Final results of the Department of Defense multicenter breast lymphatic mapping trial

Role of SPECT-CT in breast cancer sentinel node biopsy when internal mammary chain drainage is observed

INTRODUCTION

SPECT-CT in the detection of the sentinel lymph node (SLN) of breast cancer offers known advantages over conventional planar lymphoscintigraphy. Sometimes, it shows atypical findings like mediastinal lymphatic drainage. We have evaluated these atypical findings showed by SPECT-CT performed in patients with migration to the internal mammary chain (IMC) and their roles in the management of the patients.

MATERIALS AND METHODS

We reviewed the 56 lymphoscintigraphies (planar and SPECT-CT) of 56 women (average age: 55 years) diagnosed with breast cancer with IMC migration observed in the planar images. We compared the two techniques, obtaining the number of depicted nodes, atypical locations, their exact anatomical location and their role in the management of the patient.

RESULTS

Planar images showed a total number of 81 IMC nodes. SPECT-CT showed 74 nodes in the IMC territory and 14 mediastinal lymphatic nodes in 6 patients. Out of the 81 IMC nodes reported by planar images, seven corresponded to mediastinal nodes. Planar and hybrid images showed 110 and 130 axillary nodes, respectively. SPECT-CT showed additional findings in five patients: three infraclavicular and two supraclavicular nodes that were exactly located. One intramammary node was discarded by the SPECT-CT as a focal skin contamination.

CONCLUSION

Mediastinal nodes are unexpected, but not uncommon findings that are important in the planning of SLN biopsy. SPECT-CT found more nodes than planar images, being able to separate mediastinal and IMC nodes, helping to exactly depict the SLN and its relations with anatomical structures.

Role of SPECT/CT in sentinel lymph node detection in patients with breast cancer

AIM

The purpose of this study was to conduct a systematic review of the published literature to assess the role (indications, advantages, and limitations) of SPECT/CT for the detection of sentinel lymph node (SLN) in breast cancer.

METHODS

The authors searched PubMed for published literature in English addressing this topic.

RESULTS

Eleven studies, published since 2006, focused on the role and value of SPECT/CT for SLN detection (SLND). They showed that SPECT/CT improved sentinel node detection and anatomical localization. One study suggested that SPECT/CT may provide a more accurate staging. Limitations for SLND with SPECT/CT include extra time and inconvenience for the patient and additional radiation dose.

CONCLUSIONS

SPECT/CT is a valuable tool for SLND, especially in difficult cases, when planar lymphoscintigraphy shows no SLN or unexpected lymphatic drainage.

Accuracy of individual descriptors and grading of nodal involvement by axillary ultrasound in patients of breast cancer

Background. Four-node sampling is a useful substitute for sentinel node biopsy in low resource settings. USG is being increasingly used as a preoperative tool to evaluate axilla. We conducted this study to assess the accuracy of different descriptors of axillary ultrasound and to formulate a model on grading of axillary involvement. Material and Methods. Thirty-four patients with clinically negative axilla underwent preoperative axillary ultrasound. The suspicious nodes were marked and details of various descriptors were noted. These nodes were sampled during axillary dissection and correlation of ultrasonographic findings with histopathological report was done to calculate accuracy of different descriptors. Based on this, a grading system of axillary lymph nodes involvement was formulated. Results. Based on the presence of various descriptors, five grades of nodal involvement could be defined. The most accurate descriptors to indicate nodal involvement were loss of hilar fat and hypoechoic internal echoes with specificity of 83% and positive predictive value of 92% each. The combination of descriptors of round shape with loss of hilar fat and hypoechoic internal echos had 100% specificity and positive predictive value. Conclusions. Grading of nodal involvement on axillary USG can be useful for selecting the most suspicious nodes for sampling during axillary dissection.

Patterns of nodal staging during breast conservation surgery in the medicare patient: will the ACOSOG Z0011 trial change the pattern of care?

ACOSOG Z0011 spares axillary dissection (AD) in breast conservation surgery (BCS) patients with T1/T2 tumors and 1-2 positive nodes. Current patterns of care and the impact of Z0011 on AD versus additional surgery rates for Medicare patients undergoing BCS are unknown. SEER data linked to Medicare claims for 1999-2005 were reviewed for women with invasive nonmetastatic breast cancer who underwent nodal staging on the same day as BCS. There were 3,280 women with T1/T2 tumors and positive nodes who underwent same-day nodal staging; 2,532 (77.2 %) of these women had 1-2 positive nodes. Assuming 25.7 % have extracapsular extension, 651 women would require AD. However, 1,881 women, or 57.4 % of those with T1/T2 tumors and positive nodes, would be spared AD. Meanwhile, among the 748 women having ≥ 3 positive nodes, 579 underwent same-day AD, but under Z0011, would now wait for permanent section. A total of 160 of these women underwent re-excision or completion mastectomy at a later date anyway, when delayed AD could be performed. The remaining 419 women with ≥ 3 positive nodes would require an additional surgery date for the sole purpose of completion AD. The Z0011 paradigm would consequently necessitate an additional surgery date for 1,070 (651 + 419) women, or 32.6 % of those with T1/T2 tumors and positive nodes. The Z0011 paradigm appears to increase the number of Medicare patients undergoing BCS who require an additional surgery date but decrease the number requiring AD to a greater extent. Future changes in the use of AD or axillary irradiation may yet modify that impact substantially.

Sentinel lymph node biopsy for breast cancer: from investigational procedure to standard practice

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.

Role of fluorine-18-labeled 2-fluoro-2-deoxy-D-glucose positron emission tomography-computed tomography in the evaluation of axillary lymph node involvement in operable breast cancer in comparison with sentinel lymph node biopsy

Purpose:

Role of (18 [F] fluorine-18-labeled 2-fluoro-2-deoxy-D-glucose [FDG] positron emission tomography-computed tomography [PET-CT]) in the evaluation of axillary lymph node involvement in T1T2N0 breast cancer and compare results with sentinel lymph node biopsy (SLNB).

Methods:

A total of 37 patients of proven T1T2N0 breast cancer were included in the study. Patients with past history of breast surgery, T3T4 disease, uncontrolled diabetes mellitus and pregnant patients were excluded from the study. Pre-operative FDG PET-CT was performed followed by sentinel lymph node (SLN) biopsy with blue dye or combined technique.

