Clinical aspects of sentinel node biopsy

Skin-sparing mastectomy for the treatment of breast cancer

BACKGROUND

Skin-sparing mastectomy (SSM) is a surgical technique that aims to maximize skin preservation, facilitate breast reconstruction, and improve cosmetic outcomes. Despite its use in clinical practice, the benefits and harms related to SSM are not well established.

OBJECTIVES

To assess the effectiveness and safety of skin-sparing mastectomy for the treatment of breast cancer.

SEARCH METHODS

We searched Cochrane Breast Cancer's Specialized Register, CENTRAL, MEDLINE, Embase, LILACS, the World Health Organization's International Clinical Trials Registry Platform (WHO ICTRP), and ClinicalTrials.gov on 9 August 2019.

SELECTION CRITERIA

Randomized controlled trials (RCTs), quasi-randomized or non-randomized studies (cohort and case-control) comparing SSM to conventional mastectomy for treating ductal carcinoma in situ (DCIS) or invasive breast cancer.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. The primary outcome was overall survival. Secondary outcomes were local recurrence free-survival, adverse events (including overall complications, breast reconstruction loss, skin necrosis, infection and hemorrhage), cosmetic results, and quality of life. We performed a descriptive analysis and meta-analysis of the data.

MAIN RESULTS

We found no RCTs or quasi-RCTs. We included two prospective cohort studies and twelve retrospective cohort studies. These studies included 12,211 participants involving 12,283 surgeries (3183 SSM and 9100 conventional mastectomies). It was not possible to perform a meta-analysis for overall survival and local recurrence free-survival due to clinical heterogeneity across studies and a lack of data to calculate hazard ratios (HR).  Based on one study, the evidence suggests that SSM may not reduce overall survival for participants with DCIS tumors (HR 0.41, 95% CI 0.17 to 1.02; P = 0.06; 399 participants; very low-certainty evidence) or for participants with invasive carcinoma (HR 0.81, 95% CI 0.48 to 1.38; P = 0.44; 907 participants; very low-certainty evidence). For local recurrence-free survival, meta-analysis was not possible, due to high risk of bias in nine of the ten studies that measured this outcome. Informal visual examination of effect sizes from nine studies suggested the size of the HR may be similar between groups. Based on one study that adjusted for confounders, SSM may not reduce local recurrence-free survival (HR 0.82, 95% CI 0.47 to 1.42; P = 0.48; 5690 participants; very low-certainty evidence).  The effect of SSM on overall complications is unclear (RR 1.55, 95% CI 0.97 to 2.46; P = 0.07, I2 = 88%; 4 studies, 677 participants; very low-certainty evidence). Skin-sparing mastectomy may not reduce the risk of breast reconstruction loss (RR 1.79, 95% CI 0.31 to 10.35; P = 0.52; 3 studies, 475 participants; very low-certainty evidence), skin necrosis (RR 1.15, 95% CI 0.62 to 2.12; P = 0.22, I2 = 33%; 4 studies, 677 participants; very low-certainty evidence), local infection (RR 2.04, 95% CI 0.03 to 142.71; P = 0.74, I2 = 88%; 2 studies, 371 participants; very low-certainty evidence), nor hemorrhage (RR 1.23, 95% CI 0.47 to 3.27; P = 0.67, I2 = 0%; 4 studies, 677 participants; very low-certainty evidence). We downgraded the certainty of the evidence due to the risk of bias, imprecision, and inconsistency among the studies. There were no data available on the following outcomes: systemic surgical complications, local complications, explantation of implant/expander, hematoma, seroma, rehospitalization, skin necrosis with revisional surgery, and capsular contracture of the implant. It was not possible to perform a meta-analysis for cosmetic and quality of life outcomes due to a lack of data. One study performed an evaluation of aesthetic outcome after SSM: 77.7% of participants with immediate breast reconstruction had an overall aesthetic result of excellent or good versus 87% of participants with delayed breast reconstruction.

AUTHORS' CONCLUSIONS

Based on very low-certainty evidence from observational studies, it was not possible to draw definitive conclusions on the effectiveness and safety of SSM for breast cancer treatment. The decision for this technique of breast surgery for treatment of DCIS or invasive breast cancer must be individualized and shared between the physician and the patient while considering the potential risks and benefits of available surgical options.

Assessment of Intraparenchymal Injection of 1% Patent Blue Dye in the Upper Outer Quadrant of the Breast to Identify Sentinel Lymph Node in Early Retro-Areolar Breast Cancer in Women: A Tertiary Centre Experience in Egypt

BACKGROUND

Sentinel lymph node biopsy is the gold standard for axillary assessment of patients with clinically node negative breast cancer. The current internationally accepted methods comprise of the usage of either a radioactive tracer, vital stains or the combination of both. However, in developing countries radioactive tracer is not widely used due to its high cost and limited availability. In addition, the classic retro-areolar blue dye injection has a high failure rate.

OBJECTIVE

Our study aimed to assess the efficacy of patent blue dye injection in the upper outer quadrant of the breast after validation by concurrent usage of radioactive nanocolloid, in comparison with the classic retro-areolar injection in identifying the sentinel node.

METHODS

A randomized control study involving 279 patients randomly divided into two groups. In group A lateral injection of 1% patent blue dye (validated by radioactive nanocolloid) was used, while subdermal patent blue dye injection in the retro-areolar space was performed in group B.

RESULTS

The new technique showed the promising results with lower failure rate (3.4%) in comparison with the classic retro-areolar patent blue injection (13.7%).

CONCLUSIONS

The lateral injection technique can be result in comparable results to the combination technique with the added benefit of being widely available and a cheaper option especially in developing countries.

The Use of the Bipedicled Deep Inferior Epigastric Perforator Flap for Unilateral Breast Reconstruction: A Systematic Review and Meta-analysis

INTRODUCTION

The use of abdominal flaps is recognized as a very advantageous approach for breast reconstruction with gradual refinements leading from the pedicled transverse rectus abdominis musculocutaneous flap to the criterion standard deep inferior epigastric perforator (DIEP) flap and its several variations. A systematic review with meta-analysis attempts to investigate the safety of the bipedicled DIEP flap for unilateral breast reconstruction.

METHODS

The literature search used "PubMed" database, and a relevant study conducted at the Queen Victoria Hospital was also included. The extraction of data included study type, follow-up, patients' age, body mass index, preexisting abdominal scars, timing of reconstruction, operating time, flap inset, pedicles' configuration, flap failure, revision, and complication rates. Proportions were pooled with Freeman-Tukey arcsine transformation, and meta-regression was performed to evaluate whether complication rates were modified by different variables.

RESULTS

Fourteen eligible articles provided an overall sample of 486 flaps, with a median follow-up of 18.5 months. In most cases, immediate reconstruction with undivided flap was performed, with equal use of extraflap and intraflap pedicles' configuration. Only 4 cases of flap failure (0.82%) were documented, with 18% overall complications and 3% fat necrosis rate. The forest plot showed significant between-study heterogeneity, and meta-regression revealed marginal positive association between older patient and complication rate.

CONCLUSIONS

Bipedicled DIEP flap for unilateral breast reconstruction is a technique that maintains the complications rate relatively low in challenging postmastectomy cases. Further comparative studies are needed to substantiate the findings of this study.

