Axillary Status Research Articles

Dynamic changes of neutrophil-to-lymphocyte ratio and platelet-to-lymphocyte ratio predicts breast cancer prognosis

BackgroundWe aimed to identify whether neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are more useful predictors after initial intention to treat than at the time of diagnosis.MethodsWe collected the medical data of 533 patients. The results of the peripheral blood sampling before the primary treatments were labeled as initial cohort, and those obtained between 24 and 36 months after initial treatment were defined as the 2nd cohort. Delayed metastasis has been defined as distant metastasis 2 years after treatment, and survival outcome was estimated and compared across groups.ResultsMedian follow-up duration was 74 months (24–162 months), and 53 patients experienced delayed metastasis. In univariate analysis, metastasis-free survival, patient age at diagnosis, tumor size, axillary lymph node metastasis, HER-2 status, initial NLR and PLR, and 2nd NLR and PLR were found to be significantly associated with delayed metastasis. However, in multivariate analysis, only the 2nd NLR and PLR were found to be significantly associated with delayed metastasis, excluding initial NLR and PLR. Metastasis-free survival was analyzed through the pattern changes of NLR or PLR. The results revealed that patients with continued low NLR and PLR values at pre- and post-treatment (low initial values and 2nd values) showed a significantly better prognosis than those with a change in value or continued high NLR and PLR.ConclusionsWe identified that patients with persistent high NLR and PLR after initial treatment have significant worse prognosis in terms of late metastasis. Therefore, these results suggest that NLR and PLR are more useful in predicting prognosis post-treatment.

The value of the intraoperative assessment of the SLN via frozen section in the post Z0011 era

IntroductionSentinel node (SN) assessment via frozen section (FS) has declined since the publication of Z0011 which modified the management of a specific group of patients with positive SN. The risk of misleading the surgeons to a preventable ALND and the cost are among the main factors for that. The aim of our study is to assess the value of FS in the post Z0011. Material and methods244 patients out of 434 were eligible for an upfront SLNB. Based on the final histology and the clinical data we selected the eligible for breast conserving surgery patients (55.4%). 78 patients had positive SN and 26 of them fulfilled the criteria of Z0011. We assessed the false negative findings, the impact on the management and the indications and value of FS in the post Z0011 era. ResultsOverall, there were 12 FN cases out of which 7 were macrometastases (8.97%). Only in one case there were > 2 positive LN and 3 patients needed mastectomy. The remaining cases fulfilled the criteria of Z0011 and needed no further surgery hence in 96.1% of the cases the axillary status was correctly assessed via FS and the reoperation rate was 1.2%. On the contrary, if FS was not used, at least 21.3% of the patents would have needed reoperation based on the today’s guidelines. DiscussionWe believe FS is still valuable and may spare a significant percentage of patients from a second operation (SNB) without leading to axillary overtreatment if used wisely.

Sentinel Node Biopsy Alone or With Axillary Dissection in Breast Cancer Patients After Primary Chemotherapy: Long-Term Results of a Prospective Interventional Study.

To ascertain, in cN0/1 breast cancer patients given primary chemotherapy followed by sentinel node biopsy (SNB), whether SNB alone is adequate axillary treatment if the sentinel nodes (SNs) are clear (pN0). 2020 guidelines do not recommend SNB in most cN1 patients with clear SNs after primary chemotherapy because the high SNB false negative rate might lead to poorer outcomes. We prospectively assigned SNB after primary chemotherapy to 353 consecutive cT2 cN0/1 patients, median age 47 years (range 22-76) treated from 2007 to 2015. If the SNs were pN0, patients generally received no further axillary treatment (SNB only); if the SNs were pN1, completion axillary dissection (AD) (SNB + AD) was usually performed. Primary outcomes were overall (OS) and disease-free (DFS) survival in SNB only versus SNB + AD patients, assessed by Kaplan-Meier and compared using log-rank test, with use of propensity scores to account for bias due to nonrandom assignment to SNB versus SNB + AD. Median follow-up was 108 months, interquartile range 66 to 136. OS and DFS did not differ significantly between the groups by propensity score- weighted comparison: 10-year OS 89% [95% confidence interval (CI): 81%- 99%] in SNB only patients versus 86% (95%CI: 78%-95%) in SNB + AD patients; 10-year DFS 79% (95%CI: 68%-92%) versus 69% (95%CI: 58%-81%). No SNB-only patient developed axillary failure. cT2 cN0/1 patients whose SNs are disease-free (pN0) after primary chemotherapy can be offered SNB (with no further axillary treatment if the SNs are negative), irrespective of axillary status beforehand, without affecting OS or DFS.