Results:

SLN was identified in 32 of 37 patients with an identification rate of 86.48% (32/37). With combined technique SLN identification rate was 100% (6/6) while with blue dye alone; it was 83.8% (26/31). Among 37 patients, 16 had axillary metastases of which 12 had macrometastases and four had micrometastases detected by immunohistochemistry (IHC). Of 12 patients with axillary macrometastases, skip metastases were present in two patients in whom SLN was negative and in two patients SLN was not identified, but axillary dissection showed metastases. PET-CT had shown sensitivity, specificity, negative predictive value and positive predictive value of 56%, 90%, 73%, and 81.8%, respectively. IHC of SLN detected four patients with micrometastases upstaging the disease by 11% (4/37).

Conclusion:

Because FDG PET-CT has a high specificity in the evaluation of axillary lymph node involvement in T1T2N0 breast cancer patients according to the results of this study if FDG PET-CT is positive in axillary lymph nodes, axillary lymph node dissection may be considered instead of SLNB.

The false-negative rate of sentinel node biopsy in patients with breast cancer: a meta-analysis

BACKGROUND

In sentinel node surgery for breast cancer, procedural accuracy is assessed by calculating the false-negative rate. It is important to measure this since there are potential adverse outcomes from missing node metastases. We performed a meta-analysis of published data to assess which method has achieved the lowest false-negative rate.

METHODS

We found 3,588 articles concerning sentinel nodes and breast cancer published from 1993 through mid-2011; 183 articles met our inclusion criteria. The studies described in these 183 articles included a total of 9,306 patients. We grouped the studies by injection material and injection location. The false-negative rates were analyzed according to these groupings and also by the year in which the articles were published.

RESULTS

There was significant variation related to injection material. The use of blue dye alone was associated with the highest false-negative rate. Inclusion of a radioactive tracer along with blue dye resulted in a significantly lower false-negative rate. Although there were variations in the false-negative rate according to injection location, none were significant.

CONCLUSIONS

The use of blue dye should be accompanied by a radioactive tracer to achieve a significantly lower false-negative rate. Location of injection did not have a significant impact on the false-negative rate. Given the limitations of acquiring appropriate data, the false-negative rate should not be used as a metric for training or quality control.

Sentinel lymph node surgery after neoadjuvant chemotherapy is accurate and reduces the need for axillary dissection in breast cancer patients

OBJECTIVE

Sentinel lymph node (SLN) surgery is widely used for nodal staging in early-stage breast cancer. This study was performed to evaluate the accuracy of SLN surgery for patients undergoing neoadjuvant chemotherapy versus patients undergoing surgery first.

SUMMARY BACKGROUND DATA

Controversy exists regarding the timing of SLN surgery in patients planned for neoadjuvant chemotherapy. Proponents of SLN surgery after chemotherapy prefer a single surgical procedure with potential for fewer axillary dissections. Opponents cite early studies with low identification rates and high false-negative rates after chemotherapy.

METHODS

A total of 3746 patients with clinically node negative T1-T3 breast cancer underwent SLN surgery from 1994 to 2007. Clinicopathologic data were reviewed and comparisons made between patients receiving neoadjuvant chemotherapy and those undergoing surgery first.

RESULTS

Of the patients, 575 (15.3%) underwent SLN surgery after chemotherapy and 3171 (84.7%) underwent surgery first. Neoadjuvant patients were younger (51 vs. 57 years, P < 0.0001) and had more clinical T2-T3 tumors (87.3% vs. 18.8%, P < 0.0001) at diagnosis. SLN identification rates were 97.4% in the neoadjuvant group and 98.7% in the surgery first group (P = 0.017). False-negative rates were similar between groups (5/84 [5.9%] in neoadjuvant vs. 22/542 [4.1%] in the surgery first group, P = 0.39). Analyzed by presenting T stage, there were fewer positive SLNs in the neoadjuvant group (T1: 12.7% vs. 19.0%, P = 0.2; T2: 20.5% vs. 36.5%, P < 0.0001; T3: 30.4% vs. 51.4%, P = 0.04). Adjusting for clinical stage revealed no differences in local-regional recurrences, disease-free or overall survival between groups.

CONCLUSIONS

SLN surgery after chemotherapy is as accurate for axillary staging as SLN surgery prior to chemotherapy. SLN surgery after chemotherapy results in fewer positive SLNs and decreases unnecessary axillary dissections.

Advances in local-regional treatment for patients with early-stage breast cancer: a review of the field

This review highlights advances in the field of the local-regional treatment for patients with early-stage breast cancer. Through the years, the surgical treatment for early-stage breast cancer has evolved into more conservative treatment, with breast-conserving measures replacing the mastectomy as the most common procedure performed to treat the primary tumor. Likewise, nodal staging has evolved so that the lymphatic mapping procedures have replaced axillary dissection, resulting in a less morbid procedure and better staging information. Advances in radiation treatment have resulted in increasingly tailored approaches to adding radiation treatment after breast-conserving surgery or mastectomy. These improvements in local-regional treatment have benefitted patients through increased breast conservation treatment, improved local control, increased survival, and improved quality of life.

Molecular and Functional Imaging of Breast Cancer

Background

Significant efforts have been directed toward developing and enhancing imaging methods for the early detection, diagnosis, and characterization of small breast tumors. Molecular and functional imaging sets the stage for enhancement of current methodology.

Methods

Current imaging modalities are described based on the molecular characteristics of normal and malignant tissue. New molecular imaging methods that have the potential for clinical use are also discussed.

Results:

Dynamic contrast-enhanced magnetic resonance imaging is more sensitive than mammography in BRCA1 carriers. It is used in screening and in the early evaluation of neoadjuvant therapy. Positron emission mammography is 91% sensitive and 93% specific in detecting primary breast cancers. Sentinel node scintigraphy is a key component of axillary lymph node evaluation. Other imaging modalities being studied include Tc99m sestamibi, radiolabeled thymidine or uridine, estrogen receptor imaging, magnetic resonance spectroscopy, and diffusion magnetic resonance imaging.

Conclusions

Molecular and functional imaging of the breast will likely alter clinical practice in diagnosing and staging primary breast cancer and assessing response to therapy since it will provide earlier information regarding the underlying biology of individual breast cancers, tumor stage, potential treatment strategies, and biomarkers for early evaluation of treatment effects.

