Intraoperative Sentinel Lymph Node Biopsy Research Articles

Is the benefit of intraoperative sentinel lymph node biopsy (SLNB) analysis using one-step nucleic-acid amplification (OSNA) negated by the need for further breast surgery?

Is the benefit of intraoperative sentinel lymph node biopsy (SLNB) analysis using one-step nucleic-acid amplification (OSNA) negated by the need for further breast surgery?

Surgical sentinel lymph node biopsy in early breast cancer. Could it be avoided by performing a preoperative staging procedure? A pilot study

SummaryBackgroundThe aim of this pilot trial was to study the feasibility of sentinel node percutaneous preoperative gamma probe-guided biopsy as a valid preoperative method of assessment of nodal status compared to surgical sentinel lymph node biopsy.Material/MethodsThis prospective study enrolled 10 consecutive patients without evidence of axillary lymph node metastases at preoperative imaging. All patients underwent sentinel node occult lesion localization (SNOLL) using radiotracer intradermic injection that detected a “hot spot” corresponding to the sentinel node in all cases. Gamma probe over the skin detection with subsequent ultrasonographically guided needle biopsy of the sentinel node were performed. The percutaneous needle core histopathological diagnosis was compared to the results of the surgical biopsy.ResultsPreoperative sentinel node identification was successful in all patients.ConclusionsThe combination of preoperative gamma probe sentinel node detection and ultrasound-guided biopsy could represent a valid alternative to intraoperative sentinel node biopsy in clinically and ultrasonographically negative axillary nodes, resulting in shorter duration of surgery and lower intraoperative risks.

Sentinel Lymph Node Biopsy for Papillary Thyroid Cancer: Commentary on the efficacy of Lateral Neck Sentinel Lymph Node Biopsy in Papillary Thyroid Carcinoma by Se Kyung Lee et al.

In their article on the efficacy of lateral neck sentinel lymph node (SLN) biopsy in papillary thyroid carcinoma, Dr. Kim’s group has detailed an impressive series of lateral neck SLN assessments for papillary thyroid cancer [1]. In their 94 patients, they were able to identify sentinel nodes in 60 (64%). In 19 of these patients, the sentinel node contained papillary thyroid cancer, leading the surgeons to perform a compartment-oriented neck dissection. They did not perform lateral neck dissection on the patients with negative sentinel node biopsies, and so sensitivity estimates are not available. Sentinel node biopsy has been a marked advance in the management of patients with breast cancer and melanoma, because it allows accurate staging of patients with minimal morbidity. This technique has resolved the morbidity of routine axillary dissection for breast cancer, and the controversy of whether or not to perform prophylactic dissections for melanoma. However, this has not yet found a place in the therapy for thyroid cancer. In my opinion, there are several reasons for this: (1) sentinel node biopsy in the confined area of the neck is technically challenging; (2) the most common node basin for papillary thyroid cancer metastasis is the level 6 nodes, an area that has already been exposed during thyroidectomy and can be dissected with limited additional morbidity; (3) ultrasound evaluation of the lateral neck is sensitive for identification of nonpalpable node metastases; and (4) lateral neck recurrence is uncommon after effective adjuvant treatment with radioiodine. The contribution by this group has effectively answered some of these issues. Using the sentinel node biopsy after thyroidectomy to assess the lateral neck, rather than just the first sentinel node that is usually in the central neck, they have resolved some of the technical issues caused by the proximity of the radiotracer injection to the nodes in question. In addition, assessing only the lateral neck nodes focused the procedure on the nodes that would not otherwise be directly accessible during the thyroidectomy. A remaining question in this area is the comparison of preoperative ultrasound evaluation of the lateral neck to the intraoperative sentinel node biopsy assessment. Unfortunately, it does not appear that this series of patients had preoperative ultrasound node mapping in order to delineate this. However, this should be a part of any further reports on this subject. Finally, the issue of whether it is important to remove these small amounts of disease, or whether they can be effectively managed by radioiodine therapy, will require careful clinical study.

