Is my patient an appropriate candidate for sentinel node biopsy? Less axillary surgery, for the right patients. Critical review and grades of recommendation

INTRODUCTION

While general conclusions of historical trials are widely recognized, the nuances regarding precise indications of Sentinel Node Biopsy (SNB) in breast cancer in complex clinical scenarios often remain a source of debate and require further elucidation.

METHODS

Two reviewers (JFB and GNM) independently searched electronic databases for studies including SNB as the main intervention. Filters were applied to retrieve only clinical trials (randomized or experimental non-randomized); non-oncological outcomes were excluded. The selected studies were considered to construct a narrative review focused on inclusion criteria and survival outcomes, followed by recommendations.

RESULTS

Fourteen (n = 14) trials were selected, including eleven (n = 11) randomized trials for upfront surgery, and three (n = 3) single-group clinical trials for surgery following neoadjuvant therapy. All trials for upfront surgery provided long-term survival data for SNB, that was equivalent or non-inferior to axillary dissection, in tumors without palpable adenopathy (caution for larger T3 and T4 tumors) - Grade of recommendation: A. In tumors up to 5 cm, complete axillary dissection is not necessary if up to two sentinel nodes are positive for macrometastasis, and radiation therapy is planned - Grade of recommendation: A. If there are more than two sentinel nodes positive for macrometastasis, or a positive node other than the sentinel one, complete axillary dissection is recommended - Grade of recommendation: A. Following neoadjuvant chemotherapy, considering 10% as an acceptable false negative rate, SNB might be offered for cN0 patients who have remained negative, and for cN1 (caution for cN2) patients become clinically negative; complete axillary dissection might not be necessary if at least two sentinel lymph nodes are retrieved, and there is no residual disease - Grade of recommendation: B.

CONCLUSION

SNB can be performed in most cases of clinically negative nodes. After neoadjuvant chemotherapy, SNB is feasible and may have acceptable performance for cN0 and cN1 tumors, although prospective survival data is still awaited.

The Feasibility and Reliability of Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy in Breast Cancer Patients With Negative Axillary Lymph Nodes-A Meta-analysis

Background

The application of sentinel lymph node biopsy (SLNB) has expanded from early breast cancer to locally advanced breast cancer with neoadjuvant chemotherapy (NAC). For patients with negative axillary lymph nodes, performing SLNB before or after NAC remains controversial.

Objectives

To evaluate the diagnostic feasibility and reliability of SLNB after NAC in breast cancer patients with negative axillary nodes at initial diagnosis.

Design

To calculate pooled identification rate (IR) and false negative rate (FNR) of SLNB after NAC on breast cancer patients with initially negative axillary nodes by enrolling relevant studies and perform subgroup analysis by the type of tracer and the number of biopsied sentinel lymph nodes in average.

Data sources and methods

The PubMed, Embase, Cochrane, Web of Science, and Scopus databases from January 1, 2002, to March 1, 2022, were searched for studies. The QUADAS-2 tool and MINORS item were employed to evaluate the quality of the included studies. I2 and Q tests were used to evaluate the heterogeneity among the studies. Random-effects model and fixed-effects model were employed to calculate the pooled IR, FNR, and 95% confidence interval (CI). Publication bias was evaluated, and sensitivity analysis was performed. Subgroup analysis was performed according to the type of tracer (single/double) and the number of biopsied sentinel lymph nodes in average (⩽2/>2).

Results

A total of 21 studies covering 1716 patients were enrolled in this study (IR = 93%, 95% CI = 90-96; FNR = 8%, 95% CI = 6-11).

Conclusion

The SLNB after NAC can serve as a feasible and reliable approach in breast cancer patients with negative axillary lymph node. In our study, no significant impact of tracer was found on the IR and FNR of SLNB, and the number of biopsy nodes >2 leads to the decreased FNR of SLNB.

Is Sentinel Lymph Node Biopsy a Viable Alternative to Axillary Lymph Node Dissection in Breast Carcinoma Patients Who Have Received Neo-Adjuvant Chemotherapy?

Background Sentinel lymph node biopsy (SLNB) is based on the hypothesis that lymph from a primary solid neoplasm drains into one or more sentinel nodes, which are the first nodes at risk for harbouring occult metastatic disease. Sentinel lymph node biopsy has replaced axillary lymph node dissection (ALND) as the standard method for axillary staging in clinically node-negative patients. It avoids the complications associated with ALND and allows assessment of nodal status in patients with clinically node-negative breast cancer. Aims and objectives The aim of this study is to determine the false negative rate and identification rate of SLNB in breast cancer patients who received neoadjuvant chemotherapy (NACT). Materials and methods We conducted a hospital-based prospective study that included 19 patients who presented with early breast cancer and were node-positive. Post NACT, intraoperatively, methylene blue and radiocolloid dye were injected in the subareolar region. During the surgery, the blue and hot nodes identified were dissected, sent for frozen section analysis, and subsequently submitted for histopathological evaluation. This was followed by a standard-level I/II/III axillary clearance with histopathological examination. Results The false-negative rate of SLNB is 25%. Sentinel lymph node biopsy was more accurate with stage II than stage III tumours, and in patients who downstaged from stage II to any stage following NACT, it was more accurate than downstaging from stage III. The average number of sentinel nodes identified was 1.9, with the maximum being seven and the minimum being one. A total of 25 sentinel lymph nodes were identified in 13 patients, with an identification rate of 68.42%. Conclusions The main clinicopathological factors that influence the false negative rate of SLNB after NACT are axillary lymph node status, stage of the tumour at presentation, and tumour downstaging. For patients for whom sentinel nodes cannot be harvested, ALND should be done.

