Impalpable Nodes Research Articles

Concordance between Axillary Ultrasound and Sentinel Biopsy in Clinically Node-Negative Early Breast Cancer

Objective: To determine the sensitivity of axillary ultrasound in detecting axillary nodal metastasis in clinically and radiologically uninvolved axillary nodes in early carcinoma breast by comparing with sentinel node biopsy histopathology on frozen section. Study Design: Comparative cross-sectional study Place and Duration of Study: Breast Clinic, CMH, Rawalpindi Pakistan, from Aug 2020 to May 2021. Methodology: Patients included in the study presented with breast cancer lesions with clinically impalpable axillary lymph nodes aged 18-75. Patients with clinically impalpable nodes underwent an ultrasound of the axilla; if suspicious nodes were found, the patient had subsequent axillary node dissection. Sentinel node biopsy (SLNB) was performed on axillary ultrasound in all patients with no suspicious or benign-looking nodes. Histopathological reporting was taken as standard. Lymph nodal status on axillary ultrasound, SLN biopsy and axillary lymph node clearance were documented and analyzed. Results: Twenty-nine patients were included who had benign-looking lymph nodes on axillary ultrasound and underwent sentinel lymph node biopsy. The mean age of the patients was 54.03 ± 7.94. Out of 29 patients, 24(82.8%) patients had negative Sentinel lymph node biopsy, and 5(17.2%) had positive Sentinel lymph node biopsy, who then underwent axillary lymph node dissection. Conclusion: Sentinel lymph node biopsy is the gold standard to determine axillary lymph nodes involved in early carcinoma breast, which seem benign on pre-operative axillary ultrasound.

PD53-04 IMAGE DIRECTED STRATIFICATION OF PATIENTS TO LYMPH NODE STAGING PROCEDURES IN PENILE CANCER IMPROVE OUTCOME? 10-YEAR STUDY IN >150 PATIENTS

You have accessJournal of UrologyPenile & Testicular Cancer: Penile & Testicular Cancer II (PD53)1 Sep 2021PD53-04 IMAGE DIRECTED STRATIFICATION OF PATIENTS TO LYMPH NODE STAGING PROCEDURES IN PENILE CANCER IMPROVE OUTCOME? 10-YEAR STUDY IN >150 PATIENTS Prakrit Kumar, Arne Juette, Davina Pawaroo, Richard Ball, Krishna Sethia, and Vivekanandan Kumar Prakrit KumarPrakrit Kumar More articles by this author , Arne JuetteArne Juette More articles by this author , Davina PawarooDavina Pawaroo More articles by this author , Richard BallRichard Ball More articles by this author , Krishna SethiaKrishna Sethia More articles by this author , and Vivekanandan KumarVivekanandan Kumar More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002080.04AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Survival in penile cancer is largely determined by lymph node (LN) metastasis. Dynamic Sentinel Node Biopsy (DSNB) staging procedure has a false negative rate of 5-13%. We use image directed stratification patients to LN staging procedures as opposed to palpability and report the outcomes including survival. METHODS: 158 consecutive patients (316 inguinal basins (IB)), who had lymph node surgery for penile cancer in a tertiary referral centre from Jan 2008 to 2018, were included in the study. All patients underwent ultrasound (US) +/-fine needle aspiration cytology (FNAC) and then MRI/ CT, if needed to stage their disease. We used combined clinical and radiological criteria to stratify patients for DSNB vs inguinal lymph node dissection (ILND). RESULTS: 241 IBs had DSNB due to clinically node negative disease (cN0) and 71 IBs had ILND due to abnormal nodes (cN+) and 4 IBs were observed due to non-drainage in sentinel node scan. 27(11.2%), 39 (54.9%) and 0 of those had nodes positive for metastasis respectively. The minimum and mean follow-up is 28 and 65 months respectively. FNR is 0%. All the 25 bilateral ILND patients had cross-sectional imaging. 13 had CT, 11 had MRI and 1 had both. Of the 108 DSNB patients, 30 had MRI, 34 had CT, and one both. 43 patients who had normal ultrasound (U1-2) and impalpable nodes did not have any cross-sectional imaging. Interestingly, only 2/43 (4.7%) patients who did not have cross-sectional imaging were DSNB-positive for micro-metastatic disease as opposed to 14/64 (21.9%) of imaged patients (p=0.03). 11 IBs in 9 patients had ILND dictated by cross-sectional imaging despite having negative US+FNAC and impalpable nodes. 3 IBs in 3 patients had metastatic disease on which 2 had CT and one MRI. We believe these 3 cases could have become a false negative in palpability+US FNAC protocols. Mean cancer specific survival (CSS) of all node-positive patients was 105 months. There was a difference in OS depending on which staging investigation was done at the outset (i.e., DSNB vs ILND (108 vs 72 months, p<0.0001). Further pN+ patients identified by DSNB had no significant difference in CSS compared to direct ILND patients (89 vs 92 months, p=0.124). CONCLUSIONS: Our enhanced clinical-radiological stratification criteria eliminated FNR for DSNB. Cross sectional imaging further sub stratifies patients in to 3 risk categories for micro-metastasis. Node positive patients had poor OS compared to node negative patients. However there was no difference in CSS in pN+ patients if either DSNB or ILND is used. This is first report of survival in lymph node staging in penile cancer. Source of Funding: none © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e917-e917 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Prakrit Kumar More articles by this author Arne Juette More articles by this author Davina Pawaroo More articles by this author Richard Ball More articles by this author Krishna Sethia More articles by this author Vivekanandan Kumar More articles by this author Expand All Advertisement Loading ...

