Non-sentinel lymph node metastases in breast cancer patients with metastatic sentinel nodes

BACKGROUND: Sentinel lymph node biopsy (SLNB) has been shown to be relatively accurate in axillary nodal staging in breast cancer. In more than half of the patients with metastatic sentinel lymph node (SLN), the SLN was the only lymph node involved in the axilla. Methods: A retrospective analysis was performed for those female Chinese breast cancer patients who underwent SLNB. All patients had axillary dissection after SLNB. Those patients with metastatic SLN were selected for analysis. Various tumour factors and SLN factors were analysed to study the association with residual lymph node metastasis. Results: A total of 139 SLNB was performed. The success rate of SLN localization, false negative rate and accuracy were 92%, 9% and 95%, respectively. Fifty-five patients had metastases in the SLN. In 38 patients (69%), SLN was the only lymph node involved in the axilla. Tumours <3 cm, a single metastatic SLN, presence of micro metastases and the absence of extracapsular spread in the SLN were associated with the absence of metastasis in the non-sentinel lymph nodes. Conclusion: Sentinel lymph node biopsy is accurate in the nodal staging of Chinese breast cancer patients. Several factors such as tumour <3 cm, a single metastatic SLN, micro metastases and the absence of extracapsular spread in the sentinel node(s) are useful predictors for the absence of residual disease in the axilla. With further studies and verification, these factors may prove to be important in determining which patients with metastatic SLN will require further axillary treatment. Until such information is available, axillary dissection should be performed when positive sentinel nodes are found.     

Effect of lymphatic tumor burden on sentinel lymph node biopsy in breast cancer

Distal obstruction of the lymphatics by tumor and extensive tumor infiltration of the draining lymph nodes may prevent migration of the tracer to the sentinel lymph node (SLN), adversely affecting SLN identification. Rerouting of lymphatic drainage may divert flow to internal mammary nodes and cause an alternative nonsentinel node to become "sentinel," increasing the risk of a false-negative result. A total of 618 breast cancer patients underwent SLN biopsy using 99mTc albumin colloid and patent blue V injected peritumorally. This was followed by standard axillary node clearance in all patients at the same operation. The overall SLN identification and false-negative rates were 96% (593/618) and 7.6% (17/223), respectively. There was no difference in the SLN identification rate and the false-negative rate with increasing axillary tumor burden (as determined by the total number of positive nodes in the axilla). Further detailed analyses are based on the 64 patients from one center (Cardiff) who had at least one positive SLN and proceeded to axillary clearance. A total of 83 positive SLNs were removed from 64 patients. Tumor burden in the positive SLN was assessed by measuring the size of the metastasis and percentage replacement of the SLN by tumor, and by documenting extranodal invasion. Increasing tumor burden in the SLN (as determined by percentage replacement of SLN by tumor and presence of extranodal invasion) was associated with decreased radioisotope uptake (p = 0.005 and p < 0.0001, respectively). There was no correlation between radioisotope uptake and the size of the metastasis in the SLN. There was no correlation between blue dye uptake, internal mammary drainage on lymphoscintiscan, and tumor burden in the positive SLN. In conclusion, increased axillary lymphatic tumor burden is not associated with failure to identify a SLN or false-negative results when both blue dye and radioisotope are used for SLN biopsy. In an individual SLN, the percentage replacement by tumor, but not the absolute size of the metastatic deposit is associated with reduced radioisotope uptake. Extranodal invasion in the SLN is a marker of lymphatic obstruction and is significantly associated with reduced radioisotope uptake. The lymphatic tumor burden does not seem to affect blue dye uptake or internal mammary drainage.     

Do cytokeratin-positive-only sentinel lymph nodes warrant complete axillary lymph node dissection in patients with invasive breast cancer?

