Sentinel-lymph-node biopsy for breast cancer--not yet the standard of care

A novel nomogram for the preoperative prediction of sentinel lymph node metastasis in breast cancer

BACKGROUND OR PURPOSE

A practical noninvasive method to identify sentinel lymph node (SLN) status in breast cancer patients, who had a suspicious axillary lymph node (ALN) at ultrasound (US), but a negative clinical physical examination is needed. To predict SLN metastasis using a nomogram based on US and biopsy-based pathological features, this retrospective study investigated associations between clinicopathological features and SLN status.

METHODS

Patients treated with SLN dissection at four centers were apportioned to training, internal, or external validation sets (n = 472, 175, and 81). Lymph node ultrasound and pathological characteristics were compared using chi-squared and t-tests. A nomogram predicting SLN metastasis was constructed using multivariate logistic regression models.

RESULTS

In the training set, statistically significant factors associated with SLN+ were as follows: histology type (p < 0.001); progesterone receptor (PR: p = 0.003); Her-2 status (p = 0.049); and ALN-US shape (p = 0.034), corticomedullary demarcation (CMD: p < 0.001), and blood flow (p = 0.001). With multivariate analysis, five independent variables (histological type, PR status, ALN-US shape, CMD, and blood flow) were integrated into the nomogram (C-statistic 0.714 [95% CI: 0.688-0.740]) and validated internally (0.816 [95% CI: 0.784-0.849]) and externally (0.942 [95% CI: 0.918-0.966]), with good predictive accuracy and clinical applicability.

CONCLUSION

This nomogram could be a direct and reliable tool for individual preoperative evaluation of SLN status, and therefore aids decisions concerning ALN dissection and adjuvant treatment.

Methods for sentinel lymph node mapping in oral cancer: a literature review

Oral cancers, excluding non-melanoma skin cancer, are the most common cancers of the head and neck. Of these, 90% are squamous cell carcinomas (SCC). Surgery, which consists of dissection of the primary tumor and lymphadenectomy, is considered a radical method of treatment. There are several ranges of cervical lymphadenectomy: selective neck dissection (SND), modified radical neck dissection (MRND), and radical neck dissection (RND). The extension of surgery depends on the stage of clinical advancement, which can be determined by TNM classification, among other methods. The greatest controversy is related to SND in patients with cN0 (no evidence of regional lymph node metastasis), which is currently standard procedure. This approach is dictated by the possibility of hidden or subclinical metastases. The use of the sentinel lymph node (SLN) concept in patients with early stage of oral cancer and appropriate methods of its mapping may lead to a reduction in the extent of the lymphadenectomy procedure, thus reducing postoperative mortality and maintaining the patient’s function and quality of life, with correct oncological results. So far, available methods for SLN mapping are based on use of markers: methylene blue dye (MBD), metastable radioactive isotope Technetium (99mTc), or the fluorescent substance indocyanine green (ICG).

Application of ultrasound-guided placement of markers for locating axillary lymph nodes of breast cancer

BACKGROUND

With the continuous improvement of pathological complete response (pCR) rate after neoadjuvant therapy (NAT), it is necessary to locate the tumor bed and axillary lymph nodes (ALNs) for subsequent surgery. Therefore, breast tissue markers emerge. This study aims to evaluate the feasibility and accuracy of ultrasound (US)-guided placement of markers for locating ALNs of breast cancer.

METHODS

A total of 285 patients who received US-guided placement of markers for locating ALNs in our hospital were selected. Among these patients, 87 patients were in the early breast cancer (EBC) group with negative ALNs and 198 ones were in the NAT group with positive ALNs. Data including the basic information of patients, position and size of ALN, process of US-guided marker placement, placement success rate, complications, detection rate of marker by imaging, and shift rate were recorded.

RESULTS

All patients were successfully undergone US-guided marker placement. And the average operation time was 2 minutes with no adverse reactions. All the patients underwent surgery successfully. US, computer tomography (CT) and magnetic resonance imaging (MRI) were used to detect the marker. The detection rate of markers by US and CT/MRI were 100% (87/87) in EBC group, and 98.5% (195/198) and 100% (198/198) by US and CT/MRI, respectively, in NAT group. The postoperative marker shift rate was 2.1% (6/285), including 3.4% (3/87) marker shift rate in EBC group and 1.5% (3/198) in NAT group, with no statistically significant difference between them.

CONCLUSIONS

US-guided marker placement in ALNs of breast cancer is simple and safe, with firm positioning and low shift rate, which is convenient for clinical promotion.

Evaluation of internal mammary lymph node biopsy during microsurgical breast reconstruction: An analysis of 230 consecutive patients

INTRODUCTION

Clinical significance of internal mammary (IM) lymph node biopsy during microvascular free flap breast reconstruction remains controversial. Some microsurgeons may choose to biopsy an IM lymph node during routine IM vessel dissection. The authors reviewed the results of IM lymph node biopsy during autologous breast reconstruction.

METHODS

A retrospective chart review of patients who underwent autologous breast reconstruction during a seven-year period (January 2010 to January 2017) was performed. Patient demographic data, disease staging, flap details, pathology reports, and adjuvant treatment were evaluated.

RESULTS

A total of 230 patients with a mean age of 52.1 (SD 9.3) underwent IM lymph node biopsy (n = 297). Single IM lymph node was removed in 169 patients, 2 nodes were removed in 56 patients, 3 nodes in 4 patients, and 4 nodes in a single patient. Histopathologic analysis demonstrated presence of IM lymph node metastasis in 16 patients (7.0%). Thirteen patients were found to have metastatic IM lymph nodes in the setting of immediate reconstruction. Three patients were found to have metastatic IM lymph nodes in the setting of delayed. Five out of 16 patients (31.3%) had negative axillary sentinel lymph node biopsy and IM lymph nodes were the only site of nodal metastases. All five of these patients were upstaged accordingly and received adjuvant therapy based on the discussion at the multidisciplinary breast tumor conference.

