Complete Node Research Articles

One Step Nucleic Acid Amplification (OSNA) - a new method for lymph node staging in colorectal carcinomas

BackgroundAccurate histopathological evaluation of resected lymph nodes (LN) is essential for the reliable staging of colorectal carcinomas (CRC). With conventional sectioning and staining techniques usually only parts of the LN are examined which might lead to incorrect tumor staging. A molecular method called OSNA (One Step Nucleic Acid Amplification) may be suitable to determine the metastatic status of the complete LN and therefore improve staging.MethodsOSNA is based on a short homogenisation step and subsequent automated amplification of cytokeratin 19 (CK19) mRNA directly from the sample lysate, with result available in 30-40 minutes. In this study 184 frozen LN from 184 patients with CRC were investigated by both OSNA and histology (Haematoxylin & Eosin staining and CK19 immunohistochemistry), with half of the LN used for each method. Samples with discordant results were further analysed by RT-PCR for CK19 and carcinoembryonic antigen (CEA).ResultsThe concordance rate between histology and OSNA was 95.7%. Three LN were histology+/OSNA- and 5 LN histology-/OSNA+. RT-PCR supported the OSNA result in 3 discordant cases, suggesting that metastases were exclusively located in either the tissue analysed by OSNA or the tissue used for histology. If these samples were excluded the concordance was 97.2%, the sensitivity 94.9%, and the specificity 97.9%. Three patients (3%) staged as UICC I or II by routine histopathology were upstaged as LN positive by OSNA. One of these patients developed distant metastases (DMS) during follow up.ConclusionOSNA is a new and reliable method for molecular staging of lymphatic metastases in CRC and enables the examination of whole LN. It can be applied as a rapid diagnostic tool to estimate tumour involvement in LN during the staging of CRC.

Major Airway Laceration Secondary to Endobronchial Ultrasound Transbronchial Lymph Node Biopsy

A 48-year-old woman underwent complete mediastinal lymph node staging for non-small-cell lung cancer. After convex endobronchial ultrasound (EBUS)-guided transbronchial biopsy of the subcarinal lymph node station (station no. 7), it was noted that a laceration had occurred in the left mainstem bronchus. The tear occurred at the medial cartilaginous-membranous junction, seemed to be full thickness into the mediastinum, and was approximately 1.5cm long. The cytologic results of all lymph node biopsies were negative and the patient underwent right upper and middle lobe bilobectomy 12 hours after the EBUS procedure. This is the first report of a serious airway injury occurring during convex EBUS lymph node biopsy.

307 Complete axillary lymph node dissection versus clinical follow-up in breast cancer patients with sentinel node micrometastases. Interim analysis of the Spanish multicenter clinical trial. AATRM 048/13/2000

307 Complete axillary lymph node dissection versus clinical follow-up in breast cancer patients with sentinel node micrometastases. Interim analysis of the Spanish multicenter clinical trial. AATRM 048/13/2000

Non-Sentinel Lymph Node Status of Patients with T1/T2 Breast Cancer and Micrometastasis in the Sentinel Lymph Node.

