Review of the role of the sentinel node biopsy in neoadjuvant chemotherapy in women with breast cancer and negative or positive axillary node at diagnosis | Revista Española de Medicina Nuclear e Imagen Molecular (English Edition)

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Ruano Pérez, A.C. Rebollo Aguirre, P. García-Talavera San Miguel, R. Díaz Expósito, S. Vidal-Sicart, J.M. Cordero García, D. Carrera Salazar, M.E. Rioja Martín" "autores" => array:9 [ 0 => array:2 [ "nombre" => "R." "apellidos" => "Ruano Pérez" ] 1 => array:2 [ "nombre" => "A.C." "apellidos" => "Rebollo Aguirre" ] 2 => array:2 [ "nombre" => "P." "apellidos" => "García-Talavera San Miguel" ] 3 => array:2 [ "nombre" => "R." "apellidos" => "Díaz Expósito" ] 4 => array:2 [ "nombre" => "S." "apellidos" => "Vidal-Sicart" ] 5 => array:2 [ "nombre" => "J.M." "apellidos" => "Cordero García" ] 6 => array:2 [ "nombre" => "D." "apellidos" => "Carrera Salazar" ] 7 => array:2 [ "nombre" => "M.E." 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Maximum intensity projection PET image of the body showed normal biodistribution in salivary glands, nasal mucosa, liver, spleen, bowel, kidneys and bladder (A). MRI showed mild enhancement on the post-contrast T1-weighted images in the left temporo-parietal area and vasogenic edema (B); PET/CT (C), PET of brain (D) and 3D reconstruction (E) images revealed a 68Ga-PSMA avid mass poorly definedin in the same area seen with MRI (F) brain biopsy specimen showed high grade ductal carcinoma." ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "S.S. Medina-Ornelas, F.O. García-Pèc)rez, C. Medel-Gamez, E. Paredes-Amoroto" "autores" => array:4 [ 0 => array:2 [ "nombre" => "S.S." "apellidos" => "Medina-Ornelas" ] 1 => array:2 [ "nombre" => "F.O." "apellidos" => "García-Pèc)rez" ] 2 => array:2 [ "nombre" => "C." "apellidos" => "Medel-Gamez" ] 3 => array:2 [ "nombre" => "E." 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Ruano Pérez, A.C. Rebollo Aguirre, P. García-Talavera San Miguel, R. Díaz Expósito, S. Vidal-Sicart, J.M. Cordero García, D. Carrera Salazar, M.E. Rioja Martín" "autores" => array:9 [ 0 => array:4 [ "nombre" => "R." "apellidos" => "Ruano Pérez" "email" => array:1 [ 0 => "rruano@saludcastillayleon.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "*" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "A.C." "apellidos" => "Rebollo Aguirre" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "b" "identificador" => "aff0010" ] ] ] 2 => array:3 [ "nombre" => "P." "apellidos" => "García-Talavera San Miguel" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "c" "identificador" => "aff0015" ] ] ] 3 => array:3 [ "nombre" => "R." "apellidos" => "Díaz Expósito" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "d" "identificador" => "aff0020" ] ] ] 4 => array:3 [ "nombre" => "S." 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"apellidos" => "Rioja Martín" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "h" "identificador" => "aff0040" ] ] ] 8 => array:1 [ "colaborador" => "Grupo de Trabajo de Cirugía Radioguiada de la SEMNIM" ] ] "afiliaciones" => array:8 [ 0 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Hospital Clínico Universitario de Valladolid, Valladolid, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, Spain" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Hospital Universitario de Salamanca, Salamanca, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] 3 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Hospital Clínico Universitario de Valencia, Valencia, Spain" "etiqueta" => "d" "identificador" => "aff0020" ] 4 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Hospital Clínico de Barcelona, Barcelona, Spain" "etiqueta" => "e" "identificador" => "aff0025" ] 5 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Hospital Universitario La Paz, Madrid, Spain" "etiqueta" => "f" "identificador" => "aff0030" ] 6 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Hospital Universitario de Tarragona Joan XXIII, Tarragona, Spain" "etiqueta" => "g" "identificador" => "aff0035" ] 7 => array:3 [ "entidad" => "Servicio de Medicina Nuclear, Hospital Universitario Ramón y Cajal, Madrid, Spain" "etiqueta" => "h" "identificador" => "aff0040" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Actualización de la biopsia del ganglio centinela tras quimioterapia neoadyuvante en el cáncer de mama sin y con afectación ganglionar al diagnóstico" ] ] "textoCompleto" => "IntroductionIn aim of this review is to describe the importance of sentinel lymph node biopsy (SLNB) in patients with breast cancer (BC) treated with neoadjuvant chemotherapy (NAC) prior to surgery.The objective of the Radioguided Surgery Working Group of the Spanish Society of Nuclear Medicine and Molecular Imaging is to describe the situation of this indication in this subgroup of patients with advanced BC and establish a series of recommendations for safely and effectively performing SLNB using radioisotopic techniques based on studies published in the literature.Historically, Nuclear Medicine in our country has played a fundamental role in the development of SLNB in BC at both an international and national level. Since 2001 several multidisciplinary consensus on the management of BC have been published in Spain, considering SLNB as the best axillary staging technique, after having replaced systematic axilliary lymph node dissection more than 10 years ago.<a class="elsevierStyleCrossRef" href="#bib0215">1</a>Indeed, based on the NSABP B-32 and the recently updated ACOSOG Z0011studies published in 2010 on the treatment of early stage BC, SLNB allows adequate lymph node staging and may even avoid the need for posterior axillary lymph node dissection in cases with lymph node involvement limited to one or two lymph nodes candidates for breast-conserving surgery.<a class="elsevierStyleCrossRefs" href="#bib0220">2–4</a>In view of the relevance of ruling out avoidable axillary lymph node dissection in patients with BC, Breast Cancer Units have progressively widened the indications of SLNB to larger sized, multicentric and/or multifocal tumors.<a class="elsevierStyleCrossRef" href="#bib0235">5</a> These tumors involve greater resection of breast tissue which, on occasions, requires complete mastectomy leading to subsequent functional and emotional damage to the woman. The use of chemotherapeutic agents in neoadjuvant treatment approaches prior to surgery is increasingly more frequent in order to preserve the breast.Based on greater knowledge of the molecular subtypes of the tumors which allows not only preservation of the breast gland but also achieves a higher percentage of pathological complete response (pCR), neoadjuvant methods are now increasingly more frequently used as a step prior to surgery in most centers in our country. In this context, the Departments of Nuclear Medicine play a predominant role, and axillary lymph node evaluation by SLNB has also been included in the staging process of BC.Indications for selective sentinel lymph node biopsySelective SLNB is indicated in all cases of BC except in inflammatory type carcinomas in which the absence of axillary involvement is specifically observed at diagnosis or after neoadjuvant treatment. This assumption is fundamental to perform the procedure with maximum guarantees within the context of health care.Indication pre- or post-neoadjuvant chemotherapyIn most centers in our country SLNB is carried out during surgery after neoadjuvant treatment. However, some centers prefer to do this procedure during initial staging. Both strategies are valid since they fulfill the main objective of SLNB which is to avoid unnecessary lymph node dissection in women without lymph node disease, although it is clear that important differences must be taken into account. The most relevant is the presence or not of clinical axillary involvement prior to neoadjuvant therapy. It is evident that on histological confirmation by metastatic lymph node puncture, SLNB prior to NAC is contraindicated and should only be performed afterwards. However, in the absence of clinical suspicion or ultrasound evidence of lymph node involvement, SLNB may be considered both before and after chemotherapy.The performance of SLNB before neoadjuvant therapy can establish the presence of lymph node involvement prior to NAC and determine the possible need for axillary lymph node dissection at the time of the second surgery and whether adjuvant axillary radiotherapy is indicated. This allows better planning regarding the type of surgical intervention to perform, especially if immediate reconstruction is foreseen since the results of the reconstruction may be altered if mammary and/or axillary radiotherapy is carried out.<a class="elsevierStyleCrossRef" href="#bib0240">6</a>To the contrary, in this surmise there is the disadvantage of submitting patients to 2 surgical interventions; one for sentinel lymph node (SLN) resection and another after neoadjuvant therapy at the mammary and axillary level in cases in which the SLN is affected.Another disadvantage is that patients never benefit from the effect of chemotherapy to the lymph nodes since axillary lymph node dissection is performed in all the cases with SLN involvement at diagnosis, increasing the morbidity associated with the procedure. The option of performing a second SLNB in this case is a strategy which is neither viable nor safe.<a class="elsevierStyleCrossRef" href="#bib0245">7</a> In addition, this ruling out of the possibility of complete axillary response implies the paradox of having to perform axillary lymph node dissection in patients with pCR after NAC of the breast, which occurs in 33.6% of triple negative tumors and up to 50% of human epidermal growth factor receptor 2 (HER2) positive tumors treated with trastuzumab.<a class="elsevierStyleCrossRef" href="#bib0250">8</a>The second option is to perform the SLNB at the end of neoadjuvant treatment. In this case the first advantage is that the procedure is carried out in a single surgical intervention, with intraoperative use of one-step nucleic acid amplification (OSNA) being feasible for the study of the SLN.<a class="elsevierStyleCrossRef" href="#bib0255">9</a> In addition to this advantage, there is the possibility of salvage treatment in women with lymph node involvement at diagnosis who have shown complete response to chemotherapy, which occurs in 33–50% of the patients.<a class="elsevierStyleCrossRefs" href="#bib0250">8,10</a>It should be noted that from a methodological point of view there are no large pre- or post-NAC differences with the radioactive isotope technique, although as described later, the injection of the radiotracer and the detection rate may differ according to the technique performed.In the current context of surgical management of BC which prioritizes conservation of the breast and greater preservation of the axilla, it seems more coherent to perform the SLNB after neoadjuvant treatment.Nonetheless, as mentioned above, both possibilities are feasible and the decision is made by multidisciplinary committees in each hospital which consider the best option for each individual case as stated in the informed consent forms signed by the patients.Evaluation of the axillary lymph nodesIn order to specify and ensure that the process is as effective as possible, thorough evaluation of the axillary lymph nodes is necessary at diagnosis as well as after neoadjuvant treatment.It is well known that the possibility of axillary lymph node involvement is directly related to the size of the primary tumor, and thus, the proportion of axillary metastasis in T1 tumors of less than 1cm is of around 15%, being 20% in T1c, 30–35% in T2 tumors less than 3cm and 45–50% in tumors larger than 3cm.<a class="elsevierStyleCrossRefs" href="#bib0265">11,12</a> Therefore, in the context of a large sized tumor requiring neoadjuvant treatment, in depth evaluation of the axillary lymph nodes should be performed, including physical examination and imaging techniques.Axillary lymph node evaluation prior to neoadjuvant chemotherapyUltrasound is the imaging technique of choice at diagnosis for detecting axillary lymph node disease, presenting a sensitivity of 50–55%. This procedure is simple and also helps to guide the biopsy puncture of lymph nodes suspected of malignancy.<a class="elsevierStyleCrossRef" href="#bib0275">13</a>It is important to point out that in the same ultrasound study a marker may be placed in the same lymph node punctured similar to the marker systematically placed in the breast tumor to evaluate the grade of response to therapy and facilitate its localization during surgery. This strategy of marking the lymph node reduces the rate of false negative results in the SLNB procedure.<a class="elsevierStyleCrossRefs" href="#bib0280">14,15</a>In the staging of locally advanced BC, magnetic resonance (MR) is increasingly used to assess the possible multifocality and multicentricity of the tumor as well as its relationship with neighboring structures such as the thoracic wall which conditions the surgical approach to be used. In addition, the axillary lymph nodes may be evaluated in the same procedure, increasing the sensitivity of ultrasonography up to 62%.<a class="elsevierStyleCrossRef" href="#bib0290">16</a>Another imaging technique is positron emission tomography (PET) which increasingly more groups are using in the staging and evaluation of response to treatment prior to surgery. PET/CT with 18F-fluorodeoxyglucose (18F-FDG) provides information related to tumor load in the breast and axilla from a metabolic point of view, having a sensitivity of 30–40% in the detection of lymph node infiltration. Both the metabolic grade estimated by the maximum standard uptake value (SUVmax) of the breast and the axilla are correlated with factors of worse prognosis (negative hormone receptors, overexpression of p53 and the triple negative group).<a class="elsevierStyleCrossRef" href="#bib0295">17</a> Moreover, its high sensitivity for detecting involvement in other organs in whole body scans within the context of a locally advanced malignant tumor should be considered.Axillary lymph node evaluation post-neoadjuvant chemotherapyAt present, no imaging technique is sufficiently accurate to identify axillary pCR in patients with BC treated with NAC.<a class="elsevierStyleCrossRef" href="#bib0300">18</a> Nonetheless, evaluation of the axilla using imaging techniques after completing neoadjuvant treatment is fundamental for deciding the SLNB technique with maximum guarantees. The criteria of absence of known axillary disease should prevail before undergoing the SLNB procedure.In cN0 BC patients with axillary involvement a new study of the axilla is not usually performed after completing NAC likely based on the uncertainty of possibly finding an inadequate initial evaluation. However, since the proportion of lymph node metastasis after NAC is 31–35%,<a class="elsevierStyleCrossRef" href="#bib0305">19</a> the utility of performing a new evaluation such as ultrasound should not be ignored in order to detect persistence or even disease progression, especially in patients with bad response of the primary tumor or cancers of the luminal subtype.<a class="elsevierStyleCrossRef" href="#bib0310">20</a>The axilla should be studied in all axillary lymph node positive (cN+) patients after completion of NAC. At present, the sensitivity of the techniques available (ultrasound, MR, 18F-FDG PET) varies greatly according to the different studies, with some considering them to be suboptimal with values from 23.9 to 34.0%<a class="elsevierStyleCrossRef" href="#bib0315">21</a> and other more optimistic studies reporting values of around 61–69.8%.<a class="elsevierStyleCrossRef" href="#bib0320">22</a>In any case, ultrasonography should be obligatory in all cases in hospitals in our country in both axillary node-negative patients and those suspected of disease progression. The use of MR and 18F-FDG PET can be considered in patients who underwent evaluation at diagnosis or in those with clinical suspicion of progression.Sentinel lymph node biopsy techniqueThe SLNB technique in BC involves the injection of a radiotracer, the study of the scintigraphic images and posterior intraoperative localization using a gamma detection probe.<a class="elsevierStyleCrossRef" href="#bib0235">5</a>Regardless of whether SLNB is performed prior to or after NAC, the procedure is similar to that used in early stage tumors, although several considerations must be taken into account.Previous planning implies knowledge of the case to be treated, the type and localization of the tumor, the possibility of previous lymph node involvement and the type of response to chemotherapy in both the breast and axilla. In this planning it is important to respect an adequate length of exploration and organize the operating room in order to guarantee the greatest probability of success.The dose of the radiotracer to be used is conditioned by the time until surgery with an approximate radioactivity of 37–111MBq (1–3mCi) of particle labeled with 99mTc. The radiotracers most commonly used in Spain are nanocolloids and rhenium sulfide nanocolloid.The injection of the radiotracer is determined by the response obtained after neoadjuvant treatment. In cases with partial response or no tumor response the injection is preferably peritumoral or intratumoral with periareolar injection being reserved for when there is no drainage and reinjection is necessary. In non palpable lesions and whenever possible, the best option is ultrasound or stereotactic guided intratumoral injection.In cases with complete tumoral response the injection can be periareolar or, if a marker has been placed in the primary tumor, it is preferable for the injection to be in this breast quadrant or even near the marker.Gamma camera detection should be done with the acquisition of planar images anterior and lateral to the thorax and axilla, evaluating the possibility of additional oblique projections or single-photon emission computed tomography (SPECT)/CT studies in each case.The report should include the number of lymph nodes visualized, as well as their location in the axillary lymph node chain and the internal mammary or intramammary lymph node chain, and cutaneous marking of the projection of the SLN of greatest importance (because of its activity or proximity to the tumor) should be made.In this phase of the procedure it is important to take into consideration the possibility of no drainage in any lymph node chain. In these locally advanced tumors lymphatic drainage of the breast is often slow and, on occasions, there may be lymph node blockage due to malignant infiltration despite the ultrasound evaluation. Therefore reinjection may therefore be necessary in some cases, with a periareolar site being preferable in this scenario.Occasionally the drainage obtained is only of the internal mammary lymph node chain and less frequently only of one intramammary lymph node. These 2 situations imply the impossibility of adequately staging the axilla, and thus, the recommendation is to also reinject the patient via the periareolar route in order to visualize the SLN corresponding to the axillary lymph node chain. If there is no axillary drainage after reinjection the most correct action would be to perform axillary lymph node dissection to complete the staging.The absence of drainage is especially relevant in patients with lymph node involvement prior to surgery since it usually indicates the persistence of important tumoral load in the axilla which has not been detected in the imaging studies.No visualization of drainage in the lymphoscintigraphy does not imply ruling out detection with a gamma detection probe. However, the surgeon should be informed to evaluate the use of a vital blue type stain to increase possible intraoperative detection.Intraoperative localization with a gamma detection probe involves resection of the lymph node(s) with significant radioactivity coinciding with those previously visualized in the scintigraphy. Based on their localization and grade of activity, it is possible to determine the SLN(s) and accessory lymph nodes.In general, one or two lymph nodes are resected in women with early stage BC. The number of lymph nodes resected in locally advanced BC is greater in both patients with and without previous lymph node involvement. This is sometimes conditioned by an excess of zealousness and by not wanting to obtain a false negative result in the axillary staging. In this sense the surgeon should have access to the lymphoscintigraphy images and it is recommendable to have a nuclear medicine specialist available during the surgical procedure to have consensus related to the need or not to continue to resect lymph nodes with low or null radioactivity. Within the context of reducing false negative results, the marking of the metastatic lymph node pre-NAC is becoming more widely practiced to ensure that it is always resected together with the SLNs.The surgical management of lymph node(s) of the internal mammary lymph node and intramammary lymph node chains in BC pre- and post-chemotherapy should be performed according to the usual procedure of each hospital.Validation of the techniqueThere are several national and international validation studies in patients treated with NAC with and without previous axillary lymph node involvement.The detection rates should be taken into account, and especially, the false negative ratio based on the result obtained after completing axillary lymph node dissection.Patients with lymph node involvement prior to neoadjuvant chemotherapyFew studies have evaluated the percentages of identification and false negative results of the SLN in cN0 patients pre-NAC. <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the most relevant studies individually and the 2 most recent metaanalyses published on this subject.<a class="elsevierStyleCrossRefs" href="#bib0265">11,19,23–29</a> The metaanalysis of 2013 included 17 studies (from 2001 to 2009) with a total of 1738 patients and established the detection rate at 95% and that of false negative results at 11.4%.<a class="elsevierStyleCrossRef" href="#bib0350">28</a> The second metaanalysis was done in 2016 and included 16 studies (from 2000 to 2015, including 2 in our country) reporting a detection rate of 96% and a false negative rate of 6%.<a class="elsevierStyleCrossRef" href="#bib0355">29</a><elsevierMultimedia ident="tbl0005"></elsevierMultimedia>The study of greatest diffusion and relevance is that by Hunt et al.,<a class="elsevierStyleCrossRef" href="#bib0265">11</a> who compared 3171 patients with clinically node-negative axilla results of patients undergoing the usual SLNB without NAC with 575 patients in whom SLNB was performed after NAC. They concluded that there were no statistically significant differences in either the detection rate (99% vs. 97.4%) or the false negative rate (4.1 vs. 5.9%), and that after 47 months of follow up the percentage of axillary recurrence was 1.2% in the post-NAC group.Therefore, both the efficacy and safety of SLNB after NAC has been demonstrated in patients with clinically node-negative axilla results at diagnosis.It is important to take into account that tumor response to NAC varies according to the molecular subtype, and that likewise, this facilitates the possibility of axillary lymph node involvement. Luminal tumors are the most numerous and present the lowest grade of tumor response which is correlated with greater lymph node involvement. In cN0 patients, persistence of tumoral disease in the breast (ypTinv) and the luminal subtype are factors which determine lymph node involvement after NAC. In addition, an age >49 years, large tumors, histological grade III and lymph node involvement after NAC (ypN+) are prognostic factors of lower disease-free survival, the latter also being considered to be an independent prognostic factor of lower overall survival.<a class="elsevierStyleCrossRef" href="#bib0310">20</a>Patients with axillary involvement prior to neoadjuvant chemotherapy<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the most relevant individual studies and the 2 metaanalyses with the largest number of patients.<a class="elsevierStyleCrossRefs" href="#bib0245">7,10,23,30–33</a> The most recent metaanalysis collected information from 19 studies (2 from Spanish groups) including a total of 3398 patients. In this metaanalysis the global percentage of SLN detection was 90.9% with 13% of false negative results, achieving pathological complete axillary response (ypN0) in 47% of the patients.<a class="elsevierStyleCrossRef" href="#bib0375">33</a><elsevierMultimedia ident="tbl0010"></elsevierMultimedia>The 3 large studies with axillary lymph node involvement prior to NAC are the ACOSOG Z1071, the SENTINA study, and the SN FNAC study.The ACOSOG Z1071 study reported a SLN detection rate of 92.9% visualizing one SLN in 12%, 2 SLNs in 23.8% and 3 SLNs or more in 57.3%. After NAC axillary pCR of 41% was achieved, with these patients benefitting from SLNB after NAC. In the group of cN1+ patients in whom 2 or more SLNs were resected and who underwent axillary lymph node dissection the rate of false negative results was 12.6%. The molecular subtype was determinant for achieving axillary pCR, being 49.4% in the triple negative group, 64.7% in HER2+ and 21.1% in the subtype with positive hormone receptors and HER-.The ACOSOG Z1071 study included patients without complete clinical axillary response, 12% of whom had palpable lymph nodes and ultrasonography was not used to discriminate patients who should not have been in the group with SLN. A posteriori, in a subgroup of 611 patients the rate of false negative results would have reduced from 12.6% to 9.8% based on a suspicious ultrasonography.<a class="elsevierStyleCrossRef" href="#bib0380">34</a>The German SENTINA study included a study arm of 592 patients with axillary lymph node involvement prior to NAC. Of these, 474 presented clinical response and were staged with SLN. This study reported the lowest percentage of detection of 80.1% with a rate of false negative results of 14.2%, conditioned by the number of lymph nodes resected which was only less than 10% when 3 or more SLNs were resected (8.6%).<a class="elsevierStyleCrossRef" href="#bib0245">7</a>The SN FNAC study performed in 2015 included 153 patients with previous histological confirmation of axillary lymph node involvement. The detection rate was 87.6% with a false negative rate of 13.7% which reduced to 8.4% on considering the presence of micrometastasis in the SLN as an indication for axillary lymph node dissection.<a class="elsevierStyleCrossRef" href="#bib0365">31</a>The results of these 3 studies support the feasibility of SLNB after NAC in patients with positive lymph nodes prior to therapy. However, in order to optimize the results several steps should be followed: adequate selection of patients (T1-3N1), use of a combined technique for lymphatic mapping (radiotracer+staining), resection of more than 2 SLNs, placement of a clip in the pathological lymph node and identification and resection during SLNB of this lymph node and consider immunohistochemistry in the SLN and complete axillary lymph node dissection even if the result of the SLN is isolated tumor cells/micrometastasis.Different groups in our country have validated and are therapeutically applying the SLNB technique, achieving detection rates greater than 90%. With the use of OSNA they are studying the possibility of metastasis in the SLN without increasing the rate of axillary lymph node recurrence.<a class="elsevierStyleCrossRef" href="#bib0370">32</a> It has been shown that axillary lymph node dissection can be avoided in these patients, salvaging 35% of luminal tumors and 66% of the HER2+ group based on the molecular subtype.<a class="elsevierStyleCrossRefs" href="#bib0385">35,36</a>It is important to point out that in the case of axillary lymph node involvement prior to NAC there are studies elaborating nomograms to predict the possibility of achieving complete axillary response (ypN0). The group of Vila et al.