CONCLUSIONS

Opportunistic internal mammary lymph node sampling during autologous breast reconstruction can be performed with minimal morbidity and has significant impact on the disease staging and adjuvant treatment.

A negative binomial regression model for risk estimation of 0-2 axillary lymph node metastases in breast cancer patients

Extensive clinical trials indicate that patients with negative sentinel lymph node biopsy do not need axillary lymph node dissection (ALND). However, the ACOSOG Z0011 trial indicates that patients with clinically negative axillary lymph nodes (ALNs) and 1-2 positive sentinel lymph nodes having breast conserving surgery with whole breast radiotherapy do not benefit from ALND. The aim of this study is therefore to identify those patients with 0-2 positive nodes who might avoid ALND. A total of 486 patients were eligible for the study with 212 patients in the modeling group and 274 patients in the validation group, respectively. Clinical lymph node status, histologic grade, estrogen receptor status, and human epidermal growth factor receptor 2 status were found to be significantly associated with ALN metastasis. A negative binomial regression (NBR) model was developed to predict the probability of having 0-2 ALN metastases with the area under the curve of 0.881 (95% confidence interval 0.829-0.921, P < 0.001) in the modeling group and 0.758 (95% confidence interval 0.702-0.807, P < 0.001) in the validation group. Decision curve analysis demonstrated that the model was clinically useful. The NBR model demonstrated adequate discriminative ability and clinical utility for predicting 0-2 ALN metastases.

The clinical significance of metastatic breast carcinoma to intramammary lymph node

The incidence of involved intramammary lymph node (intra-MLN) with breast carcinoma (BC) is rare. Its clinical significance and impact on the clinical decision making is unclear. A total of 113 BC cases with at least one positive intra-MLN were collected from 11 academic institutions. The inclusion criteria were subsequent axillary lymph node dissection, and the availability of information on T-stage, size of node metastasis, extranodal extension status, biomarkers status, and clinical follow-up. Stage 4 cases and/or neo-adjuvant treated patients were excluded. AJCC TN-stage was calculated twice, with and without intra-MLN. Five-year overall survival (OS) and relapse (local and/or distant)-free survival (RFS) were calculated and correlated with the clinicopathologic variables. Excluding intra-MLN, TN-stage correlated with OS (P = .016) but not with RFS (P = .19). However, when intra-MLN was included, TN-stage correlated with both OS (P < .001) and RFS (P = .016). In the multivariate analysis, when intra-MLN was excluded, only radiation therapy (RT) correlated with RFS (HR = 0.19, 95% CI: 0.054-0.66, P = .009). However, when intra-MLN was included in the TN-stage both RT (HR = 0.13, 95% CI: 0.04-0.45, P = .001) and TN-stage 3 (HR = 8.92, 95% CI: 1.47-54, P = .017) correlated with RFS. Tumor multifocality was the only variable correlated with OS when the intra-MLN involvement was excluded. When intra-MLN was included, multifocality became insignificant but TN-stage 3 correlated with OS (HR = 8.59, 95% CI: 1.06-69.71, P = .044). Positive intra-MLN is an independent factor in predicting both RFS and OS.

Minimal Sentinel Node Procedure for Staging Early Breast Cancer

Aims and Background

Sentinel lymph node dissection (SLND) has recently been evaluated as a new staging technique for early breast cancer. To minimize the extent of surgery, the feasibility of eradicating primary breast lesions and the relative sentinel lymph nodes (SLN) under regional anesthesia was evaluated in this study.

Methods and Study Design

A selected population of 76 patients with suspected operable breast cancer and no clinically palpable lymph nodes was enrolled in the study. Intra- and perilesional administration of a radiotracer was performed. Lymphoscintigraphy was carried out to confirm the drainage pathway and locate the SLN. The following day, after inducing a nervous block induction of the ipsilateral intercostal nerves, we performed the surgical procedure with the help of a hand-held gamma-detecting probe. In case the primary lesion was diagnosed as invasive carcinoma by frozen section, the SLN and the remaining axillary lymph nodes (non-SLNs) were removed. The status of SLN and non-SLNs was compared.

Results

The primary breast lesion was located and excised in all cases (identification rate: 100%). Lymphoscintigraphy positively identified SLNs in 40/45 (89%) patients; in five patients no lymphatic drainage was detected. In 38 cases an average of 1.5 SLNs and 14 non-SLNs per patient were removed and pathologically analyzed; the remaining two patients showed SLNs in the internal mammary chain, which were not excised. Twenty-nine percent of the patients showed metastatic disease in the lymph nodes examined. Of all patients with affected nodes, 55% had cancer cells only in the SLN. No false negatives (skip metastases) were found. No immediate or long-term anesthesia-related complications (eg pleural lesions, intravascular injection) were observed.

Conclusions

Our data confirm the feasibility of single radiotracer administration for both occult lesion and SLN localization as well as the usefulness of SLND in staging early breast cancer. Regional anesthesia resulted in easy management and good patient compliance. This time-saving procedure allowed the completion of the whole surgical plan, reducing the recovery time without modifying the effectiveness of surgery.

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.

Sentinel Lymph Node and Breast Cancer Staging: Final Results of the Turin Multicenter Study

Aim of the study

Validation of the sentinel node (SN) technique in breast cancer by means of lymphoscintigraphy.

Materials and methods

From December 1996 to January 1999 102 T1-T2 breast carcinoma cases were recruited in Turin. 99mTc-human serum albumin colloids were injected subdermally the day before surgery (mean activity, 5.2 ± 2.5 MBq). Scintigraphic imaging was performed after injection. After identification of the SN during surgery by a hand-held gamma probe, the SN was excised and sent for histologic examination. SN histology was compared with that of other axillary nodes.

