Sentinel node biopsy performed before preoperative chemotherapy for axillary lymph node staging in breast cancer

Sentinel node (SN) biopsy in breast cancer patients following preoperative chemotherapy is associated with a decreased identification rate and an increased false-negative rate when compared to SN biopsy performed in untreated patients. We performed SN biopsy in 21 breast cancer patients scheduled for preoperative chemotherapy using either vital blue dye alone (n = 11) or in combination with a radiocolloid (n = 10). Following a mean of four cycles of preoperative chemotherapy, surgery to the breast and complete axillary lymph node dissection was performed irrespective of the SN status. A mean of 1.9 SNs were identified in all 21 patients, 12 were SN negative and 9 were SN positive. Preoperative chemotherapy decreased mean tumor size from 40.2 to 17.7 mm and breast conservation was possible in 14 of 21 patients (67%). All SN-negative patients and three of nine SN-positive patients had negative lymph nodes in the axillary specimen, whereas six of nine patients with a positive SN revealed lymph node metastases following preoperative chemotherapy. SN biopsy performed before preoperative chemotherapy found a 100% identification rate with no false-negative results. Following preoperative chemotherapy, SN-negative patients may forego a complete axillary dissection.     

Sentinel lymph node biopsy and low axillary node sampling for breast cancer

Since sentinel lymph node(SLN) biopsy has a higher negative predictive value than that of four-node sampling, SLN biopsy might become the new acknowledged standard of clinical care for patients with early breast cancer. SLN biopsy is widely used in Western countries despite the lack of data from randomized trials. Clinical practice guidelines document that SLN biopsy should be performed with prudent informed consent and thorough surgical technique. Before surgeons replace axillary dissection with SLN biopsy as the staging procedure at their institution, they should perform backup axillary dissection until a detection rate of more than 90% and a false-negative rate of less than 5% are achieved. Recently, SLN biopsy has more often been indicated for multicentric breast cancer, larger tumors, prior excisions, and noninvasive carcinoma. While SLN biopsy is widely used in Western countries, there is little experience in Japan. If randomized studies, clinical practice guidelines, and the coverage of lymphoscintigraphy under health insurance were introduced, SLN biopsy would be used more widely in Japan.     

乳腺癌前哨淋巴结活检对腋窝淋巴结转移的预警价值研究

目的探讨乳腺癌前哨淋巴结(sentinel lymph node,SLN)预警腋窝淋巴结转移的价值. 方法对56例乳腺癌行亚甲蓝前哨淋巴结定位、活检和腋窝淋巴结清扫术,标本常规行HE染色、免疫组化病理检查. 结果 SLN成功检出52例(52/56,92.8%),常规病理检查证实SLN转移22例;SLN无转移,但非SLN发现转移者1例,假阴性率为4.3%(1/23).常规病理检查无转移的29例患者,免疫组化检测发现1例CK-19( )、EMA( ),另1例CK-19( ),CEA( ),而所属非前哨淋巴结无肿瘤转移. 结论乳腺癌亚甲蓝前哨淋巴结定位、活检可以预示腋窝淋巴结转移.     

Sentinel node biopsy in breast cancer

Axillary lymph node dissection (ALND) is an important tool in staging patients with breast cancer. However, this procedure has several sequelae and complications and improvement in early diagnosis has led to an increasing number of cases of ALND in which axillary nodes are found to be negative. Sentinel node (SN) biopsy appears to be a less invasive alternative to ALND. The aim of the present study was to assess whether SN is a reliable indicator for axillary staging. We studied 126 consecutive patients with T1-T2 breast cancer and clinically negative axilla. In each case, 30-70 MBq of 99mTC-labelled colloidal albumin was injected subdermally close to the tumour and SN was visualised by lymphoscintigraphy. Surgery was performed 24 h after injection and the SN was removed under the guidance of a gamma ray-detecting probe. ALND was then undertaken in all cases. A histopathologic examination of the SNs was then made and the findings compared with the status of the other axillary nodes. SNs were identified and biopsied in 115/126 patients (91.3%) and correctly predicted the axillary status in 110/115 cases (95.6%). In five cases (4.4%), SNs were found to be negative, but other axillary nodes were positive. Our data confirm that SN biopsy is a good method for staging the axilla in patients with breast cancer. However, before SN biopsy can replace ALND in daily clinical practice, some technical aspects must be standardized, and clinical trials are required in order to clarify the prognostic impact of false-negative cases.     

