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

High-frequency contrast-enhanced ultrasound in discriminating benign and malignant superficial lymph nodes: a diagnostic comparison

BACKGROUND

Lymph nodes are critical immune system components, filtering harmful substances and acting as indicators in various disease states, including cancer. Accurate differentiation between benign and malignant superficial lymph nodes is essential for diagnosis and treatment planning. However, conventional diagnostic methods often lack the required precision. High-frequency contrast-enhanced ultrasound (H-CEUS) offers improved temporal resolution and visualization of microvascular structures, potentially providing better diagnostic accuracy than standard contrast-enhanced ultrasound (CEUS).

METHODS

This study included 77 patients with suspected abnormalities in superficial lymph nodes. Each patient underwent H-CEUS and CEUS examinations, with diagnoses confirmed through biopsy or surgical resection. The diagnostic performance of H-CEUS and CEUS was evaluated using sensitivity, specificity, positive predictive value, negative predictive value, and accuracy. Chi-square tests and ROC curve analysis were employed to compare the efficacy of H-CEUS and CEUS in differentiating benign from malignant lymph nodes.

RESULTS

H-CEUS demonstrated superior diagnostic performance over CEUS, with higher sensitivity (95.92% vs. 83.67%), specificity (92.86% vs. 57.14%), and accuracy (94.80% vs. 74.03%). H-CEUS enhanced microvascular morphology visualization, facilitating more accurate differentiation between benign and metastatic lymph nodes. The area under the ROC curve for H-CEUS (0.944) was significantly greater than that for CEUS (0.704), indicating improved diagnostic capability.

CONCLUSION

H-CEUS offers enhanced accuracy in diagnosing the nature of superficial lymph nodes, potentially improving clinical decision-making for patients with suspected lymph node malignancies. These findings support the integration of H-CEUS into routine clinical practice to achieve better diagnostic outcomes.

First study on the efficiency of 99mTc-rituximab for sentinel lymph node mapping and biopsy in oral squamous cell carcinoma

OBJECTIVE

To explore the clinical efficiency of using the sentinel lymph node (SLN) imaging agent 99mTc-rituximab for lymphoscintigraphy and SLN biopsy (SLNB) in oral squamous cell carcinoma (OSCC) patients.

METHODS

A retrospective study was conducted on 23 patients with OSCC who underwent 99mTc-rituximab lymphoscintigraphy and SLNB. The cohort comprised 16 men (69.6%) and 7 women (30.4%) with a median age of 64.0 years (range: 33-90 years). All patients received a preoperative peritumoral injection of 99mTc-rituximab. The SLN detection rates (SDRs) of SLN imaging and SLNB were analyzed. The localizations of SLNs were counted. Patients were followed up after surgery. Differences were considered significant for a p-value of less than 0.05.

RESULTS

The SDRs of lymphoscintigraphy and SLNB were 91.3% (21/23) and 100.0% (23/23), respectively. The SDRs of lymphoscintigraphy for patients in pathological stages I/II and III/IVa were 100.0% (15/15) and 75.0% (6/8), respectively. Among the 2 patients with negative imaging results, both were stage IVa and both had SLN metastasis. The SLNs were located in levels Ib, IIa, IIb, III, and IV, accounting for 45.0% (18/40), 40.0% (16/40), 10.0% (4/40), 2.5% (1/40), and 2.5% (1/40), respectively. The median follow-up duration was 32.0 months (range: 13.0-68.0 months). During follow-up, none of the 23 patients (100.0%) showed lymph node (LN) metastasis. As a result, the sensitivity, negative predictive value (NPV), and accuracy were all 100.0%.

CONCLUSIONS

The application of 99mTc-rituximab for SLN imaging and SLNB in OSCC patients demonstrated high detection rates and accuracy, holding significant clinical value.

Discordance between peritumoral and subareolar injections for mapping sentinel lymph nodes in the breast

PURPOSE

Sentinel node biopsy (SNB) is a common staging tool for breast cancer. Initially, peritumoral (PT) injections were used, however subareolar (SA) injections were later introduced to simplify the technique. Controversy remains regarding whether PT and SA injections map the same sentinel lymph nodes (SLNs). This study aimed to determine whether the regional location of breast SLNs differs when using PT versus SA injections using a large dataset from a single institution.

METHODS

A total of 1035 patients who underwent breast SNB (PT injections: n = 858 and SA injections: n = 177) with lymphoscintigraphy and SPECT/CT were included. The identified SLN locations using SA injections were compared with those using PT injections. Differences in drainage proportions and odds ratios (ORs) for each clockface breast region and the whole breast were calculated using a two-proportion z-test and Fisher's Exact Test.

RESULTS

A higher proportion of internal mammary SLNs were identified using PT injections for the whole breast (0.30 versus 0.09) and for all breast regions, with all regions showing statistical significance except the upper outer quadrant. Similarly, ORs showed identification of internal mammary SLNs was significantly higher when using PT injections (4.35, 95% CI 2.53 to 7.95). There were no significant differences in identifying axillary SLNs between injection sites.

CONCLUSION

This is the largest cohort study to compare the regional location of breast SLNs identified using PT injections versus SA injections. Discordance was shown in the SLNs identified between injection techniques, with PT injections more frequently identifying internal mammary SLNs.

Tracing Sentinel Lymph Nodes and Inhibiting Lymphatic Metastasis with TiN Nanobipyramids Through Photothermal Therapy

Background

The lymphatic system is the major route of cancer metastasis, and sentinel lymph nodes (SLNs) are the first station for the spread of cancer cells. Accurate identification of SLNs by tracers during surgery is crucial for SLN biopsy and lymphadenectomy. However, conventional monomodal tracers such as blue dyes and carbon nanoparticles often induce a misjudgment of SLNs and thus are still unsatisfying for clinical applications. In addition, SLN imaging agents with therapeutic capabilities to achieve perfect theranostics have been less exploited.

Purpose

Titanium nitride (TiN) nanostructures have the advantages of high stability and low cost and show superior plasmonic properties over both the visible and near-infrared (NIR) regions. Herein we report on the synthesis of TiN nanobipyramids (NBPs) with large sizes for multimodal SLN mapping.

Methods

A hydrothermal method and post nitridation treatment were used to prepare the TiN NBPs. Bright- and dark-field imaging of SLNs with TiN NBPs were performed. The effect of TiN NBP size on SLN tracing was studied. The effect of TiN NBP-based photothermal ablation of SLNs combined with removal of primary tumors on pulmonary metastasis was studied.

