Is axillary lymph node dissection always necessary in breast cancer patients with a positive sentinel node?

Axillary lymph node dissection (ALND) is recommended for patients with breast cancer metastasis to a sentinel lymph node (SLN). However in 40-70% of cases, the SLN may be the only area of metastasis in the dissected axillary contents. In patients with a positive SLN, independently predictive factors for non-SLN metastasis include size of the primary tumor, the size of the SLN metastases, extracapsular extension, and the proportion of positive SLN's among all identified SLNs. Some authors have developed scores and nomograms to estimate a patient's risk for non-SLN metastases. These scores and nomograms should be applied prospectively to a large numper of SLN positive patients who thereafter undergo completion ALND. It is necessary to verify the predictive validity of these scores before we recommend the abandonment of ALND in patients with a very low likelihood of non-SLN metastasis. In this article we review the various predictive factors of non-SLN involvement and the scores or nomograms which have been developed to predict the likelihood of a positive ALND after a positive SLN biopsy.     

Is sentinel lymph node mapping relevant for colon cancer?: a feasibility study

BACKGROUND: Sentinel lymph node (sln) technique using blue injection is controversial for colon cancer. The aim of this study was to evaluate the feasibility and interest of sentinel node detection to identify the ultrastaging rate detecting occult nodal micrometastases missed on routine H&E examination. METHODS: During surgery blue dye was injected subserously around the tumor in 30 patients operated for a colon cancer. The first lymph nodes to turn blue were noted as sln. For each sln three examination levels were performed; if no tumor was detected by H&E examination, a cytokeratine immunohistochemistry study was performed. RESULTS: For each case, one or more sln were found (100%). The median number of lymph nodes examined and of sln found was, respectively, 23 (range 10-55) and 2 (1-4). There were 21 pN0 tumors, among which we found two cases (9%) with a micrometastasis and one case of isolated tumor cells detected, resulting in a 14% (3/21) ultrastaging for pTxN0. The sln was positive in five patients out of nine with a N+ disease. CONCLUSIONS: Sln detection was a successful technique when there was no evident lymph node involvement, no primary large lesion or no associated liver metastasis. Focused examination of the sln identified 10-20% of additional ultrastaging disease for staged pT1, 2, 3N0M0 tumor. This may have an important implication for follow-up and adjuvant treatment in future protocols.     

Is sentinel lymph node biopsy more accurate than axillary dissection for staging nodal involvement in breast cancer patients?

Today evaluation of axillary involvement can be routinely performed with the technique of sentinel lymph node biopsy (SLNB). One of the greatest advantages of SLNB is the nearly total absence of local postoperative complications. It is important to understand whether SLNB is better than axillary lymph-node dissection (ALND) for staging axillary nodal involvement. The aim of the study was to evaluate the axillary staging accuracy comparing three different methods: axillary dissection, sentinel node biopsy with the traditional 4-6 sections and sentinel node biopsy with complete analysis of the lymph node. 527 consecutive patients (525 females and 2 males) with invasive breast cancer < or = 3 cm and clinically negative axillary nodes were divided into 3 different groups: group A treated with axillary dissection, group B treated with sentinel nodal biopsy analysed with 4-6 sections, and group C treated with sentinel node biopsy with analysis of the entire node. All patients underwent a quadrantectomy to treat the tumor. Group differences and statistical significance were assessed by ANOVA. The percentages of N+ in group A and group B were 25.80% and 28% respectively, while in the third group it rose to 45%, or almost half the patients. The differences among the three groups were statistically significant (p = 0.02). From our analysis of the data it emerges that axillary dissection and sentinel node biopsy with analysis of 4-6 sections have the same accuracy in staging the nodal status of the axilla; analysis of the entire sentinel lymph node revealed an increased number of patients with axillary nodal involvement, proving more powerful in predicting nodal stage. SLNB with complete examination of the SLN removed can be considered the best method for axillary staging in breast cancer patients with clinical negative nodes. In our study, the percentage of metastases encountered after complete examination of SLN was 45% compared to the accuracy of axillary dissection that was only 25.8%. Moreover, this approach avoids the useless axillary cleaning in about 55-60% of cases, decreasing postoperative morbidity and mortality.     

Is sentinel lymph node mapping indicated for isolated local and in-transit recurrent melanoma?

