Sentinel Lymph Node Biopsy With Metastasis: Can Axillary Dissection Be Avoided in Some Patients With Breast Cancer?

PURPOSE: Recent studies have suggested that the sentinel lymph node (SLN) biopsy is an accurate alternative staging procedure for women with breast cancer. The goal of this study was to identify a subset of breast cancer patients in whom metastatic disease was confined only to the SLN. MATERIALS AND METHODS: From two institutions, we recruited 222 women with breast cancer for SLN biopsy. A SLN biopsy was performed in each patient, followed by an axillary dissection in 182 patients. Histologic and immunohistochemical cytokeratin stains were used on all SLNs. RESULTS: The SLN was identified in 220 (97.8%) of the 225 biopsies. Evidence of metastatic breast cancer in the SLN was found in 60 (27.0%) of the 222 patients. Of these patients, 32 (53.3%) had evidence of tumor in the SLN only. By multivariate analysis, two factors were found to be significantly associated with a higher likelihood of tumor involvement in the non-SLNs: primary tumor size larger than 2.0 cm (P = .0004) and macrometastasis (> 2.0 mm) in the SLN (P = .002). Additional analysis revealed that none (0%; 95% confidence interval, 0% to 18.5%) of the 18 patients with primary tumors ≤ 2.0 cm and micrometastasis to the SLN had remaining axillary lymph node involvement. CONCLUSION: The primary tumor size and metastasis size in the SLN are independent factors in predicting the incidence of tumor in the non-SLNs. Therefore, the SLN biopsy alone may be adequate for staging and/or therapy decision making in patients with primary breast tumors ≤ 2.0 cm and micrometastasis in the SLN.

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Targeted axillary dissection in breast cancer by marking lymph node metastasis with a magnetic seed before starting neoadjuvant treatment

Journal of Surgical Case Reports ◽

10.1093/jscr/rjz344 ◽

2019 ◽

Vol 2019 (11) ◽

Cited By ~ 1

Author(s):

Joaquín Luis García-Moreno ◽

Ana María Benjumeda-Gonzalez ◽

Marta Amerigo-Góngora ◽

Piero José Landra-Dulanto ◽

Yisela Gonzalez-Corena ◽

...

Keyword(s):

Breast Cancer ◽

Lymph Node ◽

Sentinel Lymph Node ◽

Lymph Node Metastasis ◽

Axillary Dissection ◽

Neoadjuvant Treatment ◽

Axillary Lymph Node Metastasis ◽

Axillary Lymph ◽

Node Metastasis ◽

Magnetic Seeds

Abstract We report the first documented clinical case of the use of magnetic seeds to mark axillary lymph node metastasis in breast cancer before neoadjuvant chemotherapy. After chemotherapy, the patient showed a complete radiological response. One single sentinel lymph node was detected using a radiotracer, while the marked node was intraoperative magnetometer-guided identified. The analysis of the nodes showed negative sentinel lymph node and positive marked node, and the subsequent targeted axillary dissection was performed. Marking axillary positive lymph nodes with a magnetic seed is a simple and effective procedure for the intraoperative localisation of the node after neoadjuvant treatment.

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Isolated tumor cells versus micro-metastasis in sentinel lymph node biopsy for T1, T2 breast cancer compared to macro-metastasis: Significance after complete axillary dissection

Journal of Clinical Oncology ◽

10.1200/jco.2009.27.15_suppl.e12028 ◽

2009 ◽

Vol 27 (15_suppl) ◽

pp. e12028-e12028

Author(s):

Y. A. Alabdulkarim ◽

E. Nassif

Keyword(s):

Breast Cancer ◽

Lymph Node ◽

Sentinel Lymph Node ◽

Tumor Cells ◽

Axillary Dissection ◽

Lymph Node Biopsy ◽

Axillary Lymph Nodes ◽

Axillary Lymph ◽

Isolated Tumor Cells ◽

Lymph Node Examination

e12028 Background: Evaluating the axillary lymph nodes is extremely important in the management of breast cancer, with the recent improvement in histopathology techniques detection of micro-metastasis and even isolated cancer cells (ITC) in a setting of sentinel lymph node examination is feasible. In this study we aim to compare the outcome and significance of; positive SLN for macro versus Micro-metastasis, and ITCs. Methods: We reviewed all the patients who had SLN for breast cancer of stage T 1–2 between April 2006 and November 2008. Identifying all those who had positive macro-metastasis, micro-metastasis, or isolated tumor cells, pathology results of the full axillary LN dissection was evaluated for each type. Results: 350 patients had SLN of these 226 had a disease of T1–2, thirty seven patients (16.3%) had full axillary dissection, of these 27/37 had positive SLN for macro-metastasis, six had micro-metastasis and 3/37 had only ITCs. The presence of other LN metastasis was detected in 8 cases (21.6%); all of them were in the macro-metastasis group. No metastasis was found in either the micro-metastasis or the ITC groups. The ITC was only detected with DCIS; while micro-metastasis was present in DCIS or IDC. No relation was identified between the histopathology grade with ITC or micro-metastasis. Conclusions: Our findings did not show any presence of lymphatic metastasis after full axillary dissection, in case of positive micro-metastasis or ITCs in SLN, compared to the group of macro-metastasis. No significant financial relationships to disclose.

