Internal Mammary Node Drainage and its Role in Sentinel Lymph Node Biopsy: The Initial ALMANAC Experience

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Should internal mammary lymph node sentinel biopsy be performed in breast cancer: a systematic review and meta-analysis

Purpose

Results from studies of internal mammary lymph node sentinel biopsy are inconsistent.

Methods

A comprehensive literature search was conducted in MEDLINE, EMBASE, Scopus, Cochrane database, and Clinical Trials. Studies reporting the rate of internal mammary lymph node sentinel biopsy (IMN-SLNB) positivity were identified. We performed pooled proportion meta-analysis using random-effects meta-analyses. The correlation of IMN and axillary lymph node (AXN) metastasis was also investigated.

Results

After application of inclusion and exclusion criteria, a total of 18 articles (total number of patients = 2427) were included. The pooled estimate for IMN-SLNB positivity rate was 15% (95% confidence interval (CI) 12–17%). Significant between-study heterogeneity was observed. Our results indicate that axillary lymph node metastasis is a strong predictor of IMN involvement (OR 6.01, 95% CI, 3.49, 10.34).

Conclusion

Internal mammary lymph nodes metastasis might be underestimated. Patients with positive axillary lymph nodes have a higher risk of internal lymph nodes metastasis. As a result, IMN-SLNB might be considered in these patients. Future work needs to be done to assess whether pathological confirmed IMN metastasis can affect patients’ survival.

Analysis of molecular markers as predictive factors of lymph node involvement in breast carcinoma

Nodal status is the most significant independent prognostic factor in breast cancer. Identification of molecular markers would allow stratification of patients who require surgical assessment of lymph nodes from the large numbers of patients for whom this surgical procedure is unnecessary, thus leading to a more accurate prognosis. However, up to now, the reported studies are preliminary and controversial, and although hundreds of markers have been assessed, few of them have been used in clinical practice for treatment or prognosis in breast cancer. The purpose of the present study was to determine whether protein phosphatase Mg2+/Mn2+ dependent 1D, β-1,3-N-acetylglucosaminyltransferase, neural precursor cell expressed, developmentally down-regulated 9, prohibitin, phosphoinositide-3-kinase regulatory subunit 5 (PIK3R5), phosphatidylinositol-5-phosphate 4-kinase type IIα, TRF1-interacting ankyrin-related ADP-ribose polymerase 2, BCL2 associated agonist of cell death, G2 and S-phase expressed 1 and PAX interacting protein 1 genes, described as prognostic markers in breast cancer in a previous microarray study, are also predictors of lymph node involvement in breast carcinoma Reverse transcription-quantitative polymerase chain reaction analysis was performed on primary breast tumor tissues from women with negative lymph node involvement (n=27) compared with primary tumor tissues from women with positive lymph node involvement (n=23), and was also performed on primary tumors and paired lymph node metastases (n=11). For all genes analyzed, only the PIK3R5 gene exhibited differential expression in samples of primary tumors with positive lymph node involvement compared with primary tumors with negative lymph node involvement (P=0.0347). These results demonstrate that the PIK3R5 gene may be considered predictive of lymph node involvement in breast carcinoma. Although the other genes evaluated in the present study have been previously characterized to be involved with the development of distant metastases, they did not have predictive potential.

Troubleshooting Sentinel Lymph Node Biopsy in Breast Cancer Surgery

BACKGROUND

Performing a sentinel lymph node biopsy (SLNB) is the standard of care for axillary nodal staging in patients with invasive breast cancer and clinically negative nodes. The procedure provides valuable staging information with few complications when performed by experienced surgeons. However, variation in proficiency exists for this procedure, and a great amount of experience is required to master the technique, especially when faced with challenging cases. The purpose of this paper was to provide a troubleshooting guide for commonly encountered technical difficulties in SLNB, and offer potential solutions so that surgeons can improve their own technical performance from the collective knowledge of experienced specialists in the field.

METHODS

Information was obtained from a convenience sample of six experienced breast cancer specialists, each actively involved in training surgeons and residents/fellows in SLNB. Each surgeon responded to a structured interview in order to provide salient points of the SLNB procedure.

RESULTS

Four of the key opinion surgical specialists provided their perspective using technetium-99 m sulfur colloid, and two shared their experience using blue dye only. Distinct categories of commonly encountered problem scenarios were presented and agreed upon by the panel of surgeons. The responses to each of these scenarios were collected and organized into a troubleshooting guide.

DISCUSSION

We present a compilation of 'tips' organized as a troubleshooting guide to be used to guide surgeons of varying levels of experience when encountering technical difficulties with SLNB.

