Sentinel Lymph Node Biopsy In Women Research Articles

Sentinel Lymph Node Staging in Early-Stage Cervical Cancer: A Comprehensive Review.

Cervical cancer (CC) continues to be a significant global public health concern, even with preventive measures in place. In women with early-stage CC, the status of lymph nodes is of paramount importance, not only for the final prognosis but also for determining the best therapeutic strategy. According to main international guidelines, pelvic full lymphadenectomy (PLND) is recommended for lymph node staging. However, in these early stages of CC, sentinel lymph node biopsy (SLNB) has emerged as a precise technique for evaluating lymph node involvement, improving its morbidity profile. We performed a literature review through PubMed articles about progress on the application of SLNB in women with early-stage CC focusing on the comparison with PET/CT and PLND in terms of oncological outcomes and diagnostic accuracy. While the superiority of SLNB is clear compared to radiologic modalities, it demonstrates no clear oncologic inferiority over PLND, given the higher detection rate of positive lymph nodes and predominance of no lymph node recurrences. However, due to a lack of prospective evidence, particularly concerning long-term oncological safety, SLNB is not the current gold standard. With careful patient selection and adherence to straightforward protocols, a low false-negative rate can be ensured. The aim of the ongoing prospective trials is to address these issues.

O078 Is there a role for SLNB in women with breast cancer >70 years old? A retrospective institutional review

Abstract Introduction The Choosing Wisely guidelines were published to de-escalate surgical staging of the axilla in women >70 years of age with early invasive breast cancer. They advised against performing a sentinel lymph node biopsy (SLNB) in clinically node negative, ER+, HER2- breast cancer. Despite these guidelines, some surgeons continue to perform SLNB for adjuvant chemo/radiotherapy guidance in this cohort. Methods A retrospective review of 347 women >70 years of age with invasive breast cancer, who underwent a SLNB between 2014 and 2022 in a single institution was performed using the Beaumont Breast Cancer Database. Data was collected on patient and tumour characteristics, subsequent management and overall survival (OS). Results Of 347 patients included, 91(26.22%) had a positive SLNB. 49 (14.1%) patients received chemotherapy. Of the 66 patients >80 years old, 1 received chemotherapy (1.5%). Total of 13/128(10.15%) patients (aged 75-79) and 35/153(22.9%) of patients (aged 70-74) received chemotherapy. Of 272 ER+/HER2- patients, Oncotype DX was performed in 102 patients (37.5%). From those, 17 patients had a high (>25) score (16.7%) and 10 received chemotherapy (58.8%). The remaining 86 had a low score (84.3%) and 4 received chemotherapy (4.7%). Conclusion Sentinel lymph node biopsy had little influence in guiding management decisions and adjuvant therapy in patients over 80 in this study. However, we found that SLNB still had a role in patients aged 70-80 and should be used selectively in this cohort. Ongoing prospective trials will expand the increasing role of Oncotype Dx and axillary US as a replacement for SLNB.

Assessment of Oncologists’ Perspectives on Omission of Sentinel Lymph Node Biopsy in Women 70 Years and Older With Early-Stage Hormone Receptor–Positive Breast Cancer

