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Verver D, Oude Ophuis CMC, Koppert LB, de Monyé C, van Deurzen CHM, Koljenović S, Bruining A, van der Hiel B, Ter Meulen S, van Akkooi ACJ, Verhoef C, Grünhagen DJ. Gamma probe and ultrasound-guided fine needle aspiration cytology of the sentinel node (GULF) trial. Eur J Nucl Med Mol Imaging 2018; 45:1926-1933. [PMID: 29700573 PMCID: PMC6132503 DOI: 10.1007/s00259-018-4014-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2018] [Accepted: 04/06/2018] [Indexed: 02/05/2023]
Abstract
PURPOSE Sentinel lymph node biopsy (SLNB) was introduced as a minimally invasive technique for nodal staging. Since associated morbidity is not negligible, it is highly relevant to pursue a more minimally invasive alternative. The purpose of this study was to prospectively evaluate the sensitivity of fine needle aspiration cytology (FNAC) with combined gamma probe and ultrasound (US) guidance in comparison with the gold standard histology of the sentinel node (SN) after SLNB for detecting metastasis. METHODS The study was designed as a prospective, multicentre, open-label, single-arm trial enrolling patients with newly diagnosed cutaneous melanoma or breast cancer between May 2015 and August 2017. Sample radioactivity was measured using a Mini 900 scintillation monitor. After FNAC, all patients underwent SLNB. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were estimated. RESULTS Accrual was terminated early following an unplanned interim analysis indicating that a FNAC sensitivity of at least 80% could not be achieved. In total 58 patients of the originally planned 116 patients underwent FNAC with gamma probe and US guidance. There were no true-positive FNAC results, 14 false-negative results and one false-positive result, and thus the sensitivity, specificity, PPV and NPV of FNAC were 0%, 98%, 0% and 75%, respectively. At least 75% of the FNAC samples had a radioactivity signal higher than the background signal. CONCLUSION FNAC with gamma probe and US guidance is not able to correctly detect metastases in the SN and is therefore not able to replace SLNB. Gamma probe-guided US is a highly accurate method for correctly identifying the SN, which offers possibilities for future research.
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Affiliation(s)
- Daniëlle Verver
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 EA, Rotterdam, The Netherlands.
| | - Charlotte M C Oude Ophuis
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 EA, Rotterdam, The Netherlands
| | - Lisa B Koppert
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 EA, Rotterdam, The Netherlands
| | - Cécile de Monyé
- Department of Radiology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075EA, Rotterdam, The Netherlands
| | - Carolien H M van Deurzen
- Department of Pathology, Erasmus Medical Center, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - Senada Koljenović
- Department of Pathology, Erasmus Medical Center, Wytemaweg 80, 3015 CN, Rotterdam, The Netherlands
| | - Annemarie Bruining
- Department of Radiology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Bernies van der Hiel
- Department of Nuclear Medicine, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Sylvia Ter Meulen
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Alexander C J van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, the Netherlands
| | - Cornelis Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 EA, Rotterdam, The Netherlands
| | - Dirk J Grünhagen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 EA, Rotterdam, The Netherlands
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Oude Ophuis CM, Koppert L(LB, Monyé CD, Deurzen CHV, Koljenović S, Akkooi ACV, Verhoef C(K, Grünhagen DJ. Gamma probe and ultrasound guided fine needle aspiration cytology of the sentinel node (GULF) trial - overview of the literature, pilot and study protocol. BMC Cancer 2017; 17:258. [PMID: 28403815 PMCID: PMC5389093 DOI: 10.1186/s12885-017-3236-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Accepted: 03/25/2017] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Sentinel node (SN) biopsy (SNB) detects clinically occult metastases of breast cancer and melanoma in 20-30%. Wound infections, seroma and lymph edema occur in up to 10%. Targeted ultrasound (US) of the SN, (with fine needle aspiration cytology (FNAC) if appropriate) has been investigated as a minimally invasive alternative, but reported sensitivity rates are too low to replace SNB. Our hypothesis is that the use of a handheld gamma probe concomitant with US may improve sensitivity. Our aim is to provide an overview of the current literature on preoperative nodal staging of clinical N0 melanoma patients, report on a pilot, and present a study protocol for a minimally invasive alternative to the SNB: Gamma probe and Ultrasound guided Fine needle aspiration cytology of the sentinel node (GULF trial). METHODS The GULF trial is a multicenter open single arm observational trial. Newly diagnosed cT1b-4N0M0 cutaneous melanoma or cT1-3N0M0 breast cancer patients, aged >18 years, presenting for SNB are eligible. 120 patients will be included for preoperative targeted gamma probe guided US and FNAC of the SN. Afterwards all patients proceed to surgical SNB. Primary endpoint is the sensitivity of FNAC. Secondary endpoints include SN identification rate and the histopathological compatibility of Core Needle Biopsy and FNAC vs. SNB. Secondary endpoints were investigated in a pilot with 10 FNACs and marker placements, and 10 FNACs combined with Core Needle Biopsy. RESULTS A pilot in 20 patients showed that SN identification rate was 90%, supporting the feasibility of this technique. DISCUSSION There is broad experience with US (in combination with FNAC) prior to SNB, but sensitivity and specificity are too low to completely abandon SNB. Promising alternative techniques potentially will replace SNB in the future but more evidence is needed in the form of prospective studies. Accurate identification of the SN for US-FNAC has been proven feasible in our pilot. When adequate sensitivity can be reached, US-FNAC provides a minimally invasive alternative for the surgical SNB procedure. TRIAL REGISTRATION The GULF trial is registered in the Netherlands Trial Registry (NTR), ID: NRT5193 . May 1st 2015.
