Concurrent Sentinel Lymph Node Biopsy Research Articles

EP.TH.322Should a concurrent sentinel node biopsy be performed when the preoperative histopathological category of B5c in a breast cancer biopsy is identified?

Abstract Aim To assess the management of sentinel lymph node biopsy (SLNB) in patients with a pre-operative B5c histopathological diagnosis. Method A retrospective study of the decision for SLNB in 31 breast cancer patients with B5c biopsy and their final histology were reviewed between 2009-2019. Factors that determine concurrent SLNB (size of mass lesion > 1cm/increasing size, DCIS > 4cm, recurrence and abnormal lymph nodes on ultrasound) were assessed. Results 15 patients (48%) with invasive disease and 7 patients (23%) with non-invasive disease had concurrent SLNB, whilst 9 (29%) patients with non-invasive disease did not receive concurrent SLNB and no patient (0%) with invasive disease failed to receive concurrent SLNB. Using the above inclusion and exclusion criteria 21 of 31 (68%) patients would have been managed correctly whilst 5 (16%) would of had unnecessary surgery and 5 (16%) would have required a second operation. Discussion In this study, 48% of patients with concurrent SLNB were identified as invasive and avoided a second operation. Although 23% of patients underwent unnecessary SNLB, no invasive disease SLNBs were missed. Solely using inclusion and exclusion criteria would not have improved results. This suggests that there must be other factors involved in correctly managing these patients. Conclusion Discussions with the patient about risk benefits of SLN complications vs repeat surgery, and patient comorbidity, in addition to radiological characteristics, may assist management decisions.

Underestimation of invasive breast carcinoma in patients with initial diagnosis of ductal carcinoma in situ: Size matters

BackgroundThe aim of our study was to identify those patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) and high risk of upstaging to invasive breast carcinoma (IBC), in whom sentinel lymph node biopsy (SLNB) should be considered. Materials and methodsOne-hundred and five DCIS patients treated with breast-conserving surgery (BCS) or mastectomy were studied. Preoperative features of the tumours were analyzed to investigate its association with underestimation of IBC on final pathology. ResultsOverall, the underestimation rate of IBC was 16.2%. The underestimation rate was highest in lesions with initial size >2 cm compared with those with size ≤2 cm (26.8% vs. 4.1%, respectively; p < 0.003). Eighty-eight patients (83.8%) underwent concurrent SLNB and only one case had lymph node involvement (1.1%). ConclusionsSLNB should be considered in DCIS patients receiving BCS with lesions greater than 2 cm since approximately one in four will harbour an IBC.

Infraestimación de carcinoma infiltrante de mama en pacientes con diagnóstico inicial de carcinoma ductal in situ: el tamaño importa

IntroductionThe aim of our study was to identify those patients with preoperative diagnosis of ductal carcinoma in situ (DCIS) and high risk of upstaging to invasive breast carcinoma (IBC), in whom sentinel lymph node biopsy (SLNB) should be considered. MethodsOne-hundred and five DCIS patients treated with breast-conserving surgery (BCS) or mastectomy were studied. Preoperative features of the tumors were analyzed to investigate its association with underestimation of IBC on final pathology. ResultsOverall, the underestimation rate of IBC was 16.2%. The underestimation rate was highest in lesions with initial size >2 cm compared with those with size ≤2 cm (26.8% vs. 4.1%, respectively; p < 0.003). Eighty-eight patients (83.8%) underwent concurrent SLNB and only one case had lymph node involvement (1.1%). ConclusionsSLNB should be considered in DCIS patients receiving BCS with lesions greater than 2 cm since approximately one in four will harbor an IBC.

Abstract P1-16-09: Magnetic sentinel node and occult lesion localization in breast cancer: Initial results of the MagSNOLL trial