OBJECTIVE: To determine the feasibility of sentinel lymph node mapping in local and in-transit recurrent melanoma. SUMMARY BACKGROUND DATA: The accuracy of intraoperative lymphatic mapping and sentinel lymphadenectomy (LM/SL) for identification of occult lymph node metastases is well established in primary melanoma. We hypothesized that LM/SL could be useful to detect regional node metastases in patients with isolated local and in-transit recurrent melanoma (RM). METHODS: Review of our prospective melanoma database of 1600 LM/SL patients identified 30 patients who underwent LM/SL for RM. Patients with tumor-positive sentinel nodes (SNs) were considered for completion lymph node dissection. RESULTS: Of the 30 patients, 17 were men and 13 were women; their median age was 57 years (range, 29-86 years). Primary lesions were more often on the extremities (40%) than the head and neck (33%) or the trunk (8%). At least 1 SN was identified in each lymph node basin that drained an RM. Of the 14 (47%) patients with tumor-positive SNs, 11 (78%) underwent complete lymph node dissection; 4 had tumor-positive non-SNs. The median disease-free survival after LM/SL was 16 months (range, 1-108 months) when an SN was positive and 36 months (range, 6-132 months) when SNs were negative. At a median follow-up of 20 months (range, 2-48 months), there were no dissected basin recurrences after a tumor-negative SNs. CONCLUSIONS: LM/SL can accurately identify SNs draining an RM, and the high rate of SN metastases and associated poor disease-free survival for patients with tumor-positive SN suggests that LM/SL should be routinely considered in the management of patients with isolated RM.     

Can axillary lymph node dissection be omitted in patients with breast cancer and positive sentinel nodes?

Sentinel lymph node biopsy has evolved as the surgical procedure of choice for women with clinically negative axillae, as part of an effort to move toward the less invasive surgical management of breast cancer. Axillary lymph node dissection remains the standard of care for patients with a positive axillary node and was previously performed on all patients with breast cancer prior to the implementation of the sentinel lymph node biopsy. There is, however, controversy regarding whether or not all patients with a positive sentinel lymph node need to undergo completion axillary dissection for either prognostic or therapeutic purposes. This article reviews the literature related to this controversial and evolving topic.     

Do bone marrow micrometastases correlate with sentinel lymph node metastases in breast cancer patients?

BACKGROUND: Sentinel lymph node biopsies (SLNB) are used to detect axillary metastases as an important prognostic indicator for breast cancer patients. Bone marrow micrometastases (BMM) have also been shown to predict prognosis. This study examines whether SLNB and BMM are associated. STUDY DESIGN: A retrospective analysis was performed on 124 stages I to III breast cancer patients treated with mastectomy or lumpectomy, SLNB, and bone marrow aspiration between 1997 and 2003. SLNB were examined for the presence of metastases by hematoxylin and eosin (H&E) stains and also by immunohistochemistry (IHC) for lymph nodes negative by H&E. The kappa statistic was used to evaluate the association (agreement) between SLNB and BMM. RESULTS: In this study population, 36 patients (29%) had micrometastases detected in their bone marrow, and 51 patients (41%) had positive sentinel lymph nodes. Of the patients with positive BMM (n = 36), 53% (19 of 36) had positive SLNB (14 of 19 by H&E and 5 of 19 by IHC). In patients with negative BMM (n = 88), 36% (32 of 88) had a positive SLNB (27 of 32 by H&E and 5 of 32 by IHC). The kappa statistic and associated 95% confidence interval indicated poor agreement between SLNB and BMM (kappa = 0.15; 95% CI = -0.03, 0.32). CONCLUSIONS: There was poor agreement between axillary metastases and micrometastases detected in the bone marrow. This study suggests that BMM and axillary metastases are not concordant findings in most patients.     

Do cytokeratin-positive-only sentinel lymph nodes warrant complete axillary lymph node dissection in patients with invasive breast cancer?

The small number of nodes harvested with lymphatic mapping and sentinel lymph node (SLN) biopsy has allowed a more detailed pathologic examination of those nodes. Immunohistochemical stains for cytokeratin (CK-IHC) have been used in an attempt to minimize the false negative rate for SLN mapping. This study examines the value of CK-IHC positivity in predicting further lymph node involvement in the axillary basin. From April 1998 through May 1999, 519 lymphatic mappings and SLN biopsies were performed for invasive breast cancer. SLNs were examined by imprint cytology, hematoxylin and eosin (H&E), and CK-IHC. Patients with evidence of metastatic disease by any of the above techniques were eligible for complete axillary node dissection (CAND). The frequency with which these modalities predicted further lymph node involvement in the axillary basin was compared. Of the 519 lymphatic mappings, 39 patients (7.5%) had a CK-IHC-positive-only SLN. Five (12.8%) of these 39 patients had at least 2 SLNs positive by CK-IHC. Twenty-six of the CK-IHC-positive-only patients underwent CAND. Three of these 26 patients (11.5%) had additional metastases identified after CAND. The sensitivity levels with which each modality detected further axillary lymph node involvement were as follows: CK-IHC, 98 per cent; H&E, 94 per cent; and imprint cytology, 87 per cent. A logistic regression to compare the prognostic value of the three modalities was performed. All were significant, with odds ratios of 19.1 for CK-IHC (P = 0.015), 5.3 for H&E (P = 0.033), and 3.86 for imprint cytology (P = 0.0059). These data validate the enhanced detection of CK-IHC for the evaluation of SLNs. Detection of CK-IHC-positive SLNs appears to warrant CAND in patients with invasive breast cancer. However, the therapeutic value of CAND or adjuvant therapies based on CK-IHC-positive SLNs would be best answered by prospective randomized trials.     