Axillary lymph node dissection for sentinel lymph node micrometastases may be safely omitted in early-stage breast cancer patients: long-term outcomes of a prospective study

OBJECTIVES

To evaluate the long-term disease-free and overall survival of patients with sentinel lymph node (SLN) micrometastases, in whom a completion axillary lymph node dissection (ALND) was systematically omitted.

BACKGROUND

The use of step sectioning and immunohistochemistry for SLN analysis results in a more accurate histopathologic examination and a higher detection rate of micrometastases. However, the clinical relevance and therapeutic implications of SLN micrometastases remain a matter of debate.

METHODS

In this prospective study, 236 SLN biopsies were performed in 234 consecutive early-stage breast cancer patients (T1, T2 <or= 3 cm, cN0 M0) between 1998 and 2002. The SLN were examined by step sectioning and stained with hematoxylin and eosin and immunohistochemistry. None of the patients with negative SLN or SLN micrometastases (International Union Against Cancer classification, >.2 mm to <or=2 mm) underwent a completion ALND or radiation to the axilla. Long-term overall and disease-free survivals were compared between patients with negative SLN and those with SLN micrometastases by log rank tests.

RESULTS

The SLN was negative in 55% of patients (123 of 224). SLN micrometastases were detected in 27 patients (27 of 224, 12%). After a median follow-up of 77 months (range, 24-106 months), neither locoregional recurrences nor distant metastases occurred in any of the 27 patients with SLN micrometastases. There were no statistically significant differences for overall (P = .656), locoregional (P = .174), and axillary and distant disease-free survival (P = .15) between patients with negative SLN and SLN micrometastases.

CONCLUSIONS

This analysis of unselected patients provides evidence that a completion level I and II ALND may be safely omitted in early-stage breast cancer patients with SLN micrometastases.

Selective Sentinel Node Plus Additional Non-Sentinel Node Biopsy Based on an FDG-PET/CT Scan in Early Breast Cancer Patients: Single Institutional Experience

BACKGROUND

This study was designed to determine whether a preoperative fluorodeoxyglucose (FDG) positron emission tomography (PET) integrated with computed tomography (CT) (FDG-PET/CT) could be used as a guide for axillary node dissection (AND) or sentinel lymph node biopsy (SNB) in breast cancer patients.

METHODS

Between February 2007 and April 2008, we performed FDG-PET/CT scans in 137 biopsy-proven breast cancer patients planning to have an SNB to select patients for either AND (PET/CT N+) or SNB (PET/CT N0). In performing SNB, we also performed additional non-SNB (ADD), which was enlarged at the lower axilla.

RESULTS

Twenty-seven patients with positive scans underwent complete AND as a primary procedure, and 110 patients with negative scans underwent SNB + ADD. There were 8 cases of false negative scans, and no case of false positive scan. The overall sensitivity, specificity, positive predictive value, and overall accuracy of FDG-PET/CT in predicting axillary metastasis were 77.1%, 100%, 100%, and 94.2%, respectively. In a subset of 110 patients with SNB + ADD, 104 patients had histologically negative SN, and 6 patients had positive SN in frozen section. Among 110 SNB + ADD cases, there were only 8 cases (7.3%) of positive axillary basins in permanent biopsy, including two cases of late positives that had micrometastases in the SN only. Through selective SNB + ADD based on an FDG-PET/CT, we have spared 27 unnecessary SNBs (true positive scans).

CONCLUSIONS

FDG-PET/CT is a specific imaging modality for predicting axillary node metastasis, and allows for a selective approach to either AND or SNB. A selective SNB + ADD based on an FDG-PET/CT reduced both unnecessary SNBs and positive axillary basins, enhancing the identification rates of SN and the accuracy of SNB.

Sentinel lymphnode biopsy in early breast cancer using methylene blue dye and radioactive sulphur colloid - a single institution Indian experience

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.

Axillary recurrence after a tumour-negative sentinel node biopsy in breast cancer patients: A systematic review and meta-analysis of the literature

BACKGROUND

Sentinel node biopsy became the standard of care before consensus on the technique was reached and without randomized studies having shown a similar or decreased axillary recurrence rate. The purpose of this study was to evaluate studies reporting on patients with a negative sentinel node biopsy.

METHODS

We performed a systematic review and meta-analysis of the literature for studies concerning clinically node-negative breast cancer patients with a tumour-negative sentinel node biopsy and no subsequent axillary node dissection. The axillary recurrence rate was determined, as well as the sensitivity of the sentinel node procedure and the differences in lymphatic mapping techniques.

RESULTS

Forty-eight studies concerning 14 959 sentinel node-negative breast cancer patients followed for a median of 34 months were selected. Sixty-seven patients developed an axillary recurrence, resulting in a recurrence rate of 0.3%. The sensitivity of the sentinel node biopsy was 100%. Uni- and multivariable variable analyses showed that the lowest recurrence rates were reported in studies performed in cancer centres, in studies that described the use of (99m)Tc-sulphur colloid, and also when investigators used the superficial injection technique or evaluated the harvested sentinel nodes with haematoxylin-eosin and immunohistochemistry staining (p<0.01).

CONCLUSIONS

In this systematic literature review, the axillary recurrence rate in sentinel node-negative patients is 0.3%, which is well within the desired range. The median sensitivity of the procedure appears to be as high as 100%. The recurrence rate is influenced by the differences in the lymphatic mapping technique.

Paget's disease of the breast: the experience of the European Institute of Oncology and review of the literature

BACKGROUND

Paget's disease of the breast is an uncommon presentation of breast malignancy, accounting for 1-3% of all the breast tumors and presents in different histopathologic patterns: in association with an underlying invasive or non invasive carcinoma, or without any underlying neoplasia. In the literature, different methods are used for the treatment. Mastectomy with or without axillary dissection has been considered as the standard treatment procedure for many years. Several studies have already shown that breast conservation with radiation therapy is an oncologically safe option. Regarding the axillary approach, several studies have documented the presence of positive sentinel lymph node even in Paget's disease alone. The objective of this study was to retrospectively analyze outcome of patients affected by Paget's breast disease and to define our institutional experience.

PATIENTS AND METHODS

Between May 1996 and February 2003, 114 patients with confirmed Paget's disease of the breast were retrieved and underwent surgery at the European Institute of Oncology of Milan, Italy. The median age of the patients was 54 years at the time of the diagnosis. In our study, the histopathological examination of the operated specimen revealed one hundred seven patients with Paget's disease associated with an underlying invasive or non invasive carcinoma, and seven patients without underlying carcinoma. Patients underwent either conservative breast surgery or mastectomy, with or without sentinel lymph node biopsy and/or axillary surgery. Each patient was evaluated after surgery at a multidisciplinary meeting to selecting systemic therapy.

