[Lymph node mapping and axillary sentinel lymph node biopsy in 243 invasive breast cancers with no palpable nodes. The south Lyon hospital center experience]

The Sentinel Lymph Node in Breast Cancer: Problems Posed by Examination During Surgery. A Review of Current Literature and Management

The presence of tumor cells can be identified in the lymph node when metastasis has occurred from the primary cancer site into the lymph node (1) If the sentinel lymph node ganglion is negative for the presence of tumor cells at the time of histological examination, the other lymph nodes are also negative in 99% of cases. If no tumor cells are identified in the sentinel lymph node ganglion by histological examination, the other lymph nodes are also negative for the presence of tumor cells in 99% of cases. The sentinel lymph node advantageously replaces axillary dissection as a staging method in breast cancer T1 and T2 (2). Approximately 40% of breast cancers metastasize to axillary lymph nodes and metastatic extension depends on disease stage. Sentinel lymph nodes are affected in the following stages: T1a (4.3%), T1b (19.5%), T1c (23.8%), T2 (48.9%), T3 (66.7%).

Current approach of the axilla in patients with early-stage breast cancer

The surgical approach of the axilla in patients with early-stage breast cancer has witnessed considerable evolution during the past 25 years. The previously undisputed gold standard of axillary-lymph-node dissection for staging has now been replaced by sentinel-lymph-node biopsy for patients with clinically negative axilla. For selected patients with limited sentinel-lymph-node involvement, completion axillary-lymph-node dissection can be omitted or replaced by axillary radiotherapy, reducing morbidity. The clinical interest of axillary staging after neoadjuvant chemotherapy is increasing and this approach might contribute to morbidity reduction, and to the further tailoring of future systemic and locoregional treatment decisions by response assessment. Refinement of the sentinel-lymph-node biopsy technique might overcome the slightly impaired success rates in this setting. New techniques for lymphatic mapping attempt to further simplify the procedure. In view of the declining influence of axillary nodal status on adjuvant therapy decision-making, ongoing clinical trials will evaluate whether sentinel-lymph-node biopsy can be avoided altogether in selected patients.

High-speed dynamic 3D photoacoustic imaging of sentinel lymph node in a murine model using an ultrasound array

Noninvasive photoacoustic sentinel lymph node (SLN) mapping with high spatial resolution has the potential to improve the false negative rate and eliminate the use of radioactive tracers in SLN identification. In addition, the demonstrated high spatial resolution may enable physicians to replace SLN biopsy with fine needle aspiration biopsy, and thus reduce the risk of associated morbidity. The primary goal of this study is to demonstrate the feasibility of high-speed 3D photoacoustic imaging of the uptake and clearance dynamics of Evans blue dye in SLNs. The photoacoustic imaging system was developed with a 30 MHz ultrasound array and a kHz repetition rate laser system. It acquires one 3D photoacoustic image of 166 B-scan frames in 1 s, with axial, lateral, and elevational resolutions of 25, 70, and 200 microm, respectively. With optic-fiber based light delivery, the entire system is compact and is convenient to use. Upon injection of Evans blue, a blue dye currently used in clinical SLN biopsy, SLNs in mice and rats were accurately and noninvasively mapped in vivo using our imaging system. In our experiments, the SLNs were found to be located at approximately 0.65 mm below the skin surface in mice and approximately 1.2 mm in rats. In some cases, lymph vessels and lymphatic valves were also imaged. The dye dynamics--accumulation and clearance--in SLNs were quantitatively monitored by sequential 3D imaging with temporal resolution of as high as approximately 6 s. The demonstrated capability suggests that high-speed 3D photoacoustic imaging should facilitate the understanding of the dynamics of various dyes in SLNs and potentially help identify SLNs with high accuracy.

Lymphatic mapping with 99mTc-Evans Blue dye in sheep

OBJECTIVE

99mTc-Evans Blue (EB) is an agent that contains both radioactive and color signals in a single dose. Earlier studies in animal models have suggested that this agent when compared with the dual-injection technique of radiocolloid/blue dye can successfully discriminate the sentinel lymph node. The aim of this study was to investigate the potential of 99mTc-EB as an agent to map the lymphatic system in an ovine model.

METHODS

Doses of 99mTc-EB (23 MBq) containing EB dye (4 mg) were administered intradermally to the limbs of four anesthetized sheep, and they were then imaged over 20-30 min using a gamma camera. The study protocol was repeated using 99mTc-antimony trisulfide colloid (ATC) and Patent Blue V dye. The lymph nodes (popliteal, inguinal, and iliac for hind limbs or prescapular for fore limbs) were identified with a gamma probe during the operative exposure, then dissected and counted in a large volume counter.

