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

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

Axillary lymph node metastases associated with small invasive breast carcinomas

BACKGROUND: Over the past 20 years the proportion of invasive breast carcinomas measuring < or = 1 cm has increased progressively. Information regarding the effect of clinical and histologic characteristics on the frequency of lymph node metastases associated with small invasive breast carcinomas is limited. METHODS: A review of Surveillance, Epidemiology, and End Results data was performed using cases diagnosed between January 1988 through December 1993. A total of 12,950 patients with invasive breast carcinomas measuring < or = 1 cm undergoing a resection of the primary tumor and an axillary lymph node dissection were included in this study. The effect of clinical and histologic characteristics on the frequency of lymph node metastases was reviewed. RESULTS: The frequency of lymph node metastases associated with T1a tumors was less than that observed from T1b tumors (9.6% vs. 14.3%; P < 0.001). Tumors with favorable histology (mucinous, papillary, and tubular carcinomas) had a lower frequency of lymph node metastases compared with all other histologic types (3.9% vs. 13.9%; P < 0.001). Increasing histologic grade was associated with an increased risk of lymph node metastases ranging from 7.8% in Grade 1 tumors to 21.0% in Grade 4 tumors (P < 0.001). Increasing patient age was associated with a progressively decreasing frequency of associated axillary lymph node metastases ranging from 22.6% in women age < 40 years to 10.2% in women age > or = 70 years (P < 0.001). CONCLUSIONS: Cases in which an axillary lymph node dissection can be avoided are those with an associated frequency of lymph node metastases < or = 5%, including T1a and T1b mucinous and tubular carcinomas, T1a papillary carcinomas, and T1a Grade 1 carcinomas.     

Incidence and prognostic significance of complete axillary downstaging after primary chemotherapy in breast cancer patients with T1 to T3 tumors and cytologically proven axillary metastatic lymph nodes.

PURPOSE: To determine the incidence and prognostic significance of eradication of cytologically proven axillary lymph node metastases in breast cancer patients treated with primary chemotherapy. PATIENTS AND METHODS: Between January 1985 and December 1994, 152 breast cancer patients with invasive T1 to T3 tumors and axillary metastases cytologically proven by fine-needle sampling underwent primary chemotherapy followed by lumpectomy or mastectomy, level I and II axillary lymph node dissection, and irradiation. We studied pathologic complete responses (pCRs) of axillary nodes and breast tumors, as well as predictors of distant metastases. RESULTS: Thirty-five patients (23%) had axillary pCRs, and 20 patients (13.2%) had pCRs of primary breast tumors. Scarff-Bloom-Richardson grade 3 tumors (P =.04) and a clinical response to chemotherapy > or = 50% (P =.003) were associated with negative axillary status at dissection. An initial tumor size < or = 3 cm (63 patients) was associated with pCR of the primary tumor (P =.02) but not with complete histologic clearance of axillary lymph nodes. The median length of follow-up was 75 months. In the univariate analysis, age greater than 40 years (P =.003), absence of residual nodal disease (P =.01), and pCR of the tumor (P =.05) were associated with better distant disease-free survival. Five-year distant disease-free survival rates were 73.5% +/- 14.9% among patients with no involved nodes at the time of surgery and 48.7% +/- 9.2% among patients with residual nodal disease. In the multivariate Cox regression analysis, parameters associated with poor distant disease-free survival were age < or = 40 years (P =.002), persistence of nodal involvement (P =.03), and S-phase fraction greater than 4% (P =.02). CONCLUSION: Our results suggest that axillary status is a better prognostic factor than response of the primary tumor to primary chemotherapy.     

