Correlation Between Clinical Nodal Status and Sentinel Lymph Node Biopsy False Negative Rate After Neoadjuvant Chemotherapy

Background

Neoadjuvant chemotherapy (NAC) is the standard treatment for locally advanced breast cancer. It is now being used to treat operable breast cancer to facilitate breast-conserving surgery, but the accuracy of sentinel lymph node biopsy (SLNB) in breast cancer patients receiving NAC remains open to considerable debate.

Methods

We enrolled 96 patients with stage II–III breast cancer who received NAC from January 2001 to July 2010. All patients underwent breast surgery and SLNB, followed immediately by complete axillary lymph node dissection (ALND). Sentinel lymph nodes were detected with blue dye and radiocolloid injected intradermally just above the tumor and then evaluated with hematoxylin and eosin and immunohistochemical staining.

Results

The overall identification rate for SLNB was 87.5?% (84/96); the false negative rate (FNR) was 24.5?% (12/49); and the accuracy rate was 85.7?% (72/84). The FNR was significantly lower in clinically node-negative patients than in node-positive patients before NAC (5.5?% vs. 35.5?%; p?=?0.001). Accuracy was also significantly higher in clinically node-negative patients than in node-positive patients before NAC (97.2?% vs. 77.1?%; p?=?0.009). The FNR was 27.3?% among 46 clinically node-positive patients before NAC who were clinically node-negative after NAC. Among 12 patients with a complete tumor response (CR), the FNR was 0?%, compared with 26.1?% for 83 patients with a partial response and stable disease (p?=?0.404).

Conclusions

Although associated with a high FNR after NAC, SLNB would have successfully replaced ALND in clinically node-negative patients before NAC and in patients with a CR after NAC.     

Measuring the Quality of Sentinel Lymph Node Biopsy in Breast Cancer Using Newly Developed Quality Indicators: A Feasibility Study

Background

Measurement of the quality of sentinel lymph node biopsy (SLNB) has not been reported beyond the false-negative rate and sentinel lymph node identification rate. This study’s purpose is to determine the feasibility of measuring 11 quality indicators (QIs) that were recently developed using a modified Delphi process.

Methods

All patients who underwent SLNB for breast cancer at a tertiary health-care center from January 1st 2005 to December 31st 2007 were identified using a SLNB registry. Patient charts were reviewed retrospectively and the QIs were abstracted.

Results

Nine of the 11 QIs were measurable: 7 required chart-level abstraction, 2 were confirmed at an institutional level, and 2 were immeasurable due to registry limitations. Of the 497 identified patients, 13 patients had failed SLNB, resulting in 484 SLNBs. The axillary positivity rate was 19%. The method of SLN identification was reported in 97% of cases, and in 388 (80%) more than one SLN was removed. All SLNs were serially sectioned according to protocol, though only 102 (21%) of pathology reports explicitly stated the cancer stage. Nearly all SLNBs were performed alongside the primary breast surgery. Among SLN-positive patients: 78 (87%) underwent axillary lymph node dissection, 10 patients refused, and chart data were missing in 2 others. No “ineligible” patients had SLNB.

Conclusion

Measurement of newly developed QIs for SLNB is feasible for abstraction from inpatient charts at a single institution. These QIs can provide baseline measures for ongoing quality assessment of SLNB using hospital chart review.     

Sentinel Node Biopsy is Indicated for Thin Melanomas?≥0.76?mm

Background

A consensus for which patients with thin melanomas (??1?mm) should undergo sentinel lymph node biopsy (SLNB) is not established. We describe a large single institution experience with SLNB for thin melanomas to determine factors predictive of nodal metastases.

Methods

Retrospective review from 2005 to 2010 identified 271 patients with thin melanomas who underwent SLNB, along with 13 additional patients not treated with SLNB who developed a nodal recurrence as first site of recurrence. Clinicopathologic characteristics were correlated with nodal status and outcome.

Results

Median age was 55?years, and 53?% of patients were male. Median Breslow thickness was 0.85?mm. Overall, a positive sentinel lymph node (SLN) was found in 22 (8.1?%) of 271 cases; 8.4?% of melanomas???0.76?mm were SLN positive with 5?% of T1a melanomas???0.76?mm and 13?% of T1b melanomas???0.76?mm having SLN metastases. Only two of 33 highly selected patients with melanomas?<0.76?mm (both T1b) had a positive SLN. Logistic regression analysis demonstrated that mitotic rate???1/mm² significantly correlated with nodal disease (p?p?p?=?0.53) but was worse for patients presenting with a nodal recurrence (p?Conclusions SLN metastases were seen in 8.4?% of thin melanomas???0.76?mm, including 5?% of T1a melanomas???0.76?mm. We believe these rates are sufficient to justify consideration of SLNB in these patients, while the indications for SLNB in melanomas?<0.76?mm remain to be defined.     

