Recent advances in sentinel lymph node biopsy for breast cancer

Determining agreement between preoperative computed tomography lymphography and indocyanine green near infrared fluorescence intraoperative imaging for sentinel lymph node mapping in dogs with oral tumours

Lymphatic drainage from the head and neck is variable with significant crossover, therefore sentinel lymph node (SLN) mapping can help ensure the appropriate lymph node(s) are sampled. To improve sensitivity, SLN mapping utilizing multiple modalities and a combination of preoperative computed tomography lymphography (CTL) and intraoperative near infrared fluorescence imaging (NIRF) with indocyanine green (ICG) +/- methylene blue (MB) dye has been suggested. The aim of this study was to describe a method for intraoperative ICG lymphography and determine agreement for SLN detection using preoperative CTL and intraoperative ICG NIRF + MB lymphography (IOL) in dogs with oral tumours. Fourteen client-owned dogs were included. All dogs had preoperative CTL with iodinated contrast and intraoperative IOL with an exoscope. Lymph nodes with CTL contrast-enhancement, blue staining or fluorescence were considered sentinel. The overall SLN identification rate was 100% when CTL and IOL were combined. A total of 57 SLNs were identified. Indocyanine green NIRF identified a greater proportion of SLNs (91%; 52/57) compared with MB (50.8%; 29/57) and CTL (42.1%; 24/57). Eighteen SLNs were identified by all three modalities with a fair level of agreement using Fleiss kappa. These findings suggest a combination of preoperative CTL with intraoperative SLN mapping techniques may greatly improve the ability to accurately detect the SLN in dogs with oral tumours.

Salvaging Breast Reconstruction: Profunda Artery Perforator Flaps Using Thoracodorsal Vessels

Background:

Over the years, the choice of recipient vessels for free flap autologous breast reconstruction has shifted from the thoracodorsal to the internal mammary vessels due to ease of flap inset and predictability of anatomy. However, thoracodorsal vessels are still great recipient vessels, and can be useful, especially in the previously failed or staged autologous breast reconstruction. In this study, we present our experience using thoracodorsal or serratus vessels for profunda artery perforator flaps.

Methods:

Of the 792 autologous free flap breast reconstruction performed, we identified 12 patients (21 flaps) who underwent reconstruction using thoracodorsal or serratus vessels from 2012 to 2017. Flap, patient characteristics, and demographic data and perioperative details were collected.

Results:

Twenty-one flaps were used to reconstruct 14 breasts in 12 patients. The mean age of patients was 49.6 years old (range, 42–54), the mean flap weight was 354.7 g (range, 170–540 g), the mean body mass index was 28 (range, 23.2–34.4), and the average operative time was 496.1 minutes (266–680). Majority of these patients underwent additional staged free flap reconstruction (following previous deep inferior epigastric perforator flaps) for severe breast contour defects (58%) and for failed previous breast reconstruction (42%). The anastomosis was performed using thoracodorsal (43%), serratus (43%), and profunda artery perforator side branch (14%) vessels.

Conclusion:

Determining appropriate flap and recipient vessels in a previously failed or staged breast reconstruction is very challenging. Thoracodorsal and serratus vessels are excellent recipient vessels in patients who already have exhausted internal mammary vessels for previous breast reconstruction.

Influence of occupation and education level on breast cancer stage at diagnosis, and treatment options in China: A nationwide, multicenter 10-year epidemiological study

The objective of this study was to evaluate the impact of occupation and education level of Chinese female breast cancer patients on their cancer staging at diagnosis, clinical and pathological features, rate of implementation, and selection of treatment.The medical charts of 4211 confirmed female breast cancer cases diagnosed between 1999 and 2008, from 7 breast cancer centers spread across the whole of China, were reviewed. Data including information on the patient's sociodemographic status, clinical and pathological characteristics, implementation of clinical examination and treatment modalities were analyzed. In parallel, the associations between different occupations and level of educational attainment were analyzed in relation to tumor stage through TNM staging, clinical and pathological characteristics, implementation of clinical examination, and treatment patterns. Multivariate logistic regression was used to identify whether the occupation and education level of patients are independent factors of TNM staging at diagnosis.There were significant differences among different occupation groups and the education level of patients in regards to pathological characteristics and treatment choice. Both the occupation and education level of patients were independent factors of TNM staging at diagnosis. For patients within the lower-income occupation or lower educational attainment group, the tumor stage was later, the rates of implementation of relevant investigations were lower, as were the rates of radiotherapy, chemotherapy, and endocrine therapy.This study suggests that strategies should work toward developing more accurate and effective breast cancer prevention and treatment strategies aimed specifically at patients with lower educational attainment levels and at specific occupation groups.

