Number Of Sentinel Lymph Node Research Articles

Intraoperative imprint cytology versus histological diagnosis for the detection of sentinel lymph nodes in breast cancer treated with neoadjuvant chemotherapy

OBJECTIVES:To compare imprint cytology and paraffin section histology for sentinel lymph node detection in women with breast cancer treated with neoadjuvant chemotherapy.METHOD:A cross-sectional study and report of the sentinel lymph node statuses of 64 patients with breast cancer who underwent intraoperative imprint cytology and neoadjuvant chemotherapy in a referral cancer institute in Rio de Janeiro, Brazil, between 2014 and 2016.RESULTS:The mean age was 51 years. The most common histological type was invasive ductal carcinoma (93.75%), and the most common differentiation grade was 2 (62.5%). Overall, 153 lymph nodes were identified, with a mean of 2.39/case. Thirty-four lymph nodes tested positive for malignancy by imprint cytology, and 55 tested positive by histology. Of the 55 positive lymph nodes, 41 (74.5%) involved macrometastases, and 14 (25.5%) involved micrometastases. There were 21 false negatives with imprint cytology, namely, 7 for macrometastases and 14 for micrometastases, resulting in a rate of 17.6%. The sensitivity of imprint cytology was 61.8%, with a specificity and positive predictive value of 100%, a negative predictive value of 82.4% and an accuracy of 86.3%. The method presented null sensitivity for the identification of micrometastases.CONCLUSIONS:The false-negative rate with imprint cytology was associated with the number of sentinel lymph nodes obtained. The rate found for complete response to neoadjuvant chemotherapy was comparable to the rates reported in the literature. The accuracy of imprint cytology was good, and its specificity was excellent for sentinel lymph node detection; however, the method was unable to detect lymph node micrometastases.

Is it time to consider the sentinel lymph node mapping the new standard in endometrial cancer

In the march issue of Lancet Oncology , Rossi et al . published the results of a prospective multicenter validation trail on robotic indocyanine green (ICG) sentinel lymph node (SLN) mapping in endometrial cancer (EC): the FIRES trial (1). In this trial, at 18 institutions, 340 patients with EC underwent a robotic ICG SLN mapping followed by a systematic pelvic lymph node dissection in every case and by a para-aortic lymph node dissection in 58% of the cases. The median number of SLNs and of total nodes removed was 2 and 19 respectively. We believe that this is a landmark trial that may lead to changes in the management recommendations for EC. The prospective multicentre design and the strong validation data derived from its large cohort of patients and the thoroughness of the lymphadenectomy represent its major strengths.

Sentinel lymph node biopsy using indocyanine green fluorescence navigation method after neoadjuvant chemotherapy for patients with clinically node-positive breast cancer.

e12108 Background: Sentinel lymph node biopsy (SNB) for initially clinically node-positive (cN1) after neoadjuvant chemotherapy (NAC) is controversial. Even if approximately 40% of node positive disease converts to node negative after NAC, SNB using blue dye (BD) and/or radioisotope (RI) agent showed the high false-negative rate (FNR) (SENTINA, ACOSOG Z1071). These trials showed the accuracy of SNB was closely related to the number of sentinel lymph nodes (SNs) removed. We presented the efficacy of indocyanine green (ICG) fluorescence navigation method for SNB in clinically node-negative (cN0) patients (ASCO2008). The ICG method can provide higher numbers of SNs and it helps to identify lymph nodes with the remained metastases. Methods: Of 1900 patients (Jan. 2010 - Dec. 2016), 242 women with cN0 or cN1 received NAC: Group 0 (cN0 before NAC, n=150), Group 1 (cN1 converted ycN0 after NAC, n=71) , Group 2 (cN1 remained ycN1 after NAC, n=21). Node status was evaluated by ultrasound. All patients underwent SNB using both ICG- and BD-method together. Fluorescence images were obtained by a CCD camera with a cut filter as a detector, light emitting diodes at 760nm as the light source. ALND was performed in Group1 and Group 2. Results: Pathological complete nodal response rate (pcNRR) was 48.4%. Table shows the number of SNs removed by ICG or BD. SNs detection rates (ICG, BD): Group 0 (98.7%, 84.7%), Group 1 (98.6%, 83.1%), Group 2 (85.7%, 47.6%). Resulting of a FNR (ICG, BD): Group 1 (5.7%, 15.3%), Group 2 (22.2%, 60.0%). Conclusions: The pcNRR and a FNR of BD in Group 1 were similar to those of SENTINA or ACOSOGZ 1071 trials. In patients who converted from cN1 to ycN0, the fluorescent ICG method showed a high detection rate of SNs and a low FNR. [Table: see text]