Abstract Background: Micrometastatic disease in the sentinel lymph node is still an indication for complete axillary lymph node dissection. To further reduce morbidity in breast cancer patients the omission of complete axillary lymph node dissection in patients with micrometastasis in the sentinel lymph node would be desirable.Methods: We retrieved our data-base and looked for the non-sentinel lymph node status in patients with micrometastasis in the sentinel lymph node.Patients with primary T1/T2 breast cancer and sentinel lymph node biopsy were examined for their sentinel lymph node status. Patients with a micrometastasis in the sentinel lymph node, who received a complete axillary lymph node dissection were eligible for evaluation. Patients with a micrometastisis in the sentinel lymph node, who did not receive complete axillary lymph node dissection and patients after primary systemic therapy were excluded.Results: 103 patients were eligible for evaluation. All patients had micrometastases (0,2 to 2,0mm) in the sentinel lymph nodes. In total 15/103 patients (14.6%) had a further metastasis in one or two non-sentinel lymph nodes. 8/103 patients (7.8%) had one macrometastasis in a non-sentinel lymph node with sizes from 2.1mm to 5.0mm. 3/103 patients (2.9%) had a micrometastasis in two non-sentinel lymph nodes and 4/103 patients (3.9%) had one micrometastasis in one non-sentinel lymph node.Mean age of the patients was 57 years, 34 (33%) being premenopausal and 69 (67%) being postmenopausal. 22 patients (21.4%) received immediate axillary dissection after sentinel lymph node biopsy, but 81 patients (78.6%) had a secondary axillary lymph node dissection after the final pathological report. In 19 patients (18.4%) the micrometastasis in the sentinel lymph node could be detected by frozen sections, in 77 patients (74.8%) by serial sections at 250µm in the paraffin embedded sentinel lymph node and in 22 patients (21.4%) by immunohistochemistry only.Discussion: As long as we are lacking reliable methods for predicting the non-sentinel lymph node status for patients with micrometastases in the sentinel lymph node, and as long as the impact of micrometastases in the axilla are subject of debate, axillary lymph node dissection should be performed after sentinel lymph node biopsy with micrometastases in the sentinel lymph node. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1034.

Eradication of Axillary Lymph Node Metastases Occurs in 74% of Patients Receiving Neoadjuvant Chemotherapy with Concurrent Trastuzumab for HER2 Positive Breast Cancer.

Abstract Background:Administration of neoadjuvant chemotherapy (NCT) can result in a pathologic complete response (pCR) in the breast and axilla which correlates with improved disease-free and overall survival. This study examines the incidence of axillary pCR and the effect of axillary pCR on disease-free survival (DFS) in patients (pts) with HER2 positive disease and biopsy-proven axillary metastases that received trastuzumab-based NCT.Material and Methods:The records of 109 consecutive pts with HER2 positive breast cancer and ultrasound-guided fine needle aspiration (FNA) biopsy-confirmed axillary metastases were analyzed. All pts received trastuzumab-based NCT prior to undergoing breast surgery with complete axillary lymph node (ALN) dissections. After surgery, patients were subdivided into those with and without residual ALN disease. Survival was evaluated by the Kaplan-Meier method.Results:Of patients with documented positive ALNs before chemotherapy, 81 (74%) had an ALN pCR. ALN pCR was not associated with estrogen receptor status, grade, tumor size or age (p=NS). The median number of nodes removed was 19 in the ALN pCR group and 18.5 in the group with residual axillary disease (p=NS). The only significant difference between the groups was that more patients in the ALN pCR group achieved complete pathologic response of disease within the breast (p<0.001) (78% with and 25% without ALN pCR, respectively). At a median follow-up of 29.1 months, DFS in the ALN pCR group (95%) was significantly greater than in the group with residual axillary disease (81%) on Kaplan-Meier analysis (p=0.02).Discussion:Trastuzumab-based NCT results in axillary pCR in 74% of patients with HER2 positive disease. These pts have improved DFS compared with patients with residual disease. The majority of patients with proven axillary metastases will have eradication of disease after treatment with trastuzumab-based NCT, and this has implications for the surgical management of the axilla in these types of pts. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1086.

Surgical practice patterns following NCCTG N0338 “Phase II trial of docetaxel and darboplatin administered every two weeks as induction therapy for stage II and stage III breast cancer.”

