Axillary Staging In Breast Cancer Research Articles

Contrast-enhanced Ultrasound Using Intradermal Microbubble Sulfur Hexafluoride in Non-invasive Axillary Staging in Breast Cancer: Are we Missing a Chance?

In the context of surgical de-escalation in early breast cancer (EBC), this study aimed to evaluate the contrast enhancement ultrasound (CEUS) sentinel lymph node (SLN) procedure as a non-invasive axillary staging procedure in EBC in comparison with standard SLN biopsy (SLNB). A subanalysis of the AX-CES study, a prospective single-arm, monocentric phase 3 study was performed (EudraCT: 2020-000393-20). The study included patients with EBC undergoing upfront surgery and SLN resection, with no prior history of locoregional treatment, and weighing between 40-85 kg. All patients underwent the CEUS SLN procedure as a non-invasive axillary staging procedure, with CEUS SLN accumulation marked using blue dye. After the CEUS SLN procedure, all patients underwent the standard mapping procedure. Data on success rate, systemic reactions, mean procedure time, mean surgical procedure, mean procedure without axillary staging, CEUS SLN appearance (normal/pathological), SLN number, and concordance with standard mapping procedure were collected. After the CEUS SLN procedure, 29 LNs among 16 patients were identified and marked. In all cases, CEUS SLN revealed at least one LN enhancement. Six (37.50%) LNs were defined as pathological after the CEUS SLN procedure. Definitive staining of CEUS SLN pathology revealed metastatic involvement in four (66.67%) of the cases. Two SLNs were identified during the CEUS SLN procedure; however, owing to the low disease burden, no change in the surgical plan was reported. The CEUS SLN procedure shows promise as a technique for non-invasive assessment of the axilla, potentially enabling safe axillary de-escalation in EBC by estimating the axillary disease burden.

Lessons from the SOUND trial and future perspectives on axillary staging in breast cancer.

Lessons from the SOUND trial and future perspectives on axillary staging in breast cancer.

Sentinel lymph node mapping in patients with breast cancer using a photoacoustic/ultrasound dual-modality imaging system with carbon nanoparticles as the contrast agent: a pilot study.

Assessing the metastatic status of axillary lymph nodes is a common clinical practice in the staging of early breast cancers. Yet sentinel lymph nodes (SLNs) are the regional lymph nodes believed to be the first stop along the lymphatic drainage path of the metastasizing cancer cells. Compared to axillary lymph node dissection, sentinel lymph node biopsy (SLNB) helps reduce morbidity and side effects. Current SLNB methods, however, still have suboptimum properties, such as restrictions due to nuclide accessibility and a relatively low therapeutic efficacy when only a single contrast agent is used. To overcome these limitations, researchers have been motivated to develop a non-radioactive SLN mapping method to replace or supplement radionuclide mapping. We proposed and demonstrated a clinical procedure using a dual-modality photoacoustic (PA)/ultrasound (US) imaging system to locate the SLNs to offer surgical guidance. In our work, the high contrast of PA imaging and its specificity to SLNs were based on the accumulation of carbon nanoparticles (CNPs) in the SLNs. A machine-learning model was also trained and validated to distinguish stained SLNs based on single-wavelength PA images. In the pilot study, we imaged 11 patients in vivo, and the specimens from 13 patients were studied ex vivo. PA/US imaging identified stained SLNs in vivo without a single false positive (23 SLNs), yielding 100% specificity and 52.6% sensitivity based on the current PA imaging system. Our machine-learning model can automatically detect SLNs in real time. In the new procedure, single-wavelength PA/US imaging uses CNPs as the contrast agent. The new system can, with that contrast agent, noninvasively image SLNs with high specificity in real time based on the unique features of the SLNs in the PA images. Ultimately, we aim to use our systems and approach to substitute or supplement nuclide tracers for a non-radioactive, less invasive SLN mapping method in SLNB for the axillary staging of breast cancer.