Intraoperative radiocolloid injection for sentinel node biopsy postneoadjuvant chemotherapy

BACKGROUND

This study sought to determine significance of radiocolloid injection timing for sentinel node biopsy (SNB) after neoadjuvant chemotherapy (NAC).

MATERIAL AND METHODS

A retrospective comparison of intraoperative (IRCI) and preoperative (PRCI) radiocolloid injection for SNB was performed in breast cancer patients who had completed NAC. The sentinel node identification rate (SNIDR) was tested for noninferiority by a two-proportion z-test. The differences between clinical demographics, pathologic demographics, and SNIDR were evaluated by Fisher exact test. The difference in the number of sentinel nodes removed was analyzed by two-sample t-test.

RESULTS

In the 6-y study period, 120 SNB were performed after NAC: 84 received PRCI and 36 received IRCI. The two groups were similar except there were fewer clinical T2 and more clinical T3 and T4 with IRCI (P = 0.0008). The SNIDR was 92.9% with PRCI and 80.6% with IRCI. By two-proportion z-test, IRCI was not "noninferior" (P = 0.5179). By Fisher exact test, the SNIDR of the two groups did not differ. The SNIDR differs only in patients who experience T downstaging (100% versus 80%, P = 0.0173). The mean number of lymph nodes removed was higher with IRCI: 3.38 versus 2.49 nodes (P = 0.0068). There were more positive SNB with IRCI: 32.1% versus 55.2%, (P = 0.0432). The incidence of nontherapeutic axillary dissection was similar between the two groups (3.6% for PRCI versus 5.6% for IRCI).

CONCLUSIONS

IRCI for SNB after NAC may be inferior to PRCI.

Meta-analysis of superficial versus deep injection of radioactive tracer and blue dye for lymphatic mapping and detection of sentinel lymph nodes in breast cancer

BACKGROUND

Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in early breast cancer. Currently, no consensus exists on the optimal site of injection of the radioactive tracer or blue dye.

METHODS

A systematic review and meta-analysis of studies comparing superficial and deep injections of radioactive tracer or blue dye for lymphatic mapping and SLNB was performed. The axillary and extra-axillary sentinel lymph node (SLN) identification rates obtained by lymphoscintigraphy and intraoperative SLNB were evaluated. Pooled odds ratios (ORs) and 95 per cent c.i. were estimated using fixed-effect analyses, or random-effects analyses if there was statistically significant heterogeneity (P < 0·050).

RESULTS

Thirteen studies were included in the meta-analysis. There was no significant difference between superficial and deep injections of radioactive tracer for axillary SLN identification on lymphoscintigraphy (OR 1·59, 95 per cent c.i. 0·79 to 3·17), during surgery (OR 1·27, 0·60 to 2·68) and for SLN identification using blue dye (OR 1·40, 0·83 to 2·35). The rate of extra-axillary SLN identification was significantly greater when deep rather than superficial injection was used (OR 3·00, 1·92 to 4·67). The discordance rate between superficial and deep injections ranged from 4 to 73 per cent for axillary and from 0 to 61 per cent for internal mammary node mapping.

CONCLUSION

Both superficial and deep injections of radioactive tracer and blue dye are effective for axillary SLN identification. Clinical consequences of discordance rates between the two injection techniques are unclear. Deep injections are associated with significantly greater extra-axillary SLN identification; however, this may not have a significant impact on clinical management.

Identification of the sentinel lymph node in the SNAC-1 trial

BACKGROUND

A combination of scintigraphy and a lymphotropic dye (patent blue dye (BD)) is the recommended technique to detect the sentinel lymph node (SLN) in early breast cancer. This study determined the effect of clinical factors on SLN identification in the sentinel node biopsy versus axillary clearance (SNAC) trial.

METHODS

A total of 1088 women were registered. Lymphatic mapping was performed using preoperative lymphoscintigraphy (LSG) and gamma probe (GP) combined with peritumoural injection of patent BD (971 patients) or BD alone (106 patients).

RESULTS

SLNs were identified in 1024 women (94%), localized with LSG in 779 (81.4%), and were identified by GP in 879 (91.8%). The BD identified SLNs in 890 of 1073 (82%) women. Three patients had allergic reactions. BD detected the SLNs in 141 of 178 women with negative LSG mapping and in 44 of 79 women with no hot SLNs detected intraoperatively. Age, body mass index (BMI) and tumour presentation (screen detected versus symptomatic) were significantly related to the identification of the SLN. For BD, the primary tumour location was significantly related to identification rate. The detection of blue SLN was significantly lower in women with inner quadrant tumours.

CONCLUSION

The combined technique resulted in a high identification rate. BD contributed to the identification of the SLNs in patients where LSG and GP failed to identify the sentinel node. Special attention to these techniques is needed in particular groups of patients such as those with high BMI, screen-detected primary tumours and tumour located in the inner quadrants.

