Sentinel node localization in breast cancer

doi:10.1016/S0001-2998(99)80030-0

Seminars in Nuclear Medicine

Volume 29, Issue 1, January 1999, Pages 57-68

https://doi.org/10.1016/S0001-2998(99)80030-0 Get rights and content

The status of the axillary nodes is the strongest known prognostic variable in patients with early breast cancer, and is routinely used in planning postoperative therapy. Conventional axillary lymph node dissection is limited by sampling error and potential morbidity. Sentinel node techniques have revolutionized the management of axillary nodes. Accurate identification and focused histologic evaluation of the sentinel node allow accurate prediction of the tumor status of other axillary nodes, thereby avoiding the morbidity and expense of a complete axillary dissection in nodenegative patients. Radiotracer techniques play an important role in the preoperative and intraoperative localization of the sentinel nodes. Optimal localization of the sentinel node requires the use of both preoperative lymphoscintigraphy and intraoperative radiosensitive probes. Lymphoscintigraphy also identifies patients with lymphatic drainage to sites other than the axilla, thereby allowing more appropriate treatment and follow-up in this subset of patients. Procedures for localizing sentinel nodes require an understanding of the kinetics of the radiopharmaceuticals or other tracers used and the detection devices employed in each institution. Both surgical and nuclear medicine personnel should understand these principles, and close cooperation between surgeons, nuclear medicine physicians, and pathologists is essential for the application of sentinel node techniques.

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The surgical management of the axilla in early breast cancer has significantly evolved over the past several decades. This chapter details the history of sentinel node dissection, as well as the indications, technical aspects, complications, histologic analysis, and oncologic outcomes of sentinel node biopsy as it compares to axillary dissection. The most current management recommendations are discussed, as are future directions.
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Citation Excerpt :
Hence, if the sentinel lymph node is metastasis-free, it follows that the rest of the lymph nodes in the lymphatic basin should also be negative. Many studies have reported that sentinel lymph node status is an accurate reflection of the lymph node basin status as a whole, and that reliable treatment decisions can be made from knowledge of the status of the sentinel lymph node in melanoma, breast cancer, and other malignancies [60–67]. In breast cancer, regional axillary lymph node status is conventionally assessed through lymph node dissection.
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Le curage standard est actuellement remis en question dans la prise en charge du cancer de la prostate. Le but de cette étude prospective est d’évaluer les performances de la technique du ganglion sentinelle (GS) par cœlioscopie chez des patients porteurs d’un cancer localisé de prostate candidats à un traitement local.
Les patients étaient injectés par voie transrectale échoguidée avec 0,3 mL/100MBq de 99^mTc-sulfure de rhénium colloïdal dans chaque lobe prostatique la veille de l’intervention. Une lymphoscintigraphie était réalisée deux heures après. La radiodétection peropératoire était réalisée avec une sonde cœlioscopique (Clerad^® Gamma Sup) suivie d’un curage extensif. Les comptages des GS étaient réalisés in vivo et confirmés ex vivo. L’analyse anatomopathologique était réalisée par HPS, suivie d’un immunomarquage si GS indemnes.
Soixante-dix patients, porteurs d’un cancer de la prostate à risque intermédiaire ou élevé de métastases ganglionnaires (D’Amico), PSA médian 9,5 ng/mL [6–130] ont été inclus dans l’étude. Le taux de détection lymphoscintigraphique a été de 94,2 % (66/70) et peropératoire de 97,0 % (68/70). Quatorze patients présentaient des métastases ganglionnaires, six uniquement dans les GS. Le taux de faux négatifs était de 2/14 (14,0 %). La région iliaque interne est le premier site métastatique (40,9 %). Un curage limité ou standard aurait ignoré respectivement 72,7 % et 59,0 % des métastases ganglionnaires.
La voie cœlioscopique est adaptée à un large repérage des GS et un curage ciblé de ces ganglions limiterait significativement le risque chirurgical du curage étendu tout en maintenant la précision de l’information.
The standard lymphadenectomy is currently a challenge in the management of prostate cancer. The aim of this prospective study was to evaluate the performance of the sentinel lymph node (SLN) by laparoscopy in patients with localized prostate cancer, candidates for local treatment.
Patients were injected transrectal ultrasound-guided with 0.3 mL/100MBq 99^mTc-Sulfur rhenium colloid in each prostatic lobe, the day before surgery. Lymphoscintigraphy was performed after 2 hours. The detection was realized intraoperatively with a laparoscopic probe (Gamma Sup Clerad^®) followed by extensive dissection. Counts of SLN were performed in vivo and confirmed ex vivo. The histological analysis was performed by HPS staining and followed by immunochemistry if SLN was free.
Seventy patients with carcinoma of the prostate at intermediate or high risk of lymph node metastases (D’Amico), PSA median 9.5 ng/mL [6–130], were included in the study. The lymphoscintigraphic detection rate was 94.2% (66/70) and intraoperative of 97.0% (68/70). Fourteen patients had lymph node metastases, six only in SLN. The false negative rate was 2/14 (14.0%). The internal iliac region is the first metastatic site (40.9%). Limited or standard lymph node dissection would have ignored respectively 72.7% and 59.0% of lymph node metastases.
The laparoscopy is adapted to a broad identification of SLN and targeted dissection of these lymph nodes significantly limits the risk of surgical extended dissection while maintaining the accuracy of the information.
Tumour location is not an independent prognostic factor for survival following a diagnosis of breast cancer
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Previous studies of patients with breast cancer have examined tumour location as a prognostic factor for survival with contradictory results. The current population-based study with 356 women examines the effect of tumour location and other important prognostic factors on survival. Univariate analyses indicated that central location (P < 0.001), a larger pathological tumour size (P = 0.003), number of positive lymph nodes (P < 0.001), younger age at diagnosis (P = 0.003), a more advanced TNM stage (P < 0.001), a higher grade (P = 0.016) and histologic type (P = 0.011) were associated with a higher risk of breast cancer death. The 10-year survival of women with central location was 33%, compared to 73% for medial and 71% for lateral (P < 0.001). However, the differences among tumour locations were markedly reduced after adjustment separately for early (P = 0.39) and advanced (P = 0.56) TNM stages, which also confirmed the results of multivariate analysis that the location does not influence survival after adjustment for other important clinicopathological characteristics.
Lymphatic Mapping and Sentinel Lymphadenectomy for Breast Cancer
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Sentinel lymph node (SN) biopsy has been validated in the treatment of breast carcinoma. Patients with previous excisional biopsy are regarded as ineligible for SN biopsy. We evaluated the results of SN biopsy for this group of patients based on confirmatory axillary lymph node dissection.
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Lymphoscintigraphy visualized one or more axillary hot spots in 84/88 patients. A successful SN biopsy was performed in 87 patients. Complete axillary lymph-node dissection showed no false-negative SN biopsy among the 87 SN procedures.
SN biopsy is a reliable and safe method following excisional biopsy as is confirmed by completion axillary lymph node dissection. Therefore, patients with previous excisional biopsy are eligible for sentinel node procedure and can be spared unnecessary axillary lymph node dissection.

