Diana Simpson

Dermal injection of radioactive colloid is superior to peritumoral injection for breast cancer sentinel lymph node biopsy: results of a multiinstitutional study.

ObjectiveTo determine the optimal radioactive colloid injection technique for sentinel lymph node (SLN) biopsy for breast cancer. Summary Background DataThe optimal radioactive colloid injection technique for breast cancer SLN biopsy has not yet been defined. Peritumoral injection of radioactive colloid has been used in most studies. Although dermal injection of radioactive colloid has been proposed, no published data exist to establish the false-negative rate associated with this technique. MethodsThe University of Louisville Breast Cancer Sentinel Lymph Node Study is a multiinstitutional study involving 229 surgeons. Patients with clinical stage T1–2, N0 breast cancer were eligible for the study. All patients underwent SLN biopsy, followed by level I/II axillary dissection. Peritumoral, subdermal, or dermal injection of radioactive colloid was performed at the discretion of the operating surgeon. Peritumoral injection of isosulfan blue dye was performed concomitantly in most patients. The SLN identification rates and false-negative rates were compared. The ratios of the transcutaneous and ex vivo radioactive SLN count to the final background count were calculated as a measure of the relative degree of radioactivity of the nodes. One-way analysis of variance and chi-square tests were used for statistical analysis. ResultsA total of 2,206 patients were enrolled. Peritumoral, subdermal, or dermal injection of radioactive colloid was performed in 1,074, 297, and 511 patients, respectively. Most of the patients (94%) who underwent radioactive colloid injection also received peritumoral blue dye injection. The SLN identification rate was improved by the use of dermal injection compared with subdermal or peritumoral injection of radioactive colloid. The false-negative rates were 9.5%, 7.8%, and 6.5% (not significant) for peritumoral, subdermal, and dermal injection techniques, respectively. The relative degree of radioactivity of the SLN was five- to sevenfold higher with the dermal injection technique compared with peritumoral injection. ConclusionsDermal injection of radioactive colloid significantly improves the SLN identification rate compared with peritumoral or subdermal injection. The false-negative rate is also minimized by the use of dermal injection. Dermal injection also is associated with SLNs that are five- to sevenfold more radioactive than with peritumoral injection, which simplifies SLN localization and may shorten the learning curve.

Defining the Optimal Surgeon Experience for Breast Cancer Sentinel Lymph Node Biopsy: A Model for Implementation of New Surgical Techniques

ObjectiveTo determine the optimal experience required to minimize the false-negative rate of sentinel lymph node (SLN) biopsy for breast cancer. Summary Background DataBefore abandoning routine axillary dissection in favor of SLN biopsy for breast cancer, each surgeon and institution must document acceptable SLN identification and false-negative rates. Although some studies have examined the impact of individual surgeon experience on the SLN identification rate, minimal data exist to determine the optimal experience required to minimize the more crucial false-negative rate. MethodsAnalysis was performed of a large prospective multiinstitutional study involving 226 surgeons. SLN biopsy was performed using blue dye, radioactive colloid, or both. SLN biopsy was performed with completion axillary LN dissection in all patients. The impact of surgeon experience on the SLN identification and false-negative rates was examined. Logistic regression analysis was performed to evaluate independent factors in addition to surgeon experience associated with these outcomes. ResultsA total of 2,148 patients were enrolled in the study. Improvement in the SLN identification and false-negative rates was found after 20 cases had been performed. Multivariate analysis revealed that patient age, nonpalpable tumors, and injection of blue dye alone for SLN biopsy were independently associated with decreased SLN identification rates, whereas upper outer quadrant tumor location was the only factor associated with an increased false-negative rate. ConclusionsSurgeons should perform at least 20 SLN cases with acceptable results before abandoning routine axillary dissection. This study provides a model for surgeon training and experience that may be applicable to the implementation of other new surgical technologies.

Utility of intraoperative frozen section analysis of sentinel lymph nodes in breast cancer.

