Lymphatic mapping and sentinel lymph node biopsy in patients with breast cancer

Radiolabeled Localization of the Sentinel Lymph Node: Dosimetric Evaluation in Personnel Involved in the Procedure

Aims and Background

Peritumoral injection of 99mTc-labeled colloids for lymphoscintigraphy and radioguided surgery does not entail any relevant radiation burden to the patients. The real issue about radiation protection concerns the personnel involved in the procedure besides the nuclear medicine personnel. The aim of our study was to evaluate the cumulative doses to personnel involved during the injection of radiolabeled compounds under ultrasound or stereotactic guidance and the radiation burden to the personnel involved in the surgical incision of the tumor 24 hours after the administration of 99mTc-labeled colloids.

Methods and Study Design

We performed environmental contamination tests (SMEAR TEST) and exposure evaluation in the operating room.

Results

In the operating room the removed activity in the analyzed samples was less than 0.5Bq/g and exposure to the personnel was less than 6μSv/h. The evaluations made during ultrasound guidance demonstrated an equivalent and effective dose less than 20μSv.

Conclusions

Our results show that during ultrasound or stereotactic administration of radiolabeled compounds the radiation burden to the personnel involved in the procedure is virtually negligible. The surgeons too are exposed to a negligible radiation dose.

Sentinel Node Detection in Breast Carcinoma

Aims and Background

The standard procedure for the evaluation of axillary nodal involvement in patients with breast cancer is still complete lymph node dissection. However, about 70% of patients are found to be free of metastatic disease while axillary node dissection may cause significant morbidity. Lymphatic mapping and sentinel lymph node (SLN) biopsy are changing this situation.

Methods and Study Design

In a period of 18 months we studied 201 patients with breast cancer, excluding patients with palpable axillary nodes, tumors >2.5 cm in diameter, multifocal or multicentric cancer, pregnant patients and patients over 80 years of age. Before surgery 99mTc-labeled colloid and vital blue dye were injected into the breast to identify the SLN. In lymph nodes dissected during surgery the metastatic status was examined by sections at reduced intervals. Only patients with SLNs that were histologically positive for metastases underwent axillary dissection.

Results

We localized one or more SLNs in 194 of 201 (96.5%) patients; when both techniques were utilized the success rate was 100%. Histologically, 21% of patients showed SLN metastases (7.8% micrometastases) and 68% of these had metastases also in other axillary nodes. None of the patients with negative SLNs developed metastases during follow-up.

Conclusions

At present there is no definite evidence that negative SLN biopsy is invariably correlated with negative axillary status; however, our study and those of others demonstrate that SLN biopsy is an accurate method of axillary staging.

Preliminary Study of Sentinel Node Identification with 99mTc Colloid and Blue Dye in Patients with Endometrial Cancer

Aims and Background

Intraoperative lymphatic mapping and sentinel node (SLN) biopsy have generated a tremendous amount of interest and are already established as part of the standard practice in the surgical management of breast cancer and melanoma. To reduce extensive radical procedures and decrease the morbidity in the treatment of gynecologic malignancies, much effort is being made to use less aggressive interventions. The purpose of our study was to determine the feasibility of SLN mapping in a group of patients with endometrial cancer at early stages.

Method and study design

Between September 2000 and May 2001 11 patients with endometrial cancer FIGO stage Ib (n = 10) and Ha (n = 1) underwent laparoscopic SLN detection during laparoscopy-assisted vaginal hysterectomy with bilateral salpingo-oophorectomy and bilateral systematic pelvic lymphadenectomy. Radioactive isotope injection was performed 24 hours before surgery and blue dye injection was performed just before surgery in the cervix at 3, 6, 9 and 12 hours. A 350 mm laparoscopic gamma scintyprobe MR 100 type 11, 99mTc settled (Pol Hi Tech), was used intraoperatively for SLN detection.

Results

Seventeen (17) SLNs were detected with lymphoscintigraphy (six bilateral and five unilateral). At laparoscopic surgery we found the same locations belonging at internal iliac lymph nodes (the so-called Lebeuf-Godard area, lateral to the inferior vesical artery, ventral to the origin of the uterine artery and medial or caudal to the external iliac vein). Fourteen (14) SLNs were negative on histological analysis and three were positive for micrometastases (mean SLN sections = 60). All other pelvic lymph nodes were negative at histological analysis. The same SLN locations detected with the gamma scintyprobe were observed at laparoscopy after patent blue dye injection.

Conclusions

Our preliminary data suggest that combined 99mTc-labeled colloid and vital blue-dye techniques are feasible for SLN detection in endometrial cancer; they represent a very promising tool to transform the management of early-stage endometrial cancer. The clinical validity of this combined technique should be evaluated prospectively.

Sentinel lymph node biopsy and aberrant lymphatic drainage in recurrent breast cancer: Findings likely to change treatment decisions

BACKGROUND AND OBJECTIVES

It is not clear whether sentinel lymph node biopsy (SLNB) can be applied to patients with a second breast cancer or recurrence occurring at previously treated breast. The purpose of this study was to assess the feasibility of SLNB procedure in patients with recurrent breast cancer.

METHODS

Patients with non-metastatic recurrent N0 breast cancer at ipsilateral breast were included. Patients were grouped according to their initial breast, axilla, and overall surgery. Presence of drainage and its pattern as well as SLNB success rate and overall axillary involvement rates were assessed. Findings were compared.

RESULTS

Out of 75 patients, mean age was 52.5 years and disease-free interval was 82 (9-312) months. Lymphatic drainage was successful in 42 (56%) patients. Drainage positivity was more frequent in patients who were previously treated with SLNB (82.6%) than in patients who underwent axillary lymph node dissection (ALND) (44.2%; P = 0,002). Aberrant lymphatic drainage was detected in 64.3% of drainage positive patients. Success rate of reoperative SLNB was 92.9%. Adjuvant treatment plan was altered in 12 (16%) patients. In 15 patients, negative SLNB prevented axillary dissection.

