Positive Sentinel Lymph Node Biopsy Research Articles

Predictive Value of Dynamic Contrast-Enhanced Breast Magnetic Resonance Imaging and Diffusion-Weighted Imaging Findings for Sentinel Lymph Node Metastasis in Early-Stage Invasive Breast Cancer.

This retrospective study aimed to evaluate the predictive value of the preoperative dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and diffusion-weighted imaging (DWI) findings of mass lesions for predicting sentinel lymph node (SLN) metastasis in early breast cancer. A total of 310 patients with suspicious mass lesions detected in preoperative MRI who subsequently underwent surgery and SLN biopsy (SLNB) between September 2015 and September 2022 were analyzed. The relationship between DCE-MRI and DWI findings and SLNB positivity was analyzed. SLNB was positive for SLN metastasis in 108 of 310 lesions. Younger age (p = 0.001) and larger lesion size (p < 0.001) were found to be associated with SLNB positivity. Findings associated with SLN metastasis included peritumoral edema in 53%, adjacent vessel sign (AVS) in 81%, and increased whole-breast vascularity (WBV) in 58% of patients with positive SLNB (p < 0.001). The SLNB positivity rate was higher in mass lesions with DCE-MRI findings of heterogenous enhancement pattern (p = 0.003), medium or rapid initial phase enhancement (p = 0.001), and washout delayed phase kinetic curve (p = 0.001). It was found that lower tumoral apparent diffusion coefficient (ADC) values (p = 0.003) and higher peritumoral/tumoral ADC ratios (p = 0.018) increased the probability of encountering SLN metastasis. Patient age, presence of peritumoral edema, presence of AVS, increased WBV, and initial phase kinetic curve of the lesions on MRI were found to be associated with SLN metastasis. We found that younger age and MR findings obtained from the perilesional area of breast cancer may be helpful in the preoperative prediction of SLN metastasis.

Acral melanoma in the Caucasian population: a comprehensive cohort study on epidemiological, clinicopathological, and prognostic features.

Acral melanoma is associated with poor prognosis. Studying the characteristics and prognosis of Caucasian patients is crucial to understand the distinct features of this tumor. To analyze the epidemiological, clinicopathological, and prognostic features of acral melanoma in Caucasian patients. We conducted a retrospective, multicenter, cohort study of acral melanoma from a database across 20 hospitals from South Europe from January 2000 through December 2019. A total of 733 acral melanomas were identified (median age, 67.5 years; 95.2%, Caucasians; 77.5% of which were located on the feet). Overall, 77.5% of cases were invasive melanomas. Foot melanomas had a higher proportion of invasive cases (80.8% vs 69.8%; p = 0.003), stages III and IV at diagnosis (24.8% vs 11.7%; p < 0.001), thicker Breslow depth (2.8 mm vs 2.0 mm; p = 0.021) and a higher rate of positive sentinel lymph node biopsy (SLNB) (30.7% vs 15.7%; p = 0.012). Thicker Breslow depth and later age of onset were risk factors for melanoma-specific survival. Thicker Breslow depth and ulceration were independent prognostic factors of relapse-free survival. Melanoma location and histopathological subtype were not associated with worse prognosis. Recurrences were a common finding (27.7%), with distant metastases appearing earlier than locoregional recurrences (1.32 years [IQR, 1.12-1.87] vs 2.14 years [IQR, 1.68-2.70]; p = 0.015). This study, the largest in a predominantly Caucasian population, underscores the unfavorable outcomes of acral melanoma. Foot melanomas exhibited delayed detection, increased invasiveness, thicker Breslow depth, increased SLNB involvement, and higher AJCC stages. The high recurrence rate and early distant metastases emphasise the critical role of intensive follow-up and routine imaging modalities to detect asymptomatic relapses.

Sentinel Lymph Node Biopsy: Is There a Role in Non-Melanoma Skin Cancer? A Systematic Review.