Feasibility of preoperative tattooing of percutaneously biopsied axillary lymph node: an experimental pilot study

BackgroundIn the last three decades, axillary lymph node dissection (ALND) has been replaced by sentinel lymph node biopsy (SLNB) in all clinically node-negative patients. However, when SLNB alone is performed in clinically node-positive patients who are rendered node-negative by neoadjuvant chemotherapy, the procedure has a high false-negative rate and other complementary procedures have been described to improve its reliability. Preoperative tattooing of the suspicious lymph node with India ink at the time of biopsy, in addition to sentinel lymph node biopsy, is a reasonable alternative. The objective of our study is to determine, in clinically node-positive patients, the feasibility of tattooing suspicious axillary lymph node at the time of percutaneous needle biopsy and its retrieval at the time of surgery.MethodsA prospective experimental study will be conducted divided into two phases—phases I and II. In phase I, 10 patients committed to undergo upfront surgery (without neoadjuvant chemotherapy) will have a suspicious lymph node tattooed by injecting India ink at the time of core needle biopsy. All patients will undergo a SLNB, during which the axilla will be inspected to determine if the tattooed lymph node can be visualized. Routine microscopic examination will follow, and concordance between the sentinel and tattooed node will also be established. In phase II, the process will be repeated for 30 patients who undergo surgery after neoadjuvant chemotherapy. The analysis will be performed in Stata version 12.DiscussionThere is a need to identify and test the techniques for the down-staged axilla in post-neoadjuvant chemotherapy patients, which are not only practical and limit the number of invasive procedures necessary but are representative of the new axillary status and help limit the extent of axillary surgery without negatively impacting outcomes. We propose that, for the patient undergoing neoadjuvant chemotherapy with a biopsy-proven disease in the axilla, this could be achieved by India ink which allows marking, identification, and retrieval of the biopsied lymph node. Retrieval of this previously biopsied lymph node along with sentinel nodes, if found to be representative of the status of the remainder of the axilla, could potentially eliminate the need for routine axillary lymph node dissection and thus limit morbidity.Trial RegistrationClinicalTrials.gov, NCT03939598. Retrospectively registered on 7 May 2019.

Identification of Sentinel Lymph Node in Breast Cancer with three Tracers (Radiocolloid, Methylene blue, and Indocyanine Green). (Case Report)

BACKGROUND: Sentinel lymph node (SNL) biopsy in breast cancer for the determination of axillary status is standard procedures in surgical treatment of early-stage breast cancer. The identification of the SNL is usually performed by radiocolloid injection or/and injection of methylene blue due. The use of indocyanine green (ICG) dye, which is fluorescent dye, which movement in breast and axillar pit, can be followed with special cameras which detect near infrared specatar of light.
 CASE REPORT: In this paper, we present case report of patient with breast cancer, where we perform SNL detection with three methods: Use of radiocolloid which we trace with static gamma camera, and intraoperatively with hand held gamma probe, methylene blue dye which movement we followed by eye contact and using indocyanine green which movement was followed by specially constructed multispectral camera, which can detect near-infrared fluorescence that is emitted by ICG and methyline blue, respectively.
 CONCLUSION: Fluorescent imaging with ICG is a sensitive, valuable, and safe method for SNL biopsy. Finding new agents that would identify the SNL, especially if they are not radioactive would be an important step in wider application of this method.

