Breast Sentinel Lymph Node Research Articles

An interactive 3D atlas of sentinel lymph nodes in breast cancer developed using SPECT/CT

BackgroundThe identification and assessment of sentinel lymph nodes (SLNs) in breast cancer is important for optimised patient management. The aim of this study was to develop an interactive 3D breast SLN atlas and to perform statistical analyses of lymphatic drainage patterns and tumour prevalence.MethodsA total of 861 early-stage breast cancer patients who underwent preoperative lymphoscintigraphy and SPECT/CT were included. Lymphatic drainage and tumour prevalence statistics were computed using Bayesian inference, non-parametric bootstrapping, and regression techniques. Image registration of SPECT/CT to a reference patient CT was carried out on 350 patients, and SLN positions transformed relative to the reference CT. The reference CT was segmented to visualise bones and muscles, and SLN distributions compared with the European Society for Therapeutic Radiology and Oncology (ESTRO) clinical target volumes (CTVs). The SLN atlas and statistical analyses were integrated into a graphical user interface (GUI).ResultsDirect lymphatic drainage to the axilla level I (anterior) node field was most common (77.2%), followed by the internal mammary node field (30.4%). Tumour prevalence was highest in the upper outer breast quadrant (22.9%) followed by the retroareolar region (12.8%). The 3D atlas had 765 SLNs from 335 patients, with 33.3–66.7% of axillary SLNs and 25.4% of internal mammary SLNs covered by ESTRO CTVs.ConclusionThe interactive 3D atlas effectively displays breast SLN distribution and statistics for a large patient cohort. The atlas is freely available to download and is a valuable educational resource that could be used in future to guide treatment.

Artificial Intelligence Helps Pathologists Increase Diagnostic Accuracy and Efficiency in the Detection of Breast Cancer Lymph Node Metastases.

The detection of lymph node metastases is essential for breast cancer staging, although it is a tedious and time-consuming task where the sensitivity of pathologists is suboptimal. Artificial intelligence (AI) can help pathologists detect lymph node metastases, which could help alleviate workload issues. We studied how pathologists' performance varied when aided by AI. An AI algorithm was trained using more than 32 000 breast sentinel lymph node whole slide images (WSIs) matched with their corresponding pathology reports from more than 8000 patients. The algorithm highlighted areas suspicious of harboring metastasis. Three pathologists were asked to review a dataset comprising 167 breast sentinel lymph node WSIs, of which 69 harbored cancer metastases of different sizes, enriched for challenging cases. Ninety-eight slides were benign. The pathologists read the dataset twice, both digitally, with and without AI assistance, randomized for slide and reading orders to reduce bias, separated by a 3-week washout period. Their slide-level diagnosis was recorded, and they were timed during their reads. The average reading time per slide was 129 seconds during the unassisted phase versus 58 seconds during the AI-assisted phase, resulting in an overall efficiency gain of 55% ( P <0.001). These efficiency gains are applied to both benign and malignant WSIs. Two of the 3 reading pathologists experienced significant sensitivity improvements, from 74.5% to 93.5% ( P ≤0.006). This study highlights that AI can help pathologists shorten their reading times by more than half and also improve their metastasis detection rate.

Sentinel lymph node identification using NIR-II ultrabright Raman nanotags on preclinical models

Surface-enhanced Raman spectroscopy (SERS) nanotags have garnered much attention as promising bioimaging contrast agent with ultrahigh sensitivity, but their clinical translation faces challenges including biological and laser safety. As breast sentinel lymph node (SLN) imaging agents, SERS nanotags used by local injection and only accumulation in SLNs, which were removed during surgery, greatly reduce biological safety concerns. But their clinical translation lacks pilot demonstration on large animals close to humans. The laser safety requires irradiance below the maximum permissible exposure threshold, which is currently not achievable in most SERS applications. Here we report the invention of the core-shell SERS nanotags with ultrahigh brightness (1 pM limit of detection) at the second near-infrared (NIR-II) window for SLN identification on pre-clinical animal models including rabbits and non-human primate. We for the first time realize the intraoperative SERS-guided SLN navigation under a clinically safe laser (1.73 J/cm2) and identify multiple axillary SLNs on a non-human primate. No evidence of biosafety issues was observed in systematic examinations of these nanotags. Our study unveils the potential of NIR-II SERS nanotags as appropriate SLN tracers, making significant advances toward the accurate positioning of lesions using the SERS-based tracer technique.