CONCLUSIONS

Reoperative SLNB seems to be technically feasible in N0 recurrent breast cancer patients. It may further avoid unnecessary ALND and lead changes in adjuvant treatment plans. J. Surg. Oncol. 2016;114:796-802. © 2016 2016 Wiley Periodicals, Inc.

Sentinel Lymph Node Biopsy in Breast Cancer: Indications, Contraindications, and Controversies

Axillary lymph node status, a major prognostic factor in early-stage breast cancer, provides information important for individualized surgical treatment. Because imaging techniques have limited sensitivity to detect metastasis in axillary lymph nodes, the axilla must be explored surgically. The histology of all resected nodes at the time of axillary lymph node dissection (ALND) has traditionally been regarded as the most accurate method for assessing metastatic spread of disease to the locoregional lymph nodes. However, ALND may result in lymphedema, nerve injury, shoulder dysfunction, and other short-term and long-term complications limiting functionality and reducing quality of life. Sentinel lymph node biopsy (SLNB) is a less invasive method of assessing nodal involvement. The concept of SLNB is based on the notion that tumors drain in an orderly manner through the lymphatic system. Therefore, the SLN is the first to be affected by metastasis if the tumor has spread, and a tumor-free SLN makes it highly unlikely for other nodes to be affected. Sentinel lymph node biopsy has become the standard of care for primary treatment of early breast cancer and has replaced ALND to stage clinically node-negative patients, thus reducing ALND-associated morbidity. More than 20 years after its introduction, there are still aspects concerning SLNB and ALND that are currently debated. Moreover, SLNB remains an unstandardized procedure surrounded by many unresolved controversies concerning the technique itself. In this article, we review the main indications, contraindications, and controversies of SLNB in breast cancer in the light of the most recent publications.

Imaging methods for the local lymphatic system of the axilla in early breast cancer in patients qualified for sentinel lymph node biopsy

Breast cancer is the most common malignancy in women in well-developed countries. Despite a constant increase in its incidence, the percentage of patients diagnosed with the disease in the non-invasive stage is also rising. This allows more frequently for the use of breast-preserving surgical techniques, involving the breast and the regional lymphatic system.

According to current guidelines of expert panels and research societies, the recommended method of identifying the sentinel lymph node is the use of an isotope marker with a dye (a combined isotope and dye method). Cooperation with a nuclear medicine unit is essential (performing a preoperative lymphoscintigraphic scan to identify the lymphatic drainage basin and sentinel lymph node). In the case of smaller centers treating breast cancer, it can be associated with a number of difficulties, including organizational ones, and also increasing general treatment costs.

A possible solution to these problems is to use alternative techniques of visualizing the sentinel lymph node, which do not require a radiotracer. In this paper we discuss the currently available methods of mapping the lymphatic system of the axillary region in patients with early breast cancer. The review is limited to reporting on methods of proven (based on clinical research) high diagnostic value.

Sentinel lymph node biopsy in breast cancer: a work in progress

The sentinel lymph node biopsy is a safe, accurate operation for the initial staging of breast cancer. Over the last decade, there has been increasing literature supporting its use, and it is now considered a standard of care for the initial evaluation of metastatic spread to the axillary lymph node chain.

Use of the dye-guided sentinel lymph node biopsy method alone for breast cancer metastasis to avoid unnecessary axillary lymph node dissection

For sentinel lymph node biopsy (SLNB), a combination of dye-guided and γ-probe-guided methods is the most commonly used technique. However, the number of institutes in which the γ-probe-guided method is able to be performed is limited, since special equipment is required for the method. In this study, SLNB with the dye-guided method alone was evaluated, and the clinicopathological characteristics were analyzed to identify any factors that were predictive of whether the follow-up axillary lymph node dissection (ALND) was able to be omitted. A total of 374 patients who underwent SLNB between 1999 and 2009 were studied. The SLN identification rate was analyzed, in addition to the false-positive and false-negative rates and the correlation between the clinicopathological characteristics and axillary lymph node metastases. The SLN was identified in 96.8% of cases, and, out of the patients who had SLN metastasis, 63.0% did not exhibit metastasis elsewhere. The sensitivity was 96.4% and the specificity was 100%. The false-negative rate was 3.6%. Univariate analyses revealed significant differences in the lymph vessel invasion (ly) status, nuclear grade (NG), maximum tumor size and the percentage of the area occupied by the tumor cells in the SLN (SLN occupation ratio) between the patients with and without non-SLN metastasis, indicating that these factors may be predictive of axillary lymph node metastasis. Multivariate analysis revealed that ly status was an independent risk factor for non-SLN metastasis. In conclusion, SLN with the dye-guided method alone provided a high detection rate. The study identified a predictive factor for axillary lymph node metastasis that may improve the patients’ quality of life.

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.

Pathologic evaluation of axillary dissection specimens following unexpected identification of tumor within sentinel lymph nodes

CONTEXT

Axillary lymph node dissection has been the standard of care after identification of a positive sentinel lymph node for breast cancer patients.

OBJECTIVE

To determine the likelihood of non-sentinel lymph node involvement for patients with negative sentinel node by frozen section, who are subsequently found to have tumor cells in the sentinel node by permanent section levels and/or cytokeratin immunohistochemistry.

DESIGN

One hundred three patients with invasive breast cancer exhibiting negative frozen section evaluation of their sentinel node, but later found to have isolated tumor cells (n  =  46), micrometastasis (n  =  46), or metastases (n  =  11) in their sentinel node by permanent sections or immunohistochemistry, were enrolled in this prospective cohort study and underwent completion axillary dissection.

RESULTS

Six of 46 patients (13%) with isolated tumor cells in their sentinel node, 15 of 46 patients (33%) with micrometastasis in their sentinel node, and 2 of 11 patients (18%) with metastasis in their sentinel node had additional findings in the nonsentinel nodes. These findings resulted in a pathologic stage change in 2 patients. Predictors of positive nonsentinel nodes were 2 or more positive sentinel nodes (P  =  .002), sentinel nodes with micrometastasis versus isolated tumor cells (P  =  .03), and those with angiolymphatic invasion (P  =  .04).

