乳癌哨兵淋巴结检测临床应用

目的：探讨乳癌哨兵淋巴结活检预测腋窝淋巴结转移状态的可靠性.方法：本组为2000年11月至2004年2月我院收治的140例乳癌患者.术中应用国产亚甲蓝注射液4～6 ml肿瘤上、外、下半圆形皮下连续注射,134例行乳癌改良根治术或患侧乳腺区段切除加腋窝淋巴结清扫术.术后解剖蓝染淋巴管,沿着色淋巴管找到蓝染的哨兵淋巴结.哨兵淋巴结及腋窝淋巴结常规行石蜡病理切片检查.5例行乳腺区段切除加哨兵淋巴结活检,1例行全乳切除加哨兵淋巴结活检（冰冻、石蜡病理检查SLN转移阴性）,未行全腋窝淋巴结清扫.结果：140例患者中136例检出哨兵淋巴结,检出率97.14%,灵敏度 88.71%,准确率94.31%,阴性预测值89.71%,假阴性率11.29%,仅哨兵淋巴结阳性7例.结论：应用亚甲蓝注射液淋巴结着色方法行乳癌哨兵淋巴结活检可以准确地预测腋窝淋巴结转移状态.     

淋巴显像及术中γ探测定位活检乳腺癌前哨淋巴结

目的：探讨淋巴显像及术中γ探测定位活组织检查乳腺癌前硝淋巴结的临床价值。方法：术前在乳腺肿瘤表面正中皮内注射37－74MBq ^99Tcm-大分子右旋糖酐（Dx)，用淋巴显像和术中γ探测定位乳腺癌 前硝淋巴结，术中切除前 淋巴结，而后行腑窝淋巴结清扫术，两标本连同切除的乳腺肿物同时送病理检查，分析和前哨淋巴结转移与腋窝淋巴结的关系。结果：31例均行淋巴显像和术中γ探测定位乳腺癌前哨淋巴结患者中，检出率为100％，有3例前哨淋巴结病理检查呈假阴性，假阴性率为25％，结论：术中γ探测是乳腺癌前哨淋巴结定位最可靠的手段。以乳腺 癌前哨淋巴结活组织检查取代常规腑窝淋巴结清扫术尚需进一步研究。     

Role of axillary ultrasound in the preoperative diagnosis of lymph node metastases in patients affected by breast carcinoma

Purpose

This study was conducted to evaluate the diagnostic accuracy of axillary ultrasound (US) alone or in combination with fine-needle-aspiration cytology (FNAC) in patients with breast carcinoma, in comparison with the final histological examination (sentinel node biopsy and/or axillary dissection).

Materials and methods

Between January 2005 and June 2008, we evaluated 427 breast cancer patients with axillary US. The findings were classified according to the following criteria: hilum and cortex morphology, ratio between longitudinal and transverse diameter and ratio between hilar and longitudinal diameter of the lymph node. Patients with breast lesions ≤3 cm (n=147) underwent FNAC of the most suspicious lymph node.

Results

Overall concordance between axillary US and final histological examination was 85%, sensitivity was 72.3% and specificity was 93.4%. Concordance between FNAC and final histological examination was 93%, sensitivity was 88.1% and specificity was 100%.

Conclusions

In 48.3% of patients, the combination of axillary US and FNAC guided treatment decisions towards immediate axillary dissection, thus sparing the patients sentinel node biopsy, with a significant reduction of costs and hospitalization time.     

