Lymph Nodes In Breast Cancer Patients Research Articles

CT Based Lymphatic Mapping and Localization – A New Method To Detect Sentinel Lymph Node in Breast Cancer Patients.

Abstract Background: Sentinel lymph node biopsy in breast cancer patients has not been extensively accepted in mainland China. The main reason is that radioisotope tracer is not available in many hospitals. The objective of this study is to explore CT based lymphatic mapping and localization. The accuracy will be evaluated comparing SLN found by CT with those found by isotope and blue dye.Methods: 18 breast cancer patients who diagnosed by core needle biopsy or excisional biopsy underwent CT scan to locate the SLN before SLNB at the same day of surgery. When CT examination performed, those patients were in supine position, with the arms stretched upward but bent at the elbow with the hands at the side of the cranium which similar to the surgical position. After local anesthesia, 2mL of iopamidol was injected subcutaneously to the peritumoral and peri-areolar areas followed by gentle massage for about 1 minute. Contiguous 2-mm-thick CT images that included the breast and axilla were obtained prior to administration of the contrast agent. After 3D CT reconstruction, the SLN was identified as the most inferiorly visible nodule in the axilla connected to the lymphatic vessel on the CT imaging monitor. A professional intervention doctor punctured the defined lymph node guided by the CT monitor using the Breast Lesion Localization Needles (interv). The needle would stay in the patient's axilla until the surgery. All the lymph nodes including the CT defined one and which marked by methylene blue dye or 99mTc-sulfur colloid tracers were removed, which then would be tested by touch imprint cytology for the intraoperative diagnosis. Patients who had positive SLN would receive axillary dissection. We evaluated the new method by comparing lymph nodes defined by CT and traditional ways.Results: In this study, the success rate of SLNB was 100% (18/18). 15 of 18 patients (83.3%) showed the direct connection of SLN and lymphatic vessels draining from the injection sites on CT monitor successfully. 13 of 15 patients' SLN localization corresponded well with SLN identified by the traditional SLN mapping. Of the 40 SLNs in 15 patients, 7 SLNs in 3 patients were positive and received the ALND. These 7 SLNs were all clearly visualized on CT monitor. Among 15 SLNs (in 15 patients) punctured by needles, 13 SLNs had the highest radioactivity by DGP-guided probe and 12 are blue dye–stained. All of the 15 SLNs had radioactivity or blue stained. None of these 18 patients showed any adverse events during or after CT examination and surgery. With the assistant of CT location, the mean time of SLNB had been shortened from 20 mins to 16 mins.Conclusion: Comparing with usual tracing method, CT guided axillary SLN mapping and localization showed good specificity and gave concordant results in locating sentinel lymph nodes. These results suggest that CT guided localization would be a valuable tool for identify sentinel lymph nodes in breast cancer patients. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1035.

Gene Promoter Hypermethylation in Tumors and Matched Affected Lymph Nodes of Breast Cancer Patients.

Abstract Gene promoter hypermethylation plays a pivotal role in breast carcinogenesis and breast cancer progression. In this study, we investigated 6 gene promoters (RASSF1A, HIN-1, RARβ2, TWIST, CCND2 and APC) for aberrant DNA methylation by real-time methylation-specific PCR in primary tumors and matched affected lymph nodes from 30 patients with breast cancer. These data were used to explore associations between gene promoter hypermethylation and clinicopathological features, including tumor cell proliferation, angiogenesis and hypoxia marker expression.Overall, gene promoter methylation levels (ratios of DNA copy numbers for methylated and reference genes) were higher in primary tumors than in matched lymph nodes. Notably, we found significant correlations between methylation levels in primary tumors and matched lymph nodes for 5 of 6 genes (P<0.05). An identical gene promoter methylation status (high or low according to the median methylation level) in primary tumors and matched lymph nodes was observed in 67% to 83% of cases. No significant associations between risk factors and gene promoter hypermethylation of the 6 genes was observed, except for the degree of spreading into nearby lymph nodes, which associated with high RASSF1A methylation levels in tumors (P=0.020) and high CCDN2 methylation levels in lymph nodes, and for HER2 expression, which was most frequently observed in tumors with low HIN-1 methylation levels (P=0.039). HIN-1 methylation levels in tumors negatively correlated with the fractions of proliferating tumor and endothelial cells determined by CD34/Ki-67 immunohistochemistry in both primary tumors (r=-0.594, P=0.001 and r=-0.619, P<0.001) and in lymph nodes (r=-0.412, P=0.024 and r=-0.400, P=0.029). Furthermore, high HIN-1 methylation levels in primary tumors tended to associate with breast tumors lacking expression of the hypoxia marker carbonic anhydrase IX in tumor cells (P=0.063) and associated stroma (P=0.086). CCND2 methylation levels in affected lymph nodes positively correlated with the ratios of the fractions of proliferating tumor cells to the fractions of proliferating endothelial cells observed in both primary tumors (r=0.418, P=0.002) and in lymph nodes (r=0.563, P=0.002).In summary, gene promoter hypermethylation in primary breast tumors and matched lymph nodes are highly correlated. Further studies with larger numbers of samples are necessary to investigate the prognostic or predictive potential of these observations. For two genes, HIN-1 and CCDN2, we observed correlations between gene promoter methylation levels and tumor cell proliferation. HIN-1 and CCDN2 are frequently lost in breast cancer and are both involved in cell cycle regulation. The biological significance of these findings needs to be further explored. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1149.

