Is it possible to refine the indication for sentinel node biopsy in high-risk ductal carcinoma in situ?

BACKGROUND: The indication for sentinel node biopsy (SNB) has not been fully established yet for patients with ductal carcinoma in situ (DCIS). AIM: To relate the conversion rate to invasive carcinoma with sentinel node positivity in high risk DCIS, and to refine the clinical presentation analysis in order to better select patients for SNB. For this purpose, a risk score was devised. METHODS: From 1998 to 2005, 151 high-risk DCIS patients from six clinical centres were included in a prospective sentinel node database. The conversion rate to invasive carcinoma was 39%. Ten of 142 (7%) successful SNBs showed a positive sentinel node (eight micrometastatic). The sentinel node was positive in 1% of pure DCIS, in 5.5% of DCIS with micro-invasion, and in 19.5% of invasive carcinoma. RESULTS: Both clinical presentation and corresponding risk score were closely related to conversion to invasive carcinoma. The association of risk score and sentinel node positivity approached but did not reach statistical significance (P=0.06); therefore a subset of further selected higher risk patients could not be defined. CONCLUSION: The relevance of SNB positivity cannot be overlooked in high-risk DCIS patients, however, because SNB is not free from morbidity and cost, more studies are needed to refine its final indication.

Diagnostic Accuracy and Impact on Management of Ultrasonography-Guided Fine-Needle Aspiration to Detect Axillary Metastasis in Breast Cancer Patients: A Prospective Study.

BACKGROUND: The axillary nodal status is essential to determine the stage of disease at diagnosis. Our aim was to prospectively assess the diagnostic accuracy of ultrasonography-guided fine-needle aspiration (US-FNA) for the detection of metastasis in axillary lymph nodes in patients with breast cancer (BC) and its impact on the therapeutic decision. MATERIALS AND METHODS: Ultrasonography (US) was performed in 407 axillae of 396 patients who subsequently underwent surgery. US-FNA was conducted when lymph nodes were detected by US. Axillary dissection (AD) was performed when US-FNA was positive for metastasis. Patients with negative US-FNA and breast tumors of 30 mm in size were candidates for selective sentinel lymph node biopsy (SLNB). The anatomopathological results of AD or SLNB were used as reference tests. RESULTS: Lymph nodes were detected by US in 207 (50.8%) axillae. Of these, US-FNA was performed on 180 (86.9%). 94 axillae (52.2%) were positive for carcinoma and 79 women received AD. US-FNA had 77.5% sensitivity, 100% specificity, 100% positive predictive value, 69.3% negative predictive value, and 85.1% diagnostic accuracy. US-FNA avoided SLNB in 18.1% of patients who underwent AD. CONCLUSIONS: Axillary US-FNA is an accurate technique in the staging of patients with BC. It allows reducing the number of SLNB and, when positive, offers a fast and useful tool.

[Sentinel lymph node biopsy technique in breast cancer surgery in a hospital without a nuclear medical service]. / Técnica del ganglio centinela en la cirugía del cáncer de mama en un hospital sin servicio de medicina nuclear.

INTRODUCTION: Knowledge of lymph node stage is the most important prognostic factor in breast cancer. The sentinel lymph node biopsy technique (SLNBT), initially developed to avoid unnecessary dissection in melanoma, has been shown to be able to predict the axillary stage of breast cancer. The difficulty of applying the SLNBT in hospitals without a nuclear medicine service has led to the existence of external teams that allow these hospitals to apply the technique. OBJECTIVE: To test the application of the SLNBT in our hospital which has no nuclear medicine service. PATIENTS AND METHODS: Coinciding with the validation of the SLNBT in the Germans Trias i Pujol Hospital in Badalona in November 1999, and with their help, the Centre Hospitalari de Manresa began to apply this technique. In 2002, the technique was used in all the hospitals of the ALTHAIA-Xarxa Assistencial de Manresa. From November 1999 to June 2005, the technique was applied in 163 patients. RESULTS: Of the 163 patients, the technical success rate was 97.55%. In 98% of the patients, the sentinel lymph node was found in the axilla. In 10.7% of the patients, the node was found in the internal mammary basin. Twenty-six percent of the axillas had metastases of over 2 mm, and 16% had micrometastases. One hundred and five patients were spared axillary dissection. CONCLUSIONS: The SLNBT can be performed in a hospital without a nuclear medicine service. This technique improves and simplifies the surgical technique and reduces length of hospital stay and morbidity.

[Radio-guided occult lesion localization combined with sentinel node biopsy in women with breast cancer]. / Radiolocalización de lesiones mamarias no palpables combinada con la biopsia del ganglio centinela en mujeres con cáncer de mama.

INTRODUCTION: The practice of intratumoral radiocolloid injection for sentinel node biopsy (SNB) allows localization of nonpalpable breast tumors in the same surgical intervention, using the technique known as radio-guided occult lesion localization (ROLL). PATIENTS AND METHOD: We present our experience with the combined use of both techniques (SNB and ROLL). A total of 233 patients were retrospectively analyzed: 65 patients underwent ROLL and 168 patients underwent wire-guided localization (control group) as the excision modality. Both groups had comparable pathologic and radiologic features. RESULTS: Complete excision of the lesion was achieved at the first attempt in only 169 patients. There were no significant differences among groups in surgical margin status (margins were adequate in 80% of ROLL patients vs 69.9% of non-ROLL patients) or in maximum specimen diameter (6.85 cm vs 6.52 cm, respectively). CONCLUSION: We conclude that ROLL is an acceptable alternative to wire-guided localization in patients with nonpalpable breast tumors undergoing SNB, leading to easier lesion excision and greater patient comfort.

