Evaluating the feasibility of repeat sentinel lymph node biopsy in ipsilateral breast tumor recurrence: Technical considerations and oncologic outcomes

INTRODUCTION

Ipsilateral breast tumor recurrence (IBTR) remains a concern despite standard treatments. Advances in early detection have shifted surgical paradigms towards less invasive approaches. While repeat sentinel lymph node biopsy (rSLNB) emerges as a viable option according to the 2023 National Comprehensive Cancer Network (NCCN) guidelines, its efficacy remains uncertain. This study aimed to assess lymphatic drainage patterns in IBTR and evaluate the feasibility of rSLNB, along with analyzing oncologic outcomes.

METHODS

A retrospective analysis involving 78 patients with IBTR who had prior breast-conserving surgery (BCS) with sentinel lymph node biopsy (SLNB) and adjuvant whole breast irradiation (WBI) at Samsung Medical Center was conducted. Data on patient characteristics, lymphatic mapping techniques, and oncologic outcomes were collected and analyzed.

RESULTS

Among 78 patients with IBTR, 82.1 % underwent successful rSLNB, predominantly detecting lymphatic drainage to the ipsilateral axilla (80.8 %). The initial tumor location correlated significantly with failed lymphatic mapping (p = 0.019). A third event occurred in 28.8 % of invasive IBTR cases, notably associated with postmenopausal status, higher T stages, and HR(-)/HER2(-) subtype (p < 0.001). The risk of a third event increased by over 50 % within a 2-year interval post-IBTR.

CONCLUSION

rSLNB in patients with IBTR, particularly for tumors initially located outside the upper-outer quadrant, demonstrated technical feasibility. The combined use of blue dye with lymphoscintigraphy may enhance rSLNB success rates. Active surveillance, especially for triple negative IBTR cases, may be important due to their aggressive nature and rapid progression potential within a short interval post-IBTR.

Nuclear medicine contribution to precision surgery in breast cancer

Nuclear medicine has significantly contributed to precision surgery in breast cancer in the past decades. Radioguided surgery (RGS) has enabled sentinel node (SN) biopsy in assessing regional nodal involvement modifying the management of patients with early breast cancer. For the axilla the SN procedure has resulted in fewer complications and better quality of life when compared with axillary lymph node dissection. Originally, SN biopsy principally concerned cT 1-2 tumours without evidence of axillary lymph node metastases. However, in last years SN biopsy is also being offered to patients with large or multifocal tumours, ductal carcinoma in situ, ipsilateral breast cancer relapse, and to patients receiving neoadjuvant systemic treatment (NST) for breast sparing surgery. Parallel to this evolution various scientific associations are trying to homogenise issues such as radiotracer choice, breast injection site, preoperative imaging standardisation and SN biopsy timing in relation to NST as well as management of non-axillary SN metastasis (e.g. internal mammary chain). Additionally, RGS is currently used to accomplish primary breast tumour excision either by intralesional radiocolloid injection or by radioactive iodine seed implantation which is also employed to target metastatic axillary lymph nodes. This latter procedure contributes to manage the node-positive axilla in combination with 18F-FDG PET/CT in an effort to tailor systemic and loco regional treatment.

Added value of repeat sentinel lymph node biopsy in FDG-PET/CT node-negative patients with ipsilateral breast cancer recurrence

PURPOSE

Repeat sentinel lymph node biopsy (rSLNB) has been suggested for axillary staging in clinically node-negative (cN0) patients with ipsilateral breast tumor recurrence (IBTR). Although rSLNB is technically feasible in this group of patients, the clinical value has not been established. We aimed to assess the added value of rSLNB in cN0 patients with IBTR who underwent optimal clinical staging with FDG-PET/CT.

METHODS

This retrospective single-center cohort study included 119 patients with IBTR-staged cT1-4N0M0 with FDG-PET/CT who underwent rSLNB between 2006 and 2020. Overall recurrence-free survival (RFS) and overall survival (OS) were calculated for subgroups with tumor-positive, tumor negative, and unsuccessful rSLNB.

RESULTS

rSLNB was successful in 79 (66%) of the 119 included patients, of whom 70 (59%) had a tumor negative and 9 (8%) a tumor-positive rSLNB; rSLNB was unsuccessful in the remaining 40 (34%) patients. Patients with a tumor-positive rSLNB had poorer overall 5-year RFS compared to patients with a tumor negative or unsuccessful rSLNB (44% vs. 86% vs. 90%, p = 0.004). Although patients with a tumor-positive rSLNB had worse RFS, the 10-year OS was comparable to a tumor negative or unsuccessful rSLNB (89% vs. 89% vs. 95%, p = 0.701).

CONCLUSION

The incidence of a tumor-positive rSLNB in patients with a negative FDG-PET/CT is low and does not change survival. Therefore, in cN0 patients with IBTR who underwent optimal clinical staging with FDG-PET/CT, we support a patient- and tumor-tailored treatment strategy in which rSLNB may be omitted.

How to Perform Repeat Sentinel Node Biopsy Safely After a Previous Mastectomy: Technical Features and Oncologic Outcomes

BACKGROUND

The latest National Comprehensive Cancer Network Breast Cancer Guidelines still discourage repeat sentinel node biopsy (SNB) after mastectomy, and the largest multicentric study available reports only 35 cases in the absence of previous axillary dissection (AD).

METHODS

From January 2003 to November 2018, 89 patients of the European Institute of Oncology with local recurrence of breast cancer after mastectomy, free of distant metastases, with a clinically negative axilla and a negative axillary ultrasound, in absence of AD, underwent lymphatic mapping before wide local excision.

RESULTS

During surgery, SNB was successful for 99% of the patients, with 14% being metastatic. Additional metastatic nodes removed by AD after a positive sentinel node occurred in 82% of cases. After a medium follow-up period of 3.7 years, the overall survival rate was 96.7%, and the disease-free survival rate was 84.4%. No axillary relapse after AD was recorded. One patient who refused human epidermal growth factor receptor 2 (HER2)-targeted treatment experienced ipsilateral axillary recurrence after a negative repeat SNB. The first axillary level was never directly irradiated because all the patients with positive repeat SNB underwent AD. For invasive luminal-like HER2-negative recurrences, the metastatic sentinel node was significantly associated with the choice to prescribe adjuvant chemotherapy (p = 0.003).