A Decision Tree To Predict Four or More Positive Axillary Lymph Nodes in Breast Cancer Patients with Positive Sentinel Node Biopsy: Determining Necessity for Regional Nodal Irradiation in the Absence of Axillary Dissection.

Abstract Background: Regional Nodal Irradiation (RNI) is indicated for breast cancer patients with ≥4 positive axillary lymph nodes (ALN). The need for RNI is unclear for women who don't undergo axillary lymph node dissection (ALND) yet have 1-3 positive sentinel lymph nodes (SLN). In an effort to guide clinician decision-making and potentially spare patients combined toxicities of ALND and radiation, the purpose of this study was to create a decision tree of clinicopathologic variable interactions to predict patients with ≥4 positive ALN.Methods: We reviewed the records of 197 women with breast tumors <5cm and 1-3 positive SLN. After ALND, patients were labeled as having < 4 or ≥ 4 positive ALN. Ten clinicopathologic predictive variables were identified for analysis: patient age, size of tumor, histological type, tumor grade, number of metastatic SLN, largest SLN metastasis size, detection method, estrogen receptor, Ki67 and lymphovascular invasion (LVI). The analysis used Chi-Square Automatic Interaction Detection (CHAID SPSS), a non-parametric, stepwise “regression tree” analysis, with Bonferroni adjusted p-values to create a decision tree.Results: 141 patients had < 4 and 56 had ≥ 4 positive ALN. Three variables were selected into the CHAID tree: LVI, the number of metastatic SLNs, and largest SLN metastasis size. 100% of patients (N=42) had < 4 positive ALN if negative for LVI and had only 1 positive SLN with a metastasis size < 0.2cm (p-value < 0.0432). For patients with LVI (N=77), 13 of 14 (93%) had < 4 positive ALN if the SLN metastasis size was < 0.2cm (p < .0014). The highest prevalence of ≥ 4 positive ALN were patients with LVI and a SLN metastasis size > 0.2cm.Conclusion: The CHAID analysis more accurately predicted patients with < 4 positive ALN compared to those with ≥4. The decision tree provides a new tool for the clinician to determine the necessity for RNI without ALND. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1026.

Isolated Tumor Cells in Axillary Lymph Nodes of Breast Cancer Patients: Differential Prognostic Impact of Single Tumor Cell(s) Versus Tumor Cell Clusters, and Microanatomic Location. New Results from the Dutch MIRROR Study.

Abstract BackgroundThe MIRROR study is the largest breast cancer cohort study on pN0(i+) and pN1mi in the sentinel node era, with central pathology review plus restaging according to the 6th AJCC classification, and separate analyses on the impact of systemic adjuvant therapy. In patients not receiving systemic therapy, pN0(i+) as final N-status was shown to be an equally independent prognosticator for disease-free survival as pN1mi compared with pN0 (SABCS 2008, #23, oral). However, pN0(i+) is a heterogeneous group, consisting of single tumor cell(s) and clusters of cells, and consisting of locations in either sinus or parenchyma. We determined the differential impact of size and microanatomic location of nodal involvement on disease-free survival.MethodsWomen operated for breast cancer in all Dutch hospitals in the years 1998-2005, with favorable characteristics (tumor size 1-3 cm and differentiation grade I-II OR tumor size <=1 cm irrespective of grade), having undergone a sentinel node procedure were selected. For this present analysis, only patients with pN0(i+) as final nodal status who had not received systemic adjuvant therapy were included (n=513). Presence of single tumor cell(s) versus tumor cell clusters, and the microanatomic location (sinus versus parenchyma) were recorded. In addition, metastatic size was measured. The primary endpoint was 5-year disease-free survival.ResultsThe 5-year disease-free survival of patients with lymph nodes containing single tumor cell(s) (n=93) was 78.6%, as compared to a 5-year disease-free survival of 77.1% of patients with small clusters of cells (n=404). After adjustment for age, log tumor size, grade, axillary treatment, and hormone receptor status, the adjusted hazard ratio for events was 1.10 (95% CI 0.67-1.78, NS) for the presence of tumor cell clusters as compared to the presence of single tumor cell(s). When including log metastasis size within the pN0(i+) group as a continuous variable in the Cox regression model, increasing metastatic size was borderline significantly associated with reduced 5-years disease-free survival with an adjusted hazard ratio of 1.27 (95% CI 1.00 – 1.61, p=0.05). The adjusted hazard ratio for events was 0.93 (95% CI 0.57-1.51, NS) for the parenchymal (n=112) versus sinusoidal microanatomic location (n=395).ConclusionSingle tumor cell(s) bear similar prognostic information as small tumor cell clusters, even though results do suggest that within the pN0(i+) group increasing size of nodal involvement is associated with reduced survival. Microanatomic location does not seem to have prognostic relevance.Support: The Netherlands organization for health research and development (ZonMw) and the Dutch Breast Cancer Trialists' Group (BOOG) Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 306.

