Sentinel Lymph Node Identification Rate Research Articles

Abstract P3-03-01: Comparison of sentinel lymph node detection performances using methylene blue in conjunction with indocyanine green or radioisotope in breast cancer patients: A prospective single-center cohort study

Abstract Aim: This cohort study aimed to compare the clinical efficacies between the novel dual tracer composed of indocyanine green (ICG) and blue dye (BD) and the conventional dual tracer composed of radioisotope and BD for sentinel lymph node (SLN) mapping in breast cancer patients. Methods: This study enrolled 471 clinically lymph node-negative patients with primary breast cancer. All the patients received mastectomy, while, for the sentinel lymph node biopsy (SLNB), they were randomized to receive BD plus radioisotope or BD plus ICG. Two hundred and twenty-seven patients received radioisotope plus BD (Control, RB group) for SLNB, while, 200 patients underwent the ICG plus BD (IB group) for SLNB. The detection performances on SLN identification rate, positive SLN counts, detection sensitivity, and false-negative rate were compared between the two groups. Following SLNB, axillary lymph node dissection (ALND) was performed only on patients with metastatic SLNs. Injection safety and potential side-effects of the two dual tracers were evaluated by a 24-month follow-up after the SLNB procedure. Results: In the IB group, 97% (194/200) of the patients who underwent the ICG and BD dual tracer injection showed fluorescent-positive lymphatic vessels within 2-5 minutes. The identification rate of SLNs was comparable between the IB group (99.0%, 198/200) and the RB group (99.6%, 270/271) (P=0.79). No significant differences were observed in identification rate of metastatic SLNs (22.5% versus 22.9%, P>0.05, RB group versus IB group, the same below), positive SLN counts (3.72±2.28 versus 3.91±2.13, P>0.05), positive metastatic SLN counts (0.38±0.84 versus 0.34±0.78, P>0.05), SLNB detection sensitivity (94.4% vs. 92.5%, P>0.05), or false-negative rate (5.6% versus 7.5%, P>0.05) between the two groups. No obvious allergic reaction or anaphylaxis, infection at the injection sites, skin necrosis or distal metastasis was reported in either group during the 24-month follow-up. Conclusions: ICG can be used as a promising alternative tracer for radioisotope in SLN mapping, and when it is combined with BD in lymphangiography, it offers comparable detection sensitivity compared to the conventional lymphatic mapping strategies that are widely used in clinical practice. Efficacy of indocyanine green vs. radioisotope + blue dye for sentinel lymph node mapping in breast cancer patients.Parameters99Tcm-Dx+BD(N=271)ICG+BD (N=200)P-valueSLN identification rate (%)99.6(270/271)99.0(198/200)0.79SLN counts3.91±2.133.72±2.280.09Metastatic SLN rate (%)22.9(62/271)25.5(51/200)0.51Metastatic SLN counts0.34±0.780.38±0.840.46Sensitivity92.5(62/67)94.4(51/54)0.96False-negative rate (%)7.5(5/67)5.6(3/54) Citation Format: Qi X, Yuan L, Zhang Y, Jiang J. Comparison of sentinel lymph node detection performances using methylene blue in conjunction with indocyanine green or radioisotope in breast cancer patients: A prospective single-center cohort study [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-03-01.

Sentinel Lymph Node Identification Rate After Neoadjuvant Chemotherapy for Breast Cancer Patients in an Asian Cancer Centre: a 16-year Experience

Sentinel Lymph Node Identification Rate After Neoadjuvant Chemotherapy for Breast Cancer Patients in an Asian Cancer Centre: a 16-year Experience

Radiation therapy after sentinel lymph node biopsy for early stage breast cancer using a magnetic tracer: Results of a single institutional prospective study of tolerance

Purpose. The aim of the study was, through a single institutional analysis of a large population of breast cancer patients, to assess the feasibility of and the tolerance to radiotherapy after the use of magnetic detection method for sentinel lymph node biopsy. Material and methodsThe super paramagnetic iron oxide particles database was collected prospectively and identified 520 cases from October 2013 to December 2016 at our institution. All of them received super paramagnetic iron oxide particles injection 20minutes before the surgical procedure and some of them received also isotope technique. Injection site for super paramagnetic iron oxide particles and isotope was periareolar. Among them, 288 patients received adjuvant radiotherapy. In our study, we evaluated the tolerance of postoperative radiotherapy. ResultsThe median age of the patients was 64 years. The median follow-up period was 16 months (range: 1–42 months). Double detection of sentinel lymph node was done in the first 30 patients (10.4%). The sentinel lymph node identification rate was 99.7% (287 out of 288). There were 34 axillary lymph node dissections, of which 58.8% were realized straightaway. The total radiation dose was 50Gy EQD2 (range: 28.5–66Gy). Regarding the occurrence of radiodermatitis, 95.8% of patients had grade 0–2 radiodermatitis and 1% had grade 3. During follow-up, 19.4% of patients developed grade 1–2 post-therapeutic fibrosis (of which 92.9% grade 1). ConclusionThe results of this large-scale study show that the radiotherapy after sentinel lymph node biopsy using super paramagnetic iron oxide particles is feasible, and that no increase of the toxicity was observed.

