Non-metastatic Sentinel Lymph Node Research Articles

ITRAQ proteomics of sentinel lymph nodes for identification of extracellular matrix proteins to flag metastasis in early breast cancer

Patients with early breast cancer are affected by metastasis to axillary lymph nodes. Metastasis to these nodes is crucial for staging and quality of surgery. Sentinel Lymph Node Biopsy that is currently used to assess lymph node metastasis is not effective. This necessitates identification of biomarkers that can flag metastasis. Early stage breast cancer patients were recruited. Surgical resection of breast was followed by identification of sentinel lymph nodes. Fresh frozen section biopsy was used to assign metastatic and non-metastatic sentinel lymph nodes. Discovery phase included iTRAQ proteomics coupled with mass spectrometric analysis to identify differentially expressed proteins. Data is available via ProteomeXchange with identifier PXD027668. Validation was done by bioinformatic analysis and ELISA. There were 2398 unique protein groups and 109 differentially expressed proteins comparing metastatic and non-metastatic lymph nodes. Forty nine proteins were up-regulated, and sixty proteins that were down regulated in metastatic group. Bioinformatic analysis showed ECM-receptor interaction pathways to be implicated in lymph node metastasis. ELISA confirmed up-regulation of ECM proteins in metastatic lymph nodes. ECM proteins have requisite parameters to be developed as a diagnostic tool to assess status of sentinel lymph nodes to guide surgical intervention in early breast cancer.

ITRAQ proteomics of sentinel lymph nodes for the identification of extra cellular matrix protein signatures that can flag metastasis in early breast cancer

BackgroundBreast cancer patients who present in the early stage of disease are affected by metastasis to the axillary group of lymph nodes. The first among this group that is affected is called as sentinel lymph node, and metastasis to this lymph node is crucial for the staging of cancer and the quality of surgical intervention. Sentinel Lymph Node Biopsy (SLNB) that is currently used to assess lymph node metastasis is neither sensitive, nor specific, is time‐consuming, thereby necessitating the identification of novel biomarkers that can flag sentinel lymph node metastasis.MethodsThis study was conducted after approval was obtained from the Institute Ethics Committee (Ref. No. IECPG‐ 27/23.01.2019, RT‐03/28.02.2019). Breast cancer patients were screened, and those with early stage were recruited in the study. Surgical resection of the breast was followed by identification of sentinel lymph nodes by methylene fluorescent technique. Histo‐pathology of fresh frozen section biopsy was used as the gold standard to assign the clinical phenotypes of metastatic (SLNM+) and non‐metastatic sentinel lymph nodes (SLNM‐). Discovery phase of the experiment included isobaric Tags for Relative and Absolute Quantitation (iTRAQ) technique comprising of six comparative experiments coupled with mass spectrometric analysis to identify differentially expressed proteins. The mass spectrometry proteomics data have been deposited to the ProteomeXchange Consortium via the PRIDE partner repository with the dataset identifier PXD027668. Validation was done by ELISA and protein concentrations were used to estimate the ROC for computing diagnostic parameters. Pathway analysis and gene ontology analysis was done to understand the relevance of the differentially expressed proteins in this study.ResultsBased on MS/MS spectra there were 7510 differentially expressed proteins comparing SLNB + and SLNB ‐. Nineteen proteins up‐regulated, and eight proteins that were down regulated in SLNB+ as compared to SLNB‐. ELISA confirmed the up‐regulation of caveolin 1, collagen α‐1, desmin, fibrillin‐1, and microfibrillar associated glycoprotein 4 in metastatic, as compared to non‐metastatic lymph nodes. These proteins are known to be integral in tumorogenesis, cell proliferation, invasion, cell survival and anti‐apoptosis. These proteins have 80%‐100%, of sensitivity and specificity to differentiate the two clinical phenotypes.ConclusionIdentified protein biomarkers have requisite diagnostic parameters to be developed as a translational tool to assess the status of sentinel lymph nodes during mastectomy procedure to guide surgical therapy of axillary lymph nodes in early breast oncology.

Detection and Characterization of Sentinel Lymph Node by Ultrasound Molecular Imaging with B7-H3-Targeted Microbubbles in Orthotopic Breast Cancer Model in Mice.

