Evaluation of sentinel lymph node biopsy after previous breast surgery for breast cancer: GATA study

Delayed Sentinel Lymph Node Dissection in Patients with a Preoperative Diagnosis of Ductal Cancer In Situ by Preoperative Injection with Superparamagnetic Iron Oxide (SPIO) Nanoparticles: The SentiNot Study

BACKGROUND

Difficulty in preoperatively assessing the risk for occult invasion or surgery that precludes future accurate axillary mapping in patients with ductal cancer in situ (DCIS) account for overutilization of SLND.

METHODS

Prospective, multicenter, cohort study, including women with any DCIS planned for mastectomy or DCIS grade 2 and > 20 mm, any DCIS grade 3, any mass-forming DCIS and any planned surgery. Patients received an interstitial SPIO injection during breast surgery, but no upfront SLND was performed. If invasion was identified on final pathology, delayed SLND (d-SLND) was performed separately with the coadministration of isotope ± blue dye (BD). Study outcomes were proportion of upfront SLNDs that were avoided, detection rates during d-SLND, and impact on healthcare costs.

RESULTS

In total, 78.7% of study participants (N = 254, mean age 60 years, mean DCIS size 37.8 mm) avoided upfront SLND. On d-SLND (median 28 days, range 9-46), SPIO outperformed Tc99 with (98.2% vs. 63.6%, p < 0.001) or without BD (92.7% vs. 50.9%, p < 0.001) and had higher nodal detection rate (86.9% vs. 32.3%, p < 0.001) and with BD (93.9% vs. 41.4%, p < 0.001). Only 27.9% of all SLNs retrieved were concordant for Tc99 and SPIO. Type of breast procedure (WLE vs. oncoplastic BCT vs. mastectomy) affected these outcomes and accounted for the low performance of Tc99 (p < 0.001). d-SLND resulted in a 28.1% total cost containment for women with pure DCIS on final pathology (4190 vs. 5828 USD, p < 0.001).

CONCLUSIONS

Marking the SLN with SPIO may avoid overtreatment and allow for accurate d-SLND in patients with DCIS.

Validation of Sentinel Lymph Node Biopsy Technique Using Dual Tracer Technique in Post Lumpectomy Early Breast Cancer Patients

Sentinel lymph node biopsy (SLNB) is the gold standard for the evaluation of axilla in clinically node-negative early breast cancers. There is limited data on the role and efficacy of the same in the post lumpectomy scenario. This prospective interventional study was conducted over 1 year on 30 post lumpectomy pT1/2 cN0 patients. SLNB was performed by preoperative lymphoscintigram using technetium-labeled human serum albumin followed by intraoperative blue dye injection. Sentinel nodes were identified based on blue dye uptake and gamma probe and sent for intra operative frozen section. Completion axillary nodal dissection was performed in all cases. The primary end point was sentinel node identification rate and accuracy of nodal frozen section. Sentinel node identification rate was 86.7% (n = 26/30) for scintigraphy alone and 96.7% (n = 29/30) using combined method. Average sentinel nodal yield/patient was 3.6 (range 0-7). Maximum yield was seen for hot and blue nodes (1.86). Sensitivity (n = 9/9) and specificity (n = 19/19) of frozen section were 100% with a false negative rate of 0% (0/19). Demographic factors such as age, body mass index, laterality, quadrant, biology, grade, and pathological T stage had no impact on the identification rate. Sentinel lymph node using dual tracer has a high identification rate and a low false negative rate post lumpectomy. Age, body mass index, laterality, quadrant, grade, biology, and pathological T size had no impact on the identification rate.

