Ratio Between Positive Lymph Nodes and Total Excised Axillary Lymph Nodes as an Independent Prognostic Factor for Overall Survival in Patients with Nonmetastatic Lymph Node-Positive Breast Cancer

Background

The status of the axillary lymph nodes in nonmetastatic lymph node-positive breast cancer (BC) patients remains the single most important determinant of overall survival (OS). Although the absolute number of nodes involved with cancer is important for prognosis, the role of the total number of excised nodes has received less emphasis. Thus, several studies have focused on the utility of the axillary lymph node ratio (ALNR) as an independent prognostic indicator of OS. However, most studies suffered from shortcomings, such as including patients who received neoadjuvant therapy or failing to consider the use of adjuvant therapy and tumor receptor status in their analysis.

Methods

We conducted a single-center retrospective review of 669 patients with nonmetastatic lymph node-positive BC. Data collected included patient demographics; breast cancer risk factors; tumor size, histopathological, receptor, and lymph node status; and treatment modalities used. Patients were subdivided into four groups according to ALNR value (<.25, .25–.49, .50–.74, .75–1.00). Study parameters were compared at the univariate and multivariate levels for their effect on OS.

Results

On univariate analysis, both the absolute number of positive lymph nodes and the ALNR were significant predictors of OS. On multivariate analysis, only the ALNR remained an independent predictor of OS, with a 2.5-fold increased risk of dying at an ALNR of ≥.25.

Conclusions

Our study demonstrates that ALNR is a stronger factor in predicting OS than the absolute number of positive axillary lymph nodes.     

Axillary Recurrence After a Tumor-Positive Sentinel Lymph Node Biopsy Without Axillary Treatment: A Review of the Literature

Background

Sentinel lymph node biopsy (SLNB) has become standard of care as a staging procedure in patients with invasive breast cancer. A positive SLNB allows completion axillary lymph node dissection (cALND) to be performed. The axillary recurrence rate (ARR) after cALND in patients with positive SLNB is low. Recently, several studies have reported a similar low ARR when cALND is not performed. This review aims to determine the ARR when cALND is omitted in SLNB-positive patients.

Methods

A literature search was performed in the PubMed database with the search terms ??breast cancer,?? ??sentinel lymph node biopsy,?? ??axillary?? and ??recurrence.?? Articles with data regarding follow-up of patients with SLNB-positive breast cancer were identified. To be eligible, patients should not have received cALND and ARR should be reported.

Results

Thirty articles were analyzed. This resulted in 7,151 patients with SLNB-positive breast cancer in whom a cALND was omitted (median follow-up of 45?months, range 1?C142?months). Overall, 41 patients developed an axillary recurrence. 27 studies described 3,468 patients with micrometastases in the SLNB, of whom 10 (0.3?%) developed an axillary recurrence. ARR varied between 0 and 3.7?%. Sixteen studies described 3,268 patients with macrometastases, 24 (0.7?%) axillary recurrences were seen. ARR varied between 0 and 7.1?%. Details regarding type of surgery and adjuvant treatment were lacking in the majority of studies.

Conclusions

ARR appears to be low in SLNB-positive patients even when a cALND is not performed. Withholding cALND may be safe in breast cancer selected patients such as those with isolated tumor cells or micrometastatic disease.     

Axillary Dissection Versus No Axillary Dissection in Elderly Patients with Breast Cancer and No Palpable Axillary Nodes: Results After 15 Years of Follow-Up

Objective

To assess the long-term safety of no axillary clearance in elderly patients with breast cancer and nonpalpable axillary nodes.

Background

Lymph node evaluation in elderly patients with early breast cancer and clinically negative axillary nodes is controversial. Our randomized trial with 5-year follow-up showed no breast cancer mortality advantage for axillary clearance compared with observation in older patients with T1N0 disease.

