Assessment Of Node Status Research Articles

Assessment of nodal status for pancreatic cancer

Assessment of nodal status for pancreatic cancer

Tailoring systematic lymphadenectomy in high-risk clinical early stage endometrial cancer: The role of 18F-FDG PET/CT

ObjectivesTo evaluate the role of FDG PET/CT in the preoperative N-staging of high-risk clinical stage I endometrial cancer. The correlation between the metabolic characteristics of endometrial tumor uptake as predictors of a) lymph-node (LN) metastases and b) recurrence, was also evaluated. MethodsSeventy-six high-risk (G2 with deep myometrial invasion, G3, serous/clear-cell carcinoma) clinical stage I endometrial cancer patients underwent preoperative PET/CT scan followed by total hysterectomy, bilateral salpingo-oophorectomy and lymphadenectomy. PET/CT images were analyzed and correlated to histological findings. Maximal and mean standardized uptake value (SUVmax, SUVmean), metabolic tumor volume (MTV), total lesion glycolysis (TLG, defined as the product between SUVmean and MTV) of endometrial lesions were calculated and correlated to: a) presence of LN metastases, b) recurrences. ResultsPET/CT resulted positive at LNs in 12/76 patients: 11/12 truly positive, 1/12 falsely positive. Conversely PET/CT was negative in 64/76 patients: 61/64 truly negative and 3/64 falsely negative. On pt-based analysis, sensitivity, specificity, accuracy, positive and negative predictive value of PET/CT in detecting LN metastases were 78.6%, 98.4%, 94.7%, 91.7%, 95.3%, respectively. A significant association was found between the presence of LN metastases and SUVmax (p=0.038), MTV (p=0.007), TLG (p=0.003) of the primary tumor. No correlations were found between the metabolic parameters and relapse (median follow-up 25.4months). ConclusionsIn high-risk clinical stage I endometrial cancer FDG PET/CT demonstrated moderate sensitivity, high specificity and accuracy for the nodal status assessment. SUVmax, MTV and TLG of the primary tumor are significantly correlated to LN metastases, while none of these parameters is predictor of recurrence.

Assessment of Sentinel Node Concept in Esophageal Cancer Based on Lymph Node Micrometastasis

The clinical significance of lymph node micrometastasis remains unclear in patients with esophageal cancer. Therefore, accurate assessment of lymph node status including micrometastasis is important when performing sentinel node (SN) navigation surgery. The purpose of the present study was to investigate the adequacy of SN concept based on lymph node micrometastasis determined by immunohistochemistry (IHC) and reverse transcription-polymerase chain reaction (RT-PCR) in patients with esophageal cancer. A total of 57 patients with esophageal cancer who were preoperatively diagnosed as having T1-T2 (cT1-T2) and N0 (cN0) were enrolled. They underwent standard esophagectomy with lymph node dissection. One day before surgery, a total of 3 mCi of 99mTechnetium-tin colloid was endoscopically injected into the submucosa around the tumor. During the operation, radioisotope uptake in the lymph nodes was measured using Navigator GPS. All dissected lymph nodes were investigated by RT-PCR using the double marker of CEA and SCC, hematoxylin-eosin (HE) staining, and IHC. Node-positive incidence identified by HE and IHC was 12.3% (7/57) and 19.3% (11/57), respectively. RT-PCR demonstrated micrometastasis in four of 46 patients without nodal metastasis determined by HE staining and IHC. No non-SN metastases were found in 42 patients without micrometastasis identified by IHC and RT-PCR of SN. Accuracy and false negative rates were 100% (57/57) and 0% (0/42), respectively. SN concept might be acceptable in patients with cT1-T2 and cN0 esophageal cancer, even in the presence of micrometastasis identified by IHC and RT-PCR.

