|Year : 2017 | Volume
| Issue : 2 | Page : 77-80
Sentinel lymph node assessment by radioactive isotope in early breast cancer patients
Sherif M Elhadidy1, Inas I Abdulhalim1, Hassan M Abdulah2, Magda E Allam1, Dalia H Morad1
1 Department of Clinical Oncology and Nuclear Medicine, Mansoura University, Mansoura, Egypt
2 Department of Surgical Oncology, National Cancer Institute, Cairo University, Cairo, Egypt
|Date of Submission||23-May-2017|
|Date of Acceptance||20-Jun-2017|
|Date of Web Publication||20-Nov-2017|
Sherif M Elhadidy
Department of Clinical Oncology and Nuclear Medicine, Mansoura University, Mansoura - 31155
Source of Support: None, Conflict of Interest: None
Background and aim The objective of this study was to report the role of sentinel lymph node assessment by radioactive isotope in early breast cancer (BC) patients.
Patients and methods This is a prospective study conducted at National Cancer Institute (NCI), Cairo, Egypt, between January 2015 and December 2016. Sentinel lymph nodes were assessed after injection of 99mTc sodium pertechnetate in 60 early BC patients without clinically palpable lymph node. The patients underwent sentinel lymph node biopsy (SLNB) with frozen section examination. Data collected included the characteristics of patients, sentinel nodes (SNs), and SLNB results.
Results Sixty patients had 62 tumors. SN was identified in 58 patients having 60 tumors (96.7%). No SN was found intraoperatively in two patients. Frozen section results showed that two patients were SN negative, whereas 58 patients were SN-positive and subsequently underwent immediate axillary lymph node dissection.
Conclusion The obtainable results from our local study in SLNB in BC concur with those seen in published similar literature.
Keywords: breast cancer, frozen section, sentinel lymph node, sentinel lymph node biopsy, 99mTc sodium pertechnetate
|How to cite this article:|
Elhadidy SM, Abdulhalim II, Abdulah HM, Allam ME, Morad DH. Sentinel lymph node assessment by radioactive isotope in early breast cancer patients. Benha Med J 2017;34:77-80
|How to cite this URL:|
Elhadidy SM, Abdulhalim II, Abdulah HM, Allam ME, Morad DH. Sentinel lymph node assessment by radioactive isotope in early breast cancer patients. Benha Med J [serial online] 2017 [cited 2018 Nov 17];34:77-80. Available from: http://www.bmfj.eg.net/text.asp?2017/34/2/77/218822
| Background|| |
Breast cancer (BC) is the most common cancer in women both in the developed and developing world . In the USA, nearly 230 000 BC cases are diagnosed annually . In Egypt, it is estimated that there will be 252 710 new cases of female BC and an estimated 40 610 people will die of this disease in 2017 . Axillary lymph node status is considered the most important prognostic factor for patients with BC, and it participates largely in the decision regarding subsequent adjuvant systemic treatment ,. Axillary lymph node dissection (ALND) for patients with BC was introduced more than 200 years ago for staging and local control ,. It is associated with an increased risk of adverse outcomes, including lymphedema in 14% of cases, limited shoulder motion in 28% of the cases, and neuropathic pain in 31% of the cases . The therapeutic advantage of removing negative nodes with respect to axillary control and survival remains questionable ,,,.
At the present time, most BC patients receive some sort of adjuvant systemic therapy irrespective of their lymph node status . On the basis of that, minimally invasive procedures for staging the axilla have been introduced. Sentinel lymph node biopsy (SLNB) in BC, a minimally invasive procedure, was first described in 1994 . Since then, it has been widely practiced with a wide literature to support its reliability for ascertaining the status of the axillary lymph nodes. Currently, SLNB is accepted as the standard of care for axillary staging in early BC ,,. In this paper, we are documenting the results of patients who underwent SLNB for BC at National Cancer Institute, Cairo, Egypt.
| Patients and methods|| |
Over a 2-year period (January 2015 to December 2016), 60 BC patients who were diagnosed and treated at NCI were selected to enter our study. The study was approved by the Research Ethical Committee and an informed consent was obtained from each participant before enrollment in the study. These patients are those who fulfilled the criteria to undergo SLNB procedure and accept to be enrolled in the study; two of them had bilateral disease. The inclusion criteria were set at the beginning of the study as for patients with histologically confirmed BC with the absence of clinically palpable lymph nodes. The study was conducted by collecting the data of 60 patients who had 62 SLNB procedures; of them, two sentinel node (SN) negative patients had only SLNB with no further ALND and 58 patients had positive SN on frozen section (FS), and immediate ALND was performed in them.