Methods

We further investigated axillary treatment in a retrospective analysis of 671 consecutive patients, aged ≥70 years, with operable breast cancer and a clinically clear axilla, treated between 1987 and 1992; 172 received and 499 did not receive axillary dissection; 20 mg/day tamoxifen was prescribed for at least 2 years. We used multivariable analysis to take account of the lack of randomization.

Results

After median follow-up of 15 years (interquartile range 14–17 years) there was no significant difference in breast cancer mortality between the axillary and no axillary clearance groups. Crude cumulative 15-year incidence of axillary disease in the no axillary dissection group was low: 5.8% overall and 3.7% for pT1 patients.

Conclusions

Elderly patients with early breast cancer and clinically negative nodes did not benefit in terms of breast cancer mortality from immediate axillary dissection in this nonrandomized study. Sentinel node biopsy could also be foregone due to the very low cumulative incidence of axillary disease in this age group. Axillary dissection should be restricted to the small number of patients who later develop overt axillary disease.     

Avoiding Axillary Treatment in Sentinel Lymph Node Micrometastases of Breast Cancer: A Prospective Analysis of Axillary or Distant Recurrence

Background

The need for axillary lymph node dissection (ALND) in breast cancer patients with sentinel lymph node (SLN) micrometastases remains controversial. The aims of the study were to evaluate the locoregional failure and outcome of breast cancer patients with sentinel node micrometastases who did not undergo completion ALND.

Methods

Between November 2000 and December 2006, SLN biopsy was successfully performed in 1178 patients with invasive breast carcinoma. Only patients with macrometastasis (>2 mm) underwent ALND, while patients with negative SLN or micrometastases did not undergo further treatment of the axilla, by either surgery or radiotherapy. Regarding adjuvant therapy decision, patients with SLN-micrometastases (pN1_mi) were considered as node-positive patients.

Results

Of 1,178 patients, 59 (5%) had micrometastases. Of those with micrometastases, 14 (24%) underwent ALND because the intraoperative study of the SLN yielded a positive result. With a median follow-up of 60 (range, 8–94) months, none of the patients with SLN micrometastases in whom ALND was omitted developed an axillary recurrence, while one patient in whom ALND was performed developed infraclavicular lymph node recurrence. One patient, who declined postoperative breast irradiation, developed breast recurrence and distant metastasis.

Conclusions

Breast cancer patients with SLN micrometastases in whom ALND was omitted had a very low locoregional failure rate. This study supports the theory that ALND might be avoided in these patients, providing that adjuvant systemic treatment equal to treatment provided to treat node-positive disease is administered. However, longer follow-up and results of additional prospective studies are needed.     

Sentinel Lymph Node Biopsy in Patients with Previous Ipsilateral Complete Axillary Lymph Node Dissection

Background

Prior ipsilateral completion axillary lymph node dissection (CALND) may be considered a contraindication to performing a sentinel lymph node (SLN) mapping in a patient with recurrent breast carcinoma. However, reoperative SLN biopsy following axillary dissection would determine if alternative lymphatic drainage pathways exist. If nodes were found to contain metastatic disease, staging and locoregional control of the disease could be affected.

Materials and Methods

An institutional breast cancer database and electronic health record (IRB No. 102554) prospectively accrued 6225 patients between 1994 and 2007. Under separate IRB approval (IRB No. 102552), this database was queried for patients with a prior history of CALND who received a SLN biopsy. Patients’ demographic, clinical, and treatment variables were recorded.

Results

Of the 6225 patients, 45 (0.7%) were identified as having previously undergone breast-conservation surgery, CALND, and ipsilateral reoperative SLN mapping and biopsy. Of the 45 patients, 13 (29%) had a successful ipsilateral reoperative SLN mapping and biopsy. Nonaxillary drainage was identified in 5 patients with reoperative SLN biopsy.

Conclusion

Reoperative SLN mapping and biopsy is feasible in the setting of local recurrence after previous CALND. This procedure performed for breast cancer recurrence provides important staging information while identifying extra-axillary drainage that could affect both staging and local control.     