Abstract Trial registration: ISRCTN: 68689512 MREC No: 13/LO/0636 UKCRN ID: 14979 INTRODUCTION: One-third of breast cancers diagnosed are non-palpable. These breast cancers require localization-guided surgery and axillary staging using sentinel lymph node biopsy (SLNB). We present our experience of the first 20 patients undergoing a novel technique of magnetic-guided lesion localization and concurrent SLNB, avoiding the need for wire-guided localization and radioisotopes. MATERIALS AND METHODS: Co-localization of the primary tumour and sentinel lymph nodes (SLNs) using a novel magnetic technique was initially undertaken on a protocol-driven predefined minimum of 10 patients with palpable breast cancers to assess the feasibility of the magnetic tracer to safely localize at the point of injection and concurrently drain to the lymphatics. In order to confirm proof of principle, the subsequent 20 patients with non-palpable breast cancers were analysed. An ultrasound-guided intra-tumoral injection of magnetic tracer was performed (0.5 mL Sienna+, Endomagnetics Ltd, UK). Once successful lesion localization was confirmed (peak magnetometer counts retained at the site of injection), the technique was undertaken in patients with non-palpable breast cancers awaiting wide local excision and SLNB. All patients underwent SLNB with the magnetic and combined technique (radioisotope and Patent Blue Dye). RESULTS: A total of 33 patients were recruited and 1 patient excluded due to breach of the trial protocol. This left a remainder of 32 patients for consideration, of which 12 patients (1 bilateral) possessed palpable breast cancer and 20 patients non-palpable breast cancer. Peak magnetometer counts were retained at the site of injection in all palpable (n=13) and non-palpable (n=20) breast cancers. Re-excisions (second operations) for involved margins were performed in 2 patients with non-palpable breast cancers (10%). The mean volume of excised specimens was 49 cm3 (SD 30.6). The SLN identification rate for the magnetic technique alone was 84% (28/33) overall and 85% (17/20) for non-palpable lesions. For the combined technique (radioisotope and blue dye) the SLN identification rate was 97% (32/33) overall and 100% (20/20) for non-palpable lesions. When the magnetic technique is combined with blue dye, the SLN identification rate overall was 97% (32/33) and for non-palpable breast cancers was 95% (19/20). The mean number of sentinel nodes excised was 1.75 versus 2.05 for the magnetic and combined techniques respectively. CONCLUSION: Magnetic lesion localization and concurrent SLNB is a feasible technique. Further optimisation and validation of this technique, in a larger trial, is required. Citation Format: Muneer Ahmed, Ashutosh Kothari, Hisham Hamed, Sumit Goyal, Tibor Kovacs, Anand David Purushotham, Bauke Anninga, Phillippa Young, Julie Scudder, Sarah McWililliams, Sarah Pinder, Quentin Pankhurst, Ian Monnypenny, Michael Douek. Magnetic sentinel node and occult lesion localization in breast cancer: Initial results of the MagSNOLL trial [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-16-09.

Magnetic sentinel node and occult lesion localization in breast cancer (MagSNOLL Trial).

Non-palpable breast cancers require localization-guided surgery and axillary staging using sentinel lymph node biopsy (SLNB). This study investigated the novel technique of magnetic-guided lesion localization and concurrent SLNB, which avoids the need for wire-guided localization and radioisotopes. An ultrasound-guided intratumoral injection of magnetic tracer (0·5 ml) was performed in a protocol-driven predefined minimum of ten patients with palpable breast cancer to assess the ability of the magnetic tracer safely to localize the tumour at the site of injection and concurrently drain to the lymphatics. Once successful lesion localization had been confirmed (peak magnetometer count retained at the centre of the tumour), the technique was undertaken in a further 20 patients with non-palpable breast cancers awaiting wide local excision and SLNB. All patients underwent SLNB with both the magnetic and standard dual (radioisotope and Patent Blue V dye) techniques. Thirty-two patients were recruited, of whom 12 (1 with bilateral disease) presented with palpable and 20 with non-palpable breast cancer. Peak magnetometer counts were retained at the tumour centre in all palpable (13) and non-palpable (20) breast cancers. Re-excisions for involved margins were necessary in two patients with non-palpable breast cancers. The sentinel lymph node identification rates were 28 of 33 procedures for the magnetic technique alone, 32 of 33 for the magnetic technique combined with blue dye, and 32 of 33 for the standard dual technique. Magnetic lesion localization is feasible, with intratumoral magnetic tracer injection combined with a periareolar injection of blue dye for subsequent SNLB.

Is sentinel lymph node biopsy always required when performing a mastectomy for ductal carcinoma in situ?

Introduction: Approximately 20% of patients with a pre-operative diagnosis of DCIS will have invasive disease on surgical excision and will require axillary staging. The National Institute for Health and Care Excellence guidelines state that patients undergoing mastectomy for ductal carcinoma in situ (DCIS) should undergo concurrent sentinel lymph node biopsy (SLNB). The aim of this study was to investigate if patients, who have undergone wide local excision for DCIS and required mastectomy subsequently, also require SLNB.

