The Initial Implementation of the Sentinel Lymph Node Biopsy (SLNB) for Breast Cancer Management in Malta

Camilleri Gail, Borg Grima Karen, Zarb Francis

Department of Radiography, Faculty of Health Sciences, University of Malta, Msida, Malta.
Department of Radiography, Faculty of Health Sciences, University of Malta, Msida, Malta..
Medical Imaging Department, Mater Dei Hospital, Msida, Malta.

DOI: 10.4236/jct.2013.43093                

Abstract

Over the past two decades, the sentinel lymph node biopsy (SLNB) based on sentinel node (SN) being the first lymph node that harbors metastases, revolutionized breast cancer management. SLNB presents much less morbidity when compared to radical axillary lymph node dissection (ALND) where all nodes are dissected irrespective of their metastatic involvement. The purpose of this study was to evaluate the effectiveness of SLNB by investigating whether the histological characteristics of the SNs identified using scintigraphy are predictive of the histological characteristics of the ALN basin. Methods: Fifty-five female breast cancer patients underwent lymphoscintigraphy and SLNB followed by ALND. The histological status of the SN/s was correlated to the histological status of the ALNs to determine whether the SN accurately stages the ALNs in breast cancer. Results: During surgery, SNs were successfully isolated in 52 out of 55 cases (94.5%) (range, 0 to 9). No SNs were identified in 3 cases (5.5%). Results demonstrate a significant association (p = 0.05) between the metastatic status of SNs and the corresponding ALNs in 42 out of 52 patients (80.8%), but with a high false-negative rate (FNR) of 37.5%. Conclusion: The findings of this study show that the sentinel node concept provides the benefits of SLNB in the majority of instances. However, further work is required in reducing the FNR. Once the effectiveness of SLNB as a staging technique is locally established, the need of ALND in SN-negative patients would be limited, thus improving the quality of life of Maltese breast cancer patients.

Keywords

Breast Cancer; Sentinel Node; Lymphoscintigraphy; Sentinel Lymph node Biopsy; Axillary Lymph Node Dissection

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	A. Chakravorty, N. Sanmugalingam, A. Shrestha, et al., “Axillary Nodal Yields: A Comparison between Primary Clearance and Completion Clearance after Sentinel Lymph Node Biopsy in the Management of Breast Cancer,” European Journal of Surgical Oncology, Vol. 37, No. 2, 2011, pp. 122-126. doi:10.1016/j.ejso.2010.10.005
[2]	E. A. Newman and L. A. Newman, “Lymphatic Mapping Techniques and Sentinel Lymph Node Biopsy in Breast Cancer,” Surgical Clinics of North America, Vol. 87, No. 2, 2007, pp. 353-364. doi:10.1016/j.suc.2007.01.013
[3]	S. Namwongprom, S. Boonyaprapa, M. Ekmahachai, et al., “Breast Lymphoscintigraphy for Sentinel Node Identification in Breast Cancers with Clinically-Negative Axillary Nodes,” Singapore Medical Journal, Vol. 46, No. 12, 2005, pp. 688-692.
[4]	X. Sun, J.-J. Liu, Y.-S. Wang, et al., “Roles of Preoperative Lymphoscintigraphy for Sentinel Lymph Node Biopsy in Breast Cancer Patients,” Japanese Journal of Clinical Oncology, Vol. 40, No. 8, 2010, pp. 722-725. doi:10.1093/jjco/hyq052
[5]	M. R. S. Keshtgar, W. A. Waddington, S. R. Lakhani, et al., “The Sentinel Node in Surgical Oncology,” SpringerVerlag, Berlin, 1999, pp. 49-89.
[6]	S. Pesek, T. Ashikaga, L. E. Krag, et al., “The FalseNegative Rate of Sentinel Node Biopsy in Patients with Breast Cancer: A Meta-Analysis,” World Journal of Surgery, Vol. 36, No. 9, 2012, pp. 2239-2251. doi:10.1007/s00268-012-1623-z
[7]	B. Duchaj, P. Chvalny, J. Vesely, et al., “Radionavigated Detection of Sentinel Nodes in Breast Carcinoma—First Experiences of Our Department,” Bratislavské Lekárske Listy, Vol. 111, No. 1, 2010, pp. 33-37.