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View full text

Sentinel node localization in breast cancer

Int J Radiat Oncol Biol Phys

J Am Coll Surgeons

Surg Oncol

Lancet

Sem Nuc Med

Sem Nuc Med

Sem Nuc Med

Cancer statistics, 1997

CA Cancer J Clin

Breast cancer (First of three parts)

N.E.J.M.

The Breast

Pathological findings from the National Surgical Adjuvant Breast Project Protocol B-06: 10-year pathologic and clinical prognostic determinants

Cancer

The importance of histologic grade in long-term prognosis of breast cancer: A study of 1,010 patients, uniformly treated at the Institut Gustave-Roussy

J Clin Oncol

Pathologic findings from the National Surgical Adjuvant Breast Cancer Project (Protocol 4)

Cancer

Some thoughts concerning the primary therapy of breast cancer

Recent Results Cancer Res

Effect of axillary nodal status on the long-term survival following mastectomy for breast carcinoma: Nodal metastases may not always suggest systemic disease

J Surg Oncol

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Cancer

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J Clin Oncol

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N Engl J Med

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J Natl Cancer Inst

Are positive nodes in breast cancer markers for incurable disease?

Ann Surg

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Ann Surg

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Br J Cancer

Axillary lymph nodes and breast cancer: A review

Cancer

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Ann Surg Oncol

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Br J Surg

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N Engl J Med

Conservation approaches for the management of stage I/II carcinoma of the breast: Milan Cancer Institute Trials

World J Surgery

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N Engl J Med

Randomized clinical trial to asses the value of breast-conserving therapy in stage I and II breast cancer: EORTC 10801 trial

J Natl Cancer Inst

Conservative treatment versus mastectomy in early breast cancer: Patterns of failure with 15 years of follow-up data. Institut Gustave-Roussy Breast Cancer Group

J Clin Oncol

Danish randomized trial comparing breast conservation therapy with mastectomy: Six years of life table analysis

J Natl Cancer Inst Monogr

The new era in breast cancer: invasion, size, and nodal involvement dramatically decreasing as a result of mammographic screening

Arch Surg

Improved axillary staging of breast cancer with sentinel lymphadenectomy

Ann Surg

Sentinel lymphadenectomy in breast cancer

J Clin Oncol

Sentinel lymphadenectomy for breast cancer in a community managed care setting

Cancer J Sci Am

Lymphatic mapping and sentinel node biopsy in the patient with breast cancer

JAMA