Yonago Acta medica 2010;53:47–52

Follow-up Results of Sentinel Lymph Node Biopsy using
the Dye-Only Method for Breast Cancer
Naotaka Uchida, Kiyosuke Ishiguro, Keiko Nakamura, Takako Suda and Motonobu
NishimuraDivision of Organ Regeneration Surgery, Department of Surgery, Tottori University Faculty of Medicine, Yonago 683-8504, JapanTo demonstrate the validity of sentinel lymph node biopsy (SLNB) using the indocyanine
green dye method (dye only method), we compared the survival of breast cancer patients
negative to SLNB without axillary lymph node dissection (ALND) (SLNB group) to that oflymph node-negative patients undergoing ALND (ALND group). We studied a total of 174
patients with T1-2N0 invasive breast cancer diagnosed at our university hospital clinicaldepartment between 2000 and 2008, with follow-up till 31 December 2009, retrospectively.
The SLNB group consisted of 108 SLNB-negative women without additional ALND (medianfollow-up, 25 months), diagnosed between May 2005 and 2008. The ALND group consisted of 66 axillary lymph node-negative women (median follow-up, 75 months) treated with
ALND between 2000 and April 2005. SLNB was performed during operation by periareolar injection using indocyanine green. All sentinel lymph nodes were examined using
the largest section along the major axis, and permanent sections were stained with hematoxylin and eosin. In the SLNB group, no patients developed axillary recurrence during
the 25-month median follow-up. The 4.5-year distant disease free survival and overall survival rates were 90.9% and 91.9%, respectively. The survival rate in the SLNB group was
equivalent to that in the ALND group. This suggests that SLNB with the dye only method
can safely replace ALND as the procedure of choice for axillary staging in breast cancer
patients with a clinically negative axilla.
Key words: breast cancer; sentinel lymph node biopsy

Axillary lymph node status is one of the mostimportant prognostic indicators for relapse andsurvival in patients with breast cancer (Fisher etal., 1970). Until the introduction of sentinel lymph
node (SLN) mapping in the early 1990s, axillary lymph node dissection (ALND) had been thestandard surgical treatment for the axilla of breast
cancer patients. However, ALND is associatedwith major problems, including acute and chronic
complications (Petrek et al., 2000).
The widespread use of screening mammography often enables detection of breast cancer at

an early stage and thus, the percentage of nodepositive patients who benefit from routine ALND isdecreasing (Bass et al., 1999). Consequently, SLN
biopsy (SLNB) has now become the new standardof care for axillary staging in early breast cancer,
and it has the potential to reduce the morbidityof the surgical procedure (Veronesi et al., 2003;
Fleissig et al., 2006; Lucci et al., 2007). The SLN
identification rate has been reported to be 96%
and SLNB sensitivity to be 93% in average (Kimet al., 2006). Many published trials have reported
false-negative rates of 5 to 10%, results which wereAbbreviations: ALND, axillary lymph node dissection; SLN, sentinel lymph node; SLNB, sentinel lymph node biopsy

47

Y. Uchida et al.

was diluted in 5 mL sterile, distilled water. Afterinduction of general anesthesia, 3- to 5-mL indocyanine green was injected intradermally into theperiareolar area. A 3- to 4-cm axillary skin incision was made 5 or 10 min after the injection, inorder to detect green-stained SLNs. Intraoperative
frozen-section analyses of the resected SLNs were
performed. All SLNs were bisected along the major axis, and postoperatively, specimens were fixed,
embedded in paraffin, and stained using standard
histopathological procedures. Patients with SLNs
that were negative for malignancy by intraoperative
analysis did not undergo additional ALND.

deemed acceptable for avoiding ALND in patientswith a negative sentinel node (Liberman, 2000;
Veronesi et al., 2003; Krag et al., 2007).
While these initial studies are promising,follow-up data have been limited, especially for
SLNB using the indocyanine green dye method(dye only method). The aim of this study was todemonstrate the accuracy of SLNB using the dye
only method without ALND, as an effective tool
for axillary staging. The survival of breast cancer
patients negative to SLNB without ALND wascompared to that of axillary lymph node-negative
patients after ALND.
Subjects and Methods