Predictors and Outcomes of Completion Axillary Node Dissection Among Older Breast Cancer Patients

Background

The role of completion axillary lymph node dissection (ALND) for older women who had sentinel lymph node-positive (SLN+) invasive breast cancer is unclear. We examined factors predictive of ALND and the association between ALND, adjuvant chemotherapy administration, and survival.

Methods

Using the Surveillance, Epidemiology, and End Results (SEER)-Medicare database, we reviewed records of women age >65 diagnosed with stage I/II breast cancer from 1998–2005. Adjusted Cox proportional hazards and multivariate logistic regression were used to identify patient and disease variables associated with ALND, and assess association between ALND and all-cause and breast cancer-specific survival.

Results

Among SLN+ patients, 88 % underwent ALND. Earlier diagnosis year, greater nodal involvement, younger age, registry location, and larger tumor size were all associated with a significantly higher likelihood of ALND. The ALND in SLN+ patients was not significantly associated with 5-year breast cancer-specific survival (hazard ratio [HR] 1.22, 95 % confidence interval [CI] 0.76–1.96). The SLN+ patients who underwent ALND were more likely to receive adjuvant chemotherapy (odds ratio [OR] 1.8, 95 % CI 1.45–2.24). However, younger age (OR 18.0, 95 % CI 14.4–23.9), estrogen receptor-negative (ER-) status (OR 4.2, 95 % CI 3.4–5.3), and fewer comorbidities (OR 2.6, 95 % CI 1.7–4.0) were all more strongly linked to receipt of chemotherapy.

Conclusions

ALND for older patients with SLN+ breast cancer is not associated with improved 5-year all-cause or breast cancer-specific survival. Younger age, fewer comorbidities, and estrogen receptor-negative (ER-) status were more strongly associated with receipt of chemotherapy than ALND. Consideration should be given to omitting ALND in older patients, particularly if findings of ALND will not influence adjuvant therapy decisions.     

Factors Affecting Lymph Node Yield in Patients Undergoing Axillary Node Dissection for Primary Breast Cancer: A Single-Institution Review

Background

A minimum of 10 level I/II axillary nodes is recommended for accurate breast cancer staging. The goal of this study was to assess the effect of neoadjuvant chemotherapy on lymph node yield at axillary lymph node dissection.

Methods

A single-institution National Comprehensive Cancer Network (NCCN) breast cancer database was queried for cases with axillary node dissection from 2000 to 2008. All dissections were performed at the same institution. Demographic, chemotherapy, and clinicopathologic data were collected. Age and body mass index at diagnosis were calculated for subset analyses. Statistical analyses used Student??s t-test or analysis of variance with Tukey multiple comparison and Fisher??s exact test.

Results

Two hundred forty patients had axillary node dissection after neoadjuvant chemotherapy; an additional 903 women with primary lymph node dissection were identified as contemporaneous control subjects. There was a far lower nodal yield in patients undergoing axillary dissection after neoadjuvant chemotherapy than those undergoing primary surgery. Patients with pathologic stage II or III disease undergoing primary surgery had more lymph nodes at axillary dissection than stage I disease.

Conclusions

Age, type of breast surgery, body mass index, and clinical stage have no effect on yield of lymph nodes at axillary lymph node dissection. Neoadjuvant chemotherapy, however, is associated with a far fewer nodes at axillary dissection, and alteration of the guidelines should be considered for this population of patients.     

Disease Recurrence in Sentinel Node-Positive Breast Cancer Patients Forgoing Axillary Lymph Node Dissection

Background

Clinically node-negative breast cancer patients usually undergo sentinel lymph node (SLN) biopsy. When metastasis is identified, completion axillary lymph node dissection (CALND) is recommended. Newer data suggest that CALND may be omitted in some women as it does not improve local control or survival.

