Axillary Lymph Node Dissection Specimen Research Articles

Clinicopathologic characteristics of early-onset breast cancer: a comparative analysis of cases from across Ghana

BackgroundBreast cancer is the commonest cancer diagnosed globally and the second leading cause of cancer-related mortality among women younger than 40 years. This study comparatively reviewed the demographic, pathologic and molecular features of Early-Onset Breast Cancer (EOBC) reported in Ghana in relation to Late Onset Breast Cancer (LOBC).MethodsA descriptive, cross-sectional design was used, with purposive sampling of retrospective histopathology data from 2019 to 2021. Reports of core or incision biopsy, Wide Local Excision or Mastectomy with or without axillary lymph node dissection specimen and matched immunohistochemistry reports were merged into a single file and analysed with SPSS v. 20.0. Descriptive statistics of frequencies and percentages were used to describe categorical variables. Cross-tabulation and chi-square test was done at a 95% confidence interval with significance established at p < 0.05.ResultsA total of 2418 cases were included in the study with 20.2% (488 cases) being EOBCs and 79.8% (1930 cases) being LOBCs. The median age at diagnosis was 34.66 (IQR: 5.55) in the EOBC group (< 40 years) and 54.29 (IQR: 16.86) in the LOBC group (≥ 40 years). Invasive carcinoma—No Special Type was the commonest tumour type with grade III tumours being the commonest in both categories of patients. Perineural invasion was the only statistically significant pathologic parameter with age. EOBC was associated with higher DCIS component (24.8% vs 21.6%), lower hormone-receptor-positive status (52.30% vs 55.70%), higher proliferation index (Ki-67 > 20: 82.40% vs 80.30%) and a higher number of involved lymph nodes (13.80% vs 9.00%). Triple-Negative Breast cancer (26.40% vs 24.30%) was the most predominant molecular subtype of EOBC.ConclusionEOBCs in our setting are generally more aggressive with poorer prognostic histopathological and molecular features when compared with LOBCs. A larger study is recommended to identify the association between relevant pathological features and early onset breast cancer in Ghana. Again, further molecular and genetic studies to understand the molecular genetic drivers of the general poorer pathological features of EOBCs and its relation to patient outcome in our setting is needed.

Is Nodal Clipping Beneficial for Node-Positive Breast Cancer Patients Receiving Neoadjuvant Chemotherapy?

In cN1 patients rendered cN0 with neoadjuvant chemotherapy, the false-negative rate of sentinel lymph node biopsy (SLNB) is <10% when ≥3 sentinel lymph nodes (SLNs) are removed. The added value of nodal clipping in this scenario is unknown. Here we determine how often the clipped node is a sentinel node when ≥3 SLNs are retrieved. We identified cT1-3N1 patients treated between 02/2018 and 10/2021 with a clipped lymph node at presentation. SLNB was performed with a standardized approach of dual-tracer mapping and retrieval of ≥3 SLNs. Clipped nodes were not localized; SLNs were X-rayed intraoperatively to determine clip location. Axillary lymph node dissection (ALND) was performed for any residual disease or retrieval of <3 SLNs. Of 269 patients, 251 (93%) had ≥3 SLNs. Median age was 51 years; the majority (92%) had ductal histology; 46% were HR+/HER2-. The median number of SLNs removed was 4 (IQR 3,5). The clipped node was an SLN in 88% (220/251) of cases. Of the 31 where the clipped node was not, 13 had a positive SLN mandating ALND, and the clip was identified in the ALND specimen. In the remaining 18, where ≥3 negative SLNs were retrieved and an ALND was not performed, the clip was not retrieved, with no axillary failures in this group (median follow-up: 55 months). When the SLNB procedure is optimized with dual tracer and retrieval of ≥3 SLNs, the clipped node is an SLN in the majority of cases, suggesting that failure to retrieve the clipped node should not be an indication for ALND.

Lower lymph node yield in axillary lymph node dissection specimens in breast cancer patients receiving neoadjuvant chemotherapy: Quality concern or treatment effect?