Changes in Surgical Management of the Axilla Over 11 Years - Report on More Than 1500 Breast Cancer Patients Treated with Neoadjuvant Chemotherapy on the Prospective I-SPY2 Trial

BACKGROUND

Axillary surgery after neoadjuvant chemotherapy (NAC) is becoming less extensive. We evaluated the evolution of axillary surgery after NAC on the multi-institutional I-SPY2 prospective trial.

METHODS

We examined annual rates of sentinel lymph node (SLN) surgery with resection of clipped node, if present), axillary lymph node dissection (ALND), and SLN and ALND in patients enrolled in I-SPY2 from January 1, 2011 to December 31, 2021 by clinical N status at diagnosis and pathologic N status at surgery. Cochran-Armitage trend tests were calculated to evaluate patterns over time.

RESULTS

Of 1578 patients, 973 patients (61.7%) had SLN-only, 136 (8.6%) had SLN and ALND, and 469 (29.7%) had ALND-only. In the cN0 group, ALND-only decreased from 20% in 2011 to 6.25% in 2021 (p = 0.0078) and SLN-only increased from 70.0% to 87.5% (p = 0.0020). This was even more striking in patients with clinically node-positive (cN+) disease at diagnosis, where ALND-only decreased from 70.7% to 29.4% (p < 0.0001) and SLN-only significantly increased from 14.6% to 56.5% (p < 0.0001). This change was significant across subtypes (HR-/HER2-, HR+/HER2-, and HER2+). Among pathologically node-positive (pN+) patients after NAC (n = 525) ALND-only decreased from 69.0% to 39.2% (p < 0.0001) and SLN-only increased from 6.9% to 39.2% (p < 0.0001).

CONCLUSIONS

Use of ALND after NAC has significantly decreased over the past decade. This is most pronounced in cN+ disease at diagnosis with an increase in the use of SLN surgery after NAC. Additionally, in pN+ disease after NAC, there has been a decrease in use of completion ALND, a practice pattern change that precedes results from clinical trials.

Surgical Planning after Neoadjuvant Treatment in Breast Cancer: A Multimodality Imaging-Based Approach Focused on MRI

Neoadjuvant chemotherapy (NACT) today represents a cornerstone in the treatment of locally advanced breast cancer and highly chemo-sensitive tumors at early stages, increasing the possibilities of performing more conservative treatments and improving long term outcomes. Imaging has a fundamental role in the staging and prediction of the response to NACT, thus aiding surgical planning and avoiding overtreatment. In this review, we first examine and compare the role of conventional and advanced imaging techniques in preoperative T Staging after NACT and in the evaluation of lymph node involvement. In the second part, we analyze the different surgical approaches, discussing the role of axillary surgery, as well as the possibility of non-operative management after-NACT, which has been the subject of recent trials. Finally, we focus on emerging techniques that will change the diagnostic assessment of breast cancer in the near future.

Axillary ultrasound after neoadjuvant therapy reduces the false-negative rate of sentinel lymph node biopsy in patients with cytologically node-positive breast cancer

OBJECTIVES

This study aimed to determine whether post-neoadjuvant therapy (NAT) axillary ultrasound (AUS) could reduce the false-negative rate (FNR) of sentinel lymph node biopsy (SLNB). We also performed subgroup analyses to identify the appropriate patient for SLNB.

METHODS

A total of 220 patients with cytologically proven axillary node-positive breast cancer who underwent both SLNB and axillary lymph node dissection (ALND) after NAT were included. We calculated the FNR of SLNB. In the case of post-NAT AUS results available, AUS was classified as negative or positive. Then the FNR of post-NAT AUS combined with SLNB was evaluated. Subgroup analyses based on the number of sentinel lymph nodes removed, molecular subtypes, and the clinical N stage were also performed.

RESULTS

The overall axillary lymph node pathological complete response rate was 45.5% (100/220). The FNR of SLNB alone was 15.8% (95%CI: 9.2 to 22.5%). Post-NAT AUS results were available for 181 patients. When combined negative post-NAT AUS results and SLNB, the FNR was reduced to 7.5% (95%CI: 2.4 to 12.7%). Subgroup analyses of the FNR for SLNB alone and negative post-NAT AUS combined with SLNB were shown as follows: in cases patients with less than three sentinel lymph nodes (SLNs) and at least three SLNs removed, the FNR was decreased from 24.5 to 13.2%, and 9.0 to 5.0%, respectively. The FNR was decreased from 20.8 to 10.5% in HR+/HER2+subgroup, 21.4 to 16.7% in HR-/HER2+subgroup, 15.9 to 7.0% in HR+/HER2- subgroup, and 0% in HR-/HER2- subgroup, respectively. For cN1 patients, the FNR was decreased from 18.1 to 12.1% while 17.1 to 3.6% for cN2 patients and 0% for cN3 patients.

CONCLUSION

Using negative post-NAT AUS may help to decrease the FNR and improve patient selection for SLNB.

Outcomes of Sentinel Node Biopsy for Women with Breast Cancer After Neoadjuvant Therapy: Systematic Review and Meta-Analysis of Real-World Data

BACKGROUND

Evidence on the accuracy of sentinel lymph node biopsy (SLNB) after neoadjuvant therapy (NAT) for patients with breast cancer is inconclusive. This study reviewed the real-world data to determine the acceptability of SLNB after NAT.

METHODS

The study searched for articles in the PubMed, EMBASE, and Cochrane Library databases. The primary outcomes were the identification rate for sentinel lymph nodes (SLNs) and the false-negative rate (FNR) for SLNB. The study also evaluated the FNR in subgroups defined by tumor stage, nodal stage, hormone receptor status, human epidermal growth factor receptor-2 status, tumor response, mapping technique, and number of SLNs removed.