Randomized clinical trial data have demonstrated that omission of surgical axillary evaluation does not affect overall survival in women 70 years and older with early-stage (clinical tumor category 1 [cT1] with node-negative [N0] disease) hormone receptor (HR)-positive and erb-B2 receptor tyrosine kinase 2 (ERBB2; formerly HER2)-negative breast cancer. Therefore, the Choosing Wisely initiative has recommended against routine use of sentinel lymph node biopsy (SLNB) in this population; however, retrospective data have revealed that more than 80% of patients eligible for SLNB omission still undergo the procedure. Multidisciplinary factors involved in these patterns remain unclear. To describe surgical, medical, and radiation oncologists' perspectives on omission of SLNB in women 70 years and older with cT1N0 HR-positive, ERBB2-negative breast cancer. This qualitative study used in-depth semi-structured interviews to explore the factors involved in oncologists' perspectives on providing care to older women who were eligible for SLNB omission. Purposive snowball sampling was used to recruit a sample of surgical, medical, and radiation oncologists representing a wide range of practice types and number of years in practice in the US and Canada. A total of 29 oncologists who finished training and were actively treating patients with breast cancer were interviewed. Interviews were conducted between March 1, 2020, and January 17, 2021. Recordings from semi-structured interviews were transcribed and deidentified. Thematic analysis was used to identify emergent themes. Among 29 physicians (16 women [55.2%] and 13 men [44.8%]) who participated in interviews, 16 were surgical oncologists, 6 were medical oncologists, and 7 were radiation oncologists. Data on race and ethnicity were not collected. Participants had a range of experience (median [range] years in practice, 12.0 [0.5-30.0]) and practice types (14 academic [48.3%], 7 community [24.1%], and 8 hybrid [27.6%]). Interviews revealed that the decision to omit SLNB was based on nuanced patient- and disease-level factors. Wide variation was observed in oncologists' perspectives on SLNB omission recommendations and supporting data. In addition, participants' statements suggested that the multidisciplinary nature of cancer care may increase oncologists' anxiety regarding SLNB omission. In this study, findings from interviews revealed that oncologists' perspectives may have implications for the largely unsuccessful deimplementation of SLNB in women 70 years and older with cT1N0 HR-positive, ERBB2-negative breast cancer. Interventions aimed at educating physicians, improving patient-physician communication, and facilitating preoperative multidisciplinary conversations may help to successfully decrease SLNB rates in this patient population.

Cost-effectiveness of Choosing Wisely guidelines for axillary observation in women older than age 70 years with hormone receptor-positive, clinically node-negative, operable breast tumors.

The Society for Surgical Oncology's Choosing Wisely guidelines recommend against sentinel lymph node biopsy (SLNB) in favor of observation in this population. Recent analyses reveal that this has not been widely adopted. The purpose of this cost-effectiveness analysis is to compare the costs and benefits associated with observation or SLNB in women >70 years old with hormone receptor-positive, clinically node-negative, operable breast cancer. A decision tree with Markov modeling was created to compare treatment strategies using long-term follow-up data from clinical trials in this population. Costs were estimated from published literature and publicly available databases. Breast cancer-specific health-state utilities were derived from the literature and expert opinion. One-way, 2-way, and probabilistic sensitivity analyses were conducted. A structural sensitivity analysis was performed to assess the effect of functional status and anxiety from nonevaluation of the axilla on cost-effectiveness. Costs and benefits, measured in life-years (LYs) and quality-adjusted life-years (QALYs), were tabulated across 10, 15, and 20 years and compared using incremental cost-effectiveness ratios (ICERs). SLNB is not cost-effective from the payer or societal perspectives with ICERs of $138,374/LY and $131,900/LY, respectively. When QALYs were considered, SLNB provided fewer QALYs (SLNB, 10.33 QALYs; observation, 10.53 QALYs) at a higher cost (SLNB, $15,845; observation, $4020). Structural sensitivity analysis revealed that SLNB was cost-effective in certain patients with significant anxiety related to axillary observation (ICER, $39,417/QALY). Routine SLNB in this population is not cost-effective. The cost-effectiveness of SLNB, however, is dependent on individual patient factors, including functional status as well as patient preference.

Abstract OT1-04-03: Sentinel lymph node biopsy versus no axillary surgery in early breast cancer clinically and ultrasonographically node negative: A multicentre prospective randomized controlled trial (VENUS trial)

