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

Concordance between freehand SPECT and conventional scintigraphy for sentinel lymph node detection in breast cancer

INTRODUCTION

Freehand SPECT can be a useful imaging technique for preoperative planning of sentinel lymph node biopsy (SLNB) as it allows localization of the sentinel node by 3D and real-time tomographic imaging and determines its depth after a few minutes of scanning. The aim of the study was to evaluate the correlation between the number of detected SNs between freehand SPECT images and lymphoscintigraphy (LS).

MATERIALS AND METHODS

100 patients with a diagnosis of invasive breast cancer and no clinical evidence of lymph node involvement prospectively underwent SLNB. The preoperative study included freehand SPECT imaging at 15min after injection and LS imaging at 25 and 60-90min after injection (early and late). The observed agreement was analyzed and a concordance study was performed between the number of SNs detected with freehand SPECT and LS.

RESULTS

The observed agreement in the detection of SNs between freehand SPECT and early LS was 72%; between freehand SPECT and late LS was 85%; and between early and late LS was 87%. In the concordance study, there was moderate concordance between freehand SPECT and early LS (kappa coefficient: 0.42); moderate-high concordance between freehand SPECT and late LS (kappa coefficient: 0.60); and moderate-high concordance between early and late LS (kappa coefficient: 0.70), with no significant differences between them (p-value=0.16).

CONCLUSION

Freehand SPECT showed a moderate-high concordance with conventional imaging studies and could be a valid alternative for the presurgical study of SLNB in breast cancer.

Omitting SLNB in Breast Cancer: Is a Nomogram the Answer?

BACKGROUNDS

Sentinel lymph node biopsy (SLNB) is standard care as a staging procedure in patients with invasive breast cancer. The axillary recurrence rate, even after positive SLNB, is low. This raises serious doubts regarding the clinical value of SLNB in early breast cancer. The purpose of this study is to select patients with low suspected axillary burden in whom SLNB might be omitted.

PATIENTS AND METHODS

We retrospectively analyzed 2015 primary breast cancer patients between 2007 and 2015, with 982 patients allocated to the training and 961 to the validation cohort. Variables associated with nodal disease were analyzed and used to build a nomogram for predicting nodal disease.

RESULTS

A total of 32.8% of patients had macrometastatic disease. A predictive model was constructed based on age, cN0, morphology, grade, multifocality, and tumor size with an area under the receiver operating characteristic curve (AUC) of 0.83. Considering a false-negative rate of 5%, 32.8% of patients could be spared axillary surgery. In a subanalysis of patients with relatively favorable characteristics, 26.8% had less than 5% chance of macrometastases.

CONCLUSIONS

We present a model with excellent predictive value that can select one-third of patients in whom SLNB is deemed not necessary because of less than 5% chance of nodal involvement. Whether missing 1 in 20 patients with macrometastatic disease is worthwhile balanced against preventing side-effects of the SLN procedure remains to be established. A number of ongoing large prospective trials evaluating the outcome of omitting SLNB are awaited. Meanwhile, this nomogram may be used for individual decision-making.

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.

Nuclear Medicine Advances in Breast Cancer Imaging

Primary breast cancer imaging can be done by various means. Mammography is the most widely used technique because of its excellent diagnostic performance, patient compliance, and cost-effectiveness ratio. Other radiological techniques (such as ultrasonography) are indicated in particular circumstances, while some (such as digital mammography and magnetic resonance imaging) seem very promising but are still under evaluation. The recent technological progress in nuclear medicine has resulted in the availability of two diagnostic procedures that have been validated by extensive international clinical experience: scintimammography with Ses-ta-MIBI and positron emission tomography (PET) with fluorodeoxyglucose (FDG). The general advantage of nuclear medicine imaging is that tumor-seeking radiopharmaceuticals accumulate in cancer lesions, which makes scintimammography and PET fundamentally different from the radiological techniques that image the tumor mainly on the basis of morphological alterations. Scintimammography is indicated for the study of breast lesions in patients in whom mammography is non-diagnostic or difficult to interpret; it may be useful also to assess and even predict the response to primary chemotherapy. FDG-PET is increasingly used in oncology and is particularly useful in breast cancer as it gives more accurate information than scintimammography in the evaluation of patients with ambiguous mammographies and in discriminating between viable tumor, fibrotic scar or necrosis following surgery, chemo- or radiotherapy. The FDG uptake in the tumor correlates with the histological grade and potential aggressiveness of breast cancer, which may have prognostic implications. In addition to its usefulness in the study of breast lesions, FDG-PET shows great efficacy in detecting lymph node involvement prior to surgery. Whole-body PET provides information on soft tissue and bone metastases in a single scanning session, and has an important clinical role in detecting recurrent metastatic disease. On the basis of the above-mentioned evidence, nuclear medicine techniques, integrated with radiological techniques, offer an interesting opportunity to improve the diagnostic imaging yield in breast cancer, which will eventually lead to better patient management. This paper reports on the latest developments in this field.

Use of Fluorescence Imaging in Combination with Patent Blue Dye versus Patent Blue Dye Alone in Sentinel Lymph Node Biopsy in Breast Cancer

PURPOSE

Near-infrared fluorescence imaging with indocyanine green (ICG) has the potential to improve sentinel lymph node (SLN) mapping in breast cancer. In this clinical trial, we compared the potential value of ICG combined with blue dye with that of blue dye alone for detecting SLNs.

METHODS

Patients undergoing SLN biopsy (SLNB) between November 2010 and November 2013 were included. Up to December 2011, SLNs were detected by using patent blue (PB) alone, and since January 2012, by using PB in combination with ICG. The patients were divided into the following two groups: group A (ICG-PB; n=96) and group B (PB; n=73), and SLN detection parameters were compared between the groups. All patients underwent level I and II axillary dissections after SLNB.

RESULTS

In group A, the SLN detection rate was 96.9% (93/96), the accuracy of detection was 98.9% (92/93), and the false-negative rate (FNR) was 3.4% (1/29). In group B, the SLN detection rate was 84.9% (62/73), the accuracy of detection was 96.8% (60/62), and the FNR was 11.1% (2/18). The ICG-PB group showed significantly superior results compared to the PB group for SLN detection (p=0.005) and a greatly improved FNR.

CONCLUSION

The combined fluorescence and blue dye-based tracer technique was superior to the use of blue dye alone for identifying SLNs, and for predicting axillary lymph node status in patients with breast cancer; in addition, the combined technique had reduced false-negative results.

