J Breast Cancer.  2011 Dec;14(4):296-300. 10.4048/jbc.2011.14.4.296.

How Many Sentinel Lymph Nodes Are Enough for Accurate Axillary Staging in T1-2 Breast Cancer?

• Ban EJ
• Lee JS
• Koo JS
• Park S
• Kim SI
• Park BW

• KMID: 2175723
• DOI: http://doi.org/10.4048/jbc.2011.14.4.296

Abstract

PURPOSE
During a sentinel lymph node biopsy (SLNB) for breast cancer, the appropriate number of sentinel lymph nodes (SLNs) to be removed for accurate axillary staging is still controversial. We hypothesized that there might be an optimal threshold number of SLNs. We investigated how many SLNs should be removed to achieve an acceptable accuracy and ensure minimal morbidity.
METHODS
We reviewed data of 328 patients with invasive breast cancer who underwent SLNB followed by complete level I and II axillary dissection between January 2004 and December 2005. The false negative rate (FNR) and accuracy of SLNB according to the number of removed SLNs were evaluated.
RESULTS
The mean number of SLNs removed was 3.0 (range, 1-14), and that of total retrieved axillary lymph nodes was 17.5 (range, 10-40). In total, 111 (33.8%) patients had positive nodes on the permanent pathological report. Among them, 12 patients had negative SLNs; thus, the overall FNR of SLNB was 10.8% (12/111) and the accuracy was 96.3% (316/328). The FNR was 26.6% for a single SLN, 8.0% for two, and 11.1% for three. In cases where four or more SLNs were removed, the FNR decreased to 0% and accuracy reached 100%.
CONCLUSION
Our data suggest that a SLNB should not only remove one or two of the hottest node(s) when other hot nodes exist. We also suggest that four might be an optimal threshold number of SLNs to be removed and that removal of more than four SLNs does not improve axillary staging accuracy.

Keyword

Breast neoplasms; False negative rate; Sentinel lymph node biopsy

MeSH Terms

Breast
Breast Neoplasms
Dietary Sucrose
Humans
Lymph Nodes
Nitriles
Pyrethrins
Sentinel Lymph Node Biopsy
Dietary Sucrose
Nitriles
Pyrethrins

Reference

1. Veronesi U, Paganelli G, Viale G, Luini A, Zurrida S, Galimberti V, et al. Sentinel-lymph-node biopsy as a staging procedure in breast cancer: update of a randomised controlled study. Lancet Oncol. 2006. 7:983–990.

2. McMasters KM, Tuttle TM, Carlson DJ, Brown CM, Noyes RD, Glaser RL, et al. Sentinel lymph node biopsy for breast cancer: a suitable alternative to routine axillary dissection in multi-institutional practice when optimal technique is used. J Clin Oncol. 2000. 18:2560–2566.

3. Hoar FJ, Stonelake PS. A prospective study of the value of axillary node sampling in addition to sentinel lymph node biopsy in patients with breast cancer. Eur J Surg Oncol. 2003. 29:526–531.

4. Krag DN. Minimal access surgery for staging regional lymph nodes: the sentinel-node concept. Curr Probl Surg. 1998. 35:951–1016.

5. Morton DL, Wen DR, Wong JH, Economou JS, Cagle LA, Storm FK, et al. Technical details of intraoperative lymphatic mapping for early stage melanoma. Arch Surg. 1992. 127:392–399.

6. Dabbs DJ, Johnson R. The optimal number of sentinel lymph nodes for focused pathologic examination. Breast J. 2004. 10:186–189.

7. McCarter MD, Yeung H, Fey J, Borgen PI, Cody HS 3rd. The breast cancer patient with multiple sentinel nodes: when to stop. J Am Coll Surg. 2001. 192:692–697.

8. Nathanson SD. Will the true sentinel node please stand? Ann Surg Oncol. 1999. 6:514–516.

9. Morton DL, Bostick PJ. Will the true sentinel node please stand? Ann Surg Oncol. 1999. 6:12–14.

10. Harlow SP, Krag DN, Julian TB, Ashikaga T, Weaver DL, Feldman SA, et al. Prerandomization Surgical Training for the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-32 trial: a randomized phase III clinical trial to compare sentinel node resection to conventional axillary dissection in clinically node-negative breast cancer. Ann Surg. 2005. 241:48–54.

11. Borgstein PJ, Pijpers R, Comans EF, van Diest PJ, Boom RP, Meijer S. Sentinel lymph node biopsy in breast cancer: guidelines and pitfalls of lymphoscintigraphy and gamma probe detection. J Am Coll Surg. 1998. 186:275–283.