Methods

Women with a positive SLN diagnosed between 1999 and 2010 were included in this review and were stratified according to whether they did or did not undergo CALND. Primary endpoints included recurrence and breast cancer-specific mortality. Differences between the groups and in time to recurrence were compared and summarized.

Results

Overall, 276 women were included: 206 (79?%) women who underwent CALND (group 1) and 70 (21?%) women in whom CALND was omitted (group 2). Group 1 patients were younger, had more SLN disease, and received more chemotherapy (P?P?>?0.05 for each). Median follow-up was 69 (range 6?C147) and 73 (range 15?C134) months for groups 1 and 2, respectively. Five (2?%) women in group 1 and three (4?%) women in group 2 died of breast cancer (P?=?0.39). Local?Cregional or distant recurrence occurred in 20 (10?%) group 1 patients and in 10 (14?%) group 2 patients (P?=?0.39). On multivariate analysis, only estrogen receptor negativity and lymphovascular invasion predicted for recurrence.

Conclusions

Omission of CALND in women with SLN disease does not significantly impact in-breast, nodal, or distant recurrence or mortality. Longer-term follow-up is needed to verify that this remains true with time.     

Accuracy of Predicting Axillary Lymph Node Positivity by Physical Examination, Mammography, Ultrasonography, and Magnetic Resonance Imaging

Background

Axillary lymph node status continues to be among the most important prognostic variables regarding breast cancer survival. We were interested in our ability to accurately predict axillary nodal involvement by using physical examination and standard breast imaging studies in combination.

Methods

A retrospective review was performed of 244 consecutive patients diagnosed with invasive breast carcinoma between May 2008 and December 2010 who underwent physical examination of the axilla, digital mammography, axillary ultrasonography, and contrast-enhanced breast magnetic resonance imaging and who had subsequent histopathologic evaluation of one or more axillary lymph nodes.

Results

A total of 62 (25%) of 244 women were found to have positive axillary lymph nodes on final histopathologic examination, 42% of whom were able to be identified preoperatively. The sensitivity for predicting axillary metastasis if any one or more examination modalities were suspicious was 56.5%. The specificity for predicting axillary metastasis if any three or more modalities were suspicious was 100%. Of the patients who had all four modalities negative, 14% were ultimately found to have histologically positive nodes at the time of surgery.

Conclusions

Physical examination and multimodal imaging in combination are useful for preoperative axillary staging and treatment planning. However, they remain inadequate definitive predictors of axillary lymph node involvement.     

Axillary Ultrasonography in Breast Cancer Patients Helps in Identifying Patients Preoperatively with Limited Disease of the Axilla

Background

The sentinel lymph node biopsy (SLNB) procedure is the method of choice for the identification and monitoring of regional lymph node metastases in patients with breast cancer. In the case of a positive sentinel lymph node (SLN), additional lymph node dissection is still warranted for regional control, although 40–65 % have no additional axillary disease. Recent studies show that after breast-conserving surgery, SLNB, and adjuvant systemic therapy, there is no significant difference between recurrence-free period and overall survival if there are ≤2 positive axillary nodes. The purpose of this study was preoperative identification of patients with limited axillary disease (≤2 macrometastases) by using ultrasonography.

Methods

Data from 1,103 consecutive primary breast cancer patients with tumors smaller than 50 mm, no palpable adenopathy, and a maximum of 2 SLNs with macrometastases were collected. The variable of interest was US of the axilla.

Results

Of the 1,103 patients included, 1,060 remained after exclusion criteria. Of these, 102 (9.6 %) had more than 2 positive axillary nodes on ALND. Selected by unsuspected US, the chance of having >2 positive lymph nodes (LNs) is substantially lower (4.2 %). This is significant on univariate and multivariate analysis. After excluding the patients with extracapsular extension of the SLN, the chance of having >2 positive LNs is only 2.6 %. For pT1–2, this is 2.2 %.