CONCLUSIONS

In specialized centers, repeat axillary SNB for patients with local recurrence after mastectomy in the absence of previous AD can represent a safe option for detection and removal of occult axillary disease that would otherwise not be excised/irradiated to achieve better local control and could possibly influence the choice of adjuvant treatments.

Contralateral Axillary Nodal Metastases: Stage IV Disease or a Manifestation of Progressive Locally Advanced Breast Cancer?

BACKGROUND

Contralateral axillary nodal metastases (CAM) is classified as stage IV disease, although many centers treat CAM with curative intent. We hypothesized that patients with CAM, treated with multimodality therapy, would have improved overall survival (OS) versus patients with distant metastatic disease (M1) and similar OS to those with locally advanced breast cancer (LABC).

METHODS

Using the NCDB (2004-2016), we categorized adult patients with node-positive breast cancer into three study groups: LABC, CAM, and M1. Kaplan-Meier curves were used to visualize the unadjusted OS. Cox proportional hazards models were used to estimate the association of study group with OS.

RESULTS

A total of 94,487 patients were identified: 122 with CAM, 12,325 with LABC, and 82,040 with M1 (median follow-up 63.6 months). LABC and CAM patients had similar histology and rates of chemotherapy and endocrine therapy receipt. However, the CAM group had significantly larger tumors, more estrogen-receptor expression, higher T-stage, and more mastectomies than the LABC group. Compared with M1 patients, CAM patients were more likely to have grade 3 and cT4 tumors. Patients with CAM and LABC had similar 5-year unadjusted OS and significantly improved OS vs M1 patients. After adjustment, LABC and CAM patients continued to have similar OS and better OS vs M1 patients.

CONCLUSIONS

CAM patients who receive multi-modal therapy with curative intent may have OS more comparable to LABC patients than M1 patients. Out data support a reevaluation of whether CAM should remain classified as M1, as N3 may better reflect disease prognosis and treatment goals.

Contralateral Axillary Metastasis in Breast Carcinoma: Case Report and Review of Literature

The clinical dilemma of management of isolated contralateral axillary metastasis (CAM) in carcinoma breast remains unsolved. We report a case of metachronous contralateral left axillary metastasis in a 54-year-old postmenopausal woman, its management, and review of literature. After ruling out distant metastasis and occult primary in the opposite breast, curative treatment was planned. She underwent left axillary lymph node dissection which on histopathology showed metastatic carcinoma. Management of CAM with curative or palliative intent and whether to consider them as locoregional or distant metastasis remains controversial. CAM may occur due to the locoregional spread of disease, and hence, curative intent of treatment should be offered to these patients.

Magnetic resonance imaging and bioimpedance evaluation of lymphatic abnormalities in patients with breast cancer treatment-related lymphedema

PURPOSE

Breast cancer treatment-related lymphedema (BCRL) evaluation is frequently performed using portable measures of limb volume and bioimpedance asymmetry. Here quantitative magnetic resonance imaging (MRI) is applied to evaluate deep and superficial tissue impairment, in both surgical and contralateral quadrants, to test the hypothesis that BCRL impairment is frequently bilateral and extends beyond regions commonly evaluated with portable external devices.

METHODS

3-T MRI was applied to investigate BCRL topographical impairment. Female BCRL (n = 33; age = 54.1 ± 11.2 years; stage = 1.5 ± 0.8) and healthy (n = 33; age = 49.4 ± 11.0 years) participants underwent quantitative upper limb MRI relaxometry (T2), bioimpedance asymmetry, arm volume asymmetry, and physical evaluation. Parametric tests were applied to evaluate study measurements (i) between BCRL and healthy participants, (ii) between surgical and contralateral limbs, and (iii) in relation to clinical indicators of disease severity. Two-sided p-value < 0.05 was required for significance.

RESULTS

Bioimpedance asymmetry was significantly correlated with MRI-measured water relaxation (T2) in superficial tissue. Deep muscle (T2 = 37.6 ± 3.5 ms) and superficial tissue (T2 = 49.8 ± 13.2 ms) relaxation times were symmetric in healthy participants. In the surgical limbs of BCRL participants, deep muscle (T2 = 40.5 ± 4.9 ms) and superficial tissue (T2 = 56.0 ± 14.8 ms) relaxation times were elevated compared to healthy participants, consistent with an edematous micro-environment. This elevation was also observed in contralateral limbs of BCRL participants (deep muscle T2 = 40.3 ± 5.7 ms; superficial T2 = 56.6 ± 13.8 ms).

CONCLUSIONS

Regional MRI measures substantiate a growing literature speculating that superficial and deep tissue, in surgical and contralateral quadrants, is affected in BCRL. The implications of these findings in the context of titrating treatment regimens and understanding malignancy recurrence are discussed.

Contralateral Axillary Lymph Node Metastases from Breast Carcinoma: Is it Time to Review TNM Cancer Staging?

BACKGROUND

Contralateral axillary lymph node metastasis (CAM) is an infrequent clinical condition currently considered an M1, stage IV, disease. Due to the absence of shared data on CAM significance and on its therapeutic approach, be it curative or simply palliative, its management is still uncertain and undoubtedly represents a clinical challenge.

PATIENTS AND METHODS

Patients with pathologically confirmed metachronous CAM were retrospectively evaluated. All patients had been managed at the European Institute of Oncology, Milan, Italy, from 1997. Patients with distant metastases at the time of CAM were excluded. Possible treatments included surgery, systemic therapy and RT (radiotherapy). Outcomes were evaluated as rates of disease-free survival (DFS) and of overall survival (OS).

RESULTS

Forty-seven patients with CAM were included in the study. Metachronous CAM occurred 73 months (range 5-500 months) after diagnosis of the primary tumor. The median follow-up time was 5.4 years (interquartile range 2.9-7.0 years). The estimated OS was 72% at 5 years (95% CI 54-83), and 61% at 8 years (95% CI 43-75). The estimated DFS was 61% at 5 years (95% CI 44-74), and 42% at 8 years (95% CI 25-59).