Positron emission tomography and sentinel lymph node dissection in breast cancer

Sentinel lymph node dissection (SLND) is emerging as the preferred method of axillary staging for breast cancer patients. To further the use of noninvasive techniques in breast cancer, positron emission tomography (PET) scans have been considered as an alternative axillary staging modality. In order to compare the 2 modalities, we studied 15 invasive breast cancer patients who had undergone a preoperative PET scan before sentinel lymphadenectomy. PET scans were compared to axillary pathology results, which were defined as the greatest diameter of nodal metastases. Primary tumor sizes ranged from 0.5 cm to 5.0 cm (median,1.5 cm) and all were ductal in origin except for 1 invasive lobular and 1 mucinous carcinoma. Ten women had completion axillary dissections. Sentinel lymph node dissection was successful in all patients with completion dissections and no false-negative results. Five patients had sentinel node metastases, but PET scans identified only 1 of these patients, resulting in 4 false-negative PET scans. Missed metastases ranged in size from a micrometastatic focus identified only by immunohistochemistry to a nodal tumor measuring 11 mm in diameter. In addition, 1 woman with a PET-positive axilla was tumor free by SLND and remains free of axillary recurrence 29 months postoperatively. Two women had mediastinal uptake by PET scanning and were found to be tumor free after computerized tomography. The results of this preliminary study suggest that PET scanning using current techniques can be used as an adjunct to SLND rather than as an alternative staging technique.     

Infiltrating breast carcinoma smaller than 0.5 centimeters. Is lymph node dissection necessary?

BACKGROUND: The incidence of axillary lymph node metastases from infiltrating breast carcinomas measuring 1.0 cm or smaller reported in the literature varies from 0% (for tumors measuring < or =0.5 cm) to 27.1% (for all tumors < or =1 cm). METHODS: The authors examined all infiltrating breast carcinomas measuring 1.0 cm or smaller with axillary lymph node dissections in patients seen at their institution between January 1990 and March 1997 (117 cases) to determine the incidence of axillary lymph node metastases. All tumors were evaluated for patient age, histologic type of tumor, modified Bloom-Richardson grade, estrogen and progesterone receptor status, ploidy, S-phase fraction, and angiolymphatic vessel invasion, to determine whether there was a relation between the indicators and axillary lymph node metastases. The authors also performed immunohistochemical stains for the basement membrane components laminin and Type IV collagen on the tumors demonstrating metastases and on an equal number of size- and date-matched tumors not demonstrating metastases. RESULTS: Twelve cases of infiltrating carcinoma with axillary lymph node metastases were identified (a 10.3% overall incidence of metastases). Lymph node metastases were not identified in any of the cases with tumors measuring < or =0.5 cm (24 cases). The incidence of axillary lymph node metastases for carcinomas 0.6-1.0 cm was 12.9% (12 of 93 cases). High nuclear grade was found to correlate with the presence of lymph node metastases (P = 0.007). No statistically significant correlation was found between the other indicators examined and axillary lymph node metastases or between basement membrane staining and axillary lymph node metastases. CONCLUSIONS: The authors concluded that infiltrating breast carcinomas measuring < or =0.5 cm are unlikely to have demonstrable axillary lymph node metastases. Lymph node dissections in these women may be unnecessary. Nuclear grade may be the best predictor of lymph node metastases in T1b tumors.     

T1 breast cancer: identification of patients at low risk of axillary lymph node metastases

Objective. The status of the axillary lymph nodes is one of the most important prognostic factors in patients with breast cancer. A panel of molecular markers of tumor aggressiveness in addition to conventional clinical and histopathologic features were analyzed in an attempt to identify a subgroup of patients with a low risk of axillary lymph node metastases. Material and methods. Data from 358 patients with T1 breast cancer who underwent level I/II axillary lymph node dissection (ALND) were investigated. Hormone receptor status, Ki-67, S-phase fraction, DNA ploidy, HER-2/neu, p53, epidermal growth factor receptor, urokinase type plasminogen activator, plasminogen activator inhibitor-1, bone marrow micrometastases as well as patient age, menopausal status, tumor site, tumor size, histologic type, tumor grade, carcinoma in situ, multifocality, and lymph vascular invasion (LVI) were studied to predict axillary lymph node status. Results. In a multivariate logistic regression analysis LVI (present v.s. not present), Ki-67 (18% v.s. <18%), tumor size (1.1–2 cm v.s. 1 cm), and histologic grade (G3 v.s. G1/2) were identified as independent predictive factors of axillary lymph node metastases. Approximately 13% of patients (n = 47) with well or moderately differentiated tumors less than or equal to 1 cm, no lymph vascular invasion, and a low Ki-67 staining were identified as having a low risk of axillary lymph node metastases of 4.3%. However, 20 patients with all four unfavorable predictive factors had a 75% incidence of axillary lymph node involvement. Conclusion. Primary tumor characteristics can be used to identify a subgroup of patients with a low risk of axillary lymph node metastases in T1 breast cancer. Preoperative risk assessment might be used to omit routine ALND in those patients at low risk of axillary lymph node metastases.     