Comparison of five different popular scoring systems to predict nonsentinel lymph node status in patients with metastatic sentinel lymph nodes: a tertiary care center experience

Sentinel lymph node biopsy (SLNB) is the current standard of care for breast cancers with no clinically palpable axillary lymph nodes. Almost 50 % of sentinel lymph node positive patients have negative non-sentinel nodes and undergo non-therapeutic axillary dissection. Five different scoring systems, reported in the literature, were compared for their predictive ability of non-SLN involvement in patients with SLN positive breast cancer. 242 patients who underwent breast surgery and SLNB were included in the study. Of these, 70 who were confirmed to have SLN metastasis and received complementary ALND and constituted the final study population. The nomograms (MSKCC, M.D. Anderson Cancer Center, Tenon model, Stanford and Turkish) were statistically compared for their prediction of non-SLN metastasis (95 % confidence interval). We have determined only two clinicopathologic (multifocality and size of the primary tumor) situations which have a statistically significant association between SLN metastasis with using a multivariate logistic regression analysis. Multifocality (P = 0.001) and size of the primary tumor (P = 0.001) were associated with a higher probability of-SLN metastasis. No predictive model was constructed that showed good area under the curve (AUC) discrimination in the validation series. Currently published predictive models lack accuracy when applied to a different population. Multi-institutional heterogenic population studies are important to determine the exact combination of scoring systems and/or nomograms.

Application of intraoperative frozen section examination in the management of female breast cancer in China: a nationwide, multicenter 10-year epidemiological study

BACKGROUND

Intraoperative frozen section examination (IFSE) during breast cancer surgery can partly reflect the status of surgical treatment since the surgical method used directly determines the purpose of IFSE use in disease management. This study aims to investigate the application of, changing trends in, and factors influencing IFSE in the management of female breast cancer in China.

METHODS

We collected the sociodemographic and clinical data of 4,211 breast cancer patients between 1999 and 2008 and statistically analyzed these data using χ2 or Fisher's exact tests.

RESULTS

A total of 2,283 (54.22%) patients with breast cancer underwent IFSE. During the 10-year study period, IFSE use was associated with an increase in the number of sentinel lymph node biopsies (SLNB) and breast-conserving surgeries (BS) performed, with significant regional differences noted in this trend (P < 0.05). Patients' education, occupation, age, tumor size estimated by preoperative palpation, and the use of imaging examinations affected the purpose of IFSE use (P < 0.05).

CONCLUSIONS

Our results show that the purpose of IFSE in the surgical treatment of breast cancer in China is gradually approaching that in developed countries. We believe that policymakers must address the differences in breast cancer treatment based on the socioeconomic status of patients. Lastly, the use of IFSE for determining tumor characteristics should be avoided as far as possible, and patient education and breast cancer screening programs tailored to the Chinese population should be established. Our findings may guide the formulation of breast cancer control strategies in China and other low-income countries.

Laparoscopic Extirpation of the Medial Iliac Lymph Nodes in Normal Dogs

OBJECTIVE

To describe a surgical technique for laparoscopic medial iliac lymph node (MILN) extirpation, and to describe the quality of biopsy specimens obtained.

DESIGN

Experimental study.

ANIMALS

Purpose-bred male hound-mix research dogs (n = 8).

METHODS

Dogs were randomized to groups of left or right-sided laparoscopic surgical approaches. Three transperitoneal portals were established with the dogs in lateral recumbency, and ipsilateral MILN dissection was achieved under CO2 pneumoperitoneum using a vessel-sealing device.

RESULTS

MILN ipsilateral to the approach were successfully identified and removed laparoscopically in 8 dogs. Observed complications included mild to moderate hemorrhage that was controlled laparoscopically in 4 dogs, and tearing of the MILN capsule during retraction and dissection in 3 dogs. No other major complications occurred and all dogs recovered uneventfully. Areas of either minor peripheral (9/9) or central (4/9) pinch artifact affected a median percentage of 5% of surface area (range, 5-30%) of bisected lymph nodes.

CONCLUSIONS

Laparoscopic MILN extirpation is feasible in dogs with normal MILN and may serve as a minimally invasive approach for excisional biopsy in the diagnostic staging of canine onocologic patients with normal-sized MILN. This lateral laparoscopic approach allows dissection of the ipsilateral MILN but precludes removal of the contralateral MILN. Minimal handling of the lymph node during dissection and removal is required to reduce the risk of capsular tear, or introduction of possible histologic artifact by tissue crush that may impact diagnosis.

