The axilla: not a no-go zone

Use of the dye-guided sentinel lymph node biopsy method alone for breast cancer metastasis to avoid unnecessary axillary lymph node dissection

For sentinel lymph node biopsy (SLNB), a combination of dye-guided and γ-probe-guided methods is the most commonly used technique. However, the number of institutes in which the γ-probe-guided method is able to be performed is limited, since special equipment is required for the method. In this study, SLNB with the dye-guided method alone was evaluated, and the clinicopathological characteristics were analyzed to identify any factors that were predictive of whether the follow-up axillary lymph node dissection (ALND) was able to be omitted. A total of 374 patients who underwent SLNB between 1999 and 2009 were studied. The SLN identification rate was analyzed, in addition to the false-positive and false-negative rates and the correlation between the clinicopathological characteristics and axillary lymph node metastases. The SLN was identified in 96.8% of cases, and, out of the patients who had SLN metastasis, 63.0% did not exhibit metastasis elsewhere. The sensitivity was 96.4% and the specificity was 100%. The false-negative rate was 3.6%. Univariate analyses revealed significant differences in the lymph vessel invasion (ly) status, nuclear grade (NG), maximum tumor size and the percentage of the area occupied by the tumor cells in the SLN (SLN occupation ratio) between the patients with and without non-SLN metastasis, indicating that these factors may be predictive of axillary lymph node metastasis. Multivariate analysis revealed that ly status was an independent risk factor for non-SLN metastasis. In conclusion, SLN with the dye-guided method alone provided a high detection rate. The study identified a predictive factor for axillary lymph node metastasis that may improve the patients’ quality of life.

Long-term outcomes of breast cancer in women aged 30 years or younger, based on family history, pathology and BRCA1/BRCA2/TP53 status

Background:

There are relatively few articles addressing long-term follow-up in women with breast cancer at very young ages.

Methods:

We have updated and extended our population-based analysis of breast cancer diagnosed at the age ⩽30 years in North-west England to include an extra 15 patients with mutation testing in BRCA1, BRCA2 and TP53, with 115 of 288 consecutive cases being tested. Kaplan–Meier curves were generated to assess overall survival, contralateral breast cancer and other second primaries.

Results:

Survival analysis of all 288 patients showed poor overall survival, although this improved from a 15-year survival of only 46% in those diagnosed between 1980 and 1989 to 58% in those diagnosed between 1990 and 1997 (P=0.05). Contralateral breast cancer rates were at a steady rate of 0.6 per 1000, although the rates in mutation carriers were ∼2 per 1000. Altogether, 16 BRCA1, 9 BRCA2 and 6 TP53 mutations have now been found among the 115 cases on whom DNA analysis has been performed. BRCAPRO accurately predicted the number of carriers for BRCA1 and BRCA2 and was sensitive and specific at the 10 and 20% threshold, respectively. However, BRCAPRO did not seem to give any weight to DCIS, which accounted for two BRCA1 carriers and three TP53 carriers and overpredicted mutations at the high end of the spectrum, with only 6 of 11 (54%) with a >90% probability having identifiable BRCA1/2 mutations.

Interpretation:

Rates of new primaries are predicted to some extent by mutation status. BRCAPRO is useful at determining those patients aged ⩽30 years to be tested.

Prognostic value of the interpectoral lymph nodes in breast cancer: A 20-year survival study

INTRODUCTION

The indication and extent of axillary lymph node dissection in breast cancer remains open to controversy.

MATERIALS AND METHOD

In this context, a 20-year survival study has been made of 1600 breast cancer patients subjected during surgical treatment to systematic dissection of the acromiothoracic vascular pedicle together with the accompanying lymph nodes (Rotter and Grossman interpectoral lymph node groups). An anatomical study of these nodes was also conducted in 100 necropsies, with the evaluation of 200 acromiothoracic vascular pedicles.

RESULTS

The interpectoral lymph nodes were anatomically present in 42% of the necropsies and in 35.1% of the patients subjected to surgery. The prognosis was much worse in cases of neoplastic infiltration of the interpectoral lymph nodes (Kaplan-Meier survival study), regardless of the influence of other prognostic factors.

CONCLUSIONS

In view of the results obtained, the designation of grade N3 of the TNM classification is proposed for malignancies with positive interpectoral lymph node infiltration.

Sentinel node biopsy should be supplemented by axillary sampling in patients with small breast cancers

Axillary clearance provides important prognostic information but is associated with significant morbidity. Sentinel node biopsy can provide staging .141 patients with node negative early breast cancers-tumour size less than 1.5 cm measured clinically or by imaging had guided axillary sampling (sentinel lymph node biopsy in combination with axillary sampling). Four node axillary sampling improved the detection rate of axillary node metastases by 13.6% as compared to blue dye sentinel node biopsy alone. Positive sampled nodes strongly indicated the likelihood of further metastatic being revealed by axillary dissection (67%). Negative sampled nodes in combination with a positive sentinel node biopsy were associated with a much lower rate of further nodal involvement in the axillary clearance (8%).

Continued axillary sampling is unnecessary and provides no further information to sentinel node biopsy in staging breast cancer

INTRODUCTION

Sentinel lymph node biopsy (SLNB) has become increasingly accepted as a diagnostic method to stage the axilla in breast cancer, selecting women with a positive sentinel node for completion axillary clearance. As SLNB became established, many surgeons supplemented SLNB to sample a minimum of four lymph nodes, on the assumption that the four-node technique is supported by randomised trial data. We hypothesised that the practice of undirected sampling to supplement SLNB adds little information to the status of the residual axilla.

METHODS

One hundred and sixty-five patients with early breast cancer were studied. Following successful identification of the sentinel node, 84 women had completion axillary dissection and 81 women had an axillary sample with at least four nodes available for pathological assessment.