The Prognostic Value of Ratio-Based Lymph Node Staging in Resected Non–Small-Cell Lung Cancer

Assessment of lymph node status is a critical issue in the surgical management of non-small-cell lung cancer (NSCLC). We sought to determine the prognostic value of metastatic lymph node ratio (LNR) in patients with radical surgery for NSCLC. We abstracted data from 480 consecutive patients undergoing radical surgery for NSCLC between 2006 and 2008 in our institution. Kaplan-Meier estimated the survival function using the number of metastatic lymph node (MLN) and LNR as categorized variables. The prognostic value of age, sex, smoking status, location of tumor, histology, pathology T stage, pathology N stage, surgical procedure, chemotherapy, MLN, and LNR were assessed using a multivariate Cox proportional hazards model for overall survival (OS) and disease-free survival (DFS). The median numbers of examined lymph nodes and MLNs were 15 and 5, respectively. Optimal cutpoints of the LNR were calculated as 0, 0 to 0.35, and greater than 0.35. Patients with higher LNR were associated with worse OS and DFS in the whole series, whereas there was no significant difference in the OS and DFS of those patients classified as pathology N2. A multivariate analysis showed that the LNR staging, smoking status, and chemotherapy were revealed to be independent prognostic factors. LNR is an independent predictor of survival in patients with NSCLC undergoing radical resection; the prognostic significance is more valuable in patients classified as pathology N1.

The quandary of N0 disease after neoadjuvant therapy for rectal cancer.

Improved outcomes after curative resection for rectal cancer have been driven in part by total mesorectal excision (TME) and the introduction of neoadjuvant chemoradiation. An equally important consideration in optimizing prognosis is accurate pathological staging, which is highly dependent on accurate assessment of lymph node status after TME. The use of neoadjuvant treatment impacts lymph node harvests and affects pathologic staging. Based on the anatomy of tumor cell spread along lymphatic pathways, Halsted was the first to suggest that en-bloc excision would provide the best chance of local and distant cancer control (1). This provides the basis of TME technique, as sharp dissection along the mesorectal fascia yields the entire mesorectum, which is the lymph nodebearing mesentery of the rectum. Secondarily, it removes any small regional metastases. Removing lymph nodes with the surgical specimen removes cancer cells, but more importantly provides information about staging, prognosis, and guides treatment decisions. For example, the United States Surveillance, Epidemiology and End Results (SEER) cancer registry database shows that for each T stage, 5-year overall and disease-free survival decreases with increasing LN involvement. The presence of lymph node metastases determines the patients most likely to benefit from adjuvant therapy (2).

Factors related to sentinel node identification in cervical cancer

Cervical cancer remains a common malignancy in women. Lymph node is one of the significant important prognostic factors. Until now, there is no reliable investigative study that can evaluate nodal status the same as the International Federation of Gynecology and Obstetrics (FIGO) clinical staging system. Radical hysterectomy and pelvic lymphadenectomy is still one option in the standard treatment of patients with early-stage cervical cancer that can reveal metastatic lymph node but which can also produce treatment-related morbidities and complications. Sentinel lymph node identification has become a valuable technique for nodal status assessment. If lymph node metastasis was identified early, then unnecessary invasive surgical operations and complications may be avoided.

Dynamic sentinel node biopsy in penile cancer: initial experiences at a Swedish referral centre