CONCLUSIONS

Our findings lend support to axillary node dissection for patients with micrometastasis or metastasis in their sentinel nodes. However, studies with clinical follow-up are needed to determine whether axillary node dissection is necessary for patients with isolated tumor cells in sentinel nodes.

Variation in management of early breast cancer in the Netherlands, 2003-2006

BACKGROUND

To describe variation in staging and primary treatment by hospital characteristics including type and volume and region in patients with early breast cancer (BC) in the Netherlands, 2003-2006 after completion of national guidelines in 2002.

METHODS

All patients newly diagnosed with invasive BC in 2003-2006 and recorded in the Netherlands Cancer Registry were included (n = 51 354). Multivariable logistic regression analyses examined the influence of patient and hospital characteristics, also by region, on type of breast surgery, axillary lymph node dissection (ALND), sentinel node procedure (SNP), and adjuvant irradiation and/or systemic treatment.

RESULTS

Patients <40 years more often underwent breast conserving surgery (BCS) in general hospitals (OR 1.4 (95%CI 1.1-1.5)) than in teaching and academic hospitals, whereas patients of 40-69 years less often received BCS in an academic hospital (OR 0.9 (95%CI 0.8-1.0)) than in teaching hospitals. Patients with pT1-2N0 cancer more often underwent primary ALND in a general hospital than in a larger teaching or academic hospital. Type of hospital did not seem to affect utilization of adjuvant systemic therapy, but patient age and tumour size and grade did. Over time, patients more often received SNP, BCS, and adjuvant systemic therapy, primary ALND being on the decline, but with substantial regional variation between geographic regions.

CONCLUSION

With detailed evidence-based national guidelines since 2002 the considerable regional and hospital variation in staging procedures and primary treatment among newly diagnosed patients with early breast cancer in the Netherlands decreased markedly, suggesting the presence of late adaptors rather than specific hospital characteristics.

Sentinel node micrometastases in breast cancer do not affect prognosis: a population-based study

Sentinel node biopsy (SNB) for axillary staging in breast cancer allows the application of more extensive pathologic examination techniques. Micrometastases are being detected more often, however, coinciding with stage migration. Besides assessing the prognostic relevance of micrometastases and the need for administering adjuvant systemic and regional therapies, there still seems to be room for improvement. In a population-based analysis, we compared survival of patients with sentinel node micrometastases with those with node-negative and node-positive disease in the era after introduction of SNB. Data from the population-based Eindhoven Cancer Registry were used on all (n = 6803) women who underwent SNB for invasive breast cancer in the Southeast Region of The Netherlands in the period 1996-2006. In 451 patients (6.6%) a sentinel node micrometastasis (pN1mi) was detected and in 126 patients (1.9%) isolated tumor cells (pN0(i+)). Micrometastases or isolated tumor cells in the SNB did not convey any significant survival difference compared with node-negative disease. After adjustment for age, pT, and grade, still no survival difference emerged pN1mi: [HR 0.9 (95% CI, 0.6-1.3)] and pN0(i+): [HR 0.4 (95% CI, 0.14-1.3)] and neither was the case after additional adjustment for adjuvant systemic therapy. Our practice-based study showed that the presence of sentinel node micrometastases in breast cancer patients has hardly any impact on breast cancer overall survival during the first years after diagnosis.

National equipment of intraoperatory gamma detection in the identification of sentinel lymph node in animal model

PURPOSE

To investigate a national equipment of intraoperatory gamma detection in the identification of sentinel lymph node.

METHODS

Thirty young adult male rats were used. After anesthetized, animals were divided into two groups of 15 animals each. Animals from group A received dextram 500 - Tc99 radiopharmaceutical and patent blue V and those from group B received only patent blue V to map the lymphatic drainage. The presence of radiation in the background area, in the area of injection and of the ex vivo sentinel lymph node of group A were measured. After the exeresis, each lymph node in group A and in group B was mixed forming a new random sequence and the radioactive reading of each lymph node was carried out, using both pieces of equipment.

RESULTS

The hottest sentinel lymph node was identified by the national equipment when radiation was measured in the area of limphatic drainage after the Dextran 500 was injected. Also, the ex vivo sentinel lymph node. The national equipment has also detected radiation in the lymph nodes that had not received radiopharmaceutical, leading to false positive, checked by the application of Mann-Whitney tests and Student's paired t-tests. The Cronbach alpha has shown high internal consistency of data 0.9416.

CONCLUSIONS

The national equipment of intraoperatory gamma detection identifies the LS and showed false positives LS and needs improvement.

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 in endometrial cancer

The aim of this study was to evaluate the possibility of identifying the sentinel lymph node and involvement of neoplastic cells in patients with endometrial carcinoma limited to the uterus, and also its correlation with the conditions of other pelvic and para-aortic lymph nodes. Forty patients with endometrial carcinoma, clinical staging I and II, were submitted to complete surgical staging through laparotomy, as recommended by FIGO in 1988. The sentinel node was investigated using patent blue dye in the myometrial subserosa. The sentinel node was excised and submitted to frozen section examination of specimen, stained with hematoxylin and eosin (H&E). Afterward, selective bilateral para-aortic and pelvic lymphadenectomy, total hysterectomy with bilateral salpingo-oophorectomy were performed. The lymph nodes excised were examined by means of paraffin-embedded slices stained with H&E and of imunohistochemistry with antikeratin antibody AE1/AE3. The sentinel lymph node was identified in 77.5% of patients (31/40), and 16.1% (5/31) presented neoplastic involvement in the node. In 25 cases of negative sentinel node, 96% (24/25) had no neoplastic involvement, and 4% (1/25) had other lymph node affected (false negative). In nine cases with no sentinel node identified, 55.5% (5/9) had lymph node involvement. The results of this study allow us to conclude that it is possible to identify the sentinel node using the methods described, and the pathologic examination significantly represents the same conditions of other pelvic and para-aortic lymph nodes.

