Assessment Of Node Status Research Articles

Diagnostic value of 18F-fluorodeoxyglucose positron-emission tomography/computed tomography for preoperative lymph node metastasis of esophageal cancer: A meta-analysis.

Objective:We determined the value of 18F-fluorodeoxyglucose positron-emission tomography/computed tomography (18FDG PET/CT) for the assessment of preoperative lymph node metastases in patients with esophageal cancer.Methods:We searched electronic database indexes for articles on PET/CT assessment of lymph node status. Information including true positives, false positives, false negatives, and true negatives was obtained. Based on these data, the pooled sensitivity, specificity, diagnostic odds ratio, and likelihood ratio were calculated using bivariate models and receiver operating characteristic curves (ROCs) were drawn.Results:Patients without neoadjuvant treatment had a pooled sensitivity and specificity (95% confidence interval [CI]) of 0.57 (0.45–0.69) and 0.91 (0.85–0.95), respectively. Patients who received neoadjuvant treatment had a pooled sensitivity and specificity of 0.53 (0.35–0.70) and 0.96 (0.86–0.99), respectively.Conclusions:The PET/CT has a high diagnostic specificity but its diagnostic sensitivity is low; thus, its diagnosis findings cannot accurately reflect the lymph node status.

The diagnostic accuracy of CT and MRI for the detection of lymph node metastases in gallbladder cancer: A systematic review and meta-analysis

BackgroundLymph node metastases (LNM) are an ominous prognostic factor in gallbladder cancer (GBC) and, when present, should preclude surgery. However, uncertainty remains regarding the optimal imaging modality for pre-operative detection of LNM and international guidelines vary in their recommendations. The purpose of this study was to systematically review the diagnostic accuracy of computed tomography (CT) versus magnetic resonance imaging (MRI) in the detection of LNM of GBC. MethodsA literature search of studies published until November 2017 concerning the diagnostic accuracy of CT or MRI regarding the detection of LNM in GBC was performed. Data extraction and risk of bias assessment was performed independently by two reviewers. The sensitivity of CT and MRI in the detection of LNM was reviewed. Additionally, estimated summary sensitivity, specificity and diagnostic accuracy of MRI were calculated in a patient based meta-analysis. ResultsNine studies including 292 patients were included for narrative synthesis and 5 studies including 158 patients were selected for meta-analysis. Sensitivity of CT ranged from 0.25 to 0.93. Estimated summary diagnostic accuracy parameters of MRI were as follows: sensitivity 0.75 (95% CI 0.6 – 0.85), specificity 0.83 (95% CI 0.74 – 0.90), LR + 4.52 (95% CI 2.55–6.48) and LR- 0.3 (95% CI 0.15 – 0.45). Small (<10 mm) LNM were most frequently undetected on pre-operative imaging. Due to a lack of data, no subgroup analysis comparing the diagnostic accuracy of CT versus MRI could be performed. ConclusionThe value of current imaging strategies for the pre-operative assessment of nodal status in GBC remains unclear, especially regarding the detection of small LNM. Additional research is warranted in order to establish uniformity in international guidelines, improve pre-operative nodal staging and to prevent futile surgery.

Application of Sentinel Lymph Node Technique to Transvaginal Natural Orifices Transluminal Endoscopic Surgery in Endometrial Cancer

Study ObjectiveThis report outlines our first experience of sentinel lymph node (SLN) mapping in the natural orifices transluminal endoscopic surgery (NOTES) technique, which is the combination of the least invasive surgical approach and the least invasive way of assessing lymph node status. DesignDescriptive study (Canadian Task Force classification III). SettingTertiary referral and educational center. PatientsFour patients with endometrial cancer clinical stage 1. InterventionsNOTES with SLN mapping using an indocyanine green–based near-infrared fluorescence imaging technique. Measurements and Main ResultsThe average operative time was 182.75 minutes (standard deviation, 34.5). Mean estimated blood loss was 67.5 mL (standard deviation, 39.4). All patients had surgical staging of International Federation of Gynecology and Obstetrics stage IA (pT1aN0). The overall detection rate and bilateral detection rate were 100% (4/4). All procedures were successfully completed without complication or conversion to conventional laparoscopy. ConclusionIn our preliminary experience, SLN mapping in NOTES surgery appears to be feasible and safe. It can be considered as an alternative method to reduce morbidity from radical lymphadenectomy and provide the benefits from the NOTES technique. However, studies in a larger population are necessary.