Clinical Practice Status of Sentinel Lymph Node Biopsy for Early-Stage Breast Cancer Patients in China: A Multicenter Study

Background

Sentinel lymph node biopsy (SLNB) was introduced over 30 years ago, but the application of SLNB in China is unclear. This study aimed to explore the real-world implementation of SLNB among early-stage breast cancer patients in China.

Methods

A multi-center, retrospective study was conducted among primary breast cancer patients from 37 hospitals in China in 2018. Their clinical data were collected and analyzed, including the implementation status of SLNB in China, subsequent processing of sentinel lymph nodes (SLNs) containing metastases, and the effect of neoadjuvant chemotherapy (NAC) on SLNB.

Results

SLNB surgery was performed on 43.5% of early-stage breast cancer patients in China and 11,942 patients who underwent SLNB were enrolled in this study. The majority of SLNBs were performed using a single mapping agent. A combination of blue dye and radiotracer or fluorescence imaging was used in only 14.9% of patients. The mean (SD) number of resected SLNs was 4.0 (2.1). For the patients with 1 or 2 positive SLNs, 83.0% of them continued to receive axillary lymph node dissection (ALND), while others did not. For the patients with three or more positive SLNs, 97.2% of them continued to receive ALND, among which 82.9% accepted radiotherapy simultaneously. Of the patients who underwent SLN surgery, 5.5% (654/11,942) were receiving NAC. Among them, 51.9% received SLNB before NAC, and the rest received SLNB after NAC. In biopsy-proven positive nodes, 64.7% positive SLNs turned negative after NAC.

Conclusion

SLNB has been promoted in China, but it is not widely used compared to in developed countries. Furthermore, the usage of the dual tracer technique in SLNB is not high. Chinese breast surgeons are more conservative regarding the omission of ALND in 1 or 2 SLNs-positive patients.

Cutaneous adverse effects of methylene blue in an animal skin-flap model

Background and objectives: Sentinel lymph node biopsy is important for metastasis surveillance in the management of a number of human cancers. Identification of sentinel lymph nodes may be facilitated by the use of several methods including methylene blue injection. However tissue necrosis is a known effect of methylene blue application. This study aimed to investigate the effects of methylene blue injection on skin flaps using a rodent model.Methods: Modified McFarlane flaps were prepared using Wistar Albino rats. Local injection of methylene blue was given to one group while saline was injected into the control group. A third group received systemic methylene blue via intraperitoneal injection. Observational and histological comparison was made between the groups to investigate the necrotic effects of methylene blue on skip flaps.Results: The control group's surviving flap areas were significantly larger than local methylene blue group's surviving flap area. However, there was no significant difference in skin flap survival area between the control group and the systemic methylene blue group. Furthermore, there is no significant difference between local and systemic methylene blue group's surviving flap areas.Conclusions: Local methylene blue injection increases skin necrosis and decreases rates of surviving flap areas in an experimental rat models.

Sentinel Lymph Node Biopsy in Early Breast Cancer: Magnetic Tracer as the Only Localizing Agent

BACKGROUND

The combined use of radioisotope and blue dye is the gold standard in sentinel lymph node (SLN) localization in early breast cancer. Superparamagnetic iron oxide (SPIO) has recently emerged as a non-inferior new tracer in sentinel lymph node mapping with fewer disadvantages. This study represents the first and the largest cohort of superparamagnetic iron oxide application in Asian population.

METHODS

Retrospective analysis of a prospectively maintained database was performed from August 2016 to December 2017. All patients with SLN localization by SPIO were included in this study.

RESULTS

A total of 328 breast cancer patients with 333 SLNB procedures were included in this study. Median age was 54 years (range 32-86). Median tumor size was 1.9 cm (range 0.1-12 cm).There were 138 breast-conserving surgeries and 195 mastectomies. All patients received injection of SPIO 1 day prior to operation. A total of 329 successful sentinel lymph node biopsy (SLNB) procedures were undertaken with 1514 sentinel lymph nodes (SLNs) identified. One hundred and fifty-three (10.1%) of the SLNs were positive for malignancy. There were 54 patients with macrometastases, 26 with micrometastases and 24 with isolated tumor cells. Sixty-seven patients underwent subsequent axillary dissection. Four patients failed sentinel lymph node identification with SPIO. The success rate of SPIO in sentinel lymph node localization was 98.8%.

CONCLUSION

SPIO represents a feasible alternative in sentinel lymph node mapping with comparably high nodal detection rate.

Prediction of pathological response to neoadjuvant chemotherapy in breast cancer patients by imaging

BACKGROUND

Diagnostic imaging is important for predicting the pathological response to chemotherapy during neoadjuvant chemotherapy (NAC) and for considering the surgical management with appropriate resection after NAC. This study was performed to examine the accuracy of the present radiological imaging for predicting the pathological complete response (pCR).

METHODS

From 188 patients in our previous JONIE1 Study, a randomized controlled trial comparing chemotherapy with and without zoledronic acid for patients with human epidermal growth factor receptor 2-negative breast cancer, we evaluated 122 patients whose tumor size was examined by magnetic resonance imaging or ultrasound at three points: before NAC; after administering fluorouracil, epirubicin, and cyclophosphamide; and after NAC. The maximum tumor diameter was evaluated by magnetic resonance imaging or ultrasound. Tumor reduction ratios were calculated at the same three points. The association between the radiological clinical response and the pCR was examined.

RESULTS

Among the 122 patients evaluated, there were 98 and 24 patients with luminal (Lum) and triple-negative (TN) subtypes, respectively. There were no patients who showed tumor progression after treatment. The radiological size of the tumors was finally reduced by an average of 58.4%. Clinical complete response and pCR were achieved in 22 (18.0%) and 15 (12.3%) patients, respectively. In the overall population (n = 122), the accuracy, sensitivity, and specificity for predicting pCR were 86.1%, 88.8%, and 66.7%, respectively. The negative predictive value and false-negative rate were 45.5% and 11.2%, respectively. According to subtypes, the accuracies were 83.7% and 95.8% in Lum and TN, respectively. Negative predictive value and false-negative rate were markedly different between the Lum (29.4% and 13.5%) and TN subtypes (100% and 0%), respectively.

CONCLUSIONS

This randomized clinical trial demonstrated that NAC was safe for operable breast cancer patients with appropriate radiological monitoring. Radiological evaluation after NAC may be a reliable method for predicting pathological response in the TN subtype, but not in the Lum subtype.

A dual modal silver bumpy nanoprobe for photoacoustic imaging and SERS multiplexed identification of in vivo lymph nodes

Multimodal imaging can provide complementary biomedical information which has huge potential in pre-clinical and clinical imaging and sensing. In this study, we introduce dual modal NIR silver bumpy nanoprobes for in vivo imaging and multiplexed detection of biomolecules by both photoacoustic imaging (PAI) and surface-enhanced Raman scattering (SERS) techniques. For this study, we used silica-coated silver bumpy nanoshell probes (AgNS@SiO₂). AgNS@SiO₂ have strong NIR-absorption and scattering properties compared with other nanostructures, and therefore, can be a good candidate for photoacoustic (PA) and SERS multimodal imaging. We obtained PA images of the skin and SLNs of rats by injecting various kinds of Raman-labeled AgNS@SiO₂. Multiplexed identification of the injected AgNS@SiO₂ was achieved by measuring SERS signals. AgNS@SiO₂ have the potential to be applied in detecting cancer biomarkers by locating biomarkers quickly using PA imaging, and identification by multiplexed target measurement using SERS signals in vivo.