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.     

Axillary Reverse Mapping: A Prospective Study in Women with Clinically Node Negative and Node Positive Breast Cancer

Background

The primary aim of axillary reverse mapping (ARM) is to prevent lymphedema by preserving arm versus breast axillary lymphatics. Concerns regarding feasibility and oncologic safety have limited the adoption of the technique. This prospective study was undertaken to investigate ARM in clinically node negative and node positive breast cancer patients.

Methods

A total of 184 patients underwent 212 ARM procedures: 155 sentinel lymph node biopsies (SLNB) without axillary lymph node dissection (ALND) (group 1) and 57 ALNDs with/without SLNB (group 2). ARM lymphatics were not preserved if they were a SLN, directly entered a SLN, or were within ALND boundaries during ALND.

Results

SLN with radioisotope alone was successful in 92 % of procedures (181 of 197). ARM identification was 47 % (73 of 155) in group 1. Criteria were met in 30 % (47 of 155) for preservation, and 25 % (38 of 155) were preserved. Of those who met preservation criteria, 81 % (38 of 47) were preserved. In group 2, ARM identification was 72 % (41 of 57); 7 met criteria for preservation and were preserved. Of the ARM nodes, 10 % (22 of 212) were SLNs (crossover). ARM nodes contained metastatic disease in one crossover and two nonsentinel ARM nodes in clinically node positive patients with N2/N3 disease.

Conclusions

ARM is a feasible technique for identification and preservation of axillary arm lymphatics with an acceptable incidence of SLN crossover. A larger sample size is needed to determine if ARM can reduce the incidence of lymphedema in patients undergoing SLNB alone and to confirm the absence of ARM metastases in clinically node negative patients undergoing ALND.     

The accuracy of sentinel lymph node biopsy in multicentric and multifocal invasive breast cancers

BACKGROUND: Sentinel lymph node biopsy (SLNB) has proved to be an accurate alternative to complete axillary lymph node dissection (ALND) in clinically node-negative breast cancer patients. Multicentric (MC) and multifocal (MF) invasive breast cancers are considered to be relative contraindications to SLNB. We examine the accuracy of SLNB in patients with MC and MF invasive breast cancers. STUDY DESIGN: From September 1996 to August 2001, a total of 3,501 patients with clinically node-negative breast cancer underwent SLNB using both blue dye and radioisotope at our institution. A total of 70 patients had MC or MF invasive breast cancer, a successful SLNB, and mastectomy for local control. All had >/=10 axillary nodes excised (including the SLN) in a planned ALND. Exclusion criteria included MC and MF in situ carcinoma; breast conservation; previous breast irradiation, ALND, or SLNB; recurrent breast cancer; neoadjuvant chemotherapy; or ALND based solely on SLNB pathologic examination. RESULTS; The incidence of axillary metastases was 54% (38 of 70). SLNB accuracy was 96% (67 of 70), sensitivity 92% (35 of 38), and false-negative rate 8% (3 of 38). All patients with an inaccurate SLNB had a dominant invasive tumor >5 cm and one patient had palpable axillary disease intraoperatively. The SLN was the only site of axillary metastasis in 37% (14 of 38). Results were compared with those of published SLNB validation studies, most of which reflect experience with single-site invasive breast cancers. No statistically significant difference was noted for accuracy, sensitivity, or false-negative rate. CONCLUSIONS: SLNB accuracy in MC and MF disease is comparable with that of published validation studies. MC and MF patients with a dominant T3 tumor (>5 cm) or axillary disease palpable intraoperatively should have a concurrent formal ALND. Our retrospective data suggest SLNB may be used as a reliable alternative to conventional ALND in selected patients with MC or MF disease. Further studies in this patient population are warranted.     

γ探测仪在乳腺癌前哨淋巴结定位活检中的应用

目的:探讨γ探测仪在临床腋窝淋巴结阴性乳腺癌前哨淋巴结定位活检术(SLNB)中的临床应用价值.方法:利用99m锝-右旋糖酐(99mTc-DX)作为前哨淋巴结(SLN)示踪剂,应用γ探测仪定位对29例临床腋窝淋巴结阴性乳腺癌病人实施SLNB,随后进行常规腋窝淋巴清扫术,分析SLNB对腋窝淋巴结转移状态的预测价值.结果:本组SLN转移率为41.67%,非SLN转移率仅为22.54%,两者有明显差异(P＜0.001).在19例常规病理SLN阴性病人中,连续切片发现2例SLN微转移.在12例SLN癌转移中,5例(41.66%)SLN为惟一的转移部位.有1例SLN阴性病人"跳跃转移".本组SLN的敏感性为92.31%,特异性为94.12%,假阴性为7.69%,准确率达96.55%.结论:SLN能准确反映早期乳腺癌腋窝淋巴结转移状态,连续切片能提高SLNB的准确性.     

