False-negative Rate Of Sentinel Lymph Node Biopsy Research Articles

Value of Sentinel Lymph Node Biopsy in Breast Cancer Surgery with Simple Pathology Facilities -An Iranian Local Experience with a Review of Potential Causes of False Negative Results

Sentinel lymph node biopsy (SLNB) is a precise procedure for lymphatic staging in early breast cancer. In a valid SLNB procedure, axillary lymph node dissection (ALND) can be omitted in node- negative cases without compromising patient safety. In this study, detection rate, accuracy and false negative rate of SLNB for breast cancer was evaluated in a setting with simple modified conventional pathology facilities without any serial sectioning or immunohistochemistry. Patients with confirmed breast cancer were enrolled in the study. SLNB and ALND were performed in all cases. Lymph node metastasis was evaluated in SLN and in nodes removed by ALND to determine the false negative rate. Pathologic assessment was carried out only by modified conventional technique with only 3 sections. Detection rate was determined either by lymphoscintigraphy or during surgery. 78 patients with 79 breast units were evaluated. SLN was detected in 75 of 79 cases (95%) in lymphoscintigraphy and 76 of 79 cases (96%) during surgery. SLN metastases was detected in 30 of 75 (40%) cases either in SLNB and ALND groups. Accuracy of SLNB method for detecting LN metastases was 92%. False negative rate was 3 of 30 of positive cases: 10%. In 7 of 10 cases with axillary lymphadenopathy, LN metastastates was detected. SLNB is recommended for patients with various tumor sizes without palpable lymph nodes. In modified conventional pathologic examination of SLNs, at least macrometastases and some micrometastases could be detected similar to ALND. Consequently, ALND could be omitted in node-negative cases with removal of all palpable LNs. We conclude that SLNB, as one of the most important developments in breast cancer surgery, could be expanded even in areas without sophisticated pathology facilities.

P3-07-25: Sentinel Lymph Node Mapping in Breast Cancer after Primary Chemotherapy.

Abstract Background The High false negativity rate and the possible of interference of primary systemic treatment (PST) and biopsy on the lymphatic drainage in the breast and axilla are the disadvantages of sentinel lymph node biopsy (SNB) after PST. The primary aim of our study was to evaluate success rate for identification and isolation of sentinel lymph node (SLN) in patients treated with PST. Secondary aims were to verify if chemotherapy and biopsy can really alter the lymphating drainage, and to identify biological and clinical factors that can influence the accuracy of this technique. Methods: Between June 2000 and April 2007, 176 consecutive operable or locally advanced breast cancer patients (T1-4N0-1M0) treated with antracyclin-based PST were enrolled in this single Institution study. Before performing a surgical biopsy and starting the treatment a lymphatic mapping was performed and the skin projection of the SLN location was then marked with permanent ink, with the aim to verify if the SLN marked did not change after biopsy and PST. Results: The SLN was removed in 164 patients, with an identification rate of 93.2% (95% confidence interval (CI) = 89.4−96.9%). Fifty patients (30.5%) had metastatic involvement at SNB, and in 21 (42.0%) of them the SLN was the only positive node. Nine patients (5.5%) had a false negative SLN. The false-negative rate was 15.3% (95% CI = 7.1−32.9%). The SNB revealed a sensitivity of 84.7% (95% CI = 73.0−96.4%), an accuracy of 94.5% (95% CI = 90.1−99.0%) and a negative predictive value of 92.1% (95% CI = 85.8−98.4%). In 163 patients (99.4%) the SLN marked at baseline was the same removed at the end of treatment, while only in 1 case (0.6%) a different SLN was identified by the lymphatic mapping performed with radioactive colloid. According to clinical and tumor characteristics the rate of identification and removal of SNB was higher in patients aged <50 (95.6%) vs >50 (91.6%), with clinical node negative (95.1%) vs positive (88.6%) and with lower grade G2 (98.0%) vs G3 (91.2%). False negative rate of SNB was higher in patients aged >50 (17.9%) vs <50 (10.0%) and with clinical node negative (17.1%) vs positive (12.5%). Lymph node involvement was significantly associated with baseline ER positivity (p=0.00595 Chi-square test). Conclusion: The identification rate, sensitivity and accuracy do not differ from other study of SNB after PST. The false-negative rate is still high and we are performing analysis to identify biological and clinical features that can influence the accuracy of this technique. To our knowledge this is the first study with an in vivo demonstration that chemotherapy and biopsy do not alter the lymphatic drainage of the breast. We are perfoming exploratory analyses to evaluate the influence of false-negative rate of SNB on overall survival (OS) and progression free survival (PFS). Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-25.