Two cases of recurrent breast cancer with regional lymph node metastases showing a complete response to trastuzumab and paclitaxel treatment

We report two cases of recurrent breast cancer with regional lymph node metastases that responded completely to treatment with trastuzumab and paclitaxel. Case 1: A 52-year-old woman, who presented with left breast cancer, underwent mastectomy and axillary lymph node dissection in July 2002. Pathological findings were as follows: invasive ductal carcinoma (scirrhous type), 2.2 cm in size, histological grade 3, positive invasion to the lymphatic and blood vessels, negative nodal status (0/11), negative ER/PgR status, and overexpression of HER 2/neu. Left axillary lymph node metastasis was noted after five months, ie, in December 2002. Four cycles of chemotherapy with doxorubicin and cyclophosphamide were administered from January 2003; however, they were not effective. The patient showed a complete response after three months of chemotherapy with trastuzumab and paclitaxel. This treatment was stopped in September 2003. She has maintained a complete response for two and a half years and was not administered any further treatment as of February 2006. Case 2: A 59-year-old woman, who presented with right breast cancer, underwent mastectomy and axillary lymph node dissection in May 2002. Pathological findings were as follows: invasive ductal carcinoma (scirrhous type), 1.8 cm in size, histological grade 2, positive invasion to the lymphatic and blood vessels, negative nodal status (0/5), positive ER and uncertain PgR status, and overexpression of HER 2/neu. She had received adjuvant hormonal therapy with tamoxifen; however, a right supraclavicular lymph node metastasis was noted in October 2004. Treatment with exemestane was not effective. However, a complete response was observed with trastuzumab and paclitaxel for four months. She has maintained a complete response for six months and was not administered any further treatment as of February 2006.     

176例乳腺癌数字化摄影的X线征象与临床病理关系的探讨

目的:探讨乳腺癌X线特点与临床、病理的关系.方法:将176患者的病灶特点,与临床资料、病理类型、腋淋巴结转移对照.结果:以单纯钙化为表现的乳腺癌多为年轻患者,50岁以下占84.4%;以钙化合并肿块者多为老年患者.导管内癌和导管内癌早期浸润的乳腺癌X线表现多为单纯钙化.以钙化合并毛刺样肿块为表现的乳腺癌具有较高的腋淋巴结转移率;以单纯蠕虫样钙化、单纯毛刺样肿块及单纯非蠕虫样钙化为表现者,腋淋巴结转移率亦较高.单纯蠕虫样钙化伴腋淋巴结转移4～9枚占75.0%(6/8);钙化合并毛刺样肿块者,腋淋巴结转移4～9枚占27.8%(10/36),10枚以上占16.7%(6/36).结论:单纯钙化多见于年轻患者,多为早期乳腺癌.蠕虫样钙化、毛刺样肿块与腋淋巴结转移阳性关系密切,是预后不良的指标.     

Initial experience with sentinel node biopsy in breast cancer at the National Cancer Center Hospital East