The small number of nodes harvested with lymphatic mapping and sentinel lymph node (SLN) biopsy has allowed a more detailed pathologic examination of those nodes. Immunohistochemical stains for cytokeratin (CK-IHC) have been used in an attempt to minimize the false negative rate for SLN mapping. This study examines the value of CK-IHC positivity in predicting further lymph node involvement in the axillary basin. From April 1998 through May 1999, 519 lymphatic mappings and SLN biopsies were performed for invasive breast cancer. SLNs were examined by imprint cytology, hematoxylin and eosin (H&E), and CK-IHC. Patients with evidence of metastatic disease by any of the above techniques were eligible for complete axillary node dissection (CAND). The frequency with which these modalities predicted further lymph node involvement in the axillary basin was compared. Of the 519 lymphatic mappings, 39 patients (7.5%) had a CK-IHC-positive-only SLN. Five (12.8%) of these 39 patients had at least 2 SLNs positive by CK-IHC. Twenty-six of the CK-IHC-positive-only patients underwent CAND. Three of these 26 patients (11.5%) had additional metastases identified after CAND. The sensitivity levels with which each modality detected further axillary lymph node involvement were as follows: CK-IHC, 98 per cent; H&E, 94 per cent; and imprint cytology, 87 per cent. A logistic regression to compare the prognostic value of the three modalities was performed. All were significant, with odds ratios of 19.1 for CK-IHC (P = 0.015), 5.3 for H&E (P = 0.033), and 3.86 for imprint cytology (P = 0.0059). These data validate the enhanced detection of CK-IHC for the evaluation of SLNs. Detection of CK-IHC-positive SLNs appears to warrant CAND in patients with invasive breast cancer. However, the therapeutic value of CAND or adjuvant therapies based on CK-IHC-positive SLNs would be best answered by prospective randomized trials.     

The association of cytokeratin-only-positive sentinel lymph nodes and subsequent metastases in breast cancer

INTRODUCTION: The purpose of this study was to better characterize the clinical significance of cytokeratin immunohistochemistry (IHC)-only-positive lymph node metastases among patients with breast cancer. METHODS: We performed a retrospective review of 334 patients who underwent sentinel lymph node (SLN) biopsy from 1 February 1997 through 31 July 2001. SLN biopsies were evaluated using standard hematoxylin and eosin (H&E) techniques. If H&E was negative, cytokeratin IHC was performed. We then evaluated the incidence of subsequent regional and distant metastatic disease. RESULTS: Cytokeratin IHC was performed on 183 sentinel node biopsies from 180 patients comprising a total of 427 sentinel lymph nodes. The procedures included lumpectomy and SLN biopsy (n = 83), mastectomy with SLN biopsy (n = 7), lumpectomy with SLN biopsy and completion axillary dissection (n = 80), and modified radical mastectomy with SLN biopsy and completion axillary dissection (n = 13). Cytokeratin IHC was negative in 175 axillary specimens and positive in 8 (4.4%) from 8 different patients. In these eight specimens, deeper sections with subsequent H&E staining additionally identified micrometastasis in four patients. Three of these 8 patients (37.5%) developed distant metastatic disease compared with 1 of the 172 patients (0.6%) with negative cytokeratin IHC (P < .001). Additionally, one of the cytokeratin-positive patients developed regional nodal metastasis compared with none of the 172 cytokeratin-negative patients. CONCLUSIONS: Cytokeratin IHC provides a clinically relevant adjunct to H&E staining for evaluating sentinel lymph nodes in breast cancer. These data suggest that patients with cytokeratin-positive sentinel nodes are at increased risk for development of regional and distant metastatic disease.     