Assessing lymph node status in patients with kidney cancer.

Accurate detection of lymph node involvement on pre-operative imaging in patients diagnosed with renal cell carcinoma (RCC) is critical for determination of disease stage, one of the most significant prognostic factors in RCC. The presence of lymph node involvement in RCC doubles a patient’s risk of distant metastasis and significantly reduces their 5-year survival. Currently, lymph node involvement in patients with RCC is evaluated with numerous modalities, with rapid advancements occurring across these modalities. The purpose of this study was to evaluate the advantages and disadvantages of each modality and utilize sensitivities and specificities to determine the highest performing modalities for accurate lymph node involvement in renal cancer. A comprehensive computer-based literature search of full-length original research English language studies of human subjects with biopsy-proven RCC was performed to evaluate publications on the diagnostic performance of color Doppler sonography (CDS), magnetic resonance imaging (MRI), lymphotrophic nanoparticle enhanced MRI (LNMRI), multidetector-row computed tomography (MDCT), F-fluoro-2-deoxyglucose positron emission tomography (FDG-PET), and PET/CT for evaluation of lymph node status in kidney cancers in articles that were published prior to May 2018. Limited studies were available for evaluating CDS performance for determination of lymph node involvement in renal cancer. While CT is the most common modality for nodal staging, due to its availability and relatively low expense, it did not demonstrate the highest performance of the modalities examined for determination of lymph node status in patients with RCC. Of the modalities examined, MRI demonstrated the highest sensitivity (92–95.7%) for detection of lymph node involvement in RCC. Studies of lymph node involvement in RCC using both MRI and CT indicated that using the current diameter criteria (greater than 1 cm) for determination of positive lymph nodes should be re-evaluated as micro-metastases are frequently overlooked. Studies evaluating lymph node involvement with FDG-PET had the highest specificity (100%), indicating FDG-PET is the preferred modality for confirming lymph node involvement and extent of involvement. However, due to the low sensitivity of FDG-PET, clinicians should be skeptical of negative reports of lymph node involvement in RCC patients. Further studies examining determination of lymph node involvement in renal cancer across modalities are greatly needed, current literature suggests utilizing a combination of MRI and FDG-PET may offer the highest accuracy.

A New N Staging System for Colorectal Cancer in the Era of Extended Lymphadenectomy.

Complete mesocolic excision is becoming popular in colon cancer surgery in Western countries, and in the tumor-node-metastasis (TNM) classification of rectal cancer, a part of the lateral pelvic lymph nodes is classified as regional. However, the appropriateness of TNM staging according to the assessment of nodal status exclusively by extended lymphadenectomy remains unclear. Using a nationwide multicenter database in Japan, we retrospectively analyzed 6866 patients with stage III colorectal cancer (CRC) treated with extended (D3) dissection. First, the best cutoff values for the number of metastatic nodes were explored. Second, the utility of the metastatic status of the main lymph nodes (i.e., at the origin of the feeding artery) and the lateral pelvic lymph nodes ("jN3" category in the Japanese staging system) as N staging criteria was evaluated. The modified N staging system that had the best risk stratification power was determined according to the Akaike information criterion (AIC). Excellent performance was noted when the number of metastatic nodes was categorized by cutoff values of "3/4" and "6/7." Categorization of nodal metastasis was proven the most clinically efficacious when classified as modified-N1 (N1 and jN3-negative), modified-N2a (N2a and jN3-negative), and modified-N2b (N2b and/or jN3-positive; AIC, 22,810.8), rather than the classification based on the TNM (AIC, 22,849.2) or Japanese staging system (AIC, 22,811.1). We structured a modified N staging system according to the number and extent of lymph node metastases. The modified system may be used in stage III cases for precise risk stratification.