RESULTS

Following successful identification of the sentinel node in 165 patients, the false negative rate (FNR) was 2/44=4.5% (95% CI 0.6-15.5), sensitivity 42/44=95.5% (84.5-99.4) and negative predictive value (NPV) 121/123=98.4% (94.2-99.8). In the axillary dissection cohort, the FNR was 2/26=7.7% (0.9-25.1), sensitivity 24/26=92.3% (74.9-99.1) and NPV 58/60=96.7% (88.5-100). In the axillary sample group, the FNR was 0/18=0% (0-18.5), sensitivity 18/18=100% (81.5-100) and NPV 63/63=100% (94.3-100). The SLNB was the only positive node in 12/26 (46.2%) in the axillary dissection group and 10/18 (55.6%) in the axillary sampling group. There was no patient in the axillary sampling group where the sample node was positive and the sentinel node negative.

CONCLUSION

Once SLNB is validated within the multidisciplinary unit, undirected sampling of the axilla following identification of the sentinel node(s) is unnecessary. The additional sampling of non-sentinel nodes has no role to play either in the assessment of a potential false negative SLNB nor as predictive information on the status of the residual axillary nodes.

Endoscopic quadrantectomy for breast cancer with sentinel lymph node navigation via a small axillary incision

A great deal of clinical experience has firmly established the concept of the sentinel lymph node (SN) in breast cancer. SN biopsy allows treatment without axillary lymphadenectomy and has made it possible to perform a surgical intervention via just a small skin incision. In partial resection of the breast (quadrantectomy), we use a double retractor to form a workspace under the skin via a small axillary incision. Resection does not require a large incision even in cases in which the cancer lesion is located in the upper inner or lower inner quadrant of the breast, as the endoscope allows the surgeon to see the workspace formed by the double retractors.

Axillary recurrence in breast cancer

AIM

To determine whether axillary recurrence reflects inadequate axillary treatment or adverse pathological features.

METHODS

The case-records were reviewed of 2122 women aged under 75 years, treated for invasive breast cancer during the time-period 1/1/86-31/12/91 in a geographically defined area. Data were abstracted on operations performed, pathological features, post-operative treatments and details of axillary recurrence. The risk of axillary recurrence was examined by pathological, treatment and patient factors.

RESULTS

Axillary recurrence was more than twice as likely after inadequate compared to adequate treatment of the axilla (adequate staging or axillary radiotherapy or clearance). Delayed treatment of the axilla was not as successful as adequate primary treatment: multiple axillary recurrences were twice as common, one third of which were uncontrolled at time of death. Inadequate surgical treatment was associated with increased rates of recurrence despite endocrine therapy, chemotherapy or radiotherapy. Lymphoedema was twice as common if axillary radiotherapy was combined with any axillary surgical procedure.

CONCLUSIONS

Axillary recurrence is more common in tumours with adverse pathology but may also result from inadequate axillary treatment. In order to minimise axillary recurrence, optimal treatment of the axilla entails adequate staging (sampling of four or more nodes) and treatment (axillary clearance or radiotherapy and endocrine therapy) in all women.

Inadequate treatment of symptomatic breast cancer

Background

Early trials that compared breast and axillary treatments showed differing recurrence rates without significant differences in survival. Consequently, there was a wide range of opinion and practice in the management of breast cancer. The present study explored this variability in surgical management to determine the impact of breast and axillary treatment on recurrence and survival.

Methods

The records of 2776 women with histologically confirmed invasive breast cancer diagnosed between 1986 and 1991 were reviewed. The relationship between adequacy of breast and axillary treatment, recurrence and survival was examined in 2122 women who had surgery with curative intent. A Cox proportional hazards model that included tumour size, node status, grade, socioeconomic status and use of adjuvant therapy was used.

Results

Inadequate treatment was associated with a significantly higher risk of local recurrence after breast-conserving surgery (relative hazard ratio (RHR) 4·19 (95 per cent confidence interval (c.i.) 2·73 to 6·43); P < 0·001). Inadequate axillary treatment was associated with a significantly higher risk of regional recurrence (RHR 2·29 (95 per cent c.i. 1·65 to 3·16); P < 0·001). The risk of death from breast cancer was significantly higher if locoregional treatment was inadequate (RHR 1·29 (95 per cent c.i. 1·07 to 1·55); P = 0·008).

Conclusion

Adequate surgery is fundamental to the optimal treatment of breast cancer. Inadequate surgery resulted in higher recurrence rates despite adjuvant treatments.

A survey of surgical management of the axilla in UK breast cancer patients

The aim of our study was to survey management of the axilla by specialist breast surgeons in the United Kingdom (UK). The questionnaire was returned by 371 surgeons, 366 (99%) were consultants and 96% treated more than 50 cases of breast cancer every year. 28% treated patients with invasive breast cancer by axillary clearance (AxCl) alone, 5% used sampling alone (AxNS), 40% used both AxCl and AxNS, 10% AxCl and sentinel lymph node (SLN) biopsy and 17% AxCl, AxNS and SLN biopsy. 9% cleared to level I, and sometimes to level II, 42% to level II and 49% to level III. 56% tried to preserve one or multiple intercostal nerves and 44% routinely divided the intercostalbrachial nerves. 52% performed SNB within trials alone and 36% out side of trials only. A range of techniques were described for the SLN biopsy procedure. There is no consistent practice of managing the axilla in the UK and standardisation is required. SLN biopsy is performed both within and outside of trials and a variety of techniques are used.