Axillary lymph node dissection (ALND) specimens should have at least ten-lymph nodes for examination according to established guidelines. Nonetheless, recent evidence suggests that neoadjuvant chemotherapy (NAC) results in fewer nodes in the specimen. We sought to examine if NAC patients have lower lymph node yield from ALND specimens and whether the number of lymph nodes in the specimen is correlated with pathologic complete response (pCR). Using the National Cancer Database (NCDB), a study cohort of female patients with node-positive, non-metastatic invasive breast cancer diagnosed from 2012 to 2015 was identified. The axillary lymph node retrieval count was compared in NAC and non-NAC patients and then correlated with pCR. A multivariable analysis was performed to identify factors that were associated with less than ten-lymph nodes in the ALND pathologic specimen. Of 56,976 patients identified, 27,197 (48%) received neoadjuvant chemotherapy; 29,779 (52%) did not. NAC patients failed to meet the ten-lymph node minimum in the ALND specimen more often than non-NAC patients (35% vs. 27%, p<0.001). NAC patients with fewer than ten-lymph nodes were more likely to have a pCR than those with ten or more (22% vs. 16%, p<0.001). On multivariable analysis, pCR of the primary tumor and receptor status were found to be independent predictors of having fewer than ten-lymph nodes in the ALND specimen. Node-positive breast cancer patients that underwent NAC were more likely to not meet the ten-lymph node standard. However, NAC patients who did not meet the minimum were also more likely to have a pCR compared to NAC patients who did. This suggests lower lymph node yield may not truly be a marker of lower quality surgery but rather a potential marker of NAC treatment effect.

The prognostic value of lymph node ratio in survival of non-metastatic breast carcinoma patients.

This study was conducted to assess the correlation between lymph node ratio (LNR) and prognosis of non-metastatic invasive breast carcinoma. This retrospective study examined 455 patients who were diagnosed with non-metastatic, unilateral invasive breast carcinoma and underwent either breast conservative surgery (BCS) or modified radical mastectomy (MRM) with axillary lymph node dissection (ALND) with at least one lymph node identified in the ALND specimen. Receiver operating characteristics (ROC) curve analysis was used to find out predictive cut-off values of the LNR and negative lymph nodes (NLN). The median follow-up duration was 38months. The median DFS and OS were 68months and 72months, respectively. 25.1% of patients had reported recurrence. The optimal cut-off value of LNR was 0.40. LNR was found to correlate significantly with pathological T (p < 0.001), pathological N (p < 0.001), and NLN (p < 0.001). Univariate analysis of the patients showed that the age group ≤ 35years, menstrual status, pathological T, nodal status, lymphovascular invasion (LVI), perineural invasion (PNI), tumor grade, estrogen receptor (ER), progesterone receptor (PR), molecular subtypes, LNR, and NLN can affect disease-free survival (DFS) (p < 0.05) and OS (p < 0.05). Multivariate analysis showed that the pathological T (p < 0.001), menstrual status (p = 0.030), and LNR (p < 0.001) were the independent prognostic factors for DFS. Pathological T (p < 0.001) and LNR (p < 0.001) were the independent prognostic factors affecting OS. LNR is the independent prognostic factor of DFS and OS for non-metastatic breast carcinoma.

Using the axillary reverse mapping technique to screen breast cancer patients with a high risk of lymphedema

BackgroundPreventing breast cancer-related lymphedema (BCRL) by preserving upper lymphatic drainage is still controversial. Our study aimed to use the axillary reverse mapping (ARM) technique in patients who underwent axillary surgery to analyse the correlation between postoperative residual ARM nodes and the occurrence of lymphedema, select candidates at high risk of developing lymphedema, and analyse the oncologic safety of ARM nodes.MethodsPatients undergoing sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) from October 2015 to February 2016 at the Peking University People’s Hospital Breast Center were prospectively recruited for the study. ARM was performed in all patients before surgery. ARM nodes were separated from SLNB and ALND specimens. Data were collected on the identification of ARM nodes before surgery, number of residual ARM nodes after surgery, nodal status, crossover rate, and correlation between residual ARM nodes and the occurrence of lymphedema.ResultsThe analysis included 78 patients. Of the 53 patients who underwent SLNB, crossover between ARM nodes and breast sentinel lymph nodes (SLNs) was seen in 22 specimens. The incidence of ARM node metastasis was 1.89% (1/53) and 25% (9/36) in the SLNB and ALND groups, respectively. The number of positive axillary lymph nodes was associated with the involvement of ARM nodes (P = 0.036). The incidence of residual ARM nodes was significantly higher in the SLNB group than in the ALND group (67.6% vs. 37.9%, P = 0.016). The incidence of lymphedema was significantly higher in the ALND group than in the SLNB group (33.3% vs. 5.4%, P = 0.003).ConclusionsFor SLNB, the ARM technique can help to resect SLNs more accurately. However, we do not recommend using the ARM technique to preserve ARM nodes in patients undergoing ALND due to oncologic safety issues. Nevertheless, we can predict patients undergoing axillary surgery who are more likely to have a high risk of lymphedema by assessing residual ARM nodes.Trial registrationThis study was registered on ClinicalTrials.gov in February 2016.The clinical trial registration number is NCT02691624.

