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Occult Breast Lesion Localization plus Sentinel Node Biopsy (SNOLL): Experience with 959 Patients at the European Institute of Oncology
Occult Breast Lesion Localization plus Sentinel Node Biopsy (SNOLL): Experience with 959 Patients at the European Institute of Oncology
but both lesion and SNs are removed together; axillary dissection is performed if the SN is positive, thus definitive treatment of malignant non-palpable lesions occurs in a single surgical session.
Monti S, Galimberti V, Trifiro G, et al (European Inst of Oncology, Milano, Italy)
Radio-guided occult lesion localization was developed in 1996 at the author’s institution to assist in the removal of nonpalpable breast lesions.1 In this particle study, the authors supplemented the ROLL technique by combining it with SNB and naming the new procedure SNOLL. The goals of SNOLL are to avoid the pitfalls of wire localization, namely, allowing achievement of negative surgical margins, if malignant, with minimal removal of surrounding healthy tissue and to perform the SNB at the same time, again if malignant. So if a woman has an abnormal image analysis that indicates the need for a diagnostic biopsy of the nonpalpable lesion, she would be consented for ROLL and excision, possible quandrantectomy (if malignant), possible SNB (if malignant), and possible complete level I-III axillary node dissection (if the SNB is positive for metastatic disease). In this study, the patient had an intratumoral injection of an immobile isotope followed by injection of the standard isotope for SN mapping injected intradermally or peritumorally. The injections were administered at the same time either the day before or the morning of surgery. Obviously, intraoperative evaluation by frozen-section analysis of the occult breast lesion is essential to make the diagnosis and, thus, convert to a quadrantectomy if malignant. Intraoperative frozen-section analyses were also performed on the SNs. The study enrolled 1046 women, 87 of whom had a benign occult lesion identified intraoperatively. No SNB was performed, and these women were eliminated from the analysis. Of the remaining 959 women, 25 had microcalcifications on mammography and no intraoperative frozen-section analyses
Ann Surg Oncol 14:2928-2931, 2007
Background.—Non-palpable breast lesions are diagnosed frequently posing the problem of localization and removal. When such lesions are malignant, axillary node status must be determined. We report our experience using radio-guided occult lesion localization (ROLL) for locating and removing non-palpable breast lesions together with sentinel node biopsy (SNB) to assess axillary status. We call the technique SNOLL. Methods.—From March 1997 to April 2004, 1046 consecutive patients presented suspicious non-palpable breast lesions and were programmed for conservative surgery and SNB. In 87 patients intraoperative histological examination revealed a benign lesion and SNB was not performed. The remaining 959 patients, with cytologically or histologically proven cancer, underwent SNOLL with immobile radiotracer injected under mammographic or ultrasound (US) guidance into the lesion, and subsequent injection of mobile tracer subdermally to localize the sentinel node (SN). Patients then underwent breast surgery and SNB. Results.—Breast lesions were localized by ROLL in 99.6% of cases and were removed radically with negative margins in 91.9% of cases. Sentinel nodes were detected in all but one case. Intraoperative or definitive histological examination revealed 776 invasive/microinvasive carcinomas and 182 with in situ disease. Sentinel nodes were positive in 154 (19.8%) of 776 invasive/microinvasive cancers and in two with ductal intraepithelial neoplasia (1.1%). Conclusions.—In SNOLL the injection procedures are performed separately,
were performed to identify the histology. These 25 women were considered positive for malignancy, and an SNB was performed. The authors did not share what the final pathology revealed, but because all 959 women had a quadrantectomy, I assume they all had cancer. Sentinel node biopsy was successful in 958 patients. My first thought after reading this article was that the concept of consenting a woman for A- to -Z procedures when you do not have a diagnosis was buried long ago for many good reasons. Eight percent of breast biopsies today are benign and should be performed out of the operating room as a percutaneous core biopsy. However, I commend the authors for their highly accurate selection of women most likely to have malignant tumors (only 87 of 1046 had benign disease). My second thought was that the goal of ROLL is to minimize removal of healthy surrounding tissue, yet all 959 of the women diagnosed with cancer had quadrantectomies. How did that procedure minimize the amount of healthy tissue removed? The 8% diagnosed with benign disease should have had a core biopsy for diagnosis in the first place, then they would not have needed any excision. Interestingly, ~10% of the quadrantectomy specimens still had close or positive margins. With partial mastectomies or lumpectomies, much less tissue is removed at the cost of higher rates of close or positive margins in the order of 20%.2 If SNOLL or ROLL can help guide the surgeons performing partial mastectomies such that it decreases the need for re-excision, then incorporating these techniques would be advantageous. Another potential advantage of SNOLL and ROLL that was not touched on by the authors is that it reduces the time and coordination needed for wire localizations. With ROLL, the injection can be administered the day before surgery, allowing surgeons to begin surgery in the early morning. Addi-
®
Breast Diseases: A Year Book Quarterly Vol 19 No 2 2008
153 153
tionally, that the 2 isotopes used in SNOLL are different enough that they do not interfere with each other is a tremendous asset. The authors did not touch on problems with shine-through or dose alteration if the primary tumor is located in the upper-outer quadrant/tail of breast, but the high identification rate of the SNs suggests that this was not an issue.
