Elsevier

Academic Radiology

Volume 16, Issue 5, May 2009, Pages 551-563
Academic Radiology

Radiology alliance health services research
Breast Cancer: Sentinel Node Identification and Classification after Neoadjuvant Chemotherapy—Systematic Review and Meta Analysis

https://doi.org/10.1016/j.acra.2009.01.026Get rights and content

Rationale and Objectives

Breast cancer is the leading cause of mortality in women worldwide. Lymphatic mapping with sentinel node biopsy has the potential to reduce the morbidity associated with breast cancer staging in women after neoadjuvant therapy.

Materials and Methods

A systematic search of world literature between 1996 and 2007 of sentinel node mapping in patients with early-stage breast carcinoma after chemotherapy was undertaken. Potentially eligible studies were identified using database-specific search strategies incorporating appropriate Boolean combinations of the keywords sentinel node biopsy or sentinel node localization or lymphatic mapping; breast cancer or malignancy or neoplasm; and preoperative or neoadjuvant chemotherapy. The electronic searches were augmented with a manual search of reference lists from identified articles. Successful lymph node mapping, defined as successful identification rate (SIR), and false-negative rate (FNR) was summarized using a bivariate random effects mixed model. The extent of heterogeneity was assessed using the inconsistency statistic. The effect of study level covariates, such as use of immunohistochemistry or dual mapping technique, and individual quality criteria, such as study design or multi-institution participation, on SIR and FNR were analyzed using metaregression.

Results

A total of 24 trials of 1799 subjects were reported that met eligibility criteria. All studies identified were published between 2000 and 2007. Lymph node involvement was found in 758 patients (37%) and ranged from 25% to 96% across studies. The proportion of patients who had successful lymph node mapping ranged from 63% to 100%, with 79% of studies reporting a rate of less than 95%. The summary successful identification rate was 0.896 (95% confidence interval [CI] 0.860–0.923) with moderate heterogeneity. The summary FNR was 0.084 (95% CI 0.064–0.109) with no significant heterogeneity. Increasing prevalence of lymph node involvement and same-day mapping and lymph node dissection both significantly reduced the FNR.

Conclusions

The present systematic review demonstrates robust estimates of successful identification rate and false-negative rates of sentinel lymph node mapping and biopsy after neoadjuvant therapy for early-stage breast cancer patients. With a 90% SIR and 8% FNR, this technique is a reliable tool for planning treatment in this population as an alternative to completion axillary lymph node dissection.

Section snippets

Study Search Strategy

We conducted this meta-analysis using guidelines from the Quality of Reports of Meta-analyses of Randomized Controlled Trials statement (44). A computerized search was performed to identify relevant articles in human subjects that evaluated sentinel node mapping of axillary lymph nodes in breast cancer following chemotherapy (between 1966 and December 2007) in the MEDLINE, EMBASE, PubMed, Web of Science, Current Concepts Medicine, and the Cochrane Library. The search was conducted using

Study Identification

A total of 1221 unique citations on preoperative or neoadjuvant chemotherapy of breast cancer and 3051 on sentinel node biopsy or mapping or localization or identification were retrieved from the initial search. Of these, 19 prospective 18, 19, 21, 22, 23, 26, 27, 28, 29, 30, 31, 33, 34, 35, 36, 37, 38, 39, 41 and five retrospective 20, 24, 25, 32, 40 trials met our inclusion criteria. The most common reasons for exclusion were use of non-human specimens, non-original research papers, and

Discussion

One in eight women in the United States will develop breast cancer by the age of 70 years 51, 52. Breast cancer accounts for one third of all cancer incidence in women (2). Radiology plays a central role in diagnosis, monitoring treatment response, and follow-up for breast cancer. The most common site for metastases is the ipsilateral axilla. Axillary lymph node dissection is recommended by the National Cancer Institute for all patients with invasive breast cancer 15, 53. SLNB has been proposed

Conclusion

The present systematic review demonstrates robust estimates of successful identification rate and FNR of sentinel lymph node mapping and biopsy after neoadjuvant therapy for early-stage breast cancer patients. With a 90% SIR and 8% FNR, this technique is a reliable tool for planning treatment in this population as an alternative to completion ALND, particularly in practice settings that can accommodate same-day mapping and surgical dissection.

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    Funded in part by the NIH/NCI 1 K07 CA108664 01A1 and the GE-AUR Radiology Research Academic Fellowship.

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