Warthin-Finkeldey giant cells in an axillary lymph node dissection specimen for breast carcinoma – A case report

Warthin-Finkeldey giant cell is a distinctive but lesser-known giant cell of lymphoid origin, which is classically associated with the prodrome of measles infection. However, its presence is not pathognomonic for measles, and the cell has been reported in a variety of reactive and neoplastic lymphoid conditions. We report a case where Warthin-Finkeldey giant cells were found in a lymph node dissection specimen for breast carcinoma in a patient who has no concurrent viral infection or lymphoproliferative disorder.

Heterogeneous Responses of Axillary Lymph Node Metastases to Neoadjuvant Chemotherapy are Common and Depend on Breast Cancer Subtype.

The objective of this study was to analyze heterogeneous responses of axillary lymph node metastasis to neoadjuvant chemotherapy and to determine to what extent they differ between tumor subtypes (TN, HER2+, HR+/HER2-). This retrospective, monocenter study included 72 consecutive, histologically node-positive breast cancers (cT1-4 cN1-3 cM0) diagnosed in the period from January 2015 to December 2016, who had received axillary lymph node dissection following neoadjuvant chemotherapy. All individual lymph node specimens were re-evaluated for the presence of tumor cells and chemotherapy effects to assess their response to neoadjuvant chemotherapy on an individual lymph node level according to the Sataloff classification. Heterogeneous axillary responses to neoadjuvant chemotherapy occurred in 47.2% of the included 72 patients. The partial response rate was significantly higher in HR+/HER2- tumors (74.2%) than in TN (28.6%) and HER2+ tumors (25.0%) (p < 0.001). The presence of at least one negative, completely responding lymph node in the axillary lymph node dissection specimen had a false-negative rate of 48.8% in predicting ypN0. It dropped below 10% if at least four completely responding negative lymph nodes were identified. Our study shows that axillary heterogeneous response rates differ significantly between tumor subtypes.

Validation of the targeted axillary dissection technique in the axillary staging of breast cancer after neoadjuvant therapy: Preliminary results

Aim.To study the feasibility and validity of ultrasound-guided pre-chemotherapy marking of metastatic axillary lymph nodes followed by targeted axillary dissection (TAD), in breast cancer patients undergoing neoadjuvant chemotherapy (NACT). Material and methodProspective diagnostic test study conducted between January 2016 and March 2018. Patients with breast cancer and indication for NACT, cN1 or cN2 axillary staging, were included. A clip was placed in the affected lymph node prior to NACT. A sentinel lymph-node biopsy (SLNB) and a clipped lymph-node biopsy (BCLIP) were conducted, followed by axillary lymph node dissection (ALND). Location rate (LR) and negative predictive value (NPV) were evaluated, taking SLNB, BCLIP and their combination (TAD) as evaluated tests and metastatic involvement in the ALND specimen as the gold standard. ResultsTwenty-three patients were included in the study. Sentinel lymph node could only be detected in 19 cases (LR = 80.61%), whereas BCLIP was successful in 22 (LR = 95.65%). The sentinel lymph node coincided with the marked lymph node in 14 patients (60.9%). We found a NPV for the SLNB of 0.85 (95%CI: 0.61–1.0), whereas for TAD it was 1.00 (95%CI: 0.74–1.0). ConclusionTAD is a feasible test for axillary restaging after NACT, with a higher success rate than SLNB.