Statistical analysis
The disease free survival period was defined as
the period from the date of operation to the dateof the first confirmation of recurrence (i.e., local recurrence or metastasis) or death from any
cause, whichever came first. The overall survival
period was defined as that from the date of operation to the date of death from any cause. The
Mann-Whitney U test or unpaired t-test was used
for comparisons of continuous outcomes, whilethe 2 test was used for comparisons of categoricalvariables. The disease free and overall survival
curves were analyzed by the log-rank test. A Cox
proportional-hazards model was used to compare
the SLNB and ALND groups, and to adjust forvariables. Significance was defined as P < 0.05.

Patients
A total of 174 patients with initial primary invasive
breast carcinomas were treated in our Clinical Department of University Hospital between January
2000 and December 2008. We divided them into
2 groups of 108 SLNB-negative patients without
ALND who were treated between May 2005 andDecember 2008 (SLNB group) and 66 axillarynode-negative patients with ALND who were treated between January 2000 and April 2005 (ALND
group). All patients had clinically negative axillas. Patients with in situ carcinomas, multicentriccarcinomas, bilateral breast carcinomas, locallyadvanced disease with primary tumors greater than
4 cm, clinically or pathologically positive axillary
lymph nodes, or who underwent systemic primary
therapy, were excluded from the study. Informed
consent was obtained from every patient. All patients were treated with breast-conserving surgery
or mastectomy. Most patients with breast-conserving surgery received radiotherapy to the wholebreast after surgery. Most patients also underwent
some type of systemic adjuvant therapy.

Results
SLNB
SLNs were identified in 130 of the 135 patients (SLN
identification rate, 96.3%). SLNs stained in frozen
sections were negative in 108 of the 130 patients(83.1%). Three of the 108 patients (2.8%) werepositive to SLNB of permanent sections stained inhematoxylin and eosin (Fig. 1). The mean number
of SLNs per patient was 1.27 (range, 1–3). Thus,
we determined 108 patients to be SLNB-negativein frozen sections, and treated them as the SLNB
group (Fig. 1).

SLNB and pathological analysis
SLNB was performed using the dye only methodwith 25 mg indocyanine green (Diagnogreen;
Daiichi Pharmaceutical, Tokyo, Japan), which48

Follow-up data of SLNB

108 patients (83.1%)
negative SLNB
in frozen section

To analyze the survival rate in this study

22 patients (16.9%)
positive SLNB
in frozen section

10 patients (45.5%) negative ALND

3 patients ( 2.8%)
positive SLNB
in permanent section

130 patients (96.3%)
SLNs, detected
135 patients
early-stage, node
negative disease

To observe

12 patients (54.5%) positive ALND

5 patients ( 3.7%) failed to detect SLNs

5 patients (100%)

negative ALND

0 patients (positive ALND

0%)

Fig. 1. Qualification of patients of the SLNB group. We analyzed the survival of 108 patients observed to be negative to
SLNB intraoperatively in frozen section and successively in permanent section. ALND, axillary lymph node dissection;
SLNB, sentinel lymph node biopsy.

tumor histology, tumor laterality, estrogen receptor
status, progesterone receptor status, HER-2 status,
menopausal status, tumor treatment and systemic
therapy.
In the SLNB group, the median follow-up
period was 25 months (range, 0–55 months). There

Survival data
Patient and tumor characteristics of the SLNB and
ALND groups are listed in Table 1. With the exception of tumor size (unpaired t-test) and followup period, differences were not significant in age,

Table 1. Patient and tumor characteristics

Age
Histology
Tumor size
Tumor laterality
Estrogen receptor status
Progesteron receptor status
HER-2 status
Menopausal status
Tumor treatment
Systemic therapy