Sentinel Lymph Node Biopsy (SLNB) aims at identifying clinically occult nodal metastases. It is the standard staging procedure for patients with T1b to T4 primary cutaneous melanoma. Moreover, it is recommended whenever the risk of a positive SLNB is >5%, according to the National Comprehensive Cancer Network Melanoma guidelines. When considering Non-Melanoma Skin Cancer (NMSC), the SLNB could play a role in tumors that mainly spreads via lymphatics, but strong evidence is missing. In this paper, the hot topics and controversies are reviewed; Methods: A PRISMA systematic review was carried out on the PubMed (MEDLINE) library from 2004-2024, searching for studies on SLNB in NMSC; Results: Seventy articles and 6379 patients undergoing SLNB for Squamous Cell Carcinoma (SCC), Merkel Cell Carcinoma (MCC), and Porocarcinoma were included. Overall, the SLNB positivity rate in these NMSCs was 24.4%, with an SNLB detection rate of 97.6%. Specifically, the SLNB positivity rate was 12.3% for high-risk cutaneous SCC, 24.4% for anogenital SCC, 29.3% for MCC, and 30.6% for Porocarcinoma. Most papers concluded that SLNB is safe, feasible, and significant in these malignancies; Conclusions: SLNB should be discussed and offered to every patient with MCC, and it should be discussed and considered in "high risk" SCC and Porocarcinoma for staging and prognostic purposes, aiming to identify a subgroup of patients who may benefit the most from early treatments.

Predictive and Prognostic Values of Glycoprotein 96, Androgen Receptors, and Extranodal Extension in Sentinel Lymph Node-Positive Breast Cancer: An Immunohistochemical Retrospective Study.

Objectives: In this paper, we investigate the association of glycoprotein 96 (GP96) and androgen receptor (AR) expression with clinicopathological factors, additional axillary lymph node burden, and their potential role in predicting 5-year overall survival (OS) and disease-free survival (DFS) in breast cancer (BC) patients with sentinel lymph node (SLN) involvement. We also explore the prognostic value of the presence of extranodal extension (ENE) in SLN. Methods: We retrospectively enrolled 107 female patients with cT1-T2 invasive BC and positive SLN biopsy. GP96 and AR expression were immunohistochemically evaluated on tissue microarrays constructed from two 2 mm diameter cores of formalin-fixed paraffin-embedded tumor tissues from each patient. ENE in SLN was measured in the highest (HD-ENE) and widest diameter (WD-ENE). Relative GP96 gene expression was determined using real-time quantitative PCR. Results: The analysis revealed ENE in SLN as the strongest predictive factor for non-SLN metastases. Patients with WD-ENE > HD-ENE had a higher risk of non-SLN metastases and worse DFS compared to those with WD-ENE ≤ HD-ENE. High GP96 expression was associated with a greater relative risk for locoregional recurrence but showed no significant impact on OS or DFS. Histological grade 3, extensive intraductal component (EIC), higher lymph node ratio (LNR), and negative AR were associated with worse DFS, while age, histological grade 3, EIC, and higher LNR were independent predictors of OS. GP96 mRNA levels were elevated in BC tissue compared to normal breast tissue. Conclusions: ENE in SLN is the strongest predictor of non-SLN involvement and could also have prognostic significance. While GP96 expression does not influence survival outcomes, AR expression could be used as a valuable biomarker in the follow-up of BC patients.

Response of mucinous breast carcinoma to neoadjuvant chemotherapy.

