Lymphedema after Sentinel Lymph Node Biopsy: Who is at Risk?

Magnetic lymphatic tracing for omission of sentinel lymph node biopsies in mastectomy patients: a community cancer center experience

BACKGROUND

Patients with ductal carcinoma in situ (DCIS) and patients undergoing risk reduction mastectomy may undergo sentinel lymph node biopsy (SLNB) at the time of mastectomy to complete axillary staging were an underlying invasive malignancy to be found on final pathology. Among patients with DCIS undergoing mastectomy, 15-29% of patients will have invasive disease on final pathology; therefore, approximately 70-85% of patients may benefit from avoiding SLNB. Superparamagnetic tracers (SPMT) have been proven to be non-inferior to the standard radioisotope and blue dye combination. SPMT remains active for several weeks, allowing a large proportion of DCIS and genetic carrier patients to potentially avoid SLNB in the setting of mastectomy. We hypothesize the use of SPMT will reduce the number of SLNB performed in patients undergoing mastectomy for DCIS and risk reduction, ultimately reducing the number of complications associated with axillary surgery. We seek to report our community cancer center's experience with SPMT and omission of SLNB in the DCIS and prophylactic mastectomy patient population.

METHODS

We performed a retrospective review of 52 female patients with DCIS or known genetic predisposition undergoing mastectomy. SPMT (Magtrace®, Endomag Ltd, Cambridge, UK) was injected ipsilateral to DCIS and bilaterally for prophylactic mastectomy patients. Our primary outcome was rate of return to the operating room (OR) for delayed SLNB. Secondary outcomes included post-operative complications within 30 days of surgery and operative time. We compared outcomes to a control group of 28 women undergoing mastectomy for DCIS or for risk reduction who underwent SLNB at their index operation in traditional fashion. Continuous variables were reported using median and interquartile ranges (IQR) and were compared using the Mann-Whitney U test. Categorical data were reported using frequency and percent and were compared using Pearson's Chi-Square or Fisher's Exact test, as appropriate. Alpha was set to 0.05 to determine statistical significance.

RESULTS

There was a total of 80 patients (52 SPMT, 28 control). Median age of SPMT patients was 49.5 (IQR 40-60.75) vs. 54.5 (48 - 65) in the traditional tracer group. vs. control group. 57.7% of SPMT patients underwent mastectomy for DCIS vs. 89.3% in the control group. Eight SPMT patients (15.4%) had invasive ductal carcinoma (IDC) on final pathology and seven of those patients underwent delayed SLNB (87.5%). None of the delayed SLNB were positive for metastatic disease. Rates of post-operative complications were similar between the two groups, including hematoma, seroma, and surgical site infection. OR times were also similar with median OR time 202 min (min) for the SPMT group vs. 195 min for the control group.

CONCLUSION

Use of SPMT avoided SLNB in 84.6% of our patients. We found no difference in rates of post-operative complications or operative times in patients using SPMT for omission of SLNB at time of mastectomy compared to the control group. Our findings suggest SLNB can be avoided in a majority of patients undergoing mastectomy for DCIS or risk reduction in the setting of genetic predisposition.

Incidence of lymphedema related to various cancers

Cancer-related lymphedema (CRL) lacks internationally accepted definition and diagnostic criteria. The accurate incidence of CRL is therefore a challenge and the condition is likely underreported. Patients treated for cancer can develop CRL as a result of surgery, chemotherapy, and/or radiotherapy, which can lead to considerable psychosocial and physical morbidity, and decreased quality of life. Determining CRL incidence is crucial to inform care access and resource allocation, to best support patients affected by this lifelong condition. This review aimed to provide the latest CRL incidence estimates. Using four core databases (MEDLINE, Embase, Web of Science Core Collection, Cochrane Library), a literature search was performed to capture publications dated between 2015 and 2023. A total of 48 articles (33 prospective studies, 15 systematic reviews) met inclusion criteria, providing a sample size of 234,079 cancer patients. Findings revealed CRL incidence across cancer types varied, reported 2-74% in breast, 8-45% in gynecological and urological, 71-90% in head and neck and 2-29% in melanoma cancers. CRL incidence varied between 3 and 21% in preventative lymphedema surgery patients. Projected increases in cancer incidence and improved survival rates are expected to further escalate CRL incidence. Healthcare systems and professionals alike must therefore prepare to meet the growing needs of CRL patients.