<a class="elsevierStyleCrossRef" href="#bib0395">37</a> evaluated 584 cT1-T4N1M0 cases with axillary pCR of 37% and found that grade 3 (odds ratio: 13.4), HER2+ (odds ratio: 4.7) estrogen receptor negative (ER−) (odds ratio: 3.5) and progesterone receptor negative (PR−) (odds ratio: 4.3) were predictors of response.Marking the metastatic lymph node biopsied prior to neoadjuvant chemotherapyAs mentioned previously, marking of the metastatic lymph node biopsied prior to NAC is increasingly more frequent since it seems logical and intuitive to consider that this axillary lymph node is the best to evaluate response to NAC. This strategy ensures resection of the lymph node and reduces the rate of false negative results, therefore the National Comprehensive Cancer Network recommends the marking of positive biopsied lymph nodes in order to posteriorly verify their resection in the definitive axillary lymph node surgery.Different marking methods of the lymph node during the pre-NAC biopsy have been described. These methods consist in placing a metallic clip or a radioactive iodine 125 (125I) seed inside the lymph node or tattoo the node with a carbon particle suspension.The possibility of tattooing the biopsied lymph node with a carbon particle suspension was recently described in 28 patients (12 after NAC). This was done at the same time as the SLNB technique, and in 27 of the 28 cases the marked node was visualized, being concordant with the SLN in all except one case without NAC. This is therefore a promising technique, although it is similar to the use of other stains and its application requires validation in future studies.<a class="elsevierStyleCrossRef" href="#bib0400">38</a>The method most frequently used is the placement of a metallic clip which facilitates control with imaging studies evaluating patient response to NAC. In the ACOSOG Z1071 study (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>) the biopsied lymph node was clipped in 32% of a subgroup of 203 patients recently analyzed. Of these, the location of the clipped node was registered in 167 patients (127 in the SLN and 40 in the lymph nodes of the axillary lymph node dissection). They found that when the marked lymph node was included among the SLNs the rate of false negative results was 7.2%, and when it was not included the false negative rate was 26.9%. These results improved when the patients were cN1 with 2 or more resected SLNs: 6.8% if the clipped lymph node was included among the SLNs and 19% when it was not among the SLNs. These authors concluded that clipping of the positive lymph node biopsied and its recovery during surgery reduced the rate of false negative results of the SLNB after NAC.<a class="elsevierStyleCrossRef" href="#bib0405">39</a><elsevierMultimedia ident="tbl0015"></elsevierMultimedia>However, intraoperative localization of the clipped lymph node is not easy despite being ultrasonographically visible. Therefore, the group of Plecha et al. proposed that a second marking procedure performed using a surgical wire several days prior to surgery increases the possibility of resection of the clipped lymph node from 83.3% to 97.0%.<a class="elsevierStyleCrossRef" href="#bib0410">40</a> Another strategy, discussed below, is the use of a 125I seed to mark the lymph node containing the clip, which achieves its resection in practically 100% of the cases.The placement of a 125I seed in the biopsied lymph node was described in 2010 by a group from the Netherlands Cancer Institute of Amsterdam. This procedure is known as the MARI procedure (marking the axilla with radioactive iodine-125 seeds)<a class="elsevierStyleCrossRef" href="#bib0415">41</a> (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). The seed is placed before initiating NAC and may be selectively removed using a gamma detection probe on completing the treatment. With the use of this approach, which did not include SLNB in 100 patients, this group recently described a detection rate of 97% with a false positive rate of 7.2% after axillary lymph node dissection.<a class="elsevierStyleCrossRef" href="#bib0420">42</a>Since US laws do not allow 125I seeds to remain in place throughout chemotherapy treatment, the MD Anderson group (Houston, TX, USA) has proposed the placement of an ultrasonographically visible metallic clip before initiating NAC and marking with 125I seeds several days prior to surgery after having completed NAC (<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>). This group developed the concept of targeted axillary dissection which consists in the combination of the SLNB technique with the detection of the positive lymph node marked with the 125I seed. To validate the procedure they studied 191 women with a positive axilla at diagnosis who underwent axillary lymph node dissection after NAC: 73 with direct dissection and 118 with previous SLNB. Of these 118 patients, the SLN was combined with marking of the lymph node with 125I in 85 cases. The targeted axillary dissection of the lymph node marked with 125I together with the SLNB improved the results, with a false negative rate of only 2% versus 10.6% with the SLNB alone. These authors suggested that this approach is the most effective and reported that the radioactive 125I seed was recovered in all the cases, and there was no interference in the localization of the SLN.<a class="elsevierStyleCrossRef" href="#bib0285">15</a>Using the same marking strategy with a 125I seed after completing NAC the group of Diego et al. performed a retrospective study of 30 patients with positive biopsied axilla lymph nodes pre-NAC who were clinically negative post-NAC. They described that in only 22 of the 30 patients (73.3%) the lymph node coincided with the seed and the SLN. The lymph node marked with the 125I seed was identified in 29/30 patients and metastatic axillary nodal disease persisted post-NAC in 11, 6 of whom also had a metastatic SLN. These results demonstrate the greater accuracy of the procedure of marking with 125I seeds versus SLNB alone.<a class="elsevierStyleCrossRef" href="#bib0280">14</a>In view of the previous arguments, the future of axillary surgery post-NAC in patients with BC who are axilla positive at diagnosis is based on the following premises:A marker should be placed in the axillary lymph node which was positive on biopsy at diagnosis, and the number of abnormal lymph nodes should be determined as an indicator of tumoral load in the axilla (cN1–N2).Prior to surgery the response to NAC should be assessed using imaging techniques. Patients without detectable nodal disease are those who would most benefit from selective SLNB.A procedure able to intraoperatively localize the marked lymph node should be established since this node is not found in a significant proportion of SLN identified. Selective radioguided axillary dissection (MARI and SLNB combined) can accurately achieve axillary staging post-NAC, identifying women with pCR who would not benefit from complete axillary lymph node dissection, with less procedure-associated morbidity.Pending questions related to management of the axilla in neoadjuvant chemotherapyThe use of SLNB has become the technique of choice for axillary lymph node staging in patients with BC in our country, being essential in all surgical units treating this disease. Biopsy of the SLN is the best criteria to reduce the indication for axillary lymph node dissection, having no repercussion on the cure and survival of the patients.Within the context of NAC not all the questions related to surgical treatment of the axilla have been resolved.Although experience has shown that similar to what occurs in early stage cancers with ACOSOG Z0011 criteria the indication for axillary lymph node dissection after neoadjuvant treatment is very reduced for cases with great tumoral load in the axilla, there is currently no scientific evidence corroborating this situation. Therefore, in tumors undergoing neoadjuvant treatment, the presence of malignant involvement of the SLN should be associated with axillary lymph node dissection. It remains to be known whether it is safe in terms of survival to not complete axillary lymph node dissection in cases of low tumoral load in the SLN (micrometastasis) or with involvement of only one SLN after having resected 2 or 3 more SLNs. Lastly, studies are needed to determine whether axillary surgery can replace axillary radiotherapy.The indication of neoadjuvant treatment is a new challenge for multidisciplinary groups and committees in our hospitals. It has been shown that greater knowledge of the molecular subtype of the tumors can predict the likelihood of response or not to NAC and the development of metastasis. The inclusion of SLNB in the evaluation of the axilla has led to continued advances in the knowledge and treatment of BC. To achieve the best results each center should review its diagnostic procedures using imaging techniques (ultrasonography, MR, 18F-FDG PET).Key points<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005">1.SLNB in patients with BC undergoing neoadjuvant treatment is an option to avoid unnecessary axillary lymph node dissection. There are relevant differences related to whether this procedure is performed pre- or post-NAC, although both approaches may be effective.</li><li class="elsevierStyleListItem" id="lsti0010">2.Following NAC correct evaluation of the stage of the axilla by ultrasonography is essential in cases with node-negative axilla results and in cases suspected of progression. In the latter cases, the use of MR and 18F-FDG PET may be considered.</li><li class="elsevierStyleListItem" id="lsti0015">3.Prior to the implementation of post-NAC a validation phase of the SLNB should be carried out in both patients with and without axillary lymph node involvement.</li><li class="elsevierStyleListItem" id="lsti0020">4.The efficacy and safety of the procedure after NAC has been demonstrated in patients with clinically node-negative axilla at diagnosis.</li><li class="elsevierStyleListItem" id="lsti0025">5.In patients who are axilla node-positive at diagnosis, SLNB after NAC is feasible but patients should be adequately selected (T1-3 N1), a combined technique should be used for lymphatic mapping (radiotracer + staining), more than 2 SLN should be resected, the pathologic lymph node should be clipped and resected during SLNB and axillary lymph node dissection should be done even if the pathologic examination of the SLN shows isolated tumor cells or micrometastasis.</li><li class="elsevierStyleListItem" id="lsti0030">6.The most frequently used pre-NAC marking methods of the biopsied lymph node are metallic clips or 125I seeds which ensure their removal in the SLNB after neoadjuvant treatment.</li><li class="elsevierStyleListItem" id="lsti0035">7.A procedure allowing intraoperative localization of the marked lymph node should be established since the marked node is not found among the SLN identified in a significant proportion of cases. Radioguided selective axillary lymph node dissection (MARI and SLNB combined) can achieve accurate axillary staging post-NAC.</li><li class="elsevierStyleListItem" id="lsti0040">8.Within the context of NAC not all the questions related to surgical treatment of the axilla have been resolved. We should continue with advances in knowledge, preserving the safety and survival of the patients.</li></ul>ConclusionsSelective SLNB using radioisotopic techniques in patients with BC who are candidates for NAC is feasible, effective and safe. Knowledge of the tumoral situation of the axilla prior to surgery using imaging techniques (ultrasound, MR, 18F-FDG PET) is essential to guarantee adequate staging and treatment of the patients. The incorporation of SLNB provides an approach to preserve the axilla which is undoubtedly the best criteria to benefit patients with BC.Conflict of interestThe authors declare no conflict of interest." "textoCompletoSecciones" => array:1 [ "secciones" => array:14 [ 0 => array:3 [ "identificador" => "xres969134" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec940080" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres969135" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec940081" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:3 [ "identificador" => "sec0010" "titulo" => "Indications for selective sentinel lymph node biopsy" "secciones" => array:1 [ 0 => array:2 [ "identificador" => "sec0015" "titulo" => "Indication pre- or post-neoadjuvant chemotherapy" ] ] ] 6 => array:3 [ "identificador" => "sec0020" "titulo" => "Evaluation of the axillary lymph nodes" "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Axillary lymph node evaluation prior to neoadjuvant chemotherapy" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Axillary lymph node evaluation post-neoadjuvant chemotherapy" ] ] ] 7 => array:2 [ "identificador" => "sec0035" "titulo" => "Sentinel lymph node biopsy technique" ] 8 => array:3 [ "identificador" => "sec0040" "titulo" => "Validation of the technique" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0045" "titulo" => "Patients with lymph node involvement prior to neoadjuvant chemotherapy" ] 1 => array:2 [ "identificador" => "sec0050" "titulo" => "Patients with axillary involvement prior to neoadjuvant chemotherapy" ] 2 => array:2 [ "identificador" => "sec0055" "titulo" => "Marking the metastatic lymph node biopsied prior to neoadjuvant chemotherapy" ] ] ] 9 => array:2 [ "identificador" => "sec0060" "titulo" => "Pending questions related to management of the axilla in neoadjuvant chemotherapy" ] 10 => array:2 [ "identificador" => "sec0065" "titulo" => "Key points" ] 11 => array:2 [ "identificador" => "sec0070" "titulo" => "Conclusions" ] 12 => array:2 [ "identificador" => "sec0075" "titulo" => "Conflict of interest" ] 13 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2017-05-01" "fechaAceptado" => "2017-06-29" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec940080" "palabras" => array:3 [ 0 => "Breast cancer" 1 => "Neoadjuvant chemotherapy" 2 => "Sentinel node" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec940081" "palabras" => array:3 [ 0 => "Cáncer de mama" 1 => "Quimioterapia neoadyuvante" 2 => "Ganglio centinela" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "The role of the selective sentinel node biopsy (SNB) is increasing in relevance in breast cancer women with indication of neoadjuvant chemotherapy (NAC). The Radiosurgery Working Group of the SEMNIM is aware of the necessity of establishing the need for SNB before or after NAC, and also how to manage patients with axillary node-negative or node-positive. There is sufficient data to assess that the SNB with radioisotope techniques is feasible and safe in all these scenarios. An adequate axilla evaluation prior to surgery and the possibility of marking prior to NAC the nodes infiltrated must be the two main pillars to guarantee the success of the SNB. It has been shown that to incorporate the SNB in breast cancer women with indication of NAC increases the rate of a conservative treatment of the axilla that will be a clear benefit for these patients." ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "Esta actualización pretende contextualizar la relevancia de la biopsia selectiva del ganglio centinela (BSGC) en mujeres con cáncer de mama e indicación de quimioterapia neoadyuvante (QTN). El Grupo de Trabajo de Cirugía Radioguiada de la SEMNIM es consciente de la variabilidad existente en nuestro país sobre todo en cuanto al momento de realizar la técnica (previa o tras la QTN) y en cuanto al manejo de pacientes con axila negativa o positiva al diagnóstico. Existe suficiente experiencia contrastada para aseverar que mediante técnicas radioisotópicas la BSGC es factible, eficaz y segura en estos escenarios. Una adecuada valoración mediante técnicas de imagen de la situación tumoral a nivel de la axila previa a la cirugía y la posibilidad del marcaje previo a la QTN de cualquier ganglio infiltrado deben ser los pilares fundamentales para garantizar el éxito de la BSGC. Es un hecho que incorporar la BSGC en el cáncer de mama con indicación de QTN favorece un tratamiento conservador de la axila, lo cual redunda en claro beneficio de las pacientes." ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "Please cite this article as: Ruano Pérez R, Rebollo Aguirre AC, García-Talavera San Miguel P, Díaz Expósito R, Vidal-Sicart S, Cordero García JM, et al. Actualización de la biopsia del ganglio centinela tras quimioterapia neoadyuvante en el cáncer de mama sin y con afectación ganglionar al diagnóstico. Rev Esp Med Nucl Imagen Mol. 2018;37:63–70." ] ] "multimedia" => array:3 [ 0 => array:8 [ "identificador" => "tbl0005" "etiqueta" => "Table 1" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at1" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:1 [ "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">cN0 \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Country \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. of patients \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-NAC size \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% detection \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">False negative rate (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Accuracy (%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yu et al.<a class="elsevierStyleCrossRef" href="#bib0325">23</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">China Taipei \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">127 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">91.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">957 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gimberges et al.<a class="elsevierStyleCrossRef" href="#bib0330">24</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">France \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">82 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T1–T3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">93.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">0 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Classe et al.<a class="elsevierStyleCrossRef" href="#bib0335">25</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">France \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">130 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T1–T3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">97.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hunt et al.<a class="elsevierStyleCrossRef" href="#bib0265">11</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">United States \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">575 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T1–T3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">97.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">97 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rebollo-Aguirre et al.<a class="elsevierStyleCrossRef" href="#bib0305">19</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Spain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">51 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T1–T3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96.5 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Takahashi et al.<a class="elsevierStyleCrossRef" href="#bib0340">26</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Japan \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T1–T4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">91.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">97.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Piñero-Madrona et al.<a class="elsevierStyleCrossRef" href="#bib0345">27</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Spain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">49 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T1–T3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">89.8 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">18 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">94.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fontein et al.<a class="elsevierStyleCrossRef" href="#bib0350">28</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Metaanalysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1738 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T1–T4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">11.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">95.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Geng et al.<a class="elsevierStyleCrossRef" href="#bib0355">29</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Metaanalysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">1456 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T1–T4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">96 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">98.7 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1639710.png" ] ] ] ] "descripcion" => array:1 [ "en" => "The most relevant validation studies of sentinel lymph node biopsy in patients with axilla lymph node involvement pior to neoadjuvant chemotherapy (NAC) treatment." ] ] 1 => array:8 [ "identificador" => "tbl0010" "etiqueta" => "Table 2" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at2" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "pCR: pathological complete response." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">cN+ \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Country \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. of patients \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-NAC size \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% detection \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">False negative rate (%) \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">% axilla pCR (ypN0) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kuehn et al.<a class="elsevierStyleCrossRef" href="#bib0245">7</a> SENTINA \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Germany \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">592 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T1–T3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">80.1 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">14.2 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52.3 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Boughey et al.<a class="elsevierStyleCrossRef" href="#bib0360">30</a> ACOSOG Z1071 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">United States \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">689 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T1–T4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">92.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">12.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">41.0 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Boileau et al.<a class="elsevierStyleCrossRef" href="#bib0365">31</a> SN FNAC \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">France \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">153 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T1–T3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">87.6 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">34.6 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rebollo-Aguirre et al.<a class="elsevierStyleCrossRef" href="#bib0260">10</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Spain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">52 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T1–T3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">84.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">8.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">42.2 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Carrera et al.<a class="elsevierStyleCrossRef" href="#bib0370">32</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Spain \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">53 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T1–T4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">5.7 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">35.4 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fontein et al.<a class="elsevierStyleCrossRef" href="#bib0350">28</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Metaanalysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">839 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T1–T4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">86.5 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.3 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">20–40 \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">El Hage Chehade et al.<a class="elsevierStyleCrossRef" href="#bib0375">33</a> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Metaanalysis \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">3398 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">T1–T4 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">90.9 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">13 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">39.2–47.1 \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1639711.png" ] ] ] ] "descripcion" => array:1 [ "en" => "The most relevant validation studies of the sentinel lymph node biopsy technique in patients with clinical axilla lymph node involvement prior to neoadjuvant chemotherapy (NAC) treatment." ] ] 2 => array:8 [ "identificador" => "tbl0015" "etiqueta" => "Table 3" "tipo" => "MULTIMEDIATABLA" "mostrarFloat" => true "mostrarDisplay" => false "detalles" => array:1 [ 0 => array:3 [ "identificador" => "at3" "detalle" => "Table " "rol" => "short" ] ] "tabla" => array:2 [ "leyenda" => "CI: confidence interval; SLN: sentinel lymph node; ALND: axillary lymph node dissection; SLNB: sentinel lymph node biopsy." "tablatextoimagen" => array:1 [ 0 => array:2 [ "tabla" => array:1 [ 0 => """ <table border="0" frame="\n \t\t\t\t\tvoid\n \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head " align="" valign="top" scope="col" style="border-bottom: 2px solid black"> \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Country \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No. of patients \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Localization technique \t\t\t\t\t\t\n \t\t\t\t</th><th class="td" title="table-head " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">False negative results (CI 95%) \t\t\t\t\t\t\n \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Boughey et al.<a class="elsevierStyleCrossRef" href="#bib0405">39</a> ACOSOG Z1071 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">United States \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">203 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Metallic clip in SLN \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.2% (2.7–15.1) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">Metallic clip in ALND \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">26.9% (11.6–47.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Donker et al.<a class="elsevierStyleCrossRef" href="#bib0420">42</a> MARI \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">The Netherlands \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">100 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">125I seed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">7.1% (2–16) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Caudle et al.<a class="elsevierStyleCrossRef" href="#bib0285">15</a> Targeted axillary dissection \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">United States \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">118 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SLNB \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">10.1% (4.2–19.8) \t\t\t\t\t\t\n \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="" valign="top"> \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">85 \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="left" valign="top">SLNB+ 125I seed \t\t\t\t\t\t\n \t\t\t\t</td><td class="td" title="table-entry " align="char" valign="top">2.0% (0.05–10.7) \t\t\t\t\t\t\n \t\t\t\t</td></tr></tbody></table> """ ] "imagenFichero" => array:1 [ 0 => "xTab1639709.png" ] ] ] ] "descripcion" => array:1 [ "en" => "Percentagef of false negative results following axillary lymph node dissection based on the method of identification of the positive node biopsied N+." ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:42 [ 0 => array:3 [ "identificador" => "bib0215" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Consenso sobre la biopsia selectiva del ganglio centinela en el cáncer de mama. Revisión 2013 de la Sociedad Española de Senología y Patología Mamaria" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Bernet" 1 => "A. Piñero" 2 => "S. Vidal-Sicart" 3 => "V. Peg" 4 => "J. Giménez" 5 => "M. Algara" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Rev Esp Patol" "fecha" => "2014" "volumen" => "47" "paginaInicial" => "22" "paginaFinal" => "32" ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0220" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer: overall survival findings from the NSABP B-32 randomised phase 3 trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D.N. Krag" 1 => "S.J. Anderson" 2 => "T.B. Julian" 3 => "A.M. Brown" 4 => "S.P. Harlow" 5 => "J.P. Costantino" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S1470-2045(10)70207-2" "Revista" => array:6 [ "tituloSerie" => "Lancet Oncol" "fecha" => "2010" "volumen" => "11" "paginaInicial" => "927" "paginaFinal" => "933" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20863759" "web" => "Medline" ] ] ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0225" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel node metastases: The American College of Surgeons Oncology Group Z0011 randomized trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.E. Giuliano" 1 => "L. McCall" 2 => "P. Beitsch" 3 => "P.W. Whitworth" 4 => "P. Blumencranz" 5 => "A.M. Leitch" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/SLA.0b013e3181f08f32" "Revista" => array:6 [ "tituloSerie" => "Ann Surg" "fecha" => "2010" "volumen" => "252" "paginaInicial" => "426" "paginaFinal" => "432" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20739842" "web" => "Medline" ] ] ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0230" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases: long-term follow-up from the American College of Surgeons Oncology Group (Alliance) ACOSOG Z0011 randomized trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.E. Giuliano" 1 => "K. Ballman" 2 => "L. McCall" 3 => "P. Beitsch" 4 => "P.W. Whitworth" 5 => "P. Blumencranz" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/SLA.0000000000001863" "Revista" => array:6 [ "tituloSerie" => "Ann Surg" "fecha" => "2016" "volumen" => "264" "paginaInicial" => "413" "paginaFinal" => "420" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27513155" "web" => "Medline" ] ] ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0235" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The EANM and SNMMI practice guideline for lymphoscintigraphy and sentinel node localization in breast cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "F. Giammarile" 1 => "N. Alazraki" 2 => "J.N. Aarsvold" 3 => "R.A. Audisio" 4 => "E. Glass" 5 => "S.F. Grant" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00259-013-2544-2" "Revista" => array:6 [ "tituloSerie" => "Eur J Nucl Med Mol Imaging" "fecha" => "2013" "volumen" => "40" "paginaInicial" => "1932" "paginaFinal" => "1947" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24085499" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0240" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Breast sentinel lymph node dissection before preoperative chemotherapy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "B.J. Grube" 1 => "C.J. Christy" 2 => "D. Black" 3 => "M. Martel" 4 => "L. Harris" 5 => "J. Weidhaas" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/archsurg.143.7.692" "Revista" => array:6 [ "tituloSerie" => "Arch Surg" "fecha" => "2008" "volumen" => "143" "paginaInicial" => "692" "paginaFinal" => "699" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18645113" "web" => "Medline" ] ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0245" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): a prospective, multicentre cohort study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "T. Kuehn" 1 => "I. Bauerfeind" 2 => "T. Fehm" 3 => "B. Fleige" 4 => "M. Hausschild" 5 => "G. Helms" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S1470-2045(13)70166-9" "Revista" => array:6 [ "tituloSerie" => "Lancet Oncol" "fecha" => "2013" "volumen" => "14" "paginaInicial" => "609" "paginaFinal" => "618" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23683750" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0250" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Pathological complete response and long-term clinical benefit in breast cancer: the CTNeoBC pooled analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Cortazar" 1 => "L. Zhang" 2 => "M. Untch" 3 => "K. Mehta" 4 => "J.P. Costantino" 5 => "N. Wolmark" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/S0140-6736(13)62422-8" "Revista" => array:6 [ "tituloSerie" => "Lancet" "fecha" => "2014" "volumen" => "384" "paginaInicial" => "164" "paginaFinal" => "172" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24529560" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0255" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Intraoperative assessment of sentinel lymph node by one-step nucleic acid amplification in breast cancer patients after neoadjuvant treatment reduces the need for a second surgery for axillary lymph node dissection" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Espinosa-Bravo" 1 => "J. Navarro-Cecilia" 2 => "M. Ramos Boyero" 3 => "S. Diaz-Botero" 4 => "B. Dueñas Rodríguez" 5 => "C. Luque López" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.breast.2016.10.002" "Revista" => array:6 [ "tituloSerie" => "Breast" "fecha" => "2016" "volumen" => "31" "paginaInicial" => "40" "paginaFinal" => "45" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27810698" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0260" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with operable breast cancer and positive axillary nodes at initial diagnosis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.C. Rebollo-Aguirre" 1 => "M. Gallego-Peinado" 2 => "R. Sánchez-Sánchez" 3 => "E. Pastor-Pons" 4 => "J. García-García" 5 => "C.E. Chamorro-Santos" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.remn.2013.03.006" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Med Nucl Imagen Mol" "fecha" => "2013" "volumen" => "32" "paginaInicial" => "240" "paginaFinal" => "245" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23684711" "web" => "Medline" ] ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0265" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sentinel lymph node surgery after neoadjuvant chemotherapy is accurate and reduces the need for axillary dissection in breast cancer patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "K.K. Hunt" 1 => "M. Yi" 2 => "E.A. Mittendorf" 3 => "C. Guerrero" 4 => "G.V. Babiera" 5 => "I. Bedrosian" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/SLA.0b013e3181b8fd5e" "Revista" => array:6 [ "tituloSerie" => "Ann Surg" "fecha" => "2009" "volumen" => "250" "paginaInicial" => "558" "paginaFinal" => "566" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19730235" "web" => "Medline" ] ] ] ] ] ] ] ] 11 => array:3 [ "identificador" => "bib0270" "etiqueta" => "12" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sentinel node biopsy in T2 breast cancers larger than 3cm and clinically negative axilla compared with the T1–T2<3cm standard indication" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. Ruano" 1 => "M. Ramos" 2 => "J.R. García-Talavera" 3 => "M.C. García Macías" 4 => "A. Martín de Arriba" 5 => "J.M. González-Orús" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:6 [ "tituloSerie" => "Rev Esp Med Nucl" "fecha" => "2008" "volumen" => "27" "paginaInicial" => "176" "paginaFinal" => "182" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18570859" "web" => "Medline" ] ] ] ] ] ] ] ] 12 => array:3 [ "identificador" => "bib0275" "etiqueta" => "13" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Value of preoperative ultrasound-guided axillary lymph node biopsy for preventing completion axillary lymph node dissection in breast cancer: a systematic review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.C. Diepstraten" 1 => "A.R. Sever" 2 => "C.F. Buckens" 3 => "W.B. Veldhuis" 4 => "T. van Dalen" 5 => "M.A. van den Bosch" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1245/s10434-013-3229-6" "Revista" => array:6 [ "tituloSerie" => "Ann Surg Oncol" "fecha" => "2014" "volumen" => "21" "paginaInicial" => "51" "paginaFinal" => "59" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24008555" "web" => "Medline" ] ] ] ] ] ] ] ] 13 => array:3 [ "identificador" => "bib0280" "etiqueta" => "14" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Axillary staging after neoadjuvant chemotherapy for breast cancer: a pilot study combining sentinel lymph node biopsy with radioactive seed localization of pre-treatment positive axillary lymph nodes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "E.J. Diego" 1 => "P.F. McAuliffe" 2 => "A. Soran" 3 => "K.P. McGuire" 4 => "R.R. Johnson" 5 => "M. Bonaventura" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1245/s10434-015-5052-8" "Revista" => array:6 [ "tituloSerie" => "Ann Surg Oncol" "fecha" => "2016" "volumen" => "23" "paginaInicial" => "1549" "paginaFinal" => "1553" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26727919" "web" => "Medline" ] ] ] ] ] ] ] ] 14 => array:3 [ "identificador" => "bib0285" "etiqueta" => "15" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Improved axillary evaluation following neoadjuvant therapy for patients with node-positive breast cancer using selective evaluation of clipped nodes: implementation of targeted axillary dissection" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.S. Caudle" 1 => "W.T. Yang" 2 => "S. Krishnamurthy" 3 => "E.A. Mittendorf" 4 => "D.M. Black" 5 => "M.Z. Gilcrease" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1200/JCO.2015.64.0094" "Revista" => array:6 [ "tituloSerie" => "J Clin Oncol" "fecha" => "2016" "volumen" => "34" "paginaInicial" => "1072" "paginaFinal" => "1078" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26811528" "web" => "Medline" ] ] ] ] ] ] ] ] 15 => array:3 [ "identificador" => "bib0290" "etiqueta" => "16" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Adding MRI to ultrasound and ultrasound-guided fine-needle aspiration reduces the false-negative rate of axillary lymph node metastasis diagnosis in breast cancer patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "S.J. Hyun" 1 => "E.K. Kim" 2 => "J.H. Yoon" 3 => "H.J. Moon" 4 => "M.J. Kim" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.crad.2015.03.004" "Revista" => array:6 [ "tituloSerie" => "Clin Radiol" "fecha" => "2015" "volumen" => "70" "paginaInicial" => "716" "paginaFinal" => "722" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25917544" "web" => "Medline" ] ] ] ] ] ] ] ] 16 => array:3 [ "identificador" => "bib0295" "etiqueta" => "17" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Semi-quantitative lymph node assessment of 18F-FDG PET/CT in locally advanced breast cancer: Correlation with biological prognostic factors" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.M. García Vicente" 1 => "A. Soriano Castrejón" 2 => "M.A. Cruz Mora" 3 => "A. González Ageitos" 4 => "M.M. Muñoz Sánchez" 5 => "A. León Martín" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00259-012-2244-3" "Revista" => array:6 [ "tituloSerie" => "Eur J Nucl Med Mol Imaging" "fecha" => "2013" "volumen" => "40" "paginaInicial" => "72" "paginaFinal" => "79" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23053321" "web" => "Medline" ] ] ] ] ] ] ] ] 17 => array:3 [ "identificador" => "bib0300" "etiqueta" => "18" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Noninvasive nodal restaging in clinically node positive breast cancer patients after neoadjuvant systemic therapy: a systematic review" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "R.J. Schipper" 1 => "M. Moossdorff" 2 => "R.G.H. Beets-Tan" 3 => "M.L. Smidt" 4 => "M.B. Lobbes" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ejrad.2014.09.020" "Revista" => array:6 [ "tituloSerie" => "Eur J Radiol" "fecha" => "2015" "volumen" => "84" "paginaInicial" => "41" "paginaFinal" => "47" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25458227" "web" => "Medline" ] ] ] ] ] ] ] ] 18 => array:3 [ "identificador" => "bib0305" "etiqueta" => "19" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sentinel lymph node biopsy in patients with operable breast cancer treated with neoadjuvant chemotherapy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A.C. Rebollo-Aguirre" 1 => "M. Gallego-Peinado" 2 => "S. Menjón-Beltrán" 3 => "J. Garcia-Garcia" 4 => "E. Pastor-Pons" 5 => "C.E. Chamorro-Santos" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.remn.2011.04.007" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Med Nucl Imagen Mol" "fecha" => "2012" "volumen" => "31" "paginaInicial" => "117" "paginaFinal" => "123" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21676504" "web" => "Medline" ] ] ] ] ] ] ] ] 19 => array:3 [ "identificador" => "bib0310" "etiqueta" => "20" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Predictive factors and value of ypN+ after neoadjuvant chemotherapy in clinically lymph node-negative breast cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "I. Fukada" 1 => "K. Araki" 2 => "K. Kobayashi" 3 => "T. Shibayama" 4 => "S. Takahashi" 5 => "R. Horii" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0162616" "Revista" => array:5 [ "tituloSerie" => "PLoS One" "fecha" => "2016" "volumen" => "11" "paginaInicial" => "e0162616" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27631393" "web" => "Medline" ] ] ] ] ] ] ] ] 20 => array:3 [ "identificador" => "bib0315" "etiqueta" => "21" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Using ultrasound and palpation for predicting axillary lymph node status following neoadjuvant chemotherapy – results from the multi-center SENTINA trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "L. Schwentner" 1 => "G. Helms" 2 => "V. Nekljudova" 3 => "B. Ataseven" 4 => "I. Bauerfeind" 5 => "N. Ditsch" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.breast.2016.11.012" "Revista" => array:6 [ "tituloSerie" => "Breast" "fecha" => "2016" "volumen" => "31" "paginaInicial" => "202" "paginaFinal" => "207" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27889596" "web" => "Medline" ] ] ] ] ] ] ] ] 21 => array:3 [ "identificador" => "bib0320" "etiqueta" => "22" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Imaging response and residual metastatic axillary lymph node disease after neoadjuvant chemotherapy for primary breast cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "T.J. Hieken" 1 => "J.C. Boughey" 2 => "K.N. Jones" 3 => "S.S. Shah" 4 => "K.N. Glazebrook" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1245/s10434-013-3118-z" "Revista" => array:6 [ "tituloSerie" => "Ann Surg Oncol" "fecha" => "2013" "volumen" => "20" "paginaInicial" => "3199" "paginaFinal" => "3204" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23846781" "web" => "Medline" ] ] ] ] ] ] ] ] 22 => array:3 [ "identificador" => "bib0325" "etiqueta" => "23" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Role of sentinel lymphadenectomy combined with intraoperative ultrasound in the assessment of locally advanced breast cancer after neoadjuvant chemotherapy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "J.C. Yu" 1 => "G.C. Hsu" 2 => "C.B. Hsieh" 3 => "C.P. Yu" 4 => "T.Y. Chao" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1245/s10434-006-9132-7" "Revista" => array:6 [ "tituloSerie" => "Ann Surg Oncol" "fecha" => "2007" "volumen" => "14" "paginaInicial" => "174" "paginaFinal" => "180" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17066228" "web" => "Medline" ] ] ] ] ] ] ] ] 23 => array:3 [ "identificador" => "bib0330" "etiqueta" => "24" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sentinel lymph node biopsy after neoadjuvant chemotherapy is accurate in breast cancer patients with a clinically negative axillary nodal status at presentation" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "P. Gimbergues" 1 => "C. Abrial" 2 => "X. Durando" 3 => "G. le Bouedec" 4 => "F. Cachin" 5 => "F. Penault-Llorca" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1245/s10434-007-9759-z" "Revista" => array:6 [ "tituloSerie" => "Ann Surg Oncol" "fecha" => "2008" "volumen" => "15" "paginaInicial" => "1316" "paginaFinal" => "1321" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18311507" "web" => "Medline" ] ] ] ] ] ] ] ] 24 => array:3 [ "identificador" => "bib0335" "etiqueta" => "25" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sentinel lymph node biopsy after neoadjuvant chemotherapy for advanced breast cancer: results of ganglion sentinelle et chimiothérapie neoadjuvante, a French prospective multicentric study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.M. Classe" 1 => "V. Bordes" 2 => "L. Campion" 3 => "H. Mignotte" 4 => "F. Dravet" 5 => "J. Leveque" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1200/JCO.2008.18.3228" "Revista" => array:6 [ "tituloSerie" => "J Clin Oncol" "fecha" => "2009" "volumen" => "27" "paginaInicial" => "726" "paginaFinal" => "732" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19114697" "web" => "Medline" ] ] ] ] ] ] ] ] 25 => array:3 [ "identificador" => "bib0340" "etiqueta" => "26" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Correlation between clinical nodal status and sentinel lymph node biopsy false negative rate after neoadjuvant chemotherapy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "M. Takahashi" 1 => "H. Jinno" 2 => "T. Hayashida" 3 => "M. Sakata" 4 => "K. Asakura" 5 => "Y. Kitagawa" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1007/s00268-012-1704-z" "Revista" => array:6 [ "tituloSerie" => "World J Surg" "fecha" => "2012" "volumen" => "36" "paginaInicial" => "2847" "paginaFinal" => "2852" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22806206" "web" => "Medline" ] ] ] ] ] ] ] ] 26 => array:3 [ "identificador" => "bib0345" "etiqueta" => "27" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Biopsia selectiva del ganglio centinela tras quimioterapia neoadyuvante en el cáncer de mama: estudio prospectivo multicéntrico para la validación y análisis de subgrupos (GEICAM 2005-07)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "A. Piñero-Madrona" 1 => "M.J. Escudero-Barea" 2 => "F. Fernández-Robayna" 3 => "J.A. Alberro-Adúriz" 4 => "A. García-Fernández" 5 => "F. Vicente-García" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ciresp.2014.01.004" "Revista" => array:6 [ "tituloSerie" => "Cir Esp" "fecha" => "2015" "volumen" => "93" "paginaInicial" => "23" "paginaFinal" => "29" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24560631" "web" => "Medline" ] ] ] ] ] ] ] ] 27 => array:3 [ "identificador" => "bib0350" "etiqueta" => "28" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Timing of the sentinel lymph node biopsy in breast cancer patients receiving neoadjuvant therapy – recommendations for clinical guidance" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:5 [ 0 => "D.B. Fontein" 1 => "W. van de Water" 2 => "J.S. Mieog" 3 => "G.J. Liefers" 4 => "C.J. van de Velde" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.ejso.2013.02.011" "Revista" => array:6 [ "tituloSerie" => "Eur J Surg Oncol" "fecha" => "2013" "volumen" => "39" "paginaInicial" => "417" "paginaFinal" => "424" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23473972" "web" => "Medline" ] ] ] ] ] ] ] ] 28 => array:3 [ "identificador" => "bib0355" "etiqueta" => "29" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "The feasibility and accuracy of sentinel lymph node biopsy in initially clinically node-negative breast cancer after neoadjuvant chemotherapy: a systematic review and meta-analysis" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "C. Geng" 1 => "X. Chen" 2 => "X. Pan" 3 => "J. Li" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1371/journal.pone.0162605" "Revista" => array:5 [ "tituloSerie" => "PLoS One" "fecha" => "2016" "volumen" => "11" "paginaInicial" => "e0162605" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27606623" "web" => "Medline" ] ] ] ] ] ] ] ] 29 => array:3 [ "identificador" => "bib0360" "etiqueta" => "30" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sentinel lymph node surgery after neoadjuvant chemotherapy in patients with node-positive breast cancer: the ACOSOG Z1071 (Alliance) clinical trial" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.C. Boughey" 1 => "V.J. Suman" 2 => "E.A. Mittendorf" 3 => "G.M. Ahrendt" 4 => "L.G. Wilke" 5 => "B. Taback" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1001/jama.2013.278932" "Revista" => array:6 [ "tituloSerie" => "JAMA" "fecha" => "2013" "volumen" => "310" "paginaInicial" => "1455" "paginaFinal" => "1461" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24101169" "web" => "Medline" ] ] ] ] ] ] ] ] 30 => array:3 [ "identificador" => "bib0365" "etiqueta" => "31" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sentinel node biopsy after neoadjuvant chemotherapy in biopsy-proven node-positive breast cancer: the SN FNAC study" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.F. Boileau" 1 => "B. Poirier" 2 => "M. Basik" 3 => "C.M. Holloway" 4 => "L. Gaboury" 5 => "L. Sideris" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1200/JCO.2014.55.7827" "Revista" => array:6 [ "tituloSerie" => "J Clin Oncol" "fecha" => "2015" "volumen" => "33" "paginaInicial" => "258" "paginaFinal" => "264" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25452445" "web" => "Medline" ] ] ] ] ] ] ] ] 31 => array:3 [ "identificador" => "bib0370" "etiqueta" => "32" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Validation of sentinel lymph node biopsy in breast cancer women N1–N2 with complete axillary response after neoadjuvant chemotherapy. Multicentre study in Tarragona" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D. Carrera" 1 => "M. de la Flor" 2 => "J. Galera" 3 => "K. Amillano" 4 => "M. Gomez" 5 => "V. Izquierdo" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.remn.2015.12.007" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Med Nucl Imagen Mol" "fecha" => "2016" "volumen" => "35" "paginaInicial" => "221" "paginaFinal" => "225" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26848141" "web" => "Medline" ] ] ] ] ] ] ] ] 32 => array:3 [ "identificador" => "bib0375" "etiqueta" => "33" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Is sentinel lymph node biopsy a viable alternative to complete axillary dissection following neoadjuvant chemotherapy in women with node-positive breast cancer at diagnosis? An updated meta-analysis involving 3,398 patients" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:6 [ 0 => "H. El Hage Chehade" 1 => "H. Headon" 2 => "O. el Tokhy" 3 => "J. Heeney" 4 => "A. Kasem" 5 => "K. Mokbel" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.amjsurg.2016.07.018" "Revista" => array:6 [ "tituloSerie" => "Am J Surg" "fecha" => "2016" "volumen" => "212" "paginaInicial" => "969" "paginaFinal" => "981" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27671032" "web" => "Medline" ] ] ] ] ] ] ] ] 33 => array:3 [ "identificador" => "bib0380" "etiqueta" => "34" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Axillary ultrasound after neoadjuvant chemotherapy and its impact on sentinel lymph node surgery: results from the American College of Surgeons Oncology Group Z1071 Trial (Alliance)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.C. Boughey" 1 => "K.V. Ballman" 2 => "K.K. Hunt" 3 => "L.M. McCall" 4 => "E.A. Mittendorf" 5 => "G.M. Ahrendt" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1200/JCO.2014.57.8401" "Revista" => array:6 [ "tituloSerie" => "J Clin Oncol" "fecha" => "2015" "volumen" => "33" "paginaInicial" => "3386" "paginaFinal" => "3393" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25646192" "web" => "Medline" ] ] ] ] ] ] ] ] 34 => array:3 [ "identificador" => "bib0385" "etiqueta" => "35" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Sentinel node biopsy after neoadjuvant chemotherapy in breast cancer. Its relation with molecular subtypes" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. Ruano" 1 => "M. Ramos" 2 => "J.R. García-Talavera" 3 => "T. Ramos" 4 => "A.S. Rosero" 5 => "J.M. González-Orus" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.remn.2014.04.003" "Revista" => array:6 [ "tituloSerie" => "Rev Esp Med Nucl Imagen Mol" "fecha" => "2014" "volumen" => "33" "paginaInicial" => "340" "paginaFinal" => "345" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24856234" "web" => "Medline" ] ] ] ] ] ] ] ] 35 => array:3 [ "identificador" => "bib0390" "etiqueta" => "36" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Selective sentinel node biopsy after intratumour administration of radiotracer in breast cancer patients treated with neoadjuvant chemotherapy in relation to the level of tumour response" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "R. Díaz-Expósito" 1 => "L. Martí-Bonmatí" 2 => "O. Burgués" 3 => "I. Casáns-Tormo" 4 => "B. Bermejo-de Las Heras" 5 => "A. Julve-Parreño" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.remn.2016.04.005" "Revista" => array:7 [ "tituloSerie" => "Rev Esp Med Nucl Imagen Mol" "fecha" => "2016" "volumen" => "35" "paginaInicial" => "358" "paginaFinal" => "364" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27246292" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0165587613003625" "estado" => "S300" "issn" => "01655876" ] ] ] ] ] ] ] 36 => array:3 [ "identificador" => "bib0395" "etiqueta" => "37" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Nomograms for predicting axillary response to neoadjuvant chemotherapy in clinically node-positive patients with breast cancer" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J. Vila" 1 => "E.A. Mittendorf" 2 => "G. Farante" 3 => "R.L. Bassett" 4 => "P. Veronesi" 5 => "V. Galimberti" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1245/s10434-016-5277-1" "Revista" => array:6 [ "tituloSerie" => "Ann Surg Oncol" "fecha" => "2016" "volumen" => "23" "paginaInicial" => "3501" "paginaFinal" => "3509" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27216742" "web" => "Medline" ] ] ] ] ] ] ] ] 37 => array:3 [ "identificador" => "bib0400" "etiqueta" => "38" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Initial results with preoperative tattooing of biopsied axillary lymph nodes and correlation to sentinel lymph nodes in breast cancer patients" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "N. Choy" 1 => "J. Lipson" 2 => "C. Porter" 3 => "M. Ozawa" 4 => "A. Kieryn" 5 => "S. Pal" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1245/s10434-014-4034-6" "Revista" => array:6 [ "tituloSerie" => "Ann Surg Oncol" "fecha" => "2015" "volumen" => "22" "paginaInicial" => "377" "paginaFinal" => "382" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25164040" "web" => "Medline" ] ] ] ] ] ] ] ] 38 => array:3 [ "identificador" => "bib0405" "etiqueta" => "39" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Identification and resection of clipped node decreases the false-negative rate of sentinel lymph node surgery in patients presenting with node-positive breast cancer (T0-4N1-2) who receive neoadjuvant chemotherapy. Results from ACOSOG Z1071 (Alliance)" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.C. Boughey" 1 => "K.V. Ballman" 2 => "H.T. Le-Petross" 3 => "L.M. McCall" 4 => "E.A. Mittendorf" 5 => "G.M. 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Continuing Education