BACKGROUND: Axillary lymph node dissection is an important procedure in the surgical treatment of breast cancer. Axillary lymph node dissection is still performed in over half of breast cancer patients having histologically negative nodes, regardless of the morbidity in terms of axillary pain, numbness and lymphedema. The first regional lymph nodes draining a primary tumor are the sentinel lymph nodes. Sentinel node biopsy is a promising surgical technique for predicting histological findings in the remaining axillary lymph nodes, especially in patients with clinically node-negative breast cancer, and a worldwide feasibility study is currently in progress. METHODS: Intraoperative lymphatic mapping and sentinel node biopsy were performed in the axilla by subcutaneous injection of blue dye (indigocarmine) in 88 cases of stage 0-IIIB breast cancer. Sentinel lymph nodes were identified by detecting blue-staining lymph nodes or dye-filled lymphatic tracts after total or partial mastectomy. Finally, axillary lymph node dissection was performed up to Levels I and II or more. RESULTS: Sentinel lymph nodes were successfully identified in 65 of the 88 cases (74%). In the final histological examination, the sentinel lymph nodes in 40 cases were negative, including four cases with non-sentinel-node-positive breast cancer (specificity, 100%; sensitivity, 86%). In nine (31%) of the 29 cases with histologically node-positive breast cancer, the sentinel lymph nodes were the only lymph nodes affected. Axillary lymph node status was accurately predicted in 61 (94%) of the 65 cases. CONCLUSIONS: Although it was the initial experience at the National Cancer Center Hospital East, sentinel node biopsy proved feasible and successful. This method may be a reasonable alternative to the standard axillary lymph node dissection in patients with early breast cancer.     

Metachronous secondary primary occult breast cancer initially presenting with metastases to the contralateral axillary lymph nodes: report of a case

We report a rare case of a 64-year-old female with metachronous secondary primary left occult breast cancer initially presenting right axillary lymph node metastases. The patient, who had received breast-conserving therapy for left breast cancer at another hospital about 4.5 years ago, came to our hospital complaining of right axillary node swelling. After both breast and systemic examination, she received complete right axillary lymph node dissection. Just after the operation, she was diagnosed with right occult breast cancer by a review of the right axillary lymph nodes and previous left breast cancer. She was followed by radiation and systemic chemoendocrine therapies. One year after axillary lymph node dissection, mammography and ultrasonography showed a new lesion in her left breast. Core needle biopsy revealed similar findings to right axillary lymph node metastasis. After salvage surgery, the diagnosis was revised. We recommend that patients without clinical findings except for axillary lymph node metastasis, especially post-breast-conserving surgery followed by radiation therapy, should be considered not only as having ipsilateral but also contralateral occult breast cancer. If there is no evidence of a primary lesion, axillary lymph node dissection needs to be carried out, and the patient should be offered the choice of radiation therapy or mastectomy followed by proper systemic therapy.     

Microinvasive breast carcinoma with extensive involvement of level III axillary lymph nodes: a case report

A 44-year-old woman presented with a right huge axillary mass. Both mammography and ultrasonography revealed a primary cancer of 2.8 cm maximum diameter in the right breast and metastases in the axillary lymph nodes, both being confirmed by aspiration cytology as ductal carcinoma. Right standard radical mastectomy with level III axillary lymph node dissection was carried out. Pathologically, the tumor was diagnosed as ductal carcinoma in situ with microinvasion (DCISM), histologic grade 3. The area of stromal invasion measured 1 mm at its widest point. Sixteen of the 17 resected axillary lymph nodes contained metastases, including six level III lymph nodes. Immunohistochemical studies of the tumor revealed overexpression of p53 protein, but not that of c-erbB-2 protein. The frequency of lymph node metastases from DCISM is reported to be very low. Therefore, the present case with extensive involvement of level III lymph nodes was unusual.      

Lymph node metastasis from ductal carcinoma in situ with microinvasion.

