Sentinel lymph node biopsy (SLNB) vs. axillary lymph node dissection (ALND) in the current surgical treatment of early stage breast cancer.

The identification and biopsy of the sentinel lymph node has become a standard method of treatment for stage I and II breast cancer in the last decades, taking into account the fact that the management of the axilla in patients with breast cancer has evolved from the routine lymphadenectomy to a selective attitude, based on the histopathological evaluation of the sentinel lymph node, as well as on the tumor and on the patients' characteristics. Since the introduction of the method into clinical practice, in 1994, different methods of identification have been used (radioisotope injection, vital blue dye, or, more recently, lipophilic contrast agent for ultrasound visualization or paramagnetic nanoparticles (NPs) or the method of indocyanine green fluorescence), each presenting certain limits, but the radioisotopic method proving the most accurate. Moreover, during the development of the method, beside the standard indications specific for T1 or T2 breast tumor, without clinical or imagistic axillary adenopathies, their extension to a series of other particular situations such as the following, has been tried: ductal carcinoma in situ, multicentre tumors, after excisional biopsy or tumors preoperatively treated by neoadjuvant chemotherapy. The aim of the paper is to present the progress made regarding the current stage in the use of sentinel lymph node technique in breast cancer, while mentioning the established indications, as well as the ones that are still debating and need further studies. Likewise, the cases in which the axillary lymph node dissection remains the major indication for treatment of the axilla, in patients with early stage breast cancer, will be discussed.

Clinical significance of the lymphoscintigraphy in the evaluation of non-axillary sentinel lymph node localization in breast cancer.

BACKGROUND: Identification and biopsy of the sentinel lymph node (SLN) in early-stage breast cancer (T1-T2N0) has become the standard method in the surgical treatment of the axilla, due to its accuracy in the evaluation of axillary lymph node status,thus avoiding extensive axillary lymph node dissection inpatients with negative SLN. The aim of our study is to highlight the role of 99mTc-nanocolloid lymphoscintigraphy in the preoperative lymphatic mapping, especially for SLN localizations outside the axilla, as well as the benefits of this technique in the accurate staging of breast cancer. MATERIALS AND METHOD: 430 patients (age 31-81 years) with breast cancer (T1-T2N0 stage) were included in the study group, who underwent lymphoscintigraphy in order to identify the sentinel lymph node in the Nuclear Medicine Department of "€œProf. Dr. Al. Trestioreanu"€ Institute of Oncology, Bucharest,between October 2008 - July 2014. Radiocolloid (99mTc-nanocolloid)was injected using peritumoral or periareolar intradermal technique, doses between 20-37 MBq (0.3-0.5 ml volume), followed by static and dynamic post-injection acquisitions.Intraoperative identification of the SLN was performed using a gamma-probe, guided by the skin marker performed preoperatively after completion of lymphoscintigraphy. RESULTS: 697 sentinel lymph nodes were identified through imaging techniques in 427 patients (99%). Of them, 364 patients had axillary localization of the SLN, while 48 patients(11%) had non-axillary (pectoral, internal mammary, supraclavicular,intra-mammary) localization and 15 patients (3%)had multiple localization (axillary and non-axillary).Intraoperative histopathological exam revealed lymphatic invasion in 74 SLN (12% macrometastases and 88% micrometastases). CONCLUSIONS: The identification and biopsy of the sentinel lymph node in stages I and IIA is a useful routine for accurate breast cancer staging, suited for axillary lymphatic drainage, as well as for unusual non-axillary SLN localization, guiding the clinician for further postoperative management of these patients.

Peculiarities of lymphatic drainage in cutaneous malignant melanoma: clinical experience in 75 cases.

UNLABELLED: In the recent years, the identification and biopsy of the sentinel lymph node (SLN) has become standard in the treatment of cutaneous malignant melanoma (CMM). In order to correctly apply the technique and to decrease the risk of false negatives,it is compulsory to track the lymphatic drainage of the primary tumor and to detect all SLN, regardless of their site. METHOD: At the Bucharest Oncologic Institute, over the last three years, selective lymphadenectomy was performed in 75 patients with CMM, stages I and II (AJCC). In 39 cases, the primary tumor was at the level of the upper and lower limbs and in 36 on the trunk. In all patients, lymphoscintigraphy was performed through intradermal injection of Nanocoll,with dynamic follow up of the radiotracer, with the purpose of finding the possible unusual locations of the SLN. RESULTS: The sentinel lymph nodes were identified in 100%of the cases. In 63 patients (84%), the primary tumor drained in only one lymphatic field and in the other 12 the drainage was towards 2 or more lymphatic basins. The CMM situated on the trunk had a particular behaviour, presenting more often (33%) with multiple nodal basin drainage. CONCLUSIONS: CMM of the trunk, mostly those situated close to the midline, but others as well, tend to drain into several lymphatic areas. The existence of interval lymph nodes and atypical lymphatic drainage, in a minor lymphatic basin,must be determined preoperatively in order to allow the biopsy of all SLN and establish the right therapy.

Occult breast lesion localization and concomitant sentinel lymph node biopsy in early breast cancer (SNOLL).

AIMS: Mammographic screening and the increasing resolution output of mammography have raised the identification number of small-size mammary lesions without clinical expression. The aim of this study was to evaluate in a prospective study the localization techique and concomitent sentinel lymph node biopsy for breast cancer (SNOLL - Sentinel lymph Node biopsy and Occult Lesion Localization). METHODS: We identified by means of imaging techniques a number of 107 patients with clinically occult suspicious breast tumors. All patients preoperatively underwent a protocol in which the injection of 99mTc-nannocolloid under imaging procedures was performed. Surgical excision was performed, guided by the hand held gammaprobe. The sentinel lymph node was identified as an axillary hot spot on the probe. RESULTS: All primary lesions were identified and were clear of invasive margins needing excision. 98 tumors proved to be malignant on frozen sections. 7 lesions could not be clearly examined through frozen section and 2 proved to be benign. 6 out of 7 suspicious lesions confirmed to be malignant on parrafin embedded sections. Sentinel lymph node was identified in a number of 95 out of 98 patients. In 14 cases complete axillary lymphadenectomy was performed. The average specimen weight was 40 grams. CONCLUSIONS: Using this technique, we removed the lesions identified prior to surgery in all cases, achieving a complete pathologic diagnostic, the necessary surgical treatment and also prognostic data by axillary lymph node assessment.

[Latest approaches in the surgical treatment of cutaneous malignant melanoma]. / Actualitati în tratamentul chirurgical al melanomului malign cutanat.

Malignant melanoma is a disease with an unpredictable evolution. Detected in stage I and II has a great chance to cure, if it is correctly treated: excisional biopsy with safety margins in accordance with tumor thickness. Lymphoscintigraphy with sentinel node identification and biopsy became compulsory for staging malignant melanoma, the role of complete lymphadenectomy would be established by publishing the MSLTII data. The sentinel node is analysed using more and more sophisticated techniques (RT-PCR) in order to detect isolated tumoral cells, although their clinical significance is not known yet. Metastases occurrence is a dramatic phenomenon because chemotherapy, radiotherapy or biologic therapy have insignificant results. The only therapeutic modality which may increase survival in this situation is surgery for some carefully selected patients.