Does failed mapping predict sentinel lymph node metastasis in cN0 breast cancer?

Aims: The clinical significance of nonvisualized sentinel lymph nodes (non-vSLNs) is unknown. The authors sought to determine the incidence of non-vSLNs on lymphoscintigraphy, the identification rate during surgery, factors associated with non-vSLNs and related axillary management. Patients & methods: A total of 30,508 consecutive SLN procedures performed at a single institution from 2000 to 2017 were retrospectively studied. Associations between clinicopathological factors and the identification of SLNs during surgery were assessed. Results: Non-vSLN occurred in 525 of the procedures (1.7%). In 73.3%, at least one SLN was identified intraoperatively. Nodal involvement was only significantly associated with SLN nonidentification (p < 0.001). Conclusion: Patients with non-vSLN had an increased risk for SLN metastasis. The detection rate during surgery was consistent, reducing the amount of unnecessary axillary dissection.

Factors predicting one or two sentinel lymph nodes to be accepted for sentinel lymph node biopsy alone after neoadjuvant therapy in initially node-positive breast cancer patients

BACKGROUND

Current guidelines recommend harvesting ≥3 sentinel nodes if sentinel lymph node biopsy (SLNB) alone is considered after neoadjuvant therapy (NAT) for initially node-positive (cN+) breast cancer. We attempted to investigate factors predicting one or two sentinel lymph nodes harvested to be accepted for SLNB alone after NAT in initially cN + patients.

METHODS

Overall, 157 patients who received NAT (clinically T1-3/N1-2/M0) and underwent SLNB were identified from a prospectively maintained database. Significant factors were identified using a multiple logistic regression model.

RESULTS

The overall SLN identification rate was 83.4%. Failed SLN identification was associated with a 2-day protocol using a single tracer (odds ratio: 0.331 [95% confidence interval {CI}: 0.132-0.830], p = 0.018), age >52 years (0.345 [0.131-0.913], p = 0.032), and lobular histology (0.156 [0.026-0.944], p = 0.043). The overall false-negative SLNB rate was 14.7%. Its increased risk was associated with radioactivity count >530 for any SLN during SLNB (96.4 [4.00-2320], p = 0.005), age ≥57 years (34.2 [1.92-610], p = 0.016), and taxane use (105 [1.02-10700], p = 0.049); its decreased risk was associated with more harvested SLNs (0.191 [0.054-0.669], p = 0.01) and dual tracers (0.101 [0.012-0.843], p = 0.034). A predictive model using these factors achieved an area under the curve of 0.935 (95% CI: 0.878-0.991).

CONCLUSION

When taxane was administered during NAT, the false-negative rate was predicted at <5% for patients aged <57 years, if 1-2 SLNs were harvested using dual tracers, and when the count of every SLN was lower than 530 after NAT in cN + breast cancer.

Non-visualized sentinel nodes in breast cancer patients; prevalence, risk factors, and prognosis

BACKGROUND

Evidence and consensus is lacking in international guidelines regarding axillary treatment recommendations for patients in whom a sentinel lymph node (SLN) cannot be visualized (non-vSLN) during the sentinel node procedure. In this study we aimed to determine the prevalence of non-vSLNs in a Dutch population of breast cancer patients and to examine predictors and survival rate for non-vSLN.

METHODS

A nationwide, retrospective, population-based study was performed including 116,920 patients with invasive breast cancer who underwent a SLN procedure in the Netherlands between January 2005 and December 2013.

RESULTS

Of the 76,472 clinically negative patients who underwent a SLN procedure, 1924 patients (2.5%) had a non-vSLN, of whom 1552 (80.7%) underwent an ALND. Multivariate analysis showed predictive factors for non-vSLN: older age (p < 0.001), diagnosis in the period 2005-2009 (p < 0.001), larger tumor size (p = 0.003), and extensive nodal involvement (p < 0.001). Multivariate survival analysis showed a significantly worse survival (HR 1.18, 95% CI 1.03-1.34, p = 0.015) for non-vSLNs patients. However, in the non-vSLN group, an ALND was not statistically significantly associated with a better survival (HR 0.96, 95% CI 0.53-1.75, p = 0.891).