Impact of status of ER, PR, HER2 and Ki-67 index on axillary lymph node metastasis of breast cancer

Aim: Axillary status evaluation and, if present, the number of metastatic lymph nodes is important in staging and adjuvant therapy planning of breast cancer. A number of clinical and pathological variables were analyzed to detect factors affecting nodal status. Methods: A total of 298 women with unilateral breast cancer operated with axillary lymph node dissection or sentinel lymph node biopsy, were retrospectively analyzed for age, localization, BIRADS category, pathological features, subtypes as Luminal A, Luminal B, HER2 positive, triple negative, Ki-67 index and number of lymph nodes involved. Results: The mean age was 54.7 years. BIRADS 5 was the most detected category in 208 (69.8%) patients. The most common pathological type was invasive ductal carcinoma in 265 patients (88.9%). The most detected tumor grade was grade 2 in 160 (31.2%). Luminal B was the most common subtype and detected in 173 patients (58.1%). Ki-67 indexes were detected between 0-14% in 69 patients (23.3%), between 15-19% in 31patients (10.4%) and above 20% in 198 patients (66.4%). Conclusions: HER2 positivity, Ki-67 index,>

Prediction of nodal staging in breast cancer patients with 1-2 sentinel nodes in the Z0011 era.

The aim of this study was to provide an innovative nomogram to predict the risk of >2 positive nodes in patients fulfilling the Z0011 criteria with 1-2 sentinel lymph nodes (SLNs) only retrieved.From 2007 to 2017, at the Breast Unit of ICS Maugeri Hospital 271 patients with 1-2 macrometastatic SLNs, fulfilling the Z0011 criteria, underwent axillary dissection and were retrospectively reviewed.A mean of 1.5 SLNs per patient were identified and retrieved. One hundred eighty-seven (69.0%) had 1-2 positive nodes, and 84 (31.0%) had >2 metastatic nodes. Independent predictors of axillary status were: positive SLNs/retrieved SLNs ratio (odds ratio [OR] 10.95, P = .001), extranodal extension (OR 5.51, P = .0002), and multifocal disease (OR 2.9, P = .003). A nomogram based on these variables was constructed (area under curve after bootstrap = 0.74).The proposed nomogram might select those patients fulfilling the Z0011 criteria, with 1-2 SLNs harvested, in whom a high axillary tumor burden is expected, aiding to guide adjuvant treatments.

Neo‐Adjuvant chemotherapy and its affects to the axilla—Can we safely downgrade axillary surgery to mirror the approach in the breast

The use of neo-adjuvant chemotherapy (NACT) to downgrade surgery in the breast from mastectomy to breast-conserving surgery is well-established. In certain patients, the use of adjuvant axillary radiotherapy can be safe and effective in place of axillary node clearance. What remains less clear are the alternative surgical options to the axilla following NACT. The aim of this study was to examine the effects of NACT in the axilla and whether downgrading axillary node clearance to axillary conserving surgery to mirror the approach in the breast may be a viable and safe practice. Patients undergoing neo-adjuvant chemotherapy were identified over a seven-year period between 2010 and 2017. Surgical plans were compared with pre- and post-chemotherapy. Histological information at the time of diagnosis was compared to surgical excision specimens. 349 patients were included for analysis, and 264 had axillary status documented at diagnosis. The average patient age was 51years, and Grade 3, ER-positive, and Her2-negative cancers made the biggest histological subgroups. Complete pathological response (CPR) was seen in the breast in 27% of cases. 19% of patients requiring mastectomy had their surgery downgraded. Following NACT, axillary CPR was seen in 42% of patients and residual axillary nodal burden was limited to four nodes in 73% of patients. Axillary conserving surgery may be a safe alternative surgical approach in the downstaged axilla following neo-adjuvant chemotherapy. Advances in perioperative identification of suspicious nodes may be needed to facilitate progress.

Would Removal of All Ultrasound Abnormal Metastatic Lymph Nodes Without Sentinel Lymph Node Biopsy Be Accurate in Patients with Breast Cancer with Neoadjuvant Chemotherapy?