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.

Comparison of sentinel lymph node biopsy guided by the multimodal method of indocyanine green fluorescence, radioisotope, and blue dye versus the radioisotope method in breast cancer: a randomized controlled trial

PURPOSE

This study aimed to evaluate the identification rate and surgery time of sentinel lymph node biopsy (SLNB) by a multimodal method (MMM) using a mixture of indocyanine green (ICG), radioisotope (RI), and blue dye (BD) compared with the RI alone.

METHODS

In this phase II randomized study, 86 patients with clinically node-negative breast cancer were enrolled and received SLNB with either MMM or RI. We compared the identification rate, number of sentinel lymph nodes (SLNs), and detection time of SLNB and evaluated the safety.

RESULTS

The mean age of the MMM group and RI group was 48.2 and 51.0 years (p = 0.12), respectively. There were no differences in histopathologic factors, including tumor size, node positivity, and hormone receptor positivity between groups. SLNs were identified in all patients of both groups (100 % in the MMM group and 100 % in the RI group). The average number of SLNs in the MMM group was more than that in the RI group (3.4 ± 1.37 vs. 2.3 ± 1.04, respectively; p < 0.001). The time to detect the first sentinel lymph node was similar in each group (6.5 ± 5.16 vs. 8.0 ± 4.35 min; p = 0.13). In the MMM group, percutaneous lymphatic drainage was visualized by fluorescent imaging in 90.7 % (39 of 43 patients). During and after the operation, there were no complications, including allergic reactions, skin staining, or necrosis.

CONCLUSIONS

This study is the first randomized trial that compared MMM using ICG, RI, and BD and the conventional RI method for SLNB. MMM is a feasible and safe method for SLNB.

Breast cancer sentinel lymph node mapping using near-infrared guided indocyanine green in comparison with blue dye

Near-infrared (NIR) fluorescence imaging using indocyanine green (ICG) was considered to have the potential to improve sentinel lymph node (SLN) mapping in breast cancer. Herein, we performed a randomized clinical trial to evaluate the effectiveness of ICG fluorescence imaging compared with blue dye imaging in SLN navigation surgery. We also analyzed lymph drainage pathways to identify targets for sentinel lymph node biopsy (SLNB). Finally, 68 consecutive patients diagnosed with breast cancer and who underwent SLNB between November 2010 and September 2012 were enrolled in the study. The cases were randomly grouped into either the ICG fluorescence or blue dye group, with 36 in the ICG fluorescence group and 32 in the blue dye group. Levels I and II axillary dissection was performed in all cases after SLNB. A single lymph drainage pathway was detected in 21 of 36 (58.3%) patients, and multiple lymph drainage pathways were detected in 15 of 36 (41.7%) cases. The detection rate of SLNB was higher by ICG fluorescence than by blue dye (97.2 vs. 81.3%, p < 0.05), as 3.6 SLNs were detected on average in the ICG fluorescence group compared to 2.1 in the blue dye group. However, the sensitivity and false-negative rate were similar in the two groups. In conclusion, ICG fluorescence was superior to blue dye for the identification of the SLN.

Preoperative lymphoscintigraphy and tumor histologic grade are associated with surgical detection of the sentinel lymph node

OBJECTIVE

To study which variables involved in the process of selective sentinel node biopsy (SSNB) influence the intraoperative detection of the sentinel lymph node.

MATERIAL AND METHODS

This was a prospective cross-sectional study in 210 patients (mean age, 54 years) diagnosed with breast cancer who underwent SSNB. We recorded clinical, radiological, radioisotope administration, surgical, and histological data as well as follow-up data. We did a descriptive analysis of the data and an associative analysis using multivariable regression.

RESULTS

Deep injection alone was the most common route of radioisotope administration (72.7%). Most lesions were palpable (57.1%), presented as nodules (67.1%), measured less than 2 cm in diameter (64.8%), were located in the upper outer quadrant (49.1%), were ductal carcinomas (85.7%), were accompanied by infiltration (66.2%), and had a histologic grade of differentiation of ii (44.8%). Preoperative scintigraphy detected the sentinel node in 97.6% of cases and 95.7% were detected during the operation. One axillary relapse was observed. In the associative study, the variables "preoperative lymphoscintigraphy" and "histologic grade of differentiation of the tumor" were significantly associated with the detection of the sentinel lymph node during the operation.

CONCLUSION

The probability of not detecting the sentinel lymph node during the surgical intervention is higher in patients with high histologic grade tumors or in patients in whom preoperative lymphoscintigraphy failed to detect the sentinel node.

Sentinel lymph node biopsy of the internal mammary chain in breast cancer

Routine removal of the internal mammary chain (IMC) sentinel node in breast cancer patients remains a subject of discussion. The aim of this study was to determine the impact of routinely performed IMC sentinel node biopsy on the systemic and locoregional treatments plan. All patients with biopsy proven breast cancer who underwent a sentinel node procedure between 2002 and 2011 were included in a prospective database. In cases of IMC drainage, successful exploration of the IMC (i.e., sentinel node removed) and surgical complications were registered. If the removed sentinel node contained malignant cells we determined if this altered the treatment plan when practising the current guidelines. In total, 119 of the 493 included patients showed IMC drainage on lymphoscintigraphy. Exploration of the IMC was performed in 107 (89 %) patients; in 86/107 (80 %) exploration was successful. In 14/107 patients (13 %) the IMC sentinel node was tumor positive. Macro and micro metastases were found in eight and six patients, respectively. In the group of patients who underwent surgical exploration of the IMC, systemic treatment was changed in none, radiotherapy treatment in 13/107 patients (11 %). Routine sentinel node biopsy of the IMC does not alter the systemic treatment. Radiotherapy treatment is altered in a small proportion of the patients; however, solid scientific evidence for this adjustment is lacking.

Indocyanine green fluorescence-navigated sentinel node biopsy showed higher sensitivity than the radioisotope or blue dye method, which may help to reduce false-negative cases in skin cancer

BACKGROUND AND OBJECTIVES

Although sentinel lymph node (SLN) biopsy using radioisotope (RI) and blue dye (BD) achieved a high detection rate, approximately 5% of melanomas with negative SLNs develop nodal metastasis. We tested a new lymphatic navigation method using indocyanine green fluorescence imaging (ICG-FI) to detect such "occult" SLNs.

