Sentinel Lymph Node False-negative Rates Research Articles

Clinical application of sentinel lymph node biopsy in patients with early breast cancer after local excision surgery

Objective To explore the clinical application value of sentinel lymph node biopsy (SLNB) in patients with early breast cancer after local excision surgery. Methods A total of 93 breast cancer patients with clinical stage Tis/T1-2N0M0 who underwent SLNB and were confirmed by using tumor mass excision biopsy from March 2012 to November 2018 in Shanxi Bethune Hospital were retrospectively analyzed. According to the postoperative paraffin pathology, the patients who were successfully detected sentinel lymph node (SLN) were divided into SLN-positive group with metastasis or SLN-negative group without metastasis. The clinicopathological data were used to analyze influencing factors of SLN metastasis and SLN detection number after excision biopsy of breast masses in the two groups. Results A total of 87 out of 93 patients were successfully detected SLN and the detection rate was 93.5% (87/93). A total of 255 SLN were detected, and the average number was 2.93 in per patient. All were subjected to rapid intraoperative freezing pathological, and 11 cases with positive SLN were detected. There were 17 patients who underwent axillary lymph node dissection (ALND), including 11 cases with positive SLN and 6 cases with SLN undetected. The paraffin pathology showed that 14 patients were confirmed as positive SLN, including 13 macrometastasis and 1 micrometastasis. The SLN false negative rate was 2.1% (3/14) of intraoperative frozen diagnosis. Univariate analysis showed that histological grade and intravascular thrombus of carcinoma were associated with SLN metastasis after breast cancer local excision; the number of SLN detection was effected by body mass index and staining method; the methylene staining method combined with radionuclide method could improve the detection rate of SLN (all P < 0.05). Multivariate analysis showed that the SLN non-detection of obesity patients was 2.651 times as much as that of normal patients (95% CI 1.592-8.194, P=0.010). Conclusion The SLNB and appropriate tracer method will have a high SLN detection rate and better clinical application value for early breast cancer patients after breast mass resection. Key words: Breast neoplasms; Mastectomy; Sentinel lymph node biopsy

Sentinel lymph node mapping with staging lymphadenectomy for patients with endometrial cancer increases the detection of metastasis

ObjectivesTo compare the performance of sentinel lymph node (SLN) mapping with staging lymphadenectomy versus staging lymphadenectomy alone for the detection of metastasis and the use of adjuvant therapies in patients with endometrial cancer. MethodsAll patients with apparent early-stage endometrial cancer (n=780) who underwent robotic-assisted hysterectomy with pelvic±aortic lymphadenectomy from July-2006 to June-2013 were compared [pelvic±aortic lymphadenectomy (n=661) versus SLN-mapped cases with pelvic±aortic lymphadenectomy (n=119)]. Isosulfan-blue and indocyanine-green with near-infrared imaging were used for SLN mapping. Clinico-pathological data, FIGO stage, GOG risk category, and adjuvant therapies were compared. ResultsNon-mapped and mapped cases were comparable with respect to BMI, histology, depth-of-invasion, and lympho-vascular space invasion. The mapped group had more pelvic lymph node (LN) harvested compared to non-mapped group (26.4±10.5 vs. 18.8±8.5, p<0.001). Aortic LN yields were identical for both groups (9.0±5.6 vs. 9.0±6.0). The mapped group had more LN metastasis detected (30.3% vs. 14.7%, p<0.001), more stage IIIC (30.2% vs. 14.5%, p<0.001), more GOG high-risk cases (32.8% vs. 21.8%, p=0.013), and received more chemotherapy+radiation (28.6% vs. 16.3%, p<0.003). The SLN was the only metastasis in 18 (50%) mapped cases with positive nodes. The SLN false negative rate was 1/36 (2.8%). Micrometastases or isolated tumor cells were identified in 22/35 (62.9%) SLN metastases. Multivariate analysis demonstrated that SLN mapping imparted a significant effect on the detection of metastatic disease [adjusted OR=3.29, p<0.001]. ConclusionsThe performance of SLN mapping with staging lymphadenectomy increased the detection of lymph node metastasis and was associated with more use of adjuvant therapies.

