The accuracy of sentinel node biopsy in breast cancer patients with the history of previous surgical biopsy of the primary lesion: Systematic review and meta-analysis of the literature

Near-infrared fluorescence lymph node template region dissection plus backup lymphadenectomy in open radical cystectomy for bladder cancer using an innovative handheld device: A single center experience

BACKGROUND

The extent of pelvic lymphadenectomy (PLND) as part of radical cystectomy (RC) for bladder cancer (BC) remains unclear. Sentinel-based and lymphangiographic approaches could lead to reduced morbidity without sacrificing oncologic safety.

OBJECTIVE

To evaluate the feasibility and diagnostic value of fluorescence-guided template sentinel region dissection (FTD) using a handheld near-infrared fluorescence (NIRF) camera in open radical cystectomy.

DESIGN, SETTING, AND PARTICIPANTS

After peritumoral cystoscopic injection of indocyanine green (ICG) 21 patients underwent open RC with FTD due to BC between June 2019 and June 2021. Intraoperatively, the FIS-00 Hamamatsu Photonics® NIRF camera was used to identify and resect fluorescent template sentinel regions (FTRs) followed by extended pelvic lymphadenectomy (ePLND) as oncological back-up.

OUTCOME MEASUREMENT AND STATISTICAL ANALYSIS

Descriptive analysis of positive and negative results per template region.

RESULTS AND LIMITATIONS

FTRs were identified in all 21 cases. Median time (range) from ICG injection to fluorescence detection was 75 (55-125) minutes. On average (SD), 33.4 (9.6) lymph nodes were dissected per patient. Considering template regions as the basis of analysis, 67 (38.3%) of 175 resected regions were NIRF-positive, with 13 (7.4%) regions harboring lymph node metastases. We found no metastatic lymph nodes in NIRF-negative template regions. Outside the standard template, two NIRF-positive benign nodes were identified.

CONCLUSION

The concept of NIRF-guided FTD proved for this group all lymph node metastases to be found in NIRF-positive template regions. Pending validation in a larger collective, resection of approximately 40% of standard regions may be sufficient and may result in less morbidity.

The Current Role of Lymph Node Dissection in Nonmetastatic Localized Renal Cell Carcinoma

PURPOSE

To explore the current role of lymph node dissection (LND) in the management of nonmetastatic localized renal cell carcinoma (RCC).

BACKGROUND

There is currently no proven benefit of LND in the setting of RCC, and its role remains controversial because of conflicting evidence. Patients who may benefit from LND are those at greatest risk of nodal disease, but the tools used to predict nodal involvement are limited due to unpredictable retroperitoneal lymphatics. The indications, templates, and extent of LND are also not standardized, adding to the ambiguity of current guidelines surrounding its use.

EVIDENCE ACQUISITION

A PubMed search of the literature from January 2017 to December 2022 was conducted using the search terms "renal cell carcinoma" or "renal cancer" in combination with "lymph node dissection" or "lymphadenectomy". Case studies and editorials were excluded, whereas studies investigating the therapeutic effect of LND were classified as either demonstrating a benefit or no benefit. References of the studies and review articles were also searched for notable studies and findings that were outside the five-year literature search. The studies in this review were restricted to the English language.

RESULTS

Only a number of studies in recent years have found an association between the extent of LND and increased survival. Most studies do not indicate an associated benefit, and some even suggest a negative effect on survival. Most of these studies are retrospective.

CONCLUSION

The therapeutic value of LND in RCC is still unclear, and although prospective data are needed, its declining rates and emerging new therapies make this unlikely. A better understanding of renal lymphatics and improved detection of nodal disease may help determine the role of LND in nonmetastatic localized RCC.

Sentinel lymph node mapping in breast cancer patients following neoadjuvant chemotherapy: systematic review and meta-analysis about head to head comparison of cN0 and cN + patients

PURPOSE

The effectiveness of sentinel lymph node (SLN) mapping and biopsy following neoadjuvant chemotherapy (NAC) in axillary lymph node staging of breast cancer (BCa) patients with initial clinical node positive status (cN +) compared to clinical node negative status (cN0) is not yet known. The aim of this meta-analysis was to compare the accuracy of SLN mapping following NAC in cN + and cN0 BCa patients.