Median (min–max) (year)
Invasive ductal carcinoma
OthersMean (min–max) (cm)
Right
Left
Positive
Negative
Positive
Negative
Positive
Negative
Missing
BeforeAfter
Breast conserving surgery± radiation therapy
Mastectomy
None
Endocrine therapy
Chemotherapy
Endocrine therapy + chemotherapy

SLNB group[108]

ALND group[66]

P value

60 (27–86)
94
14
1.6 (0.5–3)
49
59
88
20
66
42
9
94
5
27
81

54 (30–87)
58
8
1.9 (0.5–3.5)
35
31
45
21
38
28
6
37
23
25
41

0.21631.0000

84

53

24
12
82
9
5

13
7
43
11
5

ALND, axillary lymph node dissection; SLNB, sentinel lymph node biopsy.
[ ], number of patients.
* P < 0.05 with unpaired t-test.

49

0.0022*0.26250.05090.77340.37570.06730.86240.2185

Y. Uchida et al.

were no axillary recurrences in the 108 patients
who underwent SLNB without ALND. A metastasis to the bone was observed in 1 patient. Threepatients died of other causes. The disease free andoverall survival rates at 4.5 years were 90.9% and91.9%, respectively (Figs. 2 and 3).

In the ALND group, the median follow-up period was 75 months (range, 0–116 months). There
were no axillary recurrences in the 66 patients who
underwent ALND. Contralateral breast cancer wasobserved in 3 patients, ipsilateral recurrence in 1
patient and cervical lymph node metastasis in 1
patient. Three patients died of other causes. The
disease free and overall survival rates at 4.5 years
were 91.7% and 98.3%, respectively (Figs. 2 and 3).
After adjusting for tumor size in Cox proportionalhazards model analysis, tumor size was not a significant predictor for both survival rates.

Disease free survival rate

(%)
100
80
60

SLNB group [108]ALND group [ 66]

40
20
0

0

1

2

3

4

5

6

7

8

9

17

7

Time after surgery
Group

Discussion

P = 0.9252

In this study, we determined the disease free andoverall survival rates in patients undergoing SLNB
without ALND, and compared with those in nodenegative patients undergoing ALND. Althoughseveral studies have validated the accuracy of
SLNB for axillary staging (Krag et al., 1998; Lo
et al., 2006; Gill, 2009), the data on the long-term
outcome of SLNB without ALND have been limited.
The 4.5-year overall and disease free survival
rates we observed in the SLNB group were 90.9%
and 91.9%, respectively. Other studies have reported that for early-stage breast cancer, the 5-year
overall survival rate was 89 to 96.7% in the SLNB
group, and 85 to 88.5% in the ALND group (Kuijt
et al., 2003; Langer et al., 2009), and that the 5-year
disease free survival rate was 87.6 to 96.0% in
the SLNB group and 87.2 to 89.9% in the ALND
group (Zavagno et al., 2008; Langer et al., 2009).
These suggest that SLNB without ALND provides
at least equivalent or improved disease free andoverall survival rates compared with ALND for
node-negative patients. This is most likely becauseof more accurate staging resulting from the focusedpathologic examination on 1 or just a few nodes.
Prospective randomized comparisons of SLNB
with routine ALND are now ongoing in the American National Surgical Adjuvant Breast and Bowel
Project Protocol-B 32 and the European ALMANAC trials.

10(year)

Number at risk

SLNB 108 96 56 21 4
ALND 66 63 58 56 54

49 35 23

Fig. 2. Changes in disease free survival rate in the SLNB
and ALND groups. The difference in prognostic significance of the disease free survival rate between groups
was P = 0.9252. ALND, axillary lymph node dissection;
SLNB, senile lymph node biopsy. [ ], number of patients.

