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Recent Advances and Concepts in SLNB (Sentinel Lymph Node Biopsy) and Management of SLNB Positive Axilla in Carcinoma Breast. Indian J Surg 2022. [DOI: 10.1007/s12262-021-03100-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022] Open
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2
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Stan F, Gudea A, Damian A, Gal AF, Papuc I, Pop AR, Martonos C. Ultrasonographic Algorithm for the Assessment of Sentinel Lymph Nodes That Drain the Mammary Carcinomas in Female Dogs. Animals (Basel) 2020; 10:E2366. [PMID: 33321917 PMCID: PMC7763578 DOI: 10.3390/ani10122366] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 12/02/2020] [Accepted: 12/04/2020] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Florin Stan
- Department of Comparative Anatomy, Faculty of Veterinary Medicine, University of Agricultural Sciences and Veterinary Medicine, 3-5 Manastur Street, 400372 Cluj Napoca, Romania; (A.G.); (A.D.); (C.M.)
| | - Alexandru Gudea
- Department of Comparative Anatomy, Faculty of Veterinary Medicine, University of Agricultural Sciences and Veterinary Medicine, 3-5 Manastur Street, 400372 Cluj Napoca, Romania; (A.G.); (A.D.); (C.M.)
| | - Aurel Damian
- Department of Comparative Anatomy, Faculty of Veterinary Medicine, University of Agricultural Sciences and Veterinary Medicine, 3-5 Manastur Street, 400372 Cluj Napoca, Romania; (A.G.); (A.D.); (C.M.)
| | - Adrian Florin Gal
- Department of Cell Biology, Histology and Embryology, Faculty of Veterinary Medicine, University of Agricultural Sciences and Veterinary Medicine, 3-5 Manastur Street, 400372 Cluj Napoca, Romania;
| | - Ionel Papuc
- Department of Semiology and Medical Imaging, Faculty of Veterinary Medicine, University of Agricultural Sciences and Veterinary Medicine, 3-5 Manastur Street, 400372 Cluj Napoca, Romania;
| | - Alexandru Raul Pop
- Department of Reproduction, Obstetrics and Reproductive Pathology, Biotechnologies in Reproduction, Faculty of Veterinary Medicine, University of Agricultural Sciences and Veterinary Medicine, 3-5 Manastur Street, 400372 Cluj Napoca, Romania;
| | - Cristian Martonos
- Department of Comparative Anatomy, Faculty of Veterinary Medicine, University of Agricultural Sciences and Veterinary Medicine, 3-5 Manastur Street, 400372 Cluj Napoca, Romania; (A.G.); (A.D.); (C.M.)
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3
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Corso G, Magnoni F, Provenzano E, Girardi A, Iorfida M, De Scalzi AM, Invento A, Colleoni M, Cassano E, Trentin C, Gullo RL, Pravettoni G, Gilardi L, Grana CM, Intra M, Galimberti V, Veronesi P, De Lorenzi F, Leonardi MC. Multicentric breast cancer with heterogeneous histopathology: a multidisciplinary review. Future Oncol 2020; 16:395-412. [PMID: 32026709 DOI: 10.2217/fon-2019-0540] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Multiple synchronous (multifocal or multicentric) ipsilateral breast cancers with heterogeneous histopathology are a rare clinical occurrence, however, their incidence is increasing due to the use of MRI for breast cancer screening and staging. Some studies have demonstrated poorer clinical outcomes for this pattern of breast cancer, but there is no evidence to guide clinical practice. In this multidisciplinary review, we reflect on pathology and molecular characteristics, imaging findings, surgical management including conservation and reconstructive options and approach to the axilla, and the role of chemotherapy and radiotherapy. Multidisciplinary discussions appear decisive in planning an appropriate surgical choice and defining the correct systemic treatment tailored to each clinical condition.
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Affiliation(s)
- Giovanni Corso
- Faculty of Medicine, University of Milan, Milan, Italy.,Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Francesca Magnoni
- Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Elena Provenzano
- NIHR Cambridge Biomedical Research Centre, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Antonia Girardi
- Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Monica Iorfida
- Division of Medical Senology, European Institute of Oncology, IRCCS, Milan, Italy
| | | | - Alessandra Invento
- Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Marco Colleoni
- Division of Medical Senology, European Institute of Oncology, IRCCS, Milan, Italy
| | - Enrico Cassano
- Division of Breast Imaging, European Institute of Oncology, IRCCS, Milan, Italy
| | - Chiara Trentin
- Division of Breast Imaging, European Institute of Oncology, IRCCS, Milan, Italy
| | - Roberto Lo Gullo
- Division of Breast Imaging, European Institute of Oncology, IRCCS, Milan, Italy
| | - Gabriella Pravettoni
- Faculty of Medicine, University of Milan, Milan, Italy.,Applied Research Division for Cognitive & Psychological Science, European Institute of Oncology, IRCCS, Milan, Italy
| | - Laura Gilardi
- Division of Nuclear Medicine, European Institute of Oncology, IRCCS, Milan, Italy
| | - Chiara Maria Grana
- Division of Nuclear Medicine, European Institute of Oncology, IRCCS, Milan, Italy
| | - Mattia Intra
- Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Viviana Galimberti
- Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Paolo Veronesi
- Faculty of Medicine, University of Milan, Milan, Italy.,Division of Breast Surgery, European Institute of Oncology, IRCCS, Milan, Italy
| | - Francesca De Lorenzi
- Division of Plastic & Reconstructive Surgery, European Institute of Oncology, IRCCS, Milan, Italy
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Khallaf E, Abdoon M, Lotfy A, Abdalaziz Y, Kamal R, Attia H. Methylene blue 1% as a sensitive and safe alternative for sentinel lymph node biopsy in early stage breast cancer: Results of a large pilot study. Breast J 2019; 25:1017-1019. [PMID: 31192513 DOI: 10.1111/tbj.13401] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 07/27/2018] [Accepted: 07/27/2018] [Indexed: 11/27/2022]
Affiliation(s)
- Emad Khallaf
- Breast Surgery Unit, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Mohamed Abdoon
- Breast Surgery Unit, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Abdelrahman Lotfy
- Breast Surgery Unit, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Youmna Abdalaziz
- Breast Surgery Unit, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Rasha Kamal
- Woman's Imaging Unit, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Hanaa Attia
- Breast Cancer Unit, Faculty of Medicine, Cairo University, Cairo, Egypt
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Mamounas EP, Kuehn T, Rutgers EJT, von Minckwitz G. Current approach of the axilla in patients with early-stage breast cancer. Lancet 2017:S0140-6736(17)31451-4. [PMID: 28818521 DOI: 10.1016/s0140-6736(17)31451-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2016] [Revised: 02/28/2017] [Accepted: 04/10/2017] [Indexed: 02/01/2023]
Abstract
The surgical approach of the axilla in patients with early-stage breast cancer has witnessed considerable evolution during the past 25 years. The previously undisputed gold standard of axillary-lymph-node dissection for staging has now been replaced by sentinel-lymph-node biopsy for patients with clinically negative axilla. For selected patients with limited sentinel-lymph-node involvement, completion axillary-lymph-node dissection can be omitted or replaced by axillary radiotherapy, reducing morbidity. The clinical interest of axillary staging after neoadjuvant chemotherapy is increasing and this approach might contribute to morbidity reduction, and to the further tailoring of future systemic and locoregional treatment decisions by response assessment. Refinement of the sentinel-lymph-node biopsy technique might overcome the slightly impaired success rates in this setting. New techniques for lymphatic mapping attempt to further simplify the procedure. In view of the declining influence of axillary nodal status on adjuvant therapy decision-making, ongoing clinical trials will evaluate whether sentinel-lymph-node biopsy can be avoided altogether in selected patients.
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Affiliation(s)
- Eleftherios P Mamounas
- University of Florida Health Cancer Center-Orlando Health, and University of Central Florida, Orlando, FL, USA.
| | - Thorsten Kuehn
- Interdisciplinary Breast Cancer Center, Department of Gynecology and Obstetrics, Klinikum Esslingen, Esslingen, Germany
| | - Emiel J T Rutgers
- Netherlands Cancer Institute, Amsterdam, Netherlands; University of Amsterdam, Amsterdam, Netherlands
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Gültekin SS, Hasdemir AO, Tokgöz S, Özgehan G, Güzel H, Yücesoy C, Öztürk E, Arıkök AT. Sentinel Lymph Node Detection by 3D Freehand Single-Photon Emission Computed Tomography in Early Stage Breast Cancer. Mol Imaging Radionucl Ther 2016; 25:97-101. [PMID: 27277327 PMCID: PMC5096627 DOI: 10.4274/mirt.81894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
Abstract
We herein present our first experience obtained by 3D freehand single-photon emission computed tomography (SPECT) (F-SPECT) guidance for sentinel lymph node detection (SLND) in two patients with early stage breast cancer. F-SPECT guidance was carried out using one-day protocol in one case and by the two-day protocol in the other one. SLND was performed successfully in both patients. Histopathologic evaluation showed that the excised nodes were tumor negative. Thus, patients underwent breast-conserving surgery alone.
