Lymphatic mapping in breast cancer

Influence of preoperative breast cancer localization techniques on rates of sentinel lymph node visualization with preoperative lymphoscintigraphy

OBJECTIVES

The use of preoperative image-guided lesion localization for impalpable breast cancer may interfere with lymphatic drainage and cause delayed or reduced visualization of sentinel lymph nodes (SLNs) on preoperative lymphoscintigraphy. The goal of this audit was to compare rates of SLN visualization in patients undergoing preoperative breast cancer localization with either Iodine 125 seeds (radio-guided occult lesion localization using Iodine 125 seeds, ROLLIS) or hook wire and those with palpable lesions where no localization was required.

PATIENTS AND METHODS

We reviewed the records of 482 patients, who underwent preoperative lymphoscintigraphy with hook wire, ROLLIS, or no localization, at three major tertiary hospitals from January 2013 to December 2017. Static lymphoscintigraphy images are performed post administration of subcutaneous periareolar Tc antimony colloid injection. The rate of SLN visualization in the three groups and time to node visualization were analyzed.

RESULTS

Four hundred and eighty-two patients underwent preoperative lymphoscintigraphy: 102 after no localization, 211 in hook wire, and 169 following ROLLIS. Very high overall rates of SLN visualization on preoperative lymphoscintigraphy were noted in all three groups; no localization group: 99% [95% confidence interval (CI), 94.7-99.8%], hook wire: 98.6% (95% CI, 95.9-99.7%) and ROLLIS: 98.8% (95% CI, 95.8-99.9%). For time to node visualization, a statistically significant difference was found between the no localization versus hook-wire group (P = 0.0015) and no localization versus ROLLIS group (P = 0.00011) but no statistically significant difference between the hook-wire and ROLLIS groups (P = 0.16) was demonstrated.

CONCLUSION

High rates of SLN visualization on preoperative lymphoscintigraphy were noted in all groups, with no significant reduction when breast lesion localization techniques were used. There was; however, an increased rate of delayed imaging required for SLN visualization in women who had undergone either type of preoperative localization compared with those who had not.

Sentinel Lymph Node Mapping and Biopsy for Breast Cancer: A Review of the Literature Relative to 4791 Procedures

The status of axillary nodes is the most important prognostic factor in breast cancer to select patient subgroups for adjuvant chemotherapy; the current standard of care for surgical management of invasive breast cancer is complete removal of the tumor by either mastectomy or lumpectomy followed by axillary lymph node dissection (ALND). The recent introduction of intraoperative lymphatic mapping and sentinel lymph node biopsy (SLND) represents a major new opportunity for appropriate and less invasive surgical management of many tumors. There is an almost uniformly enthusiasm concerning the potential of this technique in breast carcinoma management, shown by published data. A peculiar attention to the so-called “sentinel node debate” in breast cancer surgery is a constant in the last years issues of the major medical journals. Even patients have become more aware about medical enthusiasm and their request of concise information on the topic and the possibilities of this approach is an increasing reality in medical practice.

The aim of this paper is to review recent literature to offer an overview about the main controversial methodological aspects and a wide analysis of reported results. The most significative international literature papers from Medline were retrieved from 1993 to September 1999, and 4782 procedures were analysed. This extensive review of the literature has confirmed accuracy, feasibility and reliability of the SN detecting technique in axillary mapping. Provided a good proficiency in SN localisation and pathological evaluation, human resources and efforts should be mainly focused on its clinical validation as an alternative to ALND instead of on further phase I–-II clinical studies.

Forearm Isosulfan blue injection in the treatment of postoperative lymphatic complications

Lymphatic leakage is an uncommon but serious complication following vascular procedures. When conservative measures fail, accurate identification and ligation of disrupted lymphatic channels is necessary to avoid recurrence. We report the case of a 52-year-old male with a left forearm lymphocele, which occurred following repair of an interosseous artery pseudoaneurysm. Successful lymphatic identification and ligation was performed using intradermal injection of Isosulphan blue dye at the time of operation.