Comparison of the indocyanine green dye method versus the combined method of indigo carmine blue dye with indocyanine green fluorescence imaging for sentinel lymph node biopsy in breast conservative therapy for stage \u2264IIA breast cancer

BackgroundFluorescence imaging (FI) is one of the methods to identify sentinel lymph nodes (SLNs). However, the procedure is technically complicated and requires procedural skills, as SLN biopsy must be conducted in dim light conditions. As an improved version of this method, we introduced a combined method (Combined mixed dye and fluorescence; CMF) consisting of indigo carmine blue dye and FI. The direct visualization of SLNs under shadowless surgical light conditions is facilitated by the addition of the blue dye. We compared the SLN detection rates of CMF with that of the indocyanine green (ICG) dye method (ICG-D).MethodsA total of 202 patients with stage ≤IIA breast cancer who underwent breast conservative therapy with separate incision from January 2004 to February 2017 were reviewed. Details of the two methods are as follows: (1) ICG-D: 10 mg of ICG was used and the green-stained SLNs were resected via a 3-4 cm axillary incision; (2) CMF: A combination of 5 mg of ICG and 4-8 mg of indigo carmine was used. After a 1.5–2 cm incision was made near the point of disappearance of the fluorescence using Photodynamic Eye (PDE), the blue-stained SLNs were resected under shadowless surgical light conditions.ResultsThere were 92 ICG-D and 110 CMF cases. CMF resulted in a significantly higher SLN detection rate than ICG-D (96.4% vs. 83.7%; p = 0.003). This difference was particularly notable in those aged ≥60 years (98.3% vs. 74.3%) and individuals with body mass index (BMI) ≥25 kg/m2 (90.3% vs. 58.3%).ConclusionCMF is an effective method to identify SLNs which is safe and efficient. CMF achieves a high SLN identification rate and most of this procedure is feasible under shadowless surgical light conditions. CMF can reliably perform SLN biopsy even in those aged ≥60 years and individuals with BMI ≥ 25 kg/m2.

Improved False-Negative Rates with Intraoperative Identification of Clipped Nodes in Patients Undergoing Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy.

Identification and resection of a clipped node was shown to decrease the false-negative rate (FNR) of sentinel lymph node biopsy (SLNB) after neoadjuvant chemotherapy (NAC) for patients presenting with initially node-positive breast cancer. Between March 2014 and March 2016, a prospective trial analyzed 98 patients with axilla-positive locally advanced breast cancer (T1-4, N1-3) to assess the feasibility and efficacy of placing clips into most suspicious biopsy-proven node. The study considered blue, radioisotope active, and suspiciously palpable nodes as sentinel lymph nodes (SLNs). The SLN identification rate was 87.8%. The median age of the patients with an SLNB (n = 86) was 44years (range 28-66years). Of these patients, 77 (88.4%) had cT1-3 disease, and 10 (11.6%) had cT4 disease. The majority of the patients (n = 66, 76.7%) had cN1, whereas 21 patients (23.3%) had cN2 and cN3. A combined method was used for 37 patients (43%), whereas blue dye alone was used for the remaining patients (57%). The clipped node was the SLN in 70 patients (81.4%). For the patients with cN1 before NAC, the FNR was found to be 4.2% (1/24) when the clipped node was identified as an SLN. However, the FNR was estimated to be as high as 16.7% (1/6) for the patients with cN1 before NAC when the clipped node was found to be a non-SLN. The study results also suggest that axillary dissection could be omitted for patients presenting initially with N1 disease and with a negativeclipped node as the SLN after NAC due to the low FNR.

Sentinel lymph node biopsy in small papillary thyroid cancer. A review on novel surgical techniques.

Sentinel lymph node biopsy (SNB) in patients with papillary thyroid carcinoma (PTC) and negative for clinically neck lymph node metastatic involvement (N0) has emerged as a promising minimally invasive procedure to detect metastatic nodes. The MEDLINE database was searched via the PubMed interface on 10 January 2018 for the MeSH headings "sentinel lymph node biopsy" and "thyroid carcinoma". Vital blue dye, radioisotope, and the combination of both techniques are used in PTC patients. These methods and the emerging role of SPECT/CT are discussed in this review. The sentinel lymph node (SLN) identification rates ranged from 0 to 100% for blue dye, 83 to 100% for radioisotopes, and 66 to 100% for the combination of both techniques, respectively. SNB based on radioisotope technique with the use of intraoperative gamma-probe is an accurate and safe method that allows the highest SLN detection rate. There is sufficient evidence to propagate the increasing use of SNB procedure that has the potential to avoid prophylactic lymph node surgery in patients clinically N0.