RESULTS

The study retrieved 61 prospective and 18 retrospective studies with 10,680 initially cN± patients. The pooled estimate of the identification rate was 0.906 (95 % confidence interval [CI], 0.891-0.922), and the pooled FNR was 0.118 (95 % CI, 0.103-0.133). In subgroup analysis, the FNR was significantly higher for the patients with estrogen receptor (ER)-negative status and fewer than three SLNs removed. The FNR did not differ significantly between the patients with and those without complete tumor response. Among the patients with initial clinical negative axillary lymph nodes, the incidence of node metastasis was 26.8 % (275/1041) after NAT.

CONCLUSION

Real-world evidence indicates that the FNR of SLNB after NAT in breast cancer is 11.8 %, exceeding only slightly the commonly adopted threshold of 10 %. The FNR is significantly higher for patients with ER-negative status and removal of fewer than three SLNs. Using a dual tracer and removing at least three SLNs may increase the accuracy of SLNB after NAT.

Sentinel lymph node mapping in breast cancer patients following neoadjuvant chemotherapy: systematic review and meta-analysis about head to head comparison of cN0 and cN + patients

PURPOSE

The effectiveness of sentinel lymph node (SLN) mapping and biopsy following neoadjuvant chemotherapy (NAC) in axillary lymph node staging of breast cancer (BCa) patients with initial clinical node positive status (cN +) compared to clinical node negative status (cN0) is not yet known. The aim of this meta-analysis was to compare the accuracy of SLN mapping following NAC in cN + and cN0 BCa patients.

METHODS

PubMed and Scopus were comprehensively reviewed to retrieve all the studies that performed SLN mapping/biopsy and standard axillary lymph node dissection on cN0 and cN + BCa patients following NAC. Pooled detection and false negative rates for N0 and N + patients including 95% confidence interval values (95% CI) were evaluated. Odds ratio (OR) and risk difference (RD) of SLN detection failure and false negative results were compared between two groups.

RESULTS

A total of 27 articles were included for SLN detection rate evaluation and 17 for false negative assessment. The OR and RD of detection failure in N + group compared with N0 group following NAC were 2.22 (p = 0.00, 95% CI 1.4-3.4) and 4% (p = 0.00, 95% CI 2-6%), respectively. The OR and RD of false negative rate were 1.6 (p = 0.01, 95% CI 1-2.6) and 8% (p = 0.02, 95% CI 1-14%), respectively.

CONCLUSION

SLN mapping in BCa patients following NAC shows high risk of detection failure and high false negative rate of SLN biopsy in cN + patients. In comparison with cN0 BCa patients, SLN mapping and biopsy after NAC was associated with almost two times higher odds of detection failure and false negative results in cN + patients; therefore, this method should not be recommended in this group of patients.

Management of the Axilla in Early-Stage Breast Cancer: Ontario Health (Cancer Care Ontario) and ASCO Guideline

PURPOSE

To provide recommendations on the best strategies for the management and on the best timing and treatment (surgical and radiotherapeutic) of the axilla for patients with early-stage breast cancer.

METHODS

Ontario Health (Cancer Care Ontario) and ASCO convened a Working Group and Expert Panel to develop evidence-based recommendations informed by a systematic review of the literature.

RESULTS

This guideline endorsed two recommendations of the ASCO 2017 guideline for the use of sentinel lymph node biopsy in patients with early-stage breast cancer and expanded on that guideline with recommendations for radiotherapy interventions, timing of staging after neoadjuvant chemotherapy (NAC), and mapping modalities. Overall, the ASCO 2017 guideline, seven high-quality systematic reviews, 54 unique studies, and 65 corollary trials formed the evidentiary basis of this guideline.

RECOMMENDATIONS

Recommendations are issued for each of the objectives of this guideline: (1) To determine which patients with early-stage breast cancer require axillary staging, (2) to determine whether any further axillary treatment is indicated for women with early-stage breast cancer who did not receive NAC and are sentinel lymph node-negative at diagnosis, (3) to determine which axillary strategy is indicated for women with early-stage breast cancer who did not receive NAC and are pathologically sentinel lymph node-positive at diagnosis (after a clinically node-negative presentation), (4) to determine what axillary treatment is indicated and what the best timing of axillary treatment for women with early-stage breast cancer is when NAC is used, and (5) to determine which are the best methods for identifying sentinel nodes.Additional information is available at www.asco.org/breast-cancer-guidelines.

Ultrasound-guided dual-localization for axillary nodes before and after neoadjuvant chemotherapy with clip and activated charcoal in breast cancer patients: a feasibility study

Background

We report on our experience of ultrasound (US)-guided dual-localization for axillary nodes before and after neoadjuvant chemotherapy (NAC) with clip and activated charcoal to guide axillary surgery in breast cancer patients.

Methods

Between November 2017 and May 2018, a dual-localization procedure was performed under US guidance for the most suspicious axillary nodes noted at initial staging (before NAC, with clip) and restaging (after NAC, with activated charcoal) in 28 cytologically proven node-positive breast cancer patients. Patients underwent axillary sampling or dissection, which involved removing not only the sentinel nodes (SNs), but also clipped nodes (CNs) and tattooed nodes (TNs). Success (or failure) rates of biopsies of SNs, CNs, and TNs and inter-nodal concordance rates were determined. Sensitivities for the individual and combined biopsies were calculated.

Results

SN biopsy failed in four patients (14%), whereas the CN biopsy failed in one patient (4%). All TNs were identified in the surgical field. Concordance rates were 79% for CNs–TNs, 63% for CNs–SNs, and 58% for TNs–SNs. Sensitivity for SN, CN, and TN biopsy was 73%, 67%, and 67%, respectively. Sensitivity was 80% for any combination of biopsies (SN plus CN, SN plus TN, SN plus CN plus TN).

Conclusions

US-guided dual-localization of axillary nodes before and after NAC with clip and activated charcoal was a feasible approach that might facilitate more reliable nodal staging with less-invasive strategies in node-positive breast cancer patients.