Results

The TiN NBPs with dual bright- and dark-field imaging functions show high drainage in lymph nodes and thus can act as a potential substitute for SLN tracing. Moreover, owing to the superior plasmonic properties of TiN nanostructures, the produced TiN NBPs show a high photothermal conversion efficiency under 1064 nm laser irradiation. TiN NBP-based photothermal ablation of metastatic LNs in the second NIR window (NIR-II) combined with surgical removal of primary tumors shows remarkable inhibition of pulmonary metastasis.

Conclusion

This study not only demonstrates TiN NBPs as a new tracer for SLN mapping, but also presents a strategy for the photothermal ablation of lymph nodes in NIR-II for the inhibition of lymphatic metastasis.

Prognostic study of sentinel lymph node biopsy in early-stage oral squamous cell carcinoma with computed tomography lymphography

PURPOSE

Occult metastasis is a prognostic factor for early-stage oral squamous cell carcinoma (OSCC). Sentinel lymph node (SLN) biopsy (SLNB) is a promising method to detect such metastases. The present study aimed to evaluate the diagnostic reliability of SLNB with computed tomography lymphography (CTL) for early-stage OSCC and to clarify patient outcomes after SLNB.

METHODS

The medical records of 42 patients with T1 or T2 cN0 OSCC who had undergone CTL the day before surgery were retrospectively collected and statistically analyzed.

RESULTS

SLNs were identified on CTL in 41 of 42 OSCC patients (97.6 %). Micrometastases were detected in 10 of 41 cases (24.4 %) and 11 of 65 SLNs (16.9 %) by intraoperative pathological diagnosis. Three cases showed occult metastasis within a year after the primary operation. Specificity and negative predictive value were 76.9 % and 90.3 %, respectively. The cumulative 5-year regional recurrence-free rate was 89.7 % in 31 SLNB-negative patients. Five-year overall and disease-free survival rates were 86.9 % and 70.1 %, respectively, in the 41 cases with identified SLNs.

CONCLUSION

CTL offers acceptable results and appears likely to be effective in treating early-stage OSCC patients with low-invasive surgery. Further investigation is necessary to compare radioisotope-based methods.

Update on Sentinel Lymph Node Methods and Pathology in Breast Cancer

Breast cancer stands out as the most commonly diagnosed cancer among women globally. Precise lymph node staging holds critical significance for both predicting outcomes in early-stage disease and formulating effective treatment strategies to control regional disease progression in breast cancer patients. No imaging technique possesses sufficient accuracy to identify lymph node metastases in the early stages (I or II) of primary breast cancer. However, the sentinel node procedure emerges as a valuable approach for identifying metastatic axillary nodes. The sentinel lymph node is the hypothetical first lymph node or group of nodes draining a cancer. In case of established cancerous dissemination, it is postulated that the sentinel lymph nodes are the target organs primarily reached by metastasizing cancer cells from the tumor. The utilization of the sentinel node technique has brought about changes in the assessment of lymph nodes. It involves evaluating the sentinel node during surgery, enabling prompt lymph node dissection when the sentinel node procedure is positive. Additionally, histological ultra-stratification is employed to uncover occult metastases. This review aims to provide an update of this valuable technique, with focus on the practical aspects of the procedure and the different histological protocols of sentinel node evaluation in breast cancer.

Lymph node metastases in breast cancer: Mechanisms and molecular imaging

Breast cancer is the most common malignant disease of women in the world. Breast cancer often metastasizes to axillary lymph nodes. Accurate assessment of the status of axillary lymph nodes is crucial to the staging and treatment of breast cancer. None of the methods used clinically for preoperative noninvasive examination of axillary lymph nodes can accurately identify cancer cells from a molecular level. In recent years, with the in-depth study of lymph node metastases, the mechanisms and molecular imaging of lymph node metastases in breast cancer have been reported. In this review, we highlight the new progress in the study of the main mechanisms of lymph node metastases in breast cancer. In addition, we analyze the advantages and disadvantages of traditional preoperative axillary lymph node imaging methods for breast cancer, and list molecular imaging methods that can accurately identify breast cancer cells in lymph nodes.

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.

Axillary management for early invasive breast cancer patients: Who will truly benefit?

Background

The implementation of sentinel lymph node biopsy (SLNB) and further completion axillary lymph node dissection (cALND) after positive sentinel lymph nodes (SLNs) on early invasive breast cancer patients should be cautiously tailored. Identifying predictors for SLN and non-sentinel lymph node (nSLN) metastases can help surgeons make better surgical decisions.

Methods

A retrospective case-control study was designed and a total of 560 eligible patients were enrolled consecutively. They were all diagnosed in our center and received appropriate medical care. According to the metastasis of SLN and nSLN, they were divided into metastatic and non-metastatic groups on two successive occasions to investigate the relationship between clinical factors, pathological factors, hematological factors and lymph node metastasis.

Results

In total, 101 (18.04%) patients developed SLN metastases, including 98 patients with macro-metastases and 3 patients with micro-metastases. Out of 97 patients receiving further cALND, 20 patients (20.62%) developed nSLN metastases. Multivariate analysis revealed that “high expression of Ki-67” and “lymphatic invasion” predicted a higher risk of SLN metastasis; and “increased number of positive SLNs” and “increased systemic inflammation index (SII)” predicted a higher risk of nSLN metastasis.

Conclusion

Surgery for early invasive breast cancer patients should be more customized and precise. Appropriate axillary management is necessary for patients with the associated predictors.

Accuracy and Limitations of Sentinel Lymph Node Biopsy after Neoadjuvant Chemotherapy in Breast Cancer Patients with Positive Nodes

Background

Axillary surgical management in patients with node-positive breast cancer at the time of diagnosis converted to negative nodes through neoadjuvant chemotherapy (NAC) remains unclear. Removal of more than two sentinel nodes (SLNs) in these patients may decrease the false negative rate (FNR) of sentinel lymph node biopsies (SLNBs). We aim to analyse the detection rate (DR) and the FNR of SLNB assessment according to the number of SLNs removed.

Methods

A retrospective study was performed from October 2012 to December 2018. Patients with invasive breast cancer who had a clinically node-positive disease at diagnosis and with a complete axillary response after neoadjuvant chemotherapy were selected. Patients included underwent SLNB and axillary lymph node dissection (ALND) after NAC. The SLN was considered positive if any residual disease was detected. Descriptive statistics were used to describe the clinicopathologic features and the results of SLNB and ALND. The DR of SLNB was defined as the number of patients with successful identification of SLN. Presence of residual disease in ALND and negative SLN was considered false negative.

