Blue-dye technique complements four-node sampling for early breast cancer

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Abstract

Aims

To examine four-node axillary sampling assisted by a blue dye (4NAS/dye) technique as a sentinel node biopsy (SNB) for breast cancer.

Methods

Lymphatic mapping was performed by injection of patent blue for 33 consecutive cases with breast cancer. Axillary sampling was performed until four nodes were obtained. This was followed by back-up axillary lymph node dissection to examine the feasibility of 4NAS/dye. The same study with 30 cases was conducted at an independent hospital to confirm the feasibility of this method. This method was then applied to 101 consecutive clinically node-negative patients to avoid axillary-node dissection, with intraoperative diagnosis made by frozen section examination.

Results

The median numbers of blue-stained nodes and nodes excised by 4NAS/dye were 1.7 and 3.4, respectively. The identification rate of sentinel lymph nodes (SNs) was 81.8% using the dye alone and 97.0% when the combination was used. Pathological examination revealed that the nodal status was correctly predicted by the dye alone in 62.5% of cases with metastasis, whereas in 100% by 4NAS/dye. The dye alone was not sufficient to identify SNs, especially in cases with prior excisional biopsy. The identification rate of SNs and the accuracy rate in another feasibility study were 100% and 92.5% in 30 consecutive cases, respectively. 4NAS/dye successfully detected SNs in 100 of 101 cases of the subsequent observational study with an acceptable post-operative axillary morbidity and thus succeeded as an SNB.

Conclusions

The 4NAS/dye method is reliable for the detection of SNs. This method could be applied to observational studies without radio-isotope.

Introduction

Axillary sentinel lymph nodes (SNs) may be identified by either radio-isotope or blue dye methods.1, 2, 3, 4 False negatives are half as frequent with a combined technique as with a single-agent SN mapping technique.5 Radio-isotope mapping of SN succeeds more often than mapping by blue dye: 92 vs 81%.6

Four-node axillary sampling has been developed as a means of staging the axilla.7 Several studies have shown four-node sampling techniques to be as accurate for prognosis as axillary lymph node dissection, with no differences in axillary recurrence rates between women staged by either method.7, 8, 9 SNB performed using radiolabelled colloid may have no advantage over four-node axillary sampling (4NAS).10 4NAS may not provide additional information in patients who have SN identified by a combination of isotope-labelled colloid and patent blue dye techniques.11

We decided to examine whether four-node axillary sampling assisted by a blue dye (4NAS/dye) is feasible at our institutions. The feasibility studies followed a suggestion for the clinical application of SNB by the American College of Surgeons, that each institution's principal investigator be required to document a 90% accuracy rate and a 90% staging accuracy in at least 30 consecutive cases of SNB followed by complete axillary lymph node dissection.12 We also present here the preliminary results of an observational study of 4NAS/dye performed after the feasibility study was completed.

Section snippets

Feasibility study

The study population comprised 33 consecutive cases with breast cancer in categories N0 and N1 of the UICC/AJCC common staging system. The Local Ethics Committee of Yokohama City University approved the study, and written informed consent was obtained from all participants. Diagnosis was made pre-operatively by fine needle biopsy in the majority of cases. Thirteen patients had undergone diagnostic excisional biopsy prior to SNB. All surgical procedures were performed by the same surgeon (T.I.)

Feasibility study

The median age of the patients was 53 years (range 26–75 years). The number of blue-stained nodes per case was 1.7±1.0 (mean±SE, range 0–4) and that of nodes excised for 4NAS/dye was 3.4±1.2 (range 0–7). The total number of nodes harvested (4NAS/dye and axillary clearance) was 18±7 (range 0–32). Details of patient characteristics are shown in Table 1. Intraoperatively, axillary nodes were identified in 27/33 cases (81.8%) by the dye alone and in 32/33 cases (97.0%) by 4NAS/dye (Fig. 1). Of the

Discussion

Although technical issues regarding the methods used to identify the SN continue to be debated, it is rather important that groups involved in SNB must determine their own false-negative rates for procedures. Such determination requires a concomitant axillary lymph node dissection to validate the accuracy.

Compared with a previous report,13 our results by the dye-alone method were unfavorable. These were attributable to a lack of experience in SNB among our surgeons and probably to the inclusion

Acknowledgements

We thank Prof RW Blamey and Prof JFR Robertson for providing Oncology Course Training Programme in Nottingham, 1999.

References (19)

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