Do the ACOSOG Z0011 Criteria Affect the Number of Sentinel Lymph Nodes Removed?

INTRODUCTION

We sought to determine if adoption of the Z0011 criteria was associated with removal of more sentinel lymph nodes (SLNs).

METHODS

In a retrospective review of a prospective database of breast cancer patients treated at our institution from 2006 to 2013, we identified 5213 eligible patients who elected to undergo breast-conserving surgery; 2372 were treated pre-Z0011 and 2841 post-Z0011. Clinicopathologic factors were collected, and univariate and multivariate models were fit to identify variables associated with number of SLNs removed.

RESULTS

Median patient age, 60 years, did not differ between groups. Median tumor size was similar in both groups: 1.1 (0.05-5.0) cm in the pre-Z0011 group and 1.2 (0.1-5.2) cm in the post-Z0011 group. The mean number of SLNs excised in the pre-Z0011 patients was 2.8 compared with 2.9 in post-Z0011 patients (p = 0.01). Three or fewer lymph nodes were removed in 1771 (75 %) pre-Z0011 patients compared with 2006 (71 %) post-Z0011 patients (p = 0.01). Factors associated with the removal of more SLNs on multivariate analysis included adoption of ACOSOG Z0011 criteria (p = 0.03), young age (p ≤ 0.0001), and large tumor size (p = 0.0005). Axillary lymph node dissection (ALND) was performed in 379 (16 %) patients pre-Z0011 compared with 68 (2 %) node-positive post-Z0011 patients (p < 0.0001).

CONCLUSIONS

Since the adoption of Z0011 criteria, we found significantly fewer patients undergoing ALND for positive SLNs. We noted a significant, slight shift in the removal of ≥4 SLNs. The Z0011 criteria were not associated with a clinically significant increase in the number of SLNs removed.

Blue dye is sufficient for sentinel lymph node biopsy in breast cancer

BACKGROUND

Most previous studies have reported superior results when blue dye and radiocolloids were used together for sentinel lymph node (SLN) biopsy in early breast cancer. Blue dye was reported to perform poorly when used alone, although more recent studies have found otherwise. This study reviewed the authors' practice of performing SLN biopsy with blue dye alone.

METHODS

This was a retrospective review of patients who underwent SLN biopsy using blue dye alone from 2001 to 2005, when SLN biopsy was performed selectively and always followed by axillary lymph node dissection (ALND), and from 2006 to 2010, when SLN biopsy was offered to all suitable patients and ALND done only when the SLN was not identified or positive for metastasis.

RESULTS

Between 2001 and 2005, 170 patients underwent SLN biopsy with blue dye alone. The overall SLN non-identification rate was 8·4 per cent. The overall false-negative rate was 34 per cent, but decreased with each subsequent year to 13 per cent in 2005. From 2006 to 2010, 610 patients underwent SLN biopsy with blue dye alone. The SLN was not identified in 12 patients (2·0 per cent) and no significant contributing factor was identified. A median of 2 (range 1-11) SLNs were identified. A non-SLN was found to be positive for metastasis in two patients with negative SLNs. Axillary nodal recurrence developed in one patient; none developed internal mammary nodal recurrence. Anaphylaxis occurred in one patient.

CONCLUSION

Blue dye performed well as a single modality for SLN biopsy. Non-identification, axillary nodal recurrence and serious allergic reactions were uncommon.

Characteristics of breast carcinoma cases with false-negative sentinel lymph nodes

BACKGROUND

In the past decade, sentinel lymph node biopsy (SLNB) has become standard for patients with early-stage clinically node-negative breast carcinoma (BC). Despite high overall surgical identification success rates with introduction of the dual-tracer techniques (dye and radiolabeled probe), false-negative rates remained unchanged in most recent meta-analyses.

PATIENTS AND METHODS

We analyzed cases with false-negative SLN biopsy results over a 12-year period in a single institution to evaluate their clinicopathologic characteristics. Sixty-three false-negative cases (3.1%) were found in 2043 successful SLN mapping procedures, all of which were followed by varying amounts of additional axillary sampling.

RESULTS

There was a higher proportion of invasive lobular carcinomas (ILCs; 23 cases [37%]) when compared with this lesion's overall reported frequency (5%-15%). The majority of invasive ductal carcinoma (IDC) cases (31 of 40) were poorly differentiated. In 80% of the ductal-type cases, 1 or more nonsentinel nodes (NSLNs) were completely or partially replaced by tumor, as opposed to less than half of such cases of the lobular type. Twenty-two cases had multiple positive NSLN metastases, which were significantly associated with larger tumor size (≥ 1.0 cm) and tumor replacement of NSLNs. Eighty-two percent of the cases with known hormone receptor status were positive for estrogen or progesterone receptors, or both.

CONCLUSION

False-negative SLN biopsy results were more often associated with a primary BC characterized by a lobular or poorly differentiated ductal histologic type or partial to complete replacement of NSLNs with tumor, or both.

Meta-analysis of sentinel lymph node biopsy at the time of prophylactic mastectomy of the breast

BACKGROUND

Prophylactic mastectomy is performed to decrease the risk of breast cancer in women at high risk for the disease. The benefit of sentinel lymph node biopsy (SLNB) at the time of prophylactic mastectomy is controversial, and we performed a meta-analysis of the reported data to assess that benefit.

METHODS

We searched MEDLINE, EMBASE and the Cochrane Library databases from January 1993 to December 2009 for studies on patients who underwent SLNB at the time of prophylactic mastectomy. Two reviewers independently evaluated all the identified papers, and only retrospective studies were included. We used a mixed-effect model to combine data.

RESULTS

We included 6 studies in this review, comprising a total study population of 1251 patients who underwent 1343 prophylactic mastectomies. Of these 1343 pooled prophylactic mastectomies, the rate of occult invasive cancer (21 cases) was 1.7% (95% confidence interval [CI] 1.1%-2.5%), and the rate of positive SLNs (23 cases) was 1.9% (95% CI 1.2%-2.6%). In all, 36 cases (2.8%, 95% CI 2.0%-3.8%) led to a significant change in surgical management as a result of SLNB at the time of prophylactic mastectomy. In 17 cases, patients with negative SLNs were found to have invasive cancer at the time of prophylactic mastectomy and avoided axillary lymph node dissection (ALND). In 19 cases, patients with positive SLNBs were found not to have invasive cancer at the time of prophylactic mastectomy and needed a subsequent ALND. Of the 23 cases with positive SLNs, about half the patients had locally advanced disease in the contralateral breast.

CONCLUSION

Sentinel lymph node biopsy is not suitable for all patients undergoing prophylactic mastectomy, but it may be suitable for patients with contralateral, locally advanced breast cancer.