Abstract 4916: Enhancing multi-organ frozen section cancer discrimination model by sharing cancer discrimination and organ classification task

Abstract Introduction: Frozen section(FS) testing is an important method that removes part or all of a patient's tissue of a suspected tumor during surgery and microscopic examination to determine a diagnosis and surgical method that requires a rapid and accurate diagnosis. In this study, we developed a deep learning model to determine the presence of cancer and the type of organ in H&amp;E FS whole slide images(WSIs) of 5 organs such as Breast(BR), Lung(LU), Stomach(ST), Breast Sentinel Lymph Node(LN), and Prostate(PR). Design: In this study, we utilized a dataset comprising 19,881 H&amp;E FS WSIs and 11,985 H&amp;E-stained formalin-fixed paraffin-embedded (FFPE) WSIs to enhance generalization. The dataset included FS and FFPE WSIs from 33 different organs sourced from The Cancer Genome Atlas (TCGA) and additional FS and FFPE WSIs from a domestic hospital and the Camelyon 16 dataset, respectively. For the FS dataset, 20% was set aside for performance evaluation, while the remaining was randomly split into a 3:1 ratio for train and validation. In our methodology, we utilized instance-based multi-instance learning (MIL) to identify patches (1024*1024 pixels, 20x mag) with a high likelihood of cancer presence in each WSI. Then, we implemented multi-task learning (MTL) to predict the presence of cancer and the organ simultaneously. Result: The table shows the WSI level performance through the 5 organs. The top 5 rows show results of MIL that only discriminate cancer. In comparison, the bottom 5 rows show results of MIL with MTL that share features from the cancer discrimination and organ classification. MIL with MTL make higher roc/auc than MIL only. Conclusion: This study explores the automated analysis of H&amp;E-stained FS WSIs using a deep-learning to discriminate cancer and classify organs. We could figure out that training cancer discrimination and organ classification simultaneously can make general features, and it leads to increased diagnostic performance. Performance Table Between MIL vs MIL + MTL Method Organ F1-score Sensitivity Specificity ROC/AUC Organ Accuracy MIL LN 0.9358 0.9669 0.6170 0.7919 NaN ST 0.9458 0.9583 0.8302 0.8943 LU 0.9577 0.9457 0.9275 0.9366 BR 0.9902 0.9895 0.9757 0.9826 PR 0.9346 0.9328 0.8786 0.9057 MIL + MTL LN 0.9448 0.9448 0.7872 0.8660 0.8816 ST 0.9771 0.9697 0.9623 0.9660 0.7595 LU 0.9700 0.9721 0.9203 0.9462 0.9509 BR 0.9932 0.9910 0.9877 0.9894 0.8979 PR 0.9480 0.9515 0.8913 0.9214 0.9803 Citation Format: Joonho Lee, Joonyoung Cho, Junho Lee, Yoon-La Choi, Kyungsoo Jung, Tae-Yeong Kwak, Sun Woo Kim, HyeYoon Chang. Enhancing multi-organ frozen section cancer discrimination model by sharing cancer discrimination and organ classification task [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 4916.

Medical image classification in breast sentinel lymph node detection

With the advent of computational imaging technologies, machine learning now provides an essential supporting modeling tool for disease detection. Breast Sentinel Lymph Node detection requires medical image classification from Raman spectral image dataset. This is achieved with a convolutional neural network, a machine learning technique. The current efforts on this literature review aim to explore a branch of deep- learning for the detection of first breast cancerous lymph node from Raman Spectroscopy Probe. With this technique, we evaluate the use of a convolutional neural network, a type of machine learning- based algorithm, used to automatically detect cancer metastases in lymph nodes with high accuracy from trained Raman Spectral Dataset.

