Sentinel was proven by histopathological examination of the non-SLNs.

Sentinel 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. An
occurrence of a node to attain metastasis, the regional metastatic disease
needs to exist. The SLN reflects the histopathological status of the whole axilla,
therefore if a 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 assessment.


 Our study shows that core biopsy had greater
sensitivity than FNA in detecting metastasis, it could approach statistical
significance. 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 to 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

 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

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.

      The size of a best lymphatic tracer
should be (in the range of 50–200 nm)big enough to remain in the sentinel lymph
nodes, small enough to allow its entry into the lymphatic capillaries while
long enough for proper SLN visualization and imaging without being transferred
to the higher tier nodes early.61-63 For the SLNs to be properly recognized
during the surgical procedure, the Nano-sized carbon particles with a diameter
of 150nm pass easily through the lymphatic capillaries and also allows
accumulation in the lymph nodes for the longer duration. In comparison, the
molecules of blue dyes are pretty small (<2 nm), allowing the easy shipping across the sentinel lymph nodes, which has the highest possibility of the false negative rate because of the rapid washing of the blue dye. 64The carbon Nanoparticles have an important application clinically. Thus, it is far better to use carbon nanoparticles than the blue dye in SLN biopsy because it is preserved for a longer time in SLNs. The blue dyes quickly diffuse through SLNs and may be retained in the level II or even level III or even on non-sentinel lymph nodes instead of being retained in the true sentinel lymph nodes. As a result, during the biopsy of SLNs using the blue dye, there might be an incorrect diagnosis, leading to unnecessary excision of more nodes and a false-negative staging. Carbon nanoparticles are retained in the SLNs thus reducing the false negative detection. In comparison to the blue dye, Carbon nanoparticles detection is more reliable and convincing because the dye is more liable to last for a lengthier 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.