Is the "10% rule" equally valid for all subsets of sentinel-node-positive breast cancer patients?

Assessment of Intraparenchymal Injection of 1% Patent Blue Dye in the Upper Outer Quadrant of the Breast to Identify Sentinel Lymph Node in Early Retro-Areolar Breast Cancer in Women: A Tertiary Centre Experience in Egypt

BACKGROUND

Sentinel lymph node biopsy is the gold standard for axillary assessment of patients with clinically node negative breast cancer. The current internationally accepted methods comprise of the usage of either a radioactive tracer, vital stains or the combination of both. However, in developing countries radioactive tracer is not widely used due to its high cost and limited availability. In addition, the classic retro-areolar blue dye injection has a high failure rate.

OBJECTIVE

Our study aimed to assess the efficacy of patent blue dye injection in the upper outer quadrant of the breast after validation by concurrent usage of radioactive nanocolloid, in comparison with the classic retro-areolar injection in identifying the sentinel node.

METHODS

A randomized control study involving 279 patients randomly divided into two groups. In group A lateral injection of 1% patent blue dye (validated by radioactive nanocolloid) was used, while subdermal patent blue dye injection in the retro-areolar space was performed in group B.

RESULTS

The new technique showed the promising results with lower failure rate (3.4%) in comparison with the classic retro-areolar patent blue injection (13.7%).

CONCLUSIONS

The lateral injection technique can be result in comparable results to the combination technique with the added benefit of being widely available and a cheaper option especially in developing countries.

The Guiding Significance of the Number of Positive Sentinel Lymph Nodes in Frozen Section for Intraoperative Axillary Dissection in Early Breast Cancer

Purpose

The results of large randomised trials have changed the treatment strategy of axillary lymph nodes. Axillary lymph node dissection (ALND) can be avoided in some patients with one to two sentinel lymph nodes (SLNs) metastasis based on final paraffin section (FPS) results which called into question the need for intraoperative frozen section (FS). This study aims to assess the guiding value of the number of positive SLN detected via FS for intraoperative ALND.

Patients and Methods

This study retrospectively analyzed data from 3303 patients with breast cancer who underwent SLN biopsy between 2015 and 2019. Combined with the FPS results, FS sensitivity, specificity, and false negative rate (FNR) were calculated and the difference in the number of positive SLNs between FS and FPS was analyzed.

Results

The overall FNR of FS was 23.21%, which was 76.47% in isolated tumor cells, 62.28% in micrometastasis, and 12.09% in macrometastatic disease. The size of SLN metastasis were significantly associated with a higher FNR (p<0.001). The accuracy rate of the number of positive SLNs detected via FS was 92.62%. Human epidermal growth factor receptor 2 (HER2) (p<0.03) and Ki67 (p<0.02) were significant factors affecting the accuracy rate.

Conclusion

FS is a effective method for SLN biopsy, ALND can be avoided in patients with one or two positive SLNs detected via FS.

Redefining Criteria to Ensure Adequate Sentinel Lymph Node Biopsy With Dual Tracer for Breast Cancer

Background

For sentinel lymph node biopsy (SLNB) in patients with breast cancer, the dual tracer of blue dye and radioisotope with the 10% rule that all nodes with radioactive count of 10% or more of the hottest node ex vivo should be removed is widely accepted. However, the cut-off point of radioactivity is being questioned for possibly excessive removal of negative nodes.

Methods

To compare different percentile rules and optimize the criteria for identifying SLNs, we established a database which prospectively collected the radioactivity, status of blue dye and the pathological results of each SLN in breast cancer patients who successfully underwent SLNB with a combination of methylene blue and radioisotope.

Results

A total of 2,529 SLNs from 1,039 patients were identified from August 2010 to August 2019. 16.4% (414/2,529) positive nodes were removed at a cost of 83.6% (2115/2,529) negative nodes removed excessively. Up to 17.9% (375/2,115) negative nodes were removed as radioactively hot nodes without blue staining. By gradually increasing the threshold by each 10%, the number of negative nodes identified reduced by 18.2% (385/2,115) with only three node-positive patients (1.0%) missed to be identified using the “40% + blue” rule. In patients with ≥ 2 SLNs removed, 12.3% (238/1,942) negative nodes avoided unnecessary removal with only 0.8% (2/239) positive patients missed with the “hottest two + blue” rule.

Conclusions

Our data indicated that the “40% + blue” rule or the “hottest two + blue” rule for SLNB with the dual tracer of blue dye and radioisotope may be considered as a potential alternative rule to minimize extra nodes resected. Nonetheless, it should be validated by prospective trials with long-term follow-up.