Técnica del ganglio centinela en la cirugía del cáncer de mama en un hospital sin servicio de medicina nuclear / Sentinel lymph node biopsy technique in breast cancer surgery in a hospital without a nuclear medical service

Introducción. El conocimiento del estado ganglionar es el factor pronóstico más importante en el cáncer de mama. La técnica del ganglio centinela, desarrollada inicialmente para evitar vaciamientos innecesarios en los melanomas, ha demostrado su capacidad para predecir el estado axilar en el cáncer de mama. La dificultad en aplicar la técnica en hospitales sin servicio de medicina nuclear ha estimulado la existencia de equipos itinerantes que han permitido aplicarla en dichos hospitales. Objetivo. Comprobar la aplicabilidad de la técnica del ganglio centinela en nuestro hospital que carece de servicio de medicina nuclear. Pacientes y método. Coincidiendo con la validación de la técnica del ganglio centinela en el Hospital Universitari Germans Trias i Pujol de Badalona (Barcelona) en noviembre de 1999, se empezó a aplicarla en el Centre Hospitalari de Manresa (Barcelona) bajo su tutela. En 2002, se generalizó su uso en todos los hospitales de ALTHAIA-Xarxa Assistencial de Manresa. De noviembre de 1999 a junio de 2005, se estudió el ganglio centinela de un total de 163 pacientes. Resultados. En el 97,55% de las 163 pacientes, la técnica se realizó con éxito. En un 98% de los casos, el ganglio centinela se encontró en la axila. En un 10,7% de los casos, había ganglio centinela en la cadena de la mamaria interna. El 26% de las axilas tenían metástasis de más de 2 mm y el 16% tenía micrometástasis. Se pudo ahorrar el vaciamiento axilar a 105 pacientes. Conclusiones. La técnica del ganglio centinela se puede practicar en un hospital que no disponga de servicio de medicina nuclear, mejora y simplifica la técnica quirúrgica y reduce la estancia hospitalaria y las secuelas (AU)

Introduction. Knowledge of lymph node stage is the most important prognostic factor in breast cancer. The sentinel lymph node biopsy technique (SLNBT), initially developed to avoid unnecessary dissection in melanoma, has been shown to be able to predict the axillary stage of breast cancer. The difficulty of applying the SLNBT in hospitals without a nuclear medicine service has led to the existence of external teams that allow these hospitals to apply the technique. Objective. To test the application of the SLNBT in our hospital which has no nuclear medicine service. Patients and methods. Coinciding with the validation of the SLNBT in the Germans Trias i Pujol Hospital in Badalona in November 1999, and with their help, the Centre Hospitalari de Manresa began to apply this technique. In 2002, the technique was used in all the hospitals of the ALTHAIA-Xarxa Assistencial de Manresa. From November 1999 to June 2005, the technique was applied in 163 patients. Results. Of the 163 patients, the technical success rate was 97.55%. In 98% of the patients, the sentinel lymph node was found in the axilla. In 10.7% of the patients, the node was found in the internal mammary basin. Twenty-six percent of the axillas had metastases of over 2 mm, and 16% had micrometastases. One hundred and five patients were spared axillary dissection. Conclusions. The SLNBT can be performed in a hospital without a nuclear medicine service. This technique improves and simplifies the surgical technique and reduces length of hospital stay and morbidity (AU)

Radiolocalización de lesiones mamarias no palpables combinada con la biopsia del ganglio centinela en mujeres con cáncer de mama / Radio-guided occult lesion localization combined with sentinel node biopsy in women with breast cancer

Introducción. La modalidad intralesional de inyección de los radiocoloides en la biopsia del ganglio centinela (BGC) permite la localización de tumores mamarios primitivos no palpables, en un mismo acto quirúrgico, mediante la técnica conocida como ROLL. Pacientes y método. Presentamos nuestra experiencia con la combinación de ambas técnicas (BGC y ROLL). Se analizó retrospectivamente a 233 pacientes: en 65 pacientes se practicó ROLL y en 168 la lesión fue localizada mediante la inserción de guías metálicas (grupo control). Ambos grupos eran comparables en cuanto a sus variables anatomorradiológicas. Resultados. La resección de la lesión se llevó a cabo en un solo tiempo en 169 pacientes. No se observaron diferencias significativas entre ambos grupos en cuanto a la afección de los márgenes quirúrgicos (márgenes correctos del 80% con ROLL frente al 69,9% sin ROLL) ni en el diámetro máximo de la pieza (6,85 frente a 6,52 cm, respectivamente). Conclusión. En pacientes sometidas a la BGC con lesiones mamarias no palpables, la técnica ROLL es una alternativa a las guías metálicas que ofrece una mayor facilidad para la exéresis y más comodidad para la paciente (AU)

Introduction. The practice of intratumoral radiocolloid injection for sentinel node biopsy (SNB) allows localization of nonpalpable breast tumors in the same surgical intervention, using the technique known as radio-guided occult lesion localization (ROLL). Patients and method. We present our experience with the combined use of both techniques (SNB and ROLL). A total of 233 patients were retrospectively analyzed: 65 patients underwent ROLL and 168 patients underwent wire-guided localization (control group) as the excision modality. Both groups had comparable pathologic and radiologic features. Results. Complete excision of the lesion was achieved at the first attempt in only 169 patients. There were no significant differences among groups in surgical margin status (margins were adequate in 80% of ROLL patients vs 69.9% of non-ROLL patients) or in maximum specimen diameter (6.85 cm vs 6.52 cm, respectively). Conclusion. We conclude that ROLL is an acceptable alternative to wire-guided localization in patients with nonpalpable breast tumors undergoing SNB, leading to easier lesion excision and greater patient comfort (AU)