Risk factors for lymphedema after breast surgery: A prospective cohort study in the era of sentinel lymph node biopsy

INTRODUCTION

The Objective was to investigate the incidence of lymphedema after breast cancer treatment and to analyze the risk factors involved in a tertiary level hospital.

METHODS

Prospective longitudinal observational study over 3 years post-breast surgery. 232 patients undergoing surgery for breast cancer at our institution between September 2013 and February 2018. Sentinel lymph node biopsy (SLNB) or axillary lymphadenectomy (ALND) were mandatory in this cohort. In total, 201 patients met the inclusion criteria and had a median follow-up of 31 months (range, 1-54 months). Lymphedema was diagnosed by circumferential measurements and truncated cone calculations. Patients and tumor characteristics, shoulder range of motion limitation and local and systemic therapies were analyzed as possible risk factors for lymphedema.

RESULTS

Most cases of lymphedema appeared in the first 2 years. 13.9% of patients developed lymphedema: 31% after ALND and 4.6% after SLNB (p < 0.01), and 46.7% after mastectomy and 11.3% after breast-conserving surgery (p < 0.01). The lymphedema rate increased when axillary radiotherapy (RT) was added to radical surgery: 4.3% for SLNB alone, 6.7% for SLNB + RT, 17.6% for ALND alone, and 35.2% for ALND + RT (p < 0.01). In the multivariate analysis, the only risk factors associated with the development of lymphedema were ALND and mastectomy, which had hazard ratios (95% confidence intervals) of 7.28 (2.92-18.16) and 3.9 (1.60-9.49) respectively.

CONCLUSIONS

The main risk factors for lymphedema were the more radical surgeries (ALND and mastectomy). The risk associated with these procedures appeared to be worsened by the addition of axillary radiotherapy. A follow-up protocol in patients with ALND lasting at least two years, in which special attention is paid to these risk factors, is necessary to guarantee a comprehensive control of lymphedema that provides early detection and treatment.

Abstract P6-09-04: Predictive factors for considering to avoid axillar lymphadenectomy in selected node positive breast cancer patients after neoadjuvant chemotherapy

Background:

To perform a systematic axillar lymphadenectomy (ALND) in clinical node positive (N+) patients after neoadjuvant chemotherapy (NACT) is currently under discussion. We aimed to study which factors are related to a pathological complete axillar response (ypN0) after NACT in order to select which patients could benefit from a sentinel lymph node biopsy without interfering with survival.

Material and methods

N+ patients who underwent ALND after NACT between June 2008 and December 2016 were retrospectively analyzed. Clinical features, molecular and histological factors, recurrence and specific mortality rates were compared between patients achieving a complete pathological axillary response vs not (ypN0 vs ypN+).

Results

345 N+ patients were reviewed. After NACT, 137 (39.6%) become ypN0[CF1] , 9 (2.6%) ypN1 mic, 113 (32.7%) ypN1, 60 (17.3%) ypN2 and 22 (6.4%) N3. Univariate analysis results regarding the predictive factors for ypN0 are detailed in [table 1]. Multivariate analyses showed molecular subtype (TN and Her2+) and clinical response as independent predictors of ypN0 [table 2]. After a mean follow-up of 58 months, overall survival was statistically superior in ypN0 vs ypN1 (p= 0.001).

Table 1.Predictive factors for ypN0 YpN0 (n = 137)YpN+ (n = 208)pAge (mean, years)58.3 ± 13.2758.59 ± 12.340.799BMI (mean)27.8±5.4927.8±5.360.973Dosis of QT (median)(%)  0.575IIA6 (31.6)13 (68.4) IIB71 (39.3)110 (60.8) IIIA28 (36.8)48 (63.2) IIIB24 (43.6)31 (56.4) IIIC7 (58.3)5 (41.7) Radiological image(%)  0.930Nodule77 (38.1)125 (61.9) Non-mass distortion10 (43.5)13 (56.5) Radiological size (median)32 (0-115)29 (0-130)0.246Suspicious a-LN by US(%)  0.486130 (30.9)37 (24.3) 25 (5.2)14 (9.2) &gt;257 (58.8)91 (59.9) Histological subtype(%)  0.093Invasive Ductal Carcinoma133 (40.9)192 (59.1) Invasive Lobular Carcinoma2 (20)8 (80) Others2 (22.2)7 (78.8) Nottingham grade(%)  &lt;0.001G11 (6.2)15 (93.8) G244 (28.6)110 (71.4) G386 (53.4)75 (46.6) Molecular-like subtype(%)  &lt;0.001Luminal A-like2 (5.3)36 (94.7) Luminal B-like (Her2 -)21(18.1)95 (81.9) Luminal B-like (Her2 +)40 (63.5)23 (36.5) HER-2 enriched (non luminal)43 (74.1)15 (25.9) Triple Negative31 (44.9)38 (55.1) Vascular invasion19 (42.2)26 (57.8)0.889Clinical Response(%)  &lt;0.001Complete61 (75.3)20 (24.7) Partial69 (31.8)148 (68.2) No response6 (20.7)23 (79.3) Progression1 (10)9 (90) Percentage are given per row.