Sentinel lymph node biopsy in breast cancer--experience with the combined use of dye and radioactive tracer at Aarhus University Hospital

One hundred and twenty-four patients with palpable tumours underwent sentinel lymph node biopsy (SLNB) and subsequent axillary lymph node dissection. Ultrasound of the axilla was used as part of the diagnostic work-up on all patients and those with lymph node metastasis verified by fine-needle aspiration biopsy (FNAB) were not included. For identifying the SLNs, a combination of Tc-99m-labelled human albumin (Solco-ALBU-RES) and blue dye (Patent Blue V) was used. No lymphoscintigraphy was performed. The SLN was successfully identified in 122 out of 124 (98%) patients and 66 (54%) patients were found to have metastatic involvement of the axillary lymph nodes. In 52 (79%) of these patients, the SLNs were the only nodes involved, 28 (54%) had micrometastasis only. The false-negative rate was 1.5%. This method has proven valid in the staging of the axilla in patients with breast cancer. The advanced techniques of serial sectioning and immunohistochemical staining further improve the diagnostic advantage offered by the SLNB, as it increases the possibility of diagnosing micrometastatic deposits.

Sentinel node skills verification and surgeon performance: data from a multicenter clinical trial for early-stage breast cancer

OBJECTIVE

Marked variations in sentinel lymph node dissection (SLND) technique have been identified, and definitive qualifications for SLND performance remain controversial. Based on previous reports and expert opinion, we predicted that 20 to 30 cases of SLND with axillary lymph node dissection (ALND) would enable surgeons to identify sentinel lymph nodes (SLN).

SUMMARY BACKGROUND DATA

In 1999, the American College of Surgeons Oncology Group initiated a prospective trial, Z0010, to evaluate micrometastatic disease in the SLN and bone marrow of women with early-stage breast cancer. Eligible patients included women with biopsy-proven T1/T2 breast cancer and clinically negative lymph nodes who were candidates for lumpectomy and SLND.

METHODS

Participating surgeons were required to document 20 to 30 SLNDs followed by immediate ALND with failure rates less than 15%. Prior fellowship or residency training in SLND provided exemption from skill requirements. Data for 5237 subjects and 198 surgeons were available for analysis.

RESULTS

Surgeons from academic (48.4%), community (28.6%), or teaching-affiliated (19.8%) institutions qualified with 30 SLND + ALND cases (64.6%), 20 cases (22.2%), or exemption (13.1%). Participants used blue dye + radiocolloid in 79.4%, blue dye alone in 14.8%, and radiocolloid alone in 5.7% of cases, achieving a 98.7% SLN identification rate. Patient factors associated with increased SLND failure included increased body mass index and age, whereas tumor location, stage, and histology, presence of nodal metastases, and number of positive nodes were not. Surgeon accrual of fewer than 50 patients was associated with increased SLND failure; however, SLND technique, specific skill qualification, and institution type were not.

CONCLUSIONS

Using a standard skill requirement, surgeons from a variety of institutions achieved an acceptably low SLND failure rate in the setting of a large multicenter trial, validating the incorporation of SLND into clinical practice.

A critical review of variables affecting the accuracy and false-negative rate of sentinel node biopsy procedures in early breast cancer

Radionuclide sentinel lymph node localization and biopsy is a staging procedure that is being increasingly used to evaluate patients with invasive breast cancer who have clinically normal axillary nodes. The most important prognostic indicator in patients with invasive breast cancer is the axillary node status, which must also be known for correct staging, and influences the selection of adjuvant therapies. The accuracy of sentinel lymph node localization depends on a number of factors, including the injection method, the operating surgeon's experience and the hospital setting. The efficacy of sentinel lymph node mapping can be determined by two measures: the sentinel lymph node identification rate and the false-negative rate. Of these, the false-negative rate is the most important, based on a review of 92 studies. As sentinel lymph node procedures vary widely, nuclear medicine physicians and radiologists must be acquainted with the advantages and disadvantages of the various techniques. In this review, the factors that influence the success of different techniques are examined, and studies which have investigated false-negative rates and/or sentinel lymph node identification rates are summarized.