Results

The SN detection rate was 86.3%; among 88 cases with an identified SN, 37 (42%) had axillary metastases; the SN was metastatic in 35 cases (sensitivity, 94.6%); in 51.3% of pN+ cases (19/37) the SN was the only metastatic site. In two of the 53 negative SNs, SN histology did not match with that of the remaining axilla (negative predictive value, 96.2%; staging accuracy, 97.7%).

Conclusions

Our results agree with those reported in the literature; however, except in clinical trials and experienced structures axillary lymph node dissection should not be abandoned when mandatory for prognostic purposes, considering that at present SN biopsy alone is not completely accurate for axillary staging, especially in the absence of an adequate learning period.

Sentinel Node Study in Early Breast Cancer

Since October 1997 60 patients with early breast cancer (T <3 cm) were studied. All patients underwent lymphoscintigraphy with two types of colloid: the first (17 pts) with a particle size <1000 nm; the second (43 pts) with a particle size <80 nm. The standard procedure consists of injection, on the day before surgery, of 70 MBq of the smaller nanocolloid in 0.4 cc saline divided over four sites, around the lesion or subdermally around the surgical scar. We utilize a low-energy, high-resolution LFOV camera for scintigraphy and a probe specific for the sentinel node during surgery. In 56/60 patients (93.3%) lymphoscintigraphy showed the sentinel node (SN). In two cases the SN was not detected presumably because of lymphatic interruption by an old surgical scar; in the other two cases the sites of injection were too close to the SN, thus masking it. In five cases (9%) the SN was not visualized with the surgical probe but in two of these drainage to the internal mammary chain was observed. The apparently lower sensitivity of intraoperative localization was due to the extra-axillary lymphatic drainage or to the vicinity of the SN to the primary lesion. The SN proved to be metastatic in 12 cases. No false-negative SNs were found. In five cases (10%) the radiolabeled lymph node was the only node containing tumor cells (micrometastases): this result depends on the combined use of hematoxylin-eosin and rapid cytokeratin staining. The application of blue dye was useful for easier identification of the SN but did not allow detection of more SNs. Our preliminary results are extremely encouraging. Considering that at the early stages of breast cancer the likelihood of lymph node metastases is low (20% in our series) and no false negative were reported in this study, we conclude that with SN biopsy axillary lymph node dissection can be avoided, making surgery less aggressive but maintaining accuracy.

Sentinel Node Biopsy in Breast Cancer: The Experience of Brescia Civic Hospital

The accuracy of the sentinel node technique in the evaluation of axillary node involvement in breast cancer was evaluated in 83 consecutive patients with monofocal T1–2 carcinoma, who were clinically N0 and who underwent lymphoscintigraphy with 99mTc-colloid integrated with intraoperative sentinel node detection by a portable probe. Lymphoscintigraphy revealed at least one sentinel node in 75 patients (90.4%), always identified by the probe. In eight patients (9.6%) the sentinel node was detected neither by lymphoscintigraphy nor by the probe. All removed lymph nodes were analyzed by hematoxylin-eosin histology and the sentinel node by immunostaining. In 28/75 patients (37.3%) at least one metastatic axillary lymph node was detected; in 16 of the 28 N+ subjects (57%) only the sentinel node was positive. The false negative rate (sentinel node negative/other axillary lymph nodes positive) was 17.85% (5/28 patients). In 9/23 patients (39%) micrometastases were found in the sentinel node only. In conclusion, specific sentinel node positivity in 57% of cases supports the validity of the sentinel node concept. Moreover, nine patients would have been considered No by standard hematoxylin-eosin histology without sentinel node-aided immunostaining. A 17.8% false negative rate calls for caution in patients with negative sentinel nodes.

Identification of Sentinel Lymph Nodes Using Contrast-Enhanced Ultrasound in Breast Cancer

Sentinel lymph node (SLN) biopsy has become the standard of care in axillary staging of breast cancer patients who are clinically node negative as it reduces the morbidity of axillary nodal dissection. SLN biopsy using blue dye and radioisotopes have high identification rates but its limitations include anaphylaxis, disposal of radioactive waste, and potential second surgery in up to 35% of patients who show nodal metastases on SLN biopsy. Contrast-enhanced ultrasound (CEUS) has the potential for SLNs to be identified without the aforementioned risks. CEUS involves the administration of intravenous contrast agents containing microbubbles of perfluorocarbon or nitrogen gas. The bubbles greatly affect ultrasound backscatter and increase vascular contrast in a similar manner to intravenous contrast agents used in CT and MRI. It is safe and easily performed with no requirement for ionizing radiation and no risk of nephrotoxicity. Microbubbles are taken up by lymph nodes when injected directly into tissues, including sub-areolar injection in the breast cancer patient. This method may prove valuable in patients with ductal carcinoma in situ, where operative SLN biopsy remains controversial, and in women undergoing prophylactic mastectomies for high risk. This technique may also have a role after neoadjuvant chemotherapy where frequently there is fibrosis in the treated SLNs.

Periareolar or Peritumoral Injection of Isosulfan Blue and the Effect on the Number of Sentinel Lymph Nodes Examined

The conduct of sentinel node biopsy (SLNBx) for breast cancer (BC) has evolved substantially since its original description. No national standards for the performance of SLNBx exist, therefore, we sought to determine the effect of isosulfan blue (ISB) injection technique on nodal harvesting and staging accuracy during SLNBx. Our main outcome measures included the number of SLNs examined and the number of positive axillae in patients undergoing SLNBx after injection of filtered sulfur colloid intradermally and either small volume ISB injected in the periareolar dermis (PA,∼0.75 cc) or large volume peritumoral (PT, 5 cc). Between January 1, 2009, and September 30, 2013, 1357 patients at an academic/community practice setting underwent SLNBx of which 966 (71.2%) were node negative. These patients ranged in age from 27 to 97 years (mean 60.1 years). The majority of patients (76%) underwent PT injection of ISB. There was no significant difference in the mean age of these two groups (61.2 PT vs 59.7 PA years). All were female. The majority of patients (72.7%) had T1 primaries. Nearly 73 per cent of patients were Luminal A/B, 10.8 per cent HER, and 16.4 per cent were triple negative. There was no significant difference in the distribution of T stage (P = 0.56) or breast cancer subtypes between the techniques (P = 0.59). The mean number of nodes examined was 3.1 (range, 1–18). PT patients had a mean of 3.5 (range, 1–18) nodes, whereas PA patients had a mean of 2.4 nodes (range, 1–10) (P < 0.001). The technical aspects of injecting ISB affect the number of nodes harvested during SLNBx but not staging accuracy.