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A nomogram to predict nonsentinel lymph node involvement in breast cancer patients with sentinel lymph node metastases.

Journal of Clinical Oncology ◽

10.1200/jco.2011.29.27_suppl.14 ◽

2011 ◽

Vol 29 (27_suppl) ◽

pp. 14-14

Author(s):

Y. Kojima ◽

K. Tsugawa ◽

K. Enokido ◽

H. Iwata ◽

S. Ohno ◽

...

Keyword(s):

Breast Cancer ◽

Multivariate Analysis ◽

Lymph Node ◽

Cancer Patients ◽

Predictive Factors ◽

Tumor Size ◽

Primary Tumor ◽

Lymphatic Invasion ◽

Breast Cancer Patients ◽

Primary Tumor Size

14 Background: Several nomograms have been described as predictors of non-sentinel axially lymph node (non-SN) metastases in breast cancer with positive sentinel nodes (SN). However, all these predicting models were based on data from western countries. The purpose of this study was to examine predictive factors of non-SN status among SN metastatic patients, in order to develop a nomogram based on Japanese large data set. Methods: This research was analyzed by using a clinical database of 11,228 Japanese breast cancer patients who registerd to cohort study as SN biopsy between March 2008 and Octover 2009 in Japan. We reviewed data retrospectively to extract patients with SN metastases who underwent complementary axillary lymph node dissection. In this cohort, we examined predictive factors of non-SN metastases. All clinical and pathologic features were analyzed to predict the non-SN status, by using univariate and multivariate logistic regression model. A receiver operating characteristic curve was constructed and the area under the curve (AUC) was calculated. Results: Among the database, SN metastases were found in 1,029 patients, and 345 (33.5%) were non-SN positive. Univariate analysis showed a significant association between non-SN involvement and primary tumor size (p<0.001), histologic grade (p=0.011), lymphatic invasion (p<0.001), venous invasion (p=0.005) and the number of involved SNs among all identified SNs (p<0.001). Tumor size (p<0.001), lymphatic invasion (p<0.001), and the size of SN metastasis (p<0.001) were associated with non-SN metastasis in multivariate analysis. Based on the multivariate analysis, we developed a scoring system to predict the likelihood of non-SN metastases in breast cancer patients with SN involvement. The discriminatory ability of our nomogram, as measured by the AUC, was 0.752. Conclusions: In patients with invasive breast cancer and a positive SN, primary tumor size, lymphatic invasion, and the size of SN metastases among all identified SNs were independently predictive of non-SN involvement, and used for a nomogram. Validation study will be performed in the future investigation.

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Is There a Need for Axillary Dissection in Breast Cancer?

Journal of the National Comprehensive Cancer Network ◽

10.6004/jnccn.2011.0017 ◽

2011 ◽

Vol 9 (2) ◽

pp. 225-230 ◽

Cited By ~ 3

Author(s):

Jason P. Wilson ◽

David Mattson ◽

Stephen B. Edge

Keyword(s):

Breast Cancer ◽

Lymph Node ◽

Sentinel Lymph Node ◽

Prognostic Factor ◽

Axillary Dissection ◽

Small Volume ◽

Significant Prognostic Factor ◽

Axillary Lymph ◽

Isolated Tumor Cells ◽

Micrometastatic Disease

The involvement of axillary nodes remains a significant prognostic factor in breast cancer. However, management has changed from complete surgical staging to sentinel lymph node biopsies. Although little controversy exists regarding patients with negative sentinel lymph node biopsies, some remains regarding what to do with patients with small volume of axillary disease. This article focuses on the examination of recent evidence in management of the axilla. It focuses on both the prognostic and therapeutic information gleaned from isolated tumor cells and micrometastatic disease and on the use of completion axillary lymph node dissections or axillary radiation in preventing regional recurrence.

