Accuracy of Methylene Blue Test as Single Technique for Sentinel Lymph Node Biopsy in Early Stages Breast Cancer

Aim: Sentinel Lymph Node Biopsy (SLNB) establishes as a gold standard for diagnostic lymph node involvement in early breast cancer. Most of the developed country does not have radiotracer and nuclear medicine facilities. Unless in Indonesia there is Methylene Blue as an alternative agent for SLNB. This study measure accuracy of sentinel lymph node biopsy as a single technique using the Methylene Blue test. Methods: This cross-sectional study enrolled 60 female patients with breast cancer stage I-II. We performed SNB using 2-5 cc of 1% Methylene-blue dye (MBD) injected to periareolar tissue and proceeded with axillary lymph nodes dissection (ALND). The histopathology results of sentinel nodes (SNs) and axillary lymph nodes (ALNs) analyze for diagnostic value assessments. Results: The identification rate of SN was 97.62 %, and the median number of identified SNs was 4 (2-7). Sentinel node metastasis was found in (19/60) % cases and % of them were macrometastases. The sensitivity and specificity of MBD were 91.67% and 96.67% respectively. The negative predictive value (NPV) of SNs to predict axillary metastasis was 96.67% (95% CI, 81-99%). Conclusion: Injection of 1% MBD as a single technique in breast cancer SNB has a favorable identification rate and predictive value.     

Micro-metastases in axillary lymph nodes: an increasing classification and treatment dilemma in breast cancer due to the introduction of the sentinel lymph node procedure

BACKGROUND: Sentinel lymph node (SN) biopsy will increasingly replace axillary lymph node dissection (ALND) for staging in breast cancer. For daily practice, examination of the SN by serial sectioning (SS) and/or immunohistochemistry (IHC) is being promoted. Use of these techniques may result into stage migration due to the increased detection of micro-metastases. The consequence may be overshooting of patients with adjuvant therapy, as the prognostic relevance of (small) micro-metastases and isolated tumor cells is unclear. METHODS: The prognostic impact of micro-metastases is determined by reviewing ALND studies with a follow up of at least 5 years, including more than 100 patients, before the SN era. Furthermore, studies in which conventionally haematoxylin-eosin (H&E) negative SNs are investigated for occult metastases by SS and/or IHC are reviewed. RESULTS: In only one of eight studies, occult metastases were an independent risk factor for reduced survival. The outcome is dependent on the size of the nodal metastasis. IHC and SS as used in the SN procedure indeed induce a shift from pNO to pN1a (according to TNM). CONCLUSION: By the thorough pathologic examination of the SN, isolated tumor cells and micro-metastases are more frequently detected. We propose to classify small micro-metastases (<0.5 mm) in a separate pN1a(min) category (min for minimal) to prevent stage migration. As the prognostic relevance of isolated tumor cells and (small) micrometastases has not been proven, the value of adjuvant therapy can be questioned for patients with otherwise good prognostic factors.     

Can magnetic resonance imaging be used to select patients for sentinel lymph node biopsy in prophylactic mastectomy?

BACKGROUND: Sentinel lymph node biopsy (SLNB) in the setting of prophylactic mastectomy (PM) remains controversial. In the current study, recent experience with PM was described and the value of preoperative magnetic resonance imaging (MRI) was analyzed in selecting patients for PM with or without SLNB. METHODS: Between January 1999 and January 2006, 529 patients underwent 613 PMs. Both preoperative magnetic resonance imaging (MRI) and SLNB were performed selectively at the discretion of the surgeon. RESULTS: Occult cancer was identified in 33 of 613 PMs (5%) (10 invasive and 23 ductal carcinoma in situ cases). PM with SLNB was performed in 393 of 529 patients (74%), 178 of whom underwent MRI. Of these, occult cancer was found in 6 of 178 patients (3%), all of whom had negative SLNB. Preoperative MRI was concordant with PM in 4 of 6 cases with occult carcinoma. The remaining 215 of 393 patients (55%) underwent PM with SLNB without MRI. Occult cancer was found in 18 of 215 patients (8%); 3 had positive SLNB. Overall, PM with SLNB spared 4 of 393 patients (1%) from axillary lymph node dissection (ALND). Among 136 patients undergoing PM alone, 57 had preoperative MRI. MRI detected 5 cancers and PM revealed an additional 4 occult carcinomas not detected by MRI. Overall, 9 of 136 patients (7%) undergoing PM alone were found to have occult cancer, 3 of which were invasive, raising the decision of reoperation with ALND. CONCLUSIONS: Occult cancer was identified in 5% of PMs. PM with or without SLNB spared only 4 of 393 patients (1%) from undergoing ALND, whereas PM alone identified unsuspected invasive disease in 3 of 136 patients (2%). When performed, MRI accurately ruled out the presence of an invasive cancer in the prophylactic breast, suggesting that MRI can be used to select patients for PM without SLNB.     