Positive sentinel lymph node biopsy predicts the number of metastatic axillary nodes of breast cancer

It remains to be clarified whether a positive sentinel lymph node biopsy (SLNB) can predict the number of metastatic axillary nodes. This study examined a consecutive series of women with unilateral invasive breast cancer who underwent axillary lymph node dissection after an intra-operative positive SLNB. The numbers of positive and negative sentinel lymph nodes (SLNs) were analyzed for a likelihood of pN1a, pN2a, and pN3a diseases as per the UICC TNM classification. Of the 368 study patients, 165 (45%) had one positive SLN and one or more negative SLNs. This result represented the most common combination of positive and negative SLNs. It was also the most predictive indicator (93%) of pN1a disease and the least predictive indicator (7% or 0%) of pN2a or pN3a disease, respectively. The numbers of positive and negative SLNs can predict the number of metastatic axillary nodes in breast cancer patients.

The utility of a real-time RT-PCR assay for the detection of metastases greater than 0.2 mm in sentinel lymph nodes of breast cancer patients confirmed by detailed histological analysis

628 Background: Analysis using real time RT-PCR for the detection of metastases in lymph nodes (LN) increases sampling but is associated with a risk of too much sensitivity as compared to histological analysis. Determining the appropriate cutoff value is important in introducing this system to routine clinical practice. Our study confirms the reliability of the cutoff values of a real-time RT-PCR assay (GeneSearch, Veridex LLC) to detect metastases larger than 0.2 mm by detailed 0.2 mm frozen section histological diagnosis. Methods: 129 sentinel and non-sentinel lymph nodes were obtained by sentinel LN biopsy from 79 breast cancer patients. All LNs were cut in half. One half of each LN was used for routine intra-operative diagnosis. The other LN half had sections cut every 0.2 mm for histological analysis. All frozen sections were H&E stained and examined by on-site pathologists. These sections were then re-stained immunohistochemically using a pancytokeratin antibody (AE1/AE3) for detecting submicrometastses. All remaining tissue between the histology sections was assayed by the real-time RT-PCR assay using the genetic markers mammaglobin (MG) and cytokeratin-19 (CK-19) (note: tissue processing method was investigational and off-label). Cutoff values were pre-set in a large US study (n = 304). Results: Compared to the histological diagnosis using 0.2 mm interval frozen sections, the real-time RT-PCR results were as follows; sensitivity of 100.0% (34/34), specificity of 93.7% (89/95), and overall accuracy of 95.3% (123/129). Submicrometastases were recognized by IHC in 3 of 95 samples (2 solitary and 1 multiple sites) diagnosed as negative by H&E-stain sections, and 3 samples were negative for RT-PCR. Conclusions: Results of 0.2 mm interval histological analysis suggest a near perfect sensitivity of the real time RT-PCR assay, allowing reliable detection of LN metastases larger than 0.2 mm. In addition, at least three samples with submicrometastases detected by immunohistochemistry for pancytokeratin were above the preset cutoff values of this real time RT-PCR assay. [Table: see text]