Removal of sonographically abnormal (up to 3) metastatic clipped nodes, without sentinel lymph node biopsy, could accurately predict axillary status in breast cancer patients receiving neoadjuvant chemotherapy. ypT and the first clipped node status were statistically significant factors for nodal pathologic complete response. This novel approach requires validation in larger studies. In patients who have node-positive breast cancer, neoadjuvant chemotherapy could result in nodal pathologic complete response (pCR) and avoid an axillary lymph node dissection (ALND). Axillary staging, in such cases, can be performed using targeted axillary dissection (TAD) with a low false negative rate. However, identification of sentinel lymph nodes (SLNs) after chemotherapy can be difficult, and currently, it is the standard to remove only one clipped node in TAD. We aimed to determine if removal of all sonographically abnormal metastatic clipped nodes, without SLN biopsy, could accurately predict the axillary status post neoadjuvant chemotherapy. Patients with breast cancer with one to three sonographically abnormal metastatic axillary nodes were prospectively recruited. Each abnormal node had histology and clip insertion before neoadjuvant chemotherapy. After chemotherapy, the patients underwent removal of clipped nodes using the Skin Mark clipped Axillary nodes Removal Technique (SMART) and ALND. Fourteen patients were recruited, having a total of 21 sonographically abnormal metastatic nodes, with nine, three, and two patients having 1, 2, and 3 malignant nodes clipped, respectively. Mean age was 55.5 years; 92.9% and 57.1% of patients had invasive ductal carcinoma and grade III tumors, respectively; and 35.7% patients achieved nodal pCR. The first clipped node predicted the axillary status with a false negative rate of 7.1%. Adding to this another second clipped node, the false negative rate was 0%. Pathologic tumor staging after neoadjuvant chemotherapy (ypT) (p = .0390) and the first clipped node pathological response status (p = .0030) were statistically significant predictors for nodal pCR. Removal of sonographically abnormal metastatic clipped nodes using SMART, without sentinel lymph node biopsy, could accurately predict axillary status. This finding needs validation in larger studies.

Preoperative Axillary Ultrasound Helps in the Identification of a Limited Nodal Burden in Breast Cancer Patients.

Since the Z0011 trial, the clinical evaluation of axillary status has been redirected to predicting nodal tumor burden rather than nodal metastases. Our study aimed to evaluate the value of clinicopathological factors and axillary ultrasound (US) for the prediction of a high nodal burden (≥3 metastatic lymph nodes) in breast cancer patients. A total of 532 consecutive patients who underwent preoperative axillary US and subsequent surgery for clinical T1-2 breast cancer with a final pathologic analysis were included. Clinical and pathologic variables were retrospectively evaluated. Univariate and multivariate statistical analyses were performed to identify the variables that were associated with a high nodal burden. Among the 532 patients, 110 (20.7%) had a high axillary nodal burden and 422 (79.3%) had a limited nodal burden. The multivariate analysis showed that suspicious axillary US findings (P < 0.001), clinical T2 stage (P = 0.011), the presence of lymphovascular invasion (P < 0.001), and estrogen receptor positivity (P < 0.001) were significantly associated with a high nodal burden. Patients with negative axillary US findings seldom had a high nodal burden, with a negative predictive value of 93.0% (294/316). Patients with suspicious axillary US findings, clinical T2 stage, lymphovascular invasion, and estrogen receptor positivity are more likely to have a high nodal burden, which may provide additional information for the treatment plan of breast cancer patients. Preoperative axillary US helps identify a limited nodal burden in breast cancer patients and has implications for axillary lymph node dissection and adjuvant treatment.

Evaluation of Prognostic Factors in Triple Negative Breast Cancer Patients with Emphasis on Angiogenesis