Sentinel Lymph Node Mapping and Biopsy in Cats with Solid Malignancies: An Explorative Study

There is increasing evidence on the utility of sentinel lymph node (SLN) biopsy (SLNB) for the staging of dogs with various malignancies; however, comparable information is missing in cats. This multi-institutional study aims at reporting the feasibility and detection rate of SLNB guided by lymphoscintigraphy and the blue dye or near-infrared fluorescent lymphography (NIRF-L) in cats with solid tumors. In total, 12 cats presented with 14 solid malignancies that underwent curative-intent surgical excision of the primary tumor and SLNB were retrospectively enrolled. The mapping technique used, location and number of SLN, correspondence with the regional lymph node (RLN), and histological status of the SLN were retrieved. The detection rate and complications of SLNB were also recorded. NIRF-L was performed in 64.3% of tumors and lymphoscintigraphy in 35.7%. The detection rate was 100% for both techniques. The SLN did not correspond (fully or partially) to the RLN in 71.4% of cases, with multiple SLN being excised in 9/14 tumors. No complications related to SLNB were recorded. At histopathology, metastases were identified in 41.7% of cats, all with mast cell tumors (MCT). SLNB guided by NIRF-L or lymphoscintigraphy is feasible and safe in cats with solid tumors and should be suggested for correct tumor staging in cats, especially with MCT.

Sentinel Lymph Node Biopsy Is Feasible in Dogs with Scars from Prior Local Excision of Solid Malignancies

Simple Summary

Sentinel lymph node (SLN) excision is gaining relevance in the management of various canine malignancies due to its recognized impact on staging and treatment choices. However, the technologies to perform SLN mapping are only available to a few referral centers, and there is increasing demand for secondary nodal staging after prior tumor excision at the primary care institution. This retrospective study investigated the feasibility and usefulness of SLN biopsy in dogs with surgical scars resulting from the removal of various solid tumors referred for further staging and/or adjuvant treatment options. Thirty-three dogs with 34 scars underwent SLN biopsy at a median of 50 days after primary tumor excision. An SLN was identified for 31/34 scars, translating to a detection rate of 91.2%. Metastases were identified with histopathology in 13/31 dogs (41.9%) and they all had an excision of a mast cell tumor. SLN biopsy should be suggested in dogs presenting with scars from prior solid tumor excision, considering the observed detection rate and the importance of knowing the metastatic status of the SLN in oncological diseases.

Abstract

Sentinel lymph node (SLN) biopsy is a well-established staging tool in canine oncology. This study aims to explore the feasibility of SLN biopsy in dogs with scars from prior excised solid malignancies that were referred for further tumor staging and/or adjuvant treatment options. Mapping was either performed using radiopharmaceutical, methylene blue, and/or near-infrared fluorescent (NIRF) imaging. Thirty-three dogs with 34 scars from prior excision of the mast cell tumor (MCT) (n = 29), soft tissue sarcoma (n = 2), oral melanoma (n = 1), subungual melanoma (n = 1), and mammary adenocarcinoma (n = 1) were retrospectively enrolled. Primary treatment consisted of curative intent/wide tumor excisions in 50.0% of dogs and marginal excision in the remaining 50.0%. The median time between tumor excision and SLN biopsy was 50 days (range 17–110 days). The procedure was successful in 31/34 scars, translating to a detection rate of 91.2%. The SLN did not correspond to the regional lymph node in 19/31 scars (61.3%). SLN metastases were histologically identified in 13/31 (41.9%) dogs, all of them affected by MCT. Based on our results, SLN biopsy using lymphoscintigraphy/methylene blue and/or NIRF is feasible in dogs presenting with scars from the prior surgical excision of solid tumors, and should be suggested for accurate nodal staging.

Differentiation Between Benign and Metastatic Breast Lymph Nodes Using Apparent Diffusion Coefficients