A decision tree to predict four or more positive axillary lymph nodes in breast cancer patients with positive sentinel node biopsy: Determining necessity for regional nodal irradiation in the absence of axillary dissection

e11540 Background: Regional nodal irradiation (RNI) is indicated for breast cancer patients with ≥ 4 positive axillary lymph nodes (ALN). The need for RNI is unclear for women with T1–2 tumors and 1–3 positive sentinel lymph nodes (SLN) who don’t undergo axillary lymph node dissection (ALND). In an effort to guide clinician decision-making and potentially spare patients combined toxicities of ALND and radiation, the purpose of this study was to create a decision tree of clinicopathologic variables to predict patients with ≥ 4 positive ALN. Methods: We reviewed the records of 197 women with T1–2 tumors and 1–3 positive SLN. All patients underwent a complete ALND to determine the number of positive ALN. The patients were divided into 2 groups: < 4 or ≥ 4 positive ALN. Ten clinicopathologic predictive variables were identified for analysis: patient age, size of tumor, histological type, tumor grade, number of metastatic SLN, largest SLN metastasis size, detection method, estrogen receptor, Ki67 and lymphovascular invasion (LVI). The analysis used Chi-Square Automatic Interaction Detection (CHAID SPSS), a non-parametric, stepwise “regression tree” analysis, with Bonferroni adjusted p-values to create a decision tree. Results: 141 (72%) patients had < 4 and 56 (28%) had ≥ 4 positive ALN. Three variables were selected into the CHAID tree based upon maximum predictability: LVI, the number of metastatic SLNs, and largest SLN metastasis size. 100% of patients (N=42) had < 4 positive ALN if negative for LVI and had only 1 positive SLN with a metastasis size < 0.2cm (p-value < 0.0432). For patients with LVI (N=77), 13 of 14 (93%) had < 4 positive ALN if the SLN metastasis size was ≤ 0.2cm (p < .0014). The highest prevalence of ≥ 4 positive ALN were patients with LVI and a SLN metastasis size > 0.2cm. Conclusions: The CHAID analysis more accurately predicted patients with < 4 positive ALN compared to those with ≥4. The decision tree provides a new tool for the clinician to determine the necessity for RNI without ALND. No significant financial relationships to disclose.

Predicting the burden of axillary disease in breast cancer patients with a positive sentinel node.

Abstract Abstract #1010 Background: Current practice is to perform a completion axillary lymph node dissection (ALND) for breast cancer (BC) patients with tumor-positive sentinel lymph nodes (SLNs). However, not all patients with positive SLNs have further ALND. Katz et al suggested a nomogram for predicting having four or more positive nodes for SLN-positive BC which could change the adjuvant radiation treatment fields. Our goal is to validate the accuracy in predicting > 4 positive axillary lymph nodes in BC patients with a positive SLN in our institution. Methods: Katz nomogram was developed from the multivariate logistic regression model using tumor histology, primary tumor size, lymphovascular space invasion, extranodal extension, the number of involved SLNs, the number of uninvolved SLNs, and the size of the largest SLN metastasis. Area Under (AUC) Receiver Operating Characteristics Curve (ROC) was calculated for the nomogram and a value more than 0.70 was accepted as providing considerable discrimination. Results: We reviewed the records of 319 patients with invasive BC and positive SLNs who underwent completion ALND at MWH of UPMC. None of these patients received neoadjuvant chemotherapy The mean age was 54.2 (30-84) years. Eighty-nine patients (27.8%) had four or more positive nodes. Histology was invasive ductal carcinoma for 86.2 % of patients. The median tumor size was 2.22 (0.5-8.0) cm. Seventy percent of patients had only one involved SLN. The median size of the largest SLN metastasis on H&E staining was 9.7 mm (range, < 0.2 to 35 mm), and 24.4% of the patients had micrometastases (2 mm). Ninety nine patients (31%) had extranodal extension. The mean predicted probability of having ≥ 4 involved axillary LNs was 31.9 % (range, 1 to 99) in patients with ≥ 4 involved axillary LNs while it was it is 9.1% (range, 0.5 to 80) in patients having < 4 axillary LN metastases (P<0.001). The AUC value was 0.809. Conclusions: The Katz nomogram developed to predict having ≥ 4 involved axillary lymph nodes in BC patients with a positive SLNs is validated in our patients. Nomograms developed at other institutions should be used with caution when counseling patients regarding the risk of additional nodal disease. This nomogram will be helpful to clinicians making adjuvant treatment recommendations in practice. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1010.

Non-image guided fine needle aspiration of palpable axillary lymph nodes in breast cancer patients.