Management of clinically node-negative groin in patients with penile cancer.

Malignant penile neoplasms are commonly squamous etiology, with the inguinal nodes being the first echelon of spread. The disease spreads to the pelvic lymph nodes only after metastases to the groin nodes, and this is the most important prognostic factor in penile carcinoma. While treatment of penile carcinoma with proven metastases to the inguinal lymph nodes mandates ilioinguinal lymph node dissection, the treatment of patients with impalpable nodes is more controversial. Overtreatment leads to excessive treatment-related morbidity in these patients, while a wait-and-see policy runs the risk of patients presenting with inguinal and distant metastases, which would have been curable at presentation. Unfortunately, no single imaging modality has been proved to be convincingly superior in the staging, and hence, management of the clinically negative groin has been subject to debate. While some high volume centers have promoted the use of dynamic sentinel lymph node biopsy, others advocate the use of the modified inguinal lymph node template to stage the groin adequately. Newer techniques such as video endoscopic inguinal lymph node dissection have been introduced as an alternative to the original radical inguinal lymphadenectomy to reduce morbidity.

Incidence and Magnitude of Complications Related to Modified Inguinal Lymph Node Dissection for Patients with Penile Squamous Cell Carcinoma

Objective: We investigated complications related to modify inguinal lymph node dissection (ILND) for penile squamous cell carcinoma (PSCC). Modified ILND was performed for poor performance status, groins with contralateral impalpable nodes in unilateral palpable nodes, and conventional indications.Methods: From April 2011 to November 2016, modified ILND was performed at the Yokohama City University Medical Center and its hospital for 16 groins of 12 patients with penile cancer. Seventeen groins of 11 patients who underwent radical ILND were compared (control group).Results: The mean age of 12 patients at surgery was 67.2 years; mean follow-up was 17.1 months. Skin edge necrosis was observed in 18.8% (3/16) in the modified ILND group. However, the percentage of skin necrosis in the radical ILND group was 94.1% (16/17), which was significantly higher than that in the modified group. The mean duration of drain placement was 6.7 ± 2.6 days, which was significantly shorter than that of the radical ILND group (p=0.005). The incidence of leg edema was 25.0%; leg edema had no influence on walking in any case. One patient died of local recurrence and two died of distant metastasis. No locoregional recurrence was reported after modified ILND. The remaining patients survived with no evidence of disease.Conclusion: Complications occurred less often for modified ILND than for radical ILND. Modified ILND might be a substitute for radical ILND in PSCC patients when dissection of impalpable intermediate-risk or high-risk nodes cannot be performed.