Evaluation of sentinel node biopsy in locally advanced breast cancer patients who become clinically node-negative after neoadjuvant chemotherapy: a preliminary study

Introduction. Controversy continues over the appropriate timing of sentinel lymph node (SLN) biopsy in locally advanced breast cancer (LABC) patients receiving neoadjuvant chemotherapy. We evaluated the feasibility and accuracy of SLN biopsy in LABC patients with cytology-proven axillary nodal metastasis who become clinically node-negative after neoadjuvant chemotherapy. Materials. 30 consecutive patients with LABC, who had become clinically node-negative after 3 cycles of neoadjuvant chemotherapy, were included in the study. They were then subjected to SLN biopsy, axillary lymph node dissection, and breast surgery. Results. Sentinel nodes were successfully identified in 26 of the 30 patients, resulting in an identification rate of 86.67%, sensitivity of 83.33%, false negative rate of 20%, negative predictive value of 72.73%, and an overall accuracy of 88.46%. No complications were observed as a result of dye injection. Conclusions. SLN biopsy is feasible and safe in LABC patients with cytology-positive nodes who become clinically node-negative after neoadjuvant chemotherapy. Our accuracy rate, identification rate, and false negative rate are comparable to those in node-negative LABC patients. SLN biopsy as a therapeutic option in LABC after neoadjuvant chemotherapy is a promising option which should be further investigated.

Sentinel lymph node biopsy in breast cancer: an analysis of the maximum number of nodes requiring excision

Sentinel lymph node biopsy (SNB) is now the standard of care in assessment of patients with clinically staged T1-2, N0 breast cancers. This study investigates whether there is a maximum number of sentinel lymph nodes (SLN) that need to be excised without compromising the false-negative (FN) rate of this procedure. Data were prospectively collected for 319 patients undergoing SNB between February 2001 and December 2006 at our institution. This data were analysed, both in terms of the order of SLN retrieval and relative isotope counts of the SLNs, in order to determine the maximum number of SLNs that need to be retrieved without increasing the FN rate. Furthermore, we investigated the relationship between SLN blue dye concentration and the presence of SLN metastases. The SLN identification rate was 97% with no false-negative cases amongst patients undergoing simultaneous axillary clearance historically during technique validation. In patients with SLN metastases, excision of the first 4 SLNs encountered results in the identification of a metastatic SLN in all cases. Although the majority (86%) of SNB metastases are in the hottest node, the SLN containing the metastasis is in the first 4 hottest nodes in 99% of patients with nodal metastases. The remaining 1% of SLN metastases were identified by blue dye. There was no statistically significant association between the SLN blue dye concentration and the presence of SLN metastases. A policy to remove a maximum of four blue and/or hot SLNs along with any palpably abnormal lymph nodes does not result in an increased false-negative rate of detection of SLN metastases.

Sentinel Lymph Node Biopsy in Breast Cancer

The axillary lymph node status is the most reliable prognostic indicator of recurrence and overall survival in patients with breast cancer. The current standard surgical procedure for the management of invasive breast cancer is the complete removal of the cancer with total axillary clearance. However, recently, selective sentinel lymph node mapping and biopsy is gaining acceptance as a useful and accurate staging procedure, as it is minimally invasive. The sentinel lymph node is the first node into which a primary cancer drains, and is thus the first node to be involved by metastases. Patients whose sentinel nodes are negative for breast cancer metastases, can be spared a more extensive axillary lymph node dissection, with reduction in the postoperative morbidity. Sentinel node mapping is usually performed by intradermal or peritumoral injection of a combination of blue dye and radiotracer. Sentinel node examination is sometimes done intraoperatively, by imprint cytology and frozen sections, for an immediate assessment, to plan the extent of surgery at a single sitting. Permanent sections of the sentinel node are studied by serial sectioning, and immunohistochemistry for cytokeratin is done to detect micrometastases which are frequently missed on hematoxylin and eosin (H&E)-stained sections. The various aspects of sentinel node examination, and its role to decide further management in patients with ductal carcinoma-in-situ, and in other clinical settings, are discussed in this review.

Sentinel lymph node biopsy in breast cancer: a comprehensive literature review

Sentinel lymph node biopsy has emerged as the new standard of care for nodal staging in early-stage breast disease. In the this review, the procedure of SLNB in breast cancer will be examined in greater detail with the aim of understanding techniques that may improve results and of identifying future research questions in this field.

Sentinel node imaging in breast cancer using superficial injections: technical details and observations

INTRODUCTION

Sentinel lymph node (SLN) biopsy is the evolving standard of care for the management of early breast cancer. Accurate identification of the SLN is paramount for success of this procedure. Various techniques are described for SLN identification, but the superficial injection techniques, advocated by the UK National Training Programme (NEW START), are validated, reproducible and rapid. Pre-operative lymphoscintigraphy provides a road map for the surgeon and requires a reporting template.

METHODS

As one of the NEW START training institutions in the UK practising this technique, we reviewed a mature series of 100 unselected, consecutive SLN lymphoscintigraphy procedures. We correlated the imaging, operative and pathology findings and have provided technical details of the technique and a template for reporting SLN lymphoscintigrams.

RESULTS

The SLN localisation rate was 99% with one failed imaging. Seven patients required delayed imaging. The mean activity of the radiocolloid injected was 14.4MBq (range 8.3-23 MBq). The SLNs were visualised in the ipsilateral axilla in 98 images, intramammary in 3, and internal mammary in 1. A mean of 1.35 nodes were classified as 'True' SLNs on imaging criteria. Intra-operatively, a mean of 1.91 SLNs were excised. 32 of 116 hot and blue nodes, 7 of 15 only blue nodes, 13 of 47 only hot and 7 of 13 parasentinel nodes harboured metastases.

CONCLUSION

The NEW START recommended, combined superficial injection techniques, have high localisation rates. Pre-operative sentinel node imaging is recommended and a template for reporting is provided.

Sentinel lymph node biopsy: technique validation at the Setúbal Medical Centre, Portugal

Aims:

To evaluate the accuracy of sentinel lymph node biopsy in breast cancer patients at this institution, using combined technetium-99m (^99mTc) sulphur colloid and patent blue vital dye.

Methods:

From March 2007 to July 2008, 50 patients with a tumour of less than 3 cm and with clinically negative axillary lymph nodes underwent sentinel lymph node biopsy (SLNB), followed by axillary lymph node dissection (ALND). Sub-areolar ^99mTc sulphur colloid injection was performed the day before surgery, and patent blue vital dye was also injected sub-areolarly at least 5 minutes before surgery. Sentinel lymph node was identified during the surgical procedure, using a gamma probe and direct vision. All sentinel nodes underwent frozen section analysis. Later haematoxylin and eosin staining and immunohistochemical analysis were performed. Finally, SLNB was compared with standard ALND for its ability to accurately reflect the final pathological status of the axillary nodes.

Results:

The sentinel lymph node (SLN) was identified in 48 of 50 patients (96%). The number of sentinel lymph nodes ranged from one to four (mean 1.48) and non-sentinel nodes ranged from seven to 27 (mean 14.33). Of the 48 patients with successfully identified SLNs, 29.17% (14/48) were histologically positive. Sensivity of the SLN to predict axilla was 93.75%; accuracy was 97.96%. The SLN was falsely negative in one patient—6.25% (1/16).

Conclusions:

The SLNB represents a major advance in the surgical treatment of breast cancer as a minimally invasive procedure predicting the axillary lymph node status. This validation study demonstrates the accuracy of the SLNB and its reasonable false negative rate when performed in our institute. It can now be used as the standard method of staging in patients with early breast cancer at this institution.