[8]	I. Bokhari, Q. Tahir, S. Rasul, et al., “Early Experience of Sentinel Lymph Node Biopsy in Breast Cancer,” Journal of Surgery Pakistan International, Vol. 14, No. 1, 2009, pp. 29-32.
[9]	V. Vijayakumar, P. S. Boerner, A. B. Jani, et al., “A Critical Review of Variables Affecting the Accuracy and False-Negative Rate of Sentinel Node Biopsy Procedures in Early Breast Cancer,” Nuclear Medicine Communications, Vol. 26, 2005, pp. 395-405. doi:10.1097/00006231-200505000-00002
[10]	G. Pechlivanides, D. Vassilaros, A. Tsimpanis, et al., “Sentinel Node Biopsy for Breast Cancer Patients: Issues for Discussion and Our Practice,” Pathology Research International, Vol. 2011, 2011, Article ID: 109712. doi:10.4061/2011/109712
[11]	R. E. Mansel, L. Fallowfield, M. Kissin, et al., “Randomized Multicenter Trial of Sentinel Node Biopsy versus Standard Axillary Treatment in Operable Breast Cancer: The ALMANAC Trial,” Journal of National Cancer Institute, Vol. 98, No. 9, 2006, pp. 599-609. doi:10.1093/jnci/djj158
[12]	W. E. Burak Jr., M. J. Walker, L. D. Yee, et al., “Routine Preoperative Lymphoscintigraphy Is Not Necessary Prior to Sentinel Node Biopsy for Breast Cancer,” The American Journal of Surgery, Vol. 177, No. 6, 1999, pp. 445-449. doi:10.1016/S0002-9610(99)00088-4
[13]	J. Leikola, “Sentinel Lymph Node Biopsy as a Diagnostic Tool in the Treatment of Breast Cancer,” Academic Dissertation, Helsinki, 2008, pp. 11-67. https://helda. helsinki.fi/bits tream/handle/10138/22788/ sentinel.pdf?sequence=1
[14]	European Commission, “Eurostat: Causes of Death Statistics—Statistics Explained,” 2012. http://epp.eurostat. ec.europa. eu/ statistics_explained/ index.php/Causes_ of_d eath_statistics
[15]	G. Camilleri, K. B. Grima and F. Zarb, “Correlation of Number and Identification of Sentinel Nodes during Radiographer Led Lymphoscintigraphy Prior to Sentinel Lymph Node Biopsy in Breast Cancer Patients,” Radiography, Vol. 18, No. 1, 2011, pp. 9-14. doi:10.1016/j.radi.2011.11.003
[16]	S. Zakaria, A. C. Degnim, C. G. Kleer, et al., “Sentinel Lymph Node Biopsy for Breast Cancer: How Many Nodes Are Enough?” Journal of Surgical Oncology, Vol. 96, No. 7, 2007, pp. 554-559. doi:10.1002/jso.20878
[17]	J. Buscombe, G. Paganelli, Z. E. Burak, et al., “Sentinel Node in Breast Cancer Procedural Guidelines,” European Journal of Nuclear Medicine and Molecular Imaging, Vol. 34, No. 12, 2007, pp. 2154-2159. doi:10.1007/s00259-007-0614-z
[18]	C. D. Collins, “The Sentinel Node in Breast Cancer: An Update,” Cancer Imaging, Vol. 5, No. A, 2005, pp. S3-S9. doi:10.1102/1470-7330.2005.0039
[19]	O. E. Nieweg, P. J. Tanis and B. B. R. Kroon, “The Definition of a Sentinel Node,” European Journal of Nuclear Medicine and Molecular Imaging, Vol. 8, No. 6, 2001, pp. 538-541. doi:10.1007/s10434-001-0538-y
[20]	A. Goyal, R. G. Newcombe, R. E. Mansel, et al., “Role of Routine Preoperative Lymphoscintigraphy in Sentinel Node Biopsy for Breast Cancer,” European Journal of Cancer, Vol. 41, No. 2, 2005, pp. 238-243. doi:10.1016/j.ejca.2004.05.008
[21]	H. Rempp, “Sentinel Lymph-Node Radiodetection in Breast Cancer: Results of a Clinical Study and Development of a Quantitative Approach,” Thesis, University of Nice Sophia Antipolis, Nice, 2003, pp. 3-83.