Sentinel node biopsy in breast cancer

Background: Sentinel lymph node biopsy (SNB) in breast cancer may be used in place of axillary lymph node dissection (ALND) if SNB accurately stages the axilla. This study assessed the success and accuracy of axillary SNB with isosulfan blue (ISB) and technetium-99 sulfur colloid (TSC) compared to ALND. Methods: Forty-two women with T1 or T2 breast cancer underwent SNB and ALND. Sixty to 90 minutes before anesthetic induction, a mixture of 3 mL ISB and 1 mCi TSC was injected around the primary cancer or prior biopsy site. Intraoperatively, the SLN was identified using a gamma detector (Neoprobe 1000) or by visualization of the blue-stained lymph node and afferent lymphatics. The SLN was excised separately, and a level I/II ALND was completed. The histologic findings of the axillary contents and SLN were compared. Results: An axillary SLN was found in 38 of 42 (90%) cases. SLN localization rate and predictive value were the same for women who had and those who had not undergone excisional biopsy before the date of SNB. Fifteen of 42 (36%) patients had lymph node metastases. The SLN was positive in all women with axillary metastases (negative predictive value, 100%). Conclusions: If confirmed by larger series, a negative SNB may eliminate the need for ALND for select women with breast cancer. Presented at the 50th Annual Cancer Symposium of The Society of Surgical Oncology, Chicago, Illinois, March 20–23, 1997.     

哨兵淋巴结活检对预测乳腺癌腋窝淋巴结转移的价值

目的 评估哨兵淋巴结（ＳＮ）活检对预测乳腺癌腋窝淋巴结（ＬＮ）转移的价值。方法 本组５２例原发乳腺癌患者,临床及Ｂ超检测腋窝ＬＮ阴性。术中在原发肿瘤周围注射亚甲蓝进行腋窝淋巴结定位和哨兵淋巴结切除（ＳＬＮＤ）,随后行腋窝淋巴结清扫（ＡＬＮＤ）。术中对部分ＳＮ、术后对全部ＬＮ（ＳＮ和非ＳＮ）行常规病理检查。结果 ５２例患者中４６例检测到ＳＮ,成功率为８８．５％;其中４４例（９５．７％）和ＳＮ可以准确     

Sentinel node biopsy for breast cancer

Sentinel node biopsy is more frequently being used as a replacement for axillary node dissection as single and multicenter trials confirm its ability to predict the presence of disease in the remaining lymph nodes. There have been a variety of techniques used with varying success and data supporting each of these techniques is presented. In addition, a number of factors have been found to influence the identification and false negative rates, and these are discussed as well. There remain many areas of controversy surrounding this new surgical technique, including: the appropriate method of pathological analysis of the sentinel node, use of lymphoscintigraphy, usefulness of internal mammary sentinel node biopsy, and use of sentinel node biopsy for ductal carcinoma in situ. The Literature is reviewed on these controversial areas.     

Sentinel node biopsy in breast cancer revisited

The axilla has long been a focus of clinicians' attention in the management of breast cancer. The approach to the axilla has undergone dramatic changes over the last century, from radical and extended radical excisions, through the introduction of sentinel node biopsy for node negative patients to the current situation where selective management of those with nodal involvement is being introduced.The introduction of lymphatic mapping and sentinel node biopsy in the 1990's has been key to the major changes that have occurred. In less than 20 years it has moved from a hypothesis to a situation where it is the default approach to almost all clinically node negative patients and is being considered in other situations where axillary clearance was previously considered standard. This article reviews the development and introduction of sentinel node biopsy, its current uncertainties and limitations, and possible future developments.     

