Sentinel Lymph Node Biopsy and Axillary Dissection in Breast Cancer: Results in a Large Series

Veronesi, Umberto; Paganelli, Giovanni; Viale, Giuseppe; Galimberti, Viviana; Luini, Alberto; Zurrida, Stefano; Robertson, Chris; Sacchini, Virgilio; Veronesi, Paolo; Orvieto, Enrico; Cicco, Concetta De; Intra, Mattia; Tosi, G; Scarpa, Daniela

doi:10.1093/jnci/91.4.368

Cited by 713 publications

(396 citation statements)

References 24 publications

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“…More recently, sentinel lymph node biopsy (SLNB) has been proposed as an alternative method for staging the axilla in women who have early breast cancer with clinically node negative axillae (Giuliano et al, 1994;Veronesi et al, 1997;McIntosh and Purushotham, 1998;Veronesi et al, 1999;Veronesi et al, 2003). The SLN is the first lymph node to receive lymphatic drainage from a tumour.…”

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The value of immunohistochemistry in sentinel lymph node histopathology in breast cancer

et al. 2005

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The optimal protocol for the histopathological examination of sentinel lymph nodes (SLNs) in breast cancer has not been determined. The value of more detailed examination using immunohistochemistry (IHC) is controversial. A total of 476 SLNs from 216 patients were reviewed. Sentinel lymph nodes were sectioned at three levels at 100 mm intervals and stained with haematoxylin and eosin (H&E). If the H&E sections showed no evidence of metastasis, then the three serial sections were stained with a murine monoclonal anti-cytokeratin antibody (CAM 5.2). Metastatic deposits were classified as macrometastasis (42.0 mm), micrometastasis (0.2 -2.0 mm) or isolated tumour cells (ITC, o0.2 mm). Of the 216 patients, 56 (26%) had metastasis as identified by H&E. Immunohistochemistry detected metastatic deposits in a further nine patients (4%), of whom four (2%) had micrometastasis and five (2%) had ITC only. Those cases with micrometastases were all, on review, visible on the H&E sections. Immunohistochemistry detects only a small proportion of metastasis in SLNs. All metastatic deposits identified by IHC were either micrometastasis or ITC. Until the prognostic significance of these deposits has been determined, IHC may be of limited value in the histopathological examination of SLNs.

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The value of immunohistochemistry in sentinel lymph node histopathology in breast cancer

et al. 2005

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“…While it is well documented that this technique accurately predicts axillary node status in over 90% of the cases, [1][2][3][4][5][6][7][8] there are many relevant clinical decisions and surgical practices that have not been completely standardized. These include: (a) immediate complete axillary dissection based on sentinel node status at intraoperative consult vs complete axillary dissection as part of a second surgical procedure; (b) clinical value of complete axillary dissection following sentinel node micrometastasis; [9][10][11] (c) clinical significance of tumor deposits less than 0.2 mm in size, detected either by hematoxylin and eosin (H&E), immunohistochemistry, or cytology alone; 12,13 (d) the best intraoperative consult detection method for metastatic disease (frozen section vs cytology); [14][15][16][17][18] (e) the definition of sentinel node micrometastatic disease at intraoperative consult; and (f) when to stop evaluating sentinel nodes in the presence of possible micrometastasis at intraoperative consult.…”

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Sentinel node micrometastasis in breast carcinoma may not be an indication for complete axillary dissection