Sentinel Lymph Node Biopsy Versus Axillary Lymphadenectomy in Patients Treated with Lumpectomy: An Analysis of Short-Term Outcomes

Sentinel lymph node biopsy (SLNB) has been shown to reduce many of the long-term complications associated with a traditional axillary lymph node dissection (ALND); however, short-term outcomes have yet to be characterized. This study was designed to identify trends and differences in 30-day outcomes of partial mastectomy with concurrent SLNB or complete ALND to more effectively determine which patients may be at risk for perioperative complications. A retrospective review of the National Surgical Quality Improvement Program database from 2010 to 2011 was performed to identify all female patients undergoing partial mastectomy with concurrent ALND or SLNB. Logistic regression analysis was used to investigate the relationship between surgical management of the axilla and 30-day complications and readmissions. Of the 6,841 patients identified, 1,877 (27.4 %) received a complete ALND. Overall, the ALND cohort demonstrated significantly more readmissions and reoperations, as well as longer operative times and fewer outpatient procedures. No difference was detected in postoperative complications between the two groups. However, after adjusting for potential confounders, ALND did not predict increased risk of 30-day morbidity or unplanned 30-day readmission compared with SLNB in patients undergoing partial mastectomy. After adjusting for potential confounders, ALND does not significantly increase the risk of 30-day postoperative overall morbidity or readmission compared with SLNB. Improvement of postoperative outcomes should focus on management of high-risk patients and perioperative complications regardless of surgical management of the axilla.

Magnetic sentinel lymph node biopsy and localization properties of a magnetic tracer in an in vivo porcine model

The standard for the treatment of early non-palpable breast cancers is wide local excision directed by wire-guided localization and sentinel lymph node biopsy (SLNB). This has drawbacks technically and due to reliance upon radioisotopes. We evaluated the use of a magnetic tracer for its localization capabilities and concurrent performance of SLNB using a handheld magnetometer in a porcine model as a novel alternative to the current standard. Ethical approval by the IRCAD Ethics Review Board, Strasbourg (France) was received. A magnetic tracer was injected in varying volumes (0.1-5 mL) subcutaneously into the areolar of the left and right 3rd inguinal mammary glands in 16 mini-pigs. After 4 h magnetometer counts were taken at the injection sites and in the groins. The magnetometer was used to localize any in vivo signal from the draining inguinal lymph nodes. Magnetic SLNB followed by excision of the injection site was performed. The iron content of sentinel lymph nodes (SLNs) were graded and quantified. All excised specimens were weighed and volumes were calculated. Univariate analyses were performed to evaluate correlation. Magnetic SLNB was successful in all mini-pigs. There was a significant correlation (r = 0.86; p < 0.01) between magnetometer counts and iron content of SLNs. Grading of SLNs on both H&E and Perl's staining correlated significantly with the iron content (p = 0.001; p = 0.003) and magnetometer counts (p < 0.001; p = 0.004). The peak counts corresponded to the original magnetic tracer injection sites 4 h after injection in all cases. The mean volume and weight of excised injection site specimens was 2.9 cm(3) (SD 0.81) and 3.1 g (SD 0.85), respectively. Injection of ≥0.5 mL magnetic tracer was associated with significantly greater volume (p = 0.05) and weight of excision specimens (p = 0.01). SLNB and localization can be performed in vivo using a magnetic tracer. This could provide a viable alternative for lesion localization and concurrent SLNB in the treatment of non-palpable breast cancer.

Prediction of underestimated invasiveness in patients with ductal carcinoma in situ of the breast on percutaneous biopsy as rationale for recommending concurrent sentinel lymph node biopsy

AimTo develop a model to predict invasion and improve the indication of concurrent sentinel lymph node biopsy (SLNB) for patients with ductal carcinoma in situ (DCIS) on minimally invasive biopsy. MethodsWe evaluated the data of 205 patients with DCIS in minimally invasive biopsy specimens. Clinical, radiological and histological variables were assessed in order to identify predictors of invasive carcinoma in final pathology using logistic regression analyses. We developed and retrospectively tested an algorithm to indicate concurrent SLNB. ResultsInvasiveness was underestimated in 18.0% (37 of 205). Univariate analysis revealed the following significant risk factors: lesion palpability, a mass lesion on ultrasound, the presence of a mammographically detectable mass, architectural distortion or density, a BI-RADS score of 5, a lesion diameter ≥50 mm, and ≥50% of histologically affected ducts. With a palpable mass, which remained the only independent predictor of invasion after multivariate adjustment, and the presence of at least three of the remaining five risk factors, the probability of invasion was 56.0%. If the prediction model had been used to indicate SLNB 9.8% (20 of 205) of patients could have been benefited (i.e. spared unnecessary or correctly recommended concurrent SLNB) compared to the factual performed SLNB procedures. Those patients with pure DCIS treated with breast conserving surgery (BCS) benefited most with a relative risk reduction of nearly 50% for unnecessary SLNB. ConclusionThe prediction model could rationally guide an informed discussion about risks and benefits of concurrent SLNB in patients with DCIS on minimally invasive biopsy.