Sentinel lymph node biopsy in breast cancer

One of the most important prognostic indicators in patients with breast cancer is axillary lymph node status. Sentinel lymph node (SLN) biopsy has emerged as a potential alternative to routine axillary dissection in clinically node-negative early breast cancer. This procedure requires a specialized but multidisciplinary approach utilizing the surgeon, nuclear radiologist and pathologist. SLN biopsy allows adequate assessment of the axillary nodal status in patients with early breast cancer, with minimal-if any-morbidity. Blue dye and lymphoscintigraphy are complementary techniques, and the success rate is maximized when the two methods are used together. Focused histopathologic examination on one or two lymph nodes most likely to contain metastases [SLN(s)], using serial sectioning and immunohistochemical techniques, allows an improved staging to be performed. Detection of metastases on SLN(s) is not only a prognostic indicator, but it also dictates whether the patient should receive further surgery and adjuvant chemotherapy. Until data regarding the long-term results of the SLN biopsy are available, this method should be considered investigational and be performed by surgeons experienced in this technique to achieve a failure rate of less than 2 per cent.     

乳腺癌前哨淋巴结活检

目的 评价前哨淋巴结活检预测腋窝淋巴结有无肿瘤转移的准确性及其临床意义。方法 用^99m锝－硫胶体作为示踪剂,用γ探测仪导向,对70例临床分期为T1－2N0M0的乳腺癌患者进行前哨淋巴结活检,所有的患者均同时行腋窝淋巴结清扫,HE染色阴性的前哨淋巴结再切片,用CK8、CK19、KP－1行免疫组织化学染色。结果 70例患者中成功发现前哨淋巴结的有67例,发现率为95.7%（67／70）。前哨淋巴结的数量为1－5枚,平均每例1.6枚。非前哨淋巴结5－20枚,平均例12.3枚。67例前哨淋巴结活检成功的患者中,29例患者（43.3%）有腋窝淋巴结转移,其中前哨淋巴结有转移者24例（35.8%）,前哨淋巴结未发现转移而非前哨淋巴结有转移者5例（7.5%）。7例患者（10.4%）只有有淋巴结为阳性淋巴结,前哨淋巴结活检的准确性为100％。43例患者的65枚HE染色阴性一的前哨淋巴结,CK8及CK19免疫组织化学染色均为阴性。结论 前哨淋巴结检能较准确地预测腋窝淋巴结转移情况,对原发灶为T1的乳腺癌,前哨淋巴结活检的准确性为100％。同一层面切片行免疫组织化学染色并不能提高淋巴结微转移癌的发现率。     

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 lymph node biopsy for sparing axillary dissection in selected patients with breast cancer

Axillary lymph nodal status in breast cancer remains one of the more important prognostic factors. In early breast cancer axillary lymph node metastasis are found only in 10-18%. It can be deduced that in all these patients a complete axillary dissection is an overtreatment. The concept of sentinel lymph node (SN) was applied to breast cancer. Of course if SN examination gives negative findings, the patient will avoid axillary lymphadenectomy. 134 patients with localized breast cancer were evaluated for enrollment into the study. In 40 (29.8%) patients lymphoscintigraphy was performed together with an injection of vital dye to identify the SN, in 94 (70.1%) only vital dye was utilized. The mapping procedure was successful in 129 cases (96.2%). In our study there was concordance between SNs and axillary nodes in 120 out off 124 cases (96.7%). The false-negative rate was 4.8% (4/83). The overall sensitivity of the SN biopsy was 91.1% (41/45), with a negative predictive value of 95.1% (79/83). Five patients had SN negative and they decided do not undergo axillary lymphadenectomy. This study demonstrates that accurate SN identification was obtained combining lymphoscintigraphy and blue dye. Moreover, each method requires a suitable learning curve. After an accurate training, complete axillary lymphadenectomy can be avoided in selected patients.     