CONCLUSION

These findings, together with those from previous studies, show that CAM outcome, particularly if measured as OS, appear better than at other sites of distant dissemination, when CAM is subjected to surgical and systemic treatments with a curative intent. Therefore, a new clinical scenario is suggested where, in the TNM system, CAM is no longer classified as a stage IV, but as an N3 disease.

Unexpected Lymphatic Drainage of the Treated Breast

This case highlights the use of lymphoscintigraphy with SPECT/CT in patients with previous chest and/or axillary surgery. A 67-year-old woman with a history of left breast carcinoma treated with lumpectomy and radiotherapy, and a second lumpectomy of the ipsilateral breast for a second breast carcinoma, underwent a lymphoscintigraphy for a new left breast lesion. Planar images visualized an alternative lymphatic drainage to the contralateral axilla and to the left paravertebral area. SPECT/CT confirmed sentinel nodes in both stations.

Altered lymphatic drainage patterns in re-operative sentinel lymph node biopsy for ipsilateral breast tumor recurrence

Background

This study aimed to evaluate the impact of previous local treatment on lymphatic drainage patterns in ipsilateral breast tumor recurrence (IBTR) based on our data on re-operative sentinel lymph node biopsy (re-SLNB) for IBTR.

Methods

Between April 2005 and December 2016, re-SLNB using lymphoscintigraphy with Tc-99 m phytate was performed in 136 patients with cN0 IBTR. Patients were categorized into two groups: the AX group included 55 patients with previous axillary lymph node dissection; the non-AX group included 69 patients with previous SLNB and 12 patients with no axillary surgery. The whole breast irradiation (RT) after initial surgery had performed in 17 patients in the AX group and 27 patients in the non-AX group.

Results

Lymphatic drainage was visualized in 80% of the AX group and 95% of the non-AX group (P < 0.01). The visualization rate of lymphatic drainage was associated with the number of removed lymph nodes in prior surgery. In the non-AX group, lymphatic drainage was visualized in 96% of patients without RT and 93% with RT. Lymphatic drainage was observed at the ipsilateral axilla in 98% of patients without RT and in 64% with RT (P < 0.0001). Aberrant drainage was significantly more common in patients with RT than without RT (60% vs. 19%, P < 0.001); it was observed mostly to the contralateral axilla (52% vs. 2%, P < 0.0001). In the AX group, patients with previous RT showed decreased lymphatic drainage to the ipsilateral axilla compared to those without RT (29% vs. 63%, P < 0.05) and increased aberrant drainage to the contralateral axilla (64% vs. 5%, P < 0.0001).

Conclusion

Lymphatic drainage patterns altered in re-SLNB in patients with IBTR and previous ALND and RT were associated with alterations in lymphatic drainage patterns.

Prospective, Multicenter, Randomized Phase III Trial Evaluating the Impact of Lymphoscintigraphy as Part of Sentinel Node Biopsy in Early Breast Cancer: SenSzi (GBG80) Trial

PURPOSE

The aim of the current work was to clarify whether a preoperative lymphoscintigraphy (LSG) enhances staging accuracy of sentinel lymph node biopsy (SLNB).

PATIENTS AND METHODS

In a prospective, multicenter, randomized phase III trial, patients with cN0 early breast cancer or extensive/high-grade ductal carcinoma in situ planned for standard radioactive-labeled colloid LSG with subsequent SLNB were randomly assigned 1:1 to receive SLNB either with knowledge of the LSG findings or without. As the false-negative rate of SLNB correlates with the number of resected sentinel lymph nodes (SLNs), our primary end point was the mean number of histologically detected SLNs per patient. One thousand one hundred two evaluable patients were necessary to demonstrate noninferiority of SLNB without LSG. Stratified one-sided 95% CI for the difference (without LSG − with LSG) in the mean number of histologically detected SLNs had to be greater than −0.27 (10% noninferiority margin). Stratification was performed according to tumor focality and trial site. Additional predefined secondary end points (rates of node-positive patients and of completion axillary lymph node dissection) were analyzed to rule out differences in the reliable detection of nodal metastases.

RESULTS

Between May 2014 and October 2015, 1,198 patients were randomly assigned in 23 German and Swiss breast centers. Modified intention-to-treat analysis (n = 1,163) showed a mean number of histologically detected SLNs of 2.21 with LSG and 2.26 without LSG (difference 0.05; stratified 95% CI, −0.18 to infinity), thus establishing noninferiority of omitting preoperative LSG. Secondary end points displayed no statistically significant differences.

CONCLUSION

We show that SLNB is equally effective irrespective of the surgeon’s knowledge of preoperative LSG results. SLNB without LSG will speed up the preoperative workflow and reduce cost.

Papillary thyroid carcinoma with bilateral axillary lymph node involvement: a case report outlining hypothesis for locoregional spread and therapeutic implications

Axillary lymph node involvement (ALNI) in well differentiated papillary thyroid carcinoma (WDPTC) is a rare sequela of disease presentation. We report a case of PTC with extensive cervical lymph node involvement, local extension to the skin of the neck and bilateral ALNI without evidence of distant disease. We posit that ALNI represents local extension of disease rather than distant metastasis. Therefore, in the absence of distant spread, ALNI should result in surgical intervention. This optimizes removal of all bulky disease and increases effectiveness of radioactive iodine (RAI) therapy. Future research centered on genomics should focus on ascertaining the behavior and prognosis of such cases, especially when anatomic spread is discordant with biologic behavior.

"Sentinel lymph node imaging with sequential SPECT/CT lymphoscintigraphy before and after neoadjuvant chemoradiotherapy in patients with cancer of the oesophagus or gastro-oesophageal junction - a pilot study"

BACKGROUND

In current best practise, curatively intended treatment for oesophageal cancer usually consists of neoadjuvant chemo-radiotherapy (nCRT) or perioperative chemotherapy, and oesophagectomy. Sentinel Lymph Node Biopsy (SLNB) has the potential to identify patients without lymph node metastases and thus improve the staging accuracy and influence treatment. The impact of neoadjuvant treatment on the lymphatic drainage of oesophageal cancers and subsequently the SLNB procedure in this tumour type has previously not been well studied.

PURPOSE

To evaluate changes in lymphatic drainage patterns of the tumour in patients with cancer of the oesophagus or gastro-oesophageal junction (GOJ) using Sentinel Lymph Node (SLN) hybrid SPECT/CT lymphoscintigraphy before and after nCRT.

