Sentinel Lymph Node Biopsy in Early Breast Cancer

The role of axillary surgery for the treatment of primary breast cancer is in a process of constant change. During the last decade, axillary dissection with removal of at least 10 lymph nodes (ALD) was replaced by sentinel lymph node biopsy (SLNB) as a staging procedure. Since then, the indication for SLNB rapidly expanded. Today's surgical strategies aim to minimize the rate of patients with a negative axillary status who undergo ALD. For some subgroups of patients, the indication for SLNB (e.g. multicentric disease, large tumors) or its implication for treatment planning (micrometastatic involvement, neoadjuvant chemotherapy) is being discussed. Although the indication for ALD is almost entirely restricted to patients with positive axillary lymph nodes today, the therapeutic effect of completion ALD is more and more questioned. On the other hand, the diagnostic value of ALD in node-positive patients is discussed. This article reflects today's standards in axillary surgery and discusses open issues on the diagnostic and therapeutic role of SLNB and ALD in the treatment of early breast cancer.     

Second Biopsy of Axillary Sentinel Lymph Node for Reappearing Breast Cancer After Previous Sentinel Lymph Node Biopsy

Background Sentinel lymph node biopsy (SLNB) is a safe and accurate axillary staging procedure for patients with primary operable breast cancer. An increasing proportion of these patients undergo breast-conserving surgery, and 5% to 15% will develop local relapses that necessitate reoperation. Although a previous SLNB is often considered a contraindication for a subsequent SLNB, few data support this concern. Methods Between January 2000 and June 2004, 79 patients who were previously treated at our institution with breast-conserving surgery and who had a negative SLNB for early breast cancer developed, during follow-up, local recurrence that was amenable to reoperation. Eighteen of these patients were offered a second SLNB because of a clinically negative axillary status an average of 26.1 months after the primary event. Results In all 18 patients (7 with ductal carcinoma-in-situ and 11 with invasive recurrences), preoperative lymphoscintigraphy showed an axillary sentinel lymph node, with a preoperative identification rate of 100%, and 1 or more SLNs (an average of 1.3 per patient) were surgically removed. Sentinel lymph node metastases were detected in two patients with invasive recurrence, and a complete axillary dissection followed. At a median follow up of 12.7 months, no axillary recurrences have occurred in patients who did not undergo axillary dissection. Conclusions Second SLNB after previous SLNB is technically feasible and likely effective in selected breast cancer patients. A larger population and longer follow-up are necessary to confirm these preliminary data.     

乳腺癌前哨淋巴结活检的研究进展

目的 报道乳腺癌前哨淋巴结活检的研究进展。方法 采用文献回顾的方法，对国外乳腺癌前哨淋巴结活检的历史、概念、活检技术以及临床应用等问题进行综述。结果 乳腺癌前哨淋巴结活检的操作方法还没有统一的标准，检出率及假阴性率变化范围广。结论 前哨淋巴结活检的临床应用还需要大量前瞻性多中心随机实验结果进一步论证。     

临床腋淋巴结阴性乳腺癌前哨淋巴结研究

目的：探讨前哨淋巴结活检术（ｓｅｎｔｉｎｅｌ ｌｙｍｐｈ ｎｏｄｅ ｂｉｏｐｓｙ, ＳＬＮＢ）在乳腺癌治疗中的应用。方法：使用专利蓝和美蓝染色,对１９９９年９月～２００１年４月连续收治的１４５例临床查体腋窝淋巴结阴性乳腺癌病人行前哨淋巴结活检术。结果：ＳＬＮＢ成功率为９６．５％（１４０／１４５）,假阴性率为２３．５％,准确率为９１．４％。病人年龄、肿瘤最大径、肿瘤部位、注射染料类型及是否活检对成功率和假阴性率无影响。结论：ＳＬＮＢ能够准确预测腋窝淋巴结的转移状况,在缩小手术范围、减少术后并发症的同时,提高了腋窝淋巴结分期的准确性;美蓝与专利蓝均可成功确定ＳＬＮ。     