Abstract Background: In early breast cancer, sentinel lymph node biopsy (SLNB) has become the gold standard of axillary evaluation. Although it has less morbidity than axillary lymph node dissection, it may still cause sequelae. Currently, patients selection for SNB has been through physical examination, but presents low sensitivity and high false negative rate. Thus, ultrasonography with biopsy of suspected lymph nodes increases the accuracy. In an attempt to further reduce the morbidity of axillary surgery, it was hypothesized that it would be possible to avoid SLNB in women with early breast cancer. The aim of this study is to compare the SLNB with no axillary surgery as an approach to the axilla in early breast cancer and negative axilla clinical and ultrasonographical. Our trial includes some subsets excluded in others similar ongoing trials: patients that will undergo mastectomy and will receive primary systemic therapy. Trial design: A multicenter, phase III, prospective, open-label, non-inferiority randomized clinical trial, including 10 study sites in Brazil that will randomize 800 early breast cancer patients.Eligibility criteria: Inclusion: woman, age ≥ 18 years, histologic diagnostic of breast carcinoma, tumor ≤ 5 cm (T1 and T2) in all exams, clinically node-negative, ultrasound node-negative or negative core biopsy/fine needle aspiration if suspect lymph node (in this situation is mandatory lymph node tissue in pathologic exam). Exclusion: metastatic disease in biopsy or image before treatment, pregnancy, breastfeed, previous diagnostic of invasive neoplasia (excluding skin cancer no melanoma). It will be allowed mastectomy and neoadjuvant treatment if patient has negative axilla and T1-2 pre-systemic therapy.Intervention and stratification: Participants in experimental group will not be undergo axillary surgery and in control group will be submitted at SLNB. The randomization will be 1:1 ratio and stratified by: tumor size (T1 and T2) and age (≥50 and < 50 years)Specific aims: the primary objective is to access whether omission of axillar surgery is not inferior than SLNB in term of disease-free survival (DFS) at 5 years (primary endpoint). Secondary endpoints are overall survival, locoregional free survival, axillary recurrence rate, to describe surgical early and later complications and to evaluate costs of procedure SLNB or no. Statistical methods: with type I error 5%, power 80% and risk ratio 0.8, considering DFS at 5 years 90% in control group non-inferior DFS at 5 years 85% in experimental group, it was calculated sample size of 400 patients randomized and with follow up in each group (lost estimated 10%). Chi-squares and Fisher's tests will be used for the univariate analyzes, and logistic regression models for adjusted analyzes. Disease-free survival analysis, disease-free survival at a distance, and overall survival will be performed, which will be compared between groups using Kaplan-Meyer curves, log-rank tests and Cox Proportional Hazards-adjusted analyzes. The analyzes will be made intention-to-treat and per protocol.Present and target accrual: the trial was activated at November 2019 and 92 patients were accrued on July 7th 2021. The estimative of finish recruitment is in 2025 and the first data analyses will be made in 2029. The trial is registered in ReBEC (Brazilian register): RBR-8g6jbf. Contact information: Prof. Dr. Giuliano Duarte, - Univertidade Estadual de Campinas - CAISM - UNICAMP, giulianomduarte@gmail.com Citation Format: Giuliano Mendes Duarte, Danielle Cristina Myiamoto Araújo, Rodrigo Menezes Jales, Júlia Yoriko Shinzato, Cassio Cardoso Filho, Renato Zocchio Torresan, Fabrício Palermo Brenelli, Maria Beatriz de PaulaLeite Kraft, Sergio Carlos Barros Esteves, Luis Otávio Zanatta Sarian, Rosemar MecedoSousa Rahal, Ruffo de Freitas, Jr, Eduardo Carvalho Pessoa, Clecio Ênio Murta Lucena, Andrea PiresSouto Damin, Jorge Villanova Biazus, Vinicius Milani Budel, Idan de Oliveira, Jr, Rene Aloisio da Costa Vieira, Júlio César Narciso Gomes. Sentinel lymph node biopsy versus no axillary surgery in early breast cancer clinically and ultrasonographically node negative: A multicentre prospective randomized controlled trial (VENUS trial) [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr OT1-04-03.

Trends in Sentinel Lymph Node Biopsies in Patients With Inflammatory Breast Cancer in the US