Precise Pathologic Examination Decreases the False-Negative Rate of Sentinel Lymph Node Biopsy in Gastric Cancer

Gastric cancer has been identified as a target for sentinel lymph node (SLN) navigational surgery. Although accurate evaluation of SLNs is essential for applying the SLN concept to gastric cancer surgery, there is no standardized pathologic examination protocol for SLNs in gastric cancer. A total of 231 SLNs from 69 patients with cT1-2, N0 gastric cancer were prospectively examined in this study. During the operation, SLNs were sliced at 2-mm intervals, and frozen sections were analyzed by hematoxylin and eosin (HE) staining in 35 patients or HE staining with rapid immunohistochemistry (IHC) for pancytokeratin (CK) in 34 patients. HE staining and CK IHC were performed postoperatively on each remaining SLN. Non-SLNs were evaluated with 2 levels of HE slides and 1 CK IHC. Of 35 patients, metastasis was identified in 10 patients by intraoperative HE staining, and in 12 patients by postoperative HE staining and CK IHC. Two patients had isolated tumor cells (ITCs) detectable by postoperative CK IHC; these patients had non-SLN metastasis. We enrolled another 34 patients and examined 147 SLNs by frozen HE and rapid IHC. In this cohort, 26 patients with negative SLNs by intraoperative examination did not have non-SLN metastasis even after deeper sectioning and CK IHC of non-SLNs (sensitivity, 100%; false negative value, 0%). Our study indicated that precise and detailed intraoperative examination decreases the false-negative rate of SLN biopsy. ITCs in SLNs should not be overlooked, and rapid IHC can be helpful for detecting ITCs intraoperatively.

Study of sentinel lymph node biopsy after preoperative chemotherapy in patients with breast cancer.

104 Background: Despite the increasing use of both sentinel lymph node biopsy (SLNB) and preoperative chemotherapy (PST) in patients with operable breast cancer, there is still limited information on the feasibility and accuracy of SLNB following PST. In this study, the feasibility and accuracy of SLNB for breast cancer patients with clinically negative lymph nodes after PST were investigated. In addition, conditions that may affect SLN biopsy detection and false-negative rates with respect to clinical tumor response and clinical tumor/nodal status before PST were analyzed. Methods: Between 2003 and 2008, 200 patients with stage II and III breast cancer previously treated with PST were enrolled in this study. The eligible criteria for PST were (a) primary tumor > 3cm or (b) positive axillary lymph node status on initial examination. FNA biopsy was performed for clinically or ultrasonographically suspicious axillary lymph nodes. The patients then underwent SLNB, which involved a combination of intradermal injection over the tumor of radiocolloid and subareolar injection of blue dye. This was followed by Level I/II axillary lymph node dissection (ALND). Results: The median patient age was 49 years, and the median primary tumor size was 4.9 cm. The overall SLN identification rate was 94.5% (189 of 200). In 178/189 patients (94%) the SLN accurately predicted the axillary status. Eleven patients had a false-negative SLN biopsies, yielding a false-negative rate of 12.9%. There were no significant differences in the SLN identification rate according to tumor classifications before PST, the clinical nodal status before PST, the clinical tumor response after PST, or pathological response of the tumor after PST, although the SLN identification rate tended to be lower in patients with a T4 primary tumor. Conclusions: Our data and some reports suggested that SLNB was feasible method for axillary staging in breast cancer patients who received PST even in patients who initially with lymph node positive disease. However, false-negative rate of SLNB in patients with clinical and pathological complete tumor response tended to be higher than other group.

How Many Sentinel Lymph Nodes Are Enough for Accurate Axillary Staging in T1-2 Breast Cancer?