BACKGROUND Intraoperative frozen section pathologic analysis of sentinel lymph node (SLN) may guide immediate (single-stage) completion axillary dissection for patients with nodal metastases. METHODS The results of 203 consecutive patients undergoing SLN biopsy who had intraoperative pathology consultation between January 1998 and September 2000 were reviewed. SLN were analyzed by standard frozen section procedures. Final pathologic analysis included hematoxylin and eosin (H&E) staining of serial sections at 2-mm intervals. RESULTS Frozen section analysis correctly identified a positive or negative result in 185 of 203 cases (overall accuracy 91%). In 17 of 53 cases, the SLNs were negative for tumor by frozen section, but positive on permanent section analysis (sensitivity 68%). The mean size of the nodal metastases was 6.2 mm and 1.5 mm in patients found to have true positive and false negative results, respectively (P <0.003). A single false positive SLN is reported. CONCLUSIONS Two thirds of the patients were spared the need for reoperative axillary lymphadenectomy.

The effect of prior breast biopsy method and concurrent definitive breast procedure on success and accuracy of sentinel lymph node biopsy

BackgroundIt has been suggested that sentinel lymph node (SLN) biopsy for breast cancer may be less accurate after excisional biopsy of the primary tumor compared with core needle biopsy. Furthermore, some have suggested an improved ability to identify the SLN when total mastectomy is performed compared with lumpectomy. This analysis was performed to determine the impact of the type of breast biopsy (needle vs. excisional) or definitive surgical procedure (lumpectomy vs. mastectomy) on the accuracy of SLN biopsy.MethodsThe University of Louisville Breast Cancer Sentinel Lymph Node Study is a prospective multi-institutional study. Patients with clinical stage T1–2, N0 breast cancer were eligible. All patients underwent SLN biopsy and completion level I/II axillary dissection. Statistical comparison was performed by χ2 analysis.ResultsA total of 2206 patients were enrolled in the study. There were no statistically significant differences in SLN identification rate or false-negative rate between patients undergoing excisional versus needle biopsy. The SLN identification and false-negative rates also were not statistically different between patients who had total mastectomy compared with those who had a lumpectomy.ConclusionsExcisional biopsy does not significantly affect the accuracy of SLN biopsy, nor does the type of definitive surgical procedure.

Radiofrequency ablation for unresectable hepatic tumors.

Abstract Background: Radiofrequency ablation (RFA) is a relatively new treatment for unresectable hepatic tumors. The purpose of this analysis was to examine the frequency of complications and local recurrence associated with RFA. Methods: Patients who underwent RFA of hepatic tumors with curative intent were included in this study. At laparotomy, RFA was performed using intraoperative ultrasound guidance. Computed tomography scans were obtained in the immediate postoperative period and every 3 to 6 months thereafter. Results: Forty patients underwent RFA for 122 hepatic tumors. Thirty-one patients had metastatic lesions from colorectal cancer; 9 had other liver tumors. Complications occurred in 8 patients. With 9.5 months median follow-up, 6 patients had local recurrence of their ablated tumors. Conclusions: Our initial experience shows that RFA can effectively eradicate unresectable hepatic tumors. The rate and severity of complications appear acceptable. However, further study is necessary to assess long-term recurrence rates and effect on overall survival.

The effect of lymphatic tumor burden on sentinel lymph node biopsy results

Increasing tumor burden in the axilla, as determined by the number of positive lymph nodes, adversely affects sentinel lymph node (SLN) identification and false‐negative rates. The University of Louisville Breast Cancer Sentinel Lymph Node Study is a prospective, multi‐institutional study. All enrolled patients underwent SLN biopsy, followed by complete level I/II axillary dissection. Participating surgeons represent a variety of practice settings, mostly community‐based private practice. A total of 229 surgeons enrolled 2206 patients between August 1997 and November 2000. SLN biopsy was performed using blue dye injection alone, radioactive colloid alone, or a combination of the two agents. Two key parameters used to measure SLN biopsy success are the SLN identification rate and SLN false‐negative rate. The overall SLN identification and false‐negative rates were 92.5% and 8.0%, respectively. With increasing numbers of positive axillary nodes, there was a decreased sentinel node identification rate. There was no difference in the false‐negative rate with increasing axillary tumor burden. Increased tumor burden in the axilla (as determined by the mean number of positive nodes) is associated with failure to identify a SLN in some cases, but is not an explanation for false‐negative results. Standard axillary dissection should be performed when a SLN cannot be identified.

