A new fluorescenttargeting tracer contrasts dual tracers in sentinel lymph node biopsy of breast cancer

Purpose: To explore the clinical application value of indocyanine green (ICG)-rituximab in sentinel lymph node biopsy. Methods: This study included 156 patients with primary breast cancer: 50 patients were enrolled in dose-climbing test, and 106 patients were enrolled in verification test. This was to compare the consistency of ICG-rituximab and combined method in the detected lymph nodes. Results: According to the verification test, the imaging rate of ICG-rituximab was 97.3%. Compared with the combined method, the concordance rate of fluorescence method was 0.991 (28 + 78/107; p < 0.001). Conclusion: For ICG-rituximab as a fluorescent targeting tracer, the optimal imaging dose of ICG 93.75 μg/rituximab 375 μg can significantly reduce the imaging of secondary lymph nodes. Compared with the combined method, it has a higher concordance rate.

vNOTES surgical staging for endometrial carcinoma in overweight patients: a case series

OBJECTIVES

The purpose of this study is to show the feasibility and surgical outcome of vNOTES retroperitoneal dissection and isolation of sentinel lymph nodes in overweight and obese patients with endometrial cancer.

MATERIALS AND METHODS

Four patients had undergone pelvic lymphadenectomy with a sentinel lymph node. Three patients were overweight, and one was obese with a BMI of 34.6 kg/m2. By using NMR mode sentinel lymph node was visualized, excised and marked separately for pathohistological analysis from the rest of the visualized lymph nodes that were then consecutively excised.

RESULTS

The mean number of overall excised lymph nodes was 12.5, and the mean number on the right side was 5.75 and 6.25 on the left side. There were no metastases verified in the pathohistological evaluation.

CONCLUSION

vNOTES retroperitoneal isolation of sentinel lymph nodes is good alternative and has its benefits, especially in overweight and obese patients with satisfying low intra- and postoperative complications.

Prognostic significance of sentinel lymph node biopsy in elderly with cutaneous melanoma: systematic review and meta-analysis

Sentinel lymph node biopsy is the most powerful prognostic indicator to date for cutaneous melanoma. Even though elderly patients have a lower incidence of sentinel node involvement, its results are still necessary for access to adjuvant therapies. This is highly relevant considering that the Western population shows an aging trend, and the incidence of melanoma has grown exponentially over the years, making elderly patients more likely to die from melanoma than younger ones. We performed a systematic review to investigate the prognostic significance of sentinel lymph node biopsy in elderly patients with melanoma. The systematic review was conducted following the PRISMA guidelines and registered in PROSPERO. The authors searched the Cochrane Database, EMBASE, PubMed, and WOS. Eligible studies for the systematic review were clinical trials, observational population studies, clinical or hospital-based cohort studies, and case-control studies. The meta-analysis was conducted using the R software program applying the meta package. Six reports were identified to meet the inclusion criteria. All studies were retrospective, non-randomized cohorts. The results obtained in this systematic review show a statistically significant influence of sentinel lymph node biopsy on disease-specific survival (HR = 2.87; 95% CI: 1.73-4.74) but also suggest that a positive result negatively impacts disease-free survival (HR = 3.41; 95% CI: 0.96-12.11). This meta-analysis shows that a positive sentinel lymph node biopsy does not imply differences in overall survival but significantly influences disease-specific survival and suggests an unfavorable impact on disease-free survival.

Sentinel lymph node biopsy for melanoma in the older population: A prospective analysis of outcomes

BACKGROUND

The use of sentinel lymph node biopsy (SLNB) in the older population, defined as those over 70 years old, has been debated since the adoption of SLNB into routine practice. Interestingly, there remains a paucity of evidence, especially regarding the rates of SLNB positivity, complications, and subsequent adjuvant therapy in those with node positivity.

METHOD

Data on patient's comorbidities, positivity rates, complication rates, and subsequent adjuvant treatments were collected prospectively from 998 patients (644 patients < 70 and 354 patients ≥ 70 years old) between 2016 and 2022.

RESULTS

Patients aged ≥ 70 were found to have a higher prevalence of comorbidities, including hypertension, diabetes and hyperlipidaemia. The mean Breslow thickness was 2.2 and 2.5 in the under and over 70 groups respectively (p = 0.03). The mean mitotic rate was found to be 3.3 in the under 70 s and 4.1 in the over 70 s (p = 0.02). Despite these results, no significant differences were observed in the positivity rates of sentinel lymph node biopsies or in the treatment options selected for positive results. The under 70 s were more likely to experience loss of sensation (p < 0.01), but no difference was found in the total number of complications between the two groups.

CONCLUSION

Although patients aged 70 and above had a greater incidence of comorbidities, the study revealed that they had lower complications rates and there was no significant variation in the SLNB positivity rate or chosen treatment options between the two age groups. This study supports the move to physiological rather than chronological age assessments in SLNB of the elderly.

Noninvasive Staging of Lymph Node Status in Breast Cancer Using Machine Learning: External Validation and Further Model Development

BACKGROUND

Most patients diagnosed with breast cancer present with a node-negative disease. Sentinel lymph node biopsy (SLNB) is routinely used for axillary staging, leaving patients with healthy axillary lymph nodes without therapeutic effects but at risk of morbidities from the intervention. Numerous studies have developed nodal status prediction models for noninvasive axillary staging using postoperative data or imaging features that are not part of the diagnostic workup. Lymphovascular invasion (LVI) is a top-ranked predictor of nodal metastasis; however, its preoperative assessment is challenging.

OBJECTIVE

This paper aimed to externally validate a multilayer perceptron (MLP) model for noninvasive lymph node staging (NILS) in a large population-based cohort (n=18,633) and develop a new MLP in the same cohort. Data were extracted from the Swedish National Quality Register for Breast Cancer (NKBC, 2014-2017), comprising only routinely and preoperatively available documented clinicopathological variables. A secondary aim was to develop and validate an LVI MLP for imputation of missing LVI status to increase the preoperative feasibility of the original NILS model.

METHODS

Three nonoverlapping cohorts were used for model development and validation. A total of 4 MLPs for nodal status and 1 LVI MLP were developed using 11 to 12 routinely available predictors. Three nodal status models were used to account for the different availabilities of LVI status in the cohorts and external validation in NKBC. The fourth nodal status model was developed for 80% (14,906/18,663) of NKBC cases and validated in the remaining 20% (3727/18,663). Three alternatives for imputation of LVI status were compared. The discriminatory capacity was evaluated using the validation area under the receiver operating characteristics curve (AUC) in 3 of the nodal status models. The clinical feasibility of the models was evaluated using calibration and decision curve analyses.

RESULTS

External validation of the original NILS model was performed in NKBC (AUC 0.699, 95% CI 0.690-0.708) with good calibration and the potential of sparing 16% of patients with node-negative disease from SLNB. The LVI model was externally validated (AUC 0.747, 95% CI 0.694-0.799) with good calibration but did not improve the discriminatory performance of the nodal status models. A new nodal status model was developed in NKBC without information on LVI (AUC 0.709, 95% CI: 0.688-0.729), with excellent calibration in the holdout internal validation cohort, resulting in the potential omission of 24% of patients from unnecessary SLNBs.

CONCLUSIONS

The NILS model was externally validated in NKBC, where the imputation of LVI status did not improve the model's discriminatory performance. A new nodal status model demonstrated the feasibility of using register data comprising only the variables available in the preoperative setting for NILS using machine learning. Future steps include ongoing preoperative validation of the NILS model and extending the model with, for example, mammography images.

Primary Melanoma Histopathologic Predictors of Sentinel Lymph Node Positivity: A Proposed Scoring System for Risk Assessment and Patient Selection in a Clinical Setting

Background and Objectives: The careful selection of adequate SLNB candidates not only aims at reducing the surgical risk while identifying SLN metastasis, but also plays a crucial role in identifying the patients eligible for adjuvant therapy. Objectives: The purpose of our study was to investigate the clinical and histologic aspects of primary melanomas that correlate with the likelihood of a positive SLNB result. Materials and Methods: A total of 101 primary melanoma patients who underwent sentinel lymph node biopsies were included in the study. General patient demographics were obtained as well as localization and melanoma-specific characteristics of primary melanoma from histologic reports in addition to data derived from SLNB melanoma histopathology reports. Results: The patients with positive SLN results had a statistically significant increased Breslow thickness (3.8 mm vs. 1.97 mm, p = 0.002), higher mitotic index rate (5/mm2 vs. 2/mm2, p = 0.009), as well as the presence of ulceration (68.4% vs. 31.6%, p = 0.007). Univariate regression analysis showed the Breslow thickness (p = 0.008), the mitotic index rate (p = 0.054), the presence of ulceration (p = 0.009), as well as the pT3-4 stage (p = 0.009) to be significant predictors of SLN positivity. The optimal cut-off values for Breslow thickness and the number of mitoses scores were determined based on ROC curve analysis. Using the Breslow thickness, mitotic index rate, presence of ulceration, and pT3-4 stage significant coefficients from the univariate regression model, a chance prediction score was developed. Conclusions: The newly developed and proposed scoring system can aid in patient selection for SLN biopsy by facilitating a more efficient risk assessment in the detection of lymph node metastases in melanoma patients.

