for identifying SLNs. Moreover, subdermal injection over the primary tumor or subareolar injection was found to enhance SLN identification, although these injection routes do not lead to detection of internal mammary SLNs. Furthermore, the accuracy of SLN diagnosis using frozen sections as well as imprint cytology improved with an increase in the number of sections, and could attain a sensitivity comparable to that obtained with routine histologic examination of permanent sections. As a result, several surgeons have begun to offer the option of forgoing ALND to patients with negative SLN. Although subsequent relapse in the axilla has not yet been reported, longer follow-up periods are needed to assess accurately the incidence of axillary failure in these negative SLN patients.

Sentinel lymph node biopsy and breast cancer

BACKGROUND AND METHOD

This paper reviews and discusses the feasibility and accuracy of sentinel lymph node (SLN) biopsy in breast cancer. A standardized method of identifying the SLN and detecting micrometastases is suggested, along with a strategy for the elimination of routine axillary lymph node dissection (ALND).

RESULTS

Although the SLN can be identified successfully by experienced practitioners using either the dye-guided or gamma probe-guided method, identification is facilitated when the two techniques are combined. To improve the likelihood of spotting metastases in the SLN, it is desirable to perform step sectioning combined with haematoxylin and eosin staining and immunohistochemistry of permanent and frozen sections. SLN biopsy is as accurate for T2 tumours as it is for T1 tumours. However, it is highly unlikely that all false-negative cases can be eliminated, even by detailed histological examination. Nevertheless, patients with T1 tumours with micrometastases in the SLN have shown no evidence of tumour in the non-sentinel nodes. In other words, ALND can be avoided in these patients, even if histological examination of the SLN fails to detect micrometastasis.

CONCLUSION

In practice, routine ALND can be avoided in patients with T1 tumours when the identified SLN proves to be histologically negative. However, investigation of long-term regional controls and of survival in a prospective randomized trial is necessary before SLN biopsy can replace routine ALND, particularly for patients with T2 tumours.

Detection of micrometastasis in the sentinel lymph nodes in breast cancer

BACKGROUND

The axillary lymph node (ALN) status is still the most important prognostic factor in the staging and treatment of breast cancer. Intraoperative lymphatic mapping and sentinel lymphadenectomy techniques were investigated in patients with early-stage breast cancer who did not have clinically palpable ALNs.

METHODS

Forty-four patients with breast cancer underwent a sentinel lymph node biopsy (SLNB), followed by a complete axillary lymphadenectomy. Sentinel lymph nodes (SLNs) were detected by means of so-called 2-way mapping with coloring matter and an isotope. Our standard protocol for evaluating metastasis in SLNs included a frozen section at 1 level for reverse transcription polymerase chain reaction (RT-PCR), plus a paraffin section at 1 level for immunohistochemistry (IHC) of cytokeratin 19, while the rest were evaluated by hematoxylin-eosin (H&E) staining.

RESULTS

SLNs were identified in 42 (95%) of 44 patients. Twenty-one patients had no metastasis in SLNs; however, ALN metastasis was found in 3 patients. Of these 3 patients, 2 had micrometastasis detected by means of either IHC or RT-PCR. Therefore the false-negative rate was decreased from 7% (3/44) to 2% (1/44). Furthermore, of the remaining 18 ALN-negative patients, micrometastasis was detected by means of either IHC or RT-PCR in 7 (39%) patients.

CONCLUSION

We suggest that SLNB is recommended to detect micrometastasis by means of H&E staining, IHC, and RT-PCR. Omitting ALN dissection referred by SLNB should be avoided if SLNs were evaluated only by H&E staining, and/or IHC without RT-PCR.

