Biopsia de ganglio centinela en pacientes con cáncer de mama y cirugía mamaria previa

Does sentinel lymph node biopsy for screening high-grade ductal carcinoma in situ of the breast cause more harm than good?

PURPOSE

Ductal carcinoma in situ (DCIS) of the breast does not metastasize to axillary lymph nodes. Yet high-grade DCIS (HgDCIS) is often subjected to Sentinel Lymph Node Biopsy (SLNB) concomitant with definitive surgery. This is to avoid further axillary surgery in the event of upstaging to invasive carcinoma, which often entails Axillary Lymph Node Dissection (ALND). We wished to examine the validity of this approach.

METHODS

This study includes a retrospective analysis of consecutive pre-operatively diagnosed HgDCIS patients from a single screening unit between December/2014 and August/2016. The main outcomes were the overall incidence of upstaging and the independent predictors of upstaging on multivariable analysis. The rates of various complications of SLNB vs ALND in four RCTs were used to calculate the upstaging rate below which SLNB could be safely omitted.

RESULTS

There were 224 eligible patients of whom 26 (11.6%) were upstaged. Axillary metastasis (pN1) occurred in two patients (0.9%). On Univariable analysis, upstaged patients were significantly younger (median (IQR) = 56.0 (51.0-63) vs 60.0 (54.0-65.0); p = 0.019). Radiological size, pathological size, type of biopsy, type of operation, and comedo-necrosis were not significant (p > 0.05). On multivariable analysis, age as a continuous variable (OR 0.93; p = 0.031) and core biopsy (OR 2.62; p = 0.036) were the only independent predictors of upstaging. Chi-square test showed that patients < 55 years whose pre-operative diagnosis was made on core biopsy were at significantly higher risk of upstaging than the others (31.8% vs 9.4%; p = 0.002).

CONCLUSION

Upstaging of HgDCIS is infrequent. According to the known rates of complications of SLNB relative to ALND, routine SLNB concomitant with surgery seems to be more harmful than its routine omission. A selective approach based on age and type of biopsy could be considered.

Influence of previous breast surgery in sentinel lymph node biopsy in patients with breast cancer

AIM

The aim of this study was to review the feasibility of selective sentinel lymph node biopsy in patients with previous surgery for breast cancer, as well as to examine the factors that may interfere with sentinel node detection.

MATERIAL AND METHODS

A retrospective review was performed on 91 patients with breast cancer and previous breast surgery, and who underwent sentinel lymph node biopsy. Patients were divided into two groups according to their previous treatment: aesthetic breast surgery in 30 patients (group I) and breast-conserving surgery in 61 (group II). Lymphoscintigraphy was performed after an intra-tumour injection in 21 cases and a peri-areolar injection in 70 cases. An analysis was made of lymphatic drainage patterns and overall sentinel node detection according to clinical, pathological and surgical variables.

RESULTS

The overall detection of the sentinel lymph node in the lymphoscintigraphy was 92.3%, with 7.7% of extra-axillary drainages. The identification rate was similar after aesthetic breast surgery (93.3%) and breast-conserving surgery (91.8%). Sentinel lymph nodes were found in the contralateral axilla in two patients (2.2%), and they were included in the histopathology study. The non-identification rate in the lymphoscintigraphy was 7.7%. There was a significantly higher non-detection rate in the highest histological grade tumours (28.6% grade III, 4.5% grade I and 3.6% grade II).

CONCLUSION

Sentinel lymph node biopsy in patients with previous breast surgery is feasible and deserves further studies to assess the influence of different aspects in sentinel node detection in this clinical scenario. A high histological grade was significantly associated with a lower detection.

[Selective biopsy of the sentinel lymph node in patients with breast cancer and previous excisional biopsy: is there a change in the reliability of the technique according to time from surgery?]

AIM

To assess the influence of time on the reliability of sentinel lymph node biopsy (SLNB) in breast cancer patients with previous excisional biopsy (EB), analyzing both the sentinel lymph node detection and the lymph node recurrence rate.

MATERIAL AND METHODS

Thirty-six patients with cT1/T2 N0 breast cancer and previous EB of the lesion underwent a lymphoscintigraphy after subdermal periareolar administration of radiocolloid, the day before SLNB. Patients were classified into two groups, one including 12 patients with up to 29 days elapsed between EB and SLNB (group A), and another with the remaining 24 in which time between both procedures was of 30 days or more (group B). Scintigraphic and surgical detection of the sentinel lymph node, histological status of the sentinel lymph node and of the axillary lymph node dissection, if performed, and lymphatic recurrences during follow-up, were analyzed.

RESULTS

Sentinel lymph node visualization at the lymphoscintigraphy and surgical detection were 100% in both groups. Histologically, three patients showed macrometastasis in the sentinel lymph node, one from group A and two from group B. None of the patients, not even those with malignancy of the sentinel lymph node, relapsed after a medium follow-up of 49.5 months (24-75).