Abstract Abstract #1013 Introduction
 While the utility of ultrasound-guided axillary lymph node FNA is well established, there is a paucity of data on non-image guided office-based FNA of palpable axillary lymphadenopathy. We investigate the sensitivity and specificity of non-image guided FNA of axillary lymphadenopathy in patients presenting with breast cancer, and report factors correlating with a positive FNA result.
 Methods
 Retrospective review of 80 consecutive patients who underwent office-based FNA of palpable axillary lymph nodes between 2004-2008, with cytology results compared with histology during axillary sentinel node or lymph node dissection. Pearson correlation, chi-square and Fisher exact tests were used to determine correlation with other clinical and pathologic data.
 Results
 Mean age was 56 with a median tumor size of 2.2 cm and 39% have pNO disease. Non-image guided axillary FNA was 82% sensitive, 100% specific, and 89% accurate. Positive predictive value was 100% and negative predictive value was 76%. Therefore only 24% of patients who had a negative FNA had axillary involvement compared to 61% for the entire group.
 A significant correlation or association was identified between positive FNA cytology and breast tumor size (p=0.02), number of pathologic positive lymph nodes (p<0.0001), presentation with a palpable breast mass (p=0.003), radiographic lymphadenopathy (p=0.0005), lymphovascular invasion (p=0.003), stage of disease (P<0.0001), and N stage (p<0.0001). There was a borderline significant association with her2neu receptor status (p=0.08).
 Age, lymph node size, ER/PR status, Ki-67 index, tumor histology, multicentric disease, degree of differentiation and nuclear grade were all not significantly correlated or associated with positive FNA.
 Conclusions
 Non-image guided FNA of palpable axillary lymphadenopathy in breast cancer patients is a very sensitive and specific test. Prompt determination of lymph node positivity benefits select patients, permitting avoidance of ultrasound, sentinel lymph node biopsy, or delay in receiving neoadjuvant therapy. This results in time and cost savings for the patient and the health care system, and expedites definitive management of the patient. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1013.

The value of preoperative axillary ultrasound staging in the management of early breast cancer.

Abstract Abstract #1023 Background: The prognosis of breast cancer is strongly associated with the presence of metastatic disease in the axillary lymph nodes at the time of diagnosis. Sentinel lymph node biopsy (SLNB) is the current standard of care for staging a clinically negative axilla in early breast cancer. Approximately 25% of women with early stage breast cancer undergoing SLNB are node positive and require completion axillary lymph node dissection (ALND). Ultrasound guided fine needle aspiration cytology (FNAC) of axillary lymph nodes is a minimally invasive technique that can be used preoperatively to stage the axilla in breast cancer patients, reducing the number of operative procedures required for staging and local control of disease. Aim: To determine the sensitivity and specificity of ultrasound guided axillary FNAC to detect positive axillary lymph nodes in breast cancer patients and to determine the number of patients who avoided unnecessary SLNB. Methods: Newly diagnosed invasive breast cancer patients were prospectively followed from January 2007 to June 2008. Patients with stage IV breast cancer, clinically node positive disease and patients who did not proceed to surgery were excluded. Criteria for a suspicious sonographic axillary node included diffuse cortical thickening >3mm, focal nodular cortical thickening and a mass-like appearance with loss of the fatty hilum. Results: 133 patients who met the inclusion criteria were diagnosed with invasive breast cancer between January 2007 and June 2008. Median age was 60 [21-87]. 49 patients had T1 tumours, 77 patients had T2, and 7 patients had T3 tumours. 126 (95%) patients had axillary ultrasounds, 44 ( 35%) of which showed abnormal axillary lymph nodes. 38 ( 86%) of these 44 patients proceeded to ultrasound guided axillary FNAC and 27 (71%) of these were positive for malignant cells. All patients with positive axillary nodal FNAC underwent axillary clearance and all had positive nodes on final histopathology. The median number of positive nodes was 2, range was 1 to 21. 26 (20%) patients avoided unnecessary SLNB. 82 patients had a negative axillary ultrasound and 27 of these had axillary node positive disease. The median number of positive nodes was 1, the range was 1 to 8.
 
 Conclusion: Ultrasound guided axillary FNAC has a high specificity and positive predictive value in radiologically suspicious nodes. A positive FNAC allows definitive treatment of the axilla in radiological node positive patients and avoids the unnecessary step of SLNB. Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 1023.