Histologic localization of sentinel lymph node metastases in breast cancer

Data from a recent study support the hypothesis that axillary lymph node metastases frequently localize near the inflow junction of the afferent lymphatic vessel. Our goal was to evaluate the microscopic location of axillary sentinel lymph node metastases in a prospective study of breast cancer patients. A total of 305 axillary sentinel lymph nodes from 213 breast cancer patients undergoing surgery at our institution were evaluated. Preoperative lymphoscintigraphy using technetium-labeled sulfur colloid and intraoperative isosulfan blue dye injection were used for identifying the sentinel lymph node. Intraoperatively, the surgeon placed a suture either at the point of entry of isosulfan blue dye or at the area with the highest radioactive counts, and this area was inked at the grossing bench before processing. Metastases were identified in 55 of the 305 lymph nodes examined. Thirty-four nodes contained metastases in both the inked half and the opposite half. Metastatic tumor was identified in the inked half alone in 18 lymph nodes. Only three nodes contained metastatic tumor in the opposite half with no tumor in the inked half (p <0.001). Similar results were found when nodes tagged at the point of blue dye entry and nodes tagged at the area with the highest radioactive counts were analyzed separately. Our findings suggest that metastatic tumor has a higher probability of being present in the region of the inflow junction of the afferent lymphatic vessel. This information may be useful in determining the optimal method for evaluating axillary sentinel lymph node specimens from breast cancer patients.     

Identification and evaluation of axillary sentinel lymph nodes in patients with breast carcinoma treated with neoadjuvant chemotherapy

Sentinel lymph node (SLN) biopsy has been shown to predict axillary metastases accurately in early stage breast cancer. Some patients with locally advanced breast cancer receive preoperative (neoadjuvant) chemotherapy, which may alter lymphatic drainage and lymph node structure. In this study, we examined the feasibility and accuracy of SLN mapping in these patients and whether serial sectioning and keratin immunohistochemical (IHC) staining would improve the identification of metastases in lymph nodes with chemotherapy-induced changes. Thirty-eight patients with stage II or III breast cancer treated with neoadjuvant chemotherapy were included. In all patients, SLN biopsy was attempted, and immediately afterward, axillary lymph node dissection was performed. If the result of the SLN biopsy was negative on initial hematoxylin and eosin-stained sections, all axillary nodes were examined with three additional hematoxylin and eosin sections and one keratin IHC stain. SLNs were identified in 31 (82%) of 38 patients. The SLN accurately predicted axillary status in 28 (90%) of 31 patients (three false negatives). On examination of the original hematoxylin and eosin-stained sections, 20 patients were found to have tumor-free SLNs. With the additional sections, 4 (20%) of these 20 patients were found to have occult lymph node metastases. These metastatic foci were seen on the hematoxylin and eosin staining and keratin IHC staining. Our findings indicate that lymph node mapping in patients with breast cancer treated with neoadjuvant chemotherapy can identify the SLN, and SLN biopsy in this group accurately predicts axillary nodal status in most patients. Furthermore, serial sectioning and IHC staining aid in the identification of occult micrometastases in lymph nodes with chemotherapy-induced changes.     

Predicting the risk for additional axillary metastases in patients with breast carcinoma and positive sentinel lymph node biopsy

OBJECTIVE: To assess whether the risk for nonsentinel node metastases may be predicted, thus sparing a subgroup of patients with breast carcinoma and a positive sentinel lymph node (SLN) biopsy completion axillary lymph node dissection (ALND). SUMMARY BACKGROUND DATA: The SLN is the only involved axillary lymph node in the majority of the patients undergoing ALND for a positive SLN biopsy. A model to predict the status of nonsentinel axillary lymph nodes could help tailor surgical therapy to those patients most likely to benefit from completion ALND. METHODS: All the axillary sentinel and nonsentinel lymph nodes of 1228 patients were reviewed histologically and reclassified according to the current TNM classification of malignant tumors as bearing isolated tumor cells only, micrometastases, or (macro)metastases. The prevalence of metastases in nonsentinel lymph nodes was correlated to the type of SLN involvement and the size of the metastasis, the number of affected SLNs, and the prospectively collected clinicopathologic variables of the primary tumors. RESULTS: In multivariate analysis, further axillary involvement was significantly associated with the type and size of SLN metastases, the number of affected SLNs, and the occurrence of peritumoral vascular invasion in the primary tumor. A predictive model based on the characteristics most strongly associated with nonsentinel node metastases was able to identify subgroups of patients at significantly different risk for further axillary involvement. CONCLUSIONS: Patients with the most favorable combination of predictive factors still have no less than 13% risk for nonsentinel lymph node metastases and should be offered completion ALND outside of clinical trials of SLN biopsy without back-up axillary clearing.     