METHODS

Patients with clinical stage T2-T3, any N-stage, M0 cancer of the oesophagus or GOJ underwent endoscopically guided peri-/intratumoral injection of radio-colloid followed by hybrid SPECT/CT lymphoscintigraphy prior to, and once again following, nCRT. SPECT/CT images were evaluated to number and location of SLNs and compared between the two examinations.

RESULTS

Ten patients were included in this pilot trial. SPECT/CT lymphoscintigraphy was performed in twenty procedures. The same Sentinel Lymph Node station before and after nCRT was observed in one single patient. In two patients, no SLN was detected before nCRT. In three patients no SLN was detected following nCRT. In four patients, the SLN stations were not the same station at baseline compared to follow-up examination.

CONCLUSIONS

The reproducibility SLN detection in patients with cancer of the oesophagus/GOJ following nCRT was very poor. nCRT appears to alter lymphatic drainage patterns and thus may affect detection of SLNs and potentially also the accuracy of an SLNB in these patients. On the basis of these initial results, we abort further patient recruitment in our institution.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR). Identifier ACTRN12618001433291 . Date registered: 27/08/2018. Retrospectively registered.

Internal Mammary Chain Sentinel Nodes in Early-Stage Breast Cancer Patients: Toward Selective Removal

BACKGROUND

Removal of internal mammary chain sentinel nodes (IMCSNs) affects prognosis and treatment of breast cancer, and internal mammary chain radiotherapy (IMCRT) can improve survival for selected patients. This study aimed to determine the effect of IMCSN biopsy on recurrence-free survival (RFS) and overall survival (OS) and to identify predictive factors for IMCSN and distant metastasis.

METHODS

Patients with IMCSNs were selected from a prospective database for the period 1999-2007. Lymphoscintigraphy was performed after intratumoral technetium-99 m injection, and all sentinel nodes were removed. Both RFS and OS were calculated for subgroups with tumor-positive, tumor-negative, or non-removed IMCSNs. Predictive factors were identified for tumor-positive IMCSNs and distant metastasis by regression analysis.

RESULTS

For 287 (85%) of 336 patients, IMCSN biopsy was performed, and metastasis was detected in 38 patients (13%). The patients with tumor-positive IMCSNs had poorer OS than the patients with no IMCSN metastasis or non-removed IMCSNs (p = 0.002). These patients also had worse RFS due to distant metastasis (p = 0.002). Axillary metastasis was predictive for tumor-positive IMCSNs (positive predictive value, 38.5%). The predictive factors for distant metastasis were tumor-positive IMCSNs (hazard ratio [HR], 2.5), non-removed IMCSNs (HR, 2.3), tumor diameter greater than 1.5 cm (HR, 3.5), and age older than 65 years (HR, 3.1; reference, < 50 years).

CONCLUSIONS

Patients with IMCSNs have worse survival due to distant metastasis. The clinically relevant predictive factor for distant metastasis is tumor larger than 1.5 cm. According to the authors' current protocol, IMCSN biopsy is performed for patients younger than 70 years who have a tumor larger than 1.5 cm, with the cardiotoxicity of the adjuvant IMCRT weighed against the survival benefit.

Comparison between single photon emission computed tomography with computed tomography and planar scintigraphy in sentinel node biopsy in breast cancer patients

Objective

Radio-guided sentinel node (SN) biopsy is a standard method used in the treatment of early breast cancer. Single photon emission computed tomography with computed tomography (SPECT/CT) has been commonly used for SN detection. SPECT/CT adds precise anatomical information of SN sites, and it is reported that more SNs may be detectable on SPECT/CT than on planar imaging. We here investigate which breast cancer patients have benefited from SPECT/CT over planar imaging.

Methods

A total of 273 breast cancer patients including 80 with ipsilateral breast tumor relapse (IBTR) underwent both multiple-view planar imaging and SPECT/CT for SN detection. The number of SNs, the patients who had benefitted from SPECT/CT, and the SN procedure failure rate were compared between SPECT/CT and planar imaging. Factors influencing the visualization of para-sternal and ipsilateral level II, III nodes, and contralateral axillary nodes were also analyzed using logistic regression analysis.

Results

The number of hot spots did not differ between SPECT/CT and multiple-view planar imaging. Eight contaminated patients and 52 patients with visualized extra-level I axillary nodes benefited from identifying precise anatomical sites. Even though radioactive nodes could be harvested in most (192/193) of the non-IBTR patients (7/8 in non-SN visible patients), no radioactive nodes could be found during surgery in 11 of 80 IBTR patients. Axillary surgery (dissection) increased the visualization of para-sternal and level II, III axillary nodes, and previous irradiation increased the visualization of contralateral axillary nodes.

Conclusion

Multiple-view planar imaging was equivalent to SPECT/CT for depicting hot nodes for radio-guided SN detection in breast cancer. SPECT/CT was useful when precise anatomical information was necessary, especially regarding sentinel lymph nodes other than ipsilateral axilla. Logistic regression analysis revealed that axillary surgery (dissection) increased the visualization of para-sternal and level II, III axillary nodes, and the only relevant factor influencing visualization of contralateral axillary SNs was previous radiation to the breast.

Anatomical classification of breast sentinel lymph nodes using computed tomography-lymphography

To evaluate the anatomical classification and location of breast sentinel lymph nodes, preoperative computed tomography–lymphography examinations were retrospectively reviewed for sentinel lymph nodes in 464 cases clinically diagnosed with node-negative breast cancer between July 2007 and June 2016. Anatomical classification was performed based on the numbers of lymphatic routes and sentinel lymph nodes, the flow direction of lymphatic routes, and the location of sentinel lymph nodes. Of the 464 cases reviewed, anatomical classification could be performed in 434 (93.5 %). The largest number of cases showed single route/single sentinel lymph node (n = 296, 68.2 %), followed by multiple routes/multiple sentinel lymph nodes (n = 59, 13.6 %), single route/multiple sentinel lymph nodes (n = 53, 12.2 %), and multiple routes/single sentinel lymph node (n = 26, 6.0 %). Classification based on the flow direction of lymphatic routes showed that 429 cases (98.8 %) had outward flow on the superficial fascia toward axillary lymph nodes, whereas classification based on the height of sentinel lymph nodes showed that 323 cases (74.4 %) belonged to the upper pectoral group of axillary lymph nodes. There was wide variation in the number of lymphatic routes and their branching patterns and in the number, location, and direction of flow of sentinel lymph nodes. It is clinically very important to preoperatively understand the anatomical morphology of lymphatic routes and sentinel lymph nodes for optimal treatment of breast cancer, and computed tomography–lymphography is suitable for this purpose.