Estudio del ganglio centinela en el cáncer de mama por el método OSNA (One-Step Nucleic Acid Amplification) tras neoadyuvancia en el Hospital Universitario de Navarra

BackgroundSelective sentinel node (SN) biopsy is the standard technique for axillary staging in breast cancer (BC). There is no consensus on the use of OSNA (One-Step Acid Nucleic Amplification) method for SN in patients undergoing neoadjuvant treatment (NAT). We have studied the results obtained in our centre to justify the advantages of its implementation. Material and methods42 cases were selected from the group of 163 patients with BC treated with NAT, who underwent OSNA of the SN, obtaining a mean of 2.1 nodes per patient. We also analyzed cytokeratin 19 (CK19) expression, tumour grade, molecular phenotype and the degree of response to NAT in these patients. The SN were studied using the OSNA technique and non-sentinel nodes using the traditional method. ResultsTumour grade was 2-3 in 97.6% of cases, phenotype luminal A (17%), luminal B (38%), triple-negative (26.1%) and HER2 (19%). The response to NAT was complete in 59.5% of patients and CK19 expression was unchanged. The nodes studied were positive in 9 patients (21.4%) in whom lymphadenectomy was performed and only one case had a non-sentinel node involvement (2.3%). ConclusionsThe OSNA method for the study of SN after NAT is far superior to the traditional method as it: It allows intraoperative detection of isolated cell group and micrometastases not detectable with traditional methods, avoiding second interventions. It avoids false negatives when the whole SN is analyzed. It shows that CK19 expression is not altered by NAT.

44 (PB-044) Poster - A multicenter cohort of breast cancer patients with long-term 125I targeted axillary dissection

Background: Targeted axillary dissection (TAD) is increasingly used for axillary staging in breast cancer. In TAD, the metastatic lymph node is marked before neoadjuvant chemotherapy (NACT). In case of axillary pCR (pathological complete response) in the marked lymph node (MLN) and sentinel node, axillary dissection can safely be omitted as this will not benefit the patient. Several marking methods for TAD exist, most using re-marking before surgery. Feasibility, learning curve, and identification rate (IR) varies.

Fine-needle aspiration cytology versus core needle lymph node biopsy in axillary staging of breast cancer

BackgroundAxillary lymph node status is an extremely important prognostic factor in evaluating and managing recently diagnosed breast cancer patients. So, preoperative evaluation of the lymph nodes in breast cancer patients with minimally invasive methods is of significant concern. Ultrasonography is the main modality used for this purpose, with advantages including the ability to help to guide the biopsy. This study aimed to compare ultrasound-guided fine-needle aspiration cytology (FNAC) and core needle biopsy (CNB) in their ability to detect metastatic disease in the axillary lymph nodes, as well as to estimate the accuracy of preoperative ultrasound-guided axillary lymph node biopsy for staging in patients with breast cancer.ResultsIn total, 108 cases were included in the study, and 55.6% (60 cases) had metastases. The sensitivity for FNAC was 83.3%, and the specificity was 100%. The sensitivity for CNB was 100% and the specificity was 100%. The negative predictive value for FNAC was 81.5%, and that for CNB was 100%. The positive predictive value was 100% for both methods.ConclusionsCNB biopsy shows higher sensitivity and accuracy than FNAC in the characterization of benign and malignant lymph nodes. FNAC is a suitable substitute when a smaller node is encountered, a node in an inaccessible site, or even an uncorrectable bleeding diathesis of the patient.

Intraoperative Sentinel Node Fine-Needle Aspiration Biopsy as a Substitute for Whole Sentinel Node Excisional Biopsy in Breast Cancer Patients. Initial Report

IntroductionSentinel Node Biopsy (SNB) is the choice procedure for axillary staging in Breast Cancer. Following the ACOSOG Z11 trial, axillary dissection is advised only in patients with more than 2 positive SNs. We aimed at exploring palpation-guided, intraoperative fine-needle aspiration biopsy of the SN as a replacement for whole SN excision in node-negative BC patients to minimize side-effects. Patients and MethodsWe included 80 patients with BC undergoing SNB between December 2020 and May 2022. After identification of the SN, the breast surgeon performed SN-FNAB. Results were compared with definitive pathological assessment. ResultsDiagnostic yield was 80%, including a “learning curve.” 58 of 64 patients with suitable samples tested negative. In this group, the Negative Predictive Value was 77.6% (IC 64.7%-87.5 %). If micro metastasis is disregarded, the NPV would increase to 86.2% (IC 74.6%-93.9%). If we accept the Z11 criterion for axillary dissection, the NPV would rise to 100%. Six patients had a positive SN-FNAB. They were all confirmed as having macro metastatic-positive SNs at the final pathological assessment, and 3 of them also displayed extra nodal extension (ENE). ConclusionWe believe that intraoperative SN-FNAB is highly accurate for swiftly depicting both low axillary tumor burden/negative cases, in whom axillary dissection is to be omitted, as well as high axillary tumor burden cases.