Reliable lymphatic drainage to axillary sentinel lymph nodes regardless of tumor location within the breast.

BACKGROUND: This analysis was performed in order to determine whether primary tumor location in breast cancer affects the axillary sentinel lymph node (SLN) identification (ID) rate, the false negative (FN) rate, incidence of axillary nodal metastases, or the number of SLN identified. METHODS: In this prospective multi-institutional study, SLN biopsy was performed on clinical stage T1-2, N0 breast cancer patients using blue dye alone or in combination with radioactive colloid, followed by completion axillary LN dissection. RESULTS: Central tumor location was associated with an improved FN rate, which may be related to reliable drainage from the subareolar lymphatic plexus. Tumor location did not significantly affect the SLN ID rate or the mean number of SLN identified. Medial tumor location was associated with a decreased rate of axillary nodal metastasis. CONCLUSIONS: Breast cancers drain reliably to the axillary lymph nodes regardless of tumor location within the breast.     

Predictors of nonsentinel lymph node metastasis in breast cancer patients

BACKGROUND: In order to define a future subset of breast cancer patients in whom the axilla may be staged by sentinel lymph node biopsy alone, the conditions under which nonsentinel axillary lymph node metastases occur must be delineated. METHODS: A prospective database including 212 breast cancer patients who underwent sentinel lymph node biopsy followed by completion axillary dissection at our institution was reviewed. A multivariate, logistic, stepwise regression was performed to evaluate the relationship between nonsentinel lymph node metastasis and patient age, primary tumor size, presence of lymphatic invasion, use of radioisotope to identify the sentinel node and degree of metastasis in the sentinel node. RESULTS: Tumor size greater than 2 cm, lymphatic invasion of the primary tumor, macrometastasis in the sentinel node, and use of radioisotope all positively correlated independently with metastasis in the nonsentinel lymph node (P = 0.0001, P = 0.0483, P = 0.0008, P = 0.0271, respectively). CONCLUSIONS: Predictors of nonsentinel axillary node metastasis exist and are important in defining those patients in whom a sentinel lymph node biopsy alone may not be adequate.     

Prediction of nonsentinel lymph node involvement in patients with a positive sentinel lymph node in malignant melanoma

Completion lymph node dissection (CLND) is routinely performed after metastatic melanoma is detected at sentinel lymph node (SLN) biopsy. Nonsentinel lymph node (NSLN) involvement is found in less than one-third of the cases. Possible predictors of NSLN involvement are examined. A retrospective review of 70 patients with a positive SLN biopsy for melanoma and drainage to one lymphatic basin was performed. The size of metastatic deposits was defined as macrometastases (>2 mm), micrometastases (< or =2 mm), a cluster of cells (10-30 grouped cells) in the subcapsular space or interfollicular zone, or isolated melanoma cells (1-20 or more individual cells) in subcapsular sinuses. Tumor stage, ulceration, SLN tumor burden, mitoses, number of positive SLNs, and total number of lymph nodes removed were examined as predictors of NSLN involvement after CLND. Two additional models based on SLN tumor burden and the number of nodes biopsied were designed. Nineteen patients (24.3%) were found to have NSLN metastases after CLND. Tumor stage, ulceration, SLN tumor burden, mitoses, number of positive SLN, and number of lymph nodes removed were not statistically significant. Residual disease at CLND stratified by SLN tumor burden was: isolated melanoma cells, 0; cluster of cells, 8 (38.1%); < or =2 mm, 5 (20.8%); and >2 mm, 6 (27.3%). A comparison of the means for the models was not predictive of NSLN involvement. None of the risk factors or models examined could predict nonsentinel lymph node involvement with melanoma. The SLN sample and minimal SLN metastatic disease when defined as isolated clusters of cells warrant further study as a potential indicator against CLND after positive SLN.     