NICE 2022 guidelines on the management of melanoma: Update and implications

AIMS

In July 2022, NICE updated the guidelines on the management of melanoma by lowering the number of follow-up appointments and sentinel lymph node biopsy (SLNB) but increasing the number of scans. This study aims to evaluate the implications of executing the new guidelines in terms of cost-effectiveness and personnel.

METHODS

All patients newly diagnosed with melanoma in 2019 at a regional skin cancer specialist center were reviewed. Data were analyzed for their journey on an idealized pathway modeled over a 5-year follow-up period when adhering to both the previous and new guidelines. Differences in the management of melanoma were elucidated by comparing these changes. The cost was quantified on a perpatient basis and the financial implication on each department was considered.

RESULTS

One hundred and ten patients were diagnosed with melanoma in 2019, stages I-III. The changes ease the burden on plastic surgery and dermatology; however, increased pressure is faced by radiologists and histopathologists. An overall cost benefit of £141.85 perpatient was calculated, resulting in a decrease of 1.22 hospital visits on average and an increase in the time spent there (19.55 min). The additional expenses of implementing the new guidelines due to the added BRAF tests, CT, and ultrasound scans are outweighed by savings from the reduction in follow-up appointments and SLNB.

CONCLUSION

The focus has shifted to less invasive procedures for lower melanoma stages and fewer follow-up appointments, at the expense of more genetic testing and imaging. This paper serves as a useful baseline for other centers to plan their service provision and resource allocation to adhere to the updated guidelines.

Variability of Sentinel Lymph Node Location in Patients with Trunk Melanoma

(1) Background: Melanoma is one of the most aggressive types of neoplasia, and the management of this pathology requires a correct staging, as well as a personalized modern oncological treatment. The main objective of the study is to determine the variability of the lymphatic drainage for patients with melanomas located on the trunk and, secondarily, to determine the features of individuals who underwent sentinel lymph node biopsy (SLNB) depending on the exact location on the trunk. (2) Methods: This retrospective, observational, single-center study included 62 cases of trunk melanoma operated between July 2019 and March 2023, in which SLNB was performed and a total of 84 lymph nodes were excised. (3) Results: Patients had a median age of 54.5 (33-78) years, with 58.1% being male; the melanomas had a median Breslow index of 2.3 (0.5-12.5) mm. Approximately 64.3% of the cohort had melanoma on the upper part of the trunk (54 cases) and 35.7% had it on the lower part (30 cases). The type of anesthesia chosen was general anesthesia in 53 cases and spinal anesthesia in 9 cases (85.5% vs. 14.5%, p < 0.001). The number of sentinel lymph nodes excised was 54 for melanomas located on the upper part of the trunk (8 cervical and 46 axillary) and 30 sentinel lymph nodes for melanomas of the lower part of the trunk (16 at the axillary level and 14 at the inguinal level). Out of the 54 LNs identified in patients with melanoma on the upper part of the trunk, 13 were positive, with a total of 12 positive lymph nodes (LNs) from the axillar basin, and only one from the cervical region. Additionally, the incidence of patients with a minimum of two identified sentinel lymph nodes was 32.2%, with a total of seven having LN involvement in two basins, and only one of these cases showed positivity for malignancy. (4) Conclusions: SLNBs were more frequent in the axillary region overall, and had more positive SLNs. Moreover, melanoma on the upper part of the trunk had a higher rate of positive SLNs compared to the lower part. Tumors located on the lower part of the truck had more positive SLNs in the axillary region than in the inguinal one.

Sentinel Lymph Node Detection in Breast Cancer: An Innovative Technique

(1) Background: Sentinel lymph node biopsy is important in the search for metastases, especially in patients with malignant breast disease. Our study proposed new techniques to prevent complications such as possible postoperative seroma formation, pain or hypoesthesia of the axillary cord and medial arm surface, as well as motor deficits, to avoid disabling outcomes and presents initial data from our experience with the sentinel lymph node biopsy technique. (2) Methods: We mainly used two radioactive tracer detection techniques and a new technique using a radiotracer called Sentimag-magtrace. The positive lymph node was located and removed to perform histologic analysis. In our study, we evaluate 100 patients who underwent breast cancer surgery. (3) Results: We calculated the identification rates of the different methods of sentinel lymph node detection and found that it was 88.9% using radioactive tracers vs. 89.5% using the magnetic tracer technology (Sentimag). (4) Conclusions: Thus, this technique avoids radiation exposure for both patients and health care providers, and can reduce costs and time.

Alternatives and reduced need for sentinel lymph node biopsy (SLNB) staging for melanoma

Sentinel lymph node biopsy (SLNB) has been introduced in the 1990s to identify patients who might benefit from completion lymph node dissection. Neither SLNB nor CLND improved survival, but SLNB staging did provide the best staging, above Breslow thickness and ulceration. The SLN status and SLN tumour burden were used in all trials until date looking at modern adjuvant systemic therapy with immune checkpoint inhibition (ICI) or targeted therapies (TT). Adjuvant ICI and TT are shifting towards stage II melanoma. The question is whether there is still role for SLNB in melanoma, in this day and age, and if so, how does the future look for SLNB staging? The SLN status and SLN tumour burden might be useful for a consultation to discuss the number needed to treat in a risk/benefit discussion. For stage IIB/C patients, it seems likely, however, that patients will forego a nuclear scan followed by the risk of surgical intervention and morbidity associated with SLNB if they opt to receive adjuvant therapy regardless of the SLNB result. For stage I/IIA, it is still required to detect high-risk patients who might benefit from adjuvant therapy. However, biomarkers are emerging, such as gene expression profilers (GEP), immunohistological signatures and liquid biopsies with ctDNA. There still is a role for SLNB staging in melanoma today, but we expect that the availability of therapeutic option independent of SLNB status as well as emergence of validated biomarkers to predict risk will reduce the need for SLNB staging in the upcoming decade to the point it will no longer be used.

The 31-gene expression profile test informs sentinel lymph node biopsy decisions in patients with cutaneous melanoma: results of a prospective, multicenter study

BACKGROUND

The 31-gene expression profile test (Class 1A: low-risk; 1B/2A: intermediate-risk; 2B: high-risk) is validated to identify patients with cutaneous melanoma who can safely forego sentinel lymph node biopsy (SLNB). The objective of the current study is to quantify SLNB reduction by clinicians using 31-GEP.

METHODS

Patients with T1-T2 tumors eligible for SLNB were seen by surgical oncologists (89.1%), dermatologists (7.8%), and medical oncologists (3.1%). After receiving 31-GEP results but before SLNB, clinicians were asked which clinical and pathological features influenced SLNB decisions (n = 191). The Exact binomial test was used to compare SLNB procedure rates to a contemporary study (78% SLNB baseline rate). Logistic regression modeling (odds ratio [OR], 95% CI) was used to identify features associated with SLNB procedure rates.

RESULTS

One hundred clinical decisions (52.4%) were influenced by the 31-GEP to forego SLNB and 70% (70/100) were not performed. Of the 30 performed, 0% (0/30) were positive. The 31-GEP influenced sixty-three clinical decisions (33.0%) to perform SLNB, and 92.1% (58/63) were performed. There was a clinically meaningful 29.4% reduction of SLNBs performed in patients with a Class 1A result relative to the baseline rate of 78.0% (p < .01). In patients ≥55 or ≥65-year-old, SLNB reduction was 32.3% (p < .01), 28.3% (p < .01), respectively. Overall, 85.3% of decisions relating to SLNB were influenced by 31-GEP results.