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? According to the current European Association of Urology Guidelines, dynamic sentinel node biopsy is the recommended approach to assess lymph node status in men with cN0 intermediate and high risk penile cancer. Nevertheless, most encouraging results derive from a limited number of studies. The present study shows a false-negative rate of 15%, comparable with or better than several previous studies. Nevertheless, the aim should be a false-negative rate of no more than 5%. We conclude that increased overall experience and the use of the complete modern dynamic sentinel node biopsy protocol are paramount to improve results. • To evaluate the false-negative rate and complication rate of dynamic sentinel node biopsy (DSNB) in penile cancer. • In this retrospective study, 58 unilaterally or bilaterally clinically lymph node negative (cN0) patients with penile cancer (57 squamous cell carcinomas and one malignant melanoma), scheduled for DSNB at the Örebro University Hospital, Sweden, between 1999 and 2011, were analysed. • Preoperative ultrasonography and fine-needle aspiration cytology of suspicious nodes were not introduced until 2008. • Patients were assessed by lymphoscintigraphy using (99m) technetium nanocolloid on the day before surgery and the dissection of sentinel nodes was aided by the lymphoscintigraphic images and intraoperative detection of radiotracer and patent blue dye. • The false-negative rate and complication rate were calculated per groin. • Of the 58 patients, 32 (55%) underwent preoperative ultrasonography. • Two patients had positive fine-needle aspiration cytology and discontinued further DSNB protocol. Of the remaining 56 patients, all but one were bilaterally cN0 and hence 111 cN0 groins were assessed by lymphoscintigraphy. • In the 55 bilaterally cN0 patients, lymphoscintigraphy visualized a bilateral sentinel node in 34 (62%). • At surgery, all excised sentinel nodes were radioactive while 43% were additionally blue. In total, at least one sentinel node was harvested in 96 (86%) of the DSNB staged groins. • A positive sentinel node was found in 11 groins (bilaterally in three patients). During a median follow-up of 21 months, two false-negative cases emerged, producing a false-negative rate of 15%. Both false-negative cases occurred during the first half of the study. The complication rate was 10%. The majority of complications were minor and transient. • DSNB is a minimally invasive staging tool in men with cN0 penile cancer, enabling early detection of metastatic disease and thus optimal care. • Our false-negative rate of 15% is comparable or even favourable in comparison with several previous studies, but far from the 5% or less that we aim for. The complication rate found is somewhat higher than previously reported. • With increased overall experience and the continued use of the complete DSNB protocol, we believe our results will improve and the complication rate will decrease.

A Prospective Single-Center Study of Sentinel Lymph Node Detection in Cervical Carcinoma: Is There a Place in Clinical Practice?

To establish the accuracy of sentinel lymph node (SLN) detection in early cervical cancer. Sentinel lymph node detection was performed prospectively over a 6-year period in 86 women undergoing surgery for cervical carcinoma by the combined method (Tc-99m and methylene blue dye). Further ultrastaging was performed on a subgroup of 26 patients who had benign SLNs on initial routine histological examination. The SLN was detected in 84 (97.7%) of 86 women by the combined method. Blue dye uptake was not seen in 8 women (90.7%). Sentinel lymph nodes were detected bilaterally in 63 women (73.3%), and the external iliac region was the most common anatomic location (48.8%). The median SLN count was 3 nodes (range, 1-7). Of the 84 women with sentinel node detection, 65 also underwent bilateral pelvic lymph node dissection, and in none of these cases was a benign SLN associated with a malignant non-SLN (100% negative predictive value). The median non-SLN count for all patients was 19 nodes (range, 8-35). Eighteen patients underwent removal of the SLN without bilateral pelvic lymph node dissection. Nine women (10.5%) had positive lymph nodes on final histology. One patient had bulky pelvic nodes on preoperative imaging and underwent removal of the negative bulky malignant lymph nodes and a benign SLN on the contralateral side. This latter case confirms the unreliability of the SLN method with bulky nodes. The remaining 8 patients had positive SLNs with negative nonsentinel lymph nodes. Fifty-nine SLNs from 26 patients, which were benign on initial routine histology, underwent ultrastaging, but no further disease was identified. Four patients (5%) relapsed after a median follow-up of 28 months (range, 8-80 months). Sentinel lymph node detection is an accurate and safe method in the assessment of nodal status in early cervical carcinoma.