Sentinel lymph node in breast cancer

PURPOSE OF REVIEW

Sentinel lymph node biopsy has become an accepted standard in staging axillary lymph nodes for breast cancer, but there are still unresolved questions regarding the application of the sentinel node procedure. The purpose of this review is to highlight recent developments in sentinel lymph node biopsy for breast cancer.

RECENT FINDINGS

Recent evidence has demonstrated that subareolar injection immediately before surgery is an acceptable and accurate alternative to peritumoral injection, and that lymphoscintigraphy is not always necessary. The use of sentinel lymph node biopsy with neoadjuvant chemotherapy and ductal carcinoma in situ continues to undergo investigation. Recently completed clinical trials will answer questions relating to the value of identifying isolated tumor cells in the sentinel node by immunohistochemistry, and the need for axillary node dissection when the sentinel node is positive.

SUMMARY

Sentinel lymph node biopsy is an accepted standard for stage I and II breast cancer, and is investigational with stage III cancer or with neoadjuvant therapy, as well as with ductal carcinoma in situ. Patients should be made aware of relevant issues as part of providing informed consent for surgery and subsequent therapy.

Multidetector-row computed tomography for the preoperative evaluation of axillary nodal status in patients with breast cancer

PURPOSE

We evaluated the effectiveness of multidetector-row computed tomography (MD-CT) for detecting axillary lymph nodal status (ALNS) in patients with breast cancer.

METHODS

We reviewed 42 patients with breast cancer. A metastatic lymph node on MD-CT was defined as oval or round, with more than 5 mm on the short axis. We evaluated ALNS preoperatively by both palpation and MD-CT findings and performed sentinel lymph node biopsy (SLNB) and complete axillary lymph node dissection (ALND).

RESULTS

For establishing the ALNS, MD-CT showed a sensitivity of 76.9%, a specificity of 96.6%, and an accuracy of 90.5%. On the basis of the MD-CT findings, misdiagnosis was made in 4 of the 42 patients, only one of which was false positive. On the other hand, one patient with a histologically negative sentinel lymph node (SLN) result had metastasis only in a non-SLN. Preoperative MD-CT showed a positive node in this patient.

CONCLUSIONS

Multidetector-row computed tomography assists in identifying women who require ALND without SLNB, with sufficient positive predictive value. False-negative detection by SLNB could be avoided with careful interpretation of the axillary lymph nodes shown by MD-CT.

Decision analysis to assess the efficacy of routine sentinel lymphadenectomy in patients undergoing prophylactic mastectomy

BACKGROUND

Patients who have invasive breast cancer identified after prophylactic mastectomy (PM) require axillary lymph node dissection (ALND) for lymph node staging (ie, directed ALND). Because the majority of these patients will be lymph node negative, sentinel lymphadenectomy (SLND) has been advocated at the time of PM to avoid the sequelae of unnecessary ALND. The objective of this study was to compare the efficacy of 2 surgical strategies, routine SLND versus directed ALND, in PM patients.

METHODS

A decision-analytic model was created to compare the 2 surgical strategies. Model estimates were derived from a systematic literature review. The endpoints that were examined to compare the 2 strategies were the number of SLNDs performed per breast cancer detected, the number of SLNDs attempted to avoid 1 ALND in a lymph node-negative patient with occult invasive cancer, and the number of axillary complications associated with each strategy.

RESULTS

The prevalence of invasive cancer in patients undergoing PM was estimated at 1.9%. At this rate, 37 SLNDs were performed per 1 breast cancer detected, and 73 SLNDs were required to avoid 1 ALND in a lymph node-negative PM patient. In 1 model scenario, the probability of complications per breast cancer detected was 9-fold greater with the SLND strategy than with the directed ALND strategy (2.7 vs 0.3). The complication rates for the 2 strategies become equivalent in the model scenario when the prevalence of occult invasive cancer was projected to 28%.

CONCLUSIONS

Routine SLND for patients undergoing PM is not warranted given the large number of procedures required to benefit 1 patient and the potential complications associated with performing SLND in all patients.

Video-assisted axillary surgery for cancer: Non-randomized comparison with conventional techniques

Endoscopic techniques have been introduced in most of surgical disciplines including surgery for breast cancer. However, there is shortage of evidence-based guidelines and oncological outcome data. We present a controlled trial of endoscopic axillary surgery for breast cancer with mid-term oncologic results. Fifty cases of axilloscopy for sentinel node biopsy, axillary sampling or full axillary dissection were included. Sentinel node biopsy was accomplished with the blue dye technique. Full axillary dissection was performed with a three-port approach with gas insufflation without liposuction. Endoscopic axillary dissection significantly lowered duration of drainage and operative blood loss. Lymph node harvest with endoscopic approach was significantly lower than with open procedure. One case developed axillary recurrence. Endoscopic sentinel node biopsy yielded identification rate of 80%. Current data do not justify the oncological safety of resectional endoscopic procedures. Endoscopically assisted axillary cancer surgery is technically feasible. The technique is valuable to maximize utility of blue dye method for sentinel lymphadenectomy in areas with no access to radio-guided surgery.

Factors affecting false-negative breast sentinel node biopsy in Chinese patients

BACKGROUND

The objective of the research was to validate our results on sentinel lymph node biopsy (SLNB) and to determine factors affecting false-negative (FN) rates of SLNB in Chinese patients with invasive breast cancers.

METHODS

A retrospective study of patients with clinically node-negative invasive breast cancer was carried out from May 1999 to April 2006. A combination of radioisotope (99m)technetium(Tc)-albumin sulfur colloid and Patent Blue V dye was used to identify the sentinel lymph node. Sentinel lymph node biopsy was followed by standard level I and II axillary dissection in all patients. Various clinicopathologic variables were analysed to determine factors associated with FN SLNB.

RESULTS

Three hundred and sixty-five Chinese patients received SLNB consecutively during the study period. Seventy-eight patients with neoadjuvant chemotherapy and 56 patients with in situ carcinoma were excluded. A total of 231 patients were studied. Sentinel lymph nodes were identified in 221 patients (95.7%). There were 10 FN, resulting in a FN rate of 12.5% and accuracy rate of 95.5%. Only the number of sentinel lymph node harvested was found to be a significant factor affecting FN rates on univariate (P < 0.009) and multivariate logistic regression (odds ratio: 2.65; 95% confidence interval: 2.57-2.73; P < 0.000).

CONCLUSIONS

In Chinese women, after this retrospective analysis of available findings, at least should sentinel nodes should be removed to reduce risk of false negativity.

Transcription-reverse transcription concerted reaction and minimal residual disease in axillary sentinel nodes of breast cancer

AIMS

To investigate the use of transcription-reverse transcription concerted reaction (TRC) to detect axillary lymph node metastases.

METHODS

Metastases in 423 lymph nodes obtained from 50 breast cancer patients were investigated by routine pathological hematoxylin and eosin (H and E) staining and quantitative analysis of carcinoembryonic antigen (CEA) mRNA by TRC. Enhanced pathological studies, serial sectioning and immunohistochemistry were conducted for cases which were negative by routine pathology, but positive by TRC.

RESULTS

Pathological examination identified metastatic disease in 67 lymph nodes. TRC CEA mRNA results were concordant with 89.8% of these cases at a threshold of 100 copies. TRC identified 30 false negative nodes, which was reduced to 15 by excluding node biopsies yielding less than 40 microg total RNA. Twelve nodes were histologically negative for cancer, but positive according to TRC. Serial sectioning and immunohistochemical analysis of these nodes revealed macrometastatic lesions in three, micrometastasis in one, and isolated tumor cells in two.

