Utility of Sentine Biopsy For B Utility of Sentine Biopsy For B p y

Utility of Sentine
el Lymph Node
Biopsy
p y For Breast Cancer
Facts and Controversies
C
Henry Mark Kuere
er, MD, PhD, FACS
Department of S
Surgical Oncology
University
y of Texas
MD Anderson Cancer Center
National Comprehen
p
nsive Cancer Network
Treatment Guidelines
• Use of sentinel node
e biopsy in breast
cancer
–Clinically negative
e axilla
–Team
Team must have ‘documented
documented
experience’
–SLN
SLN positive
iti or no
one identified
id tifi d needs
d
axillary node disse
ection
St Gallen Interrnational Expert
St.
Consensu
us Meeting
• A negative sentinel lymph node is now
accepted as allowin
ng avoidance of
axillary dissection
• Micrometastatic
Mi
t t ti dise
di ease, particularly
ti l l
isolated cells, are a subject of research
J Clin Oncol,
Oncol, 2003
Lymphatic Map
Mapping
ping Technique
L
Lymphosc
Lymphosci
h cintigraphy
i i
h
Blue--dye Injection
Blue
Gamma
a-Probe
Surgical
g
Lymph
y phatic
phatic Mapping
pp g
S i lL
Sentinel
Lyymph
hN
Node
d
Sentinel Lymph Node Biopsy
Optimal
O ti l Technique
T h i
Multi Institutional registry
Multi-Institutional
- 99 surgeons enrolled 806 pa
atients
- Attempted SN biopsy followe
ed by ALND in all patients
- Single-agent (blue dye or ra
adiocolloid alone, N=244),
or dual-agent (N=562)
Results:
SN ID-rate
ID rate
# SN
False neg.
Single-age
ent
86%
1.5
11.8%
Dual-agent P
90%
ns
2.1
.001
5.8%
<.05
.05
McMasters et al,
al, JCO
JCO,, 2000.
Nodal Micro
ometastases
Definitions and
d AJCC Staging
Occult nodal disease
Clinically node neg
gative
Microscopically no
ode positive
Micrometastases
Tumor deposit < 2 mm
Evidence of diseas
se using techniques more
sensitive than con
nventional methods
Serial sections
IHC
PCR
Detection of Micrometastases in Breast Cancer
Patients with Negative
e Routine H&E Staining
Study
Friedman et al
Bettelheim et al
Wells
e s et a
al
Trojani et al
Hainsworth et al
Bussolati et al
Chen et al
De Mascarel et al
Nasser et al
Occult
O
l
Micromets(%)
43/456 (9%)
83/921 (9%)
7/45
/ 5 (15%)
( 5%)
21/150 (14%)
41/343 (12%)
12/50 (24%)
(
)
23/80 (29%)
50/218 (23%)
(
)
50/159 (31%)
Detection
D
i T
Technique
h i
Serial Sections
IHC
X
X
X
X
X
X
X
X
X
X
X
X
X
Prognostic Signifiicance of “Occult”
Axillary Metastases
Study
Trojani
T
j i
Sedmak
Ludwig
g
Patients
162
45
921
Chen
80
De Mascarel 218
Hainsworth 343
Histologic
Hi
t l i
Examination
IIncidence
id
off
D
Decrease
iin Di
DiseaseOccult Mets (%)
Free Survival (%)
IImmuno
Immuno
Multiple
p Section
ns/
Immuno
Immuno
Immuno
Immuno
14
11
9
22
11
16
29
23
12
16
10
15
2003 AJCC Breasst Cancer Staging:
IHC Positive and Is
solated Cells = pN0
•
•
•
•
•
pN0(i-) No metastasis histologically, neg IHC
pN0(i+)
N0(i+) ITCs,
ITC no clust
l ter > 0
0.2
2 mm
pN0(mol-) negative (R
RT-PCR)
pN0(mol+) positive (RT
T-PCR)
pN1mi micrometastasis (>
( 0.2 mm, none >
2.0 mm)
Singletary et al, JCO, 2002.
