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prognosis of breast cancer is strongly associated withthe presence or absence of metastatic disease in theaxillary lymph nodes

Nodal staging


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60-70% of:

1) patients with breast cancers have no

involvement of axillary lymph nodes atdiagnosis2) patients with positive sentinel lymph nodesurvive more than 10 years after breast

cancer diagnosis3) lymph node sentinel procedures undergoaxillary dissection4) patients with breast carcinoma diagnosis

undergo direct axillary dissection


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60-70% breast lesions have no axillarylymph node metastases

70% node free pts at dx have >10 yssurvival


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N1 (mobile path. axillarynodes)

N2 (fixed axillary nodes)

N3 (axilla+internal mammarychain)

M1 (sovraclavear,laterocervical, contralat intmamm)

chemio and/or hormontherapy

chemio + radio therapy

preop neoadjuvant chemio

Pres or abs of nodal involvement influences prognosis and therapy.

EurJSurgOncol 2007


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Ann Surg 1983;198:681-684Ann Surg 1985;202:702-707

Independent prognostic factor 30% 10-yr survival w/both axillary and IM basins + 53-55% w/either axillary or IM nodal basins + 80% when neither involved

Increased risk of IM node + when primary > 2 cm or age < 40

75%


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Clinical sensitivity 34-76%US sensitivity 36-92%US - FNAB sensitivity 36-100%

EurJSurgOncol 2007


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Axillary lymph nodedissection (ALND)

Sentinel lymph nodeprocedure (SLNP)

Sentinel lymph nodeassessement prior tosurgery

lymphedema, pain,seroma, limitedmovements, paresthesia

operating timegamma cameradye-radiotracer $radiation expos.

ClinicalUS

CEUSUS guided biopsy

Ann Surg Oncol. 2007;14:2928-31.


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Injection site (30-60MBq99

Tc nanocolloid): subareolar (nonpalpable or multiple tumors) subdermal in the site of the tumor peritumoral (poorer detection)Identification: via hand-held gamma probe if radiotracer ( 99m Tc) visually if lymphotropic dye (if alone, higher FN)

Sentinel lymph node is thefirst node receivingmetastatic cells from the

primary tumor.


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T1 (2cm),T2 (2-5cm) clinically nodenegative

multicentric breast ca (IEO with no axillarymets after 24 mths fu)*

DCIS (not everybody) * DCISM* Locally advanced tumor prior to neoadjuvant

chemotherapy *

Eur J Surg Oncol. 2006 Jun;32(5):507-1Ann Surg Oncol. 2006 Apr;13(4):483-900

Ann Surg Oncol. 2007 Aug;14(8):2202-8Breast Cancer Res Treat 2006;98:311-4


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DCIS 5% sln+ >1cm ->25% sln+DCIS on presurgical

assessement -> IDC on surgery


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Palpable axillary nodesAnatomical lymphatic system disrupted ->

localisation failure (skip mets) Previous neoadjuvant chemotherapy Previous excisional biopsy Clinically positive limph nodes

M1

Honig et al. State of the art of neoadjuvant chemotherapy in breastcancer. GMS Ger Med Sci. 2005;3:Doc08


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Advanced ageHigh body mass index

Massive metastasis invasion(skip metastasis) Tumor location other thanUOQ>3mm node slicesMICROMETASTASES

WJSO 2005;5:132EJSO 2007;7:198


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Can Assoc Radiol J 2005;56:289-296


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Radiol Med 2005;109:330-344

false positive

QuickTime and adecompressor

are needed to see this picture.


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> 10 mm size

Absence of fatty hilumCortical diffuse thickening >2-3mmCircular shape - L/T diameter >2Longitudinal total axis/hilum >50%Sharply demarcated border compared with surroundingfatty tissueHypoechoic internal echoCortical focal thickeningSmall vessels along cortex

Focal vasculature lossNodal vessels dislocation

Australasian Radiology 2006; 50:122-126

Diagn Cytopathol. 2002 ;26:69-74Radiol Med 2005;109:330-344


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US guided-FNAB

PPV 97-100%NPV 56.6-62%Sensit 84-94.7%Specif 91-100%

Australasian Radiology 2006; 50:122-126Diagn Cytopathol. 2002 ;26:69-74Radiol Med 2005;109:330-344Eur Radiol 2005;15:1044-1050

Am J Surg 2007;193:16-20Radiology 2008;246:81-9-

US

PPV 61.3-79%NPV 50-77.2%Sensit 45.2-92%Specif 86.6-100%

Discrepancies due to operator dependanceand equipment dependance


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US guided-FNAB

sensit tumor size and gradesensit clinically pos nodes > clin negSimilar sensit IDC and ILCFN due to sampling error or lecture error(pathologist absent during sampling)

Australasian Radiology 2006; 50:122-126Diagn Cytopathol. 2002 ;26:69-74Radiol Med 2005;109:330-344Eur Radiol 2005;15:1044-1050

Am J Surg 2007;193:16-20Radiology 2008;246:81-9-


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3. All of them4. Prior to possible SLNP c+d undergo US guided

samplinga) axilla

d) axillac) axilla

b) Internal mamm. chain

Which one undergoes SLNP? 1. Only a+b SLNP2. Only c+d SLNP


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FNAB (21G)

Core biopsy (14-16G)

US FNAB versus BIOPSY


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preoperative US sampling-> 8-24% sparing vs SLNP

World J Surg. 2007;31:1153-4.Am J Surg 2007; 194:524-526

timecostsradiotracer - blue dye morbidity

additional surgery


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in favour of US guided FNABin favour of US guided FNABPositive PV ~ 100% - Negative PV ~ 67%

Krishnamurthy S et al. Cancer ;95, 2002

Oruwari JU et al. Am J Surg; 184, 2002

Bedrosian I et al. Ann Surg Oncol; 10, 2003Deurloo EE et al. Eur J Cancer 39, 2003

Kuenen-Boumeester V et al. Eur J Cancer; 39, 2003

Sapino A et al. Br J Cancer; 88, 2003

Lemos S et al. Eur J Gynaecol Oncol; 26, 2005

Mobbs LM et al. JDMS; 21, 2005

Ciatto S et al.Br Cancer Res Treat; 103, 2007


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in favour of US guided Core Biopsyin favour of US guided Core Biopsy The sensitivity of US-FNAB was 86.9%, the specificity was

78.6%, and the accuracy was 84% The sensitivity of US-Core was 86.2%, the specificity was

95.8%, and the accuracy was 89% Hatada T et al. J Am Coll Surg; 190, 2003

The sensitivity of US-Core was 90%, the specificity was100%, and the accuracy was 92%.

Topal U et al. Eur J Radiol;36, 2005

Damera A et al Br J Cancer; 89, 2003

Nori J et al. Radiol Med; 109, 2005


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US guided FNAB

With FNAB we can use afan-like approach with asingle pass

capillarity - suction technique


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US guided Core

Biopsy With core there is no

proof that multiple passes

do not damagethe lymphatic networkreducing the accuracy of theSLN procedure

Technical difficulties if vessels nearby

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