Sentinel lymph node biopsy in breast cancer: a technical and clinical appraisal

Concordance between freehand SPECT and conventional scintigraphy for sentinel lymph node detection in breast cancer

INTRODUCTION

Freehand SPECT can be a useful imaging technique for preoperative planning of sentinel lymph node biopsy (SLNB) as it allows localization of the sentinel node by 3D and real-time tomographic imaging and determines its depth after a few minutes of scanning. The aim of the study was to evaluate the correlation between the number of detected SNs between freehand SPECT images and lymphoscintigraphy (LS).

MATERIALS AND METHODS

100 patients with a diagnosis of invasive breast cancer and no clinical evidence of lymph node involvement prospectively underwent SLNB. The preoperative study included freehand SPECT imaging at 15min after injection and LS imaging at 25 and 60-90min after injection (early and late). The observed agreement was analyzed and a concordance study was performed between the number of SNs detected with freehand SPECT and LS.

RESULTS

The observed agreement in the detection of SNs between freehand SPECT and early LS was 72%; between freehand SPECT and late LS was 85%; and between early and late LS was 87%. In the concordance study, there was moderate concordance between freehand SPECT and early LS (kappa coefficient: 0.42); moderate-high concordance between freehand SPECT and late LS (kappa coefficient: 0.60); and moderate-high concordance between early and late LS (kappa coefficient: 0.70), with no significant differences between them (p-value=0.16).

CONCLUSION

Freehand SPECT showed a moderate-high concordance with conventional imaging studies and could be a valid alternative for the presurgical study of SLNB in breast cancer.

Assessing the Sentimag system for guiding sentinel node biopsies in patients with breast cancer

INTRODUCTION

Sentinel lymph node biopsy for breast cancer is a method to localize and excise the first draining lymph node from an invasive cancer of the breast. The histopathologic evaluation of the sentinel lymph node is used for predicting recurrence and survival and thus, guiding oncologists for treatment-decision making to administer adjuvant therapies. The ability to identify the sentinel node depends on methods to map lymphatic drainage from the breast to the sentinel node and accurately discriminate that node from other non-sentinel lymph nodes of the axilla.

AREAS COVERED

This review covers the clinical demand for technologies to assist the surgeon in intraoperative lymphatic mapping to specifically identify the sentinel lymph node in patients with breast cancer. Performance characteristics are reviewed for superparamagnetic iron oxide tracers used in lymphatic mapping compared to other current available technologies for lymphatic mapping.

EXPERT OPINION

The Magtrace (superparamagnetic iron oxide tracer) Sentimag (handheld magnetic probe) system is an FDA-approved technology for intraoperative lymphatic mapping to facilitate sentinel lymph node biopsy in breast cancer with technologic performance characteristics that are equivalent to 99Technetium-sulfur colloid. Barriers to broader utilization primarily center around the need for nonmetallic devices to be used for the conduct of surgery, which would interfere with the paramagnetic method for tracer localization.

Silencing of long noncoding RNA MIAT inhibits the viability and proliferation of breast cancer cells by promoting miR-378a-5p expression

Myocardial infarction–associated transcript (MIAT) is a long noncoding RNA that plays a critical role in a variety of diseases. Accordingly, this study probed into the possible interaction mechanism between MIAT and miR-378a-5p in breast cancer. Concretely, MIAT and miR-378a-5p expressions in breast cancer tissues and cells were measured. After transfection with siMIAT and miR-378a-5p inhibitor, the viability and proliferation of breast cancer cells were examined by cell counting kit-8 and colony formation assays. The expressions of apoptosis-related proteins were detected. According to the results, MIAT was highly expressed in breast cancer tissues and cells. MIAT silencing could decrease Bcl-2 expression, viability, and proliferation of breast cancer cells and increase the expressions of cleaved caspase-3 and Bax. MIAT and miR-378a-5p could directly bind to each other, and MIAT silencing promoted the expression of miR-378a-5p. miR-378a-5p expression was low in breast cancer tissues. The miR-378a-5p inhibitor enhanced the viability and proliferation of breast cancer cells and partially reversed the effects of MIAT silencing on the breast cancer cells. In conclusion, MIAT silencing inhibits the viability and proliferation of breast cancer cells by promoting miR-378a-5p, indicating the potential of MIAT as a new target for the treatment of breast cancer.