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Axillary Lymph Nodes: US-guided Fine-Needle Aspiration for Initial Staging of Breast Cancer—Correlation with Primary Tumor Size

Radiology ◽

10.1148/radiol.2463061463 ◽

2008 ◽

Vol 246 (1) ◽

pp. 81-89 ◽

Cited By ~ 102

Author(s):

Susan L. Koelliker ◽

Maureen A. Chung ◽

Martha B. Mainiero ◽

Margaret M. Steinhoff ◽

Blake Cady

Keyword(s):

Breast Cancer ◽

Fine Needle Aspiration ◽

Tumor Size ◽

Primary Tumor ◽

Needle Aspiration ◽

Axillary Lymph Nodes ◽

Axillary Lymph ◽

Primary Tumor Size ◽

Fine Needle ◽

Initial Staging

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Surgical Management of the Axilla in Breast Cancer

10.2310/cgso.16007 ◽

2017 ◽

Author(s):

Cory Donovan ◽

Armando E Giuliano

Keyword(s):

Breast Cancer ◽

Lymph Node ◽

Sentinel Lymph Node ◽

Sentinel Lymph Node Biopsy ◽

Lymph Nodes ◽

Axillary Dissection ◽

Lymph Node Biopsy ◽

Clinical Staging ◽

Axillary Lymph ◽

Node Biopsy

The management of the axilla in breast cancer has shifted from axillary dissection in all patients to sentinel lymph node biopsy (SLNB) alone for most patients, including patients with sentinel lymph node metastases. Although important to clinical staging, physical examination alone does not accurately predict axillary metastasis. There are some circumstances where SLNB is contraindicated or should be used with caution. The impact of SLNB after neoadjuvant chemotherapy remains unproven, but its use is reasonable for some patients. Patients with tumor-free sentinel lymph nodes or nodes with micrometastatic disease require no further axillary surgery. Most patients with one to three lymph nodes positive for macrometastatic disease who undergo segmental mastectomy and radiation do not require an axillary lymph node dissection (ALND). There has not been a dramatic increase in axillary recurrence or a decrease in survival with the decreased use of ALND. In the future, with improvements in genomic analysis, ALND and even SLNB may be even less important in local control and prognosis. This review contains 9 figures, 7 tables and 52 references. Key words: ACOSOG Z0011, axilla, axillary dissection, axillary radiation, breast cancer, macrometastasis, micrometastasis, sentinel lymph node biopsy

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Sentinel Lymph Node Dissection versus Complete Axillary Dissection in Invasive Breast Cancer

10.1093/med/9780199384075.003.0022 ◽

2017 ◽

Author(s):

Rachel J. Kwon

Keyword(s):

Breast Cancer ◽

Lymph Node ◽

Sentinel Lymph Node ◽

Lymph Node Dissection ◽

Invasive Breast Cancer ◽

Axillary Dissection ◽

Lymph Node Biopsy ◽

Axillary Lymph ◽

Node Dissection ◽

Sentinel Node Dissection

This chapter provides a summary of a landmark study in breast surgical oncology: the Z0011 trial. In patients with invasive breast cancer and positive sentinel lymph nodes, does complete axillary lymph node dissection improve survival relative to sentinel node dissection alone? Starting with that question, it describes the basics of the study, including funding, year study began, year study was published, study location, who was studied, who was excluded, how many patients, study design, study intervention, follow-up, endpoints, results, and criticism and limitations. The chapter briefly reviews other relevant studies and information, gives a summary and discusses implications, and concludes with a relevant clinical case involving axillary dissection versus sentinel lymph node biopsy only.

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Predicting non-sentinel lymph node involvement in breast cancer patients

Journal of Clinical Oncology ◽

10.1200/jco.2006.24.18_suppl.531 ◽

2006 ◽

Vol 24 (18_suppl) ◽

pp. 531-531

Author(s):

H. E. Kohrt ◽

R. A. Olshen ◽

W. H. Goodson ◽

R. V. Rouse ◽

L. Bailey ◽

...

Keyword(s):