Review of the role of the sentinel node biopsy in neoadjuvant chemotherapy in women with breast cancer and negative or positive axillary node at diagnosis

Actualización de la biopsia del ganglio centinela tras quimioterapia neoadyuvante en el cáncer de mama sin y con afectación ganglionar al diagnóstico

R. Ruano Péreza,

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rruano@saludcastillayleon.es

Corresponding author.

, A.C. Rebollo Aguirreb, P. García-Talavera San Miguelc, R. Díaz Expósitod, S. Vidal-Sicarte, J.M. Cordero Garcíaf, D. Carrera Salazarg, M.E. Rioja Martính, Grupo de Trabajo de Cirugía Radioguiada de la SEMNIM

a Servicio de Medicina Nuclear, Hospital Clínico Universitario de Valladolid, Valladolid, Spain

b Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, Spain

c Servicio de Medicina Nuclear, Hospital Universitario de Salamanca, Salamanca, Spain

d Servicio de Medicina Nuclear, Hospital Clínico Universitario de Valencia, Valencia, Spain

e Servicio de Medicina Nuclear, Hospital Clínico de Barcelona, Barcelona, Spain

f Servicio de Medicina Nuclear, Hospital Universitario La Paz, Madrid, Spain

g Servicio de Medicina Nuclear, Hospital Universitario de Tarragona Joan XXIII, Tarragona, Spain

h Servicio de Medicina Nuclear, Hospital Universitario Ramón y Cajal, Madrid, Spain