Results

A total of 368 patients with invasive breast cancer who underwent surgery after complete NAC were studied. Of them, 85 patients met the eligibility criteria and were enrolled in the study. The mean age at diagnosis was 50.8 years. Systematic lymphadenectomy was performed in all patients, with an average of 10 lymph nodes removed. The DR of SLNB was 92.9%, and the FNR was 19.1. The median number of SLNs removed was 3, and at least, three SLNs were obtained in 42 patients (53.2%). When at least three sentinel nodes were removed, the FNR decreased to 8.7%.

Conclusions

In this cohort, the SLN assessment was associated with an adequate DR and a high FNR. Removing three or more SLNs decreased the FNR from 19.1% to 8.7%. Complementary approaches may be considered for axillary lymph node staging after neoadjuvant chemotherapy. The study was approved by our institution's ethics committee (Instituto de Investigacion Sanitaria Hospital 12 de Octubre (imas12), Universidad Complutense de Madrid, Madrid, Spain) (https://clinicaltrials.gov/ct2/show/NCEI:20/0048).

Sentinel Lymph Node Methods in Breast Cancer

Breast cancer is the most frequent cancer diagnosed in women worldwide. Accurate lymph node staging is essential for both prognosis (of early-stage disease) and treatment (for regional control of disease) in patients with breast cancer. The sentinel lymph nodes are the regional nodes that directly drain lymph from the primary tumor. No imaging modality is accurate enough to detect lymph node metastases when a primary breast cancer is at an early stage (I or II), but sentinel lymph node biopsy is a highly reliable method for screening axillary nodes and for identifying metastatic (including micro-metastatic) disease in regional lymph nodes. Despite the widespread use of sentinel lymph node biopsy for early-stage breast cancer, relevant variations have been described regarding practical aspects of the procedure, and some variability has initially been reported regarding the rates of intraoperative sentinel lymph node identification and of false-negative findings, most likely because of differences in the size of the populations being investigated and in lymphatic mapping techniques. Nevertheless, using adequate learning curves and once a multidisciplinary team is experienced with the procedure, improved levels of accuracy are achieved.

Early Institutional Experience of Dual Tracer and Single-Photon Emission Computed-Tomography/Computed-Tomography Mapping for Sentinel Node Biopsy: A Report of Two Early-Stage Breast Cancer

Intraoperative sentinel lymph node mapping (SLNM) with methylene blue dye (MBD) tracer has been the recommended method to detect SLN in early-stage breast cancer patients in low-resource settings. However, the use of MBD alone is hampered by the high false-negative rate; thus, it requires coupling with other mapping methods if the appropriate infrastructure and services are available. In this article, we present two prospective cases detailing our initial experience using the gold-standard dual tracer technique (DTT: MBD and 99mTc-nanocolloid radioisotope) in combination with hybrid single-photon emission computed-tomography/computed-tomography (SPECT/CT) preoperative mapping for image-guided SLN biopsy (SLNB). Overall, both studies were successful in identifying the SLNs, which aided in mapping the possible anatomical spread of the disease.

The impact of drainage pathways on the detection of nodal metastases in prostate cancer: a phase II randomized comparison of intratumoral vs intraprostatic tracer injection for sentinel node detection

INTRODUCTION

Previous studies indicated that location and amount of detected sentinel lymph nodes (SLNs) in prostate cancer (PCa) are influenced where SLN-tracer is deposited within the prostate. To validate whether intratumoral (IT) tracer injection helps to increase identification of tumor-positive lymph nodes (LNs) better than intraprostatic (IP) tracer injection, a prospective randomized phase II trial was performed.

METHODS

PCa patients with a > 5% risk of lymphatic involvement were randomized between ultrasound-guided transrectal injection of indocyanine green-[^99mTc]Tc-nanocolloid in 2 depots of 1 mL in the tumor (n = 55, IT-group) or in 4 depots of 0.5 mL in the peripheral zone of the prostate (n = 58, IP-group). Preoperative lymphoscintigraphy and SPECT/CT were used to define the location of the SLNs. SLNs were dissected using combination of radio- and fluorescence-guidance, followed by extended pelvic LN dissection and robot-assisted radical prostatectomy. Outcome measurements were number of tumor-bearing SNs, tumor-bearing LNs, removed nodes, number of patients with nodal metastases, and metastasis-free survival (MFS) of 4-7-year follow-up data.

RESULTS

IT-injection did not result in significant difference of removed SLNs (5.0 vs 6.0, p = 0.317) and histologically positive SLNs (28 vs 22, p = 0.571). However, in IT-group, the SLN-positive nodes were 73.7% of total positive nodes compared to 37.3% in IP-group (p = 0.015). Moreover, significantly more node-positive patients were found in IT-group (42% vs 24%, p = 0.045), which did not result in worse MFS. In two patients (3.6%) from whom the IT-tracer injection only partly covered intraprostatic tumor spread, nodal metastases in ePLND without tumor-positive SNs were yielded.

CONCLUSIONS

The percentage-positive SLNs found after IT-injection were significantly higher compared to IP-injection. Significantly more node-positive patients were found using IT-injection, which did not affect MFS. IT-injection failed to detect nodal metastases from non-index satellite lesions. Therefore, we suggest to combine IT- and IP-tracer injections in men with visible tumor on imaging.

Sentinel Lymph Node Biopsy in Breast Cancer with 99mTc-Tilmanocept: A Multicenter Study on Real-Life Use of a Novel Tracer

^99mTc-tilmanocept is a novel radiopharmaceutical for sentinel lymph node (SLN) biopsy in breast cancer. Our aim was to describe results with ^99mTc-tilmanocept in a heterogeneous group of breast cancer patients scheduled for SLN biopsy. Methods: Radiotracer preparation followed the manufacturer's indications. Local protocols for SLN detection within 9 participant centers were not changed for the entire duration of the study. In total, 344 patients with T1-T4, N0-N2 breast cancer (352 lesions) were included. Superficial (intradermal or periareolar) or deep (peritumoral or intratumoral) injections were performed. The doses were adjusted depending on the scheduled time for surgery. Results: Lymphoscintigraphy was able to depict at least 1 SLN in 339 of 352 breast lesions (96.3%), and the intraoperative SLN detection rate reached 97.2%. On univariable analysis, SLN detection rates did not differ by age, clinical T or N stage, tumor location, histologic subtype, or prior neoadjuvant therapy. Lymphoscintigraphy showed higher SLN detection in patients with a normal weight (body mass index < 25) than in those who were overweight or obese (body mass index ≥ 25), at 99.2% versus 94.6%, respectively (P = 0.031). The proportion of patients with preoperative lymphoscintigraphic detection or excised SLNs was higher with superficial than deep injections. Reinjected cases were significantly lower when superficial injection was chosen first (P < 0.001). Injection site and the tumor markers human epidermal growth factor receptor 2 and estrogen receptor had an impact on preoperative SLN visualization and intraoperative localization. In 80 cases, SLN biopsy resulted in a positive lymph node. During a mean follow-up of 19 mo, no axillary recurrences were observed. Conclusion: Whatever the protocol, ^99mTc-tilmanocept showed good results in a heterogeneous breast cancer population, although the best results were achieved when a superficial injection was chosen.