The role of lymph node sampling and radiotherapy in the management of the axilla in early breast cancer

Management of the axilla in early breast cancer is an issue of ongoing debate. We reviewed our experience in 312 patients who underwent axillary lymph node sampling between 1994 and 1998, of whom 81 patients (24%) had axillary lymph node metastasis. There have been two axillary recurrences, one associated with local recurrence to the breast and one presenting with distant metastasis. There were no patients with isolated axillary disease as their only site of recurrence and no axillary failures in the node-positive group treated with axillary sampling and radiotherapy. Axillary lymph node sampling effectively stages the axilla. This can safely be followed by radiotherapy to the axilla in case of lymph node metastasis. Axillary lymph node sampling forms a sound basis to develop new techniques, such as sentinel lymph node biopsy currently investigated by ongoing trials.

Increased mortality from breast cancer and inadequate axillary treatment

BACKGROUND

The assessment of axillary nodal status remains divisive: inaccurate staging may result in untreated axillary disease, and appropriate adjuvant therapy not being delivered. The impact of inadequate axillary treatment on survival remains controversial. We analyse the impact of failure to adequately assess the axillary nodal status on survival.

METHODS

All women with confirmed breast cancer in a 15-year period were identified, and the original pathology reports examined, and details of radiotherapy obtained. The survival of women by axillary sample size was compared to a reference group of women and corrected for nodal status, tumour size, age, deprivation category and speciality of treating surgeon.

FINDINGS

Sampling less than four nodes is associated with a significantly increased risk of death. This cannot be due to understaging the extent of axillary disease nor is fully explainable by differential prescription of adjuvant therapies. We conclude that the survival of the women studied may have been adversely effected by inadequate axillary treatment.

Prognostic and predictive indicators in operable breast cancer

Because of its biological heterogeneity and wide spectrum of responsiveness to different treatments, breast cancer is a complex disease of difficult clinical management. Over the past several years, knowledge of the molecular mechanisms regulating normal and aberrant cell growth leading to cancer has been enhanced. These advances have enabled the identification of an increasing number of surrogate biomarkers, which have been correlated with prognosis or used as predictors of response to specific treatments. Axillary nodal status, age, tumor size, pathologic grade, and hormone receptor status are the established prognostic and/or predictive factors for selection of adjuvant treatments. The role of new biomarkers, such as p53, HER2/neu, angiogenesis, and the proliferation index value, is promising; however, the clinical value of their determination must be provided by prospective clinical studies.

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.

Prognostic importance of tumor angiogenesis in breast carcinoma with adjuvant chemotherapy

Tumor angiogenesis is believed to be related to prognostic factors involved in tumor development and metastasis. Using immunohistochemical methods, we evaluated tumor angiogenesis in 42 early invasive breast cancer patients (T1-2, NO-1-2, M0). Four patients received tamoxifen, 25 patients received CAF or CA, and 15 patients received CMF as adjuvant therapy. The median follow-up was 47 (range 24-119) months. Ten patients (43.5%) in the node-positive group and 2 patients (10.5%) in the node-negative group relapsed (p = 0.019). The mean microvessel count (MVC) was 60.3 3.05 per 200x field (range: 16-95). MVCs of postmenopausal and premenopausal patients were 50.13 +/- 5.74 and 68.64 +/- 4.11, respectively, in the axillary lymph node (ALN)-negative patient group (p = 0.04). Staining was moderate to strong in 13 (68%) ALN-negative and in 17 (74%) ALN-positive patients (p > 0.05), and was also moderate to strong in 82% of premenopausal patients and in 50% of postmenopausal patients (p = 0.037). There was no significant relationship between angiogenesis and p53, nor was angiogenesis significantly associated with the patient ER status and tumor size. No significant correlations were found between OS/DFS and Factor VIII staining or p53 (log rank test, p > 0.05). Of all ALN-negative patients with increased angiogenesis, one patient of the CMF group relapsed, but no recurrence occurred in patients undergoing anthracycline-based chemotherapy (p > 0.05). On the other hand, of all ALN-positive patients with increased angiogenesis, 5/14 patients treated with anthracylcine and 2/2 CMF-treated patients relapsed (p = 0.175). Despite the statistical insignificance, anthracycline-based adjuvant chemotherapy appears to be more effective than CMF as regards relapse prevention particularly in early ALN-positive breast cancer patients with increased angiogenesis. Additional studies are necessary to demonstrate the clinical importance of angiogenesis.

The sentinel node negative axilla: is it a no-go zone?

The technique of sentinel node biopsy (SNB) presents a great opportunity to reduce the morbidity of surgical treatment of breast cancer. Using either dye, isotope or a combination, after completing a learning process a sensitivity of 80-99% may be achieved. Most surgeons would aim for a sensitivity of 95% but this will mean that 5% of patients will be under-staged, with disease within the axilla and possibly inappropriate advice with regard to adjuvant systemic therapy. Injudicious use of sentinel biopsy will lead to more local relapses and may diminish or neutralize gains from systemic therapy.

The psychological impact of post-operative arm morbidity following axillary surgery for breast cancer: a critical review

In this paper we review the published research that has investigated the psychological impact of arm morbidity associated with axillary dissection for early breast cancer. This critique is particularly timely given the drive towards minimally invasive techniques, such as sentinel node biopsy, which aim to reduce the incidence and severity of post-operative arm problems. Reported symptoms are multifactorial and include numbness, pain, swelling, weakness/stiffness, and restricted shoulder mobility of the affected arm. Conclusions from the few studies that have investigated the severity, incidence, duration and psychological impact of such disability are often limited by methodological problems. We identify these limitations and examine assessment tools used to determine the psychological impact of lymphoedema. The paper highlights the need for methodological rigor in study design, and the careful selection of appropriate, sensitive, reliable and clinically meaningful outcome measures to evaluate the impact of post-operative arm morbidity.