Assessment of sentinel lymph node biopsy after neoadjuvant chemotherapy for breast cancer in two subgroups: Initially node negative and node positive converted to node negative - A systemic review and meta-analysis

BACKGROUND

Neoadjuvant chemotherapy (NAC) is increasingly used to treat patients with breast cancer, but the reliability of sentinel lymph node biopsy (SLNB) following chemotherapy is in doubt. In this meta-analysis, we aimed to evaluate studies that examine the results of SLNB after NAC to assess identification rate (IR) and false-negative rate (FNR).

MATERIALS AND METHODS

Systemic searches were performed in the PubMed, ISI Web of Sciences, Scopus, and Cochrane databases from January 1, 2000, to November 30, 2016, for studies of SLNB after NAC for breast cancer and followed by axillary lymph node (LN) dissection in two subgroups: initially node negative and node positive converted to node negative. Two reviewers independently review quality of included studies. A random-effects model was used to pool IR and FNR with 95% confidence intervals (CI), and heterogeneity among studies was assessed by I 2 and Q-test.

RESULTS

A total of 23 studies with 1521 patients in the initially node-negative subgroup and 13 studies with 1088 patients in the node-positive converted to node-negative subgroup, were included in this meta-analysis with IR and FNR of 94% (95% CI: 92-96) and 7% (95% CI: 5-9) in the initially node-negative subgroup and 89% (95% CI: 85-94) and 13% (95% CI: 7-18) in the node-positive converted to node-negative subgroup, respectively.

CONCLUSION

Our meta-analysis showed acceptable IR and FNR in initially node-negative group and it seems feasible in these patients, but these parameters did not reach to predefined value in node-positive converted to node-negative group, and thus, it is not recommended in these patients.

Sentinel node biopsy after neoadjuvant chemotherapy for breast cancer with axillary node metastasis: A survey of clinical practice

BACKGROUND

A survey of breast surgeons was conducted to evaluate changes in clinical practice regarding sentinel node biopsy (SNB) among clinically node-negative patients after neoadjuvant chemotherapy for breast cancer with axillary node metastasis.

METHODS

We conducted two surveys among 252 members of the Korean Breast Cancer Society. The questionnaire comprised a case presentation and two associated questions. The case outlined a woman diagnosed with right breast cancer; core needle biopsy had confirmed invasive ductal carcinoma and tumor size was 4 cm on imaging examination. Fine needle aspiration examination for axillary lymph node enlargement showed metastatic carcinoma. The patient underwent neoadjuvant chemotherapy and tumor size was decreased by 2 cm; axillary lymph node enlargement was not observed on palpitation or imaging examination. Finally, the patient underwent breast conserving surgery. Survey recipients were asked: 1. Would you perform SNB in this patient? 2. If you perform SNB and no axillary node metastasis is seen, would you perform additional axillary lymph node dissection (ALND)?

RESULTS

The response rate was 28.2% (71/252) and 15.1% (38/252) in 2013 and 2017, respectively. For the first question, the SNB to ALND ratio increased significantly from 54% versus 46% in 2013 to 92% versus 8% in 2017 (p < 0.001). The proportion of surgeons performing no additional ALND versus additional ALND increased from 38% versus 54% in 2013 to 53% versus 37% in 2017, but did not reach statistical significance (p = 0.1).

CONCLUSIONS

These data show that application of SNB among clinically node-negative patients after neoadjuvant chemotherapy for breast cancer with node metastasis has increased among surgeons in Korea.

Role of number of sentinel nodes in predicting non-sentinel node metastasis in breast cancer

Objective

The aim of the present study was to determine how many sentinel lymph nodes (SLNs) are appropriate for predicting non-SLN metastasis in breast cancer.

Methods

The association between clinicopathological features and non-SLN metastasis was retrospectively analyzed in 472 patients who underwent axillary lymph node dissection (ALND) following SLN biopsy. Another 251 patients who underwent only SLN biopsy without ALND were analyzed and followed up for 2 years.

Results

A large tumor size, positive SLN, and HER-2 positivity were independent predictors of non-SLN metastasis. There were significant differences in non-SLN metastasis between patients with one negative SLN and patients with an absence of negative SLNs. There was no significant difference in non-SLN metastasis between patients with one negative SLN and two or more negative SLNs. The recurrence-free survival rate for patients who did not undergo ALND was 99.6% (245/246).

Conclusion

Surgeons should ensure that the number of SLNs obtained is appropriate. The presence of one negative SLN is enough in SLN biopsy. Considering the invasiveness of the surgery, two or more negative SLNs may be unnecessary.

Selective Sentinel Lymph Node Biopsy and Primary Systemic Therapy in Breast Cancer

Aims and background

Sentinel lymph node biopsy has become an ordinary method for breast cancer staging. Neoadjuvant chemotherapy has been considered one of the contraindications for sentinel lymph node biopsy due to potential secondary fibrosis and lymphatic distortion. Timing and influence on sentinel lymph node biopsy result by primary systemic therapy are current and controversial topics.

Methods and study design

The experience in the medical literature is reviewed. A search was performed in the following databases: Medline (through Pubmed), EMBASE, Tripdatabase and Cochrane Library, between January 1998 and December 2008.

Results and conclusions

After analyzing the conclusions from 42 series and waiting for the end of related prospective trials, it could be concluded that sentinel lymph node biopsy is a useful diagnostic tool that should be integrated in the algorithm for the management of breast cancer patients when primary systemic therapy is needed.