How many cases are enough for accreditation in sentinel lymph node biopsy in breast cancer?

BACKGROUND: There is considerable argument concerning the number of sentinel node biopsy cases with axillary dissection that surgeons should perform before they are eligible on abandoning axillary dissection in negative sentinel node patients. DATA SOURCES: Papers that (1) address directly or indirectly the subject of credentialing or of learning curve, (2) report on a surgeon's performance, (3) are reported as feasibility or learning curve studies, or both, (4) discuss the learning curve issue, and (5) express an expert's opinion on the learning curve. CONCLUSIONS: The number of procedures of the learning curve can not be fixed for all surgeons. Only surgeons in specialized breast cancer centers can succeed in meeting current recommendations with 20 to 30 cases. Surgeons from affiliated community hospitals will need more than 30 cases, whereas broad-based surgeons might need as many as 60 cases with their current caseload. Not all surgeons will be able to offer the procedure to their patients by the current recommendations.     

Radioisotope lymph node mapping in nonsmall cell lung cancer: can it be applicable for sentinel node biopsy?

BACKGROUND: Previous studies on intrathoracic lymph node mapping have focused on the validity of a sentinel node concept, but not on the usefulness for sentinel node biopsy. METHODS: The subjects were 15 patients clinically diagnosed with N0 nonsmall cell lung cancer. Technetium-99m tin colloid was injected into the peritumoral area 1 day preoperatively and a time course of tracer migration was monitored by scintigraphy. A hand-held gamma probe counter was used to count the intrathoracic lymph node stations. Resected nodes were also counted to assess the accuracy of the intrathoracic counting. RESULTS: Serial scintigraphies showed that the tracer migrated through airways and the appearance resembled hot nodes. On intrathoracic counting, 50% of the nodal stations appeared positive; however, only 23% of these apparently positive nodal stations were ultimately shown to be truly radioactive. The true positive and true negative rates of detecting intrathoracic hot nodes were 100% and 56%, respectively. Because the counts of the nodal stations could include the counts from the hot primary tumor ("shine-through") or airway radioactivity, legitimate hot nodes were identified after dissecting all the apparently positive nodal stations. Two of the 9 patients in whom hot nodes were identified had nodal metastatic disease and actually had tumor cells within the hot nodes. The only complication related to the preoperative injection of technetium-99m was a minor pneumothorax. CONCLUSIONS: Although radioisotope intrathoracic lymph node mapping is safe, it appears to be unsuitable for sentinel node biopsy because shine-through and the airway-migrated radioactive tracer complicated the intrathoracic counting. Only serial scintigraphy could distinguish hot nodes from airway migration.     

Is extended lymph node dissection necessary for gastric cancer in elderly patients?

OBJECTIVE: To compare the outcome after limited and extended gastric resections to find out whether extended lymph node dissection is indicated for gastric cancer in elderly patients. DESIGN: Retrospective study. SETTING: University hospital, Japan. SUBJECTS: 182 patients over 75 years of age with gastric cancer who had gastric resections from 1980 to 1995. INTERVENTIONS: 161 patients had limited lymph node dissection (limited group) and 21 had extended lymph node dissection (extended group). MAIN OUTCOME MEASURES: Histopathological features, morbidity, mortality, and long-term survival. RESULTS: Postoperative morbidity was 27% (n = 44) in the limited group and 57% (n = 12) in the extended group, and postoperative mortality was 1% (n = 2) in the limited group and 10% (n = 2) in the extended group; these differences are significant (p = 0.005 and p = 0.002). The 5-year survival did not differ significantly between the two groups. Only the T classification and presence of lymph node metastases had a significant influence on the outcome of gastric cancer in elderly patients. CONCLUSIONS: The presence of lymph node metastases is a critical factor in the prognosis of gastric cancer, and extended lymph node dissection has therefore been recommended. However, extended lymph node dissection in elderly patients did not influence the 5-year survival; in addition, the mortality and morbidity in the extended group were higher than in the limited group. Extended lymph node dissection is therefore usually not indicated for gastric cancer in elderly patients.     

