Axillary recurrence in sentinel lymph node-negative breast cancer patients

BackgroundSentinel lymph node biopsy (SLNB) was developed to axillary lymph node dissection (ALND) in the treatment of breast cancer. SLNB is predictive of axillary node status. Major concern is the occurrence of a false-negative SLN. Purpose of this study is to determine the rate of axillary recurrence in our series of unselected patients.Patients and methodsAll patients with a negative SLNB from November 1999 to December 2006 have been treated and followed at our unit. Information on patients' characteristics, treatment and follow-up has been collected.ResultsEight-hundred and four patients with negative SLNB did not receive ALND. After a median follow-up of 38.8 months, 21 patients had distant metastases, four had axillary relapse, nine had an in-breast recurrence and two had both. All patients with axillary recurrence received axillary dissection and systemic adjuvant therapy. They are all presently alive and free from disease.ConclusionData from this series, the largest from a general hospital, showed that isolated axillary node recurrence after negative SLNB is rare (<1%) and comparable with those reported from referral cancer institutions. We confirm that SLNB for the treatment of early breast cancer patients of a community-based hospital is safe and reliable.     

Axillary recurrence following conservative surgery and radiotherapy in early breast cancer

At the institute, since the late 1980s, there has been a uniform treatment protocol for the management of the regional lymph nodes in patients referred for radiotherapy following breast-conserving surgery. An analysis of 2,277 consecutive patients referred for radiotherapy between 1989 and 1992, with particular reference to regional lymph node management, has been undertaken. Axillary surgery alone was used in 517 patients (23%); 1,191 (52%) patients had no axillary surgery but had radiotherapy to the axilla, and infraclavicular and supraclavicular fossae by a single anterior field, delivering 40 Gy in 15 daily fractions over 3 weeks; and 474 patients (21%) had axillary surgery followed by radiotherapy. Ninety-five patients (4%) underwent no axillary treatment. There was a total of 155 axillary recurrences with a median follow-up of 5.9 years, giving an actuarial nodal control rate of 94% at 5 years (95% confidence interval (CI) 93.1-95.1). The overall survival at 5 years was 86% (95% CI 84.6-87.5). There was a trend towards improved axillary control with surgery alone compared with radiotherapy alone (4.5% versus 5.9% actuarial axillary failure rate at 5 years). An extremely low incidence of brachial plexus neuropathy secondary to radiotherapy was reported. The multidisciplinary treatment protocol used gave a high rate of regional node control, with minimal recorded morbidity.     

Axillary recurrence after negative sentinel lymph node biopsy under local anesthesia in breast cancer

The procedure known as sentinel lymph node biopsy (SLNB) under local anesthesia (LA) allows surgical teams to avoid the uncertainties of frozen tissue examination and to perform axillary dissection on patients who have been informed of the risks of lymph node invasion prior to the procedure.     

Axillary dissection in breast cancer revisited

The pathological status of the axillary nodes remains the single most determining factor for survival, local recurrence and disease-free interval in operable breast cancer. Radical axillary dissection results in better local control with or without systemic disease in all operable cases. In pathologically negative cases, radical axillary dissection decreases local recurrence rates and perhaps prolongs disease-free survival. In pathologically positive cases, radical axillary dissection improves local control only. Radical axillary dissection avoids axillary irradiation and so decreases the risk and the importance of lymphoedema. Perfect axillary dissection does not show a decisive advantage over less complete axillary dissection when the 'quality' of surgery is measured by lymphoscintigraphy, but it should be kept in mind that only total control of the local situation can ensure a patient free of distal spread at the time of first therapy.     

Axillary surgery in breast cancer patients

Surgeons have routinely removed ipsilateral axillary lymph nodes from women with breast cancer for over 100 years. The procedure provides important staging information, enhances regional control of the malignancy and may improve survival. As screening of breast cancer has increased, the mean size of newly diagnosed primary invasive breast cancers has steadily decreased and so has the number of women with lymph node metastases. Recognising that the therapeutic benefit of removing normal nodes may be low, alternatives to the routine level I/II axillary lymph node dissection have been sought. A decade ago sentinel lymph node biopsy (SLNB) was introduced. Because of its high accuracy and relatively low morbidity, this technique is now widely used to identify women with histologically involved nodes prior to the formal axillary node dissection. Specifically, SLNB has allowed surgeons to avoid a formal axillary lymph node biopsy in women with histologically uninvolved sentinel nodes, while identifying women with involved sentinel nodes who derive the most benefit from a completion axillary node dissection. Despite the increasing use of SLNB for initial management of the axilla in women with breast cancer, important questions remain regarding patient selection criteria and optimal surgical methods for performing the biopsy. This article discusses the evolution of axillary node surgery for women with breast cancer.     