BACKGROUND: Widespread use of mammography has increased the detection of ductal carcinoma in situ with microinvasion (DCISM) in pathology specimens. Currently there is disagreement regarding the incidence of axillary metastasis from DCISM. The controversy centers on whether complete lymphadenectomy is indicated for axillary staging, given its morbidity and the reportedly minimal rate of axillary involvement in these patients. Intraoperative lymphatic mapping and sentinel lymphadenectomy (SLND) may obviate complete axillary lymph node dissection in selected breast carcinoma patients. In intraoperative lymphatic mapping, isosulfan blue dye is used to demonstrate the course of lymphatic flow from the breast tumor to the first draining or sentinel lymph node. This blue-stained lymph node is selectively excised for pathologic examination; its tumor status is used to predict the tumor status of the other axillary lymph nodes. The authors examined whether SLND would be suitable for staging DCISM. METHODS: From February 1992 to January 1997, 14 patients with DCISM underwent intraoperative lymphatic mapping and SLND at the John Wayne Cancer Institute in Santa Monica, California. Clinical and pathologic data were prospectively collected. RESULTS: Primary DCISM tumors ranged in size from 0.9 to 6.5 cm. Nine patients presented with mammographic abnormalities, two patients presented with Paget's disease and a palpable lesion, and three patients presented with palpable lesions. Two patients (14.3%) had tumor-involved sentinel lymph nodes. One of these patients had two sentinel lymph nodes, both of which contained single cancer cells identified by immunohistochemistry. The other patient had 1 sentinel lymph node, in which a 0.3-cm metastasis was revealed by light microscopy. Completion axillary dissection was performed on both patients and revealed no further tumor positive lymph node metastases. CONCLUSIONS: SLND can detect lymph node micrometastases (tumor deposits <2 mm) in patients with DCISM. The clinical relevance of these micrometastases is unknown, but their existence shows that DCISM can involve the lymph nodes.     

Clinicopathological Characteristics of Primary Breast Cancer in Older Geriatric Women: A Study of 39 Japanese Patients over 80 Years Old

The number of primary breast cancers occurring in elderly women is increasing in Japan. Optimization of treatment regimens in this age group requires precise evaluation of the biological aggressiveness of these tumors as well as the performance status and extent of tumor spread. In 39 breast cancer patients who were at least 80 years old, we examined several parameters; the form of surgical therapy, the lymph node status, presence or absence of distant metastases, the histological type and grade of atypia, and overexpression of the c-erbB-2 oncoprotein in the cancer cells. They were correlated with the clinical outcome of the patient. Of the 33 patients who underwent a mastectomy and axillary lymph node dissection, five died from cancer recurrence. Only one out of 22 patients without lymph node metastases died from cancer, while four out of the eight patients with metastases to three or more lymph nodes died from cancer recurrence within 2.7 years of surgery. The overall survival curves also differed between patients with low-risk histological tumors or grade 1 or 2 invasive ductal carcinoma and those with grade 3 invasive dnctal/lobular carcinoma. Overexpression of c-erbB-2 also affected survival. Regional recurrence occurred in three out of the six patients for whom only lumpectomy or simple mastectomy was performed. These results indicate that, although primary breast cancer occurring in patients over 80 years old was largely of low-grade malignancy, patients with three or more lymph node metastases, invasive ductal/lobular carcinomas of grade 3, or c-erbB-2 overexpression frequently exhibited an aggressive clinical course.     

乳腺癌前哨淋巴结活检术前临床可疑腋淋巴结超声引导针吸细胞学检测的临床意义

目的:评估腋淋巴结可疑阳性的乳腺癌患者,在前哨淋巴结活检术前行超声引导腋淋巴结针吸细胞学检测的临床意义。方法:回顾性分析了257 例超声提示腋淋巴结异常或腋淋巴结临床查体可触及的原发性乳腺癌患者的腋淋巴结针吸细胞学检测结果及常规病理结果。结果:超声引导腋淋巴结针吸细胞学检测乳腺癌可疑腋淋巴结的敏感性、特异性、准确性、阳性预测值和阴性预测值分别为76.3% 、100% 、80.9% 、100% 和50.5% 。76.3% 的患者通过针吸细胞学检测准确地预测了腋淋巴结转移,避免了接受前哨淋巴结活检术。50.5% 的超声提示腋淋巴结异常但针吸细胞学阴性的患者可接受前哨淋巴结活检术替代腋淋巴结清扫术。结论:超声引导腋淋巴结穿刺针吸细胞学检测可快速、较为准确地判定乳腺癌患者腋淋巴结的状况,应该作为前哨淋巴结活检术前的筛查手段。      

Reappraisal of internal mammary node metastases as a prognostic factor in patients with breast cancer.