Abstract P2-01-15: Clinical application of multimodal fluorescent-radioactive system in advanced breast cancer patients with neoadjuvant therapy; interim analysis for 65 patients

Abstract Purpose This study aimed to evaluated the identification rate and operation time of sentinel lymph node biopsy (SLNB) by a multimodal fluorescent-radioactive system (MFS) using a mixture of indocyanine green (ICG), radioisotope (RI) compared with the RI alone in advanced breast cancer patients with neoadjuvant therapy. Methods In this phase II randomized study, we enrolled 65 patients with advanced breast cancer with neoadjuvant therapy. Then, they received SLNB with either MFS or RI. We compared the identification rate, operation time of SLNB and number of sentinel lymph nodes. We also evaluated the safety. We analyzed the data of 65 patients for interim analysis. Results The mean age of the MFS group and RI group was 51.7 and 45.9 years (p=0.024), respectively. There were no differences in histopathological characteristics, including tumor size, node positivity, and hormone receptor status between two groups. The radiologic study showed the clinically complete response in axillary lymph nodes after neoadjuvant therapy. In MFS group, sentinel lymph nodes (SLNs) were identified in 30 patients and we could not identify the SLNs in one patient. In RI group, we identified the SLNs in 33 patients and also could not identify them in one patient. (p=0.947). The average numbers of SLNs in the MFS and RI group were similar. (2.32±1.10 vs. 2.18 ± 1.57, respectively; p=0.668) The operation time of SLNB was similar in the each group (11.65 ± 6.49 vs. 9.47 ± 6.26, respectively, p= 0.174) There were no complication, including allergic reactions, skin staining or necrosis. Conclusions This study is the randomized trial that compared MFS using ICG and RI and the conventional RI method for SLNB in the advanced breast cancer with neoadjuvant therapy. The multimodal fluorescent-radioactive system is a feasible and safe method for SLNB for the breast cancer patients with neoadjuvant therapy. We will evaluate the 130 patients for final analysis. Citation Format: Lee S, Jung S-Y, Kim S-K, Lee ES, Lee MH, Park SJ, Kang H-S, Lee KS, Park IH, Sim SH, Kim Y, Kwon Y, Joo J, Kang SH. Clinical application of multimodal fluorescent-radioactive system in advanced breast cancer patients with neoadjuvant therapy; interim analysis for 65 patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-15.

Periareolar or Peritumoral Injection of Isosulfan Blue and the Effect on the Number of Sentinel Lymph Nodes Examined

The conduct of sentinel node biopsy (SLNBx) for breast cancer (BC) has evolved substantially since its original description. No national standards for the performance of SLNBx exist, therefore, we sought to determine the effect of isosulfan blue (ISB) injection technique on nodal harvesting and staging accuracy during SLNBx. Our main outcome measures included the number of SLNs examined and the number of positive axillae in patients undergoing SLNBx after injection of filtered sulfur colloid intradermally and either small volume ISB injected in the periareolar dermis (PA,∼0.75 cc) or large volume peritumoral (PT, 5 cc). Between January 1, 2009, and September 30, 2013, 1357 patients at an academic/community practice setting underwent SLNBx of which 966 (71.2%) were node negative. These patients ranged in age from 27 to 97 years (mean 60.1 years). The majority of patients (76%) underwent PT injection of ISB. There was no significant difference in the mean age of these two groups (61.2 PT vs 59.7 PA years). All were female. The majority of patients (72.7%) had T1 primaries. Nearly 73 per cent of patients were Luminal A/B, 10.8 per cent HER, and 16.4 per cent were triple negative. There was no significant difference in the distribution of T stage (P = 0.56) or breast cancer subtypes between the techniques (P = 0.59). The mean number of nodes examined was 3.1 (range, 1-18). PT patients had a mean of 3.5 (range, 1-18) nodes, whereas PA patients had a mean of 2.4 nodes (range, 1-10) (P < 0.001). The technical aspects of injecting ISB affect the number of nodes harvested during SLNBx but not staging accuracy.

