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.     

1枚前哨淋巴结阳性早期乳腺癌保腋窝的可行性分析

目的探讨1枚前哨淋巴结（sentinel lymph node,SLN）阳性的早期乳腺癌患者保腋窝（omitting axillary dissection,OAD）的可行性。方法用美蓝作为示踪剂先行乳腺癌前哨淋巴结活检术（sentinel lymph node biopsy,SLNB）,根据快速冰冻病理结果分为SLN阴性组与1枚SLN阳性组,随后两组均行常规腋窝淋巴结清扫（axillary lymph node dissection,ALND）以解剖出非前哨淋巴结（non—sentinellymphnode,NSLN）,比较两组间NSLN的阳性率。结果SLN阴性组30例,1例NSLN阳性,阳性率为3．3％,准确性为96．7％（29／30）;1枚SLN阳性组30例,仅3例NSLN阳性,阳性率为10．0％;两组阳性率差异无统计学意义（X^2=1．071,P=0．612）。全组随访1～48个月,均无区域淋巴结复发。结论1枚SLN阳性的早期乳腺癌患者可考虑OAD。     

Long-term morbidity of patients with early breast cancer after sentinel lymph node biopsy compared to axillary lymph node dissection

BACKGROUND AND OBJECTIVES: Sentinel lymph node biopsy (SLNB) is widely accepted as an excellent method in the management of early breast cancer in patients with clinically negative axillary lymph nodes. Since SLNB requires less traumatic surgery to the axilla than axillary lymph node dissection (ALND), it was assumed to result in reduced shoulder/arm morbidity. However, data on long-term morbidity after SNLB are sparse. The present study was set up to compare long-term arm/shoulder morbidity as well as oncological outcome after SLNB versus ALND in patients with early breast cancer. METHODS: Oncological outcome, objective shoulder/arm morbidity, and subjective complaints after SLNB or ALND for T1 breast cancer were assessed after a minimum follow-up of 20 months. RESULTS: One hundred thirty four patients were included in the study. Thirty-one patients underwent SNLB only, 103 patients had SLNB followed by ALND or ALND only. Loss of strength and hypaesthesia were less frequent after SLNB. No lymph oedema occurred after SNLB without adjuvant radiotherapy. Subjective complaints concerning pain, hypaesthesia, and paresthesia were more common in the ALND group. No axillary recurrence developed in either group. CONCLUSIONS: Isolated SLNB in node-negative pT1 breast cancer patients is a highly efficient tool to reduce postoperative long-term morbidity without compromising the local control of the disease. The reported ameliorations should favour SLNB as staging and treatment modality in patients suffering from early breast cancer.     

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.     

Subjective morbidity and quality of life after sentinel node biopsy and axillary lymph node dissection for breast cancer

BACKGROUND AND OBJECTIVES: Sentinel node (SN) biopsy is a minimally invasive surgical method for axillary staging in patients with breast cancer. The aim of this study was to evaluate mid-term morbidity after SN biopsy and axillary lymph node (ALN) dissection in patients with breast cancer receiving breast-sparing treatment, and to determine its impact on quality of life (QOL). METHODS: One hundred fifteen patients with breast cancer underwent breast-conserving treatment with SN biopsy alone (Group 1: n = 54), ALN dissection with or without SN biopsy (Group 2: n = 51), or SN biopsy followed by later ALN dissection (Group 3: n = 10). RESULTS: The mean post-operative follow-up was 20.3 months (range: 10-31 months) in Group 1, 24.3 months (range: 10-33 months) in Group 2, and 19.1 months (range: 12-28 months) in Group 3. Arm-shoulder pain was reported by 21.2% of patients in Group 1, 52.9% in Group 2, and 60% in Group 3 (P = 0.002). An arm swelling sensation was reported by 0% of patients in Group 1, 21.6% in Group 2, and 10% in Group 3. Dysesthesias were reported by 5.7% of patients in Group 1, 51% in Group 2, and 50% in Group 3 (P < 0.001). The mean global QOL self-rating score was 7.6 in Group 1, 7.6 in Group 2, and 7.7 in Group 3 (no significant difference). CONCLUSIONS: SN biopsy is associated with significantly lower mid-term morbidity than ALN dissection.     

Radiation field design and regional control in sentinel lymph node-positive breast cancer patients with omission of axillary dissection

BACKGROUND:

Randomized data suggest that axillary clearance is not necessary in select, clinically lymph node‐negative women with positive sentinel lymph node (SLN) biopsies (SLNBs) who undergo breast‐conserving surgery or receive whole‐breast radiotherapy and systemic therapy. The additional value of axillary radiotherapy in these patients is unknown.