Does ultrasound evaluation of the axilla increase the rate of axillary lymph node dissection in early stage clinically node negative breast cancer patients?

BackgroundManagement and axillary staging of breast cancer has become less invasive and more conservative, over the decades. Considering Z011, axillary lymph node dissection (ALND) can be avoided in T1-2 N0-1 breast cancers with one or two positive sentinel lymph nodes (SLNs), if they are candidates for breast conserving surgery and radiotherapy. The aim of this study was to recognize if pre-operative axillary US evaluation in early-stage breast cancer could lead to more ALND in post Z011 era.Method463 breast cancer patients were evaluated. 368 early-stage breast cancer patients (T1-2 N0) were included. We did not perform axillary US in early stage clinically node negative patients; however, 97 patients had axillary US prior to our visit. If axillary US could detect more than two suspicious LNs, US guided biopsy was performed. The remaining clinically node negative patients underwent upfront SLNB. ALND was performed if more than two SLNs were metastatic, or US-guided ALN biopsy proved metastatic involvement.Results97 patients had axillary US evaluation before the surgery. 67 patients (69.2%) did not have any suspicious US detected axillary LNs, 17 patients (17.5%) had one, 7 patients (7.2%) had two, and 6 patients (6.2%) had more than two suspicious LNs according to their axillary US evaluation. Those with more than two suspicious LNs underwent ALN US-guided biopsy. Metastatic involvement of the LNs was proved in all of them and they underwent upfront ALND. ALND revealed more than 2 metastatic LNs in 2/6 patients (33.3%). 91 patients who were evaluated by axillary US, had less than two US detected suspicious LNs and underwent SLNB. Amongst 24 patients with one or two US detected suspicious LNs, 1/24 patient had more than two positive SLNs and underwent ALND. In this group 15.6% underwent ALND and 5.2% of them were unnecessary according to the recent guidelines. Axillary US had a false positive rate of 36.6%. The sensitivity of axillary US in distinguishing patients with more than two suspicious LNs in clinically node negative patients was 25%. In the second group (without pre-operative axillary US evaluation), SLNB was performed. 204/272 patients (75%) did not have LN metastasis. 54/272 patients (19.9%) had one or two metastatic SLNs and according to Z011, ALND was omitted. 5.1% had more than two metastatic SLNs and underwent ALND.ConclusionUS evaluation of the axilla in early stage, clinically node negative breast cancer patients, is not sensitive enough to recognize more than two metastatic ALNs. It leads to more unnecessary ALND. Despite the small number of patients in this study, these results question the rationale of axillary US guided biopsy in low burden (less than two) suspicious LNs. looking for an imaging modality with a higher sensitivity in detecting the Burdon of axillary metastatic involvement is mandatory.

Feasibility and validation of the targeted axillary dissection technique in the axillary staging of breast cancer after neoadjuvant therapy: Definitive results

Aimto study the feasibility and value of “Targeted Axillary Dissection” (TAD) in cN1 breast cancer (BC) patients undergoing neoadjuvant chemotherapy (NACT), in order to avoid unnecessary axillary lymph node dissection (ALND). Materials and methodsDesign: Prospective observational study. Inclusion criteria: Patients with histologically confirmed cN1 staging BC and treated with NACT between January 2016 and August 2019 who accomplished clinical response. Method: Fine-Needle Aspiration (FNA) positive axillary nodes were marked with a metallic clip prior to neoadjuvant treatment. All patients were summited to TAD and ALND. Analysis of data: We performed [1]: a feasibility analysis of clinical, radiological and pathological variables, as well as difficulties and complications of the TAD [2]; a diagnostic test study of the sentinel lymph node biopsy (SLNB), clipped lymph node biopsy (BCLIP) and their combination (TAD), using ALND as the Gold Standard. Results60 patients were included. 43 patients (71.7%) had a complete clinical lymph node response to NACT. Neither limitations nor complications in clip placement were found. Intraoperative location of the clipped node was problematic in 7 cases (11.7%). The pathological complete response rate (pCR) was 30.5% (18 patients) and ypN0 staging rate was 38.3% (23 patients). Sensitivity values of each technique were: SLNB: 80.9% (95%CI: 61.8–100); BCLIP: 80.8% (95%CI: 63.7–97.8); TAD: 92.6% (95%CI: 80.9–100) with negative predictive values of: SLNB: 84.6% (95%CI: 68.8–100); BCLIP: 81.0% (95%CI: 63.7–97.8); TAD: 91.3% (95%CI: 77.6–100). ConclusionTAD is feasible and valid to rule out axillary metastatic involvement in cN1 breast cancer patients who respond to NACT.