The clinical implication of the number of lymph nodes harvested during sentinel lymph node biopsy and its effects on survival outcome in patients with node-negative breast cancer

BackgroundThe optimal number of sentinel lymph nodes (SLN) that need to be harvested to achieve favorable survival outcome during a SLN biopsy (SLNB) has not yet been established. MethodsSix hundred and thirteen patients with clinically node-negative breast cancer who underwent SLNB were reviewed. Survival outcomes according to the number of total harvested lymph nodes (THLNs), defined as the sum of enumerated SLNs and non-SLNs were analyzed. ResultsPatients with only 1 THLN showed lower recurrence-free survival (RFS) as compared to those with ≥2 THLNs (p = 0.049). In multivariate analysis, only 1 THLN was associated with poor RFS (HR = 2.711; p = 0.029). ConclusionsRemoving at least 2 lymph nodes during SLNB may be acceptable. Harvesting only 1 lymph node should be undertaken cautiously because of false negative results and increasing the subsequent recurrence rate.

Impact of previous surgery on sentinel lymph node mapping: Hybrid SPECT/CT before and after a unilateral diagnostic breast excision

BackgroundEarlier studies have shown conflicting results regarding the accuracy of sentinel lymph node biopsy after previous breast surgery, especially after a surgical biopsy. PurposeTo compare lymph drainage patterns before and after a diagnostic unilateral surgical biopsy using the exact anatomical localisation of sentinel lymph nodes defined by SPECT/CT. Material and methodsThirty-seven women planned for unilateral surgical excision of an unsuspicious breast lesion were prospectively examined between September 2011 and January 2015. Hybrid SPECT/CT lymphoscintigraphy of the thorax and neck region with bilateral subareolar injections of 99mTc-Nanocoll was performed one week before and six weeks after surgery. The non-operated side served as a control. The primary outcome measure was the concordance between pre- and postoperative number and localisation of sentinel lymph nodes. ResultsSentinel lymph node detection rate with SPECT/CT on operated sides was 91.9 per cent (34 of 37 procedures), to be compared with a detection rate of 93.7 per cent on all non-operated sides (104 of 111 procedures, P = 0.771). Partial or total concordance regarding the localisation and number of sentinel lymph nodes was 85.7 per cent (30 out of 35) on operated and 88.9 per cent (32 out of 36 patients) on non-operated breast sides (P = 0.735). ConclusionBreast surgery slightly decreased the concordance between pre- and postoperative sentinel lymph nodes, but this finding was not statistically significant. Our results thus support that it is feasible to perform a sentinel lymph node biopsy after previous breast excisional surgery with an acceptable level of safety.

Predictive factors of non-sentinel lymph node involvement in breast cancer patients with positive sentinel lymph nodes; a 5‑year single centre experience

Background The aim of our study was to determine the number of sentinel nodes (SN) and non-sentinel nodes (NSN) involved and to identify predictive factors of non-sentinel lymph node involvement in breast cancer patients.

Abstract P3-01-10: Sentinel lymph node biopsy after neoadjuvant chemotherapy for patients with clinically node-positive breast cancer: A single institution retrospective evaluation

