Sentinel Lymph Node Biopsy In Patients Research Articles

Accuracy of sentinel node mapping in Marjolin ulcer: Comparison of three different injection techniques

BackgroundMarjolin ulcer is a specific type of squamous cell cancer that can benefit from the use of lymphoscintigraphy.The purpose of this study was to evaluate 3 different injection techniques for sentinel node biopsy in patients with Marjolin ulcer. MethodsForty-eight patients with Marjolin ulcer (27 male and 21 female) ranging in age from 24 to 85 years were included in our study. Intratumoral (IT), peritumoral (PT) and periscar (PS) tissue injections of radiotracer were done in 9, 10, and 29 patients respectively. Injections were done 2–4 h before surgery. Lymphoscintigraphy was done for mapping the lymphatic drainage. During surgery, lymphatic mapping and sentinel node biopsy was performed using a handheld gamma probe. After harvesting sentinel nodes, regional lymph node dissection was done. ResultSentinel node detection rate was higher in the PS group as compared to the IT and PT groups (89.6% vs. 50% and 22.2%) respectively. False negative rate was 0%. Pathologically involved sentinel nodes were detected in 16% of the included patients of our study which led to management change. None of the patients with pathologically non-involved sentinel nodes developed regional lymph node recurrence. ConclusionLymphatic mapping and sentinel node biopsy is feasible in Marjolin ulcer with high detection rate and low false negative cases which by detection of regional lymph node involvement can potentially change the management of patients. Injection site may be an important factor influencing the success of the procedure and injection of the mapping material in the peri-scar normal skin proximal to the lesion is the best technique.

The Role of Sentinel Node Biopsy in the Era of Adjuvant Therapy for Melanoma.

Sentinel lymph node biopsy (SLNB) is a surgical procedure aimed to detect nodal metastases in patients with clinically occult disease. Since the advent of new systemic therapies, its role in melanoma has been extensively debated over the last years. In this article, three possible scenarios are discussed, considering the SLNB impact on the management of melanoma patients. First, pT1b and pT2a patients with negative SLNB (stages IA and IB) and those with positive SLNB (stage IIIA) would all not benefit from adjuvant treatment. Therefore, SLNB might be avoided in these categories of patients. Second, in IIB and IIC, melanoma patients are already candidates for adjuvant treatment; therefore, SLNB in patients with T3b, T4a, or T4b melanoma would not change treatment decisions. On the other end of the spectrum, patients with pT2b and pT3a melanomas (clinical stage IIA) represent the only two groups whose management would be significantly affected by the SLNB status, being adjuvant therapy only indicated for SLN-positive patients. Further studies are needed to investigate which melanoma patient deserves SLNB.

Sentinel lymph node biopsy for breast cancer during pregnancy: A comprehensive update.

Pregnant patients diagnosed with breast cancer (PrBC) may receive substantially different treatments compared to general population, considering that certain treatment options cannot be applied during pregnancy due to their potential harmful effects to the foetus. Regarding the use of sentinel lymph node biopsy (SLNB) in pregnant patients, potential concerns include foetal harm from radiation exposure, possible teratogenic effects of blue dyes and maternal anaphylaxis to isosulfan. The main objective of the present systematic review is to summarize and present current knowledge and up-to-date evidence about the safety and efficacy of SLNB in PABC. MEDLINE, Google Scholar and UpToDate databases were searched up to 22 January 2023. Articles studying the safety and effectiveness of SLNB in patients for PrBC were eligible for inclusion in the present review. In total, 63 articles that met the inclusion criteria were included in this study. Forty-seven articles were strongly in favour of performing SLNB in PABC, 4 articles were partially in favour, 10 articles were strongly against and 2 articles were partially against performing SLNB in PABC. Sub-categorization based on type of study showed that the majority of studies in favour were of higher level of evidence than those against. Furthermore, there were overall 12 studies reporting on outcomes. There were overall 382 women with PrBC that underwent SLNB. Full data were reported for 237 cases. Overall live birth rate was 95.8%, while overall neonatal complication rate was 3.4%. No case of maternal side effects or anaphylactic reaction, maternal death, stillbirth and neonatal death was reported (0%). Sentinel lymph node biopsy seems to be safe and effective technique for breast cancer during pregnancy.

Advantages of contrast-enhanced ultrasound in the localization and diagnostics of sentinel lymph nodes in breast cancer.