Axillary reverse mapping: five-year experience

BACKGROUND

We hypothesize that mapping the lymphatic drainage of the arm with blue dye (axillary reverse mapping, ARM) during axillary lymphadenectomy decreases the likelihood of disruption of lymphatics and subsequent lymphedema.

METHODS

This institutional review board-approved study from May 2006 to October 2011 involved 360 patients undergoing SLNB and/or ALND. Technetium sulfur colloid (4 mL) was injected subareolarly and 5 mL of blue dye was injected subcutaneously in the volar surface ipsilateral upper extremity (ARM). Data were collected on variations in lymphatic drainage, successful identification and protection of arm lymphatics, crossover, and occurrence of lymphedema.

RESULTS

A group of 360 patients underwent SLNB and/or ALND. A total of 348 patients underwent a SLNB. Of those, 237/348(68.1%) had a SLNB only and 111/348(31.9%) went on to an ALND due to a positive axilla. An additional 12/360(3.3%) axilla had ALND due to a clinically positive axilla/preoperative core needle biopsy. In 96%(334/348) of patients with SLNB, breast SLNs were hot but not blue; crossover (SLN hot and blue) was seen in 14/348(4%). Blue lymphatics were identified in 80/237(33.7%) of SLN incisions and in 93/123(75.4%) ALND. Average follow-up was 12 months (range 3 to 48 months) and resulted in a SLNB lymphedema rate of 1.7%(4/237) and ALND of 2.4%(3/123).

CONCLUSIONS

ARM identified significant lymphatic variations draining the upper extremities and facilitated preservation. Metastases in ARM-identified lymph nodes were acceptably low indicating that ARM is safe. ARM added to present-day ALND and SLNB may be useful to lower lymphedema rates.

Lymphoscintigraphy with peritumoral injection versus lymphoscintigraphy with subdermal periareolar injection of technetium-labeled human albumin to identify sentinel lymph nodes in breast cancer patients

BACKGROUND

Preoperative lymphoscintigraphy is without doubt a valid method for the detection of the sentinel lymph node (SLN). There has been considerable debate regarding the optimal site for the introduction of the tracer; various sites include peritumoral (PT), periareolar (PA), subdermal, and intradermal injection.

PURPOSE

To evaluate retrospectively the lymphoscintigraphic identification rate of peritumoral (PT) injection versus subdermal periareolar (PA) injection in the detection of SLNs in breast cancer.

MATERIAL AND METHODS

Between October 2002 and December 2011, a cohort of 906 consecutive patients with biopsy proven breast cancer underwent 914 SLN biopsy procedures. A total of 339 procedures (Group A) were performed using a PT deep injection of radiotracer while 575 procedures (Group B) adopted a subdermal PA injection of radiotracer towards the upper outer quadrant, regardless of the site of the carcinoma. All the patients underwent synchronous excision of the breast cancer and SLN biopsy.

RESULTS

SLNs were identified in the lymphoscintigram in 308/339 cases (90.85%) of Group A (PT injection) and in 537/575 cases (93.39%) of Group B (PA injection). Furthermore, in 2/339 patients (0.58%) of Group A, internal mammary lymph nodes were found at lymphoscintigraphy, whereas no internal mammary sentinel nodes were found in the Group B patients. The intraoperative identification rate of axillary SLNs was 99.41% (337 of 339) in the Group A patients and 99.65% (573 of 575) in the Group B patients. There was no significant difference in the two groups between the incidence of the number of SLNs detected and the incidence of identification of positive SLNs.

CONCLUSION

PT versus PA injection of radiotracer showed comparable success rates for axillary SLN identification, and can be considered a rapid and reliable method.

Serum levels of matrix metalloproteinase-9 predict lymph node metastasis in breast cancer patients

Matrix metalloproteinases (MMPs) are proteolytic enzymes that play important roles in cancer progression and metastasis. Although serum MMP expression is known to correlate with the primary lesion of breast cancer, there has yet to be a study regarding the correlation between serum MMP expression and metastatic lesions, particularly lymph nodes. The present study evaluated the correlation of serum and lymph node MMP expression with axillary node metastasis. The preoperative serum levels of MMP-2 and MMP-9 in 77 patients with breast cancer and in 10 patients with benign breast tumor were determined by ELISA and zymography. One hundred and twelve axillary lymph nodes were collected for zymography during breast cancer surgery. Significantly higher serum levels of MMP-2 and MMP-9 were found in breast cancer patients compared to patients with benign tumor. High serum levels of MMP-2 and MMP-9 were significantly associated with node metastasis. ELISA and zymography results for serum MMP-2 and MMP-9 correlated significantly, with a Pearson correlation coefficient (r) of 0.76 for MMP-2 (P=0.001) and 0.81 for MMP-9 (P=0.001). In terms of lymph node, total MMP-2, MMP-9 and MMP-9 activity were significantly higher in metastatic than in non-metastatic nodes. There was a correlation between serum and lymph node MMP-9 levels on zymographic measurements (r=0.34, P=0.011), but not in terms of MMP-2 levels. Serum MMP-9 levels may have a diagnostic value for predicting axillary node metastasis.