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Affiliation(s)
- Charlotte M.C. Oude Ophuis
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 Rotterdam, EA The Netherlands
| | - Lisa (Linetta) B. Koppert
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 Rotterdam, EA The Netherlands
| | - Cécile de Monyé
- Department of Radiology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 Rotterdam, EA The Netherlands
| | | | - Senada Koljenović
- Department of Pathology, Erasmus Medical Center, Wytemaweg 80, 3015 Rotterdam, CN The Netherlands
| | - Alexander C.J. van Akkooi
- Department of Surgical Oncology, Netherlands Cancer Institute – Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 Amsterdam, CX The Netherlands
| | - Cornelis (Kees) Verhoef
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 Rotterdam, EA The Netherlands
| | - Dirk J. Grünhagen
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Groene Hilledijk 301, 3075 Rotterdam, EA The Netherlands
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Wu JL, Tseng HS, Yang LH, Wu HK, Kuo SJ, Chen ST, Chen DR. Prediction of axillary lymph node metastases in breast cancer patients based on pathologic information of the primary tumor. Med Sci Monit 2014; 20:577-81. [PMID: 24714517 PMCID: PMC3989944 DOI: 10.12659/msm.890345] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Axillary lymph nodes (ALN) are the most commonly involved site of disease in breast cancer that has spread outside the primary lesion. Although sentinel node biopsy is a reliable way to manage ALN, there are still no good methods of predicting ALN status before surgery. Since morbidity in breast cancer surgery is predominantly related to ALN dissection, predictive models for lymph node involvement may provide a way to alert the surgeon in subgroups of patients. MATERIAL AND METHODS A total of 1325 invasive breast cancer patients were analyzed using tumor biological parameters that included age, tumor size, grade, estrogen receptor, progesterone receptor, lymphovascular invasion, and HER2, to test their ability to predict ALN involvement. A support vector machine (SVM) was used as a classification model. The SVM is a machine-learning system developed using statistical learning theories to classify data points into 2 classes. Notably, SVM models have been applied in bioinformatics. RESULTS The SVM model correctly predicted ALN metastases in 74.7% of patients using tumor biological parameters. The predictive ability of luminal A, luminal B, triple negative, and HER2 subtypes using subgroup analysis showed no difference, and this predictive performance was inferior, with only 60% accuracy. CONCLUSIONS With an SVM model based on clinical pathologic parameters obtained in the primary tumor, it is possible to predict ALN status in order to alert the surgeon about breast cancer counseling and in decision-making for ALN management.