Accurate identification and assessment of sentinel lymph node (SLN) using noninvasive imaging methods can play a vital role in tumor staging, surgical planning, and prognostic evaluation. In this study, we assessed the efficacy of B7-H3-targeted molecular-ultrasound imaging for the early SLN detection, and characterization in a mouse model of orthotopic breast cancer. We established a mouse breast cancer model with lymph node metastasis by injecting MAD-MB 231 cells which were engineered to express firefly luciferase reporter gene into the fat pad of the right 4th mammary gland in female BALB/c nude mice. The sole lymph node (LN) close to the tumor was regarded as the SLN for imaging investigation, which included metastatic and non-metastatic SLNs. The LN in the right 4th mammary gland from normal mice was used as normal control (normal mice LN). The commercially available preclinical streptavidin-coated, perfluorocarbon-containing lipid-shelled microbubbles (VisualSonics, Toronto, Canada) were used to generate B7-H3-targeted microbubbles (MBB7-H3) and control microbubbles (MBControl). Then, ultrasound molecular imaging (USMI) was performed using a high-resolution transducer (MS250; center frequency, 21MHz; Vevo 2100; VisualSonics, Toronto, Canada) after intravenous injection of microbubbles. The SLN was clearly detected and located under conventional (B-mode) and contrast-enhanced ultrasonography with microbubble injection. The metastatic SLNs showed a markedly higher signal from B7-H3-targeted microbubbles (MBB7-H3) compared to the non-metastatic SLNs and normal LNs. The metastatic SLN was further confirmed by ex vivo bioluminescence imaging and eventually verified by histological analysis. Our findings suggest the potential value of USMI using B7-H3 targeted microbubbles in breast cancer and establish an effective imaging method for the non-invasive detection and characterization of SLN.

Contrast enhanced computed tomography assessment of superficial inguinal lymph node metastasis in canine mammary gland tumors.

Mammary gland neoplasms are predominant in dogs. However, sentinel lymph node (SLN) status assessment criteria have not been established for these cases. In this retrospective, secondary analysis, diagnostic case control study, CT images of 65 superficial inguinal SLNs were obtained before and 1, 3, 5, and 10 min after intravenous administration of contrast agent (iopamidol 370mgI/mL). The presence and degree of postcontrast enhancement were assessed, by means of the median absolute density value and the maximum absolute density value at any time point in the center and in the periphery of each SLN measured in Hounsfield units (HU), before and after contrast agent administration. These values were compared with histopathological findings postsurgical excision. Receiver operating characteristic analysis was conducted. The absolute density values ranged widely at each time point and within each group of nodes (negative, positive, control group). At all time points, the median density value in the center and in the periphery was significantly higher in metastatic than in non-metastatic SLNs (P≤.014). Among the parameters tested, the median absolute density value measured in the periphery of the SLN 3min after injection showed the highest sensitivity, specificity, and accuracy (AUC) (87.5%, 82.1%, and 92.1% respectively), with a cutoff value of 50.9HU. The maximum absolute density value at any time point in the center and periphery of the SLNs was also significantly higher in metastatic SLNs compared to non-metastatic (P≤.001). With a cutoff value of 59.5HU, the maximum absolute density value in the periphery of the SLN displayed high sensitivity and specificity (87.5% and 89.3%, respectively). The results of this study support the hypothesis that contrast enhanced CT imaging may aid in the assessment of SLN metastasis in dogs with mammary gland neoplasms.

Contrast‐enhanced ultrasound for sentinel lymph node mapping in the routine staging of canine mast cell tumours: A feasibility study

Canine mast cell tumours (MCTs) typically spread to lymph nodes (LNs) before reaching distant sites, and LN assessment is an important part of MCT staging. Sentinel LN (SLN) mapping techniques to identify draining LNs are being developed and could improve the accuracy of MCT staging. The primary objective of this feasibility study was to determine the safety and effectiveness of contrast-enhanced ultrasound (CEUS) to identify SLNs. Secondary objectives were to determine if the SLNs identified by CEUS coincided with the regional LN predicted by the anatomical lymphosomes, if previous MCT excision altered CEUS SLN findings, and if CEUS could identify MCT nodal metastases. Between June 2017 and March 2019, 59 dogs with 62 MCTs were enrolled. No adverse events related to CEUS were reported. CEUS detected at least 1 SLN in 59/62 MCTs (95.2%, 95% CI: 86.5-99.0%). In only 32/59 (54.2%) MCTs, clinicians would have correctly predicted the SLN(s) identified by CEUS. Among the 35 MCTs that had histological examination of the SLN(s), the prevalence of metastasis was 60% (95% CI: 42.1-76.1%). Additional staging procedures did not reveal any metastases in dogs with histologically non-metastatic SLNs. Integration of CEUS SLN mapping into the routine staging of MCTs is promising, but future studies are required to refine this procedure and to investigate if it would translate into a clinical benefit.

