Axillary Ultrasonography to Detect Recurrence After Sentinel Node Biopsy in Breast Cancer

Background Sentinel node biopsy (SNB) for breast cancer has a false-negative rate of approximately 5%. Initial reports of follow-up show lower axillary recurrence rates than expected. We performed axillary ultrasonography to determine whether occult recurrences could be detected. Methods In a community hospital setting, 289 patients who had SNB for breast cancer in a single surgeon’s practice underwent axillary examination by the surgeon followed by axillary ultrasonography by a dedicated breast radiologist. Ultrasonography was performed one time from 4 to 79 months (median, 25 months) after surgery. Five patients with suspicious nodes had ultrasound-guided fine-needle aspiration, and one had a core biopsy. Results No patient had suspicious nodes on clinical examination. Only six patients had ultrasound findings that warranted intervention. Five patients had benign cytological characteristics, and one had a benign core biopsy result. No evidence of axillary recurrence was found in any patient. Conclusions Axillary ultrasonography did not detect occult metastases in any patient and is not recommended for routine follow-up after SNB. The lack of ultrasound evidence of metastasis suggests that the recurrence rate is likely to remain low.     

Axillary Recurrence After Sentinel Node Biopsy

Background Sentinel node biopsy (SNB) has evolved as the standard of care in the surgical staging of breast cancer. This technique is accurate for surgical staging of axillary nodal disease. We hypothesized that axillary recurrence after SNB is rare and that SNB may provide regional control in patients with microscopic nodal involvement.Methods With institutional review board approval, SNB was performed with peritumoral injection of ^99mTc-labeled sulfur colloid. From 1996 to 2003, 1167 patients were entered into a prospective cancer database after surgical therapy; 916 patients consented to long-term follow-up. Fifty-two patients (5.7%) did not map successfully and were excluded, leading to a study population of 864 patients. The median follow-up was 27.4 months (range, 1–98 months).Results The median number of sentinel nodes harvested was 2, and 633 (73%) patients had negative sentinel nodes. Thirty (4.7%) of those sentinel node–negative patients underwent completion axillary dissection, whereas 592 (94%) patients were followed up with observation. A total of 231 (27%) had positive sentinel nodes: 158 (68%) of these patients underwent completion axillary dissection, and 73 (32%) were managed with observation alone. Two (.32%) patients who were sentinel node negative had an axillary recurrence; one of these patients had undergone completion axillary dissection. No patient in the observed sentinel node–positive group had an axillary recurrence (odds ratio, .37; P = .725).Conclusions On the basis of a median follow-up of 27.4 months, axillary recurrence after SNB is extraordinarily rare regardless of nodal involvement, thus indicating that this technique provides an accurate measure of axillary disease and may impart regional control for patients with node-positive disease.     

Canadian Association of General Surgeons and American College of Surgeons Evidence-Based Reviews in Surgery. 27.: Quality-of-life outcomes with sentinel node biopsy versus standard axillary treatment in patients with operable breast cancer

Objective: To compare quality of life and arm morbidity outcomes among patients with clinically node-negative invasive breast cancer who received either sentinel lymph node biopsy (SNB) or standard axillary treatment. Methods: A total of 1031 patients were randomly assigned to either SNB (n = 515) or standard axillary surgery (n = 516). Sentinel node biopsy was performed before the breast tumour was removed, according to a standardized protocol that used a radiopharmaceutical compound and a blue dye with routine preoperative lymphoscintigraphy. Standard axillary treatment was defined as either an axillary lymph node dissection or 4-node axillary sampling. Outcomes were evaluated by patients' self-assessments of arm morbidity and quality of life. The patients completed the assessments using the Functional Assessment of Cancer Therapy — Breast scale, version 4 (FACT-B) at follow-up visits 1, 3, 6, 12 and 18 months after the procedure. Results: The relative risks of any lymphedema and sensory loss for the SNB group compared with the standard axillary surgery group at 12 months were 0.37 (95% confidence interval [CI] 0.23–0.60, absolute rates 5% v. 13%) and 0.37 (95% CI 0.27–0.50, absolute rates 11% v. 31%), respectively. Drain usage, length of stay in hospital and time to resumption of normal day-to-day activities after surgery were significantly lower in the SNB group (p < 0.001), and axillary operative time was reduced (p = 0.06). Overall patient-recorded scores for quality of life and arm functioning were significantly better in the SNB group throughout the follow-up period (p ≤ 0.003). These benefits were observed with no increase in anxiety levels in the SNB group (p ≥ 0.05). Conclusion: Sentinel node biopsy is associated with reduced arm morbidity and better quality of life than standard axillary treatment, and it should be the treatment of choice for patients who have early-stage breast cancer with clinically negative nodes.     