Conclusions

The risk of more than 2 positive axillary nodes is relatively small in patients with cT1–2 breast cancer. US of the axilla helps in further identifying patients with a minimal risk of additional axillary disease, putting ALND up for discussion.     

Management of Contralateral Axillary Sentinel Lymph Nodes Detected on Lymphoscintigraphy for Breast Cancer

Background

Detection of a contralateral axillary sentinel lymph node (SLN) during lymphoscintigraphy for breast cancer is rare, and its significance and management are unclear. The purpose of this study was to review our experience and analyze our results together with similar patients in the literature to identify common characteristics and propose a management strategy.

Methods

A PubMed search was performed for articles describing patients in whom contralateral axillary drainage was identified on lymphoscintigraphy. Additionally, a chart review was performed of all patients who had lymphoscintigraphy for breast cancer at our institution.

Results

At our institution, two of 988 (0.3 %) consecutive patients were identified with contralateral axillary drainage on lymphoscintigraphy. Twenty-seven publications describing 105 patients with contralateral axillary drainage were found. This comprised our study group of 107 patients. Lymphoscintigraphy patterns varied depending on the history and type of prior surgery. A history of chest/axillary surgery was significantly associated with absence of an ipsilateral SLN (p < 0.05). This was observed in 84.2 % of patients with prior axillary lymph node dissection versus 33.3 % with prior SLN. Contralateral SLN biopsy was attempted in 85 patients (79.4 %); 22 (20.6 %) were positive for tumor. In 17 patients (15.9 %), the contralateral node was the only positive SLN.

Conclusions

These findings suggest that contralateral uptake on lymphoscintigraphy, though rare (0.2 %), is clinically significant and such nodes should undergo excision. Because contralateral uptake is significantly associated with prior chest/axillary surgery, routine lymphoscintigraphy should be considered in this group, as it has potential to change disease stage and management.     

Preoperative Axillary Ultrasound and Fine-needle Aspiration Biopsy in the Diagnosis of Axillary Metastases in Patients with Breast Cancer: Predictors of Accuracy and Future Implications

Background

The utility of axillary lymph node dissection after sentinel lymph node biopsy has been called into question. We sought to determine the sensitivity, specificity, and accuracy of axillary ultrasound and fine-needle aspiration biopsy (FNAB) in the identification of axillary nodal metastasis in early breast cancer patients.

Methods

Data of patients with stage I and II breast cancer who underwent surgery and staging were reviewed. Axillary ultrasound findings were assessed and lymph node status recorded after axillary dissection. The data were cross-tabulated, and test characteristics were calculated.

Results

Of 235 patients, none demonstrated more than 2 positive sentinel lymph nodes. Ductal carcinoma was present in 68 %, estrogen and progesterone receptors were positive in 81 and 64 %, respectively, Her-2/neu was positive in 10 %, and 36 % were axillary node positive. The sensitivity and specificity of ultrasound alone were 55 and 88 %, respectively. Predictors of abnormal ultrasound included size of metastasis, estrogen receptor and Her-2 status, tumor grade, and presence of lymphovascular invasion. Addition of FNAB increased the sensitivity and specificity to 69 and 100 %. In conjunction with FNAB, the positive and negative predictive values were 100 and 54 %, respectively. Ten percent of patients with nodal metastases demonstrated a positive FNAB. Patients with a positive FNAB did not harbor more nodal metastases or a greater proportion of gross extranodal disease compared to patients not subjected to FNAB.

Conclusions

Axillary ultrasound with FNAB has an accuracy of >70% in this series. It is easily performed and may avoid unnecessary sentinel lymph node biopsy in a significant number of patients.     