Medical image classification in breast sentinel lymph node detection

Medical image classification in breast sentinel lymph node detection

Detection of Sentinel Lymph Nodes During Breast Cancer Surgery: A Literature Overview

Introduction. Detecting metastases is an important part of successful breast cancer treatment. Usually, the tumor tissue first spreads to the sentinel lymph nodes. Removal of the latter during surgery and histological examination allows to assess the patient’s di­sease stage, prognosis and treatment. The literature provides more than one approach or a combination of them, allowing us to accurately identify the breast’s sentinel lymph nodes and avoid removing all axillary lymph nodes. Purpose. To review the methods of intraoperative detection of breast sentinel lymph nodes presented in the literature. Research material and methods. Publications were searched using the specialized information search system Google Scholar. Keywords used in the search: breast sentinel lymph nodes, intraoperative detection. After evaluating the exclusion criteria, the review was based on 25 scientific publications. Results. 4 individual measures and 2 combinations of them can be used to detect sentinel breast lymph nodes during surgery. The materials used can be injected in 6 different ways. Conclusions. The combination of technetium-99m radiocolloid and methylene blue can be evaluated as the best method for intraoperative detection of sentinel lymph nodes in breast cancer patients. On the other hand, due to radiation and operating costs, more attention is being paid to the use of indocyanine green, superparamagnetic iron oxide, methylene blue dye, and the detection of metastases without surgery. Superficial methods of injecting the substance should be combined with deep ones due to the possibility of detecting extra-axillary sentinel lymph nodes of the breast. Ultimately, all decisions must be made on a case-by-case basis.

Breast Sentinel Lymph Node Cancer Detection from Mammographic Images Based on Quantum Wavelet Transform and an Atrous Pyramid Convolutional Neural Network

This study proposes an optimal approach to reduce noise in mammographic images and to identify salt-and-pepper, Gaussian, Poisson, and impact noises to determine the exact mass detection operation after these noise reductions. It therefore offers a method for noise reduction operations called quantum wavelet transform filtering and a method for precision mass segmentation called the image morphological operations in mammographic images based on the classification with an atrous pyramid convolutional neural network (APCNN) as a deep learning model. The hybrid approach called a QWT-APCNN is evaluated in terms of criteria compared with previous methods such as peak signal-to-noise ratio (PSNR) and mean-squared error (MSE) in noise reduction and accuracy of detection for mass area recognition. The proposed method presents more performance of noise reduction and segmentation in comparison with state-of-the-art methods. In this paper, we used the APCNN based on the convolutional neural network (CNN) as a new deep learning method, which is able to extract features and perform classification simultaneously, but it is intended as far as possible, empirically for the purpose of this research to be able to determine breast cancer and then identify the exact area of the masses and then classify them according to benign, malignant, and suspicious classes. The obtained results presented that the proposed approach has better performance than others based on some evaluation criteria such as accuracy with 98.57%, sensitivity with 90%, specificity with 85%, and also ROC and AUC with a rate of 86.77.

Analysis of non-sentinel lymph node status on 10-year overall survival among patients with breast cancer and sentinel lymph node metastasis.

e12584 Background: To investigate retrospectively the effect of non-sentinel lymph node status (non-SLN) on 10-year overall survival (OS) and non-SLN metastasis risk factors in patients with breast cancer and sentinel lymph node (SLN) metastasis. Methods: A large population (n = 15510) underwent SLN dissection in Cancer Hospital, Chinese Academy of Medical Sciences from 2011 to 2022. In total, 3033 (19.6%) cases had at least one SLN metastasis, which underwent axillary lymph node (ALN) dissection. The clinicopathological characteristics and their relationship with non-SLN status were analyzed. Among patients from 2011-2012(n = 132), the effect of non-SLN status on 10-year OS and disease-free survival (DFS) with SLN metastasis were also analyzed. Results: In 3033 patients with SLN metastasis, the mean age was (50.42±10.59) years. The average number of SLN metastasis in each patient was 1.75±1.21, the average number of SLN detected was 4.89±2.03 and the average number of ALN removed was 22.36±8.88. The number of SLN metastasis≥2 and positive lympho-vascular invasion were risk factors of non-SLN metastasis ( P&lt; 0.05), but not the age, T stage and histological grade. In 132 patients from 2011-2012, a median follow-up of 9.1 years (interquartile range, 7.3-9.5 years), the non-SLN metastasis occurred in 60 cases (45.5%), DFS 70.8%, OS 85.9%; non-SLN non-metastasis occurred in 72 cases (54.5%), DFS 85.6%, OS 90.4%. There was no significant difference between two groups in DFS(χ² = 0.61, P = 0.43) and OS (χ² = 0.06, P = 0.81). Conclusions: The number of SLN metastasis≥2 and positive lympho-vascular invasion were risk factors of non-SLN metastasis. There were no significant differences between non-SLN metastasis group and non-metastasis group in DFS and OS.

