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Factors Influencing Non-sentinel Node Involvement in Sentinel Node Positive Patients and Validation of MSKCC Nomogram in Indian Breast Cancer Population. Indian J Surg Oncol 2015; 6:337-45. [PMID: 27065658 DOI: 10.1007/s13193-015-0431-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2014] [Accepted: 06/15/2015] [Indexed: 12/23/2022] Open
Abstract
Current guidelines recommend completion axillary lymphnode dissection (ALND) when sentinel lymphnode (SLN) contains metastatic tumor deposit. In consequent ALND sentinel node is the only node involved by tumor in 40-70 % of cases. Recent studies demonstrate the oncologic safety of omitting completion ALND in low risk patients. Several nomograms (MSKCC, Stanford, MD Anderson score, Tenon score) had been developed in predicting the likelihood of additional nodes metastatic involvement. We evaluated accuracy of MSKCC nomogram and other clinicopathologic variables associated with additional lymph node metastasis in our patients. A total of 334 patients with primary breast cancer patients underwent SLN biopsy during the period Jan 2007 to June 2014. Clinicopathologic variables were prospectively collected. Completion ALND was done in 64 patients who had tumor deposit in SLN. The discriminatory accuracy of nomogram was analyzed using Area under Receiver operating characteristic curve (ROC). SLN was the only node involved with tumor in 69 % (44/64) of our patients. Additional lymph node metastasis was seen in 31 % (20/64). On univariate analysis, extracapsular infiltration in sentinel node and multiple sentinel nodes positivity were significantly associated (p < 0.05) with additional lymph node metastasis in the axilla. Area under ROC curve for nomogram was 0.58 suggesting poor performance of the nomogram in predicting NSLN involvement. Sentinel nodes are the only nodes to be involved by tumor in 70 % of the patients. Our findings indicate that multiple sentinel node positivity and extra-capsular invasion in sentinel node significantly predicted the likelihood of additional nodal metastasis. MSKCC nomogram did not reliably predict the involvement of additional nodal metastasis in our study population.
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Ashturkar AV, Pathak GS, Deshmukh SD, Pandave HT. Factors predicting the axillary lymph node metastasis in breast cancer: is axillary node clearance indicated in every breast cancer patient?: factors predicting the axillary lymphnode metastases in breast cancer. Indian J Surg 2011; 73:331-5. [PMID: 23024536 DOI: 10.1007/s12262-011-0315-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2010] [Accepted: 02/20/2011] [Indexed: 11/26/2022] Open
Abstract
The study was carried out to find out predictors of axillary lymph node metastasis in breast cancer and to evaluate its significance in selecting the group of patients in whom axillary dissection could be avoided. Ninety-five breast cancer patients who underwent mastectomy and axillary dissection were included in the study. Factors like patient's age, tumor size, histopathological type, histological grade and estrogen and progesterone receptor status were correlated with the axillary metastases. Out of 95 cases axillary metastasis was found in 47 (49.47%) cases. There was no correlation between patient's age and tumor size with axillary metastasis (p > 0.05). Based on histopathological typing tumors like ductal carcinoma in situ, tubular carcinoma and mucinous carcinoma showed less tendency for axillary metastasis (p < 0.046). Association was found between histological grade and estrogen receptor and progesterone receptor positivity with presence of axillary metastasis (p < 0.001 and 0.002 respectively). The findings in this study indicate that breast cancer patients having favorable histological type, grade I tumors and estrogen and progesterone receptor negative tumor are good candidates to avoid axillary dissection.