RESULTS

Seven patients had "pure" Paget's disease of the breast and one hundred seven had the disease associated with an underlying carcinoma. As surgical techniques 71 mastectomies and 43 breast conserving surgeries have been performed. Complete axillary dissection was done in patients with clinically positive lymph node and/or sentinel lymph node biopsy positive. Sentinel lymph node biopsy was performed in nineteen patients with invasive component and five were positive and underwent axillary dissection. Eleven sentinel lymph node biopsies were done in patients with non invasive component and none of them was positive. Adjuvant systemic therapies were based on the final tumor, node and metastasis stage: thirty patients received adjuvant chemotherapy alone, fourteen received endocrine treatment alone, twenty-six patients were evaluated to receive both chemo and endocrine therapy. The median duration of follow up was 73 months and was updated in the last 6 months. Five patients developed local recurrence, one had regional recurrence, another two had loco-regional recurrences and fourteen had distant metastasis as a first event. Malignancy-related deaths were censored in the statistical analyses cancer for and due to another tumor in eleven patients. Additionally, deaths were not related to malignancy totally in thirteen patients.

CONCLUSIONS

Screening examination and imaging techniques are fundamental. Breast conserving surgery combined with breast irradiation for patients with invasive and non invasive breast carcinoma has become the treatment of first choice. All surgical conservative approaches should include the complete nipple-areolar complex and margins of resected specimen free of tumor. Thanks to the evolution of the conservative approach, good cosmetic result can be obtained. To be informed about the axillary lymph node status and to avoid the patient to have a second surgical approach, sentinel lymph node biopsy should be performed.

Significance of sentinel lymph node micrometastases in human breast cancer

BACKGROUND

The significance of micrometastatic disease in the sentinel lymph nodes (SLN) of patients with invasive breast cancer has been questioned. The objective of our study was to review the impact of micrometastatic carcinoma detected by SLN biopsy.

STUDY DESIGN

Between January 1997 and May 2004, 2,408 patients with invasive breast cancer and an SLN with micrometastatic (N0[i+], N1mi) or no metastatic (N0[i-]) disease were identified through our breast database. Slide review was performed and reclassified by the 6(th) edition of the American Joint Committee on Cancer Staging Manual. Of these, 27 were excluded from analysis because of evidence of macrometastatic disease on slide review or enrollment in the American College of Surgeons Oncology Group Z10 study.

RESULTS

Of 2,381 patients, 2,108 were N0(i-), 151 were N0(i+), and 122 were N1mi. Overall and disease-free survivals of patients with an N1mi SLN were substantially worse than those in patients with an N0(i-) SLN (p < 0.001 and p=0.006, respectively). Additional positive non-SLNs were identified in 15.5% (15 of 97) of N1mi patients and 9.3% (10 of 107) of N0(i+) patients undergoing completion axillary lymph node dissection. Overall survival of the N0(i+) SLN patients not undergoing axillary dissection was substantially less than those undergoing axillary dissection (p=0.02).

CONCLUSIONS

Detection of micrometastatic carcinoma (N1mi) in the SLNs of invasive breast cancer patients is a major indicator of poorer survival compared with N0(i-) patients. Although survival of patients with an N0(i+) SLN does not statistically differ from that of N0(i-) patients, 9.3% of these patients had additional axillary nodal disease on axillary dissection, and N0(i+) patients had a decreased survival when axillary dissection was omitted.

Sentinel lymph node mapping for primary breast cancer

The tumor status of the axillary lymph nodes is the single most important predictor of survival for patients with primary breast cancer. Because of its essential role in staging, regional control, and perhaps survival, axillary lymph node dissection (ALND) has long been the standard of care for patients with operable breast cancer. During the past decade, the introduction and development of sentinel lymph node dissection (SLND) for primary breast cancer have allowed surgeons to determine the tumor status of the axilla without a standard level I and II ALND. Several well-designed studies have documented that SLND is an effective way of assessing axillary nodal status with minimal morbidity and high accuracy. We address the current status and future directions of SLND for primary breast cancer.

Intraoperative injection of technetium-99m sulfur colloid is effective in the detection of sentinel lymph nodes in breast cancer

BACKGROUND

Our objective was to determine if intraoperative injection of technetium-99m-labeled sulfur colloid is as effective as preoperative injection in the detection of sentinel lymph nodes (SLNs).

METHODS

Two hundred consecutive patients with breast cancer underwent SLN biopsy examination. Radiocolloid was injected in the preoperative area (group A) or immediately after induction of anesthesia in the operating room (group B).

RESULTS

The SLN detection rate was similar for groups A (96%) and B (100%; P = .2). Radioactive SLNs were detected in 95% of patients in group A and in 97% of patients in group B (P = .1). The mean number of SLNs harvested was 1.6 and 2.1 for groups A and B, respectively. There was no significant difference in positive SLNs between groups (P = .11).

CONCLUSIONS

Intraoperative injection of sulfur colloid is highly effective in the detection of SLNs, avoiding patient discomfort and surgical schedule delays.

Survival outcomes in node-negative breast cancer patients evaluated with complete axillary node dissection versus sentinel lymph node biopsy

BACKGROUND

Sentinel lymph node (SLN) biopsy combined with microstaging-associated immunohistochemical staining for cytokeratin more accurately assigns patients to their corresponding diagnostic stage. The purpose of this study was to compare the survival outcomes of node-negative patients who received an SLN biopsy with historical control data of node-negative patients who received routine complete axillary lymph node dissection (CALND) in the pre-SLN biopsy era.

METHODS

Under institutional review board approval, 2458 node-negative invasive breast cancer patients between the ages of 25 and 94 years (mean, 60 years) were treated at our institution from January 1986 to May 2004. Of these 2458 patients, 604 (25%) were evaluated with CALND, whereas 1854 (75%) were evaluated with SLN biopsy. All were treated according to the current stage-specific guidelines. Kaplan-Meier graphs of overall survival and disease-free survival were constructed for each group of patients, and the two groups were compared by using the log-rank test.

RESULTS

Overall survival and disease-free survival for the CALND and SLN biopsy groups did not differ significantly (P = .98). The average number of lymph nodes extracted in the pre-SLN biopsy group was 18, whereas the average number of SLNs extracted in the post-SLN biopsy group was 3.