Assessment of lymph node status in gallbladder cancer: location, number, or ratio of positive nodes

BackgroundAssessment of lymph node status is a critical issue in the surgical management of gallbladder cancer. The aim of this study was to compare the anatomical location of positive nodes, number of positive nodes, and lymph node ratio (LNR) as prognostic predictors in gallbladder cancer.MethodsWe conducted a retrospective analysis of 135 patients with gallbladder cancer who underwent a radical resection with regional lymphadenectomy. A total of 2,245 regional lymph nodes were retrieved (median, 14 per patient). The location of positive nodes was classified according to the AJCC staging manual (7th edition). ‘Optimal’ cutoff values were determined for the number of positive nodes and LNR based on maximal χ2 scores calculated with the Cox proportional hazards regression model.ResultsLymph node metastasis was found histologically in 59 (44%) patients. The ‘optimal’ cutoff values for the number of positive nodes and LNR were determined to be three nodes and 10%, respectively. Univariate analysis identified location of positive nodes (pN0, pN1, pN2; P < 0.001), number of positive nodes (0, 1 to 3, ≥4; P < 0.001), and LNR (0%, 0 to 10%, >10%; P < 0.001) as significant prognostic factors. Multivariate analysis identified number of positive nodes as an independent prognostic factor ( P = 0.004); however, location of positive nodes and LNR failed to remain as an independent variable.ConclusionsThe number of positive lymph nodes better predicts patient outcome after resection than either the location of positive lymph nodes or LNR in gallbladder cancer. Dividing the number of positive lymph nodes into three categories (0, 1 to 3, or ≥4) is valid for stratifying patients based on the prognosis after resection.

Is axillary dissection unnecessary in patients with a positive sentinel lymph node?

Recently, the American College of Surgeons Oncology Group (ACOSOG) reported the results of the Z-0011 trial [1, 2]. The data indicated that axillary lymph node dissection (ALND) could be safely omitted in selected patients with a positive sentinel lymph node (SLN) who undergo breast conservation therapy (BCT) with wholebreast irradiation and appropriate systemic therapy. However, questions have been raised regarding the Z-0011 results and whether we should change clinical practice [3]. The historic role of ALND in breast cancer includes (a) assessment of nodal status, (b) prevention of axillary recurrence, and (c) the possibility of survival benefit from the removal of positive axillary nodes [4]. In 1985, however, 10-year outcomes from the National Surgical Adjuvant Breast and Bowel Project (NSABP) B-04 study were published and showed that clinically node-negative patients showed no survival advantage with immediate ALND compared to observation and delayed ALND if clinical nodal disease developed [5]. Twenty-five followup study also confirmed that ALND does not reduce the incidence of systemic recurrence or improve survival [6]. Nevertheless, patients with an untreated axilla had a significantly greater risk of axillary recurrence compared to those who either received axillary radiotherapy or underwent ALND. Therefore, this landmark study did not lead to the abandonment of ALND, although it was extremely influential in our thinking about breast cancer biology [3]. In practice, ALND had remained in use as a reliable method of assessing nodal status and preventing axillary recurrence [4]. In the last decade of the twentieth century, SLN biopsy appeared to allow the reliable staging of patients as nodepositive or node-negative. Fewer lymph nodes are removed with SLN biopsy, allowing more focused histopathological analysis, including multiple sectioning with hematoxylin– eosin (H&E) staining supplemented with immunohistochemical staining. More intense examination has led to increased identification of micrometastases in the lymph nodes [7]. As SLN biopsy is more accurate than ALND, it has replaced the latter method for assessing axillary nodal status in clinically node-negative patients. Therefore, the role of ALND has been limited to the prevention of axillary recurrence. ALND is highly effective in preventing axillary recurrence irrespective of the clinical nodal status [4]. However, the Z-0011 study demonstrated a remarkably low rate of axillary recurrence in SLN-positive patients who did not undergo ALND. Axillary recurrence rates were similar between each arm with 4 (0.9 %) patients in the SLN biopsy group compared with 2 (0.5 %) in the ALND group. SLN biopsy would be a preferable procedure if it could achieve locoregional control as effective as that of ALND without adversely affecting survival [2]. Nevertheless, there are limitations to the Z-0011 trial. As many surgeons were unwilling to randomize patients because they considered it unethical not to perform ALND, the trial was closed early without accruing sufficient numbers of patients, and may lack statistical power to show whether ALND is always necessary if the SLN is positive. In this study, moreover, the eligibility requirements M. Noguchi (&) Department of Breast and Endocrine Surgery, Kanazawa Medical University Hospital, Uchinada-daigaku 1-1, Kahoku, Ishikawa 920-0293, Japan e-mail: nogumasa@kanazawa-med.ac.jp