A pilot study to examine the experiences and attitudes of women with breast cancer towards one versus two-step axillary surgery

PurposeTo elicit the views, experiences and preferences of women with clinically node negative breast cancer towards intra-operative sentinel lymph node biopsy (SLNB) analysis. MethodsFocus groups with 14 women with breast cancer from two UK centres; one group had undergone the standard practice of waiting two weeks for results of their axillary surgery, the other had experienced the intra-operative SLNB analysis. ResultsWomen generally were unaware about their lymph nodes, what their function is and how they are removed. Preference was indicated for intra-operative sentinel lymph node biopsy (SLNB) analysis provided clear descriptions were given about the risk of experiencing false negative and false positive results. DiscussionAdopting an intra-operative analysis technique of axillary nodes was viewed as an excellent option by women from both centres. The immediacy of knowing the results was seen as a great advantage for their physical and psychological well being and more cost effective.

Validation study on the clinical usefulness of the ICG fluorescence method for detecting sentinel lymph node in early-stage breast cancer in comparison with the dye method.

1122 Background: Sentinel lymph node (SLN) biopsy using indocyanine green (ICG) fluorescence method is a technique that utilizes the fluorescing property of ICG reagent that is used in the dye method. Flow of lymph can be confirmed as real time image from outside the body, and this method is the best for intra-operative sentinel lymph node biopsy. To assess the diagnostic performance of SLN biopsy using ICG fluorescence technique, prospective multicenter study was performed compared with blue dye method. Methods: Patients with T1-3 primary breast cancer without lymph node metastasis were assigned in this study. A combination of ICG as a fluorescence emitting source and indigocarmine as a blue dye were injected in the subreolar area and lymphatic flows were traced with PDE camera (a charge coupled device, Hamamatsu Photonics Co, Japan) and a real time image guided surgery enabled to identify the florescence signal of SLN after meticulous dissection. Extracted lymph nodes were examined for the first SLN or the second and further SLNs and classified in terms of ICG fluorescence, blue dye. Primary endpoint in this study is the difference in the number of lymph nodes identified by the fluorescence and the dye method. Secondary endpoints are identification rate, metastatic rate to SLNs and metastatic rate by order of SLNs. Results: Ninety-nine eligible patients were included in this study. The number of lymph nodes identified by fluorescence method was significantly larger than dye method (p<0.001). The SLN identification rate of fluorescence and dye method was 99% and 78%, respectively (p<0.001). Twenty of 99 patients had a positive SLN and ICG fluorescence method identified all these patients. The first SLN identified had both ICG fluorescence and blue dye (77%) or ICG fluorescence alone (23%). Of the 20 patients with lymph node metastasis, 100% was positive in the first SLN. Conclusions: SLN biopsy using ICG fluorescence achieves a high identification rate and is superior to dye method. The first SLN identified by ICG fluorescence method represents the exact axillary status. Direct comparison between ICG fluorescence and radio isotope method is currently on the way.

Outcomes of Immediate Breast Reconstruction in Patients Undergoing Single-Stage Sentinel Lymph Node Biopsy and Mastectomy

The ability to more definitively plan breast reconstruction after obtaining final histologic analysis of the sentinel lymph node biopsy (SLNB) has led several groups to advocate a staged approach to SLNB and mastectomy. Certain disadvantages are inherent in that approach, including increased patient morbidity, financial expense, and inconvenience. A retrospective review was conducted 195 procedures in which mastectomy and SLNB were performed in a single stage with immediate breast reconstruction (IBR) over a 10-year period. Long-term outcomes were analyzed within the context of patient characteristics and SLNB results. Intraoperative SLNB analysis was found to be a reliable method for planning IBR, as there were no patients noted to have untoward sequelae as a result of a false-negative SLNB, and the probability of postmastectomy radiation therapy was predictable based on the intraoperative SLNB results. We advocate that SLNB be performed in a single stage with mastectomy and IBR.

Intraoperative assessment of sentinel lymph nodes in breast cancer.