Repeat Sentinel Lymph Node Surgery in Recurrent Breast Cancer: Peritumoral vs. Periareolar Injections

BACKGROUND

In the setting of recurrent cancer, there is no standard methodology regarding the technical aspects of repeat sentinel lymph node (rSLN) surgery. We analyzed our institutional experience with attempted rSLN surgery to determine the optimal injection technique.

MATERIALS AND METHODS

Single site, retrospective review of patients with prior lumpectomy for breast cancer who presented with recurrent or new ipsilateral breast cancer and underwent attempt at rSLN surgery from 2008 to 2017. Patients with prior mastectomy or no prior ipsilateral axillary operation were excluded.

RESULTS

A total of 141 patients were included; 103 (73%) underwent successful rSLN biopsy procedure. Lymphoscintigraphy showed aberrant drainage in 32 (26%). Periareolar (PA) injection resulted in failed mapping in 23/99 (23%) and aberrant drainage in 25/85 (29%). By comparison, peritumoral (PT) injection had a 14/38 (37%) incidence of failed mapping and 7/37 (19%) aberrant drainage (P = .11 and .23, respectively). Of the patients with successful sentinel lymph node (SLN) biopsy procedure via PA injection, 11/76 (14%) were positive for metastatic disease as compared with 2/24 (8%) in PT injection. Sixteen patients had lymph node metastases; 13 (81%) were SLNs, including 3 positive aberrant SLNs. Five-year regional recurrence rates were 11.4% (95% confidence interval, 0%-21.5%) and 0% for PA and PT injection techniques, respectively.

CONCLUSION

PA and PT injections had a similar incidence of SLN identification and aberrant drainage. Preoperative lymphoscintigraphy is beneficial in patients with recurrent breast cancer given the higher incidence of aberrant drainage in this population. Patients who underwent PA injections had a higher incidence of regional recurrences but this difference was not statistically significant.

Ultrasonographic Algorithm for the Assessment of Sentinel Lymph Nodes That Drain the Mammary Carcinomas in Female Dogs

The status of sentinel lymph nodes (SLNs) is decisive in staging, prognosis, and therapeutic approach. Using an ultrasonographic examination algorithm composed of B-mode, Doppler technique, contrast-enhanced ultrasound (CEUS) and elastography, this study aimed to determine the diagnostic performance of the four techniques compared to histopathological examination. 96 SLNs belonging to 71 female dogs with mammary gland carcinomas were examined. After examinations, mastectomy and lymphadenectomy were performed. Histopathological examination confirmed the presence of metastases in 54 SLNs. The elasticity score had the highest accuracy-89.71%, identifying metastases in SLNs with 88.9.9% sensitivity (SE) and 90.5% specificity (SP), ROC analysis providing excellent results. The S/L (short axis/long axis) ratio showed 83.3% SE and 78.6% SP as a predictor of the presence of metastases in SLN having a good accuracy of 81.2%. On Doppler examination, the resistivity index(RI) showed good accuracy of 80% in characterizing lymph nodes with metastases versus unaffected ones; the same results being obtained by CEUS examination. By assigning to each ultrasonographic parameter a score (0 or 1) and summing up the scores of the four techniques, we obtained the best diagnostic performance in identifying lymph node metastases with 92.2% accuracy. In conclusion, the use of the presented algorithm provides the best identification of metastases in SLNs, helping in mammary carcinoma staging and appropriate therapeutic management.

Sentinel node occult lesion localization technique for impalpable breast cancer

BACKGROUND

Mammographic screening has enabled earlier detection of breast cancer, with 25-35% of malignancies being non-palpable at diagnosis. Accurate removal and sentinel node biopsy for staging these lesions are crucial to successful management. Both these aspects are achieved by peritumoural localization with radioisotope and lymphoscintigraphy for sentinel lymph node (SN) mapping using the sentinel node and occult lesion localization (SNOLL) technique. This study reports SNOLL outcomes in a large cohort of women with non-palpable breast cancers to assess its performance and promote its logistic advantages.

METHODS

This retrospective cohort study used data from BreastSurgANZ Quality Audit supplemented with private case notes. Inclusion criteria were females >18 years, with invasive breast cancer that was asymptomatic and non-palpable at presentation, who underwent SNOLL (n = 450). Primary outcomes were proportion of successful lesion localization, proportion of patients requiring re-excision and volume of tissue excised. Secondary outcomes focused on lymphoscintigraphy success rate in detecting sentinel nodes and SN positivity rates.

RESULTS

Tumours were successfully removed with the initial SNOLL procedure in 449 cases (99.8%). The re-excision rate was 15.1% (n = 68). The mean total excision volume was 54.69 cm3 (95% CI 51.49-57.88 cm3 ; range 2.75-195.33 cm3 ), with a mean closest circumferential margin of 7.05 mm (95% CI 6.60-7.49 mm; range 0 to ≥10 mm). Lymphoscintigraphy was successful in 96.9% (n = 436) of cases. Sentinel nodes were successfully identified and removed in 99.6% (n = 448) of cases. SN positivity rate was 18.4%.

CONCLUSION

SNOLL is an efficient and effective technique for localizing non-palpable invasive breast lesions while simultaneously identifying sentinel nodes.

The application of methylene blue coloration technique in axillary lymph node dissection of breast cancer

Background

To analyze the associated factors that affect the coloration of methylene blue (MB) in axillary lymph node dissection (ALND) of patients with breast cancer and to explore the tracer effect of MB in high axillary lymph node metastasis, to guide surgical treatment.

Methods

We recruited 170 patients who underwent ALND, all of them were injected MB before operation. We analyzed the relationships between the clinical factors of age, body mass index (BMI), molecular typing, TNM staging, neoadjuvant chemotherapy, injection time and position and the MB coloration by univariate and multivariate analyses. A total of 84 cases were selected for observation of the application value of MB during intervention involving the lymph nodes upper axillary vein.