Limitation in gamma probe localization of the sentinel node in breast cancer patients with large excisional biopsy

BACKGROUND: Radiolocalization and selective biopsy of the sentinel node to correctly predict the status of remaining lymph nodes may provide an alternative to axillary dissection in selected breast cancer patients with clinically negative lymph nodes. STUDY DESIGN: In a nonrandomized, multicenter clinical trial, gamma probe localization for lymphatic mapping and sentinel node biopsy along with axillary dissection was performed on 75 patients with invasive breast cancer and clinically negative lymph nodes. The accuracy of the sentinel node biopsy to correctly predict the status of the remaining axillary lymph nodes was established through standard pathologic investigation. RESULTS: A sentinel node was identified in 70 of 75 patients with a technical success rate of 93%. Of these 70 patients, 21 (30%) had axillary nodal metastases identified pathologically. Four of these 21 (19%) had sentinel nodes negative for metastases. All 4 false-negative patients had prior excisional biopsies. The false-negative group had a larger mean maximal biopsy dimension than the true-positive group. Eleven of the 21 patients with axillary metastases had a diagnosis made by core needle biopsy with no false negatives. CONCLUSIONS: The accuracy of the sentinel node biopsy in correctly predicting the status of remaining axillary lymph nodes may be limited in patients with large excision before radiolocalization of the sentinel node. Our findings suggest that excisional biopsy should be avoided prior to lymphatic mapping for sentinel node biopsy.     

Use of lymphoscintigraphy defines lymphatic drainage patterns before sentinel lymph node biopsy for breast cancer

BACKGROUND: Lymphoscintigraphy (LSG) can identify lymphatic drainage patterns before sentinel lymph node (SLN) biopsy is performed in patients with early-stage breast cancer, but the importance of extraaxillary SLNs seen on LSG is unknown. We assessed whether drainage patterns seen on LSG were associated with histologic findings in axillary SLNs recovered at SLN biopsy. STUDY DESIGN: From a prospectively maintained database, we identified 1,201 clinically node-negative patients with invasive breast cancer who underwent preoperative LSG and axillary SLN biopsy. Patient and tumor characteristics, LSG results, and final SLN pathology results were examined. RESULTS: LSG showed drainage to internal mammary (IM) nodes in 1.6% of patients, axillary nodes in 68.1%, both IM and axillary nodes in 19.8%, and no drainage in 10.3%. Drainage to IM nodes was observed for tumors in all quadrants of the breast. Patients with IM drainage had a younger median age than patients without IM drainage (51.8 versus 58.3 years, respectively; p < 0.001). The intraoperative axillary SLN identification rate was higher when axillary drainage was observed on LSG than when it was not observed (98.7% versus 93.0%, respectively; p < 0.001), but the LSG drainage pattern was not associated with pathologic status of the SLN or number of metastatic SLNs. At a median followup of 32 months, 4 patients had regional nodal recurrence. CONCLUSIONS: Almost one-fourth of patients had lymphatic drainage to the extraaxillary lymph nodes, particularly the IM nodes, seen on LSG. Extraaxillary drainage seen on LSG did not preclude identification of axillary SLNs at operation. Longterm followup of patients with lymphoscintigraphic evidence of extraaxillary drainage is needed to determine whether regional and systemic recurrence patterns differ in these patients.     