Abstract CS01-1: The role of pathological staging of the axilla and sentinel lymph node biopsy before versus after neoadjuvant chemotherapy

Abstract Neoadjuvant (neo) chemotherapy (CTX) is standard of care for managing pts that present with locally advanced/inoperable breast cancer. This strategy is also routinely offered to women whose cancers are resectable but where primary tumor downstaging is expected to improve lumpectomy eligibility and cosmesis. In the latter scenario it must be clear that CTX is an indicated component of the multidisciplinary care, so that risk of over-treatment is minimized. For many pts, the value of CTX is documented by the size and molecular marker status of the primary invasive tumor. In others, the value of CTX will be confirmed by histopathologic evidence of metastatic disease in the axillary nodal basin, established by either percutaneous needle biopsy or sentinel lymph node (SLN) biopsy. Once the decision has been made to pursue neoCTX, the multidisciplinary treatment team should be proactive in designing the management algorithm for the axilla, and this plan should address the pre- as well as post-neoCTX phases. These decisions can have important implications with regard to prognostic value, treatment planning, and surgical morbidity. Reconciling the desires to minimize treatment toxicity while maximizing disease control and information regarding tumor biology can be quite challenging. The accuracy of SLN biopsy prior to delivery of CTX is well-established. The SLN is clearly more definitive than axillary ultrasound and image-guided FNA biopsy, where the false negative rates approach 20%. Pts that undergo a pre-CTX SLN biopsy documenting node- negative disease are clearly in an advantageous position- these pts can proceed onto neoCTX followed by breast-only surgery/radiation. The major downside to this approach is the need for coordinating the pre-treatment surgical plan. The algorithm becomes more complex when the neoCTX pt has documented node-positive disease (established via FNA or SLN). For these pts, it is presently unclear whether a completion axillary lymph node dissection (ALND) is always necessary in conjunction with the breast surgery following delivery of the CTX. If clinically-evident axillary disease persists, then ALND will be therapeutic in regional control of disease. If however, the axillary disease appears to have been down-staged, then the value of the completion ALND is less clear. NeoCTX can completely clear nodal metastases in 25% of cases, and in up to half of node-positive breast cancer the initial/pretreatment SLN biopsy will have resected the only metastatic nodes present in the axilla. In this scenario, the completion ALND and documenting the presence versus absence of post-treatment residual disease primarily serves the purpose of providing prognostic value, and potentially affects loco regional radiation planning. Whether or not regional XRT should be routinely offered in lieu of the completion ALND is a subject of ongoing debate. Another option is to perform post-treatment SLN biopsy for definitive assessment of chemosensitivity in cases of initially node-positive disease, with the hope that a negative post-treatment SLN biopsy can obviate the need for ALND, however single-institution retrospective studies as well as prospective clinical trials (ACOSOG Z1071) have revealed broad variation in accuracy, with SLN false negative rates ranging from 10-40%. Finally, it has been suggested by many clinicians that neoCTX pts should undergo SLN biopsy following completion of the CTX (concomitantly with their breast surgery) without any up-front axillary staging. This approach avoids multiple exposures to general anesthesia and minimizes likelihood of the pt facing the longterm ALND morbidity. On the other hand, this approach is still fraught with the uncertainty of SLN accuracy related to treatment effects on the false negative rates. Furthermore, this strategy eliminates the possibility of differentiating the pts who presented with node-negative disease from those who were actually node-positive at diagnosis but whose disease was down staged by the neoCTX. It can be argued that this distinction has relevant implications regarding prognosis and benefits of regional XRT. Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr CS01-1.

Abstract S2-1: The role of sentinel lymph node surgery in patients presenting with node positive breast cancer (T0-T4, N1-2) who receive neoadjuvant chemotherapy – results from the ACOSOG Z1071 trial