RESULTS

Simple and complex (dual) drainage patterns were visible on the scans, and the sentinel node was more radioactive than higher tier nodes in a chain, for both radiotracers. For 99mTc-EB, maximum radioactive uptake was achieved at 3-6 min for popliteal lymph nodes, 12-14 min for iliac nodes, and 13-14 min for prescapular nodes. 99mTc-ATC resulted in maximum radioactive uptake at 4-6 min for popliteal lymph nodes, 13 min for an inguinal node, 13-20 min for iliac nodes, and 18 min for a prescapular node. Following 99mTc-EB injection, 15/15 lymph nodes harvested were all radioactive and blue. For 99mTc-radiocolloid/Patent Blue V injection, 8/14 nodes were radioactive and blue, and 6/14 nodes were radioactive only.

CONCLUSIONS

The soluble radiotracer 99mTc-EB appeared to be a useful lymphoscintigraphic agent in sheep, in which radioactive counts from superficial lymphatic channels and lymph nodes were sufficient for planar imaging. In comparison with 99mTc-antimony trisulfide colloid, both tracers discriminated the sentinel lymph node up to 50 min after administration; however, 99mTc-EB had the advantage of providing radioactive (gamma probe) and color signals simultaneously during the operative exposure.

Is the "10% rule" equally valid for all subsets of sentinel-node-positive breast cancer patients?

BACKGROUND

In breast cancer, a combination of radioisotope and blue dye mapping maximizes the success and accuracy of sentinel node (SLN) biopsy. When multiple radioactive nodes are present, there is no single definition of isotope success, but the popular "10% rule" dictates removal of all SLN with counts >10% of the most radioactive node. Here we determine how frequently a positive SLN would be missed by the 10% rule.

METHODS

Between 9/96 and 12/04, we performed 6,369 successful SLN biopsies using (99m)Tc sulfur colloid and isosulfan blue dye, removing as SLN all radioactive and/or blue nodes, and taking counts from each node ex vivo. Standard processing of all SLNs with a benign frozen section included hematoxylin and eosin (H&E) staining, serial sectioning, and immunohistochemistry (IHC).

RESULTS

33% of patients (2,130/6,369) had positive SLNs. Of these patients, 1,387/2,130 (65%) had >1 SLN identified. The most radioactive SLN was benign in 29% (398/1,387), and 107/1,387 (8%) had a positive SLN that was neither blue nor the hottest. From this group 1.7% (24/1387) of patients had positive SLN with counts <10% radioactive counts of the hottest node. The 10% rule captured 98.3% of positive nodes in patients with multiple SLNs. No patient characteristics were predictive of failure of the 10% rule.

CONCLUSION

With combined isotope and blue dye mapping, the 10% rule is a robust guideline and fails to identify only 1.7% (24/1387) of all SLN-positive patients with multiple SLNs. This guideline appears to be equally valid for all subsets of patients.

Sentinel lymphnode biopsy in early breast cancer using methylene blue dye and radioactive sulphur colloid - a single institution Indian experience

BACKGROUND

Axillary lymph node dissection is an established procedure in breast cancer staging. However, it is associated with unpleasant side effects. A promising alternative to assess axillary lymph node status in early breast cancer patients is Sentinel Lymph Node Biopsy (SLNB). Isosulfan blue has traditionally been the dye used to identify the Sentinel Lymph Node (SLN). This article is a validation study of SLNB using methylene blue dye and radioactive sulphur colloid in early breast cancer Indian patients. MATERIALS #ENTITYSTARTX00026;

METHODS

With written informed consent, 100 patients with cytology or biospy proven carcinoma breast, clinical stage T1/ T2 N0 M0, underwent SLNB using combination of methylene blue dye & radioactive technetium 99m sulphur colloid as a part of validation study from June 2003 to February 2006. After validation study, from March 2006 to February 2007, 35 patients have undergone SLNB followed by complete axillary clearance in only those patients with SLNB being positive for metastases.

RESULTS

In all 100 patients of the validation study SLN was identified. Total number of cases with positive axillary nodes was 27, out of which SLN was only positive node for metastases in 69% of cases. The overall sensitivity, specificity, positive predictive valve and negative predictive valve of SLNB 96.2%, 100%, 100% and 98.6% respectively with false negative rate of 3.7%. In subsequent 35 patients who underwent SLNB followed by complete axillary clearance, SLNs was identified in all the cases.

CONCLUSIONS

SLNB is effective in early breast cancer patients of Indian population. SLNB using combination of methylene blue dye and radio-active Tc99m sulphur colloid can stage the axilla with high accuracy & low risk of false negativity in early breast cancer patients.