METHODS:

The authors identified 326 patients with positive SLNBs who underwent breast‐conserving surgery without axillary lymph node dissection from 1997 to 2009. SLN tumor deposits measured ≤0.2 mm in 58% of patients, 0.3 to 2.0 mm in 35% of patients, and >2 mm in 7% Patients. Ninety‐three percent of patients received adjuvant radiotherapy. Radiation fields were categorized as standard tangents, high tangents, comprehensive (tangents plus supraclavicular), or partial breast to reflect coverage of the axilla. Standard tangents included both prone and supine positions. Regional failure was defined as recurrence in the ipsilateral supraclavicular, axillary, or internal mammary lymph nodes.

RESULTS:

The median follow‐up was 55 months (range, 1‐158 months). The 4‐year rates of regional control, local control, disease‐free survival, and overall survival were 99%, 98%, 95%, and 91%, respectively. Three patients had regional recurrences. Two of those patients received adjuvant radiotherapy with standard supine tangents, and 1 patient did not receive radiotherapy. No regional recurrences occurred among 66 patients who received radiotherapy in the prone position.

CONCLUSIONS:

Regional control was high (99% at 4 years) in patients who had low‐volume SLN disease who did not undergo axillary dissection, regardless of whether the axilla was irradiated. Whole‐breast radiation alone, including in the prone position, is sufficient treatment after breast‐conserving surgery for select patients with tumor‐containing SLNs who omit axillary dissection. Cancer 2012;. © 2011 American Cancer Society.     

乳腺癌前哨淋巴结活检研究进展

近年来,乳腺癌的发病率越来越高,乳腺癌治疗方式也在不断改进,但手术仍然是早期乳腺癌治疗的主要手段。对于早期乳腺癌,前哨淋巴结活检术（sentinel lymph node biopsy,SLNB）是一种安全、精确的手术方式,已逐渐替代腋窝淋巴结清扫术（axillary lymph node dissection,ALND）成为早期乳腺癌治疗的标准术式。随着研究的深入,SLNB的应用范围更广,术后生活质量显著改善,但其操作尚需要进一步统一规范。在前哨淋巴结微转移、宏转移、前哨淋巴结活检阳性的老年患者以及新辅助化疗的前哨淋巴结活检等方面尚未达成共识,还需要更多大型多中心前瞻性的随机试验来进一步论证。     

The sensitivity of axillary staging when using sentinel node biopsy in breast cancer

AIMS: We aimed to study factors, which enhance the sensitivity of sentinel node biopsy. METHODS: Three hundred and sixty-three clinically node negative breast cancer patients with successful sentinel node biopsy were studied. All focally radioactive and/or blue nodes in the axilla were harvested. All palpably suspicious lymph nodes were also removed for a similar histological evaluation. RESULTS: Sentinel node metastases were found in 129 patients. The metastasis was detected in the three first retrieved sentinel nodes in 126 cases and in the fourth or fifth node in three cases. The 'hottest' sentinel node was not the involved one in 18 cases. Five patients with tumour negative sentinel nodes had metastases in other palpably suspicious nodes. CONCLUSIONS: Harvesting all focally radioactive and/or blue nodes and other palpably suspicious nodes minimises the false negative rate in sentinel node biopsy. Removal of more than five nodes does not significantly improve the sensitivity of axillary staging.     

Cosmetic outcome of breast conserving therapy after sentinel node biopsy versus axillary lymph node dissection

INTRODUCTION: Next to locoregional control, good cosmetic outcome is one of the main goals of breast conserving treatment (BCT) for breast cancer surgery. Factors affecting cosmetic outcome are well known. The sentinel node (SN) procedure avoids lymphedema in the breast, which might influence cosmetic outcome. The aim of this study was to evaluate the cosmetic outcome of BCT after the SN procedure compared to that after axillary lymph node dissection (ALND).METHODS: The subjects were 20 patients who underwent ALND and 20 patients who underwent the SN procedure. After a minimum follow-up period of 43 months, we photographed each patient. Fifteen healthy women served as control subjects. We used the percentage breast retraction assessment index (pBRA=BRA/reference length x 100) to compare cosmetic outcome.RESULTS: The median pBRAs of the ALND group and SN group (14.3 and 6.71, respectively) significantly differed ( p=0.001). The pBRA of the SN group was comparable to the pBRA (6.1) of the control group ( p=0.317).CONCLUSION: Cosmetic outcome of BCT after the SN procedure was superior compared to the cosmetic outcome after ALND. This is an important additional reason to implement the SN procedure in routine daily practice.     