CONCLUSION

TRC for the detection of CEA mRNA may complement routine pathological examination by sentinel lymph node biopsy (SNB) in early breast cancer. We have started an enhanced pathological examination with serial sectioning on all excised sentinel nodes to set the best threshold for the TRC method.

Contraindications of sentinel lymph node biopsy: are there any really?

BACKGROUND

One of the most exciting and talked about new surgical techniques in breast cancer surgery is the sentinel lymph node biopsy. It is an alternative procedure to standard axillary lymph node dissection, which makes possible less invasive surgery and side effects for patients with early breast cancer that wouldn't benefit further from axillary lymph node clearance. Sentinel lymph node biopsy helps to accurately evaluate the status of the axilla and the extent of disease, but also determines appropriate adjuvant treatment and long-term follow-up. However, like all surgical procedures, the sentinel lymph node biopsy is not appropriate for each and every patient.

METHODS

In this article we review the absolute and relative contraindications of the procedure in respect to clinically positive axilla, neoadjuvant therapy, tumor size, multicentric and multifocal disease, in situ carcinoma, pregnancy, age, body-mass index, allergies to dye and/or radio colloid and prior breast and/or axillary surgery.

RESULTS

Certain conditions involving host factors and tumor biologic characteristics may have a negative impact on the success rate and accuracy of the procedure. The overall fraction of patients unsuitable or with multiple risk factors that may compromise the success of the sentinel lymph node biopsy, is very small. Nevertheless, these patients need to be successfully identified, appropriately advised and cautioned, and so do the surgeons that perform the procedure.

CONCLUSION

When performed by an experienced multi-disciplinary team, the SLNB is a highly effective and accurate alternative to standard level I and II axillary clearance in the vast majority of patients with early breast cancer.

Sentinel lymph node biopsy is feasible for breast cancer patients after neoadjuvant chemotherapy

BACKGROUND

Despite the increasing use of both sentinel lymph node (SLN) biopsy and neoadjuvant chemotherapy (NAC) in patients with operable breast cancer, information on the feasibility and accuracy of sentinel node biopsy following neoadjuvant chemotherapy is still quite limited. Therefore, we investigated the feasibility and accuracy of sentinel lymph node biopsy for breast cancer patients after NAC.

METHODS

A total of 104 patients with Stage II and III breast cancers, previously treated by NAC, were enrolled in the study. All patients were clinically node-negative after NAC. The patients underwent SLN biopsy, which involved a combination of an intradermal injection of radiocolloid and a subareolar injection of blue dye over the tumor. This was followed by completion axillary lymph node dissection (ALND).

RESULTS

SLN could be identified in 97 of 104 patients (identification rate, 93.3%). In 93 of the 97 patients (95.9%), the SLN accurately predicted the axillary status. Four patients' SLN biopsies were false negative, resulting in a false-negative rate of 10.0%. The SLN identification rate tended to be lower among patients with T4 primary tumors prior to NAC (62.5%).

CONCLUSION

The SLN identification and false-negative rates were similar to rates in non-neoadjuvant studies. The SLN accurately predicted metastatic disease in the axilla of patients with tumor response following NAC.

Emerging use of nanoparticles in diagnosis and treatment of breast cancer

The biological application of nanoparticles is a rapidly developing area of nanotechnology that raises new possibilities in the diagnosis and treatment of human cancers. In cancer diagnostics, fluorescent nanoparticles can be used for multiplex simultaneous profiling of tumour biomarkers and for detection of multiple genes and matrix RNA with fluorescent in-situ hybridisation. In breast cancer, three crucial biomarkers can be detected and accurately quantified in single tumour sections by use of nanoparticles conjugated to antibodies. In the near future, the use of conjugated nanoparticles will allow at least ten cancer-related proteins to be detected on tiny tumour sections, providing a new method of analysing the proteome of an individual tumour. Supermagnetic nanoparticles have exciting possibilities as contrast agents for cancer detection in vivo, and for monitoring the response to treatment. Several chemotherapy agents are available as nanoparticle formulations, and have at least equivalent efficacy and fewer toxic effects compared with conventional formulations. Ultimately, the use of nanoparticles will allow simultaneous tumour targeting and drug delivery in a unique manner. In this review, we give an overview of the use of clinically applicable nanoparticles in oncology, with particular focus on the diagnosis and treatment of breast cancer.

Sentinel lymph node biopsy examination for breast cancer patients with clinically negative axillary lymph nodes after neoadjuvant chemotherapy

BACKGROUND

The feasibility and accuracy of sentinel lymph node (SLN) biopsy examination for breast cancer patients with clinically node-negative breast cancer after neoadjuvant chemotherapy (NAC) have been investigated under the administration of a radiocolloid imaging agent injected intradermally over a tumor. In addition, conditions that may affect SLN biopsy detection and false-negative rates with respect to clinical tumor response and clinical nodal status before NAC were analyzed.

METHODS

Seventy-seven patients with stages II and III breast cancer previously treated with NAC were enrolled in the study. All patients were clinically node negative after NAC. The patients then underwent SLN biopsy examination, which involved a combination of intradermal injection over the tumor of radiocolloid and a subareolar injection of blue dye. This was followed by standard level I/II axillary lymph node dissection.

RESULTS

The SLN could be identified in 72 of 77 patients (identification rate, 93.5%). In 69 of 72 patients (95.8%) the SLN accurately predicted the axillary status. Three patients had a false-negative SLN biopsy examination result, resulting in a false-negative rate of 11.1% (3 of 27). The SLN identification rate tended to be higher, although not statistically significantly, among patients who had clinically negative axillary lymph nodes before NAC (97.6%; 41 of 42). This is in comparison with patients who had a positive axillary lymph node before NAC (88.6%; 31 of 35).

CONCLUSIONS

The SLN identification rate and false-negative rate were similar to those in nonneoadjuvant studies. The SLN biopsy examination accurately predicted metastatic disease in the axilla of patients with tumor response after NAC and clinical nodal status before NAC. This diagnostic technique, using an intradermal injection of radiocolloid, may provide treatment guidance for patients after NAC.

Comparison of intraparenchymal and intradermal injection for identification of the sentinel node in patients with breast cancer

BACKGROUND

Sentinel lymph node (SLN) mapping with radioisotope and blue dye has been advocated for the staging of clinically negative axillae in patients with breast cancer. The optimal radiotracer injection technique is still being defined. This study compares the results of intraparenchymal and intradermal injection of technetium 99m (Tc 99m) sulfur colloid to establish an optimal method for SLN localization.

METHODS

Consecutive patients (n = 435) with clinically T0-2N0 breast cancer had SLN biopsy performed by a single surgeon. All patients but one received injections of both blue dye and Tc 99m sulfur colloid; one patient had injection of blue dye only and was excluded from analysis. Blue dye injections were intraparenchymal in all patients. The results of intraparenchymal (n = 107) and intradermal (n = 327) injections of radioisotope were compared for the following endpoints: 1) successful SLN identification, 2) false-negative rate, and 3) ratio of SLN/axillary background isotope counts.