Developing new therapeutic methods and exploring other possible future strategies in Triple Negative Breast Cancer (TNBC) is an area of interest. Angiogenesis is one such sought for area that can even serve as a targeted therapy in this subset of breast cancer. The objective of the study was to evaluate the prognostic factors in TNBC patients with emphasis on angiogenesis. Prospectively 120 patients with histologically confirmed breast cancer from June 2015 to July 2019 were included. The Colour Doppler evaluation of breast lump and axilla in terms of RI, PI and Vmax was done. Patients were categorized as having ‘high’ or ‘low’ RI, PI and Vmax on the basis of their mean value. Immunohistochemistry (IHC) was performed on viable tumour blocks obtained from mastectomy specimen using CD31 vascular endothelial staining. The idea was to obtain Microvascular Density (MVD) by counting all immunostained vessels at magnification of 400x. The association between TNBC and non TNBC with well-known Doppler parameters, tumour size, clinical lymph node status, number of positive lymph nodes, tumour grade, stage of disease and hormonal receptor status was investigated. Also the association between high and low MVD with these prognostic parameters were evaluated. A total of 120 patients were included in the study with the mean age of 42.43±7.73 years (range 30-65 years). The mean RI, PI and Vmax were 0.92±0.26, 2.19±1.84 and 16.52±10.70 respectively. The comparison between TNBC and non-TNBC with prognostic parameters showed significant association with age of patients, duration of disease, use of oral contraceptive pills (>1 year), tumour size, histological grade, RI and MVD (p=0.041, p=0.011, p=0.002, p=0.029, p=0.026, p=0.014 and p=0.007 respectively). The MVD value >13.17 (high) was found in 45 (37.5%) patients while 75 (62.5%) patients had low MVD value ( 16.52) was significantly associated with tumour size (p<0.001), axillary lymph node (p=0.022), clinical stage (p=0.015), histological grade (p<0.001), RI (p<0.001), ER status (p<0.001) and HER2 over expression (p=0005). TNBC is a subset of breast cancer showing aggressive biological behaviour as seen by presence of poor prognostic marker and increased vascularity.

An AN OBSERVATIONAL STUDY OF SLN MAPPING IN PATIENTS OF LOCALLY ADVANCED BREAST CANCER FOLLOWING NCT

Background : Locally advanced breast carcinoma (LABC) includes a wide range of clinical scenarios- advanced primary tumors (T4), advanced nodal disease and inflammatory carcinomas(1). Traditionally, treatment of LABC included a combination of Chemotherapy, Radiation and Surgery(2). However, there has been a shift to Neoadjuvant Chemotherapy in recent times.(3)&#x0D; Histological status and the number of axillary lymph nodes with metastasis is one of the most important prognostic factors and most powerful predictor of recurrence and survival in patients of breast carcinoma and remains so, even after neo-adjuvant chemotherapy. (3) Information derived from the sentinel lymph node is considered valuable, with less discomfort to the patient when compared with axillary dissection.(4) However, its role in detecting nodal metastasis after neo-adjuvant chemotherapy in LABC is still debatable and definitive studies to evaluate its role are still evolving. (5)&#x0D; Materials and Methods: Patients of LABC were evaluated using ultrasonography (USG) of axilla. Neo-adjuvant chemotherapy (NACT) was administered and patients were reassessed by USG of axilla. Thirty patients with node negative axillary status were subjected to Sentinel lymph node mapping using isosulfan blue followed by Modified Radical Mastectomy and Axillary Lymph Node Dissection. Histopathological evaluation of stained and unstained lymph nodes done and the data, thus obtained, was statistically analysed.&#x0D; &#x0D; Results: Sentinel lymph node biopsy performed using Isosulfan Blue dye alone, after neo-adjuvant chemotherapy predicts the status of axillary lymph nodes with low accuracy.&#x0D; &#x0D; Conclusions: Further studies would be required to establish the role of sentinel lymph node biopsy in patients with LABC after NACT.

Combined positive axillary lymph node marking with iodine-125 seeds and sentinel lymph node biopsy in breast cancer patients treated with neoadjuvant chemotherapy