Diagnostic Accuracy of Magnetometer-Guided Sentinel Lymphadenectomy After Intraprostatic Injection of Superparamagnetic Iron Oxide Nanoparticles in Intermediate- and High-Risk Prostate Cancer Using the Magnetic Activity of Sentinel Nodes

Due to the high morbidity of extended lymph node dissection (eLND) and the low detection rate of limited lymph node dissection (LND), targeted sentinel lymph node dissection (sLND) was implemented in prostate cancer (PCa). Subsequently, nonradioactive sentinel lymph node (SLN) detection using magnetic resonance imaging (MRI) and a magnetometer after intraprostatic injection of superparamagnetic iron oxide nanoparticles (SPIONs) was successfully applied in PCa. To validate the reliability of this approach, considering the magnetic activity of SLNs or whether it is sufficient to dissect only the most active SLNs as shown in other tumor entities for radio-guided sLND, we analyzed magnetometer-guided sLND results in 218 high- and intermediate-risk PCa patients undergoing eLND as a reference standard. Using a sentinel nomogram to predict lymph node invasion (LNI), a risk range was determined up to which LND could be dispensed with or sLND only would be adequate. In total, 3,711 LNs were dissected, and 1,779 SLNs (median, 8) were identified. Among 78 LN-positive patients, there were 264 LN metastases (median, 2). sLND had a 96.79% diagnostic rate, 88.16% sensitivity, 98.59% specificity, 97.1% positive predictive value (PPV), 93.96% negative predictive value (NPV), 4.13% false-negative rate, and 0.92% additional diagnostic value (LN metastases only outside the eLND template). For intermediate-risk patients only, the sensitivity, specificity, PPV, and NPV were 100%. Magnetic activities of SLNs were heterogeneous regardless of metastasis. The accuracy of predicting the presence of metastases for each LN from the proportion of activity was only 57.3% in high- and 65% in intermediate-risk patients. Patients with LNI risk of less than 5% could have been spared LND, as no positive LNs were found in this group. For patients with an LNI risk between 5% and 20%, sLND-only would have been sufficient to detect almost all LN metastases; thus, eLND could be dispensed with in 36% of patients. In conclusion, SPION-guided sLND is a reliable alternative to eLND in intermediate-/high-risk PCa. No conclusions can be drawn from magnetic SLN activity regarding the presence of metastases. LND could be dispensed with according to a nomogram of predicted probability for LNI of 5% without losing any LN-positive patient. Patients with LNI risk between 5% and 20% could be spared eLND by performing sLND.

Management of the Axilla in Early Breast Cancer

Management of the axilla in early breast cancer patients has significantly evolved in the last several decades. With the arrival of the sentinel lymph node biopsy, surgical practice for axillary staging in patients with early breast cancer has become gradually less invasive and formal axillary lymph node dissection has been confined to selected patients. Over the last two decades, evidence from randomized clinical trials have allowed for the de-escalation of axillary surgery in the management of early stage breast cancer. Advances in the staging and treatment of the axilla constitute a key component in determining initial surgical planning and therapeutic strategies in the treatment of early breast cancer. This chapter provides an updated review on the history, evolution, and current practices for axillary management in patients with early breast cancer, with particular attention to the surgical recommendations and controversial scenarios of the evolving management of the axilla.

Troubleshooting Sentinel Lymph Node Biopsy in Breast Cancer Surgery

BACKGROUND

Performing a sentinel lymph node biopsy (SLNB) is the standard of care for axillary nodal staging in patients with invasive breast cancer and clinically negative nodes. The procedure provides valuable staging information with few complications when performed by experienced surgeons. However, variation in proficiency exists for this procedure, and a great amount of experience is required to master the technique, especially when faced with challenging cases. The purpose of this paper was to provide a troubleshooting guide for commonly encountered technical difficulties in SLNB, and offer potential solutions so that surgeons can improve their own technical performance from the collective knowledge of experienced specialists in the field.

METHODS

Information was obtained from a convenience sample of six experienced breast cancer specialists, each actively involved in training surgeons and residents/fellows in SLNB. Each surgeon responded to a structured interview in order to provide salient points of the SLNB procedure.

RESULTS

Four of the key opinion surgical specialists provided their perspective using technetium-99 m sulfur colloid, and two shared their experience using blue dye only. Distinct categories of commonly encountered problem scenarios were presented and agreed upon by the panel of surgeons. The responses to each of these scenarios were collected and organized into a troubleshooting guide.

DISCUSSION

We present a compilation of 'tips' organized as a troubleshooting guide to be used to guide surgeons of varying levels of experience when encountering technical difficulties with SLNB.

Discordance between number of scintigraphic and perioperatively identified sentinel lymph nodes and axillary tumour recurrence

BACKGROUND

In breast cancer, sentinel node biopsy is considered the standard method to assess the lymph node status of the axilla. Preoperative identification of sentinel lymph nodes (SLN) is performed by injecting a radioactive tracer, followed by lymphoscintigraphy. In some patients there is a discrepancy between the number of lymphoscintigraphically identified sentinel nodes and the number of nodes found during surgery. We hypothesized that the inability to find peroperatively all the lymphoscintigraphically identified sentinel nodes, might lead to an increase in axillary recurrence because of positive SLNs not being removed.