RESULTS

Intradermal radioisotope injection was as effective as intraparenchymal radioisotope injection, identifying the SLN in 99.4% and 92.5% of cases, respectively. False-negative rates for both radioisotope injection techniques were < or = 5%. Ratios of SLN/axillary background isotope counts were higher with intradermal than with intraparenchymal injection (193/1 vs 41/1). Patient follow-up has revealed no axillary recurrence of tumor.

CONCLUSIONS

Intradermal radioisotope injection for SLN identification appears to be a highly accurate technique with acceptable false-negative and SLN identification rates. Compared with intraparenchymal isotope injection, the intradermal technique is associated with higher levels of isotope uptake by the SLN, facilitating SLN identification.

Blue-dye technique complements four-node sampling for early breast cancer

AIMS

To examine four-node axillary sampling assisted by a blue dye (4NAS/dye) technique as a sentinel node biopsy (SNB) for breast cancer.

METHODS

Lymphatic mapping was performed by injection of patent blue for 33 consecutive cases with breast cancer. Axillary sampling was performed until four nodes were obtained. This was followed by back-up axillary lymph node dissection to examine the feasibility of 4NAS/dye. The same study with 30 cases was conducted at an independent hospital to confirm the feasibility of this method. This method was then applied to 101 consecutive clinically node-negative patients to avoid axillary-node dissection, with intraoperative diagnosis made by frozen section examination.

RESULTS

The median numbers of blue-stained nodes and nodes excised by 4NAS/dye were 1.7 and 3.4, respectively. The identification rate of sentinel lymph nodes (SNs) was 81.8% using the dye alone and 97.0% when the combination was used. Pathological examination revealed that the nodal status was correctly predicted by the dye alone in 62.5% of cases with metastasis, whereas in 100% by 4NAS/dye. The dye alone was not sufficient to identify SNs, especially in cases with prior excisional biopsy. The identification rate of SNs and the accuracy rate in another feasibility study were 100% and 92.5% in 30 consecutive cases, respectively. 4NAS/dye successfully detected SNs in 100 of 101 cases of the subsequent observational study with an acceptable post-operative axillary morbidity and thus succeeded as an SNB.

CONCLUSIONS

The 4NAS/dye method is reliable for the detection of SNs. This method could be applied to observational studies without radio-isotope.

Primary tumor characteristics predict sentinel lymph node macrometastasis in breast cancer

Selective sentinel lymphadenectomy (SSL) is rapidly becoming the standard of care in the surgical management of patients with early breast cancer. Sentinel lymph node macrometastasis has been well documented in the literature to have a higher risk of nonsentinel node tumor involvement when compared to micrometastasis. The aim of our study was to determine the primary tumor characteristics associated with sentinel node macrometastasis that will allow us to preoperatively determine this subgroup of patients at risk. This study was a retrospective review of 644 patients who underwent successful SSL as part of their surgical treatment of breast cancer at the University of California San Francisco Carol Franc Buck Breast Care Center from November 1997 to August 2003. All patients underwent preoperative lymphoscintigraphy followed by wide excision or mastectomy and sentinel lymphadenectomy with or without axillary lymph node dissection. One hundred twenty-two patients had positive sentinel nodes on histology. Micrometastasis was present in 43 of these patients and macrometastasis in the remaining 79. Statistical analysis showed that a tumor size greater than 15 mm, poor tubule formation by the tumor cells, and lymphovascular invasion were significantly associated with sentinel node macrometastasis. A high mitotic count showed a trend but was not significant in our study. Patients with a tumor size greater than 15 mm, poor tubule formation, and lymphovascular invasion are at risk of having sentinel node macrometastasis. These patients can be identified preoperatively based on imaging and biopsy criteria, allowing the option of selective intraoperative pathologic evaluation of the sentinel node and immediate completion axillary dissection as necessary.

Lymphoscintigraphic sentinel node identification in patients with breast cancer: the role of SPECT-CT

PURPOSE

Lymph node status is a major factor in determining the stage, appropriate therapy and outcome in patients with breast cancer. It is therefore of clinical importance to accurately identify all sentinel nodes (SNs) for each individual tumour before surgery. The purpose of this study was to assess the role of SPECT-CT lymphoscintigraphy in SN identification in patients with breast cancer.

METHODS

Lymphoscintigraphy comprising planar and SPECT-CT acquisition was performed in 157 consecutive patients with breast cancer (mean age 54.7+/-10.6, range 27-81 years) with a palpable mass (n=100), with a non-palpable mass (n=52) or post lumpectomy (n=5). Planar and SPECT-CT images were interpreted separately and the two imaging techniques were compared with respect to their ability to identify hot nodes.

RESULTS

Planar imaging alone was negative for identification of hot nodes in 15% of the patients. SPECT-CT alone was negative in 10% and both techniques were negative in 9% of the patients. Forty-six of the total of 361 (13%) hot nodes identified by lymphoscintigraphy were detected only on SPECT-CT, including 21 nodes obscured by the scattered radiation from the injection site, nine adjacent nodes misinterpreted on planar images as a single node and 16 nodes which were missed on planar images and detected on SPECT data. SPECT-CT detected additional sites of drainage unexpected on planar images, including axillary (n=23 patients), internal mammary (n=5 patients), interpectoral (n=3 patients) and intramammary (n=2 patients) lymph node sites. Fourteen of the 329 (4%) hot lesions seen on planar images were false positive non-nodal sites of uptake that were accurately assessed by SPECT-CT and further validated by surgery. In a single patient, SPECT-CT was negative while planar images identified the SN.

CONCLUSION

SPECT-CT may improve the preoperative localisation of draining nodes in patients with breast cancer. It may detect hot nodes missed by planar imaging, exclude non-nodal false positive sites of uptake and accurately localise axillary and extra-axillary nodes.

The Effect of Sentinel Node Tumor Burden on Non–Sentinel Node Status and Recurrence Rates in Breast Cancer

BACKGROUND

Routine axillary lymph node dissection (ALND) after selective sentinel lymphadenectomy (SSL) in the treatment of breast cancer remains controversial. We sought to determine the need for routine ALND by exploring the relationship between sentinel lymph node (SLN) and non-SLN (NSLN) status. We also report our experience with disease relapse in the era of SSL and attempt to correlate this with SLN tumor burden.

METHODS

This was a retrospective study of 390 patients with invasive breast cancer treated at a single institution who underwent successful SSL from November 1997 to November 2002.

RESULTS

Of the 390 patients, 115 received both SSL and ALND. The percentage of additional positive NSLNs in the SLN-positive group (34.2%) was significantly higher than in the SLN-negative group (5.1%; P = .0004). The SLN macrometastasis group had a significantly higher rate of positive NSLNs (39.7%) compared with the SLN-negative group (5.1%; P = .0001). Sixteen patients developed recurrences during follow-up, including 6.1% of SLN-positive and 3.3% of SLN-negative patients. Among the SLN macrometastasis group, 8.7% had recurrence, compared with 2.2% of SLN micrometastases over a median follow-up period of 31.1 months. One regional failure developed out of 38 SLN-positive patients who did not undergo ALND.

CONCLUSIONS

ALND is recommended for patients with SLN macrometastasis because of a significantly higher incidence of positive NSLNs. Higher recurrence rates are also seen in these patients. However, the role of routine ALND in patients with a low SLN tumor burden remains to be further determined by prospective randomized trials.