Impact of identification of internal mammary sentinel lymph node metastasis in breast cancer patients

BACKGROUND

Accurate assessment of the internal mammary (IM) nodal basin can impact prognosis and treatment in breast cancer. The goal of this study was to identify characteristics associated with positive IM sentinel lymph nodes (SLNs) and the impact on adjuvant treatment.

METHODS

Clinically node-negative breast cancer patients who underwent SLN dissection including removal of IM SLNs were identified and medical records were reviewed. Statistical analysis was performed using Fisher's exact test and rank-sum tests with a significance level of 0.05.

RESULTS

IM SLNs were removed in 71 patients, 60 (85 %) had negative IM SLNs, whereas 11 (15 %) had positive IM SLNs. Clinicopathologic characteristics were similar between the groups. The majority of patients in both groups had axillary SLNs removed (95 % in the node-negative group vs. 91 % in the node-positive group). Four patients (36 %) with positive IM SLNs had axillary metastasis; thus, IM nodal metastases were the only nodal metastases in 64 % of patients with positive IM SLNs. The identification of IM metastases altered adjuvant therapy in 5 (45 %) patients with positive IM SLNs.

CONCLUSIONS

Patients with positive IM SLNs have clinicopathologic features similar to those of patients with negative IM SLNs limiting the ability to predict IM nodal metastasis preoperatively. The identification of IM nodal metastases significantly impacts treatment decisions, especially when IM nodes are the only site of nodal metastasis. Removal of IM SLNs should be considered when lymphoscintigraphy reveals IM drainage.

A meta-analysis of internal mammary lymph node metastasis in breast cancer patients

BACKGROUND

Knowing the status of the internal mammary lymph (IML) nodes is important for accurate staging and appropriate selection of subsequent treatment in breast cancer. We conducted a meta-analysis to clarify the rate of IML node metastasis in breast cancer patients and discussed the importance of this finding.

METHODS

We retrieved articles from the literature that reported positive rates of IML node metastasis in breast cancer patients. The quality of the selected articles was assessed using the 'Methodological Index for Non-Randomized Studies'. The heterogeneity was tested, and publication bias was assessed using a funnel plot. Finally, the positive rate of IML node metastasis in breast cancer patients was calculated using the random-effects model.

RESULTS

15 articles met the inclusion criteria and a total of 4,248 patients were included in the analysis. Heterogeneity across the studies was statistically significant (p = 0.014); thus, the random-effects model was used and the calculated positive rate of IML node metastasis was 23% (95% confidence interval (CI), 0.21-0.25).

CONCLUSIONS

Approximately 23% of the breast cancer patients had IML node metastases, for which the prognosis is generally poor. Accurate staging and integrated treatment are necessary to improve the survival of these patients.

Results of a national training programme in sentinel lymph node biopsy for breast cancer

BACKGROUND

New Start, a structured, validated, multidisciplinary training programme in sentinel lymph node biopsy (SLNB), was established to allow the introduction and rapid transfer of appropriate knowledge and technical skills to ensure safe and competent practice across the UK.

METHODS

Multidisciplinary teams attended a theory/skills laboratory course, following which they performed 30 consecutive SLNBs, either concurrently with their standard axillary staging procedure (training model A) or as stand-alone SLNB (training model B). SLNB was performed according to a standard protocol using the combined technique of isotope ((99m) Tc-labelled albumin colloid) and blue dye. An accredited New Start trainer mentored the first five procedures in the participant's hospital, or all 30 if stand-alone. Validation standards for model A and B were a localization rate of at least 90 per cent. In addition, for model A only, in which a minimum of ten patients were required to be node-positive, a false-negative rate (FNR) of 10 per cent or less was required.

RESULTS

From October 2004 to December 2008, 210 SLNB-naive surgeons, in 103 centres, performed 6685 SLNB procedures. The overall sentinel lymph node (SLN) localization rate was 98·9 (95 per cent confidence interval 98·6 to 99·1) per cent (6610 of 6685) and the FNR 9·1 (7·9 to 10·5) per cent (160 of 1757). The FNR was related to nodal yield, ranging from 14·8 per cent for one node and declining to 9·7, 6·6, 4·7 and 4·1 per cent for two, three, four and more than four SLNs respectively. No learning curve was identified for localization or FNR.

CONCLUSION

The programme successfully trained a wide range of UK breast teams to perform safe SLNB and suggested that a standard injection protocol and structured multidisciplinary training can abolish learning curves.