Decision analysis to assess the efficacy of routine sentinel lymphadenectomy in patients undergoing prophylactic mastectomy

BACKGROUND: Patients who have invasive breast cancer identified after prophylactic mastectomy (PM) require axillary lymph node dissection (ALND) for lymph node staging (ie, directed ALND). Because the majority of these patients will be lymph node negative, sentinel lymphadenectomy (SLND) has been advocated at the time of PM to avoid the sequelae of unnecessary ALND. The objective of this study was to compare the efficacy of 2 surgical strategies, routine SLND versus directed ALND, in PM patients. METHODS: A decision-analytic model was created to compare the 2 surgical strategies. Model estimates were derived from a systematic literature review. The endpoints that were examined to compare the 2 strategies were the number of SLNDs performed per breast cancer detected, the number of SLNDs attempted to avoid 1 ALND in a lymph node-negative patient with occult invasive cancer, and the number of axillary complications associated with each strategy. RESULTS: The prevalence of invasive cancer in patients undergoing PM was estimated at 1.9%. At this rate, 37 SLNDs were performed per 1 breast cancer detected, and 73 SLNDs were required to avoid 1 ALND in a lymph node-negative PM patient. In 1 model scenario, the probability of complications per breast cancer detected was 9-fold greater with the SLND strategy than with the directed ALND strategy (2.7 vs 0.3). The complication rates for the 2 strategies become equivalent in the model scenario when the prevalence of occult invasive cancer was projected to 28%. CONCLUSIONS: Routine SLND for patients undergoing PM is not warranted given the large number of procedures required to benefit 1 patient and the potential complications associated with performing SLND in all patients.     

An axilla scoring system to predict non-sentinel lymph node status in breast cancer patients with sentinel lymph node involvement

Background. Axillary lymph node dissection (ALND) is the current standard of care for breast cancer patients with sentinel lymph node (SN) involvement. However, the SN is the only involved axillary node in a significant proportion of these patients. Here we examined factors predictive of non-SN involvement in patients with a metastatic SN, in order to develop a scoring system for predicting non-SN involvement.Materials and Methods. This study was based on a prospective database of 337 patients who underwent SN biopsy for breast cancer, of whom 81 (24) were SN-positive; we examined factors predictive of non SN involvement in the 71 of these 81 women who underwent complementary ALND. All clinical and histological criteria were recorded and analysed according to non-SN status, by using Chi-2 analysis, Students t-test, and multivariate logistic regression.Results. Univariate analysis showed a significant association between non-SN involvement and histological primary tumor size (p=0.0001), SN macrometastasis (p=0.01), the method used to detect SN metastasis (H&E versus immunohistochemistry) (p=0.03), the number of positive SNs (p=0.049), the proportion of involved SNs among all identified SNs (p=0.0001) and lymphovascular invasion (p=0.006). Histological primary tumor size (p=0.006), SN macrometastasis (p=0.02) and the proportion of involved SNs among all identified SNs (p=0.03) remained significantly associated with non-SN status in multivariate analysis. Based on the multivariate analysis, we developed an axilla scoring system (range 0–7) to predict the likelihood of non-SN metastasis in breast cancer patients with SN involvement.Conclusion. In patients with invasive breast cancer and a positive SN, histological primary tumor size, the size of SN metastases, and the proportion of involved SNs among all identified SNs were independently predictive of non-SN involvement.     