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Affiliation(s)
- Salih Sinan Gültekin
- Dışkapı Yıldırım Beyazıt Training and Research Hospital, Clinic of Nuclear Medicine, Ankara, Turkey, Phone: +90 533 761 49 91 E-mail:
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He PS, Li F, Li GH, Guo C, Chen TJ. The combination of blue dye and radioisotope versus radioisotope alone during sentinel lymph node biopsy for breast cancer: a systematic review. BMC Cancer 2016; 16:107. [PMID: 26883751 PMCID: PMC4754824 DOI: 10.1186/s12885-016-2137-0] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2015] [Accepted: 02/07/2016] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Pei-Sheng He
- The Second Department of General Surgery, Chongqing Three Gorges Central Hospital, 165 Xincheng Road, Chongqing, 404000, China
| | - Feng Li
- The Second Department of General Surgery, Chongqing Three Gorges Central Hospital, 165 Xincheng Road, Chongqing, 404000, China.
| | - Guan-Hua Li
- The Second Department of General Surgery, Chongqing Three Gorges Central Hospital, 165 Xincheng Road, Chongqing, 404000, China
| | - Can Guo
- The Second Department of General Surgery, Chongqing Three Gorges Central Hospital, 165 Xincheng Road, Chongqing, 404000, China
| | - Tian-Jin Chen
- The Second Department of General Surgery, Chongqing Three Gorges Central Hospital, 165 Xincheng Road, Chongqing, 404000, China
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Ahmed M, Purushotham AD, Horgan K, Klaase JM, Douek M. 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. Br J Surg 2014; 102:169-81. [PMID: 25511661 DOI: 10.1002/bjs.9673] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2014] [Revised: 06/24/2014] [Accepted: 09/16/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in early breast cancer. Currently, no consensus exists on the optimal site of injection of the radioactive tracer or blue dye. METHODS A systematic review and meta-analysis of studies comparing superficial and deep injections of radioactive tracer or blue dye for lymphatic mapping and SLNB was performed. The axillary and extra-axillary sentinel lymph node (SLN) identification rates obtained by lymphoscintigraphy and intraoperative SLNB were evaluated. Pooled odds ratios (ORs) and 95 per cent c.i. were estimated using fixed-effect analyses, or random-effects analyses if there was statistically significant heterogeneity (P < 0·050). RESULTS Thirteen studies were included in the meta-analysis. There was no significant difference between superficial and deep injections of radioactive tracer for axillary SLN identification on lymphoscintigraphy (OR 1·59, 95 per cent c.i. 0·79 to 3·17), during surgery (OR 1·27, 0·60 to 2·68) and for SLN identification using blue dye (OR 1·40, 0·83 to 2·35). The rate of extra-axillary SLN identification was significantly greater when deep rather than superficial injection was used (OR 3·00, 1·92 to 4·67). The discordance rate between superficial and deep injections ranged from 4 to 73 per cent for axillary and from 0 to 61 per cent for internal mammary node mapping. CONCLUSION Both superficial and deep injections of radioactive tracer and blue dye are effective for axillary SLN identification. Clinical consequences of discordance rates between the two injection techniques are unclear. Deep injections are associated with significantly greater extra-axillary SLN identification; however, this may not have a significant impact on clinical management.
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Affiliation(s)
- M Ahmed
- Research Oncology, Division of Cancer Studies, King's College London, London
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Ratchaworapong K, Thanawut S, Yodavudh S, Chottanapund S. Rate of sentinel lymph node identification using isosulfan blue dye in breast cancer patients at Charoenkrung Pracharak Hospital, Thailand. ASIAN BIOMED 2014. [DOI: 10.5372/1905-7415.0804.322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Abstract
Background: The sentinel lymph node (SLN) is the first lymph node to receive lymphatic drainage from a primary breast tumor. If the SLN contains no metastatic tumor, then it is unlikely other lymph nodes will contain breast cancer metastasis. When the SLN does contains metastasis, an axillary lymph node dissection (ALND) is recommended to further stage the axilla and to maintain locoregional control. SLNs can be identified by using a dye, radioisotope, or combined techniques.
Objective: To determine the rate of SLN identification using isosulfan blue dye in breast cancer patients at Charoenkrung Pracharak Hospital, Thailand, and factors that affect it.
Methods: This prospective study of 106 consecutive cases breast cancer enrolled 105 women (1 bilateral breast cancer case) between October 2011 and October 2013 at Charoenkrung Pracharak Hospital. Clinical and pathological features were analyzed for the effectiveness of SLN identification using isosulfan blue dye.
Results: The rate of SLN identification using isosulfan blue dye in breast cancer patients at Charoenkrung Pracharak Hospital was 92%. The method was safe and well tolerated in early-stage breast cancer patients.
Conclusion: The effectiveness of sentinel node identification using isosulfan blue dye in breast cancer patients at Charoenkrung Pracharak Hospital is consistent with that shown in studies from other countries.
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Affiliation(s)
| | - Sarawut Thanawut
- Department of Surgery, Charoenkrung Pracharak Hospital, Thailand
| | - Sirisanpang Yodavudh
- Department of Pathology, Charoenkrung Pracharak Hospital, Bangkok 10120, Thailand
| | - Suthat Chottanapund
- Department of Surgery, Bamrasnaradura Infectious Diseases Institute, Nontaburi 10110, Thailand
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Axillary concordance between superficial and deep sentinel node mapping material injections in breast cancer patients: systematic review and meta-analysis of the literature. Breast Cancer Res Treat 2014; 144:213-22. [DOI: 10.1007/s10549-014-2866-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2013] [Accepted: 01/27/2014] [Indexed: 10/25/2022]
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Caruso G, Cipolla C, Costa R, Morabito A, Latteri S, Fricano S, Salerno S, Latteri MA. Lymphoscintigraphy with peritumoral injection versus lymphoscintigraphy with subdermal periareolar injection of technetium-labeled human albumin to identify sentinel lymph nodes in breast cancer patients. Acta Radiol 2014; 55:39-44. [PMID: 23926236 DOI: 10.1177/0284185113493775] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Preoperative lymphoscintigraphy is without doubt a valid method for the detection of the sentinel lymph node (SLN). There has been considerable debate regarding the optimal site for the introduction of the tracer; various sites include peritumoral (PT), periareolar (PA), subdermal, and intradermal injection. PURPOSE To evaluate retrospectively the lymphoscintigraphic identification rate of peritumoral (PT) injection versus subdermal periareolar (PA) injection in the detection of SLNs in breast cancer. MATERIAL AND METHODS Between October 2002 and December 2011, a cohort of 906 consecutive patients with biopsy proven breast cancer underwent 914 SLN biopsy procedures. A total of 339 procedures (Group A) were performed using a PT deep injection of radiotracer while 575 procedures (Group B) adopted a subdermal PA injection of radiotracer towards the upper outer quadrant, regardless of the site of the carcinoma. All the patients underwent synchronous excision of the breast cancer and SLN biopsy. RESULTS SLNs were identified in the lymphoscintigram in 308/339 cases (90.85%) of Group A (PT injection) and in 537/575 cases (93.39%) of Group B (PA injection). Furthermore, in 2/339 patients (0.58%) of Group A, internal mammary lymph nodes were found at lymphoscintigraphy, whereas no internal mammary sentinel nodes were found in the Group B patients. The intraoperative identification rate of axillary SLNs was 99.41% (337 of 339) in the Group A patients and 99.65% (573 of 575) in the Group B patients. There was no significant difference in the two groups between the incidence of the number of SLNs detected and the incidence of identification of positive SLNs. CONCLUSION PT versus PA injection of radiotracer showed comparable success rates for axillary SLN identification, and can be considered a rapid and reliable method.
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Affiliation(s)
- Giuseppe Caruso
- Department of Medical Biotechnologies and Forensic Medicine – Section of Radiological Sciences, AOU Policlinico Paolo Giaccone – University of Palermo, Palermo, Italy
| | - Calogero Cipolla
- Department of Oncology, Division of General and Oncological Surgery, AOU Policlinico Paolo Giaccone – University of Palermo, Palermo, Italy
| | - Renato Costa
- Department of Internal Medicine, Division of Nuclear Medicine, AOU Policlinico Paolo Giaccone – University of Palermo, Palermo, Italy
| | - Alessandra Morabito
- Department of Internal Medicine, Division of Nuclear Medicine, AOU Policlinico Paolo Giaccone – University of Palermo, Palermo, Italy
| | - Stefania Latteri
- Department of Medical Biotechnologies and Forensic Medicine – Section of Radiological Sciences, AOU Policlinico Paolo Giaccone – University of Palermo, Palermo, Italy
| | - Salvatore Fricano
- Department of Oncology, Division of General and Oncological Surgery, AOU Policlinico Paolo Giaccone – University of Palermo, Palermo, Italy
| | - Sergio Salerno
- Department of Medical Biotechnologies and Forensic Medicine – Section of Radiological Sciences, AOU Policlinico Paolo Giaccone – University of Palermo, Palermo, Italy
| | - Mario Adelfio Latteri
- Department of Oncology, Division of General and Oncological Surgery, AOU Policlinico Paolo Giaccone – University of Palermo, Palermo, Italy
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Chagpar AB, McMasters KM. Sentinel lymph node biopsy for breast cancer: from investigational procedure to standard practice. Expert Rev Anticancer Ther 2014; 4:903-12. [PMID: 15485323 DOI: 10.1586/14737140.4.5.903] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Sentinel lymph node biopsy, popularized in melanoma, has revolutionized the management of breast cancer. While the morbidity associated with axillary node dissection was once thought to be a requisite risk in order to appropriately stage the axilla, large validation studies have demonstrated that sentinel lymph node biopsy is a minimally invasive technique that can accurately predict nodal status. This technique has become an accepted practice in many centers, but there remain many controversies surrounding the technique itself, the pathologic evaluation of the sentinel node and the optimal management of patients with minimal nodal disease. The historic roots of this technique are discussed, along with the controversial issues surrounding the technique and the clinical trials that are currently ongoing.