Application of a carbon nanoparticle suspension for sentinel lymph node mapping in patients with early breast cancer: a retrospective cohort study

BackgroundTo stage axillary lymph nodes in women with early-stage breast cancer, sentinel lymph node biopsy (SLNB), rather than axillary lymph node dissection (ALND), has been employed. Moreover, different tracer methods have various advantages and disadvantages. In recent years, carbon nanoparticle suspensions (CNSs) have been used as lymph node tracers during surgeries for thyroid cancer, gastric cancer, and colorectal cancer. The study retrospectively analyzed the feasibility and accuracy of CNS for sentinel lymph node (SLN) mapping in patients with early breast cancer.MethodsThis single-center, retrospective study included breast cancer patients who underwent SLNB from January 1, 2016, to December 31, 2017, in the Department of Breast Cancer, Guangdong General Hospital. All patients received standard SLNB surgery using a CNS tracer.ResultsA total of 332 cases were included in this study. The SLN identification rate was 99.1% (329/332), and the mean number of SLNs was 2.6 (range, 1–6). SLN metastasis was found in 62 (18.8%) cases, of which 90.3% were found to be macrometastases. The sensitivity of SLNB was 95.9% (47/49), with a specificity of 100% (42/42), a positive predictive value of 100% (47/47), a negative predictive value of 95.5% (42/44), and a false-negative rate of 4.1% (2/49).ConclusionThe identification and predictive values of a CNS tracer for SLNB were satisfactory.

Real-time navigation system for sentinel lymph node biopsy in breast cancer patients using projection mapping with indocyanine green fluorescence.

Inability to visualize indocyanine green fluorescence images in the surgical field limits the application of current near-infrared fluorescence imaging (NIR) systems for real-time navigation during sentinel lymph node (SLN) biopsy in breast cancer patients. The aim of this study was to evaluate the usefulness of the Medical Imaging Projection System (MIPS), which uses active projection mapping, for SLN biopsy. A total of 56 patients (59 procedures) underwent SLN biopsy using the MIPS between March 2016 and November 2017. After SLN biopsy using the MIPS, residual SLNs were removed using a conventional NIR camera and/or radioisotope method. The primary endpoint of this study was identification rate of SLNs using the MIPS. In all procedures, at least one SLN was detected by the MIPS, giving an SLN identification rate of 100% [95% confidence interval (CI) 94-100%]. SLN biopsy was successfully performed without operating lights in all procedures. In total, 3 positive SLNs were excised using MIPS, but were not included in the additional SLNs excised by other methods. The median number of SLNs excised using the MIPS was 3 (range 1-7). Of procedures performed after preoperative systemic therapy, the median number of SLNs excised using the MIPS was 3 (range 2-6). The MIPS is effective in detecting SLNs in patients with breast cancer, providing continuous and accurate projection of fluorescence signals in the surgical field, without need for operating lights, and could be useful in real-time navigation surgery for SLN biopsy.

Abstract P5-22-15: Hormone receptor status is a predictive factor for axillary lymph node recurrence after sentinel lymph node biopsy

Abstract Background Axillary staging is important for predicting prognosis, and for local control in early breast cancer. Sentinel lymph node biopsy (SLNB) is a widely accepted method to avoid unnecessary axillary lymph node dissection (ALND). Since the ACOSOG Z0011 trial was published, we have refrained from ALND for selected patients with positive SLNB results. However, some cases have shown regional lymph node recurrences after SLNB without axillary dissection. The purpose of this study is to identify risk factors for recurrences, to ensure a safe axillary surgery. Methods A retrospective review of 1011 patientswho underwent SLNB without ALND between June 2004 and March 2017 was performed. Since October 2012, we have not performed ALND in patients (a) with 1 or 2 positive sentinel lymph nodes (SLNs), (b) with positive SLNs that are unmatted or not gross extra nodal extension, (C) in whom clinical tumor size is <5 cm, and (d) who receive adjuvant endocrine therapy or chemotherapy and radiotherapy. Cases of mastectomy, lumpectomy with a positive margin and additional resection or boost radiotherapy, and bilateral cancer were included. SLNs were identified using technetium sulfur colloid and indigo carmine blue dye, and were bisected in parallel to the long axis of the nodes. The sections were stained with hematoxylin and eosin. Adjuvant systemic and/or radiation treatment was delivered as per the National Comprehensive Cancer Network and the Japanese Breast Cancer Society clinical practice guidelines and was based on the patients' pathological and clinical traits. Results Of the 1011 patients, 969 had negative and 42 had positive SLNs. The median age of patients was 59 years (range 21-88). The median invasive breast tumor size was 15 mm (range 0.05-85), with 1.9% tumors being pathological T3 lesions; 127 patients (12.3%) developed lymphatic vessel invasion. SLNs identification rate was 99.4%. The median number of SLNs removed per patient was 2 (range 1-7). After follow-up of a median 78.5 months, 10 patients (1.0%) had an axillary recurrence and all of them had negative SLN metastasis. The median time to axillary recurrence was 26 months (range 9-94). The hormone receptor (HR) status was significantly related to axillary recurrence (p=0.008). While triple negativity had a tendency to relate (p=0.06), human epidermal growth factor receptor 2 (HER2) status did not correlate with axillary recurrence (p=0.13). Tumor subtypes and axillary recurrence SLNB without ALND (n=1011)Axillary recurrenceP valueHR positive72650.009HR negative1615 HER2 positive12130.13HER2 negative7667 Triple Negative10030.06Not Triple Negative7877 DCIS1240 DCIS: Ductal carcinoma in situ Conclusions As reported previously, the axillary recurrence rate after SLNB was low. Our results show that HR negativity was a significant factor for axillary recurrence. Although the ACOSOG Z0011 trial criteria focused on ALNB positive cases, they do not mention the tumor subtypes. Our findings show that HR negative patients without ALND have to follow up carefully. Citation Format: Sekine C, Nakano S, Mibu A, Otsuka M, Oinuma T. Hormone receptor status is a predictive factor for axillary lymph node recurrence after sentinel lymph node biopsy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P5-22-15.