Outcome of sentinel lymph node biopsy in breast cancer using dye alone: a single center review with a median follow-up of 5 years

Purpose

Various techniques are used for sentinel lymph node biopsy (SLNB) in breast cancer. While subareolar injection with dye alone is a relatively easy method, few studies have reported the outcome with a follow-up period. This study presents our results of SLNB using dye alone.

Methods

Between November 2002 and December 2010, 701 patients with breast cancer underwent SLNB using subareolar injection of indocyanine green or indigo carmine. Sentinel lymph node (SLN)-negative patients were followed without axillary lymph node dissection (ALND).

Results

SLNs were detected in 654 of 701 patients (93.3 %), and the rate increased to 98.1 % over the course of the study. The mean number of SLNs removed was 1.5. There was no significant difference in the detection rate between two dyes. No adverse events resulted from the injection of dyes. Of the 654 patients, 136 (20.8 %) had SLN metastasis. Five hundred patients were followed without ALND. Thirty-six patients experienced disease relapse during a median follow-up of 60 months. Thirteen patients (2.6 %) had regional lymph node relapse, and eight of them could undergo salvage lymph node dissection. The 5-year disease-free and overall survival rates were 92.4 and 96.1 %, respectively.

Conclusion

SLNB using subareolar injection with dye alone was safe and feasible even after a long follow-up.     

Desmoplastic Melanoma: Is There a Role for Sentinel Lymph Node Biopsy?

Background

The utility of sentinel lymph node biopsy (SLNB) for desmoplastic melanoma (DM) is debated. We describe a large single-institution experience with SLNB for DM to determine clinicopathologic factors predictive of SLN metastasis.

Methods

Retrospective review identified 205 patients with DM who underwent SLNB from 1992 to 2010. Clinicopathologic characteristics were correlated with SLN status and outcome.

Results

Median age was 66 years, and 69 % of patients were male. Median Breslow thickness was 3.7 mm. In 128 cases (62 %), histologic subtype data was available; 61 cases (47.7 %) were mixed and 67 cases (52.3 %) were pure DM. A positive SLN was found in 28 cases (13.7 %); 24.6 % of mixed and 9 % of pure DM had SLN metastases. Multivariable analysis demonstrated that after controlling for age, histologic subtype correlated with SLN status [odds ratio: 3.0 for mixed vs pure, 95 % confidence interval: 1.1–8.7; p < .05]. Completion lymph node dissection was performed in 24 of 28 positive SLN patients with 16.7 % of cases having additional nodal disease. After a median follow-up of 6.3 years, 38 patients developed recurrence and 61 patients died. Positive SLN patients had a significantly higher risk of melanoma-related death compared with negative SLN patients (p = .01).

Conclusions

The overall risk for SLN metastasis for DM is 13.7 % and is significantly higher for mixed (24.6 %) compared with pure (9.0 %) DM. We believe that these rates are sufficient to justify consideration of SLNB for both histologic variants, especially since detection of SLN disease appears to predict a higher risk for melanoma-related death.     

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.

     

Can intraoperative frozen section influence the extension of central neck dissection in cN0 papillary thyroid carcinoma?

Purpose

Ipsilateral central compartment node dissection has been proposed to reduce the morbidity of prophylactic bilateral central compartment node dissection in papillary thyroid carcinoma (PTC), but it carries the risk of contralateral metastases being overlooked in approximately 25 % of patients. We aimed to verify if frozen section examination (FSE) can identify patients who could benefit from bilateral central compartment node dissection.

Methods

All the consenting patients with clinically unifocal PTC, without any preoperative evidence of lymph node involvement, observed between September 2010 and September 2011 underwent total thyroidectomy plus bilateral central compartment node dissection. Ipsilateral central compartment nodes were sent for FSE.

Results

Forty-eight patients were included. Mean number of removed nodes was 13.2?±?6.8. Final histology showed lymph node metastases in 21 patients: ipsilateral in 15, bilateral in 6. FSE accurately predicted lymph node status in 43 patients (27 node negative, 16 node positive). Five node metastases were not detected at FSE: three were micrometastases (≤2 mm). Sensitivity, specificity and overall accuracy of FSE in definition of N status status were 80.7, 100, and 90 %, respectively.