Sentinel lymph node biopsy (SLNB) reduces the morbidity of axillary clearance and is the standard of care for patients with clinically node-negative breast cancer. The ability to analyse the sentinel node during surgery enables a decision to be made whether to proceed to full axillary clearance during primary surgery, thus avoiding a second procedure in node-positive patients. Current evidence for intraoperative sentinel node analysis following SLNB in breast cancer was reviewed and evaluated, based on articles obtained from a MEDLINE search using the terms 'sentinel node', 'intra-operative' and 'breast cancer'. Current methods for evaluating the sentinel node during surgery include cytological and histological techniques. Newer quantitative molecular assays have been the subject of much recent clinical research. Pathological techniques of intraoperative SLNB analysis such as touch imprint cytology and frozen section have a high specificity, but a lower and more variably reported sensitivity. Molecular techniques are potentially able to sample a greater proportion of the sentinel node, and could have higher sensitivity.

Follow-up after intraoperative sentinel node biopsy of N0 neck oral cancer patients

The objective of the study was to evaluate the validity of sentinel node (SN) biopsy in early oral cancer patients focusing on the accuracy of intraoperative diagnoses of SN status, recurrences in follow-up and impact on patient survival. Previously untreated N0 oral cancer patients were candidates for the study. Using a radioisotope method, an intraoperative SN biopsy was performed. Patients with a positive frozen section of SN underwent immediate neck dissection as a single-stage procedure; they were followed in our outpatient clinic. Forty-five cT1-2N0 patients with squamous cell carcinoma were analyzed. There were seven patients with positive SN, five of whom were detected by intraoperative frozen section analysis. The sensitivity, specificity and accuracy of the intraoperative frozen section analysis of SN were 71.4, 100 and 95.6%, respectively. There were 13 recurrences in the course of all patients treated. Those with positive SN showed a tendency toward recurrence. Three patients with negative SN suffered from delayed ipsilateral neck recurrence. These were considered false negatives at a rate of 7.9%. The 5-year overall survival rate of all patients was 91.1%. SN-positive patient survival was significantly poorer than that of SN-negative patients. Positive SN had a negative impact on the survival. SN biopsy was shown to be a valuable method for determining the neck status of early oral cancer patients. The concordance rate of intraoperative multislice frozen section analysis of SN and patient neck status at the time of operation was 95.6%. SN-positive patients exhibited a tendency toward cancer recurrence. There were three cases of false negatives not conforming to the SN concept and their rate was 7.9%. Positive SN had a negative impact on patient survival.

Sentinel lymph node biopsy in melanoma patients

Appropriate surgical management of regional lymph nodes is critical in patients with cutaneous melanoma. The use of intraoperative lymphatic mapping and sentinel lymph node biopsy (SLNB) has increased significantly in the past decade. SLNB is performed as minimally invasive procedure that provides accurate staging of melanoma patients with no clinically detectable nodal disease. In many melanoma units across the world, it became the standard for detection of occult regional node metastasis in patients with intermediate-thickness primary melanoma. Use of SLNB in patients with thin melanomas is still under evaluation. Although SLNB has been established as staging procedure in melanoma patients, its therapeutic role is still not clear. Large-scale ongoing randomized trials should elucidate whether SLNB with complete lymphadenectomy has a survival benefit in melanoma patients with early lymph node metastases compared to 'watch-and-wait' policy (observation).

321 Usefulness of clinical exploration, ultrasound and MRI for the assessment of axillary lymph nodes status previous to the performance of sentinel node

The development of intraoperative sentinel node biopsy (SLNB) analysis methods, such as One-Step Nucleic Acid Amplification (OSNA), has made single-stage procedures possible.We investigated the incidence of OSNA-detected lymph node positivity, comparing it to conventional histopathology, the incidence of non-SLNB node disease for the OSNA positive patients, and the breast re-operation rate, to assess the benefit from single-stage procedures.This was a single-centre series of 573 consecutive patients undergoing SLNB (173 histopathology and 400 OSNA).OSNA-detected SLNB macrometastasis was similar to routine histopathology, with more micrometastasis detected (p < 0.001). Non-SLNB involvement in the OSNA group was similar to documented histopathological series. 27.6% of OSNA patients avoided further surgery because of OSNA. The median time for OSNA results was 42 min.OSNA is an effective method for detecting SLNB-metastasis. It is easily used in clinical practice, providing reliable results and negating the need for a second axillary operation.