Results

Of 170 cases, 138 cases (81.17%) were colored. Univariate analysis showed that significant differences were observed between differing BMI’s (χ²=24.074, P<0.0001) and injection times (χ²=41.207, P<0.0001). Multivariate analysis showed that injection time (P=0.016) was the clinical factor associated with MB coloration. More than 60 minutes before surgery and MB injection, the possibility of methylene blue colored was 0.088 times higher than 10 minutes (P=0.010, 95% CI, 0.014, 0.554). MB was used to track the lymph node upper axillary vein with a sensitivity of 12.5%, a specificity of 100%, a false negative rate of 87.50%, and a false positive rate of 0; the kappa coefficient was 0.051 (χ²=0.679, P=0.404).

Conclusions

Among the clinical factors, MB coloration was worse more than 60 minutes before ALND. Using the technology of MB color, lymph nodes can be clearly identified. It has great guiding value for the doctors who learn the operation initially. However, it is still prudent to use MB for high lymph node dissection.

Prognostic impact of repeat sentinel lymph node biopsy in patients with ipsilateral breast tumour recurrence

BACKGROUND

Ipsilateral breast tumour recurrence (IBTR) has an unfavourable prognosis, with a significant subsequent risk of distant recurrence. Repeat sentinel lymph node biopsy (rSLNB) has recently been demonstrated to be technically feasible and useful in tailoring adjuvant treatment plans in patients with IBTR. The prognostic impact of rSLNB in patients with IBTR remains unclear. This study analysed the risk of distant recurrence after IBTR, and evaluated the prognostic impact of rSLNB and other patient and tumour characteristics on distant recurrence-free survival.

METHODS

Data were obtained from the SNARB (Sentinel Node and Recurrent Breast Cancer) study. Cox proportional hazards analyses were performed to assess the prognostic effect of tumour, patient and treatment factors on distant recurrence-free survival.

RESULTS

Of the 515 included patients, 230 (44·7 per cent) had a tumour-negative rSLNB and 46 (8·9 per cent) a tumour-positive rSLNB. In 239 patients (46·4 per cent) the rSLNB procedure was unsuccessful. After a median follow-up of 5·1 years, 115 patients (22·3 per cent) had developed a recurrence. The overall 5-year distant recurrence-free survival rate was 84·2 (95 per cent c.i. 80·7 to 87·7) per cent. An interval of less than 2 years between primary breast cancer treatment and ipsilateral recurrence (P = 0·018), triple-negative IBTR (P = 0·045) and absence of adjuvant chemotherapy after IBTR (P = 0·010) were independently associated with poor distant recurrence-free survival. The association between the outcome of rSLNB and distant recurrence-free survival was not statistically significant (P = 0·682).

CONCLUSION

The outcome of rSLNB is not an important prognostic factor for distant recurrence, and its value as a staging tool in patients with IBTR seems disputable.

Predictive risk factors for sentinel lymph node nonvisualization on planar lymphoscintigraphy using an intratumoral injection in patients with primary breast cancer

OBJECTIVES

Lymphoscintigraphy is considered a useful tool to optimize sentinel lymph node (SLN) identification. Nonvisualization of the SLN is associated with a lower SLN identification rate. The aim of this study was to identify preoperative factors associated with SLN nonvisualization on lymphoscintigraphy.

PATIENTS AND METHODS

A total of 2050 consecutive SLN procedures were evaluated from clinically node-negative breast cancer patients. Planar lymphoscintigraphy was performed at 3 h after an intratumoral injection of technetium-99m-nanocolloid. This technique was used for extra-axillary SLN identification. Patient, tumor, and treatment characteristics were analyzed for association with SLN nonvisualization. Factors with a P-value less than 0.1 in univariate analysis were included in a multivariate logistic regression model.

RESULTS

The SLN visualization rate was 86.7%. In multivariate logistic regression, age of at least 70 years [odds ratio (OR): 3.24; 95% confidence interval (CI): 2.14-4.91)], BMI of at least 30 (OR: 1.93; 95% CI: 1.39-2.69), T3/T4-tumors (OR: 2.70; 95% CI: 1.37-5.32), medially/centrally located tumors (OR: 1.52; 95% CI: 1.17-1.99), previous mantle field radiation (OR: 4.04; 95% CI: 1.74-9.35), nonpalpable tumors (OR: 1.88; 95% CI: 1.36-2.60), and presence of iodine seeds (OR: 1.35; 95% CI: 1.02-1.78) were associated significantly with nonvisualization on lymphoscintigraphy. Nonvisualization was the strongest independent predictor of unsuccessful intraoperative SLN identification (P<0.001). Overall, the SLN identification rate was 97.7% because of the use of additional imaging and blue dye.

CONCLUSION

This study reports new tumor and treatment-related risk factors for nonvisualization on lymphoscintigraphy by using an intratumoral injection in primary breast cancer. We recommend a periareolar subcutaneous injection to improve SLN visualization in patients with limited prognostic and therapeutic relevance of internal mammary chain SLN identification.

Long-Term Outcome After Retro-Areolar Versus Peri-Tumoral Injection of Superparamagnetic Iron Oxide Nanoparticles (SPIO) for Sentinel Lymph Node Detection in Breast Cancer Surgery

BACKGROUND/OBJECTIVE

SPIO is effective in sentinel node (SN) detection. No nuclear medicine department is needed, and no allergic reactions have occurred. This study aimed to compare retro-areolar and peri-tumoral SPIO injections regarding skin staining, detection rates and number of SNs.

METHODS

Data on staining size, intensity and cosmetic outcome (0-5; 0 = no problem) were collected by telephone interviews with 258 women undergoing breast conservation. SN detection and the number of SNs were prospectively registered in 332 women.

RESULTS

After retro-areolar and peri-tumoral injections, 67.3% and 37.8% (p < 0.001) developed skin staining, with remaining staining in 46.2 vs. 9.4% after 36 months (p < 0.001). Initial mean size was 16.3 vs. 6.8 cm (p < 0.001) and after 36 months, 6.6 vs. 1.8 cm² (p < 0.001). At 75.1% of 738 interviews, staining was reported paler. After retro-areolar injections, cosmetic outcome scored worse for 2 years. The mean (median) scores were 1.3(0) vs. 0.5(0) points, and 0.2(0) vs. 0.1(0) points, at 12 and 36 months, respectively. Overall detection rates were 98.3% and 97.4% (p = 0.43) and the number of SNs 1.35 vs. 1.57 (p = 0.02) after retro-areolar and peri-tumoral injections. Injection, regardless of type, 1-27 days before surgery increased detection rates with SPIO, 98.0% vs. 94.2% (p = 0.06) ,and SN numbers, 1.56 vs. 1.27 (p = 0.003).