PurposeDuring a sentinel lymph node biopsy (SLNB) for breast cancer, the appropriate number of sentinel lymph nodes (SLNs) to be removed for accurate axillary staging is still controversial. We hypothesized that there might be an optimal threshold number of SLNs. We investigated how many SLNs should be removed to achieve an acceptable accuracy and ensure minimal morbidity.MethodsWe reviewed data of 328 patients with invasive breast cancer who underwent SLNB followed by complete level I and II axillary dissection between January 2004 and December 2005. The false negative rate (FNR) and accuracy of SLNB according to the number of removed SLNs were evaluated.ResultsThe mean number of SLNs removed was 3.0 (range, 1-14), and that of total retrieved axillary lymph nodes was 17.5 (range, 10-40). In total, 111 (33.8%) patients had positive nodes on the permanent pathological report. Among them, 12 patients had negative SLNs; thus, the overall FNR of SLNB was 10.8% (12/111) and the accuracy was 96.3% (316/328). The FNR was 26.6% for a single SLN, 8.0% for two, and 11.1% for three. In cases where four or more SLNs were removed, the FNR decreased to 0% and accuracy reached 100%.ConclusionOur data suggest that a SLNB should not only remove one or two of the hottest node(s) when other hot nodes exist. We also suggest that four might be an optimal threshold number of SLNs to be removed and that removal of more than four SLNs does not improve axillary staging accuracy.

Abstract P1-01-03: Accuracy of Sentinel Lymph Node Biopsy in Large and Multifocal/Multicentric Breast Carcinoma — Systematic Review

Abstract Introduction: Sentinel lymph node biopsy (SLNB) is well established for management of small unifocal breast cancers. As confidence in SLNB increases, use of SLN-based management has increased and it is now often used for axillary staging in cases of multifocal (MF) and multicentric (MC) breast cancer and larger tumors although its role in the management of these tumors is controversial. The aim of this study is to systematically review the evidence for SLNB in axillary staging for newly diagnosed invasive breast cancer that is MF/MC or greater than 30mm in diameter. Studies reporting accuracy of SLNB in these situations are reviewed and implications for patient management are discussed. Methods: Medline was searched, identifying 3,461 studies of SLNB in breast cancer. Of these, 57 abstracts met the eligibility criteria which were: (a) original studies that reported (b) outcomes of SLNB in invasive breast cancer and (c) outcomes separately for a population of women with tumors that were either MF/MC or diameter 30mm or greater. Following review of full text articles, 36 studies were excluded as they did not meet criteria; two more studies were added after review of reference lists. Results: 23 studies met inclusion criteria and reported 20,687 cases of SLNB. This included data on accuracy for 1,541 MF, 369 MC, and 1,646 larger tumors. All included studies were case series; no randomized controlled trials were identified. Injection for lymphatic mapping was variably performed in site and technique and was variably reported. For MF cancers (n=976; 8 studies), success rate for identification of a SLN was 86-100%, SLN positivity rate 42-59%, false negative rate (FNR) 6-33%(with 4 of the 7 case series reporting false negative rates over 21%). The overall accuracy for MF tumors was 75-97%. For MC cancers (n=262; 4 studies): success rate for identification of a SLN 92-96%, SLN positivity rate 50-61%, FNR 0-8% and accuracy 96-100%. For ‘multiple breast cancer’ (n=688; 8 studies combining MF/MC cases): success rate for identification of a SLN 93-100%, SLN positivity rate 11-63%, FNR 6-13%, and accuracy 93-98%. For larger tumors (n=1646; 9 studies): success rate for identification of a SLN 86-100%, SLN positivity rate 42-59%, FNR 3-16.2% and accuracy 88-97.7%. For MF/MC and larger cancers overall non-SLN positivity rates were up to 82%; axillary recurrence rates were low but not often reported. Conclusion: Although the evidence suggests that success rate and FNR of SLNB in MF/MC and larger tumors are similar to small unifocal cancers, node positivity rates are higher in these breast cancers and this translates to higher rates of understaging in real terms. High rates of non-SLN positivity for these tumors compared to rates for lower risk tumors mean that omitting ALND in the case of a positive SLNB risks leaving disease in the axilla more often than previously accepted. Thus the evidence supports the use of ALND in the majority of cases when the SLNB is positive. Women must be made aware that the high likelihood of positive axillary lymph nodes in MF/MC and larger breast tumors. Relying on SLNB-based management means accepting a higher risk of understaging and/or under treatment than when using SLNB based management for lower risk tumors. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-01-03.