METHODS

Patients who underwent sentinel node biopsy between January 2000 and July 2010 were identified from a prospectively collected database. The number of lymphoscintigraphically and peroperatively identified sentinel nodes were reviewed and compared. Axillary recurrences were scored.

RESULTS

1368 patients underwent a SLN biopsy. Median follow up was 58.5 months (range 12-157). Patient and tumour characteristics showed no significant differences. In 139 patients (10.2%) the number of radioactive nodes found during surgery was less than preoperative scanning (group 1) and in 89.8% (N = 1229) there were equal or more peroperative nodes identified than seen lymphoscintigraphically (group 2). In group 1, 0/139 patients (0%) developed an axillary recurrence and in the second group this was 25/1229 (2.0%) respectively. No significant difference between groups regarding axillary recurrence, sentinel node status and distant metastasis was found.

CONCLUSION

Axillary recurrence rate is not influenced by the inability to remove all sentinel nodes during surgery that have been identified preoperatively by scintigraphy.

Sentinel nodes identified by computed tomography-lymphography accurately stage the axilla in patients with breast cancer

BACKGROUND

Sentinel node biopsy often results in the identification and removal of multiple nodes as sentinel nodes, although most of these nodes could be non-sentinel nodes. This study investigated whether computed tomography-lymphography (CT-LG) can distinguish sentinel nodes from non-sentinel nodes and whether sentinel nodes identified by CT-LG can accurately stage the axilla in patients with breast cancer.

METHODS

This study included 184 patients with breast cancer and clinically negative nodes. Contrast agent was injected interstitially. The location of sentinel nodes was marked on the skin surface using a CT laser light navigator system. Lymph nodes located just under the marks were first removed as sentinel nodes. Then, all dyed nodes or all hot nodes were removed.

RESULTS

The mean number of sentinel nodes identified by CT-LG was significantly lower than that of dyed and/or hot nodes removed (1.1 vs 1.8, p <0.0001). Twenty-three (12.5%) patients had ≥2 sentinel nodes identified by CT-LG removed, whereas 94 (51.1%) of patients had ≥2 dyed and/or hot nodes removed (p <0.0001). Pathological evaluation demonstrated that 47 (25.5%) of 184 patients had metastasis to at least one node. All 47 patients demonstrated metastases to at least one of the sentinel nodes identified by CT-LG.

CONCLUSIONS

CT-LG can distinguish sentinel nodes from non-sentinel nodes, and sentinel nodes identified by CT-LG can accurately stage the axilla in patients with breast cancer. Successful identification of sentinel nodes using CT-LG may facilitate image-based diagnosis of metastasis, possibly leading to the omission of sentinel node biopsy.

Clinical trial of combined radio- and fluorescence-guided sentinel lymph node biopsy in breast cancer

BACKGROUND

Combining radioactive colloids and a near-infrared (NIR) fluorophore permits preoperative planning and intraoperative localization of deeply located sentinel lymph nodes (SLNs) with direct optical guidance by a single lymphatic tracer. The aim of this clinical trial was to evaluate and optimize a hybrid NIR fluorescence and radioactive tracer for SLN detection in patients with breast cancer.

METHODS

Patients with breast cancer undergoing SLN biopsy were enrolled. The day before surgery, a periareolar injection of indocyanine green (ICG)-99mTc-radiolabelled nanocolloid was administered and a lymphoscintigram acquired. Blue dye was injected immediately before surgery. Intraoperative SLN localization was performed using a γ probe and the Mini-FLARE™ NIR fluorescence imaging system. Patients were divided into two dose groups, with one group receiving twice the particle density of ICG and nanocolloid, but the same dose of radioactive 99mTc.

RESULTS

Thirty-two patients were enrolled in the trial. At least one SLN was identified before and during operation. All 48 axillary SLNs could be detected by γ tracing and NIR fluorescence imaging, but only 42 of them stained blue. NIR fluorescence imaging permitted detection of lymphatic vessels draining to the SLN up to 29 h after injection. Doubling the particle density did not yield a difference in fluorescence intensity (median 255 (range 98-542) versus 284 (90-921) arbitrary units; P = 0.590) or signal-to-background ratio (median 5·4 (range 3·0-15·4) versus 4·9 (3·5-16·3); P = 1·000) of the SLN.

CONCLUSION

The hybrid NIR fluorescence and radioactive tracer permitted accurate preoperative and intraoperative detection of the SLNs in patients with breast cancer.

REGISTRATION NUMBER

NTR3685 (Netherlands Trial Register; http://www.trialregister.nl).