Current management of the axilla in patients with clinically node-negative breast cancer: a nationwide survey of United Kingdom breast surgeons

Background

Precise knowledge of axillary lymph node status is essential in the treatment of operable carcinoma of the breast. For many years, axillary nodal clearance (ANC) has been an integral part of the conventional management of early-stage breast cancer. During the last few decades the trend of these surgical procedures has been one of decreasing invasiveness in order to try and achieve a much lower level of morbidity. To help reach this improved level of treatment the concept of the sentinel lymph node (SLN) was utilized. Recent studies have shown that SNB can provide an accurate assessment of the axillary nodal status in clinically node negative patients, negating the need to remove the majority of the axillary contents and thus reducing morbidity. A recent meta-analysis of all the literature to date appears to reveal that the dual technique (blue dye and technetium-labelled sulfur) is the gold-standard for successful identification of the SLN in the context of early-stage breast cancer. We aim to highlight the on-going wide range of differing methods employed, and compare this to the gold-standard recommended guidelines.

Methods

A questionnaire was devised to provide a snapshot overview of the current management of the axilla in patients with clinically node-negative T1 invasive breast cancer amongst UK beast surgeons in August 2006.

Results

Of the 271 UK surgeons, 74 (27.3%) performed ANC as the initial management of the axilla in patients with clinically node negative T1 invasive breast cancer, 56 (20.7%) used axillary node sampling (not directed by sentinel node mapping) and a total of 141 (52.0%) used the technique of SNB, of which 50 (18.5%) used blue dye alone and 91 (33.6%) used a combination of blue dye and radioisotope.

Conclusion

Despite the obvious advantages, our survey has revealed that the procedure is only used by 52% of British breast surgeons in this subgroup of patients (clinically node negative, tumour equal of smaller than 2 cm) most of whom have no disease within the axilla. The reasons for this include limited hospital resources and lack of surgeons training and accreditation and ARSAC license (nuclear medicine license).

Lymphedema following axillary lymph node dissection for breast cancer

Lymphedema is a relatively common, potentially serious and unpleased complication after axillary lymph node dissection (ALND) for breast cancer. It may be associated with functional, esthetic, and psychological problems, thereby affecting the quality-of-life (QOL) of breast cancer survivors. Objective measurements (preferentially by measuring arm volumes or arm circumferences at predetermined sites) are required to identify lymphedema, but also subjective assessment can help to determine the clinical significance of any volume/circumference differences. Lymphedema per se predisposes to the development of other secondary complications, such as infections of the upper limb, psychological sequelae, development of malignant tumors, alterations of the QOL, etc. The risk of lymphedema is associated with the extent of ALND and the addition of axillary radiation therapy. Treatment involves the application of therapeutic measures of the so-called decongestive lymphatic therapy. Prevention is of key importance to avoid lymphedema formation. The application of the sentinel lymph node biopsy in the management of breast cancer has been associated with a reduced incidence of lymphedema formation.

Is Routine Sentinel Lymph Node Biopsy Indicated in Women Undergoing Contralateral Prophylactic Mastectomy? Magee-Womens Hospital Experience

INTRODUCTION

The routine use of sentinel node biopsy (SLNB) at the time of prophylactic mastectomy remains controversial. This retrospective study was undertaken to determine if SLNB is justified in patients undergoing CPM.

METHODS

Between 1999 and 2004, 155 patients underwent contralateral prophylactic mastectomy (CPM) at the Magee-Womens Hospital of University of Pittsburgh Medical Center. Eighty patients (51.6%) had SLNB performed at the time of CPM. The therapeutic mastectomy and the CPM specimens were evaluated for histopathology. Goldflam's classification was used to determine the risk of malignancy in the CPM specimens.

RESULTS

Pathology in the therapeutic mastectomy specimens included 105 (68%) invasive carcinomas and 50 (32%) in-situ carcinomas. Multicentricity and/or multifocality were reported in 49.7%, and 70% were estrogen receptor positive. Two invasive breast cancers and three cases of DCIS were diagnosed in 155 CPM specimens (n = 5, 3.2%). The median number of SLN identified was 2 (range 1-6) from the CPM axilla. Two patients had positive SLNB for metastatic carcinoma (n = 2/80, 2.5%) with no primary tumor identified in the prophylactic mastectomy specimen. In both patients the therapeutic mastectomy was for recurrent invasive carcinoma in patients with a prior history of axillary node dissection. Occult carcinoma was found in five prophylactic mastectomy specimens: two invasive and three DCIS. Only 1 out of the 75 patients not undergoing SLNB at the time of their initial surgery would have required axillary staging for a previously undiagnosed invasive cancer in the CPM specimen on final pathology. Of all 155 patients undergoing CPM, only 4 (2.5%) had identified final pathologic findings where axillary staging with SLNB was beneficial. There was no evidence of arm lymphedema in any patient who had undergone CPM and SLNB at a median follow-up of 24 months.

CONCLUSION

Although SLNB is a minimally invasive method of axillary staging, this retrospective study does not support its routine use in patients undergoing CPM.

Locoregional therapy of breast cancer: maximizing control, minimizing morbidity

The goal of locoregional therapy in breast cancer has remained unchanged for a century: the eradication of all malignant cells from the breast and draining lymph nodes, hopefully prior to them having spread to distant organs. However, how we accomplish this goal has changed dramatically over this time period and our success in achieving this goal has been greatly enhanced by improvements in breast imaging and systemic therapies. The therapeutic importance of surgery and radiation has been underestimated in recent years and is thought to have minimal impact on long-term outcome. More recent data have reputed this contention and the relationship between local control and survival in breast cancer is becoming increasingly apparent. This article will review the importance of attaining optimum local control with minimum morbidity and examine where the future of locoregional therapy of breast cancer may lie.

