Agarwal Gaurav, Rajan Sendhil, Gambhir Sanjay, Lal Punita, Krishnani Narendra, Kheruka Subhash
Department of Endocrine & Breast Surgery, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Raebareli Road, Lucknow, Uttar Pradesh, 226014, India.
Department of Nuclear Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS), Lucknow, Uttar Pradesh, India.
World J Surg. 2016 Jul;40(7):1583-9. doi: 10.1007/s00268-015-3222-2.
Sentinel lymph node biopsy (SLNB) is the standard of care for staging N0 primary early breast cancers (EBC). Patients in developing countries mostly present with large (LOBC) or locally advanced cancers (LABC) and are treated with neo-adjuvant chemotherapy (NACT). Accuracy of SLNB in staging stage III N0 and post-NACT N0 patients is uncertain. This prospective validation study on LOBC/LABC patients compared the accuracy of SLNB between primary versus post-NACT surgery.
Fifty T3/T4, N0 patients undergoing primary surgery (Group I) and 70 LOBC/LABC (index stage) treated with NACT and N0 at the time of surgery (Group II) were inducted. Validation SLNB was performed using low-cost methylene-blue and (99m)Tc-Antimony colloid. SLN identification (IR) and false-negative (FNR) rates were compared between the groups. Sub-group analysis was done in Group II per index tumor and nodal stage to identify factors predicting SLN IR and FNR in post-NACT patients. SLN IR and FNR in both groups were compared with those in previously published SLN validation study and meta-analysis in EBC.
Using combination of blue-dye and radio-colloid, post-NACT SLN IR and FNR (82.9, 13.5 %) were far inferior to T3/T4 primary surgery group (94, 7.7 %; p values 0.034, 0.041) and in EBC. SLN IR using blue-dye alone was dismally low in post-NACT LABCs. Factors predicting unidentified post-NACT SLN and false-negative SLNB included young age, LVI, skin infiltration, extra-nodal spread or N2a stage, and UOQ tumors.
Accuracy of SLNB in T3, N0 tumors undergoing primary surgery is comparable to that of SLNB for N0 EBC. In post-NACT patients, SLNB IR are lower and FNR are higher. Factors predictive of non-identification and false-negative SLNB include pre-NACT skin involvement (T4b), N2a stage or extra-nodal invasion and LVI, and to a lesser extent, young age and UOQ location of the tumor.
前哨淋巴结活检（SLNB）是N0期原发性早期乳腺癌（EBC）分期的标准治疗方法。发展中国家的患者大多表现为大肿瘤（LOBC）或局部晚期癌症（LABC），并接受新辅助化疗（NACT）。SLNB在III期N0患者和NACT后N0患者分期中的准确性尚不确定。这项针对LOBC/LABC患者的前瞻性验证研究比较了原发性手术与NACT后手术中SLNB的准确性。
纳入50例接受原发性手术的T3/T4、N0患者（I组）和70例接受NACT治疗且手术时为N0的LOBC/LABC（索引期）患者（II组）。使用低成本的亚甲蓝和（99m）Tc-锑胶体进行验证性SLNB。比较两组之间的前哨淋巴结识别（IR）率和假阴性（FNR）率。在II组中按索引肿瘤和淋巴结分期进行亚组分析，以确定预测NACT后患者SLN IR和FNR的因素。将两组的SLN IR和FNR与先前发表的EBC中SLN验证研究和荟萃分析中的结果进行比较。
使用蓝色染料和放射性胶体联合，NACT后SLN IR和FNR（82.9%，13.5%）远低于T3/T4原发性手术组（94%，7.7%；p值分别为0.034、0.041）以及EBC中的情况。在NACT后的LABC中，单独使用蓝色染料时SLN IR极低。预测NACT后未识别的SLN和假阴性SLNB的因素包括年轻、淋巴管浸润、皮肤浸润、结外扩散或N2a期以及UOQ肿瘤。
原发性手术的T3、N0肿瘤中SLNB的准确性与N0期EBC的SLNB相当。在NACT后的患者中，SLNB的IR较低而FNR较高。预测未识别和假阴性SLNB的因素包括NACT前皮肤受累（T4b）、N2a期或结外侵犯以及淋巴管浸润，在较小程度上还包括年轻和肿瘤的UOQ位置。