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Affiliation(s)
- Anees B Chagpar
- Division of Surgical Oncology, University of Louisville, KY 40202, USA.
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Aoyama K, Kamio T, Ohchi T, Nishizawa M, Kameoka S. Sentinel lymph node biopsy for breast cancer patients using fluorescence navigation with indocyanine green. World J Surg Oncol 2011; 9:157. [PMID: 22132943 PMCID: PMC3269998 DOI: 10.1186/1477-7819-9-157] [Citation(s) in RCA: 72] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2011] [Accepted: 12/02/2011] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND There are various methods for detecting sentinel lymph nodes in breast cancer. Sentinel lymph node biopsy (SLNB) using a vital dye is a convenient and safe, intraoperatively preparative method to assess lymph node status. However, the disadvantage of the dye method is that the success rate of sentinel lymph node detection depend on the surgeon's skills and preoperative mapping of the sentinel lymph node is not feasible. Currently, a vital dye, radioisotope, or a combination of both is used to detect sentinel nodes. Many surgeons have reported successful results using either method. In this study we have analyzed breast lymphatic drainage pathways using indocyanine green (ICG) fluorescence imaging. METHODS We examined the lymphatic courses, or lymphatic vessels, in the breast using ICG fluorescence imaging, and applied this method to SLNB in patients who underwent their first operative treatment for breast cancer between May 2006 and April 2008. Fluorescence images were obtained using a charge coupled device camera with a cut filter used as a detector, and light emitting diodes at 760 nm as a light source. When ICG was injected into the subareola and periareola, subcutaneous lymphatic vessels from the areola to the axilla became visible by fluorescence within a few minutes. The sentinel lymph node was then dissected with the help of fluorescence imaging navigation. RESULTS The detection rate of sentinel nodes was 100%. 0 to 4 states of lymphatic drainage pathways from the areola were observed. The number of sentinel nodes was 3.41 on average. CONCLUSIONS This method using indocyanine green (ICG) fluorescence imaging may possibly improve the detection rate of sentinel lymph nodes with high sensitivity and compensates for the deficiencies of other methods. The ICG fluorescence imaging technique enables observation of breast lymph vessels running in multiple directions and easily and accurately identification of sentinel lymph nodes. Thus, this technique can be considered useful.
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Affiliation(s)
- Kei Aoyama
- Department of Surgery II, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Takako Kamio
- Department of Surgery II, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Tetsuya Ohchi
- Department of Surgery II, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Masako Nishizawa
- Department of Surgery II, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
| | - Shingo Kameoka
- Department of Surgery II, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, Tokyo, 162-8666, Japan
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15
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Gentilini O, Veronesi P, Botteri E, Soggiu F, Trifirò G, Lissidini G, Galimberti V, Musmeci S, Raviele PR, Toesca A, Ratini S, Castillo AD, Colleoni M, Talakhadze N, Rotmensz N, Viale G, Veronesi U, Luini A. Sentinel Lymph Node Biopsy in Multicentric Breast Cancer: Five-Year Results in a Large Series from a Single Institution. Ann Surg Oncol 2011; 18:2879-84. [DOI: 10.1245/s10434-011-1694-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Indexed: 12/16/2022]
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16
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Kaklamanos IG, Birbas K, Syrigos K, Bonatsos VG, Bonatsos G. Prospective comparison of peritumoral and subareolar injection of blue dye alone, for identification of sentinel lymph nodes in patients with early stage breast cancer. J Surg Oncol 2011; 104:37-40. [DOI: 10.1002/jso.21897] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2010] [Accepted: 01/28/2011] [Indexed: 11/05/2022]
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Neves RI, Reynolds BQ, Hazard SW, Saunders B, Mackay DR. Increased post-operative complications with methylene blue versus lymphazurin in sentinel lymph node biopsies for skin cancers. J Surg Oncol 2010; 103:421-5. [PMID: 21400527 DOI: 10.1002/jso.21845] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2010] [Accepted: 11/29/2010] [Indexed: 11/10/2022]
Abstract
BACKGROUND Sentinel lymph node biopsy (SNLB) is the standard of care in staging of melanoma and other skin cancers. Early studies used lymphazurin (LZ) for SLNB. A national shortage of LZ promoted methylene blue (MB) as an alternate stain. OBJECTIVE This study compares complication rates between LZ and MB in SLNB patients, and the reliability dyes in locating sentinel lymph nodes. METHODS Charts were reviewed for patients who underwent SLNB for skin cancers between September 2006 and November 2008 at Penn State Hershey Medical Center. The type and quantity of dye, the presence of blue stained sentinel nodes, and any complications were recorded. RESULTS Ninety-three patients underwent SLNB (46 LZ, 47 MB). The amount of dye used was similar (avg. 0.93 ml LZ, 1.24 ml MB). The complication rate of LZ was 8.7%, and MB was 25.5%. There was significantly more (P = 0.003) skin graft complications in the MB patients (6/12) versus LZ (0/15). CONCLUSIONS There is a higher rate of complications with MB, especially with skin grafting. The reported risk of anaphylaxis with LZ has not been reported in volumes <2 ml. The sentinel lymph node identification rate is historically similar between dyes, and in this study was noted to be higher with LZ.
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Affiliation(s)
- Rogerio I Neves
- Department of Surgery, College of Medicine, The Pennsylvania State University, Hershey, Pennsylvania, USA.
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Glynn RW, Williams L, Dixon JM. A further survey of surgical management of the axilla in UK breast cancer patients. Ann R Coll Surg Engl 2010; 92:506-11. [PMID: 20522293 PMCID: PMC3182795 DOI: 10.1308/003588410x12664192075819] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2010] [Indexed: 02/06/2023] Open
Abstract
INTRODUCTION The aims of this study were to investigate the practice of axillary lymph node management within different units throughout the UK, and to assess changes in practice since our previous survey in 2004. SUBJECTS AND METHODS A structured questionnaire was sent to 350 members of the British Association of Surgical Oncology. RESULTS There were 177 replies from respondents who managed more than 100 patients a year with breast cancer. Of these: 12 did not perform axillary ultrasound at all in their centre; 17 (10%) employed axillary node clearance (ANC) on all patients; 122 (69%) performed sentinel node biopsy (SNB) with dual localisation; and 111 respondents had attended the New Start Course. Radioisotope was most frequently injected 2 h or more before operation. Just 13 surgeons were convinced of the value of dissecting internal mammary nodes visualised on a scan. Reasons for not using dual localisation included lack of nuclear medicine facilities, no local ARSAC licence holder, no probe, and no funding. Sixty-six surgeons stated that, if they had an ARSAC licence and could inject the radioactivity in theatre, this would be a major improvement. In addition, 83 (47%) did not perform SLNB in patients receiving neo-adjuvant chemotherapy. CONCLUSIONS Despite significant changes since 2004, substantial variation remains in management of the axilla. A number of surgeons are practicing outwith current guidelines.
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Affiliation(s)
- Ronan W Glynn
- Edinburgh Breast Unit, Western General HospitalEdinburgh, UK
| | - Linda Williams
- Public Health Sciences, School of Medicine, University of EdinburghEdinburgh, UK
| | - J Michael Dixon
- Edinburgh Breast Unit, Western General HospitalEdinburgh, UK
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Cheng G, Kurita S, Torigian DA, Alavi A. Current status of sentinel lymph-node biopsy in patients with breast cancer. Eur J Nucl Med Mol Imaging 2010; 38:562-75. [PMID: 20700739 DOI: 10.1007/s00259-010-1577-z] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2010] [Accepted: 07/18/2010] [Indexed: 12/17/2022]
Abstract
Axillary node status is the most important prognostic indicator for patients with invasive breast cancer. Sentinel lymph-node biopsy (SLNB) is widely accepted and the preferred procedure for identifying lymph-node metastasis. SLNB allows focused excision and pathological examination of the most likely axillary lymph nodes to receive tumor metastases while avoiding morbidities associated with complete axillary nodal dissection. Since its introduction in the early 1990s, the process of SLNB has undergone continual modification and refinement; however, the procedure varies between institutions and controversies remain. In this review, we examine the technical issues that influence the success of lymph node mapping, discuss the controversies, and summarize the indications and contraindications for axillary node mapping and biopsy in clinical practice.
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Affiliation(s)
- Gang Cheng
- Division of Nuclear Medicine, Department of Radiology, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
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Abstract
The axillary lymph node status is the most reliable prognostic indicator of recurrence and overall survival in patients with breast cancer. The current standard surgical procedure for the management of invasive breast cancer is the complete removal of the cancer with total axillary clearance. However, recently, selective sentinel lymph node mapping and biopsy is gaining acceptance as a useful and accurate staging procedure, as it is minimally invasive. The sentinel lymph node is the first node into which a primary cancer drains, and is thus the first node to be involved by metastases. Patients whose sentinel nodes are negative for breast cancer metastases, can be spared a more extensive axillary lymph node dissection, with reduction in the postoperative morbidity. Sentinel node mapping is usually performed by intradermal or peritumoral injection of a combination of blue dye and radiotracer. Sentinel node examination is sometimes done intraoperatively, by imprint cytology and frozen sections, for an immediate assessment, to plan the extent of surgery at a single sitting. Permanent sections of the sentinel node are studied by serial sectioning, and immunohistochemistry for cytokeratin is done to detect micrometastases which are frequently missed on hematoxylin and eosin (H&E)-stained sections. The various aspects of sentinel node examination, and its role to decide further management in patients with ductal carcinoma-in-situ, and in other clinical settings, are discussed in this review.