CONCLUSIONS

The survival rate among node-negative breast cancer patients who received an SLN biopsy alone has proven to have no significant difference (P = .98) from the survival rate among node-negative patients who received a CALND. SLN biopsy alone should replace CALND as the primary tool for axillary staging of breast cancer in node-negative patients.

Lymphoscintigraphic sentinel node identification in patients with breast cancer: the role of SPECT-CT

PURPOSE

Lymph node status is a major factor in determining the stage, appropriate therapy and outcome in patients with breast cancer. It is therefore of clinical importance to accurately identify all sentinel nodes (SNs) for each individual tumour before surgery. The purpose of this study was to assess the role of SPECT-CT lymphoscintigraphy in SN identification in patients with breast cancer.

METHODS

Lymphoscintigraphy comprising planar and SPECT-CT acquisition was performed in 157 consecutive patients with breast cancer (mean age 54.7+/-10.6, range 27-81 years) with a palpable mass (n=100), with a non-palpable mass (n=52) or post lumpectomy (n=5). Planar and SPECT-CT images were interpreted separately and the two imaging techniques were compared with respect to their ability to identify hot nodes.

RESULTS

Planar imaging alone was negative for identification of hot nodes in 15% of the patients. SPECT-CT alone was negative in 10% and both techniques were negative in 9% of the patients. Forty-six of the total of 361 (13%) hot nodes identified by lymphoscintigraphy were detected only on SPECT-CT, including 21 nodes obscured by the scattered radiation from the injection site, nine adjacent nodes misinterpreted on planar images as a single node and 16 nodes which were missed on planar images and detected on SPECT data. SPECT-CT detected additional sites of drainage unexpected on planar images, including axillary (n=23 patients), internal mammary (n=5 patients), interpectoral (n=3 patients) and intramammary (n=2 patients) lymph node sites. Fourteen of the 329 (4%) hot lesions seen on planar images were false positive non-nodal sites of uptake that were accurately assessed by SPECT-CT and further validated by surgery. In a single patient, SPECT-CT was negative while planar images identified the SN.

CONCLUSION

SPECT-CT may improve the preoperative localisation of draining nodes in patients with breast cancer. It may detect hot nodes missed by planar imaging, exclude non-nodal false positive sites of uptake and accurately localise axillary and extra-axillary nodes.

Continued axillary sampling is unnecessary and provides no further information to sentinel node biopsy in staging breast cancer

INTRODUCTION

Sentinel lymph node biopsy (SLNB) has become increasingly accepted as a diagnostic method to stage the axilla in breast cancer, selecting women with a positive sentinel node for completion axillary clearance. As SLNB became established, many surgeons supplemented SLNB to sample a minimum of four lymph nodes, on the assumption that the four-node technique is supported by randomised trial data. We hypothesised that the practice of undirected sampling to supplement SLNB adds little information to the status of the residual axilla.

METHODS

One hundred and sixty-five patients with early breast cancer were studied. Following successful identification of the sentinel node, 84 women had completion axillary dissection and 81 women had an axillary sample with at least four nodes available for pathological assessment.

RESULTS

Following successful identification of the sentinel node in 165 patients, the false negative rate (FNR) was 2/44=4.5% (95% CI 0.6-15.5), sensitivity 42/44=95.5% (84.5-99.4) and negative predictive value (NPV) 121/123=98.4% (94.2-99.8). In the axillary dissection cohort, the FNR was 2/26=7.7% (0.9-25.1), sensitivity 24/26=92.3% (74.9-99.1) and NPV 58/60=96.7% (88.5-100). In the axillary sample group, the FNR was 0/18=0% (0-18.5), sensitivity 18/18=100% (81.5-100) and NPV 63/63=100% (94.3-100). The SLNB was the only positive node in 12/26 (46.2%) in the axillary dissection group and 10/18 (55.6%) in the axillary sampling group. There was no patient in the axillary sampling group where the sample node was positive and the sentinel node negative.

CONCLUSION

Once SLNB is validated within the multidisciplinary unit, undirected sampling of the axilla following identification of the sentinel node(s) is unnecessary. The additional sampling of non-sentinel nodes has no role to play either in the assessment of a potential false negative SLNB nor as predictive information on the status of the residual axillary nodes.

Sentinel node skills verification and surgeon performance: data from a multicenter clinical trial for early-stage breast cancer

OBJECTIVE

Marked variations in sentinel lymph node dissection (SLND) technique have been identified, and definitive qualifications for SLND performance remain controversial. Based on previous reports and expert opinion, we predicted that 20 to 30 cases of SLND with axillary lymph node dissection (ALND) would enable surgeons to identify sentinel lymph nodes (SLN).

SUMMARY BACKGROUND DATA

In 1999, the American College of Surgeons Oncology Group initiated a prospective trial, Z0010, to evaluate micrometastatic disease in the SLN and bone marrow of women with early-stage breast cancer. Eligible patients included women with biopsy-proven T1/T2 breast cancer and clinically negative lymph nodes who were candidates for lumpectomy and SLND.

METHODS

Participating surgeons were required to document 20 to 30 SLNDs followed by immediate ALND with failure rates less than 15%. Prior fellowship or residency training in SLND provided exemption from skill requirements. Data for 5237 subjects and 198 surgeons were available for analysis.

RESULTS

Surgeons from academic (48.4%), community (28.6%), or teaching-affiliated (19.8%) institutions qualified with 30 SLND + ALND cases (64.6%), 20 cases (22.2%), or exemption (13.1%). Participants used blue dye + radiocolloid in 79.4%, blue dye alone in 14.8%, and radiocolloid alone in 5.7% of cases, achieving a 98.7% SLN identification rate. Patient factors associated with increased SLND failure included increased body mass index and age, whereas tumor location, stage, and histology, presence of nodal metastases, and number of positive nodes were not. Surgeon accrual of fewer than 50 patients was associated with increased SLND failure; however, SLND technique, specific skill qualification, and institution type were not.

CONCLUSIONS

Using a standard skill requirement, surgeons from a variety of institutions achieved an acceptably low SLND failure rate in the setting of a large multicenter trial, validating the incorporation of SLND into clinical practice.

