Initial Sentinel Lymph Node Biopsy Research Articles

Sentinel lymph node biopsy should be considered for clinically node-negative breast cancer regardless of BRCA1/2 mutation status.

BackgroundBRCA1/2 mutations lead to an elevated risk of breast cancer. None involved in whether BRCA1/2 mutation status will affect the first decision-making of sentinel lymph node (SLN) biopsy or not for clinically node-negative breast cancer. We retrospectively investigated whether BRCA1/2 mutation status influenced SLN involvement rate and survival outcomes after sentinel lymph node biopsy (SLNB) for Chinese clinically node-negative breast cancer patients.MethodsPatients who underwent SLNB at initial were enrolled and divided according to BRCA1/2 mutation status. Germline DNA for BRCA1/2 testing was derived from blood samples. SLN involvement rate and clinicopathological characteristics were analyzed using the Chi-square test. Kaplan–Meier univariate and multivariate Cox regression analysis was performed to compare survival between groups.ResultsAccording to BRCA1/2 mutation test criteria, 156 Chinese women receiving initial SLNB with clinically node-negative breast cancer were selected—thirty-one patients identified as BRCA1/2 mutation carriers and 102 as non-carriers were enrolled. Non-carriers seemed to be with a more advanced TNM stage (P<0.01) compared to the non-carrier group. Once SLN involved, the patient will receive axillary lymph node dissection in which BRCA1/2 mutation did not increase the rate (P=0.73). Disease-free survival (DFS) (P=0.48) and recurrence-free survival (RFS) (P=0.79) are comparable between groups, even after adjustment for clinicopathological characteristics, systemic treatment, and surgical management of breast [DFS, hazard ratio (HR) =1.63, confidence interval (CI): 0.48–5.54, P=0.43; RFS, HR =0.75, CI: 0.14–3.89, P=0.73].ConclusionsSLNB should be considered for clinically node-negative breast cancer regardless of BRCA1/2 status.

Utility of Repeat Sentinel Lymph Node Biopsy for cN0 Ipsilateral Breast Tumor Recurrence in Patients Initially Treated with Breast-Conserving Surgery and Sentinel Lymph Node Biopsy

Background: The concept of sentinel lymph node biopsy (SLNB) has been introduced recently in cases with cN0 ipsilateral breast tumor recurrence (IBTR) after initial SLNB. However, data on survival following repeat SLNB (re-SLNB) are not sufficient. Methods: Patients who developed IBTR and underwent re-SLNB at our institution were included. The prognosis of patients who had axillary lymph node dissection (ALND) omitted by negative SLNs were investigated. Results: Sixty-nine patients were included. The median observation period after re-SLNB was 61 months. Among the 47 patients who had ALND omitted by negative SLNs at the ipsilateral axilla, only 1 patient had axillary lymph node recurrence, and the disease-free survival, distant disease-free survival, and overall survival at 5 years were89.3%, 91.6% and 97.9%, respectively. Conclusions: The survival outcome of ALND omission following re-SLNB was acceptable, indicating that re-SLNB is a clinically useful procedure once validated in a larger study.

Abstract 49. ICG Fluorescence with Lymphoscintigraphy for Sentinel Node Biopsy in Head and Neck Cutaneous Melanoma: A Reproducible, Reliable Means to Improve False Negative Rates