The yield of SPECT/CT for anatomical lymphatic mapping in patients with breast cancer

The recently introduced hybrid single-photon emission computed tomography camera with integrated CT (SPECT/CT) fuses tomographic lymphoscintigrams with anatomical data from CT. The purpose of this study was to explore this sophisticated technique in lymphatic mapping in breast cancer patients. We studied 134 patients who underwent SPECT/CT immediately after late planar imaging when these images showed an unusual drainage pattern (85 patients), a pattern that was difficult to interpret (27 patients), or nonvisualization (22 patients). Planar imaging suggested 271 sentinel nodes in 112 of the 134 patients (84%). SPECT/CT showed 269 of these same nodes and indicated that two sites of radioactivity were caused by skin contamination. SPECT/CT visualized 19 additional sentinel nodes in 15 patients, of whom 11 had non-visualization on planar images. One or more tumour-positive sentinel nodes were seen in 27 patients, and in 4 of these patients (15%), these were visualized only by SPECT/CT. SPECT/CT had no additional value for the surgical approach in 11 patients with persisting nonvisualization (8%), and was of questionable value in 67 other patients (50%). Based on the SPECT/CT images, a more precise incision was made in 48 patients (36%), an extra incision was made in 6 (4%), and an incision was omitted in 2 (1.5%). SPECT/CT detected additional sentinel nodes and showed the exact anatomical location of sentinel nodes in breast cancer patients with inconclusive planar images. SPECT/CT was able to visualize drainage in patients whose planar images did not reveal a sentinel node. Therefore, SPECT/CT facilitates surgical exploration in difficult cases and may improve staging.

Implications of Isolated Tumor Cells in Sentinel Lymph Nodes of Breast Cancer Patients

Purpose: Sentinel lymph node (SLN) biopsy has replaced unnecessary axillary dissection in breast cancer surgery except when the nodes are positive for macrometastasis. But guidelines for isolated tumor cells (ITCs) found in SLNs has not yet been established and further study is ongoing. The goal of this study was to consider the implication of the isolated tumor cells found in the SLNs of Korean breast cancer patients. Methods: Between September 2003 and March 2008, 985 primary breast cancer patients underwent SLN biopsy. On reviewing the medical records, 81 patients were found to have ITCs in SLNs without macrometastasis or micrometastasis. ITCs were detected by serial sectioning and immunohistochemistry. Results: The mean number of detected SLNs was 3.5±1.7. Thirty three patients had multifocally distributed ITCs and 9 had ITCs in multiple SLNs whose N stage was N0 (i＋). Completion axillary dissection has been performed in 9 patients and 3 of them (33.3%) finally were found to be N1 or N1mi. Conclusion: The characteristics of ITCs are not clear yet and their prognostic value is still under investigation. Until the significance of ITCs found in SLNs become definite, axillary dissection should be more aggressively considered.

Strategies for optimizing pathologic staging of sentinel lymph nodes in breast cancer patients

Due to the extensive pathologic evaluation of the sentinel lymph node (SLN), micrometastases are frequently observed. If micrometastases are clinically relevant, the histopathologic examination of SLNs should be sensitive enough to detect them. The probability of detecting micrometastases was calculated when examining the SLN according to the current Dutch pathology protocol and strategies evaluated to optimize the chance of detection. The dimensions of 20 consecutive axillary SLNs in patients with cT1-2N0 breast cancer were measured. In a mathematical model, the probability of detecting micrometastases in a SLN was calculated. Similarly, strategies to optimize the probability of detecting micrometastases were explored. When applying the pathology guidelines, the calculated probability to detect a micrometastasis was 18% for a 200-microm micrometastasis and 69% for a 2.0-mm metastasis in a median sized SLN. To detect the smallest micrometastasis in a median-sized SLN with a 95% probability, the interval between the sections must be decreased to 200 microm, and 20 levels from both halves must be examined. Given a prognostic significance of micrometastases, our current pathology guidelines are not sensitive enough. The number of sections should be increased, while the interval between cuts should be no more than 200 microm.

Minimal Disease in Sentinel Nodes

Isolated tumor cells and micrometastases represent low-volume or minimal disease in the regional lymph nodes of breast cancer patients as compared to macrometastases. Sentinel lymph node biopsy is a functional selection and removal of the most likely site of regional metastasis, and gives pathologists the opportunity to concentrate detection techniques on a limited number of lymph nodes. Consequently, more lesions belonging in the two mentioned staging categories are discovered in sentinel lymph nodes. Despite some publications contradicting stochastic models of breast cancer, micrometastases seem to reflect a prognosis intermediate between the node-negative and macrometastatic nodal status, and they also reflect a risk of non-sentinel node involvement slightly higher than that associated with a node-negative status. Data are more contradictory as concerns isolated tumor cells. This minireview summarizes the definitions, their inconsistencies, pathological protocols aiming at the detection of minimal nodal disease, the prognostic impact and non-sentinel node involvement related risk of such nodal lesions, and their therapeutic consequences.