Sentinel lymph nodes (SLNs) are the first station of lymph nodes that extend from the breast tumor to the axillary lymphatic drainage. The pathological status of these LNs can predict that of the entire axillary lymph node. Therefore, the accurate identification of SLNs is necessary for sentinel lymph node biopsy (SLNB) to replace axillary lymph node dissection (ALND). The quality of life and prognosis of breast cancer patients are related to proper surgical treatment after the precise identification of SLNs. Some of the SLN tracers that have been identified include radioisotope, nano-carbon, indocyanine green (ICG), and methylene blue (MB). However, these tracers have certain limitations, such as pigmentation, radiation dangers, and the requirement for costly detection equipment. Ultrasound contrast agents (UCAs) have good specificity and sensitivity, and thus can compensate for some shortcomings of the mentioned tracers. This technique is also being applied to SLNB in patients with breast cancer, and can even provide an initial judgment on SLN status. Contrast-enhanced ultrasound (CEUS) has the advantages of high distinguishability, simple operation, no radiation harm, low cost, and accurate localization; therefore, it is expected to replace the traditional biopsy methods. In addition, it can significantly enhance the accuracy of SLN localization and shorten the operation time.

Factors causing failure of the sentinel node technique in mammary tumors larger than 4 cm without clinical axillary invasion

IntroductionThe high detection rate of the sentinel lymph node (SLN) in breast cancer is a quality criterion of the procedure. The aim of our work is to identify the failure factors (FF) of the SLN biopsy in tumors larger than 4 cm. Material and methodsThis is a prospective series of patients with breast tumors larger than 4 cm without clinical axillary involvement. The colorimetric method was used in 52% of cases and the dual method in 48% of cases. ResultsThe failure rate (FR) is 13%. The FF with a statistically significant difference are axillary invasion (P: .03; OR: 6.58) and the presence of lympho-vascular emboli (LVE) (P < .05; OR: 4.95). It should be noted that lympho-vascular emboli only concern those found in the peri-tumoral area. On the other hand, age over 60 years, Body mass index (BMI) over 30 and Ki 67 over 14 are not determining factors. DiscussionSener finds a more important FR when more than 10 lymph nodes of the axillary dissection are reached compared to the axillary hollows free from any neoplastic infiltration (P: .002; OR: 9.19). The FR for Gimbergues was statistically correlated with lymph node status (0% for pN0 tumors, versus 55% for pN1–N2 tumors). For Brenot-Rossi, the existence of LVE is a significant failure factor (P = .004).For other factors (obesity, advanced age), the data in the literature are contradictory. ConclusionThe infiltration of the axillary fossa and the existence of LVE constitute the main FF of SLN biopsy in patients with tumors larger than 4 cm without clinical axillary invasion.

The Integrated i31-GEP Test Outperforms the MSKCC Nomogram at Predicting SLN Status in Melanoma Patients.

Sentinel lymph node biopsy (SLNB) for patients with cutaneous melanoma is primarily a prognostic procedure that broadly identifies patients who may have disease progression and may warrant additional intervention. However, 88% of patients undergoing SLNB receive a negative result and of those, some will succumb to their disease. One clinical utility of the integrated 31-GEP test, which combines gene expression data with clinicopathologic factors to provide a personalized, precise risk of SLN positivity, is SLNB guidance. This study compared the i31-GEP for SLNB to a nomogram that predicts SLN positivity using only clinicopathologic factors. Patients with T1-T2 tumors and known SLN status (N=465) were analyzed by the i31-GEP for SLNB and a nomogram developed at Memorial Sloan Kettering Cancer Center (MSKCC). A 5% risk threshold was used to conform with national guidelines. In patients with <5% predicted risk, SLN positivity was 2.7% (3/111) for i31-GEP versus 10.0% (11/110, p=0.026) for MSKCC. In each T-category, the i31-GEP maintained a false-negative rate below the 5% risk threshold in those predicted to have a <5% risk, while the MSKCC nomogram did not. Integrating the 31-GEP with traditional factors outperformed a nomogram that uses clinicopathologic factors alone to predict SLN status. Incorporating the i31-GEP into clinical practice could improve identification of patients for SLNB, resulting in better risk-aligned management.

Sentinel Lymph Node Biopsy vs No Axillary Surgery in Patients With Small Breast Cancer and Negative Results on Ultrasonography of Axillary Lymph Nodes

