Sentinel Node Biopsy In Breast Cancer Research Articles

Outcome of axillary staging in early breast cancer: a meta-analysis

Axillary lymph node dissection (ALND) is associated with significant morbidity, whilst sentinel node biopsy (SNB) has the potential to minimize complications in the management of breast cancer. The aim of this study was to systematically appraise the outcome of SNB when compared to ALND. A comprehensive search for published trials examining outcomes after SNB for breast cancer was performed using medline and cross-referencing available data. Each study was reviewed and data extracted. Primary outcomes were nodal positivity and surgery-related morbidity. A total of 9,608 patients were identified from trials comparing ALND and SNB. The overall rate of axillary lymph node positivity for those with no clinically palpable nodes was 28.8% for ALND and 27.6% for SNB (OR = 1.00, 95% CI = 0.86-1.17, P = 0.956), though there was a trend for superior detection of metastatic disease with SNB when this was compared with ALND alone (OR = 1.22, 95% CI = 0.95-1.57, P = 0.122). Patients who undergo SNB are significantly less likely to suffer post-operative morbidity relative to ALND: risk of infection (OR = 0.58, 95% CI = 0.42-0.80, P = 0.0011), seroma (OR = 0.40, 95% CI = 0.31-0.51, P = 0.0071), arm swelling (OR = 0.30, 95% CI = 0.14-0.66, P = 0.0028) and numbness (OR = 0.25, 95% CI = 0.1-0.59, P = 0.0018). SNB is at least equivalent to ALND in detecting metastatic disease in the axilla. SNB is the optimum approach in terms of morbidity for the assessment of axillary metastasis in clinically node negative breast cancer.

Post-Neoadjuvant Chemotherapy Sentinel Lymph Node Biopsy Is Reliable in Breast Cancer: A Prospective Study in Chinese Patients.

Abstract Background: Sentinel lymph node biopsy (SLNB) for breast cancer patients before chemotherapy is currently being practiced in a world wide scale. However, obvious disadvantage of a second surgical procedure after neoadjuvant chemotherapy (NAC) has been noted. Considering that metastasis in axillary lymph node would probably be eradicated by NAC making axillary lymph node dissection (ALND) completely unnecessary, SLNB performed after NAC could be a choice. Nonetheless, it is still controversial for a fear of impaired detection rate and accuracy. Therefore we carried out a prospective study by one single surgical team to compare SLNB between post-NAC patients and non-NAC patients.Methods: Operable invasive breast cancer patients confirmed by core needle biopsy before treatment with clinical N0 or N1 axilla were enrolled. Exclusion criteria included noninfiltrating cancer, inflammatory carcinoma and clinically fixed axillary lymph node. SLNB followed by ALND was performed in one single operation by the same surgical team for all patients either afer NAC or without NAC. Single methylene blue was used for SLN tracing with 2ml injected subcutaneously into the areola area and the mapping procedure was started 5 minutes later. SLN and ALND specimens were examined by 2 independent pathologists under standard pathological procedures.Results: From Dec 2007 to May 2009, 50 patients without NAC and 49 patients after NAC were prospectively enrolled. SLNB and ALND were performed as scheduled. In the post-NAC group, 19 had clinical N0 axilla and 30 had N1 axilla before treatment. SLNB was successful in 46 patients with 1.6 SLNs detected on average (range 1 to 5) and the average number of lymph nodes taken out in ALND was 15.4 (range 7 to 33). We found 9 with SLN(+)/ALN(+), 5 with SLN(+)/ALN(-), 2 with SLN(-)/ALN(+), and 29 with SLN(-)/ALN(-). In the non-NAC group, 40 had clinical N0 axilla and 10 had N1 axilla before surgery. SLNB was successful in 48 patients with 1.7 SLNs detected on average (range 1 to 6) and the average number of lymph nodes taken out in ALND was 16.8 (range 8 to 38). We found 4 with SLN(+)/ALN(+), 10 with SLN(+)/ALN(-), 1 with SLN(-)/ALN(+), and 33 with SLN(-)/ALN(-). Detection rate, accuracy, and false negative rate was 93.9% (46 of 49), 95.7% (44 of 46) and 11.8% (2 of 17) in post-NAC group and 96% (48 of 50), 97.9% (44 of 46) and 6.7% (1 of 15) in non-NAC group, respectively. There was no statistical difference between post-NAC group and non-NAC group in either detection rate (p=0.409), accuracy (p=0.525) or false negative rate (p=0.548).Conclusions: This prospective study in Chinese breast cancer population shows that post-NAC SLNB has both satisfactory detection rate and accuracy with acceptable false negative rate, being comparable to non-NAC patients. Our results also showed that using methylene blue only in SLNB for breast cancer is an ideal choice where radio detection method is not available.Summary of pathological resultsGrouppost-NAC (N=49)non-NAC (N=50)SLNB successful4648Average SLNs detected1.6 (range 1 to 5)1.7 ( range 1 to 6)Average ALNs taken out15.4 (range 7 to 33)16.8 (range 8 to 38)SLN+ / ALN-94SLN+/ ALN+510SLN- / ALN+21SLN- / ALN-2933 Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1014.