2010 AJCC S
Sta
aging
i Ch
Changes
• pN0(i+): Cluster < 0.2
2 mm
• Classification of ITC
C more stringent
– Not to exceed 200 cells on one
histologic section
• Stage I now TWO GROUPS
G
– IA:
– IB:
T1
T0
T1
NO
N1m
mi
N1m
mi
MO
M0
M0
Edge et al, 2009
Newer Data: Isola
ated Tumor Cells
• Netherlands retrospective
e analysis:
– de Boer et al; NEJM; 2009
9
• Women w/o adjuvant therapy
– 856 women node negative
e 5y DFS: 86%
– 553 women ITCs 5y DFS: 77%
– 343 women micromets 5y DFS: 78%
• Caveats
P<0 001
P<0.001
– Only 2% received chemo, 11% hormonal
– Benefit expected to be less with
h appropriate systemic therapy
Newer Data: Isola
ated Tumor Cells
• Major Caveats
– Only 2
2.2%
2% received chemotherapy and
ad tumors > 1 cm
>70% of patients ha
– 5-year
5 year distant metasstases free rate very
similar in node nega
ative group versus the
ITC/Micromet group
p who received adjuvant
therapy (2.8% vs. 2..6%)
SLN Trials
R
Recent
t Res
R ults
lt from
f
US
Trials
T i l 19
998 2004
998-2004
Practice Patterns: US
U National Cancer
Database 1998 - 2005
Bilimoria K, et al. J Clin Oncol 2009
U S
U.
S. Prospective Randomized
R
Trials
• Better understand impact of SLN biopsy in
management of earlyy stage breast cancer
• Accrual > 11,000 patiients
• Firmly establish SLN biopsy as standard of
care
- NSABP B
B--32 (PI: Krag
K )
Krag)
- ACOSOG Z0010,
Z0010 Z0011
Z
(PI: Giuliano)
NSABP Pro
otocol B-32
B 32
Clinically
y Ne
egative
g
Axilla
RANDOM
MIZATION
SLN Biopsy*
p y and
Axillary Dissection
* IHC performed on Neg
SLNs
SLN Biopsy
Pathologically
Possitive SLN
Pathologically
Negative** SLN
Negative
A
Axillary
Dissection
No Axillary
Dissection
NSABP BB-32 Fals
se Negative Rate
9.7
7%
(7.6 - 11.9)*
*95%
95% CI
Julian et al, SABC, 2004
NSABP
PB
B--32
Sentinel Node by
b Biopsy Type
Type
Technical
False
Success % Negative Rate
%
Overall
97.1
1
9.7
FNA/Core
97.0
0
8.0
Incisional
97.6
6
97.3
3
14.3
15.2
P=0.8
83
P=0.02
Excisional
B-32
Clinically Negative Axilllary Nodes
Randomizatio
on
GROUP 1
GROUP 2
SN +AD
SN
Stratification
• Age
• Clinical Tumor Size
• Type of Surgery
Intraop cytology & postop
HE
SN Pos
SN Neg
(SN+AD)
FU
1,975 patients
SN p
pos
+ AD
SN Neg
g
(SN only)
FU
2,011 patients
B-32 Anallysis
y
Plan
 3,989 - SN neg (71% of 5611)
99 9% - follow-up inform
mation
 99.9%
 7.92 years - average tim
me on study
 Primary endpoints OS, DFS, Regional Control
 Study powered to detec
ct 2% difference OS
Krag et al ASCO 2010
B-32 DFS
NSABP Pro
otocol B-32
60
6
40
20
Trt
SNR+AD
SNR
N
De
eaths
1975 315
2011 336 HR=1.05 p
p=0.542
0
%D
Disease-F
Free
80
100
Disease-Free
Disease
Free Survival for Sen
ntinel Node Negative Patients
Data as of December 31, 2009
0
2
Krag et al Lancet Oncol 2010
4
Years After
Af
Entry
6
8
Krag et al ASCO 2010
B-32 RR
Local and Regio
g nal Recurrences
as First Events
Gro
oup 1
Group 2
54 (2
2.7%)
49 (2.4%)
Axillary
2 (0
0 1%)
0.1%)
8 (0.3%)
(0 3%)
Extra-axillary
y
5 ((0.25%
6 (0.3%)
(
)
Local
Krag et al Lancet Oncol 2010
Krag et al ASCO 2010
B-32 Morbidity
Residual Morbidity at
a End of Follow-up
• Lower in SN group
• Not nonexistent
Shoulder abduction deficit
Group 1
SN + AD
19%
Group 2
SN
13%
Arm volume difference >5%
%
28%
%
17%
%
Arm numbness
31%
8%
Arm tingling
13%
7%
Krag et al Lancet Oncol 2010
Ashikaga et al JSO, 2010
All differences p<0.001
Effect of Occult Meta
astases on Survival in
“Node-Negative” Pa
atients: NSABP B-32
• Occult metastases: 15.9%
• Independent predicttor of prognosis
• Overall survival diffe
erence: 1.2%
– 94.6% v. 95.8%
• Concluded no cliniccal benefit of serial
sectioning and or IH
HC
Weaver et al, NEJM, 2011
NSABP
P B-32
Overall Co
onclusions
 No significant differe
ences were observed
OS, DFS, or Regionall Control SLN vs AD
 Morbidity decreased
When the
Wh
th SN is
i negative,
ti
SN surgery alone
l
with no further AD is appropriate, safe, and
effective therapy for breast cancer patients
ve lymph nodes.