CONCLUSION

SPIO is effective and facilitates planning for surgery. Peri-tumoral injection reduced staining with a similar detection rate. Staining was not considered a cosmetic problem among most women. Injecting SPIO 1-27 days before surgery increased the detection rate by 3.8% and increased the number of SNs by 0.3.

Triple-site radiotracer application in breast lymphoscintigraphy and sentinel node discordance

Sentinel lymph node (SLN) biopsy (SLNB) has demonstrated accuracy in the axillary staging of breast cancer patients. Despite variability in selection criteria and technique, an SLN is consistently identified in approximately 96% of cases and in most series predicts the status of remaining axillary LNs in >95% of cases. The false-negative rate of sentinel lymph node biopsy (SLNB) was originally reported as 5%–10% (sensitivity 90%–95%), but improved rates are attainable by experienced surgeons. Radiolocalization with lymphoscintigraphy (LSG) increases SLN identification rates. LSG is a useful tool to establish the abnormal lymphatic drainage patterns and to detect the extra-axillary nodes, particularly internal mammary nodes. Despite controversy regarding the optimal injection method, studies have generally suggested high concordance between the various radiotracer application sites and axillary SLN identification. Discordant SLN identification would have implications for nodal staging as the true SLN might not be identified with individual injection techniques. In the current study, imaging from consecutive patients presenting for breast LSG over a-19 month period was retrospectively reviewed. Radiotracer application was performed with simultaneous injection of peritumoral, subcutaneous, and subareolar regions. This application method provided a mechanism to assess the LSG drainage patterns with a view to assessing injection site concordance and SLN identification rates. Data from 123 breast LSG patients were reviewed. Using our radiotracer technique, the axillary SLN identification rate was 98%. A single axillary node was detected in 110, two axillary nodes were detected in 10, and no axillary node was detected in three patients. Among those 10 patients in whom two axillary nodes were seen, at least two cases of discordant drainage occurred from different injection sites. This study demonstrates that different LSG injection sites can result in the identification of different axillary sentinel nodes although this appears to be a rare event. This finding may be of clinical importance if the true SLN is sought. In addition, the multisite injection technique appears to be an optimal method of axillary SLN identification, with high SLN detection rates.

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.

A Novel Indocyanine Green Fluorescence-Guided Video-Assisted Technique for Sentinel Node Biopsy in Breast Cancer

BACKGROUND

The equipment to detect indocyanine green (ICG) fluorescence for sentinel lymph node (SLN) biopsy in breast cancer is not widely accessible nor optimal. The fluorescence appears as a poorly defined white shine on a black background, and dimmed lighting is required. The aim of this study was to assess the feasibility, accuracy and healthcare costs of a novel approach for SLN biopsy by a video-assisted ICG-guided technique.

METHODS

The technique for detecting SLN was radioisotope (RI) in 194 cases, video-assisted ICG-guided in 70 cases and a combined method in 71 cases. In the video-assisted ICG group, a full HD laparoscopic system equipped with xenon lamps was used for a laser-free detection of ICG within a colored and magnified high-resolution image.

RESULTS

Detection of ICG fluorescence using a laparoscope with a near-infrared filter provided a highly defined and colored image during SLN biopsy. SLN was identified in 100% of patients in all groups. Multiple SLNs were identified in 0.5% of RI patients, in 12.9% of ICG patients and in 14.1% of ICG + RI patients (p < 0.0001). In ICG + RI group, 95.1% of lymph nodes were radioactive and 92.7% were fluorescent. Operative times and healthcare costs were equivalent between groups.

CONCLUSIONS

Video-assisted ICG-guided technique is a feasible and surgeon-friendly method for SLN biopsy, with equivalent efficacy compared to RI, providing an accurate staging of the axilla.

Quantum dot-NanoLuc bioluminescence resonance energy transfer enables tumor imaging and lymph node mapping in vivo

A small luciferase protein (Nluc) was conjugated to QDs as a bioluminescence resonance energy transfer (BRET) pair. The conjugate showed 76% BRET efficiency and lymph node mapping was successfully performed. The cRGD peptide was conjugated to QD-Nluc for tumor targeting. The self-illuminating QD-Nluc showed excellent energy transfer in a living system and offered an optimal tumor-to-background ratio (>85).

Current Management of the Axilla

Despite advances in estimating prognosis and predicting response to adjuvant systemic therapy, the status of the axillary lymph nodes remains a critical component in initial surgical planning and in determining therapeutic strategies for patients with breast cancer. Buoyed by evidence from multi-institutional randomized clinical trials, the last 2 decades have witnessed remarkable and practice-changing advances in our approach to the axilla. This review concentrates on the current best practice in axillary management for both node-negative and node-positive patients, with particular focus on the evolving management of the axilla in the era of neoadjuvant systemic therapy.

Precise intraoperative sentinel lymph node biopsies guided by lymphatic drainage in breast cancer

The purpose of this study was to present a novel surgical method for intraoperative precise sentinel lymph node biopsy (SLNB) and to determine its clinical efficacy and sensitivity in breast cancer patients. The sentinel lymph nodes (SLNs) were preoperatively evaluated by axillary ultrasound. The intraoperative detection of SLNs was guided by lymphatic drainage pathway. The lymphatic vessels and SLNs were visualized. During operation, we searched for all the true SLNs (trSLNs), para-SLNs (paSLNs) and post-SLNs (poSLNs) followed lymphatic drainage ducts. After precisely locating the lymphatic channels and lymph node, all the lymph nodes that firstly receive lymphatic drainage are designated as trSLNs. We precisely distinguished the trSLNs, paSLNs and poSLNs. We found the average number of trSLNs ranged from1 to 6. In addition, we assessed the novel technique in a total of 125 breast cancer patients. trSLNs were successfully identified in all patients (detection rate: 100 %). The accuracy of trSLNs is 99.2%. Data from our study strongly suggest that our method is a feasible and effective for the detection of precise trSLNs in breast cancer with real-time observations. (ClinicalTrials.gov number, NCT02651142).

Sentinel lymph node mapping using SPECT/CT and gamma probe in endometrial cancer: an analysis of parameters affecting detection rate

PURPOSE

SPECT/CT after pericervical injection of technetium-99 m-nanocolloid was shown to be suitable for sentinel lymph node (SLN) mapping in endometrial cancer (EC). The aim of this study was to analyze factors affecting successful SLN detection by means of SPECT/CT such as imaging findings, patient characteristics and tumor biology in a large cohort of patients.