(%)

Overall survival rate

100
80
60

SLNB group [108]ALND group [ 66]40

P = 0.1862

20
0

0

1

2

3

4

5

6

7

8

9

20

9

Time after surgery
Group

10
(year)

Number at risk

SLNB 108 97 57 21 4
ALND 66 63 60 59 58

52 37 27

Fig. 3. Changes in overall survival rate in the SLNB and
ALND groups. The difference in prognostic significanceof the overall survival rate between groups was P = 0.1862.
ALND, axillary lymph node dissection; SLNB, senile
lymph node biopsy. [ ], number of patients.

50

Follow-up data of SLNB

In our study with a median follow-up periodof 25 months, there were no axillary recurrences in
the SLNB group. All of our patients were negative
to SLNB with the dye only method, which was successively defined in hematoxylin and eosin staining
only of the largest single section of the SLN, and so
isolated tumor cells or a micrometastasis may havebeen overlooked. We calculated the mean rate ofaxillary recurrence in SLNB-negative patients tobe 0.51% from results of 8 different studies witha mean follow-up period of 34.9 months (Salem,2009). Thus far in the current literature, research
has not provided evidence that SLN micrometastasis leads to axillary recurrence or distant disease,which supports the theory that formal ALND may
be omitted in these patients (Langer et al., 2005).
In patients with isolated tumor cells or micrometastasis who received adjuvant therapy, diseasefree survival was improved (de Boer et al., 2009).
These results suggest that adjuvant treatment contributes to the low axillary failure rate, and that
good disease free survival may have resulted ingood overall survival in our SLNB group, because
90% of the patients in our study received systemic
adjuvant therapy. Another reason for our results
may be the short follow-up period, but a mediantime interval of 19 months for local recurrence
after ALND has been reported in another study(Newman et al., 2000).
We used indocyanine green dye at SLNB. Indocyanine green dye has been commonly used inclinical practice and the safety has been establishedwhen SLNB was introduced. Furthermore, the side
effect associated with allergy has been concerned
about other dyes. Nationwide questionnaire survey
on SLNB reported no side effects for indocyanine
green dye (Tsugawa et al., 2009).
The main limitation of the present study isthat patient groups studied in 2 different periodsof time were compared. However, follow-up procedures and adjuvant treatments were similar forboth groups, because all patients had early-stage,node-negative disease. Second, although mostpatient and tumor characteristics were similar inboth groups, there were significantly more patientswith larger tumor size in the ALND group than in
the SLNB group. However, tumor size was not asignificant predictor for the disease free and overall
survival rates after adjusting for the factor in Cox
proportional-hazards model analysis.
In conclusion, survival in node-negative breast
cancer patients undergoing SLNB with the dye
only method without ALND was equivalent to thatin node-negative breast cancer patients undergoing ALND. This suggests that SLNB with thedye only method can safely replace ALND as theprocedure of choice for axillary staging in breast
cancer patients with a clinically negative axilla.

References
1 Bass SS, Lyman GH, McCann CR, Ku NN, Berman
C, Durand K, et al. Lymphatic mapping and sentinel
lymph node biopsy. Breast J 1999;5:288–295
2 de Boer M, van Deurzen CH, van Dijck JA, Borm GF,
van Diest PJ, Adang EM, et al. Micrometastases or isolated tumor cells and the outcome of breast cancer. N
Engl J Med 2009;361:653–663.
3 Fisher B, Slack NH. Number of lymph nodes examined
and the prognosis of breast carcinoma. Surg Gynecol
Obstet 1970;131:79–88.
4 Fleissig A, Fallowfield LJ, Langridge CI, Johnson L,
Newcombe RG, Dixon JM, et al. Post-operative arm
morbidity and quality of life Results of the ALMANAC
randomised trial comparing sentinel node biopsy withstandard axillary treatment in the management of patients with early breast cancer. Breast Cancer Res Treat
2006;95:279–293.
5 Gill G. Sentinel-lymph-node-based management or
routine axillary clearance? One-year outcomes of sentinel node biopsy versus axillary clearance (SNAC): a
randomized controlled surgical trial. Ann Surg Oncol
2009;16:266–275.
6 Kim T, Giuliano AE, Lyman GH. Lymphatic mappingand sentinel lymph node biopsy in early-stage breast
carcinoma: a metaanalysis. Cancer 2006;106:4–16.
7 Krag D, Weaver D, Ashikaga T, Moffat F, Klimberg
VS, Shriver C, et al. The sentinel node in breast cancer – a multicenter validation study. N Engl J Med
1998;339:941–946.
8 Krag DN, Anderson SJ, Julian TB, Brown AM, Harlow
SP, Ashikaga T, et al. Technical outcomes of sentinellymph-node resection and conventional axillary-lymphnode dissection in patients with clinically node-negative
breast cancer: results from the NSABP B-32 randomised
phase III trial. Lancet Oncol 2007;8:881–888.