Table 2.Multivariate analysis logistic regression of clinical predictive factors of ypN0. OR95% Confidence Intervalp valueMolecular subtype   No-luminal vs Luminal7,7483,913-15,343&lt;0,001Clinical response   Response vs not response6,8491,834-25,5710,04OR: Odd ratio. No-luminal includes: luminal B (HER2 +), HER2 Henriched and triple negative. Luminal includes: Luminal A and Luminal B (HER2 -).

Conclusions

A remarkable percentage of N+ became ypN0 after NATC. Molecular subtype and complete clinical response were independent predictive factors of ypN0. We propose to offer the benefit of a targeted axillary procedure in those patients.

Citation Format: Fernandez-Gonzalez S, Falo Zamora C, Nuñez D, Vethencourt A, Pla MJ, Soler T, Guma A, Perez X, Gil M, Ponce J, Garcia A. Predictive factors for considering to avoid axillar lymphadenectomy in selected node positive breast cancer patients after neoadjuvant chemotherapy [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P6-09-04.

Abstract P3-13-07: Is radiofrequency ablation better than lumpectomy for margin status in breast cancer? Results of a randomized clinical trial

PURPOSE: To study the safety and efficacy of ultrasound-guided percutaneous radiofrequency ablation (RFA) as local treatment for breast cancer and to intraoperatively evaluate the margin status after RFA in comparison with lumpectomy.

MATERIAL and METHODS: Preliminary in vitro RF ablation experimentation with two mastectomy specimens was performed to test the electrode, practice the ultrasound technique and evaluate the macroscopic and microscopic effects of RF. Then, aprospective, randomized open-label phase II clinical trial (NCT02281812) was conducted in a single institution from 2013-2017. Forty subjects, mean age 64 (range 46-86), with ductal infiltrating carcinoma of the breast ≤2 cm were randomly assigned to RFA plus lumpectomy or lumpectomy alone. Margin status, tumor cell viability (TCV) after RFA (by nicotinamide adenine dinucleotide (NADH) and Cytokeratin 18 (CK18) staining), adverse events and local recurrences were evaluated by univariable and multivariable analyses (SPSS statistical software).

RESULTS: In the experimental design with mastectomies, the only procedural complication was a skin burn at the entrance site of the electrodes. We learned that the tip of the electrodes should cut cross the tumor by at least 10mm.

The clinical trial includes two groups: study group (n=20) and control group (n=20). NADH and CK18 staining demonstrated absence of TCV after RFA with at least one of the two techniques. The percentage of intraoperatively affected surgical margins was higher in the control group although local adverse effects after surgery was higher in the RFA treatment arm. Three study subjects presented local infection (two had partial irradiation of the breast) and none in the control group. Median follow up was 25 months (range 1–83). No recurrence or second surgery was required during the study period.

Outcomes RFA group (n = 20)Control group (n=20)p valueSpecimen weight (median, gr)42 (24-80)27 (11-60)0.004Specimen volume (median, ml)369 (259-847)201 (100-602)0.004Positive margin (intraoperative)4/20 (20%)11/20 (55%)0.022Pathological size (median, mm)11.5 (5-20)10.5 (6-16)0.07Local Adverse effect8/20 (40%)1/20 (5%)0.01Breast Inflammation5/20 (25%)1/20 (5%)0.182Breast Infection3/20 (15%)0/20 (0%)0.23RFA: radiofrequency ablation. n=number of subjects

CONCLUSION: RFA seems effective in the cases considered and could be more accurate than lumpectomy in terms of obtaining more free margins. Surgical excision associated with RFA leads to a higher amount of local adverse effects, especially if combined with partial irradiation of the breast. RFA could be considered as a less invasive treatment in tumors smaller than 20 mm; however, this warrants further investigation.