Establishing Axillary Sentinel Lymph Node Biopsy (SLNB) for Early Breast Cancer in the United Kingdom: A Survey of the National Training Program.

Abstract IntroductionThe UK National training programme (NEWSTART) for SLNB in breast cancer was established in 2004. This unique national educational initiative aimed at providing structured, standardised training with a focus on multidisciplinary team (MDT) delivery. Patient safety was the primary aim and central audit and validation was integral to the program.We conducted a national survey 4 years after its introduction with the aim of obtaining a snap shot of the training program and identifying if there are any common barriers that might limit participation and progression in SLNB training.MethodologyIn collaboration with the Association of Breast Surgeons (ABS) in the UK, paper and electronic questionnaires were sent to 400 registered surgeons. The questionnaire was divided into three sections, exploring the SLNB concept, training and post training experiences.ResultsMost (97%) of breast surgeons are convinced by the evidence for SLNB as standard of care for early breast cancer. 64% of respondents use SLNB to stage clinically node negative breast cancers, of whom 23% use it as a standalone procedure in their practice.The NewStart program begins with a theory day, which has been completed by 86% of respondants. Participants then either follow an apprentiship model of training (completed by 29%) or a proctorship model for which there is initially an in-house training phase (completed by 49%) and then a validation phase (completed by 41%). 38% of surgeons were dissatisfied with the time it takes to complete the in house training, and 87% with the time it takes to complete the validation phase. Logistical and funding issues were the main problems cited.The majority of surgeons (86%) use the recommended SLNB detection technique (combined isotope and blue dye), with 47% continuing to use the dual localisation method. 14% use either blue dye or isotope alone, without scintiscan imaging. Only 10% offer intra operative diagnosis, of which the majority (6%) use touch imprint cytology. These low figures are due to logistical constraints, including lack of on-site pathologists, funding and time. 31% included their results in their most recent surgical appraisal.ConclusionsThe NEW START program introduced and set a standard of care in a systematic method. It was unique in the sense that training was validated across a comprehensive national health service, translating specialist standards to every unit in the country, over a relatively short time frame. The majority of breast surgeons in the UK are convinced by the evidence for SLNB, and so most now use SLNB in their practice for staging clinically node negative breast cancer. Reasons for not conducting SLNB or IOD are logistical rather than lack of belief in the procedure. Barriers to uptake and progress were as expected - logistical and financial rather than attitudinal. The majority of respondents who completed their training did so within the anticipated time line. The majority of centres do not perform intra-operative assessment of the SLN due to lack of resources which means node positive patients have to undergo a second operation. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1020.