Axillary intranodal pressure measurement: A complementary technique for detection of lymph node metastasis in breast cancer patients

Background: There is growing evidence that intranodal pressure (INP) can predict metastatic sentinel lymph nodes (SLNs). The objective of this study was to measure and utilize INP to evaluate the metastatic involvement of axillary SLNs in breast cancer patients. Materials and Methods: INP was measured in 73 clinically node-negative (cN0) breast cancer patients who were candidate for SLN biopsy. Clinical evaluation of the lymph node, coupled with frozen section analysis of the same excised SLN, was conducted. The level of suspicion (LOS) was used to assess the likelihood of metastases in the SLNs by the surgeons. Then, the miniature catheter tip pressure transducer was used to measure INP in the operation room. Finally, excised SLN was sent for permanent pathologic analysis as a gold standard for the evaluation of SLNs metastatic.Results: We identified the statistically significant increase in INP in nodes containing tumor metastasis in comparison with tumor-free SLNs (19.17 ± 13.63 vs. 8.82 ± 4.23) (P = 0.003). We considered the cutoff value for INP at 16 mmHg, which resulted in sensitivity of 80% and specificity of 87%. When the combination of INP above 16 mmHg and the LOS were taken into account for determining the likelihood of metastatic involvement of the LNs, the sensitivity and specificity were 87.5% and 91.7%, respectively. Conclusion: Our data suggest that INP measurement has the potential to help surgeons differentiate metastatic and nonmetastatic SLNs in combination with LOS. Meanwhile, it can be used along with frozen analysis to decrease false-negative rate.

Combined 68Ga-NOTA-Evans Blue Lymphoscintigraphy and 68Ga-NOTA-RM26 PET/CT Evaluation of Sentinel Lymph Node Metastasis in Breast Cancer Patients.

In this study, we applied a new strategy to identify sentinel lymph node (SLN) metastasis by combining 68Ga-NOTA-Evans Blue (68Ga-NEB) for SLN mapping and 68Ga-NOTA-RM26 for LN metastasis detection in breast cancer patients. A total of 24 female patients with breast cancer diagnosed by core biopsy or suspected by mammography or ultrasonography were recruited and provided informed consent. All patients underwent 68Ga-NEB and 68Ga-NOTA-RM26 PET/CT imaging. Visual analysis of 68Ga-NEB PET/CT images was used to determine SLNs, and then compared with the 68Ga-NOTA-RM26 results and histopathological findings. SLNs were visualized in 24 of 24 patients (100.0%) within 4.0-10.0 (5.6 ± 1.4) min. All patients were pathologically diagnosed with breast cancer, and 12 patients had ipsilateral lymph node metastasis. By combining 68Ga-NEB and 68Ga-NOTA-RM26 images, 7/12 (58.3%) patients showed mild to intense uptake of 68Ga-NOTA-RM26 in SLNs, 1/12 patient (8.3%) had moderate uptake of 68Ga-NOTA-RM26 in the non-SLNs rather than SLN, indicating possible bypass lymphatic drainage, partially accounting for the false negatives in SLN biopsy during surgery. No false positives were found. The SUVmax of 68Ga-NOTA-RM26 activity in metastatic SLNs was significantly higher than that in non-metastatic SLNs (2.2 ± 2.3 vs 0.7 ± 0.1, P = 0.047). This study manifests the value of combination of 68Ga-NEB and 68Ga-NOTA-RM26 dual tracer PET/CT in preoperative evaluation of SLN metastasis in breast cancer patients, especially in those patients with lymphatic obstruction and bypass drainage. In general, positive 68Ga-NOTA-RM26 uptake in either SLN or other lymph nodes can apply lymph node dissection rather than intraoperative SLN biopsy.