CONCLUSION

Time elapsed between EB and SLNB does not influence the reliability of this latter technique as long as a superficial injection of the radiopharmaceutical is performed, proving a very high detection rate of the sentinel lymph node without evidence of lymphatic relapse during follow-up.

[Sentinel node biopsy in patients with multifocal and multicentric breast cancer: A 5-year follow-up]

OBJECTIVE

Sentinel lymph node biopsy (SLNB) as a staging procedure in multiple breast cancer is a controversial issue. We have aimed to evaluate the efficacy of sentinel node (SN) detection in patients with multifocal or multicentric breast cancer as well as the safety of its clinical application after a long follow-up.

MATERIAL AND METHODS

A prospective descriptive study was performed. Eighty-nine patients diagnosed of multiple breast cancer (73 multifocal; 16 multicentric) underwent SLNB. These patients were compared to those with unifocal neoplasia. Periareolar radiocolloid administration was performed in most of the patients. Evaluation was made at an average of 67.2 months of follow-up (32-126 months).

RESULTS

Scintigraphic and surgical SN localization in patients with multiple breast cancer were 95.5% and 92.1%, respectively. A higher percentage of extra-axillary nodes was observed than in the unifocal group (11.7% vs 5.4%) as well as a significantly higher number of SN per patient (1.70 vs 1.38). The rate of SN localization in multicentric cancer was slightly lower than in multifocal cancer (87.5% vs 93.1%), and the finding of extra-axillary drainages was higher (20% vs 10%). Number of SN per patient was significantly higher in multicentric breast cancer (2.33 vs 1.57). No axillary relapses have been demonstrated in the follow-up in multiple breast cancer patients group.

CONCLUSIONS

SLNB performed by periareolar injection is a reliable and accurate staging procedure of patients with multiple breast cancer, including those with multicentric processes.

[Incidence of axillary recurrence after a negative sentinel lymph node result in early stages of breast cancer: a 5-year follow-up]

The sentinel lymph node (SLN) biopsy is currently the procedure of choice for axillary node staging in initial stages of breast cancer. The purpose of this study is to establish our false negative rate within a 5-year follow-up period in 258 patients with breast cancer staged with this procedure.

METHODS

A retrospective study on 258 consecutive T1-T2<3 cm pN0 staged breast carcinomas treated from January 1, 2001 to December 31, 2005 was performed. The combined technique of isotope plus blue dye was used for detection. The subjects underwent a minimum follow-up of 5 years, mean 81 months, with an end of follow-up at December 31, 2010. Evidence of axillary recurrence, tumor recurrence in the breast and signs of disease progression or death were the events collected and analyzed.

RESULTS

Of the 258 patients, 3 false negatives (1.1%) with axillary recurrence were detected at 10, 11 and 29 months of the surgery. This did not have a significant repercussion in the survival analysis on the contrary to the existence of breast recurrence or the appearance of distant metastasis in 4.7% and 6.2% patients, respectively. Global survival related with the cancer was 93.0 (240/258) and disease free survival was 89.1% (230/258).

CONCLUSION

The risk of developing axillary recurrence after a negative SLN without axillary node dissection is low enough to consider the SLN procedure to be the best approach for axilla staging in early breast cancer. This staging technique also makes it possible to achieve local disease control without diminishing the survival of the patients.

Reproducibility of lymphoscintigraphy before and after excisional biopsy of primary breast lesions: a study using superficial peri-areolar injection of the radiotracer

OBJECTIVE

A major controversial issue in the sentinel node biopsy of the breast is the applicability of sentinel node mapping in patients with the history of previous excisional biopsy of the breast lesions. In the current study, we evaluated the reproducibility of lymphoscintigraphy before and after excisional biopsy of the primary breast lesions using superficial peri-areolar injection of the radiotracer.

MATERIAL AND METHODS

Eighteen patients scheduled for excisional biopsy of breast lesions were included into the study. The patients received intra-dermal injection of the radiotracer in the peri-areolar area of the index quadrant 1 to 2h before surgery. Imaging was performed the day after surgery. Immediately after completion of the first imaging, the patients received another injection of the radiotracer with the same technique, dose, and location. Other sets of lymphoscintigraphy imaging were taken immediately and 4h post second injection. The two sets of lymphoscintigraphy images were compared.

RESULTS

In 2 patients, sentinel node could not be identified in either set of images. In the remaining 16 patients, one sentinel node was detected in both lymphoscintigraphy image sets. The sentinel nodes of the second image sets were all in the same location of the first sets with at least 5 times higher count.

CONCLUSIONS

Excisional biopsy of the primary breast lesions does not seem to change the superficial lymphatic drainage pattern from the areola of the breast and sentinel node mapping can be performed after this procedure using superficial periareolar technique.