51

Y. Uchida et al.

9 Kuijt GP, van de Poll-Franse LV, Voogd AC, Nieuwenhuijzen GA, Roumen RM. Survival after negative sentinel lymph node biopsy in breast cancer at least equivalent to after negative extensive axillary dissection. Eur J
Surg Oncol 2003;29:216–220.
10 Langer I, Marti WR, Guller U, Moch H, Harder F,
Oertli D, et al. Axillary recurrence rate in breast cancer
patients with negative sentinel lymph node (SLN) or
SLN micrometastases: prospective analysis of 150 patients after SLN biopsy. Ann Surg 2005;241:152–158.
11 Langer I, Guller U, Hsu-Schmitz SF, Ladewig A, Viehl
CT, Moch H, et al. Sentinel lymph node biopsy is associated with improved survival compared to level I & II
axillary lymph node dissection in node negative breast
cancer patients. Eur J Surg Oncol 2009;35:805–813.
12 Liberman L. Pathologic analysis of sentinel lymph
nodes in breast carcinoma. Cancer 2000;88:971–977.
13 Lo YF, Hsueh S, Ma SY, Chen SC, Chen MF. Radioguided sentinel lymph node biopsy in early breast cancer:
experience at Chang Gung Memorial Hospital. Chang
Gung Med J 2006;29:458–467.
14 Lucci A, McCall LM, Beitsch PD, Whitworth PW,
Reintgen DS, Blumencranz PW, et al. Surgical complications associated with sentinel lymph node dissection (SLND) plus axillary lymph node dissection
compared with SLND alone in the American College ofSurgeons Oncology Group Trial Z0011. J Clin Oncol
2007;25:3657–3663.

15 Newman LA, Hunt KK, Buchholz T, Kuerer HM, Vlastos G, Mirza N, et al. Presentation, management andoutcome of axillary recurrence from breast cancer. Am
J Surg 2000;180:252–256.
16 Petrek JA, Pressman PI, Smith RA. Lymphedema: current issues in research and management. CA Cancer J
Clin 2000;50:292–307.
17 Salem A. Sentinel lymph node biopsy in breast cancer: a comprehensive literature review. J Surg Educ2009;66:267–275.
18 Tsugawa K, Nakamura S. The results of a questionnaire
survey on sentinel lymph node biopsy for breast cancer
patients in Japan. Nyugan No Rinsho 2009;24:265–270(in Japanese with English abstract).
19 Veronesi U, Paganelli G, Viale G, Luini A, Zurrida
S, Galimberti V, et al. A randomized comparison ofsentinel-node biopsy with routine axillary dissection inbreast cancer. N Engl J Med 2003;349:546–553.
20 Zavagno G, De Salvo GL, Scalco G, Bozza F, Barutta
L, Del Bianco P, et al. A Randomized clinical trial on
sentinel lymph node biopsy versus axillary lymph nodedissection in breast cancer: results of the Sentinella/
GIVOM trial. Ann Surg 2008;247:207–213.
Received April 2, 2010; accepted April 23, 2010
Corresponding author: Naotaka Uchida, MD, PhD

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