Prognostic Implications of Positive Nonsentinel Lymph Nodes Removed During Selective Sentinel Lymphadenectomy for Breast Cancer (original) (raw)
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Introduction: Although sentinel lymph node biopsy (SLNB) is the gold standard for clinical and radiological negative axillae in breast cancer, the subsequent management of positive nodes is currently under scrutiny with the Z0011 trial publication causing much debate. Our aim was to determine whether there were any predictive factors in our cohort of patients that could assist in the decision of whether the patient required a further axillary lymph node clearance. Methods: A retrospective analysis of a prospectively maintained database of patients who underwent SLNB and their histology was performed. Univariate and multivariate analysis was performed to identify any predictive factors. Results: Our Breast Unit performed 457 SLNB over the three years. The mean age of patients was 61.9 years (range 31-89 years). Of these 457 SLNB, 122 (26.7%) were positive for metastatic involvement, and of these patients only 34% were found to have further lymph node involvement after axillary lymph node clearance (ALNC). Only 8% of our total patient cohort had non sentinel node involvement at completion ALNC. Using univariate analysis, lymphovascular invasion (p0.009), grade (p0.007) and size (p0.006) were all significant predictors for having a positive ALNC. Conclusion: Only 8% of the total number of patients had an additional positive lymph node found in their completion axillary clearance. Our results add to this existing knowledge on the subject, and show that there are certain factors which should be carefully considered pre-operatively in order to help inform patient and surgeon choice regarding management of the axilla.
Indian Journal of Surgical Oncology, 2021
The ACOSOG Z0011 study, heralded as a "practice changing" trial, suggested that women with T1-2 breast cancer with 1-2 SLN+, undergoing breast conservation therapy, need not be offered further ALND. However, whether these results are applicable to all women in the Indian setting, it remains debatable. A retrospective audit of all cN0 operated from 2013 to 2018 was conducted. We analyzed the percentage of additional LN positive (LN+) in the ALND group and compared it to the ACOZOG Z11 trial. Of the 2350 cN0 with EBC who underwent LAS, 687 (29%) had positive lymph nodes on final histopathology. Five hundred ninety-seven (86.9%) patients had 1-2 LN+, 40 (5.8%) patients had 3 LN+, and 50 (7.3%) had 4 or more nodes positive. Demographic features in the ACOSOG Z11 are different from those in our study, looking at ACOZOG Z11 versus our cohortmedian pT 1.7 cm versus 3 cm, 45% micrometastasis versus 99.16% macrometastasis, and 28-30% grade 3 tumors versus 73.7%. In our cohort 31.82% of the 1-2 LN positive had additional LN+ on ALND. Keeping in mind the difference in clinicopathological features between our cohort and that of ACOZOG Z0011 and that 31.82% of women had additional LN+ on ALND, it may not be appropriate to apply the results of the ACOSOG Z0011 trial directly to our general population. Possibly, only a select subset of patients who match the trial population of the ACOSOG Z11 could be offered observation of the axilla and validated nomograms can be used to identify high-risk patients.
Introduction: For patients with clinically negative axilla, sentinel lymph node biopsy (SLNB) is the standard method for axillary staging Because the SLBNs are the only positive nodes in approximately 40-70% of patients with pathologically proven positive axillae after completion axillary lymph node dissection (ALND), the treatment of patients with a positive SLBN has been reconsidered and the development of predictive tools that select the patients whom routine ALND could be avoided safely. Purpose: to characterize the patients in whom completion ALND can be avoided in spite of positive SLNB. Patients and methods: This retrospective study included all patients who had SLNB at The characteristics of the special group with positive SLNB and node-negative upon completion ALND were studied. Results: out of 66 patients with clinically negative axillae, SLNB was negative in 36 patients, with no more ALND, J Cancer Sci Clin Ther 2020; 4 (1): 001-014 Journal of Cancer Science and Clinical Therapeutics 2 and SLNB was positive in 30 patients for whom completion ALND was done, and revealed that 63.4% (19 out of 30 patients) had no other positive nodes after completion ALND. Conclusion: In patients with clinically negative axillae and positive sentinel SLNB, A combination of multiple predictive parameters as, the number of positive SLNs, the ratio between metastatic SLNs and total number of SLN retrieved, extracapsular invasion, and lymphovascular invasion were significant predictors for the risk of non-SLN involvement and can identify the patients with positive SLNB for whom routine ALND could be safely avoided.