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            "identificador" => "aff0040"
          ]
        ]
        "correspondencia" => array:1 [
          0 => array:3 [
            "identificador" => "cor0005"
            "etiqueta" => "&#8270;"
            "correspondencia" => "Corresponding author&#46;"
          ]
        ]
      ]
    ]
    "titulosAlternativos" => array:1 [
      "es" => array:1 [
        "titulo" => "Actualizaci&#243;n de la biopsia del ganglio centinela tras quimioterapia neoadyuvante en el c&#225;ncer de mama sin y con afectaci&#243;n ganglionar al diagn&#243;stico"
      ]
    ]
    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">In aim of this review is to describe the importance of sentinel lymph node biopsy &#40;SLNB&#41; in patients with breast cancer &#40;BC&#41; treated with neoadjuvant chemotherapy &#40;NAC&#41; prior to surgery&#46;</p><p id="par0010" class="elsevierStylePara elsevierViewall">The objective of the Radioguided Surgery Working Group of the Spanish Society of Nuclear Medicine and Molecular Imaging is to describe the situation of this indication in this subgroup of patients with advanced BC and establish a series of recommendations for safely and effectively performing SLNB using radioisotopic techniques based on studies published in the literature&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">Historically&#44; Nuclear Medicine in our country has played a fundamental role in the development of SLNB in BC at both an international and national level&#46; Since 2001 several multidisciplinary consensus on the management of BC have been published in Spain&#44; considering SLNB as the best axillary staging technique&#44; after having replaced systematic axilliary lymph node dissection more than 10 years ago&#46;<a class="elsevierStyleCrossRef" href="#bib0215"><span class="elsevierStyleSup">1</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Indeed&#44; based on the NSABP B-32 and the recently updated ACOSOG Z0011studies published in 2010 on the treatment of early stage BC&#44; SLNB allows adequate lymph node staging and may even avoid the need for posterior axillary lymph node dissection in cases with lymph node involvement limited to one or two lymph nodes candidates for breast-conserving surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0220"><span class="elsevierStyleSup">2&#8211;4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">In view of the relevance of ruling out avoidable axillary lymph node dissection in patients with BC&#44; Breast Cancer Units have progressively widened the indications of SLNB to larger sized&#44; multicentric and&#47;or multifocal tumors&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">5</span></a> These tumors involve greater resection of breast tissue which&#44; on occasions&#44; requires complete mastectomy leading to subsequent functional and emotional damage to the woman&#46; The use of chemotherapeutic agents in neoadjuvant treatment approaches prior to surgery is increasingly more frequent in order to preserve the breast&#46;</p><p id="par0030" class="elsevierStylePara elsevierViewall">Based on greater knowledge of the molecular subtypes of the tumors which allows not only preservation of the breast gland but also achieves a higher percentage of pathological complete response &#40;pCR&#41;&#44; neoadjuvant methods are now increasingly more frequently used as a step prior to surgery in most centers in our country&#46; In this context&#44; the Departments of Nuclear Medicine play a predominant role&#44; and axillary lymph node evaluation by SLNB has also been included in the staging process of BC&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Indications for selective sentinel lymph node biopsy</span><p id="par0035" class="elsevierStylePara elsevierViewall">Selective SLNB is indicated in all cases of BC except in inflammatory type carcinomas in which the absence of axillary involvement is specifically observed at diagnosis or after neoadjuvant treatment&#46; This assumption is fundamental to perform the procedure with maximum guarantees within the context of health care&#46;</p><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Indication pre- or post-neoadjuvant chemotherapy</span><p id="par0040" class="elsevierStylePara elsevierViewall">In most centers in our country SLNB is carried out during surgery after neoadjuvant treatment&#46; However&#44; some centers prefer to do this procedure during initial staging&#46; Both strategies are valid since they fulfill the main objective of SLNB which is to avoid unnecessary lymph node dissection in women without lymph node disease&#44; although it is clear that important differences must be taken into account&#46; The most relevant is the presence or not of clinical axillary involvement prior to neoadjuvant therapy&#46; It is evident that on histological confirmation by metastatic lymph node puncture&#44; SLNB prior to NAC is contraindicated and should only be performed afterwards&#46; However&#44; in the absence of clinical suspicion or ultrasound evidence of lymph node involvement&#44; SLNB may be considered both before and after chemotherapy&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">The performance of SLNB before neoadjuvant therapy can establish the presence of lymph node involvement prior to NAC and determine the possible need for axillary lymph node dissection at the time of the second surgery and whether adjuvant axillary radiotherapy is indicated&#46; This allows better planning regarding the type of surgical intervention to perform&#44; especially if immediate reconstruction is foreseen since the results of the reconstruction may be altered if mammary and&#47;or axillary radiotherapy is carried out&#46;<a class="elsevierStyleCrossRef" href="#bib0240"><span class="elsevierStyleSup">6</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">To the contrary&#44; in this surmise there is the disadvantage of submitting patients to 2 surgical interventions&#59; one for sentinel lymph node &#40;SLN&#41; resection and another after neoadjuvant therapy at the mammary and axillary level in cases in which the SLN is affected&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Another disadvantage is that patients never benefit from the effect of chemotherapy to the lymph nodes since axillary lymph node dissection is performed in all the cases with SLN involvement at diagnosis&#44; increasing the morbidity associated with the procedure&#46; The option of performing a second SLNB in this case is a strategy which is neither viable nor safe&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">7</span></a> In addition&#44; this ruling out of the possibility of complete axillary response implies the paradox of having to perform axillary lymph node dissection in patients with pCR after NAC of the breast&#44; which occurs in 33&#46;6&#37; of triple negative tumors and up to 50&#37; of human epidermal growth factor receptor 2 &#40;HER2&#41; positive tumors treated with trastuzumab&#46;<a class="elsevierStyleCrossRef" href="#bib0250"><span class="elsevierStyleSup">8</span></a></p><p id="par0060" class="elsevierStylePara elsevierViewall">The second option is to perform the SLNB at the end of neoadjuvant treatment&#46; In this case the first advantage is that the procedure is carried out in a single surgical intervention&#44; with intraoperative use of one-step nucleic acid amplification &#40;OSNA&#41; being feasible for the study of the SLN&#46;<a class="elsevierStyleCrossRef" href="#bib0255"><span class="elsevierStyleSup">9</span></a> In addition to this advantage&#44; there is the possibility of salvage treatment in women with lymph node involvement at diagnosis who have shown complete response to chemotherapy&#44; which occurs in 33&#8211;50&#37; of the patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0250"><span class="elsevierStyleSup">8&#44;10</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">It should be noted that from a methodological point of view there are no large pre- or post-NAC differences with the radioactive isotope technique&#44; although as described later&#44; the injection of the radiotracer and the detection rate may differ according to the technique performed&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In the current context of surgical management of BC which prioritizes conservation of the breast and greater preservation of the axilla&#44; it seems more coherent to perform the SLNB after neoadjuvant treatment&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">Nonetheless&#44; as mentioned above&#44; both possibilities are feasible and the decision is made by multidisciplinary committees in each hospital which consider the best option for each individual case as stated in the informed consent forms signed by the patients&#46;</p></span></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Evaluation of the axillary lymph nodes</span><p id="par0080" class="elsevierStylePara elsevierViewall">In order to specify and ensure that the process is as effective as possible&#44; thorough evaluation of the axillary lymph nodes is necessary at diagnosis as well as after neoadjuvant treatment&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">It is well known that the possibility of axillary lymph node involvement is directly related to the size of the primary tumor&#44; and thus&#44; the proportion of axillary metastasis in T1 tumors of less than 1<span class="elsevierStyleHsp" style=""></span>cm is of around 15&#37;&#44; being 20&#37; in T1c&#44; 30&#8211;35&#37; in T2 tumors less than 3<span class="elsevierStyleHsp" style=""></span>cm and 45&#8211;50&#37; in tumors larger than 3<span class="elsevierStyleHsp" style=""></span>cm&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">11&#44;12</span></a> Therefore&#44; in the context of a large sized tumor requiring neoadjuvant treatment&#44; in depth evaluation of the axillary lymph nodes should be performed&#44; including physical examination and imaging techniques&#46;</p><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Axillary lymph node evaluation prior to neoadjuvant chemotherapy</span><p id="par0090" class="elsevierStylePara elsevierViewall">Ultrasound is the imaging technique of choice at diagnosis for detecting axillary lymph node disease&#44; presenting a sensitivity of 50&#8211;55&#37;&#46; This procedure is simple and also helps to guide the biopsy puncture of lymph nodes suspected of malignancy&#46;<a class="elsevierStyleCrossRef" href="#bib0275"><span class="elsevierStyleSup">13</span></a></p><p id="par0095" class="elsevierStylePara elsevierViewall">It is important to point out that in the same ultrasound study a marker may be placed in the same lymph node punctured similar to the marker systematically placed in the breast tumor to evaluate the grade of response to therapy and facilitate its localization during surgery&#46; This strategy of marking the lymph node reduces the rate of false negative results in the SLNB procedure&#46;<a class="elsevierStyleCrossRefs" href="#bib0280"><span class="elsevierStyleSup">14&#44;15</span></a></p><p id="par0100" class="elsevierStylePara elsevierViewall">In the staging of locally advanced BC&#44; magnetic resonance &#40;MR&#41; is increasingly used to assess the possible multifocality and multicentricity of the tumor as well as its relationship with neighboring structures such as the thoracic wall which conditions the surgical approach to be used&#46; In addition&#44; the axillary lymph nodes may be evaluated in the same procedure&#44; increasing the sensitivity of ultrasonography up to 62&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0290"><span class="elsevierStyleSup">16</span></a></p><p id="par0105" class="elsevierStylePara elsevierViewall">Another imaging technique is positron emission tomography &#40;PET&#41; which increasingly more groups are using in the staging and evaluation of response to treatment prior to surgery&#46; PET&#47;CT with <span class="elsevierStyleSup">18</span>F-fluorodeoxyglucose &#40;<span class="elsevierStyleSup">18</span>F-FDG&#41; provides information related to tumor load in the breast and axilla from a metabolic point of view&#44; having a sensitivity of 30&#8211;40&#37; in the detection of lymph node infiltration&#46; Both the metabolic grade estimated by the maximum standard uptake value &#40;SUVmax&#41; of the breast and the axilla are correlated with factors of worse prognosis &#40;negative hormone receptors&#44; overexpression of p53 and the triple negative group&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0295"><span class="elsevierStyleSup">17</span></a> Moreover&#44; its high sensitivity for detecting involvement in other organs in whole body scans within the context of a locally advanced malignant tumor should be considered&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Axillary lymph node evaluation post-neoadjuvant chemotherapy</span><p id="par0110" class="elsevierStylePara elsevierViewall">At present&#44; no imaging technique is sufficiently accurate to identify axillary pCR in patients with BC treated with NAC&#46;<a class="elsevierStyleCrossRef" href="#bib0300"><span class="elsevierStyleSup">18</span></a> Nonetheless&#44; evaluation of the axilla using imaging techniques after completing neoadjuvant treatment is fundamental for deciding the SLNB technique with maximum guarantees&#46; The criteria of absence of known axillary disease should prevail before undergoing the SLNB procedure&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In cN0 BC patients with axillary involvement a new study of the axilla is not usually performed after completing NAC likely based on the uncertainty of possibly finding an inadequate initial evaluation&#46; However&#44; since the proportion of lymph node metastasis after NAC is 31&#8211;35&#37;&#44;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">19</span></a> the utility of performing a new evaluation such as ultrasound should not be ignored in order to detect persistence or even disease progression&#44; especially in patients with bad response of the primary tumor or cancers of the luminal subtype&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">20</span></a></p><p id="par0120" class="elsevierStylePara elsevierViewall">The axilla should be studied in all axillary lymph node positive &#40;cN&#43;&#41; patients after completion of NAC&#46; At present&#44; the sensitivity of the techniques available &#40;ultrasound&#44; MR&#44; <span class="elsevierStyleSup">18</span>F-FDG PET&#41; varies greatly according to the different studies&#44; with some considering them to be suboptimal with values from 23&#46;9 to 34&#46;0&#37;<a class="elsevierStyleCrossRef" href="#bib0315"><span class="elsevierStyleSup">21</span></a> and other more optimistic studies reporting values of around 61&#8211;69&#46;8&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0320"><span class="elsevierStyleSup">22</span></a></p><p id="par0125" class="elsevierStylePara elsevierViewall">In any case&#44; ultrasonography should be obligatory in all cases in hospitals in our country in both axillary node-negative patients and those suspected of disease progression&#46; The use of MR and <span class="elsevierStyleSup">18</span>F-FDG PET can be considered in patients who underwent evaluation at diagnosis or in those with clinical suspicion of progression&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Sentinel lymph node biopsy technique</span><p id="par0130" class="elsevierStylePara elsevierViewall">The SLNB technique in BC involves the injection of a radiotracer&#44; the study of the scintigraphic images and posterior intraoperative localization using a gamma detection probe&#46;<a class="elsevierStyleCrossRef" href="#bib0235"><span class="elsevierStyleSup">5</span></a></p><p id="par0135" class="elsevierStylePara elsevierViewall">Regardless of whether SLNB is performed prior to or after NAC&#44; the procedure is similar to that used in early stage tumors&#44; although several considerations must be taken into account&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Previous planning implies knowledge of the case to be treated&#44; the type and localization of the tumor&#44; the possibility of previous lymph node involvement and the type of response to chemotherapy in both the breast and axilla&#46; In this planning it is important to respect an adequate length of exploration and organize the operating room in order to guarantee the greatest probability of success&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The dose of the radiotracer to be used is conditioned by the time until surgery with an approximate radioactivity of 37&#8211;111<span class="elsevierStyleHsp" style=""></span>MBq &#40;1&#8211;3<span class="elsevierStyleHsp" style=""></span>mCi&#41; of particle labeled with <span class="elsevierStyleSup">99m</span>Tc&#46; The radiotracers most commonly used in Spain are nanocolloids and rhenium sulfide nanocolloid&#46;</p><p id="par0150" class="elsevierStylePara elsevierViewall">The injection of the radiotracer is determined by the response obtained after neoadjuvant treatment&#46; In cases with partial response or no tumor response the injection is preferably peritumoral or intratumoral with periareolar injection being reserved for when there is no drainage and reinjection is necessary&#46; In non palpable lesions and whenever possible&#44; the best option is ultrasound or stereotactic guided intratumoral injection&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">In cases with complete tumoral response the injection can be periareolar or&#44; if a marker has been placed in the primary tumor&#44; it is preferable for the injection to be in this breast quadrant or even near the marker&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">Gamma camera detection should be done with the acquisition of planar images anterior and lateral to the thorax and axilla&#44; evaluating the possibility of additional oblique projections or single-photon emission computed tomography &#40;SPECT&#41;&#47;CT studies in each case&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">The report should include the number of lymph nodes visualized&#44; as well as their location in the axillary lymph node chain and the internal mammary or intramammary lymph node chain&#44; and cutaneous marking of the projection of the SLN of greatest importance &#40;because of its activity or proximity to the tumor&#41; should be made&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">In this phase of the procedure it is important to take into consideration the possibility of no drainage in any lymph node chain&#46; In these locally advanced tumors lymphatic drainage of the breast is often slow and&#44; on occasions&#44; there may be lymph node blockage due to malignant infiltration despite the ultrasound evaluation&#46; Therefore reinjection may therefore be necessary in some cases&#44; with a periareolar site being preferable in this scenario&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Occasionally the drainage obtained is only of the internal mammary lymph node chain and less frequently only of one intramammary lymph node&#46; These 2 situations imply the impossibility of adequately staging the axilla&#44; and thus&#44; the recommendation is to also reinject the patient via the periareolar route in order to visualize the SLN corresponding to the axillary lymph node chain&#46; If there is no axillary drainage after reinjection the most correct action would be to perform axillary lymph node dissection to complete the staging&#46;</p><p id="par0180" class="elsevierStylePara elsevierViewall">The absence of drainage is especially relevant in patients with lymph node involvement prior to surgery since it usually indicates the persistence of important tumoral load in the axilla which has not been detected in the imaging studies&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">No visualization of drainage in the lymphoscintigraphy does not imply ruling out detection with a gamma detection probe&#46; However&#44; the surgeon should be informed to evaluate the use of a vital blue type stain to increase possible intraoperative detection&#46;</p><p id="par0190" class="elsevierStylePara elsevierViewall">Intraoperative localization with a gamma detection probe involves resection of the lymph node&#40;s&#41; with significant radioactivity coinciding with those previously visualized in the scintigraphy&#46; Based on their localization and grade of activity&#44; it is possible to determine the SLN&#40;s&#41; and accessory lymph nodes&#46;</p><p id="par0195" class="elsevierStylePara elsevierViewall">In general&#44; one or two lymph nodes are resected in women with early stage BC&#46; The number of lymph nodes resected in locally advanced BC is greater in both patients with and without previous lymph node involvement&#46; This is sometimes conditioned by an excess of zealousness and by not wanting to obtain a false negative result in the axillary staging&#46; In this sense the surgeon should have access to the lymphoscintigraphy images and it is recommendable to have a nuclear medicine specialist available during the surgical procedure to have consensus related to the need or not to continue to resect lymph nodes with low or null radioactivity&#46; Within the context of reducing false negative results&#44; the marking of the metastatic lymph node pre-NAC is becoming more widely practiced to ensure that it is always resected together with the SLNs&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">The surgical management of lymph node&#40;s&#41; of the internal mammary lymph node and intramammary lymph node chains in BC pre- and post-chemotherapy should be performed according to the usual procedure of each hospital&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Validation of the technique</span><p id="par0205" class="elsevierStylePara elsevierViewall">There are several national and international validation studies in patients treated with NAC with and without previous axillary lymph node involvement&#46;</p><p id="par0210" class="elsevierStylePara elsevierViewall">The detection rates should be taken into account&#44; and especially&#44; the false negative ratio based on the result obtained after completing axillary lymph node dissection&#46;</p><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Patients with lymph node involvement prior to neoadjuvant chemotherapy</span><p id="par0215" class="elsevierStylePara elsevierViewall">Few studies have evaluated the percentages of identification and false negative results of the SLN in cN0 patients pre-NAC&#46; <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a> shows the most relevant studies individually and the 2 most recent metaanalyses published on this subject&#46;<a class="elsevierStyleCrossRefs" href="#bib0265"><span class="elsevierStyleSup">11&#44;19&#44;23&#8211;29</span></a> The metaanalysis of 2013 included 17 studies &#40;from 2001 to 2009&#41; with a total of 1738 patients and established the detection rate at 95&#37; and that of false negative results at 11&#46;4&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">28</span></a> The second metaanalysis was done in 2016 and included 16 studies &#40;from 2000 to 2015&#44; including 2 in our country&#41; reporting a detection rate of 96&#37; and a false negative rate of 6&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">29</span></a></p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0220" class="elsevierStylePara elsevierViewall">The study of greatest diffusion and relevance is that by Hunt et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">11</span></a> who compared 3171 patients with clinically node-negative axilla results of patients undergoing the usual SLNB without NAC with 575 patients in whom SLNB was performed after NAC&#46; They concluded that