Sentinel negative sentinel node biopsy. 55-57 Giuliano et

lymph node biopsy is the preferred criteria for axillary staging in breast
cancer. A sentinel lymph node is described as the first lymph node in a
regional basin that receives lymphatic drainage from the site of the primary
tumor. In patients with positive axillary lymph nodes, regional control is most
important. ALND can achieve both goals but it is recognized as the most morbid
part of breast cancer surgery. SLNB is a substitute to ALND for staging axilla
in early breast cancer patients with minimal morbidity.


SLN biopsy is a trustworthy, mechanism for standard level
standard level I/II axillary dissection. 
The main component the lymphatic mapping that permits the axillary nodes
to assess. Occurrence of node to
attain metastasis, regional metastatic disease needs to exist. The SLN reflects the histopathological status of the whole axilla,
therefore if finding of the SNL is negative, that indications the nodal basin
to be negative as well.  In 1992,
Morton’s group tested the SNL biopsy with more than 500 melanoma patients.
Successfully removing the sentinel node, along with the remaining regional
lymph nodes. 54 The
pathology of the sentinel node claimed to show 99% accuracy of remaining
regional nodal status. Other institutions authorized complete lymphadenectomy
and histopathological examination, addition to follow-up to distinguish
potential recurrences in undissected nodal basins shadowing a negative sentinel
node biopsy. 55-57

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Giuliano et al. 19 also
illustrated the initial experience with SNL biopsy for breast cancer, by using
vital blue dye injection, it was proven by histopathological examination of the
non-SLNs. 58 By using a
technetium sulfur colloid injection and operating a hand-held ?-probe for
detection, Krag et al. 22 stated a
primary series of breast cancer SLN biopsies.

Lately, several randomized clinical trials the
SOUND 59 and NCT 01821768 60 randomized amongst SNB and non-SNB
following negative US/FNA findings including the early breast cancer patients.
Such trials revealed the prerequisite for SNB in cases with negative ultrasound
(US)-guided fine-needle aspiration cytology (FNA) of doubtful LNs. Numerous
other investigative tools were used to identify negative axillary node (cN0)
status in these trials. For example: The palpation of the axilla, the US
imaging using or computed tomography (CT), or intervention with FNA for
suspicious LNs. Hence, a significant thought for an exclusion of SNB or ALND
differs on an extremely accurate preoperative staging for axillary LNs


results show that although core biopsy had greater sensitivity than FNA in
detecting metastasis, it could not approach statistical significance, perhaps
mainly owing to the lesser patients. Our study also reported three vital
findings. Primary, the high accuracy rate of CNB between preoperative
diagnostic axillary staging and final histological findings, representing the
superiority of CNB over FNA. Following, the objective predictors of decisive
pathological negative node status were related with the clinical
characteristics of breast cancer and the investigative means used to assess the
axillary LNs. Lastly, our study also found that CNB for axillary staging in
terms of safety and simplicity was parallel to FNA procedure.

 In this current study, we found out during the US
findings, abnormal LNs among the breast cancer patients while a negative CNB
result had a comparatively lower rate of positive LNs and a lower rate of
non-SLN metastasis than patients with a negative FNA. The accuracy of FNA and
CNB compared to the final histological diagnosis of LNs was 90.8% in FNA while
96.2% in CNB. Precisely, Sensitivity was 76.0% in FNA and 90.0% in CNB and
positive predictive value of FNA 87.2% and CNB 94.2% (Table 2).

Our study
comprised several experienced surgeons and allowed a variety of sampling
devices to simulate actual clinical practice. While axillary node FNA is
technically easy to perform for one skilled in image-guided procedures, the surgeons
must obtain an aspirate that is both adequate in the amount of material and at
the same time not overly bloody, to enable an optimal interpretation. It is unclear
why there were fewer false negative results when multiple FNA entries were
achieved, as the total number of needle excursions likely did not differ greatly.
Maybe the chance of obtaining a better sample was increased by using different entry
sites or obtaining less blood mixed with cells from the node. The number of
slides used, the actual number of excursions and length of procedure were not
recorded, which could have affected the results. In some institutions, a
pathologist is present when cytologic samples are obtained and can request
additional sampling if the specimen is estimated suboptimal; the presence of a
pathologist at the time of sampling could have improved the yield from FNA. In
our institution, immunostains may be used to aid in interpretation when FNA
alone is performed. Our pathologists have extensive experience in cytopathology
but in this study, there were no immunostains used in the cytologic evaluation;
because the pathologists knew that additional tissue would be studied by core
biopsy, a reason that may have decreased the sensitivity of FNA. Amongst
patients with breast cancer, US-guided
core needle biopsy of axillary lymph nodes can yield a high accuracy rate with
no substantial complications.

