The risk factors for sentinel lymph node metastasis in our study were consistent with those in the Memorial Sloan-Kettering Cancer Center nomogram. The Memorial Sloan-Kettering Cancer Center nomogram is a useful tool that could accurately predict the probability of sentinel lymph node metastasis in our breast cancer patients. Axillary surgical staging might be avoided in patients with a predictive value of <16% and axillary lymph node dissection might be done directly in those with a predictive value >70%, while other patients should still accept sentinel lymph node biopsy.
Internal mammary lymph node (IMLN) metastasis has a similar prognostic importance as axillary lymph nodal involvement in breast cancer patients. Even though TNM staging has incorporated the internal mammary sentinel lymph node biopsy (IM-SLNB) concept since the 6th edition of the American Joint Committee on Cancer, IM-SLNB has not been performed routinely and has remained a subject of discussion. In fact, accurate staging could not be achieved by depending on the status of the axillary sentinel lymph node alone, which might lead to under-stage and under-treatment. The recent studies of Caudle et al. 1 and Gnerlich et al. 2 showed again that IM-SLNB was a minimally invasive technique for the efficient evaluation of the status of internal mammary sentinel lymph nodes (IM-SLN) with high safety and feasibility. Gnerlich et al. 2 reported no complications in their study, and Caudle et al. 1 found only two intraoperative surgical complications, but both were resolved smoothly. In our current study, there is no pneumothorax on postoperative chest radiography and no postoperative bleeding. IM-SLNB had made a more accurate lymph node staging and improved the decision making of the adjuvant radiotherapy of the IMLN, and even adjuvant systemic therapy in some cases.Caudle et al. 1 suggested that IM-SLNB should be performed in patients who revealed IM-SLN drainage by preoperative lymphoscintigraphy. Even though the success rate of IM-SLNB has reached 72-100 %, 3,4 the visualization rate of IM-SLN was low (mean 13 %; range 0-37 %), 3-5 which has been the restriction for both clinical study and daily practice of IM-SLNB to date. In the retrospective analysis of Caudle et al., 1 only 71 cases (8.8 %) of 808 patients (from 1998 to 2011) underwent IM-SLNB according to preoperative lymphoscintigraphy. In order to improve the preoperative visualization rate of IM-SLN, we established a modified technology, 5 which could significantly improve the preoperative visualization rate of the IM-SLN (70.2 %, 203/289, the latest data). With the combination of the intraoperative c-probe, the detection rate of IM-SLN could reach 77.2 % (223/289; p \ 0.05). The algorithm of our study is shown in Figs. 1 and 2. In the study, all patients who determined IMLN map ? (hotspot on lymphoscintigraphy and/or detected intraoperative cprobe) underwent IM-SLNB. We found the site of IMSLNs concentrated in the second and third intercostal space (85.4 %, 176/206). The involvement rate of IM-SLN was 8.8 % (17/193) when the axillary lymph nodes (ALN) were negative, and 23.3 % when the ALN were positive. These results were in accordance with the form study of extended radical mastectomy, 9,10 which could reflect the accuracy of IM-SLNB indirectly.The IMLN metastases related significantly to the status of ALN. In the study of Veronesi et al.,11 IMLN were positive in 29.1 % of patients with ALN metastases and only 9.1 % with negative ALN (p \ 0.001). Gnerlich et al.2 also confirmed that the number of the positive ALN was the only independent predictor of IM-S...
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