The Effect of Sentinel Node Tumor Burden on Non–Sentinel Node Status and Recurrence Rates in Breast Cancer

ArticleinAnnals of Surgical Oncology 12(9):705-11 · October 2005with7 Reads
Impact Factor: 3.93 · DOI: 10.1245/ASO.2005.08.020 · Source: PubMed
Abstract

Routine axillary lymph node dissection (ALND) after selective sentinel lymphadenectomy (SSL) in the treatment of breast cancer remains controversial. We sought to determine the need for routine ALND by exploring the relationship between sentinel lymph node (SLN) and non-SLN (NSLN) status. We also report our experience with disease relapse in the era of SSL and attempt to correlate this with SLN tumor burden. This was a retrospective study of 390 patients with invasive breast cancer treated at a single institution who underwent successful SSL from November 1997 to November 2002. Of the 390 patients, 115 received both SSL and ALND. The percentage of additional positive NSLNs in the SLN-positive group (34.2%) was significantly higher than in the SLN-negative group (5.1%; P = .0004). The SLN macrometastasis group had a significantly higher rate of positive NSLNs (39.7%) compared with the SLN-negative group (5.1%; P = .0001). Sixteen patients developed recurrences during follow-up, including 6.1% of SLN-positive and 3.3% of SLN-negative patients. Among the SLN macrometastasis group, 8.7% had recurrence, compared with 2.2% of SLN micrometastases over a median follow-up period of 31.1 months. One regional failure developed out of 38 SLN-positive patients who did not undergo ALND. ALND is recommended for patients with SLN macrometastasis because of a significantly higher incidence of positive NSLNs. Higher recurrence rates are also seen in these patients. However, the role of routine ALND in patients with a low SLN tumor burden remains to be further determined by prospective randomized trials.