Does use of axillary ultrasound in clinically node‐negative patients receiving neo‐adjuvant systemic therapy for breast cancer lead to surgical overtreatment?

Increased use of neo‐adjuvant chemotherapy (NAC) for breast cancer has raised uncertainty regarding staging of the axilla, particularly for patients with a clinically negative axillary physical examination (PE). We sought to determine whether axillary ultrasound (AUS) prior to NAC to identify occult nodal disease is beneficial in patients with a clinically negative examination by evaluating the difference in nodal burden on final pathology in those with abnormal vs normal AUS. A retrospective review of an institutional cancer registry identified patients who underwent NAC for breast cancer and had a pretreatment AUS. Differences in the number of positive lymph nodes (PLN) in patients with a normal axillary PE and abnormal vs normal AUS prior to NAC were determined. A total of 120 patients who received NAC had a negative axillary PE prior to treatment. Fifty‐three had an abnormal AUS and biopsy‐proven lymph node (LN) involvement. In patients with an abnormal AUS, median number of PLNs at surgery was 1 vs 0 for those with a normal AUS (mean difference of 2.12, P < .0001). Of those patients with an abnormal AUS and biopsy‐proven LN involvement, 87% underwent axillary lymph node dissection (ALND) and nearly half had no PLN on final pathology (N = 23, 43%). Patients with a clinically negative axilla and an abnormal AUS were more likely to have PLN at the time of surgery. However, almost half of those patients had no residual LN involvement. Routine AUS prior to NAC may lead to more extensive surgical management of the axilla.     

Klinische Wertigkeit und zukünftige Aspekte der "Sentinel Node Biopsy" beim Mammakarzinom

INTRODUCTION: In view of its predictive potential, axillary nodal status plays a particularly important role in breast cancer. The concept of sentinel node biopsy (SNB) revealed an accurate method with low postoperative morbidity for staging the axilla in patients with lymph node-negative breast cancer. The aim of this study was to show that SNB alone must have a place in routine clinical work and is reliable after preoperative chemotherapy (PC) and also in patients with multicentric tumors (MC). PATIENTS AND METHOD: Between April 1997 and March 2002, a total of 300 SNBs were performed in patients with uni- or bilateral breast cancer. Of them, 45 who had completed PC and 13 with multicentric lesions underwent SNB followed by axillary dissection. The sentinel nodes (SN) were labelled with a blue dye and radioactive colloids. Median follow-up was 33.6 months (range 8.2-67.0) (StAw 1.4). RESULTS: The detection rate in the learning phase was 81.8% and later 93.5%, independently of the size of the primary tumor. Overall accuracy and negative predictive value of the first 55 patients, after PC and in those with MC came to 97.8% and 96.7%, 97.6%, 95.8% and 100%, respectively. Through focused pathologic examination, staging was improved in 11.3% of patients. A year after the procedure, one patient developed recurrence. Morbidity after SNB alone was significantly lower than after axillary dissection. CONCLUSION: Our experience shows SNB to be reliable and accurate for axillary staging in breast cancer patients. Morbidity after SNB alone was low. Conclusive data on the local recurrence rate are not yet available. Under certain conditions, SNB appears to have future clinical potential, even in patients with PC and MC, which must be confirmed in further multicentric studies.In the meantime, this method has attained definite value in the surgical therapy of breast cancer patients.     