Sentinel lymph node biopsy (SLNB) is the standard of care for axillary node staging of patients with early breast cancer (BC), but its necessity can be questioned since surgery for examination of axillary nodes is not performed with curative intent. To determine whether the omission of axillary surgery is noninferior to SLNB in patients with small BC and a negative result on preoperative axillary lymph node ultrasonography. The SOUND (Sentinel Node vs Observation After Axillary Ultra-Sound) trial was a prospective noninferiority phase 3 randomized clinical trial conducted in Italy, Switzerland, Spain, and Chile. A total of 1463 women of any age with BC up to 2 cm and a negative preoperative axillary ultrasonography result were enrolled and randomized between February 6, 2012, and June 30, 2017. Of those, 1405 were included in the intention-to-treat analysis. Data were analyzed from October 10, 2022, to January 13, 2023. Eligible patients were randomized on a 1:1 ratio to receive SLNB (SLNB group) or no axillary surgery (no axillary surgery group). The primary end point of the study was distant disease-free survival (DDFS) at 5 years, analyzed as intention to treat. Secondary end points were the cumulative incidence of distant recurrences, the cumulative incidence of axillary recurrences, DFS, overall survival (OS), and the adjuvant treatment recommendations. Among 1405 women (median [IQR] age, 60 [52-68] years) included in the intention-to-treat analysis, 708 were randomized to the SLNB group, and 697 were randomized to the no axillary surgery group. Overall, the median (IQR) tumor size was 1.1 (0.8-1.5) cm, and 1234 patients (87.8%) had estrogen receptor-positive ERBB2 (formerly HER2 or HER2/neu), nonoverexpressing BC. In the SLNB group, 97 patients (13.7%) had positive axillary nodes. The median (IQR) follow-up for disease assessment was 5.7 (5.0-6.8) years in the SLNB group and 5.7 (5.0-6.6) years in the no axillary surgery group. Five-year distant DDFS was 97.7% in the SLNB group and 98.0% in the no axillary surgery group (log-rank P = .67; hazard ratio, 0.84; 90% CI, 0.45-1.54; noninferiority P = .02). A total of 12 (1.7%) locoregional relapses, 13 (1.8%) distant metastases, and 21 (3.0%) deaths were observed in the SLNB group, and 11 (1.6%) locoregional relapses, 14 (2.0%) distant metastases, and 18 (2.6%) deaths were observed in the no axillary surgery group. In this randomized clinical trial, omission of axillary surgery was noninferior to SLNB in patients with small BC and a negative result on ultrasonography of the axillary lymph nodes. These results suggest that patients with these features can be safely spared any axillary surgery whenever the lack of pathological information does not affect the postoperative treatment plan. ClinicalTrials.gov Identifier: NCT02167490.

De-Implementation of Low-Value Care for Women 70 Years of Age or Older with Low-Risk Breast Cancer During the COVID-19 Pandemic

BackgroundOlder women with early-stage estrogen receptor-positive (ER+) invasive breast cancer (IBC) are at risk for overtreatment. Guidelines allow for sentinel lymph node biopsy (SLNB) and radiotherapy omission after breast-conserving surgery (BCS) for women 70 years of age or older with T1, clinical node negativity (cN0), and ER+ IBC. The study objective was to evaluate radiotherapy and SLNB de-implementation in older women with low-risk IBC after the resource limitations of the COVID-19 pandemic.MethodsAn institutional database was analyzed to identify women 70 years of age or older who received BCS for IBC from 2012 to 2022. The patients were divided into two cohorts: (1) patients with low-risk IBC (pT1, cN0, and ER+/HER2–) who were eligible for radiotherapy and SLNB omission and (2) patients with high-risk IBC (pT2-T4, cN+, ER–, or HER2+) who were ineligible for therapy omission. Clinicopathologic variables in both cohorts were analyzed.ResultsThe study enrolled 881 patients. For the patients with low-risk IBC, the annual rates of radiotherapy were stable from 2012 to 2019. However, radiotherapy utilization decreased significantly from 2020 to 2022 (58% in 2012 vs 36% in 2022; p = 0.04). In contrast, radiotherapy usage among the patients with high-risk IBC was stable from 2012 to 2022 (79% in 2012 vs 79% in 2022; p = 0.95). Among the patients with low-risk IBC, SLNB rates decreased from 86% in 2012 to 56% in 2022, but this trend predated those in 2020. The factors significantly associated with SLNB and receipt of radiotherapy among the patients with low-risk IBC were younger age, larger tumors, grade 3 disease, and involved nodal status (p < 0.01).ConclusionThis study demonstrated appropriate and sustained de-escalation of radiotherapy in older women with low-risk IBC after the COVID-19 pandemic.

Incidental Thyroid Tissue in Sentinel Nodes From Oral Squamous Cell Carcinoma.

Sentinel node biopsy (SNB) is a surgical staging test in which sentinel nodes (SNs) undergo intensive histological analysis. SNB diagnoses early cancer spread, but can also reveal unexpected findings within the SNs. We review cases of incidental thyroid cells (TC) found in SNs from patients with oral squamous cell carcinoma (OSCC) to assess the prevalence of TC, and the clinical significance of these. Multicenter retrospective review of SNB performed for cT1-T2N0 OSCC. Incidental TC were identified by TTF-1 or thyroglobulin positivity. Anatomical location of nodes containing TC, TC morphology, and ongoing management/follow up of this incidental finding was recorded. Neck dissections performed during the same period were reviewed to establish the expected incidence of TC in neck nodes without serial sectioning analysis. 278 SNB cases were reviewed. Ten procedures detected TC in nine patients (10/278, 3.6%). During the same time period 725 neck dissections were performed, six containing TCs (6/725, 0.8%). One patient underwent SNB twice with TC identified on both occasions. Three patients had both OSCC metastasis and thyroid cells. All SNB patients with TC identified underwent thyroid USS with no primary tumours identified. Three patients underwent thyroidectomy, in all cases no primary thyroid tumour was found. Prevalence of incidental TC in SNs appears to be higher than that reported in neck dissections, these are not likely to be clinically relevant and can be managed on a conservative basis in the absence of clear metastatic features. Multicentre retrospective cohort study, 3 Laryngoscope, 134:1278-1281, 2024.