Surgical complications following sentinel lymph node biopsy guided by γ-probe and methylene blue in 113 tumour-bearing dogs

Sentinel lymph node biopsy (SLNB) is an accepted veterinary surgical procedure given the impact of early detection of nodal metastases on staging of several canine malignancies. This study aims at reporting the incidence and risk factors for surgical complications of SLNB in tumour-bearing dogs. A total of 113 client-owned dogs that underwent tumour excision and SLNB guided by γ-probing and blue dye were retrospectively enrolled. Recorded variables included: signalment, location and number of extirpated lymphocenters and nodes, time for SLNB, histopathological status of excised nodes. Incidence of SLNB complications was calculated. They were classified as minor and major based on severity and required treatment, and as short-term (0-30 days) and long-term (31-90 days). Univariate analysis with generalized linear model with binomial error estimated the association between variables and incidence of SLNB complications. Significance was set at 5%. Median overall time for SLNB was 25 min. Surgeons excised one node in 38% of dogs and multiple nodes in 62% of cases, belonging to one (62%) or multiple (38%) lymphocenters. Metastases were detected in 45% of nodes. No intraoperative complications occurred. The overall incidence of postoperative complications of SLNB was 21,24%, the majority of which (91.67%) were minor. Only increasing dogs' weight was associated with an increased incidence of SLNB complications (p = .00976). Sentinel lymphadenectomy was associated with a relatively low incidence of complications, most of which were self-limiting. The low morbidity and previously reported impact on staging of SLNB justify its implementation to collect data for prognostic studies.

Beyond Sentinel Lymph Node: Outcomes of Indocyanine Green-Guided Pelvic Lymphadenectomy in Endometrial and Cervical Cancer

BACKGROUND

The aim of our study was to compare the number of lymph nodes removed during indocyanine green (ICG)-guided laparoscopic/robotic pelvic lymphadenectomy with standard systematic lymphadenectomy in endometrial cancer (EC) and cervical cancer (CC).

METHODS

This is a multicenter retrospective comparative study (Clinical Trial ID: NCT04246580; updated on 31 January 2023). Women affected by EC and CC who underwent laparoscopic/robotic systematic pelvic lymphadenectomy, with (cases) or without (controls) the use of ICG tracer injection within the uterine cervix, were included in the study.

RESULTS

The two groups were homogeneous for age (p = 0.08), Body Mass Index, International Federation of Gynaecology and Obstetrics (FIGO) stages (p = 0.41 for EC; p = 0.17 for CC), median estimated blood loss (p = 0.76), median operative time (p = 0.59), and perioperative complications (p = 0.66). Nevertheless, the number of lymph nodes retrieved during surgery was significantly higher (p = 0.005) in the ICG group (n = 18) compared with controls (n = 16).

CONCLUSIONS

The accurate and precise dissection achieved with the use of the ICG-guided procedure was associated with a higher number of lymph nodes removed in the case of systematic pelvic lymphadenectomy for EC and CC.

Radiomics-based signature of breast cancer on preoperative contrast-enhanced MRI to predict axillary metastasis

Aim: This study aimed to predict axillary metastasis using radiology features in dynamic contrast-enhanced MRI. Methods: This study included 243 breast lesions confirmed as malignant based on axillary status. Most outcome-predictive features were selected using four machine-learning algorithms. Receiver operating characteristic analysis was used to reflect diagnostic performance. Results: Least absolute shrinkage and selection operator was used to dimensionally reduce 1137 radiomics features to three features. Three optimal radiomics features were used to model construction. The logistic regression model achieved an accuracy of 97% and 85% in the training and test groups. Clinical utility was evaluated using decision curve analysis. Conclusion: The novel combination of radiomics analysis and machine-learning algorithm could predict axillary metastasis and prevent invasive manipulation.

