title: Multifocality and multicentricity are not contraindications for sentinel lymph node biopsy in breast cancer surgery.
abstract: BACKGROUND
  After the availability of the results of validation studies, the sentinel lymph node biopsy (SLNB) has replaced routine axillary dissection (AD) as the new standard of care in early unifocal breast cancers. Multifocal (MF) and multicentric (MC) tumors have been considered a contraindication for this technique due to the possible incidence of a higher false-negative rate. This prospective study evaluates the lymphatic drainage from different tumoral foci of the breast and assesses the accuracy of SLNB in MF-MC breast cancer.
  
  
  METHODS
  Patients with preoperative diagnosis of MF or MC infiltrating and clinically node-negative (cN0) breast carcinoma were enrolled in this study. Two consecutive groups of patients underwent SLN mapping using a different site of injection of the radioisotope tracer: a) "2ID" Group received two intradermal (i.d.) injections over the site of the two dominant neoplastic nodules. A lymphoscintigraphic study was performed after each injection to evaluate the route of lymphatic spreading from different sites of the breast. b) "A" Group had periareolar (A) injection followed by a conventional lymphoscintigraphy. At surgery, both radioguided SLNB (with frozen section exam) and subsequent AD were planned, regardless the SLN status.
  
  
  RESULTS
  A total 31 patients with MF (n = 12) or MC (n = 19) invasive, cN0 cancer of the breast fulfil the selection criteria. In 2 i.d. Group (n = 15) the lymphoscintigraphic study showed the lymphatic pathways from two different sites of the breast which converged into one major lymphatic trunk affering to the same SLN(s) in 14 (93.3%) cases. In one (6.7%) MC cancer two different pathways were found, each of them affering to a different SLN. In A Group (n = 16) lymphoscintigraphy showed one (93.7%) or two (6.3%) lymphatic channels, each connecting areola with one or more SLN(s). Identification rate of SLN was 100% in both Groups. Accuracy of frozen section exam on SLN was 96.8% (1 case of micrometastasis was missed). SLN was positive in 13 (41.9%) of 31 patients, including 4 cases (30.7%) of micrometastasis. In 7 of 13 (53.8%) patients the SLN was the only site of axillary metastasis. SLNB accuracy was 96.8% (30 of 31), sensitivity 92.8 (13 of 14), and false-negative rate 7.1% (1 of 14). Since the case of skip metastasis was identified by the surgeon intraoperatively, it would have been no impact in the clinical practice.
  
  
  CONCLUSIONS
  Our lymphoscintigraphic study shows that axillary SLN represents the whole breast regardless of tumor location within the parenchyma. The high accuracy of SLNB in MF and MC breast cancer demonstrates, according with the results of other series published in the literature, that both MF and MC tumors do not represent a contraindication for SLNB anymore.
authors.affiliation: Department of Surgical Sciences, University of Insubria, Varese, Italy. albertaferrari@libero.it
authors.forename: Alberta
authors.initials: A
authors.lastname: Ferrari
authors.forename: Paolo
authors.initials: P
authors.lastname: Dionigi
authors.forename: Francesca
authors.initials: F
authors.lastname: Rovera
authors.forename: Luigi
authors.initials: L
authors.lastname: Boni
authors.forename: Giorgio
authors.initials: G
authors.lastname: Limonta
authors.forename: Silvana
authors.initials: S
authors.lastname: Garancini
authors.forename: Diego
authors.initials: D
authors.lastname: De Palma
authors.forename: Gianlorenzo
authors.initials: G
authors.lastname: Dionigi
authors.forename: Cristiana
authors.initials: C
authors.lastname: Vanoli
authors.forename: Mario
authors.initials: M
authors.lastname: Diurni
authors.forename: Giulio
authors.initials: G
authors.lastname: Carcano
authors.forename: Renzo
authors.initials: R
authors.lastname: Dionigi