Abstract P3-01-05: A feasibility study of sentinel lymph node detection and analysis of safety to omit axillary lymph node dissection in clinically node-negative breast cancer patients after neoadjuvant chemotherapy

Abstract Background: Concerns still remain about lower sentinel node (SN) detection and higher false-negative rates (FNR) in breast cancer patients treated with neoadjuvant chemotherapy (NAC), especially those who are clinically node-positive before NAC. It is necessary to analyze the validity of sentinel node biopsy (SNB) after NAC and evaluate whether the SN identification rate and FNR for clinically N0 (cN0) patients after NAC would be acceptable or not in order to omit axillary lymph node dissection (ALND). Objectives and methods: We identified SN by radioisotopic methods followed by completion of ALND in cN0 patients after NAC from 2013 to 2016 as part of a clinical research study (SNB group, N=68) to analyze the accuracy of SNB, and retrospectively investigated the prognosis of patients treated with NAC from 2006 to 2012 (control group, N=92) to evaluate whether the validity of SNB would be acceptable or not. Results: Mean patient ages in the SNB group and control group were 51.0 years and 49.5 years, respectively (p=0.17), and the distribution of intrinsic subtypes was not significantly different between the two groups. The numbers of cN1≤ before NAC in the SNB group and control group were 85.5% (57/68) and 80.4% (74/92), respectively (p=0.58), and the pathological complete response rates were 25.0% (17/68) and 19.6% (18/92), respectively (p=0.41). Lymphoscintigraphy using 99mTc-phytate acid was performed in the SNB group, and hot spots were detected at the ipsilateral axilla in 62 of 68 (91.2%) patients, in all of whom SNs could be identified by using a gamma-probe. The FNR, which indicates no metastasis in SNs and metastasis in non-SN, was 5.9% (4/68). Among these four patients, three were of the luminal type while one was triple negative. The number of patients without metastasis in both SN and non-SN, which are candidates for omission of ALND, was 26 of 68 (38.2%). They included eight of nine HER2-enriched patients and six of 13 luminal-HER2 patients. Conversely, there were no false-negative cases in these subtypes. Moreover, all SNs were identified even if there were metastases in SNs. Regarding the prognosis of the control group, the 10-year disease free survival of post-NAC N0 (ypN0) (52/92, 56.5%) and ypN1≤ (40/92, 43.5%) were 80.7% and 61.2%, respectively (p=0.08); in addition, the 10-year overall survival of yN0 and ypN1≤ were 90.4% and 72.6% (p=0.26). Thus, the prognosis of ypN1≤ was not significantly inferior to that of ypN0. If omission of ALND were performed for false negative cases, then the risk of axillary relapse would be a concern. However, these data indicate the possibility that 5.9% of FNR as shown in the SNB group would not have much influence on prognosis. Conclusion: The accuracy of SN detection by radioisotopic methods for cN0 breast cancer after NAC was not maintained like that for -early breast cancer although it was better than the results of previous studies. However, there were no false-negative cases in HER2-enriched and luminal-HER2 subtypes, which could be potential candidates for omission of ALND. In addition, omission of ALND for false-negative patients would have less influence on the prognosis. Citation Format: Maeno K, Yamamoto K, Ono M, Oba T, Iesato A, Ono K, Ito T, Kanai T, Ito K-I. A feasibility study of sentinel lymph node detection and analysis of safety to omit axillary lymph node dissection in clinically node-negative breast cancer patients after neoadjuvant chemotherapy [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P3-01-05.