[22]	K. M. McMasters, S. L. Wong, T. M. Tuttle, et al., “Preoperative Lymphoscintigraphy for Breast Cancer Does Not Improve the Ability to Identify Axillary Sentinel Lymph Nodes,” Annals of Surgery, Vol. 231, No. 5, 2000, pp. 724-731. doi:10.1097/00000658-200005000-00013
[23]	F. Marchal, P. Rauch, O. Morel, et al., “Results of Preoperative Lymphoscintigraphy for Breast Cancer Are Predictive of Identification of Axillary Sentinel Lymph Nodes,” World Journal of Surgery, Vol. 30, No. 1, 2006, pp. 55-62. doi:10.1007/s00268-005-0145-3
[24]	C. De Cicco, M. Cremonesi, A. Luini, et al., “Lymphoscintigraphy and Radioguided Biopsy of the Sentinel Axillary Node in Breast Cancer,” Journal of Nuclear Medicine, Vol. 39, No. 12, 1998, pp. 2080-2084.
[25]	A. E. Giuliano, D. M. Kirgan, J. M. Guenther, et al., “Lymphatic Mapping and Sentinel Lymphadenectomy for Breast Cancer,” Annals of Surgery, Vol. 220, No. 3, 1994, pp. 391-398. doi:10.1097/00000658-199409000-00015
[26]	G. M. Filippakis and G. Zografos, “Contraindications of Sentinel Lymph Node Biopsy: Are There Any Really?” World Journal of Surgical Oncology, Vol. 5, No. 29, 2007, p. 10. doi:10.1186/1477-7819-5-10
[27]	B. R. Krynyckyi, S. C. Kim and C. K. Kim, “Preoperative Lymphoscintigraphy and Triangulated Patient Body Marking Are Important Parts of the Sentinel Node Process in Breast Cancer,” World Journal of Surgical Oncology, Vol. 3, 2005, p. 56. doi:10.1186/1477-7819-3-56
[28]	A. H. Chakera, B. Hesse, Z. Burak, et al., “EANMEORTC General Recommendations for Sentinel Node Diagnostics in Melanoma,” European Journal of Nuclear Medicine and Molecular Imaging, Vol. 36, No. 10, 2009, pp. 1713-1742. doi:10.1007/s00259-009-1228-4
[29]	M. E. Straver, P. Meijnen, G. van Tienhoven, et al., “Sentinel Node Identification Rate and Nodal Involvement in the EORTC 10981-22023 AMAROS Trial,” Annals of Surgical Oncology, Vol. 17, No. 7, 2010, pp. 1854-1861. doi:10.1245/s10434-010-0945-z
[30]	Department of Health and Ageing, “Sentinel Lymph Node Biopsy in Breast Cancer: MSAC Reference 1065 Assessment Report,” Commonwealth of Australian Government Publishing Service, Canberra, 2006. http://www.msac.gov.au/internet/msac/publishing.nsf/Content/BCDC2A9D05A33761CA2575AD0082FD32/$File/1065%20-%20Sentinel%20Lymph%20Node%20Biopsy%20Report.pdf
[31]	M. H. E. Doting, “Sentinel Lymph Node Biopsy in Breast Cancer and Melanoma,” Thesis, University Library, Groningen, 2007, pp. 43-82.