Feasibility of sentinel lymph node biopsy in breast cancer patients clinically suspected of axillary lymph node metastasis on preoperative imaging

Background

Generally, sentinel lymph node biopsy (SLNB) is performed in patients with clinically negative axillary lymph node (LN). This study was to assess imaging techniques in axillary LN staging and to evaluate the feasibility of SLNB in patients clinically suspected of axillary LN metastasis on preoperative imaging techniques (SI).

Methods

A prospectively maintained database of 767 breast cancer patients enrolled between January 2006 and December 2009 was reviewed. All patients were offered preoperative breast ultrasound, magnetic resonance imaging, and positron emission tomography scanning. SI patients were regarded as those for whom preoperative imaging was “suspicious for axillary LN metastasis” and NSI as “non-suspicious for axillary LN metastasis” on preoperative imaging techniques. Patients were subgrouped by presence of SI and types of axillary operation, and analyzed.

Results

For 323 patients who received SLNB, there was no statistically significant difference in axillary recurrence (P=0.119) between SI and NSI groups. There also was no significant difference in axillary recurrence between SLNB and axillary lymph node dissection (ALND) groups in 356 SI patients (P=0.420). The presence of axillary LN metastasis on preoperative imaging carried 82.1% sensitivity and 45.9% specificity for determining axillary LN metastasis on the final pathology.

Conclusions

SLNB in SI patents is safe and feasible. Complications might be avoided by not performing ALND. Therefore, we recommend SLNB, instead of a direct ALND, even in SI patients, for interpreting the exact nodal status and avoiding unnecessary morbidity by performing ALND.

Contrast enhanced ultrasound of sentinel lymph nodes

Sentinel lymph nodes are the first lymph nodes in the region that receive lymphatic drainage from a primary tumor. The detection or exclusion of sentinel lymph node micrometastases is critical in the staging of cancer, especially breast cancer and melanoma because it directly affects patient's prognosis and surgical management. Currently, intraoperative sentinel lymph node biopsies using blue dye and radioisotopes are the method of choice for the detection of sentinel lymph node with high identification rate. In contrast, conventional ultrasound is not capable of detecting sentinel lymph nodes in most cases. Contrast enhanced ultrasound with contrast specific imaging modes has been used for the evaluation and diagnostic work-up of peripherally located suspected lymphadenopathy. The method allows for real-time analysis of all vascular phases and the visualization of intranodal focal “avascular” areas that represent necrosis or deposits of neoplastic cells. In recent years, a number of animal and human studies showed that contrast enhanced ultrasound can be also used for the detection of sentinel lymph node, and may become a potential application in clinical routine. Several contrast agents have been used in those studies, including albumin solution, hydroxyethylated starch, SonoVue^®, Sonazoid^® and Definity^®. This review summarizes the current knowledge about the use of ultrasound techniques in detection and evaluation of sentinel lymph node.

The false-negative rate of sentinel node biopsy in patients with breast cancer: a meta-analysis

BACKGROUND

In sentinel node surgery for breast cancer, procedural accuracy is assessed by calculating the false-negative rate. It is important to measure this since there are potential adverse outcomes from missing node metastases. We performed a meta-analysis of published data to assess which method has achieved the lowest false-negative rate.

METHODS

We found 3,588 articles concerning sentinel nodes and breast cancer published from 1993 through mid-2011; 183 articles met our inclusion criteria. The studies described in these 183 articles included a total of 9,306 patients. We grouped the studies by injection material and injection location. The false-negative rates were analyzed according to these groupings and also by the year in which the articles were published.

RESULTS

There was significant variation related to injection material. The use of blue dye alone was associated with the highest false-negative rate. Inclusion of a radioactive tracer along with blue dye resulted in a significantly lower false-negative rate. Although there were variations in the false-negative rate according to injection location, none were significant.

CONCLUSIONS

The use of blue dye should be accompanied by a radioactive tracer to achieve a significantly lower false-negative rate. Location of injection did not have a significant impact on the false-negative rate. Given the limitations of acquiring appropriate data, the false-negative rate should not be used as a metric for training or quality control.

What is the accuracy of sentinel lymph node biopsy for gastric cancer? A systematic review

BACKGROUND

In gastric cancer, the utility of sentinel lymph node (SLN) biopsy has not been established. SLN may be a good predictor of the pathological status of other lymph nodes and thus the necessity for more extensive surgery or lymph node dissection. We aimed to identify and synthesize findings on the performance of SLN biopsies in gastric cancer.

METHODS

Electronic literature searches were conducted using Medline, EMBASE, and the Cochrane Central Register of Controlled Trials from 1998 to 2009. Titles and abstracts were independently rated for relevance by a minimum of two reviewers. Techniques, detection rates, accuracy, sensitivity, specificity, and false-negative rates (FNRs) were analyzed. Analysis was performed based on the FNR.

RESULTS

Twenty-six articles met our inclusion criteria. SLN detection using the dye method (DM) was reviewed in 18 studies, the radiocolloid method (RM) was used in 12 studies, and both dye and radiocolloid methods (DUAL) were used in 5 studies. The DM had an overall calculated FNR of 34.7% (95% confidence interval [CI] 21.2, 48.1). The RM had an overall calculated FNR of 18.5% (95% CI 9.1, 28.0). DUAL had an overall calculated FNR of 13.1% (95% CI -0.9, 27.2).

CONCLUSION

Application of the SLN technique may be practical for early gastric cancer. The use of DUAL for identifying SLN may yield a lower FNR than either method alone, although statistical significance was not met.

Efficiency of ultrasound and ultrasound-guided fine needle aspiration cytology in preoperative assessment of axillary lymph node metastases in breast cancer

PURPOSE

We performed this study to detect preoperative axillary metastases with ultrasound (US)-guided fine needle aspiration biopsy (FNAB), to eliminate the need for time-consuming and costly sentinel lymph node (SLN) scintigraphy and biopsy steps in the treatment of breast cancer patients, and in that of with suspicious US findings, and to evaluate the accuracy of preoperative US-guided FNAB for patients with suspicious lymph node metastases on US.