Axillary recurrence rate in breast cancer patients with negative sentinel lymph node (SLN) or SLN micrometastases: prospective analysis of 150 patients after SLN biopsy

OBJECTIVE

To assess the axillary recurrence rate in breast cancer patients with negative sentinel lymph node (SLN) or SLN micrometastases (>0.2 mm to <or=2.0 mm) after breast surgery and SLN procedure without formal axillary lymph node dissection (ALND).

SUMMARY BACKGROUND DATA

Under controlled study conditions, the SLN procedure proved to be a reliable method for the evaluation of the axillary nodal status in patients with early-stage invasive breast cancer. Axillary dissection of levels I and II can thus be omitted if the SLN is free of macrometastases. The prognostic value and potential therapeutic consequences of SLN micrometastases, however, remain a matter of great debate. We present the follow-up data of our prospective SLN study, particularly focusing on the axillary recurrence rate in patients with negative SLN and SLN micrometastases.

METHODS

In this prospective study, 236 SLN procedures were performed in 234 patients with early-stage breast cancer between April 1998 and September 2002. The SLN were marked and identified with 99m technetium-labeled colloid and blue dye (Isosulfanblue 1%). The excised SLNs were examined by step sectioning and stained with hematoxylin and eosin and immunohistochemistry (cytokeratin antibodies Lu-5 or CK 22). Only patients with SLN macrometastases received formal ALND of levels I and II, while patients with negative SLN or SLN micrometastases did not undergo further axillary surgery.

RESULTS

The SLN identification rate was 95% (224/236). SLN macrometastases were found in 33% (74/224) and micrometastases (>0.2 mm to <or=2 mm) in 12% (27/224) of patients. Adjuvant therapy did not differ between the group of SLN-negative patients and those with SLN micrometastases. After a median follow-up of 42 months (range 12-64 months), 99% (222/224) of evaluable patients were reassessed. While 1 patient with a negative SLN developed axillary recurrence (0.7%, 1/122), all 27 patients with SLN micrometastases were disease-free at the last follow-up control.

CONCLUSIONS

Axillary recurrences in patients with negative SLN or SLN micrometastases did not occur more frequently after SLN biopsy alone compared with results from the recent literature regarding breast cancer patients undergoing formal ALND. Based on a median follow-up of 42 months-one of the longest so far in the literature-the present investigation does not provide evidence that the presence of SLN micrometastases leads to axillary recurrence or distant disease and supports the theory that formal ALND may be omitted in these patients.

Preoperative Lymphoscintigraphy and Internal Mammary Sentinel Lymph Node Biopsy Do not Enhance the Accuracy of Lymphatic Mapping for Breast Cancer

Lymphoscintigraphy (LS) may identify sentinel lymph nodes (SLNs) outside the axilla. Biopsy of these nodes could improve the accuracy of lymphatic mapping (LM) for breast cancer (BC) if a significant number of tumor-positive extra-axillary sentinel nodes are identified. To address this, we evaluated the impact of the use of preoperative LS and biopsy of axillary and internal mammary SLNs in women with BC. From October 1997 to July 2003, 175 women with breast cancer received technetium sulfur colloid, and images were obtained. Isosulfan blue dye was injected intraoperatively, and LM of the axillary and internal mammary lymph node basins was performed with a hand-held gamma probe. The anatomic location and histologic status of all SLNs identified with LS and LM was recorded, and the impact of the findings on LS and internal mammary LM were evaluated. LS showed SLN in 127/175 (73%) women and “hot spots” were found with the gamma probe in 142/175 (81%). At least one SLN was identified by LM in 168/175 (96%) patients, and 48/168 (29%) had metastases. One hundred sixty-two of 168 (96%) patients had SLN exclusively in the axilla. Only 10 of 175 (6%) women had internal mammary (IM) SLNs seen on LS. LM identified IM sentinel nodes in 6 of these 10 patients, but none were involved with tumor. Preoperative lymphoscintigraphy and biopsy of internal mammary sentinel nodes do not enhance the accuracy of lymphatic mapping for breast cancer. Omitting lymphoscintigraphy reduces the complexity and cost of lymphatic mapping without compromising the identification of tumor-positive sentinel nodes.

Australasian Experience and Trials in Sentinel Lymph Node Biopsy: The RACS SNAC Trial

PURPOSE

Sentinel lymph node biopsy (SLNB) has been rapidly adopted by surgical oncologists in the management of invasive breast cancer. This study reviews the Royal Australasian College of Surgeons (RACS) Sentinel Node versus Axillary Clearance (SNAC) trial and reports an interim analysis of the first 150 subjects. Other currently open multi-institutional randomized trials in SLNB are reviewed.

METHODS

The SNAC trial is a multicentre, centrally randomized, phase III clinical trial. Subjects are randomized to SLNB alone (with completion axillary clearance, AC, for sentinel node-positive patients) or AC plus SLNB, with stratification according to age (< 50 years, more than or equal to 50 years), primary tumour palpability (palpable vs impalpable), lymphatic mapping technique (blue dye plus scintigraphy vs blue dye alone) and centre.

RESULTS

The trial was launched in May 2001 in two centres. Randomization continues currently at the rate of approximately 30 subjects per month (total, 1,012 at the time of writing) from 32 participating centres in Australia and New Zealand. Data from the first 150 subjects have been analysed to assess: compliance with randomized treatment allocation; measures of test performance for SLNB (detection, removal, sensitivity, specificity and false-negative rates); measures of arm volume, function, symptoms and quality of life; and sample size estimates.

CONCLUSIONS

The SNAC trial is one of the fastest accruing clinical trials in Australasia. It is on track to determine whether differences in morbidity, with equivalent cancer-related outcomes, exist between SLNB and AC for women with early breast cancer.

Axillary recurrence after sentinel lymph node biopsy

Sentinel lymph node biopsy (SLNB) without further axillary dissection in patients with sentinel node-negative breast carcinoma appears to be a safe procedure to ensure locoregional control. During a median follow-up of 35 months the false-negative rate was 1% in our study population of 185 patients.

BACKGROUND

The objective of this prospective study is to provide data on follow-up of patients with primary operable breast carcinoma staged with SLNB without axillary lymph node dissection (ALND) if the sentinel lymph nodes (SLNs) were tumour-negative.

METHODS

One hundred and eighty-five patients were enrolled. Preoperative dynamic and static lymphoscintigraphy were performed; both a vital blue dye and a gamma detection probe were used intraoperatively. Patients with tumour-positive SLNs received completion ALND or if no SLNs could be identified. All patients were monitored according to regional follow-up protocols.