Histopathology report on colon cancer specimens; measuring surgical quality, an increasing stress for surgeons

Introduction. Improving the quality of surgical resections by evaluating surgical specimens is probably the most important feedback a surgeon can receive. Moreover, prognosis of patients with colon cancer is based on achieving appropriate resection margins and assessment of lymph node status. For these reasons we aim to provide a retrospective analysis on colon cancer specimens operated by a single surgical team.

The Application of Gene Expression Profiling in Predictions of Occult Lymph Node Metastasis in Colorectal Cancer Patients.

A key factor in determining the likely outcome for a patient with colorectal cancer is whether or not the tumour has metastasised to the lymph nodes—information which is also important in assessing any possibilities of lymph node resection so as to improve survival. In this review we perform a wide-range assessment of literature relating to recent developments in gene expression profiling (GEP) of the primary tumour, to determine their utility in assessing node status. A set of characteristic genes seems to be involved in the prediction of lymph node metastasis (LNM) in colorectal patients. Hence, GEP is applicable in personalised/individualised/tailored therapies and provides insights into developing novel therapeutic targets. Not only is GEP useful in prediction of LNM, but it also allows classification based on differences such as sample size, target gene expression, and examination method.

71P - Is sentinel lymph node biopsy necessary in breast cancer patients who were diagnosed as initially clinically node-negative before neoadjuvant chemotherapy?

Background: Neoadjuvant chemotherapy (NAC) is established for treatment of locally advanced disease and is being used increasingly for early-stage breast cancer. And sentinel lymph node biopsy (SLNB) for clinically node-negative (cN0) breast cancer patients after NAC is performed as a daily procedure. The purpose of this study was to identify the group that can omit SLNB in patients with cN0 breast cancer at diagnosis before NAC. Methods: A retrospective analysis was performed of 69 patients who were diagnosed as cN0 before NAC and underwent SLNB between 2005 and 2016. Before NAC, all patients underwent clinical assessment of lymph node status by ultrasound. We judged patients to be node-negative when ultrasound showed no suspicious nodes, and if axillar lymph nodes were swelling, fine needle aspiration cytology was performed. 62 patients received anthracycline-based chemotherapy and 6 patients received taxane alone. SLNB procedure and partial resection was done after NAC in all patients. Lymphatic mapping was performed with radioactive colloid and lymphatic blue dye. Results: Median follow-up time was 48 months. Success rate for the identification and removal of SLNs was 94.2% (65/69). The median number of SLNs removed was 2. In breast cancer patients who were diagnosed as cN0 before NAC, only 5 patients (7.2%) represented SLN involvement and were performed axillar dissection. And the SLNs were the only positive nodes in 3 patients. No SLN metastases were observed in 11 patients who were diagnosed as clinical complete response (cCR) by ultrasound and MRI. But 5 patients (9.3%) had positive SLN in the 54 patients who were diagnosed as clinical partial response or clinical stable disease (p = 0.38). Tumor size, hormone receptor status and HER2 status did not influence the positive rate of SLN metastases. No axillar lymph node recurrence was observed within follow-up period. Conclusions: Our results show that SLNB is necessary even in breast cancer patients who were diagnosed as cN0 before NAC. But SLNB may be omitted in breast cancer patients who were diagnosed as cN0 before NAC and as cCR by ultrasound and MRI after NAC. Legal entity responsible for the study: Jichi Medical University Funding: None Disclosure: All authors have declared no conflicts of interest.

PL 01.04 What is the Optimal Management of Screen-Detected Lung Cancers

PL 01.04 What is the Optimal Management of Screen-Detected Lung Cancers

Carcinoma escamocelular cutáneo del tronco y las extremidades: utilidad del ganglio centinela en su estadificación

Squamous Cell Carcinoma (SCC) is associated with a more aggressive biological behaviour in the presence of risk factors. High risk SCC may present with lymph node metastasis in 21% of patients, with the consequent reduction in overall survival. The physical examination lymph nodes can have a false-negative rate between 15% and 39%, thus requiring the need to find a new diagnostic tool that allows a more precise evaluation of lymph node involvement. Sentinel lymph node biopsy has been reported in case series of patients with head and neck SCC, and genital SCC, but there are few case reports about skin SCC of the trunk and extremities. The aim of this review is to describe the indications and feasibility of using sentinel lymph node biopsy to assess lymph node status in patients with skin SCC of trunk and limbs.