Purpose: Head and neck melanoma is associated with a high false negative sentinel lymph node biopsy (SLNB) rate. Our group previously demonstrated the combination of radiotracer and ICG SPY Elite navigation system was feasible and more sensitive compared to standard vital dye and radioactive tracer for SLNB. The goal of this report was to analyze our experiences utilizing ICG fluorescence with lymphoscintigraphy for SLNB in head and neck cutaneous melanoma. Methods: Data was collected for consecutive head and neck cutaneous melanoma patients who underwent radioisotope lymphocintigraphy and indocyanine green SPY-Elite SNLB by the senior author from 2012–2015. False negative rate of SLNB was defined as the proportion of patients with false negative SLNB (regional nodal recurrence with negative initial SLNB) to patients with true positive and false negative SLNB, as well as the false negative incidence, defined as the proportion of patients with false negative SLNB to all patients. Results: There were 68 eligible patients, eleven positive SNLB, 55 true negative SLNB and two false negative SLNB. FNR and FNI were 15.3% and 3%, respectively. Mean follow up for true negative patients was 746 days. Conclusion: The importance of accurate SLNB in head and neck melanoma cannot be underscored. False negative rates in the literature for head and neck melanoma patients are reported as high as 44%. Our results demonstrate that concomitant radioactive and fluorescence for SLN identification in head and neck melanoma is reliable, reproducible and has produced a low false negative SLNB rate.

The interplay between hospital and surgeon factors and the use of sentinel lymph node biopsy for breast cancer.

Background:Several surgeon characteristics are associated with the use of sentinel lymph node biopsy (SLNB) for breast cancer. No studies have systematically examined the relative contribution of both surgeon and hospital factors on receipt of SLNB.Objective:To evaluate the relationship between surgeon and hospital characteristics, including a novel claims-based classification of hospital commitment to cancer care (HC), and receipt of SLNB for breast cancer, a marker of quality care.Data Sources/Study Design:Observational prospective survey study was performed in a population-based cohort of Medicare beneficiaries who underwent incident invasive breast cancer surgery, linked to Medicare claims, state tumor registries, American Hospital Association Annual Survey Database, and American Medical Association Physician Masterfile. Multiple logistic regression models determined surgeon and hospital characteristics that were predictors of SLNB.Results:Of the 1703 women treated at 471 different hospitals by 947 different surgeons, 65% underwent an initial SLNB. Eleven percent of hospitals were high-volume and 58% had a high commitment to cancer care. In separate adjusted models, both high HC (odds ratio [OR] 1.53, 95% confidence interval [CI] 1.12–2.10) and high hospital volume (HV, OR 1.90, 95% CI 1.28–2.79) were associated with SLNB. Adding surgeon factors to a model including both HV and HC minimally modified the effect of high HC (OR 1.34, 95% CI 0.95–1.88) but significantly weakened the effect of high HV (OR 1.25, 95% CI 0.82–1.90). Surgeon characteristics (higher volume and percentage of breast cancer cases) remained strong independent predictors of SLNB, even when controlling for various hospital characteristics.Conclusions:Hospital factors are associated with receipt of SLNB but surgeon factors have a stronger association. Since regionalization of breast cancer care in the U.S. is unlikely to occur, efforts to improve the surgical care and outcomes of breast cancer patients must focus on optimizing patient access to SLNB by ensuring hospitals have the necessary resources and training to perform SLNB, staffing hospitals with surgeons who specialize/focus in breast cancer and referring patients who do not have access to SLNB to an experienced center.

Sentinel lymph node biopsy before mastectomy and immediate breast reconstruction does not significantly delay surgery in early breast cancer.

Sentinel lymph node biopsy (SLNB) before mastectomy and immediate breast reconstruction (IBR) may help to avoid the negative cosmetic effects of radiotherapy on reconstructed breasts in lymph node-positive patients. Concerns have been raised regarding possible delays whilst awaiting the SLNB result prior to definitive surgery, which needs to be performed within 31 days of cancer diagnosis. The aim was to investigate whether initial SLNB delays mastectomy and IBR. All patients who had IBR between January 2005 and 2007 were reviewed retrospectively. Before October 2005 axillary staging was performed simultaneously with mastectomy and IBR (Group I). After October 2005, SLNB was performed as an initial procedure and patients with positive SLNB were only offered a temporary tissue expander to be replaced by autogenous reconstruction after completing the cancer treatment (Group II). Date of diagnosis and waiting times were recorded and the two groups were compared. Different reasons for delays in treatment were studied. One hundred and thirty-nine IBR (123 patients) were included in the statistical analysis (67 IBR in Group I and 72 IBR in Group II). Seventy-one patients (57.7%) had no delay (mean waiting time of 23 days). Fifty-two patients (42.3%) had delay longer than 31 days (mean waiting time of 66 days). Group I patients had a mean waiting time (standard deviation) of 38.8 (38) days and Group II patients 42.7 (24) days (p = 0.51). In this group of patients, SLNB before mastectomy and IBR does not significantly delay definitive breast cancer surgery.

