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Sentinel Node in Clinical Practice: Implications for Breast Cancer Treatment and Prognosis
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences.
2012 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The introduction of sentinel lymph node biopsy (SLNB) has conveyed several new issues, such as the risk of false negativity, long-term consequences, the prognostic significance of micrometastases and whether ALND can be omitted in sentinel lymph node- (SLN) positive patients.

Archived SLN specimens from 50 false negative patients and 107 true negative controls were serially sectioned and stained with immunohistochemistry. The detection rate of previously unknown metastases did not differ between the false and the true negative patients. The risk of false negativity was higher in patients with multifocal or hormone receptor-negative tumours, or if only one SLN was found.

In a Swedish multicentre cohort, 2216 SLN-negative patients in whom ALND was omitted were followed up for a median of 65 months. The isolated axillary recurrence rate was only 1.0%, and the overall survival was high (93%).

The survival of 3369 breast cancer patients (2383 node-negative (pN0), 107 isolated tumour cells (pN0(i+), 123 micrometastases (pN1mi) and 756 macrometastases (pN1)) was analysed. The 5-year cause-specific and event-free survival was worse for pN1mi and pN1 patients than for pN0 patients. There was no difference in survival between pN0(i+) and pN0 patients.

Tumour and SLN characteristics in 869 SLN-positive patients were compared between those with and without non-SLN metastases, and the Tenon score was calculated. The risk of non-SLN metastases was higher in case of SLN macrometastases (compared with micrometastases), a high positive/total SLN ratio and Elston grade 3 tumours, and increased with increasing tumour size. The area under the curve (AUC) for the Tenon score was 0.65, and the test thus performed inadequately in this population.

In conclusion, despite the risk of false negativity, SLNB with omission of ALND in SLN-negative patients appears to be safe even in the long term. The presence of micrometastases is of prognostic importance and should entail adjuvant treatment. The need for ALND in patients with SLN micro- and even macrometastases has been questioned, but the occurrence of non-SLN metastases is hard to predict, and strong evidence for the safe omission of ALND is lacking.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2012. , 55 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 754
Keyword [en]
breast cancer, sentinel node, micrometastases, survival, non-sentinel node metastases
National Category
Surgery
Identifiers
URN: urn:nbn:se:uu:diva-171078ISBN: 978-91-554-8316-6 (print)OAI: oai:DiVA.org:uu-171078DiVA: diva2:511102
Public defence
2012-05-12, Aulan, Ingång 21, Västmanlands Sjukhus, Västerås, 09:15 (English)
Opponent
Supervisors
Available from: 2012-04-20 Created: 2012-03-15 Last updated: 2012-08-01Bibliographically approved
List of papers
1. Serial sectioning of breast cancer sentinel nodes does not significantly improve false negativity rate
Open this publication in new window or tab >>Serial sectioning of breast cancer sentinel nodes does not significantly improve false negativity rate
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(English)Manuscript (preprint) (Other academic)
Keyword
breast cancer, sentinel node, false negativity, serial sectioning
National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-171038 (URN)
Available from: 2012-03-15 Created: 2012-03-15 Last updated: 2012-08-01
2. Axillary recurrence rate 5 years after negative sentinel node biopsy for breast cancer
Open this publication in new window or tab >>Axillary recurrence rate 5 years after negative sentinel node biopsy for breast cancer
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2012 (English)In: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 99, no 2, 226-231 p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Sentinel lymph node (SLN) biopsy has replaced axillary lymph node dissection (ALND) as the standard axillary staging procedure in breast cancer. Follow-up studies in SLN-negative women treated without ALND report low rates of axillary recurrence, but most studies have short follow-up, and few are multicentre studies.

METHODS: Between September 2000 and January 2004, patients who were SLN-negative and did not have ALND were included in a prospective cohort. Kaplan-Meier estimates were used to analyse the rates of axillary recurrence and survival. The risk of axillary recurrence was also compared in centres with high and low experience with the SLN biopsy (SLNB) technique.

RESULTS: A total of 2195 patients with 2216 breast tumours were followed for a median of 65 months. Isolated axillary recurrence was diagnosed in 1·0 per cent of patients. The event-free 5-year survival rate was 88·8 per cent and the overall 5-year survival rate 93·1 per cent. There was no difference in recurrence rates between centres contributing fewer than 150 SLNB procedures to the cohort and centres contributing 150 or more procedures.

