Tumour location size and grade

Tumour location and size influences the successful identification of the SLN but not the false-negative rate. Tumours located in the upper outer quadrant appear to have a higher SLN identification rate compared to other tumour locations (ALMANAC trial: upper outer 98.2% vs. 89.1% lower inner, p = 0.008; NSABP-32 trial: 98.7% outer central vs 93.9% lower inner, p < 0.0001) (11,31). The simplest explanation relates to the shorter transit distance for the blue dye or radioisotope from the injection site to the axilla. Tumour size did not affect successful identification of SLN in the ALMANAC study but was found to adversely affect SLN identification in the NSABP-32 trial (T3 95.9% vs. T2 98.4%, p = 0.03) (11, 31).

Tumour grade does not influence successful identification of the SLN but may adversely affect the false-negative rate (false-negative rate grade I 0% vs. grade II 4.7% vs. grade III 9.6%, p = 0.022) (11). grade III tumours have a higher incidence of nodal metastases, thereby have an increased risk of lymphatic obstruction and re-routing of tracer leading to a false-negative result. High false-negative rates may have a direct adverse impact on patient care including accurate staging, treatment decision making and long-term outcomes including survival. Therefore, caution is required when applying the SLNB procedure in patients at considerably increased risk of lymph node positive disease.

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