Staging of the Axilla in Breast Cancer and the Evolving Role of Axillary Ultrasound.

Axillary lymph nodes have long been recognized as a route for breast cancer to spread systemically. As a result, staging of the axilla has always played a central role in the treatment of breast cancer. Anatomic staging was believed to be important for two reasons: 1) it predicts prognosis and guides medical therapy, and 2) it is a potential therapy for removal of disease in the axilla. This paradigm has now been called into question. Prognostic information is driven increasingly by tumor biology, and trials such as the ACOSOG Z0011 demonstrates removal of axillary disease is not therapeutic. Staging of the axilla has undergone a dramatic de-escalation; however, sentinel lymph node biopsy (SLNB) is still an invasive surgery and represents a large economic burden on the healthcare system. In this review, we outline the changing paradigms of axillary staging in breast cancer from emphasis on anatomic staging to tumor biology, and the evolving role of axillary ultrasound, bringing patients less invasive and more personalized therapy.

Pretherapeutic Imaging for Axillary Staging in Breast Cancer: A Systematic Review and Meta-Analysis of Ultrasound, MRI and FDG PET.

Background: This systematic review aimed at comparing performances of ultrasonography (US), magnetic resonance imaging (MRI), and fluorodeoxyglucose positron emission tomography (PET) for axillary staging, with a focus on micro- or micrometastases. Methods: A search for relevant studies published between January 2002 and March 2018 was conducted in MEDLINE database. Study quality was assessed using the QUality Assessment of Diagnostic Accuracy Studies checklist. Sensitivity and specificity were meta-analyzed using a bivariate random effects approach; Results: Across 62 studies (n = 10,374 patients), sensitivity and specificity to detect metastatic ALN were, respectively, 51% (95% CI: 43–59%) and 100% (95% CI: 99–100%) for US, 83% (95% CI: 72–91%) and 85% (95% CI: 72–92%) for MRI, and 49% (95% CI: 39–59%) and 94% (95% CI: 91–96%) for PET. Interestingly, US detects a significant proportion of macrometastases (false negative rate was 0.28 (0.22, 0.34) for more than 2 metastatic ALN and 0.96 (0.86, 0.99) for micrometastases). In contrast, PET tends to detect a significant proportion of micrometastases (true positive rate = 0.41 (0.29, 0.54)). Data are not available for MRI. Conclusions: In comparison with MRI and PET Fluorodeoxyglucose (FDG), US is an effective technique for axillary triage, especially to detect high metastatic burden without upstaging majority of micrometastases.

Patient-reported Upper Limb Function After Sentinel Lymph Node Biopsy for Breast Cancer: A Prospective Observational Study

IntroductionSentinel lymph node biopsy (SLNB) is the standard procedure for axillary staging in breast cancer. There is a lack of consistency in studies reporting on upper limb morbidity after SLNB. We present a prospective study evaluating upper limb function after SLNB using the validated quickDASH questionnaire. Materials and MethodsConsecutive patients who underwent wide local excision and SLNB were included in the study. Arm function was assessed using the quickDASH questionnaire at 3 time points – prior to surgery and 2 weeks and 3 months after SLNB. The scores obtained were labeled as A, B, and C respectively. The mean and median scores were compared using the paired t test and Wilcoxon signed rank test. ResultsNinety-nine patients met all inclusion criteria and were included in the final analysis. The mean A, B, and C scores were 8.46, 16.05, and 13.36. The median A, B, and C scores were 2.27, 7.5, and 4.54. There was a statistically significant difference between mean and median A and B scores, B and C scores, and A and C scores. A similar trend was observed in patients with better preoperative upper limb function. Patients with a higher body mass index had significantly worse B and C scores. ConclusionThere is a significant deterioration in upper limb function following SLNB. This improves at 3 months but does not reach baseline levels. Larger studies with long-term follow-up are required to establish the extent of upper limb functional morbidity and natural course of functional recovery after SLNB.

