Sentinel lymph node biopsy in breast cancer: a comprehensive literature review

Predictive factors of non-sentinel lymph node disease in breast cancer patients with positive sentinel lymph node

INTRODUCTION

Management of positive sentinel lymph node biopsy (SLNB) in breast cancer remains a matter of debate. Our aim was to evaluate the incidence and identify predictive factors of non-sentinel lymph node metastases.

METHODS

Retrospective review of all cN0 breast cancer patients treated between January 2013 and December 2017, with positive SLNB that were submitted to ALND.

RESULTS

Of the 328 patients included, the majority of tumors were cT1 or cT2, with lymphovascular invasion in 58.4% of cases. The mean isolated nodes in SLNB was 2.7, with a mean of 1.6 positive nodes, 60.7% with extracapsular extension. Regarding ALND, a mean of 13.9 nodes were isolated, with a mean of 2.1 positive nodes. There was no residual disease in the ALND in 50.9% of patients, with 18.9% having ≥4 positive nodes. In the multivariate analysis, lymphovascular invasion, extracapsular extension in SLN, largest SLN metastases size (>10 mm) and ratio of positive SNL (>50%) were independent predictors of non-sentinel lymph node metastases. These four factors were used to build a non-pondered score to predict the probability of a positive ALND after a positive SLNB. The AUC of the model was 0.69 and 81% of patients with score = 0 and 65.6% with score = 1 had no additional disease in ALND.

CONCLUSION

The absence of non-sentinel lymph node metastases in the majority of patients with 1-2 positive SLN with low risk score questions the need of ALND in this population. The identified predictive factors may help select patients in which ALND can be omitted.

Predictive factors of non-sentinel lymph node disease in breast cancer patients with positive sentinel lymph node

INTRODUCTION

Management of positive sentinel lymph node biopsy (SLNB) in breast cancer remains a matter of debate. Our aim was to evaluate the incidence and identify predictive factors of non-sentinel lymph node metastases.

METHODS

Retrospective review of all cN0 breast cancer patients treated between January 2013 and December 2017, with positive SLNB that were submitted to ALND.

RESULTS

Of the 328 patients included, the majority of tumors were cT1 or cT2, with lymphovascular invasion in 58.4% of cases. The mean isolated nodes in SLNB was 2.7, with a mean of 1.6 positive nodes, 60.7% with extracapsular extension. Regarding ALND, a mean of 13.9 nodes were isolated, with a mean of 2.1 positive nodes. There was no residual disease in the ALND in 50.9% of patients, with 18.9% having ≥ four positive nodes. In the multivariate analysis, lymphovascular invasion, extracapsular extension in SLN, largest SLN metastases size (>10 mm) and ratio of positive SNL (> 50%) were independent predictors of non-sentinel lymph node metastases. These four factors were used to build a non-pondered score to predict the probability of a positive ALND after a positive SLNB. The AUC of the model was 0.69 and 81% of patients with score = 0 and 65.6% with score = 1 had no additional disease in ALND.

CONCLUSION

The absence of non-sentinel lymph node metastases in the majority of patients with 1-2 positive SLN with low risk score questions the need of ALND in this population. The identified predictive factors may help select patients in which ALND can be omitted.

Nonselective Lymph Node Dissection and Sentinel Lymph Node Mapping and Biopsy

Clinical staging is important for determining the extent of disease in animals with malignant cancers. The status of the lymph node will help determine whether adjuvant treatment is indicated. Historically, the regional anatomic lymph node has been sampled to determine the presence or absence of metastatic disease, but there is increasing evidence that the regional anatomic lymph node is often different to the sentinel lymph node. As a result, several sentinel lymph node mapping techniques have been described for more accurate clinical staging of oncologic patients.

Axillary nodal metastases in Italian early breast cancer patients with positive sentinel lymph node: can axillary node dissection be avoided by using predictive nomograms?

AIMS AND BACKGROUND

Clinical guidelines recommend axillary lymph node dissection (ALND) in cases of metastatic sentinel lymph node (SNL) in patients with clinically node-negative early breast cancer. However, a relevant number of ALND could be avoided in a subset of patients in whom the risk of non-SNL metastases is low. In order to define this population, several authors have proposed mathematical models, which have been validated in many studies. These studies reached different conclusions regarding which model demonstrated the best statistical discrimination power, mainly due to differences in clinical and pathologic variables used, and particularly differences in the number of dissected SLNs.

