Barnas, Daniel F, MD

Bleznak, Aaron D, MD, FACS

English

Lehigh Valley Health Network: LVHN Scholarly Works

Lehigh Valley Health NetworkLVHN Scholarly WorksDepartment of SurgeryRadioactive Counts and Sentinel Node Positivityin Breast Cancer Patients; A Single Surgeon’sLongitudinal ExperienceDaniel F. Barnas MDLehigh Valley Health Network, Daniel_F.Barnas@lvhn.orgAaron D. Bleznak MD, FACSEastern Virginia Medical SchoolFollow this and additional works at: https://scholarlyworks.lvhn.org/surgeryPart of the Other Medical Specialties Commons, and the Surgery CommonsThis Poster is brought to you for free and open access by LVHN Scholarly Works. It has been accepted for inclusion in LVHN Scholarly Works by anauthorized administrator. For more information, please contact LibraryServices@lvhn.org.Published In/Presented AtBarnas, D. F., & Bleznak, A. D. (2012). Radioactive Counts and Sentinel Node Positivity in Breast Cancer Patients; A Single Surgeon’sLongitudinal Experience. LVHN Scholarly Works. Retrieved from https://scholarlyworks.lvhn.org/surgery/22 1Lehigh Valley Health Network, Allentown, Pennsylvania; 2Assistant Professor of Clinical Surgery, Eastern Virginia Medical SchoolRadioactive Counts and Sentinel Node Positivity in Breast Cancer Patients;A Single Surgeon’s Longitudinal ExperienceBarnas, D.F.1; Bleznak, A. D.2References:1.	 	Giuliano,	AE,	et.	al.	Improved	axillary	staging	of	breast	cancer	with	sentinel	lymphadenectomy.	Ann	Surg.	Sep	1995;	222(3):	394-92.	 	Martin	RC	2nd,	Edwards	MJ,	Wong	SL,	et	al.	Practical	guidelines	for	optimal	gamma	probe	detection	of	sentinel	lymph	nodes	in	breast	cancer:	Result	of	a	multi-institutional	study.	Surgery	2000;	128:139–144	3.	 	McCarter	MD,	Yeung	H,	Fey	J,	Borgen	PI,	Cody	HS.	The	breast	cancer	patient	with	multiple	sentinel	nodes:	When	to	stop?	J	Am	Coll	Surg.	2001;	192:692–694.	 	Schrenk	P,	Rehberger	W,	Shamiyeh	A,	Wayand	W.	Sentinel	node	biopsy	for	breast	cancer:	Does	the	number	of	sentinel	nodes	removed	have	an	impact	on	the	accuracy	of	finding	a	positive	node?	J	Surg	Onc.	2002;	80:130–1365.	 	Woznick	A,	Franco	M,	Bendick	P,	Benitez	PR.	Sentinel	lymph	node	dissection	for	breast	cancer:	how	many	nodes	are	enough	and	which	technique	is	optimal?	Am	J	Surg.	2006;	191:330–3336.	 	Ban,	EJ,	et.	al.	How	many	sentinel	lymph	nodes	are	enough	for	accurate	axillary	staging	in	t1-2	breast	cancer?	J	Breast	Cancer.	2011	Dec;	14(4):	296-3007.	 	Zakaria	S,	Degnim	AC,	Kleer	CG,	Diehl	KA,	Cimmino	VM,	Chang	AE,	Newman	LA,	Sabel	MS.	Sentinel	lymph	node	biopsy	for	breast	cancer:	How	many	nodes	are	enough?	J	Surg	Oncol.	2007	Dec	1;	96(7):554–5598.	 	Chagpar	AB,	Carlson	DJ,	Laidley	AL,	et	al.	Factors	influencing	the	number	of	sentinel	lymph	nodes	identified	in	patients	with	breast	cancer.	Am	J	Surg.	2007;	194:860–865Objective:Pathologic	nodal	staging	employing	the	technique	of	lymphatic	mapping	and	sentinel	lymph	node	(SLN)	biopsy	has	become	the	standard	of	care	for	patients	with	invasive	breast	cancer.1	Most	surgeons	utilize	a	radioactive	tracer,	with	or	without	preoperative	lymphoscintigraphy,	alone	or	in	conjunction	with	a	vital	blue	dye	to	identify	the	pertinent	nodes.		