Nanocarbon Tracer and Areola Injection Site Are Superior in the Sentinel Lymph Node Biopsy Procedure for Breast Cancer

Background. Axillary lymph node (ALN) staging is the most effective method to evaluate the condition of patients with breast cancer, their choice of treatment options, and prognosis. The sentinel lymph node (SLN) status assessment is the key to sentinel lymph node biopsy (SLNB) in patients with breast cancer. The choice of tracer and tracer injection sites affects SLNB. Objective. This study mainly analyzes the best tracer for SLNB and the best choice of tracer injection site. Methods. A total of 165 breast cancer patients who underwent SLNB were selected and injected with methylene blue or 99mTc-labeled sodium phytate or nanocarbon 20 min before biopsy. The number of SLNs detected by different tracers in different injection sites such as peritumoral tissue (PT) and subareolar area (SA) was counted, and the sensitivity, specificity, and positive/negative prediction rates were recorded and compared. Results. The detection success rate, average detection number of SLNs, and detection accuracy of the nanocarbon tracer were higher than the other two. The detection sensitivity, specificity, and positive and negative prediction rates of nanocarbon for SLNB were also higher than those of the other two tracers. When comparing the performance of tracers in different injection sites, it was found that the detection of three tracers injected in the SA was better than the injection in the PT. Conclusion. For women with early-stage breast cancer, nanocarbon can be used as the preferred tracer for SLNB to determine the status of the patient’s ALNs, and the areola area can be used as the best injection site.

Cost-Effectiveness Analysis of Intraoperative Frozen Section in Women with Breast Cancer: Evidence from South of Iran

Background

Breast cancer is one of the most prevalent malignancies in women worldwide, and the rate of breast cancer is increasing among Iranian women. The purpose of this study is to determine the cost-effectiveness of intraoperative frozen section analysis in women with breast cancer.

Methods

This study was a cost-effectiveness analysis, which was implemented as a cross-sectional study from a societal perspective. In this case, total direct and indirect costs were calculated, and the study outcome was involved in preventing reoperation. A data collection form has been used to collect the cost and effectiveness data. The sample size was comprised of all the patients referred to the hospitals of Shiraz University of Medical Sciences for breast cancer surgery in 2019. The patients were studied in two different groups, including individuals who received frozen counseling during surgery, and individuals who did not receive it. A one-way sensitivity analysis was performed for this case. Moreover, the Tree Age and Microsoft Excel Software were employed for analyzing processes.

Results

The results demonstrated that the mean costs of frozen and non-frozen patients were 4168$ and 3843$ purchasing power parity (PPP), respectively. In addition, the effectivenesses were 0.996 for the former and 0.8 for the latter. Furthermore, the incremental cost-effectiveness ratio (ICER) was 1658.2 PPP$. This issue revealed that the frozen section procedure during surgery was more cost-effective than the other case. Because, the cost-effectiveness of this option was below the threshold. Besides, the one-way sensitivity analysis confirmed the robustness of the study results.

Conclusion

The results showed that performing frozen sections during surgery in women with breast cancer was more cost-effective than ignoring them. Indeed, the frozen section can prevent the costs of subsequent reoperations.

The impact of age and nodal status on variations in oncotype DX testing and adjuvant treatment

Oncotype DX (ODX) recurrence score (RS) is a validated tool to guide the use of adjuvant chemotherapy (AC) in hormone receptor+/HER2- breast cancer. In this analysis, we examine (1) characteristics associated with ODX testing and (2) the association between ODX RS and receipt of AC across age and nodal status. Women with HR+/HER2–, early-stage (T1-2, N0-1) breast cancers from 2010–2017 in the National Cancer Database were included. 530,125 met inclusion and 255,971 received ODX testing. Older women were less likely to receive testing; however, nodal positivity increased use of testing. High ODX RS was associated with increased mortality, though the association was not consistent across age and was most strongly associated with mortality among younger, node-negative women. Older women with high ODX RS, regardless of nodal status, were less likely to receive AC. Clinicians may be employing ODX RS to support treatment decisions against the receipt of AC.