Combining Indocyanine Green and Tc99-nanocolloid does not increase the detection rate of sentinel lymph nodes in early stage cervical cancer compared to Indocyanine Green alone

ObjectiveTo investigate whether combining two independent tracers increases the SLN-detection rate in cervical cancer. MethodsConsecutive women with early stage cervical cancer planned for a robotic radical hysterectomy or a robotic radical trachelectomy with sentinel lymph node (SLN) detection were included. After cervical injections of Indocyanine green (ICG) and Tc99-nanocolloid (Tc99), near-infrared fluorescence imaging and a gamma probe were used to identify SLNs in the upper and lower paracervical pathways (UPP/LPP). A strict surgical algorithm was adhered to and the SLNs were defined as SLN-ICG, SLN-ICG+Tc99 or SLN-Tc99. In FIGO-stage ≥IA2 cancers a full pelvic lymph node dissection (PLND) was performed after detection of SLNs. The primary endpoint was the SLN detection rate per tracer and combination of tracers. Secondary endpoints were sensitivity and mapping rates of the SLN algorithm per tracer and combination of tracers. ResultsIn the sixty-five analyzed women, the bilateral mapping rate was 98.5% for ICG and 60% for Tc99 (p < 0.01). Combining the tracers did not increase the bilateral detection rate. In three women (5%) Tc99 identified ICG-negative non-metastatic SLNs without impact on the bilateral detection rate. Eight women (12%) had lymph node metastases (LNMs), all had at least one metastatic SLN. Seven (35%) of the 20 metastatic SLNs were detected by ICG only and 12 (60%) were ICG and Tc99 positive. ConclusionSLN detection rate was significantly higher using ICG compared with Tc99. ICG identified all patients with LNMs. Combining ICG and Tc99 did not improve the bilateral detection rate of SLNs.

Abstract P3-03-19: Tumor cell detection and immune profiling of lymph nodes from breast cancer patients by mass cytometry

Abstract Introduction: A sentinel lymph node (SN) is the primary node draining the tumor and is assumed to be affected early in the metastatic process. Detection of metastases in SN is a standard procedure in breast cancer diagnostics based on microscopic evaluation (morphology and immunohistochemistry), determining the need for removal of all axillary glands for inspection which again is crucial for tailoring adjuvant therapy. The identification by microscopy is time-consuming and has a risk for false negative results. We hypothesize that the immune profile of SN changes with the presence of tumor cells, even at very low frequencies (micrometastases). By using a multi marker approach to characterize millions of cells from sentinel lymph nodes with and without metastases we aimed at identifying both tumor cells but also characterize a tumor specific immune response. This dual approach might provide an opportunity for a more sensitive test for SN diagnostics. Material and Methods: We established a mass cytometry assay containing 38 markers (antibodies) using CyTOF technology to combine immune profiling with identification of breast cancer cells. Cell suspensions from 14 metastatic axillary lymph nodes (ALNmet), 16 metastatic sentinel lymph nodes (Snmet) and 14 non-metastatic sentinel lymph nodes (SN) from breast cancer patients from the clinical observational trial Oslo2 (early, operable breast cancer patients representing all subtypes) were successfully analyzed by the multimarker panel (single cell resolution). Results: By using mass cytometry, we detected tumor cells (gated as PanKeratin+/CD45- cells) in 86% (26/30) metastatic lymph nodes (ALNmet and Snmet) and in 14% (2/14) non-metastatic lymph nodes (SN). Further, the leukocyte population, identified as CD45+ cells, was gated into 15 subpopulations, mainly comprising different subsets of B and T cells, monocytes and NK cells. By comparing the leukocyte composition in the ALNmet with those in SN samples we identified a significant increase in the abundance of CD8+ memory phenotype, TFH and TCRγδ cells and a decrease in the CD4+ subpopulation in ALNmet compared to the SN samples. The Snmet samples had smaller deposits of tumor cells than the ALNmet samples, and we found no significant differences in leukocyte composition between Snmet and SN samples. Interestingly, when looking at the activation marker CD56, we observed a significant higher expression in the CD4RO, CD8RO, TFH and Treg subpopulations of Snmet samples compared to SN samples. Conclusion: In this study we identified a significant difference in immune cell composition in lymph nodes with and without metastases (ALNmet compared to SN samples). We also identified activation markers unique for subpopulations of lymphocytes in Snmet, but not in negative lymph nodes (SN). We were also able to detect and identify micrometastases in most lymph nodes where morphological examination had identified them, but in addition found tumor cells in two samples scored as negative. The results will be validated in a larger sample series. Citation Format: Russnes HG, Rye IH, Huse K, Schlichting E, Garred O, Mykelbust JH. Tumor cell detection and immune profiling of lymph nodes from breast cancer patients by mass cytometry [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-03-19.