Impact of axillary lymph node dissection on breast cancer outcome in clinically node negative patients

BACKGROUND:

The regional lymph node control and survival impact of axillary dissection in breast cancer has been the subject of multiple randomized trials, with various results. This study reviews and conducts a meta‐analysis of contemporary trials of axillary dissection in patients with early stage breast cancer.

METHODS:

A systematic MEDLINE review identified 3 randomized trials published between January 2000 and January 2007 of axillary dissection versus no dissection in clinically lymph node negative early stage breast cancer patients. A fourth trial of axillary radiotherapy versus no axillary treatment was also identified and included in this review. Meta‐analyses were performed for survival, axillary recurrence, metastatic disease, and ipsilateral breast recurrence.

RESULTS:

All trials reported a higher rate of axillary recurrence (1.5%‐3%, median follow‐up 5‐15 years) in the absence of axillary dissection or radiotherapy. Overall survival was similar with and without definitive axillary treatment in 3 of the 4 trials, with an increased rate of nonbreast cancer‐related death in the observation arm of the fourth trial. Meta‐analyses found no significant difference in overall survival (odds ratio [OR] 1.55; 95% confidence interval [CI], 0.74‐3.24), metastases (OR 0.91; 95% CI, 0.65‐1.29), or ipsilateral breast recurrence (OR 1.11; 95% CI, 0.68‐1.83) associated with axillary treatment. A significantly lower rate of axillary recurrence was seen after lymphadenectomy (OR 0.28; 95% CI, 0.11‐0.73, P<.01).

CONCLUSIONS:

Axillary dissection does not confer a survival benefit in the setting of early stage clinically lymph node negative breast cancer. Although the rate of axillary failure was increased in the absence of dissection, the absolute risk was found to be extremely low. Cancer 2009. © 2009 American Cancer Society.     

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。     

纳米碳示踪剂在乳腔镜腋窝淋巴结清扫中的应用

目的:探讨纳米碳示踪剂技术在乳腔镜腋窝淋巴结清扫中的应用价值.方法:收集2015年6月至2018年6月我院住院的cN0-1期乳腺癌患者共60例,将患者随机分为纳米碳辅助乳腔镜组(观察组)和常规乳腔镜组(对照组),每组30例,分析纳米碳示踪的前哨淋巴结在患者中的检出结果,并比较两组清扫淋巴结情况、手术时间及术后并发症的发...     

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.     

Morbidity of breast cancer patients following complete axillary dissection or sentinel node biopsy only: a comparative evaluation

Introduction The usefulness of routine axillary dissection (AD) at levels I–II in breast cancer patients has been questioned for years because of the high postoperative morbidity in the shoulder and arm region, and the increasing number of patients with negative nodes. Sentinel node biopsy (SNB) was hoped both to reduce morbidity and to improve the reliability of staging. This study was designed to provide more evidence in this matter by comparing the follow-up data of patients with AD and those with SNB only. Method One hundred forty patients who had undergone AD between 1993 and 1996 were questioned for their subjective and objective symptoms using a questionnaire and subsequently subjected to a clinical examination. Their data were compared with those of 57 patients who had undergone SNB only between 1998 and 2000. Results Local recurrences have not been seen to date. The difference between the two groups in terms of a loss of quality of life was negligible. The differences in overall complaints, number of symptoms, pain, limited range of motion of the operated upper extremity, numbness, paresthesias, and arm swelling as well as perceived disability in activities of daily living were significantly in favor of SNB. The length of hospital stay was significantly shorter for SNB patients. Conclusion SNB appears to be an accurate procedure for axillary nodal staging in breast cancer patients and is associated with reduced postoperative morbidity and length of hospital stay. But it is still investigational and should not be implemented as therapeutical standard before results of randomized trials are published.     

临床腋淋巴结阳性乳腺癌患者行全腋窝淋巴结清扫的应用探讨

背景与目的:临床腋淋巴结阳性乳腺癌患者常规行全腋窝淋巴结清扫,本研究探讨改良根治术时采用改进L3组淋巴结清扫方式的临床应用及意义.方法:322例临床腋淋巴结阳性的乳腺癌患者中,154例采用改进的L3组淋巴结清扫方式,168例行常规Auchinclos改良根治术,对两种手术方式所用时间和术后不良反应进行比较,同时随访观察患者的无病生存率.结果:两种手术方式所用手术时间、术后不良反应差异无统计学意义(P＞0.05),行改进术式患者腋下淋巴结总数及L3组淋巴结数较常规术式多,两组差异有统计学意义(P＜0.05),L3组淋巴结未转移患者5年无病生存率为68.6％,L3组淋巴结转移患者5年无病生存率为35.7％,差异有统计学意义(P＜0.05).结论:对临床腋淋巴结阳性乳腺癌患者行L3组淋巴结清扫具有一定的临床应用价值,采用改进的淋巴结清扫方式,便于L3组淋巴结的清扫.     