Morphology-based criteria for ultrasonic assessment of axillary lymph node status in primary breast cancer

To evaluate the morphology-based criteria for the ultrasonic assessment of axillary lymph node in primary breast cancer. A total of 2256 T0-2N0 patients underwent axillary ultrasound preoperatively. Lymph nodes were classified as normal if no node was found or cortex thickness was even and < 3 mm; abnormal, (1) if cortex thickness was even but ≥ 3 mm or (2) focally thickened cortex ≥ 3 mm or (3) fatty hilum was absent. The patients in the abnormal group underwent ultrasound guided fine-needle aspiration (US-FNA). Except for positive lymph nodes, all the others underwent sentinel lymph node biopsy (SLNB). In this series, 692 (30.7%) were pathologically confirmed positive LNs. Among them, 214 (9.5%) were identified by US-FNA. And 361 were abnormal according to the above mentioned criteria. The proportions were 11.6%, 54.8% and 33.5% in Group 1-3 respectively. The sensitivity, specificity, positive and negative predictive values of these criteria alone were 35.8%, 92.8%, 68.7% and 76.6% respectively. The present morphology-based criteria for the ultrasonic assessment of lymph node status is both effective and practical in primary breast cancer.

Surgical sentinel lymph node biopsy in early breast cancer. Could it be avoided by performing a preoperative staging procedure? A pilot study

SummaryBackgroundThe aim of this pilot trial was to study the feasibility of sentinel node percutaneous preoperative gamma probe-guided biopsy as a valid preoperative method of assessment of nodal status compared to surgical sentinel lymph node biopsy.Material/MethodsThis prospective study enrolled 10 consecutive patients without evidence of axillary lymph node metastases at preoperative imaging. All patients underwent sentinel node occult lesion localization (SNOLL) using radiotracer intradermic injection that detected a “hot spot” corresponding to the sentinel node in all cases. Gamma probe over the skin detection with subsequent ultrasonographically guided needle biopsy of the sentinel node were performed. The percutaneous needle core histopathological diagnosis was compared to the results of the surgical biopsy.ResultsPreoperative sentinel node identification was successful in all patients.ConclusionsThe combination of preoperative gamma probe sentinel node detection and ultrasound-guided biopsy could represent a valid alternative to intraoperative sentinel node biopsy in clinically and ultrasonographically negative axillary nodes, resulting in shorter duration of surgery and lower intraoperative risks.

P2-08-04: Computer-Derived Breast MRI Features Have Complementary Value for Preoperative Selection of Systemic Drug Therapy in Node-Negative Stage-I/II Breast Cancer Patients.