The standard of care for inflammatory breast cancer (IBC) is neoadjuvant chemotherapy, total mastectomy with axillary lymph node dissection (ALND), and postmastectomy radiation therapy. Existing studies suggest that sentinel lymph node biopsy (SLNB) may not be reliable in IBC. The use and frequency of SLNB in women with IBC is not well characterized. To determine the frequency and temporal trend of SLNB in patients with IBC. This retrospective cohort study used the National Cancer Database, a nationwide hospital-based cancer registry, and included women who were diagnosed with nonmetastatic IBC and underwent axillary surgery from 2012 to 2017. Data were analyzed from January 2021 to May 2021. Any SLNB, including SLNB alone and SLNB followed by ALND, and ALND alone. Scatterplot fit with a linear regression model were used to evaluate the yearly increase of any SLNB use. Multivariable logistic regression models to evaluate the association of study variables with the outcome of any SLNB. This study included a total of 1096 women (mean [SD] age, 56.1 [12.9] years) who were 18 years or older with nonmetastatic IBC diagnosed between 2012 and 2017. Of the 186 of 1096 women (17%) who received any SLNB, 137 (73.7%) were White individuals; and of the 910 of 1096 women (83%) who received an ALND only, 676 (74.3%) were White individuals. Among women undergoing any SLNB, 119 of 186 (64%) did not undergo a completion ALND. There was a statistically significant increasing trend in the use of SLNB from 2012 to 2017 (22 of 205 patients [11%] vs 32 of 148 patients [22%]; P = .004). In multivariable analysis, the use of SLNB was associated with diagnosis year (2017 vs 2012; odds ratio [OR], 2.26; 95% CI, 1.26-4.20), clinical nodal status (cN3 vs 0; OR, 0.39; 95% CI, 0.22-0.67), and receipt of reconstructive surgery (OR, 1.80; 95% CI, 1.09-2.96). The findings of this cohort study suggest that there is frequent and increasing use of SLNB in patients with IBC that is not evidence-based or supported by current treatment guidelines.

Can We Successfully De-Escalate Axillary Surgery in Women Aged ≥ 70 Years with Ductal Carcinoma in Situ or Early-Stage Breast Cancer Undergoing Mastectomy?

Omission of sentinel lymph node biopsy (SLNB) in older women with clinically node-negative, hormone receptor-positive (HR+) early-stage breast cancer undergoing lumpectomy is accepted, given established low rates of regional recurrence. The safety of omitting SLNB in women undergoing mastectomy is unknown and may differ depending on extent of breast disease and variation in radiotherapy use. From 2006 to 2018, 123 cTis and 328 cT1-2 HR+/HER2- tumors from 410 women aged ≥ 70 years who underwent mastectomy and SLNB were included (41 bilateral cases). The rate of nodal positivity and effect of nodal positivity on adjuvant therapy use were examined. Median age was 74 years; 21% of patients had positive sentinel lymph nodes, 7% had micrometastases, and 14% had macrometastases. Of cases of cTis tumors, 31% were upstaged to invasive carcinoma; 1% had macrometastases. Fewer cases of cT1 than cT2 tumors had macrometastases [13% (26/200) versus 29% (37/128); p < 0.001]. Eight percent of patients with pT1 tumors (18/228) and 27% of patients with pT2 tumors (30/113) received chemotherapy. Most patients with pT1, pN1 disease (78%; 25/32) did not receive chemotherapy. Rates of locoregional recurrence were similar between patients with cT1 or cT2 tumors with and without nodal metastases (median follow-up, 4.5 years). Women aged ≥ 70 years with cTis and cT1N0 HR+/HER2- tumors who underwent mastectomy had low rates of nodal positivity, similar to rates reported for lumpectomy. Given this and the RxPONDER results, omission of SLNB may be considered, as findings are unlikely to alter adjuvant therapy recommendations.

Multicentre study of the risk of invasive cancer and use of sentinel node biopsy in women with a preoperative diagnosis of ductal carcinoma in situ.

Ductal carcinoma in situ (DCIS) in the breast that is diagnosed by biopsy implies a risk of upstaging to invasive carcinoma (IC) on final pathology. These patients require a sentinel lymph node biopsy (SLNB) for axillary staging. A two-stage procedure is not always feasible and precise selection of patients who should be offered SLNB is crucial. The aims were: to determine the rate of upstaging, and use of redundant and required SLNB in women with a preoperative diagnosis of DCIS; and to identify patient and tumour characteristics that increase the risk of upstaging. Patients with DCIS treated between 2008 and 2016 were identified using Orbit operation planning system software, and those suitable for the study were selected based on review of the medical records. Upstaging rates and proportions of redundant and required SLNBs were calculated. Associations between clinicopathological characteristics and upstaging were analysed using univariable and multivariable logistic regression analyses. Of 1368 patients initially identified, 975 women with a preoperative diagnosis of DCIS were included in the study. Tumours in 246 of these patients (25·2 per cent) were upstaged to IC. Redundant SLNB was performed in 392 of 975 women (40·2 per cent). Forty-four patients (4·5 per cent) with a final diagnosis of IC were not offered SLNB and thus potentially undertreated. In adjusted analysis, DCIS size, palpability and mass formation identified by breast imaging were associated with increased risk of upstaging. The Van Nuys classification was not associated with upstaging. Most patients with IC on final pathology underwent SLNB, but a considerable number of patients with DCIS had a redundant SLNB. Lesion size, palpability and mass formation, but not Van Nuys classification group, are suggested risk factors for upstaging.