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Affiliation(s)
- Amrut V Ashturkar
- Department of Pathology, Shrimati Kashibai Navale Medical College and General Hospital, Narhe, Pune, 411041 India
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van Wely BJ, Teerenstra S, Schinagl DAX, Aufenacker TJ, de Wilt JHW, Strobbe LJA. Systematic review of the effect of external beam radiation therapy to the breast on axillary recurrence after negative sentinel lymph node biopsy. Br J Surg 2010; 98:326-33. [PMID: 21254004 DOI: 10.1002/bjs.7360] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/21/2010] [Indexed: 11/11/2022]
Abstract
BACKGROUND Axillary recurrence after negative sentinel lymph node biopsy (SLNB) in patients with invasive breast carcinoma remains a concern. Previous investigations to identify prognostic factors for axillary recurrence identified that a disproportionate number of patients with an axillary recurrence after negative SLNB were not treated with external beam radiation therapy (EBRT) of the breast as part of initial treatment. This finding prompted a systematic review to test the hypothesis that EBRT to the breast reduces the risk of axillary recurrence after negative SLNB. METHODS A literature search was performed in PubMed, the Cochrane Library and the Spanish-language database LILACS to identify articles publishing data regarding follow-up of sentinel lymph node (SLN)-negative patients. Reports and articles lacking information on the initial treatment were excluded. RESULTS Forty-five articles were accepted for review. A total of 23,357 SLN-negative patients were identified with median follow-up ranging from 15 to 102 months. Some 18,878 patients were treated with EBRT to the breast as part of their initial treatment. One hundred and twenty-seven patients with an axillary recurrence were identified, of whom 73 had EBRT as part of their initial treatment. Meta-analysis showed that EBRT was associated with a lower rate of axillary recurrence (P < 0·001), but this finding was subject to heterogeneity. CONCLUSION This review and meta-analysis showed that EBRT is associated with a significantly lower axillary recurrence rate after negative SLNB.
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Affiliation(s)
- B J van Wely
- Department of Surgery, Radboud University, Nijmegen Medical Centre,Nijmegen, The Netherlands.
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Safety of avoiding routine use of axillary dissection in early stage breast cancer: a systematic review. Breast Cancer Res Treat 2010; 125:301-13. [DOI: 10.1007/s10549-010-1210-7] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2010] [Accepted: 09/30/2010] [Indexed: 10/18/2022]
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van der Ploeg IMC, Nieweg OE, van Rijk MC, Valdés Olmos RA, Kroon BBR. Axillary recurrence after a tumour-negative sentinel node biopsy in breast cancer patients: A systematic review and meta-analysis of the literature. Eur J Surg Oncol 2008; 34:1277-84. [PMID: 18406100 DOI: 10.1016/j.ejso.2008.01.034] [Citation(s) in RCA: 113] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2007] [Accepted: 01/29/2008] [Indexed: 12/16/2022] Open
Abstract
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.
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Affiliation(s)
- I M C van der Ploeg
- Department of Surgery, The Netherlands Cancer Institute - Antoni van Leeuwenhoek Hospital, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
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Dian D, Straub J, Scholz C, Mylonas I, Rack B, Sommer H, Janni W, Friese K. Influencing factors for regional lymph node recurrence of breast cancer. Arch Gynecol Obstet 2007; 277:127-34. [PMID: 17763863 DOI: 10.1007/s00404-007-0432-3] [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] [Received: 03/19/2007] [Accepted: 07/30/2007] [Indexed: 11/27/2022]
Abstract
INTRODUCTION We investigated whether the risk of developing regional lymph node recurrence was dependant on the number of lymph nodes removed. OBJECT We followed 2,961 patients of whom 50 (1.69%) developed regional recurrent disease during a median period of 73 months (4-192 months). RESULT For those women who had involved lymph nodes at initial surgery we were able to establish an inverse correlation between the development of local recurrence and the number of lymph nodes removed in multivariate analysis. For women who had no affected lymph nodes, the number of lymph nodes removed did not influence the incidence of local recurrence. CONCLUSION We conclude from these data that women who have negative nodal status at surgical staging do not benefit from further systematic axillary resection with regard to regional lymph node recurrence. For those women, however, who have confirmed axillary metastasis, systematic axillary resection lowers the risk of regional lymph node recurrence depending on the number of lymph nodes removed.
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Affiliation(s)
- Darius Dian
- University Hospital München, Maistrasse 11, Munich, 80337, Germany.
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Ponzone R, Maggiorotto F, Mariani L, Jacomuzzi ME, Magistris A, Mininanni P, Biglia N, Sismondi P. Comparison of two models for the prediction of nonsentinel node metastases in breast cancer. Am J Surg 2007; 193:686-92. [PMID: 17512277 DOI: 10.1016/j.amjsurg.2006.09.031] [Citation(s) in RCA: 64] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2006] [Revised: 09/04/2006] [Accepted: 09/04/2006] [Indexed: 11/27/2022]
Abstract
BACKGROUND It is debated whether all patients with a positive sentinel node dissection (SLND) should be submitted to axillary lymph node dissection (ALND). Models have been developed to estimate the likelihood of nonsentinel node (non-SLN) metastases. METHODS The accuracy of the Memorial Sloan-Kettering Cancer Center (MSKCC) nomogram and MD Anderson scoring system for the prediction of non-SLN status was tested in a consecutive series of 186 SLN-positive breast cancer patients. A multivariate analysis was performed to assess which parameters independently predicted the presence of non-SLN metastases. RESULTS The predictive accuracy of the MSKCC nomogram measured by the receiver operating characteristic curve was 0.71, and it was best in patients with <10% risk of non-SLN metastases (sensitivity 100% and specificity 96%). The MD Anderson score predicted non-SLN involvement with low accuracy because it classified 85% of the patients in the intermediate-risk groups. Only SLN macrometastases and tumor multifocality independently predicted non-SLNs involvement. CONCLUSIONS The MSKCC nomogram can help individualize the surgical treatment of SLN-positive breast cancer when the likelihood of further axillary involvement is low or surgical risks are higher.