Competing considerations in regional nodal treatment for early breast cancer

The purpose of this article was to review the patterns and morbidity of regional recurrence (RR) in patients with early breast cancer, efficacy of salvage therapy for RR, and complications of regional nodal treatment. A retrospective evaluation of 1,158 patients with stage I or stage II breast cancer treated with conservative surgery and radiotherapy (RT) between 1979 and 1994 was performed. Seven hundred fifty patients underwent axillary surgery, and 229 patients received RT as their only treatment of the regional lymphatics. Regional nodal RT was given to 168 patients who also had axillary surgery. The regional lymphatics of 11 patients were not treated. The patterns and morbidity of RR, relapse management, and complications related to regional nodal treatment were reviewed from the patients' records. With a median follow-up of 88 months, a total of 31 patients (2.7%) developed a RR. Nine of 31 patients (29%) with an RR experienced significant morbidity, including pain, fungating tumor, dysphagia, dyspnoea, and/or sensory motor changes at diagnosis. Nineteen patients (61%) had symptomatic residual or progressive regional disease after salvage therapy at last follow-up or death. Six of nine patients (67%) who developed an isolated axillary recurrence and underwent salvage surgery had no further axillary recurrence. The addition of regional nodal RT to breast irradiation significantly increased the incidence of symptomatic pneumonitis (1% without regional nodal RT and 4% with regional nodal RT, p < 0.001). Combined axillary dissection and nodal irradiation resulted in a significantly higher incidence of arm edema compared with either alone (9.5% with axillary dissection, 6.1% with RT to the axilla and supraclavicular fossa, and 31% with combined modality therapy, p < 0.001). Five of 380 patients (1%) who received RT to the axilla and/or supraclavicular fossa developed a transient brachial plexus neuropathy. Although RR was uncommon in patients treated with axillary surgery and/or regional nodal irradiation, salvage therapy failed to eradicate the recurrence in approximately two thirds of the patients with a RR. Ongoing research is essential to optimize regional control with an acceptable level of risk of treatment complications. Sentinel lymph node biopsy, if validated as an accurate method of staging the axilla in patients with breast cancer, would allow selective avoidance of regional nodal treatment and hence the associated morbidity.

Treatment of the axilla in early breast cancer: past, present and future

BACKGROUND

The optimal treatment of the axilla in early breast cancer is controversial. The present study reviews the pattern and predictors of regional recurrence (RR) and prognosis after RR in patients with early breast cancer treated by conservative surgery and radiotherapy (CS + RT). Implications of the results on current practice and future directions are explored.

METHODS

Between 1979 and 1994, 1158 patients with stage I or II breast cancer were treated with CS + RT at Westmead Hospital. Two groups of patients were compared: 782 patients who underwent axillary dissection (axillary surgery group) and 229 patients who received radiotherapy (axillary RT group) as the only axillary treatment. At least 10 lymph nodes were dissected in 82% of the axillary surgery group. Of the women in the RT group, 90% received RT to the axilla and supraclavicular fossa (SCF) only and 10% also received RT to the internal mammary chain (IMC).

RESULTS

With a median follow-up period of 79 months for the axillary surgery group and 111 months for the axillary RT group, 27 patients developed a RR (2.8% and 2.2%, respectively). Seven patients (0.9%) in the axillary surgery group and three patients (1.3%) in the axillary RT group developed a RR in the axilla (P, not significant). Of the patients with SCF recurrences, 14 (1.8%) were in the axillary surgery group and one (0.4%) in the axillary RT group (P, not significant). One patient in the axillary surgery group developed concurrent axillary and SCF recurrences, while a patient in the axillary RT group developed an IMC recurrence. Twenty (74%) of the 27 patients with a RR developed a concurrent or subsequent distant relapse (30% and 44%, respectively). In the pathologically node-positive patients, the axillary recurrence rate was higher in those who had less than five nodes removed (17%) than those who had 10 or more nodes removed (0%; P = 0.01). The SCF recurrence rate was higher in patients with four or more positive axillary nodes (9.5%) than in those with 0-3 positive nodes (1.5%; P = 0.003).

CONCLUSION

Adequate treatment of the axilla by surgery or RT alone is associated with a low rate of RR. The incidence of distant relapse was substantial in patients who developed a RR, which gives emphasis to the importance of optimizing local-regional control.

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.

Sentinel node biopsy for breast cancer may have little to offer four-node-samplers

The aims of the study were to determine how often four node axillary sampling (4NAS) encompasses the sentinel node (SN) and to compare the relative sensitivity of 4NAS with sentinel node biopsy (SNB) for axillary node staging. 200 patients with breast cancer were preoperatively injected with 27 MBq 99m-Tc-labelled colloid adjacent to the tumour. At operation, standard 4NAS was performed. Each node was counted ex vivo using a probe. A search was then made to find a node with higher counts in vivo directed by the probe. If found, it was excised. Each node was submitted separately to pathology. A SN was identified in 191 patients (96%). The SN was contained in the 4NAS in 153 patients (80%) and identified separately in 38 patients (20%). Of 60 node-positive patients, 49 were positive by 4NAS and SNB, the SN was not identified in 2 and in 8 the SN was falsely negative compared with 4NAS. For 1 patient, the SN was positive and the 4NAS negative. SNB performed using radiolabelled colloid has no advantage over 4NAS when nodes are assessed by standard histological technique.

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.

Accuracy of axillary MR imaging in treated breast cancer for distinguishing between recurrent tumour and treatment effects: does intravenous Gd-DTPA enhancement help in cases of diagnostic dilemma?

AIM

To evaluate the sensitivity and specificity of axillary magnetic resonance imaging (MRI) in symptomatic patients, who had previously been treated for breast cancer, compared with clinical outcome after a minimum of 1 year.

METHODS

One hundred and five patients underwent axillary MRI examinations and were diagnosed as axillary tumour, metastatic tumour, treatment effect or normal.