CONCLUSION

In this prospective, multicenter study, clinicians demonstrated clinically meaningful use of the 31-GEP test to forego or pursue SLNB in patients with T1-T2 tumors resulting in a significant, risk appropriate decrease in SLNBs.

Predictive Factors for Unnecessary Axillary Dissection According to SLN Metastasis in T1, T2 Stage Breast Cancer

The axillary nodes' status is essential in determining the treatment algorithm according to complete clinical staging. Unnecessary axillary lymph node dissection (ALND) has been prevented after sentinel lymph node biopsy (SLNB) has occurred in current practice. However, approximately half of patients with positive SLNB do not have axillary metastatic lymph nodes. Our study aims to predict unnecessary ALND in patients with SLN metastases by evaluating the patients' clinicopathological data. In total, 221 patients with macrometastasis in SLNB who underwent completion ALND were evaluated retrospectively. Patients were divided into two groups: patients with metastases only in the sentinel lymph node and additional axillary lymph nodes. Univariate and multivariate logistic regression analyses were used to analyze the correlation between SLN metastasis and axillary lymph node metastasis; clinicopathological characteristics, including patient age, menopause status, tumor size and grade, receptor status proliferative marker status, and molecular subtypes of the tumor. In the evaluation of T1-2, cN0 breast cancer patients with SLNB in the form of macrometastasis, only SLNB metastasis was found in 118 (53.4%) patients. In 103 (46.6%) patients, additional axillary node metastasis was observed. The risk of additional nodal spread correlated with patient age older than fertility age (age of 49) (p = 0.015, OR: 1.96, 95% CI: 1.14-3.39) and the number of increased metastatic sentinel nodes (p < 0.001). In line with the data shown by our study, the rate of axillary metastases increases in patients over the age of fertility and as the number of metastatic SLNs increases.

Optimizing treatment approaches for patients with cutaneous melanoma by integrating clinical and pathologic features with the 31-gene expression profile test

BACKGROUND

Many patients with low-stage cutaneous melanoma will experience tumor recurrence, metastasis, or death, and many higher staged patients will not.

OBJECTIVE

To develop an algorithm by integrating the 31-gene expression profile test with clinicopathologic data for an optimized, personalized risk of recurrence (integrated 31 risk of recurrence [i31-ROR]) or death and use i31-ROR in conjunction with a previously validated algorithm for precise sentinel lymph node positivity risk estimates (i31-SLNB) for optimized treatment plan decisions.

METHODS

Cox regression models for ROR were developed (n = 1581) and independently validated (n = 523) on a cohort with stage I-III melanoma. Using National Comprehensive Cancer Network cut points, i31-ROR performance was evaluated using the midpoint survival rates between patients with stage IIA and stage IIB disease as a risk threshold.

RESULTS

Patients with a low-risk i31-ROR result had significantly higher 5-year recurrence-free survival (91% vs 45%, P < .001), distant metastasis-free survival (95% vs 53%, P < .001), and melanoma-specific survival (98% vs 73%, P < .001) than patients with a high-risk i31-ROR result. A combined i31-SLNB/ROR analysis identified 44% of patients who could forego sentinel lymph node biopsy while maintaining high survival rates (>98%) or were restratified as being at a higher or lower risk of recurrence or death.

LIMITATIONS

Multicenter, retrospective study.

CONCLUSION

Integrating clinicopathologic features with the 31-GEP optimizes patient risk stratification compared to clinicopathologic features alone.

Exploratory Study of Superparamagnetic Iron Oxide Dose Optimization in Breast Cancer Sentinel Lymph Node Identification Using a Handheld Magnetic Probe and Iron Quantitation

Simple Summary

Sentinel lymph node biopsy (SLNB) using super magnetic iron oxide (SPIO) and magnetic probes is expected to be a simple and safe method of detecting cancerous lymph nodes without using radioisotopes (RIs). A multicenter trial of SLNB was conducted using a handheld magnetic probe and SPIO (Rizobist^®) and its non-inferiority with the conventional RI method. The quantity of iron in SLN was measured to examine the necessary dosage and administration method for sufficient SLN detection in the case of this test. Further, a clinical trial was conducted to determine the possibility of SLNB with a half-dose of SPIO (1.0 mL → 0.5 mL), and the resulting iron volume measured at that time was also examined. This study demonstrates that sufficient iron content reaches SLN even at an SPIO dose of 0.5 mL.

Abstract

This exploratory study compared doses of ferucarbotran, a superparamagnetic iron oxide nanoparticle, in sentinel lymph nodes (SLNs) and quantified the SLN iron load by dose and localization. Eighteen females aged ≥20 years scheduled for an SLN biopsy with node-negative breast cancer were divided into two equal groups and administered either 1 mL or 0.5 mL ferucarbotran. Iron content was evaluated with a handheld magnetometer and quantification device. The average iron content was 42.8 µg (range, 1.3–95.0; 0.15% of the injected dose) and 21.9 µg (1.1–71.0; 0.16%) in the 1-mL and 0.5-mL groups, respectively (p = 0.131). The iron content of the closest SLN compared to the second SLN was 53.0 vs. 10.0 µg (19% of the injected dose) and 34.8 vs. 4.1 µg (11.1%) for the 1-mL and 0.5-mL groups, respectively (p = 0.001 for both). The magnetic field was high in both groups (average 7.30 µT and 6.00 µT in the 1-mL and 0.5-mL groups, respectively) but was not statistically significant (p = 0.918). The magnetic field and iron content were correlated (overall SLNs, p = 0.02; 1-mL, p = 0.014; 0.5-mL, p = 0.010). A 0.5-mL dose was sufficient for SLN identification. Primary and secondary SLNs could be differentiated based on iron content. Handheld magnetometers could be used to assess the SLN iron content.

Effect of non-sentinel metastasis on adjuvant treatment decisions and survival in Z0011 eligible non-screened detected breast cancer population

Background

The Z0011 trial results have shown that axillary lymph node dissection (ALND) can be avoided in cT1-2 patients undergoing breast conservation surgery with 1–2 metastatic sentinel lymph nodes (SLNs). We compared the clinicopathological characteristics of the Z0011 eligible non-screen detected breast cancer patients’ cohort with the Z0011 trial study population. Additionally, we have explored the effect of non-sentinel metastasis on adjuvant treatment decisions and survival.

Methods

The details of early breast cancer (EBC) patients fulfilling Z0011 eligibility criteria were retrieved from a prospectively maintained database (2013–2017) and electronic medical records. We used Statistical Package for the Social Sciences 25 and Stata V15 for the data analysis.

Results

128/194 (66%) sentinel lymph node biopsy positive patients had fulfilled the Z0011 inclusion criteria. Compared to the Z0011 study, our cohort patients were younger, with more aggressive disease (higher T2, Grade 3), had a higher rate of macrometastasis (82.8% versus 58.8%) and non-SLN metastasis (48% versus 27%). The information gained by ALND had changed decisions for chemotherapy in 3% and no change of radiotherapy in Z0011 eligible patients. Further nodal positivity in completion ALND was not significantly associated with overall survival (p = 0.86) and disease-free survival (p = 0.5).

Conclusion

Z0011 eligible Indian EBC patients are significantly different from the Z0011 study population, with younger age of presentation, higher grade, a higher rate of both SLN macro metastasis and non-SLN positivity. The impact of non-sentinel metastasis on adjuvant treatment decisions and survival is minimal.

Identification of the lymph node metastasis-related automated breast volume scanning features for predicting axillary lymph node tumor burden of invasive breast cancer via a clinical prediction model

Breast cancer has become the malignant tumor with the highest incidence in women. Axillary lymph node dissection (ALND) is an effective method of maintaining regional control; however, it is associated with a significant risk of complications. Meanwhile, whether the patients need ALND or not is according to sentinel lymph node biopsy (SLNB). However, the false-negative results of SLNB had been reported. Automated breast volume scanning (ABVS) is a routine examination in breast cancer. A real-world cohort consisting of 245 breast cancer patients who underwent ABVS examination were enrolled, including 251 tumor lesions. The ABVS manifestations were analyzed with the SLNB results, and the ALND results for selecting the lymph node metastasis were related to ABVS features. Finally, a nomogram was used to construct a breast cancer axillary lymph node tumor burden prediction model. Breast cancer patients with a molecular subtype of luminal B type, a maximum lesion diameter of ≥5 cm, tumor invasion of the Cooper's ligament, and tumor invasion of the nipple had heavy lymph node tumor burden. Molecular classification, tumor size, and Cooper's ligament status were used to construct a clinical prediction model of axillary lymph node tumor burden. The consistency indexes (or AUC) of the training cohort and the validation cohort were 0.743 and 0.711, respectively, which was close to SLNB (0.768). The best cutoff value of the ABVS nomogram was 81.146 points. After combination with ABVS features and SLNB, the AUC of the prediction model was 0.889, and the best cutoff value was 178.965 points. The calibration curve showed that the constructed nomogram clinical prediction model and the real results were highly consistent. The clinical prediction model constructed using molecular classification, tumor size, and Cooper's ligament status can effectively predict the probability of heavy axillary lymph node tumor burden, which can be the significant supplement to the SLNB. Therefore, this model may be used for individual decision-making in the diagnosis and treatments of breast cancer.