Sentinel lymph node biopsy in patients with multifocal breast cancer.

BACKGROUND: Multifocal or multicentric breast cancer has been suggested as a contraindication for sentinel node biopsy (SNB). However, recent studies have demonstrated that all quadrants of the breast drain through common afferent channels to a common axillary sentinel node. This should mean that the presence of multifocal tumour should not affect the lymphatic drainage. The purpose of this study was to evaluate the feasibility and accuracy of SNB in patients with multifocal breast cancer using a peritumoural injection technique for sentinel lymph node (SN) mapping. METHODS: In the ALMANAC multicentre trial validation phase, we took SNB samples from 842 patients with node negative, invasive breast cancer with use of a blue dye and radiolabelled colloid mapping technique at the peritumoural injection site. All patients underwent standard axillary treatment after SNB. Seventy-five of the 842 patients had multifocal lesions on final histopathologic examination. The following analysis is focused on patients with multifocal lesions. RESULTS: A mean number of 2.4 SNs were identified in 71 of 75 patients (identification rate: 94.7%). Thirty-one patients had a positive SN, 40 a negative SN. Standard axillary treatment confirmed the SN to be negative in 37 of 40 patients, whereas three patients revealed positive non-sentinel lymph nodes (false-negative rate: 8.8%). Overall SN biopsy accurately predicted axillary lymph node status in 68 of 71 patients (95.8%). CONCLUSION: SNB accurately staged the axilla in multifocal breast cancer and may become an alternative to complete axillary lymph node dissection in node negative patients with multifocal breast cancer.     

Lymphatic mapping and sentinel node harvesting in patients with recurrent breast cancer

AIMS: To evaluate the feasibility and consequences of lymphatic mapping and a ("repeat") sentinel lymph node (SLN) procedure in patients with breast cancer relapse after previous breast and axillary surgery. METHODS: Review and presentation of a patient cohort. All SLN procedures included lymphoscintigraphy and blue dye injection technique. RESULTS: Twelve cases are described: two patients after a previous SLN procedure and ten after a previous complete axillary lymph node dissection (ALND). Ten patients (83%) had a successful repeat SLN biopsy. After previous ALND, lymphoscintigraphy revealed drainage towards the internal mammary chain in three patients, and contralateral axillary drainage in four. Based on the information from the "repeat" SLN biopsy further treatment strategy was altered in seven of the 12 patients. CONCLUSION: Lymphatic mapping and (repeat) SLN biopsy is possible and can be informative in patients who present with a relapse of breast cancer after previous surgery for primary breast cancer.     

Omitting axillary lymph node dissection in sentinel node negative breast cancer patients is safe: a long term follow-up analysis

PURPOSE: To evaluate the rate of axillary recurrences in sentinel node (SN) negative breast cancer patients without further axillary lymph node dissection (ALND). PATIENTS AND METHODS: Between October 1994 and November 1999, all SN negative breast cancer patients who did not underwent complete ALND were enrolled in this prospective study. SN biopsy was performed by using the triple technique which combines preoperative lymphoscintigraphy, intraoperative use of blue dye, and a handheld gamma probe to visualize and localize the SN. SNs were examined by standard hematoxylin and eosin (H&E) staining and immunohistochemistry (IHC). During the first year after surgery all patients underwent clinical examination at 3 monthly intervals. This follow-up interval was prolonged to 6 month after the first year. RESULTS: From the 104 patients, 93 (89%) underwent breast-conserving therapy; all remaining patients were treated by modified radical mastectomy. In 91 cases a ductal carcinoma and in 13 cases a lobular carcinoma was diagnosed. One SN was removed in 80, two SNs in 18, and three SNs in 2 patients. Twenty patients received systemic therapy based on age and primary tumor characteristics. After a median follow-up of 57 month only one axillary recurrence was observed. During follow-up three patients developed distant metastases. One of these patient with metastases to the bone is alive with evidence of disease. The remaining two patients died 9 and 19 month after surgery. CONCLUSIONS: Our long term follow-up results indicate that survival is excellent (98%) and local axillary control is adequate (99%) after omitting ALND in a group of 104 SN negative breast cancer patients.     

