Sentinel lymph node biopsy in breast cancer using blue dye with or without isotope localization

Comparison of the Diagnostic Value Between Real-Time Reverse Transcription-Polymerase Chain Reaction Assay and Histopathologic Examination in Sentinel Lymph Nodes for Patients With Gastric Carcinoma

OBJECTIVES

Sentinel lymph node (SLN)-based diagnosis in gastric cancers has shown varied sensitivities and false-negative rates in several studies. Application of the reverse transcription-polymerase chain reaction (RT-PCR) in SLN diagnosis has recently been proposed.

METHODS

A total of 155 SLNs from 65 patients with cT1-2, N0 gastric cancer were examined. The histopathologic results were compared with results obtained by real-time RT-PCR for detecting molecular RNA (mRNA) of cytokeratin (CK)19, carcinoembryonic antigen (CEA), and CK20.

RESULTS

The sensitivity and specificity of the multiple marker RT-PCR assay standardized against the results of the postoperative histological examination were 0.778 (95% confidence interval [CI], 0.577-0.914) and 0.781 (95% CI, 0.700-0.850), respectively. In comparison, the sensitivity and specificity of intraoperative diagnosis were 0.819 (95% CI, 0.619-0.937) and 1.000 (95% CI, 0.972-1.000), respectively. The positive predictive value of the multiple-marker RT-PCR assay was 0.355 (95% CI, 0.192-0.546) for predicting non-SLN metastasis, which was lower than that of intraoperative diagnosis (0.813, 95% CI, 0.544-0.960).

CONCLUSIONS

The real-time RT-PCR assay could detect SLN metastasis in gastric cancer. However, the predictive value of the real-time RT-PCR assay was lower than that of precise histopathologic examination and did not outweigh that of our intraoperative SLN diagnosis.

Sentinel lymph node biopsy in breast cancer: a work in progress

The sentinel lymph node biopsy is a safe, accurate operation for the initial staging of breast cancer. Over the last decade, there has been increasing literature supporting its use, and it is now considered a standard of care for the initial evaluation of metastatic spread to the axillary lymph node chain.

Reliability of frozen section in breast sentinel lymph node examination

OBJECTIVES

Sentinel lymph node (SLN) examination in breast carcinoma is crucial to spare patients unnecessary lymph node (LN) dissection. The specificity and accuracy of SLN examination by frozen section has been variable in many studies. This study aims to describe our experience in frozen section (FS) analysis of SLN.

METHODS

We have retrospectively analyzed data from 449 axillary SLN subjected to FS examination from 440 patients with breast cancer. All patients had free axillary LN clinically.

RESULTS

Out of 449 cases, no false positive cases were found on FS (specificity of 100 %). Twenty-six cases were false negative (6 interpretation-related reasons and 20 technical-related reasons). The overall sensitivity was 84 % with a total accuracy rate of 93 % and interpretation sensitivity of 96 %. Three cases were deferred. Twenty-two of the false negative cases were micrometastases, whereas 4 were macrometastases. The interpretation-related false negative cases were not related to the subtype of carcinoma (ductal vs. lobular). However, they were all of low nuclear grade.

CONCLUSION

These findings are similar to most published data. FS is a reliable method for evaluating SLN. The most common cause of false negative diagnosis is sampling error. More attention should be paid to low-grade tumors. Moreover, in FS analysis, we recommend to totally submit SLNs that are less than 5 mm in diameter, bisecting them if possible, and to serially section SLNs that are at least 5 mm at 2-mm intervals.

Analysis of sentinel node involvement in gastric cancer

BACKGROUND & AIMS

Sentinel node navigation surgery (SNNS) is performed for patients with early gastric cancer. Because sentinel nodes (SNs) to gastric cancer exist but they have not been well-described, we attempted to validate the SN concept at the micrometastasis level.

METHODS

For 53 patients who underwent curative gastrectomy for T1/T2 (<4 cm) N0 gastric cancer, SNNS was performed with radioactive tin colloid and/or indocyanine green, and subsequent modified D1 lymphadenectomies were added. Whole formalin-fixed paraffin-embedded tissues of all resected lymph nodes from these patients were cut into 5-mum thick serial step sections at 85-mum intervals, and occult metastases were examined immunohistochemically.

RESULTS

Metastases were detected in 3 (1.5%) of 204 SNs and 3 (0.33%) of 901 non-SNs in pN0 cases and in 18 (46%) of 39 SNs and 3 (1.9%) of 158 non-SNs in pN1 cases. On a patient basis, metastases were detected in 4 (9%) of 46 pN0 patients, 2 (4%) each in SNs and non-SNs, and in 7 pN1 patients, of whom 7 and 4 had SN and non-SN metastases, respectively. The sensitivity, false-negative rate, and accuracy of SN identification by SNNS were 82%, 18%, and 96%, respectively, at the occult metastasis level. However, on the basis of the concept of the sentinel lymphatic station (SLS), which represents all lymphatic stations to which SNs belong, metastases were always limited to the lymph nodes in SLS in the 11 cases with metastases. Non-SN metastases occurred in 3 (60%) of 5 patients with SN metastases >2.0 mm in diameter but not in 4 patients with SN metastases </=2.0 mm in diameter.