CONCLUSION

Patients with non-vSLNs had less favorable disease characteristics and a worse survival compared to patients with a visualized SLN. Performing an ALND was not associated with a significantly better survival in patients with non-vSLNs. However, further research on the necessity of axillary treatment in this specific patient group is required.

Breast cancer lymphoscintigraphy: Factors associated with sentinel lymph node non visualization

OBJECTIVE

To evaluate factors associated with non identification of the sentinel lymph node (SLN) in lymphoscintigraphy of breast cancer patients and analyze the relationship with SLN metastases.

MATERIAL AND METHODS

A single-center, cross-sectional and retrospective study was performed. Forty patients with lymphoscintigraphy without sentinel lymph node identification (negative lymphoscintigraphy - NL) were enrolled. The control group included 184 patients with SLN identification (positive lymphoscintigraphy - PL). Evaluated factors were age, body mass index (BMI), tumor size, histology, localization, preoperative breast lesion hookwire (harpoon) marking and SLN metastases. The statistical analysis was performed with uni- and multivariate logistic regression models and matched-pairs analysis.

RESULTS

Age (p=0.036) or having BMI (p=0.047) were the only factors significantly associated with NL. Being ≥60 years with a BMI ≥30 increased the odds of having a NL 2 and 3.8 times, respectively. Marking with hookwire seems to increase the likelihood of NL, but demonstrated statistical significance is lacking (p=0.087). The other tested variables did not affect the examination result. When controlling for age, BMI and marking with the harpoon, a significant association between lymph node metastization and NL was not found (p=0.565).

CONCLUSIONS

The most important factors related with non identification of SLN in the patients were age, BMI and marking with hook wire. However, only the first two had statistical importance. When these variables were controlled, no association was found between NL and axillary metastases.

[Evaluation of the efficacy of sentinel node detection in breast cancer: chronological course and influence of the incorporation of an intra-operative portable gamma camera]

AIM

To define the sentinel node identification rate in breast cancer, the chronological evolution of this parameter and the influence of the introduction of a portable gamma camera.

MATERIAL AND METHODS

A retrospective study was conducted using a prospective database of 754 patients who had undergone a sentinel lymph node biopsy between January 2003 and December 2011. The technique was mixed in the starting period and subsequently was performed with radiotracer intra-peritumorally administered the day before of the surgery. Until October 2009, excision of the sentinel node was guided by a probe. After that date, a portable gamma camera was introduced for intrasurgical detection.

RESULTS

The SN was biopsied in 725 out of the 754 patients studied. The resulting technique global effectiveness was 96.2%. In accordance with the year of the surgical intervention, the identification percentage was 93.5% in 2003, 88.7% in 2004, 94.3% in 2005, 95.7% in 2006, 93.3% in 2007, 98.8% in 2008, 97.1% in 2009 and 99.1% in 2010 and 2011. There was a significant difference in the proportion of identification before and after the incorporation of the portable gamma camera of 4.6% (95% CI of the difference 2-7.2%, P = 0.0037).

CONCLUSIONS

The percentage of global identification exceeds the recommended level following the current guidelines. Chronologically, the improvement for this parameter during the study period has been observed. These data suggest that the incorporation of a portable gamma camera had an important role.

Current status of sentinel lymph-node biopsy in patients with breast cancer

Axillary node status is the most important prognostic indicator for patients with invasive breast cancer. Sentinel lymph-node biopsy (SLNB) is widely accepted and the preferred procedure for identifying lymph-node metastasis. SLNB allows focused excision and pathological examination of the most likely axillary lymph nodes to receive tumor metastases while avoiding morbidities associated with complete axillary nodal dissection. Since its introduction in the early 1990s, the process of SLNB has undergone continual modification and refinement; however, the procedure varies between institutions and controversies remain. In this review, we examine the technical issues that influence the success of lymph node mapping, discuss the controversies, and summarize the indications and contraindications for axillary node mapping and biopsy in clinical practice.