Abstract PD2-07: Real-time navigation for sentinel lymph node biopsy in breast cancer patients using projection mapping with indocyanine green fluorescence

Abstract Background) Sentinel lymph node (SLN) biopsy using indocyanine green fluorescence (fICG) method showed equal or better identification rate compared with blue dye or radioisotope (RI) method. In the fICG method, lymphatic vessels which drain into the SLNs can be seen through skin or subcutaneous tissue using near infrared camera (Photodynamic Eye®: PDE), and we can easily find the SLNs. However, whenever we observe the fluorescence images, we have to hold the PDE, turn off the operating light, and look at a monitor because fluorescence images cannot be seen directly. Medical imaging projection system (MIPS) is a new device which detects fluorescent emission from the organ and projects their images on the location of the fluorescence emission (Panasonic Connected Solutions Company, Japan). Projected images can be adjusted following the body movement or deformation of the organ. Therefore, MIPS could provide an option for real-time navigation for the SLN biopsy. The aim of this study was to evaluate the clinical utility of the MIPS. Patients and methods) Patients with clinically node-negative primary breast cancer underwent the fICG SLN biopsy using MIPS. Primary endpoint was identification rate of the fICG method using MIPS. At first, the study was conducted as an interventional study because the MIPS was the unapproved medical device. After approval of the MIPS, this study was conducted as an observational study. The study protocol was approved by the institutional review board at Kyoto University Hospital. All patients provided informed consent to participate in this study. Results) Between March 2016 and May 2017, 39 patients (40 procedures) underwent the fICG method SLN biopsy using MIPS. The median age was 55 years (range 32–74 years), and the median body mass index was 20.4 kg/m2 (range 17.7–27.7 kg/m2). About half had tumor stage T1 (58%) and 8 (20.0%) had DCIS. 8 procedures (20%) were performed after preoperative systemic therapy (PST). As MIPS itself can illuminate the operating field, SLN biopsy using MIPS was successfully performed without operating light in all procedures. At least one SLN was detected using MIPS for all procedures and the identification rate was 100% (95% CI: 91–100%). Median number of SLNs detected by MIPS was 3 (range 1–9) for all procedures, and 3 (range 2–8) for procedures after PST. Two pathologically positive SLNs and one SLN which included isolated tumor cells were detected by MIPS. In 25 procedures, RI was also used. 62 of 97 SLNs detected by MIPS (64%) were also detected by RI. However, no SLNs were detected only by RI. Conclusions) Although we still may not be able to avoid RI method because 25/40 (62.5%) procedures required the combined use of RI method, the fICG methods SLN biopsy using MIPS, which showed comparable identification rate of SLN with the conventional methods, could be useful tool with a view of allowing us to perform a real-time navigation surgery. Acknowledgements) This study was supported by Acceleration Transformative research for Medical innovation, Japan Agency for Medical Research and Development (AMED). Citation Format: Takada M, Takeuchi M, Suzuki E, Sato F, Matsumoto Y, Torii M, Sakita-Kawaguchi N, Nakayama Y, Okuda T, Nishino H, Seo S, Hatano E, Toi M. Real-time navigation for sentinel lymph node biopsy in breast cancer patients using projection mapping with indocyanine green fluorescence [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr PD2-07.

Comparison of sentinel lymph node detection performances using blue dye in conjunction with indocyanine green or radioisotope in breast cancer patients: a prospective single-center randomized study.

Objective:This randomized study aimed to compare the clinical efficacy between the novel dual tracer composed of indocyanine green (ICG) and blue dye (BD) and the conventional dual tracer composed of radioisotope and BD for sentinel lymph node (SLN) mapping in patients with breast cancer.Methods:This study enrolled 471 clinically lymph node-negative patients with primary breast cancer. All patients underwent mastectomy, and those undergoing sentinel lymph node biopsy (SLNB) were randomized to receive blue dye plus radioisotope (RB group) or BD plus ICG (IB group). The detection performances on SLN identification rate, positive SLN counts, detection sensitivity, and false-negative rate were compared between the two groups.Results:In the IB group, 97% (194/200) of the patients who underwent the ICG and BD dual tracer injection showed fluorescent-positive lymphatic vessels within 2–5 min. The identification rate of SLNs was comparable between the IB group (99.0%, 198/200) and the RB group (99.6%, 270/271) (P = 0.79). No significant differences were observed in the identification rate of metastatic SLNs (22.5% vs. 22.9%, P > 0.05, RB group vs. IB group, the same below), positive SLN counts (3.72 ± 2.28 vs. 3.91 ± 2.13, P > 0.05), positive metastatic SLN counts (0.38 ± 0.84 vs. 0.34 ± 0.78, P > 0.05), SLNB detection sensitivity (94.4% vs. 92.5%, P > 0.05), or false-negative rate (5.6% vs. 7.5%, P > 0.05) between the two groups. Conclusions:ICG can be used as a promising alternative tracer for radioisotope in SLN mapping, and when it is combined with BD in lymphangiography, it offers comparable detection sensitivity compared to the conventional lymphatic mapping strategies that are widely used in clinical practice.

Use of Sentinel Lymph Node Biopsy after Neoadjuvant Chemotherapy in Patients with Axillary Node-Positive Breast Cancer in Diagnosis.