Citation Format: Garcia-Tejedor A, Guma A, Soler T, Valdivieso A, Petit A, Contreras N, Chappuis CG, Falo C, Pernas S, Anselem A, Fernandez-Montoli E, Pla MJ, Burdio F, Ponce J. Is radiofrequency ablation better than lumpectomy for margin status in breast cancer? Results of a randomized clinical trial [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-13-07.

Abstract P2-08-58: Prognostic factors of survival in node positive breast cancer patients after neoadjuvant chemotherapy in a large series after 5y follow-up: Can response overcome the poor prognosis of nodal stage?

Background: Status of the axilla is one of the most significant prognostic factors in breast cancer (BC) patients. On the other hand, response to neoadjuvant chemotherapy (NACT) is related to survival. The aim of the present study is to analyze which prognostic factors impact most on Node positive (N+) BC patient survival after NATC. Material and methods: Retrospective analyses on a series of N+ BC patients treated with NATC based on anthracyclines and taxanes +/- trastuzumab if HER2 positive tumors, between June 2008 and December 2016. Clinical, radiological and pathological outcomes have been evaluated. Residual cancer burden (RCB) 1 and the neoadjuvant response index (INR) 2 have been recorded. Survival was calculated with Kaplan-Meier survival curve since the start of NATC to the first documented disease recurrence (DFS) or death (OS). Hazard ratios (HRs) with 95% CIs were estimated with cox proportional hazards regression analysis and subgroups were compared with a two-sided log-rank test. Results: A total of 345 N+ BC patients were included. Pathological complete response was achieved in 72 (20.8%) patients. After NACT, 137 (39.6%) become ypN0, 9 (2.6%) ypN1 mic, 113 (32.7%) ypN1, 60 (17.3%) ypN2 and 26 (7.6%) N3. Those independent predictive factor of ypN0 were molecular subtype (TN and Her2+) with OR: 7.7, p&lt;0.001 and clinical response with OR 6.88, p: 0.04. At a mean follow-up of 58 months there have been 73 (21.1%) recurrences: 9 (2.3%) local, 45 (13%) systemic, 15 (4.3%) systemic+ local, 3 (0.9%) axilla, 1 (0.3%) supraclavicular. The estimated 5y OS was 87.8%. The univariate analysis according to DSF is detailed in Table1.

Adjusted univariate anaalysis cox regression of clinical and pathological factors of desease free survivalBMI10.989-1.010.963AGE0.9960.953-1.0420.876Dose NATC0.9940.979-1.0080.402Clinical Stage1.4021.077-1.8260.012Rx Image1.260.803-1.9940.311Rx size1.0090.995-1.0240.217Number suspicious ALN1.0950.801-1.4970.57Molecular subtype TN,HER20.8800.534-1.450.616Nottinghan grade1.0460.753-1.4530.789Histological subtype1.4651.044-2.0570.27MOlecular subtype1.1510.956-1.3850.137Vascular invasion1.6761.137-24710.009Clinical response2.3691.709-3.284&lt;0.001Fibrosis tumor bed0.980.972-0.989&lt;0.001Nodal fibrosis&gt;50%1.7950.874-3.6860.111Pathological tumoral response1.6861.175-2.4180.005ypN03.561.853-6.838&lt;0.001NRI0.330.192-0.565&lt;0.001RCB1.2741.106-1.4680.001

In the multivariate model those parameters that were independently prognostic were clinical response HR: 5.44 (IC95% 2.275-13.042, p&lt;0.001) and clinical stage HR: 2.364 (IC95% 1.018-5.490, p: 0.045). Conclusions: The most significant prognostic factor in our N+ series was response to NATC, followed by clinical stage. Those independently predictive factors of axillar response (ypN0) were molecular subtype (TN and Her2+) and clinical response. In conclusion, in those patients with chemo sensitive tumors, lymphadenectomy could be safely spared with a more selective axillary approach.

Citation Format: Fernandez S, Garcia A, Vethencourt A, Vazquez S, Petit A, Pla MJ, Ortega R, Pérez J, Gil M, Ponce J, Pernas S, Lopez A, Falo C. Prognostic factors of survival in node positive breast cancer patients after neoadjuvant chemotherapy in a large series after 5y follow-up: Can response overcome the poor prognosis of nodal stage? [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-58.