Eccrine Porocarcinoma: Clinical and Histopathological Study of 14 Patients with Special Emphasis on Sentinel Lymph Node Biopsy.

Eccrine porocarcinoma is a rare skin adnexal tumour that affects elderly people. Most eccrine porocarcinomas are stage I or II according to the American Joint Committee on Cancer. The prognosis is good in early stages, but worsens when advanced. Since information on the use of sentinel lymph node biopsy in these patients is scarce, this study examined the records of all patients with eccrine porocarcinoma treated at Helsinki University Hospital during a 17-year period and focused on sentinel lymph node biopsy patients. The study identified 14 patients (9 male, 5 female). There were 2 metastases to the lymph nodes and 2 recurrences at initial referral to our institution. All primary tumours had wide local excision and 6 patients also had sentinel lymph node biopsy, of whom none had positive lymph nodes. There were no new metastases or recurrences during follow-up. Three patients died of causes other than eccrine porocarcinoma. When comparing the wide local excision only and wide local excision with sentinel lymph node biopsy groups, no parameters reached statistical significance. The decision process of the multidisciplinary tumour board meeting on whether to perform sentinel lymph node biopsy was not clear, perhaps due to the limited knowledge of eccrine porocarcinoma. Further studies and international collaboration are warranted.

Role of Sentinel Lymph Node Biopsy for Skin Cancer Based on Clinical Studies

The sentinel lymph node is the first lymph node from the primary tumor. Sentinel lymph node biopsy (SLNB) is a surgical procedure that can detect occult nodal metastasis with relatively low morbidity. It may also have a therapeutic effect via regional disease control. The Multicenter Selective Lymphadenectomy-I (MSLT-I) trial revealed a prognostic benefit from SLNB in melanoma patients. However, it remains unclear whether there is a prognostic benefit from SLNB in patients with nonmelanoma skin cancer owing to a lack of randomized prospective studies. Nevertheless, SLNB provides important information about nodal status, which is one of the strongest factors to predict prognosis and may guide additional nodal treatment. Currently, SLNB is widely used in the management of not only patients with melanoma but also those with nonmelanoma skin cancer. However, the utilization and outcomes of SLNB differ among skin cancers. In addition, SLNB is not recommended for routine use in all patients with skin cancer. In this review, we provide a summary of the role of SLNB and of the indications for SLNB in each skin cancer based on previously published articles.

Oncologic outcomes for different axillary staging techniques in nodal positive breast cancer undergoing neoadjuvant systematic treatment: A cancer registry study.

e12571 Background: The optimal axillary staging technique for patients with nodal positive breast cancer undergoing neoadjuvant systemic treatment (NAST) is unclear. Less invasive, targeted approaches like targeted axillary dissection (TAD) or sentinel-lymph node biopsy (SLNB) recently showed false-negative rates &lt; 10% compared to axillary lymph node dissection (ALND). Oncologic outcomes, however, are unknown. Methods: We identified nodal positive breast cancer patients undergoing NAST from 2016 to 2021 with at least 1-year follow-up and available information regarding axillary staging from the state cancer registry of Baden-Wuerttemberg, Germany. Invasive disease-free survival (iDFS) was assessed using Kaplan-Meier statistics and multivariate cox regression models (adjusted for age, pN stage, pT stage, and tumor biologic subtype). Results: A total of 2403 patients with a median follow-up of 23.2-months after surgery were identified: 1963 underwent ALND, 407 underwent SLNB (in 230 cases, three or more sentinel nodes (SLNs) were removed and in 177 cases, 1-2 SLNs were removed), and 33 underwent TAD. The proportion of patients with pN+ stage within these four groups was 54%, 31%, 26%, and 35%, respectively ( P &lt; 0.001). Significant differences in iDFS between the ALND, SLNB, and TAD groups were observed (log rank P = 0.046): iDFS 2 years after surgery was 74.5% (ALND), 80.2% (SLNB ≥3 removed SLNs), 85.6% (SLNB &lt; 3 removed SLNs), and 88.4% (TAD), respectively. iDFS after 4 years was 61.5% (ALND), 69.1% (SLNB ≥3 removed SLNs), and 74.6% (SLNB &lt; 3 removed SLNs), respectively. Multivariate cox regression analysis showed no significant influence of different axillary staging techniques on iDFS: HR 0.91 (95% CI 0.55 to 1.52) for SLNB with ≥3 removed SLNs, HR 0.99 (95% CI 0.59 to 1.67) for SLNB with &lt; 3 removed SLNs (reference = ALND). Conclusions: This data suggests that ALND provides no benefit in terms of iDFS compared to targeted approaches like TAD or SLNB for patients with nodal positive breast cancer undergoing NAST. Future studies with longer-term follow-up are welcomed to fully inform this discussion.