Review of the role of the sentinel node biopsy in neoadjuvant chemotherapy in women with breast cancer and negative or positive axillary node at diagnosis

The role of the selective sentinel node biopsy (SNB) is increasing in relevance in breast cancer women with indication of neoadjuvant chemotherapy (NAC). The Radiosurgery Working Group of the SEMNIM is aware of the necessity of establishing the need for SNB before or after NAC, and also how to manage patients with axillary node-negative or node-positive. There is sufficient data to assess that the SNB with radioisotope techniques are feasible and safe in all these scenarios. An adequate axilla evaluation prior to surgery and the possibility of marking prior to NAC the nodes infiltrated must be the two main pillars to guarantee the success of the SNB. It has been shown that to incorporate the SNB in breast cancer women with indication of NAC increases the rate of a conservative treatment of the axilla that will be a clear benefit for these patients.

Detectability of Hygroscopic Clips Used in Breast Cancer Surgery

Sonographically detectable clips were introduced over the last decade. We retrospectively studied the rate and duration of sonographically detectable clip detectability in patients with breast cancer who had sonographically detectable clips inserted over a 2-year period. Nine of 26 patients had neoadjuvant chemotherapy, with all clips remaining detectable 140 to 187 days after insertion. Six of the 9 had intraoperative sonographic localization, with 1 reoperation (17%). Eleven additional patients with nonpalpable tumors and sonographically detectable clips had intraoperative sonographic localization with 1 reoperation (9%). In 1 patient, a sonographically detectable clip enabled intraoperative identification of a suspicious lymph node. There were no complications or clip migration. Sonographically detectable clips are helpful in breast cancer surgery with and without neoadjuvant chemotherapy, remaining detectable for many months and often averting preoperative localization and scheduling difficulties.

The Feasibility and Accuracy of Sentinel Lymph Node Biopsy in Initially Clinically Node-Negative Breast Cancer after Neoadjuvant Chemotherapy: A Systematic Review and Meta-Analysis

Background

With the increased use of neoadjuvant chemotherapy (NAC) in breast cancer, the timing of sentinel lymph node biopsy (SLNB) has become increasingly important. In this study, we aimed to evaluate the feasibility and accuracy of SLNB for initially clinically node-negative breast cancer after NAC by conducting a systematic review and meta-analysis.

Methods

We searched PubMed, Embase, and the Cochrane Library from January 1, 1993 to November 30, 2015 for studies on initially clinically node-negative breast cancer patients who underwent SLNB after NAC followed by axillary lymph node dissection (ALND).

Results

A total of 1,456 patients from 16 studies were included in this review. The pooled identification rate (IR) for SLNB was 96% [95% confidence interval (CI): 95%-97%], and the false negative rate (FNR) was 6% (95% CI: 3%-8%). The pooled sensitivity, negative predictive value (NPV) and accuracy rate (AR) were 94% (95% CI: 92%-97%, I² = 27.5%), 98% (95% CI: 98%-99%, I² = 42.7%) and 99% (95% CI: 99%-100%, I² = 32.6%), respectively. In the subgroup analysis, no significant differences were found in either the IR of an SLNB when different mapping methods were used (P = 0.180) or in the FNR between studies with and without immunohistochemistry (IHC) staining (P = 0.241).

Conclusion

Based on current evidence, SLNB is technically feasible and accurate enough for axillary staging in initially clinically node-negative breast cancer patients after NAC.

A mini-review on factors and countermeasures associated with false-negative sentinel lymph node biopsies in breast cancer

Sentinel lymph node biopsy (SLNB) is a new surgical technique for local axillary lymph nodes (ALNs) of breast cancer. Large-scale clinical trials have confirmed that undergoing SLNB and ALN dissection (ALND) showed no significant difference for sentinel lymph node (SLN)-negative patients in terms of disease-free survival, overall survival and recurrence-free survival. However, false-negative results are still the main concern of physicians as well as patients who undergo SLNB instead of ALND. The American Society of Breast Surgeons established a task force to suggest acceptable standards for SLNB. In 2000, the task force recommended that the identification rate for SLNB be 85% or higher and the false-negative rate be 5% or lower. This review focuses on clinical factors (tumor volume, multifocal/multi-center cancers, neoadjuvant chemotherapy and skip metastasis), tracer techniques and pathological factors affecting SLNB and explores methods for reducing the false-negative rate.

Targeting and limiting surgery for patients with node-positive breast cancer

The presence of axillary nodal metastases has a significant impact on locoregional and systemic treatment decisions. Historically, all node-positive patients underwent complete axillary lymph node dissection; however, this paradigm has changed over the last 10 years. The use of sentinel lymph node dissection has expanded from its initial role as a surgical staging procedure in clinically node-negative patients. Clinically node-negative patients with small volume disease found on sentinel lymph node dissection now commonly avoid more extensive axillary surgery. There is interest in expanding this role to node-positive patients who receive neoadjuvant chemotherapy as a way to restage the axilla in hopes of sparing women who convert to node-negative status from the morbidity of complete nodal clearance. While sentinel lymph node dissection alone may not accomplish this goal, there are novel techniques, such as targeted axillary dissection, that may now allow for reliable nodal staging after chemotherapy.

Sentinel lymph node biopsy alone after neoadjuvant chemotherapy in patients with initial cytology-proven axillary node metastasis

Purpose

Neoadjuvant chemotherapy (NAC) has been recently used to downstage breast cancer. However, in patients with initial axillary lymph node (ALN) metastasis, ALN dissection regardless of the NAC response remains the standard treatment. The purpose of this study was to identify the feasibility and accuracy of sentinel lymph node biopsy (SLNB) after NAC in patients with ALN metastasis at diagnosis.

Methods

From January 2007 to August 2013, data of patients who were diagnosed with invasive breast cancer and ALN metastasis and treated with NAC followed by definitive surgery in two centers were collected retrospectively. A total of 386 patients were enrolled and classified into five groups according to surgical procedure for the ALNs and pathologic results.