The aim of this study was to determine the range of apparent diffusion coefficient (ADC) values for benign axillary lymph nodes in contrast to malignant axillary lymph nodes, and to define the optimal ADC thresholds for three different ADC parameters (minimum, maximum, and mean ADC) in differentiating between benign and malignant lymph nodes. This retrospective study included consecutive patients who underwent breast MRI from January 2017–December 2020. Two-year follow-up breast imaging or histopathology served as the reference standard for axillary lymph node status. Area under the receiver operating characteristic curve (AUC) values for minimum, maximum, and mean ADC (min ADC, max ADC, and mean ADC) for benign vs malignant axillary lymph nodes were determined using the Wilcoxon rank sum test, and optimal ADC thresholds were determined using Youden’s Index. The final study sample consisted of 217 patients (100% female, median age of 52 years (range, 22–81), 110 with benign axillary lymph nodes and 107 with malignant axillary lymph nodes. For benign axillary lymph nodes, ADC values (×10⁻³ mm²/s) ranged from 0.522–2.712 for mean ADC, 0.774–3.382 for max ADC, and 0.071–2.409 for min ADC; for malignant axillary lymph nodes, ADC values (×10⁻³ mm²/s) ranged from 0.796–1.080 for mean ADC, 1.168–1.592 for max ADC, and 0.351–0.688 for min ADC for malignant axillary lymph nodes. While there was a statistically difference in all ADC parameters (p<0.001) between benign and malignant axillary lymph nodes, boxplots illustrate overlaps in ADC values, with the least overlap occurring with mean ADC, suggesting that this is the most useful ADC parameter for differentiating between benign and malignant axillary lymph nodes. The mean ADC threshold that resulted in the highest diagnostic accuracy for differentiating between benign and malignant lymph nodes was 1.004×10⁻³ mm²/s, yielding an accuracy of 75%, sensitivity of 71%, specificity of 79%, positive predictive value of 77%, and negative predictive value of 74%. This mean ADC threshold is lower than the European Society of Breast Imaging (EUSOBI) mean ADC threshold of 1.300×10⁻³ mm²/s, therefore suggesting that the EUSOBI threshold which was recently recommended for breast tumors should not be extrapolated to evaluate the axillary lymph nodes.

Techniques for sentinel node biopsy in breast cancer

INTRODUCTION

Sentinel node biopsy (SNB) is the standard of care in women with breast cancer (BC) and clinically non suspicious axillary lymph nodes (LNs), due to its high negative predictive value (NPV) in the assessment of nodal status. SNB has significantly reduced complications related to the axillary lymph node dissection, such as lymphedema and upper limb dysfunction.

EVIDENCE ACQUISITION

The gold standard technique for SNB is the blue dye (BD) and technetium labelled nanocolloid (Tc-99m) double technique. However, nuclear medicine is not available in all Institutions and several new tracers and devices have been proposed, such as indocyanine green (ICG) and superparamagnetic iron oxides (SPIO). All these techniques show an accuracy and detection rate not inferior to that of the standard technique, with different specific pros and cons. The choice of how to perform a SNB primarily depends on the surgeon's confidence with the procedure, the availability of nuclear medicine and the economic resources of the Institutions. In this setting, new tracers, hybrid tracers and imaging techniques are being evaluated in order to improve the detection rate of sentinel lymph nodes (SNs) and minimize the number of unnecessary axillary surgeries through an accurate preoperative assessment of nodal status and to guide new minimally invasive diagnostic procedures of SNs. In particular, the contrast-enhanced ultrasound (CEUS) is an active field of research but cannot be recommended for clinical use at this time.

EVIDENCE SYNTHESIS

The ICG fluorescence technique was superior in terms of DR, as well as having the lowest FNR. The DR descending order was SPIO, Tc, dual modality (Tc/BD), CEUS and BD.

CONCLUSIONS

This paper is a narrative review of the most common SNB techniques in BC with a focus on recent innovations.

Sentinel-Lymph-Node Multicenter Trials

Well executed multicenter clinical trials often provide significant evidence and support for, or against, foundational aspects of clinical procedures perceived to improve clinical management of a medical condition. In this review, discussed are reports of multicenter clinical trials designed to investigate sentinel lymph node biopsy procedures in seven types of cancer: breast, melanoma, head and neck, gastric, colon, uterine, and vulvar-with focus on the most recent reports of the hypotheses, objectives, parameters, data, results, implications, and impacts of the included trials. Such trials generally enroll more subjects, in shorter time periods, than do single-center studies. Such studies generally also have greater diversities among investigator practitioners and investigative environments than do single-center studies. The greater number of subjects provides more power to statistical analyses performed in such studies. The more rapid accrual usually results in data being more consistently acquired. The diversities of practitioners and environments may produce results that are more conservative than might be obtained from more "focused" studies; however, diversities in a study often identify implicitly results that are more robust-that is results applicable by more practitioners and applicable in more environments.