The predictive value of sentinel lymph node biopsy in locally advanced breast cancer patients who have undergone neoadjuvant chemotherapy

With the increasing usage of neoadjuvant chemotherapy (NAC) in locally advanced breast cancer (LABC), there is the need to investigate the routine axillary node dissections performed in this group of patients. Controversy exists about the utility of sentinel node biopsy (SNB), either before or after NAC. With the addition of trastuzumab in the treatment of Her2/neu-positive LABC patients, the validity of SNB in this subset population needs to be investigated. A retrospective study of 20 patients who underwent NAC for LABC was undertaken. The pathology of the axillary nodes, sentinel nodes, and primary tumor after neoadjuvant chemotherapy were examined. Twenty patients underwent NAC with doxorubicin and cyclophosphamide, followed sequentially by paclitaxel and carboplatin, with or without trastuzumab based on Her2/neu status. Post chemotherapy, 20 patients underwent mastectomy or lumpectomy with SNB with axillary node dissections. The overall accuracy of SNB was 95 per cent with a false-negative rate of 14 per cent (1/7). In Her2/neu-positive patients, overall accuracy was 100 per cent (8/8) and a false-negative rate of zero per cent. Sentinel node biopsy is a viable option in patients who have undergone NAC. Her2/neu-positive patients who had undergone NAC with trastuzumab had comparable accuracy for sentinel node biopsy in predicting axillary node status.     

Utility of axillary ultrasound examination to select breast cancer patients suited for optimal sentinel node biopsy

BACKGROUND: Because sentinel node (SN) biopsy (SNB) is known to produce false-negative results, we examined the usefulness of axillary ultrasound (AUS) in selecting patients suitable for optimal SNB. METHODS: A positive AUS finding (positive AUS) was defined as an echo pattern of a homogeneously hypoechoic SN without an echo-rich center, indicating massive to extensive nodal involvement. The identification of SNs was performed, and complete axillary dissection was carried out. RESULTS: A total of 262 women were enrolled into the study (T1 disease = 94; T2 disease = 145; and T3 disease = 23). The incidence of positive AUS increased with increasing size of breast tumor (P <0.0001). The overall identification and false-negative rates were 88.2% and 10.8%, respectively. However, when limited to AUS-negative patients, SNs were identified in 205 of 208 patients (98.6%), and the false-negative rate was 1.7%. CONCLUSIONS: AUS should be included in the preoperative procedure for the selection of breast cancer patients suitable for SNB.     

Feasibility of axillary ultrasound in the quality assessment of sentinel node biopsy in breast cancer surgery.

BACKGROUND AND AIMS: The purpose of this study was to evaluate the efficacy of high-resolution axillary ultrasound (AU) in detecting the rate of recurrence after a negative sentinel node (SN) biopsy in patients with breast cancer and without additional axillary dissection. MATERIALS AND METHODS: The operating oncologic surgeon performed 196 consequent sentinel node biopsies during surgery of breast cancer. The sentinel nodes were identified by using preoperative lymphoscintigraphy, intraoperative gamma probe and Patent Blue dye. A routine postoperative follow-up of the patients were performed every 3rd month including clinical examinations, blood chemistry and mammography. After 31 months (range 14-49 months), a high-resolution AU was performed for 107 patients with a negative sentinel node during surgery and without axillary dissection, to visualize any abnormal lymph nodes in the axilla. If necessary, large core biopsies were undertaken to obtain histology of abnormal axillary nodes. RESULTS: The SNs were visualized during preoperative lymphoscintigraphy in 167/196 (85%) and found during the surgery in 163/167 (98%) of patients. The mean number of removed SN were 1.7+/-0.8. The SN metastasis were found in 29% (56/196) of patients. During the follow-up, abnormal nodes were identified during AU in only 4/107 patients. Core biopsies confirmed benign histology in three patients and one case of lymphoma was detected. CONCLUSIONS: There were no axillary recurrences of breast cancer after a negative SN biopsy during the 2.6 year follow-up. Axillary ultrasound is a useful tool in the quality control of patients with negative SN biopsy and without diagnostic axillary dissection.     

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.     