Sequential Sentinel Node Scintigraphy With Planar and SPECT/CT Images Revealed Contralateral Drainage From Ipsilateral Breast Tumor Relapse in a Patient With Bilateral Breast Cancer

Radio-guided sentinel node (SN) biopsy is routinely performed in patients with early breast cancer. However, repeated SN scintigraphy in ipsilateral breast tumor relapse (IBTR) often shows extra-axillary drainage, including contralateral axilla. A patient diagnosed with bilateral breast cancer, of which one was IBTR, was studied by sequential radio-guided SN mapping, radiocolloid injection to an IBTR breast and scanning, and then radiocolloid injection to the other breast and scanning. This revealed the lymphatic flow from the IBTR breast to the contralateral axilla. Sequential method may help to depict contralateral axillary lymphatic flow from an IBTR breast in patients with bilateral breast cancer.

Influence of previous breast surgery in sentinel lymph node biopsy in patients with breast cancer

AIM

The aim of this study was to review the feasibility of selective sentinel lymph node biopsy in patients with previous surgery for breast cancer, as well as to examine the factors that may interfere with sentinel node detection.

MATERIAL AND METHODS

A retrospective review was performed on 91 patients with breast cancer and previous breast surgery, and who underwent sentinel lymph node biopsy. Patients were divided into two groups according to their previous treatment: aesthetic breast surgery in 30 patients (group I) and breast-conserving surgery in 61 (group II). Lymphoscintigraphy was performed after an intra-tumour injection in 21 cases and a peri-areolar injection in 70 cases. An analysis was made of lymphatic drainage patterns and overall sentinel node detection according to clinical, pathological and surgical variables.

RESULTS

The overall detection of the sentinel lymph node in the lymphoscintigraphy was 92.3%, with 7.7% of extra-axillary drainages. The identification rate was similar after aesthetic breast surgery (93.3%) and breast-conserving surgery (91.8%). Sentinel lymph nodes were found in the contralateral axilla in two patients (2.2%), and they were included in the histopathology study. The non-identification rate in the lymphoscintigraphy was 7.7%. There was a significantly higher non-detection rate in the highest histological grade tumours (28.6% grade III, 4.5% grade I and 3.6% grade II).

CONCLUSION

Sentinel lymph node biopsy in patients with previous breast surgery is feasible and deserves further studies to assess the influence of different aspects in sentinel node detection in this clinical scenario. A high histological grade was significantly associated with a lower detection.

Contribution of SPECT/CT for sentinel node localization in patients with ipsilateral breast cancer relapse

Background

In recent years repeat sentinel node (SN) biopsy has been proven to be feasible in local breast cancer recurrence (LBCR). However, in these patients SNs outside the ipsilateral axilla are frequently observed. This study evaluates the contribution of SPECT/CT for SN localization and surgical adjustment in LBCR patients.

Methods

SN biopsy was performed in 122 LBCR patients (median age 60.5 years, range 24–87), enrolled from August 2006 to July 2015. Median disease-free time lapse was 109.5 months (range 9–365). Axillary lymph node dissection (ALND) had previously been performed in 55 patients, SN biopsy in 44, both techniques in 13 and fine-needle aspiration in 10. Primary breast cancer treatment included radiotherapy in 104 patients (85.3 %) and chemotherapy in 40 (32.8 %). Preoperative lymphatic mapping, using planar scintigraphy (PS) and SPECT/CT included report of SN location according to lymph node territory. In case of a territorial PS-SPECT/CT mismatch, surgery was adjusted according to SPECT/CT findings.

Results

SPECT/CT SN visualization rate was higher than PS (53.3 % vs. 43.4 %, p n.s.) with, in total, 19 additional SN (118 vs. 99, p n.s.). PS-SPECT/CT territory mismatch, found in 60 % (39/65) of patients with SN visualization, led to surgical adjustment in 21.3 % (26/122) of patients. The SN procedure was finally performed in 104 patients resulting in a 65.7 % surgical retrieval rate with a total of 132 removed SNs (1.86/patient). SN metastases were found in 17/71 patients (23.9 %), in 16 of them (94 %) in ipsilateral basins outside the axilla or in the contralateral axilla.

Conclusion

Using SPECT/CT there is a trend to visualize more SNs in LBCR, providing at the same time important anatomical information to adjust intraoperative SN procedures. The addition of SPECT/CT to the standard imaging protocol may lead to better staging mainly in patients presenting drainage outside the ipsilateral axilla.

Meta-analysis of aberrant lymphatic drainage in recurrent breast cancer

Background

Sentinel node biopsy (SNB) in recurrent breast cancer offers targeted axillary staging compared with axillary lymph node dissection (ALND) or no treatment. The evidence for lymphatic mapping in recurrent breast cancer is reviewed, focusing on aberrant drainage and its implications for patient management.

Methods

A meta-analysis of studies evaluating lymphatic mapping in recurrent breast cancer was performed. Outcomes included sentinel node identification, aberrant lymphatic pathways and metastatic node rates in aberrant drainage and ipsilateral axilla. Pooled odds ratios (ORs) and 95 per cent confidence intervals (c.i.) were estimated using fixed-effect analyses, or random-effects analyses in the event of statistically significant heterogeneity.

Results

Seven studies reported data on lymphatic mapping in 1053 patients with recurrent breast cancer. The intraoperative sentinel node identification rate was 59·6 (95 per cent c.i. 56·7 to 62·6) per cent, and significantly greater when the original axillary surgery was SNB compared with ALND (OR 2·97, 95 per cent c.i. 1·66 to 5·32). The rate of aberrant lymphatic drainage identification was 25·7 (23·0 to 28·3) per cent, and significantly greater when the original axillary surgery was ALND (OR 0·27, 0·19 to 0·38). The metastatic sentinel node rate was 10·4 (8·6 to 12·3) per cent, and a significantly greater metastatic nodal burden was identified in the ipsilateral axilla (OR 6·31, 1·03 to 38·79).