METHODS

Thirty-four skin cancer patients received SLN biopsy with the following three methods: RI (99Tc-tin colloid), BD (2% patent blue), and ICG (0.5% indocyanine green). Lymph nodes detected by any of the three methods were counted as SLNs.

RESULTS

ICG-FI detected more SLNs in 8 out of the 34 cases (24%). The average numbers of SLNs detected by ICG-FI, RI, and BD were 2.18, 1.76, and 1.73, respectively. Interestingly, ICG-FI not only detected more SLNs in one basin (ICG-FI: 1.64, RI: 1.50, and BD: 1.51 SLNs per basin), but also detected additional SLNs in other basins (ICG-FI: 1.32, RI: 1.18, and BD: 1.15 basins per case).

CONCLUSION

ICG-FI detected SLNs more efficiently than did the conventional methods, and these "occult" SLNs may offer an explanation for some false-negative cases. We recommend using ICG-FI in addition to a conventional method to reduce the risk of overlooking these "occult" SLNs.

High rate of solitary sentinel node metastases identification by fluorescence-guided lymphatic imaging in breast cancer

BACKGROUND

The lymph node status was shown to be an important prognostic factor for breast cancer, but controversial issues remain. There has been increased focus on optimizing the visualization of lymph nodes for an accurate and selective approach to axillary lymph nodes. Fluorescence-guided lymphatic imaging is a potential candidate for further research on remaining controversies.

METHODS

Forty-seven patients were subject to injection of indocyanine green for navigation to the SLN based on fluorescent dye retention detection. In two groups, patients either received intended axillary lymph node dissection (ALND) and sentinel lymph node biopsy (SLNB) for superstaging or isolated SLNB for minimal-invasive staging. The prospective study was designed to evaluate the technical feasibility with focus on solitary positive SLN.

RESULTS

Visualization of lymphatic vessels with bright fluorescence of the SLN was feasible in 46 of 47 patients. Eighteen of 19 nodal positive patients were correctly identified with a sensitivity of 94.7% in all patients after ALND. After immunohistochemistry, in 19 of 25 overall nodal positive patients (76%) the SLN was the only positive lymph node.

CONCLUSION

Fluorescence-guided imaging using fluorescence retention detection allows transcutaneous navigation with a high rate of solitary positive SLN identification as an alternative technique for further research.

ICG fluorescence-guided sentinel node biopsy for axillary nodal staging in breast cancer

BACKGROUND

Sentinel lymph node (SLN) biopsy is a selective approach to axillary staging of breast cancer with reduced morbidity. Current detection methods including radioisotope and blue dye show good results but some drawbacks are remaining. Indocyanine green (ICG) fluorescence detection was evaluated as a new method for SLN biopsy in breast cancer allowing both transcutaneous visualization of lymphatic vessels and intraoperative identification of SLN.

METHODS

Forty-three women with clinically node negative breast cancer received subareolar injection of ICG for fluorescence detection of SLN. All patients underwent either planned axillary lymph node dissection (ALND) with SLN biopsy or selective SLN biopsy to determine need for ALND. Clinical feasibility, detection rate, sensitivity, and axillary recurrence after isolated SLN biopsy were analyzed.

RESULTS

Overall ICG fluorescence imaging identified 2.0 SLN in average in 42 of 43 patients (detection rate: 97.7%). Metastatic involvement of the SLN was found in 17 of 18 nodal positive patients by conventional histopathology (sensitivity: 94.4%). Immunohistochemistry revealed isolated tumor cells in five further cases. There was only one false-negative case in 43 patients (5.6%). In 17 of 23 overall nodal positive patients, the SLN was the only positive lymph node. After a median follow-up of 4.7 years none of the patients presented with axillary recurrence.

CONCLUSION

ICG fluorescence imaging is a new method for SLN biopsy in breast cancer with acceptable sensitivity and specificity comparable to conventional methods. One advantage of this technique is that it allows transcutaneous visualization of lymphatic vessels and intraoperative lymph node detection without radioisotope.

Sentinel lymph node biopsy in breast cancer guided by indocyanine green fluorescence

BACKGROUND

Sentinel lymph node (SLN) biopsy with radioisotope and blue dye has been used successfully for axillary staging in breast cancer. This study evaluated the feasibility of fluorescence detection of SLNs with indocyanine green (ICG) for lymphatic mapping and SLN biopsy.

METHODS

Thirty women with breast cancer had a periareolar injection of ICG for fluorescence detection of SLN using a near-infrared camera. Twenty also received (99m)Tc-labelled sulphur radiocolloid for SLN scintigraphy. All patients underwent axillary lymph node dissection. Detection rate and sensitivity of both methods were the study endpoints.

RESULTS

Visualization of lymphatic vessels by fluorescence detection depended on the dose of ICG. ICG imaging identified SLNs in 29 of 30 women (detection rate 97 per cent). Nineteen of 21 patients had metastatic SLN involvement (sensitivity 90 per cent) with false-negative results in two. Among the 20 patients who had both methods, ICG fluorescence and radiocolloid identified SLNs in 20 and 17 patients respectively. Metastatic lymph nodes were diagnosed in 12 and ten of 13 patients (sensitivity 92 and 77 per cent). False-negative rates were 8 and 23 per cent respectively.

CONCLUSION

ICG fluorescence allowed transcutaneous imaging of lymphatic vessels and SLN detection, thus combining the advantages of radioisotope and blue dye methods.

Is there any benefit from sentinel lymph node biopsy using the combined radioisotope/dye technique in breast cancer patients with clinically negative axilla?

OBJECTIVE

We evaluated the eventual benefits from sentinel lymph node biopsy (SLNB) in comparison with axillary lymph node dissection (ALND) using a combined radioisotope/dye technique versus dye alone in breast cancer patients.

METHODS

SLNB was performed in 501 breast cancer patients (250 patients with dye alone and 251 with combined technique). Patients were divided in three groups: (A) clinical stage T1,2N0 (SLNB followed by ALND only in cases with positive histology), (B) clinical stage T1,2N0 (SLNB followed by ALND), and (C): advanced clinical stage (SLNB immediately followed by ALND). The incidence of recurrences and surgery morbidity was comparatively evaluated.