Sentinel Lymph Node Biopsy in Breast Cancer. Principle, Difficulties and Pitfalls

Sentinel Lymph node biopsy (SLNB) represents the standard approach in a newly diagnosed breast cancer for axillary staging in cases of clinical node negative. This represents a major prognostic factor and the biopsy of sentinel lymph node for early breast cancer is used as guidance in surgical and oncological treatment. Although for many decades, axillary lymph node dissection was the standard approach for breast cancer treatment and staging, this pathway was abandoned due to significant risk of lymphedema, infection, nerve and vessels injury or dysfunction of the shoulder. Therefore, significant improvement in the quality of life was seen for patients diagnosed with early breast cancer after SLNB was introduced as standard. The principle of SLNB is based on the hypothesis that tumor drains in the lymphatic system in an orderly manner and if the first lymphatic station is clear of disease, it is highly unlike that the tumor has spread further above. We present in our paper the indications with principles and difficulties in identification of sentinel node.

Head and neck melanoma: outcome and predictors in a population-based cohort study

Background

To evaluate predictive clinico-pathological characteristics on outcome in head and neck melanoma (HNM) in a population-based study with particular emphasis on the prognostic effect of sentinel lymph node biopsy (SLNB), Charlson comorbidity index (CCI) and distinct tumor localisations.

Methods

Here we primarily describe a retrospective multicenter population-based cohort study with 402 patients having undergone resection with curative intent of HNM between 2010 and 2017. SLNB was used in the diagnosis of 79 HNM patients. Outcome was analyzed, focusing on SLNB, CCI as well as tumor localisation. Overall survival (OAS) und recurrence free survival (RFS) was examined by uni- and multivariate analysis.

Results

Histopathologically verified lymph node metastasis according to SLNB was associated with impaired RFS in HNM patients (p = 0.004). Especially in higher tumor stages, the sole implementation of SLNB improved survival significantly in the present cohort (p = 0.042). With most of the HNM being located in the face, melanoma of the scalp and neck could be linked to deteriorated patient’s outcome in uni- as well as multivariate analysis (p = 0.021, p = 0.004).

Conclusions

SLNB is a useful tool in predicting development of distant metastasis after HNM resection with curative intent. Especially in higher tumor stages, performing a SLNB ameliorated survival of HNM patients. Additionally, CCI as well as a distinct tumor localisations in HNM were identified as important risk factors in our population-based cohort study.

Surgical Management of the Axilla of HER2+ Breast Cancer in the Z1071 Era: A Propensity-Score-Matched Analysis of the NCDB

INTRODUCTION

We aim to analyze survival outcomes for sentinel lymph node biopsy (SLNB) versus axillary lymph node dissection (ALND) in human epidermal growth factor receptor (HER2)+ infiltrative ductal carcinoma (IDC) that demonstrate complete clinical response (cCR) to neoadjuvant systemic therapy (NAST) after initial presentation with clinical N1 (cN1) disease.

METHODS

NCDB 2004-2017 was utilized for the analysis. Female patients with unilateral HER2+ IDC, stage cT1-T4 cN1, who demonstrated cCR to NAST with reported definitive axillary surgical management were included. Patients were propensity score matched, and overall survival (OS) was compared. Cox regression analysis was used to identify survival predictors.

RESULTS

6453 patients were selected, of whom 2461 (38.1%) had SLNB and 3992 (69.1%) had ALND as definitive axillary surgical management. The trend of SLNB utilization increased from 20% in 2012 to 50% in 2017. A total of 2454 patients were matched from each group with adequate adjustment for all variables. There was no difference in OS between SLNB versus ALND (84.03 ± 0.36 versus 84.62 ± 0.42 months; p = 0.522). Cox regression identified age, cT stage, primary tumor response to NAST, ypN+, and endocrine therapy as significant OS predictors. In subgroup analysis of patients with ypN+ who had SLNB as a definitive procedure, primary tumor response to NAST and continuation of adjuvant chemotherapy were associated with improved OS.

CONCLUSION

In cN1 HER2+ IDC patients who demonstrate cCR to NAST, SLNB is a reasonable definitive procedure for axillary management with comparable OS outcomes to ALND. However, higher-level data are required to determine the appropriate management in the case of ypN+.

Staging of the Axilla in Breast Cancer and the Evolving Role of Axillary Ultrasound

Axillary lymph nodes have long been recognized as a route for breast cancer to spread systemically. As a result, staging of the axilla has always played a central role in the treatment of breast cancer. Anatomic staging was believed to be important for two reasons: 1) it predicts prognosis and guides medical therapy, and 2) it is a potential therapy for removal of disease in the axilla. This paradigm has now been called into question. Prognostic information is driven increasingly by tumor biology, and trials such as the ACOSOG Z0011 demonstrates removal of axillary disease is not therapeutic. Staging of the axilla has undergone a dramatic de-escalation; however, sentinel lymph node biopsy (SLNB) is still an invasive surgery and represents a large economic burden on the healthcare system. In this review, we outline the changing paradigms of axillary staging in breast cancer from emphasis on anatomic staging to tumor biology, and the evolving role of axillary ultrasound, bringing patients less invasive and more personalized therapy.

Pathologic nodal staging for clinically node negative soft tissue sarcoma of the extremities

BACKGROUND AND OBJECTIVES

Synovial, clear cell, angiosarcoma, rhabdomyosarcoma, and epithelioid (SCARE) soft tissue sarcoma are at risk for nodal involvement, although the nodal positivity rates and impact on prognostication in clinically node negative patients are not well described.

METHODS

Patients with extremity SCARE sarcoma without clinical nodal involvement undergoing surgical resection in the National Cancer Database (2004-2017) were included. Logistic regression was used to evaluate the likelihood of nodal surgery and nodal positivity. Kaplan-Meier method and Cox regression were used to assess associations of nodal status to overall survival.

RESULTS

We included 4158 patients, and 669 patients (16%) underwent regional lymph node surgery (RLNS). On multivariable logistic analysis, patients with epithelioid (odds ratio [OR]: 3.77; p < .001) and clear cell (OR: 6.38; p < .001) were most likely to undergo RLNS. Forty-five patients (7%) had positive nodes. Clear cell sarcoma (14%) and angiosarcoma (13%) had the highest rates of nodal positivity. Patients with positive nodes had reduced 5-year overall survival, and the stratification was largest in clear cell and angiosarcoma.

CONCLUSION

Discordance exists between selection for pathologic nodal evaluation and factors associated with nodal positivity. Clinically node negative patients with clear cell and angiosarcoma should be considered for pathologic nodal evaluation.

National Variations in the Work-Up, Investigation, and Surgical Management of Ductal Carcinoma In Situ of the Breast across Canadian Surgeons

Variation in the management of Ductal Carcinoma In Situ (DCIS) of the breast occur at both national and international levels. The aim of this study is to determine the degree of, and reasons behind, this variation in the workup and treatment of DCIS among Canadian surgeons. We developed a 35-question survey involving the pre-, peri, and post-operative management of DCIS using SurveyMonkey^®. The survey was sent out via email and responses were analyzed using SurveyMonkey^® and Microsoft Excel. 51/119 (43%) of the Canadian General Surgeons contacted participated in this study. Some variation was observed in the utilization of pre-operative imaging with 29/48 (60%) surgeons routinely using ultrasound. Perceived contraindications to breast conserving therapy also varied with multicentricity (54%) and the presence of diffuse microcalcifications (13%). Nearly all respondent's (98%) patients had access to immediate breast reconstruction following a mastectomy but 14/48 (29%) of respondents' patients were required to travel a mean distance of 300 km to undergo the procedure. Substantial variation was also seen during follow-up with half (52%) of surgeons following up patients for >1 month in their surgical clinic. There is considerable variation in the management of DCIS among Canadian Surgeons. The present study indicates the need for pan-Canadian, evidence-based guidelines to ensure a standardized management strategy for patients with DCIS.