The	literature	suggests	that	all	nodes	which	have	gamma	counts	>	10	times	the	background	count	should	be	considered	sentinel	nodes	and	retrieved2,	as	should	all	clinically	suspicious	nodes	and	any	with	blue	dye.	There	is	literature	describing	the	number	of	SLNs	that	should	be	removed	to	minimize	the	false	negative	rate,3,4,5,6	but	these	all	represent	the	results	of	multiple	surgeons	and	do	not	consider	the	possible	impact	of	increased	experience.	At	our	institution	we	utilized	a	single	surgeon,	longitudinal	database	to	determine	the	degree	to	which	the	SLN	counts	correlate	to	the	presence	of	metastasis	and	if	we	could	identify	an	optimal	number	of	SLNs	to	remove	to	minimize	false	negative	rate	and	the	number	of	nodes	retrieved.	Methods:•	 	Retrospective	review	of	a	prospectively	maintained	database.•	 	Chronicles	a	single	surgeon’s	breast	cancer	SLN	biopsy	experience	from	1997-2011.	•	 	The	first	seven	years	routinely	using	the	dual	tracer	technique	and	the	final	seven	utilizing	radioisotope	routinely	and	blue	dye	for	inability	to	perform	cutaneous	mapping.		•	 	823	SLN	procedures	were	attempted	•	 	152	patients	(19%)	met	the	inclusion	criteria	of	at	least	one	positive	SLN	and	one	negative	SLN	and	mapping	performed	by	radioactive	counts	(see	Figure	1).		•	 	Patients	that	had	a	failed	mapping	or	had	only	blue	dye	used	in	their	mapping	were	excluded.		•	 	We	then	correlated	the	SLN	radioactive	counts	and	the	pathology	for	each	patient.		The	presence	of	metastasis	in	the	most	radioactive	node(s)	was	then	noted.		•	 	Chi	Square	analysis	was	used	to	compare	the	rates	of	identification	of	metastasis	in	the	most	radioactive	nodes.		Conclusions:We	employed	a	prospectively	collected	database	of	823	consecutive	lymphatic	mapping/sentinel	node	biopsies	for	breast	cancer	performed	by	a	single	surgeon,	to	discern	whether	a	surgeon	can	limit	the	number	of	radioactive	nodes	he	or	she	removes.		This	is	increasingly	important	given	the	trend	towards	eliminating	intraoperative	nodal	assessment	for	metastases.		In	that	subset	of	our	node	positive	patients	who	had	at	least	one	negative	SLN,	removing	only	the	most	radioactive	node	would	have	under	staged	almost	one-third	(31%)	of	patients	while	removing	the	two	most	radioactive	nodes	under	stages	only	8%.		These	data,	from	a	single	surgeon,	are	concordant	with	previously	published	findings	from	larger	databases	documenting	the	experiences	of	multiple	surgeons.4,7,8	For	reasons	that	are	unclear,	there	is	a	statistically	significant	improvement	of	sensitivity	in	finding	metastases	in	the	most	radioactive	SLN	seen	with	increasing	experience;	the	biologic	rationale	for	this	is	unclear	and	the	false	negative	rate	(6%)	would	still	prove	unacceptable.		For	maximum	accuracy,	we	will	continue	to	remove	all	nodes	with	radioactive	counts	greater	than	10%	of	the	hottest	node	and	we	will	utilize	blue	dye	for	those	procedures	in	which	radioisotope	mapping	fails.			Results:•	 	Of	the	original	823	patients	in	which	SLN	biopsy	was	attempted,	790	procedures	had	successful	identification	of	at	least	1	SLN	(96%).		