RESULTS

The overall successful identification rate in patients of groups A and B was 97.7% (95.3% with dye and 99.3% with dye and isotope, P = 0.04) and in patients of group C 96.1% (93.3% with dye and 1000% with the combined technique, P = 0.02). The false-negative rate did not reach statistical significance between groups. Although locoregional recurrence rate was similar in groups A and B (less than 1.88%) the distant metastasis rate was significantly lower in group A (0.9 vs. 6.6%, P = 0.04). Arm edema was significantly more frequent in group B (0 vs. 5.3%, P = 0.02).

CONCLUSION

The combined technique, improves the ID rate of SLNs in patients with breast cancer. The recurrence rate in the axilla was negligible and the metastasis-free rate was better in patients treated with SLNB alone, which further supports the concept that ALND has no clinical relevance and adds nothing more than morbidity to breast cancer patients with clinically node-negative disease.

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.

Regional radiotherapy versus an axillary lymph node dissection after lumpectomy: a safe alternative for an axillary lymph node dissection in a clinically uninvolved axilla in breast cancer. A case control study with 10 years follow up

BACKGROUND

The standard treatment of the axilla in breast cancer used to be an axillary lymph node dissection. An axillary lymph node dissection is known to give substantial risks of morbidity. In recent years the sentinel node biopsy has become common practice. Future randomized study results will determine whether the expected decrease in morbidity can be proven.

METHODS

Before the introduction of the sentinel node biopsy, we conducted a study in which 180 women of 50 years and older with T1/T2 cN0 breast cancer were treated with breast conserving therapy. Instead of an axillary lymph node dissection regional radiotherapy was given in combination with tamoxifen (RT-group). The study group was compared with 341 patients, with the same patient and tumour characteristics, treated with an axillary lymph node dissection (S-group).

RESULTS

The treatment groups were comparable, except for age. The RT-group was significantly older than the S-group. The median follow up was 7.2 years. The regional relapse rates were low and equal in both treatment groups, 1.1% in RT-group versus 1.5% in S-group at 5 years. The overall survival was similar; the disease free survival was significant better in the RT-group.

CONCLUSION

Regional recurrence rates after regional radiotherapy are very low and equal to an axillary lymphnode dissection.

Introduction of sentinel node biopsy and stage migration of breast cancer

AIM

The purpose of this study was to examine in a large population based group of breast cancer patients treated in a regular care setting whether the introduction of the Sentinel Node Biopsy (SNB) led to detection of a higher percentage of patients with positive regional lymph nodes.

METHODS

The study includes 3665 early breast cancer patients, aged 30-85 years, diagnosed in the period 1997-2002 and registered at the Regional Cancer Registry of the Comprehensive Cancer Centre Middle Netherlands. During this period the SNB was introduced. The outcome of staging was compared for groups staged with or without SNB. A logistic regression model was used to adjust for age, calendar period and tumour size.

RESULTS

Overall a quarter of all patients over the period 1997-2002 underwent a SNB as method of lymphatic staging. The use of SNB clearly increased over time: from 2% in 1998 to 65% in 2002. The percentage node positive patients also rose significantly; before introduction of the SNB 30% of all patients were diagnosed with positive lymph nodes, and after SNB introduction this percentage was 40%. The increase is largely explained by the increase of patients diagnosed with only micrometastases. Adjustment did not change the results.

CONCLUSION

In conclusion, introduction of the SNB in early breast cancer led to significant upstaging of breast cancer patients treated in a regular care setting, due to the detection of more micrometastases. Since the relevance of micrometastases for long term survival is not yet known, this upstaging potentially led to over treatment of patients. On the other side, for some patients axillary lymph node dissection was prevented by the SNB procedure, preventing comorbidity.

The influence of wire localisation for non-palpable breast lesions on visualisation of the sentinel node

PURPOSE

In our clinic, patients with occult breast lesions are treated with a sentinel node biopsy combined with wire-guided tumour excision. The aim of this retrospective study was to determine the influence of the sequence of wire localisation and sentinel node procedure on visualisation of the sentinel node.

METHODS

A total of 136 patients had a wire-guided tumour excision combined with a sentinel node procedure. Sixty-six patients had guide wire localisation prior to the sentinel node procedure. Seventy patients had sentinel node visualisation before insertion of the guide wire.

RESULTS

The sentinel node was visualised in 41 (62%) of the patients who first underwent guide wire localisation. In the group of patients who underwent visualisation of the sentinel node before placement of the guide wire, the sentinel node was visualised in 62 (89%). This is a significant difference in visualisation (p<0.001).

CONCLUSION

This study shows that guide wire localisation prior to the sentinel node procedure negatively influences visualisation of the sentinel node.

Axillary sentinel lymph nodes in breast cancer: a single lymphatic pathway drains the entire mammary gland

AIM

To report the pattern of lymphatic mapping following intrasubdermal injections of radiocolloid and of blue dye in different sites of the breast.

METHODS

Prior to surgery 137 breast cancer patients underwent intrasubdermal injection of 30-50 MBq 99mTc-colloidal albumin over the tumour site (ISI group). Ten minutes before surgery, 2 ml patent blue was injected in the subareolar area (SAI group) in 117/137 patients, while 20 patients received intrasubdermal blue-dye in the quadrant opposite the tumour site (OQI group). The different injection routes were considered concordant when the hottest sLN was also blue.

RESULTS

In 134/137 patients radiocolloid drained to one or more axillary nodes, while blue nodes were found in 98/117 SAI patients and in 17/20 OQI patients. Multiple hot nodes were found in 63/134 cases and multiple blue nodes in 35/115. In patients in whom both tracers reached the axilla, the hottest node was also blue in 108/115 cases (93/98 SAI and 15/17 OQI patients). In the seven discordant cases, the hottest node was not blue, but in two cases the blue node was also radioactive.

CONCLUSIONS

Superficial lymphatic drainage from the breast most frequently merges to a single axillary lymph node, irrespective of the site of tracer injection. In a few cases different injection sites identify different, often closely interconnected sLNs.

Analysis of technical and clinical variables affecting sentinel node localization in patients with breast cancer after a single intradermal injection of 99mTc nanocolloidal albumin

AIM

To investigate the technical, clinical and pathological findings that can, potentially, affect pre-operative lymphoscintigraphy in visualizing sentinel lymph node (SLN) and intra-operative probe detection of SLN in patients with breast cancer.