Impact of internal mammary lymph node drainage identified by preoperative lymphoscintigraphy on outcomes in patients with stage I to III breast cancer

BACKGROUND

Involvement of internal mammary (IM) lymph nodes is associated with a poor prognosis for patients with breast cancer. This study examined the effect of drainage to IM nodes identified by lymphoscintigraphy on oncologic outcomes.

METHODS

A prospectively maintained breast cancer patient database at the University of Texas MD Anderson Cancer Center was used to identify patients with stage I to III breast cancer who underwent preoperative lymphoscintigraphy with peritumoral injection of colloid and intraoperative lymphatic mapping from 1996 to 2005. Medical records were reviewed of 1772 patients who had drainage to any lymph node basin on lymphoscintigraphy but who did not undergo IM nodal biopsy. Patients with IM drainage, with or without axillary drainage, were compared with patients without IM drainage. Local-regional recurrence, distant disease-free survival (DDFS), and overall survival were evaluated.

RESULTS

We identified IM drainage in 334 patients (18.8%). Patients with IM drainage were significantly younger, less likely to have upper outer quadrant tumors, and more likely to have smaller and medial tumors than patients without IM drainage. Rates of IM irradiation did not differ between the 2 groups. The median follow-up time was 7.4 years. On multivariate analysis, IM drainage was significantly associated with a worse DDFS (hazard ratio, 1.6; 95% confidence interval, 1.03-2.6; P = .04) but not local-regional recurrence or overall survival.

CONCLUSIONS

IM drainage on preoperative lymphoscintigraphy was found to be significantly associated with worse DDFS. Further study is needed to determine the role of lymphoscintigraphy in the personalization of breast cancer staging and therapy.

Sentinel lymph node biopsy after previous axillary surgery: A review

BACKGROUND

The utility of axillary lymph node dissection (ALND) in the management of breast cancer is currently under close scrutiny. At primary diagnosis the use of sentinel lymph node biopsy (SLNB) has restricted ALND for proven nodal disease, however the management of the axilla at local (in-breast) relapse is less clearly defined with many undergoing routine ALND. This review examines the role of SLNB in the re-operative setting with the objective of developing an axillary management algorithm for use at in-breast local relapse, and restricting ALND to node-positive recurrent cancers.

METHODS

We reviewed published reports of SLNB at local relapse in women who had previously undergone axillary surgery either as lymph node biopsy, SLNB, axillary sampling (AS) or axillary lymph node dissection (ALND).

RESULTS

There have been no randomised trials. Six reports with 327 cases were identified; of which 61% (199/327) had previous SLNB or ALND with <9 nodes removed. There was an overall successful sentinel lymph node (SLN) localisation at re-operation of 69% (227/327), range of 51-100%. In patients who have previously had limited axillary surgery (<9 nodes removed), the rate of successful SLN localisation was 83% (165/199), range of 68-100% and 142/165 (86%, range 80-100%) were node negative. In these highly selected patients no axillary recurrences were noted in those who had a negative SLN at re-operation after 26-46 months follow up.

CONCLUSION

SLNB at in-breast relapse is feasible and safe with successful localisation related to the extent of previous axillary surgery.

Management of the axilla in patients with breast cancer

This article reviews the changes in management of the axilla in patients with breast cancer in the last decade. It discusses the recent advances, existing controversies and provides evidence-based guidelines for use in clinical practice.Sentinel lymph node (SLN) biopsy has replaced the more morbid axillary lymph node dissection (ALND) and four node sampling for axillary nodal staging. Blue dye guided four node sampling is an acceptable alternative when radioisotope facilities are not available. ALND is reserved for patients with proven axillary lymph node involvement.Preoperative axillary ultrasound and fine-needle aspiration cytology or core biopsy of suspicious lymph nodes reliably identifies around 30% of node positive patients. Intraoperative assessment of the SLN using frozen section or real time molecular assays enables surgeons to perform one stage ALND in node positive patients. For those patients in whom intra-operative SLN assessment is negative, but whose final pathology reveals SLN metastasis, standard treatment has been to perform a completion ALND. Predictive models can be used to identify a lowrisk group of SLN-positive patients in whom routine ALND may not be necessary. In the future, completion ALND for microscopic disease will not be the standard of care but axillary radiotherapy may be an alternative with equal control and less morbidity.

Patterns of treatment for early stage breast cancers at the M. D. Anderson Cancer Center from 1997 to 2004

BACKGROUND

The objectives of this study were to examine the patterns of use for adjuvant therapy and the changes in surgical practice for patients with early stage breast cancer and to describe how recent large clinical trial results impacted the patterns of care at The University of Texas M. D. Anderson Cancer Center (MDACC).

