Intraoperative Assessment Of Sentinel Lymph Nodes Research Articles

Intraoperative spectroscopic evaluation of sentinel lymph nodes in breast cancer surgery.

Sentinel lymph node (SLN) biopsy is a standard procedure for patients with breast cancer and normal axilla on imaging. Positive SLNs on histological examination can lead to a subsequent surgery for axillary lymph node clearance (ALNC). Here we report a non-destructive technique based on autofluorescence (AF) imaging and Raman spectroscopy for intra-operative assessment of SLNs excised in breast cancer surgery. A microscope integrating AF imaging and Raman spectroscopy modules was built to allow scanning of lymph node biopsy samples. During AF-Raman measurements, AF imaging determined optimal sampling locations for Raman spectroscopy measurements. After optimisation of the AF image analysis and training of classification models based on data from 85 samples, the AF-Raman technique was tested on an independent set of 81 lymph nodes comprising 58 fixed and 23 fresh specimens. The sensitivity and specificity of AF-Raman were calculated using post-operative histology as a standard of reference. The independent testset contained 66 negative lymph nodes and 15 positive lymph nodes according to the reference standard, collected from 78 patients. For this set of specimens, the area under the receiver operating characteristic (ROC) curve for the AF-Raman technique was 0.93 [0.83-0.98]. AF-Raman was then operated in a regime that maximised detection specificity, producing a 94% detection accuracy: 80% sensitivity and 97% specificity. The main confounders for SLN metastasis were areas rich in histiocytes clusters, for which only few Raman spectra had been included in the training dataset. This preliminary study indicates that with further development and extension of the training dataset by inclusion of additional Raman spectra of histiocytes clusters and capsule, the AF-Raman may become a promising technique for intra-operative assessment of SLNs. Intra-operative detection of positive biopsies could avoid second surgery for axillary clearance.

A prospective comparison of a modified miniaturised hand-held epifluorescence microscope and touch imprint cytology for evaluation of axillary sentinel lymph nodes intraoperatively in breast cancer patients.

The management of axillary lymph nodes in early-stage breast cancer patients has changed considerably, with the primary focus shifting from the examination of sentinel lymph nodes (SLNs) to toward the detection of all macro-metastases. However, current methods, such as touch imprint cytology (TIC) and frozen sections, are inadequate for clinical needs. To address this issue, we proposed a novel miniaturised epifluorescence widefield microscope (MEW-M) to assess SLN status intraoperatively for improved diagnostic efficiency. A prospective, side-by-side comparison of intraoperative SLN evaluation between MEW-M and TIC was performed. A total of 73 patients with 319 SLNs consecutive enrolled in this study. MEW-M showed significantly superior image quality compared to TIC (median score 3.1 vs 2.1, p < 0.0001) and had a shorter time to issue results (10.3 vs 19.4 min, p < 0.0001). Likelihood ratio analysis illustrated that the positive likelihood ratio value of MEW-M compared with TIC was infinitely great vs 52.37 (95% CI, 21.96-124.90) in model 1 (classifying results into negative/positive), infinitely great vs 52.37 (95% CI, 21.96-124.90) in model 2 (classifying results into macro-metastasis/others, and TIC results followed the same classification as model 1), respectively. Similarly, the negative likelihood ratio values of MEW-M compared with TIC were 0.055 (95% CI, 0.018-0.160) and 0.074 (95% CI, 0.029-0.190) in model 1; and 0.019 (95% CI, 0.003-0.130) vs 0.020 (95% CI, 0.003-0.140) in model 2, respectively. MEW-M is a promising technique that can be utilised to provide a rapid and accurate intraoperative assessment of SLN in a clinical setting to help improve decision-making in axillary surgery.

Lymph Node and Distant Metastases in Phyllodes Tumor of the Breast.

A 54-year-old woman who incidentally noticed a "knot" in her left breast subsequently underwent excisional biopsy which yielded a diagnosis of malignant neoplasm with sarcomatous features. Given the broad differential diagnosis and imaging findings, the patient underwent bilateral mastectomy and intraoperative sentinel lymph node assessment. An 8.5 cm tumor that was further classified as a malignant phyllodes tumor was identified in the left breast, while the frozen section interpretation came back as positive for metastatic disease which resulted in left axillary lymphadenectomy. Two months later the patient progressed to distant metastatic disease and unfortunately passed away within 6 months after her initial diagnosis. Lymph node metastasis in phyllodes tumor is an exceptionally rare event for which patients usually do not undergo intraoperative sentinel lymph node examination; however high clinical suspicion of metastatic disease would be evidence for further investigation.