Enhanced Axillary Evaluation Using Reflector-Guided Sentinel Lymph Node Biopsy: A Prospective Feasibility Study and Comparison With Conventional Lymphatic Mapping Techniques

BackgroundRecently there are efforts to use sentinel lymph node biopsy (SLNB) techniques after neoadjuvant chemotherapy (NAC) to minimize axillary surgery. However, studies have shown higher false negative rates in this scenario, which might result in inaccurate assessment of treatment response and patient prognosis as well as leaving residual disease behind. In this study, we describe the use of reflector-guided excision of the percutaneously biopsied node (PBN) as an aid to conventional SLNB and its predictor of the axillary status after NAC. Patients and MethodsThis was a single-institution analysis of patients who underwent axillary fiducial-reflector placement and subsequent SLNB compared with conventional SLNB. ResultsNineteen patients in the reflector group were matched with 19 patients who underwent conventional SLNB (conventional group). The PBN was identified in the SLNB in 19 patients (100%) in the reflector group and in 9 patients (47.3%) in the conventional group (P = .002). In the remaining 10 patients in the conventional group, the PBN was identified in the axillary lymph node dissection specimen in 4 patients (21%) and not identified in 6 patients (31.7%). Among the 38 patients, traditional mapping failed to identify the PBN in 13 patients (34.2%). The PBN was negative in 10 patients (36%) and positive in 18 patients (64%); no additional positive nodes were identified among patients with a negative PBN, correctly reflecting the status of the axilla in 100% of cases. ConclusionMapping failure after NAC might compromise SLNB. Reflector-guided excision of the PBN is not only facile and feasible, but more accurately reflects the status of the axilla after NAC.

Intraoperative prediction of the two axillary lymph node macrometastases threshold in patients with breast cancer using a one-step nucleic acid cytokeratin-19 amplification assay.

The aim of the present study was to assess the sensitivity, specificity and practicality of using a one-step nucleic acid amplification (OSNA) assay during breast cancer staging surgery to predict and discriminate between at least 2 involved nodes and more than 2 involved nodes and facilitate the decision to provide axillary conservation in the presence of a low total axillary node tumour burden. A total of 700 consecutive patients, not treated with neo-adjuvant chemotherapy, received intraoperative sentinel lymph node (SLN) analysis using OSNA for cT1-T3 cN0 invasive breast cancer. Patients with at least one macrometastasis on whole-node SLN analysis underwent axillary lymph node dissection (ALND). The total tumour load (TTL) of the macrometastatic SLN sample was compared with the non-sentinel lymph node (NSLN) status of the ALND specimen using routine histological assessment. In total, 122/683 patients (17.9%) were found to have an OSNA TTL indicative of macrometastasis. In addition, 45/122 (37%) patients had NSLN metastases on ALND with a total positive lymph node burden exceeding the American College of Surgeons Oncology Group Z0011 trial threshold of two macrometastatic nodes. The TTL negative predictive value was 0.975 [95% confidence interval (CI), 0.962–0.988]. The area under the curve for the receiver operating characteristic curve was 0.86 (95% CI, 0.81–0.91), indicating that SLN TTL was associated with the prediction (and partitioning) of total axillary disease burden. OSNA identifies a TTL threshold value where, in the presence of involved SLNs, ALND may be avoided. This technique offers objective confidence in adopting conservative management of the axilla in patients with SLN macrometastases.

A Novel Less-invasive Approach for Axillary Staging After Neoadjuvant Chemotherapy in Patients With Axillary Node-positive Breast Cancer by Combining Radioactive Iodine Seed Localization in the Axilla With the Sentinel Node Procedure (RISAS): A Dutch Prospective Multicenter Validation Study

BackgroundIn 1 of 3 patients with initial lymph node-positive (cN+) breast cancer, neoadjuvant chemotherapy (NAC) results in an axillary pathologic complete response (ax-pCR). This urges the need for a less-invasive axillary staging method. Recently introduced less-invasive procedures have been insufficient in accurately identifying ax-pCR. Therefore, we propose a novel less-invasive axillary staging procedure: the Radioactive Iodine Seed localization in the Axilla with the Sentinel node procedure (RISAS), a combination of the procedure of marking axillary lymph nodes with radioactive iodine seeds (MARI) and sentinel lymph node biopsy (SLNB). Patients and MethodsIn the present open single-arm multicenter validation study, 225 cN+ (biopsy-proven) patients will undergo the RISAS procedure, in which a positive lymph node is marked by an iodine-125 seed before NAC. After NAC completion, this iodine-125 seed-marked lymph node is removed, together with any additional sentinel lymph nodes. The RISAS procedure is subsequently followed by completion axillary lymph node dissection (ALND). The RISAS lymph nodes will be compared with the lymph nodes from the completion ALND specimen. The primary endpoint is accuracy of the RISAS procedure. The identification rate, false-negative rate, negative predictive value, and possible concordance between the MARI and SLNB will be reported. ConclusionThe present prospective multicenter RISAS trial will enable us to validate the combination of MARI and SLNB for assessing the axillary response to NAC in cN+ patients. If RISAS proves to be an accurate axillary staging procedure, ALND could safely be abandoned in the case of ax-pCR confirmed using the RISAS procedure.