Conclusion

Lymphatic mapping is feasible in recurrent breast cancer. It avoids ALND in over 50 per cent of patients who have undergone SNB, and allows the 4 per cent of patients with metastatically involved aberrant nodes to receive targeted surgical and adjuvant therapies.

Interaction between vascularized lymph node transfer and recipient lymphatics after lymph node dissection-a pilot study in a canine model

BACKGROUND

Vascularized lymph node transfer (VLNT) has become more widespread for surgical treatment of lymphedema. However, interaction between a transferred lymph node and the recipient lymphatic system in relieving lymphedema has not been identified. The aims of this study were to investigate anatomic changes in the lymphatic system in the forelimb of a canine after lymph node dissection and irradiation and to clarify the interaction between the transferred lymph node and recipient lymphatics.

MATERIALS AND METHODS

Two adult female mongrel canines were used for this exploratory study. The unilateral axillary and lower neck node dissections were performed, and 15-Gy irradiation was applied on postoperative day 3. After 1 y, a VLNT flap was harvested from the lower abdominal region and inset in the axilla with vascular anastomoses. The girth of each forelimb was determined with a tape measure at different time points. Indocyanine green fluorescence lymphography and lymphangiography were performed before and after each surgery to evaluate morphologic changes in the lymphatics.

RESULTS

Both canines revealed identical changes in the lymphatic system, but only one canine developed lymphedema. After lymph node dissection, a collateral lymphatic pathway formed a connection to the contralateral cervical node. After VLNT, an additional collateral pathway formed a connection to the internal mammary node via the transferred node in the axilla.

CONCLUSIONS

The findings suggest that the lymphatic system has a homing mechanism, which allows the severed lymphatic vessels to detect and connect to adjacent lymph nodes. VLNT may create new collateral pathways to relieve lymphedema.

Prevalence and clinical significance of supra- or infraclavicular drainage on preoperative lymphoscintigraphy in women with breast cancer

OBJECTIVE

Preoperative sentinel lymph node (SLN) mapping by lymphoscintigraphy is helpful to evaluate extra-axillary SLNs over a wider range than the blue dye method. However, the clinical value of extra-axillary SLNs remains uncertain. The goal of this study was to determine the prevalence and clinical significance of supra- or infraclavicular drainage on preoperative lymphoscintigraphy in women with breast cancer.

MATERIALS AND METHODS

We retrospectively reviewed the files of 942 consecutive breast cancer women who underwent preoperative lymphoscintigraphy for SLN biopsy at our institution between April 2004 and March 2015.

RESULTS

Supra- or infraclavicular drainage was detected in 5/942 women (0.5%) on preoperative lymphoscintigraphy. An axillary hot spot was detected in all five women, and a positive axillary SLN was detected in four women. Breast tumor locations were the upper inner or outer quadrants in four women and the lower outer quadrant in one woman. The median follow-up period was 75 months (mean: 92; range: 26-111 months). Recurrence outside the axilla was found in three (60%) women. The woman with a negative SLN status did not undergo adjuvant chemotherapy, but developed extra-axillary lymph node recurrence 3 years after primary surgery. No patient died of metastatic breast cancer at the last follow-up.

CONCLUSIONS

The detection of the supra- or infraclavicular SLNs on lymphoscintigraphy may provide additional staging information to tailor individual treatment regimens with regard to the potential risk of recurrence or metastasis of breast cancer.

The hidden sentinel node in breast cancer: Reevaluating the role of SPECT/CT and tracer reinjection

INTRODUCTION

Lymphoscintigraphy with planar imaging is considered a helpful tool to depict lymph node drainage in patients with invasive breast cancer. Single Photon Emission Computed Tomography with integrated CT (SPECT/CT) is usually performed to detect sentinel nodes (SN)s in breast cancer patients showing non-visualisation on lymphoscintigraphy. Incorporation of new SN indications (recurrent surgery, previous radiotherapy, or neo-adjuvant chemotherapy) has led to an increase of non-visualisation rates. The present study evaluates the contribution of SPECT/CT and tracer reinjection for SN-visualisation in breast cancer patients without drainage on lymphoscintigraphy.

METHODS

Between 1st of July 2008 and 6th of November 2014 in total 1968 patients underwent a SN breast procedure, using intra-tumoural tracer administration. SPECT/CT was performed in 284 breast cancer patients with non-visualisation of SNs on lymphoscintigraphy. If SN non-visualisation persisted, a second radiotracer injection with repeated imaging was performed when logistics allowed this. Univariate analysis was applied to evaluate SPECT/CT visualisation rates in specific subgroups.

RESULTS

The SPECT/CT visualisation rate was 23.2% (66/284). Univariate analysis revealed no significant subgroups influencing SPECT/CT visualisation. In patients receiving reinjection after persistent SPECT/CT non-visualisation the SN-visualisation rate reached 62.1% (36/58). Intraoperatively, the SN-identification rate using a gamma probe and blue dye was 87.9% (175/199) and 32.9% (28/85) for, respectively, primary and recurrent surgery after non-visualisation on lymphoscintigraphy.

CONCLUSION

In this evaluation including new breast cancer SN indications, SPECT/CT scored lower than reinjection to visualise SNs in patients with non-visualisation on lymphoscintigraphy. Consequently, our institutional protocol has been readjusted.

Sentinel Lymph Node Detection in Contralateral Axilla at Initial Presentation of a Breast Cancer Patient: Case Report

The main basin for breast lymphatic drainage is ipsilateral axilla. However, extra-axillary drainage may be seen in some patients. The most common extra-axillary site is internal mammary chain, while contralateral axillary drainage is an extremely rare situation in previously untreated patients. We describe a case of untreated right breast retroareolar carcinoma with contralateral axillary drainage detected on preoperative lymphoscintigraphy. Contralateral axillary dissection was performed based on the result of frozen section examination of the sentinel lymph node (SLN) which turned out to burden micrometastasis. Postoperative histopathological examination revealed invasive ductal carcinoma metastasis in 17 out of 22 lymph nodes from the ipsilateral axillary dissection, whereas 14 lymph nodes from contralateral axillary dissection other than the SLN were nonmetastatic. In our opinion, determination of contralateral axillary metastasis in primary staging process had a major contribution to the management of the patient.