Sentinel node biopsy in male breast cancer

OBJECTIVE: Male breast cancer is a rare disease and axillary status is the most important prognostic indicator. Lymphoscintigraphy associated with gamma-probe guided surgery has been proved to reliably detect sentinel nodes in female patients with breast cancer. This study evaluates the feasibility of the surgical identification of sentinel node by using lymphoscintigraphy and a gamma-detecting probe in male patients, in order to select subjects who would be suitable for complete axillary lymphadenectomy. METHODS: Colloid human albumin labelled with 99Tc was administered to 18 male patients with breast cancer and clinically negative axillary lymph nodes. Lymphoscintigraphy was performed the day before surgery. An intraoperative gamma-detecting probe was used to identify sentinel nodes during surgery. RESULTS: Lymphoscintigraphy and biopsy of the sentinel node were successful in all cases. A total of 20 sentinel nodes were removed. Pathological examinations showed 11 infiltrating ductal carcinomas, two intraductal carcinomas and five intracystic papillary carcinomas. Six patients (33%) had positive sentinel node (micrometastases were found in three patients). These patients underwent axillary dissection; in five of them (83%) the sentinel node was the only positive node. Twelve patients (67%) showed negative sentinel nodes; in all of them no further surgical treatments were planned. CONCLUSIONS: As in women, lymphoscintigraphy and sentinel node biopsy under the guidance of a gamma-detecting probe proved to be an easy method for the detection of sentinel nodes in male breast carcinoma. In male patients with early stage cancer, sentinel node biopsy might represent the standard surgical procedure in order to avoid unnecessary morbidity after surgery, preserving accurate staging of the disease in the axilla.     

Use of ultrasound-guided axillary node core biopsy in staging of early breast cancer

The aim of this study was to see how effective ultrasound-guided needle biopsy was at detecting lymph node involvement in patients with early breast cancer. Patients with newly diagnosed invasive breast cancer underwent axillary ultrasound (US) where lymph node size and morphology were noted. A core biopsy (CB) was undertaken of any node greater than 5 mm in longitudinal section. Patients with benign CBs proceeded to sentinel lymph node (SLN) biopsy, whereas those with malignancy underwent axillary lymph node dissection (ALND). US and CB findings were correlated with final surgical histology in all cases. One hundred and thirty-nine patients were examined, of whom 52.5% had lymph node metastases on final histology. One hundred and twenty-one patients (87%) underwent axillary node CB. The overall sensitivity of CB for detecting lymph node metastases was 53.4% (60.3% for macrometastases; 26.7% for micrometastases). The US morphological characteristics most strongly associated with malignancy were absence of a hilum and a cortical thickness greater than 4 mm. However, one third of patients with normal lymph node morphology had nodal metastases, and only 12% of these were diagnosed on CB. CB of axillary lymph nodes can diagnose a substantial number of patients with lymph node metastases, allowing these patients to proceed directly to ALND, avoiding unnecessary SLN biopsy.     

Sentinel lymph node identification in breast cancer patients

PURPOSE: To evaluate the predictive value of sentinel lymph node biopsy versus axillary node dissection on lymph node status in patients with T1-T2 breast cancer. MATERIAL AND METHODS: Twenty-nine patients with T1 and 12 with T2 breast carcinoma and clinically N0 axillary lymph nodes, underwent lymphoscintigraphy following the administration of 99mTc-human albumin nanocolloids. The tracer was injected subdermally, over the tumor mass, in the 34 patients with palpable lesions and peritumorally (n=3) or intratumorally (n=4), under stereotactic or ultrasound guidance, in the 7 patients with non-palpable lesions. Anterior and lateral planar images were acquired 15 min after the injection of the tracer and repeated every 30 min up to 3 hr until identification of sentinel lymph node. At the end of the scintigraphic study, sentinel node skin projection was marked using a dermographic pen. Eighteen hours after lymphoscintigraphy, sentinel lymph node was identified and removed during surgery by hand-held gamma probe, then, the remaining axillary lymph nodes were dissected. All surgical specimens underwent histologic examination. Sentinel lymph nodes free of metastasis at histology, underwent additional examination with immunohistochemistry using monoclonal antibodies against cytokeratin and EMA to search for micrometastases. RESULTS: Sentinel lymph node was identified in the 34 patients injected subdermally and in the 3 patients injected peritumorally, while it remained undetected in the 4 patients injected intratumorally except for one case in which it was isolated by radioguided surgery but not scintigraphically. Sentinel nodes resulted free of metastases both at histology and immunohistochemistry in 32 cases and metastatic in 6. In the 32 patients with non-metastatic sentinel lymph nodes the other axillary nodes were also free of metastases. Among the 6 metastatic sentinel lymph nodes, in 3 cases they were the only metastatic nodes of the axilla while in the other 3 cases metastases were spread to other axillary nodes. CONCLUSIONS: In agreement with previous studies, our results showed that sentinel lymph node radioguided biopsy is a simple and reliable method for predicting axillary lymph nodes status and for avoiding axillary dissection in early breast cancer patients with sentinel node free of metastases.     