Reoperative sentinel lymph node biopsy in ipsilateral breast cancer relapse

Sentinel lymph node biopsy (SLNB) is controversial following ipsilateral breast tumour relapse (IBTR) and previous axillary surgery. We retrospectively assessed the feasibility, outcomes and utility of this procedure. Eighteen patients with IBTR who underwent reoperative SLNB were identified. Fifteen women had previously undergone axillary lymph node dissection and three SLNB for breast cancer. Twelve of 16 patients underwent successful lymphoscintigraphy (LSG). Lymphatic drainage patterns varied widely - ipsilateral axilla (5), contralateral axilla (5), and ipsilateral internal mammary (5). Two patients had drainage to more than one nodal basin. Nine of 12 patients demonstrated drainage outside of the ipsilateral axilla. Reoperative SLNB was successful in 12/18 of patients - 4 ipsilateral axilla, 1 ipsilateral internal mammary, 1 ipsilateral intramammary, 4 contralateral axilla. Two patients had sentinel nodes in multiple nodal basins. Positive sentinel node was found in one successful case (contralateral axilla) and isolated tumour cells in two (1 contralateral axilla, 1 ipsilateral internal mammary). In conclusion, reoperative SLNB is feasible. Lymphatic drainage patterns vary widely and preoperative LSG is vital to facilitate identification of sentinel nodes in unusual sites. Its prognostic and therapeutic significance warrants further study.

Micrometastases or Isolated Tumor Cells and the Outcome of Breast Cancer

The association of isolated tumor cells and micrometastases in regional lymph nodes with the clinical outcome of breast cancer is unclear. We identified all patients in The Netherlands who underwent a sentinel-node biopsy for breast cancer before 2006 and had breast cancer with favorable primary-tumor characteristics and isolated tumor cells or micrometastases in the regional lymph nodes. Patients with node-negative disease were randomly selected from the years 2000 and 2001. The primary end point was disease-free survival. We identified 856 patients with node-negative disease who had not received systemic adjuvant therapy (the node-negative, no-adjuvant-therapy cohort), 856 patients with isolated tumor cells or micrometastases who had not received systemic adjuvant therapy (the node-positive, no-adjuvant-therapy cohort), and 995 patients with isolated tumor cells or micrometastases who had received such treatment (the node-positive, adjuvant-therapy cohort). The median follow-up was 5.1 years. The adjusted hazard ratio for disease events among patients with isolated tumor cells who did not receive systemic therapy, as compared with women with node-negative disease, was 1.50 (95% confidence interval [CI], 1.15 to 1.94); among patients with micrometastases, the adjusted hazard ratio was 1.56 (95% CI, 1.15 to 2.13). Among patients with isolated tumor cells or micrometastases, the adjusted hazard ratio was 0.57 (95% CI, 0.45 to 0.73) in the node-positive, adjuvant-therapy cohort, as compared with the node-positive, no-adjuvant-therapy cohort. Isolated tumor cells or micrometastases in regional lymph nodes were associated with a reduced 5-year rate of disease-free survival among women with favorable early-stage breast cancer who did not receive adjuvant therapy. In patients with isolated tumor cells or micrometastases who received adjuvant therapy, disease-free survival was improved.

Optimal timing of radioactive tracer for sentinel node biopsy in breast cancer patients

611 Background: While sentinel node biopsy (SNB) is well established as a minimally invasive means of staging the axilla in breast cancer patients, the optimal timing of injection of technetium 99m sulfur colloid (Tm) for SNB remains unclear. Methods: In a prospective multicenter study of 4131 patients who had a SNB for breast cancer followed by axillary node dissection, 3305 patients had a SNB using Tm with the elapsed time from injection to SNB being recorded. These 3305 patients formed the cohort of interest for this study. The dose of Tm remaining at the time of SNB was calculated with the formula mCiremaining=mCiinjected*0.5^(elapsed hours/6). Patients with injection of Tm ≤12h and >12h were compared using SPSS. Results: The mean age of the 3305 patients in this study was 60 years, with a mean tumor size of 1.8 cm. A sentinel node (SN) was identified in 95% of patients. SN identification (ID) was not affected by mCi injected (p=0.88), mCi remaining at time of SNB (p=0.13), or type of Tm (filtered vs. unfiltered, p=0.37). There was a statistically non-significant trend of more SN's removed in the ≤12h group (3.2 vs. 2.5, p=0.06). False negative rate was not affected by mCi injected (p=0.39), mCi remaining at time of SNB (p=0.24), or type of Tm (filtered vs. unfiltered, p=1.00). The overall false negative (FN) rate was 8.0%. Of the 3305 patients in this study, 3221 were injected ≤12h prior to SNB and 84 were injected >12h prior to SNB. For the patients injected ≤12h compared to >12h, there was no difference in SN ID rate, FN rate, counts of the hottest node, or background counts despite more mCi injected and less mCi remaining at SNB in the >12h cohort (see Table). Conclusions: Injecting Tm >12h prior to SNB has an acceptable SN identification rate, and the FN rate was not significantly different than injecting Tm ≤12h prior to SNB. [Table: see text] No significant financial relationships to disclose.

