Primary Tumor Characteristics Predict Sentinel Lymph Node Macrometastasis in Breast Cancer
ABSTRACT Selective sentinel lymphadenectomy (SSL) is rapidly becoming the standard of care in the surgical management of patients with early breast cancer. Sentinel lymph node macrometastasis has been well documented in the literature to have a higher risk of nonsentinel node tumor involvement when compared to micrometastasis. The aim of our study was to determine the primary tumor characteristics associated with sentinel node macrometastasis that will allow us to preoperatively determine this subgroup of patients at risk. This study was a retrospective review of 644 patients who underwent successful SSL as part of their surgical treatment of breast cancer at the University of California San Francisco Carol Franc Buck Breast Care Center from November 1997 to August 2003. All patients underwent preoperative lymphoscintigraphy followed by wide excision or mastectomy and sentinel lymphadenectomy with or without axillary lymph node dissection. One hundred twenty-two patients had positive sentinel nodes on histology. Micrometastasis was present in 43 of these patients and macrometastasis in the remaining 79. Statistical analysis showed that a tumor size greater than 15 mm, poor tubule formation by the tumor cells, and lymphovascular invasion were significantly associated with sentinel node macrometastasis. A high mitotic count showed a trend but was not significant in our study. Patients with a tumor size greater than 15 mm, poor tubule formation, and lymphovascular invasion are at risk of having sentinel node macrometastasis. These patients can be identified preoperatively based on imaging and biopsy criteria, allowing the option of selective intraoperative pathologic evaluation of the sentinel node and immediate completion axillary dissection as necessary.
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ABSTRACT: The initial 18 months experience of performing intraoperative imprint cytology for patients with breast cancer undergoing sentinel lymph node biopsy is described for a single institution. The learning process is compared with published results from institutions with many years of experience in order to assess progress in reaching those ideal results, and the methodology used by these institutions is reviewed. A retrospective review was undertaken of the intraoperative imprint cytology results from 103 patients with breast cancer (yielding a total of 170 lymph nodes) who underwent imprint cytology of their sentinel lymph node. The intraoperative imprint cytology results were compared with the final histopathological results. Details regarding the primary tumour characteristics and metastatic deposit size were recorded. The sensitivity for imprint cytology was 31.1%, with a specificity of 100% and overall accuracy of 77.8%. The sensitivity for detecting macrometastases (>2 mm diameter) was 61.9% and the sensitivity for micrometastases (<2 mm diameter) and including isolated tumour cells was 4.2%. The differences in sensitivity in comparison with many studies in the literature are multifactorial, and include technical aspects, such as the methodology used in the final histopathological and intraoperative evaluation of the sentinel lymph nodes, interpretative difficulties, and much lower case numbers. Furthermore, these numbers represent early experience and methods to improve sensitivity and overall accuracy are detailed in this paper.Pathology 08/2006; 38(4):321-7. DOI:10.1080/00313020600820922 · 2.62 Impact Factor
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ABSTRACT: Lymph node status is the most reliable prognostic indicator for the clinical outcome of patients with most solid cancers. Because it is the first node draining the primary cancer, the sentinel lymph node (SLN) is most likely to harbor metastatic cancer cells. The tumor size of primary breast cancer is highly correlated with SLN metastasis. If the SLN is negative, the negative predictive value of the remaining nodal basin exceeds 95%. It appears that even using different techniques from different institutions, the successful rate to harvest the SLN is more than 95%. The false-negative rate is about 5-10% in most series. Breast cancer patients with early detection and a negative SLN have a significantly improved survival rate. The SLN data in breast cancer is so convincing that SLN information has been incorporated into the new American Joint Committee on Cancer (AJCC) classification of breast cancer. The therapeutic value of additional lymph node dissection after a positive SLN for breast cancer is still controversial. Follow-up data from breast cancer patients is somewhat limited, but available information shows that patients with negative SLNs fare much better. In summary, several important patterns of metastasis can be established based on the current SLN experience: 1) The earlier the breast cancer is found, the less the metastatic potential. 2) In most cases, breast cancer follows an orderly progression of metastasis to the SLN. 3) A small subgroup of patients may develop systemic dissemination without SLN involvement. Since metastatic cancer is usually incurable, it is important for oncologists to detect and resect an early breast cancer without delay. The challenge in the future will be to dissect these different patterns of metastasis based on molecular or genetic markers. Such information will be critical to select high-risk patients for adjuvant therapy.The Breast Journal 09/2006; 12(5 Suppl 2):S128-33. DOI:10.1111/j.1075-122X.2006.00326.x · 1.43 Impact Factor
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ABSTRACT: Internationally, there is no consensus on the pathology protocol to be used to examine the sentinel lymph node (SN). At present, therefore, various hospitals use different SN pathology protocols of which the effect has not been fully elucidated. We hypothesized that differences between hospitals in SN pathology protocols affect subsequent surgical treatment strategies. Patients from four hospitals (A-D) were prospectively registered when they underwent an SN biopsy. In hospitals A, B, and C, three levels of the SN were examined pathologically, whereas in hospital D, at least seven additional levels were examined. In the absence of apparent metastases with hematoxylin and eosin examination, immunohistochemical examination was performed in all four hospitals. In total, 541 eligible patients were included. In hospital D, more patients were diagnosed with a positive SN (P < .001) as compared with hospitals A, B, and C, mainly because of increased detection of isolated tumor cells. This led to more completion axillary lymph node dissections in hospital D (66.3% of patients (P < .0001), compared with 29.0% in hospitals A, B, and C combined). Positive non-SNs were detected in 13.9% of patients in hospital D, compared with 9.7% in hospitals A, B, and C (P = .70). That is, in 52.4% of patients in hospital D, a negative completion axillary lymph node dissection was performed, compared with 19.3% of patients in hospitals A, B, and C combined. Differences in SN pathology protocols between hospitals do have a substantial effect on SN findings and subsequent surgical treatment strategies. Whether ultrastaging and, thus, additional surgery can offer better survival remains to be determined.Annals of Surgical Oncology 11/2006; 13(11):1466-73. DOI:10.1245/s10434-006-9084-y · 3.94 Impact Factor