Lymphatic transit rate as a predictive parameter for nodal metastasis in primary limb malignant melanoma

BackgroundThe status of sentinel lymph node (SLN) is one of the most predictive prognostic factors in patients with clinically localized malignant melanomas (MMs). However, since the positive SLN metastatic rate is as low as 20%, it is desirable to minimize SLN biopsy performance with imaging. By dynamic lymphoscintigraphy, we have proposed the lymphatic transit rate (LTR), the value that the distance between the primary lesion and SLN is divided by scintigraphic saturation time. LTR represents the scintigraphic saturation velocity and can be used for evaluation of metastasis of skin cancers. MethodsDynamic lymphoscintigraphy data from 36 lymph nodes in 36 patients with primary MM on the limb were analyzed. The initial sites of the MMs were the lower limb in 24 patients and the upper limb in 12 patients. Histopathologically, nodal metastasis was found in 10 patients. ResultsIn the lower limb MM, the mean LTRs were 3.49 cm/min in histologically non-metastatic SLNs and 4.49 cm/min in histologically metastatic SLNs (P = 0.0056). In the upper limb MM, the mean LTRs were 2.59 cm/min in non-metastatic SLNs and 3.94 cm/min in metastatic SLNs (P = 0.0162). Thus, significantly higher LTRs were obtained in the metastatic SLNs. All SLNs with LTR < 4.0 cm/min in the lower limb MM and those with LTR < 3.0 cm/min in the upper limb MM were non-metastatic. ConclusionLTR is a useful predictive indicator for nodal metastasis and SLN biopsy performance in MMs.

Lymphatic transit rate as a novel predictive parameter for nodal metastasis in primary truncal skin cancers.

Prediction of nodal metastasis in skin cancer before sentinel lymph node (SLN) biopsies is ideal to avoid unnecessary SLN biopsy performance. Primary truncal skin cancers are characterized by the lymphatic flow that drains from the primary lesion, occasionally to plural nodal basins. The scintigraphic appearance time (SAT), defined as the time between radionuclide injection and first SLN visualization, can potentially predict nodal metastasis, and a short SAT is a predictive parameter for metastasis. We recently introduced a novel method to measure the lymphatic flow rate using dynamic lymphoscintigraphy exhibiting a time-activity curve in the SLN. The time at which the count reaches a plateau in the SLN is termed the scintigraphic saturation time (SST) and can be a good alternative to the SAT. Moreover, the value obtained by division of the distance between the primary lesion and the SLN by the SST was termed the lymphatic transit rate (LTR), which represents the scintigraphic saturation velocity. In the present study, we evaluated LTR as a predictive parameter for nodal metastasis. Data for 22 lymph nodes from 18 patients with primary truncal skin cancers were used. Histopathologically, nodal metastasis was determined in nine nodes of eight patients. Because the mean LTR were 1.84cm/min in non-metastatic SLN and 2.38cm/min in metastatic SLN, the LTR was significantly higher in metastatic SLN than in non-metastatic SLN. All SLN with LTR of less than 1.8cm/min were histopathologically evaluated as non-metastatic. The LTR may be a predictive indicator for nodal metastasis.

Intraoperative detection of sentinel lymph node metastases inbreast carcinoma by Fourier transform infrared spectroscopy.

