Predictors of completion axillary lymph node dissection in patients with immunohistochemical metastases to the sentinel lymph node in breast cancer.

BACKGROUND: Axillary lymph node dissection (ALND) in patients with immunohistochemistry (IHC)-determined metastases to the sentinel lymph node (SLN) is controversial. The goal of this study was to examine factors associated with ALND in IHC-only patients. METHODS: Retrospective review of an institutional SLN database from July 1997 to July 2003 was performed. We compared sociodemographic, pathologic, and therapeutic variables between IHC-only patients who had SLN biopsy alone and those that had ALND. RESULTS: Our study group consisted of 171 patients with IHC-only metastases to the SLN. Young age, estrogen receptor negative status, high Memorial Sloan-Kettering Cancer Center nomogram score, and chemotherapy were associated with ALND. Among patients who had ALND (n = 95), 18% had a positive non-SLN. Rates of systemic therapy were similar between those with and without positive non-SLNs at ALND. No axillary recurrences were observed in this series with a median follow-up of 6.4 years. The percentage of patients who were recurrence-free after 5 years was 97% (95% confidence interval, 92.1-98.6). CONCLUSIONS: On the basis of our findings and the lack of prospective randomized data, the practice of selectively limiting ALND to IHC-only patients thought to be at high risk and to patients for whom the identification of additional positive nodes may change systemic therapy recommendations seems to be a safe and reasonable approach.

Surgical management of the axilla: do intramammary nodes matter?

BACKGROUND: The therapeutic significance of intramammary lymph nodes is uncertain. The purpose of this study was to identify the appropriate surgical management of the axilla in intramammary node-positive patients undergoing sentinel lymph node (SLN) biopsy. METHODS: A retrospective review of consecutive patients staged between September 1996 and December 2004 was performed. Intramammary node identification and pathologic findings were compared with the status of axilla. RESULTS: Among 7,140 patients, intramammary nodes were identified in 151 (2%). Positive intramammary nodes were identified in 36 patients (24%). Axillary disease was identified in 61% of intramammary node-positive patients. No additional axillary disease was identified when axillary lymph node dissection was performed in intramammary node-positive patients with negative axillary SLN biopsy results. CONCLUSIONS: The results suggest that completion axillary lymph node dissection may be based on the status of axillary SLN biopsies in clinically node negative patients when intramammary lymph node metastases are identified in the breast specimens.

Intraoperative evaluation of sentinel lymph nodes in invasive lobular carcinoma of the breast.

BACKGROUND: In breast cancer treatment, sentinel lymph node (SLN) evaluation is used to identify patients who may benefit from axillary lymph node dissection (ALND). Intraoperative evaluation (IE) of SLNs facilitates immediate ALND. Controversy exists regarding the accuracy of intraoperative SLN evaluation for patients with invasive lobular carcinoma (ILC) compared to invasive ductal carcinoma (IDC). METHODS: Using breast cancer registry data from January 2003 to March 2008, the intraoperative SLN evaluation of 66 ILC and 810 IDC patients was compared to the final SLN pathology result and to the performance of ALND. RESULTS: In ILC, the sensitivities of IE for isolated tumor cells (.2 mm and 2.0 mm, N1a-3a, n = 21) were 0%, 17%, and 71%, respectively. The specificity was 100%. IE identified 16/27 (59%) of SLN-positive (N1mi, N1a-3a) axillae, resulting in synchronous ALND. Delayed ALND for false negative IEs (11/27, 41%) occurred in 7/11 patients (64%). In IDC, the sensitivities of IE for N0(i+) (n = 60), N1mi (n = 75), and N1a-3a (n = 129) metastases were 0%, 7%, and 71%, respectively. The specificity was 99.6%. IE identified 97/204 (48%) of SLN-positive (N1mi, N1a-3a) axillae, resulting in synchronous ALND. Delayed ALND for false negative IEs (107/204, 52%) occurred in 38/107 patients (36%). CONCLUSIONS: Sensitivity and specificity of intraoperative SLN evaluation is very similar in ILC and IDC patients. Intraoperative SLN evaluation facilitated synchronous ALND in concordance with recommended practice guidelines.