CONCLUSIONS

The sentinel node concept held true at the occult metastasis level in 96% of patients with gastric cancer, and the accuracy of SNNS was elevated to 100% by introducing the concept of the sentinel lymphatic station. The size of SN metastasis was a predictive factor for metastasis beyond the sentinel node.

Radiofrequency ablation of small breast cancer followed by surgical resection

BACKGROUND

With the growing demand from patients for less-invasive procedures, the shift from surgical extirpation to ablative local control of breast tumors is an emerging focus in breast cancer care. This study was performed to determine the feasibility and safety of treating small breast cancer with radiofrequency (RF) ablation.

METHODS

Patients with biopsy-proven invasive or non-invasive breast cancer underwent RF ablation under general anesthesia. Before RF ablation, all patients were confirmed to have a localized lesion using imaging modalities. Wide excision or total mastectomy with sentinel lymph node biopsy or axillary lymph node dissection was performed. The resected tumor was examined histologically with hematoxylin-eosin (H&E) and nicotinamide adenine dinucleotide-diaphorase (NADH) staining.

RESULTS

Ten patients completed the treatment without RF ablation-related complications. The mean tumor size was 1.1 cm (range: 0.5-2.0 cm). Histological evaluation of the ablated tissue using H&E staining revealed a spectrum of changes ranging from complete coagulation necrosis of tumor cells to normal-appearing tumor cells. However, NADH-diaphorase showed no staining of viable tumor cells in the RF-ablated region in all of the patients.

CONCLUSIONS

RF ablation is promising as a minimally invasive ablation technique in the local treatment of invasive or non-invasive breast cancer. However, further study is necessary before RF ablation can replace conventional breast conservation therapy for patients with small breast cancer.

Pathological Evaluation of Sentinel Lymph Nodes for Breast Cancer

Recently, sentinel lymph node (SLN) biopsy has been employed to avoid unnecessary lymph node dissection, because SLN negativity for carcinoma metastases may imply an extremely low possibility of non-SLN involvement. Pathological evaluation is essential, but standardized procedures have not yet been determined. Intraoperative consultation, either by frozen section (multiple slices are desirable) or touch imprint cytology, are usually very useful. Their accuracy, however, is variable and depends on the procedures used, but specificity is characteristically 100%, and the missed metastatic focus is always quite minute. After fixation, multiple sections, immunohistochemistry, and their combination will be able to detect small metastatic foci more frequently. The clinical significance of small or submicro- or occult metastases have not yet been clarified, and further investigations are needed. If the SLN is positive for carcinoma metastases, both the procedure for detection and the size of the metastatic focus should be clarified on the pathological reports.

Failure of sentinel lymph node mapping in patients with breast cancer1 1No competing interests declared

BACKGROUND

Lymphatic mapping with sentinel lymphadenectomy (SL) has become more widely used as an alternative to axillary dissection for the staging of breast cancer. This study was conducted to evaluate the potential associations of patient and tumor characteristics with the lymphatic mapping failure rate.

STUDY DESIGN

Between September 1996 and April 2003, 1,094 breast cancer patients participated in a single-institution prospective SL protocol, which was conducted using technetium 99 m sulfur colloid alone to identify sentinel lymph nodes. During the validation phase, consisting of the first 80 patients, all patients had SL followed by axillary dissection. Beginning with the 81st patient, the standard technique consisted of radiolabeled colloid injection in a peritumoral distribution 16 to 24 hours before the operation, followed by SL alone for node-negative patients.

RESULTS

Of 1,094 consecutive patients, 62 (5.7%) did not map. Patients having more than 10 involved lymph nodes had a significantly higher incidence of mapping failure (40.9%) than those who were node-negative (5.3%) (odds ratio = 9.19, p = 0.002). Age was a factor predictive of mapping failure for node-negative patients 70+ years of age (odds ratio = 3.14, p = 0.018). Biopsy technique, tumor size, tumor location, cell type, and surgeon experience were not predictors of mapping failure, regardless of node status.

CONCLUSIONS

The lymphatic mapping failure rate was associated with both anatomic and pathologic factors. Patients with extensive nodal involvement had a significantly greater chance of mapping failure. Among node-negative patients, those who were older were more likely to have mapping failure than those who were younger, suggesting that decreased breast density in postmenopausal women might provide an anatomic explanation for nonmapping.

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.