Sentinel Node Biopsy in Patients With Breast Carcinoma Without Axillary Involvement at Diagnosis Receiving Primary Systemic Therapy

BackgroundPrimary systemic therapy (PST) has acquired great importance in breast cancer (BC) in the last few years. In this scenario, even if it is accepted to perform SLNB before PST, most of the guidelines remark the advantages of this practice after it, such as avoiding another surgery to the patient, a rapid start of the treatment and no need of axillary dissection in cases of pathologic complete response (pCR). Nevertheless, the lack of knowledge of the initial axillary state and the need to practice axillary dissection with any axillary disease are claimed to be some other disadvantages. There are no randomized studies yet that can conclude the optimal timing of SLNB in PST, so for the moment we may settle for our common practice. Patients and MethodsWe studied all the cases attended in the Breast Unit that joined the inclusion criteria between 2011 and 2019 in our hospital and we compared the group with SLNB before PST with the group with SLNB after PST in terms of unnecessary axillary dissection and description features. ResultsWe included 223 female patients diagnosed with BC and without clinical nor radiological axillary disease (cN0), who had received NAC and SLNB performed before or after it. We observed a higher proportion of high-grade histological tumors (G3), tumors with aggressive phenotypes (Basal like and Her 2 enriched), and younger women in the group of SLNB before NAC compared with the SLNB after NAC group (P < .01). Despite this, we did not find any difference in the number of positive SLNBs or in the number of ALND performed between the 2 groups. We found a higher proportion of ALND with all the lymph node (LN) negatives in the SLNB before NAC group. ConclusionTaking into account that in the observation period we did not use ACOSOG Z0011 criteria with all the SLNBs, we figure out what would have been the real results nowadays following these criteria. In this scenario we conclude that patients with luminal phenotype seemed to benefit from practicing SLNB before NAC in terms of avoiding axillary dissections. We could not make any conclusion in the rest of the phenotypes. However, prospective studies are needed to confirm if this affirmation could be proved.

Population-based validation of the melanoma institute australia (MIA) and the memorial sloan-kettering cancer center (MSKCC) predictive tool for sentinel node status in patients with melanoma.

9571 Background: Patients with primary cutaneous melanoma are selected for sentinel lymph node biopsy (SLNB) based upon their risk of a positive SLN being identified. To improve upon stage-based categorization, the Memorial Sloan Kettering Cancer Center (MSKCC) and Melanoma Institute Australia (MIA) developed predictive models. Which model is more clinically useful is currently unclear. Methods: Consecutive patients undergoing SLNB from 2007-2021 were identified from the Swedish Melanoma Registry (SweMR), which covers 99% of patients with invasive cutaneous melanoma in Sweden. The predicted probability of SLN positivity was calculated using the MSKCC and limited MIA models (using mitotic rate as absent/present instead of count and excluding the optional variable lymphovascular invasion) for each patient. The operating characteristics of the models were assessed and compared. The “clinical utility” of each model was assessed using decision curve analysis (DCA) and compared with a strategy of performing SLNB on all patients. Results: In total 10,089 patients were included; the median Breslow thickness was 1.8 mm, 33.7% were ulcerated, and 1,802 patients had a positive SLN (17.9%). Both the MSKCC and limited MIA models were well calibrated across the full range of predicted probabilities, and had similar external area under curve (AUC), MSKCC 70.8% (95% CI 69.5-72.1%) and MIA 70.3% (95% CI 68.9-71.7%). When new models were constructed to compare the incremental value of the additional parameters of either nomogram over Breslow thickness alone, the AUCs were 70.1%, 71.6% and 72.0% for Breslow alone, MIA parameters and MSKCC parameters, respectively. At a risk threshold of 5%, DCA indicated no added net benefit for either model compared to performing SLNB for all patients. At risk thresholds of 10% or higher, both models added net benefit compared to SLNB for all. The greatest benefit was observed from use of the models in patients with T2 melanomas when a threshold of 10% was used to select patients for SLNB. In that setting, use of the nomograms led to a net reduction in seven avoidable SLNBs per 100 patients for the limited MIA nomogram and eight for the MSKCC nomogram, when compared to a strategy of SLNB for all. Conclusions: This study confirms the statistical performance of both the MSKCC and limited MIA models in a large, nationally-representative dataset. However, clinical utility as assessed by DCA demonstrated that using the models only improved selection for SLNB when a risk threshold of at least 10% was employed, and then mainly for T2 melanomas. Either further development of the nomograms, or other strategies, are needed to improve selection at lower risk thresholds.