•	 	There	were	25	procedures	in	which	a	SLN	was	unable	to	be	identified	(3%)	and	8	false	negative	procedures	(1%)•	The	node	with	the	highest	count	was	positive	for	metastatic	disease	in	105	(69%).		•	 	Removing	the	two	nodes	with	the	highest	counts	identified	140	(92%)	node	positive	patients.•	 	Removing	the	two	nodes	with	the	highest	counts	resulted	in	a	false	negative	rate	of	2.6%.	•	 	In	the	final	2	years	(2009-2011)	of	data	collection,	26	of	32	of	the	study	cohort	had	the	metastasis	identified	in	the	node	with	the	highest	radioactive	counts	(81%)	•	 	In	only	2	of	the	32	cases	done	during	2009-2011	were	the	metastasis	not	found	in	one	of	the	two	most	radioactive	nodes.	•	 	In	only	1	of	the	152	cases	done	were	the	metastasis	not	found	in	one	of	the	three	most	radioactive	nodes.	•	 	When	comparing	the	rates	of	identifying	the	metastasis	in	the	single	most	radioactive	node	between	1997-2008	and	2009-11,	the	difference	was	statistically	significant	(p=0.000104),	but	there	was	no	difference	when	comparing	rates	for	the	two	most	radioactive	nodes.825 P atien tsW ith SLN B825 P atien tsW ith SLN B800 S uccessfu lM app ings800 S uccessfu lM app ings25 Fa ilu res toM ap25 Fa ilu res toM ap792 S LN B792 S LN B8 Fa lse N egativeS LN B8 Fa lse N egativeS LN B748 S LN B w ithT echn itium +/-B lue D ye748 S LN B w ithT echn itium +/-B lue D ye44 SLN B w ithB lue D ye O nly44 SLN B w ithB lue D ye O nly224 S LN B +224 S LN B +516 T rueN egative516 T rueN egative8 Fa lse N egative8 Fa lse N egative155 > 1 SLN + &> 1 S LN -155 > 1 SLN + &> 1 S LN -69 A ll SLN s+69 A ll SLN s+152 P atien tsW ith C om ple teD ata152 P atien tsW ith C om ple teD ata3 Patien tsIncom p le teD ata3 Patien tsIncom p le teD ataPhotograph	1.	Sentinel	lymph	node	both	blue	and	hot	with	lymphatic	channel	from	2004.Figure	1.	Patient	Inclusion	CriteriaFigure	2.	Graph	showing	the	percentages	of	metastases	found	in	the	hottest	nodes.		Table 1.  Patient CharacteristicsAge 29-87Mean 55Gender Female: 150Male: 2Tumor Type Invasive Ductal: 136Invasive Lobular: 16Tumor Size 0.3-6.5 cmMedian 1.7 cmER StatusPositive: 126Negative: 22Not Reported: 4Her 2 StatusPositive: 25Negative: 122Not Reported: 5Number of Sentinel Nodes 1-6Median: 3Parients with Disease Past The Sentinel Nodes 29 of 116 patients (25%)Table 2.  Metastases in the hottest nodes. Over the last two years of the study the metastasis was more frequently found in the hottest node.Time Frame Metastases in the MostRadioactive NodeMetastases in TwoMost Radioactive Nodes1997-2008 79/120 (65%) 110/120 (91%)2009-2011 26/32 (81%) 30/32 (93%)Chi Square p = 0.000104 p = Not Significant010PercentYears304050607080901001997-2011 1997-2008 2009-201120Hottest NodeHottest 2 NodesHottest 3 Nodes

Radioactive Counts and Sentinel Node Positivity in Breast Cancer Patients; A Single Surgeon’s Longitudinal Experience

https://scholarlyworks.lvhn.org/cgi/viewcontent.cgi?article=1021&context=surgery

Radioactive Counts and Sentinel Node Positivity in Breast Cancer Patients; A Single Surgeon’s Longitudinal Experience

Abstract

Similar works

Full text

Available Versions

Lehigh Valley Health Network: LVHN Scholarly Works