Abstract Background: The utility of sentinel lymph node (SLN) surgery after neoadjuvant chemotherapy (NAC) in patients presenting with node-positive breast cancer has not been determined. The American College of Surgeons Oncology Group (ACOSOG) Z0171 trial was designed to evaluate SLN surgery after NAC in women presenting with node positive disease. Methods: ACOSOG Z1071 enrolled women with clinical T0-4, N1-2, M0 breast cancer receiving NAC. At the time of surgery, all patients were to undergo SLN surgery followed by axillary lymph node dissection (ALND). The primary endpoint was false negative rate (FNR) in women with cN1 disease with 2 or more SLNs reviewed. Positive SLNs were defined as metastases &amp;gt;0.2mm on H&amp;E. The protocol encouraged dual tracer technique. A Bayesian study design with a non-informative prior was chosen to assess whether the probability that the SLN surgery FNR is greater than 10%. Results: From July 2009 to July 2011, 756 patients were enrolled from 136 institutions. Fifteen women were ineligible and 33 withdrew. Of 708 evaluable pts (668 cN1, 40 cN2), 643 had a SLN identified and an ALND (607 cN1, with indeterminate SLN results in 2); 52 pts (48 cN1) had no SLN identified and had ALND; 11 underwent ALND only (all cN1), and 2 pts had SLN only (both cN1). In patients with SLN and ALND, the SLN identification rate was 92.5% (92.7% in cN1, 90% in cN2). SLN correctly identified nodal status in 84% of the 695 pts [258 of pathologically node negative and 327 of pathologically node positive; cN1: 83.8% (549/655), cN2: 90.0% (36/40)]. Of the 643 pts with a SLN identified there was a complete pathologic response in 40.3% (40.3 % for cN1 and 50% for cN2). Of the pts with a positive SLN, the SLN was the only site of disease in 40%. For pts with cN1 disease with 2+ SLNs identified with residual nodal disease, the SLN FNR was 12.8%. In pts with dual tracer technique the FNR was 11.1%. There were no FN results among pts with cN2 disease with 2+ SLNs reviewed. Of the 40 pts with a false negative SLN of the 528 cN1 patients with 2+ SLNs examined, the number of positive nodes at ALND was 1 (50.0%); 2 (25%); 3 (10.0%) and 4–9 (15.0%). Conclusions: NAC resulted in eradication of lymph node disease in 40% of node positive breast cancer patients. SLN surgery after NAC in node positive breast cancer pts correctly identified nodal status in 84% of all patients and was associated with a FNR of 12.8%. The FNR of SLN is higher than the prespecified study endpoint of 10%. Further analysis of factors associated with FNR such as clinical response, histological findings and axillary ultrasound findings is warranted prior to widespread use of SLN in these patients. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr S2-1.

Accuracy of sentinel lymph node biopsy in patients with large primary breast tumors.

Patients with large breast tumors are increasingly undergoing neoadjuvant treatment to downstage local disease; however, accurate staging of the axilla before the initiation of chemotherapy remains problematic. In the current study, the authors report on the accuracy of sentinel lymph node (SLN) biopsy in such patients to determine the feasibility of applying this technique before induction chemotherapy. One hundred three patients with 104 tumors classified as American Joint Committee on Cancer (AJCC) T2 (tumor >/= 2 cm but </= 5 cm) or larger were recruited at the University of Pennsylvania and the Mayo Clinic. In the majority of cases, combined blue dye and radiotracer was used for SLN identification. After SLN identification, a completion axillary lymph node dissection was performed in 87 cases. The SLN was evaluated with hematoxylin and eosin and immunohistochemistry. The SLN was identified in 99% of cases. The overall rate of lymph node metastasis was 59% (95% exact confidence interval [95% CI], 49-68%) (61 of 104 cases). The SLN false-negative rate was 2% (95% exact CI, < 1-11.5%) (2 patients). In 56 tumors >/= 3 cm, 1 false-negative result (2% [95% exact CI, < 1-15%]) was identified, and the rate of lymph node metastasis was 62.5% (95% exact CI, 48. 5-75%) (35 of 56 tumors). Within 30 SLN positive patients with tumors >/= 3 cm and complete axillary lymph node dissection, 3 of 8 patients (37.5% [95% exact CI, 8.5-75.5%]) with micrometastasis (</= 2 mm) to the SLN had positive non-SLN compared with 21 of 22 patients (95.5% [95% exact CI, 77-100%]) with macrometastasis (> 2 mm) to the SLN (P = 0.002). SLN biopsy for patients with large breast tumors is technically feasible and highly accurate. SLN biopsy should be considered for the staging of clinically negative axilla in patients scheduled to receive neoadjuvant chemotherapy.