Radioguided sentinel lymph node biopsy in breast cancer surgery.

The concept of sentinel lymph node biopsy in breast cancer surgery relates to the fact that the tumor drains in a logical way through the lymphatic system, from the first to upper levels. Therefore, the first lymph node met (the sentinel node) will most likely be the first to be affected by metastasis, and a negative sentinel node makes it highly unlikely that other nodes are affected. Because axillary node dissection does not improve prognosis of patients with breast cancer (being important only to stage the axilla), sentinel lymph node biopsy might replace complete axillary dissection to stage the axilla in clinically N0 patients. Sentinel lymph node biopsy would represent a significant advantage as a minimally invasive procedure, considering that, after surgery, about 70% of patients are found to be free from metastatic disease, yet axillary node dissection can lead to significant morbidity. Furthermore, histologic sampling errors can be reduced if a single (sentinel) node is assessed extensively rather than few histologic sections in a high number of lymph nodes per patient. Although the pattern of lymph drainage from breast cancer can be variable, the mammary gland and the overlying skin can be considered as a biologic unit in which lymphatics tend to follow the vasculature. Therefore, considering that tumor lymphatics are disorganized and relatively ineffective, subdermal and peritumoral injection of small aliquots of radiotracer is preferred to intratumoral administration. (99m)Tc-labeled colloids with most of the particles in the 100- to 200-nm size range would be ideal for radioguided sentinel node biopsy in breast cancer. Lymphoscintigraphy is an essential part of radioguided sentinel lymph node biopsy because images are used to direct the surgeon to the site of the node. The sentinel lymph node should have a significantly higher count than that of background (at least 10:1 intraoperatively). After removal of the sentinel node, the axilla must be reexamined to ensure that all radioactive sites are identified and removed for analysis. The sentinel lymph node should be processed for intraoperative frozen section examination in its entirety, based on conventional histopathology and, when needed, immune staining with anticytokeratin antibody. The success rate of radioguidance in localizing the sentinel lymph node in breast cancer surgery is about 94%--97% in institutions where a high number of procedures are performed and approaches 99% when combined with the vital blue dye technique. At present, there is no definite evidence that negative sentinel lymph node biopsy is invariably correlated with negative axillary status, except perhaps for T1a-b breast cancers, with a size of < or =1 cm. Randomized clinical trials should elucidate the impact of avoiding axillary node dissection on patients with a negative sentinel lymph node on the long-term clinical outcome of patients.     

Role of ultrasound-guided core needle biopsy of axillary lymph nodes in the initial staging of breast carcinoma