METHODS

PubMed and Scopus were comprehensively reviewed to retrieve all the studies that performed SLN mapping/biopsy and standard axillary lymph node dissection on cN0 and cN + BCa patients following NAC. Pooled detection and false negative rates for N0 and N + patients including 95% confidence interval values (95% CI) were evaluated. Odds ratio (OR) and risk difference (RD) of SLN detection failure and false negative results were compared between two groups.

RESULTS

A total of 27 articles were included for SLN detection rate evaluation and 17 for false negative assessment. The OR and RD of detection failure in N + group compared with N0 group following NAC were 2.22 (p = 0.00, 95% CI 1.4-3.4) and 4% (p = 0.00, 95% CI 2-6%), respectively. The OR and RD of false negative rate were 1.6 (p = 0.01, 95% CI 1-2.6) and 8% (p = 0.02, 95% CI 1-14%), respectively.

CONCLUSION

SLN mapping in BCa patients following NAC shows high risk of detection failure and high false negative rate of SLN biopsy in cN + patients. In comparison with cN0 BCa patients, SLN mapping and biopsy after NAC was associated with almost two times higher odds of detection failure and false negative results in cN + patients; therefore, this method should not be recommended in this group of patients.

Lymphoscintigraphy in the Time of COVID-19: Effect of Molybdenum-99 Shortage on Feasibility of Sentinel Node Mapping

Background: In the current study, we reported our experience on sentinel node mapping of breast cancer patients during the extreme shortage of Mo99-Tc99m generators using Tc-99m phytate. Methods and Results: During the period from March 7, 2019, to April 18, 2020, due to disruption of molybdenum supply chain, we used low specific activity Tc-99m pertechnetate elute (0.5-2 mCi of ^99mTcO₄ in 5 mL) for each kit preparation. Two or three intradermal periareolar injections were done for each patient (0.02-0.1 mCi/0.2 mL for each injection). Immediately following injection, dynamic lymphoscintigraphy was done. Surgery was done the same day of injection and the axillary sentinel node was sought using a gamma probe. Overall, 35 patients were included in the study. The specific activity of the Tc-99m elute (in 5 mL) used for kit preparation was 2 mCi/10 mg in four, 1.5 mCi/10 mg in eight, 1.25 mCi/10 mg in eight, 1 mCi/10 mg in three, 0.75 mCi/10 mg in five, and 0.5 mCi/10 mg of ^99mTc-Phytate in seven patients. For the first four groups of patients, we used two 0.2 mL injections, while in the latter two groups, three 0.2 mL injections were used. At least one sentinel node was detected in all patients but three in whom axilla was involved. Conclusion: Sentinel node biopsy can be achieved with low specific activity of Tc-99m elute at the time of Mo99-Tc-99m generator shortage. If special personal protection is used, sentinel node mapping can be done in nuclear medicine departments with excellent results despite the COVID-19 pandemic and disruption of generator shipment.

Sentinel lymph node biopsy in muscle-invasive bladder cancer: single-center experience

OBJECTIVE

In this study, the validity of sentinel node biopsy procedure as our index test was assessed and compared with bilateral pelvic lymphadenectomy for staging and detecting the regional lymph nodes metastasis in patients with muscle-invasive bladder cancer (MIBC).

METHODS

Consecutive series of cases with T1-T4 urothelial MIBC were included. Following the injection of radiotracer, sentinel nodes were sought using a handheld gamma probe and all hot nodes were harvested. Bilateral pelvic lymphadenectomy was done for all patients following sentinel node biopsy. The tumor specimen, sentinel nodes, and excised lymph nodes were evaluated histopathologically. Same as the other midline tumors, detection rate and false negative rates were calculated using patient basis and side basis methods.

RESULTS

By evaluating each patient as a unit of analysis, sentinel nodes were detected in 35 of 41 patients (85%), 13/16 (81%) of the neoadjuvant chemotherapy (NAC) and 22/25 (88%) of the no-neoadjuvant chemotherapy (No-NAC) participants. The false negative rate was 3/7 (42%): 1/3 (33%) for NAC, and 2/4 (50%) for No-NAC patients. By evaluating each hemipelvis as a unit of analysis, sentinel nodes were detected in 53 of 82 hemipelves (65%), 19/32 (66%) of the NAC, and 34/50 (68%) of the No-NAC hemipelves. No false-negative result was found by assessing each hemipelvis as a unit of analysis.