Patient’s characteristics were age, sex, bilaterality, and hormonal status. Tumor characteristics were histological type, tumor size, lymphovascular invasion, tumor grade, perineural invasion, and hormonal receptors. SN characteristics were the number of SNs removed, FS result, hematoxylin and eosin (H&E) result, immunohistochemistry result, and ALND result (in case of positive SN).
Sentinel lymph node identification procedures
SLNB was performed using isotope, and was all carried out under general anesthesia. The radiotracer is injected late afternoon on the day before the procedure in the area where the SLNB is planned to be carried out early in the morning the next day.
A volume of 1.5 ml of 99mTc sodium pertechnetate with activity ranging from 5 to 100 mCi (185–3700 MBq) is introduced in a vial. Four syringes are prepared from this vial, and each syringe contains 0.1–0.2 ml of 99mTc albumin colloid containing 0.2–0.4 mCi (7.4–14.4 MBq). The material is injected at four peritumoral sites or in the periareolar area in cases with multifocal or multicentric cancers, and then the nurse performs gentle breast massage for 30 min to facilitate migration of the particles to the axilla. Postinjection imaging is performed using gamma camera. Anterior and lateral views are obtained 15 min postinjection and continued until the SN is visualized. A lymph node is called SN when it is a hot node by using the γ-detection probe. After the removal of the SN, the axillary basin is checked for residual radioactivity; a count less than 10% of the hottest SN is considered a background activity. The SN(s) is/are sent for FS. At the FS laboratory, each lymph node is sliced perpendicular to its long axis; touch preparations are submitted from the cut surfaces and stained with modified Giemsa stain.
Data were fed to the computer and analyzed using IBM SPSS software package version 20.0 (SPSS Inc., Chicago, Illinois, USA). Qualitative data were described using number and percentage.
| Results|| |
Between January 2015 and December 2016 (2-year period), 60 BC patients were selected among patients diagnosed and treated at NCI. These 60 patients were seen to be suitable for the SLNB procedure. The median age was 48 years; the mean age was 49.2±10.4 years. Patients in this series are mostly premenopausal (61.7%). Infiltrating ductal carcinoma was seen in 51 (85%) of patients, whereas lobular carcinoma was seen in eight (13.3%) patients. There was one (1.7%) case of ductal carcinoma in situ. The tumor size was T1 in 20 (33.3%) patients, T2 in 38 (63.3%) patients, and T3 in two (3.3%) patients. Grade II tumors were seen in 41 (68.3%) patients, grade III tumors in 15 (25%) patients, and grade I tumors were seen only in four (6.7 %) patients. Lymphovascular invasion was seen in 25 (41.7%) patients and perineural invasion was seen in 15 (25%) patients. There were 10 (16.7%) patients with multifocal disease and five (8.3%) patients with multicentric disease. Almost 70% of our patients were estrogen hormone receptor positive, whereas 63.3% were progesterone hormone receptor positive and 41.7% were human epidermal growth factor receptor positive ([Table 1]). The SLNB procedure was successfully carried out in 58 out of 60 patients (96.7% success rate). Two out of the 60 patients had bilateral disease, and thus there were 60 SLNB procedures performed. A radiolabeled technetium was used to map and localize the SN in all patients. In two cases, the SN was not identified; thus, ALND was performed immediately on these two patients.
|Table 1 Patients’ and tumor characteristics (60 patients, two of them having bilateral cancer)|
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Intraoperative sentinel node identification
SN was identified intraoperatively in 60 out of 62 tumors (96.7%); two patients had bilateral disease. The number of SNs harvested was one in 18 (30%) cases, two in 30 (50%) cases, three in nine (15%) cases, four in two (3.3%) cases, and five in one (1.7%) case ([Table 2]).
|Table 2 Details of sentinel lymph node findings in 60 patients who underwent sentinel lymph node biopsy|
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Sentinel node results
Of the 60 SLNBs, FS examinations resulted in 58 (96.6%) positive SNs, and all had immediate ALND. The remaining two (3.33%) cases were reported as negative SNs by FS and, consequently, no ALND was performed on them. H&E staining of SN revealed results similar to those of FS.