Intraoperative sentinel lymph node evaluation in patients with node-positive breast cancer status post neoadjuvant systemic therapy - An institutional experience

Recent studies have shown the feasibility and utility of sentinel lymph node (SLN) biopsy in patients with biopsy proven node-positive breast cancer after neoadjuvant chemotherapy. We reviewed our experience in intraoperative SLN evaluation in such cases and its effect on axillary management. A retrospective analysis of breast cancer patients (2015–2018) with a biopsy-proven positive axillary lymph node, who received neoadjuvant systemic therapy and underwent intraoperative SLN assessment was performed. Intraoperative SLN assessment results were compared with final pathology. Its accuracy and effect on axillary management is summarized. We identified 106 patients with positive axillary lymph node and neoadjuvant systemic therapy between the ages of 28 and 75 years who had SLN biopsy and lumpectomy (33) or mastectomy (73). Three or more SLNs were identified in 91 cases (86 %). The previously biopsied lymph node was identified as one of the sentinel lymph nodes in 93 cases (88 %). There is a high concordance rate between frozen section diagnosis and final diagnosis on sentinel lymph nodes. No false positive case and seven false negative frozen section diagnosis cases (diagnosed as negative on frozen section and positive on permanent sections) were identified. False-negative frozen section diagnosis correlated with low-volume nodal disease and obscuring tumor bed changes. Almost half of the positive lymph nodes were converted to negative after neoadjuvant chemotherapy. SLN biopsy with intraoperative frozen section evaluation after neoadjuvant systemic therapy in node-positive patients is an effective way to minimize axillary surgery.

Evaluation of Intraoperative Frozen Section Analysis with Final Histopathology Results for Sentinel Lymph Node Biopsy: Z0011 Criteria Eligible Versus Ineligible Breast Cancer Patients.

Background Intraoperative frozen section analysis (FSA) of sentinel lymph nodes (SLNs) declined in the post American College of Surgeons Oncology Group Z0011 (ACOSOG Z0011) trial era. However, for those patients who do not meet the ACOSOG Z0011 criteria, FSA continues to be a valuable tool in intraoperative decision-making for axillary lymph node dissection (ALND). The aim of this study was therefore to retrospectively evaluate the benefit and accuracy of FSA of Z0011 criteria eligible versus ineligible patients and identify possible predictive factors for false negative results. Methods Intraoperative FSA was performed on SLNs of 522 cT1–T3 breast cancer patients between 2008 and 2013. Clinicopathologic characteristics were retrospectively assessed by chart review. Results Overall FSA sensitivity and specificity was 67.8% and 100%. Sensitivity was generally higher for macrometastasis than for micrometastasis. The Z0011 eligible group showed a sensitivity and specificity of 72.7% and 100% versus 62.1% and 100% in the Z0011 ineligible group. Importantly, subgroup analysis of ≤ 2 versus > 2 positive SLNs of the Z0011 eligible group demonstrated both a 100% specificity and sensitivity. Several clinicopathologic factors were associated with a higher rate of false negative results in the Z0011 ineligible patient group. FSA was beneficial for 22.2% of Z0011 ineligible patients and for only 0.6% of Z0011 eligible patients regarding intraoperative decision-making for ALND. Conclusions FSA continues to be especially beneficial in the intraoperative assessment of SLNs in the Z0011 ineligible group to prevent second stage ALND. Despite an overall lower FSA sensitivity in the Z0011 eligible patient group, FSA offers in both groups a comparable high sensitivity and diagnostic accuracy for macrometastasis.

Axillary management based on American college of surgeons oncology group Z0011 criteria makes it possible to omit intraoperative diagnosis of sentinel lymph nodes in early breast cancer patients.

The ACOSOG Z0011 trial has resulted in the omission of axillary lymph node dissection (ALND) in early breast cancer patients with one or two metastatic sentinel lymph nodes (SLNs). There has been increasing interest in the necessity of intraoperative assessment of SLNs in patients treated based on the Z0011 criteria. We evaluated the utility of intraoperative assessment in these eligible patients. A total of 1396 patients were treated following the Z0011 criteria from April 2012 to December 2019. We examined the proportion and clinicopathological features of patients who underwent ALND due to three or more metastatic SLNs and the sensitivity of intraoperative assessment. Only 16 (1.1%) patients had three or more metastatic SLNs diagnosed by intraoperative assessment, and they immediately underwent ALND. Of the clinicopathological factors, high clinical tumor stage (p=0.002) and high Ki-67 labeling index value (p=0.056) were more likely to be associated with the presence of three or more metastatic SLNs. The major independent risk factor for three or more metastatic SLNs was high clinical tumor stage (OR 3.94 [95% CI 1.42-11.0]; p=0.009). Intraoperative assessment had low sensitivity (70.5%) and a high false-negative rate (29.5%) in detecting SLN metastases. The main finding of our study was the small proportion of patients who required ALND due to three or more metastatic SLNs according to the Z0011 criteria. The Z0011 strategy enables intraoperative assessment of SLNs to be omitted in early breast cancer patients.