Conclusions

FSE is accurate in predicting node metastases in clinically unifocal node negative PTC and can be useful in determining the extension of central compartment node dissection. False-negative results are reported mainly in case of micrometastases, which usually have limited clinical implications.     

Sentinel Lymph Node Biopsy in Multicentric Breast Cancer: Five-Year Results in a Large Series from a Single Institution

Purpose

This study was designed to present the 5-year results of patients with multicentric breast cancer who underwent sentinel lymph node biopsy (SLNB) in a single institution.

Methods

Between June 1999 and December 2007, 337 patients with multicentric breast cancer and a clinically negative axilla underwent lymphatic mapping by a single periareolar/peritumoral (n = 306) or a double peritumoral or subdermal injection (n = 31) of ^99mTc-HSA nanocolloids. The sentinel lymph node (SLN) was evaluated by intraoperative frozen section and axillary dissection was performed only in cases of positive SLNB.

Results

The median age of the patients was 48 (range, 22–81) years. The mean number of hot spots identified was 1.4 in the whole series, 1.3 in patients who received a single injection, and 1.7 in those who received a double injection (P < 0.001). The mean number of removed SLNs was 1.7 (median, 1; range, 1–7) with an identification rate of 100%. A total of 138 patients with negative SLNB (n = 134) or isolated tumor cells in the SLN (n = 4) did not receive completion axillary lymph node dissection (CALND). In these latter patients, a total of 27 events (19.5%) occurred with 3 patients (2.2%) developing axillary recurrences after a median follow-up of 5 years (range, 17–134 months).

Conclusions

Axillary lymph node reappearance was infrequent among patients with multicentric breast cancer, having negative SLNB and no CALND. We recommend SLNB as the standard procedure for nodal staging in patients with multicentric breast cancer and a clinically negative axilla.     

An Opportunity to Ensure High-Quality Melanoma Care Through the Use of a Preoperative Treatment Algorithm

Background

Studies have demonstrated variable adherence to published melanoma treatment guidelines. Payers have used algorithms to preapprove certain tests and treatments. Our objective was to develop a preoperative treatment assessment algorithm to ensure patients with melanoma receive recommended care.

Methods

A treatment algorithm was developed using existing guidelines. Records of patients presenting with melanoma between September 2010 and May 2012 were reviewed. Surgical care was classified as having been adherent or nonadherent with the guideline-based algorithm. The algorithm was incorporated into a Web site for preoperative treatment verification.

Results

A treatment algorithm was developed on the basis of three critical pieces of preoperative data: Breslow thickness, presence of adverse primary tumor prognostic factors, and regional lymph node metastases. Treatment options included wide local excision (WLE), sentinel lymph node biopsy (SLNB), and completion/formal lymph node dissection. Of 328 patients evaluated, 316 (96 %) were treated according to the guideline-based algorithm. Causes of variation from predicted treatment included patient preference, severe comorbidities, difficult tumor location, and uncertain depth. All departures (n = 12) were in clinically node-negative patients: six patients did not undergo SLNB as indicated, and six underwent SLNB that was not concordant with the algorithm. An algorithm-embedded Web site was designed for preoperative verification of planned procedures.

Conclusions

As a proof of principle, an algorithm was developed to preoperatively verify that proposed melanoma treatments are concordant with established guidelines. These three pieces of information could be required during precertification, and nonconcordant treatment plans could prompt a peer-to-peer discussion. After additional pilot testing, the algorithm could offer a novel approach for quality improvement and provide a preoperative, prospective safeguard to ensure high-quality care for melanoma patients.     

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.     

Sentinel Lymph Node Biopsy Using Intraoperative Indocyanine Green Fluorescence Imaging Navigated with Preoperative CT Lymphography for Superficial Esophageal Cancer

Background

The sentinel lymph node (SLN) concept has been gaining attention for gastrointestinal neoplasms but remains controversial for esophageal cancer. This study evaluated the feasibility of SLN identification using intraoperative indocyanine green (ICG) fluorescence imaging (IGFI) navigated by preoperative computed tomographic lymphography (CTLG) to treat superficial esophageal cancer.

Methods

Subjects comprised 20 patients clinically diagnosed with superficial esophageal cancer. Five minutes after endoscopic submucosal injection of iopamidol around the primary lesion using a four-quadrant injection pattern with a 23-gauge endoscopic injection sclerotherapy needle, three-dimensional multidetector computed tomography was performed to identify SLNs and lymphatic routes. ICG solution was injected intraoperatively around the tumor. Fluorescence imaging was obtained by infrared ray electronic endoscopy. Thoracoscope-assisted standard radical esophagectomy with lymphadenectomy was performed to confirm fluorescent lymph nodes detected by CTLG.