Clinical, histologic, and biologic prognostic factors were examined in 144 patients with invasive breast cancer. It was determined whether variable prognostic factors, especially internal mammary lymph node metastases, would serve as a basis for the prognosis of breast cancer. In a univariate study, overall survival was significantly correlated with tumor size, axillary lymph node status, axillary and internal mammary lymph node metastases, and DNA ploidy status. Especially among patients with one to three positive axillary nodes, survival in case of internal mammary involvement were significantly lower than without internal mammary involvement. In a multivariate study, only axillary and internal mammary lymph node metastases were recognized as important, independent prognostic factors of survival, but neither axillary lymph node status nor DNA ploidy status appeared as important prognostic factors. It was concluded that internal mammary lymph node metastases is additional prognostic factor, especially in patients with one to three positive axillary nodes. Because axillary and internal mammary lymph node metastases could not be predicted from their clinical assessment, axillary lymph node dissection and biopsy of internal mammary nodes may be a useful staging procedure for these patients.     

Histopathological predictors of axillary lymph node metastases in patients with Breast Cancer

Background  A tumor 30 mm or less in diameter is a standard candidate for breast conserving surgery (BCS) in Japan. Axillary lymph node metastases (ALNM) is the most important prognostic factor for survival in patients with breast cancer, but the role of axillary node dissection has been controversial. Histopathological predictive factors of axillary lymph node involvement have not been established. The purpose of this study was to determine the association between the incidence of ALNM and histopathological factors by univariate and multivariate analysis. Methods  Sixty-five patients with noninvasive ductal carcinoma, and 993 patients with tumors 30 mm or less in diameter who underwent axillary dissection between 1988 and 1997 at our institute were reviewed. The association between ALNM and 13 histopathological factors (size, age, histological subtype, histological invasiveness, lymphatic invasion, vascular invasion, macroscopic classification, histological daughter mass, ductal spread, ER, PgR, p-53, and c-erbB-2) were analyzed by univariate and, when significant, by multivariate analysis. Results  Only one patient with noninvasive ductal carcinoma had ALNM, and 33.1% of 993 patients with a tumor 30 mm or less in size had ALNM. Multivariate analysis identified six factors as independent predictors for ALNM: lymphatic invasion, size, histological invasiveness, macroscopic classification, age and histological daughter mass. Conclusions  Axillary lymph node dissection can be omitted in patients with noninvasive ductal carcinoma. Histopathological features of tumors 30 mm or less in diameter can be used to estimate the risk of ALNM, and routine axillary node dissection might be spared in selected patients at minimal risk of ALNM, if the treatment decision is not influenced by lymph node status, such as in elderly patients.     

Predictive Role of Tumor Size in Breast Cancer with AxillaryLymph Node Involvement - Can Size of Primary Tumor beused to Omit an Unnecessary Axillary Lymph Node Dissection?

Background: Breast cancer is the most common cancer among women worldwide. The aim of this study wasto investigate the relationship between tumor size and axillary lymph node involvement (ALNI) in patients withinvasive lesions, to find the best candidates for a full axillary dissection. Additionally, we evaluated the associationbetween tumor size and invasive behavior. The study was based on data from 789 patients with histopathologicallyproven invasive breast cancer diagnosed in Shohada University hospital in Tehran, Iran (1993-2009). Cinicaland histopathological characteristics of tumors were collected. Patients were divided into 6 groups accordingto primary tumor size: group I (0.1-≤1cm), II (1.1-≤2cm), III (2.1-≤3cm), IV (3.1-≤4cm), V (4.1-≤5cm) andVI (>5cm). The mean(±SD) size of primary tumor at the time of diagnosis was 3.59±2.69 cm that graduallydeclined during the course of study. There was a significant correlation between tumor size and ALNI (p<0.001).A significant positive correlation between primary tumor size and involvement of surrounding tissue was alsofound (p<0.001). The mean number of LNI in group VI was significantly higher than other groups (p<0.05).Weobserved more involvement of lymph nodes, blood vessels, skin and areola-nipple tissue with increase in tumorsize.We found 15.3% overall incidence of ALNI in tumors ≤2 cm, indicating the need for more investigation toomit full axillary lymph node dissection with an acceptable risk for tumors below this diameter. While in patientswith tumors ≥2 cm, 84.3% of them had nodal metastases, so the best management for this group would be a fullALND. Tumor size is a significant predictor of ALNM and involvement of surrounding tissue, so that an exactestimation of the size of primary tumor is necessary prior to surgery to make the best decision for managementof patients with invasive breast cancer.     