OBJECTIVE: To evaluate the role of US-guided core biopsy in detection of metastatic axillary lymph nodes in preoperative staging of breast cancer. MATERIALS AND METHODS: US-guided core biopsy of suspicious axillary lymph nodes was performed in 39 patients with breast cancer. Biopsy results were compared to the axillary dissection results. Sensitivity, specificity and accuracy of the core biopsy in the detection of malignancy were calculated. RESULTS: Thirty-nine patients were assessed with biopsy; 30 patients were found to have metastatic carcinoma and nine had benign reactive hyperplasia. In 26 of 30 cases with biopsy-proven metastatic disease, there were malignant lymph nodes detected at axillary dissection. Four cases that had positive biopsy results and negative axillary dissection were accepted as complete response to chemotherapy. In three of nine cases with benign reactive hyperplasia, axillary dissection revealed metastatic disease. No significant complications were observed other than pain responding to analgesics. The sensitivity, specificity and accuracy of core biopsy in detection of malignancy were 90%, 100% and 92%, respectively. The results were statistically significant (p<0.001). CONCLUSION: Ultrasonographically detected lymph nodes can be easily assessed by US-guided biopsy. Core biopsy is a reliable and easily performed method without significant complications.     

MR imaging-guided axillary node biopsy for breast cancer: initial findings

The aim of this study was to evaluate the usefulness and feasibility of preoperative sentinel node needle biopsy of the breast under guidance of open MR imaging, a method that we developed. Nine patients with breast cancer in whom the axillary lymph nodes were not palpable underwent preoperative sentinel node needle biopsy under real-time MR imaging guidance. The sentinel nodes were identified before the biopsy using CT and MR imaging. Diagnostic ability of this method was compared with that of the operative diagnosis. Sentinel nodes were correctly identified in all 9 patients. The MR imaging-guided sentinel node needle biopsy was performed for all of the 9 patients, and, in 7 (77.8%) of the 9, a specimen sufficient for pathologic evaluation was obtained; and in 6, whether malignancy existed was precisely diagnosed. No serious complications were noted. This experience indicates the possibility of a precise diagnosis of whether the sentinel node in breast cancer is benign or malignant without surgery.     

Sentinel lymph node biopsy after percutaneous diagnosis of nonpalpable breast cancer.

PURPOSE: To determine the technical success rate of sentinel lymph node biopsy in women with nonpalpable infiltrating breast cancer diagnosed by using percutaneous core biopsy and to determine the frequency with which sentinel lymph node biopsy obviated axillary dissection. MATERIALS AND METHODS: Retrospective review revealed 33 women who underwent sentinel node biopsy after percutaneous core biopsy diagnosis of nonpalpable infiltrating breast cancer. Sentinel nodes were identified with radioisotope and blue dye; the procedure was technically successful if sentinel nodes were found at surgery. All sentinel nodes were excised. Axillary dissection was performed if tumor was present in sentinel nodes. RESULTS: Sentinel nodes were found at surgery in 30 women (91%). Sentinel nodes were identified with both radioisotope and blue dye in 22 (73%) of these women, with only radioisotope in six (20%), and with only blue dye in two (7%). Sentinel nodes were found in 12 (80%) of 15 women in the first half of the study versus all 18 (100%) women in the second half (P = .08). Sentinel nodes were free of tumor in 23 (77%) of 30 women. In six (86%) of seven women with tumor in sentinel nodes, the sentinel nodes were the only nodes with tumor. CONCLUSION: Sentinel node biopsy was successful in 30 women (91%) with nonpalpable infiltrating carcinoma diagnosed with percutaneous core biopsy and obviated axillary dissection in 23 women (70%). Using both radioisotope and blue dye may increase the success rate. A learning curve exists, and success improves with experience.     

Technical aspects of sentinel node lymphoscintigraphy for breast cancer.

OBJECTIVE: A significant morbidity risk is associated with axillary nodal dissections for breast cancer. Many treatment decisions are based on axillary nodal status. Lymphatic mapping and sentinel node biopsy have been investigated to determine if the histology of the sentinel node reflects the remaining lymph node basin. We describe the technical aspects of sentinel node lymphoscintigraphy for breast cancer. METHODS: Ninety-three patients had lymphoscintigraphy for breast cancer. Patients with palpable lesions had 4 concentric injections around the site and lesions requiring localization had injections made through tubing connected to the localizing wire introducer needle. Immediate static images were acquired and the sentinel node was marked for surgery. Marks were reverified using a handheld gamma probe. RESULTS: Lymph nodes were visualized by lymphoscintigraphy in 87% of cases. Time to visualization of lymph nodes ranged from 1-120 min with a mean of 28 min. An average of 1.5 nodes were visualized. The overall success rate for identifying the sentinel node at time of surgery was 85%. CONCLUSION: We conclude that lymphoscintigraphy for breast cancer is a detailed procedure that requires coordination with radiology and surgery teams to ensure proper identification of sentinel lymph nodes.     