Impact of sentinel lymph node frozen section evaluation to avoid combined treatment in early-stage cervical cancer

BackgroundThe need for radical surgery followed by adjuvant chemoradiation may be reduced by abandoning radical surgery in patients in whom lymph node involvement is detected intra-operatively.ObjectivesTo analyze, in a retrospective...

A prospective multicenter trial on sentinel lymph node biopsy in patients with early-stage cervical cancer (SENTIX).

Sentinel lymph node (SLN) biopsy has been increasingly used in the management of early-stage cervical cancer. It appears in guidelines as an alternative option to systematic pelvic lymphadenectomy. The evidence about safety is, however, based mostly on retrospective studies, in which SLN was combined with systematic lymphadenectomy. SENTIX is a prospective multicenter trial aiming to prove that less-radical surgery with SLN is non-inferior to treatment with systematic pelvic lymphadenectomy. The primary end point is recurrence rate; the secondary end point is the prevalence of lower-leg lymphedema and symptomatic pelvic lymphocele. The reference recurrence rate was set up conservatively at 7% at 24 months after treatment. With a sample size of 300 patients treated per protocol, the trial is powered to detect a non-inferiority margin of 5% (90% power, p = 0.05) for recurrence rate, 30% reduction in the prevalence of symptomatic lymphocele or lower-leg lymphedema, with reference rates of 30% and 6% at 12 months (p = 0.025, Bonferroni correction). The patients eligible for SENTIX have stage IA1/LVSI+, IA2, IB1 (<2 cm for fertility sparing), with negative LN on pre-operative imaging. Intra-operatively, patients are excluded when there is a failure to detect SLN on both sides of the pelvis in cases of more advanced cancer (stage >IB1), or a positive intra-operative SLN assessment. The quality of SLN pathology evaluation will be assessed by central review. Three interim safety analyses are pre-planned when 30, 60, 150 patients complete 12 months' follow-up. The first patient was enrolled into the study in June 2016 and, by June 2018, 340 patients had been enrolled. The first analysis of secondary outcomes should be available in 2019 and the oncological outcome of 300 patients at the end of 2021. The trial is registered as a CEEGOG trial (CEEGOG CX-01), ENGOT trial (ENGOT-Cx 2), and at the ClinicalTrials.gov database (NCT02494063).

The intraoperative assessment of sentinel nodes – Standards and controversies

Intraoperative assessment of sentinel lymph nodes (SLNs) has the advantage of allowing breast cancer patients with tumor-positive SLNs to avoid a second surgery by immediately proceeding to axillary lymph node dissection (ALND). However, there are several reasons why the use of intraoperative assessment should be questioned. Whereas ALND was traditionally advised for all breast cancer patients with tumor-positive lymph nodes for axillary staging and locoregional control, more recent studies have demonstrated safety of omitting ALND in a substantial number of patients.In addition, there are concerns about the accuracy of intraoperative assessment methods including frozen section analysis, touch preparation cytology and one-step nucleic acid amplification. Moreover, intraoperative assessment of SLNs denies patients the opportunity to contribute to their treatment planning. In our opinion, intraoperative assessment of axillary lymph nodes should be reserved for patients who still have a strict indication for ALND. Patients with clinical node negative disease (cN0) and one or two positive SLNs can be safely treated with breast conserving surgery and radiotherapy. There has been more controversy for cN0 patients who are treated with mastectomy since radiotherapy is not routinely administered in these patients. However, there is increasing evidence that ALND may be omitted in patients undergoing mastectomy who have a low tumor-burden in their SLNs. Therefore, we defend the position that in cN0 patients undergoing mastectomy, SLNB should be performed and full pathologic evaluation of the SLN should be awaited. In cN0 patients undergoing neoadjuvant systemic therapy (NST) intraoperative assessment of SLNs can be omitted since ALND will not provide therapeutic benefit. It is being hypothesized that patients with limited axillary disease prior to NST who remain node-positive after NST could be treated safely with axillary radiotherapy instead of ALND. In these patients, omitting intraoperative assessment might be a reasonable option. In patients with extensive nodal disease prior to NST intraoperative assessment of axillary lymph nodes should be performed.