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Affiliation(s)
- Vijaya V Mysorekar
- Department of Pathology, M.S. Ramaiah Medical College, MSR Nagar, MSRIT post, Bangalore - 560 054, India.
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Fearmonti RM, Gayed IW, Kim E, Bedrosian I, Hunt KK, Meric-Bernstam F, Feig B, Ghonimi E, Warneke C, Babiera GV. Intra-individual comparison of lymphatic drainage patterns using subareolar and peritumoral isotope injection for breast cancer. Ann Surg Oncol 2009; 17:220-7. [PMID: 19680729 DOI: 10.1245/s10434-009-0633-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2008] [Revised: 06/29/2009] [Accepted: 06/29/2009] [Indexed: 12/13/2022]
Abstract
BACKGROUND Controversy exists in the literature regarding the optimal site for lymphatic mapping in breast cancer. This study was designed to characterize lymphatic drainage patterns within the same patient after subareolar (SA) and peritumoral (PT) radiopharmaceutical injections and examine the impact of reader interpretation on reported drainage. METHODS In this prospective trial, 27 women with breast cancer underwent sequential preoperative SA and PT injections of 0.5 to 2.7 mCi of technetium-99 m filtered sulfur colloid 3 days or more apart. Patterns of radiopharmaceutical uptake were reviewed independently by two nuclear medicine physicians. Inter-reader agreement and injection success were assessed in conjunction with observed drainage patterns. RESULTS There was near perfect inter-reader agreement observed on identification of axillary LN drainage after PT injection (P = 0.0004) and substantial agreement with SA injection (P = 0.0344). SA injection was more likely to drain to only axillary LNs, whereas PT injection appeared more likely to drain to both axillary and extra-axillary LNs, although no statistically significant differences were found. All patients with extra-axillary drainage after PT injection (n = 6 patients) had only axillary drainage after SA injection. Dual drainage was observed for six patients with PT injection and one patient with SA injection. CONCLUSIONS Our findings suggest that radiopharmaceutical injected in the SA location has a high propensity to drain to axillary LNs only. After controlling for patient factors and demonstrating inter-reader agreement, the inability to demonstrate statistically significant differences in drainage based on injection site suggests that lymphatic drainage patterns may be a function of patient and tumor-specific features.
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Affiliation(s)
- Regina M Fearmonti
- Department of Plastics-Reconstructive Surgery, Duke University School of Medicine, Durham, NC, USA
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Noguchi M, Inokuchi M, Zen Y. Complement of peritumoral and subareolar injection in breast cancer sentinel lymph node biopsy. J Surg Oncol 2009; 100:100-5. [DOI: 10.1002/jso.21308] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Clímaco F, Coelho-Oliveira A, Djahjah MC, Gutfilen B, Correia AHP, Noé R, da Fonseca LMB. Sentinel lymph node identification in breast cancer: a comparison study of deep versus superficial injection of radiopharmaceutical. Nucl Med Commun 2009; 30:525-32. [DOI: 10.1097/mnm.0b013e32832cc25b] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
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Roses RE, Kumar R, Alavi A, Czerniecki BJ. The Role of Lymphatic Mapping and Sentinel Lymph Node Biopsy in the Staging of Breast Cancer. PET Clin 2009; 4:265-76. [PMID: 27157099 DOI: 10.1016/j.cpet.2009.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The widespread application of sentinel lymph node biopsy in the evaluation of patients with breast cancer has allowed for the more limited, selective treatment of regional lymph nodes and decreased the number of complete regional dissections performed in patients without nodal metastases. Surgical excision and pathologic evaluation of nodes for metastases allow for reliable staging and prediction of additional lymph node metastases. Sentinel lymph node biopsy also enables a meticulous histologic evaluation of multiple sections augmented by immunohistochemical staining. The current role of sentinel lymph node biopsy in the staging of breast cancer and ongoing controversies relating to the procedure are discussed.
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Affiliation(s)
- Robert E Roses
- Department of Surgery, University of Pennsylvania School of Medicine, 4 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Rakesh Kumar
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Abass Alavi
- Department Section, Radiology, University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - Brian J Czerniecki
- Department of Surgery, University of Pennsylvania School of Medicine, 4 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104, USA; Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
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Ogasawara Y, Ikeda H, Takahashi M, Kawasaki K, Doihara H. Evaluation of breast lymphatic pathways with indocyanine green fluorescence imaging in patients with breast cancer. World J Surg 2009; 32:1924-9. [PMID: 18330628 DOI: 10.1007/s00268-008-9519-7] [Citation(s) in RCA: 74] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND In patients with early breast cancer, sentinel lymph node biopsy (SLNB) has been emerging as a new standard of care. The use of SLNB with a blue dye is convenient and safe, but it requires a high level of technical skill. Recently, an instrument that can provide fluorescence imaging of lymphatic flow has been introduced. In the present study, we analyzed breast lymphatic pathways and discussed its potential as a modality to complement the use of SLNB with a blue dye. METHODS Thirty-seven consecutive patients with breast cancer were examined. To obtain fluorescence imaging, an invisible near-infrared fluorescence imaging system was used. After indocyanine green was subdermally injected in the subareolar site and at two sites around the tumor, the subcutaneous lymphatic drainage pathway (LDP) was observed. RESULTS In 27 (72.9%) of the patients, the number of LDP from the periareolar area was one or two. In 21(63.6%) of 33 patients with subdermal injection around the tumor, no LDP was observed from the peritumoral area. Lymphatic connection between the peritumoral area and the periareolar area was observed very frequently (91.7%). In 26 (70.3%) of the patients, multiple routes joined together and only one route was ultimately directed to the axilla. Significant correlation was seen between body mass index (BMI) and the transit time to the axilla after injection (p = 0.0038). Additionally, a significant correlation was seen between the number of LPD from the periareolar area and the distance between detected SLNs and the fluorescence line-disappearing point (p = 0.034). CONCLUSIONS This instrument can provide some important information, and can be an available and reliable navigator for SLNB with a blue dye.
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Affiliation(s)
- Yutaka Ogasawara
- Department of Cancer and Thoracic Surgery, Okayama University Graduate School of Medicine, Dentistry and Pharmaceutical Sciences, 2-5-1 Shikata-cho, Okayama-City, Okayama 700-8558, Japan.
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Koo BY, Jeong SG, Eom TI, Kang HJ, Kim LS. The Number of Removed Lymph Nodes for an Acceptable False Negative Rate in Sentinel Lymph Node Biopsy for Breast Cancer. J Breast Cancer 2009. [DOI: 10.4048/jbc.2009.12.2.100] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Bon Young Koo
- Division of Breast and Endocrine Surgery, College of Medicine, Hallym University, Anyang, Korea
| | - Seong Gu Jeong
- Division of Breast and Endocrine Surgery, College of Medicine, Hallym University, Anyang, Korea
| | - Tae Ik Eom
- Division of Breast and Endocrine Surgery, College of Medicine, Hallym University, Anyang, Korea
| | - Hee Joon Kang
- Division of Breast and Endocrine Surgery, College of Medicine, Hallym University, Anyang, Korea
| | - Lee Su Kim
- Division of Breast and Endocrine Surgery, College of Medicine, Hallym University, Anyang, Korea
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The Accuracy of Sentinel Lymph Node Biopsy in the Treatment of Multicentric Invasive Breast Cancer Using a Subareolar Injection of Tracer. World J Surg 2008; 32:2483-7. [DOI: 10.1007/s00268-008-9719-1] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Somashekhar SP, Zaveri Shabber S, Udupa Venkatesh K, Venkatachala K, Vasan Thirumalai MM. Sentinel lymphnode biopsy in early breast cancer using methylene blue dye and radioactive sulphur colloid - a single institution Indian experience. Indian J Surg 2008; 70:111-9. [PMID: 23133037 DOI: 10.1007/s12262-008-0033-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2007] [Accepted: 05/15/2008] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Axillary lymph node dissection is an established procedure in breast cancer staging. However, it is associated with unpleasant side effects. A promising alternative to assess axillary lymph node status in early breast cancer patients is Sentinel Lymph Node Biopsy (SLNB). Isosulfan blue has traditionally been the dye used to identify the Sentinel Lymph Node (SLN). This article is a validation study of SLNB using methylene blue dye and radioactive sulphur colloid in early breast cancer Indian patients. MATERIALS #ENTITYSTARTX00026; METHODS With written informed consent, 100 patients with cytology or biospy proven carcinoma breast, clinical stage T1/ T2 N0 M0, underwent SLNB using combination of methylene blue dye & radioactive technetium 99m sulphur colloid as a part of validation study from June 2003 to February 2006. After validation study, from March 2006 to February 2007, 35 patients have undergone SLNB followed by complete axillary clearance in only those patients with SLNB being positive for metastases. RESULTS In all 100 patients of the validation study SLN was identified. Total number of cases with positive axillary nodes was 27, out of which SLN was only positive node for metastases in 69% of cases. The overall sensitivity, specificity, positive predictive valve and negative predictive valve of SLNB 96.2%, 100%, 100% and 98.6% respectively with false negative rate of 3.7%. In subsequent 35 patients who underwent SLNB followed by complete axillary clearance, SLNs was identified in all the cases. CONCLUSIONS SLNB is effective in early breast cancer patients of Indian population. SLNB using combination of methylene blue dye and radio-active Tc99m sulphur colloid can stage the axilla with high accuracy & low risk of false negativity in early breast cancer patients.