Intraoperative identification and analysis of lymph nodes at laparoscopic colorectal cancer surgery using fluorescence imaging combined with rapid OSNA pathological assessment

BackgroundStandard surgical practice for colorectal cancer involves resection of the primary lesion and all draining lymph nodes. Accurate intraoperative assessment of nodal status could allow stratified resectional extent. One-step nucleic acid (OSNA) can provide a rapid method of interrogating nodal tissue, whilst near-infrared (NIR) laparoscopy together with indocyanine green (ICG) can identify relevant nodal tissue intraoperatively.MethodsICG was administered around the tumour endoscopically prior to the operation. Fluorescent nodes identified by NIR were marked and submitted for whole-node OSNA analysis. Further fresh lymph nodes dissected from the standard resection specimen were examined and analysed by both conventional histology and OSNA. In addition, the status of the fluorescent nodes was compared to that of non-ICG nodes to assess their predictive value.ResultsSixteen patients were recruited with a total final lymph node count of 287. 78 fresh lymph nodes were identified on fresh dissection for both histological and OSNA assessment with an analytical concordance rate of 98.7% (77/78). OSNA sensitivity was 1 (0.81–1, 95% CI) and specificity 0.98 (0.91–1, 95% CI). Six patients had a total of nine nodes identified intraoperatively by ICG fluorescence. Of these nine nodes, one was positive for metastasis on OSNA. OSNA analysis of the ICG-labelled node matched the final histological nodal stage in 3/6 patients (two being N0 and one N1). The final pathological nodal stage of the other three was N1 or N2, while the ICG nodes were negative.ConclusionOSNA is highly concordant with standard histology, although only a minority of nodes identifiable by full pathological analysis were found for OSNA on fresh dissection. OSNA can be combined with NIR and ICG lymphatic mapping to provide intraoperative assessment of nodal tissue in patients with colorectal cancer.

Preoperative staging of nodal status in gastric cancer.

An accurate preoperative staging of nodal status is crucial in gastric cancer, because it has a great impact on prognosis and therapeutic decision-making. Different staging methods have been evaluated for gastric cancer in order to predict nodal involvement. So far, no technique could meet the necessary requirements, which include a high detection rate of infiltrated lymph nodes and a low frequency of false-positive results. This article summarizes different staging methods used to assess lymph node status in patients with gastric cancer, evaluates the evidence, and proposes to establish new methods.

Dynamic sentinel node biopsy for penile cancer: an initial experience in an Irish Hospital.

The presence of nodal metastases is the single most important prognostic factor in penile cancer. However, reliable assessment of nodal status in clinically node-negative (cN0) patients poses a challenge. Approximately 20% of these patients harbour occult nodal metastases. Currently available non-invasive radiological investigations are unreliable in excluding micrometastatic disease. Dynamic sentinel node biopsy (DSNB) is a minimally invasive procedure for assessing lymph node involvement. We report our initial experience with DSNB in assessing the status of regional lymph nodes in cN0 penile cancer patients. DSNB was performed in penile cancer patients with at least one cN0 groin. All patients undergoing DSNB at our institution were included. Lymphoscintigraphic images were obtained from all patients, after intradermal, peritumoral injection of a Technetium-99m nanocolloid. The sentinel nodes were defined as the nodes identified on lymphoscintigraphy, which were also radioactive intraoperatively using a gamma probe. In total, 18 groins from 11 patients underwent DSNB. Of these, 11 patients underwent bilateral DSNB and 4 had unilateral DSNB. The mean (range) age of patients at the time of presentation of their primary tumour was 63 (39-78) years. A mean of 1.2 nodes per groin was retrieved. One lymph node was positive in one patient, who subsequently underwent a bilateral inguinal lymph node dissection. Overall, the median (range) follow-up was 12.8 (2.7-31.3) months with no local or regional recurrences. Further cases and longer follow-up will define the accuracy of this technique in the Irish population.