Reliable lymphatic drainage to axillary sentinel lymph nodes regardless of tumor location within the breast

BACKGROUND This analysis was performed in order to determine whether primary tumor location in breast cancer affects the axillary sentinel lymph node (SLN) identification (ID) rate, the false negative (FN) rate, incidence of axillary nodal metastases, or the number of SLN identified. METHODS In this prospective multi-institutional study, SLN biopsy was performed on clinical stage T1-2, N0 breast cancer patients using blue dye alone or in combination with radioactive colloid, followed by completion axillary LN dissection. RESULTS Central tumor location was associated with an improved FN rate, which may be related to reliable drainage from the subareolar lymphatic plexus. Tumor location did not significantly affect the SLN ID rate or the mean number of SLN identified. Medial tumor location was associated with a decreased rate of axillary nodal metastasis. CONCLUSIONS Breast cancers drain reliably to the axillary lymph nodes regardless of tumor location within the breast.

Sentinel Lymph Node Biopsy for Breast Cancer: Improvement in Results Over Time

Abstract:  Many modifications in the technique of sentinel lymph node (SLN) biopsy for breast cancer have taken place since it was first introduced. This analysis was undertaken to determine, in a large multi‐institutional study, whether SLN biopsy results have improved over time. Patients with clinical stage T1–2, N0 breast cancer were enrolled in this prospective study between August 1997 and February 2002. SLN biopsy was performed using blue dye and/or radioactive colloid along with completion level I/II axillary dissection in all patients. The majority of subjects included in this study represent the surgeons’ initial experience with SLN biopsy for breast cancer. Statistical comparison of the SLN identification (ID) rate and false‐negative (FN) rate were performed by chi‐squared analysis. A total of 3370 subjects from 300 surgeons were enrolled in the study. Collectively the SLN ID rate, as well as the mean number of SLNs removed per patient has improved, while the FN rate has remained fairly constant over time. The improved ID rate may be related to improved technical details, while the FN rate has not changed significantly. This highlights the ongoing need for surgeons to perform backup axillary dissection during their initial learning phase. 

Palpable Breast Carcinomas: A Hypothesis for Clinically Relevant Lymphatic Drainage in Sentinel Lymph Node Biopsy

Abstract: Previous studies have shown that independent of tumor size, palpable breast tumors have a higher incidence of lymph node metastasis compared with nonpalpable tumors. This study further examines this phenomenon using a large sentinel lymph node (SLN) database. Data from a prospective, institutional review board (IRB)‐approved, multi‐institutional study from the University of Louisville Breast Cancer Sentinel Lymph Node Study Group was used. From August 1997 through December 2001, 3192 patients with clinical T1 and T2 N0 breast cancer underwent SLN biopsy, most with a combined technique of radioactive colloid and blue dye, followed by level I/II axillary dissection. Patients with palpable tumors tended to be younger (mean age 58 years) compared with nonpalpable tumors (mean age 61 years). The incidence of positive axillary metastasis was significant between palpable and nonpalpable tumors (43% and 23%, respectively), independent of tumor size by logistic regression (p = 0.0001). The SLN identification rate was significantly different between palpable and nonpalpable tumors (95% versus 91%, respectively; p < 0.0001). A unifying theory to explain the phenomenon that palpable tumors, stage for stage, are associated with a higher rate of nodal metastasis is that palpable tumors are, on average, closer to the skin and the rich network of dermal lymphatics. We believe that the dermal lymphatics of the breast represent a clinically relevant metastatic pathway to the axilla.