Effect of Axillary Lymph Node Dissection after Sentinel Lymph Node Biopsy on Overall Survival in Patients with T1 or T2 Node-positive Breast Cancer: Report from the Korean Breast Cancer Society

Background

The effect of axillary lymph node dissection (ALND) after sentinel lymph node biopsy (SLNB) in patients with clinically node-negative patients in preoperative evaluations on overall survival (OS) is uncertain. The study aimed to evaluate the difference of survival between node-positive patients who underwent SLNB alone and those who received ALND after SLNB using the Korean Breast Cancer Society registry.

Methods

We enrolled 2,581 patients who met the eligibility criteria. All enrolled patients had T1 or T2 breast cancer, and received mastectomy or breast-conserving treatment followed by documented adjuvant systemic therapy.

Results

There were 197 patients with SLNB alone and 2,384 patients with ALND after SLNB. Smaller tumor size, lower number of nodal metastasis, and higher proportion of breast-conserving surgery were found in patients with SLNB alone than in those with ALND after SLNB. There was no significant difference in OS between the two groups by the log-rank test. ALND after SLNB showed no significant improvement in OS in multivariate analysis.

Conclusions

ALND in patients with sentinel metastasis who have T1 or T2 breast cancer receiving adjuvant systemic therapy may not have improved OS.     

Complete Axillary Lymph Node Dissection Versus Clinical Follow-up in Breast Cancer Patients with Sentinel Node Micrometastasis: Final Results from the Multicenter Clinical Trial AATRM 048/13/2000

Background

It has been suggested that selective sentinel node (SN) biopsy alone can be used to manage early breast cancer, but definite evidence to support this notion is lacking. The aim of this study was to investigate whether refraining from completion axillary lymph node dissection (ALND) suffices to produce the same prognostic information and disease control as proceeding with completion ALND in early breast cancer patients showing micrometastasis at SN biopsy.

Methods

This prospective, randomized clinical trial included patients with newly diagnosed early-stage breast cancer (T < 3.5 cm, clinical N0, M0) who underwent surgical excision as primary treatment. All had micrometastatic SN. Patients were randomly assigned to one of the two study arms: complete ALND (control arm) or clinical follow-up (experimental arm). Median follow-up was 5 years, recurrence was assessed, and the primary end point was disease-free survival.

Results

From a total sample of 247 patients, 14 withdrew, leaving 112 in the control arm and 121 in the experimental arm. In 15 control subjects (13 %), completion ALND was positive, with a low tumor burden. Four patients experienced disease recurrence: 1 (1 %) of 108 control subjects and 3 (2.5 %) of 119 experimental patients. There were no differences in disease-free survival (p = 0.325) between arms and no cancer-related deaths.

Conclusions

Our results strongly suggest that in early breast cancer patients with SN micrometastasis, selective SN lymphadenectomy suffices to control locoregional and distant disease, with no significant effects on survival.     

The number of nodes removed as well as the template of the dissection is independently correlated to cancer-specific survival after radical cystectomy for muscle-invasive bladder cancer

Purpose

To assess the impact of the number of lymph nodes removed and of the template of dissection during radical cystectomy for bladder cancer on patients’ survival rates.

Materials and methods

We evaluated 282 consecutive patients who underwent radical cystectomy for muscle-invasive or high-grade superficial bladder cancer between 1995 and 2011. Exclusion criteria were incomplete follow-up data and neo-adjuvant or adjuvant treatments. Patients were divided into groups according to the most informative cut-point of number of lymph nodes retrieved and of the template of dissection. The cancer-specific survival rates were estimated by the Kaplan–Meier method. The univariate and multivariable forward-stepwise Cox proportional hazards regression were applied to analyze the survival outcomes.

Results

The mean (SD) follow-up was 59.2 ± 44.3 months, and the mean (SD) age of the entire cohort population was 68.3 ± 8.3 years. The cancer-specific survival rates were 58.7 and 47.7 % at 5 and 10 years, respectively. Considering both node-positive and node-negative patients, those with at least 14 LNs removed and those submitted to extended or super-extended PLND experienced significantly higher cancer-specific survival at both univariate and multivariable analysis.