Methylene Blue Near-Infrared Fluorescence Imaging in Breast Cancer Sentinel Node Biopsy.

Simple SummaryCurrently the gold standard for sentinel node biopsy in breast cancer patients is radioactive nanocolloid and a blue dye. In the age of fluorescence guided surgery new fluorophores are used and methylene blue presents some fluorescent properties. This study is the first in a clinical series presenting the possible use of methylene blue as a fluorescent dye for the identification of sentinel nodes in breast cancer sentinel node biopsy. We presented a feasibility of this new method and also in additional experiments because of the quenching effect limitation, found possible dilution of methylene blue presenting improved fluorescence. Introduction: Fluorescence-based navigation for breast cancer sentinel node biopsy is a novel method that uses indocyanine green as a fluorophore. However, methylene blue (MB) also has some fluorescent properties. This study is the first in a clinical series presenting the possible use of MB as a fluorescent dye for the identification of sentinel nodes in breast sentinel node biopsy. Material and methods: Forty-nine patients with breast cancer who underwent sentinel node biopsy procedures were enrolled in the study. All patients underwent standard simultaneous injection of nanocolloid and MB. We visualized and assessed the sentinel nodes and the lymphatic channels transcutaneously, with and without fluorescence, and calculated the signal-to-background ratio (SBR). We also analyzed the corresponding fluorescence intensity of various dilutions of MB. Results: In twenty-three patients (46.9%), the location of the sentinel node, or the end of the lymphatic path, was visible transcutaneously. The median SBR for transcutaneous sentinel node location was 1.69 (range 1.66–4.35). Lymphatic channels were visible under fluorescence in 14 patients (28.6%) prior to visualization by the naked eye, with an average SBR of 2.01 (range 1.14–5.6). The sentinel node was visible under fluorescence in 25 patients (51%). The median SBR for sentinel node visualization with MB fluorescence was 2.54 (range 1.34–6.86). Sentinel nodes were visualized faster under fluorescence during sentinel node preparation. Factors associated with the rate of visualization included diabetes (p = 0.001), neoadjuvant chemotherapy (p = 0.003), and multifocality (p = 0.004). The best fluorescence was obtained using 40 μM (0.0128 mg/mL) MB, but we also observed a clinically relevant dilution range between 20 μM (0.0064 mg/mL) and 100 μM (0.032 mg/mL). Conclusions: For the first time, we propose the clinical usage of MB as a fluorophore for fluorescence-guided sentinel node biopsy in breast cancer patients. The quenching effect of the dye may be the reason for its poor detection rate. Our analysis of different concentrations of MB suggests a need for a detailed clinical analysis to highlight the practical usefulness of the dye.

Analysis on factors behind sentinel lymph node metastasis in breast cancer by color ultrasonography, molybdenum target, and pathological detection

BackgroundThis study aimed to identify the factors underlying the metastasis of breast cancer and sentinel lymph nodes and to screen and analyze the risk factors of sentinel lymph node metastasis to provide a reference and basis for clinical work.MethodsA total of 99 patients with breast cancer were enrolled in this study. These patients received treatment in our hospital between May 2017 and May 2020. The general information, characteristics of the color Doppler echocardiography, molybdenum, conventional pathology, and molecular pathology of the patients were collected. Factors influencing sentinel lymph node metastasis in breast cancer patients were retrospectively analyzed.ResultsIn this study, age, tumor diameter, BI-RADS category, pathology type, expression profiles of CK5/6, EGFR, and CK19, and TP53 and BRAC1/2 mutations were independent risk factors for sentinel lymph node metastasis in breast cancer (P < 0.05). The number and locations of tumors, quadrant of tumors, regularity of tumor margins, presence of blood flow signals, presence of posterior echo attenuation, presence of calcification, histological grade, molecular typing, and mutations of BRAF, ATM, and PALB2 were irrelevant factors (P > 0.05).ConclusionsIn conclusion, age, tumor diameter, BI-RADS category, invasive type, expression of CK5/6, EGFR, and CK19, and mutations in TP53 and BRAC1/2 were positively correlated with sentinel lymph node metastasis. These independent risk factors should be given more attention in clinical studies to strengthen the management and control of sentinel lymph node metastasis in high-risk breast cancer and support early chemotherapy or targeted therapy.