Lymphatic mapping and sentinel lymph node biopsy in early-stage breast carcinoma: a metaanalysis

BACKGROUND

Lymphatic mapping with sentinel lymph node biopsy has the potential for reducing the morbidity associated with breast carcinoma staging. It has become a widely used technology despite limited data from controlled clinical trials.

METHODS

A systematic review of the world's literature of sentinel lymph node (SLN) biopsy in patients with early-stage breast carcinoma was undertaken by using electronic and hand searching techniques. Only studies that incorporated full axillary lymph node dissection (ALND), regardless of SLN results, were included. Individual study results along with weighted summary measures were estimated using the Mantel-Haenszel method. The correlations of outcomes with the study size, the proportion of positive lymph nodes, the technique used, and the study quality were evaluated.

RESULTS

Between 1970 and 2003, 69 trials were reported that met eligibility criteria. Of the 8059 patients who were studied, 7765 patients (96%) had successfully mapped SLNs. The proportion of patients who had successfully mapped SLNs ranged from 41% to 100%, with > 50% of studies reporting a rate < 90%. Lymph node involvement was found in 3132 patients (42%) and ranged from 17% to 74% across studies. The false-negative rate (FNR) ranged from 0% to 29%, averaging 7.3% overall. Eleven trials (15.9%) reported an FNR of 0.0, whereas 26 trials (37.7%) reported an FNR > 10%. Significant inverse correlations were observed between the FNR and both the number of patients studied (r = - 0.42; P < 0.01) and the proportion of patients who had successfully mapped SLNs nodes (r = - 0.32; P = 0.009).

CONCLUSIONS

Lymphatic mapping with SLN biopsy is used widely to reduce the complications associated with ALND in patients with low-risk breast carcinoma. This systematic review revealed a wide variation in test performance.

Is early dynamic lymphoscintigraphy for detection of sentinel lymph nodes always achievable in breast tumor?

OBJECTIVE

In this article, we will discuss the achievement of early dynamic lymphoscintigraphic protocol and compare detection of sentinel node between benign and malignant breast tumors, and whether pathologic factor is related or not.

METHODS

During a six-month period, consecutive fifty-nine patients were enrolled into our study. The average age of patients was 47.6 +/- 9.8 years and all of them were clinically suspected of having breast cancer. The average tumor was 2.1 +/- 1.1 cm in size. First, Tc-99m sulfur colloid was injected around corners of palpable mass or biopsy cavity by the hybrid injection method. Immediately thereafter, dynamic protocol of lymphoscintigraphy, with 10 sec per frame for 60 frames was performed by established simultaneous dual-head vertical angle imaging technique. And delayed two-hour image was also acquired. All patients underwent surgery sixteen to twenty hours later and had a final pathological diagnosis.

RESULTS

Among 59 patients, 14 of them were diagnosed with fibroadenoma and the other 45 cases with malignant conditions, infiltrating duct carcinoma mostly. The average age of the two groups was similar. From the summation image of dynamic study, identified axillary sentinel nodal activity was found as 80% in the group of benign breast tumor, but only 48% in the group of malignant breast tumor. In more than 88% of patients, sentinel lymph node was detectable on the delayed two-hour image between the two groups.

CONCLUSIONS

Early dynamic protocol of pre-operative lymphoscintigraphy is helpful to clarify the relationship between the local lymphatic drainage basin and sentinel nodal uptake. However, this short period of protocol is not always achievable to detect sentinel node, especially in the group with breast malignant lesions.

American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer

PURPOSE

To develop a guideline for the use of sentinel node biopsy (SNB) in early stage breast cancer.

METHODS

An American Society of Clinical Oncology (ASCO) Expert Panel conducted a systematic review of the literature available through February 2004 on the use of SNB in early-stage breast cancer. The panel developed a guideline for clinicians and patients regarding the appropriate use of a sentinel lymph node identification and sampling procedure from hereon referred to as SNB. The guideline was reviewed by selected experts in the field and the ASCO Health Services Committee and was approved by the ASCO Board of Directors.

RESULTS

The literature review identified one published prospective randomized controlled trial in which SNB was compared with axillary lymph node dissection (ALND), four limited meta-analyses, and 69 published single-institution and multicenter trials in which the test performance of SNB was evaluated with respect to the results of ALND (completion axillary dissection). There are currently no data on the effect of SLN biopsy on long-term survival of patients with breast cancer. However, a review of the available evidence demonstrates that, when performed by experienced clinicians, SNB appears to be a safe and acceptably accurate method for identifying early-stage breast cancer without involvement of the axillary lymph nodes.

CONCLUSION

SNB is an appropriate initial alternative to routine staging ALND for patients with early-stage breast cancer with clinically negative axillary nodes. Completion ALND remains standard treatment for patients with axillary metastases identified on SNB. Appropriately identified patients with negative results of SNB, when done under the direction of an experienced surgeon, need not have completion ALND. Isolated cancer cells detected by pathologic examination of the SLN with use of specialized techniques are currently of unknown clinical significance. Although such specialized techniques are often used, they are not a required part of SLN evaluation for breast cancer at this time. Data suggest that SNB is associated with less morbidity than ALND, but the comparative effects of these two approaches on tumor recurrence or patient survival are unknown.

Impact of axillary nodal metastases on lymphatic mapping and sentinel lymph node identification rate in patients with early stage breast cancer

PURPOSE

The aim of this study was to define the impact of the presence of axillary nodal metastases on lymphatic mapping and sentinel lymph node (SLN) identification rate in patients with early breast cancer.

METHODS

Two hundred and forty-six lymphatic mapping procedures were performed with both labelled nanocolloid and blue dye, followed by SLN biopsy and/or complete axillary dissection. The following parameters were recorded: patient's age, tumour laterality and location, tumour size, tumour histology, tumour stage, tumour grade, lymphovascular invasion, radiotracer injection site (subdermal-peritumoural/peri-areolar), SLN visualisation at lymphoscintigraphy, SLN metastases (presence/absence, size) and other axillary metastases (presence/absence, number). Discriminant analysis was used to analyse the data.