SC02.03 Surgery for Ground Glass Opacity: Sublobar Resection?

SC02.03 Surgery for Ground Glass Opacity: Sublobar Resection?

THE CRITERIA FOR LYMPH NODE METASTATIC DISEASE IN UTERINE CERVIX CANCER PATIENTS BASED ON MRI FINDINGS

Introduction. The state of pelvic and retroperitoneal lymph nodes is an important prognostic factor for cervical cancer. Lymph node size is the most widely used CT and MR criteria for assessing lymph node status. Lymph nodes measuring more than 1cm in the short axis diameter are considered malignant. However this criterion (nodal size) is not foolproof because of a high percentage of diagnostic errors. The purpose of the study was to develop objective MRI criteria for assessing lymph node metastasis in patients with cervical cancer by measuring the short- and the long-axis diameters of lymph nodes, short axis/long axis ratio (configuration index) and to evaluate their diagnostic value. Materials and methods. The prospective study included 31 patients with histologically confirmed cervical cancer, who underwent radical surgery with standard lymph node dissection. Sixty removed lymph nodes were evaluated. MRI examinations were performed using a 1.5 T scanner in T2- weighted images (T2-WI), T1-WI and T2 weighted sequences with fatty tissue signal suppressing and diffusionweighted MRI. Results. Lymph nodes measuring ≥0.8 cm in the short axis diameter were considered suspicious for metastatic disease. The sensitivity and specificity with a cutoff of ≥0.8cm were 68 % (CI 48.3‑82.9) and 80 % (CI 63.8‑90.3), respectively; the positive and negative predictive values were 71 % and 78 %, respectively; and the accuracy was 75 % (CI 62.7‑84.3). The short axis/long axis ratio (configuration index) of &lt;1.47 indicated a likelihood of pathology in the lymph node. The absence of the hypointense signal from the fatty hilum of lymph nodes was considered as a predictor of lymph node metastasis. The analysis of this criterion showed 80 % sensitivity (CI 60.4‑91.6), 85.7 % specificity (60.4‑91.6), 80 % PPV, 85.1 % NPV and 83.3 % accuracy (CI 60.4‑91.6). Conclusion. Lymph node size of ≥0.8 cm in the short axis diameter and the short axis/long axis ratio (configuration index) of &lt;1.47 appeared to be significant MRI criteria in the assessment of lymph node metastasis. The additional use of MRI criterion such as the absence of the hypointense signal from the fatty hilum of the lymph node made it possible to improve diagnostic accuracy up to 92 % (CI 80.9–97.4).

Assessment of lymph node status in rectal cancer by imaging

Assessment of lymph node status in patients with rectal cancer is important before operation and neoadjuvant treatment because it has an influence on definition of operative plan, strategy of chemoradiotherapy and prognosis of the patients with rectal cancer. The imaging modalities that can be used to assess lymph node status include magnetic resonance imaging (MRI), endorectal ultrasonography (ERUS), multi-row detector computer tomography (MDCT), and PET-CT. The existing imaging criteria for metastatic lymph nodes in rectal cancer have not been reached. Combined with morphologic and functional imaging characteristics can be accurately predict metastatic lymph nodes. Based on the size of lymph node, the accuracy of rectal cancer N stage defined by imaging modality is poor. If the border and signal intensity of lymph nodes are used to predict the metastasis, the sensitivity and specificity can be significantly improved. However, the reproducibility needs an improvement because of limitation in imaging quality and difference in ability of imaging interpretation. In comparison, ultra small superparamagnetic iron oxide MRI (USPIO-MRI) has relatively higher reproducibility in definition of the metastatic lymph nodes while it is not permitted as an imaging tool used in clinical practice. In addition, USPIO-MRI has been used to evaluate the lymph node response to chemotherapy. As functional imaging tool, DW-MRI has high sensitivity in detection of lymph nodes, while the specificity is low. In contrast, PET-CT has lower sensitivity because of the limitation in imaging resolution, which can not find the small metastatic lymph nodes. ERUS and high resolution MRI have similar ability in distinguishing metastatic and benign nodes within mesorectum. While MRI and DW-MRI have greater diagnostic view than ERUS, thus they can effectively screen and diagnose the pelvic lateral lymph nodes and rectal upper arteriovenous lymph nodes. MDCT is the better choice in screening chest and abdominal metastatic lymph nodes compared with other modalities. The proper selection of imaging modality or combination of multi-modalities is necessary for special purpose in clinical practice.