Abstract P4-08-08: Biomarkers to predict distant recurrence free survival after neoadjuvant endocrine therapy in breast cancer. A long follow up retrospective study

Background:

Neoadjuvant endocrine therapy (NET) is gaining more acceptances for the management of estrogen receptor (ER) positive breast cancer (BC). Rate of patients achieving pathological complete response is very low and Ki67 suppression and PEPI score are the only prognostic factors associated with relapse free survival.

The aim of our study was to identify biomarkers of prediction of distant relapse risk that could help clinicians in the decision-making of systemic adjuvant treatment in patients previously treated with NET

Material & Methods:

Retrospective study of 119 postmenopausal women with ER or progesterone receptor (PR) positive BC treated with NET in ICO-HUB from 1997 to 2009. Clinical-pathological data and treatments administered were reviewed. IHC expression of ER, PR, Ki67, Androgen receptor (AR), BCL-2, Cyclin D1 (CD1), p16, p53, CD 44 and synaptophysin were analyzed in post-NET surgical formalin-fixed paraffin-embedded tumor samples through a tissue microarray. Survival was calculated by Kaplan-Meier method. Univariate and multivariate analysis of variables associated with distant relapse free survival (DRFS) was evaluated by Cox proportional hazard model.

Results:

Mean age was 74 (63-88). cT: T2 5%, T3 6.5%, T4 43.5%. cN: N0 59%, N1 25%, N2-3 16%. Stage: I 21%, II 49.5%, III 29.5%. Histological subtype: ductal 84%, lobular 6%, others 10%. Histological grade: G1 20%, G2 55%, G3 25%.

Vascular invasion 15%. NET: Aromatase Inhibitors 64%, SERM 36%. Median duration of NET 8.5 months. Clinical Response: Complete 4%, Partial 55%, Stable 37%, Progression 4%. Surgery: Lumpectomy 72%, Mastectomy 28%;Lymphadenectomy 70.5%, Sentinel lymph node biopsy 6%, No surgical approach of axilla 23.5%. Surgical specimen: ypT1 36%, ypT2 54%, ypT3 6%, ypT4 4%; ypN0 28%, ypN1 22%, ypN2 13.5%, ypN3 12% ypNx 23.5%. Surgical margins: Negative 89% Positive 11%. Median fibrosis rate 20% (0-95). PR and Ki67 showed a statistically significant decrease after NET(p&lt;0,05) but no ER (p=0,29).

Adjuvant treatment: chemotherapy 7%, radiotherapy 76%, endocrine therapy 96%. Median follow-up: 104 months. Only 21 patients developed distance relapse. Median OS was 139 months [95% CI = 98-181]. Univariate analysis for DRFS showed statistically significant differences in cN (HR=3), histological grade 3 (HR=3.61), ypN (HR=3.62), p16 (HR=6.1) and p53 (HR=2.79). Multivariate analysis of post-NET biomarkers showed that negative nuclear p16 expression (HR=4.79)and positive p53 (HR=2.83)were independently associated with worse DRFS. In multivariate analysis of all clinico-pathological and molecular factors, histological grade 3 (HR=2.82) was the sole DRFS independent factor.

Conclusions:

Negative nuclear p16 expression and positive p53 post-NET were associated with worseDRFS. Whenall clinico-pathological and molecular factors were analysed, G3 was the sole DRFS independent factor. Patients with G3, negative p16 or positive p53 after NET could probably benefit from adjuvant chemotherapy or CDK 4-6 inhibitors treatment. In our series, we did not find usefulness in analysing ER, PR and Ki67 post-NET changes to predict DRFS.

Citation Format: Gil-Gil M, Morilla I, Petit A, Soler T, Perez-Martin X, Guma A, Pla MJ, Ortega R, Garcia-Tejedor A, Falo C, Montal R, Perez-Casanova L, Loayza C, Pernas S. Biomarkers to predict distant recurrence free survival after neoadjuvant endocrine therapy in breast cancer. A long follow up retrospective study [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P4-08-08.

Reoperations after primary breast conserving surgery in women with invasive breast cancer in Catalonia, Spain: a retrospective study

BACKGROUND

Although complete tumor resection is accepted as the best means to reduce recurrence, reoperations after lumpectomy are a common problem in breast cancer. The aim of this study was to assess the reoperation rates after primary breast conserving surgery in invasive breast cancer cases diagnosed in Catalonia, Spain, between 2005 and 2011 and to identify variations based on patient and tumour characteristics.