Letter to the Editor regarding manuscript entitled: Completion axillary dissection can safely be omitted in screen detected breast cancer patients with micrometastases. A decade's experience from a single institution. Grabau D, Dihge L, Ferno M, Ingvar C, Ryden L. Eur J Surg Oncol. 2013 Jun;39(6):601–7

Grabau et al. tackle the very topical subject of identifying breast cancer patients where completion axillary lymph node dissection (ALND) can be omitted in the presence of positive findings at sentinel node biopsy. 1 Grabau D. Dihge L. Ferno M. Ingvar C. Ryden L. Completion axillary dissection can safely be omitted in screen detected breast cancer patients with micrometastases. A decade's experience from a single institution. Eur J Surg Oncol. 2013 Jun; 39: 601-607 Abstract Full Text Full Text PDF PubMed Scopus (11) Google Scholar In a retrospective review of 1458 patients undergoing sentinel node biopsy for primary, unilateral breast cancer, they identify 62 (of 757) screen-detected and 81 (of 701) symptomatic patients with micrometastases. Only 3 of 62 (5%) screen-detected patients with micrometastases had further metastases on completion ALND compared to 18 of 81 (22%) symptomatic patients (p = 0.01). They conclude that ‘completion ALND can safely be omitted in screen-detected breast cancer patients with micrometastases in the sentinel nodes’. Letter to the Editor regarding response to manuscript entitled: Completion axillary dissection can safely be omitted in screen detected breast cancer patients with micrometastases. A decade's experience from a single institution. Grabau D, Dihge L, Ferno M, Ingvar C, Ryden L. Eur J Surg Oncol. 2013 Jun;39(6):601–7European Journal of Surgical OncologyVol. 39Issue 11PreviewThank you very much for your interest in our article. You report results from your own department where you do not find any significant difference in positive completion axillary dissection (ALND) in patients with micrometastases in sentinel nodes as a function of the mode of presentation (screen-detected vs. symptomatic). On the contrary you find a tendency to more positive completion ALND specimens in screen-detected patients with micrometastases in sentinel nodes. Full-Text PDF

Is the sentinel lymph node biopsy more sensitive for the identification of positive lymph nodes in breast cancer than the axillary lymph node dissection?

Since the routine clinical use of the sentinel lymph node (SLN) procedure, questions have been raised concerning an increase in the overall percentage of node-positive patients. The goal of our study was to compare the sensitivity of the SLN procedure and the axillary lymph node dissection (ALND) for the identification of positive lymph nodes in breast cancer.The incidence of axillary node metastasis in SLNB and ALND specimens from patients undergoing operative treatment of a primary breast carcinoma was compared retrospectively.Logistic regression models were used to analyze the effect of various predictors on the presence of positive lymph nodes. We constructed a multivariate model including the procedure and these predictors that have shown to be related to lymph node involvement in univariate analysis. The probability of finding positive lymph nodes was thus calculated in both groups correcting for relevant predictors of lymph node involvement.The SLNB group included 830 patients, the ALND group 320. In a multivariate analysis, adjusting for the number of foci, tumor location in the breast, tumor size, LVI, ER, PR, tumor grade and histological subtype, the probability of finding positive lymph nodes was higher with SLNB procedure than with an ALND. However, this difference was not statistically significant (OR 0.7635; CI 0.5334-1.0930, p 0.1404).For comparable tumors, SLNB procedure is at least as sensitive as ALND for detecting positive lymph nodes.

Novel surgical technique to selectively remove metastatic axillary lymph nodes in breast cancer patients after neoadjuvant chemotherapy: The MARI procedure—Marking of the axilla with radioactive iodine seeds.