Detailed Lymph Node Sectioning of Papillary Thyroid Carcinoma Specimen Increases the Number of pN1a Patients.

Papillary thyroid carcinoma (PTC) is a common endocrine malignancy, frequently presenting with lymph node metastasis at the time of diagnosis. Lymph node staging (N) partly determines treatment, follow-up, and prognosis. Since 2011, our institution has employed a more comprehensive histopathological work-up of lymph nodes in patients with PTC. We sought to retrospectively determine the value of serial lymph node level sectioning in PTCs with negative preoperative lymph node status (pN0) as a method to increase the sensitivity of detecting metastatic disease. We included all patients that underwent thyroidectomy and central neck dissection and subsequent comprehensive lymph node level sectioning due to PTC with an initial pN0 status between the years 2011 and 2015 at our institution. Sixty-seven cases of PTC with a median of 10 metastatic free lymph nodes identified per case were included. After serial lymph node sectioning of the central compartment, 11 cases (16%) revealed lymph node metastasis, six of which (55%) presented with a small primary tumor (<20mm, T1). Of all T1 tumors with initial pN0 status, 18% (T1a) and 9% (T1b) reached a pN1 stage after comprehensive lymph node sectioning. Cases with altered lymph node status had a median of 15 identified lymph nodes as compared to ten in cases that remained negative. We conclude that comprehensive lymph node sectioning increased the sensitivity of detecting metastases in PTC and altered the pathological TNM staging (pTNM) for a significant number of patients. Although of limited prognostic significance, the method should be considered as an adjunct tool when assessing lymph node status of PTC as a part of the routine histological work-up to ensure an accurate cancer staging.

Microphthalmia transcription factor in malignant melanoma predicts occult sentinel lymph node metastases and survival.

Microphthalmia transcription factor (Mitf) is involved in melanocyte development and differentiation. We previously reported that Mitf expression, as detected by immunohistochemical analysis, is an independent prognostic marker in patients with intermediate-thickness melanoma. However, the clinical significance of Mitf expression in melanoma is not well delineated. In this prospective study, we attempted to demonstrate the correlation between Mitf expression in primary melanoma and the sentinel lymph node status and prognosis. We prospectively examined primary cutaneous melanomas from 94 patients undergoing nodal staging by sentinel lymph node biopsy. We quantified the percentage of tumor cells whose nuclei stained with the Mitf antibody visually. Survival curves were generated using the Kaplan-Meier method. The correlation between Mitf expression and nodal status was evaluated using the Mann-Whitney U-test. Here we demonstrate that Mitf expression is directly correlated with both disease-free survival (DFS) and overall survival (OS) over a median follow-up of 28.5 months. The mean DFS and OS in the eight patients whose melanomas did not stain positive for Mitf were 15.75±3.36 months (median, 12 months) and 38.17±5.18 months (median, 29 months), respectively. These results are significantly lower than those for patients who showed evidence of Mitf expression, in whom the mean DFS and OS were 66.1±4.03 months (median, not reached, P=0.0001) and 66.75±38.17 months (median, not reached, P=0.0001), respectively. The mean DFS and OS with greater than 25% (67 patients) of the melanoma cells staining positive for Mitf expression were 78.37±2.78 and 82.38±1.6 months, respectively, compared with 26.37±3.2 months (P=0.0001) and 44.53±4.5 months (P=0.0001), respectively, with up to 25% (27 patients) of cells stained positive for Mitf expression. In addition, there was a significant relationship between Mitf expression and nodal status, as evaluated by sentinel node biopsy. For example, none of the melanomas with greater than 50% Mitf expression had a positive sentinel node biopsy. Our study shows that expression of the molecular marker Mitf in primary cutaneous melanomas is a useful tool in assessing lymph node status. Mitf immunostaining in the primary tumor serves as a reliable predictor of occult lymph node metastases, as well as a favorable prognosticator of DFS and OS in melanoma patients.