PurposeThis study aimed to evaluate the effects of sentinel lymph node biopsy (SLNB) on recurrence and survival after neoadjuvant chemotherapy (NAC) in breast cancer patients with cytology-proven axillary node metastasis.MethodsWe selected patients who were diagnosed with invasive breast cancer and axillary lymph node metastasis and were treated with NAC followed by curative surgery between January 2007 and December 2014. We classified patients into three groups: group A, negative sentinel lymph node (SLN) status and no further dissection; group B, negative SLN status with backup axillary lymph node dissection (ALND); and group C, no residual axillary metastasis on pathology with standard ALND.ResultsThe median follow-up time was 51 months (range, 3–122 months) and the median number of retrieved SLNs was 5 (range, 2–9). The SLN identification rate was 98.3% (234/238 patients), and the false negative rate of SLNB after NAC was 7.5%. There was no significant difference in axillary recurrence-free survival (p=0.118), disease-free survival (DFS; p=0.578) or overall survival (OS; p=0.149) among groups A, B, and C. In the subgroup analysis of breast pathologic complete response (pCR) status, there was no significant difference in DFS (p=0.271, p=0.892) or OS (p=0.207, p=0.300) in the breast pCR and non-pCR patients.ConclusionThese results suggest that SLNB can be feasible and oncologically safe after NAC for cytology-determined axillary node metastasis patients and could help reduce arm morbidity and lymphedema by avoiding ALND in SLN-negative patients.

Local-Regional Metastases and Mortality After Sentinel Biopsy and Complete Dissection of Axillary Lymph Nodes in Patients with Early Invasive Breast Cancer.

Introduction:Current, standard procedure for evaluation of axillary lymph node pathological (PH) status has been sentinel lymph node biopsy (SLNB). To demonstrate the long-term validity of sentinel lymph node biopsy (SLNB) using the radioactive isotope only Technetium 99m albumin-colloid (Tc99m) we compared the loco-regional recurrence and mortality of breast cancer patients with negative SLNB without axillary lymph node dissection (ALND) (SLNB group) to that of lymph node-positive patients undergoing ALND (ALND group).Aim:The aim of our study is to evaluate the results of long-term monitoring of patients with early invasive breast cancer in which the radio-actively guided axillary SLN biopsy and complete ALND were studied, with special emphasis on local-regional recurrence and mortality.Patients and methods: We studied a total of 63 patients with T1-2early invasive breast cancer diagnosed at Clinic for general and abdominal surgery, Clinical Center University of Sarajevo (CCUS) between 2004 and 2007, with follow-up till 2013, retrospectively, who met the criteria for inclusion. Preoperative peritumorous injection of radioactive isotope (Tc99m albumin-colloid) is done on the Clinic for Endocrine and Nuclear Medicine-CCUS. Intra and postoperative pathohistological (PH)examination of SLN node (or nodes) and PH examination of lymph nodes after complete ALND was done at the Clinic for Clinical Pathology and Cytology-CCUS. Statistical evaluation was done by statistical program MedCalc Statistical Software, version 18.10. Depending on the given variables were used: mean, standard deviation, median values, 95% CI for median value, Chi-square test, D’Agostino-Pearson test, Kaplan-Maier curve of survival. Defined level of significance was p<0,05.Results:The SLNB group consisted of 33 SLN-negative women and ALND group consisted of 30 axillary lymph node-positive women. The sentinel node identification rate was 100%. In the SLNB group no patients has developed axillary recurrence during the follow-up. The mortality rate in the SLNB group was equivalent to that in the ALND group.Conclusions:The SLN biopsy conducted with only a radioactive isotope TC 99m have the same results as loco-regional recurrence and mortality as well as the complete ALND method and may be the method of choice for the treatment of axillary in breast cancer patients and the clinically negative axillary lymph node (or nodules) with the notion that patients should be micro metastases given special attention during long-term monitoring.

A Novel Color Fluorescence Navigation System for Intraoperative Transcutaneous Lymphatic Mapping and Resection of Sentinel Lymph Nodes in Breast Cancer: Comparison with the Combination of Gamma Probe Scanning and Visible Dye Methods

Background: This study evaluated the clinical efficacy of a novel imaging system (HyperEye Medical System [HEMS]; Mizuho Corp., Tokyo, Japan) that uses the near-infrared (NIR) fluorescence of indocyanine green to analyze sentinel lymph node (SLN) biopsies for the staging of breast cancer. Methods: This study enrolled 91 patients with histologically confirmed breast cancer that was clinically node negative with a tumor size <3 cm. We compared SLN identification rates between HEMS and conventional methods (gamma probe scanning using a colloidal radioisotope [RI] and a blue dye method) by analyzing the relationships of lymphatic to axillary lesions and SLNs. Results: The identification rate of SLNs was 100% using HEMS, 97.8% using the RI method, and 95.6% using the blue dye method. Two types of lymphatic pathway (LP) were detected in 39 patients (42.9%) and also clearly identified using HEMS-captured color and NIR fluorescence. The incidence of two or more SLNs was significantly higher in patients with a two-route LP to the axilla group than in those with only one route (p < 0.001; 43.6 vs. 9.6%). Conclusions: The HEMS NIR fluorescence color imaging method is a promising potential modality for higher-level identification of SLNs than a standard combination of the RI and blue dye methods.