CONCLUSION: This study confirmed the low risk of axillary recurrence 5 years after SLNB for breast cancer without ALND.

National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-171035 (URN)10.1002/bjs.7820 (DOI)000303148200012 ()22180063 (PubMedID)
Available from: 2012-03-15 Created: 2012-03-15 Last updated: 2017-12-07Bibliographically approved
3. Breast Cancer Survival in Relation to the Metastatic Tumor Burden in Axillary Lymph Nodes
Open this publication in new window or tab >>Breast Cancer Survival in Relation to the Metastatic Tumor Burden in Axillary Lymph Nodes
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2010 (English)In: Journal of Clinical Oncology, ISSN 0732-183X, E-ISSN 1527-7755, Vol. 28, no 17, 2868-2873 p.Article in journal (Refereed) Published
Abstract [en]

Purpose The aim of this study was to determine the prognostic significance of lymph node micrometastases in patients with breast cancer. Patients and Methods Between September 2000 and January 2004, 3,369 patients with breast cancer were included in a prospective cohort. According to their lymph node status, they were classified in the following four groups: 2,383 were node negative, 107 had isolated tumor cells, 123 had micrometastases, and 756 had macrometastases. Median follow-up time was 52 months. Kaplan-Meier estimates and the multivariate Cox proportional hazard regression model were used to analyze survival. Results Five-year cause-specific and event-free survival rates were lower for patients with micrometastases (pN1mi) than for node-negative (pN0) patients (94.1% v 96.9% and 79.6% v 87.1%, respectively; P = .020 and P = .032, respectively). There was no significant survival difference between node-negative patients and those with isolated tumor cells. The overall survival of pN1mi and pN0 patients did not differ. Conclusion This study demonstrates a worse prognosis for patients with micrometastases than for node-negative patients.

National Category
Medical and Health Sciences
Identifiers
urn:nbn:se:uu:diva-135559 (URN)10.1200/JCO.2009.24.5001 (DOI)000278548000010 ()
Available from: 2010-12-14 Created: 2010-12-07 Last updated: 2017-12-11Bibliographically approved
4. Prediction of non-sentinel lymph node status in breast cancer patients with sentinel lymph node metastases: evaluation of the tenon score
Open this publication in new window or tab >>Prediction of non-sentinel lymph node status in breast cancer patients with sentinel lymph node metastases: evaluation of the tenon score
2012 (English)In: Breast Cancer : Basic and Clinical Research, ISSN 1178-2234, E-ISSN 1178-2234, Vol. 6, 31-38 p.Article in journal (Refereed) Published
Abstract [en]

INTRODUCTION:

Current guidelines recommend completion axillary lymph node dissection (cALND) in case of a sentinel lymph node (SLN) metastasis larger than 0.2 mm. However, in 50%-65% of these patients, the non-SLNs contain no further metastases and cALND provides no benefit. Several nomograms and scoring systems have been suggested to predict the risk of metastases in non-SLNs. We have evaluated the Tenon score.

PATIENTS AND METHODS:

In a retrospective review of the Swedish Sentinel Node Multicentre Cohort Study, risk factors for additional metastases were analysed in 869 SLN-positive patients who underwent cALND, using uni- and multivariate logistic regression models. A receiver operating characteristic (ROC) curve was drawn on the basis of the sensitivity and specificity of the Tenon score, and the area under the curve (AUC) was calculated.

RESULTS:

Non-SLN metastases were identified in 270/869 (31.1%) patients. Tumour size and grade, SLN status and ratio between number of positive SLNs and total number of SLNs were significantly associated with non-SLN status in multivariate analyses. The area under the curve for the Tenon score was 0.65 (95% CI 0.61-0.69). In 102 patients with a primary tumour <2 cm, Elston grade 1-2 and SLN metastases ≤2 mm, the risk of non SLN metastasis was less than 10%.

CONCLUSION:

The Tenon score performed inadequately in our material and we could, based on tumour and SLN characteristics, only define a very small group of patients in which negative non-sentinel nodes could be predicted.

National Category
Surgery
Identifiers
urn:nbn:se:uu:diva-171037 (URN)10.4137/BCBCR.S8642 (DOI)22346360 (PubMedID)
Available from: 2012-03-15 Created: 2012-03-15 Last updated: 2017-12-07Bibliographically approved

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