Sentinel lymph node (SLN) biopsy is a routine surgical staging procedure in clinically lymph node-negative breast cancer. Fourier transform infrared (FTIR) spectroscopy, a technique based on the biochemical composition of the tissue, has previously been found to be capable of differentiating between normal and malignant tissue. The aim of the present study was to explore the intraoperative use of FTIR spectroscopy for rapidly identifying metastatic SLNs, and distinguishing between metastatic and non-metastatic tissue. Freshly removed SLNs from patients with breast cancer were analysed. Samples were measured by FTIR spectroscopy before histopathological diagnosis. The FTIR spectrum of each sample identified ten bands from 2000 to 900 cm(-1) . The peak position, intensity and full width at half maximum of each absorbent band were measured, and the relative intensity ratios calculated. Canonical discriminant analysis was performed to discriminate between metastatic and non-metastatic samples. A total of 149 SLNs were removed from 49 patients. Histopathological examination confirmed 38 metastatic and 111 non-metastatic SLNs. Eighteen of 29 parameters were significantly different between the metastatic and non-metastatic SLNs. Five parameters were selected as independent factors to form discriminant functions. The sensitivity, specificity and accuracy of this method were 94·7, 90·1 and 91·3 per cent respectively. The accuracy of histological analysis of frozen sections was 100 per cent. FTIR spectroscopy is a promising technique for the real-time diagnosis of SLN metastasis during breast cancer surgery. Surgical relevance Sentinel lymph node (SLN) biopsy is a highly accurate predictor of overall axillary status and has become the standard in disease staging in clinically node-negative breast cancer. A rapid and accurate intraoperative assessment of metastatic spread to the SLN provides the necessary information for the surgeon to proceed with immediate axillary dissection. The results of this research indicate that Fourier transform infrared (FTIR) spectroscopy is a rapid, accurate, non-destructive and cost-effective molecular method that can be used to detect SLN metastasis during surgery. FTIR analysis could be useful for the intraoperative diagnosis of lymph node metastases at large institutions, thereby reducing the workload of pathologists, as well as in regions lacking pathologists such as in developing countries.

Contrast-enhanced ultrasonography in qualitative diagnosis of sentinel lymph node metastasis in breast cancer: A meta-analysis.

This meta-analysis aims to determine the accuracy of contrast-enhanced ultrasonography (CEUS) in the qualitative diagnosis of metastatic sentinel lymph node (SLN) for patients with breast cancer. We screened PubMed, Embase, Web of Science, Cochrane Library, CISCOM, CINAHL, Google Scholar, CBM, and CNKI databases. All analyses were calculated using the STATA software, version 12.0 (Stata Corp, College Station, TX, USA). We calculated the summary statistics for sensitivity (Sen), specificity (Spe), positive and negative likelihood ratios (LR + /LR-), diagnostic odds ratio (DOR) and receiver operating characteristic (SROC) curve. Thirteen articles that met all inclusion criteria were included in this meta-analysis. A total of 876 breast cancer patients were assessed, including 372 patients with metastatic SLN and 504 patients without metastatic SLN. All SLN were histologically confirmed after conducting CEUS. The pooled Sen was 0.80 (95%CI = 0.76-0.84); the pooled Spe was 0.94 (95% CI = 0.91-0.96). The pooled LR + was 6.28 (95%CI = 3.61-10.92); the pooled negative LR - was 0.218 (95% CI = 0.10-0.31). The pooled DOR of CEUS in qualitative diagnosis of SLN metastasis was 49.10 (95% CI = 27.89-86.45). The area under the SROC curve was 0.937 (standard error [SE] =0.0128). Our meta-analysis suggests that CEUS may have high a diagnostic accuracy in testing for metastatic SLN in breast cancer. Thus, CEUS may be a good tool for differential diagnosis between metastatic and non-metastatic SLN.

Increase of DC-LAMP+ mature dendritic cell subsets in dermatopathic lymphadenitis of mycosis fungoides.

Little is known about the immunological milieu of the skin-draining lymph nodes (LNs) in mycosis fungoides (MF). We studied dendritic cell (DC) subsets in the dermatopathic lymphadenitis of MF patients. We immunohistochemically examined DC subsets and their distribution in 16 LN samples from 14 patients with MF (N1 LN, eight patients; N2, four; and N3, four), and we compared them with non-metastatic sentinel LNs from eight patients with melanoma. The number of S-100 protein+ DCs was markedly increased in the LNs from the MF patients and the major component was DC-LAMP+ mature DCs in the outer and paracortex areas, where DC-SIGN+ immature DCs were relatively decreased in proportion. In contrast, DC-SIGN+ cells were relatively increased in proportion compared to DC-LAMP+ cells in the medulla. Although no significant difference was observed in the proportions of CD1a+ or Langerin+ DCs among the N1, N2, and N3 nodes, CD163+ M2-type macrophages were increased in number in the N2 and N3 nodes. Our observations indicate that mature DCs accumulate in the outer and paracortex areas in dermatopathic lymphadenitis and M2-type macrophages might increase in number during disease progression.