Preoperative Contrast-Enhanced Ultrasound (CEUS) Combined with 125I Seeds Localization in Sentinel Lymph Node Biopsy for Breast Cancer

Objective

To assess the clinical value of contrast-enhanced ultrasound (CEUS) technology in predicting axillary lymph nodes status before surgery, and to explore the feasibility of sentinel lymph nodes (SLNs) localization guided by CEUS combined with ¹²⁵I implantation for breast cancer.

Methods

From August 2017 to February 2019, 115 patients were included in this prospective study. Before surgery, a microbubble (SonoVue) was injected intradermally next to the areola. The enhancement patterns of SLNs were recorded and ¹²⁵I seeds were deployed into the enhanced nodes. Then, all patients underwent standard sentinel lymph node biopsy (SLNB) and all ¹²⁵I seeds were found out guided by a gamma detector in surgery. The localization was considered successful if ¹²⁵I seeds were implanted in/beside the nodes.

Results

SLNs in 103 cases were successfully identified, the success rate was 89.6% (103/115), 118 SLNs were detected in total. ¹²⁵I seeds were deployed successfully in 99 cases, and all of the ¹²⁵I-labeled SLNs were then successfully detected by combined method (radionuclides and blue dye). The accuracy of ¹²⁵I seeds localization was 96.1% (99/103). Based on the enhancement patterns recorded, 34 cases were predicted to have SLNs metastasis (metastasis in 27 cases and no metastasis in 7 cases confirmed by postoperative pathology) and 65 cases were predicted to have no SLNs metastasis (metastasis in 5 cases and no metastasis in 60 cases by pathology). The positive predictive value and negtive predictive value of CEUS in assessing axillary status were 79.4% (27/34) and 92.3% (60/65), respectively. The axillary metastasis rate in CEUS combined with ¹²⁵I seeds localization was 27.3% (27/99), while the metastasis rate in the combined method of SLNB was 32.3% (32/99). The sensitivity of ¹²⁵I seeds localization was 84.4% (27/32), the false-negative rate was 15.6% (5/32), and the consistency evaluation was excellent (Kappa value=0.880, P<0.001).

Conclusion

CEUS combined with ¹²⁵I seeds implantation can locate SLNs accurately and has excellent consistency with the combined method. The enhancement patterns can provide helpful predicting information of axillary status preoperatively. However, more studies are needed to be carried out to verify our outcomes and explore the feasibility of applying CEUS technology in clinical work.

Clinical benefit of baseline imaging in Merkel cell carcinoma: Analysis of 584 patients

BACKGROUND

Merkel cell carcinoma (MCC) guidelines derive from melanoma and do not recommend baseline cross-sectional imaging for most patients. However, MCC is more likely to have metastasized at diagnosis than melanoma.

OBJECTIVE

To determine how often baseline imaging identifies clinically occult MCC in patients with newly diagnosed disease with and without palpable nodal involvement.

METHODS

Analysis of 584 patients with MCC with a cutaneous primary tumor, baseline imaging, no evident distant metastases, and sufficient staging data.

RESULTS

Among 492 patients with clinically uninvolved regional nodes, 13.2% had disease upstaged by imaging (8.9% in regional nodes, 4.3% in distant sites). Among 92 patients with clinically involved regional nodes, 10.8% had disease upstaged to distant metastatic disease. Large (>4 cm) and small (<1 cm) primary tumors were both frequently upstaged (29.4% and 7.8%, respectively). Patients who underwent positron emission tomography-computed tomography more often had disease upstaged (16.8% of 352), than those with computed tomography alone (6.9% of 231; P = .0006).

LIMITATIONS

This was a retrospective study.

CONCLUSIONS

In patients with clinically node-negative disease, baseline imaging showed occult metastatic MCC at a higher rate than reported for melanoma (13.2% vs <1%). Although imaging is already recommended for patients with clinically node-positive MCC, these data suggest that baseline imaging is also indicated for patients with clinically node-negative MCC because upstaging is frequent and markedly alters management and prognosis.

Practical consensus recommendations for neo-adjuvant chemotherapy in triple negative breast cancer

This manuscript provides a practical and easy to use consensus recommendation to community oncologists on how to use neoadjuvant chemotherapy in triple negative breast cancer patients.

Repeat Sentinel Lymph Node Biopsy for Ipsilateral Breast Tumor Recurrence After Breast Conserving Surgery With Sentinel Lymph Node Biopsy: Pooled Analysis Using Data From a Systematic Review and Two Institutions

Introduction: Best surgical approach of axillary staging remains controversial in locally recurrent breast cancer. We evaluated the reliability of repeat sentinel lymph node biopsy (reSLNB) in patients with ipsilateral breast tumor recurrence (IBTR) after breast conserving surgery (BCS) with sentinel lymph node biopsy (SLNB) in terms of identification rate (IR) and false negative rate (FNR). To address the FNR, we identified patients who underwent sequential axillary lymph node dissection (ALND) after reSLNB.

Methods: A systematic search of PubMed, EMBASE, and Cochrane Library were conducted to identify patient-level data from articles. We searched for data of patients who underwent BCS with SLNB for primary breast cancer and who underwent sequential ALND after reSLNB due to local recurrence. Patients data was also identified by the same criteria at two institutions.

Results: In total, 197 peer-reviewed publications were obtained, of which 20 included patients who met the eligibility criteria. Data from 464 patients were collected. From the two institutions, 31 patients were identified. A total of 495 patients were pooled. The IR of reSLNB was 71.9% (356/495). To address the FNR of reSLNB, 171 patients who underwent ALND after reSLNB were identified. The FNR and accuracy of reSLNB were 9.4% (5/53) and 97.1% (165/170), respectively.

Conclusion: Our pooled data analysis showed that the FNR of reSLNB is lower than 10%, indicating that this operation is a reliable axillary surgery in patients with IBTR after they underwent BCS.

Management of the positive sentinel lymph node in the post-MSLT-II era

BACKGROUND AND OBJECTIVES

The publication of MSLT-II shifted recommendations for management of sentinel lymph node biopsy positive (SLNB+) melanoma to favor active surveillance. We examined trends in immediate completion lymph node dissection (CLND) following publication of MSLT-II.

METHODS

Using a prospective melanoma database at a high-volume center, we identified a cohort of consecutive SLNB+ patients from July 2016 to April 2019. Patient and disease characteristics were analyzed with multivariate logistic regression to examine factors associated with CLND.

RESULTS

Two hundred and thirty-five patients were included for analysis. CLND rates were 67%, 33%, and 26% for the year before, year after, and second-year following MSLT-II. Factors associated with undergoing CLND included primary located in the head and neck (59% vs 33%, P = .003 and odds ratio [OR], 5.22, P = .002) and higher sentinel node tumor burden (43% vs 10% for tumor burden ≥0.1 mm, P < .001 and OR, 8.64, P = .002).

CONCLUSIONS

Rates of CLND in SLNB+ melanoma decreased dramatically, albeit not uniformly, following MSLT-II. Factors that increased the likelihood of immediate CLND were primary tumor located in the head and neck and high sentinel node tumor burden. These groups were underrepresented in MSLT-II, suggesting that clinicians are wary of implementing active surveillance recommendations for patients perceived as higher risk.

Methylene Blue Absorption in Sentinel Lymph Node Biopsy for Early Breast Cancer after Neoadjuvant Chemotherapy

INTRODUCTION

Chemotherapy is claimed to cause lymphatic drainage damage because of the tumor cell's apoptosis process. This event might cause decreased marker (radioactive solution and/or blue dye) absorption on sentinel lymph nodes (SLN). In this study, the researchers used methylene blue only and wished to evaluate the methylene blue absorption of the SLNB procedure on early-stage breast-cancer patients after neoadjuvant chemotherapy (NAC).

MATERIALS AND METHODS

The method used was the historical cohort study conducted from 2016-2019 in Indonesia. Samples were collected from 117 patients of stage I and II breast cancer with clinically negative axillary lymph nodes, who were then grouped into post-NAC and no-NAC (control group), in which SLNB procedures were conducted on the two groups by using single-method methylene blue. The results of methylene blue absorption were then analyzed by the Chi-square hypothesis test.