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Affiliation(s)
- Riccardo Ponzone
- Academic Division of Gynecological Oncology, Institute for Cancer Research and Treatment of Candiolo, Strada Provinciale 142, 10060 Candiolo, Turin, Italy.
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Fernández-Aguilar S, Simon P, Buxant F, Fayt I, Nöel JC. Is complete axillary lymph node dissection neccessary in T1 stage invasive pure tubular carcinomas of the breast? Breast 2005; 14:325-8. [PMID: 16085240 DOI: 10.1016/j.breast.2004.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2004] [Revised: 11/29/2004] [Accepted: 12/15/2004] [Indexed: 10/25/2022] Open
Abstract
The purpose of this study was to evaluate the frequency of axillary lymph node metastasis in invasive pure (not mixed) tubular carcinomas of the breast and to compare our results to other series published in the literature. We analyzed 16 cases of pure tubular carcinoma measuring 2 cm or less in diameter from our database from 1988 to 2004 diagnosed in lumpectomy and mastectomy specimens with associated axillary lymph node dissection. Histopathologic features were reviewed in all patients. In all cases, no axillary lymph node metastasis was observed (0%). These data slightly differ from the results of some studies recently published in the literature, in which the overall nodal involvement in pure tubular carcinomas ranges from 0% to 20%. We conclude that in invasive pure tubular carcinomas of the breast measuring less than 2 cm in diameter, complete axillary lymph node dissection should be avoided, and we propose a sentinel lymph node analysis instead.
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Affiliation(s)
- Sergio Fernández-Aguilar
- Department of Pathology, Erasmus University Hospital, 808 Route de Lennik, 1070 Brussels, Belgium.
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Giard S, Chauvet MP, Houpeau JL, Baranzelli MC, Carpentier P, Fournier C, Belkacemi Y, Bonneterre J. Le ganglion sentinelle sans curage systématique dans le cancer du sein : bilan d'une expérience de 1000 interventions. ACTA ACUST UNITED AC 2005; 33:213-9. [PMID: 15894205 DOI: 10.1016/j.gyobfe.2005.03.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2004] [Accepted: 03/15/2005] [Indexed: 02/06/2023]
Abstract
OBJECTIVE To assess daily practice of 1000 sentinel node (SN) biopsies in breast cancer. PATIENTS AND METHOD Prospective review of 1000 consecutive sentinel node biopsies between February 2001 and June 2004. Analyses concerned technical aspects of sentinel node detection, pathologic results of the tumor and sentinel node, treatment and follow-up. RESULTS Nine hundred and seventy-eight SN were detected (98.7%). In univariate analyses, age, pathologic tumor size (20 mm) and method of detection (blue dye or isotopic vs. combined) were statistically significant. One hundred and fifty-six cases (16%) underwent immediate axillary dissection (AD), whereas 116 (12%) had a delayed AD. There were 923 invasive or micro-invasive carcinoma with detected SN: 282 SN (30.5%) were involved, either with macrometastases (166) or with micrometastases (116), 34% had positive non-sentinel node. Age and metastasis size were predictive for AD involvement. Sixteen percent of micrometastatic SN had positive AD, there was no predictive factor for axillary involvement. After a median follow-up of 20 months, there were 4 axillary recurrences: 1 (0.1%) after negative SN without AD, 1 (0.1%) after positive SN with positive AD, 1 (4.3%) after micrometatastatic SN without AD, and 1 (8.3%) after macrometastatic SN without AD. There were 55 ductal carcinoma in situ and 54 micro-invasive cancer: positive SN (with negative AD) were detected in only 2 cases (2.3%). There were initially 112 ductal carcinoma in situ diagnosed by percutaneaous biopsy, 25 of them (22%) had invasive disease on definitive histology. Among there, 12 had involved SN (with 4 positive AD). DISCUSSION AND CONCLUSION With a high detection rate and low recurrence rate, SN biopsy is considered in our institute as a reliable procedure and is used to evaluate regional nodal status of early breast cancer. Thus, 70% of AD can be omitted.