Abstract Background: Typical guidelines for adjuvant systemic drug therapy require assessment of lymph node status, tumor extent and grade. Increasing interest exists, however, for preoperative therapy (neoadjuvant drug therapy and preoperative partial breast irradiation). Here, representative excision specimens are not available to assess eligibility for systemic therapy. Moreover, tumor grade may be difficult to assess in core biopsies resulting in underestimation rates up to 40%. Contrast-enhanced MRI has been shown to correlate with underlying tumor biology, but it is unknown whether it can complement eligibility criteria for systemic drug therapy. Purpose: To assess the complementary value of MRI to determine eligibility for systemic drug therapy prior to breast-conserving surgery in node-negative stage-I/II breast cancer patients. Materials and methods: Patients with preoperative node-negative invasive breast cancer ≥1.0 cm and eligible for breast-conserving therapy after conventional breast imaging and MRI were consecutively included between February 2000 and March 2007. Informed consent was obtained from all patients. Eligibility to systemic therapy was determined on the basis of national guidelines using age, size, tumor grade, as well as axillary lymph node status at final pathology. Twenty temporal and morphological features of contrast uptake at MRI were automatically analyzed by a previously build CAD workstation1,2. Preoperative lymph node status was derived from ultrasound-guided fine-needle aspiration. Multivariate logistic regression and receiver-operating characteristics (ROC) analysis was used to assess associations between preoperative features (age, ER status, computer-extracted MRI features) and eligibility to systemic therapy based on post-operative features (tumor size, grade, lymph node status). Results: Three-hundred-and-eighty-six patients were included. The mean patient age was 58 years. The mean tumor size at pathology was 1.6 cm. Tumor grade was I, II and III in 128 (33%), 163 (42%), and 94 (24%) of tumors, respectively. Post-operative lymph node status was positive in 115/386 (30%) patients. In total, 262/386 (68%) patients were eligible for systemic drug therapy based on post-operative pathology. Multivariate analysis of preoperatively available features yielded ER status, and principle components 1, 6, 8 and 15 of the computer-extracted features. These components describe tumor volume and shape, heterogeneity of contrast uptake, late-enhancement kinetics, and probability of malignancy. The resulting model correlated with the Adjuvant! program (R=0.55, p&amp;lt;0.0001). The area under the ROC curve was 0.82 (p&amp;lt;0.0001). Without the model, agreement between preoperative and postoperative assessment of eligibility to drug therapy was 232/386 (60%) at 15/124 (12%) overestimation rate. With the MRI model, it increased to 258/386 (67%) (p=0.004) without increasing overestimation rate. Conclusion: Computer-analysis of contrast-enhanced MRI has potential to complement preoperative selection of stage I/II node-negative breast-cancer patients for systemic drug therapy. Ref: 1. Gilhuijs et al., Radiology 2002; 225: 907–916 2. Deurloo et al., Radiology 2005; 234: 693–701 Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P2-08-04.

Sentinel lymph node biopsy for breast cancer patients using fluorescence navigation with indocyanine green.

BackgroundThere are various methods for detecting sentinel lymph nodes in breast cancer. Sentinel lymph node biopsy (SLNB) using a vital dye is a convenient and safe, intraoperatively preparative method to assess lymph node status. However, the disadvantage of the dye method is that the success rate of sentinel lymph node detection depend on the surgeon's skills and preoperative mapping of the sentinel lymph node is not feasible. Currently, a vital dye, radioisotope, or a combination of both is used to detect sentinel nodes. Many surgeons have reported successful results using either method. In this study we have analyzed breast lymphatic drainage pathways using indocyanine green (ICG) fluorescence imaging.MethodsWe examined the lymphatic courses, or lymphatic vessels, in the breast using ICG fluorescence imaging, and applied this method to SLNB in patients who underwent their first operative treatment for breast cancer between May 2006 and April 2008. Fluorescence images were obtained using a charge coupled device camera with a cut filter used as a detector, and light emitting diodes at 760 nm as a light source. When ICG was injected into the subareola and periareola, subcutaneous lymphatic vessels from the areola to the axilla became visible by fluorescence within a few minutes. The sentinel lymph node was then dissected with the help of fluorescence imaging navigation.ResultsThe detection rate of sentinel nodes was 100%. 0 to 4 states of lymphatic drainage pathways from the areola were observed. The number of sentinel nodes was 3.41 on average.ConclusionsThis method using indocyanine green (ICG) fluorescence imaging may possibly improve the detection rate of sentinel lymph nodes with high sensitivity and compensates for the deficiencies of other methods. The ICG fluorescence imaging technique enables observation of breast lymph vessels running in multiple directions and easily and accurately identification of sentinel lymph nodes. Thus, this technique can be considered useful.

Positron Emission Tomography For Locally Advanced Cervical Cancer: A Survey Assessing Canadian Practice Patterns And Access

Positron emission tomography (PET) imaging has emerged as a valuable tool in the management of locally advanced cervical cancer (LACC), both in assessment of lymph node status and determination of response to chemoradiotherapy (CRT). The aim of this study was to survey Canadian radiation oncologists (ROs) to determine access to PET imaging for LACC patients and assess current practice patterns.