196 Background: An important benefit of neoadjuvant chemotherapy (NAC) is the increase in breast-conserving surgery. At present the response of axillary lymph node metastases to chemotherapy cannot be accurately assessed. Therefore axilla-conserving therapy is not yet a benefit. We aimed to assess a new surgical method to evaluate the axillary response: the MARI procedure, which stands for Marking of the Axillary lymph node with Radioactive Iodine seeds. Methods: Prior to NAC, proven tumor-positive axillary lymph nodes were marked with a Iodine-125 seed. After NAC, the marked lymph node was selectively removed with the use of a gamma-detection probe. A complementary axillary lymph node dissection was performed to assess whether pathological response in the marked node was indicative for the pathological response in the additional lymph nodes. Results: Tumor-positive axillary lymph nodes were successfully marked with Iodine-125 seeds in 68 patients. The marked lymph node (MARI-node) was surgically detected and selectively removed after NAC in all patients. The pathological response to chemotherapy in the MARI-node was indicative for the overall response in the additionally removed lymph nodes. In 47 patients the MARI-node contained residual disease (n=45 macrometastasis, n= 2 ITC). Thirty-five of them had macro- or micro metastases in the complementary axillary lymph node dissection specimen. In 21 patients the MARI-node was tumor negative. In 2 patients a macro metastasis was found in the additionally removed nodes, in 2 patients ITC were found and in the remaining 17 patients no residual tumor was found in the additionaly removed lymphnodes. (false negative rate of the MARI procedure: 9.5%). Conclusions: This study shows that marking and selectively removing metastatic lymph nodes after NAC is feasible. The tumor-response in the marked lymph node may be used to tailor further axillary treatment, and herewith enabling axilla-conserving surgery after neoadjuvant chemotherapy.

Occult axillary lymph node metastases do not have prognostic significance in early stage breast cancer.

Axillary lymph node status is one of the most powerful prognostic indicators in patients with breast cancer and has implications for adjuvant treatment. It has been demonstrated that enhanced histologic evaluation of axillary lymph nodes, including serial sectioning of paraffin tissue blocks and immunohistochemical (IHC) staining, increases the rate of detection of occult metastases. The clinical significance of occult lymph node metastases has been the subject of debate. In the current study, the authors identified 267 patients who underwent axillary lymph node dissection (ALND) between 1987 and 1995 and were lymph node negative according to a routine pathologic evaluation, which included the complete submission of all lymph nodes and an examination of 1 hematoxylin and eosin (H&E)-stained section per paraffin block. Patients did not receive systemic chemotherapy or hormone therapy. All of the dissected lymph nodes from these patients were re-evaluated by intensified pathologic methods (serial sectioning with H&E levels plus IHC). Occult metastases were categorized by detection method and size. The clinical significance of the occult metastases was determined. Thirty-nine patients (15%) who had lymph node-negative results on routine evaluation of their ALND specimens had occult metastases identified. Eight of these patients (20%) had macrometastases >2.0 mm, 15 (40%) had micrometastases (range, >0.2 mm to ≤2 mm), and 16 (40%) had isolated tumor cells (≤0.2 mm). The presence of occult metastases and the size of metastases did not affect recurrence-free or overall survival. The presence of occult metastasis did not have clinical significance in this cohort of patients with early stage breast cancer.

Discordance of Intraoperative Frozen Section Analysis with Definitive Histology of Sentinel Lymph Nodes in Breast Cancer Surgery: Complementary Axillary Lymph Node Dissection is Irrelevant for Subsequent Systemic Therapy

BackgroundIn breast cancer surgery, intraoperative frozen section (FS) analysis of sentinel lymph nodes (SLNs) enables axillary lymph node dissection (ALND) during the same operative procedure. In case of discordance between a “negative” FS analysis and definitive histology, an ALND as a second operation is advocated since additional lymph node metastases may be present. The clinical implications of the subsequent ALND in these patients were evaluated.Materials and MethodsBetween November 2000 and May 2008, 879 consecutive breast cancer patients underwent surgery including sentinel lymph node biopsy (SLNB) with intraoperative FS analysis of 2 central cuts from axillary SLNs. Following fixation and serial sectioning, SLNs were further examined postoperatively with hematoxylin and eosin (H&E) and immunohistochemical techniques. For patients with a discordant FS examination, the effect of the pathology findings of the subsequent ALND specimen on subsequent nonsurgical therapy were evaluated.ResultsFS analysis detected axillary metastases in the SLN(s) in 200 patients (23%), while the definitive pathology examination detected metastases in SLNs in another 151 patients (17%). A complementary ALND was performed in 108 of the 151 patients with discordant FS. Additional tumor positive axillary lymph nodes were found in 17 patients (16%), leading to “upstaging” in 7 (6%). Subsequent nonsurgical treatment was adjusted in 4 patients (4%): all 4 had more extensive locoregional radiotherapy; no patient received additional hormonal and/or chemotherapy.ConclusionDiscordance between intraoperative FS analysis and definitive histology of SLNs is common. In this selection of patients, a substantial proportion had additional lymph node metastases, but postsurgical treatment was rarely adjusted based on the findings of the complementary ALND.