METHODS

One hundred and forty-two consecutive female patients with, clinically, a solitary, small breast cancer and clinically N0 axilla were enrolled. Preoperative lymphoscintigraphy was performed by a single intradermal injection of 99mTc nacolloidal albumin (Nanocoll) the day before surgery. For radioguided surgery two gamma probes with diameters of 11 mm and 15 mm, and set up with a count rate ranging from 1 to 4 s were used. The following variables were evaluated: patient's age, radiotracer dose, volume of injectate, primary tumour location, primary tumour size, and presence and extension of axillary nodal metastases.

RESULTS

Lymphoscintigraphy showed high sensitivity in visualizing the SLN (98% success rate) and it resulted in a rapid technique since SLN was visualized within 30 min from injection in 85.21% of cases for the whole series. The probe detection rate was also very high (97.8% success rate): the mean per cent uptake in the SLN was 0.98. Statistical analysis showed that no parameter was found to have significantly influenced either SLN visualization at lymphoscintigraphy or SLN probe detection at surgery.

CONCLUSION

In our experience, lymphoscintigraphy performed by a single intradermal injection of Nanocoll was an effective and rapid technique for visualizing axilla SLNs in breast cancer patients. Moreover, this technique appeared to be independent of any technical, clinical and pathological findings.

Number of Metastatic Sentinel Nodes As Predictor of Axillary Involvement in Patients with Breast Cancer

BACKGROUND AND OBJECTIVES

More than half of patients with positive sentinel node (SN) have no metastases in non-sentinel nodes (NSNs) on axillary lymph node dissection (ALND). The aim of this study was to investigate factors predictive of NSNs involvement, in order to identify patients with metastatic disease confined to the SN which might avoid ALND.

METHODS

ALND was performed in 167 patients with metastatic SN. Axillary NSNs status was correlated with the size of SN metastases, the size of the primary tumor and the occurrence of lymphovascular invasion. In 72 cases, the radiotracer (Tc-99m albumin colloid) marked multiple (in most cases 2 or 3) nodes. In this group, NSNs status was correlated with the number of metastatic radioactive nodes (1 or > 1), and with the above mentioned histopathologic factors.

RESULTS

NSNs metastases were found in 57/167 cases (34.1%), the rate increasing proportionate to the size of both SN metastases (p < 0.0001) and primary tumor (p = 0.0075), while no significant correlation was found for lymphovascular invasion (p = 0.1769). At univariate and multivariate analysis of findings from the 72 cases with multiple probe-detected hot nodes, positivity in more than one hot node was the strongest predictor of NSN involvement (p = 0.0019).

CONCLUSIONS

The identification and excision of multiple hot nodes can be useful in the prediction of NSNs involvement in patients with metastatic SN.

Intradermal radioisotope injection optimises sentinel lymph node identification in breast cancer

AIM

Currently there is no consensus on the optimal technique for sentinel lymph node (SLN) identification in patients with breast cancer. The aim was to compare the efficacy of intraparenchymal and intradermal isotope injection in sentinel lymph node mapping for breast cancer.

METHODS

One hundred and twenty-five patients with histologically confirmed invasive breast cancer underwent SLN mapping using radioisotope and isosulphan blue dye followed by a back-up axillary dissection. The first 80 patients had intraparenchymal (IP) injection of radioisotope given in four portions around the tumor. The remaining 45 patients had an intradermal (ID) injection given at a single site over the tumour. Both groups had isosulphan blue dye injected around the tumour. Sentinel node(s) were identified using a combination of lymphoscintigraphy, blue dye and an intra-operative hand held gamma probe.

RESULTS

The preoperative lymphoscintigram (LSG) demonstrated a SLN significantly more often in the ID isotope group compared to the IP isotope group (P=0.002). A combination of blue dye and isotope successfully located the SLN in 96% of the intraparenchymal group and 100% of the intradermal group.

CONCLUSION

Our results suggest that intradermal isotope injection in combination with intraparenchymal blue dye optimises the localization of the sentinel lymph node in breast cancer.

Sentinel node biopsy for breast cancer: is it already a standard of care? A survey of current practice in an Italian region

BACKGROUND

Although sentinel node biopsy (SNB) is becoming the standard approach for axillary staging in patients with small breast cancer, criteria for patient selection and some technical aspects of the procedure have yet to be clearly defined. The aim of the present survey was therefore to investigate the way in which SNB is used by general surgeons working in the Veneto region, Italy.

METHODS

A 29-item questionnaire regarding various aspects of SNB practice was mailed to surgeons in charge of breast surgery in all the 56 surgical centres of the region.

RESULTS

The rate of response to the questionnaire was 82.1% (n = 46); 69.6% (n = 32) of the respondents routinely perform SNB in their clinical practice. Most of the interviewed surgeons (93.5%) expressed the belief that the acceptable false negative rate should be < or =5%. However, among the surgeons who perform SNB, only 34.4% performed more than 20 SNB during the learning phase. Indications are limited to tumours of < or =1 cm by 31.2% (n = 10) of respondents, < or =2 cm by 46.9% (n = 15) and < or =3 cm by 21.9% (n = 7). Almost all respondents (93.7%) agreed that a clinically positive axilla is a contraindication to SNB, while opinions differed widely concerning other potential contraindications. In most of the centres considered, SN identification is undertaken on the day before surgery using a subdermal injection of 30-50 MBq of 99mTc-albumin-nanocolloid followed by lymphoscintigraphy.

CONCLUSIONS

SNB is currently performed in the majority of hospitals in the Veneto region. However, the training phase and criteria used for patient selection differ from centre to centre. Certified training courses and shared guidelines are therefore highly desirable.

Stage migration in breast cancer: surgical decisions concerning isolated tumour cells and micro-metastases in the sentinel lymph node

AIMS

Sentinel lymph node biopsy has replaced the axillary lymph node dissection (ALND) in primary surgery for breast cancer in many hospitals and is expected to become the standard of care in due time. Since the sentinel lymph node is subjected to more extensive pathologic examination than the lymph nodes in the axillary dissection specimen, more patients are found to be node positive (N+); however many of them contain micro-metastases (<or=2mm). The consequence may be an overshoot of therapy: additional surgery for non-metastatic lymph nodes or systemic adjuvant therapy.

METHODS

We examined 34 (out of a series of 38) clinically T1 (cT1) patients who had a SLN biopsy with or without ALND and compared them to a matched historical control group.