Abstract P3-20-06: Magseed/magtrace-guided surgery in breast cancer- an institutional perspective

Abstract Background/Purpose: Superparamagnetic iron oxide (SPIO)-based techniques like Magseed and Magtrace offer alternatives for breast lesion and sentinel lymph node (SNL) localization. Magseeds placed under ultrasound guidance offer logistical and safety advantages compared to traditional wire-localization or radioactive seed placement. Further, Magtrace injection is a viable SNL-localization alternative that overcomes radiation safety, skin necrosis, and allergic reactions associated with traditional 99mTc colloid and Methylene blue/Isosulfan blue dyes. To evaluate the effectiveness of these techniques in surgical practice, we report the implementation of Magseed and Magtrace at Baylor St. Luke’s Medical Center. Methods: We retrospectively reviewed prospectively collected data from the 128 female patients undergoing Magseed/Magtrace procedures from October 2019 to December 2020. Demographics and clinical characteristics were summarized, and surgical outcomes analyzed including margin status, re-excision rates, post-operative breast and axilla complications, successful localization and detection rates. Results: Patients presented with varied diagnoses including 98 (77%) with invasive carcinoma, 21 (16%) with DCIS, and 9 (7%) with fibroadenoma, papillary, or other lesions. 50 patients (39%) underwent neoadjuvant therapy. Mean BMI at surgery was 27.33 kg/m2 (range, 17.80-48.65) and mean age was 57.26 years (range, 27-86). Breast density varied, 5 (4%) categorized as almost entirely fatty, 69 (54%) as heterogeneously dense, 12 (9%) as extremely dense, and 39 (30%) with fibroglandular density. For breast size there were 2 (2%) A cups, 13 (10%) B cups, 16 (13%) C cups, 10 (8%) D cups, 8 (6%) DD cups, 2 (2%) DDD cups, 1 (.8%) F cup, and 12 (9%) with in between breast size (A-DDD). 108 patients (84%) had on-table Magtrace injection and 52 (41%) had Magseed localization. 18 (14%) patients had Methylene blue/Isosulfan blue dye or Technetium-99 used with Magseed and/or Magtrace. There was a 100% (52/52) success rate of lesion localization using Magseed and a 94% (101/108) success rate of SLN detection using Magtrace. Magtrace brown skin staining occurred in 12/108 patients (11%). Breast complications occurred in 43 patients (34%), with bruising/hematoma in 30/43 (70%), seroma in 7/43 (16%), and infection in 4/43 (9%). Axilla complications occurred in 11 patients (9%): 5/11 (45%) had bruising/hematoma, 6/11 (55%) had seroma, and 1/11 (9%) had infection. Positive margins were seen in 11 (9%) patients with re-excision performed in 8 women (6%). Conclusions: Magseed and Magtrace are comparable to standard practices in terms of practicality, surgical implementation, and risk of surgical complications and re-excision, providing a rationale for the adoption of SPIO-based techniques. By putting these surgical techniques into practice and evaluating their success in excising a wide range of lesions and monitoring complications, there is possibility of introducing new, innovative techniques into a standardized clinical setting within surgical oncology. Magseed/Magtrace Procedures at BSLMCRaw NumberPercentageTechniquesMagtrace Only6047%Magseed Only1915%Magtrace + Magseed3124%Isotope1713%Blue Dye11%Skin Staining Post-Op.1211%Breast Complication4334%Wound Complication921%Infection49%Bruising/Hematoma3070%Seroma716%Patients with &amp;gt;1 complication49%Axilla Complication119%Wound Complication00%Infection19%Bruising/Hematoma545%Seroma655%Patients with &amp;gt;1 complication19%Re-excision Rate86%Histological TypesER+, HER2-7055%ER+10078%HER2+2016%TNB1310% Citation Format: Jessica Montalvan, Logan Healy, Huma Javaid, Ivan Marin, Brian Menegaz, Cary Hsu, Eric Silberfein, Elizabeth Bonefas, Stacey Carter, Alastair Thompson. Magseed/magtrace-guided surgery in breast cancer- an institutional perspective [abstract]. In: Proceedings of the 2021 San Antonio Breast Cancer Symposium; 2021 Dec 7-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2022;82(4 Suppl):Abstract nr P3-20-06.

Frozen section telepathology service: Efficiency and benefits of an e-health policy in South Tyrol.