Groin recurrence rate in vulvar cancer patients treated with inguinal sentinel node biopsy

Objective: Sentinel lymphnode biopsy (SNB) is an option for patients with early stage vulvar cancer, groin recurrence rates are low and therapy related morbidity is minimal compared to complete inguinofemoral lymphadenectomy. The aim of this retrospective observational study was to evaluate the safety of SNB in women with vulvar cancer by assessing the groin recurrence rate in our center.

Sentinel Lymph Node Biopsy (SLNB) ‘really is’ the standard of care across the UK

Introduction: In the UK the introduction of SLNB in women with clinical and Ultrasound normal axillae was rolled out with a standardized approach defined by the NEW START program. Our aim was to assess availability and uniformity of practice within breast units and across deaneries and cancer networks.

Disparities and Trends in Sentinel Lymph Node Biopsy Among Early-Stage Breast Cancer Patients (1998-2005)

Sentinel lymph node biopsy (SLNB), an acceptable alternative to axillary lymph node dissection for staging patients with breast cancer, was introduced to clinical practice in the late 1990s. We assessed demographic, clinical, and facility-related factors associated with SLNB in women with early-stage breast cancer and evaluated trends in these factors over time. Data on early-stage breast cancers (T1a, T1b, T1c, and T2N0) diagnosed between January 1, 1998, and December 31, 2005, were extracted from the National Cancer Database, a hospital-based registry. Patient demographics, tumor stage, type of lymph node surgery, type of breast cancer surgery, health insurance, treatment facility type, and area-level education and income variables were collected. Multivariable logistic regression analyses were performed to assess predictive factors associated with SLNB, temporal differences in factors associated with SLNB, and differences in rates of SLNB by facility type, race/ethnicity, and type of health insurance over time. The total analytic study population included 490,899 women. The use of SLNB increased from 26.8% in 1998 to 65.5% in 2005. Factors associated with lower likelihood of SLNB over the study period included being older (odds ratio [OR] = 0.80, 95% confidence interval [CI] = 0.78 to 0.92 for those aged 72 or older compared with those aged 51 or younger), being of racial/ethnic minority (OR = 0.76, 95% CI = 0.74 to 0.78 for African Americans compared with whites), having no health insurance (OR = 0.77, 95% CI = 0.73 to 0.80 for uninsured compared with having private insurance), having certain government insurance plans (for Medicaid, OR = 0.81, 95% CI = 0.78 to 0.84, and for Medicare at age <65 years, OR = 0.83, 95% CI = 0.80 to 0.87, both compared with private insurance), residing in zip codes with lower proportion of high school graduates (OR = 0.88, 95% CI = 0.86 to 0.89) or with lower median income (OR = 0.79, 95% CI = 0.77 to 0.81), and receiving treatment in facility types other than a teaching or research hospital (for community hospital, OR = 0.84, 95% CI = 0.82 to 0.86; for community cancer center, OR = 0.86, 95% CI = 0.84 to 0.87). The associations with insurance status and sociodemographic characteristics were more pronounced in 2005 than in 1998. For example, the adjusted annual rates of SLNB in 1998 were 0.29 in whites, 0.26 in African Americans, and 0.35 in Hispanics; in 2005 the respective rates were 0.70, 0.64, and 0.67. Although use of SLNB increased from 1998 to 2005, disparities persisted in receipt of SLNB that are based on nonclinical factors, including sociodemographic characteristics and insurance status.

Is axillary dissection needed in node-positive breast cancer?

The standard of care in the management of the axilla for a woman with breast cancer was traditionally a level I and II axillary lymph node dissection (ALND). Since the pivotal studies in the mid-1990s, sentinel lymph node biopsy (SLNB) in breast carcinoma has come to replace ALND in women with clinically negative axillas. With the increased use of SLNB in women who present with breast carcinoma, the role of completion ALND for a positive sentinel lymph node has been challenged. We review the literature available and discuss future directions in identifying a subgroup who may avoid an ALND.