Is the clinically positive axilla in breast cancer really a contraindication to sentinel lymph node biopsy?

BACKGROUND: Clinically positive axillary nodes are widely considered a contraindication to sentinel lymph node (SLN) biopsy in breast cancer, yet no data support this mandate. In fact, data from the era of axillary lymph node dissection (ALND) suggest that clinical examination of the axilla is falsely positive in as many as 30% of cases. Here we report the results of SLN biopsy in a selected group of breast cancer patients with palpable axillary nodes classified as either moderately or highly suspicious for metastasis. STUDY DESIGN: Among 2,027 consecutive SLN biopsy procedures performed by two experienced surgeons, clinically suspicious axillary nodes were identified in 106, and categorized as group 1 (asymmetric enlargement of the ipsilateral axillary nodes moderately suspicious for metastasis, n = 62) and group 2 (clinically positive axillary nodes highly suspicious for metastasis, n = 44). RESULTS: Clinical examination of the axilla was inaccurate in 41% of patients (43 of 106) overall, and was falsely positive in 53% of patients (33 of 62) with moderately suspicious nodes and 23% of patients (10 of 44) with highly suspicious nodes. False-positive results were less frequent with larger tumor size (p = 0.002) and higher histologic grade (p = 0.002), but were not associated with age, body mass index, or a previous surgical biopsy. CONCLUSIONS: Clinical axillary examination in breast cancer is subject to false-positive results, and is by itself insufficient justification for axillary lymph node dissection. If other means of preoperative assessment such as palpation- or image-guided fine needle aspiration are negative or indeterminate, then SLN biopsy deserves wider consideration as an alternative to routine axillary lymph node dissection in the clinically node-positive setting.     

Is massage following dye injection necessary in sentinel node biopsy in breast cancer?

In sentinel node biopsy of breast cancer, massaging of the dye injection site following subdermal injection of blue dye does not improve sentinel node detection rate or the time needed for sentinel node biopsy. It may reduce the number of false negative sentinel nodes.     

Is ultrasound of the retroperitoneum a valuable staging method in selecting testicular cancer patients for primary retroperitoneal lymph node dissection?

OBJECTIVE: In nonseminomatous testicular cancer patients with normal serum tumor markers and no distant metastasis, postorchiectomy surgery is a valid treatment option if the disease extension into the retroperitoneum is not advanced. We assessed the ability of ultrasound (US) to exclude the presence of bulky retroperitoneal disease. MATERIALS AND METHODS: One hundred and forty testicular cancer patients underwent US and computed tomography (CT) of the retroperitoneum. US results were analyzed using three cutoffs: 5 cm (conventional staging), 3 cm (based on the minimal sonographical dimension of actual bulky disease) and 0 cm ('clean retroperitoneum' or any detectable nodes), and were compared with CT data using the 5-cm cutoff ('gold standard'). RESULTS: The sensitivity, specificity, overall accuracy, positive and negative predictive values of US in detecting of bulky retroperitoneum for the 5-cm cutoff were 83, 96, 93, 88 and 94%, for the 3-cm cutoff 100, 91, 94, 80 and 100%, and for the 0-cm cutoff 100, 66, 74, 49 and 100%, respectively. CONCLUSIONS: In stage I and IIA/B marker-negative nonseminomas if the treatment strategy is surgery, US may facilitate the selection process; the report of a clean retroperitoneum safely excludes the presence of bulky disease and may be an indication for lymphadenectomy, although in case of positive findings a CT should be performed.     

Systemic treatment after sentinel lymph node biopsy in breast cancer: who, what, and why?

SLNB, although subject to numerous technical problems, has nonetheless shown great promise in predicting the status of the remaining axillary lymph nodes. The growing use of SLNB has presented the opportunity of using immunohistochemical and molecular markers to detect occult micrometastases. These micrometastases may be important for more accurate staging and prediction of patient outcomes. Current standards for the use of systemic therapy recommend multidrug chemotherapy for all but the most favorable disease (T1a/b, NO). The detection of micrometastases by SLNB in this low-risk group may change treatment recommendations to include systemic therapy. Because of the significant frequency of false-negative results in SLNB, which will depend upon the surgeon's experience, caution is urged in determining when ALND can be safely eliminated in patients with a negative SLNB.