Mucinous breast carcinoma (MBC) is thought to be a favorable-differentiated form of invasive breast cancer and is rarely preferred for neoadjuvant chemotherapy (NAC). The study aimed to define the response of MBCs to NAC. A review was made of the demographic, clinicopathologic characteristics, management and follow-up data of 70 patients diagnosed with MBC between May 2010 and December 2020 by examining the patients' historical files and oncology records. The median age, tumor size, and follow-up period of patients were 52.9 (range: 32-87) years, 25.8 (range: 8-88) mm, and 61.5 (range: 18-143) months, respectively. Of the 70 patients, 45 had conservative surgery, 25 had a mastectomy, and 22 had axillary clearance due to a positive sentinel node biopsy or clinical axilla. Eight patients (11.4%) received NAC. Twenty-one patients (30.0%) received adjuvant chemotherapy, whereas almost all the patients received hormone therapy. The preoperative core biopsy diagnosis of four of eight patients receiving NAC was unspecified invasive breast carcinoma. NAC was used as treatment in patients who were younger, had tumors larger in diameter, had tumors with an initial higher T-stage, and especially those with clinically positive axilla, and tumors with a higher Ki-67 index. Despite these preference criteria, both the overall mastectomy and axillary clearance rates were significantly higher in these patients. Two local and five systemic recurrences were observed in the follow-up period. NAC had no significant contribution to survival. It may be concluded that NAC is not sufficiently effective in either helping to diminish the need for mastectomy by downsizing the tumor, or in preventing axillary clearance in MBCs, and no significant benefit on survival could be observed. In addition, the results may emphasize the importance of identifying the MBC subtype, and the significant association between the degree of response to NAC and the subtype.

Translated article] Multicenter Analysis of the Surgical Management and Adjuvant Therapy of Patients With Melanoma and a Positive Sentinel Lymph Node Biopsy.

Complete lymph node dissection (CLND) was the standard practice for patients with melanoma and a positive sentinel lymph node biopsy (SLNB) until the results of two clinical trials published in 2016 and 2017 demonstrated that it did not improve melanoma-specific survival (MSS). However, it continues to be performed in some scenarios. No studies have ever been published on lymph node management after a positive SLNB in the routine clinical practice in our setting. To determine the evolution of the indication for CLND in patients with a positive SLNB, as well as the characteristics associated with its performance. We conducted a multicenter retrospective observational study with patients with skin melanoma and positive sentinel lymph nodes diagnosed from 2017 through 2022 at 8 Spanish centers and 1 Italian center. A total of 430 patients were included, 54% men, with 323 (75.1%) aged between 45 and 80 years. A total of 133 cases (31%) exhibited Breslow thickness >4mm, 206 cases (49%) were ulcerated, and in 213 cases (55.7%), lymph node metastasis was >1mm. Isolated lymphadenectomy or followed by adjuvant therapy was performed in 146 patients (34.1%). After multivariate logistic regression, the factors associated with the performance of CLND were the acral lentiginous melanoma histological subtype, lymph node metastasis size >1mm, extracapsular spread, and the participant hospital. Age >80 years was inversely associated. While the frequency of CLND in patients with melanoma and positive SLNB has decreased, the indication for systemic adjuvant therapy in these patients has increased. However, CLND is still indicated in patients with high-risk characteristics.

Enhanced Risk Stratification for Sentinel Lymph Node Biopsy in Head and Neck Melanoma Using the Merlin Assay (CP-GEP).

Sentinel lymph node biopsy (SLNB) for head and neck melanomas involves complex challenges due to intricate lymphatic networks and delicate anatomic structures. The Merlin Assay (CP-GEP), merging clinicopathologic data with gene expression profiling, offers a non-invasive method to identify patients who have a low risk for nodal metastasis, potentially sparing these low-risk patients from surgical procedures. This study evaluated 250 clinically node-negative patients with stage I, II, or III melanoma from the Mayo Clinic and University Hospitals Cleveland Medical Center who had tumors in the head and neck region diagnosed between 2004 and 2021. All the patients underwent SLNB. The Merlin Assay, using the CP-GEP model, combines patient age at diagnosis, Breslow thickness, and gene expression of eight specific genes from the primary tumor to predict the risk of nodal metastasis. The SLNB positivity rate was 14% overall, and CP-GEP predicted a possible 40.8% reduction in SLNB procedures with a negative predictive value (NPV) of 98%. For 215 SLNB-negative patients (5-year recurrence-free survival [RFS] of 76.9%, distant metastasis-free survival [DMFS] of 84.3%, and melanoma-specific survival [MSS] of 90.6%), CP-GEP improved risk stratification by identifying 100 patients as low risk with 5-year RFS of 86.1%, DMFS of 92.7%, and MSS of 95.3%. Among 167 T1-T2 patients, the SLNB positivity rate was 8.4%, and CP-GEP achieved an SLNB reduction rate of 56.3% with an NPV of 98.9%. The Merlin Assay effectively categorizes head and neck melanoma patients by risk, enabling more accurate clinical decision-making regarding SLNB and follow-up evaluation, especially for early-stage melanoma patients.