Evaluation of Serum MicroRNAs (miR-9-5p, miR-17-5p, and miR-148a-3p) as Potential Biomarkers of Breast Cancer

Background

MicroRNAs (miRNAs) play important roles in the initiation and progression of cancers. The purpose of the present study was to evaluate the use of serum miRNA biomarkers in the early diagnosis of breast cancer.

Methods

The expression levels of miR-9-5p, miR-17-5p, and miR-148a-3p were analyzed by quantitative reverse transcription-polymerase chain reaction in 49 patients with newly diagnosed breast cancer and 49 healthy controls. The associations between miR-9-5p, miR-17-5p, and miR-148a-3p levels and clinicopathological parameters were also analyzed. Regression analysis and sensitivity and specificity analyses were used to determine the diagnostic efficacy of the miRNAs.

Results

Serum levels of miR-9-5p and miR-148a-3p were significantly higher in breast cancer patients than in healthy controls (both P < 0.05), but miR-17-5p levels were not different between the two groups (P = 0.996). Serum miR-9-5p levels were markedly higher in patients with human epidermal growth factor receptor 2- (HER2-) positive breast cancer than in those with HER2-negative breast cancer (P = 0.049). Serum levels of miR-9-5p and miR-148a-3p were positively correlated with the presence of breast cancer, and both miRNAs had high sensitivity and specificity for the diagnosis of breast cancer.

Conclusions

These findings provide evidence that serum miR-9-5p and miR-148a-3p levels may be used as noninvasive biological markers for the clinical diagnosis of breast cancer.

Identification and preservation of stained non-sentinel lymph nodes in breast cancer

Sentinel lymph nodes (SLNs) are the first lymph nodes that receive lymphatic drainage from the breast. However, all stained lymph nodes are dissected as SLNs during surgery. The present study aimed to identify and preserve the stained non-SLNs and evaluate the safety during sentinel lymph node biopsy (SLNB) in breast cancer. SLNB was performed with a methylene blue and indocyanine green double-tracer technique. The first lymph node, which was connected with lymphatic vessels from the breast, was designated as the true SLN. The lymph node that was directly connected with the output lymphatic duct of the SLN was defined as post-SLN (poSLN), whereas the stained poSLN was designated as non-SLN. Both the stained SLN and non-SLN were sent to the pathological department for definitive diagnosis. The present study demonstrated that intraoperative dissection of the lymphatic network could distinguish true SLNs and stained non-SLNs. The number of stained lymph nodes was time-dependent. Not all stained lymph nodes were real SLNs, whereas the poSLNs would be stained if the staining time interval was inappropriate. The data indicated that the poSLNs were negative for metastasis when the SLNs were negative for metastasis. Stained lymph nodes may contain non-SLNs in addition to SLNs. Resection of all stained lymph nodes is not recommended. To reduce the morbidity due to SLNB complications, the identification and preservation of stained non-SLNs during SLNB is feasible and warrants further study in the era of precision medicine.

Clinical Practice Status of Sentinel Lymph Node Biopsy for Early-Stage Breast Cancer Patients in China: A Multicenter Study

Background

Sentinel lymph node biopsy (SLNB) was introduced over 30 years ago, but the application of SLNB in China is unclear. This study aimed to explore the real-world implementation of SLNB among early-stage breast cancer patients in China.

Methods

A multi-center, retrospective study was conducted among primary breast cancer patients from 37 hospitals in China in 2018. Their clinical data were collected and analyzed, including the implementation status of SLNB in China, subsequent processing of sentinel lymph nodes (SLNs) containing metastases, and the effect of neoadjuvant chemotherapy (NAC) on SLNB.

