THE ROLE OF INTRAOPERATIVE FROZEN SECTION OF SENTINEL LYMPH NODES IN UPFRONT BREAST CONSERVATION CANCER SURGERY
Abstract
Objective: Sentinel lymph node biopsy is the standard of care in clinically negative axilla in breast cancer patients for which frozen section (FS) is routinely performed intraoperatively. The objective of this study was to justify the use of FS in terms of number of tests performed and their impact on decision-making and cost saving.
Materials and Methods: We retrospectively reviewed our prospectively maintained data from January 2014 to January 2018 for intraoperative FS in upfront breast conservation surgery patients.
Results: A total of 357 patients were studied. All were female. Median age was 50 years (24–84). Mean tumour size was 29.11 mm. Numbers of sentinel lymph nodes identified were 1 in 50 (14.2%) patients, 2 in 121 (33.89%) patients and ≥3 in 186 (52%) patients. Number of positive sentinel lymph nodes was 0 in 264 (73.9%) patients, 1 in 62 (17.4%) patients, 2 in 20 (5.6%) patients and ≥3 in 11 (3.08%) patients. Axillary lymph node dissection (ALND) was offered to 30 (8.4%) patients as per the American College of Surgeons Oncology Group Z0011. The results for ALND showed that only 8 (2.3%) out of 30 patients had positive nodes identified in the additional axillary nodes dissected. Sensitivity of FS was 97% and specificity was 98.86%. False-negative rate was 3.22%.
Conclusion: Intraoperative FS can be safely omitted in early breast cancer patients undergoing upfront breast conservation cancer surgery due to high sensitivity and specificity leading to low false-negative rates. ALND can be performed as a second operation as warranted only in a minority of patients.
Key words: American College of Surgeons Oncology Group Z0011 trial, axillary lymph node dissection, intraoperative frozen section, sentinel lymph node biopsy
References
Bland CS. The Halsted mastectomy: Present illness and past history. West J Med 1981;134:549-55.
Fisher B, Wolmark N, Redmond C, et al. Findings from NSABP protocol no. B-04: Comparison of radical mastectomy with alternative treatments. II. The clinical and biologic significance of medial-central breast cancers.
Cancer 1981;48:1863-72.
Fisher B, Bauer M, Margolese R, et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 1985;312:665-73.
Giuliano AE, Kirgan DM, Guenther JM, et al. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Ann Surg 1994;220:391-8.
Krag D, Weaver D, Ashikaga T, et al. The sentinel node in breast cancer a multicenter validation study. N Engl J Med 1998;339:941-6.
Veronesi U, Paganelli G, Viale G, et al. A randomized comparison of sentinel-node biopsy with routine axillary dissection in breast cancer. N Engl J Med 2003;349:546-53.
Krag DN, Anderson SJ, Julian TB, et al. Sentinel-lymphnode resection compared with conventional axillarylymph-node dissection in clinically node-negative patients with breast cancer: Overall survival findings from the NSABP B-32 randomised phase 3 trial. Lancet Oncol 2010;11:927-33.
Fortunato L, Amini M, Farina M, et al. Intraoperative examination of sentinel nodes in breast cancer: Is the glasshalf full or half empty? Ann Surg Oncol 2004;11:1005-10.
Weiser MR, Montgomery LL, Susnik B, et al. Is routine intraoperative frozen-section examination of sentinel lymph nodes in breast cancer worthwhile? Ann Surg Oncol 2000;7:651-5.
van de Vrande S, Meijer J, Rijnders A, et al. The value of intraoperative frozen section examination of sentinel lymph nodes in breast cancer. Eur J Surg Oncol 2009;35:276-80.
Arora N, Martins D, Huston TL, et al. Sentinel node positivity rates with and without frozen section for breast cancer. Ann Surg Oncol 2008;15:256-61.
Lyman GH, Giuliano AE, Somerfield MR, et al. American Society of Clinical Oncology guideline recommendations for sentinel lymph node biopsy in early-stage breast cancer. J Clin Oncol 2005;23:7703-20.
Giuliano AE, McCall L, Beitsch P, et al. Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: The American college of surgeons oncology group Z0011 randomized trial. Ann Surg 2010;252:426-32.
Bishop JA, Sun J, Ajkay N, et al. Decline in frozen section diagnosis for axillary sentinel lymph nodes as a result of the American college of surgeons oncology group Z0011 trial. Arch Pathol Lab Med 2016;140:830-5.
Gentilini O, Veronesi U. Abandoning sentinel lymph node biopsy in early breast cancer? A new trial in progress at the European institute of oncology of Milan (SOUND: Sentinel node vs observation after axillary UltraSouND). Breast 2012;21:678-81.
Rónká R, Smitten KV, Sintonen H, et al. The impact of sentinel node biopsy and axillary staging strategy on hospital costs. Ann Oncol 2004;15:88-94.
Lim J, Govindarajulu S, Sahu A, et al. Multiple step-section frozen section sentinel lymph node biopsy a review of 717 patients. Breast 2013;22:639-42.
Poling JS, Tsangaris TN, Argani P, et al. Frozen section evaluation of breast carcinoma sentinel lymph nodes: A retrospective review of 1,940 cases. Breast Cancer Res Treat 2014;148:355-61.
Russo L, Betancourt L, Romero G, et al. Frozen section evaluation of sentinel lymph nodes in breast carcinoma: A retrospective analysis. Ecancermedicalscience 2017;11:774
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