METHODS

The study included 5486 women who were diagnosed with stage I through IIIA breast cancer between 1997 and 2004 and received their treatment at MDACC. A chi-square trend test and multivariate logistic regression model were used to assess changes in treatment patterns over time.

RESULTS

Among lymph node-positive patients, the use of anthracycline plus taxane chemotherapy increased from 17% in 1997 to 81% in 2004 (P < .001). Meanwhile, the use of anthracyclines without taxanes dropped from 76% to 20% (P < .001) between 1997 and 2000. For postmenopausal patients who received endocrine therapy, the use of tamoxifen was replaced increasingly by the use of aromatase inhibitors (from 100% on tamoxifen in 1997 to 14% in 2004; P < .001). The percentage of women who underwent initial sentinel lymph node biopsy increased significantly during the period from 1997 to 2004 (from 1.8% to 69.7%, respectively, among patients who underwent mastectomy; and from 18.1% to 87.1%, respectively, among patients who underwent breast-conserving surgery; P < .001).

CONCLUSIONS

The results from this study suggested that key findings from adjuvant therapy and surgical procedures from large clinical trials often prompt immediate changes in the patient care practices of research hospitals like MDACC.

Resolving the controversies surrounding lymphatic mapping in breast cancer

Sentinel lymph node biopsy has rapidly become the standard of care in the primary treatment of breast cancer. Most of the initially identified potential contraindications towards the procedure, such as nonpalpability, large tumor size, pregnancy and being previously operated in the breast or axilla, have been ruled out, whereas multifocality represents an unsolved problem. There is no consensus about the best use of the technique in patients receiving neoadjuvant treatment. There is no place for sentinel lymph node biopsy in pure ductal carcinoma in situ, but it can be used for large high-grade in situ cancer diagnosed through core biopsy, especially if a mastectomy is planned. Morbidity is low, and the recurrence rates reported so far are reassuring. However, long-term results are lacking, and results from ongoing randomized trials are awaited.

Sentinel lymph node in breast cancer

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

SUMMARY

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

Should internal mammary chain (IMC) sentinel node biopsy be performed?

INTRODUCTION

Although the status of the regional lymph nodes is an important determinant of prognosis in breast cancer, harvesting sentinel nodes (SN) detected in the internal mammary chain (IMC) is still controversial.

AIMS

To determine in how many patients a positive IMC-SN might change the systemic or locoregional adjuvant therapy, with a possible benefit in outcome.

PATIENTS AND METHODS

During 6 1/2 years data of T1-2 breast cancer patients, having an SN procedure, were prospectively collected. Our policy was not to explore the IMC even if it was the only localization of an SN.

RESULTS

In 86 of 571 patients lymphoscintigraphy showed an IMC-SN. In 64 of these, the axillary SN was negative and only 25 of these patients did not have an indication for adjuvant systemic treatment based on their tumor characteristics. In the literature, IMC metastases are found in 0-10% of axillary negative patients. Routine IMC-SN biopsies would have resulted in an indication for adjuvant systemic therapy in 2-3 of our patients. Four parasternal recurrences were found during a median follow-up of 51 months.

CONCLUSIONS

Harvesting IMC-SNs is a procedure of which only a limited number of patients have therapeutical benefit. Even with a thorough selection of patients, the extra morbidity of the procedure should be weighed against the potential benefit for the patient.

Management of the axilla in women with breast cancer

The approach towards axillary surgery should be selective and flexible, with its management tailored to patient choice and tumour characteristics, and concordant with local practice guidelines and available resources. Sentinel-lymph-node biopsy has been embraced as a standard of care in many centres around the world and has revolutionised management of the axilla during the past decade. Nonetheless, data for long-term outcomes remain scarce, and there are persistent variations in practice and inconsistencies in methodology. An international perspective has been sought on important issues relating to management of the axilla, which includes not only the indications and techniques for sentinel-lymph-node biopsy, but also lymph-node sampling, axillary-lymph-node dissection, and observation alone. In this Review, we initially present an overview, which focuses on biological models of lymphatic networks within the breast and patterns of tumour dissemination. A set of key questions are posed with preliminary comments from the authors, followed by a series of collective viewpoints from experts within several different countries.

Current management of the axilla in patients with clinically node-negative breast cancer: a nationwide survey of United Kingdom breast surgeons

Background

Precise knowledge of axillary lymph node status is essential in the treatment of operable carcinoma of the breast. For many years, axillary nodal clearance (ANC) has been an integral part of the conventional management of early-stage breast cancer. During the last few decades the trend of these surgical procedures has been one of decreasing invasiveness in order to try and achieve a much lower level of morbidity. To help reach this improved level of treatment the concept of the sentinel lymph node (SLN) was utilized. Recent studies have shown that SNB can provide an accurate assessment of the axillary nodal status in clinically node negative patients, negating the need to remove the majority of the axillary contents and thus reducing morbidity. A recent meta-analysis of all the literature to date appears to reveal that the dual technique (blue dye and technetium-labelled sulfur) is the gold-standard for successful identification of the SLN in the context of early-stage breast cancer. We aim to highlight the on-going wide range of differing methods employed, and compare this to the gold-standard recommended guidelines.