RESULTS

At MRI, 48 patients had axillary tumour, 51 had metastatic tumour (37 had both), 27 had treatment effect and 22 were normal. At outcome (median follow-up, 484 days), 54 patients were positive for axillary tumour, 59 for metastatic disease (40 had both), 21 had treatment effect alone and 18 were clear. Magnetic resonance imaging showed 89% sensitivity, 100% specificity and 94% accuracy for recurrent axillary tumour, and 85% sensitivity, 98% specificity and 90% accuracy for metastatic tumour. Soft tissue plaques were the commonest axillary disease pattern seen (37). Small volume soft tissue plaques gave the most diagnostic difficulty. Non-dynamic enhancement with intravenous Gadopentetate dimeglumine (Gd-DTPA) in a subset of 34 patients improved sensitivity for axillary tumour from 40 to 74%, and improved diagnostic confidence in 11 patients (32%). Magnetic resonance imaging had a positive management impact leading to treatment alteration in 45 patients, 43 of whom had recurrent axillary and/or metastatic tumour.

CONCLUSIONS

Tumour plaques were the commonest pattern of recurrent axillary disease. Forty-eight percent of the patients had metastatic deposits identified by MRI. Magnetic resonance imaging had excellent specificity (100%) and good sensitivity (89%) for recurrent axillary tumour compared with outcome at 1 year, which was improved by non-dynamic administration of Gd-DTPA in 32% of the subset who received it.

Impact of axillary dissection on staging and regional control in breast tumors < or = 10 mm--the DBCG experience. The Danish Breast Cancer Cooperative Group (DBCG), Rigshisoutalet, Copenhagen, Denmark

Data from 4771 patients with tumor diameters < or = 10 mm were analyzed. Results of surgery and pathoanatomical examinations indicated that nodal status was related to diameter, but not to number of nodes removed. More axillary metastases were found in group T1b tumors than in T1a. In 8% of tumors, at least 4 positive nodes were identified. Mean number of positive nodes was related to number of nodes removed, and when 10 or more nodes were removed a significantly lower axillary recurrence rate and better recurrence-free survival were demonstrated, confirming that axillary surgery has two goals: staging and regional disease control. Age, receptor status, grade and histological type, but not tumor location, were related to prognosis. In accordance with the classical prognostic factors, it was not possible to define a patient group where axillary surgery was superfluous. We conclude that proper staging and regional control renders a full axillary level I-II dissection necessary.

Efferent vascular invasion in the axillary nodes in breast carcinoma: a potent prognostic factor

Tumour cells in the efferent vessels of the axillary nodes in breast cancer (EV status) have been associated with poor prognosis since 1979. A prospective study (1980-1989) of all the nodes from 1037 consecutive female patients with unilateral breast cancer whose treatment included axillary node dissection yielded 471 node-positive cases. Tumour cells were found in the efferent nodal vessels of 210 patients, while 252 were negative. In the remaining 9 patients efferent nodal vessels could not be identified. At follow-up, 62% of the node-positive patients had died of breast carcinoma, in contrast to 32% of node-negative patients. The prognosis in cases with 1-3 versus 4+ tumour-bearing nodes was highly significant, 36% and 64%, respectively having died of breast carcinoma,. Prognosis was not dependent on the number of EV+ nodes in those cases showing efferent vascular invasion, one positive node was enough. Differentiation between these nodal growth forms thus provides a strong prognostic indicator, available to all with access to routine surgical pathology. We confirmed the significance of both variables using Cox's regression analysis and showed that the number of positive nodes adds significant prognostic information to that of EV status, which is the stronger of the two prognostic indicators. EV+ patients with more than three positive nodes have more than a three times higher risk of dying than EV- patients with three or fewer positive nodes.

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.

Sentinel Lymph Node Biopsy in Breast Cancer

One of the most important prognostic indicators in patients with breast cancer is axillary lymph node status. Sentinel lymph node (SLN) biopsy has emerged as a potential alternative to routine axillary dissection in clinically node-negative early breast cancer. This procedure requires a specialized but multidisciplinary approach utilizing the surgeon, nuclear radiologist and pathologist. SLN biopsy allows adequate assessment of the axillary nodal status in patients with early breast cancer, with minimal—if any—morbidity. Blue dye and lymphoscintigraphy are complementary techniques, and the success rate is maximized when the two methods are used together. Focused histopathologic examination on one or two lymph nodes most likely to contain metastases [SLN(s)], using serial sectioning and immunohistochemical techniques, allows an improved staging to be performed. Detection of metastases on SLN(s) is not only a prognostic indicator, but it also dictates whether the patient should receive further surgery and adjuvant chemotherapy. Until data regarding the long-term results of the SLN biopsy are available, this method should be considered investigational and be performed by surgeons experienced in this technique to achieve a failure rate of less than 2 per cent.

Role of axillary surgery in early breast cancer: review of the current evidence

BACKGROUND

Controversy continues to surround the best practice for management of the axilla in patients with early breast cancer (EBC), particularly the clinically negative axilla. The balance between therapeutic and staging roles of axillary surgery (with the consequent morbidity of the procedures utilized) has altered. This is due to the increasing frequency of women presenting with early stage disease, the more widespread utilization of adjuvant chemoendocrine therapy and, more recently, the advent of alternative staging procedures, principally sentinel node biopsy (SNB). The aim of the present review is to critically analyse the current literature concerning the preferred management of the axilla in early breast cancer and make evidence-based recommendations on current management.

METHODS

A review was undertaken of the English language medical literature, using MEDLINE database software and cross-referencing major articles on the subject, focusing on the last 10 years. The following combinations of key words have been searched: breast neoplasms, axilla, axillary dissection, survival, prognosis, and sentinel node biopsy.

RESULTS

Despite the trend to more frequent earlier stage diagnosis, levels I and II axillary dissection remain the treatment of choice in the majority of women with EBC and a clinically negative axilla.