| Discussion|| |
This is a prospective study of 58 early BC patients in whom SLNB was performed during 2 years (2015–2016). SLNB in BC, a minimally invasive procedure, was first described in 1994 . Since that time, it gained a substantial ground and it is now accepted as the standard of care for axillary staging in clinically negative axilla BC patients ,,. We used a radioactive isotope (99mTc pertechnitate) for SN identification. Our identification rate was 96.7%, which is in accordance with most of the published literature ,,. Tumor multifocality and multicentricity are no longer contraindications to perform SLNB. Current point of view suggests that there is/are specific SN(s) for the whole breast gland. It has been shown that success rates and false negative rates of SLNB in multifocal and multicentric cancers are similar to those for unifocal cancers ,,,,. In the past, big tumor size was one of the limiting factors to do SLNB, but this has changed recently. Nowadays, SLNB is being performed to patients with tumor size as big as 5 cm or more as long as the axilla is clinically negative, although the chances of finding a positive SN increases as the tumor size increases ,, It has been thought before that any past surgical procedure in the breast would alter the lymphatic channels and drainage and consequently make SLNB inaccurate. This concept has been challenged and, at the present time, SLNB is being carried out for patients who even had excisional biopsy for the index tumor ,,. In our series, almost 95% of patients had one to three SNs removed at the time of SLNB. Studies have shown that the average number of SNs removed at the time of SLNB is three . The identification of more than one SN may be attributed to migration of isotope or blue dye from the true SN to second line nodes or just a normal anatomic variation in which the lymphatics of a given site in the breast drain simultaneously . We performed intraoperative FS for all the SNs in this series. It allowed us to do immediate ALND for the SN-positive cases, which was ∼97% of the patients in this study. There was an agreement between FS results and H&E results (96.7 and 96.7%).
In conclusion, despite the low number of patients in this study, the obtainable results from our local experience in SLNB in BC concur with those seen in similar published literature. A large local multicentric similar study is needed to know more about BC in Egypt, with special emphasis on the applicability and suitability of SLNB technique in our patients.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Siegel R, Naishadham D, Jemal A. Cancer statistics, 2012. CA Cancer J Clin 2012; 62:10–29.
Fisher B, Bauer M, Wickerham DL, Redmond CK, Fisher ER, Cruz AB et al.
Relation of number of positive axillary nodes to the prognosis of patients with primary breast cancer. An NSABP update. Cancer 1983; 52:1551–1557.
Carter CL, Allen C, Henson DE. Relation of tumor size, lymph node status, and survival in 24,740 breast cancer cases. Cancer 1989; 63:181–187.
Cotlar AM, Dubose JJ, Rose DM. History of surgery for breast cancer: radical to the sublime. Curr Surg 2003; 60:329–337.
Halsted WS. The results of operations for the cure of cancer of the breast performed at the Johns Hopkins Hospital fromJune 1889 to January 1894. Ann Surg 1894; 20:497–555.
Fleissig A, Fallowfield LJ, Langridge CI, Johnson L, Newcombe RG, Dixon JM et al.
Post-operative arm morbidity and quality of life. Results of the ALMANAC randomised trial comparing sentinel node biopsy with standard axillary treatment in the management of patients with early breast cancer. Breast Cancer Res Treat 2006; 95:279–293.
Fisher B, Redmond C, Fisher ER, Bauer M, Wolmark N, Wickerham DL et al.
Ten-year results of a randomized clinical trial comparing radical mastectomy and total mastectomy with or without radiation. N Engl J Med 1985; 312:674–681.
Haffy BG, Ward B, Pathare P, Salem R, McKhann C, Beinfield M et al.
Reappraisal of the role of axillary lymph node dissection in the conservative treatment of breast cancer. J Clin Oncol 1997; 15:691–700.
Sosa JA, Diener-West M, Gusev Y, Choti MA, Lange JR, Dooley WC et al.
Association between extent of axillary lymph node dissection and survival in patients with stage I breast cancer. Ann Surg Oncol 1998; 5:140–149.
Baxter N, McCready D, Chapman JA, Fish E, Kahn H, Hanna W et al.
