Technical details for the sentinel node biopsy in breast cancer: a guide for the training process

Detection of CK-19 mRNA-positive cells in the peripheral blood of breast cancer patients with histologically and immunohistochemically negative axillary lymph nodes

BACKGROUND

To investigate the incidence of direct hematogenous spread of cancer cells in patients with early-stage breast cancer by studying the presence of occult tumor cytokeratin-19 (CK-19) mRNA(+) cells in the peripheral blood in relation to the status of sentinel (SLNs) and (ALNs) axillary lymph nodes.

PATIENTS AND METHODS

SLNs and ALNs from 111 patients with operable stage I-II breast adenocarcinoma were evaluated for the presence of tumor cells by hematoxylin-eosin (H&E) staining and, if negative, by immunohistochemistry (IHC) using an anti-CK-19 antibody. Peripheral blood was also analyzed for the presence of CK-19 mRNA(+) cells by nested RT-PCR, before the initiation of adjuvant treatment and in CK-19 mRNA(+) patients following the completion of adjuvant chemotherapy and hormonal treatment.

RESULTS

After both H&E staining and IHC analysis, 29 (26%) patients were ALN negative (N0). In 78 (70%) patients H&E staining and in four (3.6%) IHC analysis revealed tumors cells, and these patients were considered as ALN positive (N+). Peripheral blood CK-19 mRNA(+) cells were detected in nine (31%) out of 29 N0 and in 31 (38%) out of 82 N + patients (P=0.5) before any adjuvant treatment. Adjuvant chemotherapy and hormone treatment resulted in the disappearance of the CK-19 mRNA(+) cells in all N0 patients and in 15 out of 31 N + patients. After a median follow-up of 40 months, all the N0 CK-19 mRNA(+) patients were relapse-free whereas four (13%) N + CK-19 mRNA(+) patients had relapsed.

CONCLUSIONS

Direct hematogenous dissemination of occult tumor cells may occur in a substantial proportion of patients with early-stage breast cancer. The prognostic implication of the detection of these cells requires long follow-up periods and further studies.

Prediction of tumour involvement in remaining axillary lymph nodes when the sentinel node in a woman with breast cancer contains metastases

Background

In a significant proportion of women with breast cancer, the sentinel node is the only involved node in the axilla. The purpose of this study was to identify factors associated with histologically positive non-sentinel lymph nodes.

Methods

Between 1997 and 2002, 800 women with early breast cancer underwent sentinel node biopsy. In 263 patients the node contained metastases, including 83 with micrometastases detected by immunohistochemistry (IHC), 40 micrometastases detected on haematoxylin, eosin and safranine (HES) staining, and 140 macrometastases. All clinical and histological criteria were recorded and analysed with reference to histology of the non-sentinel node.

Results

The risk of metastasis in the non-sentinel lymph node was related to the volume of the tumour in the sentinel node. Non-sentinel nodes were involved in five (6·0 per cent) of 83 women when the sentinel node contained only micrometastatic cells detected on IHC, and in three (7·5 per cent) of 40 women when micrometastases were detected by HES, compared with 55 (39·3 per cent) of 140 when the sentinel node contained macrometastases on HES staining. Univariate analysis revealed a significant association between non-sentinel node involvement and type of metastasis within the sentinel node, clinical primary tumour size, palpable axillary lymph nodes before operation, pathological primary tumour size and the presence of peritumoral lymphovascular invasion. On multivariate analysis, the type of metastasis within the sentinel node (P < 0·001), histological tumour size greater than 20 mm (P = 0·017) and the presence of palpable axillary nodes before operation (P = 0·014) remained significant.

Conclusion

Clinical and pathological factors associated with sentinel node histology can reliably predict women for whom further axillary clearance is recommended, but it is not yet possible to determine a subgroup of patients in whom the sentinel node is the only involved node and for whom further axillary treatment may be unnecessary.

Extra-axillary sentinel node biopsy in breast cancer staging--is it necessary?

AIMS

The aim of this study was to assess the value of lymphoscintigraphy in general and extra-axillary lymph node biopsy in particular, based on our experience with sentinel biopsy in 128 consecutive woman undergoing surgery for breast cancer.

METHODS

Sentinel node biopsy was performed with the aid of isotope, hand held gamma probe, blue dye and lymphoscintigraphy in 83 patients. Injection technique was peritumoral or intratumoral. Lymphoscintigraphy was performed 2-4 h following isotope injection.