with clinically negativ
American College of Surgeons
Oncology Gro
oup SLN Trial
T1 and T2
2 Tumors
Clinicallyy Neg
gative Axilla
g
BREAST CON
NSERVATION
Z10
Bone Marrow
IHC
Z11
SLN Biopsy
B
Randomization
Axillary Observation
+
Axilla
ary Observation
Axillary Dissection
ACOSOG Z00
010 - Methods
• SLNs p
processed - standard pathology
p
gy
and H&E staining
• SLNs neg by H&E subjected to IHC for
cytokeratin (investtigators blinded to
results)
l )
Z0010 T
Treatm
ment Variables
V i bl
Total SLNs Removed
Median (Min, Max)
Missing
ALND Performed,
P f
d N(%)
Yes
No
Missing
Chemotherapy, N(%)
Yes
No
Missing
2 (0,32)
689
Hormonal Rx, N(%)
Yes
No
Missing
2943(67.9)
1389(32.1)
878
925(18.0)
4203(82.0)
82
Radiation Rx, N(%)
Yes
No
Missing
3884(90.8)
394(9.2)
932
Any Adj Rx, N(%)
Yes
No
Missing
4210(98.4)
68(1.6)
932
2297(53)
2035(47)
878
Overall Rate IHC Positive SLNs Z10
5210 Elig
gible and
E al able
Evaluable
e Patients
SLN H&E Positive
N=1215
N
1215 (24%)
IHC Negative
N=2977
N
2977 (90%)
SLN H&E Negative
N=3995 (76%)
IHC Positive
N 349 (10%)
N=349
ACOSOG Z0010: Occcult Micrometastases
• 5-year overall survival was significantly higher with a negative vs. positive result for:
− SLN H&E (≈ 96% vs. 93%; P = .0009)
− BM IHC (95% vs. 90%; P = .01)
• SLN IHC was NOT significantly associated with overall survival.
Overall Survival
Multivariable Analysis
(Positive vs. Negative)
HR ((95% CI))
P Value
SLN H&E
1.44 (1.11-1.88)
.007
BM IHC
1 88 (1.12-3.17)
1.88
(1 12 3 17)
.017
017
SLN IHC
0.98 (0.62-1.54
.93
BM IHC
2
2.22
(1.21-4.10)
.011
All Patients
SLN H&E– Patients
Giuliano et al JAMA 2011
ACOSOG Z10
0 Conclusions
• IHC detected SLN me
etastases do not
appear to impact overall survival
• Routine examination of SLN by IHC is not
supported in this patie
ent population by this
study
ACOSOG Z0011:
A Randomized Trial of Axillary
Node Dissection
n in Women with
Clinical T1-2 N0 M0
M Breast Cancer
who have a Posittive Sentinel Node
Giuliano AE, McCall L, Beitsch
B
PD, Whitworth PW,
Blumencranz PW,
PW Leitch AM
M Saha S
M,
S, Hunt K,
K Morrow M,
M
Ballm
man KV
Giuliano et al JAMA 2011
Study Population Schema 5/99–12/04
106 (27.4%) patients
treated with
w
ALND
h d additio
had
dditionall positive
iti
nodes removed
beyo
ond SLN
72.6% patients
p
treated with
w
SLND
had all positive
p
nodes
d removed
d with
ith the
th
techn
nique
Patient Characteristics Z11
•
•
•
•
Median age:
g 55 yyea
ars
70% T1 tumors
82% ER
ER-positive
iti di
dissease
All pa
patients
e s had
ad nod
od
de pos
positive
eb
breast
eas
cancer (overall low burden)
– 58% had only one n
node positive
– Only 21% had ≥ 3 positive
p
nodes
Locoregion
nal Recurrences
R
Recurrence
Local (Breast)
Regional (Axilla,
Supraclavicular)
Total Locoregional
ALND
A
(4
420 pts)
SLND
(436 pts)
15
5 (3.6%)
8 (1.8%)
2 (0.5%)
4 (0.9%)
17 (4.1%)
12 (2.8%)
P = 0.11
Median follow-up = 6.3 years
Regional
R
i
l re
ecurrence seen in
i only
l 0.7%
0 7% off
the entire population
p
Disease--Free Survival
100
90
80
% Recurre
ence-Free and Aliive
70
60
50
40
30
ALND
No ALND
20
P-value = 0.14
10
0
0
1
2
3
4
Time (Years)
(
5
6
7
8
43
Overall Survival
100
90
80
70
% Alive
60
50
40
30
ALND
No ALND
20
P-value = 0.25
10
0
0
1
2
3
4
Time (Years)
(
5
6
7
8
44
IMPORTAN
NT Caveats
• WHOLE BREAST
T RADIATION
• Breast conse
erving therapy
• Adjuvant System
mic Therapy
45
Adjuvant Sys
stemic Therapy
A
ALND
SLND
Chemotherapy
57.9%
58.0%
Hormonal therapy
46.4%
46.6%
Either/Both
96.0%
97.0%
P = N.S.