The Clinical Value of Hybrid Sentinel Lymphoscintigraphy to Predict Metastatic Sentinel Lymph Nodes in Breast Cancer

Hybrid imaging techniques can provide functional and anatomical information about sentinel lymph nodes in breast cancer. Our aim in this study was to evaluate which imaging parameters on hybrid sentinel lymphoscintigraphy predicted metastatic involvement of sentinel lymph nodes (SLNs) in patients with breast cancer. Among 56 patients who underwent conventional sentinel lymphoscintigraphy, 45 patients (age, 53.1 ± 9.5years) underwent hybrid sentinel lymphoscintigraphy using a single-photon emission computed tomography (SPECT)/computed tomography (CT) gamma camera. On hybrid SPECT/CT images, we compared the shape and size (long-to-short axis [L/S] ratio) of the SLN, and SLN/periareolar injection site (S/P) count ratio between metastatic and non-metastatic SLNs. Metastatic involvement of sentinel lymph nodes was confirmed by pathological biopsy. Pathological biopsy revealed that 21 patients (46.7%) had metastatic SLNs, while 24 (53.3%) had non-metastatic SLNs. In the 21 patients with metastatic SLNs, the SLN was mostly round (57.1%) or had an eccentric cortical rim (38.1%). Of 24 patients with non-metastatic SLNs, 13 patients (54.1%) had an SLN with a C-shape rim or eccentric cortex. L/S ratio was 2.04 for metastatic SLNs and 2.38 for non-metastatic SLNs. Seven (33%) patients had T1 primary tumors and 14 (66%) had T2 primary tumors in the metastatic SLN group. In contrast, 18 (75%) patients had T1 primary tumors and six (25%) had T2 tumors in the non-metastatic SLN group. S/P count ratio was significantly lower in the metastatic SLN group than the non-metastatic SLN group for those patients with a T1 primary tumor (p = 0.007). Hybrid SPECT/CT offers the physiologic data of SPECT together with the anatomic data of CT in a single image. This hybrid imaging improved the anatomic localization of SLNs in breast cancer patients and predicted the metastatic involvement of SLNs in the subgroup of breast cancer patients with T1 primary tumors.

319P - Characteristics of Breast Cancer Patients with False-Negative Sentinel Node Biopsy

ABSTRACT Aim: There are only limited studies that analyzed the clinical significance of false-negative (FN) in sentinel node biopsy (SNB) with sufficient sample size. The aim of this study was to identify the risk factors for FN in SNB and to analyze the clinical significance of that in patients with breast cancer. Methods: Patients with invasive breast cancer who underwent SNB followed by axillary node dissection between 1995 and 2013 were retrospectively identified. We excluded patients with ductal carcinoma in situ or those who had recieved preoperative chemotherapy. A total of 189 patients with FN in SNB were compared to 413 women with true-negative (TN) in SNB. Logistic regression analysis was used to identify risk factors associated with FN result and Cox regression analysis was performed to assess the clinical impact of that. Results: Histologic type, lymphovascular invasion, location of main lesion, tumor size, and administration of adjuvant chemotherapy were associated with FN in SNB. Multivariate analysis showed that ductal carcinoma, tumor located at upper outer quadrant, and larger tumor were significant independent risk factors for FN; adjusted odds ratios representing 2.82 (95% CI: 1.58 to 5.04), 1.74 (95% CI: 1.22 to 2.49), and 1.29 (95% CI: 1.08 to 1.53), respectively. Patients with FN in SNB showed worse disease-free survival (DFS) than those with TN, corresponding to 5-year DFS rates of 86.4% and 94.7%, respectively and an adjusted hazard ratio of 3.87 (95% CI: 1.84 to 8.12; p Conclusions: This study showed that patients with FN in SNB presented worse prognosis than those with TN even with adjuvant treatment. In patients with ductal carcinoma, with larger tumor size, and with tumors located at the upper outer quadrant, it would be necessary to make an effort to find out metastatic non-sentinel nodes with a suspicion after SNB. Disclosure: All authors have declared no conflicts of interest.