CONCLUSIONS

Sentinel node biopsy is a feasible method for lymph node staging in MIBC, including patients with a history of NAC. To optimize the sensitivity, the decision regarding the lymphadenectomy is best to be based on the pathological status of sentinel node harvested from each hemipelvis separately as the unilateral finding of a sentinel node, does not rule out the possibility of metastatic involvement of contralateral pelvic lymph nodes.

Influence of previous breast surgery in sentinel lymph node biopsy in patients with breast cancer

AIM

The aim of this study was to review the feasibility of selective sentinel lymph node biopsy in patients with previous surgery for breast cancer, as well as to examine the factors that may interfere with sentinel node detection.

MATERIAL AND METHODS

A retrospective review was performed on 91 patients with breast cancer and previous breast surgery, and who underwent sentinel lymph node biopsy. Patients were divided into two groups according to their previous treatment: aesthetic breast surgery in 30 patients (group I) and breast-conserving surgery in 61 (group II). Lymphoscintigraphy was performed after an intra-tumour injection in 21 cases and a peri-areolar injection in 70 cases. An analysis was made of lymphatic drainage patterns and overall sentinel node detection according to clinical, pathological and surgical variables.

RESULTS

The overall detection of the sentinel lymph node in the lymphoscintigraphy was 92.3%, with 7.7% of extra-axillary drainages. The identification rate was similar after aesthetic breast surgery (93.3%) and breast-conserving surgery (91.8%). Sentinel lymph nodes were found in the contralateral axilla in two patients (2.2%), and they were included in the histopathology study. The non-identification rate in the lymphoscintigraphy was 7.7%. There was a significantly higher non-detection rate in the highest histological grade tumours (28.6% grade III, 4.5% grade I and 3.6% grade II).

CONCLUSION

Sentinel lymph node biopsy in patients with previous breast surgery is feasible and deserves further studies to assess the influence of different aspects in sentinel node detection in this clinical scenario. A high histological grade was significantly associated with a lower detection.

Sentinel lymph node biopsy in breast cancer

OBJECTIVES

To report our experience in sentinel lymph node biopsy (SLNB) in early breast cancer. 

METHODS

This is a retrospective study conducted at King Khalid University Hospital, Riyadh, Kingdom of Saudi Arabia between January 2005 and December 2014. There were 120 patients who underwent SLNB with frozen section examination. Data collected included the characteristics of patients, index tumor, and sentinel node (SN), SLNB results, axillary recurrence rate and SLNB morbidity.  

RESULTS

There were 120 patients who had 123 cancers. Sentinel node was identified in 117 patients having 120 tumors (97.6% success rate). No SN was found intraoperatively in 3 patients. Frozen section results showed that 95 patients were SN negative, those patients had no immediate axillary lymph node dissection (ALND), whereas 25 patients were SN positive and subsequently had immediate ALND. Upon further examination of the 95 negative SN's by hematoxylin and  eosin (H and E) and immunohistochemical staining for doubtful H and E cases, 10 turned out to have micrometastases (6 had delayed ALND and 4 had no further axillary surgery). Median follow up of patients was 35.5 months and the mean was 38.8 months. There was one axillary recurrence observed in the SN negative group. The morbidity of SLNB was minimal. 

CONCLUSION

The obtainable results from our local experience in SLNB in breast cancer, concur with that seen in published similar literature in particular the axillary failure rate. Sentinel lymph node biopsy resulted in minimal morbidity.

[Selective biopsy of the sentinel lymph node in patients with breast cancer and previous excisional biopsy: is there a change in the reliability of the technique according to time from surgery?]

AIM

To assess the influence of time on the reliability of sentinel lymph node biopsy (SLNB) in breast cancer patients with previous excisional biopsy (EB), analyzing both the sentinel lymph node detection and the lymph node recurrence rate.

MATERIAL AND METHODS

Thirty-six patients with cT1/T2 N0 breast cancer and previous EB of the lesion underwent a lymphoscintigraphy after subdermal periareolar administration of radiocolloid, the day before SLNB. Patients were classified into two groups, one including 12 patients with up to 29 days elapsed between EB and SLNB (group A), and another with the remaining 24 in which time between both procedures was of 30 days or more (group B). Scintigraphic and surgical detection of the sentinel lymph node, histological status of the sentinel lymph node and of the axillary lymph node dissection, if performed, and lymphatic recurrences during follow-up, were analyzed.

RESULTS

Sentinel lymph node visualization at the lymphoscintigraphy and surgical detection were 100% in both groups. Histologically, three patients showed macrometastasis in the sentinel lymph node, one from group A and two from group B. None of the patients, not even those with malignancy of the sentinel lymph node, relapsed after a medium follow-up of 49.5 months (24-75).