Internal mammary lymph nodes and sentinel node biopsy in breast cancer

The long-term follow-up of patients treated with extended radical mastectomy has proved that the internal mammary node (IMN) status is an important prognosticator of breast cancer. Patients with isolated IMN involvement seem to have the same outcome as those with limited axillary disease, and these patients may therefore be overstaged in the TNM system. Sentinel node biopsy (SNB) of IMNs may be an ideal staging procedure, but lymphatic mapping studies demonstrate that data from extended radical mastectomy series cannot be extrapolated to patients suitable for SNB, where the IMN involvement is <5% overall, and around 1% for IMN metastases without axillary disease. Current evidence does not allow internal mammary SNB to be recommended as a standard procedure, but as patients with IMN involvement may benefit from adjuvant systemic treatment, internal mammary SNB should be further studied in this context.

Clinical and pathologic factors predicting axillary lymph node involvement in breast cancer

The diagnosis of axillary disease remains a challenge in the management of breast cancer and is a subject of controversy. In 1998, the Japanese Breast Cancer Society conducted a study assessing axillary lymph node involvement in breast cancer. The study included (a) clinical assessment by pre-operative imaging modalities, (b) histologic assessment for peritumoral lymphatic invasion, (c) biologic assessment by gelatinolytic activity using film in situ zymography, and (d) sentinel lymph node (SLN) biopsy. Clinical assessments by CT, PET, and US as well as biologic assessment were limited in their ability to detect axillary lymph node disease, although these imaging techniques may be useful to exclude node-positive patients from the need for SLN biopsy. Histologic assessment for peritumoral lymphatic invasion was useful, particularly for detecting false-negative cases by SLN biopsy. Nevertheless, the utility of SLN biopsy in assessing axillary nodal status was confirmed. Axillary lymph node dissection (ALND) can be avoided in patients with a small tumor and a negative SLN. However, further studies will be required to investigate the value of SLN biopsy for predicting regional control and survival before it can replace routine ALND as the optimal staging procedure for operable breast cancer.

National practice patterns of sentinel lymph node dissection for breast carcinoma

BACKGROUND

The sentinel node is the first regional lymph node to receive tumor cells that metastasize through the lymphatic channel from a primary tumor. The tumor status of the sentinel node should reflect the tumor status of the entire regional node basin. Sentinel lymph node dissection (SLND) has recently been investigated for use in patients with early breast carcinoma to avoid the sequelae of complete axillary lymph node dissection (ALND). Published studies of SLND in breast cancer patients identify marked variations in technique, and there are few guidelines for credentialing surgeons to perform SLND.

STUDY DESIGN

The purpose of this study was to assess the current practice of SLND for breast cancer in the United States. A 27-item questionnaire was mailed to 1,000 randomly selected Fellows of the American College of Surgeons. Responses were anonymous. Statistical analysis was performed using SAS software (SAS Institute, Cary, NC).

RESULTS

Response rate was 41% (n = 410), and 77% of those who responded performed SLND for breast cancer. The majority (60%) of surgeons responding routinely ordered preoperative lymphoscintigraphy. Of those who did lymphoscintigraphy, 28% removed internal mammary lymph nodes when lymphoscintigraphy showed drainage to these nodes. Ninety percent of surgeons used both blue dye and radiocolloid. Eighty percent of centers responding performed routine immunohistochemistry on sentinel lymph nodes, and 15% performed reverse transcription polymerase chain reaction. Ninety-six percent of surgeons performed SLND for primary tumors 5 cm or smaller, and 95% performed SLND for an excisional cavity 6 cm and smaller. Twenty-eight percent performed SLND for high-grade ductal carcinoma in situ, and 28% of respondents performed 10 or fewer SLND procedures with subsequent ALND before performing SLND alone. Surgeons learned SLND through courses (35%), oncology fellowships (26%), observation of other surgeons (31%), or were self-taught (26%).

CONCLUSIONS

The majority of surgeons in the United States use similar technique for SLND breast cancer. But, there was marked variation in the number of SLND cases validated by an ALND before performing SLND only.

Internal mammary lymph node drainage patterns in patients with breast cancer documented by breast lymphoscintigraphy

BACKGROUND

Metastases to internal mammary lymph nodes (IMN) may occur in patients with breast cancer and may alter treatment recommendations. The purpose of this study was to identify the frequency of IMN drainage in patients undergoing breast lymphoscintigraphy and sentinel lymph node dissection (SLND).