乳腺癌腋窝淋巴结跳跃式转移的临床病理研究

目的 探讨乳腺癌腋窝淋巴结跳跃式转移与患者临床病理特征的关系及其对预后的影响.方法 回顾性分析1502例行完全腋窝淋巴结清除术乳腺癌患者的临床资料,观察腋窝淋巴结跳跃式转移的发生规律,分析其与患者临床病理特征的关系及对预后的影响.结果 有淋巴结转移者814例,其中腋窝淋巴结跳跃式转移者119例,占14.6%;跳跃式转移中,最常见的是从第Ⅰ、Ⅱ水平跳过第Ⅲ水平至腋尖,发生率为5.2%.跳跃式转移的发生与患者的年龄、肿瘤大小、临床分期以及雌激素受体状态均无关(均P＞0.05).Ⅰ～Ⅱ期患者中,跳跃式转移组的10年无病生存率较非跳跃式转移组低(58.5%∶ 77.3%,P＝0.003);Ⅲ期患者中,两组的10年无病生存率差异无统计学意义(50.0%∶ 57.6%,P＝0.457).Cox多因素分析显示,肿块大小、淋巴结转移数目、淋巴结结外是否受侵及是否发生跳跃式转移,是影响患者预后的独立因素.结论 某些常见的临床病理指标尚不能准确地预测腋窝淋巴结跳跃式转移的发生;早期乳腺癌发生跳跃式转移者预后差,对其应坚持严格而规范的治疗.     

Axillary metastasis in clinically node-negative breast cancer

Aim of work

This study investigates the factors related to metastasis detection in a sentinel lymph node biopsy (SLN) in patients without clinical axillary involvement.

乳腺癌术中反向腋窝淋巴作图研究进展

腋窝反向淋巴作图是国外近两年提出的旨在保护上肢淋巴回流通路的一项新的微创技术,其目的在于通过作图示踪上肢淋巴回流通路,术中尽量予以保护,从而减少上肢水肿这一乳腺癌术后常见并发症的发生.     

Axillary reverse mapping for breast cancer

The axillary reverse mapping (ARM) technique has been developed to map and preserve arm lymphatic drainage during axillary lymph node dissection (ALND) and/or sentinel lymph node (SLN) biopsy, thereby minimizing arm lymphedema. However, several problems remain to be resolved in the practical application of this technique. This article presents a review of current knowledge regarding ARM and discusses the practical applicability and relevance of this technique. Identification rates of ARM nodes were insufficient using blue dye. Although this was improved using radioisotopes, radioisotopes alone do not permit visual mapping of ARM lymphatics. Fluorescence imaging may be useful to improve the identification rate of ARM nodes and lymphatics. On the other hand, the ARM nodes may be involved with metastatic foci in patients with extensive axillary lymph node metastases. Moreover, the SLN draining the breast may be the same as the ARM node draining the upper extremity in a minority of patients. These issues represent important drawbacks of the ARM procedure. The success of ARM in reducing lymphedema has not yet been determined. Further studies are needed before this can be accepted as a standard procedure in surgical management of breast cancer.     

Axillary recurrence in women with a negative sentinel lymph node and no axillary dissection in breast cancer

OBJECTIVES: Sentinel lymph node biopsy (SLNB) is widely used for staging breast cancer. SLNB accurately determines axillary lymph node status with a low false negative rate. There remains concern that omitting axillary dissection may lead to recurrence in the axilla, and impact long term survival. The purpose of this study was to determine the frequency of axillary lymph node recurrence in patients who had a negative sentinel lymph node and did not undergo axillary node dissection. METHODS: Data was collected on all patients who had negative SLNB at Roswell Park Cancer Institute between July 1997 and June 2002. Demographics, type of operation, postoperative systemic, and radiation therapy, co-morbidity score, hormone receptor status, and the pathologic features of the tumor were abstracted for each patient. For each woman with recurrence, the dates of recurrence, the site(s) of recurrence, and the treatment for recurrence were recorded. RESULTS: With a median follow-up of 33 months, 15 of 335 (4.5%) women who had negative SLNBs and who did not undergo completion axillary dissection developed a cancer recurrence. Only two patients (0.6%) had an axillary recurrence. CONCLUSIONS: The rate of axillary recurrence following a negative sentinel node biopsy is the same or less than axillary lymph node dissection (ALND) alone. Concerns that omitting completion axillary dissection following a negative SLNB will increase the rate of axillary recurrence appear unfounded.     