Intra-operative sentinel lymph node biopsy (SNB) using an RT-PCR based assay allows savings in theatre utilisation and hospital stay

Introduction: Theatre times are slightly increased with intra-operative sentinel node analysis (ioaSNB), however node positive patients avoid a second hospital admission and a second operation. It is uncertain if overall this leads to changes in theatre and hospital bed utilisation.

Positive sentinel lymph node biopsy predicts the number of metastatic axillary nodes of breast cancer

It remains to be clarified whether a positive sentinel lymph node biopsy (SLNB) can predict the number of metastatic axillary nodes. This study examined a consecutive series of women with unilateral invasive breast cancer who underwent axillary lymph node dissection after an intra-operative positive SLNB. The numbers of positive and negative sentinel lymph nodes (SLNs) were analyzed for a likelihood of pN1a, pN2a, and pN3a diseases as per the UICC TNM classification. Of the 368 study patients, 165 (45%) had one positive SLN and one or more negative SLNs. This result represented the most common combination of positive and negative SLNs. It was also the most predictive indicator (93%) of pN1a disease and the least predictive indicator (7% or 0%) of pN2a or pN3a disease, respectively. The numbers of positive and negative SLNs can predict the number of metastatic axillary nodes in breast cancer patients.

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.

Sentinel Lymph Node Identification and Radical Hysterectomy with Lymphadenectomy in Early Stage Cervical Cancer: Laparoscopy Versus Laparotomy

Study Objective To estimate the feasibility and results of sentinel lymph node identification and radical hysterectomy with pelvic lymphadenectomy entirely completed by laparoscopy versus laparotomy in early stage cervical cancer. Design Retrospective, nonrandomized clinical study (Canadian Task Force classification II-2). Setting Acute care, teaching hospital. Patients From September 2000 through January 2005, 50 consecutive patients with International Federation of Gynecology and Obstetrics stage IA 2, IB 1, and IIA disease less than 4 cm underwent radical hysterectomy and lymphadenectomy with intraoperative sentinel lymph node biopsy. Interventions The operation was performed entirely by laparoscopy in 20 patients and using the conventional abdominal approach in 30. Feasibility of sentinel lymph node identification, surgical morbidity, overall survival, and recurrence rate–free survival in both groups were compared. Measurements and Main Results The overall detection rate of the sentinel lymph node was 100% (false negative 0%). A mean of 2.50 sentinel nodes/patient was detected in the laparotomy group compared with a mean of 2.55 nodes in the laparoscopic group (p = .874). Bifurcation of the right common iliac artery was the most frequent nodal location. Blood loss and length of stay were significantly lower in the laparoscopic group, but surgical time was significantly longer. The median follow-up was 35 months (range 5–57) in the laparotomy group and 22.5 (range 2–52) in the laparoscopic group. Differences in overall survival and disease-free survival were not observed. Conclusion Sentinel lymph node identification and radical hysterectomy in the initial treatment of early stage cervical cancer can be performed safely by laparoscopy with lower morbidity and overall survival and recurrence-free survival similar to standard laparotomy.

Regarding Intraoperative Lymphatic Mapping and Sentinel Lymph Node Biopsy

Regarding Intraoperative Lymphatic Mapping and Sentinel Lymph Node Biopsy

Submission of blue dye sentinel node for intraoperative frozen section does not impact on operating time

The purpose of this study was to evaluate the utility of performing a selective intraoperative sentinel lymph node biopsy (SLNB) in breast cancer patients.Patients in this prospective study were women with breast cancer seen at our hospital in 2014. These patients were divided into 2 groups on the basis of the clinical criteria age, tumor size, and molecular subtype: (1) Group A: women with clinical criteria indicative of the need to perform an intraoperative analysis of the sentinel lymph node (SLN); and (2) Group B: women in whom postoperative analysis of the SLN was performed. The final anatomopathologic findings obtained for the SLNs were analyzed and the sensitivity, specificity, positive predictive value, and negative predictive value of the clinical criteria used to decide between intraoperative or postoperative analysis of the SLN were estimated.A total of 170 patients were included: 106 in group A and 64 in group B. The number of positive SLNs was 29 (22 in group A and 7 in group B; P = .09). The sensitivity of our clinical criteria for establishing the indication to perform an axillary SLNB was 75.86% (95% confidence interval [CI], 56.05%-88.98%), the specificity was 40.43% (95% CI, 32.35%-49.03%), the positive predictive value was 20.75% (95% CI, 13.73%-29.95%), and the negative predictive value was 89.06% (95% CI, 78.16%-95.12%).The clinical findings used to decide whether or not to perform an SLNB exhibit low sensitivity and specificity and must therefore not be used to decide the need for an intraoperative SLNB.