Recommendations at MD
M Anderson for + SLN?
• Must be individualizzed
• No dissection:
–T1/T2
–Less than 3 positiive SLN
–If
If Whole-breast
Whole breast ra
adiotherapy
–Receiving system
mic therapy
Caudle, Hunt, Kuerer
K
et al Ann Surg Oncol, 2011
Recommendationss for Axillary Node
Dissection at MD Anderson
• Positive SLN
–Mastectomy
M t t
–Partial breast radiiotherapy
py
–Neoadjuvant chem
motherapy
Caudle, Hunt, Kue
erer et al Ann Surg Oncol, 2011
Compllicated
Does the axilla ne
eed to be treated
when posiitive SLN?
Many radiation
M
di ti
o
oncologists
will treat the
a
axilla
when a positive
S
SLN
is obtained and no
d
dissection
is performed
Extende
ed Field
Radioth
herapy?
*
*
*
• Which
Whi h patients?
ti t ?
•Recent presented
p
M
MA.20
results
•Concern for over
treatment/risk
T icity?
Toxic
i ?
• Overall Survival for early Stage II breast
cancer very high (>9
90%)
• What will be the long term effects on
h lth
healthy:
–Lymphatics?
y p
Sentine
el Node
Evolving
Controvversies
Is a Complete Axillary
A
Lymph
Node Dissection Necessary
When a Sentine
el Lymph Node
Contains Metastases ?
Is a Complete Axillary Lymph
Node Dissectiion Necessary
When a Sentinel Lymph Node
Contains Me
etastases ?
ANSW
WER:
F the
For
th majorit
j itty
t off patients
ti t
NO
O
Clinicopathologic Factors Predicting
Involvement of No
onsentinel Axillary
Nodes in Women with
w Breast Cancer
R. Hwang
R
Hwang, S.
S Krishnamurthy,
Krishnamurthy K.
K Hunt
Hunt, N
N. Mirza
Mirza, F
F. Ames
Ames, B
B.
Feig, H. Kuerer, E. Singletary, G.
G Babiera, F. Meric, J. Akins, J.
Neely and M. Ross
Ann Surg Onc, 2003
Multivariate
M lti
i t Pre
P edictive
di ti Model
M d l
1 26-28 70
1.26-28.70
P
Value
0 024
0.024
Coefficient
2
4.1
1
1.42-11.89
0.009
1
LV invasion
3.7
1
1.15-11.70
0.028
1
No. SLN  3
0.19
0.04-0.93
0.04
-2
Characteristic
Odds
Ratio
60
6.0
Tumor size > 2 cm
SLN met > 2 mm
95% CI
Nomogram for Predicting the Likelihood
of Additional SLN Me
etastases in Patients
with a Possitive SLN
• Pathological size, nuc
clear grade,
lymphovascular invas
sion, multifocality, ERreceptor status, method of detection of SLN
metastases; number of
o positive SLNs; and
number of negative SLNs
S
• Validated prospective
ely in 1545 patients
J Clin Onc
O 2007
http://www.mskcc.org//mskcc/html/15938.cfm
Can Axillary Radiation Be
Substituted fo
or Completion
p
Axillary Lyymph Node
Disse
Di
ection
ti
When a Sen
ntinel Lymph
N d C
Node
Contains
t i s Metastases
M t t
?