Post-Neoadjuvant Chemotherapy Sentinel Lymph Node Biopsy Is Reliable in Breast Cancer: A Prospective Study in Chinese Patients.

Abstract Background: Sentinel lymph node biopsy (SLNB) for breast cancer patients before chemotherapy is currently being practiced in a world wide scale. However, obvious disadvantage of a second surgical procedure after neoadjuvant chemotherapy (NAC) has been noted. Considering that metastasis in axillary lymph node would probably be eradicated by NAC making axillary lymph node dissection (ALND) completely unnecessary, SLNB performed after NAC could be a choice. Nonetheless, it is still controversial for a fear of impaired detection rate and accuracy. Therefore we carried out a prospective study by one single surgical team to compare SLNB between post-NAC patients and non-NAC patients.Methods: Operable invasive breast cancer patients confirmed by core needle biopsy before treatment with clinical N0 or N1 axilla were enrolled. Exclusion criteria included noninfiltrating cancer, inflammatory carcinoma and clinically fixed axillary lymph node. SLNB followed by ALND was performed in one single operation by the same surgical team for all patients either afer NAC or without NAC. Single methylene blue was used for SLN tracing with 2ml injected subcutaneously into the areola area and the mapping procedure was started 5 minutes later. SLN and ALND specimens were examined by 2 independent pathologists under standard pathological procedures.Results: From Dec 2007 to May 2009, 50 patients without NAC and 49 patients after NAC were prospectively enrolled. SLNB and ALND were performed as scheduled. In the post-NAC group, 19 had clinical N0 axilla and 30 had N1 axilla before treatment. SLNB was successful in 46 patients with 1.6 SLNs detected on average (range 1 to 5) and the average number of lymph nodes taken out in ALND was 15.4 (range 7 to 33). We found 9 with SLN(+)/ALN(+), 5 with SLN(+)/ALN(-), 2 with SLN(-)/ALN(+), and 29 with SLN(-)/ALN(-). In the non-NAC group, 40 had clinical N0 axilla and 10 had N1 axilla before surgery. SLNB was successful in 48 patients with 1.7 SLNs detected on average (range 1 to 6) and the average number of lymph nodes taken out in ALND was 16.8 (range 8 to 38). We found 4 with SLN(+)/ALN(+), 10 with SLN(+)/ALN(-), 1 with SLN(-)/ALN(+), and 33 with SLN(-)/ALN(-). Detection rate, accuracy, and false negative rate was 93.9% (46 of 49), 95.7% (44 of 46) and 11.8% (2 of 17) in post-NAC group and 96% (48 of 50), 97.9% (44 of 46) and 6.7% (1 of 15) in non-NAC group, respectively. There was no statistical difference between post-NAC group and non-NAC group in either detection rate (p=0.409), accuracy (p=0.525) or false negative rate (p=0.548).Conclusions: This prospective study in Chinese breast cancer population shows that post-NAC SLNB has both satisfactory detection rate and accuracy with acceptable false negative rate, being comparable to non-NAC patients. Our results also showed that using methylene blue only in SLNB for breast cancer is an ideal choice where radio detection method is not available.Summary of pathological resultsGrouppost-NAC (N=49)non-NAC (N=50)SLNB successful4648Average SLNs detected1.6 (range 1 to 5)1.7 ( range 1 to 6)Average ALNs taken out15.4 (range 7 to 33)16.8 (range 8 to 38)SLN+ / ALN-94SLN+/ ALN+510SLN- / ALN+21SLN- / ALN-2933 Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1014.