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Affiliation(s)
- S Giard
- Département de sénologie, centre Oscar-Lambret, 3, rue Frédéric-Combemale, 59020 Lille cedex, France.
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Aubard Y, Mollard J, Fermeaux V. Comment éviter les aléas de l’examen extemporané du ganglion sentinelle dans le cancer du sein ? ACTA ACUST UNITED AC 2004; 32:981-4. [PMID: 15567689 DOI: 10.1016/j.gyobfe.2004.09.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2004] [Accepted: 09/24/2004] [Indexed: 11/22/2022]
Abstract
The sentinel lymph node procedure is now admitted by many teams for axillary evaluation in the early stage of breast cancer. The classical technique consists in an intraoperative examination of the sentinel lymph node under general anaesthesia during tumorectomy, deciding whether or not complete axillary lymphadenectomy must be done. Intraoperative examination seems to us to have a poor predictive value. In the case of a false positive, the surgeon would perform lymphadenectomy unnecessarily, while a false negative would mean that the patient would have to be re-operated for lymphadenectomy once the definitive results have become available. For all these reasons, we propose the detection of the sentinel lymph node under local anaesthesia and to await its definitive analysis before carrying out tumorectomy on the patient and axillary lymphadenectomy if necessary under general anesthesia. Hence, we consider that the best way to avoid the uncertainties of an intraoperative examination of the sentinel lymph node is not to carry out intraoperative examinations.
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Affiliation(s)
- Y Aubard
- Service de gynécologie-obstétrique, CHU Dupuytren, 2, avenue Martin-Luther-King, 87042 Limoges, France.
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van der Vegt B, Doting MHE, Jager PL, Wesseling J, de Vries J. Axillary recurrence after sentinel lymph node biopsy. Eur J Surg Oncol 2004; 30:715-20. [PMID: 15296984 DOI: 10.1016/j.ejso.2004.05.015] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/20/2004] [Indexed: 11/30/2022] Open
Abstract
UNLABELLED 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.
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Affiliation(s)
- B van der Vegt
- Department of Surgical Oncology, University Hospital Groningen, P.O. Box 30.001, 9700 RB Groningen, The Netherlands
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Kang SH, Kang JH, Choi EA, Lee ES. Sentinel lymph node biopsy after neoadjuvant chemotherapy. Breast Cancer 2004; 11:233-41; discussion 264-6. [PMID: 15550841 DOI: 10.1007/bf02984543] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND We surveyed single-center and multi-center studies pertaining to sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy to compare the results with those of our current study to evaluate the feasibility and accuracy of SLNB after neoadjuvant chemotherapy. METHODS From October 2001 to July 2003, 80 patients who had neoadjuvant chemotherapy underwent curative surgery and axillary lymph node dissection (ALND) after SLNB at the Center for Breast Cancer, National Cancer Center. A MEDLINE search was performed using the keywords breast cancer, sentinel lymph node biopsy, and neoadjuvant chemotherapy. RESULTS Our results showed that 42 (52.6%) of 80 patients had downstaging of the primary tumor; 9 patients (11.3%) had pathologic complete response (pCR) and 33 (41.3%) had pathologic partial response (pPR). 26 patients (32.5%) showed complete axillary clearance after neoadjuvant chemotherapy. Among them, 5 patients (6.3%) revealed pCR of both the primary tumor and axillary metastasis. SLNB was successful in 61 of 80 patients (76.3%) and there were 3 false negatives, yielding a false negative rate (FNR) of 7.3% (3/41), a negation prediction value (NPV) of 87.0%(20/23), and an accuracy of 95.1% (58/61). Thirteen out of 16 studies retrieved by to MEDLINE pertaining SLNB after neoadjuvant chemotherapy concluded its feasibility and accuracy with a identification rate of 82%-100% and a FNR of 17-100%. CONCLUSION Most studies, including ours, concluded that SLNB after neoadjuvant chemotherapy is accurate and could be an alternative to ALND.
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Affiliation(s)
- Seok Hyung Kang
- National Cancer Center, Madu-1-dong 809,san-gu, Goyang-si, Gyeonggi-do, 411-769, Korea.
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