Sentinel Lymph Node Biopsy for Breast Cancer: Current Controversies

Abstract:   Sentinel lymph node biopsy (SLNB) has replaced the routine level I and II axillary lymph node dissection (ALND) for women with clinically node-negative T1 and T2 breast cancer. Studies have shown that SLNB is highly predictive of axillary nodal status with a false-negative of rate less than 10%. Our purpose was to address some of the ongoing controversies about this procedure, including technical issues, use of preoperative lymphoscintigraphy, internal mammary lymph node biopsy, criteria for patient selection (in intraductal carcinoma?), its staging accuracy, and the clinical approach when a SLNB was found to be negative or positive on pathologic examination. After the revision of the American Joint Committee on Cancer (AJCC) staging system for breast cancer in 2002, the evaluation of internal mammary lymph nodes and determination of micrometastases by hematoxylin-eosin or by immunohistochemistry have become increasingly important in staging of patients. Recent guideline recommendations developed by the American Society of Clinical Oncology (ASCO) Expert Panel in 2005 are also discussed. Long-term follow-up results of ongoing studies will provide more accurate assessment of the prognostic significance of SLNB and its value in the prevention of breast cancer-related morbidity in axillary staging compared to ALND.      

Sentinel Lymph Node Biopsy in Breast Cancer: Canadian Practice Patterns

Background: Recent data suggest sentinel lymph node biopsy (SLNBx) for invasive breast cancer (IBC) is widely performed in the United States, often outside of a clinical trial. We sought to describe SLNBx practice patterns in Canada, as well as criteria for abandonment of concurrent axillary lymph node dissection.Methods: All active (n = 1172) general surgeons in Canada were sent a 31-item questionnaire.Results: Of the 519 respondents who treated IBC, 138 (27%) performed SLNBx, whereas 378 (73%) did not. Surgeons who did not perform SLNBx most commonly cited a lack of adequate resources (64%). Of the 138 surgeons who performed SLNBx, 16% participated in one of the ongoing multicenter clinical trials. Of the 39 (28%) surgeons who abandoned routine concurrent axillary lymph node dissection, 20 (51%) performed <30 combined procedures before performing SLNBx alone. On multivariate analysis, surgical oncology training (P = .005), increasing proportion of practice devoted to breast disease (P < .001), and number of days per week in the operating room (P < .001) were associated with the use of SLNBx.Conclusions: In contrast to the United States, SLNBx for IBC in Canada was not as common, and few surgeons participated in clinical trials. Fellowship-trained surgical oncologists and surgeons with a high exposure to breast disease seemed to be most involved in the development of SLNBx for IBC.Presented at the 55th annual meeting of the Society of Surgical Oncology, Denver, Colorado, March 2002.     

乳腺癌前哨淋巴结活检：共识与展望

乳腺癌前哨淋巴结活检(sentinel lymph node biopsy, SLNB)已迅速替代腋窝淋巴结清扫术(axillary lymph node dissection, ALND)成为大多数早期乳腺癌的标准治疗.作为一项腋窝准确分期的微创活检技术,SLNB代表着乳腺癌外科治疗的发展水平(state of the art).然而,SLNB的广泛开展可能超越了已有的支持证据,仍有一些问题尚未明确.基于乳腺癌SLNB循证医学证据的临床指南和专家共识有助于指导我们的临床实践.     

乳腺癌前哨淋巴结活检的研究进展

目的总结乳腺癌前哨淋巴结活检（SLNB）的研究现状和进展。方法复习近年来国内外的相关文献,对乳腺癌SLNB的概念、适应证、活检技术、提高检出准确率的方法、病理学检查方法、转移灶类型、临床应用等进行综述。结果 SLNB的适应证在不断扩大。示踪剂、影像学检查和病理学检查技术的发展有助于对乳腺癌前哨淋巴结（SLN）状态的评估。乳腺癌SLNB的操作方法还没有统一的标准,对其能否指导选择性的腋窝淋巴结清扫的争议较大,且SLNB的SLN检出率及假阴性率变化范围较大。结论 SLNB已成为乳腺癌外科治疗的重要辅助手段,但其操作尚需进一步规范,其临床应用范围还需要大量前瞻性、多中心的随机试验进一步论证。     

Sentinel Lymph Node Biopsy in Pregnant Women with Breast Cancer

Background

Sentinel lymph node biopsy (SNB) in pregnant women with breast cancer is uncommonly pursued given concern for fetal harm. This study evaluated efficacy and safety outcomes in pregnant breast cancer patients undergoing SNB.