RESULTS

Twenty-one of 34 (62%) patients showed tumour cells in their SLN's. From these 21 patients in 13 (62%) the SLNs contained isolated tumour cells, of which 10 (77%) were detected only by immunohistochemistry (IHC), in four (19%) the SLNs contained micrometastases, and in four (19%) macrometastases. From 16 patients with isolated tumour cells or micrometastases in the SLN who underwent a regular ALND one had an H&E detected isolated tumour cell in a non-SLN and one patient with isolated tumour cells in the SLN who did not get a regular ALND developed an axillary recurrence 11 months after the primary treatment. On the other hand, three of four (75%) patients with macrometastases in the SLN had pathologically involved non-SLNs. In the majority (70%) of patients of the historical control group no lymph node involvement was seen. The percentage of macrometastases staged as lymph node positive in the control group was the same as in the studied group.

CONCLUSION

Most patients with cT1 breast cancer with isolated tumour cells or micrometastases in the SLN will not benefit from additional axillary dissection; 88% had a negative ALND. Since we cannot select the group that will benefit from ALND, this is still indicated in case of isolated tumour cells or micrometastases in the SLN. Since most of the affected SLNs show isolated tumour cells and are classified as pN0(i+), stage migration due to more meticulous pathologic examination does not occur according to the TNM classification. However some patients do not benefit from the introduction of the SLN, due to the high incidence of isolated tumour cells or micrometastases in the SLN. Many more patients than expected still end up with an ALND.

Subareolar injection for sentinel lymph node location in breast cancer

AIM

Several different injection techniques are currently used for sentinel node (SN) identification in patients with breast cancer. Some studies suggest that the subareolar plexus drains lymph from the whole breast to the same axillary SN. In order to test this hypothesis, we ascertained whether subareolar blue dye injection and subdermal radioisotope injection close to the tumour identify the same axillary nodes.

METHODS

One day prior to surgery, 50 patients with breast cancer underwent subdermal injection of 30-40MBq of 99m-Tc colloidal albumin (Nanocoll) at the site of the cutaneous projection of the tumour. Ten minutes before surgery, each patient received a subareolar injection of 2-3cc of patent blue. All axillary radioactive nodes and blue-stained nodes were excised and a histologic examination was made.

RESULTS

Radioisotope marked the SNs in 47/50 (94%) cases, and the blue dye in 43/50 cases (86%). In three cases, SNs were not identified with either method. Of the 43 cases in which both the tracers reached the axilla, in 40 (93%) the SN was hot and blue-stained, while in 3 cases the two tracers identified different nodes.

CONCLUSIONS

Our findings suggest that subareolar injection and subdermal injection elsewhere in the breast usually identify the same SN. Subareolar injection appears to be particularly valuable in patients with multicentric or deep non-palpable breast tumours.

Axillary lymph node ratio and total number of removed lymph nodes: predictors of survival in stage I and II breast cancer

AIMS

Presence of axillary lymph node metastases is considered the most important prognostic factor for breast cancer survival. In a period of increasing popularity for the sentinel node procedure, clarity about the possible relation between axillary dissection and survival is essential. This study investigated whether the total number of removed lymph nodes and the ratio of invaded/removed lymph nodes (lymph node ratio (LNR) would prove to be independent prognostic factors for survival.

METHODS

Data from 453 consecutive patients with stage I or II breast cancer were studied retrospectively. The total number of removed lymph nodes and the LNR were analysed for their prognostic value in comparison with known prognostic factors.

RESULTS

Node-negative patients with < 14 lymph nodes removed had a 10 year survival of 79% compared with 89% in patients with > or = 14 lymph nodes removed (P=0.005). The 10 year survival for patients with an LNR > or = 0.2 was 52%, compared with 73% for patients with an LNR < 0.2 (P<0.0001). A Cox proportional hazards model showed that, for node-negative patients, only age and total number of removed lymph nodes were significant prognostic factors. For node-positive patients, age, total number of removed lymph nodes and the LNR were significant risk factors for survival outcome. The LNR was also significantly associated with the presence of distant metastases during follow-up (hazard ratio 3.56, range 1.63-7.77).

CONCLUSIONS

In stage I and II breast cancer, a favourable prognosis was found for node-negative patients with > or = 14 removed lymph nodes. Before axillary lymph node dissection with its well-defined survival prognosis is replaced by less invasive staging methods, long-term survival using new staging techniques needs to be defined. For node-positive patients, the LNR proved to be an excellent predictor for survival outcome or development of metastatic disease. Selection of lymph node-positive patients based on the LNR may guide specific adjuvant treatment choices.

Dynamic sentinel node biopsy for penile cancer: reliability of a staging technique

PURPOSE

We determine the value of dynamic sentinel node biopsy for staging squamous cell carcinoma of the penis.

MATERIALS AND METHODS

A total of 90 patients with clinically node negative penile cancer were prospectively entered in this study. Preoperative lymphoscintigraphy was performed after intradermal injection of 99mtechnetium nanocolloid around the primary tumor. The sentinel node was intraoperatively identified with the aid of intradermal administered patent blue dye and a gamma ray detection probe. Histopathological examination of sentinel nodes included serial sectioning and immunohistochemical staining. Regional lymph node dissection was performed only if metastasis was found in a sentinel node. Median followup was 36 months (range 5 to 95).

RESULTS

Lymphoscintigraphy visualized 217 sentinel nodes in 159 inguinal regions of 88 patients. A total of 208 sentinel nodes were intraoperatively identified in 149 inguinal regions of 88 patients. Sentinel node metastasis was found in 19 inguinal regions of 18 patients. Four of 8 patients with unilateral clinical stage N1 disease had a tumor positive sentinel node on the opposite site. Regional recurrence after excision of a tumor negative sentinel node or after nonvisualization was seen in 5 patients, resulting in a false-negative rate of 22% (5 of 23). The 3-year disease specific survival was 98% and 71% for patients with a tumor negative or tumor positive sentinel node, respectively (p = 0.0018).

CONCLUSIONS

Occult lymph node metastases in penile cancer can be detected with a sensitivity of about 80% by dynamic sentinel node biopsy, including preoperative lymphoscintigraphy, vital dye and a gamma ray detection probe.

Dynamic sentinel node biopsy for penile cancer: reliability of a staging technique

PURPOSE

We determine the value of dynamic sentinel node biopsy for staging squamous cell carcinoma of the penis.