METHODS

Patients with a suspicious breast lump or histopathologically proven breast cancer underwent breast-axillary US. Increase in lymph node size, cortical thickening, non-hilar cortical flow, and hilar changes were evaluated with gray scale-color Doppler US. FNAB was performed if US results were suspicious for malignancy.

RESULTS

Thirty-eight axillary lymph nodes (ALN) underwent FNAB. ALN dissection, SLN scintigraphy, and biopsy steps were bypassed in 23 axillas with positive ALN FNAB (60.5%). The sensitivity of ALN FNAB was 88.46%; specificity and positive predictive value were 100%; and negative predictive value was 66.6% (inadequate cytology included; 76.7%, 100%, 100%, 53.3%, respectively). Asymmetrical cortical thickening, non-hilar cortical flow, and increase in hypoechogenity were only detected in metastatic nodes. Cortical thickening, and lymph node and breast mass size was higher in the metastatic group.

CONCLUSION

By performing FNAB on suspicious lymph nodes, the routine, high-cost SLN scintigraphy and intraoperative gamma probe steps may be skipped, and axilla dissection can be performed directly. This leads to the elimination of the need for SLN investigation in more than half of the patients. The assessment of ALN metastases with preoperative US-guided FNAB is a cost-effective method with high specificity, that eliminates the need for costly and time-consuming SLN scintigraphy and biopsy steps, and helps in preoperative staging.

Classification of Metastatic versus Non-Metastatic Axillary Nodes in Breast Cancer Patients: Value of Cortex-Hilum Area Ratio with Ultrasound

PURPOSE

To investigate the significance of the cortex-hilum (CH) area ratio and longitudinal-transverse (LT) axis ratio and the blood flow pattern for diagnosis of metastatic axillary lymph nodes by ultrasound in breast cancer patients.

METHODS

From October 2005 to July 2006, we prospectively evaluated axillary nodes with ultrasound in 205 consecutive patients who had category 4B, 4C or 5 breast lesions according to the Breast Imaging Reporting and Data System-Ultrasound (BI-RADS-Ultrasound®). Among the 205, there were 24 patients who had pathologic verification of breast cancer and axillary lymph node status. For a total of 80 axillary nodes we measured the areas of the cortex and hilum of lymph nodes and calculated the area ratio. We also measured the length of the longitudinal and transverse axis of the lymph nodes and calculated the length ratio. We evaluated the blood flow pattern on power Doppler imaging and classified each lymph node into a central or peripheral pattern. Diagnostic performance was analyzed according to positive criteria for lymph node metastasis (CH area ratio >2, LT axis ratio <2, peripheral type on power Doppler imaging).

RESULTS

The sensitivity of the CH area ratio was superior to that of the LT axis ratio (94.1% vs. 82.3%, p=0.031) and to that of the blood flow pattern (94.1% vs. 29.4%, p=0.009). For specificity, all three evaluating parameters had high values (89.1-95.6%) and no significant differences were found (p=0.121). The CH area ratio had a better positive predictive value than the LT axis ratio (94.1% vs. 80.0%, p=0.030) and power Doppler imaging (94.1% vs. 66.6%, p=0.028). For the negative predictive value, the CH area ratio was superior to the LT axis ratio (95.6% vs. 86.6%, p=0.035) and the blood flow pattern (95.6% vs. 63.0%, p=0.027).

CONCLUSION

We recommend the CH area ratio of an axillary lymph node on ultrasound as a quantitative indicator for the classification of lymph nodes. The CH area ratio can improve diagnostic performance when compared with the LT axis ratio or blood flow pattern.

Prospective study of 2-[¹⁸F]fluorodeoxyglucose positron emission tomography in the assessment of regional nodal spread of disease in patients with breast cancer: an Ontario clinical oncology group study

PURPOSE

2-[(18)F]fluorodeoxyglucose (FDG) positron emission tomography (PET) is potentially useful in assessing lymph nodes and detecting distant metastases in women with primary breast cancer.

PATIENTS AND METHODS

Women diagnosed with operable breast cancer within 3 months underwent FDG-PET at one of five Ontario study centers followed by axillary lymph node assessment (ALNA) consisting of sentinel lymph node biopsy (SLNB) alone if sentinel lymph nodes (SLNs) were negative, SLNB with axillary lymph node dissection (ALND) if SLNB or PET was positive, or ALND alone if SLNs were not identified.

RESULTS

Between January 2005 and March 2007, 325 analyzable women entered this study. Sentinel nodes were found for 312 (96%) of 325 women and were positive for tumor in 90 (29%) of 312. ALND was positive in seven additional women. Using ALNA as the gold standard, sensitivity for PET was 23.7% (95% CI, 15.9% to 33.6%), specificity was 99.6% (95% CI, 97.2% to 99.9%), positive predictive value was 95.8% (95% CI, 76.9% to 99.8%), negative predictive value was 75.4% (95% CI, 70.1% to 80.1%), and prevalence was 29.8% (95% CI, 25.0% to 35.2%). Using logistic regression, tumor size was predictive for prevalence of tumor in the axilla and for PET sensitivity. PET scan was suspicious for distant metastases in 13 patients; three (0.9%) were confirmed as metastatic disease and 10 (3.0%) were false positive.

CONCLUSION

FDG-PET is not sufficiently sensitive to detect positive axillary lymph nodes, nor is it sufficiently specific to appropriately identify distant metastases. However, the very high positive predictive value (96%) suggests that PET when positive is indicative of disease in axillary nodes, which may influence surgical care.

Methylene blue dye-related changes in the breast after sentinel lymph node localization

OBJECTIVES

The purpose of this study was to investigate the frequency and appearance of changes in the breast on sonography in patients after breast cancer surgery including sentinel lymph node localization using methylene blue dye.