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Affiliation(s)
- S P Somashekhar
- Department of Surgical Oncology, Manipal Comprehensive Cancer Centre, Manipal Hospital, Airport Road, Bangalore, 560 017 India
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Comparison of Different Injection Sites of Radionuclide for Sentinel Lymph Node Detection in Breast Cancer. Clin Nucl Med 2008; 33:262-7. [DOI: 10.1097/rlu.0b013e3181662fc7] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Subareolar blue dye only injection sentinel lymph node biopsy could reduce the numbers of standard axillary lymph node dissection in environments without access to nuclear medicine. J Cancer Res Clin Oncol 2007; 134:667-72. [PMID: 18026990 DOI: 10.1007/s00432-007-0333-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2007] [Accepted: 11/08/2007] [Indexed: 02/06/2023]
Abstract
PURPOSE The gold standard of axillary sentinel lymph node biopsy (SLNB) in breast cancer is the combination of radioactive colloid and blue dye injection. Worldwide, numerous hospitals without access to radioactive tracers still perform a routine complete axillary lymph node dissection (ALND). We retrospectively analyzed the false negative rate and identification rate of SLNB with injection of blue dye in the absence of radioactive colloid and compared the subareolar (SA) and the peritumoral (PT) injection. PATIENTS AND METHODS Two hundred and fourteen patients with clinically node negative unifocal breast cancer of up to 3 cm in size who underwent SLNB followed by ALND were included. Patent Blue V was injected at the SA site in 120 patients or at the PT site in 94 patients. RESULTS Thirty-seven (31%) patients in the SA group and 28 (29.8%) in the PT group were node-positive by ALND. The mean number of SLNs identified was 3.1 in the SA group and 1.6 in the PT group. The SLN identification rate was 91.7% for the SA group and 80.9% for the PT group (P = 0.017). The false negative rate was 3.6% in the SA group and 11.8% in the PT group (P = 0.032). CONCLUSIONS Our study shows an acceptable low false negative rate for the SA blue dye only injection and confirms the higher identification rate of SA versus PT localisation. This technique could have spared 67.5% (81 out of 120) of our patients the ALND and could replace ALND of early breast cancer patients in environments without access to nuclear medicine.
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Kargozaran H, Shah M, Li Y, Beckett L, Gandour-Edwards R, Schneider PD, Khatri VP. Concordance of Peritumoral Technetium 99M Colloid and Subareolar Blue Dye Injection in Breast Cancer Sentinel Lymph Node Biopsy. J Surg Res 2007; 143:126-9. [PMID: 17950081 DOI: 10.1016/j.jss.2007.02.054] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2007] [Revised: 02/20/2007] [Accepted: 02/26/2007] [Indexed: 02/06/2023]
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Rodier JF, Velten M, Wilt M, Martel P, Ferron G, Vaini-Elies V, Mignotte H, Brémond A, Classe JM, Dravet F, Routiot T, de Lara CT, Avril A, Lorimier G, Fondrinier E, Houvenaeghel G, Avigdor S. Prospective Multicentric Randomized Study Comparing Periareolar and Peritumoral Injection of Radiotracer and Blue Dye for the Detection of Sentinel Lymph Node in Breast Sparing Procedures: FRANSENODE Trial. J Clin Oncol 2007; 25:3664-9. [PMID: 17485709 DOI: 10.1200/jco.2006.08.4228] [Citation(s) in RCA: 102] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Purpose To determine the optimal injection path for blue dye and radiocolloid for sentinel lymph node (SLN) biopsy in early breast cancer. Patients and Methods A prospective randomized multicentric study was initiated to compare the peritumoral (PT) injection site to the periareolar (PA) site in 449 patients. Results The detection rate of axillary SLN by lymphoscintigraphy was significantly higher (P = .03) in the PA group (85.2%) than in the PT group (73.2%). Intraoperative detection rate by blue dye and/or gamma probe was similar (99.11%) in both groups. The rate of SLN detection was somewhat higher in the PA group than in the PT group: 95.6% versus 93.8% with blue dye (P = .24) and 98.2% versus 96.0% by probe (P = .16), respectively. The number of SLNs detected by lymphoscintigraphy and by probe was significantly higher in the PA group than in the PT group, 1.5 versus 1.2 (P = .001) and 1.9 versus 1.7 (P = .02). The blue and hot concordance was 95.6% in the PA group and 91.5% in the PT group (P = .08). The mean ex vivo count of the SLN was significantly higher in the PA group than in the PT group (P < .0001). Conclusion This study strongly validates the PA injection technique given the high detection rate (99.1%) of SLN and the high concordance (95.6%) between blue dye and the radiotracer, as well as higher significant ex and in vivo counts, improving SLN probe detection.
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Affiliation(s)
- Jean-François Rodier
- French Comprehensive Cancer Centers of Strasbourg, Toulouse, Lyon, Nantes, Bordeaux, Marseille, France.
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Piñero-Madrona A, Nicolás-Ruiz F, Galindo-Fernández PJ, Illana-Moreno J, Canteras-Jordana M, Parrilla-Paricio P. Aspectos técnicos de interés en la localización de drenajes linfáticos en la biopsia del ganglio centinela del cáncer de mama. Cir Esp 2007; 81:264-8. [PMID: 17498455 DOI: 10.1016/s0009-739x(07)71316-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The sentinel node is defined as the node with the highest probability of being involved in the case of lymphatic spread from a tumor. Accurate identification and biopsy of this node can avoid unnecessary lymphadenectomies. The aim of this study was to determine if there are differences in the number of isolated sentinel lymph nodes in breast cancer according to whether a mixed technique (vital dye plus isotopic tracer) or radiotracer alone is used and if there are differences in the detection of more than one lymphatic basin and in the number of lymphatic nodes depending on the site of tracer injection. PATIENTS AND METHOD A total of 173 sentinel lymph node biopsies in 173 women with breast cancer were studied taking into account the technique (mixed [n = 109] or radiotracer alone [n = 64]) and the location of tracer injection (periareolar [n = 81], intra and/or peritumoral [n = 92]). The number of lymphatic basins and the number of sentinel nodes were compared among the distinct groups resulting from the combination of the 2 parameters. RESULTS Simultaneous drainage to both the axilla and internal mammary chain was more frequent with the intra-periareolar technique. The number of identified nodes was significantly higher when mixed techniques were compared, and was higher with periareolar injection than with the intra-peritumoral route. CONCLUSIONS In breast cancer sentinel lymph node biopsy, the number of identified nodes is not influenced by the use of a mixed technique or radiotracer alone. However, the number of identified nodes is higher with the periareolar route than with the intra-peritumoral route. Intra-peritumoral injection of the tracer shows a higher frequency of internal mammary chain drainage than periareolar injection, although this difference was not statistically significant.
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Affiliation(s)
- Antonio Piñero-Madrona
- Servicio de Cirugía General, Hospital Universitario Virgen de la Arrixaca, Murcia, España.
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Yen RF, Kuo WH, Lien HC, Chen THH, Jan IS, Wu YW, Wang MY, Chang KJ, Huang CS. Radio-guided sentinel lymph node biopsy using periareolar injection technique for patients with early breast cancer. J Formos Med Assoc 2007; 106:44-50. [PMID: 17282970 DOI: 10.1016/s0929-6646(09)60215-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND/PURPOSE Sentinel lymph node (LN) biopsy has been widely adopted in the axillary staging of clinical node-negative breast cancer patients. This study aimed to evaluate the accuracy of radio-guided sentinel LN (SLN) biopsy (SLNB) using the periareolar injection technique for predicting the histopathologic status of axillary LNs in early breast cancer patients. METHODS Between November 2003 and November 2004 in the National Taiwan University Hospital, radio-guided SLNB using the periareolar injection technique was consecutively performed in 213 female patients with early breast cancer (stage T1 and T2) but without clinically palpable axillary LN and previous chemotherapy. Two mCi of filtered (0.22 microm) (99m)Tc-sulfur colloid were injected in the afternoon 1 day before surgery (2-day protocol) or 1 mCi of the same radiopharmaceutical was injected on the morning of the surgery (1-day protocol). During surgery, a handheld gamma probe was used to identify the LNs with radioactivity in the axilla. A node was deemed a SLN if its radioactivity was >10% of the hottest node. All the SLNs identified were removed for histology. RESULTS Radioactive SLN was identified at surgery in 207 patients. The SLN identification rate was 97.2% (207/213). Of these 207 patients, 163 patients had received both SLNB and axillary LN dissection. Among these 163 patients, 77 patients had LN metastases and four had negative SLN but positive non-SLN. The false-negative rate of SLNB for the detection of axillary LN metastases was 5.2% (4/77). There were no statistical differences between false-negative and SLN positive groups for all factors. CONCLUSION Our study suggests that SLNB with periareolar injection of radiocolloid provides valuable information on the axillary nodal status in patients with early breast cancer.