MATERIALS AND METHODS

A total of 90 patients with clinically node negative penile cancer were prospectively entered in this study. Preoperative lymphoscintigraphy was performed after intradermal injection of 99mtechnetium nanocolloid around the primary tumor. The sentinel node was intraoperatively identified with the aid of intradermal administered patent blue dye and a gamma ray detection probe. Histopathological examination of sentinel nodes included serial sectioning and immunohistochemical staining. Regional lymph node dissection was performed only if metastasis was found in a sentinel node. Median followup was 36 months (range 5 to 95).

RESULTS

Lymphoscintigraphy visualized 217 sentinel nodes in 159 inguinal regions of 88 patients. A total of 208 sentinel nodes were intraoperatively identified in 149 inguinal regions of 88 patients. Sentinel node metastasis was found in 19 inguinal regions of 18 patients. Four of 8 patients with unilateral clinical stage N1 disease had a tumor positive sentinel node on the opposite site. Regional recurrence after excision of a tumor negative sentinel node or after nonvisualization was seen in 5 patients, resulting in a false-negative rate of 22% (5 of 23). The 3-year disease specific survival was 98% and 71% for patients with a tumor negative or tumor positive sentinel node, respectively (p = 0.0018).

CONCLUSIONS

Occult lymph node metastases in penile cancer can be detected with a sensitivity of about 80% by dynamic sentinel node biopsy, including preoperative lymphoscintigraphy, vital dye and a gamma ray detection probe.

The effect of prior breast biopsy method and concurrent definitive breast procedure on success and accuracy of sentinel lymph node biopsy

BACKGROUND

It has been suggested that sentinel lymph node (SLN) biopsy for breast cancer may be less accurate after excisional biopsy of the primary tumor compared with core needle biopsy. Furthermore, some have suggested an improved ability to identify the SLN when total mastectomy is performed compared with lumpectomy. This analysis was performed to determine the impact of the type of breast biopsy (needle vs. excisional) or definitive surgical procedure (lumpectomy vs. mastectomy) on the accuracy of SLN biopsy.

METHODS

The University of Louisville Breast Cancer Sentinel Lymph Node Study is a prospective multi-institutional study. Patients with clinical stage T1-2, N0 breast cancer were eligible. All patients underwent SLN biopsy and completion level I/II axillary dissection. Statistical comparison was performed by chi(2) analysis.

RESULTS

A total of 2206 patients were enrolled in the study. There were no statistically significant differences in SLN identification rate or false-negative rate between patients undergoing excisional versus needle biopsy. The SLN identification and false-negative rates also were not statistically different between patients who had total mastectomy compared with those who had a lumpectomy.

CONCLUSIONS

Excisional biopsy does not significantly affect the accuracy of SLN biopsy, nor does the type of definitive surgical procedure.

Comparison between periareolar and peritumoral injection of radiotracer for sentinel lymph node biopsy in patients with breast cancer

BACKGROUND

The technique of sentinel lymph node (SLN) biopsy in patients with breast cancer varies among reports, and the optimal method remains to be established, particularly with regard to the site of radiotracer injection. The aim of this study was to compare periareolar and peritumoral injection of radiotracer in detecting SLN in patients with breast cancer.

METHODS

Patients with T1-2 breast cancer (n = 155) were enrolled in this study. In phase 1 (n = 62), SLN biopsy was performed by using peritumoral injection of blue dye alone followed by backup axillary lymph node dissection. In phase 2, SLN biopsy was performed by using peritumoral injection of blue dye and peritumoral (group A, n = 41) or periareolar (group B, n = 52) injection of technetium 99m tin colloid.

RESULTS

In phase 1, the detection rate of SLN was 81% and the false-negative rate was 5.6%, indicating our skill in SLN biopsy. In phase 2, the success rate of lymphoscintigraphy was significantly (P <.001) higher in group B (90%) than in group A (51%). The mean ex vivo radioactivity of SLN in group B (117 counts per second; range, 5 to 900) was also significantly (P <.05) higher than in group A (51 counts per second; range, 8 to 260). In addition, the detection rate of SLN was significantly (P <.05) higher in group B (100%) than in group A (90%).

CONCLUSIONS

Periareolar injection of radiotracer for SLN biopsy is superior to peritumoral injection because of its simplicity, achieving a high success rate in lymphoscintigraphy and SLN detection.

Treatment of 100 patients with sentinel node-negative breast cancer without further axillary dissection

BACKGROUND

The sentinel node biopsy technique for breast cancer has been validated extensively in phase I and II studies. However, no data from phase III randomized clinical studies are available. It remains controversial whether a histologically negative sentinel node biopsy without further axillary dissection can be considered to be good clinical practice.

METHODS

One hundred consecutive patients with breast cancer who had a negative sentinel node biopsy without additional axillary dissection were studied prospectively between 1997 and 2000 in order to identify tumour recurrence and to assess the morbidity of the sentinel node procedure. Special attention was paid to axillary or locoregional recurrence, distant metastases and overall survival. One year after the procedure patients were sent a questionnaire to assess any functional impairment of the arm or shoulder.

RESULTS

Median follow-up was 24 (range 16-40) months. One patient had an axillary relapse 14 months after the initial diagnosis of breast cancer. She died after 2 years from metastatic disease. There were no other local axillary recurrences. There was a 94 per cent response rate to the questionnaire. Twelve patients developed mild disabilities, of whom two said that they had to change their hobbies, sports or daily activities owing to the sentinel node procedure. No patient developed lymphoedema or needed physiotherapy after the operation.

CONCLUSION

When strict criteria for the sentinel node biopsy procedure are used, the sentinel node biopsy without further axillary dissection after a negative histological investigation is a safe procedure. It may therefore be considered to be the standard of care for the treatment of patients with breast cancer.

Micro-metastases in axillary lymph nodes: an increasing classification and treatment dilemma in breast cancer due to the introduction of the sentinel lymph node procedure

BACKGROUND

Sentinel lymph node (SN) biopsy will increasingly replace axillary lymph node dissection (ALND) for staging in breast cancer. For daily practice, examination of the SN by serial sectioning (SS) and/or immunohistochemistry (IHC) is being promoted. Use of these techniques may result into stage migration due to the increased detection of micro-metastases. The consequence may be overshooting of patients with adjuvant therapy, as the prognostic relevance of (small) micro-metastases and isolated tumor cells is unclear.