Sentinel node biopsy in breast cancer revisited

The axilla has long been a focus of clinicians' attention in the management of breast cancer. The approach to the axilla has undergone dramatic changes over the last century, from radical and extended radical excisions, through the introduction of sentinel node biopsy for node negative patients to the current situation where selective management of those with nodal involvement is being introduced. The introduction of lymphatic mapping and sentinel node biopsy in the 1990's has been key to the major changes that have occurred. In less than 20 years it has moved from a hypothesis to a situation where it is the default approach to almost all clinically node negative patients and is being considered in other situations where axillary clearance was previously considered standard. This article reviews the development and introduction of sentinel node biopsy, its current uncertainties and limitations, and possible future developments.

Sentinel Lymph Node Biopsy Status Correlates with Postoperative Stimulated Thyroglobulin Levels in Low-risk Papillary Thyroid Cancer Patients

OBJECTIVE

Radioactive iodine (RAI) remnant ablation in low-risk papillary thyroid cancer (PTC) is controversial. Current patient selection guidelines recommend the use of postoperative stimulated thyroglobulin (stim-Tg), neck dissections, and sonography but fail to include sentinel lymph node biopsy (SLNB). The objective of this study was to evaluate the correlation between SLNB status and postoperative stimulated thyroglobulin as a surrogate marker of clinical outcome.

METHODS

Retrospective chart review of low-risk PTC patients who underwent a total thyroidectomy with SLNB at the McGill Thyroid Cancer Center. SLNBs were obtained using methylene blue dye. Biochemical measurements were acquired between 4 and 12 weeks postoperatively. Statistical analyses were performed using logistic regression models and receiver operating characterisitc (ROC) curves. A P-value <.05 was considered significant.

RESULTS

Ninety-six patients were included in this study. The positive SLNB rate was 14.6%. The mean postoperative Tg level was 1.41 μg/L. There were no significant correlations between the SLNB and the covariates analyzed (age, gender, histology, tumor size, and thyrotropin levels). Patients with negative SLNB were significantly more likely to have a lower stim-Tg (P<.0001). When postoperative Tg was analyzed as a categorical variable, a threshold of <1 μg/L was significantly associated with a negative SLNB, with a sensitivity and specificity (determined by ROC curves) of 0.86 and 0.88, respectively.

CONCLUSION

There exists a correlation between SLNB and postoperative Tg. This creates the possibility of a new approach to RAI administration among low-risk PTC patients incorporating SLNB to the current guidelines.

Breast cancer characteristics-comparison of preoperative and postoperative values

Breast cancer characteristics obtained at the time of diagnosis are important for setting the basic strategy of the treatment. Reliability of preoperative investigation differs for various features of the disease. The aim of this study was to ascertain the agreements and differences between preoperative and postoperative values. This retrospective study analyzed the results of 617 women with primary surgery of the breast and axilla. Cohen's kappa coefficient has been employed to measure the degree of agreement between preoperative and postoperative values. Substantial or "almost perfect" agreement has been documented for the histological type of the tumors, their histopathological grade, proliferation index Ki67, as well as for estrogen, progesterone, and HER-2/neu receptors. Substantial differences exist between preoperative and postoperative diagnoses of invasiveness of the tumor, determination of the size of the tumors, and the number of tumor foci. Preoperative imaging and clinical examination of lymph nodes exhibited unacceptably high false negative rates. Heterogeneity of breast cancer cell population, methodology of histology examinations, and insufficient imaging of lymph nodes are the major limitations precluding satisfactory accuracy of preoperative diagnosis. Preoperatively diagnosed in situ carcinomas, as well as multifocal lesions, were the most often sources of diagnostic failures.

Accuracy and axilla sparing potentials of sentinel lymph node biopsy with methylene blue alone performed before versus after neoadjuvant chemotherapy in breast cancer: a single institution experience

INTRODUCTION

The timing of sentinel lymph node biopsy (SLNB) of breast cancer in the neoadjuvant setting is still controversial. We retrospectively analyzed a Chinese patient cohort with neoadjuvant chemotherapy (NAC) to evaluate the accuracy and axilla sparing potentials of different SLNB timings with methylene blue alone for lymphatic mapping.

MATERIALS AND METHODS

Patients with NAC and axillary lymph node dissection (ALND) and either pre- or post-NAC SLNB were eligible. Clinicopathological characteristics, identification rate (IR), false-negative rate (FNR), accuracy, and positive-predictive value were calculated and compared between the pre- and post-NAC SLNB group using appropriate statistical methods. Axilla sparing potentials of different SLNB timings were evaluated and compared.