Clinical use of an intra-operative RT-PCR assay for the detection of metastases in sentinel lymph nodes of breast cancer patients at the Institut Jules Bordet

11100 Background: A molecular assay (GeneSearch™ BLN Assay, Veridex, LLC), CE marked and approved by the FDA, has been in clinical use at our institution for over 18 months to intra-operatively detect metastases ≥0.2 mm in the sentinel lymph nodes (SLNs) in breast cancer patients. After a small validation study (N=78, sensitivity = 92.3%, specificity = 96.9%) the assay was adopted as the only intra-operative SLN test used at the Institut Jules Bordet. This is the first report of the post-market assay performance. Methods: One SLN per patient is cut into approximately 2 mm sections. Alternating sections are processed fresh in the BLN assay. The assay detects mRNA expression of mammaglobin and CK19. Predetermined cutoffs are set to detect metastases ≥0.2 mm. The BLN Assay results are used to make intra-operative decisions for same surgery axillary lymph node dissections (ALND). The remaining alternating sections of the SLN are examined later by permanent section H&E. Results: Since August 2006, the BLN Assay has been used for intra-operative ALND decision-making on 100 patients. The assay intra-operatively detected all 15 H&E-positive SLNs. The assay was in agreement with 93% of the H&E-negative SLNs (79 of 85) and was positive when H&E was negative for 6 SLNs. One of these 6 SLNs had a 0.3 mm size metastasis detected by IHC alone. The average turn around time for the assay was 39 minutes for all 100 patients, and was 35 minutes for the second 50 patients. Conclusions: The BLN Assay results shows high correlation to permanent section H&E results that take 2–3 days, and its timing permits same-surgery ALND when nodes are found positive for metastases. In clinical use, agreement of assay results and permanent section H&E results (94%, 94/100) is similar to the agreement found in an earlier validation study (96.2%, 75/78). Perfect agreement is not expected since the two tests are evaluating different sections of the node. The BLN Assay is beneficial to our patients by reducing the need for second surgeries while being practical and cost effective for the institution to perform. Author Disclosure Employment or Leadership Consultant or Advisory Role Stock Ownership Honoraria Research Expert Testimony Other Remuneration Veridex Veridex

The prevalence of and risk factors for four or more metastatic axillary lymph nodes in breast cancer patients undergoing sentinel node biopsy

Our aim was to investigate the prevalence of and risk factors for having four or more positive axillary lymph nodes among breast cancer patients undergoing sentinel node (SN) biopsy. Between February 2005 and July 2007, 1,062 breast cancer patients with the clinical tumour size not larger than 3 cm underwent SN biopsy and axillary clearance (AC), when SN was positive. These patients were identified in a prospectively collected database. Four or more positive axillary nodes were detected in 68 patients representing 6% of the entire study population and 16% of the 436 node positive cases. Features regarded as predictive for a very low risk included (1) T1a or T1b tumours, (2) grade I tumours, (3) tumours with a favourable subtype, that is mucinous, tubular or medullary breast cancer, (4) no nodal macrometastases and (5) SN ratio lower than 0.5. Only few patients with T1a-b tumours or grade 1 tumours, as well as those with minimal involvement of the sentinel nodes have four or more positive axillary lymph nodes. However, these risk factors can be definitely assessed only after surgery, decreasing their value in the clinical decision making.

SPECT-CT: A new tool for localisation of sentinel lymph nodes in breast cancer patients

Introduction Sentinel lymph node biopsy has become a widely accepted procedure for axillary lymph node staging in patients with breast cancer. Aim The aim of this study was to determine the advantages of using SPECT-CT instead of planar scintigraphy in the presurgical localisation of sentinel lymph nodes. Methods We prospectively included 25 consecutive patients with breast cancer who were admitted to our department for SLN localisation. Patients were divided into two groups, depending on whether neoadjuvant chemotherapy had been received (B, n = 6) or not (A, n = 19). Four doses (1.0 mCi each) of 99mTc-nanocolloid were injected intradermallly in all patients, and SPECT-CT and planar images were acquired. All patients underwent surgery and SLN localisation with a hand-held gamma probe. Any axillary “hot spots” were resected. The kappa index (ki) was calculated using surgical findings as the gold standard. Results In group A, the SLN was correctly detected in 17/19 patients (89.5%) with SPECT-CT and in 12/19 (63.2%) with planar images. The correlation between SPECT-CT and surgical findings (ki 0.91) was better than between planar images and surgical findings (ki 0.57). In group B, the results of SPECT-CT and planar images were identical, with accurate localisation of the SLN in 5/6 patients (ki 0.76). Conclusions The results of this study suggest that SPECT-CT may be useful for locating the SLN in breast cancer patients, as it provides accurate localization of the SLN with useful anatomical information. This may allow the surgeon to search exclusively for SLN viewed on SPECT-CT, and avoid false negative and false positive results.