DaPeCa-1: diagnostic accuracy of sentinel lymph node biopsy in 222 patients with penile cancer at four tertiary referral centres - a national study from Denmark.

To estimate the diagnostic accuracy of sentinel lymph node biopsy (SNB) in patients with penile cancer and assess SNB complications in a national multicentre setting. Retrospectively data were collected from records in four university centres by one medical doctor covering all SNBs performed in Denmark between 1 January 2000 and 31 December 2010. Patients had either impalpable lymph nodes (LNs) in one or both groins, or had a palpable inguinal mass from which aspiration cytology failed to reveal malignancy. Patients were injected with nanocolloid technetium and had a scintigram recorded before the SNB. The primary endpoint was LN recurrence on follow-up. The secondary endpoint was complications after SNB. Diagnostic accuracy was computed. In all, 409 groins in 222 patients were examined by SNB. The median (interquartile range) follow-up of patients who survived was 6.6 (5-10) years. Of 343 negative groins, eight were false negatives. The sensitivity was 89.2% (95% confidence interval 79.8-95.2%) per groin. Interestingly, four of 67 T1G1 patients had a positive SNB. In all, 28 of 222 (13%) patients had complications of Clavien-Dindo grade I-IIIa. Penile cancer SNB with a close follow-up stages LN involvement reliably and has few complications in a national multicentre setting. Inguinal LN dissection was avoided in 76% of patients.

Optimal management of T1G2 penile cancer remains unclear

Whether or not inguinal lymphadenectomy benefits patients with superficial penile carcinoma and clinically impalpable lymph nodes is a controversial issue. New evidence supports active surveillance for patients with T1G1 tumours and inguinal lymphadenectomy for those with T1G3 cancer, but the optimal management of patients with T1G2 disease remains unclear.

Role Of Ultrasound Of Axilla Prior To Sentinel Node Biopsy

Background: Preoperative ultrasound of the axilla in breast cancer patients detects number of impalpable lymph nodes. Fine needle aspiration cytology (FNA) will reduce the need for SLNB, this has clinical, emotional and financial advantages to both patient and surgeon.

Non-invasive and minimally invasive staging of regional lymph nodes in penile cancer

The management of the regional lymph nodes in penile cancer patients, particularly when these lymph nodes are impalpable, remains controversial. Prophylactic bilateral inguinal lymphadenectomy is associated with high morbidity and is often unnecessary. However, there is no non-invasive or minimally invasive staging technique that can determine the lymph node status of penile cancer patients with 100% accuracy. We reviewed the current literature to examine the role of non-invasive and minimally invasive techniques for staging regional lymph nodes in penile cancer with particular reference to clinically impalpable disease. Cross-sectional imaging (un-enhanced CT and MRI) modalities have a role in the assessment of patients with palpable inguinal basins and in locating distant metastases, but are unreliable in staging impalpable regional lymph nodes. The spatial resolution of lymphotropic nanoparticle enhanced MRI (LNMRI) and positron emission tomography (PET)/CT are limited to several millimetres and so these modalities cannot reliably detect micro-metastases (<2 mm). Ultrasound (US) and fine-needle aspiration cytology (FNAC) are indicated in staging palpable inguinal basins but are unreliable in isolation in the assessment of impalpable lymph nodes. They are, however, useful as an adjunct to dynamic sentinel lymph node biopsy (DSLNB) in lowering false-negative rates. While we await staging modalities that can equal the results of DSLNB with fewer disadvantages, histological staging in the form of DSLNB remains the best minimally invasive staging modality we can offer at risk patients presenting with clinically node negative groins.