De-Escalating the Extent of Sentinel Lymph Node Biopsy in Patients With Ductal Carcinoma in Situ Undergoing Mastectomy

BACKGROUND

Sentinel lymph node biopsy (SLNB) for axillary staging in patients with ductal carcinoma in situ (DCIS) undergoing mastectomy is debated due to low nodal positivity rate and risk of morbidity. Standard SLNB entails removing all lymph nodes (LN) that have a radioactive count > 10% of the most radioactive node, contain blue dye or are palpably suspicious. In this study, we hypothesize that judicious SLNB with attempt to remove only the node with the highest radioactive count provides sufficient pathologic information while minimizing morbidity.

METHOD

A single institution prospective database was retrospectively reviewed to identify women with DCIS who underwent mastectomy and SLNB between 2010 and 2022. Patient characteristics, number of SLNs retrieved, pathologic results and long-term upper extremity complications were analyzed.

RESULTS

A total of 743 LNs were removed in 324 pts. Median (IQR) age was 62 (51-70) years. Dual tracer technique, with technetium-99m labeled radiocolloid and blue dye, was used in 311 (96%) pts, whereas single agent (radioisotope or blue dye alone) was utilized in 9 (2.8%) and 4 (1.2%) patients, respectively. Median (IQR) number of SLN removed was 2 (1-3) (range 1-9). In 99% of cases, the SLN with the highest radioactive count was identified among the first 3 dissected LNs. Final pathology revealed upstaging to invasive cancer in 27.5% (n = 89) of the breasts and nodal positivity in 1.9% (n = 6) of the patients. In all 6 cases, metastatic disease was identified in the LN with highest radioactive count among the LNs retrieved. No additional metastatic nodes were identified after > 3 SLN had been removed. At median follow-up of 57 (range 28-87) months, 8.3% (n = 27) of pts complained of long-term upper extremity symptoms. 7.1% (23 pts) were referred to physical therapy for symptoms such as swelling, fullness, heaviness, stiffness, or sensory discomfort in the upper extremity and/or axillary cording. Long-term upper extremity complications were higher when > 3 SLNs compared to ≤ 3 SLNs were removed (10.4% vs. 6.5%, P = .005).

CONCLUSION

In this cohort of patients with DCIS undergoing mastectomy who were upstaged on final pathology to node positive invasive cancers, the SLN with the highest radioactive count provided sufficient information for axillary staging. Acknowledging that the "hottest" LN is not always the first 1 removed, these data support an increased likelihood of developing long-term complications when more than 3 SLNs are removed. Rather than comprehensive removal of all SLNs meeting the standard "10% rule," prioritizing the sequence of removal to the highest count provides the same prognostic information with reduced morbidity.

Decompression of Axillary Vein: An Essential Adjunct for Advanced Lymphedema

BACKGROUND

In advanced lymphedema, lymphovenous anastomosis (LVA) can be a solution based on using the pressure gradient between the high-pressure lymphatics and the low-pressure veins. If the vein pressure is high, the effect of surgery will be less optimal. This study evaluated the effect of axillary vein perivascular scar release on LVA.

METHODS

This is a retrospective study of 40 upper limb stage 2 and 3 lymphedema patients divided into 2 groups with an average follow-up of 33 months (minimum of at least 12 months): the scar release group ( n = 25) and the control group ( n = 15). All patients underwent LVA with or without lymph node transfer. Demographic data, outcome (volumetric change and bioimpedence analysis [BIA]), and major vein (axillary, basilic, and cephalic) diameter changes were evaluated.

RESULTS

Both groups showed significant reduction in volume and BIA parameters after LVA. The scar release group (24 of 25 with lymph node transfer and 1 without) showed statistically higher reduction of BIA analysis compared with the control group at 1, 6, and 12 months after LVA. The changes in the major veins after axilla scar release showed significant changes in all 3 veins. There was a significant correlation between cephalic vein diameter reduction and BIA measurement.