RESULTS

SLNs were identified by labelled nanocolloid alone in 94.7% of tumours, by blue dye alone in 93.5% and by the combined technique in 99.2%. Discriminant analysis showed the gamma probe SLN identification rate to be significantly limited by the presence of axillary nodal metastases. In particular, the size of SLN metastases and the number of other axillary metastases were the most important variables in reducing the gamma probe SLN identification rate (p = 0.004 and p = 0.002, respectively). On the other hand, high tumour grade was the only parameter limiting the blue dye SLN identification rate.

CONCLUSION

The accuracy of lymphatic mapping with labelled nanocolloid is limited by the presence of axillary nodal metastases, and particularly by the degree of SLN tumoural invasion and the presence and number of other axillary nodal metastases. Neither of these elements seems to interfere with the blue dye identification rate. The combination of the two tracers maximises the SLN identification rate.

Accuracy of intraoperative imprint cytology for sentinel lymph node evaluation in the treatment of breast carcinoma

BACKGROUND

The current report provides results from a large retrospective analysis of intraoperative imprint cytology performed on axillary sentinel lymph nodes (IIC(N)) removed over the course of 2137 breast surgeries (4905 lymph nodes). It is hoped that these results may serve as benchmarks for those interested in using this technique.

METHODS

The current study included 2078 patients with T1-2 invasive breast carcinoma who underwent sentinel lymph node biopsy (SLNB) and IIC(N). Lymph nodes were bivalved, imprinted, stained with Diff-Quik (Baxter Diagnostics, McGaw Park, IL), and reviewed by a cytopathologist. A positive intraoperative diagnosis led to immediate complete axillary lymph node dissection (CALND). On final pathology, lymph nodes found to be negative on hematoxylin and eosin staining were submitted for cytokeratin staining.

RESULTS

Of the 2137 cases for which SLNB was performed, 673 were found to have positive lymph node status on final pathology. Of these 673 cases, 359 were identified by IIC(N), resulting in a sensitivity rate of 53.3%. The specificity and overall accuracy rates for this technique were 99.5% and 85.0%, respectively. In IDC cases, IIC(N) had a sensitivity rate of 55.5%, compared with 38.7% in ILC cases. Based on these results, the reoperative CALND rate was calculated to be approximately 14.7%, with 54.5% of these reoperative procedures being performed for cases in which lymph nodes positive only for micrometastases were found. Macrometastasis-positive lymph nodes that went undetected by IIC(N) were present in only 154 of the 2137 cases examined (7.2%).

CONCLUSIONS

IIC(N) accurately predicts final lymph node status in 85.0% of patients. Although the accuracy of this technique varies with tumor size and type, IIC(N) remains a time-efficient and cost-effective adjunct to SLNB.

Sentinel lymph node biopsy after neoadjuvant chemotherapy

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.

Clinical Practice Guidelines for the Use of Axillary Sentinel Lymph Node Biopsy in Carcinoma of the Breast: Current Update

Axillary sentinel lymph node biopsy (SLNB) has been adopted as a suitable alternative to traditional level I and II axillary dissection in the management of clinically node-negative (N0) breast cancers. There are two current techniques used to identify the sentinel node(s): radiopharmaceutical, technetium sulfur colloid, and isosulfan blue dye (used in the United States) and technetium-labeled albumin and patent blue dye (used in Europe). (The labeled albumin is not U.S. Food and Drug Administration [FDA] approved in the United States.) SLNB to replace axillary dissection should only be performed by surgeons and patient management teams with appropriate training and experience. Although both radiocolloid and blue dye are used together by most surgeons, and training should be in both techniques, some experienced surgeons use one or the other almost exclusively. In addition, surgical pathologists must recognize the need to examine these small specimens with great care, using a generally adopted protocol. Imprint cytology or frozen sections may be used, followed by additional sections for light microscopy. Immunochemical staining with cytokeratin or other techniques to identify "submicroscopic" metastasis is often used, but the results should not be used to influence clinical decisions with respect to adjuvant therapy. "Failed" SLNB implies the surgeon's failure to identify the sentinel nodes, in which case a complete dissection is performed. A "false-negative" SLNB implies the finding of metastasis in the excised sentinel nodes by light microscopy after a negative frozen section examination. Whether a false-negative SLNB mandates completion axillary dissection is controversial, with clinical trials currently under way to answer this question. Although SLNB was initiated to accompany breast-conserving treatment, it is equally useful in patients undergoing mastectomy. It is more difficult to perform with mastectomy. When using blue dye only, SLNB may require a separate incision because of time constraints between injection and identification of the blue-stained nodes; radiocolloid usually does not. Completion axillary dissection after false-negative SLNB is more difficult after mastectomy. SLNB is a useful procedure that may save 70% of women with clinically negative (N0) axillae and all of those with pathologically negative axillae from the morbidity of complete axillary dissection. Ideally the sentinel nodes should be able to identified in more than 95% of patients, with a false-negative rate of less than 5%. Until these rates can be achieved consistently, however, surgeons should not abandon traditional axillary dissection.

An Argument against Routine Sentinel Node Mapping for DCIS

Indications for sentinel lymph node mapping (SLNM) for patients with ductal carcinoma in situ (DCIS) of the breast are controversial. We reviewed our institutional experience with SLNM for DCIS to determine the node positive rate and clarify indications for nodal staging in patients with DCIS. Since 1998 we have used SLNM to stage breast cancer patients using both blue dye and radiocolloid. In DCIS patients, SLNM has been reserved for patients considered at high risk for harboring coexistent invasive carcinoma or treated by mastectomy. All sentinel nodes were evaluated with serial sectioning, hematoxylin and eosin staining, and immunohistochemical evaluation for cytokeratins. We identified 44 patients with 46 cases of DCIS (two patients with bilateral disease). SLNM identified at least one sentinel node in all cases. In all cases, the sentinel node(s) were negative for axillary metastasis. We calculated the binomial probability of observing 0 of 46 cases as negative when the expected incidence according to published reports in the surgical literature was 13 per cent and found a P value of <0.01. Based on this case-series observation, we conclude SLNM should not be routinely performed for patients with DCIS. We now use SLNM only for DCIS patients treated by mastectomy.

