Sentinel Lymph Node Biopsy in Early-Stage Breast Cancer

A systematic review 1 including 69 studies with a total of 8059 subjects was abstracted in DARE. Lymphatic mapping with sentinel lymph node (SLN) biopsy is used widely to reduce the complications associated with complete axillary lymph node dissection in patients with low-risk breast carcinoma. The proportion of patients who had successfully mapped SLNs ranged from 41% to 100%, with over 50% of studies reporting a rate < 90%. The false-negative rate (FNR) ranged from 0% to 29%, averaging 7.3% overall.

In a randomized trial 2 (n=516) comparing sentinel node biopsy (+ evacuation if sentinel node was positive) (group 1) with sentinel node biopsy followed by evacuation (group 2), axillary metastases were found during surgery in 92 patients in group 1 and 82 patients in group 2. The false negative rate in group 2 was 8.8% (axillary metastases were found at evacuation in 8 patients in whom sentinel node biopsy was negative). During a median follow-up of 46 months, there were no clinical axillary recurrences in either group.

According to 8 observational studies 3 4 5 6 7 8 9 10 with a median follow-up of 3 - 5 years, the rate of axillary recurrence was about 0.3%.

In a prospective, multicenter, randomized phase III trial 11, patients with cN0 early breast cancer or extensive/high-grade ductal carcinoma in situ planned for standard radioactive-labeled colloid lymphoscintigraphy (LSG) with subsequent SLN biopsy (SNLB) were randomly assigned 1:1 to receive SLNB either with knowledge of the LSG findings or without. Modified intention-to-treat analysis (n = 1163) showed a mean number of histologically detected SLNs of 2.21 with LSG and 2.26 without LSG (difference 0.05; stratified 95% CI -0.18 to infinity), thus establishing noninferiority of omitting preoperative LSG. Secondary end points displayed no statistically significant differences.

A meta-analysis 12 assessing the use of SLNB following neoadjuvant chemotherapy (NAC) in patients presenting with clinically positive lymph nodes included 3398 patients. The pooled estimate of the FNR was 13% and that of the identification rate was 91%. The adjusted axillary pathological complete response rate was 47%. A trend toward significance was observed with only clinical stage N1 (cN1) disease whereby clinical stage N1 was associated with an increased axillary pathological complete response rate when compared to N2 or N3 disease (P = .06).

Comment: The quality of evidence is downgraded by imprecise results (few events in randomized trials). The skill of the operator appears to influence the sensitivity of sentinel node biopsy in detecting axillary metastases.

References

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