Sentinel lymph node biopsy in endometrial cancer: Meta-analysis of 26 studies

Objective The validity of the sentinel lymph node (SLN) procedure for the assessment of nodal status in patients with endometrial cancer is unclear. We aimed to assess the diagnostic performance of this procedure. Methods We searched the PubMed and Embase databases for studies published before June 1, 2011. Eligible studies had a sample size of at least 10 patients, and reported the detection rate and/or sensitivity of the SLN biopsy. Results We identified 26 eligible studies, which included 1101 SLN procedures. The overall weighted-mean number of harvested SLNs was 2.6. The detection rate and the sensitivity were 78% (95% confidence interval [CI] = 73%–84%) and 93% (95% CI = 87%–100%), respectively. Significant between-study heterogeneity was observed in the analysis of the detection rate ( I-squared statistic, 80%). The use of pericervical injection was correlated with the increase of the detection rate ( P = 0.031). The hysteroscopic injection technique was associated with the decrease of the detection rate ( P = 0.045) and the subserosal injection technique was associated with the decrease of the sensitivity ( P = 0.049), if they were not combined with other injection techniques. For the detection rate, significant small-study effects were noted ( P < 0.001). Conclusions Although SLN biopsy has shown good diagnostic performance in endometrial cancer, such performance should be interpreted with caution because of significant small study effects. Current evidence is not yet sufficient to establish the true performance of SLN biopsy in endometrial cancer.

Sentinel-lymph-node procedure in colon and rectal cancer: a systematic review and meta-analysis

No consensus exists on the validity of the sentinel-lymph-node procedure for assessment of nodal status in patients with colorectal cancer. We aimed to assess the diagnostic performance of this procedure. We searched Embase and PubMed databases for studies published before March 20, 2010. Eligible studies had a prospective design, a sample size of at least 20 patients, and reported the rate of sentinel-lymph-node positivity. Individual patient data were requested for localisation and T-stage stratification. A subset of reports with high methodological quality was selected and analysed. We identified 52 eligible studies, which included 3767 sentinel-lymph-node procedures (2961 [78·6%] colon and 806 [21·4%] rectal carcinomas). Most tumours 2339 (62·1%) were stage T3 or T4. 1887 (50·1%) of patients were male, 1880 (49·9%) female. Mean overall weighted-detection rate was 0·94 (95% CI 0·92-0·95), at a pooled sensitivity of 0·76 (0·72-0·80) with limited heterogeneity (χ(2)=286·08, degrees of freedom=51; p=0·003). A mean weighted upstaging of 0·15 (95% CI 0·12-0·19) was noted. Individual patient data were available from 19 studies that included 1168 patients. Analysis of these data showed no significant difference in sensitivity between colon (0·86 [95% CI 0·83-0·90]) and rectal cancer (0·82 [0·77-0·88]; p=0·23). Also, there was no dependency of sensitivity on T stage for both colon (pT1: 0·79 [95% CI 0·73-0·84], pT2: 0·76 [0·62-0·90], pT3: 0·73 [0·59-0·87], pT4: 0·73 [0·53-0·93]) and rectal cancer (T1 or T2: 0·81 [0·52-0·94] vs T3 or T4: 0·80 [0·51-0·93]). The subgroup of eight studies with high methodological quality showed a mean detection rate of 0·96 (95% CI 0·90-0·99) for colonic tumours and 0·95 (0·75-0·99) for rectal tumours, and a mean sensitivity of 0·90 (95% CI 0·86-0·93) for colonic tumours and 0·82 (0·60-0·93) for rectal tumours. The sentinel-lymph-node procedure shows a low sensitivity, regardless of T stage, localisation, or pathological technique. For every patient diagnosed with colon or rectal cancer without clinical evidence of lymph-node involvement or metastatic disease, this procedure in addition to conventional resection should be considered, since the prognostic information provided by this technique could be clinically significant. Cancer Center Amsterdam Foundation, Amsterdam, Netherlands.