Sentinel lymph node dissection and the current status of American trials on breast lymphatic mapping

The current national sentinel lymph node (SLN) clinical trials for breast carcinoma address the prognostic and therapeutic utility of SLN dissection (SLND) in women with early-stage, clinically node-negative breast cancer. Following completion of these studies, overall survival, disease-free survival, morbidity, and quality of life of patients will be compared. Surgeon participation is crucial to the ongoing success of clinical trials in the field of breast cancer surgery.

Intraoperative use of isosulfan blue in the treatment of persistent lymphatic leaks

BACKGROUND

Lymphatic leaks are a major source of morbidity after lower extremity vascular surgery. We determined the ability of isosulfan blue (Lymphazurin) use to identify and help ligate offending lymphatics, and compared postoperative complication rates and length of stay versus nonoperative therapy alone.

METHODS

From January 1993 through March 2002, we identified 15 patients with lymphatic leaks. The first group consisted of 5 patients treated nonoperatively. The second group was 10 patients (11 explorations) treated operatively aided by isosulfan blue, after a trial of nonoperative therapy.

RESULTS

Isosulfan blue identified the leak in 10 of 11 cases. Mean drainage time for the nonoperative group was 47.6 days versus 1.8 days for the operative group (P = 0.036). Within the operative group, the mean drainage time during their initial conservative treatment phase was 15 days versus 1.8 days after surgery (P < 0.01). Complications were significantly less in the operative group (P < 0.05). Postoperative length of stay was a mean of 4.7 days versus 8.1 days for nonoperative patients (P = not significant).

CONCLUSIONS

Intraoperative isosulfan blue use accurately identifies disrupted lymphatic channels and helps ensure definitive ligation. This simple procedure is associated with fewer complications, and a trend toward shorter hospital stay.

Sentinel lymph node biopsy followed by delayed mastectomy and reconstruction

BACKGROUND

The role of sentinel lymph node (SLN) biopsy with total mastectomy is evolving. In patients who desire mastectomy with immediate reconstruction, the final pathologic results of the SLN may create unique problems. Specifically, if the SLN is found to be positive on final pathology, the reconstructed patient would generally require a potentially difficult re-operation on the remaining axillary nodes. The purpose of this study was to review the results of patients who underwent an initial SNL biopsy followed by a planned mastectomy and reconstruction.

METHODS

A chart review of patients who underwent staged SLN biopsy with subsequent definitive procedure between 1997 and 2001 was conducted. These were evaluated with regard to type of tumor, status of sentinel node, and design of subsequent operation.

RESULTS

There were 40 patients who underwent an initial SLN biopsy followed by a staged mastectomy with reconstruction. Tumors included high-grade carcinoma in situ (n = 4), infiltrating ductal carcinoma (n = 28), invasive lobular carcinoma (n = 4), mucinous carcinoma (n = 1), adenoid cystic carcinoma (n = 1), and mixed ductal and lobular carcinoma (n = 2). Tissue biopsy was obtained by either open (n = 9) or needle (n = 31) technique. Twenty-five patients had a negative SLN biopsy and a delayed total mastectomy with immediate reconstruction. Positive SLNs were identified in 15 patients (37%). Eight patients had macroscopic nodal metastases and underwent a delayed modified radical mastectomy and immediate reconstruction. Seven patients had microscopic nodal metastases and 3 declined further axillary dissection. They proceeded with total mastectomy and immediate reconstruction.

CONCLUSIONS

These data suggest that a substantial proportion of patients treated with SLN biopsy, simple mastectomy, and reconstruction will have positive sentinel lymph nodes. Thus, the ideal approach for patients who wish to have reconstruction should involve an initial SLN biopsy as a separate procedure. If the SLN is benign, the patient may undergo a total mastectomy with immediate reconstruction. However, a patient with a positive SLN may proceed to a modified radical mastectomy with immediate reconstruction. This treatment algorithm eliminates a potentially difficult reoperation on the axilla following reconstruction.

Axillary lymph node metastases: a statistical analysis of various parameters in MRI with USPIO

PURPOSE

To assess the value of plain vs. iron oxide-enhanced MRI vs. the combined study (plain + postcontrast) based on qualitative and quantitative parameters of three pulse sequences.