Incidence of a Positive Sentinel Lymph Node Biopsy in Screen-Detected Early Breast Cancer.

Introduction Current guidelines advocate for a sentinel lymph node biopsy (SLNB) in patients with invasive breast cancer with negative axillary ultrasonography. However, emerging evidence has contradicted this, and SLNB omission has been found to be non-inferior in selected low-risk breast cancers. This retrospective study aimed to evaluate the incidence of SLNB in screen-detected invasive breast cancer. The secondary outcome was to identify risk factors in patients with positive SLNB and further axillary disease. Methods All screen-detected histologically confirmed invasive breast cancer and no evidence of spread to ipsilateral axillary lymph nodes (LNs) on ultrasound scans referred from screening between January 2018 and December 2019 were included in the study. All patients underwent surgical excision of the tumor as either breast conservation surgery or mastectomy, along with sentinel node biopsy. SLNB was performed using the dual technique of radioactive dye and blue dye. Results One hundred forty-nine patients were included in the study, all of whom were females. The mean patient age was 61.9 years old, with the majority 65 (43.6%) of the patients being in their 60s. Breast-conserving surgery (BCS) was performed in 138 (92.6%)patients. Eighty (53.7%) patients presented with right breast cancer. The mean size of invasive cancer was 15 mm. The mean total tumor size, including invasive and in situ, was 20.9 mm. One hundred twenty-seven (85.2%)patients had unifocal presentations, 69 (46.3%) oftumor foci were in the upper outer quadrant (UOQ), 122 (81.9%) of all tumors were ductal carcinoma, 81 (54.4%)patients had histologically grade 2 carcinomas, 135 (90.6%) of all patient tumors were ER-positive, HER2-negative, and six (4%) were ER-positive, HER2-positive. Twelve (8.05%) out of 149 included patients had positive sentinel LN biopsy. Of those 12 patients, eight (66.7%) had one to two nodes sampled, three (25%) had three to four nodes, and one (8.3%)had five or more nodes sampled. Out of 12 positive SNB patients, 11 had completed axillary node clearance (ANC) as per the National Institute for Health and Care Excellence (NICE) guidelines: nine (81.8%) had no further disease, and two (18.2%) had four positive nodes. The mean number of nodes taken in ANC was 15.8± 11.5. Of the two patients with positive axillary disease, one had BCS, and the other had a mastectomy. Both were grade 3 IDC, and the mean size was 57.5 mm. Nine patients died within four years of diagnosis, with four due to distant breast metastasis. Conclusion Only 8% of patients had positive SLNB in screen-detected breast cancer, which may supportthe previous studies of omitting SLNB being non-inferior but only in selected postmenopausal small early breast cancers with normal axillary ultrasound in the absence of any other risk factors. However, close follow-up will be required for disease-free survival, overall survival, and locoregional recurrence in this cohort.

Is Axillary Lymph Node Dissection Needed? Clinicopathological Correlation in a Series of 224 Neoadjuvant Chemotherapy-Treated Node-Positive Breast Cancers

Axillary lymph node status is valuable in determining systemic and radiation therapy. Following neoadjuvant therapy for patients with clinically involved axillary nodes, the role of axillary lymph node dissection (ALND) following a positive sentinel lymph node biopsy (SLNB) is a subject of controversy. We retrospectively analyzed 224 neoadjuvant chemotherapy-treated node-positive breast cancer cases and evaluated the role of ALND in optimizing staging accuracy and treatment outcomes. About 63 (27.8%) underwent ALND based on post neoadjuvant persistent positive lymph nodes on exam /imaging. SLNBs were performed in 161 (71.9%) patients as initial surgical planning; 67 (41.6%) patients had positive SLNB results, and 51 (76.1%) underwent further ALND. In patients with 1 positive sentinel lymph node, follow-up ALND yielded additional positive lymph nodes in 10.5% of cases, whereas in patients with 2 or more positive sentinel lymph nodes, follow-up ALND yielded additional positive lymph nodes in 87.5% of cases. The presence of 2 positive macro-metastatic sentinel lymph nodes significantly predicts additional nodal involvement, especially in patients without a pathologic complete response. De-escalation of axillary surgery to SLNB alone in this context may be safely considered in neoadjuvant-treated clinical node positive patient with <2 positive sentinel lymph nodes. Our findings help guide surgeons to appropriately select patients who can potentially benefit from ALND for locoregional control and recommendation for adjuvant radiation.