I am not sure how SNOLL or ROLL actually helped the authors, because 90% or more of their patients will have quadrantectomy; however, for those of us performing lumpectomies and partial mastectomies for core biopsy-proven malignancie, SNOLL is quite enticing.
Selective Application of Axillary Node Dissection in Elderly Women with Early Breast Cancer
years). Seventy-five percent underwent ALND. Women with higher risk disease and younger age were more likely to undergo ALND. Five year unadjusted CSS in women who did and did not receive ALND was 92.1% and 90.6%, respectively, with a HR of 0.85, P = 0.002. Using the propensity analysis method, the adjusted HR for CSS associated with ALND was 0.89, P = 0.066. Discussion.—After adjusting for differences in the probability of receiving ALND, no clinically or statistically significant difference in survival was observed among women who received ALND when compared with those who did not, although we could not account for differences in co-morbidity or use of systemic therapy between groups. Conclusion.—Surgeons select elderly women with early stage breast cancer for ALND with a negligible impact on CSS.
Aziz D, Gardner S, Pritchard K, et al (Univ of Toronto; Sunnybrook Health Sciences Centre, Toronto) Ann Surg Oncol 14:652-659, 2007
Background.—Routine use of axillary lymph node dissection (ALND) has been questioned in elderly women. This study examines whether selective application of ALND in early stage breast cancer affects breast cancer-related survival. Methods.—From the Surveillance, Epidemiology, and End Results (SEER) database, records of women ≥70 years of age with stage I or II breast cancer diagnosed between 1990 and 1995 were reviewed. Hazard ratios (HR) of causespecific survival (CSS) between women receiving ALND and those who did not were compared. To minimize the potential for bias in the selection of women to receive ALND, HR of CSS was compared within propensity analysis deciles. Results.—20,151 women entered the analysis. Median follow up was 6 years (interquartile range 4.33-7.67
154 154
®
C. Laronga, MD
In this retrospective review of over 20,000 elderly women treated between 1990 and 1995, 75% had an ALND. Those more likely to have this operation were younger patients and had more aggressive disease. With a median followup duration of 6 years, there was a 1.5%
Breast Diseases: A Year Book Quarterly Vol 19 No 2 2008
References 1. Paganelli G, Di Cicco C, Luini A, et al. Radioguided surgery in nonpalpable breast lesions. Eur J Nucl Med. 1997;24:893. 2. Waljee JF, Hu ES, Newman LA, Alderman AK. Predictors of reexcision among women undergoing breast-conserving surgery for cancer. Ann Surg Oncol. 2008;15:1297-1303.
unadjusted advantage in cancer-specific survival for those undergoing ALND. After applying a propensity analysis, this difference was not statistically significant (P = 0.066). However, it was not possible to determine the use of systemic therapy or differences in comorbidity with this data set. Survival differences in randomized breast cancer trials are infrequently demonstrated with variations in local or regional treatment. Any survival difference may be further obscured in this study, as patients were more likely to die of other unrelated causes due to their age. In National Surgical Adjuvant Breast and Bowel Project study B04, observation of the axilla with delayed dissection did not influence overall survival,1 although the trial has been criticized as being underpowered to detect any difference. A retrospective study from British Columbia of women over age 75 years found no difference in survival between those who did and did not undergo axillary dissection.2 In this same study, there was a statistically significant cancer-specific survival advantage for women 65-74 years old undergoing axillary dissection. In the entire cohort,
but both lesion and SNs are removed together; axillary dissection is performed if the SN is positive, thus definitive treatment of malignant non-palpable lesions occurs in a single surgical session.