Abstract Background: In patients with clinically node-negative breast cancer sentinel lymph node biopsy (SLNB) offers accurate staging information with considerably less morbidity than a full axillary lymph node dissection (ALND). However, for clinically node-positive (cN1) patients who undergo neoadjuvant chemotherapy SLNB is thought to have a high false-negative rate and not suitable for this population. We sought to evaluate the false-negative rate (FNR) of SLNB following chemotherapy in patients initially presenting with cN1 breast cancer at a single institution. Methods: Patients undergoing neoadjuvant chemotherapy diagnosed with cN1 breast cancer between October 2004 and February 2014 were identified from the University of California, San Francisco cancer registry. All patients underwent single agent mapping with Tc99 and SLNB followed by completion axillary lymph node dissection (ALND). Pathologic complete response, number of sentinel nodes removed and FNR were calculated. Results: Of the 80 patients who underwent SLNB and ALND, 43 had residual metastatic disease in the nodes producing a nodal pCR of 46.25% (95%CI. 35.0%-57.8%). In 14 patients, cancer was not identified in the SLNs but was discovered in the lymph nodes retrieved by ALND, resulting in an overall FNR of 32.6% (95% CI, 19.1%-48.5%). 49 patients had only 1 SLN removed. Of the patients with only 1 SLN removed, a false-negative SLN was identified in 9 of the 21 patients with a positive node for a FNR of 42.9% (95% CI, 21.8%-66.0%). Of the patient with more than 1 SLN removed, 5 of 18 patients with a positive node had a false-negative SLN yielding a FNR of 27.8% (95% CI, 9.7%-53.5%). Only 14 patients had more than two SLNs excised. Conclusion: Recent studies including the French GANEA 2 and ACOSOG Z1071 trials demonstrated a significant decrease in FNR when more than 1 SLN was excised. In this retrospective study however a single SLN was sampled from most patients. The FNR from this study was more than three times the generally accepted threshold of 10%. This substantial FNR further supports the need to remove more than 1 SLN during surgery in order to accurately assess nodal disease. Furthermore the implementation of a dual mapping technique would likely facilitate this process. Citation Format: Gallant E, Ewing C, Wong J, Esserman L, Alvarado M. Sentinel lymph node biopsy after neoadjuvant chemotherapy for patients with clinically node-positive breast cancer: A single institution retrospective evaluation. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-01-10.

Abstract P3-01-01: Fluorescence navigation system using indocyanine green (ICG) instead of radioisotope for sentinel lymph node (SLN) biopsy in early breast cancer

Abstract Background: Dual localisation methods with blue dye and radioisotope are commonly employed for SLN identification but potential drawbacks include allergic reactions, staining of cutaneous/surgical breast tissue, radiation exposure and mandatory licencing. A majority of studies have reported near 100% identification rates using the fluorescent tracer ICG in combination with standard tracer agents. A feasibility study (ICG-10) has confirmed high sensitivity of ICG fluorescence mapping for SLN detection in early breast cancer with 95% of nodes both blue and fluorescent. This follow-on study has specifically evaluated a combination of ICG with blue dye for SLN localization. Methods: As an observational cohort study, 50 consecutive patients (49 female; 1 male) with core biopsy proven unilateral invasive (37 cases) or non-invasive (13 cases) breast cancer underwent SLN biopsy with blue dye and ICG. All patients were clinically and sonographically node negative. Axillary surgery (SLN biopsy) followed neoadjuvant chemotherapy in 5 patients (10%). The median patient age was 48 years and for primary surgical patients median tumor size was 19mm. Patients received a dual peri-areolar/intradermal injection of blue dye [2ml 2.5% Patent Blue] and ICG [2mls 0.5%] after induction of anaesthesia. The number of sentinel nodes for each patient was recorded numerically and whether blue, fluorescent or both. Subcutaneous lymphatics were visualised with a photodynamic eye camera and nodal and procedural detection rates calculated for ICG alone and in combination with blue dye. Results: Final analysis was performed on a total of 87 nodes retrieved from 50 patients with an average nodal count of 1.8 per patient (range 1 – 4). Eighty-four nodes were blue and fluorescent and 3 nodes fluorescent only with no harvesting of non-blue, non-fluorescent nodes. At least one transcutaneous lymphatic channel was visible in all cases. Nodal detection rates for ICG alone and combined with blue dye were 100% (87/87) and 96% (84/87) respectively. Metastases (&amp;gt;0.2mm) were present in 18 nodes which were all blue and fluorescent and a total of 10 patients had at least one positive node (node positivity rate = 20%). The procedural detection rate was 96% (48/50) for blue dye and 100% (50/50) for ICG with 2 patients having fluorescent only nodes which were deemed sentinel (4%). No serious adverse reactions were noted. Conclusion: ICG fluorescence navigation system permits real-time visualization of lymphatic tissues and provides an additional dimension to SLN biopsy using methodology which is sensitive, valuable and safe. These results confirm accuracy of ICG fluorescence for SLN identification with nodal sensitivity of 96% for a combination of blue dye and ICG. With further refinements of the technique, use of ICG as a sole tracer may be possible agent without concerns about excessive nodal yield but improved patient convenience and costs. Citation Format: Benson JR, Pitsinis V, Provenzano E, Wishart GC. Fluorescence navigation system using indocyanine green (ICG) instead of radioisotope for sentinel lymph node (SLN) biopsy in early breast cancer. [abstract]. In: Proceedings of the Thirty-Eighth Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2015 Dec 8-12; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2016;76(4 Suppl):Abstract nr P3-01-01.