Diagnostic accuracy of frozen section and patterns of nodal spread in high grade endometrial cancer: A secondary outcome of the SENTOR prospective cohort study

ObjectivesThe study aimed to define the accuracy of intraoperative frozen section (FS) for the detection of metastases in sentinel lymph node biopsy (SLNB) and describe the pattern of lymph node (LN) spread and relation to molecular classifiers in patients with high-grade endometrial cancer (EC). MethodsWe performed a secondary outcome of clinicopathologic data from the Sentinel Lymph Node Biopsy versus Lymphadenectomy for Intermediate- and High-Grade Endometrial Cancer Staging (SENTOR) prospective cohort study evaluating SLNB in patients with clinical stage I high-grade EC (ClinicalTrials.gov ID: NCT01886066). The primary outcome was the sensitivity of FS of the sentinel lymph node (SLN) specimen, compared to a standardized ultrastaging protocol. Secondary outcomes included the pattern and characteristics of LN spread. ResultsThere were 126 patients with high-grade EC with a median age of 66 years (range:44–86) and a median Body Mass Index (BMI) of 26.9 kg/m2 (range:17.6–49.3). FS was performed on surgical specimens from 212 hemipelves; SLNs were identified in 202 specimens (95.7%) and fatty tissue alone was identified in 10 specimens (4.7%). Of the 202 hemipelves in which SLNs were identified, 24 were positive for metastatic disease on final pathology. Initial FS correctly identified only 12, yielding a sensitivity of 50% (12/24, 95% CI 29.6–70.4) and a negative predictive value of 94% (178/190, 95% CI 89–96.5). A total of 24 patients (19%) had LN metastases: 16 (13%) had isolated pelvic metastases, 7 (6%) had both pelvic and para-aortic metastases and 1 (0.8%) had an isolated para-aortic metastasis. ConclusionsIntraoperative FS of SLNs in high-grade EC patients has poor sensitivity. Since isolated para-aortic metastases are rare, para-aortic lymphadenectomy may be omitted in patients in which SLNs were successfully mapped to the pelvis.

Abstract P5-01-05: A Predictive Model for Axillary Pathologic Response after Neoadjuvant Chemotherapy for Clinically Node-Positive Breast Cancer

Abstract Purpose: Neoadjuvant chemotherapy (NAC) has resulted in the eradication of axillary lymph node metastasis in approximately 40% of patients. Sentinel lymph node biopsy (SLNB) could be an alternative surgical procedure for these patients to avoid complications from axillary lymph node dissection (ALND). However, high false-negative rates of SLNB for clinically node-positive patients were reported in previous prospective trials. The aim of the present study was to evaluate clinicopathological factors and imaging characteristics by MRI and ultrasound (US) as predictors of axillary pathologic complete response (ypN0) after NAC, which enables to identify candidates for SLNB in patients with clinically node-positive disease. Patients and methods: We identified 177 patients with clinically node-positive breast cancer who received NAC from May 2009 to May 2021. All patients underwent MRI and US before and after NAC. Patients were judged to be node-positive when they have the cytologically-proven nodal disease by fine-needle aspiration (FNA) or suspicious lymph nodes by diagnostic imaging. Lymph nodes with the cortical thickness (&amp;gt;3.5mm), loss of fatty hilum, or round shape (short-axis/long-axis ratio &amp;gt; 0.5) were defined as suspicious lymph nodes. To develop a predictive model for ypN0, the association between ypN0 status and clinicopathological and imaging characteristics was assessed by multivariate logistic regression analysis. The area under the receiver operating characteristic (ROC) curve was used to evaluate discrimination by the model. The model was further evaluated in the validation cohort with 20 patients who received NAC from March 2021 to December 2021. Results: The median age was 54.0 (range: 22-79) years and the mean tumor size was 3.97 ±2.29cm. Of 177 patients, 90 (50.8%) patients had luminal, 47 (26.6%) had HER2-positive, and 40 (22.6%) had triple-negative disease. Sequential anthracycline and taxane were administered for 157 (88.7%) patients, and 45 (95.7%) patients with HER2-positive-disease received concomitant anti-HER2 agents preoperatively. Overall, 77 (43.5%) patients achieved ypN0. Independent predictors of ypN0 status were clinical stage N1 (odds ratio [OR]: 9.17 vs. cN2-3, p=0.002), absence of lymphadenopathy after NAC (OR: 8.54, p&amp;lt; 0.001), breast complete response (CR) by MRI (OR: 5.96, p&amp;lt; 0.001), HER2 positivity (OR: 3.80, p=0.008), nuclear grade (NG) 3 (OR: 2.77 vs. NG1-2, P=0.020) and hormone receptor negativity (OR: 2.52, p=0.048). In a model using these predictors, the area under the ROC curve was 0.887 (95% confidence interval: 0.839-0.935, p&amp;lt; 0.001). The sensitivity, specificity, positive predictive value and negative predictive value of the model were 80.0%, 82.8%, 77.9% and 84.5%, respectively. In the validation cohort, the sensitivity, specificity, positive predictive value and negative predictive value were 66.7%, 90.9%, 85.7% and 76.9%, respectively. Among 84 patients who were predicted ypN0 by the model, SLNB was performed in 42 (50.0%) patients, and the identification rate of SLN was 95.2% (40/42). Overall, ALND was omitted in 38 (45.2%) patients and irradiation to regional lymph nodes was performed in 23 (60.5%) out of 38 patients. After a median follow-up of 53.9 months, 5-year recurrence-free survival was comparable between patients with or without ALND (78.0% vs. 94.4%, p=0.259). Conclusions: Our predictive model based on clinicopathological factors and imaging characteristics by MRI and US could help to identify good candidates for the omission of ALND after NAC in patients with clinically node-positive breast cancer. Citation Format: Akiko Matsumoto, Saki Naruse, Yuka Isono, Yuka Maeda, Ayana Sato, Miki Yamada, Tatsuhiko Ikeda, Hiromitsu Jinno. A Predictive Model for Axillary Pathologic Response after Neoadjuvant Chemotherapy for Clinically Node-Positive Breast Cancer [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P5-01-05.