Contralateral lymph node recurrence in breast cancer: Regional event rather than distant metastatic disease. A systematic review of the literature

AIMS

After treatment for breast cancer, some patients experience a contralateral lymph node recurrence (CLNR). Traditionally, contralateral nodes are considered a distant site. However, aberrant lymph drainage after previous surgery is common. This might indicate that CLNR is a regional event. This study aimed to review the literature to determine prognosis after CLNR.

METHODS

PubMed was searched up until July 2014. Articles on CLNR with or without ipsilateral breast tumour recurrence (IBTR), and repeat sentinel node (SN) studies reporting on positive contralateral nodes were included. Exclusion criteria were synchronous contralateral breast cancer and synchronous distant events.

RESULTS

24 articles were included, describing 48 patients. Of these 48, 26 patients had an isolated CLNR, 7 IBTR and clinically detected CLNR, and 15 IBTR with a positive contralateral repeat SN. Isolated CLNR occurred earlier (45.9 months) than IBTR with CLNR (126.6 months, p < 0.001) or with a positive contralateral repeat SN (217.2, p = 0.02). Surgical treatment was described for 38 patients, and consisted of axillary lymph node dissection for 34 (89.5%). Information on adjuvant therapy was available for 27 patients, 21 (77.8%) received chemotherapy. Follow-up information after CLNR was available for 23 patients (47.9%). Mean follow-up was 50.3 months. Overall survival and disease-free survival were 82.6% [95% CI 67.1-98.1] and 65.2% [45.7-84.7] respectively at last follow-up.

CONCLUSIONS

Although observed in a small population, the survival of CLNR is not comparable to distant disease. Most patients received locoregional and systemic treatment suggesting a curative approach. This indicates that CLNR should be regarded as a regional event.

Invasive mucinous carcinoma arising in ectopic axillary breast tissue: a case report and literature review

BACKGROUND

Invasive mucinous carcinoma arising in ectopic axillary breast tissue is an uncommon diagnosis. While some published medical literature makes recommendations regarding the management of ectopic primaries, many of these recommendations are outdated. We therefore hope to provide general guidance with the management of this rare entity.

CASE REPORT

We report a case of a 70-year-old woman with primary invasive mucinous carcinoma of ectopic breast tissue. A literature study was performed on primary ectopic breast carcinoma. This case report with review of the literature was performed to provide rationales for a more conservative treatment based upon current data and treatment paradigms. Although the diagnosis of primary ectopic breast carcinoma is uncommon, the presence of a suspicious nodule along the mammary ridge should alert the clinician to consider the possibility of this diagnosis. A mammogram and ultrasound of the nodule were performed and the suspicious nodule was biopsied, confirming the diagnosis. Breast conservation was performed with standard nodal evaluation.

CONCLUSIONS

The management of primary ectopic breast carcinoma should be based upon current breast conservation techniques of orthotopic breast cancer. Current data suggest that standard treatment paradigms remain applicable to this rare clinical entity.

Management of sentinel node re-mapping in patients who have second or recurrent breast cancer and had previous axillary procedures

BACKGROUND

In patients with recurrent or second primary ipsilateral breast cancer, axillary staging is the key factor in locoregional control and a strong prognostic characteristic. The efficient evaluation of lymphatic drainage of re-sentinel lymph node biopsies (re-SLNBs) has remained a challenge in the management of ipsilateral primary or recurrent breast cancer patients who are clinically lymph node negative. This study explores whether a SLNB for patients with primary or recurrent breast cancer is possible after previous axillary surgery. It evaluates potential reasons for mapping failure that might be associated with patients in this group.

METHODS

Between March 2006 and November 2013, 458 patients were subjected to a breast SLNB. A lymphoscintigraphy procedure was performed on 330 patients for sentinel lymph node (SLN) mapping on the day of surgery. Seven patients with either a second primary cancer in the same breast or recurrent breast cancer were described. Two of these seven patients had axillary lymph node dissection (ALND) during previous treatments and five had SLNB. A dual mapping method was used for all patients. Preoperative lymphoscintigraphy was performed four hours before surgery.

RESULTS

SLNs were successfully remapped in six of seven (85.7%) patients, of whom five (71.43%) had previously undergone SLNB and two (28.57%) previous ALND. Localizations of SLNs were ipsilateral axillary in three patients, ipsilateral internal mammary in one patient, and contralateral axillary in two patients. An altered distribution of lymph nodes was discovered in both patients with previous ALND. In one of the two patients, metastases were found in an aberrant lymph drainage basin at the location of a non-ipsilateral axillary node (contralateral axillary SLN). The second previously ALND patient had an internal mammary SLN. In one patient, mapping was unsuccessful and the SLN was not identified.

CONCLUSIONS

Altered lymphatic drainage incidence increases following breast-conserving surgery for an initial breast cancer, and the location of SLNs becomes unpredictable at the time of a second primary or recurrent ipsilateral breast cancer. This leads to the necessity of using a radionuclide (lymphoscintigraphy) for a successful re-mapping procedure. A re-SLNB is precise and beneficial even though there are few patients. A lymphoscintigraphy can identify SLNs at their new unpredicted location.

Individualized image-based lymph node irradiation for prostate cancer

Controversy surrounds the benefit of whole pelvis radiotherapy (WPRT) over prostate-only radiotherapy (PORT) for intermediate-risk and high-risk patients with prostate cancer. In the PSA screening era, two large randomized trials as well as multiple retrospective studies comparing WPRT with PORT have been performed, albeit with contradictory results. Data regarding the use of WPRT in patients with biochemical recurrence after prostatectomy are scarce. As a consequence, the practice of WPRT varies worldwide. Advanced highly accurate imaging methods for the detection of lymph node metastases in patients with prostate cancer have been developed, such as PET, single photon emission computed tomography (SPECT), diffusion-weighted MRI and magnetic resonance lymphography (MRL). The use of these new imaging methods might improve nodal irradiation, as they can be used not only for selection of patients, but also for accurately determining the target volume to reduce geographical miss. Furthermore, these new techniques can enable dose escalation to involved lymph nodes.