Sentinel node biopsy using indocyanine green in oral/oropharyngeal cancer.

BackgroundsRadioactive tracer-based detection has been proposed as a standard procedure in identifying sentinel nodes for cN0 oral/oropharyngeal carcinoma. However, access to radioactive isotopes may be limited in some surgical centers, and there is potential risk of the radioactive tracers to the operators. This study was designed to evaluate the feasibility of near-infrared fluorescence imaging with indocyanine green combined with blue dye mapping in sentinel node biopsy for cN0 oral/oropharyngeal carcinoma.MethodsTwenty-six cases of previously untreated oral/oropharyngeal carcinoma staged cT1-2N0M0 were enrolled in this study. One milliliter of indocyanine green (5 mg/ml) and 1.5 ml of methylene blue (1 mg/ml) were injected sequentially around the primary tumor in a four-quadrant pattern before skin incision. After elevation of the platysma flap and posterior retraction of the sternocleidomastoid muscle, fluorescence images were taken with a near-infrared detector, with special attention paid to any blue-dyed lymph nodes. Lymph nodes identified first with fluorescent hot spots with or without blue dye were defined as sentinel nodes, and they were harvested and sent for pathologic study.ResultsSentinel nodes were successfully harvested in all 26 cases. The number of sentinel nodes (SNs) per case varied from 1 to 9, with an average of 3.4. Routine pathology demonstrated occult metastasis exclusively in SNs in four cases (15.4 %). No tracer-associated side effects occurred in this series.ConclusionsNear-infrared imaging using indocyanine green combined with methylene blue mapping is a feasible and reliable new method for SN biopsy in cN0 oral/oropharyngeal carcinoma.

The use of isotope injections in sentinel node biopsy for breast cancer: are the 1- and 2-day protocols equally effective?

Sentinel lymph nodes are mapped using 99mTechnetium, injected on day of surgery (1-day protocol) or day before (2-day protocol). This retrospective cohort study compares efficacy between the two protocols. Histopathology for all unilateral sentinel lymph node biopsies (March 2012–March 2013) in a single centre were reviewed. Number of sentinel lymph nodes, non-sentinel lymph nodes and pathology was compared. 2/270 (0.7 %) in 1-day protocol and 8/192 (4 %) in 2-day protocol had no sentinel lymph nodes removed (p = 0.02). The median (range) number of sentinel lymph nodes removed per patient was 2 (0–7) and 1 (0–11) in the 1- and 2-day protocols respectively (p = 0.08). There was a trend for removing more non-sentinel lymph nodes in 2-day protocol [1-day: 52/270 (19 %); 2-day: 50/192 (26 %), p = 0.07]. Using 2-day, sentinel lymph node identification failure rate is higher, although within acceptable rates. The 1 and 2 day protocols are both effective, therefore choice of protocol should be driven by patient convenience and hospital efficiency. However, this study raises the possibility that 1-day may be preferable when higher sentinel lymph node count is beneficial, for example following neoadjuvant chemotherapy.

Sentinel Node Biopsy for the Head and Neck Using Contrast-Enhanced Ultrasonography Combined with Indocyanine Green Fluorescence in Animal Models: A Feasibility Study.

BackgroundSentinel node navigation surgery is gaining popularity in oral cancer. We assessed application of sentinel lymph node navigation surgery to pharyngeal and laryngeal cancers by evaluating the combination of contrast-enhanced ultrasonography and indocyanine green fluorescence in animal models.MethodsThis was a prospective, nonrandomized, experimental study in rabbit and swine animal models. A mixture of indocyanine green and Sonazoid was used as the tracer. The tracer mixture was injected into the tongue, larynx, or pharynx. The sentinel lymph nodes were identified transcutaneously by infra-red camera and contrast-enhanced ultrasonography. Detection time and extraction time of the sentinel lymph nodes were measured. The safety of the tracer mixture in terms of mucosal reaction was evaluated macroscopically and microscopically.ResultsSentinel lymph nodes were detected transcutaneously by contrast-enhanced ultrasonography alone. The number of sentinel lymph nodes detected was one or two. Despite observation of contrast enhancement of Sonazoid for at least 90 minutes, the number of sentinel lymph nodes detected did not change. The average extraction time of sentinel lymph nodes was 4.8 minutes. Indocyanine green fluorescence offered visual information during lymph node biopsy. The safety of the tracer was confirmed by absence of laryngeal edema both macro and microscopically.ConclusionsThe combination method of indocyanine green fluorescence and contrast-enhanced ultrasonography for detecting sentinel lymph nodes during surgery for head and neck cancer seems promising, especially for pharyngeal and laryngeal cancer. Further clinical studies to confirm this are warranted.

