The Role of Selective Lymphadenectomy in Breast Cancer

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.

Does Failure to Visualize a Sentinel Node on Preoperative Lymphoscintigraphy Predict a Greater Likelihood of Axillary Lymph Node Positivity?

BACKGROUND

Sentinel lymph node (SLN) mapping has become the standard of care for axillary staging in women with early-stage breast cancer. The purpose of the study was to investigate the hypothesis that nonvisualization of SLN on lymphoscintigraphy (LSG) predicts a subset of patients at risk of having a substantial burden of axillary tumor as evidenced by higher rate of lymph node involvement.

STUDY DESIGN

We retrospectively reviewed the records of 1,500 patients who underwent dual-tracer SLN mapping for breast cancer between 1999 and 2004. LSG were reported as negative or positive.

RESULTS

Ninety-one percent had axillary SLN(s) identified on LSG imaging. In 133 of 134 (99.3%) patients with a negative LSG, SLN(s) was identified intraoperatively either by blue dye or hand-held gamma detection. SLN was positive in 28.4% of LSG nonvisualized group and was positive in 29.1% of LSG visualized group (p>0.05). A significantly higher percentage of women older than 50 years of age had nonvisualization of SLN (p<0.0001). Body mass index (calculated as kg/m2) was >30 in 42.5% of LSG nonvisualized group and in 26.3% in LSG visualized group (p<0.0001).

CONCLUSIONS

Failure to demonstrate axillary uptake by LSG appears to be related to technical factors and patient-related factors, such as body mass index and older age, but does not adversely affect SLN identification. The equivalent rate of positive SLNs in patients with a positive or negative LSG supports the null hypothesis that "failure to visualize" on LSG does not identify a subset of patients at higher risk of being axillary lymph node positive.

Increased false negative rates in sentinel lymph node biopsies in patients with multi-focal breast cancer

There are few data about the reliability of sentinel node biopsy in patients with multi-focal breast cancer. The aim of this study was to determine the factors affecting the identification and accuracy of the sentinel node, comparing multifocality with other variables, using peritumoral isosulfan blue dye injection technique alone. Between 1998 and 2001, 122 patients with clinically negative nodes from a single institute were eligible for sentinel lymph node biopsies (SLNBs). All patients underwent conventional axillary lymph node dissection (ALND). SLNs were identified in 111 of 122 (91%) cases, and analyzed by hematoxylin and eosin. Twenty-one patients with multifocal breast cancer were determined by clinical or pathologic examination (gross or microscopic). Success in locating the sentinel node was unrelated to patient's age, tumor size, type, location, histological or nuclear grade, multifocality, or a previous surgical biopsy. SLNBs accurately predicted the status of the axilla in 104 of the 111 patients (93.7%), while 18 of the 21 patients with multi-focal breast cancer (85.7%) had successful lymphatic mapping. The false negative (FN) rate was 11.3% among patients with successful SLNBs. Multifocality and tumor size (>2 cm) were associated significantly with decreased accuracy and increased FN rates (for multifocality, p = 0.007 and p = 0.006, and for tumor size >2 cm, p = 0.04 and p = 0.05, respectively) in binary logistic regression analysis, whereas excisional biopsy, tumor location in the upper outer quadrant and patient's age did not significantly affect the accuracy and FN rates in univariate analysis. These results suggest sentinel lymph node biopsy using peritumoral isosulfan blue injection method alone can accurately predict axillary status in patients with clinically negative nodes, but patients with multi-focal disease and large tumor size may not be ideal candidates.

Educating patients on sentinel lymph node dissection for breast cancer

PURPOSE

This article reviews the current literature on lymphatic mapping and sentinel lymph node dissection (SLND) for breast cancer and presents educational information for patients who are considering undergoing this procedure.

OVERVIEW

Lymphatic mapping with SLND has been tested widely in patients with breast cancer, primarily in the context of clinical trials. Research studies have found a high degree of accuracy, with the sentinel lymph node (SLN) predicting the status of the axillary node basin. The ability of the surgeon to identify the SLN and the accuracy of the technique correlate with the number of procedures conducted. With the increase in the number of patients having lymphatic mapping and SLND for breast cancer who may not be part of a clinical trial, there is a need for educational materials to help clinicians teach patients about the procedure.

CLINICAL IMPLICATIONS

Because of the complexity of the information, patients need both written and verbal information to decide whether to undergo an SLND. In the setting of a clinical trial, patient education materials add to the informed consent document. As the use of SLND for breast cancer becomes more common, the need for clear, concise, informative patient education materials is even more imperative.

The role of sentinel lymph node biopsy in women undergoing prophylactic mastectomy

BACKGROUND

Indications for prophylactic mastectomy (PM) range from LCIS to BRCA 1-2 positive, cosmesis, and cancer phobia. Occult cancers have been found in up to 5% of PM cases. Consequently, consideration must be given to the role of sentinel lymph node (SLN) biopsy as a diagnostic procedure in these patients as PM excludes the subsequent option of SLN biopsy.