First Three Sentinel Lymph Nodes Accurately Stage the Axilla in Breast Cancer

Sentinel lymph node (SLN) biopsy is the preferred method of assessing lymph nodes in breast cancer. Recent literature suggests increasing morbidity with increased number of SLN removed. However, controversy exists regarding the number of SLN that should be removed. A retrospective review of patients undergoing SLN biopsy for breast cancer from 2003 to 2005 was performed. Data analyzed included the number of SLNs, nodes per specimen, and pathology. The order of SLN removal was documented and the first positive lymph node noted. Three hundred fifty-three patients underwent successful SLN biopsy. On average, only one surgical SLN was identified. However, the average number of pathologically identified SLN was 1.3. Nodal disease was identified in 79 patients (22.4%). The first SLN was positive in 70 of those patients (88.6%). Six additional patients were diagnosed by the second SLN (76 of 79 [96.2%]), and all 79 patients were identified within the first three nodes. All patients with nodal disease were identified within three SLNs. These data support the concept that surgeons do not need to remove all identifiable sentinel nodes. Moreover, surgeons could consider limiting the number of excised SLNs to three.

Technique and clinical consequences of sentinel lymph node biopsy in colorectal cancer

Sentinel lymph node biopsy (SLNB) in colorectal cancer (CRC) is a controversial issue. Different detection techniques, various protocols for the histopathological work-up of the SLN and a greatly differing experience between the investigators make the comparison of the available studies problematic. Nevertheless, it is clear, that the successful clinical application of SLNB in breast cancer and melanoma cannot simply be transferred into colorectal cancer treatment. In this paper we try to define the current status of clinical application of this technique in CRC by means of a literature review and our own experience. Moreover, the background and the potential clinical implications of additionally small tumor deposits in the SLN (so-called "upstaging") is critically reviewed. Summarizing the results, it is clear, that the value of SLNB in CRC is still unclear. If current techniques are to be applied outside a study protocol and no patient selection is performed the correct identification of macrometastases needs further investigation. Although still under debate, there is otherwise growing evidence, that -at least if RT-PCR-techniques are used- the detection of small tumor deposits in the SLN may be of prognostic and therefore clinical value. Future studies should focus on two subjects: First, alternative detection techniques and careful patient selection may clarify, if an improvement of the sensitivity to detect macrometastases is feasible. Second, large prospective trials using a standardized histopathological lymph node assessment should compare SLN and Non-SLN for its incidence to bear small tumor deposits. If SLNB proves to be sensitive, the prognostic and predictive value of these additional findings should be clarified.

A Randomized Clinical Trial on Sentinel Lymph Node Biopsy Versus Axillary Lymph Node Dissection in Breast Cancer