CONCLUSIONS

The release of perivascular scar in the axillary vein may result in better outcome after LVA. This is based on the finding that scar release shows correlation between cephalic vein diameter reduction and BIA measurement suggesting reduction of venous pressure in the peripheral vein increasing the pressure gradient between the lymphatic and venous system allowing better outflow after LVA.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, III.

MRI Detection of Lymph Node Metastasis through Molecular Targeting of C-C Chemokine Receptor Type 2 and Monocyte Hitchhiking

Biopsy is the clinical standard for diagnosing lymph node (LN) metastasis, but it is invasive and poses significant risk to patient health. Magnetic resonance imaging (MRI) has been utilized as a noninvasive alternative but is limited by low sensitivity, with only ∼35% of LN metastases detected, as clinical contrast agents cannot discriminate between healthy and metastatic LNs due to nonspecific accumulation. Nanoparticles targeted to the C-C chemokine receptor 2 (CCR2), a biomarker highly expressed in metastatic LNs, have the potential to guide the delivery of contrast agents, improving the sensitivity of MRI. Additionally, cancer cells in metastatic LNs produce monocyte chemotactic protein 1 (MCP1), which binds to CCR2+ inflammatory monocytes and stimulates their migration. Thus, the molecular targeting of CCR2 may enable nanoparticle hitchhiking onto monocytes, providing an additional mechanism for metastatic LN targeting and early detection. Hence, we developed micelles incorporating gadolinium (Gd) and peptides derived from the CCR2-binding motif of MCP1 (MCP1-Gd) and evaluated the potential of MCP1-Gd to detect LN metastasis. When incubated with migrating monocytes in vitro, MCP1-Gd transport across lymphatic endothelium increased 2-fold relative to nontargeting controls. After administration into mouse models with initial LN metastasis and recurrent LN metastasis, MCP1-Gd detected metastatic LNs by increasing MRI signal by 30-50% relative to healthy LNs. Furthermore, LN targeting was dependent on monocyte hitchhiking, as monocyte depletion decreased accumulation by >70%. Herein, we present a nanoparticle contrast agent for MRI detection of LN metastasis mediated by CCR2-targeting and demonstrate the potential of monocyte hitchhiking for enhanced nanoparticle delivery.

The Antimicrobial Peptide Merecidin Inhibit the Metastasis of Triple-Negative Breast Cancer by Obstructing EMT via miR-30d-5p/Vimentin

Purpose: To investigate the inhibitory effect of antimicrobial peptide merecidin on triple-negative breast cancer (TNBC) and the mechanism of inhibiting epithelial-mesenchymal transformation (EMT) by regulating miR-30d-5p/vimentin. Methods: TNBC cell lines (MDA-MB-231, MDA-MB-468) were treated with merecidin to assess proliferation, migration, invasion ability, and EMT. Confocal laser localization was used to examine the role of merecidin and TNBC cells. The relationship between merecidin and miR-30d-5p was determined through RT-qPCR and dual-luciferase reporter gene, and the relationship between merecidin and vimentin was verified through pulling down the experiment. The effects of miR-30d-5p on the migration and invasion ability of TNBC cells were confirmed through scratch and transwell experiments. Vimentin levels, tumor volume, shape, size, and weight were observed in the MDA-MB-231 subcutaneous tumor model in nude mice. Results: merecidin inhibited the proliferation, migration, invasion, and EMT of TNBC cells. merecidin was primarily located in the cytoplasm of TNBC cells, and the expression of miR-30d-5p was low in TNBC cells. merecidin significantly up-regulated the expression of miR-30d-5p. miR-30d-5p negatively regulated vimentin. merecidin could bind to vimentin in vitro. miR-30d-5p inhibited the migration and invasion ability of TNBC cells, while vimentin promoted their migration and invasion ability. Down-regulation of miR-30d-5p or overexpression of vimentin partially counteracted the inhibitory effects of merecidin on TNBC cell migration, invasion ability, and EMT. In nude mouse tumor models, merecidin significantly suppressed tumor growth. Conclusion: Merecidin effectively blocks the EMT process and inhibits the migration and invasion of TNBC cells by regulating miR-30d-5p/vimentin.