Current Study:: EORTC 10981
• SLN-Positive
• Tumor < 3 cm
*
• 3485 Patients
• Randomized Trial
•ALND vs. Axillaryy Radiotherapyy
Sentinel No
ode Biopsy
p y
Before or After
Neoad
djuvant
Chemoth
herapy ?
SLN Biopsy Before
Neoadjuvant Therapy
• Commits patients to
o an extra axillary
operation
• SLN Negative: Two operations
• SLN Positive: Comm
mits patients to
axillaryy lymph
y p node dissection with a
positive SLN before
e therapy
Conversion of Axiillary Metastases:
FNA Positive to Pa
athologic Negative
POSITIVE
191
patients
FAC X 4
Pathologic
NEGATIVE
43 patients
23%
%
Median # LNs R
Removed = 16
Kuerer et al, Ann Surg,
Surg, 1999
Conversion of Axiillary Metastases:
FNA Positive to Pa
athologic Negative
POSITIVE
109
patients
HER2+
Trastuzu
umab
+ A orr T
Pathologic
NEGATIVE
81 patients
74%
%
Median # LNs Remo
oved = 19
CANCER,, 2010
CANCER
Impact of Nodal Diseas
se Eradication on DFS
Independent Prrognostic Factor
Cumulattive Proportion Surviving Disea
ase-free
1.0
Nodal Disease Eradicated
0.9
08
0.8
0.7
0.6
Residual Nodal Disease
0.5
0.4
0.3
0.2
P=0
0.00003
00003
0.1
0.0
0
10
20
30
40
50
60
70
80
90
100
110
120
Months
Annals of Surgery, 1999
SNB Affter NC
Multi--Center Stud
Multi
dies: NSABP BB-27
(n=4
428)
• Identification Ratte: 85%
• With blue
bl dye:
d
7
78%
• With isotope
p + blue
b
dye:
y 88
88--89%
• False Negative Rate:
R
11%
• With blue dye: 14%
1
• With isotope + blue
b
dye: 8.4%
8 4%
Mamounas EP: J Clin Oncol, 2005
SNB Affter NC
Meta--Analysis of Single
Meta
S
Single-Institution
and MultiMulti-Ce
enter Studies
•
•
•
•
Xi ett all M D Anderson
Xing
A d
21 studies
1273 patients
Identification Rates: 72
72--100%
1
–Pooled estima
ate: 90%
• False Negative Rates: 0-33%
3
–Pooled estima
ate: 12%
Conclusion: SNB is a reliable tool for
planning treattment after NC
SNB After NC: Sing
gle Institution Series
Positive Axillary
y Nodes Before NC
Author
Stage
Shen, 2006
T1
T1--T4, N1N1-N3
Lee, 2006
T1-T4, N1
T1(Palpable
(P l bl and
d FNA (+)
or > 1cm thick with
loss of fat hilum on
US and SUV > 2.5
Newman,
2007
Resectable
T1--3, N1
T1
(FNA (+) under US)
All
# Pts
(No
ode +))
Success
Rate ( %)
FN Rate
(%)
Accurate
69
9(40)
93
25
No
219
9 (124)
78
6
Yes
40
0 (28)
98
11
Yes
328
8 (172)
84
11.6
ACOSOG
G Z1071
SLN surgery aftter neoadjuvant
chemotherapy
py fo
or node p
positive
breast cancer
c
PI - Judy C. Boughey
B
MD
Z1071 schema
s
T1--4 N1T1
N1-2 invasivve breast cancer
(Pretreatment
axillary ultrasou
und with FNA or core biopsy
documenting axilllary metastases)
REGIST
TER*
↓
Patients receive chemotherapy
(stratify patients byy age,
age stage and
number of cycles and tyype of chemotherapy)
↓
REGIST
TER*
↓
SLN and
d ALND
Alternativ
Alt
tives to
t SLN
Biopsy B
BEFORE
Neoad
djuvant
j
Chemottherapy?