Ex vivo MRI of axillary lymph nodes in breast cancer

Purpose To provide a strategy for precise co-localization of lymph nodes on axillary lymph-node dissection (ALND) specimens both on pathology and MR. To identify nodal features suggestive of metastatic involvement on a node-to-node basis. Materials and methods National Institutional review-board approved this prospective study of 18 patients with breast cancer referred for ALND. Ex vivo T1 and inversion recovery (IR) T2 WI of ALND specimens tightly positioned within scaled plastic cranes was performed immediately after surgery. The correspondence of MR-based or pathologically based nodes location was assessed. The MR size and morphological presentation of metastatic and normal nodes were compared (Student's t-test or Mann–Whitney test). Quantitative variables were compared using Pearson coefficient. Results 207 nodes were retrieved on pathology and 165 on MR. MR–pathological correlation of nodes location was high regarding MR-identified nodes ( r = 0.755). An MR short axis threshold of 4 mm yielded the best predictive value for metastatic nodal involvement (Se = 78.6%; Sp = 62.3%). Irregular contours (Se = 35.7%; Sp = 96.7%), central nodal hyper-intensity on IR T2 WI (Se = 57.1%; Sp = 91.4%), and a cortical thickness above 3 mm (Se = 63.6%; Sp = 83.2%) were significantly associated with metastatic involvement. Conclusion Ex vivo MR allows node-to-node correlation with pathology. Morphological MR criteria can suggest metastatic involvement.

Sentinel lymph node biopsy is associated with improved survival compared to level I & II axillary lymph node dissection in node negative breast cancer patients

Objective The few long-term follow-up data for sentinel lymph node (SLN) negative breast cancer patients demonstrate a 5-year disease-free survival of 96–98%. It remains to be elucidated whether the more accurate SLN staging defines a more selective node negative patient group and whether this is associated with better overall and disease-free survival compared with level I & II axillary lymph node dissection (ALND). Methods Three-hundred and fifty-five consecutive node negative patients with early stage breast cancer (pT1 and pT2 ≤ 3 cm, pN0/pN SN0) were assessed from our prospective database. Patients underwent either ALND ( n = 178) in 1990–1997 or SLN biopsy ( n = 177) in 1998–2004. All SLN were examined by step sectioning, stained with H&E and immunohistochemistry. Lymph nodes from ALND specimens were examined by standard H&E only. Neither immunohistochemistry nor step sections were performed in the analysis of ALND specimen. Results The median follow-up was 49 months in the SLN and 133 months in the ALND group. Patients in the SLN group had a significantly better disease-free ( p = 0.008) and overall survival ( p = 0.034). After adjusting for other prognostic factors in Cox proportional hazard regression analysis, SLN procedure was an independent predictor for improved disease-free (HR: 0.28, 95% CI: 0.10–0.73, p = 0.009) and overall survival (HR: 0.34, 95% CI: 0.14–0.84, p = 0.019). Conclusions This is the first prospective analysis providing evidence that early stage breast cancer patients with a negative SLN have an improved disease-free and overall survival compared with node negative ALND patients. This is most likely due to a more accurate axillary staging in the SLN group.

SNOLL technique in 959 patients with non-palpable breast cancer

In 1 of 3 patients with initial lymph node-positive (cN+) breast cancer, neoadjuvant chemotherapy (NAC) results in an axillary pathologic complete response (ax-pCR). This urges the need for a less-invasive axillary staging method. Recently introduced less-invasive procedures have been insufficient in accurately identifying ax-pCR. Therefore, we propose a novel less-invasive axillary staging procedure: the Radioactive Iodine Seed localization in the Axilla with the Sentinel node procedure (RISAS), a combination of the procedure of marking axillary lymph nodes with radioactive iodine seeds (MARI) and sentinel lymph node biopsy (SLNB).In the present open single-arm multicenter validation study, 225 cN+ (biopsy-proven) patients will undergo the RISAS procedure, in which a positive lymph node is marked by an iodine-125 seed before NAC. After NAC completion, this iodine-125 seed-marked lymph node is removed, together with any additional sentinel lymph nodes. The RISAS procedure is subsequently followed by completion axillary lymph node dissection (ALND). The RISAS lymph nodes will be compared with the lymph nodes from the completion ALND specimen. The primary endpoint is accuracy of the RISAS procedure. The identification rate, false-negative rate, negative predictive value, and possible concordance between the MARI and SLNB will be reported.The present prospective multicenter RISAS trial will enable us to validate the combination of MARI and SLNB for assessing the axillary response to NAC in cN+ patients. If RISAS proves to be an accurate axillary staging procedure, ALND could safely be abandoned in the case of ax-pCR confirmed using the RISAS procedure.