Optimal assessment of lymph node status in gallbladder cancer

BackgroundLymph node (LN) metastasis is an important prognostic factor in gallbladder cancer (GBCA). LN status has been adopted as a critical element of staging systems. However, the influence of total lymph node count (TLNC) remains unclear. We determined the optimal minimum TLNC and compared the prognostic significance of LN status indices in GBCA. MethodsWe retrospectively reviewed medical records of 128 patients with T2 or greater GBCA who underwent LN dissection. We analyzed overall survival (OS) and relevance of the number of metastatic LNs, ratio of metastatic LNs to retrieved LNs (LNR), and TLNC in predicting OS. ResultsThe median OS durations were 120, 35, and 18 months in T2, T3, and T4 GBCA. Five-year OS rates were 73%, 43%, and 0% in T2, T3, and T4 GBCA. LN status did not significantly impact OS in T2 or T4 GBCA. However, all LN indices were significantly correlated with OS in T3 GBCA. Furthermore, multivariate analysis revealed that a metastatic LN count of more than four and a TLNC of more than eight were independent prognostic factors of OS in T3 GBCA. ConclusionsTLNC and the number of positive LNs may be more important prognostic factors than LNR in T3 GBCA. Additionally, accurate staging may not be achieved in cases of T3 GBCA if the total number of retrieved LNs is less than eight. Thus, to ensure proper staging, we recommend that surgeons harvest more than eight LNs in patients with T3 GBCA.

A modified sentinel node and occult lesion localization (SNOLL) technique in non-palpable breast cancer: a pilot study

BackgroundThe spread of mammographic screening programs has allowed an increasing amount of early breast cancer diagnosis. A modern approach to non-palpable breast lesions requires an accurate intraoperative localization, in order to achieve a complete surgical resection. In addiction, the assessment of lymph node status is mandatory as it represents a major prognostic factor in these patients. The aim of this study is to evaluate the reliability of a modified technical approach using a single nanocolloidal radiotracer to localize both sentinel node and breast occult lesion.MethodsTwenty-five patients with a single non-palpable breast lesions and clinically negative axilla were enrolled. In the same day of surgery, patients underwent intratumoral and peritumoral administration of 99mTc-labeled nanocolloid tracer under sonographic guidance. A lymphoscintigraphy was performed to localize the sentinel lymph node and its cutaneous projection was marked on the skin in order to guide the surgeon to an optimal incision. During surgery an hand-held gamma-detection probe was used to select the best surgical access route and to guide localization of both occult breast lesion and sentinel lymph node. After specimen excision, the surgical field was checked with the gamma-probe to verify the absence of residual sources of significant radioactivity, thereby ensuring a radical treatment in a single surgical session and minimizing normal tissue excision.ResultsBoth targeted breast lesion and sentinel lymph node were localized and removed at the first attempt in every patients and histopathological diagnosis of malignancy was confirmed in 25/26 samples. Non-palpable lesions were included within the surgical margins in all patients and in all samples surgical margins were free from neoplastic infiltration thus avoiding any further reintervention. Only two patients showed metastatic involvement of sentinel lymph node.ConclusionsThe modified sentinel node and occult lesion localization (SNOLL) technique performed with a single injection of nanocolloidal radiotracer has shown an excellent intraoperative identification rate of both non-palpable lesion and sentinel lymph node. This procedure offers, as opposed to standard techniques, an accurate, simple and reliable approach to the management of non-palpable breast cancer.