623 Background: Neoadjuvant therapy plays an important role in breast cancer treatment. Unlike patients who undergo surgery followed by adjuvant therapy,there are no established guidelines for surgical management following neoadjuvant therapy. Methods: Surgical practice patterns from 50 patients in N0338 “Phase II trial of Docetaxel and Carboplatin administered every two weeks as induction therapy for Stage II and Stage III breast cancer” were reviewed. The protocol did not mandate surgical therapy leaving the decision to the treating surgeon and patient. Results: 66% of patients underwent mastectomy (M) and 33% underwent breast conservation therapy (BCT). Three (9%) had immediate reconstruction. Eight (24%) underwent contralateral prophylactic M. Residual tumor size did not always impact primary surgical therapy. In the M group 4 (12%) had no residual disease, 15 (45%) < 2cm and 14 (42%) > 2cm; whereas, in the BCT group 1 (6%) had no residual disease, 12 (70%) < 2cm and 4 (24%) > 2cm. Axillary lymph node (ALN) staging varied tremendously. Three (6%) patients presented with palpable lymphadenopathy and proceeded to complete axillary lymph node dissection (ALND) after chemotherapy (CT). Fine needle aspiration (8) or core needle biopsy (7) of the axilla was performed in 15 (30%) patients before CT; 1 was negative and went on to have sentinel lymph node biopsy (SLNB) after CT; 14 (94%) were positive with 13 (86%) going on to ALND and 1 SLNB after CT. Five (10%) underwent SLNB prior to CT. One (20%) was positive and went on to have ALND after CT; 4 (8%) were negative and had no further ALN staging. A total of 19 (39%) had SLNB after neoadjuvant therapy; 13 (68%) were positive and underwent ALND; 1 SLNB failed; 2 of 5 that were negative underwent ALND with 1 having a positive lymph node. Ten (20%) underwent ALND with no pre-operative staging with 8 being positive for ALN metastases. Conclusions: Review of study data from multiple institutions revealed no consistent criteria in selection of surgical intervention for the breast tumor or ALN staging. There remains a need for further research in this area to establish standard practice guidelines. Support from NIH, sanofi-aventis, Amgen, Breast Cancer Research Foundation. No significant financial relationships to disclose.

Endoscopic Ultrasonography-Guided Fine Needle Aspiration (EUS-FNA) in Mediastinal Restaging After Neoadjuvant Therapy in Patients with Non-Small Cell Lung Cancer (NSCLC). Preliminary Results

Background: Multimodal therapy is the standard of care for NSCLC in stages IIIa and some IIIb. Survival of patients with residual lymph node (LN) disease after neoadjuvant therapy plus surgery does not differ from that of patients not submitted to surgery. Therefore, it is crucial to identify the patients with complete LN response before surgery. Few data in the literature suggest that EUS-FNA could be useful for mediastinal restaging in these group of patients. Aim: To investigate the accuracy of EUS-FNA in the mediastinal restaging of patients with NSCLC after neoadjuvant therapy. Methods: Cross-sectional study that includes patients with NSCLC treated with neoadjuvant therapy and surgical candidates in whom a restaging of the mediastinum before surgery is indicated. All patients had been staged by any technique before radiochemotherapy, with cytological or histological confirmation of malignant LN. Detailed information on the location of the metastatic LN in the pre-therapeutic workup was available in all cases and supplied according the standard ganglionic map of the mediastinum of Mountain to ensure sampling of the same LN during restaging. EUS-FNA was performed under conscious sedation with a lineal echoendoscopy (Olympus®UCT-160) and a 22G needle (EchoTip EUSN-3 Cook Ireland Ltd). Metastatic LN in the pre-therapeutic staging was/were sampled first (maximum of 3 passes) and evaluated by an on-site cytopathologist. If negative, the other LN were then sampled in order to assess the global impact of EUS-FNA in this setting. A mediastinoscopy was performed after EUS-FNA in all patients before surgery. Gold standard was the pathological examination of LN obtained by mediastinoscopy or surgical specimen. Results: 21 patients were included. LN were located in region 7 (n=10), 4L (n=2), 4R (n=5), 7+4R (n=2) and 5 (n=1). One patient was excluded before restaging due to disease progression. Performance characteristics of EUS-FNA in the remaining 20 patients were: sensitivity 42%, specificity 100%, PPV 100%, NPV 53% and accuracy 65%. False negatives were due to micrometastases (n=2) or lack of visualization of the lymph node (n=5; 4 of them located in region 4R). Mediastinoscopy could have been avoided in 13 patients (65%). Conclusion: EUS-FNA seems to be able to substitute mediastinoscopy for mediastinal restaging in a high percentage of patients with NSCLC after neoadjuvant therapy. Lack of a good visualization of 4R region or micrometastases are the causes of EUS-FNA failure.

Endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA) in mediastinal restaging after neoadjuvant therapy in patients with non-small cell lung cancer (NSCLC): preliminary results

Background: Multimodal therapy is the standard of care for NSCLC in stages IIIa and some IIIb. Survival of patients with residual lymph node (LN) disease after neoadjuvant therapy plus surgery does not differ from that of patients not submitted to surgery. Therefore, it is crucial to identify the patients with complete LN response before surgery. Few data in the literature suggest that EUS-FNA could be useful for mediastinal restaging in these group of patients.

Is the sentinel lymph node biopsy accurate for patients with initially clinically axilla-positive locally advanced breast cancer after neoadjuvant chemotherapy?.

Abstract Abstract #5123 Background: Approximately one third of patients with locally advanced breast cancer (LABC) have no axillary metastatic lymph node(s) after neoadjuvant chemotherapy (NAC). Axillary dissection could be omitted in these patients if SLNB is negative. The aim of this study is to evaluate the accuracy of sentinel lymph node biopsy (SLNB) after NAC for LABC.
 Materials and Methods: Between January 1992 to May 2008, a total of 69 patients with clinical or radiological positive axilla (N1 or N2) in LABC were enrolled in this study. After NAC, all patients underwent SLNB followed by complete axillary lymph node dissection. SLNB was performed with either a combined detection using blue dye and radiocolloid or blue dye alone. All the sentinel lymph nodes were examined by multisection hematoxylin eosin staining and cytokeratin- immunohistochemistry, whereas the non-sentinel nodes were examined by routine histology.
 Results: Sentinel lymph nodes were successfully identified in 58 patients among 69 patients (85%). The median age was 46 (range 25 to 76). The clinical stages before chemotherapy were as follows: IIB:46%, IIIA: 22%, and IIIB: 32%, respectively. All of 58 patients had either clinically or radiologically suspicious node-positive disease based on ultrasound findings before neoadjuvant chemotherapy. Pathologic complete response were obtained in 5 patients (9%). The false negative rate was found to be 17.4 % (8/46), whereas the accuracy rate was 86.2% (50/58) among patients with succesful lymphatic mapping.
 Conclusion: The accuracy of the SLNB procedure seems to be not reliable in patients with locally advanced disease with a positive axilla before NAC therapy due to its high false negative rates. Therefore, complete axillary dissection is still required in patients with a positive-axilla before chemotherapy. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5123.

Intraoperative cytologic evaluation of sentinel lymph nodes in patients with breast carcinoma by scrape preparation

Intraoperative evaluation of sentinel lymph nodes (SLNs) in patients with breast carcinoma allows surgeons to complete axillary lymph node dissection in one procedure if any SLN shows metastasis. The accuracy of intraoperative pathological diagnosis is critical for decision-making. The purpose of this study was to evaluate our rapid intraoperative cytologic diagnosis of SLN through comparing with the final surgical pathologic diagnosis of the corresponding lymph nodes. A total of 454 SLNs from 159 consecutive female patients with a preoperative diagnosis of breast carcinoma over 3-year period were included in this study. After gross examination of each bisected lymph node, a scrape preparation was prepared for each submitted lymph node and was stained by the rapid Papanicolaou method. The intraoperative cytologic diagnosis was compared with the final surgical pathologic diagnoses. The overall sensitivity of intraoperative cytology was 52.5% with specificity of 100%. There were 17 false-negative cases. Of them, six nodes had isolated tumor cells, seven nodes had micrometastasis (0.2-2 mm), and four nodes had macrometastasis (>2 mm). There were no interpretive errors identified. The size of metastasis and tumor grade appeared to be significant factors in detecting metastasis by cytology. In addition, subsequent non-SLN involvement was 9% in patients with micrometastasis versus 50% in patients with macrometastasis (P < 0.05). Our study shows that the intraoperative cytologic evaluation of SLNs in breast carcinoma is a reasonably accurate method. The majority of false-negative cases were due to micrometastasis and isolated tumor cells.