Sentinel node biopsy in breast cancer: results in a large series

Sentinel lymph node biopsy (SLNB) is an appropriate method for the evaluation of axillary status in cases of early breast cancer. We report our experience in treating cases evaluated using SLNB. We analyzed a total of 1192 cases assessed by means of SLNB from July 1999 to December 2007. SLNB processing was successfully completed in 1154 cases with the use of blue dye or radiolabeled 99mTc-Dextran-500, or both. Of these 1154 patients, 857 were N0(i-) (no regional lymph node metastasis, negative immunohistochemistry, IHC), 96 were N0(i+) (no regional lymph node metastasis histologically, positive IHC, no IHC cluster greater than 0.2 mm) and 201 were N1mi (greater than 0.2 mm, none greater than 2.0 mm). Most of the tumors (70%) were invasive ductal carcinomas and tumors were staged as T1 in 770 patients (65%). A total of 274 patients underwent SLNB and axillary dissections up to April 2003. The inclusion criteria were tumor size equal to or less than 3 cm in diameter, no clinically palpable axillary lymph nodes, no neoadjuvant therapy. In 19 cases, the SLN could not be identified intraoperatively. A false-negative rate of 11% and a negative predictive value of 88.2% were obtained for the 255 assessable patients. The overall concordance between SLNB and axillary lymph node status was 92%. SLNB sensitivity for nodes was 81% and specificity was 100%. The higher sensitivity, specificity, accuracy, and lower false-negative rates of SLNB suggest that this method may be an appropriate alternative to total axillary dissection in early breast cancer patients.

342 Touch-imprint cytology false negative patients opt for non-standard management of the axilla

We evaluated the feasibility and prognostic effect in axillary recurrence or survival of sentinel lymph node biopsy (SLNB) in patients with cytology-proven, node-positive breast cancer after neoadjuvant chemotherapy (NAC).This is a retrospective study of 329 patients who were diagnosed with invasive breast cancer and axillary lymph nodes (ALN) metastasis and treated with NAC followed by curative surgery at Samsung Medical Center between January 2007 and December 2013. We analyzed and compared outcomes including prognoses and survival rates among all groups.The median age at the time of surgery was 44.4 years. The median follow-up time was 37 months (range, 1-91 months). The sentinel lymph node (SLN) identification rate was 96.7% (117 of 121 patients). The median number of retrieved SLNs was 4.0 (range, 1-7), and 57 patients had negative SLNs on frozen-section analysis. The false negative rate of SLNB after NAC was 7.8% (5 of 64 patients). In survival analysis, there was no difference in the overall survival (P = .2) and the regional recurrence-free survival (P = .297) among Groups 1, 2, and 4.SLNB may be feasible after NAC for node-positive breast cancer and may help reduce surgical morbidity by avoiding the need for standard axillary lymph node dissection in some patients. We suggest that future studies with a large number of patients and a longer follow-up period are necessary to support the use of SLN surgery as an alternative to axillary lymph node dissection in this patient population.

Sentinel Lymph Node Biopsy in Patients Who Have Negative Conversion of Axillary Lymph Node after Neoadjuvant Chemotherapy for Node Positive Breast Cancer.

Abstract Background: Sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NAC) has been currently debatable. It is possible that the tumor response to chemotherapy may alter the lymphatic drainage thus causing lower SLN identification rate and higher false negative rate. Further, the response of NAC can be different in each lymph nodes. It is doubtful whether SLNB can accurately predict axillary lymph node (ALN) status after NAC. The aim of this study to determine the identification rate, the false-negative rate, and the accuracy of SLNB after NAC for node positive breast cancer.Patients and Methods: A prospective study was initiated to evaluate the results of SLNB after NAC. From January 2007 to April 2009, 81 patients with positive axillary lymph nodes enrolled from two institutions after IRB-approved. They received NAC and then evaluated negative conversion of metastatic lymph node with both PET and breast US. All of them underwent ALN dissection after SLNB with subareolar intradermal injection technique using radioisotope. We evaluated the identification rate, false negative rate, accuracy of SLNB according to the response of chemotherapy in axillary lymph nodes (negative conversion group or remaining positive group).Results: Before the NAC, 31 patients had multiple axillary lymph node metastasis and 50 patients had single metastasis. After NAC 44 cases (54.3%) turned into negative node and 37 cases (45.7%) remained positive nodes. Total identification rate was 80.2% (65 of 81), false negative rate was 19.0% (8 of 42) and accuracy was 87.7% (57 of 65). In negative conversion group showed 84.1% (37 of 44) of identification rate, 21.1% (4 of 19) of false negative rate, 89.2% (33 of 37) of accuracy. In remaining positive group revealed 75.7% (28 of 37) of identification rate, 17.4% (4 of 23) of false negative rate, 85.7% (24/28) of accuracy. There was no statistical significant difference of identification rate, false negative rate, accuracy of SLNB among the two group after NAC (p=0.343, p=0.534, p=0.478, respectively).Conclusion: This study showed relatively low detection rate and accuracy, high false-negative rate of SLNB, even if the positive nodes changed to negative node after NAC. Thus sentinel lymph node biopsy after NAC for node positive breast cancer should be cautious. Since this study had small number of negative conversion patients, further larger prospective studies are required for more proper conclusion. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1022.

