title: One Step Nucleic Acid Amplification (OSNA) positive micrometastases and additional histopathological NSLN metastases: Results from a single institution over 53 months.
abstract: BACKGROUND
  The role of sentinel lymph node micrometastases on histopathological analysis is controversial in axillary staging and management in clinically node negative breast cancer. Long-term studies addressing the clinical relevance of occult breast cancer in sentinel lymph nodes based on molecular analysis are lacking. One Step Nucleic Acid Amplification (OSNA), a highly sensitive assay of cytokeratin 19 mRNA, is used intra-operatively for the detection of lymph node macro- and micrometastases in breast cancer.
  
  
  OBJECTIVE
  The aim of this study is to review the rate of micrometastases and further histopathological NSLN metastases, in our unit following the introduction of OSNA in Guildford.
  
  
  METHODS
  Data was collected prospectively from the period of introduction 01/12/2008 to 31/05/2013. All patients eligible for sentinel lymph node biopsy were offered OSNA and operations were performed by the consultant breast surgeons. Presence or absence of micro-metastases depends on the agreed cut-off point on the amplification curve. On detection of micrometastases (+) and positive but inhibited (i+) metastases, a level 1 axillary clearance (ANC) was performed and for a macrometastasis (++), a level 3 ANC was carried out.
  
  
  RESULTS
  66% of the patients had negative SLN (n = 672) and 34% (n = 336) had positive sentinel lymph nodes who had further axillary surgery. Of these, 45% (n = 152/336) had macrometastases, 40% (n = 136/336) had micrometastases and 15% (48/336) had positive but inhibited results. There was no difference in the patient demographics and tumour characteristics in the various positive SLN groups. In patients with micrometastases, 15% (20/136) had further positive NLSNs and a further 6% (8/136) had >4 overall positive nodes (SLN + NSLN) thus requiring adjuvant supraclavicular/chest wall radiotherapy (p < 0.05). 25% of node positive patients had further NLSN metastases (85/336) and in these patients, the ratio of positive SLN/harvested SLN (+SLN/SLN) is constant at 1:1. This shows the likelihood of further positive NSLNs if all the harvested lymph nodes are positive. This linear trend is present in both micro-and macrometastases, thus correlating with the size and number of NSLN metastases.
  
  
  CONCLUSIONS
  Our study reflects the tumour burden of NSLNs based on the molecular analysis of the SLN. OSNA has the potential to accurately identify axillary micrometastases. Micro-metastases are important as some of the patients with micrometastases had overall four positive nodes [SLN + NSLN] (criteria for radiotherapy in the absence of other adverse clinicopathological features). Also, our study highlights certain factors that predict the NSLN metastases, pending validation by further prospective long-term data. This will allow accurate calculation of the axillary tumour burden, particularly in patients with micro-metastases.
authors.affiliation: Department of Breast and Oncoplastic Surgery, Royal Surrey County Hospital, Guildford, UK. Electronic address: mbabar@tcd.ie.
authors.forename: M
authors.initials: M
authors.lastname: Babar
authors.affiliation: Department of Breast and Oncoplastic Surgery, Royal Surrey County Hospital, Guildford, UK.
authors.forename: R
authors.initials: R
authors.lastname: Madani
authors.affiliation: Department of Histopathology Royal Surrey County Hospital, Guildford, UK.
authors.forename: P
authors.initials: P
authors.lastname: Jackson
authors.affiliation: Department of Breast and Oncoplastic Surgery, Royal Surrey County Hospital, Guildford, UK; University of Surrey, Guildford, UK.
authors.forename: G T
authors.initials: GT
authors.lastname: Layer
authors.affiliation: Department of Breast and Oncoplastic Surgery, Royal Surrey County Hospital, Guildford, UK.
authors.forename: M W
authors.initials: MW
authors.lastname: Kissin
authors.affiliation: Department of Breast and Oncoplastic Surgery, Royal Surrey County Hospital, Guildford, UK.
authors.forename: T E
authors.initials: TE
authors.lastname: Irvine
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001365:Axilla; D001943:Breast Neoplasms / Q000175:diagnosis / Q000235:genetics* / Q000556:secondary; D004273:DNA, Neoplasm / Q000032:analysis*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008198:Lymph Nodes / Q000473:pathology*; D008875:Middle Aged; D061206:Neoplasm Micrometastasis; D021141:Nucleic Acid Amplification Techniques / Q000379:methods*; D012189:Retrospective Studies; D021701:Sentinel Lymph Node Biopsy / Q000379:methods*; D013997:Time Factors
chemical_list: D004273:DNA, Neoplasm
keywords: Axillary nodal clearance; Micrometastases; Non-sentinel lymph node metastases; OSNA