Objective/BackgroundTelepathology has been widely adopted to allow intraoperative pathology examinations to be performed remotely and for obtaining second opinion teleconsultation. In the Italian northern region of South Tyrol, the widespread geographical distances and consequent cost for the health system of having a travelling pathologist cover intraoperative consultations in peripheral hospitals was a key driver for the implementation of a telepathology system.MethodsIn 2010, four Menarini D-Sight whole slide scanners to digitize entire pathology slides were placed in the peripheral hospitals of Merano, Bressanone, Brunico, and in the hub hospital of Bolzano. Digital workstations were also installed to allow pathologists to remotely perform intraoperative consultations with digital slides. This study reviews the outcome after 12 years of telepathology for this intended clinical use.ResultsAfter an initial validation phase with 100 cases which yielded a sensitivity of 65% (CI 43–84%) and specificity of 100% (CI 95–100%), there were 2058 intraoperative consultations handled by telepathology. The cases evaluated were mainly breast sentinel lymph nodes, followed by urological, gynecological and general surgical pathology frozen section specimens. There were no false-positive cases and 165 (8%) false-negative cases, yielding an overall sensitivity and specificity of 65% (CI 61–69%) and 100% (CI 99–100%), respectively.ConclusionTelepathology is reliable for remote intraoperative diagnosis and, despite technical issues and initial acquaintance issues, proved beneficial for patient care in satellite hospitals, improved standardization, promoted innovation, and resulted in cost savings for the health system.

Breast cancer-The catalyst of contemporary trials design.

Surgical trials in breast cancer have catalyzed contemporary trial design for solid organ cancers and are a prime example of surgeons taking the lead in clinical trial design. Surgeons have lead trials that have improved patient outcomes and quality of life without sacrificing oncologic safety. We have evolved from radical mastectomy to breast conservation and sentinel node biopsy. Contemporary trial design in breast cancer now focus on personalizing care based on tumor genomics.

Ovarian tissue cryopreservation in a patient with breast cancer during pregnancy: a case report

BackgroundFertility preservation using ovarian tissue cryopreservation (OTC) in patients with certain diseases, especially those needing chemo- or radiotherapy, is becoming routine in various Western countries. Our hospital is the first and until now the only centre in China to use this method. The question of whether treatment of breast cancer during pregnancy (PrBC) should be similar to non-pregnant young patients with breast cancer is controversial. To our knowledge, this is the first report worldwide to use OTC as fertility preservation for PrBC.Case presentationDuring the 29th week of pregnancy, a 24-year-old woman underwent needle aspiration cytology of a left breast tumour. Ultrasound and cytology revealed BI-RADS 4a grade. Oncologists recommended termination of the pregnancy. Caesarean section was performed at week 32, and ovarian tissue samples were collected for OTC to preserve fertility and ovarian endocrine function. Twenty-three ovarian cortex slices were cryopreserved. It is estimated that 13,000 follicles were cryopreserved. Breast nodules and sentinel lymph node biopsy suggested invasive micropapillary carcinoma. Neoadjuvant chemotherapy was started within 1 week after diagnosis. After six courses of neoadjuvant chemotherapy, targeted drug therapy and goserelin acetate, left mastectomy and left axillary lymph node dissection were performed. In total, 23 doses of radiotherapy, eight trastuzumab targeted therapy treatments, and 17 pertuzumab + trastuzumab double targeted therapy treatments were performed after breast cancer surgery. Until now, more than 2 years after delivery, the ovarian function still is good, and no signs of a negative impact of OTC have been observed. Goserelin acetate injections, administered every 28 days, are planned to last for the next 5 years. In addition, endocrine therapy with anastrozole was started after breast cancer surgery and also is scheduled for 5 years.ConclusionOTC for fertility preservation in patients with PrBC does not delay breast surgery, radiotherapy or chemotherapy, which is essential for effective treatment of breast cancer. We assess this method as a promising fertility preservation method which was used here for the first time worldwide in a patient who developed breast cancer during pregnancy.