Results

At SLNB after NAC, sentinel lymph nodes (SLNs) that stained blue or were hot, including suspicious nodes, were identified; the SLN identification and false-negative rates was 96% and 10%, respectively. There was no difference in the overall survival among the groups. For patients who revealed a pathologic complete node response, there was a significant difference in the disease-free survival rate between the SLNB only and complete ALN dissection groups (p=0.031). However, the rate of axillary recurrence demonstrated no significant differences among the groups (p>0.050).

Conclusion

SLNB after NAC in breast cancer patients with initial ALN metastasis may help identify downstaging to negative nodal status and thereby reduce the surgical morbidity by avoiding standard ALN dissection.

Macroscopic handling and reporting of breast cancer specimens pre- and post-neoadjuvant chemotherapy treatment: review of pathological issues and suggested approaches

Neoadjuvant chemotherapy (NACT) is used increasingly in the treatment of invasive breast cancer and presents challenges for the pathologist in the handling and interpretation of tissues. Potential issues include pathological identification and localization of the residual tumour site; how best to assess pathological response (given the diversity of scoring systems described); the timing and assessment of axillary node biopsy; and the value of retesting any residual tumour for dissonance between core biopsy and post-treatment residual cancer cells for biomarker expression such as oestrogen and progesterone receptors and human epidermal growth factor receptor 2 (HER2). The role of the pathologist is critical in modern NACT approaches to breast cancer and is likely to remain challenging as novel agents and newer biomarkers become available. In this manuscript we review these issues and describe some practical approaches to handling and reporting these samples in the routine histopathology laboratory.

Impact of neoadjuvant chemotherapy on locoregional surgical treatment of breast cancer

Preoperative (neoadjuvant) chemotherapy (NC) has become the standard of care for patients with locally advanced breast cancer and is being increasingly used in those with large operable disease. Its main clinical advantages from a surgical therapy standpoint include the potential for conversion of patients requiring mastectomy to breast-conservation candidates, the potential for improving the cosmetic outcome following lumpectomy by decreasing the size of the primary breast tumor even if the patient is a lumpectomy candidate at presentation, and the potential for converting patients who present with positive axillary nodes and who would initially require axillary lymph node dissection to candidates for sentinel lymph node biopsy alone. Important steps are required from the time of diagnosis until the time of surgical resection to ensure successful locoregional therapy outcomes in patients treated with NC. They include accurate assessment of the location and extent of the primary breast tumor and determination of axillary nodal status before and after NC. This information is critical for successful execution of the surgical plan and to optimize the use of adjuvant radiotherapy following NC. In the future, development of more active neoadjuvant chemotherapy regimens and novel molecular and imaging techniques will undoubtedly lead to further individualization of breast cancer surgical management following NC, including the possibility of avoiding surgical resection in cases with a high likelihood of achieving a pathological complete response.

A prospective feasibility study of sentinel node biopsy by modified Indigocarmine blue dye methods after neoadjuvant chemotherapy for breast cancer

BACKGROUND

Although sentinel lymph node biopsy (SLNB) is a standard staging method for assessing nodal status of breast cancer patients, SLNB after neoadjuvant chemotherapy (NAC) remains controversial. The aim of this study was to validate the practicality and accuracy of SLNB by our modified Indigocarmine blue dye methods following NAC.

METHODS

One hundred consecutive cases with breast cancers treated by NAC were enrolled in this study. After NAC, all patients underwent SLNB performed by our modified Indigocarmine blue dye methods without radioisotope, followed by back-up axillary lymph node dissection (ALND).

RESULTS

Sentinel nodes (SNs) were identified in 94 cases (identification rate, 94%); the accuracy was 94.7% (89/94 cases); and the false negative rate (FNR) 13.5% (5/37 cases). For cases with vs. without clinically evident metastatic nodes before NAC, the identification rate was 92.4% (61/66 cases) vs. 97.1% (33/34 cases); the accuracy 91.8% (56/61 cases) vs. 97.0% (32/33 cases) and the FNR 16.1% (5/31 cases) vs. 0% (0/6 case), respectively. There were six patients without identified SNs, three of them had metastatic nodes. False negatives occurred in five cases; in four, fewer than two sentinel nodes had been removed.

CONCLUSION

Following NAC, the accuracy of SLNB by modified Indigocarmine blue dye methods is adequate compared with other tracers. In patients in whom no SNs have been identified, lymphatic metastasis is likely and therefore ALND is recommended. For patients with cN0 prior to NAC, SLNB by modified Indigocarmine blue dye methods is clinically feasible, though controversial for patients with positive nodes.

Sentinel node biopsy after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer: the SN FNAC study

PURPOSE

An increasing proportion of patients (> 30%) with node-positive breast cancer will obtain an axillary pathologic complete response after neoadjuvant chemotherapy (NAC). If sentinel node (SN) biopsy (SNB) is accurate in this setting, completion node dissection (CND) morbidity could be avoided.

PATIENTS AND METHODS

In the prospective multicentric SN FNAC study, patients with biopsy-proven node-positive breast cancer (T0-3, N1-2) underwent both SNB and CND. Immunohistochemistry (IHC) use was mandatory, and SN metastases of any size, including isolated tumor cells (ypN0[i+], ≤ 0.2 mm), were considered positive. The optimal SNB identification rate (IR) ≥ 90% and false-negative rate (FNR) ≤ 10% were predetermined.

RESULTS

From March 2009 to December 2012, 153 patients were accrued to the study. The SNB IR was 87.6% (127 of 145; 95% CI, 82.2% to 93.0%), and the FNR was 8.4% (seven of 83; 95% CI, 2.4% to 14.4%). If SN ypN0(i+)s had been considered negative, the FNR would have increased to 13.3% (11 of 83; 95% CI, 6.0% to 20.6%). There was no correlation between size of SN metastases and rate of positive non-SNs. Using this method, 30.3% of patients could potentially avoid CND.