The aim of this multicenter randomized trial was to assess the efficacy and safety of sentinel lymph node (SLN) biopsy compared with axillary lymph node dissection (ALND). All studies on SLN biopsy in breast cancer report a variable false negative rate, whose prognostic consequences are still unclear. From May 1999 to December 2004, patients with breast cancer < or =3 cm were randomly assigned to receive SLN biopsy associated with ALND (ALND arm) or SLN biopsy followed by ALND only if the SLN was metastatic (SLN arm). The main aim was the comparison of disease-free survival in the 2 arms. A total of 749 patients were randomized and 697 were available for analysis. SLNs were identified in 662 of 697 patients (95%) and positive SLNs were found in 189 of 662 patients (28.5%). In the ALND group, positive non-SLNs were found in 18 patients with negative SLN, giving a false negative rate of 16.7% (18 of 108). Postoperative side effects were significantly less in the SLN group and there was no negative impact of the SLN procedure on psychologic well being. At a median follow-up of 56 months, there were more locoregional recurrences in the SLN arm, and the 5-year disease-free survival was 89.9% in the ALND arm and 87.6% in the SLN arm, with a difference of 2.3% (95% confidence interval: -3.1% to 7.6%). However, the number of enrolled patients was not sufficient to draw definitive conclusions. SLN biopsy is an effective and well-tolerated procedure. However, its safety should be confirmed by the results of larger randomized trials and meta-analyses.

O-66 New efficient breast cancer sentinel node biopsy technique for all

O-66 New efficient breast cancer sentinel node biopsy technique for all

Sentinel lymph node biopsy for breast cancer: How many nodes are enough?

Sentinel lymph node (SLN) biopsy using blue dye and radioisotope often results in the removal of multiple SLNs. We sought to determine whether there is a point where the surgeon can terminate the procedure without sacrificing accuracy. One thousand one hundred ninety-seven patients from University of Michigan and the Mayo Clinic undergoing SLN biopsy formed the study population. Surgeons removed all SLNs until counts within the axilla were less than 10% of the highest node ex vivo and recorded the order in which they were removed. The mean number of SLNs removed per patient was 2.5 (range 1-9). Approximately 42% of patients had three or more lymph nodes removed, while 19% had four or more lymph nodes removed. Eighteen percent of patients (132/725) at University of Michigan and 22% (103/472) at Mayo Clinic had a positive SLN. Ninety-eight percent (231/235) of patients with lymph node metastases were identified by the 3rd SLN while 100% were identified by the 4th SLN. Among patients undergoing SLN biopsy for breast cancer, the only positive SLN is rarely identified in the 4th or higher node. Terminating the procedure at the 4th node may lower the cost of the procedure and reduce morbidity.

A nonrandomized follow-up comparison between standard axillary node dissection and sentinel node biopsy in breast cancer

In many countries sentinel node biopsy (SNB) has become the standard of care in breast cancer based on a large number of observational studies but without results from prospective randomized trials. The goal of our study was to evaluate the oncological safety of the SNB in breast cancer in a multicenter, nonrandomized setting with comparable groups. Between 1996/05 and 2004/11, 2942 patients from 14 departments in Austria with unicentric, unilateral, invasive disease without neoadjuvant therapy were collected in a database. The recommendations of the Austrian Sentinel Node Study Group were to complete a training period (phase I) with 50 cases of SNB followed by axillary lymph node dissection (ALND) to prove a detection rate of > or = 90% and a false-negative rate of < or = 5%. In the executing period (phase II), SNB was followed by ALND only if the sentinel node (SN) contained metastases. We compared the results on disease-free survival, local recurrence rates, distant recurrence rates and overall survival of both groups. Cases from phases I and II generated groups I (n=671) and 2 (n=2271 cases), respectively. Overall mean follow-up time: 34.41 months. SNB followed by ALND only in cases with metastases in the SN is a safe procedure and at least equal to ALND in all cases.

Medium-term follow-up data after sentinel node biopsy alone for breast cancer

Aims In patients with early breast cancer sentinel node biopsy (SNB) proved to be an accurate procedure for axillary staging with significantly reduced morbidity. Medium- and long-term observational studies are needed to establish, whether SNB alone is able to prevent locoregional recurrence without impairing long-term survival. Methods 298 patients with invasive breast cancer were subjected to SNB in a prospective audit. Lymphatic mapping was performed with blue dye and radiocolloids. 180 patients had SNB alone (group 1), while 118 subsequently underwent axillary dissection (AD; group 2). In ten patients AD was omitted despite the tumor burden in the SN. Clinical follow-up studies were performed at regular intervals. The mean follow-up time was 47 months in group 1 (range 7–90) and 46 months in group two (range 1–87 months). Results Sentinel nodes were identified in 286 out of 298 patients (96%). One patient in group 1 developed axillary and simultaneous supraclavicular lymph node recurrence. After AD regional relapses have so far not been observed. One ipsilateral local recurrence was detected in each group. Five patients in group 1 and 15 patients in group 2 developed distant metastases. Three out of six and eight out of nine patients, respectively, died of their advanced disease. All patients with SN tumor infiltration not subjected to AD are alive and well. Conclusions Axillary recurrence is rare after sentinel node biopsy alone. Its rate is comparable to that after AD, even in patients with SN micrometastases. These conclusions are confirmed by reports in the literature.