SPECT/CT scans allow precise anatomical location of sentinel lymph nodes in breast cancer and redefine lymphatic drainage from the breast to the axilla

BACKGROUND

Historical studies of lymphatic drainage of the breast have suggested that the lymphatic drainage of the breast was to lymph nodes lying in the antero-pectoral group of nodes in the axilla just lateral to the pectoral muscles. The purpose of this study was to confirm this is not correct.

METHODS

The hybrid imaging method of SPECT/CT allows the exact anatomical position of the sentinel lymph node (SLN) in the axilla to be documented during pre-operative lymphoscintigraphy (LS) in patients with breast cancer. We have done this in a series of 741 patients. The Level I axillary nodes were defined as anterior, mid or posterior. This was related to the anatomical location of the primary cancer in the breast.

RESULTS

A SLN was found in the axilla in 97.8% of our patients. Just under 50% of SLNs located in the axilla were not in the anterior group and lay in the mid or posterior group of Level I axillary nodes. There was a SLN in a single node field in 460 patients (63%), two node fields in 261(36%), three node fields in 6 and four node fields in 1 patient.

CONCLUSION

Axillary lymphatic drainage from the breast is not exclusively to the anterior (or antero-pectoral) group of Level I nodes.

SYNOPSIS

SPECT/CT lymphoscintigraphy shows that the breast does not always drain to the anterior group of Level I lymph nodes in the axilla but may drain to the mid axilla and/or posterior group in about 50% of patients with breast cancer regardless of the location of the cancer in the breast. These data redefine lymph drainage from the breast to axillary lymph nodes.

Sentinel lymph node biopsy using indigo carmine blue dye and the validity of '10% rule' and '4 nodes rule'

This is the study which assessed sentinel lymph node biopsy (SNB) using indigo carmine blue dye and the validity of the '10% rule' and '4 nodes rule'. Patients (302) were performed SNB using the combined radioisotope (RI)/indigo carmine dye method. Excised SLNs were confirmed whether they were stained and numbered in order of RI count and the percentage of radioactivity as compared to the hottest node was calculated. The relationship between histological diagnosis, dyeing and RI count was assessed. All the patients were detected SLN. Positive nodes were identified in 84 (27.8%) patients and were identified up to the third degree of hottest. All the hottest positive nodes were stained by indigo carmine. From the results, removing the three most radioactive SLNs identified all cases of nodal metastasis without complications. These stopping rules were valid and useful under indigo carmine use too.

[Breast cancer--diagnosis and treatment in a Alesund hospital]

BACKGROUND

We wanted to check if our routines for diagnosing and treating primary operable breast cancer and ductal carcinoma in situ were concordant with national guidelines and quality standards.

MATERIAL AND METHODS

Data were retrospectively collected from medical journals for all relevant patients operated at Alesund Hospital, Norway from 1.11.02 to 1.05.08.

RESULTS

487 breasts were operated in 478 patients. A triple-diagnostic approach (mammography/ultrasound, clinical examination and biopsy) was used in 98 % of patients and ultrasound-guided core-needle-biopsy in 86 %. For 82 % of patients one visit in an out-patient-department was enough to conclude with a malignant diagnosis. A sentinel node biopsy was taken for 378 of 457 (83 %) patients operated in the axilla; a sentinel node was found in 93 % of them. Three (median) sentinel nodes were removed (spread in the range 1 - 12). 51 % of patients had breast-conserving surgery. From diagnosis of cancer to completion of all surgical procedures, 57 patients (12 %) had two operations, three (0.6 %) had three operations (in the breast and axilla), and 89 % of patients had completed all surgery within three weeks.13 % of patients had postoperative complications. After axillary lymph-node dissection, 20 % of patients had lymph-oedema/shoulder/arm pain. Three patients had ipsilateral relapse in the breast or thoracic wall. None had axillary relapse after sentinel-node biopsy. The median observation time was 26 months (0 - 66 months).

INTERPRETATION

The results of diagnosis and treatment in our hospital are in good accordance with our national guidelines and quality standards.

A novel method for sentinel lymph node biopsy by indocyanine green fluorescence technique in breast cancer

We investigated the feasibility of sentinel lymph node (SLN) biopsy using indocyanine green (ICG) technique in 411 patients with early breast cancer at three institutes. ICG, a fluorescence source, and blue dye were injected into the subareolar area to enable real-time image-guided surgery and identification of SLN fluorescence after meticulous dissection. The subcutaneous lymphatic channels were precisely detected in all cases. SLN identification rate was 99% (408/411) with a mean of 2.3 nodes identified per patient. Thirty-nine cases (9.5%) had SLNs involved and all of them were ICG positive. Thus, the ICG technique has a high SLN identification rate comparable with that of the radioisotope method.