False Negative Rate of Sentinel Lymph Node Biopsy in Multicentric and Multifocal Breast Cancers May be Higher in Cases with Large Additive Tumor Burden

We aimed to evaluate the feasibility of sentinel lymph node biopsy (SLNB) in multicentric/ multifocal breast cancer. In this prospective study, 23 women with multicentric/multifocal breast cancer underwent SLNB at our institution from April 2002 to February 2006. Presence of preoperative axillary metastases was confirmed by FNA. Patients underwent sub-areolar radiopharmaceutical injection +/- isosulfan blue to perform SLNB, then completion ALND. The false-negative (FN) rate of SLNB was determined based upon final pathology. Twenty women with multicentric and three with multifocal invasive carcinoma were enrolled. The SLN identification rate was 100%. The overall FN rate of SLNB was 15% (95% CI 0.0466, 0.4281). Both cases with FN SLNB had multicentric disease, pathologic stage III breast cancer and a larger tumor burden compared with the study population. SLNB using sub-areolar injection is feasible for patients with multicentric/multifocal breast cancer yet may be associated with a higher FN rate in patients with large additive tumor burden.

Subareolar injection may not always identify the same sentinel lymph nodes as peritumoral injection in breast cancer.

Abstract Abstract #1022 Background. Sentinel lymph node (SLN) biopsy is widely accepted as a standard surgical procedure for early breast cancer, but the optimal site for injection of mapping tracers is still controversial. We evaluated whether a combination of peritumoral injection and subareolar injection can improve the identification rate of SLN biopsy and decrease the false-negative rate.
 Methods. From August 2006 to April 2008, 155 patients with biopsy-proven operable breast cancer underwent SLN biopsy with peritumoral injection of radioisotope (Tc-99m-phytate) and subareolar injection of blue dye (patent blue dye).
 Results. The overall identification rate for blue and/or radioactive (hot) lymph nodes was 99.4% (154/155); the identification rate of blue-dyed lymph nodes was 98.1% (152/155) and of hot lymph nodes was 96.8% (150/155). A total number of the excised SLNs were 379 in these 154 patients, and the average number of SLNs in each patient was 2.4 (range, 1-9). The average number of SLNs was 2.0 (range, 1-8) for blue dye and 1.9 (range, 1-6) for radioactive (hot). Two hundred twenty-six nodes (59.6%) were blue and hot, while 79 were blue-only and 74 were hot-only. Consequently, no concordance between the hot node and the blue node was found in 14 of 154 patients (9.1%). Eight of these 14 patients had separate blue-only nodes and hot-only nodes (so-called sequential mismatch). Four patients had SLNs identified by blue dye only, whereas 2 patients had SLNs localized solely by radioisotope labeling. On the other hand, metastatic disease was identified in SLNs of 40 of 154 patients (26.0%). A number of positive SLNs were 55 in these 40 patients, where 34 nodes (61.8%) were blue and hot, 9 were blue-only and 12 were hot-only. Among these 40 patients, 30 patients (75.0%) had blue and hot positive SLN. Four patients had blue-only positive SLN and 4 patients had hot-only positive SLN. Two patients had separate blue-only positive SLN and hot-only positive SLN. The SLN was the only positive node in 24 of the 41 positive SLN mapping (60%). Consequently, the false-negative rates were 9.8% (4/41) for peritumoral injection and 9.8% (4/41) for subareolar injection. There were no significant differences between peritumoral and subareolar injection. However, both injection methods complemented each other, thereby decreasing the false-negative rate to 0%. It is important to note that metastatic disease was identified by peritumoral injection in 4 patients in which the SLN was hot-only. At a median follow-up of 10.5 months (range, 2-22 months), there were no axillary recurrences in any of the 155 patients.
 Conclusions. Subareolar injection may not always identify the same SLN as peritumoral injection. Subareolar injection of blue dye and peritumoral injection of radioisotope improves the identification rate of the SLN and decrease the false-negative rate of SLN biopsy. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1022.

Sentinel lymph node biopsy after neoadjuvant chemotherapy is accurate in breast cancer patients with a clinically negative axillary nodal status at presentation.