Sentinel node biopsy versus low axillary sampling in women with clinically node negative operable breast cancer

BackgroundSentinel node biopsy (SNB) was initially conceived as excision of the first station axillary lymph node(s) (LN) identified by radioactive and/or blue dye uptake. The definition was subsequently enlarged to also include palpable lymph nodes in the vicinity of sentinel node(s) (SN). We reasoned that the excision of this combination of nodes might be best achieved by sampling the lower axilla.MethodsEach patient underwent low axillary sampling (LAS) and identification of SN in the excised specimen followed by complete axillary lymph node dissection (ALND). LAS was defined as excision of all fibrofatty tissue overlying the second digitation of serratus anterior below the intercostobrachial nerve and was carried out following a pre-operative injection of radioactive colloid and an intra-operative injection of blue dye. Blue and/or hot nodes (B&/HN) in the dissected tissue and remaining axilla, along with any palpable nodes within the sampled tissue, were defined as SN. The primary endpoint of the study was to compare false negative rates (FNR) of SN with that of LAS in predicting axillary LN status (NCT00128362).FindingsThe study was performed between March 2004 and December 2011 in 478 women with clinically node negative axilla. On histopathological evaluation the median tumor size was 2.5 cm and axillary nodal metastases were found in 34.1% of patients. The FNR of SNB (12.7%, 95% CI 8.1–19.4) and LAS (10.5%, 95% CI 6.6–16.2) were not significantly different (p = 0.56). The FNR of B&/HN alone, without palpable nodes, (29.0%, 95% CI 22.5–36.6) was significantly inferior to those of SNB (p = 0.0007) and LAS (p = 0.0003).InterpretationLAS is as accurate as SNB in predicting axillary LN status in women with clinically node negative operable breast cancer. Confining SNB procedure to excision of B&/HN, significantly increases the risk of leaving behind metastatic lymph nodes in the axilla. LAS is an effective and low cost procedure that minimizes axillary surgery and can be implemented widely.Registry Name: Clinicaltrials.gov.Registration Number: NCT00128362.     

Sentinel node biopsy in breast cancer: validation study and comparison of blue dye alone with triple modality localization

Background: Sentinel node biopsy (SNB) for breast cancer patients is a new technique with the potential to provide an accurate staging of the axillary nodal status while avoiding the morbidity of an axillary dissection. The objective of the present study is to validate the use of sentinel node biopsy in a New Zealand hospital and to compare the ability of patent blue dye (PB) alone with triple modality (TM) (preoperative lymphoscintigraphy, intraoperative gamma probe and intraoperative blue dye) to identify the sentinel node. Methods: A total of 104 patients who had a palpable breast lump that was confirmed to be malignant by radiology and cytology and a clinical diagnosis of stage I or stage II breast cancer, were enrolled for SNB and randomly assigned to triple modality or blue dye alone for the localization of the sentinel node. Axillary dissection was performed after the sentinel node(s) had been removed. Results: There were 63 patients in the PB group and 41 patients in the TM group. Both groups are comparable, with a similar mean age and primary tumour size. A sentinel node was identified in 57 (90%) of the PB group patients and 40 (98%) of the TM group patients. Of these 23 (37%) of the PB group and 23 (56%) in the TM group had axillary nodes positive for malignancy. There was one false negative SNB in the PB group and two false negative results in the TM group. Therefore, the PB group had an accuracy of 98% and a sensitivity of 96% compared to an accuracy of 95% and a sensitivity of 91% for the TM group. Conclusion: The results of the present study validate the use of SNB in suitable breast cancer patients. Identification and the accuracy of the sentinel node localization were similar between the two groups. Therefore, in hospital centres without adequate access to a nuclear medical facility, it would be feasible to conduct SNB using blue dye alone.     

Delayed diagnosis of breast cancer as a result of normal mammograms

Review of the effects of a normal mammogram on the treatment of 36 women with palpable breast carcinomas during a two-year period showed that 17 patients had biopsies performed within two months of their normal mammograms and 19 patients had biopsies delayed for three to 24 months. Of the 17 who had biopsies within one month of a normal mammogram, three (17.6%) had extension of disease to axillary nodes. Of 19 patients whose biopsy was delayed, cancer was found in axillary nodes of 11 (57.9%). Normal mammograms should not preclude biopsy of a breast mass.     