Axillary disease recurrence after sentinel lymph node dissection for breast carcinoma

BACKGROUND: Surgical recommendation for early-stage breast carcinoma includes removal of the primary breast tumor and evaluation of the axillary lymph nodes on the ipsilateral side. Sentinel lymph node dissection (SLND) is increasingly being used to evaluate axillary lymph nodes in clinically lymph node negative patients as an alternative to axillary lymph node dissection (ALND). Results from SLND are highly predictive of metastatic involvement in the axilla, and are associated with fewer side effects. However, the greatest concern with SLND alone is the potential for a higher rate of axillary lymph node recurrence. The purpose of the current study was to review data collected on 700 consecutive patients with early-stage breast carcinoma who underwent SLND without concomitant ALND. METHODS: A retrospective study was conducted using the oncology registry at Park Nicollet Health Services (Minneapolis, MN). Consecutive breast carcinoma cases with SLND only for axillary surgery, from January 28, 1999 to December 31, 2003, were included in the study. During this period, 700 patients with breast carcinoma were identified who had SLND alone. Fifty-two patients were excluded from the analysis because they had ductal carcinoma in situ. RESULTS: With a median follow-up of 33 months (range, 2-73 mos), axillary lymph node recurrence occurred in 4 of 647 (0.62%) patients overall. In these 4 patients, the axillary lymph node recurrences were isolated to the axillary lymph nodes and amenable to surgery. CONCLUSIONS: Data from the current study showed that axillary lymph node recurrence after SLND occurred very infrequently in early-stage breast carcinoma, and these results were comparable to other studies.     

Axillary recurrence after negative sentinel lymph node biopsy without axillary dissection: a study on 479 breast cancer patients.

AIMS: To determine the axillary recurrence rate in breast cancer patients with negative sentinel lymph nodes (SLN) who did not undergo further axillary lymph node dissection (ALND), and to establish whether this conservative axillary approach leads to an increased recourse to diagnostic axillary biopsy during the follow-up period because of the clinical suspicion of nodal recurrence. METHODS: In 479 patients, operated on for early breast cancer between 1998 and 2002 in five institutions, SLN biopsy was negative and no further axillary surgery was performed. SLN was localized using subdermal injection with 30-50 MBq of 99m-Tc-colloidal albumin. Follow-up controls were performed at 6-monthly intervals. RESULTS: The mean number of SLNs removed was 1.4 per patient. Most patients (90.6%) were given adjuvant systemic therapy, based on the primary tumour characteristics. At a median follow-up of 35.8 months, no clinical axillary recurrence was found. No patient underwent surgical axillary biopsy for suspicious clinical or ultrasonographic findings. CONCLUSIONS: Our results confirm that SLN biopsy without ALND in SLN-negative patients with early breast cancer is not followed by clinically evident axillary recurrence in the short-term.     

Axillary lymph-node dissection for positive sentinel nodes in breast cancer patients.

AIM: The aim was to identify a subset of breast cancer patient with positive sentinel nodes (SNs) for whom secondary axillary clearance would be unnecessary.METHODS: Between March 1999 and May 2001, 288 patients with T0-T2 breast cancer less than 3cm in diameter had SN detection either by a colorimetric method or using a combined technique. SNs were stained with haematoxylin and eosin (H&E). For all negative SNs, serial sections and immunochemistry (IHC) were performed. All patients with positive SNs underwent a complete axillary lymph node dissection. One hundred and twenty patients were SN positve.RESULTS: Non-sentinel node positivity (NSNP) was closely associated with the size of the tumour (14.3%, 54.1% and 51.8% for pT1a-b, pT1c and pT2 tumours respectively) and with the size of the SN metastasis: 15.9% IHC detected micrometastasis, 33.3% and 78.8% micro- and macrometastasis detected with H&E staining respectively. NSNP was found in 24.0% and 42.8% of patients with pT1c breast cancer and with micrometastasis detected by IHC and H&E staining. The node positivity rate reached 81.1% for pT1c lesions with macrometastasis in the SN. For the patients with pT2 breast cancer, these rates were 12.5% (IHC), 28.5% (H&E) 91.1% (macrometastasis).CONCLUSIONS: We are unable to isolate precisely a subset of patients for whom total axillary lymph node dissection would be unnecessary. A subset of 14 small tumours (<1cm diameter) demonstrated micrometastases in the SN without NSNP.     

Axillary recurrence after sentinel lymph node biopsy.

Sentinel lymph node biopsy (SLNB) without further axillary dissection in patients with sentinel node-negative breast carcinoma appears to be a safe procedure to ensure locoregional control. During a median follow-up of 35 months the false-negative rate was 1% in our study population of 185 patients. BACKGROUND: The objective of this prospective study is to provide data on follow-up of patients with primary operable breast carcinoma staged with SLNB without axillary lymph node dissection (ALND) if the sentinel lymph nodes (SLNs) were tumour-negative. METHODS: One hundred and eighty-five patients were enrolled. Preoperative dynamic and static lymphoscintigraphy were performed; both a vital blue dye and a gamma detection probe were used intraoperatively. Patients with tumour-positive SLNs received completion ALND or if no SLNs could be identified. All patients were monitored according to regional follow-up protocols. RESULTS: The SLNs were identified in 179 out of the 185 patients. In 73 patients the SLNs were tumour-positive and in 106 patients tumour-negative. The median follow-up was 35 months (range 17-59). In one SLN-negative patient an axillary recurrence occurred 26 months after the SLNB (false-negative rate: 1%). CONCLUSIONS: SLNB without ALND appears to be a safe procedure to ensure locoregional control in SLN-negative breast carcinoma, if carried out by an experienced team.