METHODS

From April 1994 to November 1999, all patients undergoing PM had SLN biopsy after four quadrant periareolar injections of radiocolloid (450 mci) and blue dye (5 cc). All patients were prospectively accrued to the computerized database of breast patients. The SLN were all evaluated with hematoxylin and eosin (H&E) as well as CAM5.2 cytokeratin immunohistochemical (CK-IHC) stains.

RESULTS

Over a 67-month period, 1,356 patients were mapped; 57 patients underwent PM in which 148 nodes (2.6 nodes per patient) were evaluated. Nodes were examined by routine H&E and CK-IHC staining. Two patients, neither of whom was found to have a cancer in the prophylactic mastectomy breast, were found to have a positive SLN by CK-IHC staining. Infiltrating carcinoma was discovered within the PM breasts of 2 additional patients. Sentinel lymph node biopsy was negative for malignancy by H&E as well as CK-IHC stains. No lymphedema has been detected in PM patients.

CONCLUSIONS

Sentinel node biopsy has been shown to be an accurate and minimally invasive method of evaluating the lymphatic basin. This study shows that the absence of known disease within the breast does not preclude the presence of occult cancer or metastatic nodal disease. Four patients (7%) had a significant change in their surgical management as a direct result of sentinel lymph node biopsy. Two patients were spared the complications of a complete axillary node dissection. This minimally invasive procedure accurately evaluated the known disease status and provided new diagnostic information. Most important, once a mastectomy is performed, the opportunity for SLN biopsy is lost should a cancer be found within the breast specimen.

Sentinel Node Biopsy in Breast Cancer: An Overview

The most powerful predictor of survival in breast cancer is the presence or absence of lymph node metastases. Lymphatic mapping and sentinel node biopsy is a new technique that provides more accurate nodal staging compared to routine histology for women with breast cancer without the morbidity of a complete lymph node dissection. Sentinel lymph node biopsy is a more conservative approach to the axilla that requires close collaboration between the surgical team, nuclear medicine, and pathology. National trials are investigating the clinical relevance of the upstaging that occurs with a more intense examination of the sentinel node. Since complaints due to the axillary node dissection are a common occurrence after definitive breast cancer surgery, if the side effects of the level I and II node dissection can be avoided, particularly in the node-negative population, a major advance in treating this disease will be made.

Lymphatic mapping in breast cancer

The most accurate predictor of survival in breast cancer is the presence or absence of lymph node metastases. Lymphatic mapping with sentinel node biopsy is a new technique that provides more accurate nodal staging compared with routine histology for women with breast cancer, but without the morbidity of a complete lymph node dissection. Sentinel lymph node (SLN) biopsy is a more conservative approach to the axilla that requires close collaboration from the surgical team, nuclear medicine, and pathology. National trials are investigating the clinical relevance of the upstaging that occurs with a more intense examination of the SLN. As is the case with breast preservation as a viable alternative to mastectomy for the definitive treatment of the primary node, selective lymphadenectomy has the ability to decrease morbidity without compromising patient care.

Sentinel node biopsy in 70 unselected patients with breast cancer: increased feasibility by using 10 mCi radiocolloid in combination with a blue dye tracer

AIMS

Lymphatic mapping and sentinel node (SN) biopsy in breast cancer contribute to more accurate staging, while using less invasive techniques. The aim of this study is to improve the accuracy and feasibility of this concept, increasing the identification rate of the SN, by using an alternative technique.

METHODS

In 70 unselected patients with primary breast cancer, of whom 51% had undergone previous excisional biopsy, lymphatic mapping was performed using 10 mCi (370 MBq) 99mTc-nanocolloid peritumorally, combined with an intradermal blue dye tracer.

RESULTS

Lymphoscintigraphy showed one or more SN in 97% and harvest of the SN was possible in all patients (identification rate 100%). Axillary metastases were found in 39%. Sensitivity of the SN biopsy was high, both after primary surgery (93%) and after previous surgery (100%). Internal mammary lymph node biopsy following lymphatic mapping was attempted in all 24 patients (34%) with parasternal SN visible on the scan and was successful in 15 patients, revealing metastatic involvement in five patients.

CONCLUSIONS

We conclude that SN biopsy, using a higher dose of peritumoral radiocolloid tracer, combined with intradermal blue dye tracer, increases feasibility in breast cancer, making this concept applicable for all patients with primary breast cancer.

Controversies in Breast Cancer

BACKGROUND: A large number of controversies about the management of breast cancer produce uncertainties for patients and physicians alike. In addition, questions are constantly raised about the true value of new approaches or treatments. METHODS: The authors have conducted a critical review of the literature on several of these issues, and they present a balanced view that can be useful for clinical decision making. RESULTS: Although new staging systems for ductal carcinoma in situ have been proposed, a consensus has not yet been reached regarding the criteria to allow tumor excision alone. The extent of benefit of the main adjuvant therapies is becoming better established, and improvement in outcomes may accrue from dose-intensive treatments and autologous stem cell or hematopoietic growth factor support. CONCLUSIONS: Progress in breast cancer management continues to evolve. Several new approaches either reduce morbidity or improve outcomes.