早期乳腺癌前哨淋巴结活检的研究进展

选择合适的早期乳腺癌病人进行腋窝前哨淋巴结活检,可以减少由腋窝淋巴结清扫导致的并发症。因为腋窝前哨淋巴结活检的假阴性率低,故对前哨淋巴结阴性的病人可以不做进一步腋窝淋巴结清扫。对前哨淋巴结阳性的病人,标准治疗是进一步腋窝淋巴结清扫。腋窝淋巴结放疗可能在保证疗效的前提下,替代腋窝淋巴结清扫,降低由腋窝淋巴结清扫的并发症。     

Contralateral uptake and metastases in sentinel lymph node mapping for recurrent breast cancer

BACKGROUND AND OBJECTIVES: Sentinel lymph node mapping as a constitutive component in the staging process for invasive breast cancer continues to gain acceptance. We have identified two patients with recurrent invasive breast cancer in whom contralateral sentinel lymph node uptake and metastases, respectively, were detected. Such findings have not been previously reported in our review of the medical literature between 1966 and October 2004. METHODS: Sentinel lymph node mapping was performed on two patients with recurrent invasive breast cancer at our institution. At the time of their index diagnosis, both had received breast conserving surgery and an axillary lymph node dissection with post-operative radiotherapy (RT). All lymph nodes and margins of resection were without tumor. Both patients remained with no evidence of disease for years until routine serial screening mammography was interpreted as suspicious. Each underwent a stereotactic biopsy of the ipsilateral breast corresponding to the mammographic abnormality. Pathology confirmed invasive ductal carcinoma. Both patients refused the recommended salvage mastectomy. PRINCIPAL RESULTS: During a second attempt at breast conservation, sentinel lymph node mapping--which is typically contraindicated for patients with prior axillary surgery--revealed contralateral axillary uptake for both patients. The respective contralateral sentinel node was excised with pathology revealing no tumor in one case, and a microscopic focus of metastatic carcinoma in the second case. MAJOR CONCLUSION: Some patients may benefit from sentinel lymph node mapping prior to salvage mastectomy. Identifying uptake in a contralateral sentinel lymph node may change the multi-disciplinary management of recurrent invasive breast cancer to include a contralateral axillary dissection, chemotherapy, and/or RT to the contralateral axilla.     

Detection of sentinel lymph nodes in gastric cancers based on immunohistochemical analysis of micrometastases

BACKGROUND AND OBJECTIVES: The sentinel lymph node (SN) theory has the potential to change the trend of surgery for gastric cancer that is based on wide resection of the stomach with dissection of regional lymph nodes. However, feasibility tests of SN mapping procedures in gastric cancers with analysis of micrometastasis are rare. This study aimed to estimate the clinical usefulness of SN mapping using a dual procedure with dye- and gamma probe-guided techniques for gastric cancers, based on immunohistochemical staining (IHC) analysis. METHODS: SN mapping procedures were performed on 41 patients with T1-T2 gastric cancer, and gastrectomy with D2 lymphadenectomy followed. All SNs and non-SNs obtained from the patients were tested by IHC analysis using anti-cytokeratin antibodies. RESULTS: Using the dual mapping procedure, SNs were detected in all patients (100%). SN was positive in all patients with lymph node metastasis except in one with non-solid type poorly differentiated adenocarcinoma with marked lymphatic permeation, thus achieving an accuracy rate of 98%. CONCLUSIONS: The method was accurate in predicting nodal status and could be an indicator for less invasive treatment in patients with gastric cancer.     

Which Treatment When?