Wire guided localisation for targeted axillary node dissection is accurate in axillary staging in node positive breast cancer following neoadjuvant chemotherapy

AimThis study investigated whether wire localisation of the histologically proven positive, clipped axillary lymph node (ALN) with subsequent targeted axillary dissection (TAD) following neoadjuvant chemotherapy (NACT) improves axillary staging in breast cancer. Materials and methodsWe performed a retrospective review of patients with primary breast cancer and core biopsy proven metastatic ALNs, that had an excellent nodal radiological response following NACT, treated at our centre between January 2016 and December 2018. The initial cohort of patients (Group 1) underwent sentinel lymph node biopsy (SLNB), with a minimum of three nodes were sampled. The subsequent cohort (Group 2) had a marker clip inserted in the metastatic ALN prior to NACT. This cohort underwent wire guided excision of the clipped node in addition to SLNB, with a minimum of three nodes sampled. ResultsA total of 47 patients were identified. Group 1 comprised 22 patients with a sentinel lymph node (SLN) identification rate (IR) of 95%. 25 patients (Group 2) underwent wire guided clip location and the SLN IR was 100% with a 92% clipped node IR. Evidence of pathological complete response (pCR) in the clipped node was associated with pCR in other nodes. ConclusionTargeted axillary dissection is a feasible technique following excellent response to NACT in selected patients with limited volume ALN metastasis, at diagnosis. The identification of the positive ALN during surgery is vital and the IR can be improved by clipping the node prior to NACT and wire guided localisation at the time of surgery.

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.

Comparison of different doses of superparamagnetic iron oxide for sentinel node biopsy in breast cancer: the superparamagnetic iron oxide for sentinel node in breast cancer : (sunrise) randomized trial

Background. Sentinel lymph node biopsy (SLNB) is the standard for axillary staging in breast cancer, Techniques for SLN include the use of radioisotope, blue dye, or a combination of both. Sentinel lymph node biopsy with 2 mL of superparamagnetic iron oxide (SPIO) tracer has shown to be non-inferior to the standard radioisotope technique in several studies. The aim of this study is to assess if the efficacy of SLN detection using Sentimag®/SiennaXP®, with different doses of the SPIO is non inferior to the conventional technique (radioisotope).

Meta-analysis of the diagnostic accuracy of ultrasound-guided fine-needle aspiration and core needle biopsy in diagnosing axillary lymph node metastasis.

Axillary lymph node status remains a significant prognostic indicator in breast cancer. Here, the diagnostic accuracy of ultrasound-guided fine-needle aspiration (US-FNA) and ultrasound-guided core needle biopsy (US-CNB) in axillary staging was compared. A comprehensive search was undertaken of all published studies comparing the diagnostic accuracy of US-CNB and US-FNA of axillary lymph nodes in breast cancer. Studies were included if raw data were available on the diagnostic performance of both US-FNA and US-CNB, and compared with final histology results. Relevant data were extracted from each study for systematic review. Meta-analysis was performed using a random-effects model. The pooled sensitivity and specificity of US-FNA and US-CNB were obtained using a bivariable model. Summary receiver operating characteristic (ROC) graphs were created to confirm diagnostic accuracy. Data on a total of 1353 patients from six studies met the inclusion criteria and were included in the final analysis. US-CNB was superior to US-FNA in diagnosing axillary nodal metastases: sensitivity 88 (95 per cent c.i. 84 to 91) versus 74 (70 to 78) per cent respectively. Both US-CNB and US-FNA had a high specificity of 100 per cent. Reported complication rates were significantly higher for US-CNB compared with US-FNA (7·1 versus 1·3 per cent; P < 0·001). Conversely, the requirement for repeat diagnostic procedures was significantly greater for US-FNA (4·0 versus 0·5 per cent; P < 0·001). US-CNB is a superior diagnostic technique to US-FNA for axillary staging in breast cancer.

Severe decrease in SpO2 and methemoglobinemia following subareolar isosulfan blue administration and clinical relevance.