Sentinel node biopsy for axillary management after neoadjuvant therapy for breast cancer: a single-center retrospective analysis with long follow-up.

Sentinel node biopsy (SNB) after neoadjuvant therapy (NAT) for breast cancer remains controversial. We conducted a retrospective study of patients who underwent SNB after NAT to evaluate the effectiveness of this procedure. A consecutive 105 women with locally advanced breast cancer (cT1-4, cN0-3, M0) were treated with NAT between 2006 and 2015. The subjects were 80 of these patients who became or remained clinically node-negative after NAT, 53 of whom had axillary management determined by SNB (group A) and the other 27 underwent axillary lymph node dissection (ALND) without SNB (group B). SNB was performed using a modified dye method. The sentinel node (SN) identification rate was 94.3% and the mean number of removed SNs was 2.4. ALND was avoided in 33 patients, who were confirmed as SN-negative. There was no difference in recurrence-free and overall survival rates between groups A and B (p=0.71 and p=0.46, respectively) during the median follow-up time of 63months. Of the 33 patients who did not undergo ALND, 10 suffered recurrence (33%). One patient (3%) had recurrence in an axillary lymph node and four had recurrence in a supraclavicular lymph node. Axillary SNB after NAT did not affect the axillary failure rate or the prognosis. SNB may be a reliable procedure, even after NAT.

Utility of single-photon emission tomography/computed tomography for sentinel lymph node localization in breast cancer patients.

Sentinel lymph node (SLN) mapping is currently a routine technique in breast cancer management and preoperative scintigraphic imaging plays a crucial role in the process of SLN detection. The guidelines recommend performing planar acquisition and optional single-photon emission tomography/computed tomography (SPECT/CT) imaging. The aim of this study was to verify whether routine performing of SPECT/CT in addition to planar imaging increases the sensitivity of SLN detection in patients with early-stage breast cancer. The secondary aims were to compare radionuclide SLN imaging with intraoperative SLN detection and identify clinical and histopathological factors affecting the SLN detection rate. A total of 153 early-stage breast cancer patients underwent lymph node scintigraphy in the years 2007-2013. Breast cancer patients with staging T1-2N0M0 were included. Planar and SPECT/CT lymphoscintigraphy were performed on the day before the surgery. The data on presence or absence of SLN, their number and localization were recorded for both methods and compared with each other as well as with intraoperative blue dye staining and histopathological findings. SPECT/CT identified SLN in 119/153 and planar scintigraphy in 114/153 patients. Identification rates were 77.7 and 74.5%, respectively. Intraoperative lymph node assessment identified SLN in 76/126 cases with an identification rate of 60.3%. Identification rates for second echelon lymph node were 34.6% for hybrid imaging and 21.2% for planar scintigraphy. Statistical analysis did not yield a significant difference in diagnostic accuracy between these methods; however, the Wilcoxon signed-rank test showed that SPECT/CT significantly increases SLN identification rate compared with planar scintigraphy and intraoperative detection. Histopathological examination of excised SLN showed that 22 nodes were metastatic. SPECT/CT visualized all of these, whereas planar imaging and intraoperative lymph node detection procedure visualized 19 and 18, respectively. No clinical and histopathological factors affecting SLN detection rate were identified. Hybrid SPECT/CT lymphatic mapping yields a high SLN detection rate in patients with early-stage breast cancer and provides lymph node localization details. It identifies more SLN than planar imaging and intraoperative SLN detection. However, its limited superiority over the remaining two methods does not support its routine use for SLN localization. We suggest using SPECT/CT for SLN detection in case of equivocal planar imaging results.

Swedish prospective multicenter trial evaluating sentinel lymph node biopsy after neoadjuvant systemic therapy in clinically node-positive breast cancer

PurposePatients with clinically node-positive breast cancer planned for neoadjuvant systemic therapy (NAST) may draw advantages from the nodal downstaging effect and reduce the extent of axillary surgery with sentinel lymph node biopsy (SLNB) performed after NAST. Since there are concerns about lower sentinel lymph node (SLN) detection and higher false-negative rates (FNR) in this setting, our aim was to define the accuracy of SLNB after NAST.MethodsThis Swedish national multicenter trial prospectively recruited 195 breast cancer patients from ten hospitals with T1–T4d biopsy-proven node-positive disease planned for NAST between October 1, 2010 and December 31, 2015. Clinically node-negative axillary status after NAST was not mandatory. SLNB was always attempted and followed by a completion axillary lymph node dissection (ALND).ResultsThe SLN identification rate was 77.9% (152/195) but improved to 80.7% (138/171) with dual mapping. The median number of SLNs was two (range 1–5). A positive SLNB was found in 52% (79/152), almost 66% (52/79) of whom had additional positive non-sentinel lymph nodes. The overall pathologic nodal response rate was 33.3% (66/195). The overall FNR was 14.1% (13/92) but decreased to 4% (2/50) when only patients with two or more sentinel nodes were analyzed.ConclusionsIn biopsy-proven node-positive breast cancer, SLNB after NAST is feasible even though the identification rate is lower than in clinically node-negative patients. Since the overall FNR is unacceptably high, the omission of ALND should only be considered if two or more SLNs are identified.