A prospective study of 100 cases of penile cancer managed according to European Association of Urology guidelines

To prospectively assess the outcome of patients treated according to the European Association of Urology (EAU) guidelines on the management of penile cancer, a system originally based on retrospective series. Between 2002 and 2005, 100 consecutive patients (median age 62 years) with penile cancer were treated at one institution; all were categorized and treated according to EAU guidelines. Data were analysed using the z-test, with significance defined as P < 0.05. Survival curves were limited to those with >12 months of follow-up (mean 29); the survival of the whole group was 92%. Of men with palpable nodes, 72% had lymph node involvement, whereas 18% of those with impalpable nodes who had lymphadenectomy according to the guidelines had lymph node disease. The grade of the primary tumour was more predictive than T stage for lymph node involvement and survival. The 3-year disease-specific survival for N0, N1 and N2 disease was 100%, 100% and 73%, respectively, and survival at 12 months for N3 disease was 67%. The median survival for those with metastases was 3 months. The overall survival of men with penile cancer is high, with a clear benefit for early lymphadenectomy in men with positive nodal disease. However, the current EAU guidelines are limited in predicting those patients with micrometastatic disease, with the result that 82% of patients undergo unnecessary prophylactic lymphadenectomy. There is a need to identify more accurate molecular markers for predicting lymph node disease, or the role of novel staging techniques must be assessed.

Dynamic Sentinel Node Biopsy in Penile Carcinoma: Evaluation of 10 Years Experience

AbstractPurpose: The aim of this study was to evaluate the results of 10 years dynamic sentinel node biopsy experience inpenile carcinoma at our institute.Patients and Methods: 140 patients with clinically node-negative groins were prospectively included. Lymphos-cintigraphy was performed after injection of 99m Technetium-nanocolloid around the primary tumour. The sentinelnode was intraoperatively identified with the aid of patent blue dye and a gamma ray detection probe. Lymph nodedissection was performed only if sentinel node metastasis was found. Median follow-up was 52 months (range 5–129).Results: Lymphoscintigraphy visualized at least 1 sentinel node in 138 patients. Sentinel node metastasis was foundin 37 inguinal regions of 31 patients. The sentinel node was the only tumour-positive node in 78% (29/37) of thedissection specimens. Complications occurred in 8% (17/206) of the operated groins. False-negative results wereencountered in 6 patients resulting in a false-negative rate of 16% (6/37 patients). 5-year disease-specific survivalwas 96% and 66% for patients with a tumour-negative sentinel node and tumour-positive sentinel node, respectively(p = 0.001).Conclusion: Dynamic sentinel node biopsy in penile carcinoma is of important diagnostic, prognostic, andtherapeutic value at the cost of only minor morbidity.# 2004 Elsevier B.V. All rights reserved.Keywords: Penis; Penile neoplasms; Sentinel node biopsy; Lymph node excision; Lymphatic metastasis;Analysis; Survival1. IntroductionThe management of impalpable nodes in patientswith penile carcinoma has been subject of controversyfor many years and various approaches have been used.The most invasive approach is elective bilateral ingu-inal lymph node dissection, and the least invasive a‘‘wait and see’’ policy. A significant disadvantage ofthe former is the accompanying morbidity. Moreover itis considered unnecessary, as the regional lymph nodebasin is not tumour-affected in up to 80% of thepatients [1]. The disadvantage of a wait and seeapproach is a possible poorer prognosis at the timethat tumour involved lymph nodes become palpableduring follow-up [2,3]. Several investigators have triedto solve the problem by setting up selection criteria ofpatients in whom elective inguinal lymphadenectomyis indicated. Histopathological characteristics of theprimary tumour, such as depth of invasion (T-stage),

Role of dynamic lymphoscintigraphy in identifying inguinal nodal metastases in penile cancer

The concept of sentinel lymph node was originally described in penile cancer. With technical developments and refinements it may have a role in staging men with penile cancer whose inguinal nodes are impalpable. We examined the current evidence supporting dynamic sentinel lymph node biopsy (DSLB). In particular we compared the false-negative rate compared to conventional inguinal lymph node dissection. Further, we discuss the advantages of the minimally invasive approach. Pioneering work in the Netherlands appears to be reducing the false-negative rates to acceptable levels. However, longer follow-up is necessary before recommending DSLB for cases of penile cancer with impalpable lymph nodes. Dynamic sentinel lymph node biopsy has great potential for avoiding the morbidity associated with inguinal lymph node dissection. More mature data is necessary prior to advocating its introduction outside of randomized controlled studies.