Incidence and predictive factors for positive non-sentinel lymph nodes in completion neck dissection following a positive sentinel node biopsy in early oral cancer

Incidence and predictive factors for positive non-sentinel lymph nodes in completion neck dissection following a positive sentinel node biopsy in early oral cancer

Prediction of non-sentinel lymph node metastases in T1–2 sentinel lymph node-positive breast cancer patients undergoing mastectomy following neoadjuvant therapy

BackgroundAxillary lymph node dissection (ALND) is the standard axillary management for breast cancer patients with positive sentinel lymph node biopsy (SLNB) after neoadjuvant therapy. Nevertheless, when that happens, the frequency of additional positive nodes is not properly evaluated. We aim to develop a prediction model to assess the frequency of additional nodal disease after a positive sentinel lymph node following neoadjuvant therapy.MethodsWe retrospectively analyzed the ultrasound and clinicopathological characteristics of breast cancer patients with 1–3 positive sentinel lymph nodes (SLN) undergoing mastectomy after neoadjuvant therapy (NAT) at our institution, and performed univariate and multivariate logistic analyses to confirm the factors affecting non-SLN metastasis. These factors were included to establish a nomogram, and the area under receiver operating characteristic curve (AUC) and decision curve analysis (DCA) were utilized to assess the validity of this model.ResultsA total of 126 breast cancer patients were ultimately included in our study, 38 (53.5%) patients were diagnosed with non-SLN metastases of all 71 patients in training set. The results of multifactorial logistic analysis suggested that lymph node metastasis ratio (LNR), short axis of lymph node and progesterone receptor (PR) were strongly associated with non-SLN metastasis. We established a nomogram using the above three variables as predictors, which yielded an area under the curve of 0.795, and validated with a favorable AUC of 0.876.ConclusionThe nomogram we constructed can accurately predict the likelihood of non-SLN metastasis in our patients with 1–3 positive SLN after NAT, which may help guide decision making regarding axillary management.

ThP1.12 - Axillary Node Clearance Following Positive Sentinel Node Biopsy: Is it Always Necessary?

Abstract Aim The study was carried out to determine what proportion of patients have residual disease on completion Axillary node clearance (ANC) following positive nodes on prior Sentinel node biopsy (SNB) and assess for correlation between possible predicting factors such as neoadjuvant chemotherapy and the absence of positive nodes at ANC. Methods Operation records of patients who had surgery for breast cancer were used to identify all patients who had Axillary node clearance done from 2020 to 2023. Patients who did not have SNB prior to ANC were excluded. Results Less than 45% of patients had residual disease on completion ANC. Data was evenly spread between ductal carcinoma and lobular carcinoma on biopsy. There was no significant correlation found between number of positive nodes found at SNB and positive nodes at ANC. More than 50% of patients who had neoadjuvant chemotherapy prior to procedure were node-negative on completion ANC. Conclusion Management of axillary disease post positive SNB remains debatable. Use of neoadjuvant chemotherapy may reduce the need for completion axillary node clearance.

Treatment Patterns and Outcomes of Stage III Melanoma Patients with Positive Sentinel Lymph Node Biopsy: A Real-Life Experience.