Initial Nodal Ultrasou
und and FNA Biopsy
Avoiding Surgiccal SLN Biopsy
Krishn
namurthy et al, Cancer 2002
Pros and Cons in Timing of SLN
Biopsy with Neoa
adjuvant Therapy
• Presence of axillaryy metastases can be
identified with eitherr SLN biopsy or FNA
before neoadjuvant therapy
• Chemotherapy
Ch
th
can eradicate
di t llymph
h
node metastases in 30 to 40%
– Axillary dissection may
m be avoided if SLN
biopsy
p yp
performed affter p
pre-op
p therapy
py
DCIS
S
Should Pa
atients with
DCIS
C S be Offered
e ed S
SLN
Biop
psy
p
y?
Sentinel Lymph
h Node Biopsy
Patients With
h ‘Pure’ DCIS
•
•
•
•
European Institute of
o Oncology
223 unselected patients with DCIS
Metastases in 3.1%
%, most micromets
C
Completion
l ti di
dissecti
tion no additional
dditi
l
mets
• Select patients – pa
alpable mass ?
Diffuse disease ?
Intra et al, Arch Surg 2003
SLN Bi
Biopsy ffor ‘‘High
‘Hi h Ri
Risk’
k’ DCIS
• DCIS with microinvasion (N=31)
– 10% Positive SLN
• ‘High-Risk’ DCIS (N=7
76)
– Palpable or mass on M
MMG
– Extensive high-grade lesions
• 12% Positive SLN
• Mastectomy = Lose ch
hance for later SLN
Klauber--DeMore,
Klauber
D
Ann Surg Onc,
Onc, 2000
MD Anderson Cancer
C
Center
S l ti U
Selective
Use off SL
LN Bi
Biopsy iin DCIS
• 399 patients with INITIAL diagnosis of DCIS
• 20% of patients will have invasive carcinoma
on final pathology
– Predictors: CORE Biop
psy diagnosis
diagnosis, age < 55
55,
HG tumors, > 4 cm on MMG
M
• 10% positive SLN (H a
and E in 93%
93%, n = 141)
– Highly selected group of
o patients
Yen et al, Journal Am
merican College of Surgeons, 2005
Reoperative Senttinel Node Biopsy
after Mas
stectomy
• Karam et al
– JACS 2008
– Recurrence: 20 patients
– 65% could find a SLN
• Intra et al
– J Surg Oncol 2007
– Four patients
– 2 had positive SLN
Technical Advancement and
Advanced Surgical Techniques
Beyond SL
LN Biopsy?
A ill
Axillary
R
Reve
erse Mapping
M
i
Thompson et al, Ann Surg Onc
2007
• Can we identify
the critical
lymphatic
pathways for the
arm, spare them
and
d preventt
lymphedema?
Feasibility and On
ncologic Safety of
ARM iin B
Breast C
Cancer P
Patients
i
• Bedrosian et al M D Anderson
•
•
•
•
•
30 patients documente
ed axillary node mets
Blue injected in the arm
m/Colloid in the breast
70% had blue lymphattic and or node
18% had mets in blue node
CONCLUSION: Not sa
afe to preserve blue
node/lymphatic
Cancer 2010
Current Indication
ns and Standards
for Sentinel Node Biopsy
Clinically NEGATIVE
E axilla
– T1,
T1 T2,
T2 T3 tumors
t
• If a SLN is found to be positive:
p
– Mastectomy: Comp
pletion dissection
– Breast Conserving w WBT: Individualize
• DCIS: High-risk forr Invasive and
receiving mastectom
my
Current Indication
ns and Standards
for Sentinel Node Biopsy
• Neoadjuvant therap
py
– Before
B f
or after
ft chem
h mo; prefer
f nodal
d l
ultrasound with FNA
A biopsy
– Risks and benefits should
s
be discussed in
detail with patient
Meta-Analysis of No
Metaon--SN Metastases
on
Associated with Micrrometastases in the
SN in Brea
ast Cancer
• 25 studies reporting on
n nonnon-SN involvement
associated with lowlow-vo
olume SN involvement
(789 pts H&E (+) SNs, 345 pts IHC (+) SNs)
• The weighted mean esstimate for non
non--SN
metastases after lowlow-volume
v
SN involvement is
around 20 %
• The incidence is aroun
nd 9 % if the SN
involvement is detecte
ed by IHC alone
Cserni G, et al: Br J Surg, 2004
Summ
Summ
mary
• SLN biopsy accurattely predict the
presence or absencce of axillary-node
axillary node
metastases in breasst cancer
• SLN bi
biopsy iis suitab
it b
bl tto evaluate
ble
l t th
the
axillary lymph node status in patients
with clinically node negative breast
ca ce
cancer