[32]	J. Bonnema and C. J. H. van de Velde, “Sentinel Lymph Node Biopsy in Breast Cancer,” Annals of Oncology, Vol. 13, No. 10, 2002, pp. 1531-1537. doi:10.1093/annonc/mdf319
[33]	A. G. Lalkhen and A. McCluskey, “Clinical Tests: Sensitivity and Specificity,” Continuing Education in Anaesthesia, Critical Care & Pain, Vol. 8, No. 6, 2008, pp. 221-223. doi:10.1093/bjaceaccp/mkn041
[34]	K. Nakashima, J. Kurebayashi, H. Sonoo, et al., “Preoperative Dynamic Lymphoscintigraphy Predicts Sentinel Lymph Node Metastasis in Patients with Early Breast Cancer,” Breast Cancer, Vol. 17, No. 1, 2010, pp. 17-21. doi:10.1007/s12282-009-0123-y
[35]	A. D. K. Hill, K. N. Tran, T. Akhurst, et al., “Lessons Learned from 500 Cases of Lymphatic Mapping for Breast Cancer,” Annals of Surgery, Vol. 229, No. 4, 1999, pp. 528-535. doi:10.1097/00000658-199904000-00012
[36]	P. J. Borgstein, S. Meijer, R. J. Pijpers, et al., “Functional Lymphatic Anatomy for Sentinel Node Biopsy in Breast Cancer: Echoes from the Past and the Periareolar Blue Method,” Annals of Surgery, Vol. 232, No. 1, 2000, pp. 81-89. doi:10.1097/00000658-200007000-00012
[37]	P. I. Haigh, N. M. Hansen, K. Qi, et al., “Biopsy Method and Excision Volume Do Not Affect Success Rate of Subsequent Sentinel Lymph Node Dissection in Breast Cancer,” Annals of Surgical Oncology, Vol. 7, No. 1, 2000, pp. 21-27. doi:10.1007/s10434-000-0021-1
[38]	R. L. Birdwell, K. L.Smith, B. J. Betts, et al., “Breast Cancer: Variables Affecting Sentinel Lymph Node Visualization at Preoperative Lymphoscintigraphy,” Radiology, Vol. 220, No. 1, 2001, pp. 47-53.
[39]	K. Motomura, H. Inaji, Y. Komoike, et al., “Combination Technique is Superior to Dye Alone in Identification of the Sentinel Node in Breast Cancer Patients,” Journal of Surgical Oncology, Vol. 76, No. 2, 2001, pp. 95-99. doi:10.1002/1096-9098(200102)76:2<95::AID-JSO1018>3.0.CO;2-D
[40]	S. L. Wong, M. J. Edwards, C. Chao, et al., “Sentinel Lymph Node Biopsy for Breast Cancer: Impact of the Number of Sentinel Nodes Removed on the False-Negative Rate,” Journal of the American College of Surgeons, Vol. 192, No. 6, 2001, pp. 684-691. doi:10.1016/S1072-7515(01)00858-4
[41]	R. Kumar, S. Jana, S. I. Heiba, et al., “Retrospective analysis of Sentinel Node Localization in Multifocal, Multicentric, Palpable, or Nonpalpable Breast Cancer,” Journal of Nuclear Medicine, Vol. 44, No. 1, 2003, pp. 7-10.
[42]	A. Chagpar, R. C. Martin 3rd, C. Chao, et al., “Validation of Subareolar and Periareolar Injection Techniques for Breast Sentinel Lymph Node Biopsy,” Archives of Surgery, Vol. 139, No. 6, 2004, pp. 614-620. doi:10.1001/archsurg.139.6.614
[43]	G. D’Eredita, C. Giardina, A. M. Guerrieri and T. Berardi, “A Further Validation of Subareolar Injection Technique for Breast Sentinel Lymph-Node Biopsy,” Annals of Surgical Oncology, Vol. 13, No. 5, 2006, pp. 701-717. doi:10.1245/ASO.2006.04.027
[44]	R. C. G. Martin 2nd, A. Chagpar, C. R. Scoggins, et al., “Clinicopathologic Factors Associated with False-Negative Sentinel Lymph-Node Biopsy in Breast Cancer,” Annals of Surgery, Vol. 241, No. 6, 2005, pp. 1005-1015. doi:10.1097/01.sla.0000165200.32722.02
[45]	S. P. Povoski, D. C. Young, M. J. Walker, et al., “Re-Emphasizing the Concept of Adequacy of Intraoperative Assessment of the Axillary Sentinel Lymph Nodes for Identifying Nodal Positivity during Breast Cancer Surgery,” World Journal of Surgical Oncology, Vol. 5, 2007, p. 18. doi:10.1186/1477-7819-5-18
[46]	Ferreira P, Baía R, António A, et al., “Sentinel lymph Node Biopsy: Technique Validation at the Setúbal Medical Centre, Portugal,” Ecancer, Vol. 3, 2009, p.124.