Upper Limb Morbidity in Newly Diagnosed Individuals After Unilateral Surgery for Breast Cancer: Baseline Results from the AMBER Cohort Study

PURPOSE

We aimed to examine potential associations between post-surgical upper limb morbidity and demographic, medical, surgical, and health-related fitness variables in newly diagnosed individuals with breast cancer.

METHODS

Participants were recruited between 2012 and 2019. Objective measures of health-related fitness, body composition, shoulder range of motion, axillary web syndrome, and lymphedema were performed within 3 months of breast cancer surgery, and prior to or at the start of adjuvant cancer treatment.

RESULTS

Upper limb morbidity was identified in 54% of participants and was associated with poorer upper limb function and higher pain. Multivariable logistic regression analysis identified mastectomy versus breast-conserving surgery (odds ratio [OR] 3.51, 95% confidence interval [CI] 2.65-4.65), axillary lymph node dissection versus sentinel lymph node dissection (OR 2.67, 95% CI 1.73-4.10), earlier versus later time from surgery (OR 1.58, 95% CI 1.15-2.18), and younger versus older age (OR 1.01, 95% CI 1.00-1.03) as significantly associated with a higher odds of upper limb morbidity, while mastectomy (OR 1.57, 95% CI 1.10-2.25), axillary lymph node dissection (OR 2.20, 95% CI 1.34-3.60), lower muscular endurance (OR 1.10, 95% CI 1.01-1.16) and higher percentage body fat (OR 1.04, 95% CI 1.00-1.07) were significantly associated with higher odds of moderate or greater morbidity severity.

CONCLUSIONS

Upper limb morbidity is common in individuals after breast cancer surgery prior to adjuvant cancer treatment. Health-related fitness variables were associated with severity of upper limb morbidity. Findings may facilitate prospective surveillance of individuals at higher risk of developing upper limb morbidity.

An Australian-based nomogram predicting nodal positivity for breast cancer in older patients

INTRODUCTION

Regional nodal status is one of the most powerful prognosticators in breast cancer. The sentinel lymph node biopsy (SLNB) evaluates the first node in the axillary lymphatic basin theorised to drain the anatomical region of breast cancer. Recent literature has appropriately raised the query of the need for SLNB for breast cancer in older patients (BCOP). Though some early-stage older patients may safely have SLNB omitted, we are potentially missing the under-represented aggressive cancers. No sentinel lymph node metastases nomogram has been developed solely from BCOP data to date. This study aimed to identify older patients with breast cancer at risk for nodal involvement using a nomogram developed from their data alone.

METHODS

A retrospective analysis of prospectively collected data on BCOP (aged ≥70 years) was performed using the Breast Surgery Quality Audit (BQA). Inclusion criteria were T1-2 invasive breast cancer patients that underwent a SLNB from 1st January 2001 to 31st December 2019. The primary outcome was nodal involvement. Data obtained from the dataset included: age, tumour type, tumour size in millimeters, histological grade, lymphovascular invasion, oestrogen receptor status, progesterone receptor status, HER2 status and referral source. Binary logistic regression was used to develop a nomogram. The model was internally validated by splitting the data set (80% for training and 20% for testing). A receiver operating characteristic curve was developed, with the area under the curve (AUC) and a calibration plot.

RESULTS

There were 22,313 patients of which 14,856 (66.6%) were symptomatic presentations and 7457 (33.4%) were screen-detected. Invasive tumour type, tumour size, tumour grade, lymphovascular invasion, oestrogen receptors, and referral source indicated a statistically significant effect on predicting a nodal positivity event (Table 1). The AUC was 0.782 (95% CI 0.776-0.789) (Fig. 1a) and demonstrated good calibration (Fig. 1b). The negative predictive value established was 85%.

CONCLUSION

We have developed an Australian sentinel lymph node metastasis nomogram for BCOP using routine histopathological data obtained pre-operatively (Fig. 2). This is the first Australian nomogram, as well as the first nomogram developed solely for BCOP - and maintains a superior AUC compared to other well-established nomograms.

Treatment and Management Experience of Idiopathic Granulomatous Mastitis in a Low-income Country

OBJECTIVE

 Reporting our experience of the management and treatment of Idiopathic granulomatous mastitis (IGM) in a low-income country by describing patients characteristics and therapy with emphasis on conservative surgical excision and postoperative care as the cornerstone of treatment.