there were no statistically significant differences in either the detection rate &#40;99&#37; vs&#46; 97&#46;4&#37;&#41; or the false negative rate &#40;4&#46;1 vs&#46; 5&#46;9&#37;&#41;&#44; and that after 47 months of follow up the percentage of axillary recurrence was 1&#46;2&#37; in the post-NAC group&#46;</p><p id="par0225" class="elsevierStylePara elsevierViewall">Therefore&#44; both the efficacy and safety of SLNB after NAC has been demonstrated in patients with clinically node-negative axilla results at diagnosis&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">It is important to take into account that tumor response to NAC varies according to the molecular subtype&#44; and that likewise&#44; this facilitates the possibility of axillary lymph node involvement&#46; Luminal tumors are the most numerous and present the lowest grade of tumor response which is correlated with greater lymph node involvement&#46; In cN0 patients&#44; persistence of tumoral disease in the breast &#40;ypTinv&#41; and the luminal subtype are factors which determine lymph node involvement after NAC&#46; In addition&#44; an age &#62;49 years&#44; large tumors&#44; histological grade III and lymph node involvement after NAC &#40;ypN&#43;&#41; are prognostic factors of lower disease-free survival&#44; the latter also being considered to be an independent prognostic factor of lower overall survival&#46;<a class="elsevierStyleCrossRef" href="#bib0310"><span class="elsevierStyleSup">20</span></a></p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0070">Patients with axillary involvement prior to neoadjuvant chemotherapy</span><p id="par0235" class="elsevierStylePara elsevierViewall"><a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a> shows the most relevant individual studies and the 2 metaanalyses with the largest number of patients&#46;<a class="elsevierStyleCrossRefs" href="#bib0245"><span class="elsevierStyleSup">7&#44;10&#44;23&#44;30&#8211;33</span></a> The most recent metaanalysis collected information from 19 studies &#40;2 from Spanish groups&#41; including a total of 3398 patients&#46; In this metaanalysis the global percentage of SLN detection was 90&#46;9&#37; with 13&#37; of false negative results&#44; achieving pathological complete axillary response &#40;ypN0&#41; in 47&#37; of the patients&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">33</span></a></p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia><p id="par0240" class="elsevierStylePara elsevierViewall">The 3 large studies with axillary lymph node involvement prior to NAC are the ACOSOG Z1071&#44; the SENTINA study&#44; and the SN FNAC study&#46;</p><p id="par0245" class="elsevierStylePara elsevierViewall">The ACOSOG Z1071 study reported a SLN detection rate of 92&#46;9&#37; visualizing one SLN in 12&#37;&#44; 2 SLNs in 23&#46;8&#37; and 3 SLNs or more in 57&#46;3&#37;&#46; After NAC axillary pCR of 41&#37; was achieved&#44; with these patients benefitting from SLNB after NAC&#46; In the group of cN1&#43; patients in whom 2 or more SLNs were resected and who underwent axillary lymph node dissection the rate of false negative results was 12&#46;6&#37;&#46; The molecular subtype was determinant for achieving axillary pCR&#44; being 49&#46;4&#37; in the triple negative group&#44; 64&#46;7&#37; in HER2&#43; and 21&#46;1&#37; in the subtype with positive hormone receptors and HER-&#46;</p><p id="par0250" class="elsevierStylePara elsevierViewall">The ACOSOG Z1071 study included patients without complete clinical axillary response&#44; 12&#37; of whom had palpable lymph nodes and ultrasonography was not used to discriminate patients who should not have been in the group with SLN&#46; <span class="elsevierStyleItalic">A posteriori</span>&#44; in a subgroup of 611 patients the rate of false negative results would have reduced from 12&#46;6&#37; to 9&#46;8&#37; based on a suspicious ultrasonography&#46;<a class="elsevierStyleCrossRef" href="#bib0380"><span class="elsevierStyleSup">34</span></a></p><p id="par0255" class="elsevierStylePara elsevierViewall">The German SENTINA study included a study arm of 592 patients with axillary lymph node involvement prior to NAC&#46; Of these&#44; 474 presented clinical response and were staged with SLN&#46; This study reported the lowest percentage of detection of 80&#46;1&#37; with a rate of false negative results of 14&#46;2&#37;&#44; conditioned by the number of lymph nodes resected which was only less than 10&#37; when 3 or more SLNs were resected &#40;8&#46;6&#37;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">7</span></a></p><p id="par0260" class="elsevierStylePara elsevierViewall">The SN FNAC study performed in 2015 included 153 patients with previous histological confirmation of axillary lymph node involvement&#46; The detection rate was 87&#46;6&#37; with a false negative rate of 13&#46;7&#37; which reduced to 8&#46;4&#37; on considering the presence of micrometastasis in the SLN as an indication for axillary lymph node dissection&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">31</span></a></p><p id="par0265" class="elsevierStylePara elsevierViewall">The results of these 3 studies support the feasibility of SLNB after NAC in patients with positive lymph nodes prior to therapy&#46; However&#44; in order to optimize the results several steps should be followed&#58; adequate selection of patients &#40;T1-3N1&#41;&#44; use of a combined technique for lymphatic mapping &#40;radiotracer<span class="elsevierStyleHsp" style=""></span>&#43;<span class="elsevierStyleHsp" style=""></span>staining&#41;&#44; resection of more than 2 SLNs&#44; placement of a clip in the pathological lymph node and identification and resection during SLNB of this lymph node and consider immunohistochemistry in the SLN and complete axillary lymph node dissection even if the result of the SLN is isolated tumor cells&#47;micrometastasis&#46;</p><p id="par0270" class="elsevierStylePara elsevierViewall">Different groups in our country have validated and are therapeutically applying the SLNB technique&#44; achieving detection rates greater than 90&#37;&#46; With the use of OSNA they are studying the possibility of metastasis in the SLN without increasing the rate of axillary lymph node recurrence&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">32</span></a> It has been shown that axillary lymph node dissection can be avoided in these patients&#44; salvaging 35&#37; of luminal tumors and 66&#37; of the HER2&#43; group based on the molecular subtype&#46;<a class="elsevierStyleCrossRefs" href="#bib0385"><span class="elsevierStyleSup">35&#44;36</span></a></p><p id="par0275" class="elsevierStylePara elsevierViewall">It is important to point out that in the case of axillary lymph node involvement prior to NAC there are studies elaborating nomograms to predict the possibility of achieving complete axillary response &#40;ypN0&#41;&#46; The group of Vila et al&#46;<a class="elsevierStyleCrossRef" href="#bib0395"><span class="elsevierStyleSup">37</span></a> evaluated 584 cT1-T4N1M0 cases with axillary pCR of 37&#37; and found that grade 3 &#40;odds ratio&#58; 13&#46;4&#41;&#44; HER2&#43; &#40;odds ratio&#58; 4&#46;7&#41; estrogen receptor negative &#40;ER&#8722;&#41; &#40;odds ratio&#58; 3&#46;5&#41; and progesterone receptor negative &#40;PR&#8722;&#41; &#40;odds ratio&#58; 4&#46;3&#41; were predictors of response&#46;</p></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0075">Marking the metastatic lymph node biopsied prior to neoadjuvant chemotherapy</span><p id="par0280" class="elsevierStylePara elsevierViewall">As mentioned previously&#44; marking of the metastatic lymph node biopsied prior to NAC is increasingly more frequent since it seems logical and intuitive to consider that this axillary lymph node is the best to evaluate response to NAC&#46; This strategy ensures resection of the lymph node and reduces the rate of false negative results&#44; therefore the National Comprehensive Cancer Network recommends the marking of positive biopsied lymph nodes in order to posteriorly verify their resection in the definitive axillary lymph node surgery&#46;</p><p id="par0285" class="elsevierStylePara elsevierViewall">Different marking methods of the lymph node during the pre-NAC biopsy have been described&#46; These methods consist in placing a metallic clip or a radioactive iodine 125 &#40;<span class="elsevierStyleSup">125</span>I&#41; seed inside the lymph node or tattoo the node with a carbon particle suspension&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">The possibility of tattooing the biopsied lymph node with a carbon particle suspension was recently described in 28 patients &#40;12 after NAC&#41;&#46; This was done at the same time as the SLNB technique&#44; and in 27 of the 28 cases the marked node was visualized&#44; being concordant with the SLN in all except one case without NAC&#46; This is therefore a promising technique&#44; although it is similar to the use of other stains and its application requires validation in future studies&#46;<a class="elsevierStyleCrossRef" href="#bib0400"><span class="elsevierStyleSup">38</span></a></p><p id="par0295" class="elsevierStylePara elsevierViewall">The method most frequently used is the placement of a metallic clip which facilitates control with imaging studies evaluating patient response to NAC&#46; In the ACOSOG Z1071 study &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41; the biopsied lymph node was clipped in 32&#37; of a subgroup of 203 patients recently analyzed&#46; Of these&#44; the location of the clipped node was registered in 167 patients &#40;127 in the SLN and 40 in the lymph nodes of the axillary lymph node dissection&#41;&#46; They found that when the marked lymph node was included among the SLNs the rate of false negative results was 7&#46;2&#37;&#44; and when it was not included the false negative rate was 26&#46;9&#37;&#46; These results improved when the patients were cN1 with 2 or more resected SLNs&#58; 6&#46;8&#37; if the clipped lymph node was included among the SLNs and 19&#37; when it was not among the SLNs&#46; These authors concluded that clipping of the positive lymph node biopsied and its recovery during surgery reduced the rate of false negative results of the SLNB after NAC&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">39</span></a></p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0300" class="elsevierStylePara elsevierViewall">However&#44; intraoperative localization of the clipped lymph node is not easy despite being ultrasonographically visible&#46; Therefore&#44; the group of Plecha et al&#46; proposed that a second marking procedure performed using a surgical wire several days prior to surgery increases the possibility of resection of the clipped lymph node from 83&#46;3&#37; to 97&#46;0&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0410"><span class="elsevierStyleSup">40</span></a> Another strategy&#44; discussed below&#44; is the use of a <span class="elsevierStyleSup">125</span>I seed to mark the lymph node containing the clip&#44; which achieves its resection in practically 100&#37; of the cases&#46;</p><p id="par0305" class="elsevierStylePara elsevierViewall">The placement of a <span class="elsevierStyleSup">125</span>I seed in the biopsied lymph node was described in 2010 by a group from the Netherlands Cancer Institute of Amsterdam&#46; This procedure is known as the MARI procedure &#40;marking the axilla with radioactive iodine-125 seeds&#41;<a class="elsevierStyleCrossRef" href="#bib0415"><span class="elsevierStyleSup">41</span></a> &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; The seed is placed before initiating NAC and may be selectively removed using a gamma detection probe on completing the treatment&#46; With the use of this approach&#44; which did not include SLNB in 100 patients&#44; this group recently described a detection rate of 97&#37; with a false positive rate of 7&#46;2&#37; after axillary lymph node dissection&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">42</span></a></p><p id="par0310" class="elsevierStylePara elsevierViewall">Since US laws do not allow <span class="elsevierStyleSup">125</span>I seeds to remain in place throughout chemotherapy treatment&#44; the MD Anderson group &#40;Houston&#44; TX&#44; USA&#41; has proposed the placement of an ultrasonographically visible metallic clip before initiating NAC and marking with <span class="elsevierStyleSup">125</span>I seeds several days prior to surgery after having completed NAC &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46; This group developed the concept of targeted axillary dissection which consists in the combination of the SLNB technique with the detection of the positive lymph node marked with the <span class="elsevierStyleSup">125</span>I seed&#46; To validate the procedure they studied 191 women with a positive axilla at diagnosis who underwent axillary lymph node dissection after NAC&#58; 73 with direct dissection and 118 with previous SLNB&#46; Of these 118 patients&#44; the SLN was combined with marking of the lymph node with <span class="elsevierStyleSup">125</span>I in 85 cases&#46; The targeted axillary dissection of the lymph node marked with <span class="elsevierStyleSup">125</span>I together with the SLNB improved the results&#44; with a false negative rate of only 2&#37; versus 10&#46;6&#37; with the SLNB alone&#46; These authors suggested that this approach is the most effective and reported that the radioactive <span class="elsevierStyleSup">125</span>I seed was recovered in all the cases&#44; and there was no interference in the localization of the SLN&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">15</span></a></p><p id="par0315" class="elsevierStylePara elsevierViewall">Using the same marking strategy with a <span class="elsevierStyleSup">125</span>I seed after completing NAC the group of Diego et al&#46; performed a retrospective study of 30 patients with positive biopsied axilla lymph nodes pre-NAC who were clinically negative post-NAC&#46; They described that in only 22 of the 30 patients &#40;73&#46;3&#37;&#41; the lymph node coincided with the seed and the SLN&#46; The lymph node marked with the <span class="elsevierStyleSup">125</span>I seed was identified in 29&#47;30 patients and metastatic axillary nodal disease persisted post-NAC in 11&#44; 6 of whom also had a metastatic SLN&#46; These results demonstrate the greater accuracy of the procedure of marking with <span class="elsevierStyleSup">125</span>I seeds versus SLNB alone&#46;<a class="elsevierStyleCrossRef" href="#bib0280"><span class="elsevierStyleSup">14</span></a></p><p id="par0320" class="elsevierStylePara elsevierViewall">In view of the previous arguments&#44; the future of axillary surgery post-NAC in patients with BC who are axilla positive at diagnosis is based on the following premises&#58;</p><p id="par0325" class="elsevierStylePara elsevierViewall">A marker should be placed in the axillary lymph node which was positive on biopsy at diagnosis&#44; and the number of abnormal lymph nodes should be determined as an indicator of tumoral load in the axilla &#40;cN1&#8211;N2&#41;&#46;</p><p id="par0330" class="elsevierStylePara elsevierViewall">Prior to surgery the response to NAC should be assessed using imaging techniques&#46; Patients without detectable nodal disease are those who would most benefit from selective SLNB&#46;</p><p id="par0335" class="elsevierStylePara elsevierViewall">A procedure able to intraoperatively localize the marked lymph node should be established since this node is not found in a significant proportion of SLN identified&#46; Selective radioguided axillary dissection &#40;MARI and SLNB combined&#41; can accurately achieve axillary staging post-NAC&#44; identifying women with pCR who would not benefit from complete axillary lymph node dissection&#44; with less procedure-associated morbidity&#46;</p></span></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0080">Pending questions related to management of the axilla in neoadjuvant chemotherapy</span><p id="par0340" class="elsevierStylePara elsevierViewall">The use of SLNB has become the technique of choice for axillary lymph node staging in patients with BC in our country&#44; being essential in all surgical units treating this disease&#46; Biopsy of the SLN is the best criteria to reduce the indication for axillary lymph node dissection&#44; having no repercussion on the cure and survival of the patients&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall">Within the context of NAC not all the questions related to surgical treatment of the axilla have been resolved&#46;</p><p id="par0350" class="elsevierStylePara elsevierViewall">Although experience has shown that similar to what occurs in early stage cancers with ACOSOG Z0011 criteria the indication for axillary lymph node dissection after neoadjuvant treatment is very reduced for cases with great tumoral load in the axilla&#44; there is currently no scientific evidence corroborating this situation&#46; Therefore&#44; in tumors undergoing neoadjuvant treatment&#44; the presence of malignant involvement of the SLN should be associated with axillary lymph node dissection&#46; It remains to be known whether it is safe in terms of survival to not complete axillary lymph node dissection in cases of low tumoral load in the SLN &#40;micrometastasis&#41; or with involvement of only one SLN after having resected 2 or 3 more SLNs&#46; Lastly&#44; studies are needed to determine whether axillary surgery can replace axillary radiotherapy&#46;</p><p id="par0355" class="elsevierStylePara elsevierViewall">The indication of neoadjuvant treatment is a new challenge for multidisciplinary groups and committees in our hospitals&#46; It has been shown that greater knowledge of the molecular subtype of the tumors can predict the likelihood of response or not to NAC and the development of metastasis&#46; The inclusion of SLNB in the evaluation of the axilla has led to continued advances in the knowledge and treatment of BC&#46; To achieve the best results each center should review its diagnostic procedures using imaging techniques &#40;ultrasonography&#44; MR&#44; <span class="elsevierStyleSup">18</span>F-FDG PET&#41;&#46;</p></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0085">Key points</span><p id="par0360" class="elsevierStylePara elsevierViewall"><ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">1&#46;</span><p id="par0365" class="elsevierStylePara elsevierViewall">SLNB in patients with BC undergoing neoadjuvant treatment is an option to avoid unnecessary axillary lymph node dissection&#46; There are relevant differences related to whether this procedure is performed pre- or post-NAC&#44; although both approaches may be effective&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">2&#46;</span><p id="par0370" class="elsevierStylePara elsevierViewall">Following NAC correct evaluation of the stage of the axilla by ultrasonography is essential in cases with node-negative axilla results and in cases suspected of progression&#46; In the latter cases&#44; the use of MR and <span class="elsevierStyleSup">18</span>F-FDG PET may be considered&#46;</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">3&#46;</span><p id="par0375" class="elsevierStylePara elsevierViewall">Prior to the implementation of post-NAC a validation phase of the SLNB should be carried out in both patients with and without axillary lymph node involvement&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">4&#46;</span><p id="par0380" class="elsevierStylePara elsevierViewall">The efficacy and safety of the procedure after NAC has been demonstrated in patients with clinically node-negative axilla at diagnosis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">5&#46;</span><p id="par0385" class="elsevierStylePara elsevierViewall">In patients who are axilla node-positive at diagnosis&#44; SLNB after NAC is feasible but patients should be adequately selected &#40;T1-3 N1&#41;&#44; a combined technique should be used for lymphatic mapping &#40;radiotracer &#43; staining&#41;&#44; more than 2 SLN should be resected&#44; the pathologic lymph node should be clipped and resected during SLNB and axillary lymph node dissection should be done even if the pathologic examination of the SLN shows isolated tumor cells or micrometastasis&#46;</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">6&#46;</span><p id="par0390" class="elsevierStylePara elsevierViewall">The most frequently used pre-NAC marking methods of the biopsied lymph node are metallic clips or <span class="elsevierStyleSup">125</span>I seeds which ensure their removal in the SLNB after neoadjuvant treatment&#46;</p></li><li class="elsevierStyleListItem" id="lsti0035"><span class="elsevierStyleLabel">7&#46;</span><p id="par0395" class="elsevierStylePara elsevierViewall">A procedure allowing intraoperative localization of the marked lymph node should be established since the marked node is not found among the SLN identified in a significant proportion of cases&#46; Radioguided selective axillary lymph node dissection &#40;MARI and SLNB combined&#41; can achieve accurate axillary staging post-NAC&#46;</p></li><li class="elsevierStyleListItem" id="lsti0040"><span class="elsevierStyleLabel">8&#46;</span><p id="par0400" class="elsevierStylePara elsevierViewall">Within the context of NAC not all the questions related to surgical treatment of the axilla have been resolved&#46; We should continue with advances in knowledge&#44; preserving the safety and survival of the patients&#46;</p></li></ul></p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0090">Conclusions</span><p id="par0405" class="elsevierStylePara elsevierViewall">Selective SLNB using radioisotopic techniques in patients with BC who are candidates for NAC is feasible&#44; effective and safe&#46; Knowledge of the tumoral situation of the axilla prior to surgery using imaging techniques &#40;ultrasound&#44; MR&#44; <span class="elsevierStyleSup">18</span>F-FDG PET&#41; is essential to guarantee adequate staging and treatment of the patients&#46; The incorporation of SLNB provides an approach to preserve the axilla which is undoubtedly the best criteria to benefit patients with BC&#46;</p></span><span id="sec0075" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0095">Conflict of interest</span><p id="par0410" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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          "titulo" => "Indications for selective sentinel lymph node biopsy"
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              "titulo" => "Indication pre- or post-neoadjuvant chemotherapy"
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          "titulo" => "Evaluation of the axillary lymph nodes"
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          "titulo" => "Sentinel lymph node biopsy technique"
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              "titulo" => "Patients with lymph node involvement prior to neoadjuvant chemotherapy"
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              "titulo" => "Patients with axillary involvement prior to neoadjuvant chemotherapy"
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              "titulo" => "Marking the metastatic lymph node biopsied prior to neoadjuvant chemotherapy"
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          "titulo" => "Pending questions related to management of the axilla in neoadjuvant chemotherapy"