Conclusions

Patients undergoing a more extended pelvic lymph node dissection, both in terms of number of LN removed and in terms of template of dissection, will experience a better cancer-specific survival. Our data support a potential role of lymphadenectomy on cancer outcome.     

Intraoperative Touch Imprint Cytology in Targeted Axillary Dissection After Neoadjuvant Chemotherapy for Breast Cancer Patients with Initial Axillary Metastasis

Background

For breast cancer patients, a false-negative rate lower than 10% can be achieved if targeted axillary dissection (TAD) is performed, which includes the excision of both biopsy-proven positive lymph nodes (BxLNs) and sentinel lymph nodes (SLNs). However, little evidence exists on the accuracy of intraoperative touch imprint cytology (ITPC) applied in TAD after neoadjuvant chemotherapy (NAC) for breast cancer patients with initial axillary metastasis. This study aimed to investigate the accuracy of ITPC in TAD after NAC.

Methods

Breast cancer patients with biopsy-confirmed nodal metastasis were prospectively enrolled in the study. After completion of NAC, all patients underwent TAD followed by axillary lymph node dissection (ALND). Then ITPC was performed to evaluate BxLNs and SLNs. The accuracy of TAD and ITPC was calculated in comparison with hematoxylin and eosin (H&E) staining of ALNs. The results of ITPC during 6 months at our center in the adjuvant setting were used for comparison.

Results

Overall, the false-negative rate of TAD was 10.8%. In a test with 92 patients, ITPC had an accuracy of 92.4%, a sensitivity of 87.9%, and a specificity of 94.9%. In the non-NAC group, ITPC showed similar accuracy (91.2%) and specificity (97.9%) but significantly lower sensitivity (68.9%; P?=?0.03).

Conclusions

The use of ITPC was feasible for TAD among breast cancer patients with biopsy-confirmed axillary metastasis who were treated with NAC. All the misses in the ITPC involved patients with micrometastases or isolated tumor cells. Use of ITPC can help decrease the number of second operations for patients with residual disease in ALNs after NAC.

     

Localization of the Sentinel Node of the Upper Outer Breast Quadrant in the Axillary Quadrants

Background

Sentinel node (SN) biopsy is associated with much less morbidity than axillary dissection. In patients with early breast cancer, lymphatic mapping and SN biopsy accurately stage the axillary nodes. Both currently available lymphatic mapping agents, radiocolloid and blue dye, have some limitations that may make perioperative or preoperative SN identification difficult. In such cases, exact knowledge of the topography of the axilla and the most probable location of the SN may be crucial.

Methods

In 12 fresh female cadavers with no history of breast carcinoma, injections of patent blue dye were used to visualize the SNs in the axillary quadrants and their lymphatic collectors from the upper outer quadrant of the breast, which is the most common location of breast cancer. The axilla was divided into quadrants with regard to the intersection of the thoracoepigastric vein and the third intercostobrachial nerve.

Results

All SNs were located within a circle of 2-cm radius of this intersection in the fatty tissue at the clavipectoral fascia. In most cases, the SN was located in the fatty tissue near the clavipectoral fascia in the lower ventral quadrant of the axilla (n = 14, 58%). In seven cases (29%), the SN was located in the upper ventral quadrant, in two cases (8%) in the upper dorsal quadrant, and in one case in the lower dorsal quadrant.

Conclusions

The results of this anatomical study may facilitate SN biopsy in patients with breast cancer.     

Impact of Preoperative Ultrasonography and Fine-Needle Aspiration of Axillary Lymph Nodes on Surgical Management of Primary Breast Cancer

Purpose

To evaluate the accuracy of preoperative ultrasonography (US) and US-guided fine-needle aspiration (US-FNA) for detecting axillary lymph node (ALN) metastasis.