ideal lymphatic tracer must have size (in the range of 50–200 nm) small enough
to pass the lymphatic capillaries and migrate promptly to the SLNs, still adequately
big enough to retain in the sentinel nodes long enough for imaging and SLNs
identification without prematurely transferring to higher tier nodes. 61-63 Nano-sized carbon particles
with an average diameter of 150 nm, which ensures that these particles pass
through the lymphatic capillaries and accumulate in the lymph nodes long enough
for the SLNs to be identified during surgery. In contrast, the blue dye
molecules are rather small (<2 nm), and thus they can quickly transport through the sentinel lymph nodes, causing color fading of blue dye and a high possibility of false negative rate. 64Hence, it should be easier applying carbon nanoparticles than using the blue dye in SLN biopsy due to its longer presentation time in SLNs. This has important clinical implications. Because the dyes quickly diffuse through SLNs, a 'blue' node may not be the true sentinel node, but instead a level II or even level III, non-sentinel node. So, non-sentinel lymph nodes might be incorrectly diagnosed as SLNs, causing more nodes to be excised than needed and a false-negative staging. Carbon nanoparticles are most expected to reduce this false negative detection by retaining in the SLNs. Carbon nanoparticles detection is more dependable and assuring than blue dye because the dye distribution in SLNs subsequent to injection of carbon nanoparticles is more liable to last for longer time. 35 We used both Carbon Nanoparticle suspension injection and radioisotope in our patients and it helped us to find accurate SLNs during FNA and CNB under ? probe followed by ultrasound which helped during surgery to locate SLN. Additionally, gamma probe has its radioactive content that provides the surgeon a sense of focus and allows detection of non-visible nodes. There is increasing evidence in the literature to support better results when both detection methods are combined, compared with the use of these techniques alone. 28 Cserni and associates 65 reported that combined technique has advantages like higher identification rate, higher accuracy level, and a lower false negative rate.     In our study core biopsy had no more morbidity than FNA, even with the largest gauge device. Use of a biopsy device with a nonthrow option should diminish the chance of vascular injury. Nevertheless, patients whose suspect node was immediately adjacent to a vessel or profound and difficult to access were not asked to participate in the study and hence were not subjected to core biopsy. Despite the statistically significant difference we observed in the number of patients reporting pain being greater during core than FNA, the majority of patients tolerated the pain equally well during both procedures, and we do not believe this should be a factor in deciding which procedure to perform. Both FNA and core biopsy were least sensitive when the node appearance was least abnormal. This can be due to difficulty in choosing the appropriate node for sampling or due to smaller metastatic deposits in the sampled node.     Limitations of our study included its small size, in particular, the small size of subgroups of needle types and number of samples obtained. Although there may have been some selection bias due to excluding patients with nodes not suited to a core biopsy, the goal of the study was to compare the two methods when both were possible. In all cases, the core biopsy was performed after the FNA, with additional lidocaine, which may have minimized the pain associated with core biopsy. FNA was always performed first because of concern that core biopsy might cause sufficient bleeding to have to abort the second sampling procedure, but the bleeding was not a substantial problem. An additional limitation of our study was some of the false negative biopsy results can probably be accredited to a failure to identify the SLN under the US. Earlier reports have shown that the SLN was not always targeted at preoperative US-guided biopsy subsequently only 64–78% of the LNs that underwent CNB corresponded to the SLN removed at surgery. 66,67 Previous studies reported that morphologically normal-appearing nodes had lymph node metastases with positivity ranging from 26 to 52%. 48,50,68,69 In our routine daily practice, we believe that the combined procedure helps to retain experience in the cytology of solid organs and provide maximum sensitivity and specificity. FNAB and CNB techniques should not be considered mutually exclusive, but as two different diagnostic modalities that complement one another. 70-73 (Table 4) Summarizes the benefits of the combined procedure. Therefore, and as shown by other investigators, the utilization of both aspirate smears and core tissue biopsy material are complementary and have added value compared to either one alone. 70-72     An earlier study which was held in 2016 included new primary breast cancer cases on the ipsilateral side that were subjected for the US guided axillary biopsies in a two-year time duration with results compared to the decisive histopathology from SLNB or ANC. They were able to find the association for CNB but not statistically suggestive in favor of either method.74According to the latest review, it didn't report absolute superiority of CNB over FNAC while reporting the experiences of the cytopathologists to have a likely influence to report the differences in the procedures.75 Undoubtedly, this explains that the operator's skills and techniques are likely to have an important part. A retrospective study reported 69.1% sensitivity of CNB and specificity of 100% (n = 650) as an outcome, 33% of patients didn't undergo SLNB. 76 The main focus of our research was tissue sampling techniques guided by ultrasound hence we included, only consecutive cancer patients who underwent US scans which introduced a selection bias. To conclude, in cases of newly diagnosed invasive breast cancer patients when accurate preoperative staging of the axilla is needed. The CNB should be encouraged as the first line biopsy method as CNB is more sensitive than FNAB.


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