Background: Advancements in managing stage III melanoma have involved the implementation of adjuvant therapies alongside a simultaneous decrease in the utilization of completion lymph node dissection (CLND) following positive sentinel node biopsy (SLNB). Methods: This retrospective study from the University of Turin's Dermatology Clinic analyzed relapse-free survival (RFS) and overall survival (OS) among stage III melanoma patients (n = 157) who underwent CLND after positive SLNB versus those who did not receive such procedure. Results: Patients without CLND had a median RFS of 49 months (95% CI 42-NA), while CLND recipients showed 51 months (95% CI 31-NA) (p = 0.139). The 48-month OS for non-CLND patients was 79.8% (95% CI 58.2-91.0) versus 79.2% (95% CI 67.5-87.0) for CLND recipients (p = 0.463). Adjusted Hazard Ratios through inverse probability treatment weighting revealed the impact of CLND to be insignificant on RFS (aHR 0.90, 95% CI 0.37-2.22) and marginal on OS (aHR 0.41, 95% CI 0.13-1.21). Conversely, adjuvant therapy significantly reduced the risk of relapse (aHR 0.46, 95% CI 0.25-0.84), irrespective of CLND. Conclusions: This study corroborates the growing evidence that CLND after positive SLNB does not enhance RFS or OS, while emphasizing the crucial role of adjuvant therapy, be it immunotherapy or targeted therapy, in reducing the risk of relapse in melanoma patients with positive SLNB.

A comprehensive analysis of metastatic disease following surgery for clinically localized cutaneous melanoma.

The National Comprehensive Cancer Network considers "baseline staging" (whole body computed tomography or positron emission tomography scans with or without brain magnetic resonance imaging scans) for all patients with asymptomatic melanoma who had a positive sentinel lymph node biopsy result. The true yield of these workups is unknown. We created cohorts of adult patients with malignant melanoma using the National Cancer Database (2012-2020) to mimic 3 common scenarios: 1) clinically node-negative disease, with positive sentinel lymph node biopsy results; 2) clinically node-negative disease, with negative sentinel lymph node biopsy results; and 3) clinically node-positive disease, with confirmed lymph node metastases. Multivariable regression, supervised decision trees, and nomograms were constructed to assess the risk of metastases based on key features. In total, 10 371 patients were in scenario 1, 55 172 were in scenario 2, and 4012 were in scenario 3. The proportion of patients with any metastatic disease (brain metastases) were as follows: 1.4% (0.3%) in scenario 1, 0.3% (<0.1%) in scenario 2, and 11.6% (1.6%) in scenario 3. On multivariable regression, Breslow depth greater than 4, ulceration, and lymphovascular invasion were associated with greater risk of metastatic disease. A supervised decision tree for patients in scenarios 1 and 2 found that the only groups with more than 2% risk of metastases were groups with T4 tumors or T2/T3 tumors with ulceration and lymphovascular invasion. Most groups had a negligible risk (<0.1%) of brain metastases. This study is the first large analysis to guide the use of imaging for cutaneous melanoma. Among patients with clinically node negative disease, metastatic disease is uncommon, and brain metastases are exceedingly rare. Further investigation could promote a tailored approach to metastatic workups guided by individual risk factors.

54814 Mitotic Rate is More Important than Breslow Thickness for Predicting Sentinel Lymph Node Biopsy Positivity and Melanoma-Associated Survival for T1 Cutaneous Malignant Melanoma Cases

54814 Mitotic Rate is More Important than Breslow Thickness for Predicting Sentinel Lymph Node Biopsy Positivity and Melanoma-Associated Survival for T1 Cutaneous Malignant Melanoma Cases

Triple-Negative Breast Cancer in Older Patients: Does SLNB Guide Therapy?