Predictors to Assess Non‐Sentinel Lymph Node Status in Breast Cancer Patients with Sentinel Lymph Node Metastasis

Abstract: The next step of sentinel lymph node biopsy (SLNB) in breast cancer is to determine which patients need axillary lymph node dissection (ALND) following a positive SLNB. A prospective database of 239 patients who underwent SLNB followed by complete ALND at Keio University Hospital from January 2001 to June 2005 was reviewed. A total of 131 patients with one or more positive sentinel lymph nodes (SLNs) were further analyzed. A univariate analysis showed a significant correlation between non‐SLN involvement and lymphatic invasion, vascular invasion, number of tumor‐involved SLNs, radioactivity of SLNs, and size of SLN metastasis (p = 0.0002, p = 0.004, p = 0.006, p = 0.04, p = 0.03, respectively). By multivariate analysis, lymphatic invasion and the number of tumor‐involved SLNs remained significant predictors of non‐SLN involvement. In breast cancer patients with a positive SLN, lymphatic invasion and the number of tumor‐involved SLNs were both independent predictors of non‐SLN involvement.     

原发乳腺癌前哨淋巴结阳性患者非前哨淋巴结转移的预测因子

【摘要】〓目的〓分析前哨淋巴结(SLN)阳性原发乳腺癌患者腋窝非前哨淋巴结(NSLN)转移的预测因子。方法〓回顾性分析212例SLN阳性并接受腋窝淋巴结清扫术的患者资料。获取的SLN均按示踪剂浓度排序并测量浸润灶大小。对各种临床及病理组织学因素数据进行单因素分析,纳入单因素分析有意义(P<0.05)的预测因素进行logistic多因素分析。结果〓多因素分析提示NSLN转移与SLN转移率(P<0.001)、SLN阴性个数(P=0.02)、染色剂浓度最小SLN转移(P=0.02)、SLN最大转移灶大小(P<0.001)有关。全部SLN转移者NSLN转移可能性较非全部SLN转移者大;随SLN阴性个数增加,NSLN转移率下降;染色剂浓度越大SLN转移机会越大,浓度最小SLN转移者较浓度最小SLN无转移者SLN ,其NSLN转移几率更高;最大转移灶>2 mm者出现NSLN转移可能性比SLN最大转移灶≤2 mm者大。结论〓SLN转移率(P<0.001)、SLN阴性个数(P=0.02)、染色剂浓度最小SLN转移(P=0.02)、SLN最大转移灶大小(P<0.001)是NSLN转移的独立预测因子。     

Pathologic Examination of the Sentinel Lymph Node: What Is the Best Method?

Abstract:   Sentinel lymph node biopsy (SLNB) has become an acceptable alternative to complete axillary dissection to determine whether breast cancer has spread to axillary lymph nodes. Yet the best method for pathologic examination of the sentinel lymph node (SLN) remains controversial. For years there has been speculation that micrometastases in axillary lymph nodes were clinically insignificant and thus lymph nodes did not require sectioning at close intervals. Yet essentially all studies, including a recent large prospective study, have found a significantly poorer prognosis associated even with metastases less than 2 mm in size—the most common definition of micrometastasis—suggesting that such small metastases cannot be safely overlooked. The use of immunohistochemistry (IHC) to detect keratin proteins will reveal metastatic breast carcinoma in about 18% of axillary lymph nodes that appear negative on routine stains. The preponderance of evidence to date suggests a significantly poorer prognosis in patients with such occult metastases, although data from large prospective studies are lacking. Molecular techniques such as polymerase chain reaction (PCR) offer even more sensitive methods for detecting occult metastasis in SLNs, although false positives are a particular problem in techniques that do not permit morphologic correlation, and for now they remain a research tool. Intraoperative examination of the SLN permits a completion axillary dissection to be performed during the same procedure if metastatic tumor is found; however, intraoperative techniques such as cytologic examination and frozen section lack sensitivity, and can result in loss of up to 50% of the SLN tissue. A proposal for optimal pathologic examination of the SLN is offered based on the above data.      

Routine preoperative lymphoscintigraphy is not necessary prior to sentinel node biopsy for breast cancer.

