Reasons for failure to identify positive sentinel nodes in breast cancer patients with significant nodal involvement.
OBJECTIVE
To analyse causes of failure of sentinel node (SN) procedures in breast cancer patients and assess the role of pre-operative ultrasound examination of the axilla.


METHODS
In 138 consecutive clinically node negative breast cancer patients with the primary tumour in situ a SN procedure with radiolabeled colloid and blue dye was performed. Radioactivity in the SN was scored as inadequate or adequate. The axillary lymph node dissection scored for number of involved nodes and presence of extranodal growth.


RESULTS
In 53/138 patients, the SN was positive for tumour. Full axillary node dissection revealed that 58/138 were node positive. So in five patients the SN failed to predict true nodal status. In 3/5, the radioactive ratio (SN vs background) was inadequate. All were found to have extensive nodal involvement. The radioactivity ratio was inadequate in 37/138 patients. This ratio was inadequate in 10 of 15 patients with > or =4 positive nodes and 27 of 123 in patients with 0-3 positive nodes (p < 0.001). If extranodal growth was present the radioactive ratio was inadequate in 13 of 18 patients, whilst this was only the case in 24 of 120 patients without extranodal growth or metastases (p < 0.001). Ultrasound (US) examination and US-guided FNAC was able to pre-operatively identify 16 of the 26 patients with four or more metastases in the axilla.


CONCLUSIONS
Extensive nodal involvement is an important cause of failure of the sentinel node biopsy. Pre-operative ultrasound examination of the axilla can avoid this in almost two thirds of these patients.
Department of Surgery, Erasmus University Medical Centre-Daniel den Hoed Cancer Centre, Rotterdam, The Netherlands.
A Y
AY
de Kanter
M B E
MB
Menke-Pluijmers
S C
SC
Henzen-Logmans
A N
AN
van Geel
C J H
CJ
van Eijck
T
T
Wiggers
A M M
AM
Eggermont
D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001365:Axilla; D044963:Biopsy, Fine-Needle; D001943:Breast Neoplasms / Q000000981:diagnostic imaging / Q000473:pathology*; D004396:Coloring Agents; D003951:Diagnostic Errors; D005260:Female; D006801:Humans; D007150:Immunohistochemistry; D007633:Keratins / Q000032:analysis; D008197:Lymph Node Excision; D008198:Lymph Nodes / Q000000981:diagnostic imaging / Q000473:pathology; D008207:Lymphatic Metastasis / Q000175:diagnosis* / Q000000981:diagnostic imaging / Q000473:pathology; D008875:Middle Aged; D009362:Neoplasm Metastasis; D011237:Predictive Value of Tests; D011300:Preoperative Care; D011877:Radionuclide Imaging; D019275:Radiopharmaceuticals; D021701:Sentinel Lymph Node Biopsy / Q000592:standards; D013668:Technetium Tc 99m Aggregated Albumin; D018084:Ultrasonography, Interventional
D004396:Coloring Agents; D019275:Radiopharmaceuticals; D013668:Technetium Tc 99m Aggregated Albumin; C083602:technetium Tc 99m nanocolloid; D007633:Keratins