Microscopic Tumor Burden in Sentinel Lymph Nodes Predicts Synchronous Nonsentinel Lymph Node Involvement in Patients With Melanoma

We and others have demonstrated that additional positive lymph nodes (LNs) are identified in only 8% to 33% of patients with melanoma who have positive sentinel LNs (SLNs) and undergo complete therapeutic LN dissection (cTLND). We sought to determine predictors of additional regional LN involvement in patients with positive SLNs. Patients with clinically node-negative melanoma who underwent SLN biopsy (1991 to 2003) and had positive SLNs were identified. Clinicopathologic factors, including extent of microscopic disease within SLNs, were evaluated as potential predictors of positive non-SLNs. Overall, 359 (16.3%) of the 2,203 patients identified had a positive SLN. Positive non-SLNs were identified in 48 (14.0%) of the 343 patients with positive SLNs who underwent cTLND. On univariate analysis, several measures of SLN microscopic tumor burden, one versus three or more SLNs harvested, tumor thickness more than 2 mm, age older than 50 years, and Clark level higher than III were predictive of positive non-SLNs; primary tumor ulceration and number of positive SLNs had no apparent impact. On multivariable logistic regression analysis, measures of SLN microscopic tumor burden were the most significant independent predictors of positive non-SLNs; tumor thickness more than 2 mm and number of SLNs harvested also predicted additional disease. A model was developed that stratified patients according to their risk for non-SLN involvement. In melanoma patients with positive SLNs, SLN tumor burden, primary tumor thickness, and number of SLNs harvested may be useful in identifying a group at low risk for positive non-SLNs and be spared the potential morbidity of a cTLND.

Feasibility of VATS (video-assisted thoracic surgery) lobectomy for clinical stage IB or II non-small cell lung cancer

7576 Background: A prospective, multi-institution feasibility study for VATS lobectomy for small NSCLC has been reported. The aim of this study was to examine the feasibility of VATS lobectomy for clinical stage IB or II NSCLC. Methods: VATS lobectomy is defined as an anatomic lobectomy using individual hilar dissection and complete lymph node(LN) dissection without rib spreading. Histologically proven clinical stage IB or II NSCLC less than 6 cm in size was eligible. Success is defined as VATS lobectomy without conversion. If success rate over 90%, VATS lobectomy is considered as feasible procedures. Secondary objectives are to evaluate the number of dissected LNs and the LN breakage, peri-operative variables, and the inflammatory mediators after VATS. As a control group, the data from forty patients who underwent lobectomy through open thoracotomy(OT) were prospectively collected. Results: This prospective phase II study enrolled 20 patients. Fourteen patients (70%) had clinical stage IB, 2 IIA, and four had IIB lung cancer. No one required conversion to thoracotomy. In-hospital mortality was 1 (5%) and morbidity was 6 (30%). Morbidity was predominantly related to atrial fibrillation and air leakage. Nine patients showed up-staging in final pathology mainly due to LN micrometastasis. Capsular breakage in subcarinal LN was 8 (40%), interlobar LN 5 (5%), and in left paratracheal LN 2 (28.6%). Compared with OT, there were no significant differences in operation time, dissected LNs, in-hospital stay, and complication rates. The rate of capsular breakage in subcarinal LN was significantly higher in VATS(table 1). Serum CRP after VATS lobectomy was maintained much lower. Conclusion: For clinical stage IB or II stage lung cancer, no conversion to open thoracotomy, comparable numbers of dissected LNs and acceptable qualities of LN dissection can lead the feasibility of VATS lobectomy (NCT00290602). Comparison between VATS and OT for stage IB or II NSCLC Variables VATS lobectomy (n=20) Open thoracotomy (n=40) p-value Age (years) 64.2 ± 9.34 63.4 ± 9.66 0.754 Male 8 31 0.004 Adenocarcinoma 18 15 0.003 Operation time (min) 200.6 ± 59.3 178.4 ± 55.7 0.158 Amount of intraoperative bleeding 212.5 ± 125.5 345.0 ± 232.3 0.021 Perioperative transfusion 0 3 0.544 Postoperative complication 6 16 0.573 Postoperative mortality 1 1 1.000 In-hospital stay (days) 10.9 ± 12.2 12.7 ± 7.8 0.514 Tumor size (cm) 3.21 ± 1.02 4.07 ± 1.50 0.024 Dissected LNs 27.9 ± 8.25 28.1 ± 6.39 0.918 CRP (mg/dL) POD #1 6.87 ± 2.76 8.97 ± 3.42 0.024 POD #2 10.07 ± 4.43 16.27 ± 6.26 0.001 POD #3 9.99 ± 4.88 16.82 ± 8.16 0.011 Capsular tears of LNs 11 16 0.409 Subcarinal LN 8 5 0.022 Interlobar LN 5 15 0.395 No significant financial relationships to disclose.