CONCLUSION

Time elapsed between EB and SLNB does not influence the reliability of this latter technique as long as a superficial injection of the radiopharmaceutical is performed, proving a very high detection rate of the sentinel lymph node without evidence of lymphatic relapse during follow-up.

Sentinel node biopsy for lymph nodal staging of uterine cervix cancer: a systematic review and meta-analysis of the pertinent literature

BACKGROUND

We reviewed the available literature on the accuracy of sentinel node mapping in the lymph nodal staging of uterine cervical cancers.

METHODS

MEDLINE and Scopus were searched by using "sentinel AND (cervix OR cervical)" as key words. Studies evaluating the accuracy of sentinel node mapping in the lymph nodal staging of uterine cervical cancers were included if enough data could be extracted for calculation of detection rate and/or sensitivity.

RESULTS

Sixty-seven studies were included in the systematic review. Pooled detection rate was 89.2% [95% CI: 86.3-91.6]. Pooled sensitivity was 90% [95% CI: 88-92]. Sentinel node detection rate and sensitivity were related to mapping method (blue dye, radiotracer, or both) and history of pre-operative neoadjuvant chemotherapy. Sensitivity was higher in patients with bilaterally detected pelvic sentinel nodes compared to those with unilateral sentinel nodes. Lymphatic mapping could identify sentinel nodes outside the routine lymphadenectomy limits.

CONCLUSION

Sentinel node mapping is an accurate method for the assessment of lymph nodal involvement in uterine cervical cancers. Selection of a population with small tumor size and lower stage will ensure the lowest false negative rate. Lymphatic mapping can also detect sentinel nodes outside of routine lymphadenectomy areas providing additional histological information which can improve the staging. Further studies are needed to explore the impact of sentinel node mapping in fertility sparing surgery and in patients with history of neoadjuvant chemotherapy.

Prevalence and risk factors of intraoperative identification failure of sentinel lymph nodes in patients affected by breast cancer

INTRODUCTION

Sentinel lymph node biopsy (SLNB) has progressively replaced complete axillary lymph node dissection in the evaluation of breast cancer patients with clinically node-negative disease. Our study investigates the rate of and risk factors involved in sentinel node identification failure.

MATERIALS AND METHODS

We collected data on SLNBs performed during 2002-2010, focusing on tumor, patient, and breast characteristics, radioactivity parameters, and operators' experience. Data were analyzed by R (v2.14.2), considering significance at P values lower than 0.05.

RESULTS

Among 1050 women who underwent an SLNB, the rate of identification failure was 2% (23/1050), which, on bivariate analysis, was seen to be significantly influenced (P<0.05) by the preoperative and intraoperative low radiotracer uptake (axilla/lesion radiotracer uptake ratio<1%), low level of experience of the specialist in nuclear medicine, luminal A subtype, and radiotracer uptake localization in internal mammary lymph nodes. On multivariate analysis, significant risk factors for sentinel node identification failure were found to be: axilla/lesion radiotracer uptake ratio less than 1%, radiotracer uptake localization in internal mammary lymph nodes, and luminal A subtype. Considering only the preoperative variables in our multivariate analysis, axilla/lesion radiotracer uptake ratio less than 1%, negative lymph node scintiscan, and radiotracer uptake localization in internal mammary lymph nodes had an area under the curve (receiver operating characteristic curve) of 96% (95% confidence interval 92-100%). Further, we built a nomogram based on these simple parameters for counseling the patient about the probability of not finding the sentinel lymph node during the surgical procedure.

CONCLUSION

The relatively low prevalence of SLNB failure (2%) is indicative of the accuracy of the procedure when performed by experienced surgeons. The sentinel node identification failure in our population seemed to be related to biological tumor factors (luminal A subtype) and probably to physiological or pathological variations in the lymphatic drainage (axilla/lesion radiotracer uptake ratio<1% and radiotracer uptake localization in internal mammary lymph nodes).

Accuracy of sentinel node biopsy in the staging of non-small cell lung carcinomas: systematic review and meta-analysis of the literature

BACKGROUND

Not all patients with non-small cell lung carcinoma (NSCLC) have mediastinal lymph node involvement and development of less invasive methods for evaluating mediastinal lymph nodes is important. Sentinel node biopsy has been used for NSCLC since 1999 to decrease the need for mediastinal lymph node dissection. In this review, we searched the literature in this regard and reported the results in a meta-analysis format.