METHODS

We retrospectively reviewed clinically node-negative patients who underwent ALND in our surgical ward after the diagnosis of breast cancer metastases on SLN biopsy from January 2000 to December 2012. The predictive accuracy of the widely used nomograms to predict the risk of additional nodal disease in our patients with SLN breast cancer metastases was measured by receiver operating characteristic curve. We then attempted to develop a new nomogram by analyzing the dataset.

RESULTS

A total of 105 patients were included in this study, with ratio of metastatic lymph node/removed lymph node of about 0.89; we found axillary nodal metastases on ALND in only 31 patients (29.5%). Applied to our dataset, Mayo nomogram showed the best area under the receiving operator characteristic curve (0.74) followed by our model (0.71). Instead, the Memorial Sloan-Kettering model showed poor discrimination, as did Tenon (0.56).

CONCLUSIONS

Based on our data, we cannot recommend the clinical use of validated predictive nomograms in order to avoid ALND. We suggest setting up a multicenter Italian study to build a model specific to our setting and based on larger series.

Choices in surgery for older women with breast cancer

Breast cancer is a major cause of mortality worldwide. As the population ages and life expectancy increases, the burden of cancer on health services will increase. Older patients with breast cancer are becoming more suitable for surgery; tailored surgical techniques and increasing healthy life expectancy alongside improved assessment of patients are aiding this trend. Surgery is also becoming a favoured treatment of personal choice for older patient with breast cancer. Evidence shows that surgery is almost always feasible for the older patient with outcomes (survival, progression, and recurrence rates) comparable to younger groups and superior to non-surgical treatments. We aim to describe the current status of surgery for the older patient with breast cancer, showing it is an option that should not be denied. Surgery should always be considered regardless of age, after evaluation of co-morbidities.

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.

Cytokeratin on frozen sections of sentinel node may spare breast cancer patients secondary axillary surgery

Background. The feasibility and accuracy of immunohistochemistry (IHC) on frozen sections, when assessing sentinel node (SN) status intraoperatively in breast cancer, is a matter of continuing discussion. In this study, we compared a center using IHC on frozen section with a center not using this method with focus on intraoperative diagnostic values. Material and Methods. Results from 336 patients from the centre using IHC intraoperatively were compared with 343 patients from the center not using IHC on frozen section. Final evaluation on paraffin sections with haematoxylin-eosin (HE) staining supplemented with cytokeratin staining was used as gold standard. Results. Significantly more SN with isolated tumor cells (ITCs) and micrometastases (MICs) were found intraoperatively when using IHC on frozen sections. There was no significant difference in the number of macrometastases (MACs) found intraoperatively. IHC increased the sensitivity, the negative predictive value, and the accuracy of the intraoperative evaluation of SN without decreasing the specificity and positive predictive value of SN evaluation. Conclusions. IHC on frozen section leads to the detection of more ITC and MIC intraoperatively. As axillary lymph node dissection (ALND) is performed routinely in some countries when ITC and MIC are found in the SN, IHC on frozen section provides valuable information that can lead to fewer secondary ALNDs.

Sentinel lymph node biopsy in primary breast cancer: trust the radiolabeled colloid method and avoid unnecessary procedures

BACKGROUND

With regard to the sentinel lymph node (SLN) procedure in breast cancer, the study analyzed the impact of discrepancies between the number of clinically and histologically identified SLN, the impact of removing additional non-hot/non-blue but clinically conspicuous lymph nodes (LN), and whether the application of blue dye for mapping is necessary.

METHODS

We analyzed 391 SLN procedures in which 928 SLN were removed. In all cases, radiolabeled colloid and blue dye were used for SLN mapping.

RESULTS

In 60 cases (15.3%), additional LN that were not identified by the surgeon were found by histological examination. In 22 cases (5.3%), tissue which clinically resembled an SLN but was histologically connective tissue, was removed. In 76 cases (19.4%), 133 non-hot/non-blue but clinically conspicuous LN were removed. These additionally removed LN, however, did not alter the axillary staging. In 50.8% of the cases (n = 471), the SLN were marked only by radiolabeled colloid. In 27 cases (2.9%), the surgeon identified the LN through blue coloration alone; however, in all of the latter cases, these SLN were not deciding for axillary staging.

CONCLUSION

The mapping agents may accumulate in axillary tissue and mimic the existence of an SLN. The radiolabeled colloid method alone gives excellent mapping results. The additional application of blue dye is avoidable. Exact surgical preparation enables removal of the SLN only and avoids removal of LN-containing adjacent tissue. The removal of further clinically identifiable enlarged non-hot LN should only be done if there is strong suspicion of metastatic involvement.