The role of sentinel node biopsy in breast cancer management: an overview

Regional lymph nodes surgical management is an integral part of breast cancer therapy. One of the most important therapeutic problems is the risk of surgical treatment which is too wide or inadequate due to the lack of correct presurgical information on the conditions of regional lymph nodes. For melanoma the problem was solved combining surgical accuracy with the slightest surgical resection, using sentinel node biopsy. In breast cancer the removal of axillary nodes proved to be unnecessary in more than 50% of cases. The first international studies on the use of sentinel node biopsy in breast carcinoma for the identification of patients who do not need axillary clearance suggest the high accuracy of the technique. Some practical problems still exist, however, and the optimisation of the method is not yet complete. The use of sentinel node biopsy in breast cancer treatment might be able to provide distinctive clinical information, which can improve our knowledge about the disease?'s biological behaviour and about its treatment.     

Redefining ultrasound appearance criteria of positive axillary lymph nodes.

OBJECTIVE: To determine objective criteria for ultrasonography (US) appearance in the diagnosis of abnormal axillary lymph nodes (ALNs) and to assess retrospectively their accuracy in preoperative staging of patients with Breast Imaging Reporting and Data System (BI-RADS) Category 5 breast lesion. METHODS: US-guided axillary fine-needle aspiration biopsy (FNAB) was performed for preoperative staging of BI-RADS Category 5 lesions in breast cancer patients seen at the Ottawa Regional Women's Breast Health Centre. Retrospectively, ALN morphology was classified into 3 categories based on US appearance: mass-like appearance, focal nodular cortical thickening (FNCT), and diffuse cortical thickening (DCT), the latter 2 with fatty hilum preservation and cortical thickening greater than 2 mm. Cytologic results from the FNAB were compared with axillary lymph node dissection (ALND) or sentinel lymph node procedure (SLNP), when available. Retrospective image-based classification was performed blind to pathology results and analyzed with Pearson's correlation coefficient, receiver operating characteristic (ROC) curves, and chi-square and Hosmer-Lemeshow tests against the cytologic ground truth. RESULTS: Eighty-six ALNs in 84 patients were sampled with an 18-gauge needle under US guidance. The number of passes per sample was related to adequate sampling of positive ALNs having mass-like morphology but not DCT or FNCT (p < 0.001). The most frequent morphologic presentation of the 86 ALNs was mass-like appearance of lymph nodes (45%), followed by DCT (35%) and FNCT (20%). Metastatic involvement was found in 34 (87%) of 39 ALNs that were mass-like, in 9 (53%) of 17 ALNs with FNCT, and in 9 (30%) of 30 ALNs with DCT. The kappa agreement between FNAB and ALND or SLNP was 0.64 for mass-like lymph nodes, 0.7 for lymph nodes with DCT, and 1.0 for FNCT. Overall sensitivity and specificity were 94% and 89%, respectively, with a positive predictive value of 97% and negative predictive value of 80%. CONCLUSIONS: Using a 2-mm threshold, FNCT and DCT warrant US-guided FNAB by an experienced radiologist as much as do mass-like lymph nodes. When biopsy is positive, axillary dissection can be performed and the sentinel node technique avoided.     