The level of axillary lymph node involvement in breast cancer is a critical decision factor for adjuvant therapy and the most important indicator of prognosis and survival. Sentinel lymph node biopsy is a minimally invasive technique with low morbidity in axillary staging of breast cancer. Radiocolloid substances (Technetium-99m) and/or blue dyes such as methylene blue or isosulfan blue are used during sentinel lymph node biopsy. Isosulfan blue stain is frequently used in sentinel lymph node biopsy and rarely causes complications. The present case report presents a severe decrease in SpO2 due to methemoglobinemia following isosulfan blue administration as well as skin and urine signs and inconsistency with clinical picture in a 67-year-old, 77 kg, ASA II female case who underwent sentinel lymph node biopsy under general anesthesia.

Abstract P3-01-16: How hot is enough for accurate sentinel lymph node axillary staging in breast cancer?

Abstract Purpose: Sentinel lymph node (SLN) biopsy is a well-established procedure for staging of the axilla in early-stage breast cancer and has replaced axillary lymph node dissection as the standard of care in patients with clinically lymph node–negative axilla. No consensus exists about the number of sentinel lymph nodes (SLNs) that should be removed based on radioactivity counts in breast cancer, although the “10% rule” is often used. In order to determine the frequency with which the hottest SLN 'fails' to be pathologically positive, and to determine which criteria best define the radioactive lymph node to be removed, we reviewed and analyzed our cases in which more than one SLN was detected and where there was also at least one pathologically positive node. Methods: We retrospectively studied 1062 breast cancer patients who underwent lymphoscintigraphy by injection of radioactive colloid and SLN biopsy between 2006 and 2015, with intraoperative determination of radioactive counts of nodes by a gamma probe. Results: A total of 247 patients (23.3%) had more than 1 SLN removed (mean 2.29); 53 patients (21.5%) had nodal metastases. Of the node-positive patients, the hottest SLN was positive in 90.6% (48 of 53). The lowest radioactive count of a positive SLN was 32% of that of the hottest node. Conclusions: In our study, most positive SLNs had the highest radioactivity and the hottest lymph node was not the pathologically positive node only in 9.4 %. Our institutional experience indicates that to obtain an acceptable false-negative rate, nodes should be removed until the 10% rule is met. Citation Format: Lee MH, Kang SH, Cho J. How hot is enough for accurate sentinel lymph node axillary staging in breast cancer? [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-01-16.

Axillary staging for breast cancer during pregnancy: feasibility and safety of sentinel lymph node biopsy.

Safety of sentinel lymph node (SLN) biopsy for breast cancer during pregnancy is insufficiently explored. We investigated efficacy and local recurrence rate in a large series of pregnant patients. Women diagnosed with breast cancer who underwent SLN biopsy during pregnancy were identified from the International Network on Cancer, Infertility and Pregnancy, the German Breast Group, and the Cancer and Pregnancy Registry. Chart review was performed to record technique and outcome of SLN biopsy, locoregional and distant recurrence, and survival. We identified 145 women with clinically N0 disease who underwent SLN during pregnancy. The SLN detection techniques were as follows: 99mTc-labeled albumin nanocolloid only (n=96; 66.2%), blue dye only (n=14; 9.7%), combined technique (n=15; 10.3%), or unknown (n=20; 13.8%). Mapping was unsuccessful in one patient (0.7%) and she underwent an axillary lymph node dissection (ALND). Mean number of SLNs was 3.2 (interquartile range 1-3; missing n=15). Positive SLNs were found in 43 (29.7%) patients and 34 subsequently underwent ALND. After a median follow-up of 48months (range 1-177), 123 (84.8%) patients were alive and free of disease. Eleven patients experienced a locoregional relapse, including 1 isolated ipsilateral axillary recurrence (0.7%). Eleven (7.6%) patients developed distant metastases, of whom 9 (6.2%) died of breast cancer. No neonatal adverse events related to SLN procedure during pregnancy were reported. SLN biopsy during pregnancy has a comparably low axillary recurrence rate as in nonpregnant women. Therefore, this method can be considered during pregnancy instead of standard ALND for early-stage, clinically node-negative breast cancer.

Axillary Staging in Breast Cancer: A Systematic Review

Axillary Staging in Breast Cancer: A Systematic Review