Validation of the Louisville Breast Sentinel Node Prediction Models and a Proposed Modification to Guide Management of the Node Positive Axilla

The ACOSOG Z11 trial is rapidly changing use of axillary dissection, but it is not known how generalizable the Z11 results are. This study compares characteristics of the Z11 patients with the larger group of sentinel node-positive patients and evaluates two previously described Louisville algorithms to determine whether they might still be useful to predict extent of axillary node involvement and guide management of the axilla. The Yale Breast Center database was queried to calculate the Louisville prediction points for patients with a positive sentinel node and to compare the predicted with actual results. Of 1215 sentinel node biopsies performed between 2004 and 2010, 282 (23%) had at least one positive node. Thirty-one per cent of these patients would have been eligible for Z11. This group had much less axillary node involvement than the 69 per cent who were ineligible. The Yale data confirmed the accuracy of the two Louisville models and showed that tumor size, number of positive sentinel nodes, and proportion of positive sentinel nodes were all significant predictors. However, these results were much more robust if at least three sentinel nodes had been removed. The Z11 patients were clearly a good risk group. The data validate the two Louisville models and suggest that the models may be useful to select patients to avoid axillary dissection, both among the currently Z11-eligible and -ineligible populations. A modified algorithm is proposed in which all patients with a positive sentinel node have at least three total nodes removed.

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Sentinel Node Biopsy Alone versus Completion Axillary Node Dissection in Node Positive Breast Cancer: Systematic Review and Meta-Analysis

International Journal of Breast Cancer ◽

10.1155/2014/513780 ◽

2014 ◽

Vol 2014 ◽

pp. 1-10 ◽

Cited By ~ 18

Author(s):

Rachna Ram ◽

Jasprit Singh ◽

Eddie McCaig

Keyword(s):

Breast Cancer ◽

Systematic Review ◽

Sentinel Node ◽

Axillary Dissection ◽

Meta Analysis ◽

Axillary Node ◽

Axillary Node Dissection ◽

Controlled Trials ◽

Positive Sentinel Node ◽

Node Dissection

Introduction. There has been recent interest in validity of completion axillary node dissection after a positive sentinel node. This systematic review aims to ascertain if sentinel lymph node dissection alone was noninferior to axillary lymph node dissection for breast cancer patients who have a positive sentinel node.Method. A systematic review of the electronic databases Embase, MEDLINE, and Cochrane Register of Controlled Trials was carried out. Only randomised trials that had patients with positive sentinel node as the study sample were included in the meta-analysis using the reported hazard ratios with a fixed effect model.Results. Three randomised controlled trials and five retrospective studies were identified. The pooled effect for overall survival was HR 0.94, 95% CI [0.79, 1.19], and for disease free survival was HR 0.83, 95% CI [0.60, 1.14]. The reported rates for locoregional recurrence were similar in both groups. The surgical morbidity was found to be significantly more in patients who had underwent axillary dissection.Conclusion. Amongst patients with micrometastasis in the sentinel node, no further axillary dissection is necessary. For patients with macrometastasis in the sentinel node, it is reasonable to consider omitting axillary dissection to avoid the morbidity of the procedure.

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Pathologic Evaluation of Axillary Dissection Specimens Following Unexpected Identification of Tumor Within Sentinel Lymph Nodes

Archives of Pathology & Laboratory Medicine ◽

10.5858/2009-0694-oar.1 ◽

2011 ◽

Vol 135 (1) ◽

pp. 131-134

Author(s):

Jessica Gutierrez ◽

Daniel Dunn ◽

Margit Bretzke ◽

Eric Johnson ◽

John O'Leary ◽

...

Keyword(s):

Lymph Node ◽

Sentinel Node ◽

Tumor Cells ◽

Axillary Dissection ◽

Frozen Section ◽

Axillary Node ◽

Axillary Node Dissection ◽

Node Dissection ◽

Isolated Tumor Cells ◽

Sentinel Nodes

Abstract Context—Axillary lymph node dissection has been the standard of care after identification of a positive sentinel lymph node for breast cancer patients. Objective—To determine the likelihood of non–sentinel lymph node involvement for patients with negative sentinel node by frozen section, who are subsequently found to have tumor cells in the sentinel node by permanent section levels and/or cytokeratin immunohistochemistry. Design—One hundred three patients with invasive breast cancer exhibiting negative frozen section evaluation of their sentinel node, but later found to have isolated tumor cells (n = 46), micrometastasis (n = 46), or metastases (n = 11) in their sentinel node by permanent sections or immunohistochemistry, were enrolled in this prospective cohort study and underwent completion axillary dissection. Results—Six of 46 patients (13%) with isolated tumor cells in their sentinel node, 15 of 46 patients (33%) with micrometastasis in their sentinel node, and 2 of 11 patients (18%) with metastasis in their sentinel node had additional findings in the nonsentinel nodes. These findings resulted in a pathologic stage change in 2 patients. Predictors of positive nonsentinel nodes were 2 or more positive sentinel nodes (P = .002), sentinel nodes with micrometastasis versus isolated tumor cells (P = .03), and those with angiolymphatic invasion (P = .04). Conclusions—Our findings lend support to axillary node dissection for patients with micrometastasis or metastasis in their sentinel nodes. However, studies with clinical follow-up are needed to determine whether axillary node dissection is necessary for patients with isolated tumor cells in sentinel nodes.