METHODS

Medline, SCOPUS, and ISI web of knowledge were searched using: "(lung AND sentinel)" with no date or language limit. Any study with more than 5 patients and enough information to calculate detection rate and sensitivity was included.

RESULTS

Overall 47 and 43 studies (including subgroups) had the criteria for detection rate and sensitivity pooling respectively. Pooled detection rate was 80.6% [76.8-84%] and pooled sensitivity was 87% [83-90%]. Using radiotracers or both radiotracers and dyes had higher detection rate and sensitivity compared to dye alone. Among studies using radiotracers, highest detection rate was in intra-operative peri-tumoral injection group and highest sensitivity was in peri-tumoral pre-operative injection group. Emerging methods of sentinel node surgery including magnetic materials, fluorescent dyes, CT contrast agents, and carbon nano-particles had promising results.

CONCLUSIONS

Sentinel node mapping using radiotracers is a feasible technique for mediastinal lymph node staging of N0 NSCLC patients. Alternative methods of sentinel node mapping are promising and warrant further studies.

Reproducibility of lymphoscintigraphy before and after excisional biopsy of primary breast lesions: a study using superficial peri-areolar injection of the radiotracer

OBJECTIVE

A major controversial issue in the sentinel node biopsy of the breast is the applicability of sentinel node mapping in patients with the history of previous excisional biopsy of the breast lesions. In the current study, we evaluated the reproducibility of lymphoscintigraphy before and after excisional biopsy of the primary breast lesions using superficial peri-areolar injection of the radiotracer.

MATERIAL AND METHODS

Eighteen patients scheduled for excisional biopsy of breast lesions were included into the study. The patients received intra-dermal injection of the radiotracer in the peri-areolar area of the index quadrant 1 to 2h before surgery. Imaging was performed the day after surgery. Immediately after completion of the first imaging, the patients received another injection of the radiotracer with the same technique, dose, and location. Other sets of lymphoscintigraphy imaging were taken immediately and 4h post second injection. The two sets of lymphoscintigraphy images were compared.

RESULTS

In 2 patients, sentinel node could not be identified in either set of images. In the remaining 16 patients, one sentinel node was detected in both lymphoscintigraphy image sets. The sentinel nodes of the second image sets were all in the same location of the first sets with at least 5 times higher count.

CONCLUSIONS

Excisional biopsy of the primary breast lesions does not seem to change the superficial lymphatic drainage pattern from the areola of the breast and sentinel node mapping can be performed after this procedure using superficial periareolar technique.

Reliability of sentinel node assay in vulvar cancer: the first Croatian validation trial

OBJECTIVE

To evaluate the reliability of sentinel node assay in early stage vulvar cancer patients by using preoperative lymphoscintigraphy.

METHODS

Technetium-99m colloid albumin was injected intradermally around the tumor for lymphoscintigraphic mapping and intraoperative hand-held gamma probe detection of sentinel nodes. For all patients, sentinel node biopsy was followed by inguinofemoral lymphadenectomy, regardless of the sentinel lymph node status.

RESULTS

From December 2008 until May 2011, 25 consecutive patients with T1 or T2 stage of vulvar squamous cell cancer were enrolled. The median age of patients was 69 years (range, 48-79). The detection of sentinel lymph node was successful in all 25 patients. A total of 36 sentinel lymph nodes were harvested and metastatic carcinoma was identified in 12 sentinel nodes from 8 patients. There was 1 patient with metastatic non-sentinel lymph node despite the negative sentinel node. Two patients with negative sentinel nodes proven by routine histopathological examination were positive by immunohistochemical staining. The sensitivity, specificity and negative predictive value of sentinel node assay with immunohistochemistry included were 89%, 100%, and 94%, respectively.

CONCLUSIONS

Lymphoscintigraphy and sentinel lymph node biopsy under gamma-detecting probe guidance proved to be an easy and reliable method for the detection of sentinel node in early vulvar cancer. Immunohistochemical analysis improves the sensitivity for the detection of regional micrometastases. The sentinel node assay is highly accurate in predicting the status of the remaining inguinofemoral lymph nodes. Our results indicate that patients best suited to SLN assay have had a simple punch biopsy to confirm the diagnosis rather than a previous tumor excision. This technique represents a true advance in the selection of patients for less radical surgery.