    • "...ed that patients had been treated with axillary radiotherapy in 2–63 % of the patients.14,16,19,29,35,40 In the majority of patients who developed an axillary recurrence (n = 24) details regarding the ..."
      The latter was observed in a study with only 14 patients. In case of macrometastatic disease in the sentinel node, 6 studies reported that patients had been treated with axillary radiotherapy in 2–63 % of the patients.14,16,19,29,35,40 In the majority of patients who developed an axillary recurrence (n = 24) details regarding the type of surgery of the primary tumor were lacking.
    [Show abstract] [Hide abstract] ABSTRACT: Background Sentinel lymph node biopsy (SLNB) has become standard of care as a staging procedure in patients with invasive breast cancer. A positive SLNB allows completion axillary lymph node dissection (cALND) to be performed. The axillary recurrence rate (ARR) after cALND in patients with positive SLNB is low. Recently, several studies have reported a similar low ARR when cALND is not performed. This review aims to determine the ARR when cALND is omitted in SLNB-positive patients. Methods A literature search was performed in the PubMed database with the search terms “breast cancer,” “sentinel lymph node biopsy,” “axillary” and “recurrence.” Articles with data regarding follow-up of patients with SLNB-positive breast cancer were identified. To be eligible, patients should not have received cALND and ARR should be reported. Results Thirty articles were analyzed. This resulted in 7,151 patients with SLNB-positive breast cancer in whom a cALND was omitted (median follow-up of 45 months, range 1–142 months). Overall, 41 patients developed an axillary recurrence. 27 studies described 3,468 patients with micrometastases in the SLNB, of whom 10 (0.3 %) developed an axillary recurrence. ARR varied between 0 and 3.7 %. Sixteen studies described 3,268 patients with macrometastases, 24 (0.7 %) axillary recurrences were seen. ARR varied between 0 and 7.1 %. Details regarding type of surgery and adjuvant treatment were lacking in the majority of studies. Conclusions ARR appears to be low in SLNB-positive patients even when a cALND is not performed. Withholding cALND may be safe in breast cancer selected patients such as those with isolated tumor cells or micrometastatic disease.
    Full-text · Article · Aug 2012 · Annals of Surgical Oncology
    0Comments 21Citations
    • "... SNB and who were not treated by completion axillary node clearance are summarised in Table 3 [38, 48–54]. Most of the studies had small numbers and relatively short followup and tended to conclude tha..."
      Results of studies in which patients with micrometastases in SNB and who were not treated by completion axillary node clearance are summarised in Table 3 [38, 48–54]. Most of the studies had small numbers and relatively short followup and tended to conclude that there was no benefit from completion axillary node clearance.
    [Show abstract] [Hide abstract] ABSTRACT: Sentinel lymph node biopsy (SLNB) is a safe and accurate minimally invasive method for detecting axillary lymph node (ALN) involvement in the clinically negative axilla thereby reducing morbidity in patients who avoid unnecessary axillary lymph node dissection (ALND). Although current guidelines recommend completion ALND when macro- and micrometastatic diseases are identified by SLNB, the benefit of this surgical intervention is under debate. Additionally, the management of the axilla in the presence of isolated tumour cells (ITCs) in SLNB is questioned. Particularly controversial is the prognostic significance of minimal SLNB metastasis in relation to local recurrence and overall survival. Preliminary results of the recently published Z0011 trial suggest similar outcomes after SNB or ALND when the SN is positive, but this finding has to be interpreted with caution.
    Full-text · Article · Aug 2011
    0Comments 9Citations
    • "...us studies of SNs were limited by small samples, lack of multivariate analyses, or short followup [26–28]. ..."
      Thus, we cannot compare these studies with the MIRROR study, which involved a detailed examination of the SN. The few previous studies of SNs were limited by small samples, lack of multivariate analyses, or short followup [26–28].
    [Show abstract] [Hide abstract] ABSTRACT: Most cancer centers now perform sentinel node (SN) biopsies. The limited number of SNs sampled compared with an axillary dissection has allowed more comprehensive lymph node analysis resulting in increased detection of micrometastases. Many node-negative cases are now reclassified as micrometastatic. Recent research on SN biopsy focuses on whether axillary dissection is always necessary when the SN is positive. Some subgroups of patients have a higher risk of more nodal metastases when completion axillary dissections were performed. This paper summarizes the different studies and examines what are the clinically relevant items to report on SN node pathology: volume or size of nodal metastasis, location within the node, extranodal extension, number of involved SN(s) and non-SN(s), total number of SN, and total number of nodes on axillary dissection, if performed.
    Full-text · Article · Mar 2011 · Pathology Research International
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    • "...ion is a key in determing the choice of candidates for completion lymph node dissection147148149150151152153154 (Table 8). Ongoing or completed/closed randomized trials such as the ACOSOG Z0010, the Nat..."
      At the present time, surgical management and systemic options in case of SLN micrometastases are controversial . Most retrospective studies have reported a substantial rate of additional lymph node metastases in patients with SLN micrometastases, with a wide range between reports, making one think that patient selection is a key in determing the choice of candidates for completion lymph node dissection147148149150151152153154 (Table 8). Ongoing or completed/closed randomized trials such as the ACOSOG Z0010, the National Surgical Adjuvant Breast and Bowel Project B32 and the International Breast Cancer Study Group 23-01, will help to fully understand whether further axillary treatment should be mandatory when the SLN is positive155156157.
    [Show abstract] [Hide abstract] ABSTRACT: A tremendous improvement in every aspect of breast cancer management has occurred in the last two decades. Surgeons, once solely interested in the extipartion of the primary tumor, are now faced with the need to incorporate a great deal of information, and to manage increasingly complex tasks. As a comprehensive assessment of all aspects of breast cancer care is beyond the scope of the present paper, the current review will point out some of these innovations, evidence some controversies, and stress the need for the surgeon to specialize in the various aspects of treatment and to be integrated into the multisciplinary breast unit team.
    Full-text · Article · Jan 2010 · World Journal of Surgical Oncology
    0Comments 18Citations
    • "...carcinoma, larger axillary nodal metastasis is reported to be associated with worse prognosis [14, 15]. It is a problem that there is no consensus on how nodal metastasis should be measured, and many st..."
      Although the diagnostic criteria of lymph node metastasis are generally based on whether cancer cells are present or absent, metastatic foci vary in size, from small sinusoidal tumor cell aggregates to large deposits of tumor completely replacing the nodal parenchyma. In breast carcinoma, larger axillary nodal metastasis is reported to be associated with worse prognosis [14, 15]. It is a problem that there is no consensus on how nodal metastasis should be measured, and many studies provide no details on methodology.
    [Show abstract] [Hide abstract] ABSTRACT: Histological findings of metastatic lymph nodes are important prognosticators in patients with gastric cancer. The aim of this study was to clarify the clinical significance of various pathological characteristics of the early phase of lymph node metastasis in patients with gastric cancer, by selecting patients with tumors that had single lymph node metastases, no serosal invasion, and no metastases to the peritoneum, liver, or distant organs. Seventy-eight patients were eligible and were entered in this study. These patients were subdivided according to the following histological characteristics of the one metastatic lymph node: size of the metastasis (i.e., amount of tumor cells [AT]), proliferating pattern (PP), intranodal location (IL), and the presence or absence of extracapsular invasion (ECI) and/or fibrotic focus (FF). Associations between clinicopathological factors, survival, and the nodal findings were examined. There were no correlations between AT or PP and any clinicopathological factors. IL was significantly correlated with venous invasion and the pathological characteristics of the primary tumor. ECI and FF were observed significantly more frequently in pT2 than in pT1 cancer. Overall survival (OS) differed significantly according to depth of invasion, venous invasion, and the presence or absence of ECI or FF, although OS was not affected by AT, PP, or IL. The 10-year overall survival rates of patients with and without ECI were 50% and 80%, respectively, while these rates for patients with and without FF were 50% and 79%, respectively. Multivariate analysis revealed that ECI and FF were significant prognosticators of survival. These results strongly suggested that the presence of ECI or FF could affect the survival of patients with gastric cancer.
    Full-text · Article · Feb 2008 · Gastric Cancer
    0Comments 16Citations
  • [Show abstract] [Hide abstract] ABSTRACT: In this paper, a new method by which some modern techniques of one dimension (1-D) spectral estimation can be extended to two dimension (2-D) cases is presented. The main point of the new method is to find the optimum separable approximation of a given autocorrelation matrix in the least square sense, so that 2-D spectral estimation can be reduced to 1-D problem. It is proved in this paper that finding the optimum separable approximation of a matrix in the least square sense is equivalent to finding separable representation of the matrix by singular value decomposition (SVD). Finally, some results of experiments are shown to illustrate the performance of the new method and to compare with other 2-D spectral estimation methods.
    No preview · Conference Paper · Apr 1984
    0Comments 2Citations
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