Survival and recurrence with or without axillary dissection in patients with invasive breast cancer and sentinel node metastasis

To evaluate overall survival and locoregional recurrence between patients with invasive breast tumours and sentinel node metastasis undergoing sentinel lymph node dissection (SLND) alone and those undergoing complete axillary lymph node dissection (ALND). In this retrospective cohort study, we reviewed the medical records of patients with invasive breast carcinoma who underwent lumpectomy at a public university hospital in Brazil between 2008 and 2018. We evaluated the overall survival and the locoregional recurrence using Kaplan–Meier and Cox regression analyses, respectively. Overall, 97 participants who underwent lumpectomy were enroled; 41 in the ALND group, and 56 in the SLND group, according to Z0011 criteria. Only 17% of the patients in the ALND group had an additional biopsy-proven axillary disease, and 83% were treated with complete dissection unnecessarily. The 5-year survival rates were 80.1% and 87.5% for SLND and ALND, respectively (p = 0.376). Locoregional recurrence was rare (1.7% and 7.3% in the SLND and ALND, respectively; p = 0.3075). Overall survival and locoregional recurrence were similar between the two groups. The de-escalation of ALND to SLND in women with metastasis in the sentinel lymph node treated with conservative surgery and radiotherapy that meet the Z0011 criteria is feasible even in developing countries.

Feasibility of arm-draining lymph node-sparing radiotherapy of breast cancer: A pilot planning study.

Lymphoedema following axillary radiotherapy for breast cancer causes significant morbidity. Our goal was to evaluate the feasibility of sparing the lymph node that drains the arm's lymphatics (ARM node) while achieving standard dose constraints for whole breast and comprehensive lymph node irradiation. Six patients underwent lymphoscintigraphy and SPECT CT to identify the breast sentinel node (SN) and ARM node. The ARM node was contoured on the SPECT CT and deformably registered to the radiotherapy treatment planning CT. Radiotherapy plans (50 Gy in 25 fractions) with VMAT technique were generated, with the aim to spare the ARM node (Mean dose <25 Gy) and achieve adequate coverage to the remaining axilla. The plan required the breast SN site (clip + 10 mm surrounding the clip) to achieve D98% > 47.5 Gy, and axillary nodal CTV excluding ARM node to achieve D90% > 45 Gy. In one patient, the ARM node was within the volume of breast SN site and sparing was not possible. For the remaining 5 patients, an ARM node-sparing plan could be successfully generated; the mean dose to the ARM node ranged from 11.2 to 23.1 Gy (median 13.8 Gy). In these 5 subjects, D90% > 45 Gy of axillary nodal CTV (range, 44.9-48.5 Gy, median 46.2 Gy) and D98% > 47.5 Gy of breast SN site were achieved. In this planning study, ARM node-sparing VMAT of the breast and lymph nodes was feasible, while maintaining adequate dosimetric coverage. However, in some individuals, localization of the ARM node in close proximity to breast SN site precluded the generation of an ARM node-sparing treatment plan.

Using the axillary reverse mapping technique to screen breast cancer patients with a high risk of lymphedema

BackgroundPreventing breast cancer-related lymphedema (BCRL) by preserving upper lymphatic drainage is still controversial. Our study aimed to use the axillary reverse mapping (ARM) technique in patients who underwent axillary surgery to analyse the correlation between postoperative residual ARM nodes and the occurrence of lymphedema, select candidates at high risk of developing lymphedema, and analyse the oncologic safety of ARM nodes.MethodsPatients undergoing sentinel lymph node biopsy (SLNB) or axillary lymph node dissection (ALND) from October 2015 to February 2016 at the Peking University People’s Hospital Breast Center were prospectively recruited for the study. ARM was performed in all patients before surgery. ARM nodes were separated from SLNB and ALND specimens. Data were collected on the identification of ARM nodes before surgery, number of residual ARM nodes after surgery, nodal status, crossover rate, and correlation between residual ARM nodes and the occurrence of lymphedema.ResultsThe analysis included 78 patients. Of the 53 patients who underwent SLNB, crossover between ARM nodes and breast sentinel lymph nodes (SLNs) was seen in 22 specimens. The incidence of ARM node metastasis was 1.89% (1/53) and 25% (9/36) in the SLNB and ALND groups, respectively. The number of positive axillary lymph nodes was associated with the involvement of ARM nodes (P = 0.036). The incidence of residual ARM nodes was significantly higher in the SLNB group than in the ALND group (67.6% vs. 37.9%, P = 0.016). The incidence of lymphedema was significantly higher in the ALND group than in the SLNB group (33.3% vs. 5.4%, P = 0.003).ConclusionsFor SLNB, the ARM technique can help to resect SLNs more accurately. However, we do not recommend using the ARM technique to preserve ARM nodes in patients undergoing ALND due to oncologic safety issues. Nevertheless, we can predict patients undergoing axillary surgery who are more likely to have a high risk of lymphedema by assessing residual ARM nodes.Trial registrationThis study was registered on ClinicalTrials.gov in February 2016.The clinical trial registration number is NCT02691624.