Abstract Abstract #1020 Background: In breast cancer, neoadjuvant chemotherapy (NAC) is widely used in order to enable a conservative surgery. In patients treated with NAC, the use of sentinel lymph node (SLN) biopsy, which is a good predictor of the axillary nodal status in previously untreated patients, is still discussed. The aim of our study was to determine clinicopathological factors that may influence the accuracy of SLN biopsy after NAC.
 Patients and methods : Between March 2001 and December 2006, 129 patients with infiltrating breast carcinoma were studied prospectively. Preoperatively, all of them underwent NAC. At surgery, SLN biopsy followed by axillary lymph node (ALN) dissection was performed. Lymphatic mapping was done using the isotope method.
 Results : The SLN identification rate was 93.8% (121/129). Fifty-six out of the 121 sucessfully mapped patients had positive ALN. Eight out of these 56 patients had tumor-free SLN (false-negative rate of 14.3%). The false-negative rate was correlated with larger tumor size (T1-T2 versus T3; p=0.045) and positive clinical nodal status (N0 versus N1-N2; p=0.003) before NAC. In particular, the false-negative rate was 0% (0/29) in N0 patients and 29.6% (8/27) in N1-N2 patients. Clinical and pathological responses to NAC did not influence the accuracy of SLN biopsy.
 Conclusion : Our results show that clinical nodal status is the main clinicopathological factor influencing the false-negative rate of SLN biopsy after NAC for breast cancer. SLN biopsy after NAC can predict the ALN status with a high accuracy in patients who are clinically lymph node negative at presentation. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1020.

Clinical Considerations on Sentinel Node Biopsy in Melanoma from an Italian Multicentric Study on 1,313 Patients (SOLISM–IMI)

Although widely used for the management of patients with cutaneous melanoma, the sentinel lymph node (SLN) biopsy (SNB) procedure raises several issues. This study was designed to investigate: the predictive factors of SLN status, the false-negative (FN) rate, and patients' prognosis after SNB. This is an observational, prospective study conducted on a large series of consecutive patients (n = 1,313) enrolled by 23 Italian centers from 2000 through 2002. A commonly shared protocol was adopted for the SNB surgical procedure and the SLN pathological examination. The SLN positive and false-negative (FN) rates were 16.9% and 14.4%, respectively (median follow-up, 4.5 years). At multivariable logistic regression analysis, the frequency of positive SLN increased with increasing Breslow thickness (p < 0.0001) and decreased in patients with melanoma regression (p = 0.024). At the multivariable Cox regression analysis, SLN status was the most important prognostic factor (hazards ratio (HR) = 3.08) for overall survival; the other statistically significant factors were sex, age, Breslow thickness, and Clark's level. Considering SLN and NSLN status, including FN cases, we identified four groups of patients with different prognoses. The 5-year overall survival of patients with positive SLNs was 71.3% in those with negative nonsentinel lymph nodes (NSLNs) and 50.4% if NSLNs were positive. Regression in the primary melanoma seems to be a protective factor from metastasis in the SLN. When correctly calculated, the SNB FN rate is 15-20%. Furthermore, the SNB is important to more precisely assess the prognosis of patients with melanoma.

Sentinel lymph node biopsy after neoadjuvant chemotherapy in inflammatory breast cancer

Background Sentinel lymph node biopsy (SLNB) demonstrates promising results as an accurate alternative to axillary lymph node dissection in patients with locally advanced breast cancer after neoadjuvant chemotherapy (NAC). However and in the view of the insufficient data on women with inflammatory breast cancer (IBC), SLNB is not recommended in this situation. The current study assessed identification and false-negative rates of SLNB after NAC for patients with IBC. Methods Between 2006 and 2009, twenty consecutive patients with clinically negative nodes after NAC for IBC (T4d) and who underwent SLNB and axillary lymph node dissection (levels I and II) by the same operator were assessed. Intraoperative Sentinel lymph node biopsy was performed with patent blue dye injections. Results The SLN could be identified in 16 of 20 patients (identification rate, 80%), the median of SLN removed per patient was 2 (range 1–3); nine (56%) had positive SLNB, and in 2 of those 9 patients (22%), the SLN was the only positive node with otherwise negative axillary nodes. Two (18%) patients' SLNB were false negative. Conclusions The SLN identification and false-negative rates after NAC for IBC were unacceptably high and based on the current findings, SLNB without systematic axillary lymph node dissection is unsuitable in this patient population.