Axillary Ultrasonography to Detect Recurrence After Sentinel Node Biopsy in Breast Cancer

Sentinel node biopsy (SNB) for breast cancer has a false-negative rate of approximately 5%. Initial reports of follow-up show lower axillary recurrence rates than expected. We performed axillary ultrasonography to determine whether occult recurrences could be detected. In a community hospital setting, 289 patients who had SNB for breast cancer in a single surgeon's practice underwent axillary examination by the surgeon followed by axillary ultrasonography by a dedicated breast radiologist. Ultrasonography was performed one time from 4 to 79 months (median, 25 months) after surgery. Five patients with suspicious nodes had ultrasound-guided fine-needle aspiration, and one had a core biopsy. No patient had suspicious nodes on clinical examination. Only six patients had ultrasound findings that warranted intervention. Five patients had benign cytological characteristics, and one had a benign core biopsy result. No evidence of axillary recurrence was found in any patient. Axillary ultrasonography did not detect occult metastases in any patient and is not recommended for routine follow-up after SNB. The lack of ultrasound evidence of metastasis suggests that the recurrence rate is likely to remain low.

99mTc-Phytate Is Better than 99mTc-Human Serum Albumin as a Radioactive Tracer for Sentinel Lymph Node Biopsy in Breast Cancer

Several radioactive agents are used for sentinel lymph node biopsy (SLNB) in breast cancer, but we are still unsure which of these is best. We retrospectively compared the effectiveness of two radioactive agents, 99mTc-phytate and 99mTc-human serum albumin (HSA), when used in combination with blue dye. A consecutive series of 533 clinically node-negative patients with a collective 539 breast carcinomas were divided into two groups for treatment with SLNB. The HSA-group consisted of 264 patients (with a collective 266 breast cancers) and the P-group consisted of 269 patients (with a collective 273 breast cancers) treated with 99mTc-HSA and 99mTc-phytate, respectively, in combination with blue dye. We analyzed the identification and radioactivity of SLNs in the two groups. The identification rate of SLN was significantly higher in the P-group than in the HSA-group. The same results were produced by analysis using the radioactive agent alone, but not by using the blue dye alone. Most importantly, the highest radioactivity of SLNs per case was more than five times higher in the P-group than in the HSA-group, and this difference was significant. Our historical analysis of the two radioactive agents used in different periods could not exclude the influence of the improved skill of the surgeons. However, because the specific accumulation of phytate in SLNs was greater than that of HSA, phytate might result in a higher SLN identification rate. Thus, 99mTc-phytate is better than 99mTc-HSA as a radioactive agent for SLNB in breast cancer.

Modifications of the Learning Curve Guidelines for Breast Cancer Sentinel Node Biopsy

Modifications of the Learning Curve Guidelines for Breast Cancer Sentinel Node Biopsy

Recent advances in haematology and oncology: graft-versus-host disease, classification and treatment of non-Hodgkin's lymphomas, and sentinel-node biopsy in breast cancer.

Recent advances in haematology and oncology: graft-versus-host disease, classification and treatment of non-Hodgkin's lymphomas, and sentinel-node biopsy in breast cancer.