Monti S, Galimberti V, Trifiro G, et al (European Inst of Oncology, Milano, Italy)
Radio-guided occult lesion localization was developed in 1996 at the author’s institution to assist in the removal of nonpalpable breast lesions.1 In this particle study, the authors supplemented the ROLL technique by combining it with SNB and naming the new procedure SNOLL. The goals of SNOLL are to avoid the pitfalls of wire localization, namely, allowing achievement of negative surgical margins, if malignant, with minimal removal of surrounding healthy tissue and to perform the SNB at the same time, again if malignant. So if a woman has an abnormal image analysis that indicates the need for a diagnostic biopsy of the nonpalpable lesion, she would be consented for ROLL and excision, possible quandrantectomy (if malignant), possible SNB (if malignant), and possible complete level I-III axillary node dissection (if the SNB is positive for metastatic disease). In this study, the patient had an intratumoral injection of an immobile isotope followed by injection of the standard isotope for SN mapping injected intradermally or peritumorally. The injections were administered at the same time either the day before or the morning of surgery. Obviously, intraoperative evaluation by frozen-section analysis of the occult breast lesion is essential to make the diagnosis and, thus, convert to a quadrantectomy if malignant. Intraoperative frozen-section analyses were also performed on the SNs. The study enrolled 1046 women, 87 of whom had a benign occult lesion identified intraoperatively. No SNB was performed, and these women were eliminated from the analysis. Of the remaining 959 women, 25 had microcalcifications on mammography and no intraoperative frozen-section analyses
Ann Surg Oncol 14:2928-2931, 2007
Background.—Non-palpable breast lesions are diagnosed frequently posing the problem of localization and removal. When such lesions are malignant, axillary node status must be determined. We report our experience using radio-guided occult lesion localization (ROLL) for locating and removing non-palpable breast lesions together with sentinel node biopsy (SNB) to assess axillary status. We call the technique SNOLL. Methods.—From March 1997 to April 2004, 1046 consecutive patients presented suspicious non-palpable breast lesions and were programmed for conservative surgery and SNB. In 87 patients intraoperative histological examination revealed a benign lesion and SNB was not performed. The remaining 959 patients, with cytologically or histologically proven cancer, underwent SNOLL with immobile radiotracer injected under mammographic or ultrasound (US) guidance into the lesion, and subsequent injection of mobile tracer subdermally to localize the sentinel node (SN). Patients then underwent breast surgery and SNB. Results.—Breast lesions were localized by ROLL in 99.6% of cases and were removed radically with negative margins in 91.9% of cases. Sentinel nodes were detected in all but one case. Intraoperative or definitive histological examination revealed 776 invasive/microinvasive carcinomas and 182 with in situ disease. Sentinel nodes were positive in 154 (19.8%) of 776 invasive/microinvasive cancers and in two with ductal intraepithelial neoplasia (1.1%). Conclusions.—In SNOLL the injection procedures are performed separately,
were performed to identify the histology. These 25 women were considered positive for malignancy, and an SNB was performed. The authors did not share what the final pathology revealed, but because all 959 women had a quadrantectomy, I assume they all had cancer. Sentinel node biopsy was successful in 958 patients. My first thought after reading this article was that the concept of consenting a woman for A- to -Z procedures when you do not have a diagnosis was buried long ago for many good reasons. Eight percent of breast biopsies today are benign and should be performed out of the operating room as a percutaneous core biopsy. However, I commend the authors for their highly accurate selection of women most likely to have malignant tumors (only 87 of 1046 had benign disease). My second thought was that the goal of ROLL is to minimize removal of healthy surrounding tissue, yet all 959 of the women diagnosed with cancer had quadrantectomies. How did that procedure minimize the amount of healthy tissue removed? The 8% diagnosed with benign disease should have had a core biopsy for diagnosis in the first place, then they would not have needed any excision. Interestingly, ~10% of the quadrantectomy specimens still had close or positive margins. With partial mastectomies or lumpectomies, much less tissue is removed at the cost of higher rates of close or positive margins in the order of 20%.2 If SNOLL or ROLL can help guide the surgeons performing partial mastectomies such that it decreases the need for re-excision, then incorporating these techniques would be advantageous. Another potential advantage of SNOLL and ROLL that was not touched on by the authors is that it reduces the time and coordination needed for wire localizations. With ROLL, the injection can be administered the day before surgery, allowing surgeons to begin surgery in the early morning. Addi-
®
Breast Diseases: A Year Book Quarterly Vol 19 No 2 2008
153 153
tionally, that the 2 isotopes used in SNOLL are different enough that they do not interfere with each other is a tremendous asset. The authors did not touch on problems with shine-through or dose alteration if the primary tumor is located in the upper-outer quadrant/tail of breast, but the high identification rate of the SNs suggests that this was not an issue.