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            0 => "C&#225;ncer de mama"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">The role of the selective sentinel node biopsy &#40;SNB&#41; is increasing in relevance in breast cancer women with indication of neoadjuvant chemotherapy &#40;NAC&#41;&#46; The Radiosurgery Working Group of the SEMNIM is aware of the necessity of establishing the need for SNB before or after NAC&#44; and also how to manage patients with axillary node-negative or node-positive&#46; There is sufficient data to assess that the SNB with radioisotope techniques is feasible and safe in all these scenarios&#46; An adequate axilla evaluation prior to surgery and the possibility of marking prior to NAC the nodes infiltrated must be the two main pillars to guarantee the success of the SNB&#46; It has been shown that to incorporate the SNB in breast cancer women with indication of NAC increases the rate of a conservative treatment of the axilla that will be a clear benefit for these patients&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">Esta actualizaci&#243;n pretende contextualizar la relevancia de la biopsia selectiva del ganglio centinela &#40;BSGC&#41; en mujeres con c&#225;ncer de mama e indicaci&#243;n de quimioterapia neoadyuvante &#40;QTN&#41;&#46; El Grupo de Trabajo de Cirug&#237;a Radioguiada de la SEMNIM es consciente de la variabilidad existente en nuestro pa&#237;s sobre todo en cuanto al momento de realizar la t&#233;cnica &#40;previa o tras la QTN&#41; y en cuanto al manejo de pacientes con axila negativa o positiva al diagn&#243;stico&#46; Existe suficiente experiencia contrastada para aseverar que mediante t&#233;cnicas radioisot&#243;picas la BSGC es factible&#44; eficaz y segura en estos escenarios&#46; Una adecuada valoraci&#243;n mediante t&#233;cnicas de imagen de la situaci&#243;n tumoral a nivel de la axila previa a la cirug&#237;a y la posibilidad del marcaje previo a la QTN de cualquier ganglio infiltrado deben ser los pilares fundamentales para garantizar el &#233;xito de la BSGC&#46; Es un hecho que incorporar la BSGC en el c&#225;ncer de mama con indicaci&#243;n de QTN favorece un tratamiento conservador de la axila&#44; lo cual redunda en claro beneficio de las pacientes&#46;</p></span>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as&#58; Ruano P&#233;rez R&#44; Rebollo Aguirre AC&#44; Garc&#237;a-Talavera San Miguel P&#44; D&#237;az Exp&#243;sito R&#44; Vidal-Sicart S&#44; Cordero Garc&#237;a JM&#44; et al&#46; Actualizaci&#243;n de la biopsia del ganglio centinela tras quimioterapia neoadyuvante en el c&#225;ncer de mama sin y con afectaci&#243;n ganglionar al diagn&#243;stico&#46; Rev Esp Med Nucl Imagen Mol&#46; 2018&#59;37&#58;63&#8211;70&#46;</p>"
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                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">cN0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Country&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46; of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-NAC size&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37; detection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">False negative rate &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Accuracy &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Yu et al&#46;<a class="elsevierStyleCrossRef" href="#bib0325"><span class="elsevierStyleSup">23</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">China Taipei&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">127&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">T3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">957&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Gimberges et al&#46;<a class="elsevierStyleCrossRef" href="#bib0330"><span class="elsevierStyleSup">24</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">France&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">82&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">T1&#8211;T3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">93&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Classe et al&#46;<a class="elsevierStyleCrossRef" href="#bib0335"><span class="elsevierStyleSup">25</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">France&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">130&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">T1&#8211;T3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Hunt et al&#46;<a class="elsevierStyleCrossRef" href="#bib0265"><span class="elsevierStyleSup">11</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">United States&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">575&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">T1&#8211;T3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rebollo-Aguirre et al&#46;<a class="elsevierStyleCrossRef" href="#bib0305"><span class="elsevierStyleSup">19</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Spain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">51&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">T1&#8211;T3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Takahashi et al&#46;<a class="elsevierStyleCrossRef" href="#bib0340"><span class="elsevierStyleSup">26</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Japan&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">T1&#8211;T4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">91&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">97&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Pi&#241;ero-Madrona et al&#46;<a class="elsevierStyleCrossRef" href="#bib0345"><span class="elsevierStyleSup">27</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Spain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">49&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">T1&#8211;T3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">89&#46;8&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">18&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">94&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fontein et al&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Metaanalysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1738&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">T1&#8211;T4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">11&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">95&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Geng et al&#46;<a class="elsevierStyleCrossRef" href="#bib0355"><span class="elsevierStyleSup">29</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Metaanalysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">1456&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">T1&#8211;T4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">96&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">98&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The most relevant validation studies of sentinel lymph node biopsy in patients with axilla lymph node involvement pior to neoadjuvant chemotherapy &#40;NAC&#41; treatment&#46;</p>"
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          "leyenda" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">pCR&#58; pathological complete response&#46;</p>"
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                0 => """
                  <table border="0" frame="\n
                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">cN&#43;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Country&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46; of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Pre-NAC size&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37; detection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">False negative rate &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">&#37; axilla pCR &#40;ypN0&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Kuehn et al&#46;<a class="elsevierStyleCrossRef" href="#bib0245"><span class="elsevierStyleSup">7</span></a><br>SENTINA&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Germany&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">592&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">T1&#8211;T3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">80&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">14&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Boughey et al&#46;<a class="elsevierStyleCrossRef" href="#bib0360"><span class="elsevierStyleSup">30</span></a><br>ACOSOG Z1071&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">United States&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">689&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">T1&#8211;T4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">92&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">12&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">41&#46;0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Boileau et al&#46;<a class="elsevierStyleCrossRef" href="#bib0365"><span class="elsevierStyleSup">31</span></a><br>SN FNAC&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">France&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">153&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">T1&#8211;T3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">87&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">34&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Rebollo-Aguirre et al&#46;<a class="elsevierStyleCrossRef" href="#bib0260"><span class="elsevierStyleSup">10</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Spain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">52&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">T1&#8211;T3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">84&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">8&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">42&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Carrera et al&#46;<a class="elsevierStyleCrossRef" href="#bib0370"><span class="elsevierStyleSup">32</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Spain&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">53&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">T1&#8211;T4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">5&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">35&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Fontein et al&#46;<a class="elsevierStyleCrossRef" href="#bib0350"><span class="elsevierStyleSup">28</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Metaanalysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">839&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">T1&#8211;T4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">86&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">20&#8211;40&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">El Hage Chehade et al&#46;<a class="elsevierStyleCrossRef" href="#bib0375"><span class="elsevierStyleSup">33</span></a>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Metaanalysis&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">3398&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">T1&#8211;T4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">90&#46;9&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">13&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">39&#46;2&#8211;47&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">The most relevant validation studies of the sentinel lymph node biopsy technique in patients with clinical axilla lymph node involvement prior to neoadjuvant chemotherapy &#40;NAC&#41; treatment&#46;</p>"
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        "etiqueta" => "Table 3"
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          "leyenda" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">CI&#58; confidence interval&#59; SLN&#58; sentinel lymph node&#59; ALND&#58; axillary lymph node dissection&#59; SLNB&#58; sentinel lymph node biopsy&#46;</p>"
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                  \t\t\t\t\tvoid\n
                  \t\t\t\t" class=""><thead title="thead"><tr title="table-row"><th class="td" title="table-head  " align="" valign="top" scope="col" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Country&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">No&#46; of patients&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">Localization technique&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th><th class="td" title="table-head  " align="left" valign="top" scope="col" style="border-bottom: 2px solid black">False negative results &#40;CI 95&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</th></tr></thead><tbody title="tbody"><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Boughey et al&#46;<a class="elsevierStyleCrossRef" href="#bib0405"><span class="elsevierStyleSup">39</span></a><br>ACOSOG Z1071&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">United States&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">203&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Metallic clip in SLN&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;2&#37; &#40;2&#46;7&#8211;15&#46;1&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">Metallic clip in ALND&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">26&#46;9&#37; &#40;11&#46;6&#8211;47&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Donker et al&#46;<a class="elsevierStyleCrossRef" href="#bib0420"><span class="elsevierStyleSup">42</span></a><br>MARI&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">The Netherlands&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">100&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top"><span class="elsevierStyleSup">125</span>I seed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">7&#46;1&#37; &#40;2&#8211;16&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td-with-role" title="table-entry ; entry_with_role_rowhead " align="left" valign="top">Caudle et al&#46;<a class="elsevierStyleCrossRef" href="#bib0285"><span class="elsevierStyleSup">15</span></a><br>Targeted axillary dissection&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">United States&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">118&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SLNB&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">10&#46;1&#37; &#40;4&#46;2&#8211;19&#46;8&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="" valign="top">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">85&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="left" valign="top">SLNB&#43; <span class="elsevierStyleSup">125</span>I seed&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="table-entry  " align="char" valign="top">2&#46;0&#37; &#40;0&#46;05&#8211;10&#46;7&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
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          "en" => "<p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">Percentagef of false negative results following axillary lymph node dissection based on the method of identification of the positive node biopsied N&#43;&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
        0 => array:2 [
          "identificador" => "bibs0015"
          "bibliografiaReferencia" => array:42 [
            0 => array:3 [
              "identificador" => "bib0215"
              "etiqueta" => "1"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Consenso sobre la biopsia selectiva del ganglio centinela en el c&#225;ncer de mama&#46; Revisi&#243;n 2013 de la Sociedad Espa&#241;ola de Senolog&#237;a y Patolog&#237;a Mamaria"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "L&#46; Bernet"
                            1 => "A&#46; Pi&#241;ero"
                            2 => "S&#46; Vidal-Sicart"
                            3 => "V&#46; Peg"
                            4 => "J&#46; Gim&#233;nez"
                            5 => "M&#46; Algara"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:5 [
                        "tituloSerie" => "Rev Esp Patol"
                        "fecha" => "2014"
                        "volumen" => "47"
                        "paginaInicial" => "22"
                        "paginaFinal" => "32"
                      ]
                    ]
                  ]
                ]
              ]
            ]
            1 => array:3 [
              "identificador" => "bib0220"
              "etiqueta" => "2"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sentinel-lymph-node resection compared with conventional axillary-lymph-node dissection in clinically node-negative patients with breast cancer&#58; overall survival findings from the NSABP B-32 randomised phase 3 trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "D&#46;N&#46; Krag"
                            1 => "S&#46;J&#46; Anderson"
                            2 => "T&#46;B&#46; Julian"
                            3 => "A&#46;M&#46; Brown"
                            4 => "S&#46;P&#46; Harlow"
                            5 => "J&#46;P&#46; Costantino"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S1470-2045(10)70207-2"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet Oncol"
                        "fecha" => "2010"
                        "volumen" => "11"
                        "paginaInicial" => "927"
                        "paginaFinal" => "933"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20863759"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            2 => array:3 [
              "identificador" => "bib0225"
              "etiqueta" => "3"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel node metastases&#58; The American College of Surgeons Oncology Group Z0011 randomized trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;E&#46; Giuliano"
                            1 => "L&#46; McCall"
                            2 => "P&#46; Beitsch"
                            3 => "P&#46;W&#46; Whitworth"
                            4 => "P&#46; Blumencranz"
                            5 => "A&#46;M&#46; Leitch"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/SLA.0b013e3181f08f32"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Surg"
                        "fecha" => "2010"
                        "volumen" => "252"
                        "paginaInicial" => "426"
                        "paginaFinal" => "432"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/20739842"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            3 => array:3 [
              "identificador" => "bib0230"
              "etiqueta" => "4"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Locoregional recurrence after sentinel lymph node dissection with or without axillary dissection in patients with sentinel lymph node metastases&#58; long-term follow-up from the American College of Surgeons Oncology Group &#40;Alliance&#41; ACOSOG Z0011 randomized trial"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;E&#46; Giuliano"
                            1 => "K&#46; Ballman"
                            2 => "L&#46; McCall"
                            3 => "P&#46; Beitsch"
                            4 => "P&#46;W&#46; Whitworth"
                            5 => "P&#46; Blumencranz"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/SLA.0000000000001863"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Surg"
                        "fecha" => "2016"
                        "volumen" => "264"
                        "paginaInicial" => "413"
                        "paginaFinal" => "420"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27513155"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            4 => array:3 [
              "identificador" => "bib0235"
              "etiqueta" => "5"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "The EANM and SNMMI practice guideline for lymphoscintigraphy and sentinel node localization in breast cancer"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "F&#46; Giammarile"
                            1 => "N&#46; Alazraki"
                            2 => "J&#46;N&#46; Aarsvold"
                            3 => "R&#46;A&#46; Audisio"
                            4 => "E&#46; Glass"
                            5 => "S&#46;F&#46; Grant"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00259-013-2544-2"
                      "Revista" => array:6 [
                        "tituloSerie" => "Eur J Nucl Med Mol Imaging"
                        "fecha" => "2013"
                        "volumen" => "40"
                        "paginaInicial" => "1932"
                        "paginaFinal" => "1947"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24085499"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            5 => array:3 [
              "identificador" => "bib0240"
              "etiqueta" => "6"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Breast sentinel lymph node dissection before preoperative chemotherapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "B&#46;J&#46; Grube"
                            1 => "C&#46;J&#46; Christy"
                            2 => "D&#46; Black"
                            3 => "M&#46; Martel"
                            4 => "L&#46; Harris"
                            5 => "J&#46; Weidhaas"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1001/archsurg.143.7.692"
                      "Revista" => array:6 [
                        "tituloSerie" => "Arch Surg"
                        "fecha" => "2008"
                        "volumen" => "143"
                        "paginaInicial" => "692"
                        "paginaFinal" => "699"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18645113"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            6 => array:3 [
              "identificador" => "bib0245"
              "etiqueta" => "7"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy &#40;SENTINA&#41;&#58; a prospective&#44; multicentre cohort study"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "T&#46; Kuehn"
                            1 => "I&#46; Bauerfeind"
                            2 => "T&#46; Fehm"
                            3 => "B&#46; Fleige"
                            4 => "M&#46; Hausschild"
                            5 => "G&#46; Helms"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S1470-2045(13)70166-9"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet Oncol"
                        "fecha" => "2013"
                        "volumen" => "14"
                        "paginaInicial" => "609"
                        "paginaFinal" => "618"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23683750"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            7 => array:3 [
              "identificador" => "bib0250"
              "etiqueta" => "8"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Pathological complete response and long-term clinical benefit in breast cancer&#58; the CTNeoBC pooled analysis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "P&#46; Cortazar"
                            1 => "L&#46; Zhang"
                            2 => "M&#46; Untch"
                            3 => "K&#46; Mehta"
                            4 => "J&#46;P&#46; Costantino"
                            5 => "N&#46; Wolmark"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/S0140-6736(13)62422-8"
                      "Revista" => array:6 [
                        "tituloSerie" => "Lancet"
                        "fecha" => "2014"
                        "volumen" => "384"
                        "paginaInicial" => "164"
                        "paginaFinal" => "172"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24529560"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            8 => array:3 [
              "identificador" => "bib0255"
              "etiqueta" => "9"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Intraoperative assessment of sentinel lymph node by one-step nucleic acid amplification in breast cancer patients after neoadjuvant treatment reduces the need for a second surgery for axillary lymph node dissection"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "M&#46; Espinosa-Bravo"
                            1 => "J&#46; Navarro-Cecilia"
                            2 => "M&#46; Ramos Boyero"
                            3 => "S&#46; Diaz-Botero"