BACKGROUND: This prospective study was performed to ascertain the added benefit of lymphoscintigraphy to a standard method of intraoperative lymphatic mapping and sentinel node biopsy for breast cancer. METHODS: Patients with invasive breast cancer were injected with 99mTc sulfur colloid prior to sentinel node biopsy; preoperative lymphoscintigraphy was then performed in half of the patient population. RESULTS: Sentinel node identification was possible in 45 of 50 patients (90%). All 14 patients (31%) with axillary nodal metastases had at least one histologically positive sentinel node (0% false negative rate). Lymphoscintigraphy revealed sentinel nodes in 17 of the 24 patients (70.8%) imaged. All 17 of these patients had one or more axillary sentinel nodes identified using intraoperative lymphatic mapping. In addition, 5 of 7 patients with a negative preoperative lymphoscintogram had an axillary sentinel lymph node(s) identified intraoperatively. None of the tumors showed drainage to the internal mammary lymph node chain by lymphoscintigraphy despite the fact that there were 5 patients with inner quadrant tumors. There was no significant advantage with respect to sentinel lymph node localization (91.7% versus 88.5%, P = not significant) or false negative rate (0%, both groups, P = not significant) in the group undergoing preoperative lymphoscintigraphy when compared with the patients in whom lymphoscintigraphy was not performed. CONCLUSIONS: Preoperative lymphoscintigraphy adds little additional information to intraoperative lymphatic mapping, and its routine use is not justified.     

Sentinel lymph node mapping following neoadjuvant chemotherapy for breast cancer

The purpose of this study was to evaluate the feasibility of sentinel lymph node mapping in patients undergoing neoadjuvant chemotherapy for breast carcinoma prior to lumpectomy or mastectomy and sentinel lymph node mapping followed by complete axillary dissection. A retrospective analysis of 14 patients from February 1998 to July 2000 with stage I to stage IIIB breast cancer diagnosed by core biopsy underwent neoadjuvant chemotherapy (doxorubicin/cyclophosphamide) prior to definitive surgery, including lumpectomy or mastectomy and sentinel lymph node mapping, followed by full axillary dissection. Thirteen of 14 patients had successful sentinel lymph node identification (93%), and all 14 underwent full axillary dissection. An average of 2.2 sentinel nodes and a median of 16 axillary lymph nodes (including sentinel nodes) were found per patient. Of the 13 patients in whom a sentinel lymph node was identified, 10 were positive for metastases (77%). Only 4 of the 10 had further axillary metastases (40%). Three patients had negative sentinel lymph nodes shown by hematoxylin and eosin and cytokeratin stainings and had no axillary metastases (0% false negative). The single patient in whom a sentinel lymph node could not be identified had stage IIIA disease with extensive lymphatic tumor emboli. Sentinel lymph node mapping is feasible in neoadjuvant chemotherapy breast cancer patients and can spare a significant number of patients the morbidity of full axillary dissection. Further study to evaluate sentinel lymph node mapping in this patient population is warranted.     

Sentinel node involvement in T0-T1 breast cancers]

STUDY AIM: Determination of axillary lymph node status is crucial in diagnosis of early breast cancer. However thanks to an early diagnosis, an increasing number of axillary lymph node dissections are free of disease. This raises questions about the need for this procedure. The study aim was to report an experience with lymphadenectomy and sentinel node mapping in patients with T0-T1 carcinoma of the breast. METHODS: Between November 1997 and December 1999, 84 consecutive women (T0-T1 N0 according to the 1987 UICC classification) with recently diagnosed breast cancer, were included in this study for identification of the sentinel lymph node (SLN). The SLN was removed and submitted for histological examination. All patients underwent axillary dissection; nodes from levels I and II (Berg's classification) were excised and submitted to histological examination. RESULTS: The average tumor diameter was 12.7 mm (range, 3 to 25 mm). The lymphatic mapping technique was obtained after injection of the isotope into the breast around the tumor in 53/84 patients: the sentinel lymph node was the only positive node in 10 patients and it was positive in 5 patients with other axillary nodes. In 15/84 patients, an intradermal injection of blue dye was used; two sentinel nodes were positive and one falsely negative. In 16/84 patients, an interdermal injection of blue dye was used to make up for. In this study, the sentinel node was positive in three patients and falsely negative in one patient. The discrepancy was due to an important involvement of an axillary area excluded from the lymphatic channels. 22/84 patients (26%) had a metastatic spread to the axillary nodes. 30/84 patients had also an isotopic captation in another lymph node group (internal mammary). CONCLUSION: This study confirms that lymphatic mapping is technically possible in the patients with T0-T1 breast cancer and that the histological characteristics of the sentinel node probably reflect the histological characteristics of the rest of the axillary lymph nodes, but do not provide any information about the other lymph node sites.     