FDG PET positive lymph nodes are highly predictive of metastasis in breast cancer

AIM: To determine whether or not fluorodeoxyglucose positron emission tomography (FDG PET) imaging when positive could obviate the necessity for sentinel lymph node biopsy and for complete axillary node dissection in patients with breast cancer. METHODS: A total of 80 female patients with a histological diagnosis of breast cancer and clinically negative axillary nodes underwent an FDG PET and sentinel lymph node biopsy (SLNB) or total axillary dissection for staging of axilla. Both SLNB and axillary dissection were performed in 72 patients, while eight patients had total axillary dissection without SLN biopsy. RESULTS: Of the 80 patients, 36 had lymph node metastasis on histopathology. SLNB was positive for metastasis in 35 (97%) of 36 patients (29 macrometastasis and seven micrometastasis). In the patient with false negative SLNB, the lymph node was completely replaced by the tumour. The FDG PET was true positive in 16 of 36 patients (sensitivity, 44%). There were two false positive studies with FDG PET, resulting in a specificity of 95%. The positive predictive value and accuracy of FDG PET for the detection of axillary lymph node metastasis were 89% and 72%, respectively. Univariate analysis revealed that higher grade of tumour, increased size and number of axillary lymph nodes were significantly associated with positive FDG PET results for axillary staging. CONCLUSION: FDG PET cannot replace histological staging using SLNB in patients with breast cancer. However, FDG PET has a high specificity and positive predictive value for staging of the axilla in these patients. The patients with higher grade of tumour, larger size and higher number of axillary lymph nodes may be considered for FDG PET scan for axillary staging.     

早期乳腺癌无创腋窝淋巴结分期的临床初步观察

目的：探讨超声检查评估乳腺癌腋窝淋巴结转移状态的临床应用价值。方法入组军事医学科学院附属医院2013年12月至2015年9月期间连续收治的282例新发 Tis-T2期乳腺癌患者,指定2名高年资超声医师行腋窝超声检查,根据淋巴结声像学参数,将患者分为转移组、未转移组或可疑组。腋窝淋巴结分期以病理学结果作为金标准,分析超声检查评估乳腺癌腋窝淋巴结转移的准确性,比较各组腋窝淋巴结转移负荷;单因素及多因素Logistic 回归分析各个声像学参数对判断腋窝淋巴结转移状态的预测价值。结果超声判断腋窝淋巴结转移组＋未转移组的灵敏度、特异度、阳性及阴性预测值、准确度分别为85．6％、87．1％、86．4％、86．3％和86．3％,Kappa 值为0．727（P ＜0．001）。在病理证实腋窝淋巴结转移患者中,超声判断未转移组的平均淋巴结转移负荷明显低于超声转移组（1．2／6．9枚,P ＜0．001）,超声判断为未转移而病理结果证实为转移的患者共16例,其中14例患者腋窝淋巴结转移负荷仅为1枚,其余2例患者分别为2枚和3枚。单因素 Logistic 回归分析显示,最大皮质厚度预测腋窝淋巴结转移诊断效能最佳（ROC 曲线下面积为0．872）;多因素 Logistic 回归分析显示,最大皮质厚度、髓质与皮质厚度比值与腋窝淋巴结转移相关（P ＜0．05）。多因素 Logistic 回归模型 ROC 曲线下面积为0．879,灵敏度及特异度分别为77．0％和85．1％。结论超声检查评估腋窝淋巴结转移具有较高的准确性;超声判断假阴性的患者腋窝淋巴结转移负荷较低。最大皮质厚度是判断腋窝淋巴结转移最主要的声像学参数。在早期乳腺癌患者中,超声检查无创评估可能是潜在的替代前哨淋巴结活检行腋窝淋巴结分期的手段。     

Subareolar injection of technetium-99m nanocolloid yields reliable data on the axillary lymph node tumour status in breast cancer patients with previous manipulations on the primary tumour: a prospective study of 117 patients

