title: A prospective feasibility trial to determine the significance of the sentinel node gradient in breast cancer: a predictor of nodal metastasis location.
abstract: BACKGROUND
  Sentinel lymph node (SN) biopsy is standard for breast cancer staging, but SN dye gradients and their significance have never been characterized. If predictive of SN metastasis location, their use for focused pathology examination might improve intraoperative imprint cytology sensitivity.
  
  
  METHODS
  This prospective trial enrolled clinically lymph node-negative patients with invasive breast cancer not undergoing neoadjuvant chemotherapy. Surgeons marked SN gradients at their bluest end. Nodal halves were examined separately by imprint cytology, and the marked SN half was correlated to metastasis location. Demographic, pathologic, and prognostic features were recorded.
  
  
  RESULTS
  Mean patient age and tumor size for the 102 patients was 59.6 years and 2.2 cm, respectively. Of 169 SNs, 159 (94.1%) had dye gradients, which varied by tumor quadrant, but not by histology, diagnosis method, grade, or stage. Among 41 marked SNs with metastases, 92.7% were present in the halves marked by the surgeon. Fourteen were confined to 1 nodal half, with 11 on the marked side and 3 on the unmarked side (P = .029). Metastases were smaller when confined to 1 versus both SN halves (0.14 vs 0.75 cm; P = .005), and smaller (0.87 vs 0.13 cm; P < .0001) when missed intraoperatively.
  
  
  CONCLUSIONS
  Dye gradients occur in most SNs and predict metastasis location. The smallest metastases are hardest to detect intraoperatively and are usually confined to the marked SN half. This suggests that marking an SN's bluest half warrants further study to explore whether its correlation to metastasis location may be exploited to focus pathologic examination and decrease the reoperative axillary dissection rate.
authors.affiliation: Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, Pennsylvania 19111, USA. richard.bleicher@fccc.edu
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Bleicher
authors.forename: Martin J
authors.initials: MJ
authors.lastname: O'Sullivan
authors.forename: Vincenzo
authors.initials: V
authors.lastname: Ciocca
authors.forename: Robin M
authors.initials: RM
authors.lastname: Ciocca
authors.forename: L Allen
authors.initials: LA
authors.lastname: Perkins
authors.forename: Eric
authors.initials: E
authors.lastname: Ross
authors.forename: Tianyu
authors.initials: T
authors.lastname: Li
authors.forename: Arthur S
authors.initials: AS
authors.lastname: Patchefsky
authors.forename: Elin R
authors.initials: ER
authors.lastname: Sigurdson
authors.forename: Natalie E
authors.initials: NE
authors.lastname: Joseph
authors.forename: Linda
authors.initials: L
authors.lastname: Sesa
authors.forename: Monica
authors.initials: M
authors.lastname: Morrow
mesh_terms: D001943:Breast Neoplasms / Q000473:pathology* / Q000601:surgery; D004396:Coloring Agents; D005240:Feasibility Studies; D005260:Female; D006801:Humans; D007432:Intraoperative Period; D008198:Lymph Nodes / Q000473:pathology; D008207:Lymphatic Metastasis / Q000175:diagnosis*; D008751:Methylene Blue; D008875:Middle Aged; D011237:Predictive Value of Tests; D012394:Rosaniline Dyes; D021701:Sentinel Lymph Node Biopsy / Q000379:methods*
chemical_list: D004396:Coloring Agents; D012394:Rosaniline Dyes; C025484:iso-sulfan blue; D008751:Methylene Blue