Methods

Patients who underwent SNB while pregnant were identified from a retrospective parent cohort of women diagnosed with breast cancer during pregnancy. Chart review was performed to tabulate patient/tumor characteristics, method/outcome of SNB, and short-term maternal/fetal outcomes.

Results

Within a cohort of 81, 47 clinically node-negative patients had surgery while pregnant: 25 (53.2 %) SNB, 20 (42.6 %) upfront axillary lymph node dissection, and 2 (4.3 %) no lymph node surgery. Of SNB patients, 8, 9, and 8 had SNB in the first, second, and third trimesters, respectively. 99 m-Technetium (99-Tc) alone was used in 16 patients, methylene blue dye alone in 7 patients, and 2 patients had unknown mapping method. Mapping was successful in all patients. There were no SNB-associated complications. At a median of 2.5 years from diagnosis, there was one locoregional recurrence, one new primary contralateral tumor, three distant recurrences, and one breast cancer death. Among patients who underwent SNB, there were 25 liveborn infants, of whom 24 were healthy, and 1 had cleft palate (in the setting of other maternal risk factors).

Conclusions

SNB in pregnant breast cancer patients appears to be safe and accurate using either methylene blue or 99-Tc. This is one of the largest reported experiences of SNB during pregnancy; however, numbers remain limited. SNB rates in this cohort were lower than in non-pregnant breast cancer patients.     

Sentinel Lymph Node Biopsy for Papillary Thyroid Cancer: 12 Years of Experience at a Single Institution

Background  

The purpose of this study was to report our experience with sentinel lymph node dissection (SLND) for papillary thyroid carcinoma, to evaluate the feasibility and safety of the procedure, and to examine its potential utility as a guide for central neck dissection.     

Halsted Revisited: Internal Mammary Sentinel Lymph Node Biopsy in Breast Cancer

OBJECTIVE: To investigate the feasibility of internal mammary sentinel lymph node biopsy as a method to refine and thereby improve nodal staging in breast cancer. SUMMARY BACKGROUND DATA: The internal mammary lymph node status is a major prognostic factor in breast cancer. If positive, prognosis is less favorable. However, staging this regional nodal basin is not performed routinely, thus discarding additional staging information. METHODS: In a consecutive series of 256 patients with primary breast cancer, sentinel node biopsy was performed based on lymphoscintigraphy, intraoperative gamma probe detection, and blue dye mapping using 10 mCi (370 MBq) (99m)Tc-nanocolloid injected peritumorally and 0.5 to 1.0 mL Patent Blue V injected intradermally. During surgery, whenever possible, both axillary and internal mammary sentinel nodes were sampled. RESULTS: Lymphoscintigraphy showed axillary sentinel nodes in 95% (243/256) and additional internal mammary sentinel nodes in 25.3% (65/256). The overall success rate of axillary sentinel node biopsy was 97% (249/256). Sampling the internal mammary basin, based on the results of lymphoscintigraphy, was successful in 63% (41/65). In three patients a small pleural lesion resulted from staging this basin. This technique revealed internal mammary metastases in 26.8% (11/41). In 7.3% (3/41), internal mammary nodes showed metastatic involvement without accompanying axillary metastases. CONCLUSIONS: Internal mammary sentinel node biopsy is feasible without serious additional complications. It improves nodal staging in breast cancer by identifying higher-risk subgroups with internal mammary nodal metastases, which might benefit from altered adjuvant treatment regimens.     

Sentinel Lymph Node Biopsy in Thyroid Cancer

World Journal of Surgery - Prophylactic central neck dissection in patients with papillary thyroid carcinoma is controversial. Sentinel node biopsy might be an adjunct to optimize surgical...     