Sentinel lymph node (SLN) biopsy is rapidly emerging as an alternative to axillary lymph node dissection (ALND) for many female breast cancer patients. In contrast, ALND remains the standard of care for male breast cancer patients with similar tumors. We evaluated the results of SLN biopsy in male breast cancer patients with clinically negative axillae. This study included all male breast cancer patients who underwent SLN biopsy at our institution between October 1999 and 2000. All patients had negative axillae on clinical examination and sonography. All patients underwent preoperative lymphoscintigraphy followed by SLN biopsy performed using a combination of isosulfan blue dye and technetium Tc 99m sulfur colloid. Tc 99m sulfur colloid was injected at a dose of 2.5 mCi 24 h before surgery (four patients) or 0.5 mCi 2–4 h before surgery (three patients). Intraoperatively, 5 ml of 1% isosulfan blue was injected adjacent to the breast tumor or biopsy cavity prior to SLN biopsy. A gamma probe was used intraoperatively in order to localize SLNs. Any node that was blue or associated with ex vivo radioactivity counts at least 10 times higher than the axillary background counts was defined as a SLN. SLNs were assessed intraoperatively using touch preparation cytologic examination. Completion ALND was performed if nodal metastases were identified. Seven patients, 44–76 years of age, were included in the study. Preoperative lymphoscintigraphy identified SLNs in five patients. Intraoperatively, SLNs were identified in all seven patients. SLNs were identified in six patients using the gamma probe and in all seven patients using blue dye. The mean number of SLNs encountered was 2.9. Findings on touch preparation cytology correlated with findings on the final pathological analysis examination in all patients. One patient had a positive SLN, this patient had three additional positive nodes identified in his completion ALND specimen. Three patients with negative SLNs had been elected preoperatively to undergo ALND regardless of findings on SLN biopsy, no positive lymph nodes were identified in the ALND specimens from these patients. These findings compare favorably with findings reported in the literature regarding SLN biopsy in female breast cancer patients. Blue dye injection and radioisotope injection were complementary. SLN biopsy should be considered for axillary staging in male breast cancer patients with clinically negative axillae.     

Follow-up of sentinel node negative breast cancer patients without axillary lymph node dissection.

BACKGROUND AND OBJECTIVES: The purpose of this study was to evaluate the feasibility of sentinel lymph node biopsy in breast cancer patients at our institution and to report the follow-up status of node-negative patients with removal of only the sentinel node. METHODS: A total of 247 breast cancer patients underwent sentinel node (SN) mapping between June of 1996 and September of 2000. The SN was identified by using a combination of vital blue dye and a radiolabeled colloid. RESULTS: A SN was identified in 227 of 247 patients (91.9%). One hundred forty-five were SN negative, 82 were SN positive. All SN-positive patients underwent axillary dissection of level I and II, whereas 83 patients with a negative SN had SN biopsy only. Median follow-up of these patients at 22 months revealed no axillary recurrence; the morbidity resulting from SN biopsy was negligible. CONCLUSIONS: Although the follow-up is very short, SN biopsy only in node-negative breast cancer patients had no negative impact on the axillary failure rate and resulted in negligible morbidity.     

Lymphoscintigraphy and gamma probe tracing in detecting breast cancer lymph node involvement: can they replace axillary lymph node dissection?

BACKGROUND: Axillary lymph node status is the most important pathological determinant of prognosis in early breast cancer. However, axillary lymph node dissection (ALND) performed for pathological assessment is not without costs and morbidity. Recently, radioisotope-guided sentinel node biopsy (SNB) has been proposed as a promising technique for staging breast cancer patients. AIM OF THE STUDY: In this study we report our experience (76 patients) in radioguided sentinel node (SN) biopsy in breast cancer. The study was divided into two phases: the first represents our learning curve, necessary to establish our guidelines for its use in clinical practice, while the second phase was aimed at assessing the feasibility of SN localization using preoperative lymphoscintigraphy and intraoperative gamma probe (GP) detection. METHODS: All patients underwent lymphoscintigraphy (LS) up to two hours after tracer delivery (99mTc-micro-nanocolloid, four i.d. injections of 200 microCi/200 miccroL around the primary lesion) 24 hours before surgery and GP tracing during surgery. Subsequently ALND was performed for pathological assessment. RESULTS: SNs were identified in 73/76 patients using LS and in 72/76 using GP. In one case the SN was detected by GP alone while in two cases GP was not able to locate the SN although it had been identified by means of LS. Thirty-three of these 73 patients had axillary node involvement. In 31/33 cases the SN was the only positive node. No positive nodes were found in the remaining 40 ALNDs where SNs were identified. Thus, according to our experience 40/73 ALNDs could have been avoided. SNB seems to be a very interesting technique but further experience in lymph node radioisotope tracing is needed.     