RESULTS

One hundred and fifteen eligible cases were included, and 58 had pre-NAC SLNB while the other 57 had post-NAC SLNB. Both groups were comparable in clinicopathological characteristics, neoadjuvant treatments and pathologic complete response rate. IR, FNR, and accuracy of SLNB, as pre-NAC versus post-NAC, were 100 versus 98.2 % (P = 0.496), 0 versus 8.0 % (P = 0.181), and 100 versus 96.4 % (P = 0.239), respectively. Post-NAC SLNB had significantly higher positive-predictive value for ALNs than pre-NAC SLNB (70.0 vs. 36.4 %, P = 0.014), suggesting as high as 63.6 % of ALND performed in the pre-NAC group could have been avoided while only 30 % of ALND in the post-NAC group were theoretically unnecessary.

CONCLUSIONS

Both SLNB timings of breast cancer patients with NAC were feasible and accurate. Although pre-NAC SLNB tends to be better in accuracy, post-NAC SLNB is significantly superior in terms of axilla sparing.

The importance of pre-operative axillary ultra-sound and intra-operative sentinel lymph node frozen section analysis in patients with early breast cancer--a 3-year study

INTRODUCTION

To ensure appropriate axillary surgery is performed at a single operation, we have sought to identify patients with involved nodes who might progress directly to axillary dissection.

PATIENTS AND METHODS

We evaluated pre-operative ultrasound of the axilla and intra-operative frozen section of sentinel lymph nodes over a 3-year period. Patients with clinical early breast cancer underwent axillary ultrasound. Abnormal nodes were defined as a cortex > 2.5 mm, loss of high echogenic medulla, and morphological changes. Any axilla containing a lymph node considered abnormal had ultrasound-directed fine needle aspiration (FNA) performed. Patients with positive cytology proceeded directly to axillary dissection. Patients with negative cytology and those with normal ultrasound proceeded to sentinel four-node biopsy using Patent Blue dye alone. A single sentinel node was evaluated by intra-operative frozen section.

RESULTS

A total of 311 patients underwent pre-operative ultrasound successfully, identifying 115 (77%) patients of the total 150 who were found to have positive lymph nodes. Overall, 196 patients underwent sentinel lymph node biopsy analysis intra-operatively. Of the 11 false negative cases in which the lymph node was found to be positive postoperatively, eight cases showed the single tested sentinel node contained cancer that was recognised on postoperative staining but not frozen section. In six, the deposit in the sentinel node was a micrometastasis. Three cases were found to contain cancer in the 'non-sentinel' node; in all, this was micrometastatic disease.

CONCLUSIONS

This study confirms the value of pre-operative ultrasound and intra-operative frozen section examination of axillary nodes. Only 3.5% of patients required two operations.

Systematic review and meta-analysis of sentinel node biopsy in thyroid cancer

Background

Sentinel node biopsy (SNB) is employed as standard treatment in some solid organ cancers to assess lymph node spread and enable targeted treatment. Several studies have investigated the role of SNB in thyroid cancer. This is a systematic review and meta-analysis of the role of SNB in the management of thyroid cancer.

Methods

A systematic search was performed in the PubMed database to identify all original articles on the role of SNB in thyroid cancer. Data on methodologies used, short-term outcomes and adverse effects were summarized, and used to address relevant clinical questions related to the application of the SNB technique in thyroid cancer.

Results

Twenty-four studies were included. The overall sentinel node (SN) detection rates for the blue dye, radioisotope and combined techniques were 83·7, 98·4 and 96 per cent respectively. A positive SN was seen in 42·9 per cent of patients with papillary thyroid cancer with an identified SN. The overall false-negative rates for the blue dye, radioisotope and combined techniques were 7·7, 16 and 0 per cent respectively. A negative frozen-section examination of the SN was unreliable in 12·0 per cent of patients. Immunohistochemical assessment of the SN showed evidence of nodal metastases in an additional 15 per cent of patients (7 of 47 sentinel nodes).

Conclusion

SNB in thyroid cancer is a promising technique that has the potential to avoid prophylactic lymph node surgery in up to 57 per cent of patients with clinically node-negative thyroid cancer.

Axillary sentinel lymph node biopsy after neoadjuvant chemotherapy for carcinoma of the breast

BACKGROUND

The timing and accuracy of axillary sentinel lymph node biopsy (SLNB) in patients who are receiving neoadjuvant chemotherapy (NACT) for breast cancer are controversial. To examine the accuracy of SLNB after NACT, the authors performed SLNB after chemotherapy on all of patients who received NACT at their institution starting in January 1997.

