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      Impact of non-axillary sentinel node biopsy on staging and treatment of breast cancer patients

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          Abstract

          The purpose of this study was to evaluate the occurrence of lymphatic drainage to non-axillary sentinel nodes and to determine the implications of this phenomenon. A total of 549 breast cancer patients underwent lymphoscintigraphy after intratumoural injection of 99mTc-nanocolloid. The sentinel node was intraoperatively identified with the aid of intratumoural administered patent blue dye and a gamma-ray detection probe. Histopathological examination of sentinel nodes included step-sectioning at six levels and immunohistochemical staining. A sentinel node outside level I or II of the axilla was found in 149 patients (27%): internal mammary sentinel nodes in 86 patients, other non-axillary sentinel nodes in 44 and both internal mammary and other non-axillary sentinel nodes in nineteen patients. The intra-operative identification rate was 80%. Internal mammary metastases were found in seventeen patients and metastases in other non-axillary sentinel nodes in ten patients. Staging improved in 13% of patients with non-axillary sentinel lymph nodes and their treatment strategy was changed in 17%. A small proportion of clinically node negative breast cancer patients can be staged more precisely by biopsy of sentinel nodes outside level I and II of the axilla, resulting in additional decision criteria for postoperative regional or systemic therapy.

          British Journal of Cancer (2002) 87, 705–710. doi: 10.1038/sj.bjc.6600359 www.bjcancer.com

          © 2002 Cancer Research UK

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          Conservative treatment versus mastectomy in early breast cancer: patterns of failure with 15 years of follow-up data. Institut Gustave-Roussy Breast Cancer Group.

          M. Le Parquier, R. A. Arriagada, F Rochard … (1996)
          A randomized trial was conducted to compare tumorectomy and breast irradiation with modified radical mastectomy. We have analyzed the patterns of failure in each arm of the trial and the prognostic factors that have an independent effect on treatment failures and overall survival. The trial included 179 patients with breast cancer of up to 20 mm in diameter at macroscopic examination. Eighty-eight patients had conservative management and 91 a mastectomy. All patients had axillary dissection with frozen-section examination. For patients with positive axillary nodes (N+), a second randomization was performed: lymph node irradiation versus no further regional treatment. Patterns of failure were determined by a competing-risk approach and multivariate analysis. A prognostic-score was determined by multivariate analysis. Overall survival, distant metastasis, contralateral breast cancer, new primary malignancy, and locoregional recurrence rates were not significantly different between the two surgical groups, or between lymph node irradiation groups. Most recurrences appeared during the first 10 years. Three distinct prognostic groups were determined taking into account age, tumor size, histologic grading, and number of positive axillary nodes. Long-term results support conservative treatment with limited surgery and systematic breast irradiation as a safe procedure for the management of small breast cancers. Four easily obtainable clinical and histologic factors may be combined in a prognostic score that is highly predictive of overall and event-free survival.
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            Sentinel lymph node biopsy in breast cancer: guidelines and pitfalls of lymphoscintigraphy and gamma probe detection.

            Paul Borgstein MD, Rik Pijpers MD, Emile F Comans MD, PhD … (1998)
            Sentinel node (SN) biopsy appears to offer an alternative to routine axillary lymph node dissection (ALND) for staging patients with breast cancer. Various techniques have been studied for identifying the SN, using vital blue dye or radioactive colloid, and initial reports are promising. The inherent limitations and pitfalls must be clearly understood before SN biopsy can be implemented in dinical practice. In a prospective trial, the feasibility of using lymphoscintigraphy and gamma probe detection for performing SN biopsy was studied. In 130 consecutive patients with T1-T2, N0 breast cancer, preoperative lymphoscintigraphy was performed with technetium 99m-colloidal albumin. During ALND, the radioactive axillary SNs were localized by the gamma probe. Histopathologic examination of the harvested SNs was compared with the status of the axillary lymph nodes. Axillary focal accumulations were clearly identified on lymphoscintigraphy in 116 patients (89%). The failure rate was significantly higher in patients who had a previous excision biopsy (36%) than in those with a palpable tumor in situ (4%). Using the gamma probe, radiolabeled axillary SNs were successfully biopsied in 122 patients (94%). Because 18 of these patients did not undergo formal lymphadenectomy, the predictive accuracy of SN biopsy was analyzed in 104 patients. Radioactive nodes revealed metastases in 44 of 104 patients (42%); in 26 of them (59%), these were the only involved axillary nodes. The SN was negative in 60 patients (58%); in one patient the ALND was found to contain metastatic disease (1.7% false negatives). Biopsy of the SN was 98% accurate in predicting the absence of nodal metastases. There are certain guidelines for performing SN biopsy by lymphoscintigraphy and gamma probe detection. Success depends primarily on an adequate functional capacity of the SN, necessary for sufficient nodal uptake to ensure accurate identification. Lymphoscintigraphy defines the pattern of lymph flow and may prevent failure or false-negative biopsies. Biopsy of the SN is a highly accurate, minimally invasive method of staging patients with breast cancer and can substantially reduce the morbidity and costs of surgical treatment by avoiding unnecessary ALND in the majority of patients.
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              Prospective observational study of sentinel lymphadenectomy without further axillary dissection in patients with sentinel node-negative breast cancer.

              Graeme E Glass, Celia N. Hansen, John M Kelley … (2000)
              Immediate complete axillary lymphadenectomy (ALND) after sentinel lymphadenectomy (SLND) has confirmed that tumor-negative sentinel nodes accurately predict tumor-free axillary nodes in breast cancer. Therefore, we hypothesized that SLND alone in patients with tumor-negative sentinel nodes would achieve axillary control, with minimal complications. Between October 1995 and July 1997, 133 consecutive women who had primary invasive breast tumors clinically
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                Author and article information

                Journal
                Journal ID (nlm-ta): Br J Cancer
                Title: British Journal of Cancer
                Publisher: Nature Publishing Group
                ISSN (Print): 0007-0920
                ISSN (Electronic): 1532-1827
                Publication date (Electronic): 23 September 2002
                Publication date (Print): 23 September 2002
                Volume: 87
                Issue: 7
                Pages: 705-710
                Affiliations
                [1 ]Department of Surgery, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
                [2 ]Department of Nuclear Medicine, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
                [3 ]Department of Pathology, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Hospital, Amsterdam, The Netherlands
                Author notes
                [* ]Author for correspondence: p_tanis@ 123456hotmail.com
                Article
                Publisher Item ID: 6600359
                DOI: 10.1038/sj.bjc.6600359
                PMC ID: 2364267
                PubMed ID: 12232750
                SO-VID: 81a41df2-360a-4293-8582-872458e0995e
                Copyright © Copyright 2002, Cancer Research UK
                History
                Date received : 04 October 2001
                Date revision received : 24 March 2002
                Date accepted : 12 April 2002
                Categories
                Subject: Clinical

                ScienceOpen disciplines: Oncology & Radiotherapy
                Keywords: staging,sentinel node,lymphoscintigraphy,breast cancer
                Data availability:
                ScienceOpen disciplines: Oncology & Radiotherapy
                Keywords: staging, sentinel node, lymphoscintigraphy, breast cancer

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