J Breast Cancer.  2006 Sep;9(3):235-240. 10.4048/jbc.2006.9.3.235.

The Result of Evaluation According to Radioactivity of Sequential Sentinel Nodes Biopsy in Breast cancer

• Oh JW
• Jung SY
• Hur H
• Lee JD
• Kim SI
• Kim SH
• Yang WI
• Yun MJ
• Park BW

• KMID: 2286654
• DOI: http://doi.org/10.4048/jbc.2006.9.3.235

Abstract

PURPOSE
Radio-guided sentinel node biopsy has become a standard method for evaluating the axillary status. However, there is no guideline for the optimum extent of sentinel lymphadenectomy. The object of this study was to assess the probability of metastases according to the sequence of radioactivity in the sentinel nodes and to determine the accuracy of the methods for evaluating metastases.
METHODS
80 consenting patients underwent sentinel lymph node biopsy using 99mTc-phytate. All the lymph nodes that showed radioactivity higher than surroundings were excised and labeled as SN1 to SN5 according to the sequential radioactivity. All the excised sentinel nodes were evaluated by frozen sectioning (FS) and permanent sectioning (PS). The sensitivity, specificity, negative predictive value and accuracy of the procedure were then analyzed according to the evaluation method.
RESULTS
All 80 patients showed a variable number of axillary sentinel node sites (SN1-SN5) and 19 patients (23.8%) had three or more sentinel node sites, with an average number of 1.98. The sensitivity, specificity, NPV and accuracy were higher on PS (94.4%, 100%, 98.4% and 98.8% respectively) than on FS (88.9%, 100%, 96.9% and 97.5% respectively). 20 patients were found to have metastatic breast cancer within the sentinel lymph nodes by IHC, but one case of a metastatic, non-sentinel node was found in the 60 patients with negative sentinel nodes, so that the final false negative rate was 4.8%. In 18 of the 20 sentinel node-positive patients(90.0%), the most radioactive lymph node (SN1) was a positive node. The removal of the most radioactive sentinel node and the 2nd most radioactive sentinel node accurately staged all 20 sentinel node-positive patients.
CONCLUSION
Careful evaluation of the sentinel nodes with FS, PS and IHC study is essential to reduce the false negative results. In addition, excision of the highest and the 2nd highest lymph nodes is essential and the excision of the 3rd highest node if any, should also be considered for obtaining a better treatment results.

Keyword

breast cancer; sentinel lymph node; sequential radioactivity

MeSH Terms

Biopsy*
Breast Neoplasms*
Breast*
Humans
Lymph Node Excision
Lymph Nodes
Neoplasm Metastasis
Radioactivity*
Sensitivity and Specificity
Sentinel Lymph Node Biopsy

Reference

1. Krag DN, Weaver DL, Alex JC, Fairbank JT. Surgical resection and radiolocalization of the sentinel lymph node in breast cancer using a gamma probe. Surg Oncol. 1993. 2:335–339.

2. Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg. 1994. 220:391–398.

3. Kuerer HM, Newman LA. Lymphatic mapping and sentinel lymph node biopsy for breast cancer: developments and resolving controversies. J Clin Oncol. 2005. 23:1698–1705.

4. Veronesi U, Paganelli G, Viale G, Luini A, Zurrida S, Galimberti V, et al. A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer. N Engl J Med. 2003. 349:546–553.

5. Schwarts GF, Guiliano AE, Veronesi U. Proceeding of the consensus conference of the role of sentinel lymph node biopsy in carcinoma or the breast April 19-22, 2001, Philadelphia, PA, USA. Breast J. 2002. 8:124–138.

6. Kuehn T, Bembenek A, Decker T, Munz DL, Sautter-Bihl ML, Untch M, et al. A concept for the clinical implementation of sentinel lymph node biopsy in patients with breast carcinoma with special regard to quality assurance. Cancer. 2005. 103:451–461.

7. Goldhirsch A, Wood WC, Gelber RD, Coates AS, Thurlimann B, Senn HJ. Meeting highlights: updated international expert consensus on the primary therapy of early breast cancer. J Clin Oncol. 2003. 21:3357–3365.