Methods

A questionnaire was devised to provide a snapshot overview of the current management of the axilla in patients with clinically node-negative T1 invasive breast cancer amongst UK beast surgeons in August 2006.

Results

Of the 271 UK surgeons, 74 (27.3%) performed ANC as the initial management of the axilla in patients with clinically node negative T1 invasive breast cancer, 56 (20.7%) used axillary node sampling (not directed by sentinel node mapping) and a total of 141 (52.0%) used the technique of SNB, of which 50 (18.5%) used blue dye alone and 91 (33.6%) used a combination of blue dye and radioisotope.

Conclusion

Despite the obvious advantages, our survey has revealed that the procedure is only used by 52% of British breast surgeons in this subgroup of patients (clinically node negative, tumour equal of smaller than 2 cm) most of whom have no disease within the axilla. The reasons for this include limited hospital resources and lack of surgeons training and accreditation and ARSAC license (nuclear medicine license).

The sentinel lymph node: Relevance in gynaecological cancers

AIMS

Sentinel lymph node (SLN) detection is widely practiced in the management of patients with malignant melanoma and beast cancer. Large studies on SLN detection and determination of nodal status have led to changes in the surgical management of the regional lymph nodes in these diseases. More recently attention has focused on other solid cancers, including gynaecological cancers.

METHODS

An extensive literature review of published reports on the SLN in gynaecological cancers was undertaken and the reports were categorised according to the level of evidence provided.

RESULTS

Vulva cancer is the most frequently investigated gynaecological cancer with regard to SLN detection because of its anatomical location and easily accessible nodal basin. Although there are no randomised controlled trials, some data suggest SLN detection in vulval cancer may alter clinical practice and reduce the number of groin lymphadenectomies. The lymphatic drainage of the other gynaecological organs is less predictable, the nodal basin less accessible or less well defined, the techniques not standardised and the evidence for the applicability of SLN detection in the management of these cancers is weak.

CONCLUSION

Sentinel lymph node detection in vulval cancer may reduce the need for radical groin lymphadenectomy and thereby reduce morbidity. SLN detection for other gynaecological cancers has little potential to alter clinical practice.

Evaluation of early versus delayed lymphoscintigraphic imaging in detecting internal mammary sentinel lymph nodes in breast cancer: A multicenter study to establish an optimal lymphatic mapping protocol

OBJECTIVE

Metastases in the internal mammary lymph nodes have an important prognostic value in breast cancer. Lymphatic mapping and sentinel node biopsy of internal mammary nodes improves staging and permits specific therapeutic strategies, thereby possibly improving final outcome. Therefore, optimal lymphoscintigraphic results are needed. Visualization of internal mammary lymph drainage, however, is influenced by several factors. We evaluated the effect of different time intervals between radioactive tracer injection and lymphoscintigraphy on visualization of internal mammary sentinel lymph nodes.

METHODS

From February 1997 to August 2001 a total of 682 eligible breast cancer patients underwent sentinel lymph node mapping. The technique involved the injection of 370 MBq (10 mCi) (99m)Tc-nanocolloid peritumorally. In 470 patients (group A) the time interval between injection of the radiocolloid and lymphoscintigraphy was 16 h, compared to 2.5 h in 212 patients (group B).

RESULTS

Patient characteristics showed no statistically significant difference between both groups for age and location of the tumour. Axillary hotspots were visualized in 97% in group A and 96% in group B. Lymphoscintigraphy showed internal mammary hotspots in 21% in group A, compared to 27% in group B. The mean number of internal mammary hotspots per patient was 1.9 in group A and 1.8 in group B.

CONCLUSIONS

We found no significant differences between early and delayed lymphoscintigraphic imaging in visualizing internal mammary sentinel lymph nodes.

Use of lymphoscintigraphy defines lymphatic drainage patterns before sentinel lymph node biopsy for breast cancer

BACKGROUND

Lymphoscintigraphy (LSG) can identify lymphatic drainage patterns before sentinel lymph node (SLN) biopsy is performed in patients with early-stage breast cancer, but the importance of extraaxillary SLNs seen on LSG is unknown. We assessed whether drainage patterns seen on LSG were associated with histologic findings in axillary SLNs recovered at SLN biopsy.