METHODS

The combined technique of peritumoral injection of radiocolloid and Lymphazurin blue for SLND was performed on 220 patients. All patients underwent preoperative lymphoscintigraphy before SLND. Lesion location by quadrant included: 110 upper outer (UOQ), 49 lower outer (LOQ), 30 upper inner (UIQ), 24 lower inner (LIQ), and 7 central.

RESULTS

Drainage to any nodal basin was observed in 184 of 220 patients (84%). IMN drainage was documented in 37 of 220 (17%) of patients. IMN drainage without evidence of axillary drainage occurred in 2 of 220 patients(1%). Drainage to the IMN based on quadrant location of the lesion was as follows: UOQ, 10%; LOQ, 27%; UIQ, 17%; LIQ, 25%; and central, 29%.

CONCLUSIONS

Internal mammary lymph node drainage shown by breast lymphoscintigraphy is common. Tumors in all quadrants may drain to IMNs, although drainage is significantly more common from quadrants other than the UOQ. Further studies are needed to determine whether lymphoscintigraphy drainage patterns identify patients at the highest risk for IMN metastases who may benefit from radiotherapy.

Sentinel lymph node biopsy as an alternative to routine axillary lymph node dissection in breast cancer patients

Sentinel lymph node (SLN) biopsy is a useful way of assessing axillary nodal status and obviating axillary lymph node dissection (ALND) in patients with node-negative breast cancer. Because SLN technology is evolving rapidly, however, variation in technique is widespread, and no standardization has yet been accomplished. This review discusses the feasibility and accuracy of this procedure and suggests the optimal method for identifying the SLN and detecting micrometastases. Although the SLN can be successfully identified by either the dye-guided or gamma probe-guided method in experienced hands, identification is facilitated when the two techniques are used together. In the gamma probe-guided method, the use of a large-sized radiotracer (particle size, 200-1000 nm) may be preferred because only one or two SLNs are identified. To increase the chance of finding metastases in SLN, it is desirable to make step sections with hematoxylin and eosin staining on permanent and frozen sections. The addition of immunohistochemistry may improve the accuracy of SLN diagnosis. The intraoperative examination of imprint cytology may be useful in determining the status of the SLNs, but further studies are needed to establish whether it has additional value when combined with the frozen section. In practice, routine ALND can be avoided when there is documentation of extensive experience and a low false-negative rate with the technique in the hands of a particular surgeon and hospital team. Particularly, SLN biopsy is more successful and has a lower false-negative rate in patients with smaller tumors. However, investigation of long-term regional control and survival in a prospective randomized trial is necessary, before SLN biopsy can replace routine ALND as the preferred staging operation for women with breast cancer.

A multicenter validation study of sentinel lymph node biopsy by the Japanese Breast Cancer Society

Several pilot studies have indicated that SLN biopsy can be used to identify axillary lymph node metastases in patients with breast cancer. To confirm this finding, a multicenter study in a variety of practice settings was performed. A total of 674 patients with breast cancer at five institutions were enrolled. The techniques of SLN identification included the vital dye-guided and the vital dye- and gamma probe-guided methods. The SLN was removed, and complete axillary lymph node dissection (ALND) was performed. SLN and ALND specimens were examined separately. The SLN was successfully identified in 214 (94%) of 227 patients using the combined dye- and gamma probe-guided methods. The SLN was identified in 332 (74%) of 447 patients using vital dye-guided method alone. Patient age of at least 21 years, medially located primary tumor, and clinically positive nodes were correlated with failure to identify the SLN. The accuracy of SLN biopsy for the detection of metastatic disease was 96% (522 of 546), and the sensitivity was 90% (203 of 226). Accuracy of 100% was achieved in the patients with tumors less than 1.6 cm in diameter. All 23 false negative results occurred with larger primary tumors. SLN biopsy can accurately predict the presence or absence of axillary lymph node metastases, particularly in patients with small (< or = 1.5 cm) breast cancers.