Sentinel Node Procedure to Select Clinically Localized Prostate Cancer Patients with Occult Nodal Metastases for Whole Pelvis Radiotherapy

BackgroundAccurate identification of men who harbor nodal metastases is necessary to select patients who most likely benefit from whole pelvis radiotherapy (WPRT). Limited sensitivity of diagnostic imaging approaches for the detection of nodal micrometastases has led to the exploration of the sentinel lymph node biopsy (SLNB). ObjectiveTo evaluate whether SLNB can be used as a tool to select pathologically node-positive patients who likely benefit from WPRT. Design, setting, and participantsWe included 528 clinically node-negative primary prostate cancer (PCa) patients with an estimated nodal risk of >5% treated between 2007 and 2018. InterventionA total of 267 patients were directly treated with prostate-only radiotherapy (PORT; non-SLNB group), while 261 patients underwent SLNB to remove lymph nodes directly draining from the primary tumor prior to radiotherapy (SLNB group); pN0 patients were treated with PORT, while pN1 patients were offered WPRT. Outcome measurements and statistical analysisBiochemical recurrence–free survival (BCRFS) and radiological recurrence-free survival (RRFS) were compared using propensity score weighted (PSW) Cox proportional hazard models. Results and limitationsThe median follow-up was 71 mo. Occult nodal metastases were found in 97 (37%) SLNB patients (median metastasis size: 2 mm). Adjusted 7-yr BCRFS rates were 81% (95% confidence interval [CI] 77–86%) in the SLNB group and 49% (95% CI 43–56%) in the non-SLNB group. The corresponding adjusted 7-yr RRFS rates were 83% (95% CI 78–87%) and 52% (95% CI 46–59%), respectively. In the PSW multivariable Cox regression analysis, SLNB was associated with improved BCRFS (hazard ratio [HR] 0.38, 95% CI 0.25–0.59, p < 0.001) and RRFS (HR 0.44, 95% CI 0.28–0.69, p < 0.001). Limitations include the bias inherent to the study’s retrospective nature. ConclusionsSLNB-based selection of pN1 PCa patients for WPRT was associated with significantly improved BCRFS and RRFS compared with (conventional) imaging-based PORT. Patient summarySentinel node biopsy can be used to select patients who will benefit from the addition of pelvis radiotherapy. This strategy results in a longer duration of prostate-specific antigen control and a lower risk of radiological recurrence.

Combined use of magnetic seed and tracer in breast conserving surgery with sentinel lymph node biopsy for non-palpable breast lesions: A pilot study describing pitfalls and solutions