Sentinel node biopsy for breast cancer patients in Japan

Sentinel node biopsy may become a standard procedure to detect lymph node metastases in early breast cancer. Numerous studies have confirmed and demonstrated the reliability of the hypothesis of sentinel node biopsy, with a high identification rate and overall accuracy connected with dye-guided and radio-guided sentinel node biopsy. To assess the benefit of sentinel node biopsy, randomized clinical trials are underway in Western countries comparing sentinel node biopsy with conventional axillary lymph node dissection. In Japan, feasibility studies on sentinel node biopsy started in the mid-1990s. The dye and radiopharmaceuticals associated with sentinel node biopsy commonly used in Western countries are not available in Japan. Japanese investigators have attempted to perform sentinel node biopsy using other dyes and radiopharmaceuticals. The results from feasibility studies have been similar to those reported previously. In conclusion, sentinel node biopsy for breast cancer patients is successful in Japan. The current status and the problems are discussed.

Sentinel lymph node biopsy without axillary dissection after an intraoperative negative histological investigation in 358 invasive breast cancer cases

BACKGROUND

Sentinel lymph node biopsy (SLNB) is an important treatment option for breast cancer patients, as it can accurately predict axillary status. Our previous study using dye with or without radioisotope showed the accuracy and sensitivity of SLNB to be 97% and 94%, respectively. Based on these results, axillary lymph node dissection (ALND) was eliminated starting in January, 1999 in patients with intraoperatively negative SLNB at our institution. The present study shows the results and outcomes of SLNB as a sole procedure for patients with invasive breast cancer.

PATIENTS AND METHODS

Three-hundred-fifty-four patients and 358 cases of invasive breast cancer (4 bilateral breast carcinoma) treated with SLNB alone after an intraoperative negative SLNB were studied prospectively from January 1999 to December 2001.

RESULTS

The number of the identified SLNs per case ranged from 1 to 8 (mean, 2.5). Of a total of 358 cases, 297 (83%) were treated with hormone therapy and/or chemotherapy, and 281 (78%) were treated with radiotherapy to the conserved breast (50 Gy+/-10 Gy boost), the axilla (50 Gy), or the both sites. After a median follow-up of 21 (range 6-42) months, no patient developed an axillary relapse. Four cases initially recurred in distant organs and one case in the conserved breast.

CONCLUSIONS

Our results indicate that an intraoperative negative SLNB without further ALND may be a safe procedure when strict SLNB is performed. To better assess the safety, however, may require longer follow-up.

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.

Therapeutic relevance of breast cancer micrometastases in sentinel lymph nodes

BACKGROUND AND METHODS

This review examines the various methods of detecting occult breast cancer metastasis in the sentinel lymph node (SLN). The prognostic relevance of such micrometastases and isolated tumour cells, and their impact on stage migration and decision making with respect to axillary dissection and adjuvant systemic therapy, are discussed.

RESULTS

Examination of SLNs by serial section with haematoxylin and eosin and/or immuno histochemical staining significantly increases the detection rate of micrometastases, even in patients with very small (T1) tumours. However, the prognostic relevance of isolated tumour cells and small micrometastases is uncertain. Moreover, deciding which patients might benefit from axillary dissection is complicated by the fact that adjuvant radiotherapy and systemic chemotherapy alone may eradicate most micrometastases.

CONCLUSION

Ongoing randomized trials comparing the results of SLN biopsy alone with those of axillary dissection should answer the question of whether isolated tumour cells and small micrometastases are clinically relevant. This should also indicate which patients with SLN micrometastasis are likely to benefit from axillary dissection. In this sense, SLN biopsy must be considered still to be at an investigative stage; outwith clinical trials complete axillary dissection should be performed on all patients with SLN micrometastasis.

Impact of non-axillary sentinel node biopsy on staging and treatment of breast cancer patients

The purpose of this study was to evaluate the occurrence of lymphatic drainage to non-axillary sentinel nodes and to determine the implications of this phenomenon. A total of 549 breast cancer patients underwent lymphoscintigraphy after intratumoural injection of (99m)Tc-nanocolloid. The sentinel node was intraoperatively identified with the aid of intratumoural administered patent blue dye and a gamma-ray detection probe. Histopathological examination of sentinel nodes included step-sectioning at six levels and immunohistochemical staining. A sentinel node outside level I or II of the axilla was found in 149 patients (27%): internal mammary sentinel nodes in 86 patients, other non-axillary sentinel nodes in 44 and both internal mammary and other non-axillary sentinel nodes in nineteen patients. The intra-operative identification rate was 80%. Internal mammary metastases were found in seventeen patients and metastases in other non-axillary sentinel nodes in ten patients. Staging improved in 13% of patients with non-axillary sentinel lymph nodes and their treatment strategy was changed in 17%. A small proportion of clinically node negative breast cancer patients can be staged more precisely by biopsy of sentinel nodes outside level I and II of the axilla, resulting in additional decision criteria for postoperative regional or systemic therapy.

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.