Contralateral axillary sentinel lymph node drainage in breast cancer: a case report

BACKGROUND: Since the introduction of sentinel node (SN) mapping in breast cancer, extra-axillary lymph node sites of breast tumor drainage are discovered in about one-quarter of cases, especially after intraparenchymal injection. In most such cases, an ipsilateral axillary SN is associated with an extra-axillary SN. Non visualization of ipsilateral axillary SN and extra-axillary SN drainage are often associated with an increased risk of axillary involvement. CASE: We report a case of contralateral axillary SN drainage on lymphoscintigraphy in a breast cancer patient with a history of bilateral reduction mammoplasty and no ipsilateral axillary lymph node involvement.     

Ductal carcinoma in situ: value of sentinel lymph node biopsy

BACKGROUND: Ductal carcinoma in situ (DCIS) represents about 20% of newly diagnosed breast carcinomas. Axillary metastasis is often related to undiagnosed DCIS with microinvasion (DCISM). The aim of this study was to confirm the interest of sentinel lymph node (SLN) biopsy in extensive DCIS. METHODS: Patients with a diagnosis of DCIS or DCISM and axillary lymph node evaluation were selected. Surgical treatment included SLN biopsy and/or axillary lymph node dissection (ALND). Serial sections were stained with hematoxylin and eosin (H&E) and with an immunohistochemical (IHC) method. When a micrometastasis was found, the breast specimen was revised searching for occult microinvasion. RESULTS: Hundred and forty patients with initial DCIS were enrolled in the study. Node metastasis was identified in 9 patients (7%) of the 128 patients with DCIS and DCISM. At final histology, 4 (10%) of the 39 patients with pure DCIS and SLN biopsy and 1 (7%) of the 14 patients with DCISM and SLN biopsy had axillary micrometastasis. Four of the 12 patients upstaged to invasive carcinoma had metastatic SLNs. CONCLUSIONS: Sentinel lymph node biopsy is valuable in patients with diffuse DCIS or DCISM who are scheduled for mastectomy in order to search for axillary micrometastases and occult breast microinvasion.     

Detection of sentinel nodes by lymphoscintigraphy and gamma probe guided surgery in vulvar neoplasia

BACKGROUND: Pathologic lymph node status is the most important prognostic factor in vulvar cancer; however, complete inguinofemoral node dissection is associated with significant morbidity. Intraoperative lymphoscintigraphy associated with gamma detecting probe-guided surgery has proved to be reliable in the detection of sentinel node (SN) involvement in melanoma and breast cancer patients. The present study evaluates the feasibility of the surgical identification of inguinal sentinel nodes using lymphoscintigraphy and a gamma detecting probe in patients with early vulvar cancer. METHODS: Technetium-99-labeled colloid human albumin was administered perilesionally in 44 patients. Twenty patients had T1 and 23 had T2 invasive epidermoid vulvar cancer; one patient had a lower-third vaginal cancer. An intraoperative gamma detecting probe was used to identify SNs during surgery. Complete inguinofemoral node dissection was subsequently performed. SNs underwent separate pathologic evaluation. RESULTS: A total of 77 groins were dissected in 44 patients. SNs were identified in all the studied groins. Thirteen cases had positive nodes: the SN was positive in all of them; in 10 cases the SN was the only positive node. Thirty-one patients showed negative SNs: all of them were negative for lymph node metastasis. CONCLUSIONS: Lymphoscintigraphy and SN biopsy under gamma detecting probe guidance proved to be an easy and reliable method for detection of SNs in early vulvar cancer. If these preliminary data will be confirmed, the technique would represent a real progress towards less aggressive treatment in patients with vulvar cancer.     