Omission of Axillary Dissection According to ACOSOG Z0011: Impact on Adjuvant Treatment Recommendations

A recent, randomized trial (ACOSOG Z0011) has demonstrated that omission of completion axillary lymph node dissection (ALND) in patients with one or two sentinel lymph node (SLN) metastases treated with breast conserving therapy (BCT) does not have a negative impact on survival. This study evaluates the impact of omitting ALND on adjuvant treatment recommendations. Performing a search of our clinical database, we identified patients meeting the main inclusion and exclusion criteria of ACOSOG Z0011 treated at the University of Heidelberg Breast Center. We performed blinded mock interdisciplinary tumor boards based on patient and tumor characteristics as well as (1) SLN information or (2) final nodal status after ALND. Differences between treatment recommendations were noted and analyzed. A total of 132 patients were included; 80.3 % of these had one and 19.7 % had two metastatic sentinel nodes with a rate of micrometastases only of 19.7 %, and 39.7 % of patients had additional nonsentinel node metastases upon ALND. Overall, there was a change in adjuvant chemotherapy in 18.2 % of cases. Treatment recommendations based on ALND lead to a more aggressive therapy in 16.6 % of cases, all of them with additional metastatic nonsentinel nodes. Chemotherapy was not recommended in only two cases (1.5 %) based on ALND. Based on ALND, irradiation of the supraclavicular and infraclavicular nodes was added in 5.3 % of patients. Completion ALND for patients with one or two metastatic sentinel nodes in pT1-2 cN0 PBC treated with BCT does have a relevant impact on adjuvant treatment. This should be considered in shared decision making.

Detection of contralateral axillary sentinel lymph node by lymphoscintigraphy in breast cancer: Prognostic implications

The role of nuclear medicine in the detection of sentinel lymph nodes (SLNs) in primary breast cancer is very useful to determine regional lymphatic drainage from the affected breast, mainly its anatomical and/or tumoral individual variability and to determine the initial tumor stage. We present the case of an infiltrating ductal carcinoma of the breast (T2) in the junction of the inner quadrants of the right breast studied by lymphoscintigraphy and gamma probe detection. Three nonmetastatic sentinel lymph nodes were found with the selective lymphadenectomy: two in the ipsilateral axilla and one in the contralateral axilla. The lymphoscintigraphic finding of the axillary sentinel lymph node contralateral to the affected breast demonstrates the individual anatomical variability which may be found in mammary drainage and emphasizes the importance of nuclear medicine imaging techniques in the detection of such nodes, generating new prognostic approaches with impact on therapeutic measures and patient follow-up.

Visualización de ganglio centinela axilar contralateral por linfogammagrafía en cáncer de mama: implicaciones pronósticas

The role of nuclear medicine in the detection of sentinel lymph nodes (SLNs) in primary breast cancer is very useful to determine regional lymphatic drainage from the affected breast, mainly its anatomical and/or tumoral individual variability and to determine the initial tumor stage. We present the case of an infiltrating ductal carcinoma of the breast (T2) in the junction of the inner quadrants of the right breast studied by lymphoscintigraphy and gamma probe detection. Three non-metastatic sentinel lymph nodes were found with the selective lymphadenectomy: two in the ipsilateral axilla and one in the contralateral axilla. The lymphoscintigraphic finding of the axillary sentinel lymph node contralateral to the affected breast demonstrates the individual anatomical variability in mammary drainage. It emphasizes the importance of nuclear medicine imaging techniques in its detection and generates new prognostic approaches with impact on therapeutic measuresand patient follow-up.

Analysis of Dendritic Cells in Sentinel Lymph Nodes of Patients With Endometrial and Patients With Cervical Cancers

The aim of this study was to identify the immune response in sentinel lymph nodes (SLNs) of patients with endometrial and patients with cervical cancers by analyzing the number of S-100-, CD1a-, CD83-positive (+) dendritic cells that are the major antigen-presenting cells. A total of 56 patients with early-stage cancer (n = 32, with cervical; n = 24, with endometrial cancer) underwent SLN biopsy. Sentinel lymph nodes and non-SLNs were stained with antibodies against S-100, CD1a, and CD83 as markers for dendritic cells to find out whether SLNs were immunomodulated compared with non-SLNs. The mean values of S-100(+) and CD1a(+) dendritic cells in both the tumor-free and the metastatic SLNs were significantly higher than those of both the tumor-free and the metastatic non-SLNs. When metastatic SLNs were compared with nonmetastatic SLNs, CD83(+) dendritic cells were found significantly more abundant in nonmetastatic SLNs. Significantly higher numbers of S-100(+) and CD1a(+) dendritic cells in the SLNs compared with those in the non-SLNs may indicate that SLNs are the first sites of immunostimulation. Immunosupression may be the underlying factor for the metastatic involvement of SLNs, which might be secondary to the significantly decreased number of mature dendritic cells in metastatic SLNs compared with tumor-free SLNs.