Patterns of Recurrence After Sentinel Lymph Node Biopsy for Breast Cancer

Background: Sentinel lymph node biopsy (SLNB) is gaining acceptance as an alternative to axillary lymph node dissection. The purpose of this study was to determine the frequency and pattern of disease recurrence after SLNB.Methods: Two-hundred twenty-two consecutive patients undergoing SLNB from April 6, 1998, to October 27, 1999, and who were 24 months out from their procedure were identified from a prospectively maintained database. Retrospective chart review and data analysis were performed to identify variables predictive of recurrence.Results: The median patient follow-up was 32 months (range, 24–43 months). A total of 159 patients (72%) were sentinel lymph node (SLN) negative and had no further axillary treatment. Five of these patients (3.1%) developed a recurrence (one local and four distant), with no isolated regional (axillary) recurrences. Sixty-three patients (28%) were SLN positive and underwent a subsequent axillary lymph node dissection. Six of these patients (9.5%) developed a recurrence (three local, one regional, and two distant). Pathologic tumor size (P < .001), lymphovascular invasion (P = .018), and a positive SLN (P = .048) were all statistically significantly associated with disease recurrence.Conclusions:With a minimum follow-up of 24 months, patients with a negative SLN and no subsequent axillary treatment demonstrate a low frequency of disease recurrence. This supports the use of SLNB as the sole axillary staging procedure in SLN-negative patients.     

Sentinel Lymph Node Biopsy After Preoperative Chemotherapy for Breast Cancer: Findings from the Austrian Sentinel Node Study Group

Background  Sentinel lymph node biopsy (SLNB) has become an accurate alternative to axillary lymph node dissection for early breast cancer. However, data are still insufficient as regards the combination of SLNB with preoperative chemotherapy (PC). Methods  The Austrian Sentinel Node Study Group investigated 167 patients who underwent SLNB and axillary lymph node dissection after 3 to 6 courses of PC. SLNB was limited to patients with a clinically negative axilla after PC. Blue dye was used in 29 cases (17%), and tracers were used in 20 (12%). A combination of the two methods was applied in most patients (n = 120; 72%). Results  At least 1 sentinel lymph node (SLN) was identified in 144 patients (identification rate, 85%): in 86% by blue dye alone, in 65% by tracers alone, and in 88% by a combination of methods. The SLN was positive in 70 women (42%) and was the only positive node with otherwise negative axillary nodes in 39 patients (23%). In 6 cases, the SLN was diagnosed as negative although tumor infiltration was detected in an upper node of the axillary basin (false-negative rate, 8%; 6 of 76 patients; sensitivity, 92%). At least 62 patients (37%) were free of tumor cells in the SLN and in the axillary nodes. Conclusion  The results of SLNB after PC are comparable to the results of SLNB without PC. Further investigation in a prospective setting is warranted to confirm these promising results.     

单用蓝染料示踪剂在乳腺癌前哨淋巴结活检中的价值

目的探讨单用蓝染料示踪剂在乳腺癌前哨淋巴结活检术(SLNB)中的临床价值。方法本研究共纳入308例患者,均采用联合法(蓝染料联合核素示踪剂)进行SLNB,分别记录单用蓝染料和联合法行SLNB的相关数据并进行对比分析。结果染料法与联合法行SLNB的成功率(93.5%比99.4%,P=0.000)、假阴性率(14.8%比3.3%,P=0.007)、准确性(89.6%比97.8%,P=0.006)和阴性预测值(74.0%比93.3%,P=0.012)的差异均有统计学意义。2种方法的成功率及假阴性率与患者年龄、肿瘤大小、肿瘤部位、组织学类型、肿瘤切检方式、乳房手术方式以及ER、PR和HER-2状况均无关(均P0.05)。染料法的假阴性率在临床腋淋巴结可疑肿大者中显著升高(P=0.042),并随前哨淋巴结检出数目增多而逐渐降低(P=0.000)。结论与联合法相比,染料法SLNB的成功率、准确性和阴性预测值显著降低,假阴性率显著升高,推荐临床实践中应尽量采用联合法,避免单用染料示踪剂进行SLNB。     

