Is sentinel lymph node biopsy without frozen section in early stage breast cancer sufficient in accordance with ACOSOG-Z0011? A retrospective review from King Chulalongkorn Memorial Hospital

Abstract

Background In 2021, there is an increased global trend for sending sentinel lymph node biopsy (SLNB) specimens for permanent section (PS) without intraoperative frozen sections (FS). This pilot study conducted in Thailand determines the re-operation rate for SLNB without FS. Method We retrospectively reviewed 239 SLNB cases without FS at King Chulalongkorn Memorial Hospital from April 2016 to April 2021. The patients were diagnosed with primary invasive breast cancer with clinically negative nodes. The clinical nodal status was assessed from physical examination. The re-operation rate was determined by the number of positive SLNs; where 3 more nodal metastases were subjected to a second surgical procedure. Result Between April 2016 and April 2021, 239 patients who had undergone SLNB in accordance with ACOSOG Z0011 criteria with PS alone was enrolled. A total of 975 SLNs were removed from these 239 patients, with an average of 4.15 nodes per patient. Out of 239 patients, 21 (8.8%) and 6 (2.5%) had metastatic disease in 1 and 2 nodes, respectively. The remaining 212 (88.7%) patients had no nodal metastasis. None of the patients were subjected to a second surgical procedure. Conclusion We conclude that the implementation of SLNB with PS analysis alone in patients who satisfy the ACOSOG Z0011 criteria, with a re-operation rate of 0%, does not have outcomes that would be altered by the standard of care additional FS analysis. With ommision of FS analysis, operation cost, operative time and anesthetic side effects are projected to decrease.

Reducing the Use of Frozen Section for Sentinel Node Biopsy in Breast Carcinoma: Feasibility and Outcome

“…On the other hand, the reduction of the operative time may allow one or two more procedures to be scheduled every day in the surgical theatre, with considerable economical savings and boosted clearance of the waiting list. The reduction in health care costs associated with this change in management of SLNBs has also been highlighted by others (20,(36)(37)(38)(39)(40). However, others reported opposite conclusions, claiming an increase in costs with the use of PS-SLNB in consideration of a higher reoperation rate (41).…”

Reconsidering the Role of Intraoperative Frozen Section in Sentinel Lymph Node Biopsy for Mastectomy Patients with Early-Stage Breast Cancer: A 5-years retrospective review from King Chulalongkorn Memorial Hospital.

“…However, recent studies suggest that iFS may be unnecessary in early-stage breast cancer patients, where tumor size and axillary lymph node status can be used as prognostic factors [8,17]. This trend has already been observed in lumpectomy cases, where iFS has been found to confer minimal diagnostic value, in accordance with the ACOSOG criteria [13,14]. A recent randomized controlled trial conducted by The European Institute of Oncology of Milan (SOUND trial) even con rmed the safety of omitting SLNB in well-selected early-stage breast cancer patients who were treated with breast-conserving surgery and had no evidence of axillary node involvement by clinical and ultrasound evaluation [18].…”

“…Our previous studies demonstrated that reoperation rates in SLNBs without iFS in breast conserving surgery patients was no different than that in SLNBs with iFS [12,13]. However, the recent NCCN guidelines permitting a few positive SLNs in mastectomy patients have raised questions about the necessity of iFS in this context.…”