Abstract P1-16-09: Magnetic sentinel node and occult lesion localization in breast cancer: Initial results of the MagSNOLL trial

Abstract Trial registration: ISRCTN: 68689512 MREC No: 13/LO/0636 UKCRN ID: 14979 INTRODUCTION: One-third of breast cancers diagnosed are non-palpable. These breast cancers require localization-guided surgery and axillary staging using sentinel lymph node biopsy (SLNB). We present our experience of the first 20 patients undergoing a novel technique of magnetic-guided lesion localization and concurrent SLNB, avoiding the need for wire-guided localization and radioisotopes. MATERIALS AND METHODS: Co-localization of the primary tumour and sentinel lymph nodes (SLNs) using a novel magnetic technique was initially undertaken on a protocol-driven predefined minimum of 10 patients with palpable breast cancers to assess the feasibility of the magnetic tracer to safely localize at the point of injection and concurrently drain to the lymphatics. In order to confirm proof of principle, the subsequent 20 patients with non-palpable breast cancers were analysed. An ultrasound-guided intra-tumoral injection of magnetic tracer was performed (0.5 mL Sienna+, Endomagnetics Ltd, UK). Once successful lesion localization was confirmed (peak magnetometer counts retained at the site of injection), the technique was undertaken in patients with non-palpable breast cancers awaiting wide local excision and SLNB. All patients underwent SLNB with the magnetic and combined technique (radioisotope and Patent Blue Dye). RESULTS: A total of 33 patients were recruited and 1 patient excluded due to breach of the trial protocol. This left a remainder of 32 patients for consideration, of which 12 patients (1 bilateral) possessed palpable breast cancer and 20 patients non-palpable breast cancer. Peak magnetometer counts were retained at the site of injection in all palpable (n=13) and non-palpable (n=20) breast cancers. Re-excisions (second operations) for involved margins were performed in 2 patients with non-palpable breast cancers (10%). The mean volume of excised specimens was 49 cm3 (SD 30.6). The SLN identification rate for the magnetic technique alone was 84% (28/33) overall and 85% (17/20) for non-palpable lesions. For the combined technique (radioisotope and blue dye) the SLN identification rate was 97% (32/33) overall and 100% (20/20) for non-palpable lesions. When the magnetic technique is combined with blue dye, the SLN identification rate overall was 97% (32/33) and for non-palpable breast cancers was 95% (19/20). The mean number of sentinel nodes excised was 1.75 versus 2.05 for the magnetic and combined techniques respectively. CONCLUSION: Magnetic lesion localization and concurrent SLNB is a feasible technique. Further optimisation and validation of this technique, in a larger trial, is required. Citation Format: Muneer Ahmed, Ashutosh Kothari, Hisham Hamed, Sumit Goyal, Tibor Kovacs, Anand David Purushotham, Bauke Anninga, Phillippa Young, Julie Scudder, Sarah McWililliams, Sarah Pinder, Quentin Pankhurst, Ian Monnypenny, Michael Douek. Magnetic sentinel node and occult lesion localization in breast cancer: Initial results of the MagSNOLL trial [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P1-16-09.

Clinical significance of breast cancer micrometastasis in the sentinel lymph node.

The advantages of sentinel lymph node biopsy (SLNB) in breast cancer patients include an enhanced pathological examination of a small number of sentinel lymph nodes (SLNs), which permits more frequent detection of micrometastasis and isolated tumor cells (ITCs). At the same time, however, SLNB raises two new concerns: whether minimal SLN involvement has a significant impact on survival and whether patients with such minimal involvement should undergo further axillary dissections. Two large randomized studies, ACOSOG Z0011 and IBCSG 23-01, have demonstrated that axillary lymph node dissection (ALND) can be avoided for select SLN-positive patients. However, for patients with macrometastasis in SLN or who do not meet the inclusion criteria of the two studies, ALND is still the standard management. On the other hand, previous studies appear to disagree on the prognostic significance of minimal SLN involvement. One of the reasons for this discrepancy is the great variability among pathological examinations for SLN. The OSNA method, which is a fast molecular detection procedure targeting cytokeratin 19 (CK19) mRNA, has the advantage of reproducibility among institutions and the capability to examine a whole lymph node within 30-40min. This novel method may thus be able to overcome the issue of variability among conventional pathological examinations.