Lymphatic mapping and sentinel lymphadenectomy in early stage breast carcinoma

The rate of axillary lymph node metastases is low in early stage breast carcinoma and axillary lymph node dissection is controversial in the treatment of these patients. Intraoperative lymphatic mapping technique is suggested for the identification of metastatic lymph nodes. Intraoperative lymphatic mapping was performed on 60 clinical stage I and II patients who were treated at Ankara Oncology Hospital between 1996-1998. Patent blue dye was injected in all cases, as the tumor was totally excised before mastectomy, into the surrounding breast tissue at four different quadrants. Presence of metastases were examined on stained lymph nodes (sentinel lymph node: SLN) by frozen-section. Modified radical mastectomy was performed including level I, II, III lymph node dissection. Metastases were evaluated on the remnants of frozen-section tissues and unstained lymph nodes (nonsentinel lymph node: nSLN) in axilla on hematoxyline-eosin stained slides and by immunohistochemistry. Forty-nine (81.6%) SLNs were identified among 60 cases. In 18 (36.7%) of these 49 patients, metastases were detected in SLNs by frozen section. In one case micrometastasis was detected in the remnants of frozen-section by immunohistochemistry though it was negative with hematoxyline-eosin. There were no metastases in nSLNs of 27 cases whose SLNs's frozen-sections were tumor free. In 3 cases SLNs were negative but metastases were detected in nSLNs (false negative: 6.1%). There were no local or systemic complications due to injections of dye. Selective lymph node dissections can be performed on early stage breast cancer patients by means of lymphatic mapping. This minimally invasive technique identifies metastatic axillary lymph nodes with a high degree of accuracy, so we can suggest that, non-metastatic patients can be treated without axillary dissection.     

Risk of internal mammary lymph node metastases and its prognostic value in breast cancer patients

The risk of an internal mammary lymph node (IMN) metastasis and its prognostic value for patients with invasive breast cancer were assessed by evaluating 142 patients who had either a mastectomy with lymph node dissection or a biopsy of the IMN. By univariate analysis, overall survival significantly correlated with the patient's age, clinical axillary node status, tumor size, and DNA ploidy, as well as histologically confirmed axillary and IMN metastases. By multivariate analysis, however, only the presence of axillary and IMN metastases appeared to be an important independent factor affecting survival. However, the incidence of IMN metastases was associated significantly with age, clinical tumor and axillary node status, tumor size, axillary lymph node metastases, and DNA ploidy. Accordingly, the patient's age, tumor size, DNA ploidy, and axillary lymph node metastases proved to be effective variable for discrimination. Consequently, in predicting the presence of IMN metastases, a diagnostic accuracy of 82%, a sensitivity of 84%, and a specificity of 82% can be achieved by a discriminant function. We conclude that the discriminant function with these four variables is effective in assessing the risk of IMN metastases. © 1993 Wiley-Liss, Inc.     

Minimally invasive surgery for breast cancer

Breast conservation surgery has become a standard operation as a minimally invasive surgery for breast cancer in Japan. Now sentinel lymph node biopsy (SLNB), day surgery, and endoscopy assisted surgery are being introduced as more minimally invasive surgeries for breast cancer. When blue dye and/or isotope are injected into the peri-tumoral breast gland, the sentinel lymph nodes (SLN) can be detected easily, and node negative patients can be selected with certainty. When no metastasis is found in SLN by frozen section, T1N0 breast cancer patients can be treated without lymph node dissection. Using this technique, day surgery for patients who have clinically node-negative small breast cancer (less than 1.5 cm in diameter) is performed under local anesthesia. We have developed an endoscopy assisted conservation surgery for breast cancer. Using endoscopy, partial or total glandectomy with radical axillary lymph node dissection is performed via a 5 cm skin incision on the middle axillary line. When the amount of glandectomy is over one third, we perform immediate reconstruction using the latissimus dorsi. These minimally invasive surgeries for breast cancer will result in a better quality of life for breast cancer patients.