Factors impacting the accuracy of intra-operative evaluation of sentinel lymph nodes in breast cancer.

Sentinel lymph node dissection (SLND) is a standard axillary staging technique in breast cancer and intraoperative sentinel lymph node (SLN) assessment is important for decision-making regarding additional treatment and reconstruction. This study was undertaken to investigate clinicopathologic factors impacting the accuracy of intraoperative SLN evaluation. Records of patients with clinically node-negative, invasive breast cancer who underwent SLND with frozen section intraoperative pathologic evaluation from 2004 to 2007 were reviewed. Intraoperative SLN assessment results were compared to final pathology. Patients with positive SLNs that were initially reported as negative during intraoperative assessment were considered false negative (FN) events. Primary tumor histology, grade, receptor status, size, lymphovascular invasion (LVI), multifocality, neoadjuvant chemotherapy or hormonal therapy, number of SLNs retrieved, and SLN metastasis size were evaluated. The study included 681 patients, of whom 262 (38%) received neoadjuvant therapy. There were 183 (27%) patients who had a positive SLN on final pathology, of whom 60 (33%) had FN events. On univariate analysis, lobular histology, favorable histology, absence of LVI and micrometastasis were associated with a higher FN rate. On multivariate analysis, favorable and lobular histology and micrometastasis were independent predictors of FN events whereas LVI and receipt of neoadjuvant therapy were not statistically significant predictors. The accuracy of intraoperative SLN evaluation for breast cancer is affected by primary tumor histology and size of the SLN metastasis. There was no significant association between neoadjuvant therapy and the FN rate by intraoperative assessment. This information may be helpful in counseling patients about their risk for a FN intraoperative SLN assessment and for planning for immediate breast reconstruction in patients undergoing mastectomy.

Accuracy of detection rate and intraoperative sentinel lymph node assessment in early-stage cervical carcinoma

Objective: This article shows our experience on sentinel lymph node (SLN) biopsy in early-stage cervical carcinoma since the technique was introduced in our Institution. The main objective is to analyze the detection rate (DR) of metastatic SLNs, identifying prognostic factors for an increased risk of nodal metastases. Our second aim was to compare the accuracy of nodal metastases DR between intraoperative analysis and postoperative ultrastaging. Materials and Methods: Forty-one women with the International Federation of Gynecology and Obstetrics stages IA2-IIA1 who underwent laparoscopic surgical treatment applying the SLN technique, from December 2011 to June 2016, at La Paz University Hospital, were included. The sentinel node was identified using technetium and methylene blue dye or indocyanine green near-infrared fluorescent imaging, analyzed intraoperatively, and compared to deferred ultrastaging. Results: SLN DR was 100%, with a bilaterality rate of 83%. Twelve (26.8%) patients had metastatic nodes, 11 of them (91.7%) detected by SLN technique, of which 9 (81.8%) had only the sentinel node affected. False-negative rate was 2.4% after ultrastaging procedure. Metastatic SLN detection with ultrastaging was 45.5% higher than the intraoperative analysis, 63.6% of which had low tumor burden. The global detection of patients with nodal metastases after SLN technique was 21.9% higher than pelvic lymphadenectomy. Conclusions: Our preliminary results corroborate that SLN biopsy selectively maps metastatic nodes and ultrastaging increases the detection of metastatic SLNs, predominantly due to low tumor burden.

Wpływ wykorzystania wniosków badania ACOSOG Z0011 na zmianę strategii postępowania diagnostyczno-terapeutycznego u chorych na raka piersi poddanych biopsji węzła wartowniczego — doniesienie wstępne