CONCLUSION

In biopsy-proven node-positive breast cancer after NAC, a low SNB FNR (8.4%) can be achieved with mandatory use of IHC. SN metastases of any size should be considered positive. The SNB IR was 87.6%, and in the presence of a technical failure, axillary node dissection should be performed. We recommend that SN evaluation with IHC be further evaluated before being included in future guidelines on the use of SNB after NAC in this setting.

Sentinel lymph node biopsy does not apply to all axillary lymph node-positive breast cancer patients after neoadjuvant chemotherapy

BACKGROUND

The aim of this study was to investigate the feasibility of sentinel lymph node biopsy (SLNB) after neoadjuant chemotherapy (NAC) in breast cancer patients with confirmed axillary nodal metastases.

METHODS

We enrolled 51 patients with breast cancer who received NAC. All patients were proven to have axillary nodal metastases by histopathology biopsy prior to NAC. They all underwent SLNB before breast surgery, and complete axillary lymph node dissection immediately followed.

RESULTS

The identification rate for SLNB was 87.5% (84/96); the false negative rate was 24.5% (12/49). The clinicopathological factors were not significantly correlated with the identification and false negative rate of the SLNB. Lymphatic mapping, blue dye or radionuclide methods tended to decrease the identification rate of SLNB (P = 0.073). Clinical nodal status before NAC has a trend to increase the false-negative rates of the SLNB (P = 0.059). For patients with N1 clinical axillary lymph nodal status, the identification rate was 93.9%, and the false negative rate was 5.9%, compared with N2-3 patients with 73.9% and 38.9%, respectively.

CONCLUSIONS

SLNB is feasible for the patients whose axillary lymph nodal status before NAC is N1. However, for N2-3 patients, SLNB cannot be used as an infallible indicator of non-SLN status.

Management of the axilla

The development and wide acceptance of sentinel lymph node biopsy (SLNB) has profoundly affected the management of breast cancer. SLNB has spared the additional morbidity of axillary lymph node dissection (ALND) without compromising diagnostic accuracy and prognostic information in patients with clinically node-negative early-stage breast cancer. It has become an invaluable tool to clinicians to guide decisions regarding adjuvant treatment. The management of breast cancer continues to advance to more minimally invasive approaches, and the role of ALND is likely to become less important in the future.

Breast cancer: Actual methods of treatment and future trends

The recent ten to twenty years have seen a substantial progress in the diagnosis and treatment of breast cancer. A rapid development of various curative options has led to the improvement of treatment outcomes, while paying more and more attention to the aspects of quality of life and cosmetic effect. In our publication, we wish to outline certain trends in the development of modern treatment of breast cancer. Among topics discussed are new forms of molecular diagnostics, new approach to the idea of sentinel node biopsy, as well as new techniques for delivery of medical procedures, the increasing use of nomograms, progress in the techniques of breast conservative treatment, modern approach to occult breast lesions, the increasing use of neoadjuvant treatment and intraoperative radiotherapy.

Intraoperative sentinel node biopsy by one-step nucleic acid amplification (OSNA) avoids axillary lymphadenectomy in women with breast cancer treated with neoadjuvant chemotherapy

BACKGROUND

There is no evidence that supports the recommendation of sentinel lymph node biopsy (SLNB) in patients with breast cancer who have treated with neoadjuvant chemotherapy (NAC) to downsize tumors in order to allow breast conservation surgery, because NAC induces anatomical alterations of the lymphatic drainage. We evaluated the effectiveness of SLNB using intraoperative one-step nucleic acid amplification (OSNA) method to detect microscopic metastases or isolated tumor cells after NAC in patients with clinically negative axillary nodes at initial presentation.

PATIENTS AND METHODS

We evaluated in patients with breast cancer and clinically negative axilla at presentation, the effectiveness of SLNB by OSNA after NAC (71 patients) or prior to NAC (40 patients).

RESULTS

The rate of SLN identification was 100% in both groups. 17 women with SLNB prior to systemic treatment showed positive nodes (14 macrometastases and 3 micrometastases), and positive SLNB were detected in 15 women with SLNB after NAC, which were 14 macrometastases and 1 micrometastase. The negative predictive value of ultrasonography was 57.5% in patients with SLNB prior to neoadjuvant therapy and 78.9% in patients with chemotherapy followed by SLNB.

CONCLUSIONS

Intraoperative SLNB using OSNA in women with clinically negative axillary lymph nodes at initial presentation who received NAC could predict axillary status with high accuracy. Also it allows us to take decisions about the indication or not to perform an axillary dissection at the moment, thus avoiding delay in the administration of chemotherapy and benefiting the patients from a single surgical procedure.

Sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with cytologically proven node-positive breast cancer at diagnosis

BACKGROUND

The performance of sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NCT) was investigated in patients with locally advanced breast cancer (LABC).

METHODS

After NCT of 178 patients with cytology-proven axillary/supraclavicular nodes metastasis at the time of diagnosis, SLNB using radioisotope was performed including completion node dissection between 2008 and 2011. The detection rate, sensitivity, false negative rate (FNR), negative predictive value (NPV) and accuracy of SLNB were analyzed.

RESULTS

SLNB was successfully performed in 169 (94.9%) patients. Tumor nonresponse and extensive residual nodal disease were found to be significantly associated with detection failure of sentinel nodes. Sensitivity, FNR, NPV, and accuracy of SLNB were 78.0, 22.0, 75.8, and 87.0%, respectively, and a greater number of retrieved SLNs increased all four of these performance measures. Conversion to node-negative disease was achieved in 69 (40.8%) patients: 24% of patients with the luminal A subtype, 51.6% of patients with the luminal B, 51.7% of patients with the HER2-enriched, and 58.5% of patients with the triple-negative breast cancer (TNBC) subtype. Luminal B, HER2-enriched, and TNBC subtypes showed comparable responses to NCT; however, the TNBC subtype had a significantly better FNR and accuracy.