CONCLUSIONS

Sentinel node biopsy has no proven superiority over axillary dissection because no randomized controlled trials have been completed to date. Despite this, SNB will become increasingly utilized due to encouraging results from major centres responsible for its development, and patient demand. Therefore if patients are not being enrolled in clinical trials strict quality controls need to be established at a local level before SNB is allowed to replace standard treatment of the axilla. Unless this is strictly adhered to there is a significant risk of an increase in the frequency of axillary relapse and possible increased understaging and resultant inadequate treatment of patients.

Antibiotic prophylaxis for post-operative wound infection in clean elective breast surgery

Antibiotic prophylaxis has been used to good effect in the prevention of post-operative wound infections in patients undergoing gastrointestinal operations. We have assessed the use of a single dose of intravenous antibiotic (Augmentin 1.2 g), given with induction of anaesthesia as prophylaxis, against post-operative wound infection in women undergoing clean, elective breast surgery. Three hundred and thirty-four patients were recruited. Of the 164 receiving antibiotic prophylaxis 29 (17.7%) had wound infections compared with 32 (18.8%) in the placebo group (P=0.79). There were no significant differences in any other post-operative infective complications. Antibiotic prophylaxis is probably not required in clean, elective breast surgery.

Correlation of vascular endothelial growth factor content with recurrences, survival, and first relapse site in primary node-positive breast carcinoma after adjuvant treatment

PURPOSE

To determine the predictive value of vascular endothelial growth factor (VEGF) for relapse-free survival (RFS) and overall survival (OS) in primary node-positive breast cancer (NPBC) after adjuvant endocrine treatment or adjuvant chemotherapy.

MATERIALS AND METHODS

VEGF was quantitatively measured in tumor cytosols from 362 consecutive patients with primary NPBC using an enzyme immunoassay for human VEGF(165). Adjuvant treatment was given to all patients, either as endocrine therapy (n = 250) or chemotherapy (n = 112). The median follow-up time was 56 months.

RESULTS

Univariate analysis showed VEGF to be a significant predictor of RFS (P =.0289) and OS (P =.0004) in the total patient population and in patients who received adjuvant endocrine treatment (RFS, P =.0238; OS, P =.0121). In the group of patients who received adjuvant chemotherapy, no significant difference was seen in RFS, but a difference was seen in OS (P =.0235). Patients with bone recurrences tended to have lower VEGF expression (median, 2.17 pg/microg DNA) than patients with visceral metastasis (4.41 pg/microg), brain metastasis (8.29 pg/microg), or soft tissue recurrences (3.16 pg/microg). Multivariate analysis showed nodal status (P =.0004), estrogen receptor (ER) status (P <.0001), and tumor size (P =.0085) to be independent predictors of RFS. VEGF was found to be an independent predictor of OS (P =.0170; relative risk [RR] = 1.82), as were ER (P <.0001; RR = 5.19) and nodal status (P =.0002; RR = 2.58). For patients receiving adjuvant endocrine treatment, multivariate analysis showed VEGF content to be an independent predictor of OS (P =.0420; RR = 1.90) but not of RFS.

CONCLUSION

The results suggest that VEGF(165) content in tumor cytosols is a predictor of RFS and OS in primary NPBC. VEGF content might also predict outcome after adjuvant endocrine treatment, but further studies in a prospective setting with homologous treatments are required.

Management of the axilla in operable breast cancer treated by breast conservation: a randomized clinical trial. Edinburgh Breast Unit

BACKGROUND

In the treatment of operable breast cancer by breast conservation, the extent of axillary dissection, the need for radiotherapy to the axilla and the morbidity associated with these procedures have not been assessed adequately.

METHODS

Patients with operable breast cancer were randomized to have level III axillary node clearance (232 patients) or axillary node sample (234 patients). Radiotherapy to the axilla was given selectively. Radiotherapy was not given to those who had an axillary clearance. In the early part of the study all patients who had node sample were treated by radiotherapy (54 patients); subsequently this was modified to include only those who were node positive. The morbidity to the shoulder and arm was assessed before and after operation by measuring upper limb volume and circumference, and combined glenohumeral and scapular movement and muscle power.

RESULTS

Comparing the two surgical policies, no difference was found in local (axillary clearance 14 versus sample 15), axillary (eight versus seven) or distant (29 versus 29) recurrence. There was no statistically significant difference in 5-year survival rate (clearance 82.1 versus sample 88.6 per cent). Morbidity was least in those who had a node sample and no radiotherapy to the axilla. Radiotherapy to the axilla in patients who had a node sample resulted in a significant reduction in range of movement of the shoulder, e.g. mean(s.e.) 2.2(0.6) cm reduction in lateral rotation at 3 years. Surgical axillary clearance was associated with significant lymphoedema of the upper limb, e.g. 4.1(0.7) per cent increase in arm volume at 3 years.

CONCLUSION

A selective policy for the management of the axilla is associated with no increase in axillary recurrence or mortality rate compared with routine axillary node clearance. Patients who are node negative after axillary sample can avoid radiotherapy or axillary clearance.

Multicentre study of ultrasonographically guided axillary node biopsy in patients with breast cancer

BACKGROUND

Axillary lymph node dissection is still performed as a staging procedure since lymph node status is the most important prognostic factor in patients with breast cancer. Sentinel node biopsy may replace routine axillary lymphadenectomy, especially in patients with small breast cancers. This study investigated whether ultrasonographically guided fine-needle aspiration cytology (FNAC) of the axillary lymph nodes in clinically node-negative patients was an accurate staging procedure to select patients for sentinel node biopsy.

METHODS

One hundred and eighty-five consecutive patients were included. All had axillary ultrasonography and detected nodes were categorized according to their dimensions and echo patterns. Ultrasonographically guided FNAC was carried out if technically possible. These results were compared with the results of the sentinel node biopsy and subsequent axillary dissection.