P53 expression in breast cancer predicts tumors with low probability of non-sentinel nodes infiltration.

Several predictive tools of non-sentinel lymph nodes neoplastic involvement when a positive sentinel lymph node is found have been described. However, molecular factors have been rarely evaluated to build these tools. The aim of this study was to establish which factors predicted non-sentinel lymph nodes infiltration in our setting, including some molecular factors. We carried out a retrospective review of 161 patients with breast cancer and a positive sentinel lymph node who had undergone axillary lymph node dissection, none of whom had received neoadjuvant treatment. Features evaluated as predictive factors for non-sentinel node positivity were: menopausal status, tumor size, histological subtype, histological grade, lymphovascular invasion, extracapsular invasion, Ki67 index, hormonal receptors, CerbB2 and p53 expression, size of sentinel lymph node metastases and number of sentinel lymph nodes affected. Tumor size (P = 0.001), size of sentinel lymph node metastases (P = 0.001), lobular invasive carcinoma (P = 0.05) and lymphovascular invasion (P = 0.006) were significantly associated with non-sentinel lymph node positivity. Tumor p53 positive expression was strongly associated with non-sentinel lymph node negativity (P = 0.000). In multivariate analysis, all these factors but tumor size maintained their significance. The discrimination power of the model calculated by the area under the receiver-operator curve was 0.811 (95% confidence interval, 0.741-0.880). p53 expression in breast cancer was highly predictive of non-sentinel lymph node negativity in our study. New studies should evaluate if it would be useful to add p53 expression to other existing predictive tools.

Evaluación de la calidad del procedimiento de biopsia selectiva del ganglio centinela en pacientes con cáncer de mama, en un hospital comarcal

ObjectiveTo assess the quality of selective sentinel lymph node biopsy in the Breast Diseases Unit of a district hospital without a Nuclear Medicine service. Methods and materialA retrospective, descriptive study was conducted in 104 patients with nonadvanced breast cancer. The day before surgery, the patients underwent lymph node mammography in the referral hospital. The self-evaluation clinical guideline of the Spanish Society of Senology and Breast Pathology was used as part of the management protocol. We studied the efficacy of sentinel lymph node detection, the sensitivity of the procedure, and the mean number of axillary sentinel lymph nodes isolated per patient. Both the overall results obtained by the Breast Diseases Unit and the results obtained individually by each of the 3 surgeons working in the unit were evaluated. ResultsThe 3 main criteria of the self-evaluation guideline were fulfilled, namely: sentinel lymph node detection in 94.2%, the sensitivity ratio in 93.2% and the mean number of sentinel lymph nodes removed, 1.66±0.84. These criteria were also fulfilled by each of the 3 surgeons working in the unit. The score of the self-assessment guideline was 33 out of 71 points, with level ii being the most prevalent level of quality. ConclusionsIn our unit, application of the guidelines published by the Spanish Society of Senology and Breast Pathology to evaluate essential and basic aspects of selective sentinel lymph node biopsy in breast cancer demonstrated that quality criteria are being met in our unit, and allowed us to promote quality improvements.

Association of the number of sentinel lymph nodes harvested with survival in breast cancer

AimsIn patients with breast cancer, the association between the number of sentinel lymph node (SLN) removed and survival is poorly known. Our objective was to evaluate this association on disease-specific survival (DSS). MethodsData of 144 517 patients with invasive T1-3M0 breast carcinoma and initial treatment with SLN biopsy were extracted from the SEER database. Univariate and multivariate analyses were performed. ResultsThe number of SLNs harvested and the completion of axillary lymph node dissection (ALND) were not associated with DSS improvement for patients without metastatic nodes. After adjustment, patients with three SLNs had a better DSS than did other groups (HR of 0.73 CI 95% [0.60–0.88], p = 0.001). This result was mainly driven by the group of patients with one metastatic LN. When patients had two or more metastatic LNs, there was no difference in DSS according to the number of SLNs or to completion of ALND. ConclusionsThe number of SLN harvested was associated with DSS. According to DSS, the optimal number of SLNs harvested was three in this large series, thereby calling into question the understaging or undertreatment of SLN biopsy in which only one or two SLNs are harvested but also the therapeutic effect of completion ALND.