Background. Publication of the results of the randomised ACOSOG Z0011 trial concerning the possibilities of conservative treatment of breast cancer patients with macrometastasis in the sentinel lymph node (SLN) increased the interest in this therapeutic option. The objective of the study was to assess the practical effects of the implementation of conclusions from the aforementioned study as well as clinical consequences of abandoning intraoperative verification of sentinel lymph nodes resected during the surgical procedure. Material and methods. A prospective analysis was made for 567 breast cancer patients subjected to sentinel node biopsy in the period 1 January to 31 October 2014. In the case of the group undergoing breast conserving treatment (BCT), routine intraoperative assessment of SLN was abandoned. The decision regarding potential radicalisation of the surgical procedure was delayed until final histopathological results were obtained. The results were compared with data from the period preceding the implementation of changes. Results. BCT was used in 73.4% of study subjects while breast amputation was performed in the remaining patients. Presence of metastatic lesions within the SLNs was detected in 23.5% of patients. In 31.8% of patients with SLN metastases, radicalisation of the surgery was abandoned versus 18.3% in the control group, 22.2% versus 5.1% in case of macrometastases; 28.0% versus 6.5% in patients undergoing BCT. These are significant results, p < 0.05). The percentage of patients subjected to reoperation was 6.9% versus 3.6% in the control group. Conclusions. Postponing the decision regarding the potential radicalisation of surgical treatment until the receipt of the final result of the histopathological sentinel node assessment may facilitate the choice of further treatment. Abandonment of routine intraoperative assessment of SLN allowed for a statistically significant increase in the percentage of follow-up axillary lymph node resection being abandoned. At the same time, no significant increase in the rate of reoperations was observed.

150. Scope for intra-operative sentinel lymph node assessment with one step nucleic acid amplification (OSNA) for CK19 messenger RNA in the light of American College of Surgical Oncology Group (ACOSOG) ZOO11 Trial, in an average District General Hospital in the UK

150. Scope for intra-operative sentinel lymph node assessment with one step nucleic acid amplification (OSNA) for CK19 messenger RNA in the light of American College of Surgical Oncology Group (ACOSOG) ZOO11 Trial, in an average District General Hospital in the UK

Can Intraoperative Sentinel Lymph Node Biopsy be Safely Avoided in Patients with Cytologically Negative Axilla?

Introduction: The importance of intraoperative sentinel lymph node biopsy in breast cancer patients has come into question after the results of the Z11 trial, which demonstrated no benefit in local or regional control with completion axillary lymph node dissection (ALND) in patients with one or two positive sentinel nodes. Previous studies have shown the advantages of preoperative ultrasound guided FNA for axillary staging in breast cancer. This retrospective analysis was performed to assess the need for intraoperative sentinel node evaluation in clinically node negative patients with negative ultrasound guided axillary FNA. Materials and Methods: Results from breast cancer patients from 2010 to present with negative axillary ultrasound-guided fine needle aspiration (USFNA) and subsequent surgical follow-up were reviewed (nZ67). Number of positive sentinel and non-sentinel lymph nodes, final nodal stage, and the size of the metastatic deposits was obtained. Results: Twelve of sixty-seven women in the study group demonstrated metastatic carcinoma in sentinel lymph nodes. Of these, seven cases of macrometastatic disease were identified, with two cases showing metastatic deposits in sentinel and non-sentinel nodes. Four cases revealed micrometastases, and one case showed isolated tumor cells on touch preparation only. The final pathologic stage in all cases with macrometastases was N1a. The negative predictive value for macrometastatic disease after a negative US-FNA was 89.6%. Conclusion: This study demonstrates that in patients with a cytologically negative axilla intraoperative assessment of sentinel lymph nodes shows no benefit, thereby preventing both the costly and time-consuming process of intraoperative sentinel lymph node assessment and morbidity of unnecessary axillary lymph node dissection.

267. Impact of Introducing Intra-operative Assessment of Sentinel Lymph Node (SLN) with OSNA (One Step Nucleic Acid Amplification) – Single Centre Series.

Background: Intra-operative assessment of SLN has advantages for patients (reduced requirements for a second operation). OSNA assessment additionally provides stratification between likely micro- and macro-metastases.

Intra-operative Sentinel Lymph Node Assessment- How many patients will avoid a second operation?

Intra-operative Sentinel Lymph Node Assessment- How many patients will avoid a second operation?

Abstract P1-01-07: Touch Imprint Cytology for Intraoperative Evaluation of Sentinel Lymph Node in Patients with Early-Stage Breast Cancer: A Five-Year Experience