METHODS

Three hundred thirty-seven consecutive patients who underwent breast-conserving surgery in 2006 underwent breast sonography during 2 years after surgery. Sentinel lymph node localization using methylene blue dye was selectively performed. We retrospectively analyzed the unexplained focal lesions not at the lumpectomy site on sonography and investigated whether these findings were associated with sentinel lymph node localization.

RESULTS

Unexplained focal lesions were identified in 36 (14.1%) of 256 patients who had undergone sentinel lymph node localization. The lesions were in the periareolar region (n = 26; outer in 16, upper in 6, inner in 2, and lower in 2) or the retroareolar region (n = 10). The lesion appeared with a fat necrosis-like pattern in the subcutaneous fat layer in 24 (66.7%) or as an irregular mass in the glandular layer in 12 (33.3%). The unexplained focal lesions were pathologically proven benign (n = 10) or were improved or stable during 2 years of imaging follow-up after surgery (n = 26). The unexplained focal lesions in 2 (2.5%) of 81 patients without sentinel lymph node localization were in the nonareolar region, and 1 of these was a recurrence.

CONCLUSIONS

After sentinel lymph node localization using methylene blue dye, breast sonography can show unexplained focal lesions in the periareolar and retroareolar regions. Although most of the changes suggest fat necrosis, an irregular parenchymal mass can develop and mimic a recurrence.

Sensitivity of axillary specimen x-ray to predict nodal count and positivity

BACKGROUND

The number of examined axillary lymph nodes (ALN) has been proposed as an indicator of prognosis along with quality and adequacy in breast cancer surgery. The purpose of this study was to examine the utility of imaging axillary specimens with x-ray (lymphogram) to determine the number of lymph nodes. We sought to determine the sensitivity and specificity of a lymphogram in identifying nodal positivity.

METHODS

Patients who underwent sentinel lymph node (SLN) and axillary lymph node dissections (ALND) were prospectively accrued to this double-blinded, single-institution trial from December 2009 to January 2011. A single physician interpreted all lymphograms for the number of ALNs and positivity determined by size, spiculations, irregularities, and calcifications.

RESULTS

Twenty female (age 50.8 ± 14.3 years) patients were accrued to the study. The lymphogram located more lymph nodes compared with pathology in 11 of 16 cases (68.8%). In these 11 cases, lymphogram identified 170 nodes and the pathologist located 132 (77.6%). Of the 16 ALND specimens, 6 were from patients naive to chemotherapy and averaged 13.8 ± 6.6 nodes; 10 were from neoadjuvant chemotherapy patients and had an average number of 14.9 ± 7.4 nodes. In neoadjuvant chemotherapy patients, sensitivity of the lymphogram to detect nodal positivity was 91.7% and specificity was 33.3%.

CONCLUSIONS

This study demonstrated that lymphogram accurately identifies nodal count. This can be used for documentation of an adequate ALND for reimbursement. Furthermore, there may be potential value of lymphogram in intraoperative determination of nodal positivity.

Trends in and outcomes from sentinel lymph node biopsy (SLNB) alone vs. SLNB with axillary lymph node dissection for node-positive breast cancer patients: experience from the SEER database

BACKGROUND

Complete axillary lymph node dissection (ALND) after a positive sentinel lymph node biopsy (SLNB) remains the standard practice. As nodal surgery has long been considered a staging procedure without a clear survival benefit, the need for ALND in all patients is debatable. The purpose of this study was to examine differences in survival for patients undergoing SLNB alone versus SLNB with complete ALND.

METHODS

Patients with breast cancer who underwent SLNB and were found to have nodal metastases were identified from the Surveillance, Epidemiology, and End Results database (1998-2004). Clinicopathologic and outcomes data were examined for patients who underwent SLNB alone versus SLNB with ALND.

RESULTS

We identified 26,986 patients with disease-positive lymph nodes; 4,425 (16.4%) underwent SLNB alone, and 22,561 (83.6%) underwent SLNB with ALND. Patients were significantly more likely to undergo SLNB alone if they were older (median 59 years old) or if the tumor was low grade and estrogen receptor positive. From 1998 to 2004, the proportion of patients with micrometastasis in the sentinel lymph nodes who underwent SLNB alone increased from 21.0 to 37.8% (P < 0.001). At a median follow-up of 50 months, there were no statistically significant differences in overall survival (OS) between patients who underwent SLNB alone versus complete ALND.

CONCLUSIONS

There is an increasing trend toward omitting ALND in patients with micrometastatic nodal disease identified by SLNB. Compared with SLNB alone, completion ALND does not seem to be associated with improved survival for breast cancer patients with micrometastasis in the sentinel lymph nodes.

High-resolution fiber optic microscopy with fluorescent contrast enhancement for the identification of axillary lymph node metastases in breast cancer: a pilot study

This prospective pilot study evaluates the potential of high-resolution fiber optic microscopy (HRFM) to identify lymph node metastases in breast cancer patients. 43 lymph nodes were collected from 14 consenting breast cancer patients. Proflavine dye was topically applied to lymph nodes ex vivo to allow visualization of nuclei. 242 images were collected at 105 sites with confirmed histopathologic diagnosis. Quantitative statistical features were calculated from images, assessed with one-way ANOVA, and were used to develop a classification algorithm with the goal of objectively discriminating between normal and metastatic tissue. A classification algorithm using mean image intensity and skewness achieved sensitivity of 79% (27/34) and specificity of 77% (55/71). This study demonstrates the technical feasibility and diagnostic potential of HRFM with fluorescent contrast in the ex vivo evaluation of lymph nodes from breast cancer patients.