METHODS

Women with invasive incident breast cancer identified from the Patient's Hospital Discharge Database [174.0-174.9 codes of the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) as the primary diagnosis] and receiving primary breast conserving surgery were included in the study and were followed up to 3 and 12 months by collecting information about repeat breast cancer surgery.

RESULTS

Reoperation rates after primary breast conserving surgery decreased from 13.0 % in 2005 to 11.7 % in 2011 at 3 months and from 14.2 % in 2005 to 12.9 % in 2011 at 12 months' follow-up. While breast conservation reoperations saw a slight, non-significant increase in the same period (from 5.7 to 7.3 % at 3 months, and from 6.0 to 7.5 % at 12 months), there was a significant decrease in radical reoperation (from 7.3 to 4.4 % at 3 months and from 8.2 to 5.4 % at 12 months). Overall, additional breast surgeries decreased among younger women.

CONCLUSIONS

Despite the rise of breast conserving surgery, reoperation rates following initial lumpectomy in Catalonia decreased by 10 % at 3 and 12 months' follow-up, remaining low and almost unchanged. Ultimately, there was also a significant decrease in mastectomies.

Abstract P2-08-31: Tumor and axillar downstaging as a prognostic factor and evaluation of effectiveness to primary chemotherapy in breast cancer: A retrospective analysis

Introduction: Evaluation of the benefit of primary chemotherapy (PC) is not easy to establish. Pathologic complete response (pCR) has been considered the main surrogate prognostic factor of patient's survival. However, patients achieving a pCR are not the only ones who benefit from PC. The purpose of our study is to find a measure of response that includes the maximum of patients that benefit from PC in terms of survival.

Patients and methods: 224 breast cancer patients were treated in Breast Cancer Unit from Institut Català d'Oncologia (ICO) L'Hospitalet with taxans and antracyclines-based PC +/- trastuzumab between 2009 and 2011. pCR was defined as no invasive carcinoma found in the tumor and in the axillary lymph nodes (ypT0/ypTis ypN0). Tumor and nodal downstaging (TNDS) was calculated according to the "neoadjuvant response index" (NRI) from Rodenhuis and also as a dichotomic variable: Positive includes those patients achieving dowstaging of both T and N plus T downstaging N0 and negatives those patients without downstaging in any of both variables. Those parameters were related to patient's overall survival (OS). Statistical analysis was performed with SPSS version 15.

Results: Median age 45.5 years (24-83). Main tumor characteristics: T2 (62.6%); N1 (50%); ductal infiltrating carcinoma (95.5%) and grade III (57.1%). Biological sub-type according to the last St Gallen classification: luminal A: 28 patients (pts); luminal B/Her2-: 61 pts; luminal B/HER2+: 34 pts; HER2+: 33 pts and triple negative: 69 pts. Pathologic complete response was achieved in 49 pts (22.5%). TNDS was evaluated in 181 patients and of those 90 was positive. According to NRI 74 patients presented cut-off&gt; 0.5 and 52 pts &gt; 0.7. Parameters related to OS were: biological subtype (P: 0.007); achieving a pCR (p: 0.007); NRI cut-off 0.5 (P: 0.001) and TNDS (p:0.000). In the multivariate analysis only TNDS and biological subtype remained statistically significant. When comparing those patients with positive vs. negative TNDS, the HR for recurrence was of 10.05 (IC 2.33 -43.57). The median OS of the series has not been reached. OS at 5y was 82.7% (IC: 77.1%-88%) and specific breast cancer OS at 5 y was 85% (IC:79.5%-90%). The number of events (breast cancer deaths) for each biological subtype according to positive vs. negative TNDS was: luminal A: 0/5 vs. 0/18; luminal B Her2-: 0/10 vs. 8/43; luminal B HER2+:0/23 vs. 2/9; HER2+: 0/22 vs. 0/2 and TN: 2/30 vs. 8/18. Survival data per subtypes and TNDS is immature due to the scarce number of events. Estimated 5y OS for TNDS positive vs. negative in luminal A: 100% vs. 100%; luminal B Her2-: 100% vs. 82%; luminal B HER2+:100 vs.77.7%; HER2+: 100% vs. 100% and TN: 93% vs. 55%, respectively.