Incidence and prediction of invasive disease and nodal metastasis in preoperatively diagnosed ductal carcinoma in situ

For breast cancer patients with a preoperative diagnosis of ductal carcinoma in situ (DCIS), sentinel lymph node (SN) biopsy has been proposed as an axillary staging procedure in selected patients with a higher likelihood of having occult invasive lesions. With detailed histological examination of primary tumors and molecular whole‐node analysis of SNs, we aimed to validate whether this selective application accurately identifies patients with SN metastasis. The subjects were 336 patients with a preoperative needle‐biopsy diagnosis of DCIS who underwent SN biopsy using the one‐step nucleic acid amplification assay in the period 2009–2011. The incidence and preoperative predictors of upstaging to invasive disease on final pathology and SN metastasis, and their correlation, were investigated. Of the 336 patients, 113 (33.6%) had invasive disease, and 6 (1.8%) and 17 (5.0%) had macro‐ and micrometastasis in axillary nodes respectively. Of the 113 patients with invasive disease, 4 (3.5%) and 9 (8.0%) had macro‐ and micrometastasis. Predictors of invasive disease included palpability, mammographic mass, and calcifications (spread >20 mm), and intraductal solid structure, but no predictor was found for SN metastasis. Therefore, even though occult invasive disease was found at final pathology, most of the patients had no metastasis or only micrometastasis in axillary nodes. Predictors of invasive disease and SN metastasis were not completely consistent, so the selective SN biopsy for patients with a higher risk of invasive disease may not accurately identify those with SN metastasis. More accurate application of SN biopsy is required for patients with a preoperative diagnosis of DCIS.     

Observational study of blue dye-assisted four-node sampling for axillary staging in early breast cancer

Background

The use of radioisotopes (RIs) is regulated and not all institutions have nuclear medicine facilities for sentinel node biopsy (SNB). We previously reported blue dye-assisted four-node axillary sampling (4NAS/dye) to be a suitable method for detecting sentinel nodes (SNs) without RIs. Here, we present an interim report on an observational study of this technique.

Methods

From May 2003 to June 2008, 234 early breast cancer patients underwent SNB with 4NAS/dye. Lymphatic mapping was performed by injection of patent blue, and axillary sampling was performed until 4 SNs were detected. Patients with metastatic SNs underwent axillary lymph node dissection (ALND) at levels I and II, while SN-negative patients did not undergo further axillary procedures.

Results

The SN identification rate was 99%. In total, 44 patients were diagnosed with metastatic disease by using the 4NAS/dye technique and underwent ALND; the remaining 189 patients did not undergo ALND (the SNB group). After a median follow-up period of 54 months, only 1 patient (0.5%) in the SNB group developed axillary recurrence. For the 4NAS/dye procedure, blue SNs were harvested in 220 patients (94%) and only unstained SNs were harvested in 13 patients (6%). Among the 44 patients with SN metastases, foci were found in blue SNs in 37 patients (84%), while they were found in only unstained SNs in 7 patients (16%).

Conclusions

SNB with 4NAS/dye is a safe and reliable technique for treatment of early breast cancer patients. This technique may be particularly useful for surgeons who do not have access to radioisotope facilities.     

Lymphatic mapping for upper gastrointestinal malignancies

Recent studies on lymphatic mapping of upper gastrointestinal (GI) malignancies have provided new insights with regard to the sentinel node (SN) concept in solid tumors. At present, the SN concept seems to be valid not only for breast cancer, but also for esophageal and gastric cancers, which have multidirectional and complicated lymphatic flows. In addition to the staging merits, individualized surgical management has been proposed for upper GI cancer based on the SN concept. Gastric cancer is now a suitable target of SN-guided surgery after breast cancer because of its anatomical situation. Laparoscopic local resection is theoretically feasible for curative treatment of SN-negative early gastric cancer. Because SNs in esophageal cancer are multiple and widespread, complete sampling of SNs is not a minimally invasive procedure, as it is in breast cancer. However, selective and modified lymphadenectomy targeting SNs for clinically N0 esophageal cancer instead of three-field lymph node dissection should become not only feasible but also clinically important. When performing chemoradiotherapy as curative treatment for cT1N0 esophageal cancer, lymphoscintigrams revealing the distribution of SNs in each individual case are useful to tailor the field of irradiation to control occult micrometastases. Although there are several issues to be resolved, this novel procedure has the potential to improve quality control in upper GI cancer.