RESULTS

The SLNs were identified in 179 out of the 185 patients. In 73 patients the SLNs were tumour-positive and in 106 patients tumour-negative. The median follow-up was 35 months (range 17-59). In one SLN-negative patient an axillary recurrence occurred 26 months after the SLNB (false-negative rate: 1%).

CONCLUSIONS

SLNB without ALND appears to be a safe procedure to ensure locoregional control in SLN-negative breast carcinoma, if carried out by an experienced team.

Breast-conserving therapy and sentinel lymph node biopsy are feasible in cancer patients with previous implant breast augmentation

BACKGROUND

Breast-conserving therapy (BCT) is reported to result in a significant rate of complications and local recurrences in patients with prior implant breast augmentation. The role of sentinel lymph node (SLN) biopsy in these patients is unknown.

METHODS

Retrospective review of patients with prior breast augmentation treated with BCT or SLN biopsy.

RESULTS

Nineteen breast cancers were treated with BCT. Of 17 breasts undergoing adjuvant radiotherapy, 11 (64.7%) retained favorable aesthetic results. Of 9 subpectoral implants, capsular contracture developed in only 1 (11.1%). During follow-up (median 3 years), 1 local recurrence (5.3%) occurred in a patient who refused adjuvant radiotherapy and systemic therapy. Eleven patients underwent SLN biopsy with an identification rate of 100% and a false-negative rate of 0%.

CONCLUSIONS

Breast-conserving therapy inclusive of radiotherapy after implant breast augmentation produced acceptable cosmetic results in nearly two-thirds of patients. Sentinel lymph node mapping in the setting of prior implant augmentation was highly successful and accurate.

Lymphatic mapping and sentinel lymphadenectomy for breast cancer

Lymphatic mapping and sentinel lymphadenectomy has become an important tool for axillary lymph node staging in women with early-stage breast cancer. This review examines data regarding the staging accuracy, indications and technical aspects of the procedure, and clinical trials investigating the technique. Multiple studies now confirm that sentinel lymphadenectomy accurately stages the axilla and is associated with less morbidity than axillary dissection. Blue dye, radiocolloid, or both can be used to identify the sentinel node, and several injection techniques may be used successfully. Many patient factors previously thought to affect accuracy of the procedure have now been shown to be of limited significance. The indications for the procedure are expanding, and the histopathologic evaluation of the sentinel node and the role of lymphoscintigraphy have been clarified. Clinical trials are now underway that will determine the prognostic significance of micrometastases and the therapeutic benefit of axillary dissection in women with and without sentinel node metastases. Incorporation of sentinel lymphadenectomy into routine clinical practice will maintain accurate axillary staging with lower morbidity and improved quality of life for women with early-stage breast cancer.

Sentinel node biopsy in breast cancer and melanoma requires adequate self‐audit

BACKGROUND

Sentinel node biopsy (SNB) is an evolving technique with potential for improving staging. Melanoma and breast cancer are the two most commonly used applications. The present study relates the author's validation data in both diseases.

METHODS

Review of a prospective database.

RESULTS

Between January 2000 and December 2001 92 cases of breast cancer were offered SNB. The first 48 had completion axillary dissection. The identification rate was 92%. There were 28 true negative, 15 true positive and one false negative case. A mean of 2.0 nodes were removed (range 1-4). Completion axillary dissection removed a mean of 15.1 nodes. The following 44 cases were offered a choice of SNB alone, axillary dissection or a combination of techniques. Thirty-seven women chose SNB alone. There was one technical failure, 28 negative SNB and eight positive SNB results. A mean of 3.1 lymph nodes were removed (range 1-9) applying a 10% rule. At 24-36 months follow up there have been no cases of locoregional recurrence. From January to December 2001 36 cases of melanoma > or =1 mm were managed with SNB. Twenty-eight SNB were negative and eight were positive (22%). At follow up (range 12-24 months) there were three locoregional recurrences, but only one of these were in the node basin determined to be previously negative by SNB (3.5%).

DISCUSSION

Sentinel node biopsy in breast cancer is a valid alternative to full axillary dissection for staging the axilla. Patients can make an informed choice to have SNB alone if they understand the limitations of the technique and possible consequences of these limitations. In melanoma SNB provides valuable prognostic information most melanoma patients prefer to have. Adequate self-audit is necessary before a patient can make an informed decision to have SNB in either disease.

[The sentinel node in invasive breast cancer. Unsolved questions and review of the national and international clinical trials]

Sentinel lymph node biopsy is a major diagnostic procedure in breast cancer surgery. Although adopted worldwide, its routine practice has not been validated yet. This article proposes a review of national and international controlled clinical trials whose aims are definitely to answer remaining unsolved questions.

Sentinel node biopsy for breast cancer: is it already a standard of care? A survey of current practice in an Italian region

BACKGROUND

Although sentinel node biopsy (SNB) is becoming the standard approach for axillary staging in patients with small breast cancer, criteria for patient selection and some technical aspects of the procedure have yet to be clearly defined. The aim of the present survey was therefore to investigate the way in which SNB is used by general surgeons working in the Veneto region, Italy.

METHODS

A 29-item questionnaire regarding various aspects of SNB practice was mailed to surgeons in charge of breast surgery in all the 56 surgical centres of the region.

RESULTS

The rate of response to the questionnaire was 82.1% (n = 46); 69.6% (n = 32) of the respondents routinely perform SNB in their clinical practice. Most of the interviewed surgeons (93.5%) expressed the belief that the acceptable false negative rate should be < or =5%. However, among the surgeons who perform SNB, only 34.4% performed more than 20 SNB during the learning phase. Indications are limited to tumours of < or =1 cm by 31.2% (n = 10) of respondents, < or =2 cm by 46.9% (n = 15) and < or =3 cm by 21.9% (n = 7). Almost all respondents (93.7%) agreed that a clinically positive axilla is a contraindication to SNB, while opinions differed widely concerning other potential contraindications. In most of the centres considered, SN identification is undertaken on the day before surgery using a subdermal injection of 30-50 MBq of 99mTc-albumin-nanocolloid followed by lymphoscintigraphy.

CONCLUSIONS

SNB is currently performed in the majority of hospitals in the Veneto region. However, the training phase and criteria used for patient selection differ from centre to centre. Certified training courses and shared guidelines are therefore highly desirable.