METHODS

One hundred and forty-five consecutive patients suffering from EC who received pre-surgical SLN mapping at our institution between 2011 and 2016 were included in this analysis. SPECT/CT data of abdomen and pelvis (mean 4:20 ± 1:20 h p.i.) were acquired after pericervical injection of technetium-99 m-nanocolloid (mean 230 ± 45 MBq) in all patients. Surgical staging was performed on the day after. Acquisition parameters, patient characteristics, SPECT/CT findings as well as histopathological results were collected.

RESULTS

A total of 282 SLNs were identified by means of SPECT/CT. Overall, preoperative and intraoperative SLN detection rates were 86%, 76% and 74% respectively. The most important factor associated with failure to detect SLNs was the presence of high bone marrow on SPECT/CT (p = 0.005). Peritoneal/abdominal radioactivity was also associated with missed SLN detection in SPECT/CT (p = 0.02). However, the presence of liver/spleen uptake on its own was not predictive for detection failure. Low numbers of detected SLNs in SPECT/CT were slightly related with older age and lower injected activity. No significant influence was found for the parameters of tumor histology and stage, lymph node involvement and the time gap between injection and imaging.

CONCLUSIONS

Venous drainage as indicated by bone marrow uptake is the most important factor associated with scintigraphic SLN detection failure. Moreover, high peritoneal and abdominal activity was also associated with detection failure. Thus, meticulous application of the radiotracer is crucial in EC.

Breast cancer

Breast cancer is one of the three most common cancers worldwide. Early breast cancer is considered potentially curable. Therapy has progressed substantially over the past years with a reduction in therapy intensity, both for locoregional and systemic therapy; avoiding overtreatment but also undertreatment has become a major focus. Therapy concepts follow a curative intent and need to be decided in a multidisciplinary setting, taking molecular subtype and locoregional tumour load into account. Primary conventional surgery is not the optimal choice for all patients any more. In triple-negative and HER2-positive early breast cancer, neoadjuvant therapy has become a commonly used option. Depending on clinical tumour subtype, therapeutic backbones include endocrine therapy, anti-HER2 targeting, and chemotherapy. In metastatic breast cancer, therapy goals are prolongation of survival and maintaining quality of life. Advances in endocrine therapies and combinations, as well as targeting of HER2, and the promise of newer targeted therapies make the prospect of long-term disease control in metastatic breast cancer an increasing reality.

Sentinel lymph node biopsy in breast cancer: a technical and clinical appraisal

Breast cancer is the most common type of cancer diagnosed in women worldwide. Regional lymph node status is one of the strongest predictors of long-term prognosis in primary breast cancer. Sentinel lymph node biopsy (SLNB) has replaced axillary lymph node dissection as the standard surgical procedure for staging clinically tumor-free regional nodes in patients with early-stage breast cancer. SLNB staging considerably reduces surgical morbidity in terms of shoulder dysfunction and lymphedema, without affecting diagnostic accuracy and prognostic information. Clinicians should not recommend axillary lymph node dissection for women with early-stage breast cancer who have tumor-free findings on SLNB because there is no advantage in terms of overall survival and disease-free survival. Starting from the early 1990s, SLNB has increasingly been used in breast cancer management, but its role is still debated under many clinical circumstances. Moreover, there is still a lack of standardization of the basic technical details of the procedure that is likely to be responsible for the variability found in the false-negative rate of the procedure (5.5-16.7%). In this article, we report the aspects of SLNB that are well established, those that are still debated, and the advancements that have taken place over the last 20 years. We have provided an update on the methodology from both a technical and a clinical point of view in the light of the most recent publications.

Does the TNM classification of solitary internal mammary lymph node metastases in breast cancer still apply?

PURPOSE

TNM classification of solitary internal mammary lymph node metastases (IMLNMs) in breast cancer varies depending on their method of detection: sentinel lymph node biopsy (pN1b) or clinical examination including radiological and/or physical examination (pN2b). This study aimed to evaluate whether there is a difference in prognosis between both groups.

METHODS

Data of all patients diagnosed with primary invasive epithelial breast cancer between 2005 and 2008 were obtained from the Netherlands Cancer Registry. Patients with IMLNMs were divided in groups according to their pN1b and pN2b status. The main outcome measures disease-free survival (DFS) after 5 years and overall survival (OS) after 8 years were analyzed using Kaplan-Meier survival analysis. Cox regression analysis was used to determine independent predictors for DFS and OS.

RESULTS

A total of 73 patients with pN1b status and 28 patients with pN2b status were included. DFS rate was 74.1% in the pN1b group compared to 85.0% in the pN2b group (p = 0.211). Regarding OS, 20.5% (pN1b) and 25.0% (pN2b) of the patients deceased within 8 years of follow-up (p = 0.589). In multivariable cox regression analysis, nodal status was not statistically significant for DFS (HR 0.29 [95% CI 0.04-2.33], p = 0.244) or OS (HR 1.04 [95% CI 0.37-2.89], p = 0.947).

CONCLUSIONS

Although the TNM classification considers pN1b and pN2b to be distinct prognostic entities, we did not observe any prognostic differences between these groups. Therefore, solitary IMLNMs may be regarded as a single category in the future and revision of TNM classification should be considered.

Is blue dye still required during sentinel lymph node biopsy for breast cancer?

Background

In early breast cancer, the optimal technique for sentinel lymph node biopsy (SLNB) is the combined technique (radioisotope and Patent Blue V) which achieves high identification rates. Despite this, many centres have decided to stop using blue dye due to blue-dye-related complications (tattoo, anaphylaxis). We evaluated the SLNB identification rate using the combined technique with and without Patent Blue V and the blue-dye-related complication rates.

Methods

Clinical and histological data were analysed on patients undergoing SLNB between March 2014 and April 2015. SLNB was performed following standard hospital protocols using the combined technique.

Results

A total of 208 patients underwent SLNB and 160 patients (342 nodes) with complete operation notes were available for final analysis. The identification rate with the combined technique was 98.8% (n = 158/160), with blue dye alone 92.5% (n = 148/160) and with radioisotope alone 97.5% (n = 156/160). A total of 76.9% (263/342) of nodes were radioactive and blue, 15.5% (53/342) only radioactive and 2.3% (8/342) only blue, 5.3% (18/342) were neither radioactive nor blue. No anaphylactic reactions were reported and blue skin staining was reported in six (3.8%) patients.

Conclusion

The combined technique should continue be the preferred technique for SLNB and should be standardised. Radioisotope alone (but not blue dye alone) has comparable sentinel node identification rates in experienced hands. National guidelines are required to optimise operative documentation.

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.