Positive axillary sentinel lymph node: Is axillary dissection always necessary?
The Breast, 2011
There is considerable interest in foregoing axillary dissection (AD) when the sentinel node (SN) is positive in early breast cancer, particularly when axillary involvement is minimal (micrometastases or isolated tumor cells). In fact, clinical practice has run ahead of the evidence, since recent population-based data indicate that AD is 'underused' in breast cancer patients when the SN is positive. Several trials are addressing the problem (IBCSG 23-01, ASCOG Z0011, EORTC AMAROS). Only Z0011 has published interim results, finding, after a median follow-up of 6.3 years, no differences in locoregional recurrence or regional recurrence between patients, with a positive SN, who received AD vs. no further axillary treatment. Our own retrospective study evaluated patients with micrometastases or isolated tumor cells in the SN who received no further axillary treatment. We found high five-year survival and low cumulative incidence of axillary recurrence, supporting the findings of Z0011 and justifying the increasingly common practice of foregoing AD in women with minimal SN involvement. It is important to sound a note of caution however: If axillary dissection is not always necessary in women with a positive axilla, it seems important to be able to reliably identify the patients at high risk of developing overt axillary disease who should receive elective AD. Ancillary analyses of the IBCSG 23-01 and AMAROS trials, still in follow-up, may be able to do this.
Annals of Breast Surgery
Background: The role of completion axillary lymph node dissection (CALND) following positive sentinel lymph node biopsy (SLNB) is being actively debated. The involvement of our unit in the POSNOC trial (which has a no-treatment arm), has prompted a review of our unit's CALND results, in order to examine predictors of involvement of non-sentinel lymph nodes (n-SLN). Methods: We retrospectively analyzed our experience of SLNB between July 2008 to 2013. A total of 1,152 breast cancer patients underwent SLNB based on lymphoscintigraphy, intraoperative gamma probe detection, and blue dye mapping using 99mTc-nanocolloid and Patent Blue V injected peri-areola. Results: Out of 1,152 SLNB performed, 224 were positive for metastatic disease; 203 patients were anesthetically capable of progressing to CALND. On univariate analysis, involved n-SLN on CALND could not be predicted by age, size of tumor, procedure performed, lymph vascular invasion, number of positive SLN, receptor status; ER, PR, HER2 or triple negative. There was a trend toward higher incidence of positive n-SLN with increasing grade, and extracapsular spread, but these did not reach statistical significance. Positive n-SLN on CALND was however predicted by macrometastases in SLN and ratio of positive nodes on SLNB. Conclusions: In our series of more than 200 SLNB, a ratio of >0.5 positive SLN yield and presence of macrometastases in positive SLN, were associated with positive n-SLN on CALND.
Journal of Cancer Therapy, 2013
Objective: Sentinel lymph node biopsy (SLNB) is a validated staging technique for breast carcinoma. Some women are exposed to have a second SLNB due to breast cancer recurrence or a second neoplasia (breast or other). Due to modified anatomy, it has been claimed that previous axillary surgery represents a contra-indication to SLNB. Our objective was to analyse the literature to assess if a second SLNB is to be recommended or not. Methods: For the present study, we performed a review of all published data during the last 10 years on patients with previous axilla surgery and second SLNB. Results: Our analysis shows that second SLNB is feasible in 70%. Extra-axillary SNs rate (31%) was higher after radical lymph node dissection (ALND) (60%-84%) than after SLNB alone (14%-65%). Follow-up and complementary ALND following negative and positive second SLNB shows that it is a reliable procedure. Conclusion: The review of literature confirms that SLNB is feasible after previous axillary dissection. Triple technique for SN mapping is the best examination to highlight modified lymphatic anatomy and shows definitively where SLNB must be performed. Surgery may be more demanding as patients may have more frequently extra-axillary SN only, like internal mammary nodes. ALND can be avoided when second SLNB harvests negative SNs. These conclusions should however be taken with caution because of the heterogeneity of publications regarding SLNB and surgical technique.