12. Krag D, Weaver D, Ashikaga T, Moffat F, Klimberg VS, Shriver C, et al. The sentinel node in breast cancer: a multicenter validation study. N Engl J Med. 1998. 339:941–946.

13. Tafra L, Lannin DR, Swanson MS, Van Eyk JJ, Verbanac KM, Chua AN, et al. Multicenter trial of sentinel node biopsy for breast cancer using both technetium sulfur colloid and isosulfan blue dye. Ann Surg. 2001. 233:51–59.

14. Woznick A, Franco M, Bendick P, Benitez PR. Sentinel lymph node dissection for breast cancer: how many nodes are enough and which technique is optimal? Am J Surg. 2006. 191:330–333.

15. Wilke LG, McCall LM, Posther KE, Whitworth PW, Reintgen DS, Leitch AM, et al. Surgical complications associated with sentinel lymph node biopsy: results from a prospective international cooperative group trial. Ann Surg Oncol. 2006. 13:491–500.

16. Krag DN, Anderson SJ, Julian TB, Brown AM, Harlow SP, Costantino JP, et al. Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol. 2010. 11:927–933.

17. Zakaria S, Degnim AC, Kleer CG, Diehl KA, Cimmino VM, Chang AE, et al. Sentinel lymph node biopsy for breast cancer: how many nodes are enough? J Surg Oncol. 2007. 96:554–559.

18. Koo BY, Jeong SG, Eom TI, Kang HJ, Kim LS. The number of removed lymph nodes for an acceptable false negative rate in sentinel lymph node biopsy for breast cancer. J Breast Cancer. 2009. 12:100–105.

19. Choi JE, Park SY, Jeon MH, Kang SH, Bae YK, Lee SJ. Optimal sampling number of sentinel lymph nodes in invasive breast cancer: results of 1,026 sentinel lymph node biopsies done by radioisotope. J Breast Cancer. 2011. 14:Suppl 1. S37–S43.

20. Oh JW, Jung SY, Hur H, Lee JD, Kim SI, Kim SH, et al. The result of evaluation according to radioactivity of sequential sentinel nodes biopsy in breast cancer. J Breast Cancer. 2006. 9:235–240.

21. Yi M, Meric-Bernstam F, Ross MI, Akins JS, Hwang RF, Lucci A, et al. How many sentinel lymph nodes are enough during sentinel lymph node dissection for breast cancer? Cancer. 2008. 113:30–37.

22. Povoski SP, Young DC, Walker MJ, Carson WE, Yee LD, Agnese DM, et al. Re-emphasizing the concept of adequacy of intraoperative assessment of the axillary sentinel lymph nodes for identifying nodal positivity during breast cancer surgery. World J Surg Oncol. 2007. 5:18.

23. Kelley MC, Hansen N, McMasters KM. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Am J Surg. 2004. 188:49–61.

24. Spillane AJ, Brennan ME. Accuracy of sentinel lymph node biopsy in large and multifocal/multicentric breast carcinoma: a systematic review. Eur J Surg Oncol. 2011. 37:371–385.

25. Gill G. SNAC Trial Group of the Royal Australasian College of Surgeons (RACS) and NHMRC Clinical Trials Centre. Sentinel-lymph-nodebased management or routine axillary clearance One-year outcomes of sentinel node biopsy versus axillary clearance? (SNAC): a randomized controlled surgical trial. Ann Surg Oncol. 2009. 16:266–275.

26. Martin RC 2nd, Edwards MJ, Wong SL, Tuttle TM, Carlson DJ, Brown CM, et al. Practical guidelines for optimal gamma probe detection of sentinel lymph nodes in breast cancer: results of a multi-institutional study. For the University of Louisville Breast Cancer Study Group. Surgery. 2000. 128:139–144.

27. Albertini JJ, Lyman GH, Cox C, Yeatman T, Balducci L, Ku N, et al. Lymphatic mapping and sentinel node biopsy in the patient with breast cancer. JAMA. 1996. 276:1818–1822.

28. Boxen I, McCready D, Ballinger JR. Sentinel node detection and definition may depend on the imaging agent and timing. Clin Nucl Med. 1999. 24:390–394.

29. Martin RC, Fey J, Yeung H, Borgen PI, Cody HS 3rd. Highest isotope count does not predict sentinel node positivity in all breast cancer patients. Ann Surg Oncol. 2001. 8:592–597.

30. Ko SS. Korean Breast Cancer Society. Chronological changing patterns of clinical characteristics of Korean breast cancer patients during 10 years (1996-2006) using nationwide breast cancer registration on-line program: biannual update. J Surg Oncol. 2008. 98:318–323.