Role of Sonography in the Diagnosis of Axillary Lymph Node Metastases in Breast Cancer: A Systematic Review

OBJECTIVE

The purpose of our study was to evaluate the accuracy of sonography and sonographically guided biopsy in the preoperative diagnosis of metastatic invasion of the axilla in patients with breast carcinoma.

MATERIALS AND METHODS

We performed a MEDLINE search (keywords, "sonography" OR "ultrasound" AND "axillary") and a manual search of the references of relevant studies and reviews of preoperative diagnosis on sonography of possible axillary metastases. The gold standard required was axillary lymph node dissection; we accepted sentinel node biopsy as an alternative gold standard. Considering the sonographic findings and the results of the sonographically guided biopsy, the sensitivity and specificity were calculated using metaanalysis. We also checked the existence of heterogeneity of the summary results.

RESULTS

Sixteen articles were selected. In sonography of axillae without palpable nodes, and using lymph node size as the criterion for positivity, sensitivity varied between 48.8% (95% confidence interval, 39.6-58%) and 87.1% (76.1-94.3%) and specificity, between 55.6% (44.7-66.3%) and 97.3% (86.1-99.9%). When lymph node morphology was used as the criterion for positivity, sensitivity ranged from 26.4% (15.3-40.3%) to 75.9% (56.4-89.7%) and specificity, from 88.4% (82.1-93.1%) to 98.1% (90.1-99.9%). The results are different if axillae with palpable nodes are included. The sonographically guided biopsy shows a sensitivity that varies between 30.6% (22.5-39.6%) and 62.9% (49.7-74.8%) and a specificity of 100% (94.8-100%). Many of the summary results obtained after meta-analysis show a heterogeneity that disappears, on occasion, on excluding the studies that use a double gold standard.

CONCLUSION

Axillary sonography is moderately sensitive and fairly specific in the diagnosis of axillary metastatic involvement. Sonographically guided biopsy of the sonographically suspicious nodes somewhat increases the specificity, which reaches 100%. Negative sonographic results do not exclude axillary lymph node metastases.

Lymphatic mapping and sentinel lymph node biopsy in early-stage breast carcinoma: a metaanalysis

BACKGROUND

Lymphatic mapping with sentinel lymph node biopsy has the potential for reducing the morbidity associated with breast carcinoma staging. It has become a widely used technology despite limited data from controlled clinical trials.

METHODS

A systematic review of the world's literature of sentinel lymph node (SLN) biopsy in patients with early-stage breast carcinoma was undertaken by using electronic and hand searching techniques. Only studies that incorporated full axillary lymph node dissection (ALND), regardless of SLN results, were included. Individual study results along with weighted summary measures were estimated using the Mantel-Haenszel method. The correlations of outcomes with the study size, the proportion of positive lymph nodes, the technique used, and the study quality were evaluated.

RESULTS

Between 1970 and 2003, 69 trials were reported that met eligibility criteria. Of the 8059 patients who were studied, 7765 patients (96%) had successfully mapped SLNs. The proportion of patients who had successfully mapped SLNs ranged from 41% to 100%, with > 50% of studies reporting a rate < 90%. Lymph node involvement was found in 3132 patients (42%) and ranged from 17% to 74% across studies. The false-negative rate (FNR) ranged from 0% to 29%, averaging 7.3% overall. Eleven trials (15.9%) reported an FNR of 0.0, whereas 26 trials (37.7%) reported an FNR > 10%. Significant inverse correlations were observed between the FNR and both the number of patients studied (r = - 0.42; P < 0.01) and the proportion of patients who had successfully mapped SLNs nodes (r = - 0.32; P = 0.009).

CONCLUSIONS

Lymphatic mapping with SLN biopsy is used widely to reduce the complications associated with ALND in patients with low-risk breast carcinoma. This systematic review revealed a wide variation in test performance.

99mTc-Evans blue dye for mapping contiguous lymph node sequences and discriminating the sentinel lymph node in an ovine model

BACKGROUND

The aim of this study was to investigate the potential of (99m)Tc-Evans blue for discriminating the sentinel lymph node in multitiered lymph node sequences by using an ovine model. (99m)Tc-Evans blue is an agent that has both radioactive and color signals in a single dose. Previous studies in smaller animal models suggested that this agent could have advantages over the dual-injection technique of radiocolloid/blue dye.

METHODS

Doses of (99m)Tc-Evans blue ( approximately 21 MBq) containing Evans blue dye (approximately 4 mg) were administered to the hind limbs or fore limbs of sheep to map the lymphatic drainage patterns, validate its ability to identify the sentinel lymph node, and examine the reproducibility of the technique. The study protocol was repeated with (99m)Tc-antimony trisulfide colloid and Patent Blue V dye. After the operative exposure, lymph nodes were identified with the gamma probe and then excised and analyzed for radioactivity (percentage of injected dose) and blue color.