CONCLUSIONS

SLNB was found to be technically feasible, but its routine use was not recommended for LABCs after NCT. However, acceptable performance was noted for locally advanced TNBCs, and thus SLNB might be safely considered in these selected patients.

Timing of the sentinel lymph node biopsy in breast cancer patients receiving neoadjuvant therapy - recommendations for clinical guidance

Neoadjuvant chemotherapy (NAC) is an increasingly important component in the treatment of both locally advanced and early-stage breast cancer. With this, a debate on the timing of the sentinel lymph node biopsy (SLNB) has emerged. At the end of the last century, the SLNB was introduced as an axillary staging modality, and this paper aims to further elucidate this issue in the context of NAC. We compiled available data on the SLNB after NAC and provide clinical guidance for timing the SLNB in this context. On the basis of our findings, we recommend that the SLNB can be performed after NAC in all cases. In patients with a clinically node-negative (cN0) status prior to NAC, the SLNB should be performed after NAC, and in case of a histologically confirmed negative SLNB, a completion axillary lymph node dissection (ALND) has no added value and can be omitted. In patients with clinically positive nodal involvement (cN+) prior to NAC, all axillary surgery can also be performed after NAC.

Sentinel node biopsy for breast cancer: past, present, and future

Sentinel node biopsy has replaced axillary lymph node dissection as the standard of care in early breast cancers. Sentinel node biopsy represents a highly accurate and less-morbid axillary staging, which allows most patients to avoid unnecessary axillary lymph node dissection and its morbidity. This review provides information including several issues which are still under debate, such as clinical significance of micrometastases, avoidance of axillary lymph node dissection for patients with positive sentinel nodes, accuracy and timing of sentinel node biopsy in patients undergoing neoadjuvant chemotherapy, and how many sentinel nodes are sufficient for removal. Finally, a new topic is introduced: superparamagnetic iron oxide (SPIO)-enhanced magnetic resonance (MR) imaging for the detection of metastases in sentinel nodes localized by computed tomography (CT)-lymphography (CT-LG) in patients with breast cancer. SPIO-enhanced MR imaging is a useful method of detecting metastases in sentinel nodes localized by CT-LG in patients with breast cancer. Patients with clinically negative nodes may be spared even sentinel node biopsy when the sentinel node is diagnosed as disease free using SPIO-enhanced MR imaging.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Locoregional lymph node involvement on 18F-FDG PET/CT in breast cancer patients scheduled for neoadjuvant chemotherapy

The optimal method for locoregional staging in patients treated with neoadjuvant chemotherapy (NAC), usually ultrasound (US) and pre- or post-chemotherapy sentinel lymph node biopsy (SLNB), remains subject of debate. The aim of this study was to assess the value of 18F-FDG PET/CT for detecting locoregional lymph node metastases in primary breast cancer patients scheduled for NAC. 311 breast cancer patients, scheduled for NAC, underwent PET/CT of the thorax in prone position with hanging breasts. A panel of four experienced reviewers examined PET/CT images, blinded for other diagnostic procedures. FDG uptake in locoregional nodes was determined qualitatively using a 4-point scale (0 = negative, 1 = questionable, 2 = moderately intense, and 3 = very intense). Results were compared with pathology obtained by US-guided fine needle aspiration or SLNB prior to NAC. All FDG-avid extra-axillary nodes were considered metastatic, based on the previously reported high positive predictive value of the technique. Sensitivity, specificity, positive predictive value, negative predictive value, and accuracy of FDG-avid nodes for the detection of axillary metastases (score 2 or 3) were 82, 92, 98, 53, and 84 %, respectively. Of 28 patients with questionable axillary FDG uptake (score 1), 23 (82 %) were node-positive. Occult lymph node metastases in the internal mammary chain and periclavicular area were detected in 26 (8 %) and 32 (10 %) patients, respectively, resulting in changed regional radiotherapy planning in 50 (16 %) patients. In breast cancer patients scheduled for NAC, PET/CT renders pre-chemotherapy SLNB unnecessary in case of an FDG-avid axillary node, enables axillary response monitoring during or after NAC, and leads to changes in radiotherapy for a substantial number of patients because of detection of occult N3-disease. Based on these results, we recommend a PET/CT as a standard staging procedure in breast cancer patients scheduled for NAC.

Surgical considerations in patients receiving neoadjuvant systemic therapy

Neoadjuvant chemotherapy is being increasingly used in the treatment of patients presenting with early-stage, operable breast cancer. Neoadjuvant chemotherapy downsizes most tumors, allowing appropriately selected patients to undergo breast-conserving therapy. Management of the axilla in patients receiving neoadjuvant chemotherapy is dictated by whether patients present with clinically node-negative or node-positive disease. Patients with clinically node-negative disease can undergo sentinel lymph node dissection after neoadjuvant chemotherapy, with axillary lymph node dissection reserved for patients with a positive sentinel lymph node. For patients with clinically node-positive disease at presentation, the current standard of care is axillary lymph node dissection. An ongoing cooperative group trial is investigating the utility of sentinel lymph node surgery in the clinically node-positive population.

Barrett's esophagus: treatments of adenocarcinomas II

The following topics are explored in this collection of commentaries on treatments of adenocarcinomas related to Barrett's esophagus: the importance of intraoperative frozen sections of the margins for the detection of high dysplasia; the preferable way for sentinel node dissection; the current role of robotic surgery and of video-endoscopic approach; the value of the Siewert's classification of adenocarcinomas; the indications of two-step esophagectomy; the evaluation of pathological complete response; the role of PET scan in staging and response assessment; the role of p53 in the selection of adenocarcinomas patients; chemotherapy regimens for adenocarcinomas; the use of monoclonal antibodies in the control of cell proliferation; he attempt to define a stage-specific strategy, and the possible indications of selective therapy; and changes in mortality rates from esophageal cancer.