METHODS

 A retrospective cohort of women with histopathological diagnosis of IGM from 2014 to 2018 at Instituto Nacional Materno Perinatal in Lima, Peru. Patients' characteristics, clinical presentation, treatment, management, postoperative care, and follow-up were analyzed.

RESULTS

 Thirty-eight patients with histopathological diagnosis of IGM were identified. Their average age was 35.9 years and 23 (60.5%) reported previous use of hormonal contraceptives. Nine (23.7%) patients had chronic mastitis with previous treatment. The time from the onset of symptoms to the first clinic consult was 5.1 months on average. Twenty-one (55.3%) patients had the lesion in the right breast, with a mean size of 6.9 cm. Conservative surgical excision was performed in all patients. Additionally, 86.8% required corticosteroids and 78.9% were treated with antibiotics. Complete remission was obtained at 141 days on average (range 44 to 292 days). Six (15.8%) women reported ipsilateral recurrence and 5 (13.2%), contralateral. The latency time was 25.5 months on average.

CONCLUSION

 The conservative surgical treatment demonstrated and close follow-up made for a high cure rate, but with recurrence similar to that reported in the literature. Use of gloves is an alternative to manage post operative wounds in a low-income country. The most frequent adverse effect was breast surgical scar.

CCND2 and miR-206 as potential biomarkers in the clinical diagnosis of thyroid carcinoma by fine-needle aspiration cytology

BACKGROUND

To investigate the relationship between cyclin D2 (CCND2) and miR-206 expression in fine-needle aspiration cytology of thyroid carcinoma.

METHODS

A total of 65 patients with thyroid carcinoma were selected as the subjects and 65 patients with benign thyroid nodules were in control group. The fine-needle aspiration cytology of thyroid nodules was performed. CCND2 and miR-206 levels were detected by PCR.

RESULTS

Compared with the patients with benign thyroid nodules, the expression level of miR-206 in fine-needle aspiration cytology of thyroid cancer patients decreased significantly and the expression level of CCND2 increased significantly. CCND2 and miR-206 expression was negatively correlated in thyroid cancer tissues. Area under curve (AUC) of miR-206 level in the diagnosis of thyroid cancer was 0.889, and the sensitivity and specificity were 92.3% and 81.5%, respectively. AUC of CCND2 level in the diagnosis of thyroid cancer was 0.837, and the sensitivity and specificity were 67.7% and 89.2%, respectively. The AUC of combined detection of CCND2 and miR-206 in the diagnosis of thyroid cancer was 0.959, and the sensitivity and specificity were 93.8% and 87.7%, respectively. The levels of miR-206 and CCND2 were significantly correlated with TNM staging and lymph node metastasis.

CONCLUSIONS

miR-206 and CCND2 may become new biomarkers for clinical diagnosis of thyroid cancer based on the fine-needle aspiration cytology of thyroid nodules.

A Nomogram for Predicting Liver Metastasis of Lymph-Node Positive Luminal B HER2 Negative Subtype Breast Cancer by Analyzing the Clinicopathological Characteristics of Patients with Breast Cancer

Background: Luminal B-like human epidermal growth factor receptor 2 negative (Luminal B [HER2-]) is the most common molecular subtype of breast cancer (BC). Since the relationship between Luminal B (HER2-) BC and liver metastasis (LM) is poorly defined, this retrospective study aimed to develop an LM risk nomogram for patients with lymph node-related (N + Luminal B [HER2-]) BC. Methods: Data were obtained for patients initially diagnosed with BC from the Tianjin Medical University Cancer Institute and Hospital. There were 30,975 Chinese female patients with stage I-III BC and follow-up confirming 1217 subsequent patients with LM, and 427 patients with N + Luminal B (HER2-). The LM risk was assessed using Cox proportional hazards regression, histogram, Venn diagram, and Kaplan-Meier survival analysis, with further analysis for patients with N + Luminal B (HER2-) BC. A nomogram was established based on the N + Luminal B (HER2-) BC data, which was validated using calibration plots. Results: The median age of 427 patients with N + Luminal B (HER2-) liver metastasis of breast cancer (BCLM) was 49 years. The largest number of patients with BCLM was diagnosed between the second to the 6th year, the longest interval from initial BC diagnosis to subsequent LM was 145 months. The patients with LM as the first site of distant metastasis which is associated with better survival were analyzed by Kaplan-Meier. The nomogram was constructed for the risk of LM that included age, menstrual status, unilateral oophorectomy, pregnancy, hepatitis B antigen, region of residence, tumor size, lymph node, clavicular lymph nodes, progesterone receptor, and lymph vessel invasion. Conclusion: We described the clinicopathological characteristics of patients with stage I-III BC, and constructed a nomogram for calculating personalized LM probabilities for patients with N + Luminal B (HER2-), which could guide future prolonged or early extensive treatment decisions.