Ratio of Positive to Total Number of Sentinel Nodes Predicts Nonsentinel Node Status in Breast Cancer Patients

Selective sentinel lymphadenectomy (SSL) has replaced axillary lymph node dissection (ALND) for many patients with early breast cancer and negative sentinel lymph nodes (SLNs). Yet many patients with a positive SLN are undergoing unnecessary ALND, as no further disease is found in the axilla. The aim of our study was to determine factors associated with additional positive lymph nodes in the axilla in patients who have a positive SLN. This was a retrospective study of patients undergoing SSL with ALND as part of their treatment for breast cancer at a single institution from November 1997 to August 2003. Only patients with one or more positive SLNs were selected for this study. There were 86 patients who fit our study criteria. Of these, 38% had further positive lymph nodes upon ALND. More than one positive SLN and a ratio of positive SLNs to total SLNs of greater than 0.5 were found to be predictors for additional axillary nodal involvement in both univariate and multivariate analyses. The number of positive SLNs and the ratio of positive SLNs to total SLNs is an indication of total tumor burden in the sentinel nodes and may be a reflection of the propensity of the tumor for further lymphatic invasion in the axillary basin.

Extracorporeal high intensity focused ultrasound treatment for patients with breast cancer

PURPOSE

To investigate the safety, efficacy and feasibility of using high-intensity focused ultrasound (HIFU) as a non-invasive treatment for patients with breast cancer.

PATIENTS AND METHODS

Twenty-two patients with breast cancer were enrolled into this non-randomized prospective trial. Disease TNM stage was classified as stage I in 4 patients, stage II(A) in 9 patients, stage II(B) in 8 patients, and stage IV in 1 patient. Tumor size ranged from 2 to 4.8 cm in diameter (mean 3.4 cm). All patients received chemotherapy, radiation and tamoxifen, following HIFU for the primary lesions. Outcome measures included radiological and pathologic assessment of the treated tumor, cosmesis, and local recurrence. A cumulative survival rate is calculated by using the Kaplan-Meier method.

RESULTS

No severe complications were encountered after HIFU. Post-operative imaging demonstrated positive response and regression of all treated lesions. Follow-up biopsy revealed coagulation necrosis of target tumor and subsequent replacement by fibroblastic tissue. After a median follow-up of 54.8 months, 1 patient died, 1 was lost to follow-up, and 20 were still alive. Two of 22 patients developed local recurrence. Five-year disease-free survival and recurrence-free survival were 95% and 89%, respectively. Cosmetic result was judged as good to excellent in 94% of patients.

CONCLUSIONS

HIFU treatment is safe, effective, and feasible for patients with breast cancer. But, large-scale, multiple-center clinical trials will be needed to determine the future role of this novel modality.

Clinical and biological aspects of sentinel node biopsy in malignant melanoma — an update

The diagnostic usefulness of sentinel lymph node biopsy (SLNB) has been well established, but its therapeutic value remains unproven. First introduced by Morton and colleagues, the SLNB procedure is now widely available, and markedly enhances our ability to pathologically stage the regional nodes. Although the SLN status is acknowledged as the most powerful indicator of prognosis in melanoma, there is no evidence to-date, of survival advantage for complete lymphadenectomy in SLN-positive patients. Also, there is no effective adjuvant therapy that could benefit these sentinel node-positive patients, as yet. Additionally, new data have emerged indicating a possible increase in local/in-transit recurrence following complete lymphadenectomy in sentinel node-positive patients. To understand fully and to evaluate these observations we need information from randomized controlled trials. Major changes have occurred following the latest revision of melanoma staging system (AJCC, 6th edition). Concerning N category, these include the incorporation of the number of metastatic lymph nodes, the tumour burden of nodal metastases, and the ulceration of the primary tumour. The data obtained from the new staging system will reflect differences in prognosis that were not previously emphasized and which, we hope, will serve as a guide to more accurate analysis of metastatic pathways in cutaneous melanoma as well as a rationale for new forms of treatment.

The results of frozen section, touch preparation, and cytological smear are comparable for intraoperative examination of sentinel lymph nodes: a study in 133 breast cancer patients

BACKGROUND

The goal of intraoperative sentinel lymph node (SLN) examination is to avoid reoperation for a positive SLN, but the ideal method of intraoperative SLN examination remains unclear, and published results vary widely.

METHODS

We evaluated the sensitivity of intraoperative frozen section (FS), touch preparation (TP), and cytological smear (CS) in 305 SLNs from 133 breast cancer patients. Each SLN was received fresh and cut into 2- to 3-mm slices; TP and CS from each cut surface and an FS of the entire SLN were obtained. Postoperative evaluation of the SLN consisted of 1 hematoxylin and eosin-stained section and of one hematoxylin and eosin-stained and one immunohistochemically stained section for cytokeratin from each of two levels 50 microm apart. Tumor cells found by any method, including immunohistochemistry, identified a positive SLN. Three pathologists blinded to the final SLN diagnosis reviewed all TP, CS, and FS; the consensus diagnosis (concordance of two or more) was used for the study.

RESULTS

FS, TP, and CS had comparable sensitivities (59%, 57%, and 59%, respectively). Each method was more sensitive in detecting macrometastases (>2 mm; 96%, 93%, and 93%, respectively) than micrometastases (< or =2 mm; 27%, 27%, and 30%, respectively). The combination of methods only marginally improved the intraoperative sensitivity. TP and CS were each responsible for a single false-positive result.

CONCLUSIONS

FS, TP, and CS are comparable for the intraoperative detection of SLN metastases, and each method is substantially better at detecting micrometastases than micrometastases. The combination of two or more techniques only marginally improves the sensitivity over that achieved by a single method.

Is the clinically positive axilla in breast cancer really a contraindication to sentinel lymph node biopsy?

BACKGROUND

Clinically positive axillary nodes are widely considered a contraindication to sentinel lymph node (SLN) biopsy in breast cancer, yet no data support this mandate. In fact, data from the era of axillary lymph node dissection (ALND) suggest that clinical examination of the axilla is falsely positive in as many as 30% of cases. Here we report the results of SLN biopsy in a selected group of breast cancer patients with palpable axillary nodes classified as either moderately or highly suspicious for metastasis.

STUDY DESIGN

Among 2,027 consecutive SLN biopsy procedures performed by two experienced surgeons, clinically suspicious axillary nodes were identified in 106, and categorized as group 1 (asymmetric enlargement of the ipsilateral axillary nodes moderately suspicious for metastasis, n = 62) and group 2 (clinically positive axillary nodes highly suspicious for metastasis, n = 44).

RESULTS

Clinical examination of the axilla was inaccurate in 41% of patients (43 of 106) overall, and was falsely positive in 53% of patients (33 of 62) with moderately suspicious nodes and 23% of patients (10 of 44) with highly suspicious nodes. False-positive results were less frequent with larger tumor size (p = 0.002) and higher histologic grade (p = 0.002), but were not associated with age, body mass index, or a previous surgical biopsy.

CONCLUSIONS

Clinical axillary examination in breast cancer is subject to false-positive results, and is by itself insufficient justification for axillary lymph node dissection. If other means of preoperative assessment such as palpation- or image-guided fine needle aspiration are negative or indeterminate, then SLN biopsy deserves wider consideration as an alternative to routine axillary lymph node dissection in the clinically node-positive setting.