Results

Lymphatic vessels and SLNs were identified preoperatively using CTLG in all cases. Intraoperative detection rates were 100% using CTLG and 95% using IGFI. Lymph node metastases were found in four cases, including one false-negative case with SLNs occupied by bulky metastatic tumor that were not enhanced with both methods. The other 19 cases, including three cases of metastatic lymph nodes, were accurately identified by both procedures.

Conclusions

Preoperative CTLG visualized the correct number and site of SLNs in surrounding anatomy during routine computed tomography to evaluate distant metastases. Referring to CTLG, SLNs were identified using IGFI, resulting in successful SLN navigation and saving time and cost. This method appears clinically applicable as a less-invasive method for treating superficial esophageal cancer.     

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.     

The Role for Sentinel Lymph Node Dissection after Neoadjuvant Chemotherapy in Patients who Present with Node-Positive Breast Cancer

Background

Sentinel lymph node (SLN) dissection has been investigated after neoadjuvant chemotherapy and has shown mixed results. Our objective was to evaluate SLN dissection in node-positive patients and to determine whether postchemotherapy ultrasound could select patients for this technique.

Methods

Between 1994 and 2010, 150 patients with biopsy proven axillary metastasis underwent SLN dissection after chemotherapy and 121 underwent axillary lymph node dissection (ALND). Clinicopathologic characteristics were analyzed before and after chemotherapy. Statistical analyses included Fisher??s exact test for nodal response and multivariate logistic regression for factors associated with false-negative events.

Results

Median age was 52?years. Median tumor size at presentation was 2?cm. The SLN was identified in 93?% (139/150). In 111 patients in whom a SLN was identified and ALND performed, 15 patients had a false-negative SLN (20.8?%). In the 52 patients with normalized nodes on ultrasound, the false-negative rate decreased to 16.1?%. Multivariate analysis revealed smaller initial tumor size and fewer SLNs removed (<2) were associated with a false-negative SLN. There were 63 (42?%) patients with a pathologic complete response (pCR) in the nodes. Of those with normalized nodes on ultrasound, 38 (51?%) of 75 had a pCR. Only 25 (33?%) of 75 with persistent suspicious/malignant-appearing nodes had a pCR (p?=?0.047).

Conclusions

Approximately 42?% of patients have a pCR in the nodes after chemotherapy. Normalized morphology on ultrasound correlates with a higher pCR rate. SLN dissection in these patients is associated with a false-negative rate of 20.8?%. Removing fewer than two SLNs is associated with a higher false-negative rate.     

Can Sentinel Lymph Node Biopsy Be Omitted in Patients With Favorable Breast Cancer Histology?

Background The widespread use of sentinel lymph node biopsy (SLNB) to replace axillary dissection has broadened the indications for axillary staging in breast cancer. Recent studies have demonstrated a finite risk of lymphedema and sensory morbidity associated with SLNB. We undertook this study to determine whether SLNB could be omitted in clinically node-negative patients with favorable-histology breast cancer.Methods We conducted a retrospective review of a prospective database of SLNBs performed at Memorial Sloan-Kettering Cancer Center from 1996 to 2003 to determine the incidence of lymph node metastases by histological subtype. For the favorable subtypes, the patients age, tumor size, estrogen receptor status, lymphovascular invasion, nuclear grade, and histological grade were compared by nodal status to determine their predictive value.Results A total of 196 cases with favorable breast cancer subtypes were identified with a 4.1% (8 of 196) sentinel lymph node (SLN) positivity rate. Each of the histological subtypes included patients with positive SLNs, with the exception of adenoid cystic (n = 4) and secretory (n = 1) breast carcinoma, which were quite rare in our series. When compared by nodal status, the patients age, tumor size, estrogen receptor status, lymphovascular invasion, nuclear grade, and histological grade failed to predict those with positive SLNs.Conclusions Patients with favorable breast cancer histology have a small risk of axillary SLN metastases. The use of SLNB in these patients should be individualized, taking into consideration the small incidence of axillary metastases and the risks and benefits associated with the SLN procedure.     

The Efficacy of Lateral Neck Sentinel Lymph Node Biopsy in Papillary Thyroid Carcinoma

Background  

Although occult lymph node metastasis to the lateral neck compartment is common in papillary thyroid carcinoma, the incidence and patterns of lateral neck node metastasis in papillary carcinoma are not known. We hypothesized that sentinel lymph node biopsy (SLNB) with radioisotope in the detection of occult lateral neck node metastasis would be useful in characterizing metastasis in papillary carcinoma.     

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.