RESULTS

In 116 patients no lymph nodes were detected by ultrasonographic imaging. Of 69 patients with visible nodes, 31 had malignant cells on FNAC. There were no false-positive results. Some 87 of 185 patients had axillary metastases on definitive histological examination. Ultrasonography was sensitive in patients with extensive nodal involvement. Failure of the examination was caused by problems learning the method, difficulty in puncturing small lymph nodes and sampling error.

CONCLUSION

In patients without palpable axillary nodes, a sentinel node biopsy could be avoided in 17 per cent since ultrasonography combined with FNAC had already diagnosed axillary metastases. The method is particularly valuable in larger breast cancers.

Management of the axilla in primary breast cancer

Treatment of the axilla with either radiotherapy or surgery remains an integral part of the management of patients with invasive breast cancer. In general, the standard treatment of the axilla involves a partial ALND (surgical clearance of axillary nodes from levels I and II). There is as yet no evidence that axillary treatment improves survival, but the issue remains controversial. Axillary lymph node dissection is an effective staging procedure and is essential for local control of disease in the axilla, although, with increased emphasis on mammographic screening and early detection, the incidence of node-positive breast cancers is decreasing. Today, only about 30% to 40% of all invasive breast cancers are node-positive. Thus, in most cases, the potential morbidity of ALND could be avoided if the status of the axillary nodes were ascertained with a less invasive procedure. The SLNB may eventually prove to be a preferred alternative to routine ALND. It must first be demonstrated, however, that SLNB (without completion ALND) does not adversely affect outcome. Randomized controlled trials must address these concerns, and surgeons must await completion of these studies before accepting SLNB as the standard of care.

Objective Assessment of Axillary Morbidity in Breast Cancer Treatment

Historically, axillary lymph node dissection (ALND) was a critical aspect of the operative management of breast cancer. Recently, the role of ALND has been questioned, with postoperative morbidity possibly overshadowing patient benefit. Our objective was to quantitatively assess the long-term morbidity of ALND in patients with breast cancer. We conducted a cross-sectional study of patients being followed by the Breast Surgery Clinic at a university-affiliated urban hospital. Ninety-five patients with unilateral breast cancer who had undergone ALND were evaluated at routine follow-up visits in the latter half of 1998. A questionnaire was used to quantify the degree of subjective findings, including arm swelling, chest wall pain, decreased mobility, and weakness. Upper extremity strength, active range of motion, and circumference were measured. Overall, 70 per cent of patients had at least one complaint, with 18 per cent having moderate to severe symptoms. Twenty-one per cent had notable decrements in strength or range of motion, 9.3 per cent of patients required chronic compression garments for lymphedema, and 6.4 per cent changed their vocational status because of surgical morbidity. We conclude that adverse effects from ALND occur commonly. Objective findings are less common, perhaps causing clinicians to underappreciate postoperative morbidity. A significant subset of patients had enduring disability.

Staging efficacy of breast cancer with sentinel lymphadenectomy

Seventy-two patients underwent dye-guided or dye- and gamma probe-guided sentinel lymphadenectomy (SLND) followed by complete axillary lymph node dissection (ALND). The results of imprint cytology, frozen sections, and permanent sections of the sentinel lymph node (SLN) were compared to each other and to the histologic findings in the nonsentinel nodes. The SLN was identified in 62 (88%) of 72 patients. Evaluation of the SLN on the permanent sections yielded a diagnostic accuracy of 95%, a sensitivity of 89%, and a specificity of 100%, although the reliability of SLN diagnosis using frozen sections or imprint cytology is limited. Therefore, it may be concluded that SLND with multiple sectioning and histopathologic examination of the SLNs can predict the presence or absence of axillary-node metastases in patients with breast cancer. However, further studies will be needed to investigate the value of SLND in respect to the long-term regional control and any possible detriment or benefit to survival, before it can replace routine ALND as the preferred staging operation for operable breast cancer.

Primary tumour characteristics and axillary lymph node status in breast cancer

This paper examines the correlation between axillary lymph node status and primary tumour characteristics in breast cancer and whether this can be used to select patients for axillary lymphadenectomy. The results are based on a retrospective analysis of 909 patients who underwent axillary dissection in our unit. Axillary lymph nodes containing metastases were found in 406 patients (44.7%), all with invasive carcinomas, but in none of the 37 carcinomas-in-situ. Nodal status was negative in all T1a tumours, but lymph node metastases were present in 16.3% and 35.7% of T1b and T1c tumours respectively. When histological grade was taken into account, positivity for grade I T1b and T1c tumours fell to 13.6% and 26.7% respectively. Lymph node metastases were found in 85% of patients with lymphovascular invasion in their tumours as compared to only 15.4% of those without and in 45.5% of oestrogen and progesterone receptor-positive tumours. When one or both hormone receptors were absent this figure was much higher. It appears that for T1a breast cancers axillary dissection is not necessary, whereas for T1b, T1c and grade I T2 tumours other histopathological parameters should be taken into consideration in deciding who should undergo axillary lymphadenectomy.

Axillary clearance in operable breast cancer: still a necessity?

Complete axillary dissection, as part of radical mastectomy, was the standard of care for the first three-quarters of this century. Long-term follow-up of these patients showed substantial cure rates for positive-node patients before systemic therapy was available, indicating a therapeutic value to nodal dissection. There was also good control of the axilla; axillary recurrence after removal of positive nodes was quite low. Even today, in patients with positive nodes, complete axillary clearance as part of a modified radical mastectomy or a breast conservation approach with lumpectomy leads to control of the axilla and complete axillary staging, allowing medical oncologists to tailor their systemic treatment to the total number of nodes involved. Today, due to a combination of factors including patient awareness and the ability of mammography to detect smaller lesions, many women present with small cancers that carry a much lower risk of axillary involvement. Whereas a complete dissection is indicated for patients with clinically involved nodes, a level I-II dissection is the standard in most centers for patients with clinically negative nodes. In those patients with very small (T1a, T1b) cancers, the role of sentinel lymphadenectomy is being explored; it may spare these patients the morbidity of complete axillary dissection.