Limited effectiveness of patent blue dye in addition to isotope scanning for identification of sentinel lymph nodes: Cross-sectional real-life study in 1024 breast cancer patients

BACKGROUND

Although morbidity is reduced when sentinel lymph node (SLN) biopsy is performed with dual isotopic and blue dye identification, the effectiveness of adding blue dye to radioisotope remains debated because side effects including anaphylactic reactions.

PATIENTS AND METHODS

Using data from a prospectively maintained database, 1884 lymph node-negative breast cancer patients who underwent partial mastectomy with SLN mapping by a dual-tracer using patent blue dye (PBD) and radioisotope were retrospectively studied between January 2000 and July 2013. Patients with tumors <3 cm and with >1 node detected by one of the two techniques (N = 1024) were included in this real-life cross-sectional study.

RESULTS

Among the 1024 patients, 274 had positive SLN detected by isotopic and/or PBD staining. Only 4 patients having no detectable radioactivity in the axilla had SLN identified only by PBD staining (blue-only) while 26 patients had SLN only identified by isotopic detection (hot-only) illustrating failure rates of 9.5% (26/274) and 1.5% (4/274), respectively. Among these four patients, two had negative lymphoscintigraphy. Therefore, the contribution of PBD to metastatic nodes identification was relevant for only 2/274 patients (0.8%). Three patients (0.3%) had an allergic reaction with PBD, and anaphylactic shock occurred in two cases (0.2%).

CONCLUSIONS

The added-value of PBD to reduce the false-negative rate of SLN mapping is only limited to the rare cases in which no radioactivity is detectable in the axilla (<1%). When a radioisotope mapping agent is available, the use of PBD should be avoided, because it can induce anaphylaxis.

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.

How Often Does Neoadjuvant Chemotherapy Avoid Axillary Dissection in Patients With Histologically Confirmed Nodal Metastases? Results of a Prospective Study

BACKGROUND

In breast cancer patients with nodal metastases at presentation, false-negative rates lower than 10 % have been demonstrated for sentinel node biopsy (SLNB) after neoadjuvant chemotherapy (NAC) when three or more negative sentinel nodes (SLNs) are retrieved. However, the frequency with which axillary dissection (ALND) can be avoided is uncertain.

METHODS

Among 534 prospectively identified consecutive patients with clinical stages 2 and 3 cancer receiving NAC from November 2013 to November 2015, all biopsy-proven node-positive (N+) cases were identified. Patients clinically node-negative after NAC were eligible for SLNB. The indications for ALND were failed mapping, fewer than three SLNs retrieved, and positive SLNs.

RESULTS

Of 288 N+ patients, 195 completed surgery, with 132 (68 %) of these patients eligible for SLNB. The median age was 50 years. Of these patients, 73 (55 %) were estrogen receptor-positive (ER+), 21 (16 %) were ER- and human epidermal growth factor receptor-2-positive (HER2+), and 38 (29 %) were triple-negative. In four cases, SLNB was deferred intraoperatively. Among 128 SLNB attempts, three or more SLNs were retrieved in 110 cases (86 %), one or two SLNs were retrieved in 15 cases (12 %), and failed mapping occurred in three cases (2 %). In 66 cases, ALND was indicated: 54 (82 %) for positive SLNs, 9 (14 %) for fewer than three negative SLNs, and 3 (4 %) for failed mapping. Persistent disease was found in 17 % of the patients with fewer than three negative SLNs retrieved. Of the 128 SLNB cases, 62 (48 %) had SLNB alone with three or more SLNs retrieved. Among 195 N+ patients who completed surgery, nodal pathologic complete response (pCR) was achieved for 49 %, with rates ranging from 21 % for ER+/HER2- to 97 % for ER-/HER2+ cases, and was significantly more common than breast pCR in ER+/HER2- and triple-negative cases.

CONCLUSIONS

Nearly 70 % of the N+ patients were eligible for SLNB after NAC. For 48 %, ALND was avoided, supporting the role of NAC in reducing the need for ALND among patients presenting with nodal metastases.

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 combination of blue dye and radioisotope versus radioisotope alone during sentinel lymph node biopsy for breast cancer: a systematic review

Background

The combination of blue dye and radioisotope is most widely used to identify sentinel lymph nodes (SLNs) in patients with breast cancer. However, some individual studies suggested that dual tracers did not have an advantage over radioisotope alone in detecting SLNs. We performed a systematic review to investigate the added value of blue dye in addition to radioisotope.

Methods

We searched Pubmed and Embase. Prospective studies that compared the combination of radioisotope and blue dye with radioisotope alone were selected. The identification rate of SLNs and the false-negative rate were the main outcomes of interest. The odds ratios (ORs) and 95 % confidential intervals (CIs) were calculated by using random-effects model.

Results

Twenty-four studies were included. The combination of radioisotope and blue dye showed higher identification rate than radioisotope alone (OR = 2.03, 95 % CI 1.53–2.69, P < 0.05). However, no statistically significant difference was revealed for patients after neoadjuvant chemotherapy (OR = 1.64, 95 % CI 0.82–3.27, P > 0.05), or for studies with high proportion of patients with positive lymphoscintigraphy (OR = 1.41, 95 % CI 0.83–2.39, P > 0.05). Dual tracers did not significantly lower the false-negative rate compared with radioisotope alone (OR = 0.76, 95 % CI 0.44–1.29, P > 0.05).

Conclusions

Although the combination of blue dye and radioisotope outperformed radioisotope alone in SLN detection, the superiority for dual tracers may be limited for patients with positive lymphoscintigraphy or for those after neoadjuvant chemotherapy. Besides, the combined modality did not help lower the false-negative rate.

Surgical treatment of nonpalpable primary invasive and in situ breast cancer

Breast cancer is the most-common cancer among women worldwide, and over one-third of all cases diagnosed annually are nonpalpable at diagnosis. The increasingly widespread implementation of breast-screening programmes, combined with the use of advanced imaging modalities, such as magnetic resonance imaging (MRI), will further increase the numbers of patients diagnosed with this disease. The current standard management for nonpalpable breast cancer is localized surgical excision combined with axillary staging, using sentinel-lymph-node biopsy in the clinically and radiologically normal axilla. Wire-guided localization (WGL) during mammography is a method that was developed over 40 years ago to enable lesion localization preoperatively; this technique became the standard of care in the absence of a better alternative. Over the past 20 years, however, other technologies have been developed as alternatives to WGL in order to overcome the technical and outcome-related limitations of this technique. This Review discusses the techniques available for the surgical management of nonpalpable breast cancer; we describe their advantages and disadvantages, and highlight future directions for the development of new technologies.