The dynamic alteration of transcriptional regulation by crucial TFs during tumorigenesis of gastric cancer

Background

The mechanisms of Gastric cancer (GC) initiation and progression are complicated, at least partly owing to the dynamic changes of gene regulation during carcinogenesis. Thus, investigations on the changes in regulatory networks can improve the understanding of cancer development and provide novel insights into the molecular mechanisms of cancer.

Methods

Differential co-expression analysis (DCEA), differential gene regulation network (GRN) modeling and differential regulation analysis (DRA) were integrated to detect differential transcriptional regulation events between gastric normal mucosa and cancer samples based on GSE54129 dataset. Cytological experiments and IHC staining assays were used to validate the dynamic changes of CREB1 regulated targets in different stages.

Results

A total of 1955 differentially regulated genes (DRGs) were identified and prioritized in a quantitative way. Among the top 1% DRGs, 14 out of 19 genes have been reported to be GC relevant. The four transcription factors (TFs) among the top 1% DRGs, including CREB1, BPTF, GATA6 and CEBPA, were regarded as crucial TFs relevant to GC progression. The differentially regulated links (DRLs) around the four crucial TFs were then prioritized to generate testable hypotheses on the differential regulation mechanisms of gastric carcinogenesis. To validate the dynamic alterations of gene regulation patterns of crucial TFs during GC progression, we took CREB1 as an example to screen its differentially regulated targets by using cytological and IHC staining assays. Eventually, TCEAL2 and MBNL1 were proved to be differentially regulated by CREB1 during tumorigenesis of gastric cancer.

Conclusions

By combining differential networking information and molecular cell experiments verification, testable hypotheses on the regulation mechanisms of GC around the core TFs and their top ranked DRLs were generated. Since TCEAL2 and MBNL1 have been reported to be potential therapeutic targets in SCLC and breast cancer respectively, their translation values in GC are worthy of further investigation.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10020-022-00468-7.

The pyroptosis-related gene signature predicts prognosis and indicates immune activity in hepatocellular carcinoma

Background

Hepatocellular carcinoma (HCC) remains one of the most common malignant tumors with poor survival. Pyroptosis is a kind of programmed cell death that can regulate the proliferation, invasion, and metastasis of tumor cells. However, the expression levels of pyroptosis-related genes (PRGs) in HCC and their relationship with prognosis are still unclear.

Methods

Our study identified 35 PRGs through bioinformatics analysis that were differentially expressed between tumor samples and nontumor samples. According to these differentially expressed genes, HCC patients could be divided into two groups, cluster 1 and cluster 2. The least absolute shrinkage and selection operator (LASSO) Cox regression method was performed to construct a 10-gene signature that classified HCC patients in the cancer genome atlas (TCGA) database into low-risk and high-risk groups.

Results

The results showed that the survival rate of HCC patients in the low-risk group was significantly higher than that in the high-risk group (p < 0.001). The validation cohort, the Gene Expression Omnibus (GEO) cohort, was divided into two risk groups based on the median risk score calculated by the TCGA cohort. The overall survival (OS) of the low-risk group was significantly better than that of the high-risk group (p = 0.007). Univariate and multivariate Cox regression analyses revealed that the risk score was an independent factor in predicting OS in HCC patients. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes analyses showed that immune-related high-risk groups were rich in genes and had reduced immune status.

Conclusions

PRGs play a significant role in tumor immunity and have the potential capability to predict the prognosis of HCC patients.

Supplementary Information

The online version contains supplementary material available at 10.1186/s10020-022-00445-0.