RESULTS

From the total of 564 early-stage patients who were referred to surgical oncologists, 117 patients were found to meet criteria of inclusion, consisting of the control group (52 patients) and the post-NAC group (65 patents). Of 65 patients who had undergone NAC treatment and SLNB procedure, it was found that 40 patients (61.5%) showed positive blue SLN. Of 52 pre-NAC breast-cancer patients, it was found that 47 patients (90.4%) showed methylene blue absorption on SLN with the p-value of 0.000 (P<0.05, significant). The relative risk value amounted to 0.522. Post-NAC patients had a tendency of decreased absorption of methylene blue.

CONCLUSION

Neoadjuvant chemotherapy can cause the decrease of methylene blue absorption on SLNB procedure.

Can Low-cost Indo Cyanine Green Florescence Technique for Sentinel Lymph Node Biopsy Replace Dual Dye (Radio-colloid and Blue Dye) Technique in Early Breast Cancer: A Prospective Two-arm Comparative Study

BACKGROUND

The objective of this study was to assess the detection and accuracy of sentinel lymph node (SLN) biopsy (SLNB) using the low-cost indocyanine green (ICG) fluorescence method and to compare this method with the gold standard dual-dye method (radio-colloid + methylene blue dye [MB]).

MATERIALS AND METHODS

One hundred patients with node-negative early breast cancer assessed clinically and by ultrasound axilla underwent an SLNB procedure using technetium-99m radio-colloid, MB, and ICG. The detection rate of SLNs and positive SLNs and the number of SLNs were compared. The injection safety of ICG and MB was evaluated.

RESULTS

One hundred female patients with a median age of 52.3 years participated in the study. Sixty-eight percent had a body mass index < 25, 85% presented with a palpable lump, of which 59% were in the outer quadrant. SLNs were identified in all 100 cases. A total of 290 SLNs were removed (mean, 2.9; range, 1-6). The identification rate with dual dye was 94%, whereas with ICG alone, it was 96%. The SLNB sensitivity rate and false negative rate were 97.6% versus 93.2% and 3.1% versus 6.2% in the ICG and dual-dye combination, respectively. None of the patients had any local or systemic reaction with ICG; 3 patients with blue dye had tattooing and staining of skin.

CONCLUSION

ICG fluorescence imaging permits real time visualization of lymphatics and provides an additional dimension to SLN biopsy that is safe and effective. These results confirm high sensitivity for fluorescence localization with comparable performance to the gold standard. ICG can reliably replace dual dye and be employed as a sole tracer for SLNB in early breast cancer.

Outcomes of Sentinel Lymph Node Biopsy Using Blue Dye Method for Early Breast Cancer - A Single-Institution Experience in the Philippines

Purpose

This study aimed to share our experience with SLNB in the Filipino population with early breast cancer.

Patients and Methods

A retrospective review was done on all patients with confirmed invasive breast carcinoma, tumor size of 5 cm or less (T1/T2), who preoperatively had no clinical signs of axillary metastasis and subsequently underwent SLNB with blue dye method from January 01, 2008 to December 31, 2017. Clinicopathologic profiles were recorded. Outcomes of patients who had SLNB only were assessed.

Results

One hundred twenty-nine patients matched the inclusion criteria with a mean age of 54.3 years. The majority (88.4%) had a total mastectomy. Invasive ductal carcinoma (65.1%) was the most common tumor. Estrogen and progesterone receptors were positive in 69% and 61.2% respectively while only 28.7% were HER2 positive. SLNB was successfully carried out in 126 (97.7%) patients with a range of 2-4 SLNs harvested. Thirty-four (26.4%) patients had completion ALND. With a median of 25 months follow-up, 75 out of 95 patients who underwent SLNB alone had follow-up data. Forty-six (61.3%) patients had seroma formation. One (1.3%) patient developed arm paresthesia, 2 (2.7%) local (chest wall) and 2 (2.7%) axillary recurrences after a negative SLNB. None of the patients developed lymphedema.

Conclusion

The blue dye method alone is acceptable and can be readily employed in institutions with limited resources. Even with the limited population, the morbidity and oncologic outcomes of patients who underwent SLNB alone were low and comparable to similar international published data. SLNB should be the preferred method for staging the axilla.

Use of Sentinel Lymph Node Biopsy and Early Physiotherapy to Reduce Incidence of Lymphedema After Breast Cancer Surgery: an Institutional Experience

Newer advances in breast cancer management have led to increased disease free survival and overall survival. It is important to prevent debilitating complications after axillary lymph node dissection (ALND) to be able to successfully translate this survival benefit to quality of life benefit. By reducing disruption of lymphatic channels, sentinel lymph node biopsy (SLNB) decreases incidence of lymphedema (LE). Initiating early physiotherapy regimens, too, improves arm symptoms. In this review, we analyze the incidence of LE at our center and compare it with western literature. Retrospective analysis of all post-surgery breast cancer 18 patients, who followed up routinely with our oncophysiotherapist, was carried out. Incidence of LE in patients undergoing SLNB or ALND was followed up for a mean period of 17.5 months. Only 3.6%, i.e., 6 patients out of 166 developed LE. Amongst 166, 80 had only SLNB; the rest had ALND (either upfront or post-positive SLNB). None of the SLNB only cohort patients developed LE. SLNB in clinically node negative axilla, followed by initiation of arm physiotherapy early in post-operative period, may reduce LE incidence in breast cancer patients.

[Decision making factors of the management of ductal carcinoma in situ of the breast with microinvasion]

INTRODUCTION

Microinvasive in situ ductal carcinomas of the breast are rare and of good prognosis. They are grouped with early stage invasive carcinomas in the TNM 2017 classification. This study assessed practitioners' treatment decisions and their justifications in comparison to the literature.

MATERIALS AND METHODS

Three clinical cases were evaluated by anonymous forms regarding sentinel node decisions, tumour bed boost irradiation and hormone therapy.

RESULTS

Sentinel lymph node was performed by 93.1%, 100% and 44.4% of the practitioners respectively. Radiation boost was a treatment option chosen by 62.1% and 61.1% of practitioners in both clinical cases. Hormone therapy was advocated for 65.5%, 94.7% and 50.0% patients depending on the clinical case.

CONCLUSION

The therapeutic attitude proposed in microinvasive breast carcinomas was heterogeneous in this study, reflecting the absence of specific recommendations. In view of the existing literature, it is not currently possible to propose recommendations for these three therapeutic options. Prospective cohorts and meta-analyses of the microinvasive subgroup could provide answers.

The Role of Completion Lymphadenectomy in Positive Regional Lymph Nodes in Melanoma: A Meta-analysis

BACKGROUND

The optimal management of melanoma with positive sentinel lymph node (SLN) remains unclear. Completion lymph node dissection (CLND) only yields additional positive non-SLN in 20% of cases and its benefits on survival remains debatable.

METHODS

An online database search of Medline was performed; key bibliographies were reviewed. Studies comparing outcomes after CLND versus observation were included. Odds ratios (ORs) with the corresponding 95% confidence intervals (CIs) by random fixed effects models of pooled data were calculated. The primary endpoints were disease-free survival (DFS), melanoma-specific survival (MSS), and overall survival (OS).

RESULTS

Search strategy yielded 117 publications. Twelve studies were selected for inclusion, comprising 7966 SLN-positive patients. Among these patients, 5306 (66.6%) subjects underwent CLND and 2660 (33.4%) patients were observed. Median Breslow thickness and ulceration were similar between groups (2.8 ± 0.6 mm versus 2.5 ± 0.8 mm, P = 0.721; and 38.8% versus 37.2%, P = 0.136, CLND versus observation, respectively). CLND was associated with statistically significant improved 3-y (71.0% versus 66.2%, OR 0.82, 95% CI 0.69-0.97, P = 0.02) and 5-y DFS (48.3% versus 47.8%, OR 0.75, 95% CI 0.59-0.96, P = 0.02) compared with observation. However, no difference was demonstrated in 3-y MSS (83.7% versus 84.7%, OR 1.09, 95% CI 0.88-1.35, P = 0.41), 5-y MSS (68.4% versus 69.8%, OR 1.02, 95% CI 0.88-1.19, P = 0.78), or OS (68.2% versus 78.9%, OR 0.93, 95% CI 0.55-1.57, P = 0.78).