The sentinel node concept in prostate cancer: Present reality and future prospects

A sentinel node (SN) is defined as the first site where cancer cells are carried by lymph flow from a tumor. If this definition (SN concept) correctly reflects the clinical reality, intraoperative SN biopsy would facilitate precise nodal staging. In malignant melanoma, a prolonged survival has been evidenced by a large-scale randomized controlled study. On the contrary, research on SN concept in deeply located cancers including prostate cancer, is still investigative, and no concrete data from clinical trials are yet available. Since 1993, several investigators have demonstrated that the SN concept could be applied in prostate cancer patients as well with high accuracy. Although promising and technically feasible in pre-clinical settings, many hurdles remain to be cleared before clinical application can be recommended. This review addresses the current status and related issues of the SN concept in prostate cancer, and discusses the future directions.

Combined Radioguided Nonpalpable Lesion Localization and Sentinel Lymph Node Biopsy for Early Breast Carcinoma

The aim of this study was to test a new strategy for radioguided management of malignant or suspicious nonpalpable breast lesions, with a combination of radioguided occult lesion localization (ROLL), sentinel lymph node (SLN) mapping, and, if necessary, immediate local surgery and SLN biopsy with a single injection of (99m)Tc-labeled dextran for the whole procedure. A total of 115 nonpalpable lesions were studied: 101 with high suspicion of malignancy from which frozen sections had been produced, and 14 carcinomas diagnosed by mammotomy. On the day before surgery, 0.2 mL of solution of dextran labeled with 15 MBq of (99m)Tc was injected into the center of the lesions under imaging guidance. All patients underwent lymphoscintigraphy and open-surgery biopsy guided by gamma probe, followed by radiographic verification of the specimen. If malignancy was detected, in cases of infiltrating or ductal carcinoma-in-situ with comedonecrosis or high nuclear grade, breast-conserving surgery and SLN biopsy were performed during the same operation. The combination of ROLL and SLN biopsy was feasible and practical. The rate of simultaneous SLN mapping by lymphoscintigraphy was 97.4% (112 of 115), and the confirmation rate for breast lesion removal by specimen radiography was 100%. It was known that 57 cases were malignant at the time of surgery. After segmental breast resection, SLN immediately underwent biopsy in 50 cases (34 infiltrating carcinomas and 16 ductal carcinoma-in-situ) with probe monitoring. Three were cytologically positive for metastasis and required full axillary dissection. ROLL and SLN biopsy are emerging procedures that can be used simultaneously. They permit exact breast lesion excision, immediate local breast surgery, and intraoperative SLN biopsy in a single procedure. The combination of radioguided nonpalpable lesion localization and SLN biopsy is a suitable alternative to working up subclinical imaging-detected breast carcinomas.

Sentinel Lymph Node Update

The introduction of intraoperative lymphatic mapping and sentinel lymph node biopsy (SLNB) has revolutionized the care of patients with early-stage breast cancer. Current guidelines recommend SLNB as a surgical alternative to axillary lymph node dissection for patients with early breast cancer and clinically negative axillary nodes. Lymphatic mapping can be performed with blue dye and/or radiocolloid. More recently, SLNB has been examined for ductal carcinoma in situ, after neoadjuvant chemotherapy, and for male breast cancer. The indications for completion axillary dissection in patients with the immunohistochemical micrometastasis in the sentinel lymph node remains controversial.

Is intraoperative lymphatic mapping and sentinel lymph node biopsy effective and safe in early-stage melanoma?

Is intraoperative lymphatic mapping and sentinel lymph node biopsy effective and safe in early-stage melanoma?