Results

SLNB surgery was performed on 43.5% of early-stage breast cancer patients in China and 11,942 patients who underwent SLNB were enrolled in this study. The majority of SLNBs were performed using a single mapping agent. A combination of blue dye and radiotracer or fluorescence imaging was used in only 14.9% of patients. The mean (SD) number of resected SLNs was 4.0 (2.1). For the patients with 1 or 2 positive SLNs, 83.0% of them continued to receive axillary lymph node dissection (ALND), while others did not. For the patients with three or more positive SLNs, 97.2% of them continued to receive ALND, among which 82.9% accepted radiotherapy simultaneously. Of the patients who underwent SLN surgery, 5.5% (654/11,942) were receiving NAC. Among them, 51.9% received SLNB before NAC, and the rest received SLNB after NAC. In biopsy-proven positive nodes, 64.7% positive SLNs turned negative after NAC.

Conclusion

SLNB has been promoted in China, but it is not widely used compared to in developed countries. Furthermore, the usage of the dual tracer technique in SLNB is not high. Chinese breast surgeons are more conservative regarding the omission of ALND in 1 or 2 SLNs-positive patients.

Convolutional Neural Network Detection of Axillary Lymph Node Metastasis Using Standard Clinical Breast MRI

BACKGROUND

Axillary lymph node status is important for breast cancer staging and treatment planning as the majority of breast cancer metastasis spreads through the axillary lymph nodes. There is currently no reliable noninvasive imaging method to detect nodal metastasis associated with breast cancer.

MATERIALS AND METHODS

Magnetic resonance imaging (MRI) data were those from the peak contrast dynamic image from 1.5 Tesla MRI scanners at the pre-neoadjuvant chemotherapy stage. Data consisted of 66 abnormal nodes from 38 patients and 193 normal nodes from 61 patients. Abnormal nodes were those determined by expert radiologist based on ¹⁸Fluorodeoxyglucose positron emission tomography images. Normal nodes were those with negative diagnosis of breast cancer. The convolutional neural network consisted of 5 convolutional layers with filters from 16 to 128. Receiver operating characteristic analysis was performed to evaluate prediction performance. For comparison, an expert radiologist also scored the same nodes as normal or abnormal.

RESULTS

The convolutional neural network model yielded a specificity of 79.3% ± 5.1%, sensitivity of 92.1% ± 2.9%, positive predictive value of 76.9% ± 4.0%, negative predictive value of 93.3% ± 1.9%, accuracy of 84.8% ± 2.4%, and receiver operating characteristic area under the curve of 0.91 ± 0.02 for the validation data set. These results compared favorably with scoring by radiologists (accuracy of 78%).

CONCLUSION

The results are encouraging and suggest that this approach may prove useful for classifying lymph node status on MRI in clinical settings in patients with breast cancer, although additional studies are needed before routine clinical use can be realized. This approach has the potential to ultimately be a noninvasive alternative to lymph node biopsy.

miR-17 as a diagnostic biomarker regulates cell proliferation in breast cancer

Background

MicroRNAs (miRNAs) have been shown to be involved in the initiation and progression of cancers in the literature. In this study, we aimed to evaluate the clinicopathological role of miR-17 in breast cancer.

Materials and methods

The expression of miR-17 was measured in 132 breast cancer tissues and paired adjacent normal tissues by using real-time quantitative polymerase chain reaction. The association between miR-17 expression levels and clinicopathological parameters was also analyzed. 3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide and flow cytometry assays were used to investigate the role of miR-17 in the regulation of breast cancer cells.

Results

The expression of miR-17 was remarkably increased in breast cancer tissues and cell lines. Clinical association analysis revealed that a high expression of miR-17 was prominently associated with poor survival time in breast cancer. Overexpression of miR-17 promoted cell proliferation and induced tumor growth.

Conclusion

Our findings clarified that the upregulation of miR-17 played a vital role in breast cancer progression and suggested that miR-17 could be used as a prognostic biomarker for breast cancer.