Impact and outcomes of routine microstaging of sentinel lymph nodes in breast cancer: significance of the pN0(i+) and pN1mi categories.

BACKGROUND: In 2003, the American Joint Committee on Cancer (AJCC) initiated the 6th edition staging criteria, including pN0(i+) and pN1mi categories for breast cancer. However, the clinical significance of these categories is debated in the literature. METHODS: A prospective registry was used to identify patients staged with sentinel lymph node (SLN) biopsy. SLN evaluation included routine serial sectioning and immunohistochemical stains. SLN biopsies performed before January 2003 were restaged according to the AJCC's 6th edition criteria. RESULTS: Of 954 SLN biopsies identified, on review, 491 N0i-, 86 N0i+, 73 N1mi, 146 N1a, 29 N2a, and 11 N3a patients were available for analysis with a median follow-up of 45.4 months. Significant prognostic and therapeutic differences existed between the groups. Differences in overall survival (OS) and recurrence-free survival (RFS) were only noted when the size of the metastases reached the N1a level. There were no statistically significant differences in OS or RFS between N0(i-) and N0(i+) or N1mi disease. Cases that were N0(i+) or N1mi were more likely to have other poor prognostic factors and to receive more aggressive therapy. CONCLUSION: SLN biopsy allows a more sensitive evaluation of lymph nodes for metastatic cells. This has led to the increased identification of very small axillary metastases. While the new microstaging categories are not yet clearly associated with a significantly decreased OS or DFS in this series, they are associated with other poor prognostic factors and more local/regional and systemic therapy. Further analysis of the microstaging categories is needed.

The utility of intraoperative evaluation of sentinel lymph nodes in breast cancer.

BACKGROUND: In breast cancer treatment, intraoperative sentinel lymph node (SLN) evaluation is used to identify patients who may potentially benefit from immediate completion of axillary lymph node dissection. METHODS: Prospectively collected breast cancer registry data identified 516 SLN biopsies between January 2003 and December 2005. Intraoperative evaluation (IE) of the SLNs was performed in 479 axillae. Final pathology by hematoxylin and eosin and, for negative nodes, by immunohistochemical stains was compared with the IE result. The effect of IE and final pathology on surgical treatment was examined. RESULTS: The sensitivities for IE of N0(i+) (n = 39), N1mi (n = 41), and N1a-3a (n = 89) metastases were 0%, 5%, and 63%, respectively. The specificity was 99.7%. IE identified 57 (44%) of SLN-positive (N1mi and N1a-3a) axillae, thus resulting in synchronous axillary lymph node dissection for those patients. Reoperation for false-negative IEs (N1mi or N1a-3a with negative IE) occurred in only 27 axillae (39%). CONCLUSIONS: IE of SLNs has adequate sensitivity and excellent specificity. In addition to allowing patients to benefit from synchronous surgery, IE helped patients to receive care in concordance with recommended practice guidelines. The false-negative IE of SLNs highlights uncertainty with the clinical significance of axillary nodal staging when only small amounts of metastatic disease are identified in the axilla.

Accuracy of intraoperative imprint cytology of sentinel lymph nodes in breast cancer.

BACKGROUND: In breast cancer treatment, immediate completion of axillary lymph node dissection (ALND) can be performed if the intraoperative sentinel lymph node (SLN) examination is positive. This study evaluates the accuracy of intraoperative imprint cytology (IC) for detecting SLN metastases. METHODS: Pathology reports from 385 SLN biopsy examinations were reviewed retrospectively. The SLNs were serially sectioned perpendicular to the long axis and IC was performed intraoperatively. The SLNs then were formalin-fixed for permanent sections. Final pathology was compared with the intraoperative IC results. RESULTS: The sensitivities for IC detection of N0(i+) (n = 36), N1mi (n = 24), and N1a-3a (n = 65) metastases were 0%, 4%, and 74%, respectively. The specificity was 100%. CONCLUSIONS: Final pathology identified 89 (23%) patients with N1 or greater disease. IC allowed 49 (55%) of these patients to undergo synchronous completion of ALND. No unnecessary completion ALNDs were performed. The sensitivity of IC decreased with decreasing size of the metastasis.