Conclusion: In our series, TNDS measured either with the NRI from Rodenhuis or as a dichotomic variable was the best parameter to evaluate response to PC in terms of OS. OS of luminal A and luminal B/Her2 negative is less influenced by PC than the rest of subgroups. In fact both subgroups have good prognosis despite their poor sensitivity to chemotherapy. Those tumors that benefit most from PC were luminal B/ Her2+; Her2+ and triple negative patients who achieved a positive TNDS.

Citation Format: Falo C, Ventura LM, Petit A, Perez J, Cañellas J, Perez L, Loayza C, Gil M, Varela M, Garcia A, Pla MJ, Lopez A, Guma A, Pernas S. Tumor and axillar downstaging as a prognostic factor and evaluation of effectiveness to primary chemotherapy in breast cancer: A retrospective analysis. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P2-08-31.

[Influence of tumor location in patients with breast cancer on the sentinel node detection]

OBJECTIVE

To evaluate the influence of tumour quadrant localization on the sentinel node (SN) detection and the visualisation of internal mammary chain (IM) drainage by radioisotopic techniques. 316 patients with breast cancer were studied. Mean age 57 years (range 29-88). All patients received 37-74 MBq of 99mTc-albumin nanocolloid in 2 ml by peritumoral injection. The breast cancer was located in the upper outer quadrant in 189 patients, in the upper inner in 57, in the lower outer in 57, in the lower inner in 55 and in the subareolar area in 18 patients. At two hours p.i., anterior and lateral chest lymphographies were obtained. The SN location was marked on the patient skin with permanent ink. SN was identified intraoperatively by the gamma probe. Histopatological analysis included imprints, delayed hematoxilin-eosin, inmunohistochemistry CAM 19-2 and PCR.

RESULTS

The scintigraphy and surgical detection was in the upper outer quadrant of 90 % and 93 % respectively; in the lower outer quadrant of 91 % and 95 %, in the upper inner quadrant of 93 % and 95 %, in the lower inner quadrant 87 % and 95 % and in the subareolar area in 94 % and 83 %. The IM chain drainage was of 6 % in the UO, in the LO of 5 %, in the UI of 12 %, in the LI of 20 % and none in subareolar.

CONCLUSIONS

Our data suggest that sentinel node location (quadrant) is not a influential factor in the scintigraphy and surgical detection. Tumours localised in internal quadrant show a higher rate of IM chain drainage.

Subdermal re-injection: a method to increase surgical detection of the sentinel node in breast cancer without increasing the false-negative rate

PURPOSE

The aim of this study was to evaluate in breast cancer whether subdermal (SB) re-injection improves surgical detection (SD) of the sentinel node (SN) in patients with negative lymphoscintigraphy on peritumoral (PT) injection, without increasing the false-negative (FN) rate.

METHODS

Group I comprised 261 patients with invasive breast cancer >3 cm and clinically negative axilla treated with primary chemotherapy. Axillary lymphadenectomy was performed in all of these patients. Group IA comprised 201 patients with PT injection, while group IB comprised 60 patients with SB injection in the tumour quadrant. Group II comprised 652 patients with breast cancer <3 cm; in 73 of these patients with negative lymphoscintigraphy, SB re-injection was performed. For lymphoscintigraphy, 37-55 MBq (99m)Tc-albumin nanocolloid in 1 ml was used for PT injection, and 18 MBq in 0.2 ml for SB injection. Five-minute images were obtained 2 h p.i. for PT injection and 20-30 min p.i. for SB injection. SD was performed 4 or 24 h p.i. Lymphoscintigraphic (LD), surgical and internal mammary (IM) detection rates were calculated. In group I, FN, negative predictive value (NPV) and accuracy (A) were calculated. Statistical analysis was performed using the chi-square test.

RESULTS

In percentages, results were as follows: Group IA: SD: 84.1, FN: 13.6, NPV: 88.9, A: 78.6, IM: 14.5*. Group IB: SD: 90, FN: 0, NPV: 100, A: 90, IM: 1.7* (*p<0.025). Group II: PT injection only: LD: 82.4, SD: 94; PT injection+SB re-injection: LD: 90, SD: 98.5. SD was 97.8** in patients with positive lymphoscintigraphy and 58.5** when lymphoscintigraphy was negative (**p<0.001).

CONCLUSION

For correct staging, including extra-axillary drainage, peritumoural injection should first be performed. When the SN is not visualised, and only in those cases, SB re-injection should be performed, which increases the SD rate without increasing the FN rate.