Regional control of head and neck melanoma with selective neck dissection.

Historically, patients with cervical metastases from melanoma of the head and neck were treated with a radical neck dissection. This study evaluates the efficacy of limiting the extent of lymphadenectomy in this high-risk population. To determine whether limiting the extent of lymphadenectomy for patients with biopsy-proven melanoma has a negative effect on regional control. Our hypothesis was that performing a more limited lymphadenectomy does not have a negative impact on regional control. A retrospective, single-cohort study was performed using a prospectively collected database of patients with head and neck melanoma with histopathologically positive lymph nodes after modified radical (MRND) or selective neck dissection (SNDs) performed at a high-volume, academic, tertiary care center. Lymphadenectomy was performed as clinically indicated. Primary end points were regional recurrence and regional recurrence free survival. Univariable and multivariable analyses were conducted using multiple patient characteristics. Forty-one patients underwent SND or MRND from 2001 through 2010. The median number of positive nodes was 1 (range, 1-16). Twenty-six patients (63%) received adjuvant radiation and 23 patients (56%) received adjuvant immunotherapy or chemotherapy. The median follow-up time was 17 months (range, 1-116 months). Regional control was achieved in 29 patients (71%). Median regional recurrence-free survival was 21 months (range, 1-116 months). Age (hazard ratio [HR], 1.13; 95% CI, 1.01-1.26), total number of nodes examined (HR, 1.05; 95% CI, 1.01-1.10), and number of sentinel lymph nodes examined (HR, 1.45; 95% CI, 1.01-2.09) were all significantly associated with increased recurrence-free survival. Tumor depth, extracapsular spread, number of nodes positive, prior SLNB, extent of lymphadenectomy, and adjuvant therapy were not significant. Limiting the extent of lymphadenectomy with frequent use of adjuvant radiation therapy is effective in achieving regional control of head and neck melanoma with cervical metastases.

Effects of variation of sentinel lymph nodes submitted during breast cancer sugery: Analysis of practice variation and costs.

94 Background: Routine node evaluation involves simple bivalving the node with slides made from the resultant surfaces. SLNs are more thoroughly evaluated with 2-3 mm slices and histologic evaluation of each slice, resulting in many more slides to review. These slides would often have immunohistochemical analysis adding to the time and cost. In early studies of SLN efficacy and accuracy, the mean number of nodes was between 2 and 3 per patient though with some variation. As the number of submitted SLNs increases, the concern of benefit of the procedure comes into question. This is a retrospective examination of all SLN procedures for the year 2012 to examine the variation in the number of SLNs submitted for focused pathologic evaluation. Variation in the number of nodes submitted by surgeon is determined along with the associated costs of the pathologic evaluation. In addition, intraoperative evaluation of lymph node status may be useful to allow for immediate axillary node dissection during the initial operation. Utilization of this procedure was also examined to determine ultimate correlation with permanent pathologic evaluation. Methods: Retrospective examination of all breast cancer patients &gt;=18 yrs who underwent SLN procedures during 2012. Introperative evaluation of lymph node for metastatic disease was also examined for correlation with permanent pathologic result. Results: 259 cases among 21 surgeons had touch prep performed. True positive number: 29. True negative number: 224. False negative number: 6. Fasle negative rate (FNR): 17.14%. Cost Effectiveness Evaluation: CPT 88307 - surg path gross and micro level V. CPT 88342 - Immunohistochemistry. CPT 88333 - Touch Prep. Pathologist time: 30 minutes per case. Conclusions: There is significant variation among surgeons as to number of cases and number of nodes submitted. There is a significantly greater number of sentinel lymph nodes examined by the pathologist as compared to the number of nodes submitted by the surgeon. The frequency of outliers is infrequent, but when it occurs there is significant cost in terms of time and dollars. The false negative rate from pathological evaluation is under study for isolated tumor cells.