Nonsentinel lymph node status after positive sentinel lymph node biopsy in early breast cancer

Axillary dissection is the current standard of care for patients with breast cancer who are diagnosed with metastasis to axillary sentinel lymph nodes (SLNs). Recently, that concept has come under increasing scrutiny because not all women with a positive SLN will need further dissection. The purpose of this study was to look at nonsentinel lymph node status in patients with breast cancer and axillary SLN metastasis in an effort to determine tumor variables that can guide further treatment if there are additional axillary nodes involved. A retrospective chart review was performed on patients with breast cancer who underwent SLN biopsy between July 1998 and April 2003. Chi2 analysis, Student t test, and multivariate analysis were used to determine the significance of tumor size, grade, location, estrogen receptor (ER) and progestrone receptor (PR) receptor status, angiolymphatic invasion, stage, and number and size of SLNs in predicting the status of nonsentinel lymph nodes. During the study interval, 116 patients were identified who underwent SLN biopsy and 34 (29.3%) had positive SLNs. All of these patients underwent complete axillary node dissection and 11 patients (32.3%) had non-SLN metastasis. The presence of palpable breast mass (P = 0.03), tumor size (P = 0.04), angiolymphatic invasion (P = 0.03), and extracapsular extension of SLN metastasis (P = 0.001) were the variables that predicted non-SLN involvement. Micrometastasis was inversely related to non-SLN involvement. In patients with breast cancer and SLN metastasis, the presence of a palpable breast mass, tumor size, angiolymphatic invasion, and extracapsular node extension increase the likelihood of identifying additional node metastasis on subsequent axillary dissection.     

Sentinel Lymph Node Biopsy Performed After Neoadjuvant Chemotherapy is Accurate in Patients with Documented Node-Positive Breast Cancer at Presentation

Background The optimal strategy for incorporating lymphatic mapping and sentinel lymph node biopsy into the management of breast cancer patients receiving neoadjuvant chemotherapy remains controversial. Previous studies of sentinel node biopsy performed following neoadjuvant chemotherapy have largely reported on patients whose prechemotherapy, pathologic axillary nodal status was unknown. We report findings using a novel comprehensive approach to axillary management of node-positive-patients receiving neoadjuvant chemotherapy. Methods We evaluated 54 consecutive breast cancer patients with biopsy-proven axillary nodal metastases at the time of diagnosis that underwent lymphatic mapping with nodal biopsy as well as concomitant axillary lymph node dissection after receiving neoadjuvant chemotherapy. All cases were treated at a single comprehensive cancer center between 2001 and 2005. Results The sentinel node identification rate after delivery of neoadjuvant chemotherapy was 98%. Thirty-six patients (66%) had residual axillary metastases (including eight patients that had undergone resection of metastatic sentinel nodes at the time of diagnosis), and in 12 cases (31%) the residual metastatic disease was limited to the sentinel lymph node. The final, post-neoadjuvant chemotherapy sentinel node was falsely negative in three cases (8.6%). The negative final sentinel node accurately identified patients with no residual axillary disease in 17 cases (32%). Conclusions Sentinel lymph node biopsy performed after the delivery of neoadjuvant chemotherapy in patients with documented nodal disease at presentation accurately identified cases that may have been downstaged to node-negative status and can spare this subset of patients (32%) from experiencing the morbidity of an axillary dissection.