Sentinel lymph node biopsy before versus after neoadjuvant chemotherapy for breast cancer

Axillary lymph node status is the most important prognostic factor in the treatment of breast cancer. In recent years, sentinel lymph node biopsy (SLNB) has replaced conventional axillary lymph node dissection for predicting axillary lymph node status with higher accuracy. Moreover, neoadjuvant chemotherapy (NAC) is being used increasingly to treat not only patients with locally advanced inoperative breast cancer, but also those with initially operable breast cancer. The application of SLNB has now expanded to include this patient population, who were not previously considered good candidates for SLNB. A number of recent studies have evaluated the feasibility and accuracy of SLNB after NAC in breast cancer patients. Moreover, SLNB has been shown to be accurate in patients scheduled to receive NAC, and repeat SLNB has been performed after NAC for patients with positive nodes detected by the initial SLNB before NAC. Thus, the optimal timing of SLNB for patients with breast cancer in the neoadjuvant setting remains controversial. This article reviews the issues surrounding SLNB before vs. after NAC, according to the published literature and our experience.     

乳腺癌哨兵淋巴结活检

近三十年来,乳腺癌的发病率呈明显上升的趋势。在美国,2001年新诊断病例为139700,死亡病例为40600,2002年新诊断病例为205000,死亡病例为40000。乳腺癌已成为美国妇女最常见的恶性肿瘤,其癌症死亡率仅次于肺癌。在我国,根据1997年的统计资料,北京、天津、上海地区不同年龄女性乳腺癌世界人口标化发病率分别为27.8/10万,30.1/10万,25.5/10万,同美国西欧相似,呈明显上升的趋势。发病率上升的同时,乳腺癌手术范围的变化也经历了一系列重要的历程:从19世纪末经     

Motion restriction and axillary web syndrome after sentinel node biopsy and axillary clearance in breast cancer

BACKGROUND: We evaluated the prevalence of motion restriction and axillary web syndrome (AWS) after sentinel node biopsy (SNB) and axillary clearance (AC) in a prospective study. AWS is a self-limiting cause of early postoperative morbidity after axillary surgery. Limited range of motion associated with palpable cords of tissue in the axilla are typical for AWS. METHODS: Altogether 85 breast cancer patients who underwent SNB only (49 patients) or SNB and AC (36 patients) were examined before and after surgery. The range of shoulder flexion and abduction and the presence of AWS were registered. RESULTS: The range of shoulder movements was restricted in 24 (45%) patients after SNB only and in 31 (86%) patients who also underwent AC (P = 0.002). AWS was encountered in 10 (20%) patients with SNB and in 26 (72%) with AC (P <0.00005). CONCLUSIONS: In the SNB group, significantly less early postoperative morbidity was observed.     

Sentinel lymph node biopsy and breast cancer

BACKGROUND AND METHOD: This paper reviews and discusses the feasibility and accuracy of sentinel lymph node (SLN) biopsy in breast cancer. A standardized method of identifying the SLN and detecting micrometastases is suggested, along with a strategy for the elimination of routine axillary lymph node dissection (ALND). RESULTS: Although the SLN can be identified successfully by experienced practitioners using either the dye-guided or gamma probe-guided method, identification is facilitated when the two techniques are combined. To improve the likelihood of spotting metastases in the SLN, it is desirable to perform step sectioning combined with haematoxylin and eosin staining and immunohistochemistry of permanent and frozen sections. SLN biopsy is as accurate for T2 tumours as it is for T1 tumours. However, it is highly unlikely that all false-negative cases can be eliminated, even by detailed histological examination. Nevertheless, patients with T1 tumours with micrometastases in the SLN have shown no evidence of tumour in the non-sentinel nodes. In other words, ALND can be avoided in these patients, even if histological examination of the SLN fails to detect micrometastasis. CONCLUSION: In practice, routine ALND can be avoided in patients with T1 tumours when the identified SLN proves to be histologically negative. However, investigation of long-term regional controls and of survival in a prospective randomized trial is necessary before SLN biopsy can replace routine ALND, particularly for patients with T2 tumours.