CONCLUSIONS

Based on this large-scale analysis, CLND improved both 3- and 5-y DFS, possibly because of increased rates of local control; however, this did not translate in improved MSS or OS. Efforts toward the identification of molecular markers associated with poor outcomes in SLN-positive patients who undergo observation are warranted.

Value of SPECT/CT for Sentinel Lymph Node Localization in the Parotid and External Jugular Chain

OBJECTIVE

Preoperative single-photon emission computed tomography/computed tomography (SPECT/CT) imaging may aid in the localization of sentinel lymph nodes (SLNs) in cutaneous head and neck malignancy and has been rigorously evaluated for deep cervical lymph nodes. The purpose of this study was to assess the sensitivity, specificity, and positive predictive value (PPV) of SPECT/CT for preoperative localization of nodal basins superficial to the sternocleidomastoid muscle, with comparison to deep nodal basins of the neck.

STUDY DESIGN

Retrospective review.

SETTING

Tertiary care center.

SUBJECTS AND METHODS

SPECT/CT images obtained preoperatively for patients undergoing SLN biopsy for cutaneous head and neck malignancy between June 2015 and June 2016 were reviewed by a blinded nuclear medicine physician and head and neck surgeon. SPECT/CT imaging was compared to intraoperatively determined SLN location via gamma probe. Sensitivity, specificity, and positive and negative predictive values were determined and compared for superficial (external jugular [EJ] and parotid) nodes vs level II nodes.

RESULTS

Fifty-three patients were included in the study. Most had cutaneous melanoma (69.8%). The PPV of EJ/parotid node identification by SPECT/CT imaging was 85.7%, specificity was 88.9%, and sensitivity was 69.2%. Comparatively, the PPV for level II nodes was 76.9%, specificity was 50%, and sensitivity was 85.7%. No significant difference in SPECT/CT predictive value was identified between EJ/parotid and level II node identification ( P > .05).

CONCLUSION

SPECT/CT imaging has strong specificity and positive predictability for preoperative localization of SLN superficial to the sternocleidomastoid muscle in cutaneous head and neck malignancy. SPECT/CT imaging may be a useful radiographic aid for preoperative SLN mapping in this patient population.

Sentinel lymph node biopsy in melanoma: Which hot nodes should be harvested and is blue dye really necessary?

OBJECTIVES

The '10% rule' has become widely accepted by surgeons performing sentinel lymph node biopsy (SLNB) for melanoma. The purpose of this study was to compare the '10% rule' with alternative node harvesting criteria. In particular, we were interested to see whether the use of blue dye had any impact on the sensitivity of the test and whether it is necessary to remove all hot nodes.

METHODS

We reviewed 537 SLNBs performed for primary melanoma from 2009-2015. SLNB was offered to all patients with 1-4 mm Breslow thickness melanoma and sentinel nodes were harvested according to the '10% rule'.

RESULTS

One hundred sixteen patients (22%) had at least one positive sentinel node and there were 45 positive nodal basins from which more than one sentinel node had been harvested. Excluding blue dye and sampling only hot nodes would have enabled a 5% reduction in nodes harvested, without any compromise in the sensitivity of the test. However, applying harvesting criteria whereby not all hot nodes are taken was associated with a loss of sensitivity, with positive sentinel nodes being missed and patients understaged.

CONCLUSIONS

Our data do not support the continued use of blue dye in SLNB for melanoma, as it does not improve the sensitivity of the test. This series adds to growing evidence, suggesting that the '10% rule' with the inclusion of blue nodes should be reconsidered and that radiocolloid tracer alone is sufficient for sentinel node localisation.

Prognostic significance of further axillary dissection in breast cancer patients with micrometastases & the number of micrometastases: a SEER population-based analysis

Aim:

To investigate the benefits of axillary dissection in patients with micrometastases.

Methods:

A review of data from the Surveillance, Epidemiology, and End Results database was performed from 2004 to 2013. Kaplan–Meier curves, Cox regression models, and propensity score matching were utilized to comprehensively evaluate the cohort.

Results:

Multivariate analysis after propensity score matching showed that patients with one to two micrometastases did not substantially benefit from axillary lymph node dissection in breast cancer-specific survival (p = 0.725). However, a subgroup analysis indicated that axillary dissection may benefit estrogen receptor-negative patients. Moreover, patients who carried three micrometastases had a significantly lower crude hazard ratio in breast cancer-specific survival.

Conclusion:

Axillary lymph node dissection may have advantages in high-risk micrometastatic patients. Patients with three micrometastases should be treated with caution.

The current study demonstrated that among patients undergoing breast-conserving surgery following radiation with T1–T2 invasive breast cancer and one to two nodal micrometastases, there was no difference in the breast cancer-specific survival for patients with and without axillary lymph node dissection. Although negative results of the Z0011 and International Breast Cancer Study Group 23–01 trials have been reported, high-risk micrometastatic patients (e.g., estrogen receptor negative, young age) may be candidates for radical axillary treatment according to the unclear radiation field and higher recurrence rate. The preliminary assessment of  three micrometastatic patients showed a lower breast cancer-specific survival than patients with one to two micrometastases. This study provides a novel perspective to the American Joint Committee on Cancer with respect to micrometastases.

Practical consensus recommendatons for Paget's disease in breast cancer

Paget's disease of the breast is a rare type of cancer of the nipple-areola complex and that is often associated with an underlying in situ or invasive carcinoma. Diagnosis and treatment of Paget's disease is controversial. Expert oncologists discuss on the update on the approaches of Paget's disease diagnosis and its treatment options. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at this practical consensus recommendations for the benefit of community oncologists.

Metastatic Melanoma in Sentinel Node-Negative Patients: The Ottawa Experience

BACKGROUND

Lymph node involvement is a major independent prognostic factor for survival in patients with malignant melanoma. Sentinel lymph node biopsy (SLNB) detection of microscopic nodal melanoma has been shown to improve both 5-year survival and 5-year disease-free survival.

OBJECTIVE

To determine the rate of metastatic melanoma in SLNB-negative patients at long-term follow-up.

METHODS

Study subjects include all 152 patients who had a negative SLNB and were followed at the Ottawa Regional Cancer Centre (ORCC) between 1999 and 2004. Patients with a follow-up period less than 6 months, more than 1 primary melanoma, and metastatic melanoma at diagnosis were excluded. Age at diagnosis, sex, Breslow thickness, ulceration, mitoses, regression, Clark level, anatomical location, development of metastatic melanoma, time to detection of metastatic disease, and time to death from melanoma were studied.

RESULTS

In this retrospective study at the ORCC, 40 of 140 (28.6%) patients with a single primary melanoma developed metastatic melanoma following negative SLNB at a mean follow-up of 63 months.

CONCLUSION

The rate of metastatic melanoma following negative SLNB at long-term follow-up at the ORCC is higher than the upper limit of rates reported in the literature (6%-24%). The reason for this is multifactorial, and the long follow-up period of 5 years allowed for detection of metastatic disease at a mean of 3.9 years. Long-term prognosis may be guarded in node-negative patients with a primary cutaneous melanoma, and surveillance by a multidisciplinary team is crucial.

Sentinel lymph node biopsy in low risk settings

BACKGROUND

Sentinel lymph node biopsy (SLNB) should be performed in patients with ductal carcinoma in situ (DCIS) undergoing mastectomy. Yet, the same logic is controversial in the setting of prophylactic mastectomy.

METHODS

Surgeons were surveyed as to their practices. Statistical analyses were performed to identify associated factors.

RESULTS

238 surgeons responded to the survey. 73.1% of respondents stated they would always perform SLNB in the setting of mastectomy for DCIS, but only 6.6% would always do so in the prophylactic setting. While generally perceived that the rate of SLN positivity in the setting of pure DCIS and prophylactic mastectomy was <5% (96.9% and 99.5%, respectively), 61.8% of surgeons who reported "always" performing SLNB in the setting of DCIS treated with mastectomy stated they "never" performed a SLNB for prophylactic mastectomy.

CONCLUSION

SLNB practice patterns for these low risk settings are disparate. Consensus is required to rationalize practice.

Sentinel Node Procedure Obsolete in Lumpectomy for Ductal Carcinoma In Situ

BACKGROUND

Patients with a preoperative needle-biopsy diagnosis of ductal carcinoma in situ (DCIS) may have an indication for a sentinel lymph node biopsy if invasive carcinoma is found. We investigated how often a positive sentinel node and invasive carcinoma occurred in patients with a preoperative diagnosis of DCIS and whether this influenced the adjuvant regime.