Clinical behavior of untreated axillary nodes after local treatment for primary breast cancer. Ann Surg Oncol 1996; 3:235–240.
Cady B. Is axillary lymph node dissection necessary in routine management of breast cancer? No. Breast J 1997; 5:246–260.
Giuliano AE, Kirgan DM, Guenther JM, Morton DL. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg 1994; 220:391–398; discussion 398-401.
Krag DN, Anderson SJ, Julian TB, Brown AM, Harlow SP, Costantino JP et al.
Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol 2010; 11:927–933.
Grube BJ, Giuliano AE. Observation of the breast cancer patient with a tumor-positive sentinel node: implications of the ACOSOG Z0011 trial. Semin Surg Oncol 2001; 20:230–237.
Giuliano AE, McCall LM, Beitsch PD, Whitworth PW, Morrow M, Blumencranz PW et al.
ACOSOG Z0011: a randomized trial of axillary node dissection in women with clinical T1-2 N0 M0 breast cancer who have a positive sentinel node. 2010 ASCO Annual Meeting. J Clin Oncol 2010; 28:18s.
Tuttle TM. Sentinel lymph node biopsy. Preferred method of axillary staging for breast cancer. Minerva Ginecol 2005; 57:293–303.
Somasundaram SK, Chicken DW, Waddington WA, Bomanji J, Ell PJ, Keshtgar MR. Sentinel node imaging in breast cancer using superficial injections: technical details and observations. Eur J Surg Oncol 2009; 35:1250–1256.
Ballarin A, Franchini Z, D’Atri C, Marchi R, Tedeschi U. Sentinel lymph-node biopsy for breast cancer. Analysis of 235 cases and review of the literature. Chir Ital 2006; 58:583–595.
Kumar R, Jana S, Heiba SI, Dakhel M, Axelrod D, Siegel B et al.
Retrospective analysis of sentinel node localization in multifocal, multicentric, palpable, or nonpalpable breast cancer. J Nucl Med 2003; 44:7–10.
Tousimis E, Van Zee KJ, Fey JV, Hoque LW, Tan LK, Cody HS 3rd et al.
The accuracy of sentinel lymph node biopsy in multicentric and multifocal invasive breast cancers. J Am Coll Surg 2003; 197:529–535.
Goyal A, Newcombe RG, Mansel RE, Chetty U, Ell P, Fallowfield L et al.
Sentinel lymph node biopsy in patients with multifocal breast cancer. Eur J Surg Oncol 2004; 30:475–479.
Spillane AJ, Brennan ME. Accuracy of sentinel lymph node biopsy in large and multifocal/multicentric breast carcinoma − a systematic review. Eur J Surg Oncol 2011; 37:371–385.
Moody LC, Wen X, McKnight T, Chao C. Indications for sentinel lymph node biopsy in multifocal and multicentric breast cancer. Surgery 2012; 152:389–396.
National Comprehensive Cancer Network. Clinical practice guidelines in oncology (NCCN Guideline) version 2. Fort Washington, PA: National Comprehensive Cancer; 2015.
Schille J, Frisell J, Ingvar C, Bergkvist L. Sentinel node biopsy for breast cancer larger than 3 cm in diameter. Br J Surg 2007; 94:948–951.
Heuts EM, van der Ent FW, Kengen RA, van der Pol HA, Hulsewe KW, Hoofwijk AG. Results of sentinel node biopsy not affected by previous excisional biopsy. Eur J Surg Oncol 2006; 32:278–281.
Dinan D, Nagle CE, Pettinga J. Lymphatic mapping and sentinel node biopsy in women with an ipsilateral second breast carcinoma and a history of breast and axillary surgery. Am J Surg 2005; 190:614–617.
Javan H, Gholami H, Assadi M, Pakdel AF, Sadeghi R, Keshtgar M. The accuracy of sentinel node biopsy in breast cancer patients with the history of previous surgical biopsy of the primary lesion: systematic review and meta-analysis of the literature. Eur J Surg Oncol 2012; 38:45–109.
Yi M, Meric-Bernstam F, Ross MI, Akins JS, Hwang RF, Lucci A et al.
How many sentinel lymph nodes are enough during sentinel lymph node dissection for breast cancer? Cancer 2008; 113:30–37.
[Table 1], [Table 2]