MATERIALS AND METHODS

Data from two sites were acquired using the same technique; therefore, this data could be pooled. T1W-SE, T2W-FSE, and 3D-PSIF were used before and 24-36 hours after MRI with ultra small particles of iron oxide (USPIO) was performed. A total of 52 lymph nodes (LNs) in nine patients (25 benign, 27 malignant) were evaluated by two readers who were visually and quantitatively blinded to the histology. Combinations of the following diagnostic parameters were compared using logistic regression analysis: the short-axis diameter of the LN, the signal distribution of the LN on postcontrast agent MRI (homogeneous or heterogeneous), and qualitatively and quantitatively determined signal changes of the LN following administration of contrast agent in the three evaluated sequences.

RESULTS

Using pre- and postcontrast data, the optimized accuracy based on the statistically most significant parameters (LN diameter > 6 mm, visual assessment of signal change on T2W-SE) was 87% (81% sensitivity, 92% specificity). Precontrast data alone yielded 75% accuracy (63% sensitivity, 86% specificity). Postcontrast data alone yielded 75% accuracy (56% sensitivity, 96% specificity).

CONCLUSION

Based on our results, USPIO-MRI improved the diagnosis of metastatic axillary LNs compared with precontrast MRI alone. Both pre- and postcontrast studies are needed. T1W-SE and T2W-PSIF did not yield significant additional information. This study may help to further improve the technique of USPIO imaging.

Breast cancer: variables affecting sentinel lymph node visualization at preoperative lymphoscintigraphy

PURPOSE

To compare patients with visualized sentinel lymph nodes (SLNs) and patients with nonvisualized SLNs, with a focus on variables affecting SLN visualization at preoperative lymphoscintigraphy and on nodal drainage basins as related to tumor location.

MATERIALS AND METHODS

One hundred thirty-six patients who had breast cancer underwent preoperative lymphoscintigraphy before SLN biopsy. Patients with visualized and nonvisualized SLNs were compared for age; tumor site, size, and histologic findings; injection guidance method; diagnostic biopsy type; interval between biopsy and lymphoscintigraphy; intraoperative identification method; and surgical identification rate. Visualized SLN drainage basins were noted.

RESULTS

Ninety-nine patients had visualized and 37 had nonvisualized SLNs, without statistically significant differences in tumor site, size, and histologic findings; injection guidance method; diagnostic biopsy type; and interval between biopsy and lymphoscintigraphy. Ninety-nine (73%) of the 136 SLNs were visualized at lymphoscintigraphy; 30 (81%) of the 37 nonvisualized SLNS were identified at surgery. Of the seven SLNs not identified at surgery, five were mapped with radiocolloid only. Patients with nonvisualized SLNs were older than those with visualized SLNs. Eleven (46%) of 24 tumors with internal mammary drainage were in the outer part of the breast.

CONCLUSION

Patients with and those without visualization differed in age, SLN identification at surgery, and surgical identification method. Nonvisualized status does not preclude axillary metastasis. In older patients with nonvisualized SLNs, blue dye may aid in SLN detection, as compared with isotope-only localization.

The Role of Lymphoscintigraphy in the Management of the Patient With Breast Cancer

INTRODUCTION

Regional nodal status is the most powerful predictor of recurrence and survival in women with breast cancer. Lymphatic mapping and sentinel lymph node (SLN) biopsy have been found to accurately predict the regional nodal status. Preoperative lymphoscintigraphy has been used in melanoma patients to identify the basins at risk for metastases when primary sites are located in watershed areas of the body. This study was performed to define the role of lymphoscintigraphy for axillary nodal staging in women with breast cancer. Specifically, can preoperative lymphoscintigraphy define a population of women with breast cancer who have multidirectional drainage or who do not drain to the axilla and need no axillary dissection?

METHODS

516 patients with invasive breast cancer were accrued in a national breast lymphatic mapping trial sponsored by the U.S. Department of Defense. Preoperative lymphoscintigraphy images were produced using filtered technetium-99 sulfur colloid. Lymphatic drainage to axillary and internal mammary sites was noted.