STUDY DESIGN

From a prospectively maintained database, we identified 1,201 clinically node-negative patients with invasive breast cancer who underwent preoperative LSG and axillary SLN biopsy. Patient and tumor characteristics, LSG results, and final SLN pathology results were examined.

RESULTS

LSG showed drainage to internal mammary (IM) nodes in 1.6% of patients, axillary nodes in 68.1%, both IM and axillary nodes in 19.8%, and no drainage in 10.3%. Drainage to IM nodes was observed for tumors in all quadrants of the breast. Patients with IM drainage had a younger median age than patients without IM drainage (51.8 versus 58.3 years, respectively; p < 0.001). The intraoperative axillary SLN identification rate was higher when axillary drainage was observed on LSG than when it was not observed (98.7% versus 93.0%, respectively; p < 0.001), but the LSG drainage pattern was not associated with pathologic status of the SLN or number of metastatic SLNs. At a median followup of 32 months, 4 patients had regional nodal recurrence.

CONCLUSIONS

Almost one-fourth of patients had lymphatic drainage to the extraaxillary lymph nodes, particularly the IM nodes, seen on LSG. Extraaxillary drainage seen on LSG did not preclude identification of axillary SLNs at operation. Longterm followup of patients with lymphoscintigraphic evidence of extraaxillary drainage is needed to determine whether regional and systemic recurrence patterns differ in these patients.

Lymphoscintigraphy Does Not Enhance Sentinel Node Identification or Alter Management of Patients With Early Breast Cancer

Lymphoscintigraphy (LS) is often performed before sentinel lymph node dissection (SLND) for breast cancer. The purpose of this study was to determine whether routine LS enhances rate of identification of sentinel nodes (SN), and if findings on LS alter either the SLND procedure or the subsequent patient management.

METHODS

LS using technetium-99m sulfur colloid (99mTc) was performed in 136 consecutive patients undergoing SLND for invasive breast cancer. Three equal aliquots of 99mTc were injected peritumorally, and LS images were obtained at 60 to 120 min after 99mTc injection. Data were collected on the success of LS to visualize SN. Information regarding body mass index (BMI), biopsy type (core vs excisional), tumor location (medial vs lateral), and SN positivity were recorded and comparison was made with success of operative SN identification. In all SLND cases, 1% lymphazurin blue dye was used in addition to the 99mTc.

RESULTS

LS failed to identify an SN in 9 of 136 cases (6.6%). Failed mappings did not correlate with biopsy type, tumor location, or SN positivity. There was a positive correlation between increased BMI and failed LS (p = <0.001). Failed LS did not predict operative SLND failure, as an SN was identified in 100% of cases (136/136), including the 9 with a failed LS. In 67% (6/9) of the failed LS, the SN was both hot and blue at operation. Internal mammary (IM) drainage was observed in 4% (6/136) of LS. Positive SN were found in 26% (35/136) of patients. Findings on LS did not affect adjuvant treatment decisions in any patient.

CONCLUSIONS

There was a correlation between failed LS and BMI, but no correlation with biopsy type or tumor location. Drainage to extraaxillary sites was rare. LS findings did not enhance success of intraoperative identification of SN or alter the postoperative management of patients with early stage breast cancer.

Does imaging in sentinel node scintigraphic localization add value to the procedure in patients with breast cancer?

Imaging sentinel nodes with pre-operative lymphoscintigraphy effectively assures successful sentinel node identification. However, sentinel nodes are still identified in the majority of image negative patients. Given the logistics and cost required to perform pre-operative lymphoscintigraphy its routine use may not be justified. It may be valuable for surgeons in the learning phase and in obese patients who have increased risk of intra-operative failed localization. A negative pre-operative lymphoscintiscan predicts inability to localize with the hand-held gamma probe. Patients with no 'hot node' on the lymphoscintiscan are more likely to have failed localization using the gamma probe only. Therefore, blue dye should be used along with the gamma probe to optimize the localization rate in these patients.

Breast Sentinel Lymph Node Navigation With Three-Dimensional Interstitial Multidetector-Row Computed Tomographic Lymphography

OBJECTIVE

Three-dimensional multidetector-row computed tomographic lymphography (3D MDCT-LG) with interstitial injection of a widely available nonionic monometric contrast medium iopamidol was used for navigation of breast sentinel lymph node (SLN) biopsy.

METHODS

3D MDCT-LG was obtained after massage of the interstitially injection sites of a total of 4-5 mL undiluted iopamidol at periareolar and peritumoral areas in 68 consecutive patients with early-stage breast cancer, using a 4 detector-row CT scanner. Drainage lymphatic patterns and SLN anatomy were assessed on 3D MDCT-LG images. 3D MDCT-LG-navigated SLN biopsy with combined use of blue dye was followed by backup axillary lymph node dissection to evaluate accuracy of SLN biopsy.