Abstract Background: Accurate intraoperative diagnosis of sentinel lymph node (SLN) metastases enables the selection of patients for axillary lymph node dissection during the same operation and reduces the need for re-operation. Touch imprint cytology (TIC) serves as a main intraoperative assessment of SLNs in our institute for over five years. The purpose of the present study is to evaluate the clinical value of TIC as an intraoperative assessment for the diagnosis of SLN. Methods: Patients treated for early-stage breast cancer between Feb-2005 and May-2010 enrolled in the study. TIC was routinely performed intraoperatively, the result of which was correlated with definitive histological assessments of serial section with Hematoxylin-Eosin staining. Subsequent immunohistochemistry staining with CK-19 and MUC-1 were performed for research purposes. The Memorial Sloan-Kettering Cancer Center (MSKCC) nomogram was applied in this retrospective study to estimate probability of SLN involvement of each case. Results: A total of 1,077 patients with early-stage breast cancer enrolled in the study, and 3,048 SLNs were successfully harvested during the surgeries. Among those, 265 (24.6%) patients proved to have at least one SLN that was positive for carcinoma. Altogether, 397 (13.0%) involved nodes were removed from patients in the aforementioned patient pool. Based on the final pathology report, the sensitivity, specificity and overall accuracy of TIC was 83.4%, 99.0% and 95.2%, respectively on a per patient basis, and 78.3%, 99.4% and 96.7%, respectively on a per node basis. The sensitivity for macrometastasis and micrometastasis are 88.6% and 39.3%, respectively on a per patient basis, while 87.4% and 31. 3%, respectively on a per node basis. Of the patients included in this study, 98.7% had a positive SLN within their first three harvested SLNs. All the patients who were at a &amp;lt;10% chance of SLNs metastases according to the MSKCC nomogram were proved to be node negative by the final pathology. Conclusion: TIC is feasible and is able to detect macrometastasis in SLNs with an acceptable accuracy for clinical use in early-stage breast cancer patients while its ability to detect micrometastasis is limited. Limiting intraoperative TIC to the first three harvested SLNs in the diagnosis of SLN metastasis may make this diagnostic procedure significantly cheaper and easier for pathologists to perform. The MSKCC nomogram could be applied as a screening tool. Intraoperative assessment for SLNs, such as TIC, could be spared for patients with extremely low MSKCC scores (&amp;lt;10%). Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-01-07.

Intraoperative sentinel lymph node assessment - does it reduce the need for a second operation?

Introduction: ISLNA is proposed as a method of avoiding a second operation in patients with a positive sentinel lymph node biopsy (SLNB). However some patients may need further surgery if the primary cancer is incompletely excised or occult disease subsequently identified. This study was conducted to determine how many patients would benefit from ISLNA by avoiding a second operation.

340 Disconcordance between number of scintigraphic and perioperatively identified sentinel lymph nodes and axillary tumour recurrence

Intraoperative assessment of sentinel lymph nodes (SLNs) has the advantage of allowing breast cancer patients with tumor-positive SLNs to avoid a second surgery by immediately proceeding to axillary lymph node dissection (ALND). However, there are several reasons why the use of intraoperative assessment should be questioned. Whereas ALND was traditionally advised for all breast cancer patients with tumor-positive lymph nodes for axillary staging and locoregional control, more recent studies have demonstrated safety of omitting ALND in a substantial number of patients.In addition, there are concerns about the accuracy of intraoperative assessment methods including frozen section analysis, touch preparation cytology and one-step nucleic acid amplification. Moreover, intraoperative assessment of SLNs denies patients the opportunity to contribute to their treatment planning. In our opinion, intraoperative assessment of axillary lymph nodes should be reserved for patients who still have a strict indication for ALND. Patients with clinical node negative disease (cN0) and one or two positive SLNs can be safely treated with breast conserving surgery and radiotherapy. There has been more controversy for cN0 patients who are treated with mastectomy since radiotherapy is not routinely administered in these patients. However, there is increasing evidence that ALND may be omitted in patients undergoing mastectomy who have a low tumor-burden in their SLNs. Therefore, we defend the position that in cN0 patients undergoing mastectomy, SLNB should be performed and full pathologic evaluation of the SLN should be awaited. In cN0 patients undergoing neoadjuvant systemic therapy (NST) intraoperative assessment of SLNs can be omitted since ALND will not provide therapeutic benefit. It is being hypothesized that patients with limited axillary disease prior to NST who remain node-positive after NST could be treated safely with axillary radiotherapy instead of ALND. In these patients, omitting intraoperative assessment might be a reasonable option. In patients with extensive nodal disease prior to NST intraoperative assessment of axillary lymph nodes should be performed.

Can Axillary Lymph Node Dissection Be Safely Omitted for Early-Stage Breast Cancer Patients with Sentinel Lymph Node Micrometastasis?

Can Axillary Lymph Node Dissection Be Safely Omitted for Early-Stage Breast Cancer Patients with Sentinel Lymph Node Micrometastasis?