Cost/Accuracy Ratio Analysis in Breast Cancer Patients Undergoing Ultrasound-Guided Fine-Needle Aspiration Cytology,Sentinel Node Biopsy,and Frozen Section of Node

We evaluated the effectiveness and the cost of axillary staging in breast cancer patients by ultrasound-guided fine-needle aspiration cytology (US-FNAC), sentinel node biopsy (SNB), and frozen sections of the sentinel node to achieve the target of the highest number of immediate axillary dissections. From January 2003 through October 2005, a total of 404 consecutive eligible breast cancer patients underwent US-FNAC of suspicious axillary lymph nodes. If tumor cells were found, immediate axillary dissection was proposed (33% of node-positive cases). If US or cytology was negative, SNB was performed. Frozen sections of the sentinel node allowed immediate axillary dissection in 31% of node-positive cases. The remaining 36% underwent delayed axillary dissection. We compared our policy with clinical evaluation of the axilla, showing better specificity of US-FNAC, the cost balanced by a 12% reduction of SNBs, and a marked reduction of unnecessary axillary dissections resulting from false-positive clinical staging. Moreover, the comparison between our policy and permanent histology of the sentinel node showed an 8% cost saving, mainly associated with the immediate axillary dissections. US-FNAC of axillary lymph nodes in breast cancer patients reliably predicts the presence of metastases and therefore refers a significant number of patients to the appropriate surgical treatment, avoiding an SNB. As cost saving to the health care system in our study is mainly related to one-step axillary surgery, US-FNAC of axillary lymph nodes and frozen section of the sentinel node generate significant cost saving for patients who have metastatic nodes.     

Lymphatic mapping in patients with breast cancer and previous augmentation mammoplasty

Sentinel lymph node biopsy (SLNB) is now an established method of axillary staging in patients with breast cancer. However, the augmented breast poses an interesting challenge to this procedure. We hypothesized that SLNB is feasible in patients with augmented breasts who subsequently develop breast cancer. A retrospective study was performed from 1995 to 2006. Ten patients with augmented breasts underwent breast conservation therapy with SLNB. Sentinel lymph nodes were identified in all 10 patients. Three patients had positive sentinel nodes. Two patients proceeded to axillary lymph node dissection (ALND), and one declined. The subsequent ALND were negative for metastatic cancer. Seven patients had negative sentinel nodes. One patient with a negative sentinel node underwent ALND with all nodes negative for metastasis. Two patients were lost to follow-up. Of the remaining eight patients, the mean duration of follow-up was 71 months. None of these patients had evidence of axillary recurrence or distant metastasis at time of last follow-up. SLNB is a feasible method of axillary node staging in patients who have undergone augmentation mammoplasty who subsequently develop breast cancer. Further studies are needed to better determine the accuracy of lymphatic mapping in this patient population.     

Sentinel node biopsy in breast cancer and melanoma requires adequate self-audit

BACKGROUND: Sentinel node biopsy (SNB) is an evolving technique with potential for improving staging. Melanoma and breast cancer are the two most commonly used applications. The present study relates the author's validation data in both diseases. METHODS: Review of a prospective database. RESULTS: Between January 2000 and December 2001 92 cases of breast cancer were offered SNB. The first 48 had completion axillary dissection. The identification rate was 92%. There were 28 true negative, 15 true positive and one false negative case. A mean of 2.0 nodes were removed (range 1-4). Completion axillary dissection removed a mean of 15.1 nodes. The following 44 cases were offered a choice of SNB alone, axillary dissection or a combination of techniques. Thirty-seven women chose SNB alone. There was one technical failure, 28 negative SNB and eight positive SNB results. A mean of 3.1 lymph nodes were removed (range 1-9) applying a 10% rule. At 24-36 months follow up there have been no cases of locoregional recurrence. From January to December 2001 36 cases of melanoma > or =1 mm were managed with SNB. Twenty-eight SNB were negative and eight were positive (22%). At follow up (range 12-24 months) there were three locoregional recurrences, but only one of these were in the node basin determined to be previously negative by SNB (3.5%). DISCUSSION: Sentinel node biopsy in breast cancer is a valid alternative to full axillary dissection for staging the axilla. Patients can make an informed choice to have SNB alone if they understand the limitations of the technique and possible consequences of these limitations. In melanoma SNB provides valuable prognostic information most melanoma patients prefer to have. Adequate self-audit is necessary before a patient can make an informed decision to have SNB in either disease.     