RESULTS

Drainage to an axillary SLN was found in 335 (65%) patients, and internal mammary or extra-axillary drainage was noted in 52 (10%) patients. By using sensitive hand-held probes and vital blue dye intraoperatively, the overall success rate of finding an axillary SLN was 85%. Of the 335 patients who had an axillary SLN identified with imaging, all had successful SLN biopsy procedures. Although no SLNs could be imaged in 181 patients, 153 (85%) of these patients had an axillary SLN identified with intraoperative mapping. For 28 patients in which lymphoscintigraphy was negative and intraoperative mapping was unsuccessful, complete axillary node dissection was performed, and 13 (46%) of these patients were found to have metastatic disease in the basin.

CONCLUSIONS

Preoperative lymphoscintigraphy can identify those women with primary breast cancers who have extra-axillary regional basin drainage such as internal mammary. The ability to image an axillary SLN was associated with a high success rate of being able to find the node intraoperatively with a combination mapping technique. In a high percentage of patients with negative lymphoscintigraphy, the SLN was identified with more sensitive hand-held probes. Therefore, patients who have a negative preoperative lymphoscintigraphy and intraoperatively are found to have no "hot" spot in the axilla with the hand-held probe still need an axillary node dissection, because 46% of these patients contain metastatic disease in the axilla.

Intraoperative Pathologic Evaluation of a Breast Cancer Sentinel Lymph Node Biopsy as a Determinant for Synchronous Axillary Lymph Node Dissection

BACKGROUND

Intraoperative pathologic evaluation of a breast cancer sentinel lymph node (SLN) biopsy permits synchronous axillary lymph node dissection (ALND), but frozen section is time consuming and potentially inaccurate. This study evaluated intraoperative gross examination and touch prep analysis (TPA) of a breast cancer SLN biopsy as determinants for synchronous ALND.

METHODS

Intraoperative gross examination/TPA were performed on the SLN of consecutive breast cancer patients from 1997 to 2000. Patients with an intraoperative "positive" SLN underwent synchronous ALND. Intraoperative results were compared with the final pathology.

RESULTS

Thirty-seven of 150 patients had a positive SLN on final pathology. Intraoperative gross examination/TPA identified 54% (20 of 37) of these patients. All intraoperative "positive" patients underwent synchronous ALND. Of 17 "false-negative" findings, 53% (9 of 17) had micrometastatic disease. There were no "false-positive" results. Overall sensitivity and specificity were 54% and 100%, respectively.

CONCLUSIONS

Gross examination/TPA are simple, rapid techniques for the intraoperative evaluation of a breast cancer SLN. As there were no false-positive results, the rationale behind SLN biopsy was preserved. These techniques permitted synchronous ALND in over half of all patients with a positive SLN. This represents a potential benefit to the patient by eliminating a second hospitalization for delayed ALND.

Role of surgery in the management of postmastectomy extremity angiosarcoma (Stewart-Treves syndrome)

Stewart-Treves syndrome (STS) is the rare occurrence of angiosarcoma in a setting of postmastectomy upper extremity lymphedema. A collective comparison of outcomes following various initial treatment options in STS has not previously been reported. We reviewed 160 cases of STS reported in the literature since 1966. We analyzed the relationship between initial treatment and survival in all 92 of these patients for whom detailed treatment and outcome data had been reported. There was no significant difference in survival comparing those initially treated with wide excision (n = 16) and those treated with amputation (n = 45) (P = 0.40). Even in the setting of initial surgical treatment, overall long-term survival was poor (<40%). There have been even fewer long-term survivors among those treated initially with regional chemotherapy (n = 7) or radiation therapy (n = 24). An update on STS and a discussion of recent advances in the understanding of its molecular pathogenesis that may result in future treatment improvements are presented.

Pathology of preinvasive and excellent-prognosis breast cancer

Evaluation of tissue and cellular samples for diagnosis, risk assessment, and prognosis in breast cancer is the subject of this review. We emphasize indicators of elevated risk for breast cancer and carcinomas in situ and indicators of good prognosis in invasive breast cancer. The importance of ductal carcinoma in situ to considerations in breast conservation and prevention is highlighted. Special types of breast cancer, immunohistochemistry, histologic grading, and the relevance of core biopsy to diagnostic certainty are considered. We also add a brief note about the escalating role of nodal micrometastases and sentinel node biopsy in the definition of minimal regional disease.