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Affiliation(s)
- Ruoh-Fang Yen
- Department of Nuclear Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan
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Ferrari A, Rovera F, Dionigi P, Limonta G, Marelli M, Besana Ciani I, Bianchi V, Vanoli C, Dionigi R. Sentinel lymph node biopsy as the new standard of care in the surgical treatment for breast cancer. Expert Rev Anticancer Ther 2007; 6:1503-15. [PMID: 17069533 DOI: 10.1586/14737140.6.10.1503] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
During the recent years, based on the results of validation studies, the sentinel lymph node biopsy has replaced routine axillary dissection as the new standard of care in early breast cancer. The technique represents a minimally invasive, highly accurate method for axillary staging, which could spare approximately 65-70% of patients unnecessary axillary dissection and its related morbidity. Several technical and clinical controversies have been raised during the development of this new technique; the authors review the most important issues, some questions have already been answered and others are still under debate. As far as the technical aspects are concerned, mapping techniques, appropriate surgical training, options for pathological examination of sentinel lymph nodes and the issue of nonaxillary sentinel lymph nodes are discussed. An update on clinical controversies demonstrates that factors such as large tumor size, palpable axillary nodes, multifocality and multicentricity, previous breast and axillary surgery, and pregnancy are no longer regarded as absolute contraindications for sentinel lymph node biopsy. Feasibility, accuracy and timing of sentinel lymph node biopsy in patients undergoing neoadjuvant chemotherapy remain unsolved issues, as well as the indication of the technique for some subgroups of in situ lesions. Finally, one of the most attractive open forums for debate will be discussed: whether or not completion of axillary dissection in the case of positive SLN is always required.
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Affiliation(s)
- Alberta Ferrari
- University of Insubria, Department of Surgical Sciences, Viale Borri 57, 21100 Varese, Italy.
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Ferrari A, Dionigi P, Rovera F, Boni L, Limonta G, Garancini S, De Palma D, Dionigi G, Vanoli C, Diurni M, Carcano G, Dionigi R. Multifocality and multicentricity are not contraindications for sentinel lymph node biopsy in breast cancer surgery. World J Surg Oncol 2006; 4:79. [PMID: 17116258 PMCID: PMC1665453 DOI: 10.1186/1477-7819-4-79] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2006] [Accepted: 11/20/2006] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND After the availability of the results of validation studies, the sentinel lymph node biopsy (SLNB) has replaced routine axillary dissection (AD) as the new standard of care in early unifocal breast cancers. Multifocal (MF) and multicentric (MC) tumors have been considered a contraindication for this technique due to the possible incidence of a higher false-negative rate. This prospective study evaluates the lymphatic drainage from different tumoral foci of the breast and assesses the accuracy of SLNB in MF-MC breast cancer. PATIENTS AND METHODS Patients with preoperative diagnosis of MF or MC infiltrating and clinically node-negative (cN0) breast carcinoma were enrolled in this study. Two consecutive groups of patients underwent SLN mapping using a different site of injection of the radioisotope tracer: a) "2ID" Group received two intradermal (i.d.) injections over the site of the two dominant neoplastic nodules. A lymphoscintigraphic study was performed after each injection to evaluate the route of lymphatic spreading from different sites of the breast. b) "A" Group had periareolar (A) injection followed by a conventional lymphoscintigraphy. At surgery, both radioguided SLNB (with frozen section exam) and subsequent AD were planned, regardless the SLN status. RESULTS A total 31 patients with MF (n = 12) or MC (n = 19) invasive, cN0 cancer of the breast fulfil the selection criteria. In 2 i.d. Group (n = 15) the lymphoscintigraphic study showed the lymphatic pathways from two different sites of the breast which converged into one major lymphatic trunk affering to the same SLN(s) in 14 (93.3%) cases. In one (6.7%) MC cancer two different pathways were found, each of them affering to a different SLN. In A Group (n = 16) lymphoscintigraphy showed one (93.7%) or two (6.3%) lymphatic channels, each connecting areola with one or more SLN(s). Identification rate of SLN was 100% in both Groups. Accuracy of frozen section exam on SLN was 96.8% (1 case of micrometastasis was missed). SLN was positive in 13 (41.9%) of 31 patients, including 4 cases (30.7%) of micrometastasis. In 7 of 13 (53.8%) patients the SLN was the only site of axillary metastasis. SLNB accuracy was 96.8% (30 of 31), sensitivity 92.8 (13 of 14), and false-negative rate 7.1% (1 of 14). Since the case of skip metastasis was identified by the surgeon intraoperatively, it would have been no impact in the clinical practice. CONCLUSION Our lymphoscintigraphic study shows that axillary SLN represents the whole breast regardless of tumor location within the parenchyma. The high accuracy of SLNB in MF and MC breast cancer demonstrates, according with the results of other series published in the literature, that both MF and MC tumors do not represent a contraindication for SLNB anymore.
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Affiliation(s)
- Alberta Ferrari
- Department of Surgical Sciences, University of Insubria, Varese, Italy
| | - Paolo Dionigi
- Dipartimento di Scienze Chirurgiche, Rianimatorie-riabilitative e dei Trapianti d'Organo, University of Pavia, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
| | - Francesca Rovera
- Department of Surgical Sciences, University of Insubria, Varese, Italy
| | - Luigi Boni
- Department of Surgical Sciences, University of Insubria, Varese, Italy
| | - Giorgio Limonta
- Department of Surgical Sciences, University of Insubria, Varese, Italy
| | - Silvana Garancini
- Department of Nuclear Medicine, University of Insubria, Varese, Italy
| | - Diego De Palma
- Department of Nuclear Medicine, University of Insubria, Varese, Italy
| | | | | | - Mario Diurni
- Department of Surgical Sciences, University of Insubria, Varese, Italy
| | - Giulio Carcano
- Department of Surgical Sciences, University of Insubria, Varese, Italy
| | - Renzo Dionigi
- Department of Surgical Sciences, University of Insubria, Varese, Italy
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Povoski SP, Olsen JO, Young DC, Clarke J, Burak WE, Walker MJ, Carson WE, Yee LD, Agnese DM, Pozderac RV, Hall NC, Farrar WB. Prospective Randomized Clinical Trial Comparing Intradermal, Intraparenchymal, and Subareolar Injection Routes for Sentinel Lymph Node Mapping and Biopsy in Breast Cancer. Ann Surg Oncol 2006; 13:1412-21. [PMID: 16957969 DOI: 10.1245/s10434-006-9022-z] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2006] [Accepted: 05/23/2006] [Indexed: 11/18/2022]
Abstract
BACKGROUND Multiple injection routes, including intradermal (ID), intraparenchymal (IP), and subareolar (SA), are used for 99mTc-sulfur colloid administration for sentinel lymph node (SLN) mapping and biopsy in breast cancer. The aim of this study was to compare localization by ID, IP, and SA injection routes based on preoperative lymphoscintigraphy and intraoperative identification. METHODS Four hundred prospectively randomized breast cancers underwent SLN mapping and biopsy. RESULTS Preoperative lymphoscintigraphy demonstrated localization to the axilla in 126/133 (95%) ID, 82/132 (62%) IP, and 96/133 (72%) SA (P < 0.001 ID vs. IP and ID vs. SA; P = 0.081 IP vs. SA), with a mean duration of preoperative lymphoscintigraphy of 139 +/- 18 minutes. Mean time to first localization when localization was demonstrated on preoperative lymphoscintigraphy was 8 +/- 14 minutes for ID, 53 +/- 49 for IP, and 22 +/- 29 for SA (P < 0.001 ID vs. IP and ID vs. SA; P = 0.003 IP vs. SA). Intraoperative identification of a SLN at the time of SLN biopsy was successful in 133/133 (100%) ID, 121/134 (90%) IP, and 126/133 (95%) SA (P < 0.001 ID vs IP; P = 0.014 ID vs. SA; P = 0.168 IP vs. SA), with a mean time from injection of 99mTc-sulfur colloid to start of SLN biopsy of 288 +/- 71 minutes. Mean intraoperative time to harvest the first SLN was 9 +/- 4 minutes for ID, 13 +/- 6 for IP, and 12 +/- 6 for SA (P < 0.001 ID vs. IP and ID vs. SA; P = 0.410 IP vs. SA). CONCLUSIONS The ID injection route demonstrated a significantly greater frequency of localization, decreased time to first localization on preoperative lymphoscintigraphy, and decreased time to harvest the first SLN. This represents the first prospective randomized clinical trial to confirm superiority of the ID route for administration of 99mTc-sulfur colloid during SLN mapping and biopsy in breast cancer.
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Affiliation(s)
- Stephen P Povoski
- Section of Surgical Oncology, Department of Surgery, Arthur G. James Cancer Hospital and Richard J. Solove Research Institute and Comprehensive Cancer Center, The Ohio State University, Columbus, OH, 43210, USA.
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38
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Kesmodel SB, Canter RJ, Terhune KP, Bauer TW, Mick R, Rosato EF, Spitz FR, Fraker DL, Alavi A, Czerniecki BJ. Use of Radiotracer for Sentinel Lymph Node Mapping in Breast Cancer Optimizes Staging Independent of Site of Administration. Clin Nucl Med 2006; 31:527-33. [PMID: 16921275 DOI: 10.1097/01.rlu.0000233070.06956.69] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE In an effort to optimize sentinel lymph node (SLN) mapping for breast cancer, sites of mapping agent administration and types of mapping agents used continue to be evaluated. This study compares SLN mapping using peritumoral (PT) or subareolar (SA) injection of radiolabeled colloid and examines the relative contributions of radiotracer and blue dye to SLN identification. MATERIALS AND METHODS A retrospective review was performed of 456 patients with breast cancer and clinically negative axillae who underwent SLN mapping. Sequential groups of patients were injected with filtered Tc-99m SC, 326 peritumorally (group 1) and 130 subareolarly (group 2). All patients had intraoperative SA injection of 1% isosulfan blue dye. RESULTS The SLN identification and isotope success rates were 97% and 96% in group 1 and 98% and 98% in group 2, respectively. Eighty-one patients (25%) in group 1 and 44 patients (34%) in group 2 had positive SLNs. Of these patients, 15% from group 1 and 14% from group 2 had only positive nodes detected by radiotracer, and 9 of these patients (6 from group 1 and 3 from group 2) had other nodes identified by both radiotracer and blue dye that were negative for metastases. Six percent of patients with positive SLNs were upstaged because of use of radiotracer. CONCLUSIONS PT and SA injection of radiotracer have comparable success rates for axillary SLN identification. Given that 15% of patients in group 1 and 14% in group 2 had only positive SLNs detected by radiotracer, independent of site of administration, radiotracer remains essential for optimizing breast SLN mapping.