Photodynamic detection of diseased axillary sentinel lymph node after oral application of aminolevulinic acid in patients with breast cancer

Benign as well as malignant tumour tissues of the breast demonstrate higher fluorescence intensity (FI) than normal breast tissue after application of a photosensitiser. As a follow-up study, we evaluated the FI of metastatic sentinel lymph nodes and metastatic axillary lymph nodes compared to nonmetastatic sentinel and axillary lymph nodes in patients with breast cancer. In all, 11 patients received 30 mg 5-aminolevulinic acid (ALA) kg(-1) bodyweight orally 3 h prior to surgery. The sentinel lymph node was marked with Nanocoll preoperatively and with a blue dye intraoperatively. Tumour excision, excision of the sentinel lymph node and an axillary lymph node dissection were performed during the same surgical session. The operation site was illuminated with blue light (400 nm) to obtain macroscopic tissue characterisation of fluorescence. Tissue samples were stored protected from light, and analysed using a fluorescence microscope. Results were correlated with histopathology. In all, 14 sentinel lymph nodes, seven axillary lymph nodes and seven primary tumours were analysed. Metastatic sentinel lymph nodes demonstrated a statistically significant higher FI than nonmetastatic sentinel lymph nodes (2630 vs 526, P<0.0001). The FI of metastatic sentinel lymph nodes, of metastatic axillary lymph nodes and of the primary tumour were comparably high, and were statistically significantly higher compared to the normal mammary tissue. Intraoperatively, only in a few cases, it was possible to recognise the metastatic sentinel lymph node macroscopically with blue light. Our study indicates that photodynamic diagnosis with ALA has a potential in the diagnosis and detection of the sentinel lymph node in patients with breast cancer, and is worth to be further investigated and developed for intraoperative photodynamic diagnosis and possibly therapy.     

Variability in axillary lymph node dissection for breast cancer

BACKGROUND: The axillary nodal status may influence the prognosis and the choice of adjuvant treatment of individual breast cancer patients. The variation in number of reported axillary lymph nodes and its effect on the axillary nodal stage were studied and the implications are discussed. METHODS: Between 1994 and 1997, a total of 4,806 axillary dissections for invasive breast cancers in 4,715 patients were performed in hospitals in the North-Netherlands. The factors associated with the number of reported nodes and the relation of this number with the nodal status and the number of positive nodes were studied. RESULTS: The number of reported nodes varied significantly between pathology laboratories, the median number of nodes ranged from 9 to 15, respectively. The individual hospitals explained even more variability in the number of nodes than pathology laboratories (range in median number 8-15, P < 0.0001). The number of reported nodes increased gradually during the study period. A decreasing trend was observed with older patient age. A higher number of reported nodes was associated with a markedly increased chance of finding tumor positive nodes, especially more than three nodes. The frequency of node positivity increased from 28% if less than six nodes to 54% if >/=20 nodes were examined, the percentage of tumors with >/=4 positive nodes increased from 4 to 31%. Multivariate analysis confirmed these results. CONCLUSIONS: This population-based study showed a large variation in the number of reported lymph nodes between hospitals. A more extensive surgical dissection or histopathological examination of the specimen generally resulted in a higher number of positive nodes. Although the impact of misclassification on adjuvant treatment will have varied, the impact with regard to adjuvant regional radiotherapy may have been considerable.     

Accuracy and reliability of sentinel node biopsy in patients with breast cancer. Single centre study with long term follow-up

Summary The aim of our study is to evaluate the frequency of false-negative (FN) sentinel node procedures in patients with breast cancer. A total of 791 breast cancer patients underwent sentinel lymph node (SLN) biopsy at our institution between July 1997 and February 2005. A 2-day protocol was used to localise the sentinel node with the injection of ^99mTc-nanocolloid. There were two phases in the study: the learning phase (50 patients) and the application phase (741 patients). In the learning phase, a complete lymphadenectomy was always performed. In the application phase, sentinel nodes were studied postoperatively with breast cancer and lymphadenectomy was performed when considered warranted by the pathological postoperative results. The median follow-up duration in the 741 patients studied during the application phase was 32.3 months (range 6–72 months). In this phase a total of 787 sentinel nodes (719 axillary and 68 intramammary chain) were obtained (range 0–5 per patient, mean 1.01), with 153 (41 with micrometastasis) positive sentinel nodes. We observed a total of three FN SLN results (0.5%). All three presented as an axillary recurrence into 24 months from operation. After a median follow-up of 32.3 months we observed only three clinical recurrences among 741 patients. Our results indicate that the sentinel node protocol can give an adequate local control.