A Prospective Study of Sentinel Lymph Node Detection in Vulval Carcinoma: Is It Time for a Change in Clinical Practice?

To determine the accuracy of sentinel lymph node (SLN) detection in vulval carcinoma and to report the reliability and safety of this procedure. For a period of 6 years, we recruited women undergoing surgery for vulval carcinoma. All women had a preoperative biopsy confirming the depth of invasion greater than 1 mm. Sentinel lymph node detection was performed using the combined method (Tc-99m and methylene-blue dye). The standard management included complete inguinofemoral lymphadenectomy. When inguinofemoral lymph nodes were found grossly to be enlarged, these nodes were debulked, and the women subsequently treated with radiotherapy with or without chemotherapy. During the last 2 years of the study, a selected group of women had an SLN dissection alone. The SLNs were ultrastaged when they were negative on routine hematoxylin and eosin examination. Among 60 women undergoing SLN detection, SLN was detected in 59 women (98.3%) with combined method. Blue dye did not detect an SLN in 3 women resulting in a 93.3% detection rate. The median SLN count was 2 nodes (range, 1-9). Of the 60 women, 41 had inguinofemoral lymphadenectomy, 4 had only enlarged inguinofemoral nodes debulked, and 15 had the SLN only removed. The non-SLN count was 9 nodes (range, 3-17). There were no false-negative SLNs. Twenty-one women (35%) had positive nodes on final histology. Ultrastaging increased detection of metastases in 6.9% of nodes relative to routine hematoxylin and eosin examination and upstaged 12% of women. The median follow-up was 24 months (range, 2-66 months). Sentinel lymph node detection is safe and accurate in assessing lymph node status in women with vulval cancer undergoing staging. The combined method using Tc-99m and methylene blue dye injection for SLN detection has the best detection rate. Routine ultrastaging of negative SLN improves the detection of nodal metastases.

Accuracy of Intraoperative Macroscopic Diagnosis of Sentinel Node Metastases in Breast Cancer: Is Accurate Prediction Possible?

Accurate intraoperative diagnosis of sentinel lymph node (SLN) metastases enables the selection of patients who require axillary lymph node dissection, thus avoiding an additional operation. In this study we investigated the accuracy of intraoperative macroscopic diagnosis of SLN metastases in patients with breast cancer. SLNs from 276 breast cancer patients with clinically negative nodes were analyzed by macroscopic examination. The results of intraoperative macroscopic diagnosis were compared with those of frozen section analysis. The sensitivity, specificity, overall accuracy, and false negative rate of SLN biopsy in the assessment of node status were 82.1%, 100%, 96.4%, and 17.9%, respectively, for frozen section analysis, and 57.1%, 95.5%, 87.7%, and 42.9%, respectively, for macroscopic evaluation. Even in patients with node metastasis >7 mm, the false negative rate of macroscopic evaluation was 11.1%. Our results suggest that macroscopic diagnosis is less effective in predicting lymph node status in breast cancer than frozen section analysis. These findings imply that intraoperative macroscopic evaluation of sentinel nodes is never predictive of the final pathology.

Recurrent Alveolar Rhabdomyosarcoma With Prior Surgery and Radiotherapy

A 7-year-old girl was diagnosed with alveolar rhabdomyosarcomas of the right crural region. The patient was initially treated with chemotherapy and surgery with wide surgical margins, with radiotherapy. The tumors relapsed in the popliteal region surrounding the popliteal vessels. The patient received sentinel lymph node biopsy for a recurrent tumor using isosulfan blue dye, with the "sentinel node" being malignant-negative, and a "nonsentinel node" positive. Sentinel lymph node biopsy with conventional blue dye alone might be insufficient to assess lymph node status in patients with recurrent rhabdomyosarcoma previously treated with surgery and/or radiotherapy.