According to recently published guidelines, histological clarification by interventional techniques should be undertaken before planning the surgical management of patients with breast carcinoma. In patients with previous manipulations on the primary tumour, peritumoural injection in the context of preoperative scintigraphic detection of the sentinel lymph nodes is not possible. The aim of this prospective study was to clarify whether subareolar injection of nanocolloid can yield reliable data on the axillary lymph node tumour status in breast cancer patients with previous manipulations on the primary tumour. To date, 117 women (age 31–80 years) with breast carcinoma have been enrolled. All of these patients had undergone a biopsy (n=88) or surgery on the primary tumour (n=29) and were without clinical suspicion of lymph node metastases. Subareolar injection of 40 MBq technetium-99m nanocolloid was carried out in at least eight deposits around the areolar margin [one deposit in the middle of each quadrant and one deposit at each quadrant intersection (0.05 ml/deposit)]. Immediately after injection, dynamic and static lymphoscintigraphy of the axillary, thoracic and cervical areas was performed in various views with a gamma camera (LEAP collimator, 256×256 matrix). Lymphatic drainage was directed exclusively to the ipsilateral axilla. Sentinel lymph node biopsy and elective dissection of axillary lymph nodes were performed in all patients. All lymph nodes removed were examined by histology and immunohistochemistry. In 26 patients, lymph node metastases were found in the sentinel lymph nodes. In six of them, non-sentinel lymph nodes also showed tumour involvement. In the remaining 91 patients, lymph node metastases could be found neither in sentinel lymph nodes nor in non-sentinel lymph nodes. In conclusion, subareolar nanocolloid injection can yield reliable information on the axillary lymph node tumour status in patients with previous manipulations on the primary tumour in the breast.     

Sentinel lymph node mapping for breast cancer: analysis in a diverse patient group.

PURPOSE: To evaluate sentinel lymph node mapping in patients with breast cancer. MATERIALS AND METHODS: Sixty-two patients with breast cancer scheduled to undergo axillary nodal dissection underwent scintigraphic localization of sentinel lymph nodes with filtered technetium 99m sulfur colloid. At surgery, isosulfan blue was injected. Sentinel nodes were identifiable by blue color and by radioactivity with hand-held gamma probe. Results were analyzed statistically. RESULTS: A sentinel lymph node was identified in 49 patients (79%). Lymph nodes were positive for metastatic disease in 26 patients (42%). The mapping success rate was 78% (n = 21) in the 27 patients with no prior surgery, 78% (n = 18) in the 23 patients with prior surgery, and 86% (n = 12) in the 14 patients with prior chemotherapy. Axillary nodes were positive in 11 (41%) of the 27 patients with no prior intervention, six (26%) of the 23 patients with prior surgery, and 10 (71%) of the 14 patients with prior chemotherapy. There were no false-negative findings in patients without prior intervention. Four patients with positive nodes had false-negative sentinel nodes. CONCLUSION: Sentinel lymph node mapping and biopsy without axillary dissection is appropriate in patients with breast cancer who have not undergone prior intervention. Further study is necessary to ascertain the accuracy of the procedure for patients who have undergone presurgical chemotherapy or previous excisional biopsy.     

Innovation in early breast cancer surgery: radio-guided occult lesion localization and sentinel node biopsy

The surgical management of non-palpable breast lesions remains controversial. At the European Institute of Oncology we have introduced a new technique, radio-guided occult lesion localization (ROLL) to replace standard methods and overcome their disadvantages. Regarding axillary dissection, probe-guided biopsy of the sentinel node (SN) is easy to apply, and the whole procedure is associated to a low risk of false negatives. We suggest that the SN technique should be widely adopted to stage the axilla in patients with breast cancer with clinically negative lymph nodes. Large-scale implementation of the sentinel node technique will reduce the cost of treatment as a result of shorter hospitalization times.     

Detection of suspicious malignant cervical lymph nodes of unknown origin: diagnostic accuracy of ultrasound-guided fine-needle aspiration biopsy with nodal size and central necrosis correlate.