Predictors of Invasive Breast Cancer in Ductal Carcinoma In Situ Initially Diagnosed by Core Biopsy

Some patients who are initially diagnosed with ductal carcinoma in situ (DCIS) by core biopsy eventually have their disease upstaged to invasive carcinoma on final excision, thus warranting some form of axillary staging. This study aimed to identify the predictors of invasive breast cancer in DCIS diagnosed by core biopsy, which could then help clinicians decide which cases of biopsy-diagnosed DCIS should undergo concurrent sentinel lymph node biopsy during excision. The records of 95 consecutive patients diagnosed with pure DCIS from 100 core biopsies from January 2005 to August 2007 were retrospectively reviewed. The clinical, radiological and pathological characteristics of these 100 cases were correlated with the presence of invasion or microinvasion on excision. Factors that are associated with invasive or microinvasive foci on excisional histology are: size of target lesion on radiography ≥ 20 mm [odds ratio: 6.738 (1.050-43.236), p = 0.044] and ≤ 10 cores obtained [odds ratio: 22.343 (2.351-212.385), p = 0.007]. Underestimation of invasive breast cancer in core biopsy-diagnosed DCIS is related to the size of the lesion on radiography, as well as the number of cores obtained during biopsy.

Role of Sentinel Lymph Node Biopsy in Ductal Carcinoma-in-situ Treated by Mastectomy

Sentinel lymph node biopsy (SLNB) is a widely accepted alternative to axillary lymph node dissection in invasive breast cancer. Its role in ductal carcinoma-in-situ (DCIS) is unclear. The purpose of this study was to determine factors associated with the subsequent diagnosis of invasive disease and to determine the role of SLNB when performing a mastectomy for DCIS. A retrospective study was conducted of all mastectomies performed on patients with a preoperative diagnosis of DCIS between 2000 and 2005 at a single tertiary-care institution. Ninety mastectomies for DCIS were included, 54 (60%) of which were performed with concurrent SLNB. Of 44 patients diagnosed preoperatively with DCIS by core biopsy only, 34 patients (63%) had a concurrent SLNB, while 10 patients (28%) were treated with mastectomy alone (P < .01). Overall, 30 patients (33%) had invasive disease, 22 of whom received concurrent SLNB. Seven SLNB patients (13%) had positive SLNs. On univariate analysis, multifocality (P = .03), multicentricity (P = .01), comedonecrosis (P = .01), and diagnosis by core biopsy (P < .001) were associated with invasive disease on pathology. On multivariate analysis, comedonecrosis (P = .04) and diagnosis by core biopsy (P < .01) were independent predictors for invasion. There was no statistically significant predictor for sentinel lymph node metastasis. Approximately one-third of patients with DCIS treated with mastectomy at our institution later had invasive disease, and factors associated with invasion have been identified. On the basis of our results, routine SLNB is recommended in this patient population.

Lymphatic mapping and sentinel lymph node biopsy in the detection of early metastasis from sweat gland carcinoma.

Several subtypes of sweat gland carcinoma have been found to demonstrate a propensity to metastasize systemically and to regional lymph nodes. The predictive value and benefit of sentinel lymph node (SLN) biopsy have been established in numerous other malignancies, but to the authors' knowledge there is little literature published to date regarding the use of SLN biopsy in patients with sweat gland carcinoma. In the current study, the authors demonstrated the utility of SLN biopsy in detecting subclinical metastases of sweat gland carcinoma, which may result in early treatment. The authors identified five patients with malignant eccrine tumors in whom SLN biopsy was performed at the study institution. Clinical and histopathologic data were reviewed. The five study cases included two cases of aggressive digital papillary adenocarcinoma (both occurring on upper extremity digits), two cases of hidradenocarcinoma (occurring on the knee and foot, respectively), and an eccrine carcinoma (occurring on the scalp). In each biopsy-established case, there was no clinical evidence of metastatic disease, and a wide local excision or amputation was performed with concurrent SLN biopsy. Four of 18 SLNs in 3 of the 5 patients (60%) were found to be positive for metastatic carcinoma, as identified in hematoxylin and eosin stains and/or cytokeratin immunohistochemical stains. All three lymph node-positive patients subsequently underwent regional lymphadenectomy and were found to have no evidence of additional metastases. The results of the current study demonstrate that SLN biopsy detects subclinical metastases from sweat gland carcinomas to regional lymph nodes. SLN mapping and biopsy at the time of resection can provide useful information with which to guide early treatment. Further studies are necessary to determine whether this procedure results in a survival benefit in patients with sweat gland carcinomas.