Patients and Methods

We retrospectively reviewed 382 breast cancer patients with clinically negative ALN who underwent US and/or US-FNA for ALN. US-FNA of ALN was performed in 121 patients with suspicious findings on US. The diagnostic performance of US alone or with the addition of US-FNA for detecting ALN metastasis was calculated on the basis of final pathologic reports of ALN surgery.

Results

Among a total of 382 patients, 129 had metastatic ALNs while 253 exhibited no signs of axillary metastasis on final pathology. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of axillary US alone were 56.6% (73/129), 81.0% (205/253), 60.3% (73/121), and 78.5% (205/261), respectively. Addition of US-FNA resulted in sensitivity, specificity, PPV, and NPV of 39.5% (51/129), 95.7% (242/253), 82.3% (51/62), and 75.6% (242/320), respectively. Excluding complete responders to neoadjuvant chemotherapy, specificity and PPV after adding US-FNA were increased to 99.6% (242/243) and 98.1% (51/52), respectively. The sensitivity and specificity of ALN metastasis were similar between the palpable and nonpalpable breast cancer groups; however, after adding US-FNA, NPV was increased in the nonpalpable breast cancer group compared with the palpable breast cancer group (p = 0.0398). By including preoperative axillary US and US-FNA, 16.2% (62/382) of all breast cancer patients were able to avoid unnecessary sentinel lymph node biopsy (SLNB).

Conclusions

The combination of axillary US and US-FNA is useful in preoperative work-up of breast cancer patients and provides valuable information for planning proper breast cancer management.     

Sentinel lymph node biopsy in early-stage breast cancer patients: improved survival through better staging?

Purpose

The objective of this review is to summarize the evidence demonstrating that the sentinel lymph node (SLN) procedure is not only associated with significantly less morbidity compared to the axillary dissection, but may also result in better staging and improved patient outcomes.

Methods

A search of MedLine and PubMed articles using the terms “sentinel lymph node biopsy”, “breast cancer”, “staging”, “morbidity”, “survival”, and “outcomes” was conducted.

Results

Breast cancer staging includes axillary evaluation as an integral component. Over the past two decades, sentinel lymph node biopsy has evolved as a technique that has an improved morbidity over traditional axillary dissection. The sentinel node(s) undergo a more intensive pathologic examination than traditional axillary contents. In the node-negative group of patients, this may have led to stage migration and potentially improved disease-free and overall survival.

Conclusion

The SLN procedure is not only associated with significantly less morbidity compared to the axillary lymph node dissection, it may also result in more accurate staging, better axillary tumor control and improved survival.     

Risk Factor for Axillary Lymph Node Metastases in Microinvasive Breast Cancer

Background

Sentinel lymph node biopsy (SLNB) in patients with ductal carcinoma in situ (DCIS) was controversial. Usually we did not do a SLN biopsy when we performed conserving operations with small-sized DCIS. However, sometimes we find DCIS with microinvasive breast cancer (MIC) after the operation. Must reoperations be performed in all patients? The incidence of axillary metastases in microinvasive breast cancer (MIC) has not been extensively studied. We determined the incidence of positive axillary lymph node (ALN) in patients with MIC and the predictive factors of ALN metastases in these patients.

Methods

Between July 1989 and December 2008, 9635 patients had operation on invasive breast cancer in Asan Medical Center. Among these patients, 319 patients had MIC. The research conducted on the 293 patients (excluded were 26 who did not receive axillary lymph node dissection or SLN biopsy). We retrospectively checked clinical and pathologic variables.

Results

There were 22 cases of ALN metastases identified in this group of patients (7.5%). Lymphatic invasion (P < .001) and positive estrogen receptor status (P = 03) were independent significant predictors of axillary metastases.

Conclusions

Microinvasive breast cancer is associated with a low rate of lymph node metastases. Some breast cancer patients with MIC at low likelihood of lymph node metastases may be spared lymph node evaluation.