MATERIALS AND METHODS

From 2005 to 2014, the records of 240 patients with needle-biopsy diagnosis of DCIS were retrospectively reviewed for postoperative pathology outcomes of the sentinel node and breast, and decisions on adjuvant treatment. Descriptive statistics and univariable and multivariable analysis were used.

RESULTS

A total of 160 of 240 patients underwent a sentinel node biopsy. Sixteen of 85 patients undergoing lumpectomy had occult invasive cancer. One patient had a micrometastasis. In patients undergoing mastectomy, 30 of 155 patients had occult invasive cancer. One patient had a micrometastasis, and 3 had a macrometastases. Eleven patients received adjuvant treatment as a result of invasive cancer. Three patients received adjuvant treatment (radiotherapy of the axilla or axillary dissection) because of node positivity. These patients underwent a primary mastectomy.

CONCLUSION

A positive sentinel lymph node biopsy in patients with needle-biopsy diagnosis of ductal DCIS is rare and rarely changes adjuvant regimes. Current Dutch guidelines should be updated.

The Impact of L-Dex(®) Measurements in Assessing Breast Cancer-Related Lymphedema as Part of Routine Clinical Practice

PURPOSE

With improved survivorship, the prevalence of breast cancer-related lymphedema (BCRL) continues to increase, leading to impairment of a patients' quality of life. While traditional diagnostic methods are limited by an inability to detect BCRL until clinically apparent, bioimpedance spectroscopy (BIS) has been shown to detect subclinical BCRL. The purpose of this study is to evaluate the role of BIS in the early detection of BCRL, as well as assessment of response to BCRL treatment.

METHODS

A retrospective review of 1,133 patients treated between November 2008 and July 2013 at two surgical practices was performed. Eligible patients (n = 326) underwent preoperative and postoperative L-Dex measurements. Patients were identified as having subclinical lymphedema if they were asymptomatic and the L-Dex score increased >10 U above baseline and were monitored following treatment. Patients were stratified by lymph node dissection technique [sentinel lymph node biopsy (SLNB) vs. axillary lymph node dissection (ALND)] and receipt of BCRL treatment.

RESULTS

The average age of the cohort was 56.2 years old, and mean follow-up was 21.7 months. Of the 326 patients, 210 underwent SLNB and 116 underwent ALND. BCRL was identified by L-Dex in 40 patients (12.3%). The cumulative incidence rate of subclinical lymphedema was 4.3% for SLNB (n = 9) and 26.7% for ALND (n = 31). Of those diagnosed with BCRL, 50% resolved following treatment, 27.5% underwent treatment without resolution, and 22.5% had resolution without treatment. The prevalence of persistent, clinical BCRL was 0.5% for SLNB and 8.6% for ALND.

CONCLUSION

This study demonstrates both the feasibility and clinical utility of implementing L-Dex measurements in routine breast cancer care. L-Dex identified patients with possible subclinical BCRL and allowed for assessment of response to therapy.

Blue dye for identification of sentinel nodes in breast cancer and malignant melanoma: a systematic review and meta-analysis

The combined technique (radioisotope and blue dye) is the gold standard for sentinel lymph node biopsy (SLNB) and there is wide variation in techniques and blue dyes used. We performed a systematic review and meta-analysis to assess the need for radioisotope and the optimal blue dye for SLNB. A total of 21 studies were included. The SLNB identification rates are high with all the commonly used blue dyes. Furthermore, methylene blue is superior to iso-sulfan blue and Patent Blue V with respect to false-negative rates. The combined technique remains the most accurate and effective technique for SLNB. In order to standardize the SLNB technique, comparative trials to determine the most effective blue dye and national guidelines are required.

Prognostic role of sentinel lymph node biopsy for patients with cutaneous melanoma: A retrospective study of surveillance, epidemiology, and end-result population-based data

Sentinel lymph node biopsy (SLNB) is a sensitive operation for finding micro-metastasis in patients with cutaneous melanoma without evidence of clinically positive lymph node findings. However, until now, no clinical trials or retrospective studies with large samples have been performed to investigate the clinical role of SLNB for cutaneous melanoma patients. In this study, we used the data of cutaneous melanoma from the Surveillance, Epidemiology, and End Results (SEER) database to compare overall survival (OS) and melanoma-specific survival (MSS) outcomes with clinical lymph node and SLN status. In total, 56,285 eligible patients were identified in this study. Cutaneous melanoma patients with clinically-positive lymph nodes had significantly shorter OS (46.1% vs 78.6%, p = 0.000) and MSS (55.8% vs 90.5, p = 0.000) compared with clinically-negative lymph node patients. Patients who underwent SLNB had significantly longer 5-year rates for OS (84.3% vs 70.1, p = 0.000) and MSS (91.5% vs 90.3, p = 0.000) compared with patients who did not undergo SLNB (lymph node observation). Patients with a negative SLNB had a significantly longer 5-year rate for OS (86.5% vs 68.1% vs 46.1, p = 0.000) and MSS (93.7% vs 75.1% 55.8%, p = 0.000) than patients who were SLNB-positive or had clinically-positive lymph nodes. This present study showed that the status of SLN is a valuable prognostic factor in patients with Breslow thickness greater than 1 mm in clinically-negative lymph node cutaneous melanoma.

The hidden sentinel node in breast cancer: Reevaluating the role of SPECT/CT and tracer reinjection

INTRODUCTION

Lymphoscintigraphy with planar imaging is considered a helpful tool to depict lymph node drainage in patients with invasive breast cancer. Single Photon Emission Computed Tomography with integrated CT (SPECT/CT) is usually performed to detect sentinel nodes (SN)s in breast cancer patients showing non-visualisation on lymphoscintigraphy. Incorporation of new SN indications (recurrent surgery, previous radiotherapy, or neo-adjuvant chemotherapy) has led to an increase of non-visualisation rates. The present study evaluates the contribution of SPECT/CT and tracer reinjection for SN-visualisation in breast cancer patients without drainage on lymphoscintigraphy.

METHODS

Between 1st of July 2008 and 6th of November 2014 in total 1968 patients underwent a SN breast procedure, using intra-tumoural tracer administration. SPECT/CT was performed in 284 breast cancer patients with non-visualisation of SNs on lymphoscintigraphy. If SN non-visualisation persisted, a second radiotracer injection with repeated imaging was performed when logistics allowed this. Univariate analysis was applied to evaluate SPECT/CT visualisation rates in specific subgroups.

RESULTS

The SPECT/CT visualisation rate was 23.2% (66/284). Univariate analysis revealed no significant subgroups influencing SPECT/CT visualisation. In patients receiving reinjection after persistent SPECT/CT non-visualisation the SN-visualisation rate reached 62.1% (36/58). Intraoperatively, the SN-identification rate using a gamma probe and blue dye was 87.9% (175/199) and 32.9% (28/85) for, respectively, primary and recurrent surgery after non-visualisation on lymphoscintigraphy.

CONCLUSION

In this evaluation including new breast cancer SN indications, SPECT/CT scored lower than reinjection to visualise SNs in patients with non-visualisation on lymphoscintigraphy. Consequently, our institutional protocol has been readjusted.

Cutaneous melanoma in children and adolescents: the Italian rare tumors in pediatric age project experience

OBJECTIVE

To describe a series of cutaneous melanoma in children collected by the Italian Rare Tumors in Pediatric Age project.

STUDY DESIGN

From 2000 to 2012, 54 patients younger than 18 years of age were prospectively registered and treated at 12 Italian pediatric centers on the basis of the same diagnostic/therapeutic recommendations and with the same forms to record clinical data.

RESULTS

Considering the estimated annual incidence in Italy, the registered cases accounted for 30% of those expected in children and 10% of adolescents. Clinically, 47% of the tumors were amelanotic and 81% were raised, 39% of cases had tumor thickness >2 mm, and 36% had lymph node involvement. For the whole series, 5-year event-free survival and overall survival rates were 75.2% and 84.6%, respectively. Patient survival correlated with tumor stage and ulceration. No relapses were recorded for T1-2 (thickness <2 mm), N0, and stage 0-I-II cases.

CONCLUSION

We suggest that the variables influencing survival in children with melanoma are the same as for adults, the clinical approach used in adults is feasible in children, and pediatric cases are more likely to have advanced disease at diagnosis but similar survival. New effective drugs are needed for advanced disease, and biological studies and international cooperative schemes are warranted.