Localización del ganglio centinela en cáncer de mama. Inyección periareolar del radiocoloide

Traditional lymphadenectomy is being replaced by sentinel node biopsy in initial management of early stage breast cancer. The aim of this study was to validate the technique in our center, where we perform preoperative lymphoscintigraphy and intraoperative detection of sentinel node, after periareolar radiotracer and peritumoral blue dye injection. Sixty patients, breast cancer stages I and II, were included. Lymphatic mapping was performed the day before surgery, after the administration of 74 MBq 99mTc sulfur colloid in periareolar subdermal tissue. Surgical detection of sentinel node through gamma probe was followed by intraoperative and occasionally delayed biopsies. Finally, full axillary node dissection was completed. Lymphoscintigraphy identified sentinel node in 78% of the patients (47/60): 43 in axilla, 4 in internal mammary chain. Probe guided axillary detection was achieved in 88% (53/60): in every patient with axillar migration in scan, in 9/13 without imaged drainage and in 1/4 with internal mammary chain migration. Sensitivity of blue dye technique was 75% (45/60), the concordance between both procedures being high. Considering both, the overall success rate of surgical detection was 90% (54/60); if we exclude those patients who showed exclusive extraaxillar drainage, the success rate reaches 95%. Malignancy was found in 24% of sentinel nodes removed (13/54); it being the only metastatic axillary node in 4/13. No false negative sentinel nodes were found. Therefore, negative predictive value and accuracy were 100%. These results allow us to validate the technique in our center.

The clinical relevance of positive sentinel nodes only versus positive nonsentinel lymph nodes in breast cancer patients

BACKGROUND

The purpose of this study was to determine the difference in clinical outcomes for patients with histologically positive sentinel lymph nodes (SLN+) compared with patients with histologically positive nonsentinel second echelon lymph nodes (NSLN+).

METHODS

Eight hundred thirteen node positive patients from a prospectively accrued database of 3200 patients who underwent sentinel node mapping were evaluated. In all, 506 of the 813 patients (62%) were SLN+ only and 307 of the 813 patients (38%) were SLN+ plus at least one NSLN+. Patients' overall survival and disease-free survival were obtained and statistical analyses performed comparing the two groups.

RESULTS

As the number of NSLN+ increased, there was a significant difference in disease-free survival (P = 0.001) and overall survival (P = 0.003) between those patients who had 0 to 4 NSLN+ and those who had 5 or more NSLN+. The SLN+ only patients did not show significant differences with respect to survival, based on the number of SLN+ (overall survival, disease-free survival; P = 0.742).

CONCLUSIONS

The survival (overall survival, disease-free survival) for patients with 3 or more SLN+ was not statistically different than for patients with 1 or 2 SLN+ (P = 0.742). However, an alteration of biologic behavior was observed when multiple NSLN+ contain metastatic breast cancer. Involvement of 5 or more NSLN+ portends a significantly (P = 0.001) worse prognosis, regardless of the number of SLN+.

Sentinel node biopsy for breast cancer patients in Japan

Sentinel node biopsy may become a standard procedure to detect lymph node metastases in early breast cancer. Numerous studies have confirmed and demonstrated the reliability of the hypothesis of sentinel node biopsy, with a high identification rate and overall accuracy connected with dye-guided and radio-guided sentinel node biopsy. To assess the benefit of sentinel node biopsy, randomized clinical trials are underway in Western countries comparing sentinel node biopsy with conventional axillary lymph node dissection. In Japan, feasibility studies on sentinel node biopsy started in the mid-1990s. The dye and radiopharmaceuticals associated with sentinel node biopsy commonly used in Western countries are not available in Japan. Japanese investigators have attempted to perform sentinel node biopsy using other dyes and radiopharmaceuticals. The results from feasibility studies have been similar to those reported previously. In conclusion, sentinel node biopsy for breast cancer patients is successful in Japan. The current status and the problems are discussed.

Peritumoural versus subareolar administration of technetium-99m nanocolloid for sentinel lymph node detection in breast cancer: preliminary results of a prospective intra-individual comparative study

The scintigraphic detection of sentinel lymph nodes (SNs) in early-stage breast cancer is a widely accepted diagnostic method. However, which radiotracer administration mode should be used is still controversial. This prospective study aimed to intra-individually compare the detection rates obtained after peritumoural versus subareolar injection with regard to SN number and localisation. Fifty-one women (age, 32-76 years) with breast cancer were investigated on two consecutive days. On day 1, 140-400 MBq technetium-99m nanocolloid was injected along the peripheral tumour margins. Static lymphoscintigrams of the axilla, thorax and neck were taken in various views 1 and 19 h p.i. On day 2, 10 MBq (99m)Tc-nanocolloid was injected subareolarly in the clock position of the tumour and dynamic and static scans were performed immediately. Thereafter, 30 MBq (99m)Tc-nanocolloid was administered peri-subareolarly and lymphoscintigrams were acquired in a dynamic and static manner. In 49/51 women, the different injection techniques disclosed the identical number and location of SNs in the axilla. In seven patients, the peritumoural injection detected additional SNs in the parasternal group. Axillary SNs were detected as early as 2-15 min following subareolar injection, both in the clock position and peri-subareolarly, as compared with about 1 h after peritumoural administration. Sixteen patients showed at least one tumour-positive SN, and nine also had tumour-positive non-SNs. One patient with a tumour-negative SN, visualised concordantly by both subareolar and peritumoural administration, demonstrated two metastatic non-SNs, yielding a false-negative rate of 5.9%. In conclusion, a simple subareolar injection in the clock position is sufficient for SN detection in breast cancer, if it is accepted that parasternal lymph node detection has no therapeutic consequences.

[Sentinel lymph node biopsy in breast cancer: technical aspects and results]

Sentinel lymph node biopsy for breast cancer has been introduced in the mid-1990s and it has now been performed on thousands of patients. Although this procedure has not been validated by randomised clinical trials, it has been rapidly adopted around the world by surgical specialists in clinical practice as a diagnostic procedure instead of the axillary lymph node dissection. The critical issue in sentinel lymph node biopsy is the false negative results which could expose the patients to axillary recurrence and lead to understaging and incorrect adjuvant therapy decisions. The current problem is to perfect the procedure for an optimal use in routine reducing this risk of false negative results. This false negative rate declines sharply when the technique is performed in selected patients by experienced surgeons using a combined detection. In this article, we review the technical aspects and results of the sentinel lymph node biopsy in breast cancer and discuss the recommendations for the optimal clinical practice.