QS113-A. Extent of Lymph Node Dissection Impacts Disease Specific Survival in Melanoma Patients

Background: Extent of lymph node (LN) dissection has been defined as a potential indicator of surgical quality for patients with various solid tumors. The objective of the current analysis was to determine: (1) the most relevant measure of extent of LN dissection, (2) identify the threshold value of the most relevant measure, and (3) examine its impact on disease specific survival (DSS) in melanoma patients undergoing therapeutic LN dissection. Methods: Patients with pathologically confirmed, node positive, cutaneous melanoma who underwent completion LN dissection were identified from the SEER database (1988-2004).

Bowen's disease with high telomerase activity

We describe an 81-year-old Japanese woman who had a palm-sized, erythematous plaque with a nodular lesion on the lateral abdomen. The biopsy specimens taken from the erythematous plaque and reddish nodule show that bowenoid changes were present in the epidermis and epidermis to dermis, respectively. A sentinel lymph node biopsy (SNB) was performed with blue dye and radioisotope in her right groin region and two lymph nodes were found to be occupied by many atypical cells. The erythematous plaque with nodular lesion was completely removed with a 3-cm margin under general anesthesia, and complete regional lymph node dissection was also performed. In addition, high telomerase activity was seen in the erythema plaque while using a telomeric repeat amplification protocol assay. In conclusion, some instances of Bowen's disease might have high telomerase activity in the atypical cells and can progress to Bowen's carcinoma. The SNB was regarded as a useful method to detect early lymph node metastases in this case.

Current technical overviews of sentinel lymph node biopsy for breast cancer

Sentinel lymph node biopsy (SLNB) is based on the hypothesis that the sentinel lymph node (SLN) reflects the lymph-node status and a negative SLN might allow complete axillary lymph node dissection (ALND) to be avoided. Although the survival outcome is still unknown, this technique has already become a standard of care for breast cancer patients. However, it is still important to discuss current techniques and some controversies. This article reviews these issues for a variety of SLNB techniques.

Number of lymph nodes harvested from a mediastinal lymphadenectomy: Results of the randomized, prospective ACOSOG Z0030 trial