PATIENTS WITH PENILE CARCINOMA BENEFIT FROM IMMEDIATE RESECTION OF CLINICALLY OCCULT LYMPH NODE METASTASES

In this retrospective study we compared the clinical outcome of early vs delayed excision of lymph node metastases in patients with penile squamous cell carcinoma. A total of 40 patients with a T2-3 penile carcinoma with lymph node metastases were included in this study. All patients initially presented with bilateral impalpable lymph nodes. In 20 patients (50%) metastases were removed when they became clinically apparent during meticulous followup (median interval 6 months, range 1 to 24). There were 20 patients (50%) who underwent resection of inguinal metastases detected on dynamic sentinel node biopsy before they became palpable. The histopathological characteristics of the tumors and lymph nodes were reevaluated. The 2 populations were similar in terms of patient age, T-stage, pathological tumor grade, vascular invasion and infiltration depth. Disease specific 3-year survival of patients with positive lymph nodes detected during surveillance was 35% and in those who underwent early resection, 84% (log rank p = 0.0017). In multivariate analysis early resection of occult inguinal metastases detected on dynamic sentinel node biopsy was an independent prognostic factor for disease specific survival (p = 0.006). Early resection of lymph node metastases in patients with penile carcinoma improves survival.

The Usefulness of Ultrasound-Guided Fine Needle Aspiration Cytology of Impalpable Neck Nodes in Patients with Lung Cancer

Background:In lung cancer patients, the presence of metastatic neck nodes is a crucial indicator of inoperabilty. So thorough physical examination of neck is always mandatory, but sometimes those are hardly palpable even by the skillful hand. Ultrasonography is a useful diagnostic method in detection of small impalpable lymph nodes and in guidance of fine needle aspiration biopsy. In this study we evaluated the clinical usefulness of ultrasonography(USG) and ultrasound-guided fine needle aspiration cytology(US-FNA) in lung cancer patients without palpable neck nodes.Methods and Materials:From Sep 2002 to Sep 2003, 36 non-small cell lung cancer patients (20 adenocarcinoma, 16 squamous cell cancer) and 10 small cell lung cancer patients without palpable neck nodes on physical examiation were enrolled. patients who had contralateral mediastinal nodal enlargement(>1cm) on chest CT were excluded. After the routine check of USG on the neck, US-FNA was done in cases with enlarged neck nodes (≥5 mm in the short axis). The presence of enlargedAddress for correspondence :Chul Ho Oak, M.D.Department of Internal Medicine, College of Medicine, Kosin University34 Amnam-dong, Suh-ku, Busan, 602-702, KoreaPhone : 051-990-6460 Fax : 051-990-3005 E-mail : oaks70@dreamwiz.com

The Usefulness of Ultrasound-Guided Fine Needle Aspiration Cytology of Impalpable Neck Nodes in Patients with Lung Cancer

Background : In lung cancer patients, the presence of metastatic neck nodes is a crucial indicator of inoperabilty. So thorough physical examination of neck is always mandatory, but sometimes those are hardly palpable even by the skillful hand. Ultrasonography is a useful diagnostic method in detection of small impalpable lymph nodes and in guidance of fine needle aspiration biopsy. In this study we evaluated the clinical usefulness of ultrasonography(USG) and ultrasound-guided fine needle aspiration cytology(US-FNA) in lung cancer patients without palpable neck nodes. Methods and Materials : From Sep 2002 to Sep 2003, 36 non-small cell lung cancer patients (20 adenocarcinoma, 16 squamous cell cancer) and 10 small cell lung cancer patients without palpable neck nodes on physical examiation were enrolled. patients who had contralateral mediastinal nodal enlargement(>1cm) on chest CT were excluded. After the routine check of USG on the neck, US-FNA was done in cases with enlarged neck nodes ( in the short axis). The presence of enlarged lymph node on USG, and of malignant cells on cytology were evaluated by the histological type and the patients' clinical stage of lung cancer. Results : Among 36 non-small lung cell cancer patients, 14 (38.8%) had enlarged neck nodes on USG, and 5 of 10 small cell lung carcinoma patients. The mean diameter of the neck nodes was 9.8 mm (range, 7-12 mm). US-FNA of 14 non-small cell lung cancer patients revealed tumor cells in eight patients (57.1%). In 5 small cell lung cancer pateints, tumor cells were found in all cases. By the result of US-FNA, the clinical stage of 8 out of 36 (22.2%) non-small cell lung cancer patients had changed, including two cases of shift from the operable IIIa to the inoperable IIIb. In small cell lung cancer patients their clinical stage was not changed after US-FNA, but their pathological diagnosis was easily done in two cases, in whom endobronchial lesions were not found on bronchoscopy. Conclusions : USG and US-FNA of neck node seem to be safe, sensitive and cost-effective diagnostic tools in the evaluation of lung cancer patients without palpable neck nodes.