Surgeon Specialization and Use of Sentinel Lymph Node Biopsy for Breast Cancer

Sentinel lymph node biopsy (SLNB) is the standard of care for axillary staging in patients with clinically node-negative breast cancer. It is not known whether SLNB rates differ by surgeon expertise. If surgeons with less breast cancer expertise are less likely to offer SLNB to these patients, this practice pattern could lead to unnecessary axillary lymph node dissections and lymphedema. To explore potential measures of surgical expertise (including a novel objective specialization measure: percentage of a surgeon's operations performed for breast cancer determined from Medicare claims) on the use of SLNB for invasive breast cancer. A population-based prospective cohort study was conducted in California, Florida, and Illinois. Participants included elderly (65-89 years) women identified from Medicare claims as having had incident invasive breast cancer surgery in 2003. Patient, tumor, treatment, and surgeon characteristics were examined. Type of axillary surgery performed. Of 1703 women who received treatment by 863 surgeons, 56.4% underwent an initial SLNB, 37.2% initial axillary lymph node dissection, and 6.3% no axillary surgery. The median annual surgeon Medicare volume of breast cancer cases was 6.0 (range, 1.5-57.0); the median surgeon percentage of breast cancer cases was 4.5% (range, 0.4%-100.0%). After multivariable adjustment of patient and surgeon factors, women operated on by surgeons with higher volumes and percentages of breast cancer cases had a higher likelihood of undergoing SLNB. Specifically, women were most likely to undergo SLNB if the operation was performed by high-volume surgeons (regardless of percentage) or by lower-volume surgeons with a high percentage of breast cancer cases. In addition, membership in the American Society of Breast Surgeons (odds ratio, 1.98; 95% CI, 1.51-2.60) and Society of Surgical Oncology (1.59; 1.09-2.30) were independent predictors of women undergoing an initial SLNB. Patients who receive treatment from surgeons with more experience with and focus on breast cancer are significantly more likely to undergo SLNB, highlighting the importance of receiving initial treatment by specialized providers. Factors relating to specialization in a particular area, including our novel surgeon percentage measure, require further investigation as potential indicators of quality of care.

Indication for sentinel lymph node biopsy for breast cancer when core biopsy shows ductal carcinoma in situ

Background The use of sentinel lymph node biopsy (SLNB) for ductal carcinoma in situ (DCIS) is controversial. Methods A total of 103 primary breast cancer patients who were diagnosed with DCIS by needle biopsy preoperatively and underwent initial SLNB were analyzed retrospectively. Results No sentinel nodal metastasis was detected in 66 patients with the final diagnosis of DCIS. However, 2 (5.4%) of 37 patients with invasive ductal carcinoma at final diagnosis had positive sentinel nodes. Multivariate logistic regression analysis identified 2 independent significant predictors of existence of invasive components: presence of a palpable tumor (odds ratio, 4.091; 95% confidential interval, 1.399–11.959; P = .010) and tumor size of 2.0 cm or larger on magnetic resonance imaging (odds ratio, 4.506; 95% confidence interval, 1.322–15.358; P = .016). Conclusions Initial SLNB should be considered for patients diagnosed with DCIS by needle biopsy when they have a high risk for harboring invasive ductal cancer preoperatively.