Bilateral axillary and internal mammary drainage in breast cancer without prior surgery during sentinel node mapping

Lymphatic drainage outside the ipsilateral axilla in breast cancer is discovered in as many as 25% of all sentinel lymph node procedures and it is evidenced by lymphoscintigraphy. Contralateral axillary drainage is a rare clinical situation, mostly if there is not prior breast surgery, but this situation is extremely exceptional if we also found internal mammary chain drainage. We have not found such a case published in literature. This atypical finding is source of doubts because it could have clinical implications in the management of patients. We present a woman just diagnosed of breast carcinoma with hot nodes in bilateral axillary and ipsilateral internal mammary chain lymph nodes, shown by preoperative lymphoscintigraphy. We review published cases with contralateral axillary drainage, which enhance the role of scintigraphic procedure in such cases and show induced controversies in selecting the most adequate management.

Repeat sentinel node biopsy in patients with locally recurrent breast cancer: a systematic review and meta-analysis of the literature

Axillary staging in patients with locally recurrent breast cancer is important for obtaining locoregional control and predicting prognosis. The aim of the present study is to determine technical feasibility, validity, aberrant drainage patterns and clinical consequences of performing repeat sentinel node biopsy (SNB) in these patients. We performed a systematic review and meta-analysis of the literature and included all studies on repeat SNB in locally recurrent breast cancer. A total of 692 patients were described, 301 after a previous SNB, 361 after a previous axillary lymph node dissection (ALND), and 30 with no previous axillary surgery. Sentinel node identification was successful in 452 of the 692 patients (65.3 %), which was significantly higher in patients who had undergone previous SNB compared to previous ALND (81.0 vs. 52.2 %) (P < 0.0001). In 175 of 405 patients with successful lymphatic mapping aberrant drainage pathways were visualized (43.2 %), which were seen more frequently after previous ALND than after previous SNB (69.2 vs. 17.4 %) (P < 0.0001). In 19.2 % of the patients the sentinel node was tumor positive and 27.5 % of these metastases were found in aberrant lymph drainage basins. Overall, 213 patients could be spared an ALND and in 17.9 % of the patients the information derived from the repeat SNB led to a change in adjuvant radiotherapy or systemic treatment plans. The procedure had a false-negative rate of 0.2 %. Repeat SNB is technically feasible and accurate. Next to sparing patients an unnecessary ALND, the information can lead to a change in adjuvant treatment strategy.

Sentinel node biopsy for oral and oropharyngeal squamous cell carcinoma in the previously treated neck

In patients with early stage oral or oropharyngeal squamous cell carcinoma (OSCC) sentinel node biopsy (SNB) is a reliable method to detect occult disease in the neck. However, patients with a history of surgery or radiotherapy in the neck may have aberrant lymphatic drainage caused by disruption of lymphatic channels. Therefore, treatment of the same levels at risk as in the primary setting may not be appropriate. The aim of our prospective observational study was to evaluate the clinical application of SNB in previously treated OSCC. Between 2003 and 2010 twenty-two patients were included. Lymph node mapping consisted of preoperative lymphoscintigraphy, SPECT/CT, intraoperative use of gamma-probe and patent blue. Endpoints were the sentinel node (SN) detection rate, unexpected lymphatic drainage patterns, negative predictive value and regional tumor control. 4/22 (18%) Patients were previously treated only on the contralateral site. The SN detection rate was 100% and unexpected drainage was found in 1/4 patients. The other 18 patients had ipsi- or bilateral previous neck treatment and a SN detection rate of 83%. The upstaging rate was 7% and 67% had unexpected lymphatic drainage patterns. The median follow-up was 22 months. Regional tumor control and negative predictive value were 100%. SNB in previously treated OSCC patients is feasible. SN detection is reliable and regional tumor control after staging by SNB is excellent. Moreover, SNB renders an assessment of the individual lymphatic drainage pattern, compensating for a potential variability after previous treatment of the neck.

Predicting lymphatic drainage patterns and primary tumour location in patients with breast cancer

Detailed knowledge of the lymphatic drainage of the breast is limited. Lymphoscintigraphy is a technique used during breast cancer treatment to accurately map patterns of lymphatic drainage from the primary tumour to the draining lymph nodes. This study aimed to create a statistical model to analyse the spread of breast cancer and primary tumour location using a large lymphoscintigraphy database, and visualise the results with a novel computational model. This study was based on lymphoscintigraphy data from 2,304 breast cancer patients treated at the Royal Prince Alfred Hospital Medical Centre in Sydney, Australia. Bayesian inferential techniques were implemented to estimate the probabilities of lymphatic drainage from each region of the breast to each draining node field, to multiple node fields, and to determine probabilities of tumour prevalence in each breast region. A finite element model of the torso and discrete model of the draining node fields were created to visualise these data and a software tool was developed to display the results ( www.abi.auckland.ac.nz/breast-cancer ). Results confirmed that lymphatic drainage is most likely to occur to the axillary node field, and that there is significant likelihood of drainage to the internal mammary node field. The likelihood of lymphatic drainage from the whole breast to the axillary, internal mammary, infraclavicular, supraclavicular and interpectoral node fields were 98.2, 35.3, 1.7, 3.1, and 0.7%, respectively; whilst the probability of lymphatic drainage to multiple node fields was estimated to be 36.4%. Additionally, primary tumours are most likely to develop in the upper regions of the breast. The models developed provide quantitative estimates of lymphatic drainage of the breast, giving important insights into understanding breast cancer metastasis and have the potential to benefit both clinicians and patients during breast cancer diagnosis and treatment.

Second primary ipsilateral breast cancer with contralateral axillary involvement: a case report and literature review

After breast-conserving surgery for an initial breast cancer, the incidence of lymphatic drainage to sites other than the ipsilateral axilla, such as the contralateral axilla, increases significantly at the time of a second primary ipsilateral breast cancer. Given the likelihood of altered lymphatic drainage, and in the absence of distant metastatic sites, consideration should be given to treating patients with a second primary ipsilateral breast cancer and contralateral axillary lymph node involvement with curative intent. This clinical issue may become more common as the incidence of second primary ipsilateral breast cancer would be expected to increase due to widespread adoption of breast-conserving surgery, improved prognosis for patients with an initial early-stage breast cancer, and highly sensitive screening modalities such as magnetic resonance imaging.