Influence of breast cancer cells on maturation and function of dendritic cells in lymph nodes in breast cancer patients

The expression pattern of the epithelial cell markers MUC1 (CA15-3, EMA), CA125 (OC125), human epithelial antigen HEA (Ber-EP4) and cytokeratins (Ck7, Ck8, Ck7/8, Ck8/18/19) was studied in seven human ovarian cancer cell lines. We analyzed the cell lines by immunofluorescence to determine the surface as well as cytoplasmic expression. Furthermore, we evaluated the mRNA expression of MUC1, Ck18 and Ck19 by reverse transcriptase-polymerase chain reaction (RT-PCR). All cell lines were positive for MUC1. However, expression patterns and staining intensity depended on the different epitope-specific antibodies. CA125, a typical serum marker for ovarian carcinomas, was positive only in two cell lines. HEA was strongly positive in three cell lines, whereas the others expressed the antigen only weakly in the cytoplasm. Ck7 was not expressed in three of the seven cell lines. Ck7/8 was detectable in all cell lines and was strongly expressed in four of them. MUC1 mRNA was expressed by all cell lines as detected by RT-PCR. These findings permit selection of a suitable marker for the detection of disseminated ovarian cancer cells.

Predictors of positive non-sentinel lymph nodes in breast carcinoma cases with sentinel lymph node biopsy

Aims: To identify factors predicting metastatic involvement of non sentinel axillary lymph nodes in breast cancer patients who underwent sentinel lymph node (SLN) biopsy followed by complete axillary dissection only in case of metastatic sentinel lymph node.Methods: A prospective database including 165 breast cancer patients who underwent SLN biopsy without further complete axillary dissection in case of non-metastatic SLN was reviewed. Primary tumor size, pathologic grade, lymphatic invasion in the primary tumor, estrogen receptor status, tumor size in the SLN and number of metastatic SLNs were tested as possible predictors of metastatic involvement of non-SLN.Results: The sentinel lymph node detection rate was 97% (160/165 patients). The mean number of SLNs per patient was 1.8 (range: 1–5). Fifty patients (31.3%) had a metastatic axillary SLN: 10 of the 42 patients with T1a or T1b breast tumors and 40 of the 118 patients with T1c≤15 mm tumors. Fifteen of the 50 patients with metastatic SLN had metastatic non-SLN. Primary tumor size, tumor size in the SLN, pathologic grade, estrogen receptor status and age were not significantly associated with metastatic involvement of non-SLN. Number of metastatic SLNs fell short of reaching statistical significance (P: NS). Lymphatic invasion in the primary tumor was the only factor significantly associated with the presence of tumor in the non SLN (P<0.01).Conclusion: In our series, only lymphatic invasion in the primary tumor was correlated with metastases detection in the non-SLN. We could not identify a subset of patients without metastatic non-SLN in patients with metastatic SLN.

Accuracy of fine-needle aspiration cytology of axillary lymph nodes in breast cancer patients

Fine-needle aspiration (FNA) cytology of axillary lymph nodes is a simple, minimally invasive technique that can be used to improve preoperative determination of the status of the axillary lymph nodes in patients with breast cancer, thereby serving as a tool with which to triage patients for sentinel versus full lymph node dissection procedures. The aim of the current study was to determine the sensitivity and specificity of FNA cytology to detect metastatic breast carcinoma in axillary lymph nodes. A total of 115 FNAs of axillary lymph nodes of breast cancer patients with histologic follow-up (subsequent sentinel or full lymph node dissection) were included in the current study. The specificity and sensitivity, as well as the positive and negative predictive values, were calculated. The positive and negative predictive values of FNA cytology of axillary lymph nodes for metastatic breast carcinoma were 1.00 and 0.60, respectively. The overall sensitivity of axillary lymph node FNA in all the cases studied was 65% and the specificity was 100%. The sensitivity of FNA was lower in the sentinel lymph node group than in the full lymph node dissection group (16% vs 88%, respectively), which was believed to be attributable to the small size of the metastatic foci in the sentinel lymph node group (median, 0.25 cm). All false-negative FNAs, with the exception of 1 case, were believed to be the result of sampling error. There was no 'true' false-positive FNA case in the current study. FNA of axillary lymph nodes is a sensitive and very specific method with which to detect metastasis in breast cancer patients. Because of its excellent positive predictive value, full axillary lymph node dissection can be planned safely instead of a sentinel lymph node dissection when a preoperative positive FNA result is rendered. .