ObjectiveTo present our initial experience in the combined procedure of intraoperative detection of axillary positive node marked with 125I seed (ML) and sentinel node biopsy (SLN) after neoadjuvant chemotherapy (NACT), in breast cancer patients. Material and methodsProspective study, January 2017 – March 2019, 16 breast cancer patients T1-3N1. TNM stage: IIA: 3, IIB: 10, IIIA: 3. Histological type ductal invasive: 14. Molecular subtype: luminal A: 3, luminal B: 9, HER2: 3, basal like: 1.The ML was marked 227±36 days before NACT (n: 10), or 1–6 days before surgery, on previously identified node by ultrasound visibility marker, hydrogel (n: 3) or three dimensional-3D (n: 3). Axillary lymphadenectomy (AD) was undertaken in 10 patients. ResultsML and SLN were identified in the surgery in 93.7 % (15/16) of the cases, in 33.3 % (5/15) ML was not among SLN, and in only one patient (1/5) was there a discrepancy between the result of ML and SLN (macrometastases vs. negative 0/2). Median number of lymph nodes SLN: 2.2±0.9 (range 1–3) and AD: 13.5±5.2 (range 7–23). In all cases, histopathological analysis of ML, 125I seed and/or marker within, correctly predicted axillary status after neoadjuvant chemotherapy. In all patients the 125I radioactive seed was recovered. ConclusionsPlacing of 125I seeds is a feasible technique for intraoperative location of axillary positive node combined with SLN. The histopathological result of ML allows the axillary status to be determined after neoadjuvant chemotherapy.

A New Model Incorporating Axillary Ultrasound After Neoadjuvant Chemotherapy to Predict Non-Sentinel Lymph Node Metastasis in Invasive Breast Cancer.

PurposeFew models with good discriminative power have been introduced to predict the risk of non-sentinel lymph node (non-SLN) metastasis in breast cancer after neoadjuvant chemotherapy (NAC). We aimed to develop a new and simple model for predicting the probability of non-SLN metastasis in breast cancer and facilitate the selection of patients who could avoid unnecessary axillary lymph node dissection following NAC.Patients and MethodsA total of 298 patients diagnosed with invasive breast cancer, who underwent SLN biopsy after completing NAC and subsequently breast surgery, were included and classified into the training set (n=228) and testing set (n=70). Univariate and multivariate analyses were used to select factors that could be determined prior to breast surgery and significantly correlated with non-SLN metastasis in the training set. A logistic regression model was developed based on these factors and validated in the testing set.ResultsNodal status before NAC, post-NAC axillary ultrasound status, SLN number, and SLN metastasis number were independent predictors of non-SLN metastases in breast cancer after NAC. A predictive model based on these factors yielded an area under the curve of 0.838 (95% confidence interval: 0.774–0.902, p< 0.001) in the training set. When applied to the testing set, this model yielded an area under the curve of 0.808 (95% confidence interval: 0.609–1.000, p= 0.003).ConclusionA new and simple model, which incorporated factors that could be determined prior to breast surgery, was developed to predict non-SLN metastasis in invasive breast cancer following NAC. Although this model performed excellently in internal validation, it requires external validation before it can be widely utilized in the clinical setting.

Application effect of fine needle aspiration cytology and sentinel lymph nodes stain assisted by contrast-enhanced ultrasound in early breast cancer

Objective To explore the application effect of fine needle aspiration cytology and sentinel lymph nodes stain assisted by contrast-enhanced ultrasound in early breast cancer. Methods A patient with early breast cancer enrolled in Beijing Friendship Hospital, Capital Medical University received fine needle aspiration cytology assisted by contrast-enhanced ultrasonography and the sentinel lymph nodes were stained with blue dye before a standard sentinel lymph nodes biopsy traced with indocyanine green. The axillary status accessed by these two methods were compared. Results Three sentinel lymph nodes were found and aspirated assisted by contrast-enhanced ultrasonography. Seven sentinel lymph nodes were obtained in sentinel lymph nodes biopsy surgery. All of these sentinel lymph nodes were negative. The stained sentinel lymph nodes could be recognized and dissected in open lymph nodes biopsy surgery. Conclusions Fine needle aspiration cytology assisted by contrast-enhanced ultrasonography could be a substitute for open sentinel lymph nodes biopsy. More related researches should be carry out to further compare these two methods. Key words: Sentinel lymph node biopsy; Ultrasonography, interventional; Biopsy, fine-needle

Analysis of Clinical-Pathological Data with Impact on Overall Survival in Male Breast Carcinoma: An International Multi-Institutional Study of 217 Cases.