Indocyanine green fluorescence lymphography during gastrectomy after initial endoscopic submucosal dissection for early gastric cancer

BACKGROUND

Indocyanine green (ICG) fluorescence lymphography can be used to visualize the lymphatic drainage of gastric cancer. Few studies have been performed to identify lymphatic drainage patterns after endoscopic submucosal dissection (ESD). ESD results in changes to lymphatics owing to fibrosis of the submucosal layer. This study aimed to evaluate the efficacy of ICG fluorescence lymphography for visualization of lymphatic drainage after ESD, and to assess its clinical application in additional gastrectomy after ESD for early gastric cancer.

METHODS

All patients who underwent gastrectomy after ESD between 2014 and 2017 in a single centre were reviewed. ICG was injected endoscopically into the submucosal layer around the ESD scar the day before surgery. At the time of surgery, lymph nodes (LNs) were visualized and lymphadenectomy was performed with near-infrared imaging. Ex vivo, all LNs were examined for the presence of fluorescence. Number of LNs resected and number of tumour-positive LNs were compared between patients who underwent near-infrared imaging and those who had conventional lymphadenectomy without intraoperative imaging.

RESULTS

Some 290 patients underwent gastrectomy after ESD, 98 with fluorescence lymphography-guided lymphadenectomy and 192 with conventional lymphadenectomy. Fluorescence lymphography visualized lymphatic drainage in all patients, without complications related to ICG injection or near-infrared imaging. Fluorescence lymphography visualized all stations containing metastatic LNs. The sensitivity for detecting LN metastasis in fluorescent stations was 100 per cent (9 of 9 stations), and the negative predictive value was 100 per cent (209 of 209). One patient with LN metastasis had one non-fluorescent metastatic LN within a fluorescent station.

CONCLUSION

Fluorescence lymphography successfully visualized all draining LNs after ESD, with high sensitivity and negative predictive value for detecting LN metastasis. Fluorescence lymphography-guided lymphadenectomy could be an alternative to systematic lymphadenectomy during additional surgery after ESD.

Evaluating the role of sentinel lymph node biopsy in patients with DCIS treated with breast conserving surgery

INTRODUCTION

The role of sentinel lymph node biopsy (SLNB) for patients with ductal carcinoma in-situ (DCIS) is limited given the rarity of nodal metastasis in non-invasive disease. Although SLNB is typically a safe procedure, there are potential complications and associated costs. The purpose of this study is to assess national surgical practice patterns and clinical outcomes with respect to the use of SLNB for DCIS in patients undergoing breast conserving surgery (BCS).

METHODS

Case-level data from the National Cancer Data Base (NCDB) was assessed to identify adult patients ≥ 18 with DCIS, who underwent BCS and SLNB. Patient demographics and hospital characteristics were grouped for analytic purposes. A multivariate analysis was performed for patient and hospital characteristics.

RESULTS

We identified 15,422 patients with DCIS undergoing BCS in 2015, of which 2,698 (18%) underwent SLNB. A multivariate analysis demonstrated a significant association between greater frequency of SLNB in patients age range of 60-69, receipt of care at a community facility, and higher nuclear grade DCIS. Positive sentinel nodes metastasis was identified in 0.9% patients undergoing BCS and SLNB for DCIS.

CONCLUSION

The role of SLNB in patients with DCIS undergoing BCS is limited and does not routinely provide meaningful information or benefit to clinical management. Despite this, nearly one in five patients undergoing BCS for DCIS had lymph node sampling performed. Given the potential increased morbidity and financial implications, this finding represents an opportunity for further education and improvement in patient selection for SLNB.

Axillary Lymph Node Evaluation Utilizing Convolutional Neural Networks Using MRI Dataset