Prospective Comparison of Intraoperative Touch Imprint Cytology and Frozen Section Histology on Axillary Sentinel Lymph Nodes in Early Breast Cancer Patients

Introduction: Since the late 1970s, sentinel lymph node biopsy (SLNB) has been used for several solid malignancies to identify lymph node metastases. This procedure is associated with less surgical morbidity than complete lymphadenectomy. Recent evidence suggests that axillary lymphadenectomy is not required for breast sentinel nodes with micrometastases (≤2 mm). Current clinical management of sentinel nodes indicates that only macrometastases (>2 mm) should be detected intraoperatively. In Japan, an intraoperative histopathological frozen section (FS) method is used to identify lymph node metastases, but this method takes more than 30 min and requires complex techniques and expensive equipment. Touch imprint cytology (TIC) is an easier, less expensive, and faster method, but its sensitivity has been shown to be low. Objective: The purpose of this study was to determine if TIC is more useful than FS in identifying macrometastases in sentinel lymph nodes in preoperative node-negative breast cancer operations. Methods: A prospective review of 49 consecutive patients with node-negative breast cancer treated with SLNB and intraoperative TIC and FS between November 2017 and June 2019 was performed. TIC samples were stained using Papanicolaou and Diff-Quick stains. Results were compared with routine postoperative paraffin sections. Results: With TIC, the Papanicolaou stain took a mean of 12 min, and the Diff-Quick stain took a mean of 10 min. Results of both TIC stain methods were the same. In contrast, the FS method took a mean of 80 min (including the transfer of specimens to a different hospital with the necessary equipment). TIC confirmed macrometastases in 5 cases. All macrometastases were diagnosed equally by the 2 techniques. Both the sensitivity and specificity of TIC were 100% for detection of macrometastases. Conclusion: TIC of SLNB for breast cancer is an easy and useful method for the detection of macrometastases of breast sentinel nodes.

The clinical study of character types of sentinel lymph nodes in patients with breast cancer in lymphatic contrast enhanced ultrasound

Objective To evaluate the diagnostic efficiency in differential diagnosis for breast sentinel lymph nodes, and to analyze the imaging characteristics of involved breast sentinel lymph node in lymphatic contrast enhanced ultrasound. Methods Sixty-one patients suspected with breast cancer from May 2017 to March 2019 in Shanghai General Hospital, Shanghai Jiao Tong University were included in the study. Ultrasound contrast agent was injected subcutaneously, and axillary lymph nodes were displayed under contrast enhanced ultrasound mode. The longitudinal diameter (anteroposterior diameter), transverse diameter, longitudinal/transverse ratio and the distance from skin surface were measured. Five types were concluded according to the imaging characteristics in lymphatic contrast enhanced ultrasound: typeⅠ, uniform enhancement; type Ⅱ, ring-shape enhancement; type Ⅲ, ununiform enhancement; type Ⅳ, regional filling defect; type Ⅴ, total filling defect. Sentinel lymph nodes were guided by wire guides and verified in pathology after excision in the operation. Results The detection rate of sentinel lymph nodes was 95.08% (58/61). Seventy-seven lymph nodes, including 21 involved nodes and 56 uninvolved nodes were detected by lymphatic contrast enhanced ultrasound in 58 patients. The longitudinal diameters and transverse diameters of involved lymph nodes were larger than those of uninvolved ones (P=0.001, 0.003). When type Ⅳ(regional filling defect) and type Ⅴ(total filling defect) were classified as involved, the sensitivity, specificity, positive-predictive value, negative-predictive value, accuracy and the area under ROC curve of predicting sentinel lymph node metastases were 85.71%, 96.43%, 90.00%, 94.70%, 93.51% and 0.911, respectively. Conclusions Lymphatic contrast enhanced ultrasound reaches a high diagnostic efficiency in qualitative analysis of breast sentinel lymph nodes. Regional filling defect and total filling defect are the imaging characteristics of involved sentinel lymph nodes in lymphatic contrast enhanced ultrasound. Key words: Contrast-enhanced ultrasound; Breast cancer; Sentinel lymph node; Differential diagnose; Diagnostic efficiency