Preservation of pectoralis minor in axillary clearance for breast cancer

BACKGROUND

There has been a gradual shift away from radical surgery towards conservation treatment for breast cancer. The pectoralis minor muscle is increasingly preserved in women undergoing axillary clearance as part of either breast conservation or mastectomy.

METHODS

A retrospective study was conducted to determine the axillary node count in 578 patients who underwent axillary clearance, 276 with removal of pectoralis minor and 302 who had the muscle preserved.

RESULTS

The mean number of nodes excised in the group who had pectoralis minor excised was 25.5 (range 8-50) compared with 24.5 (range 9-68) in the preservation group.

CONCLUSION

For the majority of patients with operable breast cancer, retention of the pectoralis minor muscle is not associated with understaging or undertreatment of the axilla.

Dye-Guided Sentinel Lymphadenectomy in Clinically Node-Negative and Node-Positive Breast Cancer Patients

BACKGROUND: Sentinel lymphadenectomy has been used to assess the axillary nodal status in patients with breast cancer in an attempt to avoid unnecessary axillary dissection. Most studies have examined the utility of this procedure in clinically node-negative patients. However, the clinical evaluation of axillary nodes is often inaccurate for both clinically node-negative and clinically node-positive patients. METHODS: We performed dye-guided sentinel lymphadenectomy in both clinically node-negative and clinically node-positive patients with breast cancer. All patients also underwent a formal axillary dissection. The results of imprint cytology, frozen sections, and permanent sections of the sentinel lymph node (SLN) werecompared with each other and with histologic findings of the nonsentinel nodes. RESULTS: The SLN was identified in 30 (79%) of 38 patients with clinically negative nodes, and in 11 (92%) of 12 patients with clinically positive nodes. Forclinically node-negative patients, SLN evaluation yielded a diagnostic accuracyof 90%, a sensitivitiy of 72%, and a specificity of 100%. For clinically node-positive patients, these values were 100%, 100% and 100%, respectively. These values were not significantly different for the two groups of patients. CONCLUSION: Sentinel lymphadenectomy may be useful in assessing the axillarynodal status of both clinically node-positive and clinically node-negative breast cancer patients.

Staging the axilla in breast cancer: an audit of lymph-node retrieval in one U.K. regional centre

AIMS

Many surgeons undertake a level 1 axillary dissection in patients with invasive breast cancer. This dissection yields a variable number of lymph nodes for histological study. In this study, we report the consequences of this policy for staging of the axilla.

METHODS

Between January 1995 and December 1995, 236 patients with a diagnosis of invasive breast cancer underwent axillary surgery.

RESULTS

A median of eight nodes was identified (range 0-30). In only 11 patients less than four nodes were identified. An increase in the number of nodes harvested was associated with a higher proportion of node-positive patients and a higher number of metastatic nodes identified.

CONCLUSIONS

We concluded that a standardized approach to axillary dissection consistently yields an adequate sample of lymph nodes for staging purposes. Most importantly, larger node samples yield higher detection rates for metastasis. This has a significant bearing on patient selection for adjuvant chemotherapy when compared with more limited sampling practices, including solitary sentinel node detection and biopsy.

Sentinel Lymphadenectomy in Breast Cancer: An Alternative to Routine Axillary Dissection

We reviewed the literature concerning sentinel lymphadenectomy in breast cancer and reached the following conclusions: (a) A combination of lymphoscintigraphy and dye-guided and/or gamma probe-guided techniques are superior to either technique alone for identifying the sentinel lymph node. (b) lmmediate and reliable intraoperative information on the sentinel node is vital for the technique's success. However, the reliability of sentinel node diagnosis using frozen sections is questionable, because micrometastatic foci cannot be identified. (c) A reverse transcriptase-polymerase chain reaction(RT-PCR)method is more sensitive than immunohistochemistry for the detection of micrometastasis in the sentinel node. (d) Until there are new tumor markers or new imaging techniques to identify axillary metastasis without operative intervention, sentinel lymphadenectomy is a highly accurate, minimally invasive way to assess disease extent. Before sentinel lymphadenectomy gains general acceptance for patients with primary breast cancer, however, a large clinical trial will be essential to verify the value of this technology.

Neuropsychometric changes in patients after carotid endarterectomy

BACKGROUND AND PURPOSE

One hundred twelve patients undergoing elective carotid endarterectomy for symptomatic and asymptomatic carotid artery stenosis were enrolled in a prospective study to evaluate the incidence of change in postoperative cerebral function.

METHODS

Patients were evaluated preoperatively and postoperatively before hospital discharge and at follow-up 1 and 5 months later with a battery of neuropsychometric tests. The results were analyzed by both event-rate and group-rate analyses. For event-rate analysis, change was defined as either a decline or improvement in postoperative neuropsychometric performance by 25% or more compared with a preoperative baseline.

RESULTS

Approximately 80% of patients showed decline in one or more test scores, and 60% had one or more improved test scores at the first follow-up examination. The percentage of declined test scores decreased and the percentage of improved test scores increased with subsequent follow-up examinations. Group-rate analysis was similar for group performance on individual tests. However, a decline in performance was seen most commonly on verbal memory tests, and improved performance was seen most commonly on executive and motor tests.

CONCLUSIONS

Neuropsychometric evaluation of patients undergoing carotid endarterectomy for significant carotid artery stenosis demonstrates both declines and improvements in neuropsychometric performance. The test changes that showed decreased performance may be associated with ischemia from global hypoperfusion or embolic phenomena, and the improvement seen may be related to increased cerebral blood flow from removal of stenosis.