Sentinel lymph node biopsy before versus after neoadjuvant chemotherapy for breast cancer

Axillary lymph node status is the most important prognostic factor in the treatment of breast cancer. In recent years, sentinel lymph node biopsy (SLNB) has replaced conventional axillary lymph node dissection for predicting axillary lymph node status with higher accuracy. Moreover, neoadjuvant chemotherapy (NAC) is being used increasingly to treat not only patients with locally advanced inoperative breast cancer, but also those with initially operable breast cancer. The application of SLNB has now expanded to include this patient population, who were not previously considered good candidates for SLNB. A number of recent studies have evaluated the feasibility and accuracy of SLNB after NAC in breast cancer patients. Moreover, SLNB has been shown to be accurate in patients scheduled to receive NAC, and repeat SLNB has been performed after NAC for patients with positive nodes detected by the initial SLNB before NAC. Thus, the optimal timing of SLNB for patients with breast cancer in the neoadjuvant setting remains controversial. This article reviews the issues surrounding SLNB before vs. after NAC, according to the published literature and our experience.

Sentinel lymph node biopsy in breast cancer patients undergoing skin/nipple-sparing mastectomy and immediate autologous reconstruction

Immediate breast reconstruction following mastectomy is an effective treatment for breast cancer patients. Among several implant options, a latissimus dorsi myocutaneous (LDM) flap is used mainly due to the ease and minimal invasiveness of the procedure. The role of sentinel lymph node (SLN) biopsy with total mastectomy is evolving. Since SLN biopsy is not included in health insurance coverage in the treatment of patients in Japan, it is not generally performed as a separate procedure due to its cost. The present study reviewed the results of seven patients who underwent initial-staged SLN biopsy followed by planned mastectomy and LDM flap reconstruction. Two patients with positive SLNs showed macrometastases and underwent modified radical mastectomy with immediate reconstruction. In contrast, cases showing negative results for sentinel lymph nodes underwent total mastectomy. There were no false-negative cases among the SLN biopsy-negative cases. When an SLN is found to be positive on final pathology, the patient with reconstruction by LDM flap generally requires a potentially difficult reoperation on the remaining axillary nodes. When initial SLN biopsy is generally performed as a separate procedure in Japan, it will be an effective method for screening the axilla for patients who wish to undergo LDM flap reconstruction.

Primary Basaloid Carcinoma of the Nipple with Associated Squamous Cell Carcinoma in Situ

Basaloid carcinomas have been documented in various anatomic locations. We describe a primary invasive adenocarcinoma of the nipple with extensive basaloid features that was also associated with squamous cell carcinoma (SCC) in situ and an aggressive behavior. A 69-year-old woman without a history of breast neoplasia presented with right nipple pain. Biopsy of the nipple revealed SCC in situ. One year later, she returned with nipple ulceration. An excisional specimen showed a 1.7 cm nodule composed of invasive sheets and ribbons of basaloid cells with numerous mitoses, extensive tumor necrosis and evidence of glandular differentiation. SCC in situ was present in the overlying epidermis. The differential diagnosis included a primary basaloid adenocarcinoma of the nipple, basal cell carcinoma of the nipple, neuroendocrine carcinoma, melanoma, basaloid variant of adenoid cystic carcinoma and metastatic disease. Immunohistochemical profile of this tumor supported a primary basaloid adenocarcinoma of the nipple. Although the initial sentinel lymph node biopsy was negative, within a year of diagnosis, the patient developed ipsilateral axillary node and pulmonary metastases. To the best of our knowledge, this is the first case of basaloid carcinoma to be documented in this anatomic site.