Background: The aim of this study was to evaluate clinical-pathological parameters with impact on overall survival (OS) in male breast carcinoma (MBC). Methodology: We assessed OS at 5 years and at 10 years respectively, as well as OS according to age, tumor size, microscopic type, histological grade, axillary lymph node status, and molecular profile. Results:Two hundred seventeen cases, with a mean age of 62 (range: 18- 85), right breast involvement (52.53%), invasive carcinoma of no special type (86.63%), G2 histological grade (55.4%), T2 (54.41%), N+ (65.89%) and Luminal A molecular subtype (85.29%) were identified. ER, PR and AR were positive in 89.71%, 83.82% and 93.29% of cases, respectively. HER2 was overexpressed in 8.33% of cases and a high Ki67 proliferation index was present in 75% of cases. The 5-year OS was 67.2%, whereas 10-year OS was 48.5%; OS was 92.7% at 5 years and 73.8% at 10 years in axillary lymph node (LN) negative cases, while OS was 59.7% at 5 years and 41.3% at 10 years in axillary LN positive cases (p=0.003). Conclusions: Age at diagnosis ( 60 years), larger tumor size, presence of LN metastases and absence of oncological treatment are negative factors influencing prognosis, with only axillary LN status (p=0.005) and triple negative molecular profile (p=0.05) being statistically significant unfavorable independent prognostic parameters in a multivariate analysis.

Association of axillary node status with clinicopathological characteristics and expression of EZH2 and CD44 in primary breast ductal carcinoma.

Objective:In order to enhance the prognostic benefit of new molecular markers, the aim of this study was to identify possible association of axillary lymph node (ALN) status and pN with clinicopathological characteristics and expression of EZH2 and CD44 in invasive ductal carcinoma (IDC) of the breast.Methods:The investigation included 106 patients with IDC who had undergone radical mastectomy at the Clinic of Endocrine Surgery in Nis. Clinicopathologic parameters and immunohistochemical expression of EZH2 and CD44 in primary IDC were investigated in relation to ALN status and pN.Results:Our univariate analysis established that T3-T4 stage, high EZH2, and high EZH2 with ER- were associated with ALN metastasis (p=0.014; 0.003; 0.013). Decreased probability for ALN involvement was found with T1 stage, and low EZH2 with ER+ (p=0.032; 0.022). Multivariant analysis established that high EZH2 in cancer cells was associated with high risk for ALN metastases (p=0.004); T1 tumors were associated with low risk (p=0.037). Higher pN was associated with high EZH2, high EZH2 with ER-, as well as an advanced clinical and disease stage (p=0.006; 0.001; p=0.002, 0.001). Lower pN was associated with ER+, and ER+ with low EZH2 (p= 0.004; 0.012). CD44 was not associated with ALN involvement, nor with pN.Conclusions:This study revealed association of EZH2 with ALN metastases, where disease stage and expression profiles of EZH2 and ER may have affected regional pN.

Incidence of axillary recurrence after negative sentinel lymph node biopsy in a retrospective cohort of breast cancer patients