METHODS

Seventy-nine women who underwent NACT between 1997 and 2008 comprised this study and were divided as follows: 4 women had stage I disease, 60 women had stage II disease, and 15 women had stage III disease, including 10 women who had multicentric disease. Thirty-nine women (49.4%) had clinical evidence of axillary metastasis (N1-N2) at the time of diagnosis. The regimen, the duration of treatment, and the number of cycles of NACT depended on clinical response. The choice of breast conservation therapy or mastectomy was based on the patient's response to treatment and patient preference. All patients underwent SLNB after NACT.

RESULTS

Seventy-three patients underwent breast conservation therapy, and 6 patients underwent mastectomy. Sentinel lymph nodes were identified in 98.7% of patients (in 1 patient, SLNB failed to capture 1 proven axillary metastasis), and 29 patients underwent full axillary lymph node dissection. Fourteen patients (17.7%) had no residual carcinoma (invasive or ductal carcinoma in situ) in their breast, 5 patients (6.3%) had residual ductal carcinoma in situ (only), and 60 patients (75.9%) had residual invasive carcinoma. One false-negative SLNB was reported in the group of 23 patients who underwent full axillary dissection after a negative SLNB. No patient had a subsequent axillary recurrence.

CONCLUSIONS

SLNB after NACT was feasible in virtually all patients and accurately selected patients who required complete level I and II axillary dissection. NACT frequently downstaged the axilla, converting patients with N1-N2 lymph node status to N0 status and also avoiding full axillary dissection in these patients.

Molecular markers of breast axillary lymph node metastasis

In breast cancer, axillary lymph node status is one of the most important prognostic variables and a crucial component to the staging system. Several clinico-histopathological parameters are considered to be strong predictors of metastasis; however, they fail to accurately classify breast tumors according to their clinical behavior and to predict which patients will have disease recurrence. Methods based on genome-wide microarray analyses have been used to identify molecular markers with respect to the development of axillary lymph node metastasis. Most of these markers can be detected in the primary tumors, which can potentially lead to the ability to identify patients at the time of diagnosis who are at high risk for lymph node metastasis, allowing for early intervention and more suitable adjuvant treatments.

Sentinel lymph node biopsy in breast cancer: a comprehensive literature review

Sentinel lymph node biopsy has emerged as the new standard of care for nodal staging in early-stage breast disease. In the this review, the procedure of SLNB in breast cancer will be examined in greater detail with the aim of understanding techniques that may improve results and of identifying future research questions in this field.

Comparison of intraoperative frozen section analysis for sentinel lymph node biopsy during breast cancer surgery for invasive lobular carcinoma and invasive ductal carcinoma

BACKGROUND

Sentinel lymph node (SLN) biopsy is the standard of care for the surgical assessment of the axilla during breast cancer surgery. However, the diagnostic accuracy of intraoperative frozen section analysis for confirming metastatic involvement of SLNs in cases of invasive lobular carcinoma (ILC) versus that of invasive ductal carcinoma (IDC) has generated controversy secondary to a frequently low-grade cytologic appearance and an often discohesive pattern displayed by metastatic lymph nodes in ILC. In the current report, we present a comparison of intraoperative frozen section analysis for confirming the presence of metastatic disease within SLNs during breast cancer surgery for ILC and IDC.

METHODS

We evaluated the results of 131 consecutive cases of ILC from 1997 to 2008 and 133 cases of IDC (selected by a random sequence generator program) from amongst 1163 consecutive cases of IDC from the same time period. All cases had at least one SLN that had both intraoperative frozen section analysis and confirmatory permanent section analysis performed.

RESULTS

No statistically significant difference was found in the sensitivity (67% vs. 75%, P = 0.385), specificity (100% vs. 100%), accuracy (86% vs. 92%, P = 0.172), false negative rate (33% vs. 25%, P = 0.385), negative predictive value (81% vs. 89%, P = 0.158), and positive predictive value (100% vs. 100%) for frozen section analysis for confirming the presence of metastatic disease within SLNs during breast cancer surgery for ILC and IDC.

CONCLUSION

Since there was no statistically significant difference in sensitivity, specificity, accuracy, false negative rate, negative predictive value, and positive predictive value between frozen section analysis of SLNs for patients with ILC and IDC, the clinical accuracy of confirming metastatic involvement of SLNs on frozen section analysis for ILC should not be considered inferior to the clinical accuracy for IDC. Therefore, frozen section analysis of all SLNs during breast cancer surgery in patients with ILC should remain the standard of care in order to reduce the risk of the need of a later, separate axillary lymph node dissection.