Predictive Factors for the Status of Non-sentinel Nodes in Breast Cancer Patients with Tumor Positive Sentinel Nodes

In patients with tumor positive sentinel nodes, axillary lymph node dissection is routinely performed while a majority of these patients have no tumor involvement in the non-sentinel nodes. The authors tried to identify a subgroup of patients with a tumor positive sentinel node without non-sentinel node tumor involvement. In 135 consecutive patients with tumor positive sentinel nodes and axillary lymph node dissection performed, the incidence of non-sentinel node involvement according to tumor and sentinel node related factors was examined. The size of the sentinel node metastasis, size of primary tumor and number of tumor positive sentinel nodes were the three factors significantly predicting the status of the non-sentinel nodes. The size of the sentinel node metastasis was the strongest predictive factor (P < 0.0001). In a subgroup of 41 patients with a stage T1 tumor and micrometastatic involvement in the sentinel node only 2 patients (5%) had non-sentinel node involvement. In patients with small primary tumors and micrometastatic involvement of the sentinel nodes, the chance of non-sentinel node involvement is small but cannot be discarded. Because the clinical relevance of micrometastases in lymph nodes is still unclear it is not advisable to omit axillary lymph node dissection even in these patients.

Emergence of sentinel node biopsy in breast cancer as standard-of-care in academic comprehensive cancer centers

BACKGROUND

Ongoing clinical trials are addressing the accuracy and safety of sentinel node biopsy (SNB) in the treatment of breast cancer; however, SNB is already increasingly being used in clinical practice. This study examined the extent and time trends of the use of SNB in stage I and II breast cancer patients.

METHODS

Clinical data were collected from stage I and II (tumor size < or =5.0 cm) breast cancer patients (n = 3003) who were treated at five comprehensive cancer centers between July 1, 1997, and December 31, 2000. Axillary surgery was classified as SNB alone, SNB + axillary node dissection (AND), AND alone, or none. Patterns of use of axillary surgery were summarized as the percentage of patients receiving each surgery type. The statistical significance of time trends for the use of SNB alone was analyzed by logistic regression models. All statistical tests were two-sided.

RESULTS

Overall, SNB alone was used in 13% of patients, SNB + AND in 22%, AND alone in 59%, and no axillary surgery in 6%. Use of SNB alone was statistically significantly associated with breast-conserving surgery of both smaller (< or =2 cm) and larger tumors (2-5 cm) (P<.001 for both associations). For stage I cancer patients treated with breast-conserving surgery (n = 1763), use of SNB increased statistically significantly over the study period, from 8% in 1997 to 9%, 14%, 15%, 22%, 42%, and 58% for the next six consecutive 6-month time intervals, respectively. After controlling for center, age, and comorbidity, the odds ratio for the use of SNB alone was 2.30 (95% confidence interval = 1.88 to 2.82) for each 6-month interval (P<.001).

CONCLUSIONS

Widespread use of SNB outside the clinical trial setting suggests that oncologists at cancer centers in our study have accepted SNB as standard-of-care for the treatment of breast cancer. This acceptance, if it occurs in other cancer centers and community practice, may affect accrual and generalizability of ongoing clinical trials of SNB.

Pre-operative lymphatic mapping and intra-operative sentinel lymph node detection in early stage endometrial cancer

Lymphatic mapping and sentinel lymph node (SLN) biopsy are becoming increasingly useful for the identification of tumour lymphatic spread in a wide variety of neoplasms, such as breast cancer and melanoma, reducing unnecessary radical lymph node resection. The aim of our study was to determine the feasibility of lymphatic mapping with both labelled colloid and patent blue violet in patients with early stage endometrial cancer. Sixteen consecutive patients with endometrial cancer, stage International Federation of Gynecology and Obstetrics (FIGO Ib), were included in the study. Lymphoscintigraphy and laparoscopically assisted intra-operative SLN detection were performed in all patients. In addition, to verify the prognostic role of this method, 12 of 16 patients were followed up for a period of at least 1 year. In 15 of 16 patients, 24 SLNs (all internal iliac lymph nodes) were detected at lymphoscintigraphy (six monolateral and nine bilateral). At histological analysis, three of the 24 were positive for micrometastases, whereas the remaining 21 were negative. No other surgically dissected lymph nodes presented metastases. At 1 year of follow-up, none of the 12 patients presented relapse of their disease. In conclusion, in endometrial cancer, both pre-operative lymphoscintigraphy and intra-operative gamma-probe detection of SLNs represent promising tools for the visualization of SLNs. The status of the latter may yield a correct representation of pelvic lymph node involvement, providing important information for further treatment.

Sentinel lymph node biopsy in patients with early-stage breast cancer: status of the National Clinical Trials

Just as the NSABP B-04 and B-06 trials have advanced our understanding of the survival impact of surgical therapy of breast cancer over the past 25 years, the current international clinical trials underway through NSABP and ACOSOG offer similar hope for improved treatment of the patient with breast carcinoma. Information from these three trials will offer: (1) survival data on sentinel node negative patients who undergo no further axillary therapy; (2) prognostic information on the importance of IHC positive sentinel lymph nodes and ICC positive bone marrow, which will lead to further studies on selective distribution of adjuvant chemo-hormonal therapy; and (3) survival data on sentinel node-positive patients who undergo no further axillary therapy. In keeping with past successes, the continued participation of surgeons in clinical trials contributes to the advancement of evidence-based therapeutic strategies for patients diagnosed with breast cancer.