Multicentre study of ultrasonographically guided axillary node biopsy in patients with breast cancer

BACKGROUND: Axillary lymph node dissection is still performed as a staging procedure since lymph node status is the most important prognostic factor in patients with breast cancer. Sentinel node biopsy may replace routine axillary lymphadenectomy, especially in patients with small breast cancers. This study investigated whether ultrasonographically guided fine-needle aspiration cytology (FNAC) of the axillary lymph nodes in clinically node-negative patients was an accurate staging procedure to select patients for sentinel node biopsy. METHODS: One hundred and eighty-five consecutive patients were included. All had axillary ultrasonography and detected nodes were categorized according to their dimensions and echo patterns. Ultrasonographically guided FNAC was carried out if technically possible. These results were compared with the results of the sentinel node biopsy and subsequent axillary dissection. RESULTS: In 116 patients no lymph nodes were detected by ultrasonographic imaging. Of 69 patients with visible nodes, 31 had malignant cells on FNAC. There were no false-positive results. Some 87 of 185 patients had axillary metastases on definitive histological examination. Ultrasonography was sensitive in patients with extensive nodal involvement. Failure of the examination was caused by problems learning the method, difficulty in puncturing small lymph nodes and sampling error. CONCLUSION: In patients without palpable axillary nodes, a sentinel node biopsy could be avoided in 17 per cent since ultrasonography combined with FNAC had already diagnosed axillary metastases. The method is particularly valuable in larger breast cancers.     

A randomized trial comparing axillary dissection to no axillary dissection in older patients with T1N0 breast cancer: results after 5 years of follow-up

SUMMARY BACKGROUND DATA: Axillary dissection, an invasive procedure that may adversely affect quality of life, used to obtain prognostic information in breast cancer, is being supplanted by sentinel node biopsy. In older women with early breast cancer and no palpable axillary nodes, it may be safe to give no axillary treatment. We addressed this issue in a randomized trial comparing axillary dissection with no axillary dissection in older patients with T1N0 breast cancer. METHODS: From 1996 to 2000, 219 women, 65 to 80 years of age, with early breast cancer and clinically negative axillary nodes were randomized to conservative breast surgery with or without axillary dissection. Tamoxifen was prescribed to all patients for 5 years. The primary endpoints were axillary events in the no axillary dissection arm, comparison of overall mortality (by log rank test), breast cancer mortality, and breast events (by Gray test). RESULTS: Considering a follow-up of 60 months, there were no significant differences in overall or breast cancer mortality, or crude cumulative incidence of breast events, between the 2 groups. Only 2 patients in the no axillary dissection arm (8 and 40 months after surgery) developed overt axillary involvement during follow-up. CONCLUSIONS: Older patients with T1N0 breast cancer can be treated by conservative breast surgery and no axillary dissection without adversely affecting breast cancer mortality or overall survival. The very low cumulative incidence of axillary events suggests that even sentinel node biopsy is unnecessary in these patients. Axillary dissection should be reserved for the small proportion of patients who later develop overt axillary disease.     