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The Microanatomic Location of Metastatic Melanoma in Sentinel Lymph Nodes Predicts Nonsentinel Lymph Node Involvement

Journal of Clinical Oncology ◽

10.1200/jco.2004.12.177 ◽

2004 ◽

Vol 22 (16) ◽

pp. 3345-3349 ◽

Cited By ~ 210

Author(s):

D.J. Dewar ◽

B. Newell ◽

M.A. Green ◽

A.P. Topping ◽

B.W.E.M. Powell ◽

...

Keyword(s):

Lymph Node ◽

Sentinel Node ◽

Metastatic Melanoma ◽

Sentinel Node Biopsy ◽

Lymph Node Involvement ◽

Positive Sentinel Node ◽

Sentinel Nodes ◽

Node Biopsy ◽

Node Involvement ◽

Nonsentinel Lymph Node

Purpose Sentinel node biopsy is now widely accepted as the most accurate prognostic indicator in melanoma, and is important in guiding management of patients with clinical stage I or II disease. Patients with a positive sentinel node have conventionally undergone completion lymphadenectomy (CLND) of the involved basin, but only 20% have involvement beyond the sentinel node, suggesting that CLND may be unnecessary for the other 80% of patients. This study seeks to identify criteria that might be used to be more restrictive in selecting those who should undergo CLND. Methods A total of 146 patients were identified who had had a positive sentinel node biopsy for malignant melanoma. Their sentinel nodes and lymphadenectomy specimens were re-evaluated pathologically. The metastatic melanoma in each sentinel node was assessed according to its microanatomic location within the node (subcapsular, combined subcapsular and parenchymal, parenchymal, multifocal, or extensive), and this was correlated with the presence of involved nonsentinel nodes in the CLND. The depth of the metastases from the sentinel node capsule was also recorded. Results The metastatic deposits in the sentinel node were subcapsular in 26.0% of patients. None of these patients had any nonsentinel nodes involved on CLND. In the patients whose sentinel node metastases had a different microanatomic location, the rate of nonsentinel node involvement was 22.2% overall. Conclusion The microanatomic location of metastases within sentinel nodes predicts nonsentinel lymph node involvement. In patients with only subcapsular deposits in the sentinel node, it is possible that CLND could safely be avoided.

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EP.TH.166Evaluation of the impact of the COVID-19 pandemic on the practice of axillary node dissection

British Journal of Surgery ◽

10.1093/bjs/znab309.024 ◽

2021 ◽

Vol 108 (Supplement_7) ◽

Author(s):

Grant Harris ◽

Alice Townend ◽

Madgi Youssef

Keyword(s):

Breast Cancer ◽

Neoadjuvant Chemotherapy ◽

Sentinel Node ◽

Axillary Node ◽

Axillary Node Dissection ◽

Delayed Presentation ◽

Positive Sentinel Node ◽

Node Dissection ◽

Node Positive ◽

The Impact

Abstract Aims The Association of Breast Surgery's "COVID-altered" guidance for management of breast cancer during the COVID-19 pandemic, includes that neoadjuvant chemotherapy was only to be used only in inoperable disease and not to downstage the axilla. Delayed presentation with increased nodal involvement was also a concern. We aim to establish if axillary node dissection (AND) increased in the context of pandemic. Methods Patients undergoing surgery for breast cancer were identified from theatre coding in a UK breast unit. Pre-COVID (March 2018 - February 2020) and COVID pandemic (March - September 2020) cohorts were compared. Indication, tumour receptor status, neoadjuvant chemotherapy (NAC) and deviation from routine practice were ascertained for those undergoing AND. Trust Caldicott and audit department approval was obtained for this retrospective review of practice. Results AND was performed in 20.2% (23/114) of breast cancer operations during the pandemic compared with 18.97% (78/411) pre-COVID. Indication for AND during the pandemic and pre-COVID respectively - clinically node positive 82.6%/79.4%; positive sentinel node biopsy 4.3%/17.9%; recurrence or metastases from contralateral cancer 13%/2.5%. NAC preceded AND in 30% of cases in both cohorts. NAC for one node positive HER2+ cancer was omitted due to the pandemic and another patient had adjuvant chemotherapy omitted for a HER2+ cancer with a single positive sentinel node mandating an AND which yielded no further positive nodes. Conclusions The COVID-19 pandemic has not significantly impacted rates of AND in our practice. However, we identified 2 patients who may have avoided AND with normal chemotherapy protocols.

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