7555 Background: Lymph node status is a major determinant of stage and survival in patients with lung cancer; however, little information is available about the yield of a mediastinal lymphadenectomy done at the time of pulmonary resection. Methods: The ACOSOG Z0030 trial is a prospective, randomized trial of mediastinal lymph node sampling versus complete mediastinal lymphadenectomy during an operation for early stage lung cancer. Total enrollment from July 1999 to February 2004 was 1,111 patients, of which 1,023 were eligible and/or evaluable. There were 524 patients who underwent complete mediastinal lymph node resection after randomization to this arm that were declared eligible and/or evaluable with lymph node data available. The number of lymph nodes examined from each station was collected beginning in January 2002. Prospectively collected data from these patients was analyzed to determine the number of lymph nodes obtained. Results: Median age was 67 (range 37–87) and 267 (52%) were men. Histology was squamous cell in 141 (27%), adenocarcinoma in 227 (44%), large cell in 22 (4%), bronchoavelolar in 32 (6%) and other non-small cell in 99 (19%). There were 317 right sided cancers and 207 left sided cancers. For lymphadenectomy for cancers in the right lung the yield from station 2R was a median of 2 lymph nodes (range 1 to 15), station 4R was 2 (1 –17), station 7 was 2 (1–24), station 8 was 1 (1–5), station 9 was 1 (1–6) and station 10R was 1 (1–10). For lymphadenectomy for cancers on the left side the yield from station 2L was 2 (1–4), station 4L was 1 (1–12), station 5 was 2 (1–18), station 6 was 2 (1–11), station 7 was 2 (1–16), station 8 was 1 (1–3), station 9 was 1 (1–8) and 10L was 2 (1–12). The total number of lymph nodes or fragments obtained for right sided cancers was a median of 13.5 (range 1 to 56) and for left sided tumors 15 (range 4 to 81). Conclusions: Although high variability exists in the actual number of lymph nodes obtained from various nodal stations, a complete mediastinal lymphadenectomy should obtain one or more lymph nodes from each mediastinal station. Adequate mediastinal lymphadenectomy should include exploration and remove of lymph nodes from stations 2R, 4R, 7, 8, and 9 for right sided cancers and stations 4L, 5, 6, 7, 8 and 9 for left sided cancers. No significant financial relationships to disclose.

Distribuição de linfonodos no mesorreto – implicações na excisão total do mesorreto

Introdução: A excisão total do mesorreto teve grande impacto na diminuição das taxas de recidiva local no câncer retal. Entretanto o número e a distribuição de linfonodos pelo mesorreto permanecem controversos. Estudos indicaram maior prevalência de linfonodos no terço posterior médio e dois terços superiores do mesorreto. Para confirmar a baixa freqüência de linfonodos distais realizamos estudo em cadáveres com maior número de corpos. Métodos: Realizamos uma excisão total do mesorreto por incisão abdominal mediana em 18 cadáveres frescos. Dividimos o mesorreto em duas porções laterais e um posterior, e definimos 3 níveis de proximal a distal. Após dissecção dos linfonodos sem solução de limpeza específica, a confirmação histológica e a determinação de localização e tamanho dos linfonodos foi realizada. Resultados: Em média, encontramos 5.0±3.7 LN/peça, com tamanho de 3.0±2.7mm. Não houve associação entre número de LN e tamanho com sexo, IMC ou idade. Constatamos maior prevalência de LN posteriores (2.8 LN/paciente) quando comparados a laterais (0.8 e 1.2 LN/paciente;p=0.02). Não houve diferenças entre os níveis do reto. Conclusão: Linfonodos no tecido mesoretal são em sua maioria pequenos e de localização posterior. Não há diminuição no número de linfonodos no terço mais distal do mesorreto.

Récidives ganglionnaires axillaires après lymphadénectomie sentinelle pour cancer du sein

The aim of this review is to summarize the current knowledge about axillary recurrences after sentinel lymph node (SLN) biopsy for breast cancer. A Pubmed search for publications (in English or French) related to breast cancer, SLN and axillary recurrence was carried out from 1995 to 2006. Under controlled conditions (notably after a learning curve concerning the multidisciplinary team), the SLN procedure proved to be a reliable method for evaluation of axillary nodal status in selected patients with early-stage invasive breast cancer. When the SLN is free of cancer cells, the rate of axillary recurrence varies from 0% to 2% with a follow-up ranging from 14 to 57 months. Recurrence after axillary lymph node dissection is similar. When isolated cancer cells or micrometastases invaded the SLN, the rate of axillary recurrence remains low, but a complete axillary lymph node dissection must be performed to reduce this rate significantly. The use of intraoperative miniaturized gamma cameras could contribute to the optimization of the SLN procedure and to reduce axillary recurrences.

