Patients' view on intraoperative diagnosis of sentinel nodes in breast cancer: is it an automatic choice?

UNLABELLED: Intraoperative detection of sentinel node metastases in breast cancer enables immediate axillary lymph node dissection. This approach, however, introduces uncertainty for patients as to the extent of surgery. Waking to find a surgical drain implies more extensive surgery and worse prognosis disease. False negative diagnoses may cause disappointment. AIM: To evaluate patients' views and preferences on intraoperative diagnosis of sentinel nodes in breast cancer. METHODS: Questionnaire based survey of 100 patients who had previously undergone sentinel node biopsy with intraoperative diagnosis using touch imprint cytology (TIC). Patients were encouraged to add free text comments. RESULTS: Sixty-four patients responded to the questionnaire. Patients rated the information provided and their understanding of the procedure highly. Fifty-nine percent of respondents overestimated the sensitivity of TIC. Ninety-five percent of patients would choose to undergo intraoperative diagnosis in future if required. Five percent of patients would choose not to undergo intraoperative diagnosis, citing the resultant uncertainty, disappointment on waking and needing time to come in terms with the diagnosis of metastases as reasons. CONCLUSION: Given the choice, most patients would choose intraoperative diagnosis, though a minority would explicitly not, due to the adverse psychological effect thereof. Despite a good understanding of the procedure, the majority of patients overestimate the sensitivity of intraoperative diagnosis of sentinel nodes, which may heighten disappointment when a false negative diagnosis occurs. Intraoperative diagnosis should not be the automatic choice and patients should be actively involved in this decision making process.

Allergy to technetium-labelled nanocolloidal albumin for sentinel node identification.

Optimal sentinel node identification requires using the combination technique with blue dye and radiocolloid. Allergic reactions to the common blue dyes in use are well recognised. In this report, we present a patient with breast carcinoma who developed a type I hypersensitivity reaction to intradermal injection of technetium-99m labelled nanocolloidal albumin. While reactions to colloids are rare, and in this case minor, operators using this radiopharmaceutical should be prepared for a potential severe anaphylactic reaction.

Detection of the sentinel lymph node in breast cancer.

INTRODUCTION: Axillary lymph node status for lymphatic staging in breast cancer is the best prognostic indicator and guides systemic treatment. Sentinel lymph node (SLN) biopsy is a novel, minimally invasive technique for lymphatic staging proven to improve quality of life. The accurate detection of the SLN is paramount for the success of the procedure. METHODS: Relevant literature was reviewed with regards to the different dyes and techniques used for the detection of SLN in breast cancer. RESULTS: Highest identification rates and lowest false negative rates are achieved by using the combined blue dye and radiocolloid technique with pre-operative imaging using a gamma camera. There is a well-recognized learning curve to successfully perform SLN biopsy. CONCLUSIONS: The concept of SLN has been well validated and is the standard of care in early breast cancer. A multidisciplinary approach and structured training is the key to the successful introduction of the technique.

Monitoring recovery after laser surgery of the breast with optical tomography: a case study.

Results are presented of a study to monitor the changes in the optical properties of breast tissue over a 12-month period after interstitial laser photocoagulation treatment of a fibroadenoma. The study involved generating cross-sectional images of the breast with a multichannel time-resolved imaging system and a nonlinear image reconstruction algorithm. Images of the internal absorbing and scattering properties revealed the expected initial inflammatory response, followed by the development of low-scattering cysts consistent with corresponding ultrasound examinations. Although results indicate that purely qualitative images can potentially provide clinically valuable data, means of enhancing diagnostic information by overcoming present limitations of the approach are discussed.

New approaches in breast cancer management: sentinel node biopsy and intraoperative radiotherapy.

Breast cancer is presenting earlier, and treatment is becoming less invasive. We review two recent changes in the approach to management. Sentinel lymph node biopsy is a minimally invasive technique to identify the first draining lymph node in direct communication with the primary tumor; it enables "selective lymphadenectomy." Axillary lymph node dissection is reserved as a therapeutic procedure only for proven node positive patients. The concept has been validated, the techniques have been optimized, and randomized controlled trials have confirmed lower morbidity without compromising regional control compared with conventional treatment. The procedure is considered by many as the standard of care for staging the axilla in early breast cancer, although several unanswered questions remain. Adequate training and experience in the technique are vital to ensure high sentinel node identification and low false negative rates. Intraoperative radiotherapy is an attractive concept that enables delivery of single fraction radiotherapy in the operating room immediately after resection of the primary tumor. It is convenient for patients and appears effective in pilot studies. Partial breast irradiation to the index quadrant has been practiced for many years in the form o brachytherapy. Trials are under way comparing intraoperative radiotherapy with conventional external bea irradiation. Intra-operative radiotherapy should not be used outside of clinical trials until the results of the current randomized trials are known.

Elastic scattering spectroscopy for intraoperative determination of sentinel lymph node status in the breast.

The ability to provide the best treatment for breast cancer depends on establishing whether or not the cancer has spread to the lymph nodes under the arm. Conventional assessment requires tissue removal, preparation, and expert microscopic interpretation. In this study, elastic scattering spectroscopy (ESS) is used to interrogate excised nodes with pulsed broadband illumination and collection of the backscattered light. Multiple spectra are taken from 139 excised nodes (53 containing cancer) in 68 patients, and spectral analysis is performed using a combination of principal component analysis and linear discriminant analysis to correlate the spectra with conventional histology. The data are divided into training and test sets. In test sets containing spectra from only normal nodes and nodes with complete replacement by cancer, ESS detects the spectra from cancerous nodes with 84% sensitivity and 91% specificity (per-spectrum analysis). In test sets that included normal nodes and nodes with partial as well as complete replacement by cancer, ESS detects the nodes with cancer with an average sensitivity of 75% and specificity of 89% (per-node analysis). These results are comparable to those from conventional touch imprint cytology and frozen section histology, but do not require an expert pathologist for interpretation. With automation of the technique, results could be made available almost instantaneously. ESS is a promising technique for the rapid, accurate, and straightforward detection of metastases in excised sentinel lymph nodes.

The emerging role and implications of sentinel node biopsy in breast carcinoma.

The surgical management of breast cancer has become less invasive in recent years. Accurate lymphatic staging remains crucial for determining adjuvant treatment and prognosis. Sentinel node biopsy enables highly accurate lymphatic staging with minimal morbidity. In this article we give a historical overview, outline the technique, give succinct guidelines for practice based on current evidence, examine recently published work as well as highlight the most important trials in progress. The advent of sentinel node biopsy for the routine treatment of breast carcinoma will have significant implications on the whole team involved in beast cancer care. Training for the entire team needs to be addressed, and preparations made as patients are likely to soon demand this procedure as part of the routine management of their breast carcinoma.