Receptor scintigraphy of non-neuroendocrine cancers with In-111 pentetreotide.

Somatostatin receptors (SR) are surface markers characterizing not only APUDomas associated with neuroendocrine identities but also malignancies without neuroendocrine expression. Recently, the somatostatin analog pentetreotide was labeled with In-111 (OctreoScan 111, Mallinckrodt Medical BV, Petten, Holland) and introduced for the in vivo visualization in man of SR-positive tissues. In the present report, SR-specific scintigraphy is evaluated as a clinical tool for tissue characterization in correlation with histological and radiological examinations. Scintigraphy was focused and performed in cancer types without neuroendocrine tissue expression such as brain (n = 6) and breast tumors (n = 9) and lymphomas (n = 5). Scintigraphy was performed for comparison at 6 and 22 h after i.v. application of 111 MBq (3 mCi) of In-111-Pentetreotide. In the breast cancer group, the primary tumor was visualized in all 9 women as well as in all 4 cases with palpable axillary lymph nodes. Three women with a negative axillary node scan and impalpable nodes had positive biopsy. In two cases, mediastinal lymph node involvement was observed. So far the role of SR-positive breast cancer (BC) scans remains unknown. It is tempting to speculate that in resected women who are histologically and scintigraphically SR positive, it might be of value in the early detection of symptom-free recurrences. High densities of SR were present within both meningiomas, the high-grade astrocytoma and the craniopharyngioma. Differentiation of low- and high-grade astrocytomas could not be successfully achieved because both grades showed intense radioactivity uptake, even though high-grade tumors lack SR. The latter might be due to the damaged blood-brain barrier and the poor radioactivity washout observed in high-grade astrocytomas. All five lymphomas could be detected due to the presence of activated lymphocytes and macrophages that express SR at a sufficient density. In conclusion, SR scintigraphy in non-neuroendocrine malignancies does not seem to be reliable for an initial tumor staging but rather more suitable for a tissue characterization and extremely useful for monitoring changes of SR expression after treatment.

Interpectoral nodes in carcinoma of the breast: requiem or resurrection.

Fifty-eight consecutive patients undergoing a modified radical mastectomy were subjected to complete dissection and pathological assessment of the interpectoral fascia and the group of lymph nodes it contains. The dissection was carried out in all patients, irrespective of whether they were palpable or not. Interpectoral nodes (IPNs) were anatomically present in 28 patients (48%) and were completely absent in 30 patients (52%). Ten patients were Stage I, 18 were Stage II, and 30 were Stage III. Of the 25% (15/58) of patients with microscopic metastasis, only 12/15 had palpable nodes; 66% (10/15) of patients had axillary and apical nodes positive. Significantly, two patients with negative nodes in the axillary and apical group had metastatic Rotter's nodes. Of the 15 patients with positive IPNs, nine had primary tumors located within the upper quadrants of the breast, whereas only five had tumors in lower quadrants and one had a centrally located tumor. The neurovascular bundle to the pectoralis major could be safely preserved in 93% (54/58) of patients. The incidence of impalpable nodes with microscopic metastasis and the evidence of exclusively metastatic interpectoral nodes with uninvolved axillary and apical nodes prompt the following conclusions: (1) interpectoral fascia and nodes should be mandatorily dissected in all patients irrespective of the nodes being palpable or not; (2) the dissection is anatomic and is associated with almost no additional morbidity; (3) the group of patients with IPNs positive and the axillary group negative, would benefit maximally from the IPN dissection. Similarly, this dissection in all other groups of patients would enable a more accurate staging and selection of therapeutic strategies.

