A treatment scale for axillary management in breast cancer

Intraoperative frozen section assessment of sentinel lymph nodes in the operative management of women with symptomatic breast cancer

BACKGROUND

Maximisation of the potential of sentinel lymph node biopsy as a minimally invasive method of axillary staging requires sensitive intraoperative pathological analysis so that rates of re-operation for lymphatic metastases are minimised. The aim of this study was to describe the test parameters of the frozen section evaluation of sentinel node biopsy for breast cancer compared to the gold standard of standard permanent pathological evaluation at our institution.

METHODS

The accuracy of intraoperative frozen section (FS) of sentinel nodes was determined in 94 consecutive women undergoing surgery for clinically node negative, invasive breast cancer (37:T1 disease; 43:T2; 14:T3). Definitive evidence of lymphatic spread on FS indicated immediate level II axillary clearance while sentinel node "negativity" on intraoperative testing led to the operation being curtailed to allow formal H&E analysis of the remaining sentinel nodal tissue.

RESULTS

Intraoperative FS correctly predicted axillary involvement in 23/30 patients with lymphatic metastases (76% sensitivity rate) permitting definitive surgery to be completed at the index operation in 87 women (93%) overall. All SN found involved on FS were confirmed as harbouring tumour cells on subsequent formal specimen examination (100% specificity and positive predictive value) with 16 patients having additional non-sentinel nodes found also to contain tumour. Negative Predictive Values were highest in women with T1 tumours (97%) and lessened with more local advancement of disease (T2 rates: 86%; T3: 75%). Of those with falsely negative FS, three had only micrometastatic disease.

CONCLUSION

Intraoperative FS reliably evaluates the status of the sentinel node allowing most women complete their surgery in a single stage. Thus SN can be offered with increased confidence to those less likely to have negative axillae hence expanding the population of potential beneficiaries.

Preoperative selection of symptomatic breast cancer patients appropriate for lymphatic mapping and sentinel node biopsy

BACKGROUND

This study examines whether preoperative ultrasound-assessed tumour diameter and diagnostic core biopsy-determined grade can be used to select those most likely to benefit from SLNB (i.e. those that are "node negative") before their definitive operation.

METHODS

Breast ultrasound (US) and a simultaneous core biopsy was performed in all patients at their initial presentation, and their estimates of tumor size and grade compared with the final pathological specimen (FPS).

RESULTS

Of the T1 group 47% had lymphatic metastases as did 49% of those with grade I or II cancers. By combining these measures, however, subgroups of patients with lower rates of nodal metastases were identified (32% of patients with T1, non-grade III disease had lymphatic disease while only 15% of those with T < 1.5 cm, non-grade III cancers had such metastases).

CONCLUSION

Combination of the US and ultrasound guided core biopsy (UGCB) may however identify subgroups unlikely to have axillary disease that are therefore suitable for SLNB.

Management of T1a Breast Cancer

Identification of early-stage breast cancers has increased over the past 2 decades primarily because of mammographic screening. The general guidelines to management of breast cancer may not apply to the smallest of these tumors, as their metastatic potential may be smaller than larger tumors. Tumors < 5 mm (T1a) carry an excellent prognosis, despite a variety of treatment approaches. However, some patients' cancer returns. There appear to be some histologic features that can predict a higher risk of axillary metastases, and therefore, a higher risk of distant metastases. Controversy exists over the extent of treatment, as to whether less than conventional treatment, such as mastectomy, axillary evaluation, and breast-conserving surgery and radiation, can be done. T1a lesions associated with extensive ductal carcinoma in situ and T1a lesions in young patients should be treated with caution if less than conventional breast treatment is to be considered. In older patients with good histologic features, axillary assessment may not be necessary. Very wide excision alone may be appropriate for some patients, but partial breast irradiation is under study and may provide a reasonable compromise. Systemic therapy for node-negative patients is not recommended. Recurrences within the breast occur later in early-stage breast cancers than with extensive-stage breast cancers, requiring annual imaging and evaluation for many years.

Intraoperative ultrasound facilitates surgery for early breast cancer

BACKGROUND

Mammogram-directed wire localization for nonpalpable cancer requires surgeon's time and coordination and some patient discomfort. Up to half of these nonpalpable lesions can be visualized by ultrasound. Use of intraoperative ultrasound streamlines the process of image-guided surgery.

METHODS

We prospectively visualized 69 nonpalpable breast cancers between January 1998 and July 2001. Ultrasound localization was performed in the operating room immediately before definitive surgery. Breast cancers were localized using either blue dye or a guide wire.

RESULTS

Ultrasound correctly localized all lesions at surgery. Negative margins for invasive carcinoma were found in 97% (67 of 69) of patients. Re-excisions were performed in only 6% (4 of 69) of patients. Overall negative margins were found in 90% (62 of 69) of patients. Most positive margins (71%) were due to the presence of noncalcified ductal carcinoma in situ. Mastectomy was necessary in 4% of patients, usually due to multifocal invasive carcinoma.

CONCLUSIONS

Increased familiarity with ultrasound has allowed the surgeon to localize breast cancer in the operating room, improving the process of image-guided surgery. Ultrasound localization is accurate, time efficient, technically feasible, and easier for the patient. The re-excision rate is very low and is similar to that for mammographic localization. Intraoperative ultrasound localization should be considered whenever a breast cancer needs image-guided excision.