RESULTS

Eighteen lymposcintigraphies were negative (21.7%). The sentinel node was found in 14 of these cases. We were unable to identify the sentinel node(s) in four patients (4/83; 4.8%). All in all 20/25 (80%) extra-axillary nodes were located and taken out. Only two of these (2/20, 10%) were positive for metastatic disease on histological examination. The adjuvant treatment plans for these patients were not altered in response to these findings. No positive extra-axillary node(s) with simultaneous normal axillary sentinel node was found.

CONCLUSIONS

In this serie, lymphoscintigraphy and biopsy of extra-axillary sentinel nodes added nothing but time, risk and cost to the procedure.

Axillary lymphadenectomy for breast cancer - the influence of shoulder mobilisation on lymphatic drainage

AIM

The purpose of the present study was to study the influence of external axillary compression dressing with immobilisation of the ipsilateral shoulder after axillary lymph node dissection (ALND) on postoperative axillary drainage.

METHODS

One hundred consecutive women with breast cancer undergoing ALND were enrolled in this study. They were allowed free shoulder movement and were compared with a matched historical control group of 60 patients, in whom the ipsilateral arm was immobilised for four days. For all patients the amount of drainage was recorded each postoperative day until drain removal. Prognostic data on drainage amounts and duration were gathered from all patients. Complications were recorded.

RESULTS

Hospital stay was the only statistically significant difference between the two groups, it was prolonged for patients with immobilisation of the arm. The parameters found to influence the drain production with a statistically significant difference were body mass index and the removal of more than 10 lymph nodes. Postoperative complications were similar in both groups.

CONCLUSIONS

External compression dressing of the axillary cavity with immobilisation of the ipsilateral arm has no impact on the postoperative drainage volume and duration. It is associated with adverse effects, such as discomfort, prolonged hospital stay and shoulder stiffness.

How many cases are enough for accreditation in sentinel lymph node biopsy in breast cancer?

BACKGROUND

There is considerable argument concerning the number of sentinel node biopsy cases with axillary dissection that surgeons should perform before they are eligible on abandoning axillary dissection in negative sentinel node patients.

DATA SOURCES

Papers that (1) address directly or indirectly the subject of credentialing or of learning curve, (2) report on a surgeon's performance, (3) are reported as feasibility or learning curve studies, or both, (4) discuss the learning curve issue, and (5) express an expert's opinion on the learning curve.

CONCLUSIONS

The number of procedures of the learning curve can not be fixed for all surgeons. Only surgeons in specialized breast cancer centers can succeed in meeting current recommendations with 20 to 30 cases. Surgeons from affiliated community hospitals will need more than 30 cases, whereas broad-based surgeons might need as many as 60 cases with their current caseload. Not all surgeons will be able to offer the procedure to their patients by the current recommendations.

Secretory carcinoma of the male breast

BACKGROUND

Secretory carcinoma is a distinctive and rare variant of breast carcinoma with a favorable prognosis because these tumors usually behave in an indolent manner. The occurrence of this type of breast cancer in males was studied.

METHODS

An extensive literature survey concerning secretory breast cancer in males was performed. Data of one case treated in our institute were added.

RESULTS

A total of 14 cases were identified, and our case was added to this series. The median age was 17 years. The duration of symptoms varied from 1 month to 21 years, and the tumor size was 1.2 to 4 cm. Surgical treatment varied from local excision only to modified radical mastectomy. Three patients received adjuvant treatment. Lymph nodes were involved in 3 of the 10 cases undergoing axillary lymph node dissection. The primary tumor was only 1.5 cm in diameter in two of those cases. None of the patients presented with systemic metastases. Only one male was reported to develop recurrence and consequently died of systemic disease.

CONCLUSIONS

Secretory breast cancer is very rare in males and seems to occur at a younger age in males than in females. A sufficient number of female cases have been reported with recurrence after local excision. Although in females lymph node metastases are rarely observed in secretory breast carcinoma smaller than 2 cm, in male patients nodal metastases might occur more frequently in smaller tumors. Therefore, mastectomy with sentinel lymph node biopsy or axillary lymph node dissection is recommended in any male case. Biological behavior seems to be similarly favorable in either sex.