Management of accidentally found pathological lymph nodes on routine screening mammography

Normal lymph nodes in the anterior part of the axilla are readily seen on routine mammography. It is important, however,to recognize pathological lymph nodes, characterized by increased attenuation, high density, a round or irregular shape and lack of fat in the hilus, as they often indicate significant diseases. We examined the final diagnosis in 22 patients referred for clinical examination from a mammographic screening programme because of pathological lymph nodes without concomitant breast malignancy. Ten of them were found to have a malignant lesion, and one had sarcoidosis. None of the malignancies had been diagnosed before screening. Among women with abnormal but impalpable nodes, only one malignancy was found (in a woman with previous breast cancer), whereas nine of 13 women with palpable nodes had malignancies. Seven malignant lymphomas were discovered, but among all 60 women of the age group in question with newly diagnosed lymphomas in the region, only 13 had pathological axillary nodes. Mammography cannot therefore be used as a screening method for lymphoma. We conclude that mammographically pathological lymph nodes in the axilla should be examined clinically and propose a simple programme for patient management.

IMMUNOSCINTIGRAPHY FOR DETECTION OF LYMPH NODE METASTASES FROM BREAST CANCER

A radiolabelled monoclonal antibody that reacts with human breast cancer was injected into the web space of each hand in eight women with breast cancer, and the axillae were scanned 16-24 h later. Scans were positive in seven axillae with palpable lymph nodes and in two axillae with impalpable lymph nodes (metastases later confirmed by needle aspiration). The scan was negative in one axilla with a palpable mass, and here no tumour cells were obtained on needle aspiration. In a man with axillary lymphoma, no specific binding of antibody was observed. This technique could lead to earlier and more precise diagnosis of lymph node metastasis in patients with breast cancer.

Oestrogen receptors and primary breast cancer.

Oestrogen receptor activity has been determined in the primary tumours from 243 patients with breast cancer and the subsequent clinical course of the disease has been followed for one to five years. Patients with oestrogen receptor-negative tumours had significantly shorter disease free intervals and survival times than those with receptor-positive tumours. Patients with large tumours, or with palpable axillary lymph nodes, or with histopathologically proven involvement of axillary lymph nodes also had a poorer prognosis than those with small tumours, impalpable nodes or histopathologically noninvaded nodes. The prognostic value of oestrogen receptor status was independent of these other three indices so that combination of receptor status and node status permitted definition of groups of patients with particularly good and particularly bad prognosis. The independence of these prognostic indices may relate to the possibility that whilst oestrogen receptor status is an index of the intrinsic biological behaviour of the tumour, nodal involvement and tumour size are more likely to reflect the chronological stage in the course of the disease at which the patient presents.

Scalene node biopsy in the pretreatment staging of carcinoma of the cervix uteri

This study reports the experience at the Ellis Fischel State Cancer Hospital with the use of scalene node biopsy for the pretreatment evaluation of patients with carcinoma of the cervix uteri. The study was stimulated by a report from the National Cancer Institutes which stated that impalpable scalene nodes contained metastatic cancer in 13 per cent of a series of 84 cases. By a meticulous biopsy technique, we were unable to confirm this high incidence. In a series of 73 cases, no impalpable lymph nodes were found to contain metastatic cancer regardless of the clinical stage of the cancer. Consequently, we have terminated the use of scalene lymph node biopsies in the staging of cervical cancer for primary treatment. The study is still in progress to evaluate patients with recurrent cervical cancer who may possibly require pelvic exenteration. Also, the procedure will be continued in patients referred for further treatment in whom carcinoma was first diagnosed as an unsuspected finding in a hysterectomy specimen.