[47]	A. Abdollahi, A. Jangjoo, Dabbagh Kakhki VR, et al., “Factors Affecting Sentinel Lymph Node Detection Failure in Breast Cancer Patients Using Intradermal Injection of the Tracer,” Revista Espa?ola de Medicina Nuclear, Vol. 29, No. 2, 2010, pp. 73-77. doi:10.1016/j.remn.2009.10.001
[48]	M. A. Lynch, J. Jackson, J. A. Kim, et al., “Optimal Number of Radioactive Sentinel Lymph Nodes to Remove for Accurate Axillary Staging of Breast Cancer,” Surgery, Vol. 144, No. 4, 2008, pp. 525-532. doi:10.1016/j.surg.2008.06.005
[49]	J. M. East, C. S. P.Valentine, E. Kanchev, et al., “Sentinel Lymph Node Biopsy for Breast Cancer Using Methylene Blue Dye Manifests a Short Learning Curve among Experienced Surgeons: A Prospective Tabular Cumulative Sum (CUSUM) Analysis,” BMC Surgery, 2009, Vol. 9, No., p. 2.doi:10.1186/1471-2482-9-2
[50]	E. Hindié, D. Groheux, I. Brenot-Rossi, et al., “The Sentinel Node Procedure in Breast Cancer: Nuclear Medicine as the Starting Point,” Journal of Nuclear Medicine, Vol. 52, No. 3, 2011, pp. 405-414. doi:10.2967/jnumed.110.081711
[51]	K. Motomura, C. Egawa, Y. Komoike, et al., “Validation and Controversy of Sentinel Node Biopsy in Breast Cancer,” Journal of Breast Cancer, Vol. 9, No. 2, 2006, pp. 74-83. doi:10.4048/jbc.2006.9.2.74
[52]	G. Cserni, S. Bianchi, V. Vezzosi, et al., “The Value of Cytokeratin Immunohistochemistry in the Evaluation of Axillary Sentinel Lymph Nodes in Patients with Lobular Breast Carcinoma,” Journal of Clinical Pathology, Vol. 59, No. 5, 2006, pp. 518-522. doi:10.1136/jcp.2005.029991
[53]	J. Cantin, H. Scarth, M. Levine, et al., “Clinical Practice Guidelines for the Care and Treatment of Breast Cancer: 13. Sentinel Lymph Node Biopsy,” Canadian Medical Association Journal, Vol. 165, No. 2, 2001, pp. 166-173.
[54]	G. Mariani, L. Moresco, G. Viale, et al., “Radioguided Sentinel Lymph Node Biopsy in Breast Cancer Surgery,” Journal of Nuclear Medicine, Vol. 42, No. 8, 2001, pp. 1198-1215.
[55]	T. Kim, A. E. Giuliano and G. H. Lyman, “Lymphatic Mapping and Sentinel Lymph Node Biopsy in EarlyStage Breast Carcinoma: A Metaanalysis,” ACS, Vol. 106, No. 1, 2005, pp. 4-16.
[56]	B. van der Vegt, M. H. Doting, P. L. Jager, et al., “Axillary Recurrence after Sentinel Lymph Node Biopsy,” European Journal of Surgical Oncology, Vol. 30, No. 7, 2004, pp. 715-720. doi:10.1016/j.ejso.2004.05.015
[57]	G. Vlastos and H. M. Verkooijen, “Minimally Invasive Approaches for Diagnosis and Treatment of Early-Stage Breast Cancer,” The Oncologist, Vol. 12, No. 1, 2007, pp. 1-10. doi:10.1634/theoncologist.12-1-1