RESULTS

After the administration of (99m)Tc-Evans blue, all lymph nodes harvested (35 of 35) in either short chains or long basins were hot and blue. The sentinel lymph nodes concentrated more radioactivity than the second-tier nodes to the extent of 2:1 to 215:1. For radiocolloid/Patent Blue V, the ratios were lower, at 2:1 to 3:1.

CONCLUSIONS

(99m)Tc-Evans blue was found to better discriminate the sentinel lymph node than (99m)Tc-antimony trisulfide colloid/Patent Blue V in variable multitier lymph node anatomy, and it is an agent that promises to have positive clinical applications.

Technique du ganglion sentinelle dans les cancers utérins : revue de la littérature

In cancer research, regional lymph node status is a major prognostic factor and a decision criterion for adjuvant therapy warranting the lymphadenectomy. The sentinel node procedure, which has emerged to reduce morbidity of extensive lymphadenectomy, remains a major step in the surgical management of various cancers. Sentinel node procedure has become a standard technique for the determination of the nodal stage of the disease in patients with melanoma, vulvar cancer and recently in breast cancer. In cervical and endometrial cancers, the sentinel node biopsy is still at the stage of feasibility. In this article, we review the technical aspects, results and clinical implications of sentinel node procedure in cervical and endometrial cancers.

Macroscopic quality control improves the reliability of blue dye-only sentinel lymph node biopsy in breast cancer

BACKGROUND

One of the problems of sentinel lymph node (SLN) biopsy is the risk of false negatives. At the Institut Curie, to reduce the false-negative rate, we have developed a histological quality control of the SLN performed by blue dye alone, which consists of verification of the SLN blue stain by the pathologist.

METHODS

A total of 324 patients underwent an SLN biopsy procedure with patent blue dye only followed by an immediate axillary dissection. Initially, SLNs were checked to ensure that they were blue by macroscopic examination. Finally, a search for immunohistochemistry micrometastasis was performed.

RESULTS

In 277 (85.5%) of 324 patients, an SLN was identified by the surgeon. After standard examination, the false-negative rate was 11.1% (10 of 90). After macroscopic checking of the 197 negative SLNs, 167 of the 197 were confirmed blue, and there were 5 false negatives, which brought the false-negative rate down to 5.6% (5 of 90). Sixty SLNs out of the 167 confirmed blue SLNs were then proved to be immunohistochemically micrometastatic, and there were 3 false negatives, giving a final false-negative rate of 2.2% (2 of 90; P =.002).

CONCLUSIONS

In this series, the procedure of pathologic analysis of the SLN has resulted in a significant reduction of the false-negative rate.

[Sentinel node involvement in T0-T1 breast cancers]

STUDY AIM

Determination of axillary lymph node status is crucial in diagnosis of early breast cancer. However thanks to an early diagnosis, an increasing number of axillary lymph node dissections are free of disease. This raises questions about the need for this procedure. The study aim was to report an experience with lymphadenectomy and sentinel node mapping in patients with T0-T1 carcinoma of the breast.

METHODS

Between November 1997 and December 1999, 84 consecutive women (T0-T1 N0 according to the 1987 UICC classification) with recently diagnosed breast cancer, were included in this study for identification of the sentinel lymph node (SLN). The SLN was removed and submitted for histological examination. All patients underwent axillary dissection; nodes from levels I and II (Berg's classification) were excised and submitted to histological examination.

RESULTS

The average tumor diameter was 12.7 mm (range, 3 to 25 mm). The lymphatic mapping technique was obtained after injection of the isotope into the breast around the tumor in 53/84 patients: the sentinel lymph node was the only positive node in 10 patients and it was positive in 5 patients with other axillary nodes. In 15/84 patients, an intradermal injection of blue dye was used; two sentinel nodes were positive and one falsely negative. In 16/84 patients, an interdermal injection of blue dye was used to make up for. In this study, the sentinel node was positive in three patients and falsely negative in one patient. The discrepancy was due to an important involvement of an axillary area excluded from the lymphatic channels. 22/84 patients (26%) had a metastatic spread to the axillary nodes. 30/84 patients had also an isotopic captation in another lymph node group (internal mammary).

CONCLUSION

This study confirms that lymphatic mapping is technically possible in the patients with T0-T1 breast cancer and that the histological characteristics of the sentinel node probably reflect the histological characteristics of the rest of the axillary lymph nodes, but do not provide any information about the other lymph node sites.