The Role of Sentinel Lymph Node Detection in the Preoperative Evaluation of Breast Cancer Patients

SummaryThe concept of sentinel lymph node biopsy (SLNB) in breast cancer surgery is based on the fact that tumours drain in a predefined way in the lymphatic system. SLNB can avoid complete axillary dissection in patients without clinical evidence of nodal involvement. The use of SLNB as a minimal invasive procedure can prevent the risk of morbidity due to axillary node dissection in the majority of breast cancer patients without metastatic disease. Many routes for administration of very low activities of radiotracers (99mTc‐labelled colloids) are known among which subdermal or peritumoural injection are most commonly used. Radiocolloids with their particles in the 5–200 nm size range are most suitable for SLNB in breast cancer. The success rate of detecting and localizing the SLN by means of a gamma probe in breast cancer surgery reaches more than 95% in experienced institutions performing a high number of procedures. Current approved indications include unifocal or multifocal resectable breast cancer (&lt;3 cm diameter) without clinically suspicious or palpable axillary lymph nodes and ductal breast cancer in situ (&gt;2 cm diameter). SLNB has also proved to be a useful and accurate procedure in the setting of preoperative chemotherapy. SLNB which requires a multidisciplinary approach represents the standard of care in many centres for patients with breast cancer.

An axilla scoring system to predict non-sentinel lymph node status in breast cancer patients with sentinel lymph node involvement

Axillary lymph node dissection (ALND) is the current standard of care for breast cancer patients with sentinel lymph node (SN) involvement. However, the SN is the only involved axillary node in a significant proportion of these patients. Here we examined factors predictive of non-SN involvement in patients with a metastatic SN, in order to develop a scoring system for predicting non-SN involvement. This study was based on a prospective database of 337 patients who underwent SN biopsy for breast cancer, of whom 81 (24%) were SN-positive; we examined factors predictive of non SN involvement in the 71 of these 81 women who underwent complementary ALND. All clinical and histological criteria were recorded and analysed according to non-SN status, by using Chi-2 analysis, Student's t-test, and multivariate logistic regression. Univariate analysis showed a significant association between non-SN involvement and histological primary tumor size (p=0.0001), SN macrometastasis (p=0.01), the method used to detect SN metastasis (H&E versus immunohistochemistry) (p=0.03), the number of positive SNs (p=0.049), the proportion of involved SNs among all identified SNs (p=0.0001) and lymphovascular invasion (p=0.006). Histological primary tumor size (p=0.006), SN macrometastasis (p=0.02) and the proportion of involved SNs among all identified SNs (p=0.03) remained significantly associated with non-SN status in multivariate analysis. Based on the multivariate analysis, we developed an axilla scoring system (range 0-7) to predict the likelihood of non-SN metastasis in breast cancer patients with SN involvement. In patients with invasive breast cancer and a positive SN, histological primary tumor size, the size of SN metastases, and the proportion of involved SNs among all identified SNs were independently predictive of non-SN involvement.

Lymphatic Mapping and Sentinel Lymph Node Biopsy for Breast Cancer: Developments and Resolving Controversies

It has now been over 10 years since lymphatic mapping and sentinel lymph node (SLN) biopsy was first used in patients with breast cancer. Since the procedure was introduced, over 1,500 studies on SLN biopsy in breast cancer have been published in the cited world medical literature. Over 11,000 women have been enrolled in National Cancer Institute–sponsored SLN biopsy trials for breast cancer, the final results of which will not be available until several years from now. In the meantime, both the National Comprehensive Cancer Network treatment guidelines in the United States and the Saint Gallen International Consensus Conference on the treatment of breast cancer have now indicated that SLN biopsy is an acceptable alternative to axillary lymph node dissection in patients with clinically nodenegative breast cancer, provided that the SLN team has documented experience with this technique. Simply stated, although long-term follow-up data are not yet available from randomized trials comparing SLN biopsy with axillary lymph node dissection, SLN biopsy has become an acceptable alternative to routine level I and II axillary lymph node dissection for women with clinically node-negative early-stage breast cancer in the United States and in several other developed countries. However, despite a clear picture of increasing integration of SLN biopsy into standard diagnostic and therapeutic strategies for breast cancer, there are several clinical scenarios in which the utility of this technique has been questioned. This article will focus on current and resolving controversies associated with breast cancer lymphatic mapping and SLN biopsy.