Inguinal Sentinel Node Dissection versus Standard Inguinal Node Dissection in Patients With Vulvar Cancer: A Comparison of the Size of Metastasis Detected in Inguinal Lymph Nodes

The conventional treatment for vulvar cancer is radical vulvectomy accompanied by en bloc inguinofemoral lymphadenectomy, but chronic lymphedema and wound breakdown both occur in more than half of operated patients. These problems are less prevalent when limited surgery is carried out, consisting of wide local excision and dissection of superficial groin nodes. Dissection of the inguinal sentinel lymph node (SLN) reportedly is a highly sensitive means of detecting metastases in the inguinal nodes. This retrospective study comprised 336 inguinal node dissections in patients with primary vulvar malignancies. Complete inguinal lymph node dissection was carried out in 284 women and SLN dissection in 52. All participants had nonpalpable inguinal nodes no larger than 1 cm in size. The investigators hypothesized that SLN dissection would disclose smaller metastases in impalpable inguinal nodes. Lymphoscintigraphy was used to detect the SLN after intradermal peritumoral injection of technetium-99m-labeled sulfur colloid. Isosulfan blue or methylene blue was injected at the same sites before dissecting the lymph nodes and radically excising the vulvar tumor. Inguinal node metastases were discovered in 58 patients, 30 of whom had no clinical evidence of nodal metastasis. The size of inguinal node metastases was compared in 7 groins having metastases detected by SLN dissection and 23 undergoing CND. Metastatic foci averaged 2.5 mm in the SLN group and 4.35 mm in the CND group-not a significant difference. There was, however, a significant difference in the size of cell clusters, smaller clusters being present in women having SLN dissection. A majority of women in both groups had stage III vulvar cancer. The size of primary vulvar tumors did not differ significantly in the SLN and CND groups. In women operated on for vulvar cancer, SLN dissection may detect smaller foci of disease than traditional CND. SLN with ultrastaging can detect isolated micrometastases and smaller clusters of metastatic cells. Whether this is clinically relevant remains to be determined.

Lymphatic mapping of ductal carcinoma in situ diagnosed by stereotactic core needle biopsy

10507 Background: About 20% of ductal carcinoma in situ (DCIS) lesions diagnosed by stereotactic core needle biopsy (SCNB) are shown to be invasive on postoperative pathology examination. Sentinel lymph node biopsy (SLNB) is an accurate method of evaluating axillary lymph nodes in patients with invasive breast cancer. The aim of this study was to review our experience with lymphatic mapping in patients with a SCNB diagnosis of pure DCIS, to evaluate the DCIS underestimation rate and consequently the risk of lymph node metastases. Methods: Files from 160 patients diagnosed with pure DCIS by SCNB between July 1999 and March 2005 were retrieved from our database. Patients with DCIS were selected for SLNB if there was concern for presence of an invasive component on the basis of size, palpability or imaging. Results: The median age of the study group was 55 years (range 29–85 years) and median DCIS size on mammography was 25 mm (range 4–96 mm). Thirty-six (23%) out of the 160 women underwent a SLNB. Macrometastases in the sentinel node were detected in seven (19%) patients and one (3%) patient was found to have a micrometastasis. Twenty (56%) of these 36 patients had invasive lesions on final pathology. Of the 124 women who did not receive SLNB, 29 (24%) turned out to have invasive lesions on postoperative evaluation. In total, 49/160 (31%) patients with pure DCIS diagnosed by SCNB had invasive breast cancer (range pT1mic-pT2) on final pathology. Finally, 88 patients underwent lymphatic staging by SLNB, basal node sampling or complete axillary lymph node dissection. Nodal involvement was present in 14 (16%) out of these 88 patients with initially diagnosed DCIS: 36% in patients with invasive breast cancer and 2% with pure DCIS on final pathology. Conclusion: Postoperative pathology examination of the specimen demonstrates DCIS underestimation in nearly one third of SCNB diagnosed DCIS patients. SLNB is of benefit for these patients as in 19% of the patients who undergo a SLNB macrometastatic disease in the sentinel node can be found. No significant financial relationships to disclose.