Breast Cancer ◽

Lymph Node ◽

Sentinel Lymph Node ◽

Tumor Size ◽

Recursive Partitioning ◽

Positive Sentinel Lymph Node ◽

Lymph Node Involvement ◽

Axillary Lymph ◽

Breast Cancer Patients ◽

Clinicopathologic Characteristics

531 Background: Current convention is to perform a completion axillary lymph node dissection (ALND) for invasive breast cancer (BC) patients (pts) with positive sentinel lymph node(s) (+SLN), even though <50% will have non-sentinel lymph node metastasis (+NSLN). Our goal was to develop and compare predictive models of NSLN status among +SLN pts to identify for whom completion ALND may be omitted. Methods: We constructed 3 models by recursive partitioning with receiver-operating-characteristic curves (RP-ROC), boosted classification and regression trees (CART), and a multivariate logistic regression (MLR) informed by CART. Models were developed using a multi-institutional database of 1,040 BC pts who underwent SLN biopsy and completion ALND at academic or community hospitals as part of a prospective, consented study. Accuracies were compared to the Memorial Sloan-Kettering Breast Cancer Nomogram (Nomogram). Results: 976 BC pts had evaluable SLNs and 285 had +SLNs; 101(35.4%) +SLN pts had +NSLNs. Tumor size, lymphovascular invasion (LVI), and SLN metastasis size were the best predictors of risk (multivariate P-values<0.001) of +NSLN. 39 of 156 +SLN pts (25%) with T1 tumors had +NSLNs vs. 62 of 129 (48%) with T2/T3 tumors. 73.7% with LVI vs 19.5% without LVI had +NSLNs. 4.7% of pts with isolated tumor cells, 42% with micrometastasis and 71% with macrometastasis in SLN had +NSLNs. MLR informed by CART identified 2 highly predictive variables, the LVI × size of SLN metastasis [OR 4.73(3.11–7.20, 95%CI), P<0.001] and tumor size × size of SLN metastasis [OR 1.18(1.10–1.26, 95%CI), P<0.001]. While RP-ROC and boosted CART stratified pts into low-risk (4.3%-9.9%), moderate-risk (33.3%-42.9%), and high-risk (62.2%-93%) groups, MLR predicted NSLN status with accuracy superior to RP-ROC, boosted CART, and the Nomogram: 83.3%, 76.7%, 67.7%, and 76.7%, respectively, after 10-fold cross validation. The Nomogram’s sensitivity was significantly inferior to those of RP-ROC, boosted CART, and MLR: 53.8%, 78.8%, 78.2%, and 78.0%, respectively. Conclusions: In pts with +SLNs, interactions between clinicopathologic characteristics are highly informative in predicting risk of +NSLN. However, neither our methods nor the Nomogram achieved sufficient accuracy to recommend a change in current clinical practice. No significant financial relationships to disclose.

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Axillary lymph node status in breast cancer staging: What patient and tumor factors affect the accuracy of ultrasound-guided fine needle aspiration?

Journal of Clinical Oncology ◽

10.1200/jco.2012.30.15_suppl.1126 ◽

2012 ◽

Vol 30 (15_suppl) ◽

pp. 1126-1126

Author(s):

Celin Chacko ◽

Beatriu Reig ◽

Tova Koenigsberg

Keyword(s):

Breast Cancer ◽

Lymph Node ◽

Sentinel Lymph Node ◽

Lymph Nodes ◽

Predictive Value ◽

Axillary Dissection ◽

Lymph Node Biopsy ◽

Axillary Lymph Nodes ◽

Axillary Lymph ◽

Ultrasound Guided

1126 Background: The purpose of the study is to evaluate the accuracy of ultrasound-guided fine needle aspiration (FNA) of axillary lymph nodes(ALNs) in patients with breast cancer and to determine factors that influence accuracy of ultrasound-guided FNA. Methods: Retrospective review of patients with breast cancer who had FNA of ALNs as well as sentinel lymph node excision or complete axillary dissection. Patients treated with neoadjuvant chemotherapy were excluded. 55 axillary FNAs in 54 patients were included in the final analysis. Pathology reports were reviewed for size of the primary tumor, FNA results, number of positive ALNs, and greatest tumor size in ALNs. FNA was performed if a suspicious lymph node was identified. Surgical sentinel lymph node biopsy or full axillary dissection were the reference standard. Micrometastases (< 0.2 mm) and isolated tumor cells in the lymph node were included in the negative group. Atypical and nondiagnostic FNA results were considered negative cytologic results. Significance was analyzed using the Mann-Whitney test. Results: Size of the primary cancer ranged from 0.3 mm to 8.5 cm. The sensitivity of FNA was 73%, with positive predictive value of 97% and negative predictive value of 52%. The NPV of FNA for primary tumors <1 cm, 1.1-2, 2.1-5 and >5 cm is 100%, 36%, 50% and 66% respectively. Correlation of primary tumor size with sensitivity of FNA was not statistically significant. The sensitivity of FNA for lymph nodes with metastatic deposit < 5mm, 6-10mm, 11-15mm, 16-20mm, and 21mm+ is 0%, 57%, 59%, 89%, and 100%, which is statistically significant (p = 0.007). The number of positive ALNs at axillary dissection is not correlated to the sensitivity of FNA. The sensitivity of FNA for 1-3, 4-9 and 10+ positive ALNs is 78%, 64% and 80%. Conclusions: Our findings indicate that FNA of suspicious axillary lymph nodes is valuable even in small tumors, which differs from the literature. The overall negative predictive value of FNA is 52%, so sentinel lymph node biopsy is essential after negative FNA. Sensitivity of FNA increases with the size of the metastatic deposit in the lymph node, but is not correlated to the number of positive ALNs found at dissection.

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