Optimal Detection of Sentinel Lymph Node Metastases by Intraoperative Radioactive Threshold and Molecular Analysis in Patients with Melanoma

The aim of this study was to optimize a protocol for radioguided biopsy of the sentinel lymph node (SLN) in patients with melanoma. The protocol was based on a combination of ex vivo counting of the nodes detected intraoperatively and analysis of the harvested nodes by hematoxylin and eosin staining plus immunohistochemistry (conventional histopathology [PATH]) and by molecular biology (reverse-transcriptase polymerase chain reaction [RT-PCR]). A total of 124 patients with primary clinical stage I-II (according to the American Joint Committee on Cancer) cutaneous melanoma underwent successful radioguided SLN biopsy. SLNs harvested for analysis included any additional nodes whose ex vivo counting rate exceeded 20% of the hottest node. All removed SLNs were examined by conventional PATH and with RT-PCR analysis for the expression of messenger RNA for tyrosinase and the melanoma antigens recognized by T cells. Complete lymph node dissection (CLND) was performed only in the case of SLN metastasis detected by PATH. Different combinations of the intraoperative parameters (only the hottest node and all nodes harvested) and of analysis (PATH and RT-PCR) were tested as predictors of clinical outcome on the basis of long-term follow-up (12-81 mo; median, 55 mo). A total of 197 SLNs were harvested, 41 of which harbored metastasis as detected by RT-PCR analysis; PATH detected metastasis in only 24 of 41 metastatic SLNs. In 5 of 41 instances, metastasis was not in the hottest SLN. The main factor determining correct classification of the SLN status was RT-PCR, which significantly improved detection of metastasis, even if applied only to the hottest node (P < 0.0001 vs. PATH analysis of either the hottest SLN or all nodes above the 20% threshold). Metastatic disease recurred locally in 5 patients who had not undergone CLND; RT-PCR analysis showed metastasis in 4 of these patients. The false-negative rate of SLN biopsy progressively decreased when applying PATH only to the hottest node (32.1%), additional RT-PCR to the hottest node (21.4%), PATH to all nodes (17.9%), and RT-PCR to all nodes (3.6%, P = 0.015 vs. PATH analysis of only the hottest SLN). On the basis of long-term follow-up (the gold standard for final clinical outcome of SLN biopsy), both 20% threshold and RT-PCR analysis should be applied for optimal detection of nodal metastases in patients with melanoma.

Comparison of outcome and recurrence-free survival after sentinel lymph node biopsy and lymphadenectomy in vulvar cancer

Objectives Lymph node status is an important prognostic factor in patients with squamous cell carcinoma (SCC) of the vulva. Complete inguinofemoral lymph node dissection (ILND) is accompanied by a high morbidity. Sentinel lymph node biopsy (SLNB) was established for less invasive lymph node (LN) staging. The aim of this study was to evaluate safety of SLNB in terms of accuracy and outcome in a clinical routine setting. Methods We retrospectively reviewed the data of patients who underwent SLNB and/or ILND for vulvar SCC in the years 1990–2007. Clinical follow-up was evaluated for histological nodal-negative patients with tumor stage T1 or T2. The false negative rate of SLNB was determined in patients who underwent both SLNB and ILND. Results Preoperative sentinel lymph node (SLN) visualization by scintigraphy was successful in 95% of all patients. SLNB was false negative in 1/45 inguinae (2.2%). All SLN were detected intraoperatively. During the follow-up period (median 24 months for SLNB and 111 months for ILND), no groin recurrences in initially nodal negative patients occurred ( n = 34, 59 inguinae). Transient lymph edema occurred in 7/18 patients after ILND (39%) and 2/16 patients (13%) after SLNB. No persistent edemas were found after SLNB and ILND. Conclusion According to our experience SLNB is feasible and accurately predicts LN status of vulvar SCC under clinical routine conditions. SLNB in vulvar cancer seems to be a safe alternative to ILND in order to reduce morbidity of surgical treatment.

Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy Is Accurate in Breast Cancer Patients with a Clinically Negative Axillary Nodal Status at Presentation

In breast cancer, neoadjuvant chemotherapy (NAC) is widely used in order to enable a conservative surgery. In patients treated with NAC, the use of sentinel lymph node (SLN) biopsy, which is a good predictor of the axillary nodal status in previously untreated patients, is still discussed. The aim of our study was to determine clinicopathological factors that may influence the accuracy of SLN biopsy after NAC. Between March 2001 and December 2006, 129 patients with infiltrating breast carcinoma were studied prospectively. Preoperatively, all of them underwent NAC. At surgery, SLN biopsy followed by axillary lymph node (ALN) dissection was performed. Lymphatic mapping was done using the isotope method. The SLN identification rate was 93.8% (121/129). Fifty-six out of the 121 successfully mapped patients had positive ALN. Eight out of these 56 patients had tumor-free SLN (false-negative rate of 14.3%). The false-negative rate was correlated with larger tumor size (T1-T2 versus T3; P = 0.045) and positive clinical nodal status (N0 versus N1-N2; P = 0.003) before NAC. In particular, the false-negative rate was 0% (0/29) in N0 patients and 29.6% (8/27) in N1-N2 patients. Clinical and pathological responses to NAC did not influence the accuracy of SLN biopsy. Our results show that clinical nodal status is the main clinicopathological factor influencing the false-negative rate of SLN biopsy after NAC for breast cancer. SLN biopsy after NAC can predict the ALN status with a high accuracy in patients who are clinically lymph node negative at presentation.

How Safe Is Sentinel Lymph Node Biopsy in Patients With Vulvar Cancer?

How Safe Is Sentinel Lymph Node Biopsy in Patients With Vulvar Cancer?

Sentinel Node Positivity Rates With and Without Frozen Section for Breast Cancer

Sentinel lymph node biopsy (SLNB) is used to detect breast cancer axillary metastases. Some surgeons send the sentinel lymph node (SLN) for intraoperative frozen section (FS) to minimize delayed axillary dissections. There has been concern that FS may discard nodal tissue and thus underdiagnose small metastases. This study examines whether evaluation of SLN by FS increases the false-negative rate of SLNB. A retrospective analysis of SLNB from 659 patients was conducted to determine the frequency of node positivity among SLNB subjected to both FS and permanent section (PS) versus PS alone. Statistical analysis was performed by the chi(2) square test, and a logistic regression model was applied to estimate the effect of final node positivity between the two groups. FS was performed in 327 patients and PS was performed in all 659 patients. Among patients undergoing both FS and PS (n = 327), the final node positivity rate was 33.0% compared with 19.6% among patients undergoing PS alone (n = 332). After adjustment for patient age, tumor diameter, grade, and hormone receptor status in a multivariate logistic regression model, there remained an increased likelihood of final node positivity for patients undergoing both procedures relative to PS alone (adjusted odds ratio, 2.1; 95% confidence interval, 1.3-3.6; P = .005). There was a higher rate of SLN positivity in specimens evaluated by both FS and PS. Therefore, evaluating SLN by FS does not underdiagnose small metastases nor produce a higher false-negative rate. Intraoperative FS offers the advantage of less delayed axillary dissections.

Sentinel node biopsy in patients with multiple breast cancer

Multicentric or multifocal breast cancer is considered a limitation for sentinel lymph node biopsy (SLNB). Studies showing that all quadrants of the breast drain via common afferent lymphatic channels indicate that multiple tumors do not affect lymphatic drainage. We therefore assessed the accuracy of SLNB in patients with multiple breast tumors. Of the 942 breast cancer patients who underwent SLNB using radioisotope at Asan Medical Center between January 2003 and December 2006, 803 had unifocal and 139 had multiple tumors. Axillary dissection after SLNB was performed on 884 patients, 757 with unifocal and 127 with multiple tumors. All patients underwent lymphatic scintigram for removal of sentinel lymph nodes (SLNs). The clinical characteristics and accuracy of SLNB was compared in patients with unifocal and multiple breast cancer. In the multiple tumor group, 2.68 +/- 0.84 SLNs were identified in 136 of 139 patients (identification rate, 97.84%); 81.5% of SLNs were identified by scintigram. The incidence of axillary metastases was 29.50% (41/139). SLNB accuracy was 97.63% (124/127), with a false negative (FN) rate of 7.89% (3/38). In the unifocal group, 2.67 +/- 0.96 SLNs were identified in 787 of 803 patients (identification rate, 98.00%); 84.8% of SLNs were identified by scintigram. The incidence of axillary metastasis was 22.04% (177/803). SLNB accuracy was 98.02% (742/757), with a FN rate of 8.62% (15/174). The accuracy and FN rate of SLNB did not differ significantly between unifocal and multiple breast cancer. The accuracy of SLNB in multiple breast cancer is comparable to its accuracy in unifocal cancer. These findings indicate that SLNB can be used an as alternative to complete axillary lymph node dissection in patients with multiple breast tumors.