Introduction: Breast cancer is the second most common cancer in the world, and the most common among women, spreading especially to the axillary lymph nodes. The axillary status is the main prognostic factor, and the sentinel lymph node biopsy (SLNB) technique is incorporated to surgical treatment. Objectives: To analyze cases of recurrence in patients with breast carcinoma after being submitted to negative SLNB. Methods: Observational, retrospective study carried out from 1999 to 2019 in a clinic in Teresina. We analyzed the cases of axillary recurrence after negative SLNB in a cohort comprised of 459 patients. The study was approved in the Research Ethics Committee, report n. 2.817.502. Results: There were two cases of axillary recurrence after negative SLNB. CASE 1: 77 year-old patient with infiltrating carcinoma of no special type in the left breast, measuring 2.2 cm (T2N0M0) - IIA. She was submitted to sectorectomy with SLNB, which was negative. Immunohistochemical: ER+, PR-, HER2 -, P53+, KI-67+ 70%, luminal B. She received radiotherapy on the breast and did not undergo hormone therapy. After four years, she presented local recurrence and was treated with segmental resection and axillary lymph node dissection. The histological analysis of the surgical specimen showed infiltrating carcinoma of no special type, measuring 1.5cm, with perineural invasion, and 4 axillary lymph node without neoplasm. She received adjuvant hormone therapy with tamoxifen. The patient was followed up for 40 months after the procedures and was free of disease, and then she was no longer being followed-up. CASE 2: 50-year old patient with invasive lobular carcinoma (right breast), submitted to sectorectomy with negative SLNB. She received postoperative radiotherapy and hormone therapy. Immunohistochemical: ER+ 90%, PR+ 90%, HER2-, KI-67+ 60%. After two years of follow-up, she presented with right axillary recurrence, and underwent axillary lymph node dissection, with 13 resected lymph nodes, of which one presented metastasis. She began on hormone therapy with anastrozole. Nowadays, 37 months after surgery, she has no evidence of recurrence. Conclusion: In this study, the rate of axillary recurrence after negative SLNB was 0.43%.

Preoperative Prediction of Lymph Node Metastasis from Clinical DCE MRI of the Primary Breast Tumor Using a 4D CNN.

In breast cancer, undetected lymph node metastases can spread to distal parts of the body for which the 5-year survival rate is only 27%, making accurate nodal metastases diagnosis fundamental to reducing the burden of breast cancer, when it is still early enough to intervene with surgery and adjuvant therapies. Currently, breast cancer management entails a time consuming and costly sequence of steps to clinically diagnose axillary nodal metastases status. The purpose of this study is to determine whether preoperative, clinical DCE MRI of the primary tumor alone may be used to predict clinical node status with a deep learning model. If possible then many costly steps could be eliminated or reserved for only those with uncertain or probable nodal metastases. This research develops a data-driven approach that predicts lymph node metastasis through the judicious integration of clinical and imaging features from preoperative 4D dynamic contrast enhanced (DCE) MRI of 357 patients from 2 hospitals. Innovative deep learning classifiers are trained from scratch, including 2D, 3D, 4D and 4D deep convolutional neural networks (CNNs) that integrate multiple data types and predict the nodal metastasis differentiating nodal stage N0 (non metastatic) against stages N1, N2 and N3. Appropriate methodologies for data preprocessing and network interpretation are presented, the later of which bolster radiologist confidence that the model has learned relevant features from the primary tumor. Rigorous nested 10-fold cross-validation provides an unbiased estimate of model performance. The best model achieves a high sensitivity of 72% and an AUROC of 71% on held out test data. Results are strongly supportive of the potential of the combination of DCE MRI and machine learning to inform diagnostics that could substantially reduce breast cancer burden.

Severe anaphylactic reaction to patent blue in breast cancer surgery

Sentinel lymph node biopsy in the surgical treatment of initial breast cancer has been increasingly adopted to assess axillary status as a way to replace total lymphadenectomy. The sentinel lymph node can be identified using coloring agents or radiopharmaceuticals. In Brazil, patent blue is the most used dye for this type of procedure, with high rates of identification and safety; however, in some cases, the use of this substance can lead to the occurrence of anaphylactic reactions. The case presented here refers to a 41-year-old female patient admitted for a surgical procedure for total mastectomy associated with sentinel lymph node biopsy with patent blue. After surgical initiation, the patient developed severe anaphylactic shock, staying 21 days in the intensive care unit (ICU) for recovery. Most anaphylactic reactions that occur in the transoperative period are mediated by IgE antibodies, resulting in the degranulation of mast cells and basophils, with the release of mediators such as histamine, prostaglandins, proteoglycans, and cytokines, leading to the clinical manifestations of anaphylaxis. There is evidence that part of the population is allergic to patent blue, and may present with manifestations ranging from hives and pruritus to severe cardiovascular collapse, requiring hospitalization in an ICU. The purpose of this article was to report a case of severe anaphylactic reaction to patent blue and to review the literature regarding this infrequent and potentially serious situation.