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Affiliation(s)
- Jia-Long Wu
- Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Hsin-Shun Tseng
- Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Li-Heng Yang
- Department of Surgery, Changhua Christian Hospital, Changhua, Taiwan
| | - Hwa-Koon Wu
- Department of Medical Imaging, Changhua Christian Hospital, Changhua County, Taiwan
| | - Shou-Jen Kuo
- Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Shou-Tung Chen
- Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
| | - Dar-Ren Chen
- Comprehensive Breast Cancer Center, Changhua Christian Hospital, Changhua, Taiwan
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Mersich T, Faludi S, Ping O, Jóbaházi J, Szabó B, Dede K, Besznyák I, Bursics A. [Evolution of sentinel lymph node biopsy in breast cancer--axillary staging in the past 15 years at the Uzsoki Street Hospital]. Magy Seb 2013; 66:320-4. [PMID: 24333976 DOI: 10.1556/maseb.66.2013.6.3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Sentinel biopsy technique was performed in Europe in 1996.It was a great improvement in the surgical treatment of breast cancer, it decreased the number of patients suffering from early and late morbidity following axillary lymph node dissection (ALND). In our paper we demonstrate the evolution of sentinel biopsy technique (SLNB), as well as the changes in our policy on axillary treatment in line with the European trends. METHODS The authors of this article give an overview and analyse the relevant literature concerning sentinel lymph node biopsy and data of patients on whom sentinel lymph node biopsy was performed from 01/01/2001 to 31/12/2012. RESULTS Between 2001 and 2013 we performed 3756 breast operations, 2742 of those were done for malignant disease. Altogether we performed 744 sentinel lymph node biopsies in the Uzsoki teaching Hospital. The proportion of SLNB patients is increasing, it was 24.6% between 2001-2006 and 29.2% between 2007-2012, respectively. The indication of SLNB is widening, there might be justification of the technique even by multifocal or multilocular disease, in male patients, after former breats surgery or even in pregnant patients. CONCLUSION Histological examination of sentinel lymph node and its effect on complex treatment of breats cancer may place the role of surgical axillary staging in a brand new aspect in the near future perhaps.
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Affiliation(s)
- Tamás Mersich
- Uzsoki Utcai Kórház Sebészeti Osztály 1145 Budapest Uzsoki u. 29
| | - Sándor Faludi
- Uzsoki Utcai Kórház Sebészeti Osztály 1145 Budapest Uzsoki u. 29
| | - Orsolya Ping
- Uzsoki Utcai Kórház Sebészeti Osztály 1145 Budapest Uzsoki u. 29
| | - Jenő Jóbaházi
- Uzsoki Utcai Kórház Sebészeti Osztály 1145 Budapest Uzsoki u. 29
| | - Balázs Szabó
- Uzsoki Utcai Kórház Sebészeti Osztály 1145 Budapest Uzsoki u. 29
| | - Kristóf Dede
- Uzsoki Utcai Kórház Sebészeti Osztály 1145 Budapest Uzsoki u. 29
| | - István Besznyák
- Uzsoki Utcai Kórház Sebészeti Osztály 1145 Budapest Uzsoki u. 29
| | - Attila Bursics
- Uzsoki Utcai Kórház Sebészeti Osztály 1145 Budapest Uzsoki u. 29
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Hieken TJ, Trull BC, Boughey JC, Jones KN, Reynolds CA, Shah SS, Glazebrook KN. Preoperative axillary imaging with percutaneous lymph node biopsy is valuable in the contemporary management of patients with breast cancer. Surgery 2013; 154:831-8; discussion 838-40. [PMID: 24074422 DOI: 10.1016/j.surg.2013.07.017] [Citation(s) in RCA: 76] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 07/19/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND ACOSOG Z11 and other studies showing little benefit to axillary dissection (ALND) for early-stage breast cancers with limited nodal disease have led to questioning the value of preoperative axillary imaging ± ultrasound-guided needle biopsy (USNB). Data are lacking on the value of this approach in identifying cases that fall outside Z11 guidelines. METHODS We studied 988 consecutive patients with invasive breast cancers who underwent operation including axillary surgery in 2010-2011. RESULTS Preoperative axillary ultrasonography (AUS) was performed in 92% and breast/axillary magnetic resonance imaging (MRI) in 51%; 82 (33.5%) of 245 patients with suspicious lymph nodes (LN) were USNB-positive. Regarding nodal status, AUS, MRI, and USNB had negative and positive predictive values of 78%, 76%, 70% and 54%, 58%, 100%, respectively. AUS/MRI visualization of one versus multiple abnormal LNs visualized predicted >2LN+ on final pathology (13.5%/15.1% % vs 30.8%/32.6%, P < .009). Among USNB-LN+ T1/T2 patients, 51.6% had 1-2 LN+ while 60% with multiple and 31% with one AUS-abnormal LN(s) had > 2LN+, P = .001. CONCLUSION In our contemporary series, preoperative AUS±USNB streamlined surgical care for 29% of node-positive patients. Two-thirds of T1/T2 USNB-LN+ patients with multiple AUS-suspicious LNs had >2LN+, suggesting they should undergo ALND without SLNB. AUS±USNB helps identify node-positive breast cancer patients who fall outside Z11 guidelines.
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