The aim of this study is to evaluate the role of convolutional neural network (CNN) in predicting axillary lymph node metastasis, using a breast MRI dataset. An institutional review board (IRB)-approved retrospective review of our database from 1/2013 to 6/2016 identified 275 axillary lymph nodes for this study. Biopsy-proven 133 metastatic axillary lymph nodes and 142 negative control lymph nodes were identified based on benign biopsies (100) and from healthy MRI screening patients (42) with at least 3 years of negative follow-up. For each breast MRI, axillary lymph node was identified on first T1 post contrast dynamic images and underwent 3D segmentation using an open source software platform 3D Slicer. A 32 × 32 patch was then extracted from the center slice of the segmented tumor data. A CNN was designed for lymph node prediction based on each of these cropped images. The CNN consisted of seven convolutional layers and max-pooling layers with 50% dropout applied in the linear layer. In addition, data augmentation and L2 regularization were performed to limit overfitting. Training was implemented using the Adam optimizer, an algorithm for first-order gradient-based optimization of stochastic objective functions, based on adaptive estimates of lower-order moments. Code for this study was written in Python using the TensorFlow module (1.0.0). Experiments and CNN training were done on a Linux workstation with NVIDIA GTX 1070 Pascal GPU. Two class axillary lymph node metastasis prediction models were evaluated. For each lymph node, a final softmax score threshold of 0.5 was used for classification. Based on this, CNN achieved a mean five-fold cross-validation accuracy of 84.3%. It is feasible for current deep CNN architectures to be trained to predict likelihood of axillary lymph node metastasis. Larger dataset will likely improve our prediction model and can potentially be a non-invasive alternative to core needle biopsy and even sentinel lymph node evaluation.

Sentinel Lymph Node Biopsy After Initial Lumpectomy (SNAIL Study)-a Prospective Validation Study

Tertiary oncology center clinicians are commonly faced with the problem of managing patients with a diagnosis of breast cancer made after lumpectomy in the Primary Health Care (PHC) setting. There are no studies or guidelines that address the further surgical management in this group of patients regarding sentinel lymph node biopsy (SLNB) and need for breast post-operative cavity excision. Prospective observational study was planned to evaluate the feasibility of SLNB and defining the need for definitive breast surgery in patients diagnosed with breast cancer after lumpectomy in PHC. The study was carried out from January 2015 to August 2017 in Tata Medical Center, India, approved by institutional review board (EC/TMC/36/14). Seventy patients who underwent lumpectomy with a definitive histological analysis of breast cancer were included in this study. Each patient had definitive breast surgery and SLNB using subareoral blue dye injection followed by validation axillary dissection. The identification rate (IR) for SLNB was 92% (64/70). The median number of SLNs removed was 2 (IQR 1, 3). There were 2 patients with false negative results resulting in false negative rate (FNR) of 11%. Overall, SLNB procedure has the sensitivity of 89%, NPV of 96%, and accuracy was 97%. Peri-areoral incision of initial surgery was associated with low IR (84%) and high FNR (33%). Final histopathology showed residual invasive cancer in 43% and ductal carcinoma in situ in 14% of patients. Among 21 patients where initial lumpectomy histopathology margin was free of cancer, residual malignancy was found in 57% of patients. Prior excision of lumps for breast cancer does not affect the accuracy of SLNB. Peri-areoral scar may be associated with high FNR and low IR, although further studies are needed to validate this statement. Definitive breast surgery is required for all patients, irrespective of initial lumpectomy histopathological margin status.

Effect of preoperative injection of superparamagnetic iron oxide particles on rates of sentinel lymph node dissection in women undergoing surgery for ductal carcinoma in situ (SentiNot study)

Background

One-fifth of patients with a preoperative diagnosis of ductal carcinoma in situ (DCIS) have invasive breast cancer (IBC) on definitive histology. Sentinel lymph node dissection (SLND) is performed in almost half of women having surgery for DCIS in Sweden. The aim of the present study was to try to minimize unnecessary SLND by injecting superparamagnetic iron oxide (SPIO) nanoparticles at the time of primary breast surgery, enabling SLND to be performed later, if IBC is found in the primary specimen.

Methods

Women with DCIS at high risk for the presence of invasion undergoing breast conservation, and patients with DCIS undergoing mastectomy were included. The primary outcome was whether this technique could reduce SLND. Secondary outcomes were number of SLNDs avoided, detection rate and procedure-related costs.

Results

This was a preplanned interim analysis of 189 procedures. IBC was found in 47 and a secondary SLND was performed in 41 women. Thus, 78·3 per cent of patients avoided SLND (P &lt; 0·001). At reoperation, SPIO plus blue dye outperformed isotope and blue dye in detection of the sentinel node (40 of 40 versus 26 of 40 women; P &lt; 0·001). Costs were reduced by a mean of 24·5 per cent in women without IBC (€3990 versus 5286; P &lt; 0·001).