RESULTS

The 3D MDCT-LG images clearly localized primary SLNs by visualizing the direct connection between these nodes and their afferent lymphatic vessels on detailed anatomy of the surrounding structures in all patients. Drainage lymphatic pathways on these images were classified into 4 patterns: single route/single SLN (39 cases, 57%), multiple routes/multiple SLNs (10 cases, 15%), single route/multiple SLNs (9 cases, 13%), and multiple routes/single SLN (10 cases, 15%). Under 3D MDCT-LG navigation, SLNs was found at the accurate location in all patients. With backup axillary lymph node dissection, metastasis was found in 14 (20%) patients, and 8 of these patients had metastasis only in the preoperatively identified SLNs. In other 5 positive patients, metastasis was found both in the SLN and non-SLNs. However, micrometastasis eventually was found only in non-SLN in an elderly patient. Overall, the sensitivity, false-negative rate, and accuracy of 3D CT-L-navigated SLN biopsy were 92% (13/14 patients), 7% (1/14 patients), and 98% (67/68 patients), respectively.

CONCLUSIONS

Topographic 3D interstitial MDCT-LG can be a widely available and reliable navigator for breast SLN biopsy.

Role of routine preoperative lymphoscintigraphy in sentinel node biopsy for breast cancer

Sentinel node biopsy (SNB) is rapidly emerging as the preferred technique for nodal staging in breast cancer. When radioactive colloid is used, a preoperative lymphoscintiscan is obtained to ease sentinel lymph node (SN) identification. This study evaluates whether preoperative lymphoscintigraphy adds diagnostic accuracy to offset the additional time and cost required. 823 breast cancer patients underwent SNB based on lymphoscintigraphy, intraoperative gamma probe detection, and blue dye mapping using 99 mTc-nanocolloid and Patent Blue V injected peritumourally. The SNB was followed by standard axillary treatment at the same operation. Preoperative lymphoscintigraphy was performed around 3 h after the radioisotope injection. Preoperative lymphoscintigraphy revealed SNs in 593 (72%) of the 823 patients imaged. SN visualisation on lymphoscintigraphy was less successful in large tumours and tumours involving the upper outer quadrant of the breast (P=0.046, P<0.001, respectively). Lymphoscintigraphy showed internal mammary sentinel nodes in 9% (62/707) patients. The SN was identified intraoperatively in 98% (581) patients who had SN visualised on preoperative lymphoscintigraphy, with a false-negative rate of 7%. In patients who did not have SN visualised on preoperative lymphoscintigraphy, the SN was identified at operation in 90% (204) patients, with a false-negative rate of 7%. The SN identification rate was significantly higher in patients with SN visualised on preoperative lymphoscintigraphy (P<0.001). SN identification rate intraoperatively using the gamma probe was significantly higher in the SN visualised group compared with the SN non-visualised group (95% vs. 68%; chi square (1 degrees of freedom (df)) P<0.001. There was no statistically significant difference in the false-negative rate and the operative time between the two groups. A mean of 2.3 (standard deviation (SD) 1.3) SNs per patient were removed in patients with SN visualised on preoperative lymphoscintigraphy compared with 1.8 (SD 1.2) in patients with no SN visualised on lymphoscintigraphy (P<0.001). Although SN visualisation on preoperative lymphoscintigraphy significantly improved the intraoperative SN localisation rate, SN was successfully identified in 90% of patients with no SN visualisation on lymphoscintigraphy. Given the time and cost required to perform routine preoperative lymphoscintigraphy, these data suggest that it may not be necessary in all cases. It may be valuable for surgeons in the learning phase to shorten the learning curve and in patients who have increased risk of intraoperative failed localisation (obese or old patients). A negative preoperative lymphoscintiscan predicts the inability to localise with the hand-held gamma probe. Therefore, if the SN is not visualised on lymphoscintigraphy then the addition of intraoperative blue dye is recommended to increase the likelihood of SN identification.

Current status of sentinel lymph node biopsy in solid malignancies

Lymphatic mapping and sentinel lymph node biopsy were first reported in 1977 by Cabanas for penile cancer. Since that time, the technique has become rapidly assimilated into clinical practice. The sentinel node concept has been validated in cutaneous melanoma and breast cancer. However, follow-up data of patients from randomised trials is needed to establish the clinical significance of sentinel lymph node biopsy before accepting the procedure as a standard of care. This technique has the potential to be utilised in all solid tumours like colon, gastric, oesophageal, lung, gynaecologic, and head and neck cancer. This paper reviews the current status of sentinel lymph node biopsy in solid tumours.