METHODS

The prognostic impact of micro-metastases is determined by reviewing ALND studies with a follow up of at least 5 years, including more than 100 patients, before the SN era. Furthermore, studies in which conventionally haematoxylin-eosin (H&E) negative SNs are investigated for occult metastases by SS and/or IHC are reviewed.

RESULTS

In only one of eight studies, occult metastases were an independent risk factor for reduced survival. The outcome is dependent on the size of the nodal metastasis. IHC and SS as used in the SN procedure indeed induce a shift from pNO to pN1a (according to TNM).

CONCLUSION

By the thorough pathologic examination of the SN, isolated tumor cells and micro-metastases are more frequently detected. We propose to classify small micro-metastases (<0.5 mm) in a separate pN1a(min) category (min for minimal) to prevent stage migration. As the prognostic relevance of isolated tumor cells and (small) micrometastases has not been proven, the value of adjuvant therapy can be questioned for patients with otherwise good prognostic factors.

Value of sentinel node biopsy in the management of breast cancer

AIMS

To determine the rate of detection of the sentinel node using both blue dye and radioisotope, and the accuracy with which the sentinel node histology reflects the nodal status of the axilla in a series of patients with clinically node-negative breast cancer.

PATIENTS AND METHODS

During a 32-month period from May 1998 to December 2000, 73 patients with clinically node-negative breast cancer underwent sentinel node biopsy immediately followed by formal axillary lymphadenectomy. The sentinel node(s) was identified using a combination of lymphoscintigraphy, blue dye and an intraoperative hand-held gamma probe.

RESULTS

The mean age of the 73 patients was 58 years (range 32-83 years). Twenty-six per cent (19/73) had previous surgical/excisional biopsy. Pre-operative lymphoscintigraphy was positive in 74% (54/73) of patients. Combination of blue dye and radioisotope was better than either method in isolation for identifying the sentinel node, yielding a success rate of 96% (70/73). A total of 32 cases proved to have positive nodal disease on histological examination. In 44% (14/32) of patients, the sentinel node was the only positive node. Forty-seven per cent (15/32) of patients in whom the sentinel node was positive also had positive nodes in the axillary nodal basin. There were 3/32 false negative cases, giving a false negative rate of 9.4%.

CONCLUSION

Sentinel node biopsy will have a role in the management of breast cancer. However, widespread adaptation of this technique awaits the results of prospective, randomised trials.

Clinical Utility of Frozen Section in Sentinel Node Biopsy in Breast Cancer

One hundred sixty-five breast cancer patients underwent a sentinel lymph node biopsy procedure over a period of 2 years. Sentinel node (SN) could be successfully localized in 157 (95%) of the patients. Complete axillary lymph node dissection was performed only if the frozen section (FS) revealed a positive SN. All SN specimens were further evaluated by hematoxylin and eosin on multiple sections and cytokeratin immunohistochemisty. The patients whose SNs were negative by FS but positive by permanent histopathologic evaluation underwent a delayed axillary lymph node dissection. SN was positive in 41 of 157 (26%) patients. Eighteen (44%) of the 41 patients with SN metastases were diagnosed intraoperatively by FS and underwent a one-stage definitive surgical treatment. The benefit of FS was most notable in patients with T1c and larger lesions.

Technical issues and pathologic implications of sentinel lymph node biopsy in early-stage breast cancer patients

BACKGROUND AND OBJECTIVES

Recent studies have demonstrated that the sentinel lymph node (sN) can be considered a reliable predictor of axillary lymph node status in breast cancer patients. However, some important issues, such as optimization of the technique for the intraoperative identification of the sN, and the clinical implications of sN metastasis as regards the surgical management of the axilla still require further elucidation. The objectives of this study was to assess (1) the feasibility of sN identification with a combined approach (vital blue dye lymphatic mapping and radioguided surgery, RGS) and the specific contribution of either techniques to the detection of the sN, and (2) the correlation between the size of sN metastasis (micrometastasis < or = 2 mm; macrometastasis > 2), primary tumour size, and the status of nonsentinel nodes (nsN) in the axilla.

METHODS

Between October of 1997 and December of 1999, 212 patients with breast cancer (average age: 61 years; range, 40-79 years) underwent sN biopsy before performing standard axillary dissection. In a subset of 153 patients, both vital blue dye (Patent Blue-V) lymphatic mapping and RGS were used to identify the sN, and the relative contribution of each of the two techniques was assessed.

RESULTS

Overall, the sN was identified in 206 of 212 patients (97.1%); at histologic examination of all dissected nodes, 77 of 206 patients had positive nodes (37.3%). The false-negative rate was 6.5% (5/77), the negative predictive value was 96.3% (129/134), and accuracy was 97.6% (201/206). Among 72 patients with positive sN, micrometastases were detected in 21 cases and macrometastases in 51. When micrometastases only were observed, the sN was the exclusive site of nodal metastasis in 17 of 21 cases (80.9%); in the remaining 4 cases (19.1%), nsN metastases were detected in 3 of 14 pT1c patients (21.5%), and 1 of 5 pT2 patients (20%). Macrometastases were detected in patients with tumors classified as pT1b or larger: the sN was the exclusive site of metastasis in 3 of 4 pT1b patients (75%), in 14 of 29 pT1c patients (48.2%), and in 3 of 18 pT2 patients (16.6%). The specific contribution of the two different techniques used in the identification of the sN was evaluated; the detection rate was 73.8% (113 of 153) with Patent Blue-V alone, 94.1% (144 of 153) with RGS alone, and 98.7% (151 of 153) with Patent Blue-V combined with RGS (P < 0.001). Noteworthy, whenever the sN was identified, the prediction of axillary lymph node status was remarkably similar (93-95% sensitivity; 100% specificity; 95-97% negative predictive value, and 97-98% accuracy) with each of the three procedures (Patent Blue-V alone, RGS alone, or combined Patent Blue-V and RGS).

CONCLUSIONS

Sentinel lymphadenectomy can better be accomplished when both procedures (lymphatic mapping with vital blue dye and RGS) are used, due to the significantly higher sN detection rate, although the prediction of axillary lymph node status remains remarkably similar with each one of the methods assessed. That patients with small tumours (<1 cm) and sN micrometastasis are very unlikely to harbour metastasis in nsN should be considered when planning randomised clinical trials aimed at defining the effectiveness of sN guided-axillary dissection.