Sentinel Lymph Node Mapping for Gastric Adenocarcinoma

The optimal extent of regional lymphadenectomy for gastric adenocarcinoma remains a controversial topic. Traditional approaches have focused on various anatomical nodal stations to define the extent of resection. In this prospective trial, we update our experience with sentinel lymph node (SLN) mapping and biopsy to augment resection of nodal metastasis in gastric carcinoma. Twenty-seven patients with gastric cancer were enrolled. SLNs were identified with isosulfan blue, resected, and sent fresh to pathology for staining and evaluation. The procedure then continued with radical gastrectomy and celiac node dissection. SLNs were identified in all cases. The average patient age was 65 years, with 12 women and 15 men. Eighteen patients had pathology-confirmed nodal metastasis. Positive SLN were found in 15 (83%); three patients had a false negative SLN mapping procedure (17%). Accuracy rate was 88.9 per cent. SLN mapping and biopsy for gastric carcinoma is feasible. However, the negative predictive value is 75 per cent, and therefore caution should be considered in using lymphatic mapping to determine extent of regional lymphadenectomy. Additionally, our study shows no utility in identifying micro-metastatic disease with immunohistochemical techniques. Although a promising modality, we do not recommend the clinical use of SLN mapping for gastric cancer.

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 biopsy for the individualization of surgical strategy for cure of early-stage colon cancer

INTRODUCTION

The requirement for nodal analysis currently confounds the oncological propriety of focused purely endoscopic resection for early-stage colon cancer and complicates the evolution of innovative alternatives such as natural orifice transluminal endoscopic surgery (NOTES) and its hybrids. Adjunctive sentinel node biopsy (SNB) deserves consideration as a means of addressing this shortfall.

METHODS

Data from two prospectively maintained databases established for multicentric studies of SNB in colon cancer that employed similar methodologies were pooled to establish technique potency selectively in T1/T2 disease (both overall and under optimized conditions) and to project potential clinical impact.

RESULTS

Of 891 patients with T1-4, M0 intraperitoneal colon cancer, 225 had T1/T2 disease. Sentinel nodes were either not found or were falsely negative in 18 patients with T1/T2 cancers (8%) as compared with 17% (112/646) in those with T3/T4 disease (P = 0.001). Negative predictive value (NPV) in the former exceeded 95%, while sensitivity [including immunohistochemistry (IHC)] was 81%. In the 193 patients with T1/T2 disease recruited from those centers contributing >22 patients, sensitivity was 89% and NPV 97%. Thus, in this cohort, SNB could have correctly prompted localized resection (obviating en bloc mesenteric dissection) in 75% (144) of patients, including 59 with T1 lesions potentially amenable to intraluminal resection alone as their definitive treatment. Forty-four patients (23.4%) would still have conventional resection, leaving three patients (1.6% overall) understaged (11% false-negative rate).

CONCLUSION

These findings support the further investigation of SNB as oncological augment for localized resective techniques. Specific prospective study should pursue this goal.

Nomogram for the prediction of having four or more involved nodes for sentinel lymph node-positive breast cancer

PURPOSE

The standard of care for patients with a positive (+) sentinel lymph node (SLN) is axillary dissection; however, for various reasons, some SLN+ patients do not undergo dissection. The purpose of this study was to define possible predictors of having four or more involved nodes to provide information for clinicians and patients making decisions about adjuvant chemotherapy and radiation.

PATIENTS AND METHODS

We reviewed the records of 402 patients with invasive breast cancer and one to three involved SLNs who underwent completion axillary dissection at two academic cancer centers. None of these patients received neoadjuvant chemotherapy. Factors associated with having four or more involved axillary nodes (SLNs and non-SLNs) were evaluated by univariate and multivariate logistic regression analysis.

RESULTS

Eighty-seven patients had four or more positive nodes. On multivariate analysis, having four or more SLNs was associated with tumor histology, primary tumor size, lymphovascular space invasion, extranodal extension, the number of involved SLNs, the number of uninvolved SLNs, and the size of the largest SLN metastasis. A nomogram to predict the probability of having four or more nodes based on patients' pathologic data was developed from the multivariate logistic regression model. A separate previously published data set of 206 SLN+ patients treated at a community hospital in another city was used to validate this model.

CONCLUSION

Patients with a low probability of having four or more nodes can be identified from known pathologic features. The nomogram developed will be helpful to clinicians making adjuvant treatment recommendations.

What’s wrong with sentinel node mapping in colon cancer?

Despite near-universal embrace of the concept and clinical relevance of lymphatic mapping for sentinel node identification and analysis for cancers of the breast and integument, the same technique has struggled to a find a role in gastrointestinal cancers in general and, perhaps, in colon cancer in particular. Despite many studies demonstrating its feasibility in malignancies of the large bowel, concern is continually aroused by the variable and often unacceptably low sensitivity rates. Additionally, many confess uncertainty as to what benefit it could ever confer to patients even if it were proven sufficiently accurate given that standard surgical resection incorporates mesenteric resection anyway. However, the huge impact sentinel node mapping has had on clinical practice in certain cancers means that each of these aspects merit careful reconsideration, from very first principles.

Anatomopathological analysis of sentinel and nonsentinel lymph nodes in breast cancer: hematoxylin-eosin versus immunohistochemistry

The authors compare the detection of metastases in sentinel lymph nodes (SLNs) and nonsentinel lymph nodes (NSLNs) using hematoxylin-eosin (HE) staining versus immunohistochemistry (IHC). Thirty-six patients with breast carcinoma undergo exeresis of the primary tumor and of 50 SLNs and 491 NSLNs. Sentinel lymph nodes are sectioned into transverse slices of 2- to 3-mm thickness, and a cytologic smear and a frozen section were obtained from each slice. The slices are completely cut into serial sections at 100-microm intervals. Two consecutive 4-microm-thick sections are then obtained from each level and were prepared for HE staining and IHC. Nonsentinel lymph nodes are evaluated similarly to SLNs. The authors obtain 4076 SLN sections and 32 012 NSLN sections, for a total of 36 088 sections. A comparison of HE staining versus IHC based on the total number of sections shows a sensitivity of 93.8%, a negative predictive value of 98.9%, and an accuracy of 99.1%. The values obtained by HE staining are similar to those obtained by IHC.