et al. 2005

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The decision whether to proceed with complete axillary node dissection based on sentinel node status is clear for patients with negative or macrometastatic disease. However, the course of action based on sentinel node micrometastasis remains controversial. We reviewed 358 cases from 6/1999 to 7/2003. All sentinel nodes were evaluated at three levels by frozen section, touch preparation, and scrape preparation. Micrometastasis was defined as tumor deposits between 0.2 and 2 mm. Size, grade, and lymphvascular invasion of the primary tumor, as well as number, status, size of metastatic disease, and presence of extranodal capsular extension of sentinel and nonsentinel nodes were recorded. Of the 358 cases, 89 had positive sentinel nodes, 29 of which represented micrometastases. Only one (3%) of the 29 cases contained a nonsentinel node with macrometastasis. In 60 of the 89 cases sentinel nodes contained macrometastases. Of these, 38 cases (63%) had metastatic tumor in nonsentinel nodes. Intraoperative consult was performed in 53 of the 89 cases with positive sentinel nodes. Only 1 of the 19 (5%) intraoperative consult cases with micrometastatic sentinel nodes had positive nonsentinel nodes, while 21 of 34 (62%) of macrometastatic sentinel nodes at intraoperative consult had tumor in nonsentinel nodes. No single variable studied discriminated between micro-vs macrometastatic disease. At intraoperative consult, macrometastatic disease was present in all three diagnostic preparations, while diagnostic material in micrometastatic sentinel nodes was usually present in only one modality. This analysis suggests that the risk of finding tumor in nonsentinel nodes differs significantly between cases with micro (3%)-vs macro (63%)-metastatic disease in sentinel nodes. This holds true for cases assessed by intraoperative consult. Considering the known morbidity of complete axillary dissection, assessments of risk vs benefit of undertaking this procedure should be performed on a case-by-case basis in patients with sentinel node micrometastases. Modern Pathology (2005) 18, 762-768, advance online publication, 11 March 2005; doi:10.1038/modpathol.3800394Keywords: axillary node dissection; breast cancer; intraoperative consult; macrometastasis; micrometastasis; nonsentinel node; sentinel node Sentinel node mapping for patients with breast cancer and clinically negative axilla has become the standard of care in many cancer centers. While it is well documented that this technique accurately predicts axillary node status in over 90% of the cases, 1-8 there are many relevant clinical decisions and surgical practices that have not been completely standardized. These include: (a) immediate complete axillary dissection based on sentinel node status at intraoperative consult vs complete axillary dissection as part of a second surgical procedure; (b) clinical value of complete axillary dissection following sentinel node micrometastasis; 9-11 (c) clinical significance of tumor deposits less than 0.2 mm in size, detected either by hematoxyli...

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“…If the sentinel lymph node is negative for malignancy, the patient can forego regular axillary lymph node dissection, since the probability that the additional dissected lymph nodes will contain metastatic tumor when the sentinel node is negative is about 5%. 4,5 Examination of the sentinel lymph nodes has been done by frozen section at many institutions. Although of lower quality than permanent sections, frozen sections permit the patient to have evaluation of the sentinel node done during their operation and avoid a second procedure.…”

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Frozen section diagnosis for axillary sentinel lymph nodes: the first six years

Mitchell

2005

Modern Pathology

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Intraoperative frozen section of axillary lymph nodes for the detection of metastatic breast cancer has been controversial because of the labor-intensive techniques necessary to obtain a highly sensitive test, and because of the uncertain significance of frequently detected submicrometastatic carcinoma. In total, 874 consecutive axillary sentinel lymph node cases examined by intraoperative frozen section over a 6-year period were reviewed retrospectively. Frozen section had a sensitivity of 60% and was 100% specific, but when cases with submicrometastatic tumor cells were considered negative, the sensitivity rose to 83%. Rare cases were called 'atypical' on frozen section; almost all of these cases were negative for carcinoma on permanent sections.

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Sentinel Lymph Node Biopsy and Axillary Dissection in Breast Cancer: Results in a Large Series

Cited by 713 publications

References 24 publications

The value of immunohistochemistry in sentinel lymph node histopathology in breast cancer

The value of immunohistochemistry in sentinel lymph node histopathology in breast cancer

Sentinel node micrometastasis in breast carcinoma may not be an indication for complete axillary dissection

Frozen section diagnosis for axillary sentinel lymph nodes: the first six years

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