                            4 => "B&#46; Due&#241;as Rodr&#237;guez"
                            5 => "C&#46; Luque L&#243;pez"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.breast.2016.10.002"
                      "Revista" => array:6 [
                        "tituloSerie" => "Breast"
                        "fecha" => "2016"
                        "volumen" => "31"
                        "paginaInicial" => "40"
                        "paginaFinal" => "45"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27810698"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            9 => array:3 [
              "identificador" => "bib0260"
              "etiqueta" => "10"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with operable breast cancer and positive axillary nodes at initial diagnosis"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;C&#46; Rebollo-Aguirre"
                            1 => "M&#46; Gallego-Peinado"
                            2 => "R&#46; S&#225;nchez-S&#225;nchez"
                            3 => "E&#46; Pastor-Pons"
                            4 => "J&#46; Garc&#237;a-Garc&#237;a"
                            5 => "C&#46;E&#46; Chamorro-Santos"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.remn.2013.03.006"
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Esp Med Nucl Imagen Mol"
                        "fecha" => "2013"
                        "volumen" => "32"
                        "paginaInicial" => "240"
                        "paginaFinal" => "245"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23684711"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            10 => array:3 [
              "identificador" => "bib0265"
              "etiqueta" => "11"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sentinel lymph node surgery after neoadjuvant chemotherapy is accurate and reduces the need for axillary dissection in breast cancer patients"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "K&#46;K&#46; Hunt"
                            1 => "M&#46; Yi"
                            2 => "E&#46;A&#46; Mittendorf"
                            3 => "C&#46; Guerrero"
                            4 => "G&#46;V&#46; Babiera"
                            5 => "I&#46; Bedrosian"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1097/SLA.0b013e3181b8fd5e"
                      "Revista" => array:6 [
                        "tituloSerie" => "Ann Surg"
                        "fecha" => "2009"
                        "volumen" => "250"
                        "paginaInicial" => "558"
                        "paginaFinal" => "566"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19730235"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            11 => array:3 [
              "identificador" => "bib0270"
              "etiqueta" => "12"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sentinel node biopsy in T2 breast cancers larger than 3<span class="elsevierStyleHsp" style=""></span>cm and clinically negative axilla compared with the T1&#8211;T2<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>3<span class="elsevierStyleHsp" style=""></span>cm standard indication"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
                            0 => "R&#46; Ruano"
                            1 => "M&#46; Ramos"
                            2 => "J&#46;R&#46; Garc&#237;a-Talavera"
                            3 => "M&#46;C&#46; Garc&#237;a Mac&#237;as"
                            4 => "A&#46; Mart&#237;n de Arriba"
                            5 => "J&#46;M&#46; Gonz&#225;lez-Or&#250;s"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:1 [
                      "Revista" => array:6 [
                        "tituloSerie" => "Rev Esp Med Nucl"
                        "fecha" => "2008"
                        "volumen" => "27"
                        "paginaInicial" => "176"
                        "paginaFinal" => "182"
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                      "titulo" => "Value of preoperative ultrasound-guided axillary lymph node biopsy for preventing completion axillary lymph node dissection in breast cancer&#58; a systematic review and meta-analysis"
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                          "etal" => true
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                        "paginaInicial" => "51"
                        "paginaFinal" => "59"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24008555"
                            "web" => "Medline"
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                    0 => array:2 [
                      "titulo" => "Axillary staging after neoadjuvant chemotherapy for breast cancer&#58; a pilot study combining sentinel lymph node biopsy with radioactive seed localization of pre-treatment positive axillary lymph nodes"
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                        "tituloSerie" => "Ann Surg Oncol"
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                        "paginaFinal" => "1553"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26727919"
                            "web" => "Medline"
                          ]
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                            3 => "E&#46;A&#46; Mittendorf"
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                        "paginaInicial" => "1072"
                        "paginaFinal" => "1078"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/26811528"
                            "web" => "Medline"
                          ]
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                    0 => array:2 [
                      "titulo" => "Adding MRI to ultrasound and ultrasound-guided fine-needle aspiration reduces the false-negative rate of axillary lymph node metastasis diagnosis in breast cancer patients"
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                          "autores" => array:5 [
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                            2 => "J&#46;H&#46; Yoon"
                            3 => "H&#46;J&#46; Moon"
                            4 => "M&#46;J&#46; Kim"
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                    ]
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                    0 => array:2 [
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                        "tituloSerie" => "Clin Radiol"
                        "fecha" => "2015"
                        "volumen" => "70"
                        "paginaInicial" => "716"
                        "paginaFinal" => "722"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25917544"
                            "web" => "Medline"
                          ]
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                    0 => array:2 [
                      "titulo" => "Semi-quantitative lymph node assessment of <span class="elsevierStyleSup">18</span>F-FDG PET&#47;CT in locally advanced breast cancer&#58; Correlation with biological prognostic factors"
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                          "autores" => array:6 [
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                            2 => "M&#46;A&#46; Cruz Mora"
                            3 => "A&#46; Gonz&#225;lez Ageitos"
                            4 => "M&#46;M&#46; Mu&#241;oz S&#225;nchez"
                            5 => "A&#46; Le&#243;n Mart&#237;n"
                          ]
                        ]
                      ]
                    ]
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                    0 => array:2 [
                      "doi" => "10.1007/s00259-012-2244-3"
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                        "tituloSerie" => "Eur J Nucl Med Mol Imaging"
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                        "volumen" => "40"
                        "paginaInicial" => "72"
                        "paginaFinal" => "79"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23053321"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0300"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Noninvasive nodal restaging in clinically node positive breast cancer patients after neoadjuvant systemic therapy&#58; a systematic review"
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                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
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                            2 => "R&#46;G&#46;H&#46; Beets-Tan"
                            3 => "M&#46;L&#46; Smidt"
                            4 => "M&#46;B&#46; Lobbes"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ejrad.2014.09.020"
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                        "tituloSerie" => "Eur J Radiol"
                        "fecha" => "2015"
                        "volumen" => "84"
                        "paginaInicial" => "41"
                        "paginaFinal" => "47"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/25458227"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Sentinel lymph node biopsy in patients with operable breast cancer treated with neoadjuvant chemotherapy"
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                          "etal" => true
                          "autores" => array:6 [
                            0 => "A&#46;C&#46; Rebollo-Aguirre"
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                            2 => "S&#46; Menj&#243;n-Beltr&#225;n"
                            3 => "J&#46; Garcia-Garcia"
                            4 => "E&#46; Pastor-Pons"
                            5 => "C&#46;E&#46; Chamorro-Santos"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.remn.2011.04.007"
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                        "tituloSerie" => "Rev Esp Med Nucl Imagen Mol"
                        "fecha" => "2012"
                        "volumen" => "31"
                        "paginaInicial" => "117"
                        "paginaFinal" => "123"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21676504"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0310"
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Predictive factors and value of ypN&#43; after neoadjuvant chemotherapy in clinically lymph node-negative breast cancer"
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                          "etal" => true
                          "autores" => array:6 [
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                            1 => "K&#46; Araki"
                            2 => "K&#46; Kobayashi"
                            3 => "T&#46; Shibayama"
                            4 => "S&#46; Takahashi"
                            5 => "R&#46; Horii"
                          ]
                        ]
                      ]
                    ]
                  ]
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                    0 => array:2 [
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                        "tituloSerie" => "PLoS One"
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                        "volumen" => "11"
                        "paginaInicial" => "e0162616"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27631393"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Using ultrasound and palpation for predicting axillary lymph node status following neoadjuvant chemotherapy &#8211; results from the multi-center SENTINA trial"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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                            1 => "G&#46; Helms"
                            2 => "V&#46; Nekljudova"
                            3 => "B&#46; Ataseven"
                            4 => "I&#46; Bauerfeind"
                            5 => "N&#46; Ditsch"
                          ]
                        ]
                      ]
                    ]
                  ]
                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.breast.2016.11.012"
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                        "tituloSerie" => "Breast"
                        "fecha" => "2016"
                        "volumen" => "31"
                        "paginaInicial" => "202"
                        "paginaFinal" => "207"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27889596"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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            21 => array:3 [
              "identificador" => "bib0320"
              "etiqueta" => "22"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Imaging response and residual metastatic axillary lymph node disease after neoadjuvant chemotherapy for primary breast cancer"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
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                            1 => "J&#46;C&#46; Boughey"
                            2 => "K&#46;N&#46; Jones"
                            3 => "S&#46;S&#46; Shah"
                            4 => "K&#46;N&#46; Glazebrook"
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                        ]
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                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1245/s10434-013-3118-z"
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                        "tituloSerie" => "Ann Surg Oncol"
                        "fecha" => "2013"
                        "volumen" => "20"
                        "paginaInicial" => "3199"
                        "paginaFinal" => "3204"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23846781"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
            22 => array:3 [
              "identificador" => "bib0325"
              "etiqueta" => "23"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Role of sentinel lymphadenectomy combined with intraoperative ultrasound in the assessment of locally advanced breast cancer after neoadjuvant chemotherapy"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
                            0 => "J&#46;C&#46; Yu"
                            1 => "G&#46;C&#46; Hsu"
                            2 => "C&#46;B&#46; Hsieh"
                            3 => "C&#46;P&#46; Yu"
                            4 => "T&#46;Y&#46; Chao"
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                        ]
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                    ]
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                  "host" => array:1 [
                    0 => array:2 [
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                        "tituloSerie" => "Ann Surg Oncol"
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                        "volumen" => "14"
                        "paginaInicial" => "174"
                        "paginaFinal" => "180"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17066228"
                            "web" => "Medline"
                          ]
                        ]
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                    ]
                  ]
                ]
              ]
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            23 => array:3 [
              "identificador" => "bib0330"
              "etiqueta" => "24"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Sentinel lymph node biopsy after neoadjuvant chemotherapy is accurate in breast cancer patients with a clinically negative axillary nodal status at presentation"
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                        0 => array:2 [
                          "etal" => true
                          "autores" => array:6 [
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                            4 => "F&#46; Cachin"
                            5 => "F&#46; Penault-Llorca"
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                    ]
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                    0 => array:2 [
                      "doi" => "10.1245/s10434-007-9759-z"
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                        "tituloSerie" => "Ann Surg Oncol"
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                        "volumen" => "15"
                        "paginaInicial" => "1316"
                        "paginaFinal" => "1321"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18311507"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "etiqueta" => "25"
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Sentinel lymph node biopsy after neoadjuvant chemotherapy for advanced breast cancer&#58; results of ganglion sentinelle et chimioth&#233;rapie neoadjuvante&#44; a French prospective multicentric study"
                      "autores" => array:1 [
                        0 => array:2 [
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                            1 => "V&#46; Bordes"
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                            3 => "H&#46; Mignotte"
                            4 => "F&#46; Dravet"
                            5 => "J&#46; Leveque"
                          ]
                        ]
                      ]
                    ]
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                    0 => array:2 [
                      "doi" => "10.1200/JCO.2008.18.3228"
                      "Revista" => array:6 [
                        "tituloSerie" => "J Clin Oncol"
                        "fecha" => "2009"
                        "volumen" => "27"
                        "paginaInicial" => "726"
                        "paginaFinal" => "732"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19114697"
                            "web" => "Medline"
                          ]
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                    ]
                  ]
                ]
              ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Correlation between clinical nodal status and sentinel lymph node biopsy false negative rate after neoadjuvant chemotherapy"
                      "autores" => array:1 [
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                          "etal" => false
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                            1 => "H&#46; Jinno"
                            2 => "T&#46; Hayashida"
                            3 => "M&#46; Sakata"
                            4 => "K&#46; Asakura"
                            5 => "Y&#46; Kitagawa"
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                        ]
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                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1007/s00268-012-1704-z"
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                        "tituloSerie" => "World J Surg"
                        "fecha" => "2012"
                        "volumen" => "36"
                        "paginaInicial" => "2847"
                        "paginaFinal" => "2852"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/22806206"
                            "web" => "Medline"
                          ]
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                      ]
                    ]
                  ]
                ]
              ]
            ]
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                0 => array:2 [
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                    0 => array:2 [
                      "titulo" => "Biopsia selectiva del ganglio centinela tras quimioterapia neoadyuvante en el c&#225;ncer de mama&#58; estudio prospectivo multic&#233;ntrico para la validaci&#243;n y an&#225;lisis de subgrupos &#40;GEICAM 2005-07&#41;"
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                        ]
                      ]
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                  ]
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                    0 => array:2 [
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                        "tituloSerie" => "Cir Esp"
                        "fecha" => "2015"
                        "volumen" => "93"
                        "paginaInicial" => "23"
                        "paginaFinal" => "29"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24560631"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
            ]
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              "identificador" => "bib0350"
              "etiqueta" => "28"
              "referencia" => array:1 [
                0 => array:2 [
                  "contribucion" => array:1 [
                    0 => array:2 [
                      "titulo" => "Timing of the sentinel lymph node biopsy in breast cancer patients receiving neoadjuvant therapy &#8211; recommendations for clinical guidance"
                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => false
                          "autores" => array:5 [
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                            1 => "W&#46; van de Water"
                            2 => "J&#46;S&#46; Mieog"
                            3 => "G&#46;J&#46; Liefers"
                            4 => "C&#46;J&#46; van de Velde"
                          ]
                        ]
                      ]
                    ]
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                  "host" => array:1 [
                    0 => array:2 [
                      "doi" => "10.1016/j.ejso.2013.02.011"
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                        "tituloSerie" => "Eur J Surg Oncol"
                        "fecha" => "2013"
                        "volumen" => "39"
                        "paginaInicial" => "417"
                        "paginaFinal" => "424"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/23473972"
                            "web" => "Medline"
                          ]
                        ]
                      ]
                    ]
                  ]
                ]
              ]
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                0 => array:2 [
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                            2 => "J&#46; Galera"
                            3 => "K&#46; Amillano"
                            4 => "M&#46; Gomez"
                            5 => "V&#46; Izquierdo"
                          ]
                        ]
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                      "titulo" => "Is sentinel lymph node biopsy a viable alternative to complete axillary dissection following neoadjuvant chemotherapy in women with node-positive breast cancer at diagnosis&#63; An updated meta-analysis involving 3&#44;398 patients"
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                            4 => "A&#46; Kasem"
                            5 => "K&#46; Mokbel"
                          ]
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                        "paginaInicial" => "969"
                        "paginaFinal" => "981"
                        "link" => array:1 [
                          0 => array:2 [
                            "url" => "https://www.ncbi.nlm.nih.gov/pubmed/27671032"
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                      "titulo" => "Axillary ultrasound after neoadjuvant chemotherapy and its impact on sentinel lymph node surgery&#58; results from the American College of Surgeons Oncology Group Z1071 Trial &#40;Alliance&#41;"
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