Lymphatic mapping and sentinel lymphadenectomy after preoperative therapy for stage II and III breast cancer

BACKGROUND

We evaluated the accuracy of sentinel lymph node dissection (SLND) in patients with stage II and III breast cancer who had received preoperative therapy.

METHODS

A prospective clinical trial evaluated 122 patients who had SLND followed by axillary lymph node dissection. Thirty-two women had stage II or III breast cancer and received preoperative doxorubicin-based chemotherapy or paclitaxel and radiotherapy.

RESULTS

A sentinel lymph node (SLN) was identified in 31 (97%) of 32 patients. The SLN predicted the status of the axillary nodes in 30 (97%) of 31 patients. Eighteen (58%) of 31 had metastases in the SLN. Eighteen of 19 patients with axillary metastases had a tumor-positive SLN (sensitivity, 95%; false-negative rate, 5%). Eight (44%) of 18 women with metastases in the SLN also had metastases in 1 or more nonsentinel nodes.

CONCLUSIONS

In this relatively small study, the accuracy of SLND in women with stage II or III breast cancer treated with preoperative therapy was similar to that achieved in early-stage breast cancer. If these results are confirmed in a larger cohort, it may be feasible to substitute SLND for routine axillary lymph node dissection in this population. This approach could reduce the morbidity of surgical therapy while preserving the accuracy of axillary staging and maintaining regional control in this high-risk population.

Lymphatic mapping in early stage breast cancer: comparison between periareolar and subdermal injection

The combination of preoperative lymphatic mapping with intra-operative probe detection is becoming the standard procedure for identifying tumour lymphatic spread at the time of initial treatment in breast cancer. There are a number of identification techniques for sentinel lymph nodes, but the concordance of the results of a sentinel lymph node biopsy with axillary lymph node dissection did not vary significantly among them. Periareolar (p.a.) injection of tracer is a new procedure specifically studied to overcome some limitations of other techniques; in two groups of patients with early breast cancer we compared the periareolar with the subdermal technique. One hundred and fifty biopsy proven breast cancer patients were consecutively enrolled in this study. This population was divided into two groups: (1) group A, including 100 cancers; lymphatic mapping was performed by s.d. injection of both blue dye and radiotracer; and (2) group B, including 50 cancers; lymphatic mapping was performed with a combination of blue dye injected p.a. and radiotracer injected s.d. For group A, with both techniques we identified one or more SLNs in 100/100 tumours; blue dye detected the SLNs in 99/100 cancers (99%), lymphoscintigraphy in 93/100 cancers (93%). The concordance rate was 92%. For group B, with both techniques we identified one or more SLNs in 49/50 cancers (98%); blue dye detected the SLNs in 48/50, lymphoscintigraphy in 46/50 cancers (92%). The concordance rate was 92%. In the present study p.a. and s.d. injection of blue dye give similar and comparable results. The periareolar technique is simpler and has several advantages over the subdermal technique.

Patterns of recurrence after sentinel lymph node biopsy for breast cancer

BACKGROUND

Sentinel lymph node biopsy (SLNB) is gaining acceptance as an alternative to axillary lymph node dissection. The purpose of this study was to determine the frequency and pattern of disease recurrence after SLNB.

METHODS

Two-hundred twenty-two consecutive patients undergoing SLNB from April 6, 1998, to October 27, 1999, and who were >or=24 months out from their procedure were identified from a prospectively maintained database. Retrospective chart review and data analysis were performed to identify variables predictive of recurrence.

RESULTS

The median patient follow-up was 32 months (range, 24-43 months). A total of 159 patients (72%) were sentinel lymph node (SLN) negative and had no further axillary treatment. Five of these patients (3.1%) developed a recurrence (one local and four distant), with no isolated regional (axillary) recurrences. Sixty-three patients (28%) were SLN positive and underwent a subsequent axillary lymph node dissection. Six of these patients (9.5%) developed a recurrence (three local, one regional, and two distant). Pathologic tumor size (P <.001), lymphovascular invasion (P =.018), and a positive SLN (P =.048) were all statistically significantly associated with disease recurrence.

CONCLUSIONS

With a minimum follow-up of 24 months, patients with a negative SLN and no subsequent axillary treatment demonstrate a low frequency of disease recurrence. This supports the use of SLNB as the sole axillary staging procedure in SLN-negative patients.

Failure to harvest sentinel lymph nodes identified by preoperative lymphoscintigraphy in breast cancer patients

Selective sentinel lymphadenectomy dissection has been demonstrated to have high predictive value for axillary staging in breast cancer patients. Preoperative lymphoscintigraphy can localize and facilitate the harvesting of sentinel lymph nodes (SNLs) with a high success rate. The failure rate of selective sentinel lymphadenectomy ranges between 2% and 8%. Details of the failures were seldom addressed. This study analyzes the causes of failure to harvest SLNs in spite of positive preoperative lymphoscintigraphy. From November 1997 through November 2000, 201 female patients with histologically confirmed and operable breast carcinoma underwent selective sentinel lymphadenectomy at the University of California, San Francisco (UCSF) Carol Franc Buck Breast Care Center. Among these patients, 183 (91%) received preoperative lymphoscintigraphy to identify axillary lymph nodes. The causes of failure to harvest the SLNs in this group of patients despite successful preoperative lymphoscintigraphy were analyzed. In our series, the failure rate of SLN identification was 7.0% (14/201). The failure rate for our first year was 11.1% (6/54), second year 9.1% (7/77), and third year 1.4% (1/70). The incidence of failure in spite of positive preoperative lymphoscintigraphy was 3.5% (6/170). The shine-through effect of the primary injection site and failure to visualize a blue lymph node were the main reasons for technical failure. Most of these cases occurred during our learning curve of the procedure. The possibility of failure to get the SLN should be explained to patients before surgery. Axillary lymph node dissection (ALND) should be done if selective SLN dissection is not successful.