BackgroundsTraditionally, breast conserving surgery for non-palpable breast cancer is guided by wire or radioactive seed and radioactive tracer for sentinel lymph node biopsy (SLNB). Alternatively, a stain-less magnetic seed and superparamagnetic iron oxide tracer (SPIO) can be combined as a radioactive-free technique. The aim of this study was to define the pitfalls we encountered during implementation of this combined technique and provide solutions resulting in an instruction manual for a radio-active free procedure. MethodsBetween January and March 2021, seventeen consecutive patients with cN0 non-palpable breast cancer were included. The magnetic seed was placed to localize the lesion and SPIO was used to identify the sentinel lymph node (SLN). A lymphoscintigraphy with Technetium-99m nano colloid was performed concomitantly in all patients as a control procedure for SPIO. Surgical outcomes are reported, including problems with placing and retrieval of the seed and SPIO and corresponding solutions. ResultsSurgical excision was successful with invasive tumor-free margins in all patients. SLN detection was successful in 82% patients when compared to Technetium-99m. The most challenging issue was an overlapping magnetic signal of the seed and SPIO. Solutions are provided in detail. ConclusionsCombined use of magnetic seed and SPIO for wide local excision and SLNB patients with non-palpable breast lesions appeared challenging due to overlapping magnetic signals. After multiple adaptations, the protocol proved to be feasible with an added advantage of eliminating the use of radioisotopes. We described the pitfalls and solutions resulting in an instruction manual for a totally radioactive-free procedure.

The 31-gene expression profile test informs sentinel lymph node biopsy decisions in patients with cutaneous melanoma: results of a prospective, multicenter study

Background The 31-gene expression profile test (Class 1A: low-risk; 1B/2A: intermediate-risk; 2B: high-risk) is validated to identify patients with cutaneous melanoma who can safely forego sentinel lymph node biopsy (SLNB). The objective of the current study is to quantify SLNB reduction by clinicians using 31-GEP. Methods Patients with T1-T2 tumors eligible for SLNB were seen by surgical oncologists (89.1%), dermatologists (7.8%), and medical oncologists (3.1%). After receiving 31-GEP results but before SLNB, clinicians were asked which clinical and pathological features influenced SLNB decisions (n = 191). The Exact binomial test was used to compare SLNB procedure rates to a contemporary study (78% SLNB baseline rate). Logistic regression modeling (odds ratio [OR], 95% CI) was used to identify features associated with SLNB procedure rates. Results One hundred clinical decisions (52.4%) were influenced by the 31-GEP to forego SLNB and 70% (70/100) were not performed. Of the 30 performed, 0% (0/30) were positive. The 31-GEP influenced sixty-three clinical decisions (33.0%) to perform SLNB, and 92.1% (58/63) were performed. There was a clinically meaningful 29.4% reduction of SLNBs performed in patients with a Class 1A result relative to the baseline rate of 78.0% (p < .01). In patients ≥55 or ≥65-year-old, SLNB reduction was 32.3% (p < .01), 28.3% (p < .01), respectively. Overall, 85.3% of decisions relating to SLNB were influenced by 31-GEP results. Conclusion In this prospective, multicenter study, clinicians demonstrated clinically meaningful use of the 31-GEP test to forego or pursue SLNB in patients with T1-T2 tumors resulting in a significant, risk appropriate decrease in SLNBs.

Multi-tracer sentinel node biopsy for patients with breast cancer after neoadjuvant chemotherapy

Background: For post-neoadjuvant chemotherapy patients with breast cancer, sentinel lymph node biopsy (SLNB) was recommended using the dual-tracer mapping technique (radioisotope plus blue dye) or placing a biopsy clip into the positive node at diagnosis and identifying it at the time of surgery due to SLN identification rates were lower and false negative rates were greater for patients with local advanced BC than those of patients with early-stage BC in the absence of NAC. Our previous clinical trial has indicated that the real-time ICG fluorescence (RT-ICG) imaging technique could improve the diagnostic sensitivity and detection accuracy for SLNB. Methods: The SLNs was detected by conventional procedures of blue-dye (Indigo carmine) plus 99mTc radioisotope (dual-tracer) and combined with concurrent RT-ICG technique. The positivity of each single SN by each single tracer (blue dye, ICG, or radioisotope alone) was counted and identified, respectively. 51 enrolled cN1patients after NAC are required to undergo SNB followed by completion axillary lymph node dissection (CND). The identification rate and false negative rate of each single tracer and their summation (triple tracer) were calculated by comparing the results of the SLNB and the histopathology of the resection specimens of CND. Results: post-neoadjuvant patients, the identification rate and false negative rate of each single procedure for SLNB was 84.3% and 5.9% when used Indigo Carmine blue, 94.1% and 0 when used ICG fluorescence, 92.2% and 3.9% when used RI, respectively. In contrast, the total calculation of triple tracer showed that identification rate reached to 96.1% and false negative rate was 0, respectively. Conclusions: Our results suggested that the multitracer technique combining blue dye, ICG, and radioisotope is effective method for detection of SLNs in post-neoadjuvant cN+ BC pts. The identification rate and false negative rate of SLNB might be improved by this multiple tracer mapping technique, particularly for patients with ypN(+) after NAC. It is considered that the multi-tracer can complement each other for what was not able to be traced and detected by the single tracer with one mapping material, and that result in totally the improvement of identification rate of SLNB.