Conclusion

Marking the sentinel node with SPIO in women having surgery for DCIS was effective at avoiding unnecessary SLND in this study. Registration number: ISRCTN18430240 (http://www.isrctn.com).

Management of the Axilla in Early Breast Cancer

Management of the axilla in early breast cancer patients has significantly evolved in the last several decades. With the arrival of the sentinel lymph node biopsy, surgical practice for axillary staging in patients with early breast cancer has become gradually less invasive and formal axillary lymph node dissection has been confined to selected patients. Over the last two decades, evidence from randomized clinical trials have allowed for the de-escalation of axillary surgery in the management of early stage breast cancer. Advances in the staging and treatment of the axilla constitute a key component in determining initial surgical planning and therapeutic strategies in the treatment of early breast cancer. This chapter provides an updated review on the history, evolution, and current practices for axillary management in patients with early breast cancer, with particular attention to the surgical recommendations and controversial scenarios of the evolving management of the axilla.

Quality Indicators for Sentinel Lymph Node Biopsy in Breast Cancer: Applicability and Clinical Relevance in a Non-screened Population

Quality Indicators for Sentinel Lymph Node Biopsy in Breast Cancer: Applicability and Clinical Relevance in a Non-screened Population: sentinel lymph node biopsy (SLNB) has replaced axillary lymph node dissection (ALND) as standard of care for management of early breast cancer. This study assessed our SLNB program against 11 published quality indicators (QIs). All breast cancer patients who underwent SLNB in our centre from June 2013-Dec 2015 were included. Clinical, pathological and follow-up data were extracted from the institutional REDCap data system. Analysis was done with SPSS 23. Following validation, 234 patients had SLNB, always performed along with primary surgery. Identification rate was 95.3% and > 1 SLN was identified in 72% of patients. SLNB positivity was 33%, of these, 100% underwent ALND. Overall 91% of QI eligible patients underwent SLNB. No ineligible patients (T4) underwent SLNB. For the patients who had radio colloid, injection criteria were met for 100%. Pathological evaluation and reporting criteria were met for 100% of patients. There were no axillary recurrences in a median follow-up of 2 years. 7.6% patients had SLN negative on frozen section but positive on final histology. 7.2% of patients with clinical negative nodes had pN2 disease in final histopathology report after surgery. Sixty percent of patients who had completion ALND had only positive SLN. This study supports the applicability of published QI of SLNB in a non-screened cohort of early breast cancer patients. Although QI were useful, modification based on patient characteristics and resource availability may be needed. These indicators can be used as audit tools to improve the overall accuracy of the procedure.

Na7CrCuW11O39.16H2O induces apoptosis in human ovarian cancer SKOV3 cells through the p38 signaling pathway

Ovarian carcinoma is a common malignant disease worldwide with a poor therapeutic response. The present study investigated the effects of Na₇CrCuW₁₁O₃₉.16H₂O (CrCuW₁₁) on ovarian cancer cell growth and investigated the mechanisms underlying its actions. The effects of CrCuW₁₁ on cell viability and apoptosis were measured by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyl-2H-tetrazolium bromide (MTT) assay, acridine orange/ethidium bromide staining and electron microscopy in human ovarian cancer SKOV3 cells. The expression of bcl-2-like protein 4 (Bax), B-cell lymphoma 2 (Bcl-2), cytochrome c, phosphorylated (p)-p38 and p38 was determined by western blot analysis. Caspase-3 activity was measured by caspase-3 activity kit. CrCuW₁₁ concentrations of 1.87×10^-3 mol. l^-1 at 12 h reduced viability induced apoptosis in SKOV3 cells in a concentration-and time-dependent manner. Forced expression of CrCuW₁₁ upregulated the expression of certain proteins (Bax, cytochrome c, and p-p38), and downregulated Bcl-2 protein expression. Furthermore, CrCuW₁₁ also enhanced caspase-3 activity. The p38 inhibitor SB203580 was able to inhibit the activity of CrCuW₁₁. Caspase-3 and p38 signaling pathways were associated with CrCuW₁₁-regulated multiple targets involved in SKOV3 cell proliferation. Therefore, the results of the present study indicated that CrCuW₁₁ may be used as a novel clinical drug for the treatment of ovarian cancer.