I am not sure how SNOLL or ROLL actually helped the authors, because 90% or more of their patients will have quadrantectomy; however, for those of us performing lumpectomies and partial mastectomies for core biopsy-proven malignancie, SNOLL is quite enticing.
Selective Application of Axillary Node Dissection in Elderly Women with Early Breast Cancer
years). Seventy-five percent underwent ALND. Women with higher risk disease and younger age were more likely to undergo ALND. Five year unadjusted CSS in women who did and did not receive ALND was 92.1% and 90.6%, respectively, with a HR of 0.85, P = 0.002. Using the propensity analysis method, the adjusted HR for CSS associated with ALND was 0.89, P = 0.066. Discussion.—After adjusting for differences in the probability of receiving ALND, no clinically or statistically significant difference in survival was observed among women who received ALND when compared with those who did not, although we could not account for differences in co-morbidity or use of systemic therapy between groups. Conclusion.—Surgeons select elderly women with early stage breast cancer for ALND with a negligible impact on CSS.
Aziz D, Gardner S, Pritchard K, et al (Univ of Toronto; Sunnybrook Health Sciences Centre, Toronto) Ann Surg Oncol 14:652-659, 2007
Background.—Routine use of axillary lymph node dissection (ALND) has been questioned in elderly women. This study examines whether selective application of ALND in early stage breast cancer affects breast cancer-related survival. Methods.—From the Surveillance, Epidemiology, and End Results (SEER) database, records of women ≥70 years of age with stage I or II breast cancer diagnosed between 1990 and 1995 were reviewed. Hazard ratios (HR) of causespecific survival (CSS) between women receiving ALND and those who did not were compared. To minimize the potential for bias in the selection of women to receive ALND, HR of CSS was compared within propensity analysis deciles. Results.—20,151 women entered the analysis. Median follow up was 6 years (interquartile range 4.33-7.67
154 154
®
C. Laronga, MD
In this retrospective review of over 20,000 elderly women treated between 1990 and 1995, 75% had an ALND. Those more likely to have this operation were younger patients and had more aggressive disease. With a median followup duration of 6 years, there was a 1.5%
Breast Diseases: A Year Book Quarterly Vol 19 No 2 2008
References 1. Paganelli G, Di Cicco C, Luini A, et al. Radioguided surgery in nonpalpable breast lesions. Eur J Nucl Med. 1997;24:893. 2. Waljee JF, Hu ES, Newman LA, Alderman AK. Predictors of reexcision among women undergoing breast-conserving surgery for cancer. Ann Surg Oncol. 2008;15:1297-1303.
unadjusted advantage in cancer-specific survival for those undergoing ALND. After applying a propensity analysis, this difference was not statistically significant (P = 0.066). However, it was not possible to determine the use of systemic therapy or differences in comorbidity with this data set. Survival differences in randomized breast cancer trials are infrequently demonstrated with variations in local or regional treatment. Any survival difference may be further obscured in this study, as patients were more likely to die of other unrelated causes due to their age. In National Surgical Adjuvant Breast and Bowel Project study B04, observation of the axilla with delayed dissection did not influence overall survival,1 although the trial has been criticized as being underpowered to detect any difference. A retrospective study from British Columbia of women over age 75 years found no difference in survival between those who did and did not undergo axillary dissection.2 In this same study, there was a statistically significant cancer-specific survival advantage for women 65-74 years old undergoing axillary dissection. In the entire cohort,