Role of axillary ultrasound examination in the selection of breast cancer patients for sentinel node biopsy

BACKGROUND: Sentinel node biopsy (SNB) is a time-consuming procedure that can be avoided in presence of axillary metastases. The aim of this study was to assess the accuracy of ultrasound scan (US) in the prediction of axillary nodes status in patients scheduled for SNB. METHODS: Axillary US was performed and when feasible, a core biopsy of suspicious nodes was taken. The nodal status as assessed by US and/or core biopsy was compared with final histology. RESULTS: Of the 132 patients enrolled, 31 (23.5%) had suspicious axillary nodes according to US; 19 (61.3%) were true positive, whereas 12 cases (38.7%) were not. In 14 of 31 suspicious cases an US-guided core-biopsy was taken, which in 11 of 14 cases (78.5%) confirmed the neoplastic involvement. Overall, core biopsy of the nodes correctly predicted the final histology in 13 of 14 cases (92.8%). CONCLUSIONS: The US of axillary nodes, possibly associated with core biopsy, improved the preoperative evaluation of breast cancer patients scheduled for SNB.     

Influence of Tumor Histology on Preoperative Staging Accuracy of Breast Metastases to the Axilla

Histologic confirmation of axillary nodal metastases preoperatively avoids a sentinel node biopsy and enables a one step surgical procedure. The aim of this study was to establish the local positive predictive value of axillary ultrasound (AUS) and guided needle core biopsy (NCB) in axillary staging of breast cancer, and to identify factors influencing yield. A prospective audit of 142 consecutive patients (screening and symptomatic) presenting from 1st December 2008–31st May 2009 with breast lesions categorized R4–R5, who underwent a preoperative AUS, and proceeded to surgery was undertaken. Ultrasound‐guided NCB was performed on nodes radiologically classified R3–R5. Lymph node size, number, and morphological features were documented. Yield was correlated with tumor size, grade, and histologic type. AUS/NCB was correlated with post surgical pathologic findings to determine sensitivity, specificity, positive and negative predictive value of AUS and NCB. A total of 142 patients underwent surgery, of whom 52 (37%) had lymph node metastases on histology. All had a preoperative AUS, 51 (36%) had abnormal ultrasound findings. 46 (90%) underwent axillary node NCB of which 24 (52%) were positive. The smallest tumor size associated with positive nodes at surgery was 11.5 mm. The sensitivity of AUS was 65%. Specificity was 81%, with a positive predictive value (PPV) of 67% and negative predictive (NPV) value of 80%. Sensitivity of U/S‐guided NCB was 75%, with a specificity of 100%, PPV 100% and NPV 64%. Sensitivity of AUS for lobular carcinoma was 36% versus 76% for all other histologies. Sensitivity of NCB for lobular cancer was 33% versus 79% for all other histologies. The most significant factor producing discordance between preoperative AUS and definitive histologic evidence of lymph node metastasis was tumor type. Accurate preoperative lymph node staging was prejudiced by lobular histology (p < 0.0019).     

Occult Breast Lesion Localization plus Sentinel Node Biopsy (SNOLL): Experience with 959 Patients at the European Institute of Oncology

Background Non-palpable breast lesions are diagnosed frequently posing the problem of localization and removal. When such lesions are malignant, axillary node status must be determined. We report our experience using radio-guided occult lesion localization (ROLL) for locating and removing non-palpable breast lesions together with sentinel node biopsy (SNB) to assess axillary status. We call the technique SNOLL. Methods From March 1997 to April 2004, 1046 consecutive patients presented suspicious non-palpable breast lesions and were programmed for conservative surgery and SNB. In 87 patients intraoperative histological examination revealed a benign lesion and SNB was not performed. The remaining 959 patients, with cytologically or histologically proven cancer, underwent SNOLL with immobile radiotracer injected under mammographic or ultrasound (US) guidance into the lesion, and subsequent injection of mobile tracer subdermally to localize the sentinel node (SN). Patients then underwent breast surgery and SNB. Results Breast lesions were localized by ROLL in 99.6% of cases and were removed radically with negative margins in 91.9% of cases. Sentinel nodes were detected in all but one case. Intraoperative or definitive histological examination revealed 776 invasive/microinvasive carcinomas and 182 with in situ disease. Sentinel nodes were positive in 154 (19.8%) of 776 invasive/microinvasive cancers and in two with ductal intraepithelial neoplasia (1.1%). Conclusions In SNOLL the injection procedures are performed separately, but both lesion and SNs are removed together; axillary dissection is performed if the SN is positive, thus definitive treatment of malignant non-palpable lesions occurs in a single surgical session.