8. Gill PG. Sentinel lymph node biopsy versus axilliary clearance in operable breast cancer: The RACS SNAC trial, a multicenter randomized trial of the Royal Australian College of Surgeons, Section of Breast Surgery, in collaboration with the National Health and Medical Research Council Clinical Trials Center. Ann Surg Oncol. 2004. 11:216S–221S.

9. Guenther JM. Subareolar versus peritumoral injection of location of sentinel lymph node. Ann Surg. 2000. 231:614–615.

10. D'Eredita G, Ferrarese F, Cecere V, Massa ST, de Carne F, Fabiano G. Subareolar Injection May Be More Accurate Than Other Techniques for Sentinel Lymph Node Biopsy in Breast Cancer. Ann Surg Oncol. 2003. 10:942–947.

11. Yoshida K, Yamamoto N, Imanaka N, Togawa T, Miyauchi M, Miyazaki M. Will subareolar injection be a standard technique for sentinel lymph node biopsy? Breast Cancer. 2002. 9:319–322.

12. Zogakis TG, Wetherille RE, Christensen RD, Ose KJ, Friedman JD, Colbert M, et al. Intraoperative subareolar injection of 99mTc-labeled sulfur colloid results in consistent sentinel lymph node identification. Ann Surg Oncol. 2005. 12:167–172.

13. Tavares MG, Sapienza MT, Galeb NA Jr, Belfort FA, Costa RR, Osorio CA, et al. The use of 99m-Tc-Phytate for sentinel node mapping in melanoma, breast cancer and vulvar cancer. Eur J Nucl Med. 2001. 28:1597–1604.

14. Koizumi M, Nomura E, Yamada Y, Takiguchi T, Makita M, Iwase T, et al. Radioguided sentinel node detection in breast cancer patients: comparison of 99mTc phytate and 99mTc rhenium colloid efficacy. Nucl Med Commun. 2004. 25:1031–1037.

15. Nieweg OE. Lymphatics of the breast and the rationale for different injection techniques. Ann Surg Oncol. 2001. 8:71S–73S.

16. Sato K, Tamaki K, Shigekawa T, Tsuda H, Kosuda S, Kusano S, et al. Clinically useful detection criteria for sentinel nodes in patients with breast cancer using a radioisotope technique. Jpn J Clin Oncol. 2002. 32:403–406.

17. 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.

18. Bourgeois P, Nogaret JM, Veys I, Hertens D, Dagnelie J, Vanhaudenaerde C, et al. How 'hot' is the pathologically positive sentinel lymph node in breast cancer patients? Nucl Med Commun. 2003. 24:513–518.

19. Camp ER, Cendan JC, Feezor R, Lind DS, Wilkinson E, Copeland EM. The hottest sentinel lymph node is not always the positive node. Am Surg. 2004. 70:475–478.

20. Martin RC, Fey J, Yeung H, Borgen PI, Cody HS 3rd. Highest isotope count does not predict sentinel node positivity in all breast cancer. Br J Surg. 2005. 92:438–442.

21. Goyal A, Newcombe RG, Mansel RE. Clinical relevance of multiple sentinel nodes in patients with breast cancer. Br J Surg. 2005. 92:438–442.

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

23. Kennedy RJ, Kollias J, Gill PG, Bochner M, Coventry BJ, Farshid G. Removal of two sentinel nodes accurately stages the axilla in breast cancer. Br J Surg. 2003. 90:1349–1353.

24. Duncan M, Cech A, Wechter D, Moonka R. Criteria for establishing the adequacy of a sentinel lymphadenectomy. Am J Surg. 2004. 187:639–642.

25. 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.

26. Baek CS, Park SY, Kang SH, Lee SJ. The classification of sentinel lymph node according to radioactivity in breast cancer. J Korean Surg Soc. 2003. 65:382–388.

27. Leidenius M, Krogerus L, Toivonen T, Leppanen E, Von Smitten K. The sensitivity of axillary staging when using sentinel node biopsy in breast cancer. Eur J Surg Oncol. 2003. 29:849–853.