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Affiliation(s)
- Susan B Kesmodel
- Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, 19104, USA
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39
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Segura M, Juncà V, Solsona J, Piqueras A, Puig S, Jimeno J, Pereira JA, Ortega M, Fernández A, Fraile M, Vidal-Sicart S, Segura A, Ferrer F, Grande L. Impacto de la disponibilidad de un servicio externo de medicina nuclear en la aplicación de la biopsia del ganglio centinela en cirugía del cáncer de mama. Cir Esp 2006; 80:96-100. [PMID: 16945307 DOI: 10.1016/s0009-739x(06)70930-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
INTRODUCTION To perform sentinel lymph node biopsy (SLNB), nuclear medicine services that have previously undergone a validation phase are required. The aim of the present study was to analyze the possibility of performing this technique with a previously validated, external nuclear medicine service and to study its impact on the indication for radical axillary lymphadenectomy (RAL) and on length of postoperative hospital stay. PATIENTS AND METHODS We performed a prospective study in a cohort of patients with breast cancer starting from the introduction of SLNB in our center, which was made possible by collaboration with an external nuclear medicine service that performed lymphoscintigraphy and sentinel node detection. Intraoperative detection was performed through a portable probe. The feasibility of the project and its clinical impact were analyzed, taking a reduction in the number of lymphadenectomies and length of hospital stay as endpoints. RESULTS A total of 196 patients with 201 breast carcinomas were treated. The most frequent interventions were tumorectomy (TC) with SLNB in 124 patients (62%), and TC with SLNB and RAL in 62 patients (31%). Sentinel node visualization on lymphoscintigraphy was achieved in 187/201 carcinomas (93.1%) and sentinel nodes were detected during the intervention in 182/187 carcinomas (97.4%). Sentinel node detection in the internal mammary chain was achieved in 23/201 carcinomas (11.4%). RAL was avoided in 131 of the 201 carcinomas (65%). Days of postoperative hospital stay with or without RAL showed a mean difference of 1.8 days (3.1 vs. 1.3; P < .001). CONCLUSION SLNB is feasible with the collaboration of an external nuclear medicine service. This technique avoids 65% of RAL and reduces length of postoperative stay by 1.8 days.
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Affiliation(s)
- Marcel Segura
- Unidad de Patología Mamaria, Servicio de Cirugía General y Servicio de Radiología (IDIMAS, CRC-MAR), Hospital Universitario del Mar, Barcelona, España.
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40
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Knauer M, Konstantiniuk P, Haid A, Wenzl E, Riegler-Keil M, Pöstlberger S, Reitsamer R, Schrenk P. Multicentric Breast Cancer: A New Indication for Sentinel Node Biopsy—A Multi-Institutional Validation Study. J Clin Oncol 2006; 24:3374-80. [PMID: 16849751 DOI: 10.1200/jco.2006.05.7372] [Citation(s) in RCA: 76] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Purpose Multicentric breast cancer has been considered to be a contraindication for sentinel node (SN) biopsy (SNB). In this prospective multi-institutional trial, SNB-feasibility and accuracy was evaluated in 142 patients with multicentric cancer from the Austrian Sentinel Node Study Group (ASNSG) and compared with data from 3,216 patients with unicentric cancer. Patients and Methods Between 1996 and 2004, 3,730 patients underwent SNB at 15 ASNSG-affiliated hospitals. Patient data were entered in a multicenter database. One hundred forty-two patients presented with multicentric invasive breast cancer and underwent SNB. Results Intraoperatively, a mean number of 1.67 SNs were excised (identification-rate, 91.5%). The incidence of SN metastases was 60.8% (79 of 130). This was confirmed by axillary lymph node dissection (ALND) in 125 patients. Of patients with positive SNs, 60.8% (48 of 79) showed involvement of nonsentinel nodes (NSNs), as did three patients with negative SNs (false-negative rate, 4.0). Sensitivity, negative predictive value, and overall accuracy were 96.0%, 93.3%, and 97.3%, respectively. Ninety-one percent of the patients underwent mastectomy, and 9% were treated with breast conserving surgery. None of the patients have shown axillary recurrence so far (mean follow-up, 28.8 months). Compared with 3,216 patients with unicentric cancer, there was a significantly higher rate of SN metastases as well as in NSNs, whereas there was no difference in detection and false-negative rates. Conclusion Multicentric breast cancer is a new indication for SNB without routine ALND in controlled trials. Given adequate quality control and an interdisciplinary teamwork of surgical, nuclear medicine, and pathology units, SNB is both feasible and accurate in this disease entity.
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Affiliation(s)
- Michael Knauer
- Department of Surgery, General Hospital, Feldkirch, Austria.
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41
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Gentilini O, Trifirò G, Soteldo J, Luini A, Intra M, Galimberti V, Veronesi P, Silva L, Gandini S, Paganelli G, Veronesi U. Sentinel lymph node biopsy in multicentric breast cancer. The experience of the European Institute of Oncology. Eur J Surg Oncol 2006; 32:507-10. [PMID: 16595168 DOI: 10.1016/j.ejso.2006.02.018] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2005] [Accepted: 02/23/2006] [Indexed: 11/24/2022] Open
Abstract
AIM To present our experience with sentinel lymph node biopsy (SLNB) performed in patients with multicentric breast cancer. METHODS Between May 2001 and May 2004, 42 patients with multicentric breast cancer and a clinically negative axilla underwent lymphatic mapping either by a single subareolar (n = 25) or a double peritumoral/subdermal injection (n = 17) of 99Tc-HSA nanocolloids. The sentinel lymph node (SLN) was evaluated by intraoperative frozen section and axillary dissection was performed only in case of positive SLN. RESULTS Mean age was 49 years (range 25-78). Mean number of SLNs identified by lymphoscintigraphy was 1.36 (range 1-5) and mean number of SLNs removed at surgery was 1.55 (range 1-5), with an identification rate of 100%. The mean number of hot spots identified by lymphoscintigraphy was similar in patients who underwent single or double injections (1.36 and 1.35, respectively). In 21 of 42 patients the SLN was positive, and in seven of these 21 patients the SLN was the only positive node. After a median follow-up of 24 months no overt axillary metastases occurred in patients with negative SLN. CONCLUSIONS The number of SLNs is not dependent on the number and site of injections. SLNB is our standard procedure for nodal staging in patients with multicentric breast cancer and a clinically negative axilla.
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Affiliation(s)
- O Gentilini
- Division of Senology, European Institute of Oncology, Milano, Italy.
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42
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Degnim AC, Grant CS. Sentinel lymph node biopsy for breast cancer: is two-site injection best? Surgery 2006; 139:630-2. [PMID: 16701095 DOI: 10.1016/j.surg.2005.12.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2005] [Accepted: 12/23/2005] [Indexed: 11/29/2022]
Affiliation(s)
- Amy C Degnim
- Department of Surgery, Mayo Clinic, Rochester, MN 55905, USA.
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Anan K, Mitsuyama S, Kuga H, Saimura M, Tanabe Y, Suehara N, Matsunaga H, Nishihara K, Abe Y, Iwashita T, Ihara T, Tamae K, Ono M, Toyoshima S. Double mapping with subareolar blue dye and peritumoral green dye injections decreases the false-negative rate of dye-only sentinel node biopsy for early breast cancer: 2-site injection is more accurate than 1-site injection. Surgery 2006; 139:624-9. [PMID: 16701094 DOI: 10.1016/j.surg.2005.11.007] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2005] [Revised: 11/22/2005] [Accepted: 11/25/2005] [Indexed: 12/01/2022]
Abstract
BACKGROUND The optimum sentinel node biopsy (SNB) mapping method for breast cancer remains to be determined. No matter which mapping agents are used, 2-site injection may be superior to 1-site injection in limiting the false-negative rate. METHODS We examined whether a double-mapping method with subareolar injection of blue dye and peritumoral injection of green dye would decrease the false-negative rate of dye-only SNB in 145 patients with early breast cancer. RESULTS The identification rate for blue-dyed and/or green-dyed (including mixed color-dyed) lymph nodes was 96.6% (140/145). Sensitivity and specificity were 95.1% (39/41) and 100% (99 of 99), respectively. Accuracy was 98.6% (138/140) with a false-negative rate of 4.9% (2/41). There were 4 patients in whom nodes of each color were found, but nodes of only 1 color were shown to be positive. The primary tumors of these 4 patients and of the 2 patients with false-negative results were located in the upper-outer quadrant of the breast. When only blue-dyed or green-dyed nodes (including mixed color-dyed nodes) were counted, the false-negative rates were 10.3% (4/39) for the subareolar mapping technique and 10.0% (4/40) for the peritumoral mapping technique. CONCLUSIONS The double-mapping method based on subareolar and peritumoral injections decreases the false-negative rate of dye-only SNB for early breast cancer. Variations in lymphatic channels may exist in the lateral half of the breast and thus may influence identification of positive sentinel nodes. This finding should be taken into account in cases of multicentric breast cancer.