Abstract P2-01-27: Sentinel lymph node biopsy by contrast-enhanced ultrasonography with sonazoid in patients with breast cancer - Prospective multicenter study

Abstract Background: The aim of this prospective study is to evaluate feasibility of the periareolar injection of contrast agent (Sonazoid (SNZ)) followed by ultrasonography (US) for identification of sentinel lymph node (SLN) in breast cancer patients with clinically negative node. Patients and Methods: Patients with T1-2N0M0 breast cancer were recruited in this study. They received the periareolar injection of SNZ followed by US to identify contrast-enhanced SLN. Fine needle aspiration biopsy (FNAB) was done for each CE-SLN. Then, they underwent SLN biopsy with the conventional method, blue dye and/or radiotracer (B/R). Results: In almost all cases, contrast-enhanced lymphatic vessels were clearly visualized US soon after the periareolar injection of SNZ, and SLN, into which lymphatic flow was draining, was easily identified. The identification rate of SLN was 98% (98/100) by SNZ and 100% (100/100) by B/R. The number of SLNs identified by SNZ (mean per patient, 1.52) was significantly (P &amp;lt; 0.001) lower than that of those by B/R (2.22). Twenty-five patients had at least one metastasis in the SLNs identified by SNZ and/or B/R. In these patients, SLNs (n=39) identified by both SNZ and B/R showed a significantly (P &amp;lt; 0.0001) higher positivity (74.4%) for metastases than those (n=19) identified by B/R alone (21.1%). Conclusion: Identification of SLN by periareolar injection of SNZ followed by US is a technically easy method and the identification rate of SLN was as high as 98%, being comparable to the conventional B/R. SLNs detected by SNZ seem to represent the true SLNs which first receive lymphatic flow from the tumor among the SLNs detected by B/R. Citation Format: Shimazu K, Ito T, Uji K, Miyake T, Motomura K, Noguchi S. Sentinel lymph node biopsy by contrast-enhanced ultrasonography with sonazoid in patients with breast cancer - Prospective multicenter study [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-27.

Abstract P2-01-10: Cumulative analysis of breast cancer sentinel lymph node identification rate by radioisotope: A 13-year experience

Abstract Purpose: To investigate the breast cancer sentinel lymph node(SLN) identification rate by radioisotope navigation over the past 13 years at a single cancer centre institution. Method: Retrospective, breast cancer sentinel lymph node data in the past 13 years was collected. Between May 2002 to August 2008, sulphur colloid was the radioisotope agent used at the institution. Between August 2008 to August 2012, the radioisotope agent was switched to phytate. Then, between September 2012 to June 2015, injection method of phytate was switched from subdermal to intradermal. The SLN identification rate from each three periods were compared and analysed. Results: In a 13-year period (May 2002~June 2015), a total of 5455 breast cancer axillary sentinel lymph node samples were collected. Each surgeon's first 50 cases were excluded, thus a reduction to 5105 samples were derived. 155 cases were bilateral. Out of the 5105 samples, 40 did not undergo radioisotope mapping. During the 13-year period, total successful SLN identification rate was 96.7%(4897/5065). During the sulphur colloid period (May 2002~August 2008), successful SLN identification rate was 99.1%(996/1005). During the subdermal phytate period (August 2008~August 2012), successful SLN identification rate was 95.1%(2200/2313). During the intradermal phytate period (September 2012~June 2015), successful SLN identification rate was 97.4%(1701/1747). After injection of radioisotope agent, lymphatic scan mapping may fail. However, radioisotope signals may still be detected by radioisotope navigator intra-operatively. During the sulphur colloid period (May 2002~August 2008), mapping failure rate was 5.2%(52/1005). SLN identification rate by intra-operative navigator after scan mapping failure was 96.1%(50/52). During the subdermal phytate period (August 2008~August 2012), mapping failure rate was 21.7%(501/2313). SLN identification rate by intra-operative navigator after scan mapping failure was 79.0%(396/501). During the intradermal phytate period (September 2012~June 2015), mapping failure rate was 12.8%(223/1747). SLN identification rate by intra-operative navigator after scan mapping failure was 83.4%(186/223). Conclusion: Different radioisotope agent may affect the identification rate of axillary sentinel lymph nodes in breast cancer patients. Change of injection method, such as from subdermal to intradermal, may improve identification rate in use of same radioisotope agent. Even when lymphatics scan mapping failed, intra-operative radioisotope navigator may still successfully identify axillary sentinel lymph nodes and avoid unnecessary dissection due to mapping failure. Citation Format: Chen Y-Y, Yu B-L, Lee C-C, Wei H-K, Lin C-W, Tsai T-J, Cheng T-Y, Chen C-M. Cumulative analysis of breast cancer sentinel lymph node identification rate by radioisotope: A 13-year experience [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-10.