前哨淋巴结快速活检在乳腺癌根治术中的意义

目的：探讨乳腺癌前哨淋巴结活检(sentinel lymph node biopsy，SLNB)的可行性和准确性，及其在乳腺癌手术中的临床应用价值。方法：对32例乳腺癌病人行SLNB，术中在肿瘤周边选二点注射1％美蓝5ml，根据肿块距腋窝的距离，5～10min后沿腋窝下皱折线切开，循蓝染淋巴管寻找前哨淋巴结(sentinel lymp hnode，SLN)。其中27例切除SLN后行腋窝淋巴结解剖(axillry lymph node dissection，ALND)，两标本同时送病理检查，了解其符合率，并评价SLNB的可行性。结果:全组均进行了SLNB识别定位，1例未取到SLN，检出率为96．9％；另一例SLN病理呈假阴性。按目前国外SLNB的评价标准，本组SLNB的敏感度为88．2％，准确性为96．9％，假阳性率为0，假阴性率为5．9％。结论:乳腺癌SLNB目前仍处于研究阶段，随着研究的深入与扩大，将成为早期乳腺癌的诊疗常规，阴性可避免ALND的痛苦。     

乳腺癌前哨淋巴结活检研究现状及进展

目的探讨乳腺癌前哨淋巴结活检(SLNB)技术的研究现状和进展。方法复习近年来国内、外的有关文献,对乳腺癌SLNB的定位、检取、状态评估、适应证和并发症进行分析与综述。结果乳腺癌SLNB能够准确定位、检取前哨淋巴结(SLN)。影像学检查和病理检测技术的发展有助于SLN状态的评估,SLNB的适应证正在不断扩大。该技术并发症少,能够准确判定腋窝分期,指导选择性的腋窝淋巴结清扫。结论 SLNB技术已成为乳腺癌外科治疗的重要手段,但其操作尚需进一步规范,以降低假阴性的发生;假阳性和有争议的适应证问题仍需继续关注。     

乳腺癌前哨淋巴结活检

18 94年 ,美国医生Halsted首创了乳腺癌根治术 ,使术后复发率由当时的 5 8%～ 85 %下降到 6% ,开创了肿瘤器官整块广泛切除和区域淋巴结清扫的经典肿瘤外科治疗原则。 2 0世纪 70年代 ,美国学者Fisher提出乳腺癌是一种全身性疾病 ,区域淋巴结并非癌细胞滤过的有效屏障 ,血流扩散更具重要意义的理论后 ,乳腺癌手术逐步向保乳手术迅速发展。近年来 ,不少学者对乳腺癌常规行腋淋巴结清扫 (axillarylymphnodedissection ,ALND)这一金标准的必要性提出质疑 ,引发了乳腺癌外科治疗的又一次革命[1] 。近期不断有资料显示 ,较小范围的腋淋巴结切…     

Sentinel Node Biopsy Before Neoadjuvant Chemotherapy Spares Breast Cancer Patients Axillary Lymph Node Dissection

Background Neoadjuvant chemotherapy in breast cancer patients is a valuable method to determine the efficacy of chemotherapy and potentially downsize the primary tumor, which facilitates breast-conserving therapy. In 18 studies published about sentinel node biopsy after neoadjuvant chemotherapy, the sentinel node was identified in on average 89%, and the false-negative rate was on average 10%. Because of these mediocre results, no author dares to omit axillary clearance just yet. In our institute, sentinel lymph node biopsy is performed before neoadjuvant chemotherapy. The aim of this study was to evaluate our experience with this approach. Methods Sentinel node biopsy was performed before neoadjuvant chemotherapy in 25 T2N0 patients by using lymphoscintigraphy, a gamma ray detection probe, and patent blue dye. Axillary lymph node dissection was performed after chemotherapy if the sentinel node contained metastases. Results Ten patients had a tumor-positive axillary sentinel node, and one patient had an involved lateral intramammary node. Four patients had additional involved nodes in the completion lymph node dissection specimen. The other 14 patients (56%) had a tumor-negative sentinel node and did not undergo axillary lymph node dissection. No recurrences have been observed after a median follow-up of 18 months. Conclusions Fourteen (56%) of the 25 patients were spared axillary lymph node dissection when the sentinel node was found to be disease free. Performing sentinel node biopsy before neoadjuvant chemotherapy seems successful and reliable in patients with T2N0 breast cancer.