OBJECTIVE: To assess the role of ultrasound-guided fine-needle aspiration biopsy (US-guided FNAB) in the diagnostic workup of suspicious malignant cervical lymph nodes in patients with palpable neck masses and without known primary cancer. The diagnostic accuracy of imaging morphologic criteria, including sizes and central necrosis for assessing suspicious malignant nodes, were also examined. METHODS: This is a retrospective study of 426 patients with palpable neck masses from an outpatient department evaluated with computed tomography, magnetic resonance imaging, or US. US-guided FNABs were performed in 102 patients with suspicious malignant cervical lymph nodes at a single institution. Cytologically positive lymph nodes (n = 12) were further validated with excisional biopsy. Negative lymph nodes (n = 90) were either excised (n = 10) or followed up by imaging studies for at least one year (n = 80). The diagnostic accuracy of the FNABs along with the imaging findings of nodal sizes and presence of central necrosis, which were classified by a consensus of 2 radiologists, were assessed. RESULTS: Twelve malignant nodes were detected with US-guided FANB with one false-positive and one false-negative result. The overall sensitivity, specificity, and accuracy for FNAB were 91.7%, 98.9%, and 98.0%, respectively. The sensitivity, specificity, and accuracy were 66.7%, 30.0%, and 34.3% for size criterion and 75.0%, 83.3%, and 82.3% for central necrosis criterion. CONCLUSIONS: The size of cervical lymph node does not appear to be an important imaging criterion for assessing suspicious malignant lymph nodes, compared with the criterion of central necrosis. US-guided FNAB is highly specific and sensitive in the diagnostic workup of suspicious malignant cervical lymph nodes in patients without known primary cancers.     

FDG-PET for axillary lymph node staging in primary breast cancer

Management of the axilla in patients with operable breast cancer is still one of the most controversial areas in clinical oncology. The best procedure to examine the lymph nodes is still standard axillary lymph node dissection; nevertheless, the morbidity associated with this procedure is well known. Based on these considerations, it is important for progress in the treatment of operable breast cancer that strategies are found that permit a less invasive method of axillary sampling which does not impair the patient's quality of life. The technique of sentinel lymph node (SLN) biopsy has recently been proposed for this purpose, with very important results. SLN has now become routine practice in the surgical management of breast cancer, and in many institutions patients with a negative SLN biopsy are spared axillary dissection, while those with a positive SLN biopsy are submitted to axillary node dissection. The good accuracy of SLN biopsy represents a significant advance in the management of primary breast cancer; however, false negative axillary results can occur in a variable percentage of patients, and the contribution of the SLN procedure to the detection of metastases in the internal mammary and supraclavicular lymph nodes is not clear. Among the recently developed imaging modalities, positron emission tomography (PET) with (18)F-fluorodeoxyglucose (FDG) has in particular been applied to the study of lymph node metastases in cancer patients. Several clinical studies have been carried out to evaluate the accuracy of PET in the axillary staging of operable primary breast cancer. These studies have sometimes provided conflicting results, either supporting the possibility of using FDG-PET to select patients who need axillary dissection or questioning whether FDG-PET can accurately assess the axillary status in primary breast cancer. All the limitations and the advantages of FDG-PET are discussed in this paper, by examining the performance of scanner technology and the possible causes of the false negative results. In the experience of the authors, comparing FDG-PET with SLN biopsy in the same series of patients, the results seem to indicate that the lower sensitivity of PET is restricted to micrometastases. Of course, this limitation of PET has to be analysed in relation to the importance of such small axillary metastases for the outcome of patients with breast cancer. The added value offered by PET in breast cancer staging in comparison with intraoperative detection of the sentinel node lies in the fact that FDG-PET is a non-invasive procedure that allows, within a single examination, the biological characterisation of breast cancer and viewing of the entire body.