Patterns of treatment for early stage breast cancers at the M. D. Anderson Cancer Center from 1997 to 2004

The objectives of this study were to examine the patterns of use for adjuvant therapy and the changes in surgical practice for patients with early stage breast cancer and to describe how recent large clinical trial results impacted the patterns of care at The University of Texas M. D. Anderson Cancer Center (MDACC). The study included 5486 women who were diagnosed with stage I through IIIA breast cancer between 1997 and 2004 and received their treatment at MDACC. A chi-square trend test and multivariate logistic regression model were used to assess changes in treatment patterns over time. Among lymph node-positive patients, the use of anthracycline plus taxane chemotherapy increased from 17% in 1997 to 81% in 2004 (P < .001). Meanwhile, the use of anthracyclines without taxanes dropped from 76% to 20% (P < .001) between 1997 and 2000. For postmenopausal patients who received endocrine therapy, the use of tamoxifen was replaced increasingly by the use of aromatase inhibitors (from 100% on tamoxifen in 1997 to 14% in 2004; P < .001). The percentage of women who underwent initial sentinel lymph node biopsy increased significantly during the period from 1997 to 2004 (from 1.8% to 69.7%, respectively, among patients who underwent mastectomy; and from 18.1% to 87.1%, respectively, among patients who underwent breast-conserving surgery; P < .001). The results from this study suggested that key findings from adjuvant therapy and surgical procedures from large clinical trials often prompt immediate changes in the patient care practices of research hospitals like MDACC.

Sentinel lymph node biopsy in breast cancer--a modified audit for surgeons in private practice.

Sentinel lymph node biopsy (SLNB) is a technique that is widely used in the management of early breast cancer. Surgeons are encouraged to validate their initial SLNB results by performing an audit in which both a SLNB and an axillary lymph node dissection (ALND) are performed. For surgeons in solo private practice this is not financially viable as the SLNB would not be paid for by the medical insurance companies. Forty consenting patients were enrolled in the audit. The initial 5 patients (group A) were entered into a traditional audit - an ALND and a SLNB. The next 35 patients (group B) formed part of a modified audit - an axillary sample was performed if the sentinel node was negative (group B1) and an ALND if the node was positive (group B2). Ninety-two per cent of patients with an ipsilateral sentinel axillary node on preoperative scintigraphy had their node identified at the time of surgery. Eight patients had evidence of lymphatic spread. Two patients had parasternal sentinel nodes which were not removed. Group A had a mean of 10.8 nodes removed, group B1 5.8 nodes, and group B2 13.2 nodes. Twenty-three of 35 patients (66%) in group B were spared an axillary dissection. The modified audit of group B allowed patients to benefit from the procedure (and thus the medical aids charged) and yet permitted our team to ascertain the accuracy of the technique in our hands. We feel this is an approach that may be used by other surgeons working alone.

Ultrasound-guided Fine Needle Aspiration Cytology prior to Sentinel Lymph Node Biopsy in Melanoma Patients

Sentinel lymph node biopsy (SLNB) allows early detection of metastases, thereby enabling early treatment in melanoma patients likely to benefit from adjuvant therapies. This prospective study analyzes the possible benefits of additional ultrasound (US) and fine needle aspiration cytology (FNAC) of sentinel nodes (SN) prior to SLNB. Over a 2-year period 127 melanoma patients with 151 SN were scheduled for SLNB. All SN were initially identified with lymphoscintigraphy, then identified and evaluated by US and the cells aspirated for cytology (FNAC). US findings and FNAC results were compared to surgical findings. Of 127 patients, 114 had one SN each, 12 had two, and one had three. In vivo US achieved a sensitivity of 79% (95% CI: 62-91%) and a specificity of 72% (95% CI: 62-81%). FNAC showed a sensitivity of 59% (95% CI: 41-76%) and a specificity of 100% (95% CI: 95-100%). The combination of these two in vivo methods achieved an overall sensitivity of 82% (95% CI: 65-93%) and an overall specificity of 72% [95% CI: 62-81%]. Combined US and FNAC provides important information prior to SLNB in that both procedures identify metastases in the lymph nodes (sensitivity > 80%). Patients with positive FNAC may proceed directly to complete lymph node dissection (cLND) instead of having initial SLNB. Thus, combined US and FNAC may prevent unnecessary anesthesia and surgical management as well reduce costs. In our study 16% (19/121) fewer SLNB procedures were carried out, subsequently replaced by cLND. For patients with a negative combination of in vivo US and FNAC, SLNB remains the best diagnostic option.