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Affiliation(s)
- Keisei Anan
- Department of Surgery, Kitakyushu Municipal Medical Center Fukuoka, Japan.
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Marchal F, Rauch P, Morel O, Mayer JC, Olivier P, Leroux A, Verhaeghe JL, Guillemin F. Results of preoperative lymphoscintigraphy for breast cancer are predictive of identification of axillary sentinel lymph nodes. World J Surg 2006; 30:55-62. [PMID: 16369717 DOI: 10.1007/s00268-005-0145-3] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
The aim of this study was to identify the variables associated with successful peroperative sentinel lymph node (SLN) localization. We studied 201 patients with T1, T2, N0 invasive breast cancer who underwent a SLN procedure from 1999 to 2003. Of these 201 patients, 55 underwent peritumoral and 146 underwent periareolar radioisotope injection before the blue dye injection. All patients were operated on by breast conservative surgery and axillary dissection after SLN biopsy. Age, weight, menopausal status, previous biopsy, localization of the tumor, results of lymphoscintigraphy, site of radiotracer injection, tumor size, tumor grade, experience of surgeons, and the number of invaded axillary nodes were analyzed to determine whether they had any significant correlation with successful identification of SLN. Variables found to have a statistically significant influence on the SLN identification rate and on preoperative lymphoscintigraphy identification were introduced into a univariate and multivariate logistic regression model. In multivariate analysis, successful lymphoscintigraphy (P < 0.0001) and the absence of metastatic axillary nodes (P < 0.005) were associated with successful identification of SLNs. The peritumoral injection of radiotracer (P < 0.001), patient age > 60 years (P < 0.003), and localization of the tumor in the upper outer quadrant (P < 0.004) were associated with failure of lymphoscintigraphic visualization of SLN. The technique of SLN detection thus appears to be better for patients with low risk of invaded axillary lymph nodes.
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Affiliation(s)
- Frédéric Marchal
- Department of Surgery, Centre Alexis Vautrin, Regional Cancer Center, Av. de Bourgogne, Vandoeuvre-Lès-Nancy, 54511, France.
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D'Eredita G, Giardina C, Guerrieri AM, Berardi T. A further validation of subareolar injection technique for breast sentinel lymph node biopsy. Ann Surg Oncol 2006; 13:701-7. [PMID: 16523366 DOI: 10.1245/aso.2006.04.027] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2005] [Accepted: 11/04/2005] [Indexed: 11/18/2022]
Abstract
BACKGROUND In this study we performed subdermal injection of (99m)Tc-labeled albumin combined with subareolar (SA) injection of blue dye, and we compared this technique with two techniques previously used in terms of the success of sentinel lymph node (SLN) identification, false-negative (FN) rate, and the overall accuracy and sensitivity of the three procedures. In all patients we performed a complete axillary lymph node dissection. METHODS From January 1999 to September 2004, a total of 195 patients with localized breast cancer were treated. Patients were subdivided into three groups. In patients in group 1 (n = 115; January 1999 to December 2001), lymphoscintigraphy together with injection of vital dye was performed; in group 2 (n = 40; January to October 2002), SA injection of blue dye alone was performed; and in group 3 (n = 40; November 2002 to September 2004), SA injection of blue dye and subdermal injection of radioisotope was performed. RESULTS The success rate of identifying an SLN by a combination of the two techniques was 95% in group 1 and 100% in group 3. The FN rate was 9% in group 1 and 0% in groups 2 and 3. The overall accuracy of lymphatic mapping was 97% in group 1 and 100% in groups 2 and 3. Sensitivity was 91% in group 1 and 100% in groups 2 and 3. CONCLUSIONS This study of SA injection for SLN biopsy using dual tracers demonstrates a high SLN identification rate and an absent FN rate. We propose that injection into the SA plexus is the optimal way to perform lymphatic mapping of the breast. This technique seems to be feasible even in patients with multicentric cancers.
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Affiliation(s)
- Giovanni D'Eredita
- Department of General and Special Surgery, University of Bari, Via S. Hahnemann, 2, Bari, 70126, Italy.
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46
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Jackson BM, Kim S, Davidson R, Schuchter L, Acs G, Czerniecki BJ. Repeat Operative Sentinel Lymph Node Biopsy. Clin Breast Cancer 2006; 6:530-2. [PMID: 16595037 DOI: 10.3816/cbc.2006.n.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Because sentinel lymph node (SLN) biopsy continues to be used for staging in patients with breast cancer, physicians treating these patients will be faced with in-breast recurrences and new primary breast cancers in the treated breast. Repeat operative SLN biopsy might be feasible in this clinical scenario. This report describes the case of a patient with an ipsilateral different-site, recurrent, infiltrating ductal carcinoma 14 months after lumpectomy; negative SLN biopsy result; and radiation therapy, now with a positive SLN biopsy result.
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Affiliation(s)
- Benjamin M Jackson
- Department of Surgery , Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA
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Chagpar AB, Martin RC, Scoggins CR, Carlson DJ, Laidley AL, El-Eid SE, McGlothin TQ, Noyes RD, Ley PB, Tuttle TM, McMasters KM. Factors predicting failure to identify a sentinel lymph node in breast cancer. Surgery 2005; 138:56-63. [PMID: 16003317 DOI: 10.1016/j.surg.2005.03.003] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Although sentinel lymph node (SLN) biopsy is widely accepted as a minimally invasive method of nodal staging, failure to identify an SLN mandates a level I/II axillary node dissection. The purpose of this study was to elucidate factors that independently predict failure to identify an SLN. METHODS Using a large multicenter prospective study of SLN biopsy for patients with invasive breast cancer, we performed univariate and multivariate regression analyses to determine clinicopathologic factors predictive of failure to identify an SLN. RESULTS Of the total 4131 patients in the study, an SLN was not identified in 249 (6.0%). Tumor location (P = .409), biopsy type (P = .079), surgery type (P = .380), and histologic subtype (P = .999) were not significant predictors of failure to identify an SLN. On multivariate analysis, age greater than 60 years (OR = 1.469; 95% CI, 1.116-1.934, P = .006), nonpalpable tumors (OR = 0.639; 95% CI, 0.479-0.852, P = .002), injection technique with blue dye alone (OR = 0.389, 95% CI, 0.259-5.86, P < .001), and surgical experience of less than 10 SLN biopsy cases (OR = 1.886; 1.428-2.492, P < .001) were significant independent predictors of failure to identify an SLN. Optimal SLN biopsy technique using an intradermal and/or subareolar injection of radioactive colloid and blue dye can improve SLN identification rates regardless of patient and tumor characteristics. CONCLUSIONS Patient age and tumor palpability significantly affect the ability to identify an SLN in patients with breast cancer. Optimal injection technique can significantly improve sentinel node identification rate regardless of these factors.
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Affiliation(s)
- Anees B Chagpar
- Division of Surgical Oncology, Department of Surgery, University of Louisville, KY, USA.
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Wada N, Imoto S, Yamauchi C, Hasebe T, Ochiai A, Ebihara S. Correlation between concordance of tracers, order of harvest, and presence of metastases in sentinel lymph nodes with breast cancer. Ann Surg Oncol 2005; 12:497-503. [PMID: 15864480 DOI: 10.1245/aso.2005.07.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2004] [Accepted: 01/19/2005] [Indexed: 01/28/2023]
Abstract
BACKGROUND There are various methods for the detection of sentinel lymph nodes (SLNs) in breast cancer by using a combined method with blue dye and radioisotope (RI) tracers. The purpose of the study was to reveal any correlation between concordance of the tracers and the order of harvest with the presence of metastases in SLNs. METHODS The outcomes were reviewed in 408 cases with stage 0 to II breast cancer; the combined method was used in which blue dye and RI were injected subcutaneously around the tumor. The radioactivity and blue staining in each harvested SLN were checked. RESULTS In 330 cases (81%), SLNs contained both blue dye and RI tracers (blue-hot cases), and in 42 (10%) and 31 (8%) cases, the SLNs contained only the blue stain (blue-only cases) and only RI (hot-only cases), respectively. The overall metastatic rate was 25% on a patient basis. Blue-only cases had a higher rate (42%) of metastasis than hot-only cases (14%). The rate of nodes containing both blue dye and RI gradually decreased from the first SLNs harvested to the third SLNs harvested. The rate of nodes containing RI only increased with the number harvested, and there was not so much change in the rate of nodes containing blue only. CONCLUSIONS These data suggest that RI tracer could detect a wide range of SLNs and that the blue dye tracer could efficiently detect SLNs with metastasis. The combined methods compensates for the deficiencies of each method and thus will probably help to prevent missing SLNs.
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Affiliation(s)
- Noriaki Wada
- Breast Surgery Division, National Cancer Center Hospital East, Kashiwa, Chiba 277-8577, Japan.
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Kuerer HM, Newman LA. Lymphatic Mapping and Sentinel Lymph Node Biopsy for Breast Cancer: Developments and Resolving Controversies. J Clin Oncol 2005; 23:1698-705. [PMID: 15755978 DOI: 10.1200/jco.2005.09.047] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Affiliation(s)
- Henry M Kuerer
- Department of Surgical Oncology, Unit 444, The University of Texas M. D. Anderson Cancer Center, 1515 Holcombe Blvd, Houston, TX 77030, USA.
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Bakker JR, Sataloff DM, Haupt HM. Breast cancer presenting in aberrant axillary breast tissue. ACTA ACUST UNITED AC 2005. [DOI: 10.1016/s1548-5315(11)70863-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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