Older breast cancer patients represent a heterogeneous population. Studies demonstrate that sentinel lymph node biopsy (SLNB) omission may be appropriate in some clinical scenarios, yet patients with triple-negative breast cancer (TNBC) are often excluded from these studies. This study evaluated differences in treatment and survival for older patients with TNBC based on SLNB receipt and result. Patients 70 years old or older with a diagnosis of cT1-2/cN0/M0 TNBC (2010-2019) who underwent surgery were selected from the National Cancer Database. Logistic regression estimated the association of SLNB with therapy, and Cox proportional hazards models estimated the association of SLNB with overall survival (OS) after adjustment for select factors. Of the 15,167 patients included in the study (median age, 77 years), 13.02% did not undergo SLNB, 5.14% had pN1 disease, 0.12% had pN2 disease, and 0.01% had pN3 disease. Most of the patients (83.9%) underwent surgery first, and 16.1% received neoadjuvant chemotherapy. Of those who underwent surgery first and SLNB, 6.2% had pN+ disease. Receipt of SLNB was associated with a higher likelihood of chemotherapy (odds ratio [OR] 1.85; 95% confidence interval [CI] 1.55-2.21), regardless of pN status. Compared with those who did not undergo a SLNB, a negative SLNB was significantly associated with lower mortality (hazard ratio [HR] 0.68; 95% CI 0.63-0.75), although there was no difference for a positive SLNB (HR 1.14; 95% CI 0.98-1.34). The patients receiving chemotherapy first showed no difference in survival based on SLNB receipt or result (p = 0.23). Most older patients with TNBC do not have nodal involvement and do not receive chemotherapy. The receipt and results of SLNB may be associated with outcomes for some who undergo surgery first, but not for those who receive neoadjuvant chemotherapy.

Staging in thick cutaneous malignant melanoma: A sequenced approach

BackgroundPatients with thick cutaneous pT4 malignant melanoma are at high risk for metastatic disease and optimal staging is poorly defined. This study examines the frequency and modality of pre-operative staging to provoke thought on optimal staging. MethodsA retrospective study was performed of patients with clinical T4N0 melanoma diagnosed between 2015-2017. The modality (sentinel lymph node biopsy and/or imaging), timing, and findings of staging investigations were assessed. ResultsOne hundred thirty-six patients with pT4a or pT4b cutaneous melanoma and clinically negative regional lymph nodes were included. Forty patients underwent no staging. Thirty-six patients underwent pre-operative imaging, and of these, regional or distant disease was identified in seven patients (19%). Another 36 patients underwent upfront sentinel lymph node biopsy concurrently with wide local excision. A positive sentinel lymph node biopsy was found in eight (22%) of these patients of which two had regional or distant metastatic disease on post-operative imaging. Of 16 who underwent a sentinel lymph node biopsy after negative pre-operative imaging, three had a positive sentinel lymph node biopsy. ConclusionStaging is non-standardized and underutilized in patients with thick melanoma. With evolving systemic treatment options, a well-defined approach to staging, with consideration for pre-operative imaging in pT4 patients, is essential for high-risk patients.

Sentinel lymph node positivity in melanoma: Which risk prediction tool is most accurate?

BackgroundSentinel lymph node biopsy for melanoma determines treatment and prognostic factors and improves disease-specific survival. To risk-stratify patients for sentinel lymph node biopsy consideration, Memorial Sloan Kettering Cancer Center and Melanoma Institute Australia developed nomograms to predict sentinel lymph node positivity. We aimed to compare the accuracy of these 2 nomograms. MethodsA multi-institutional study of patients with melanoma receiving sentinel lymph node biopsy between September 2018 and December 2022 was performed. The accuracy of the 2 risk prediction tools in determining a positive sentinel lymph node biopsy was analyzed using receiver operating characteristic curves and area under the curve. ResultsIn total, 532 patients underwent sentinel lymph node biopsy for melanoma; 98 (18.4%) had positive sentinel lymph node. Increasing age was inversely related to sentinel lymph node positivity (P < .01); 35.7% of patients ≤30 years had positive sentinel lymph node compared with 9.7% of patients ≥75 years. When we analyzed the entire study population, accuracy of the 2 risk prediction tools was equal (area under the curveMemorial Sloan Kettering Cancer Center: 0.693; area under the curveMIA: 0.699). However, Memorial Sloan Kettering Cancer Center tool was a better predictor in patients aged ≥75 years (area under the curveMemorial Sloan Kettering Cancer Center: 0.801; area under the curveMelanoma Institute Australia: 0.712, P < .01) but Melanoma Institute Australia tool performed better in patients with a higher mitotic index (mitoses/mm2 ≥2; area under the curveMemorial Sloan Kettering Cancer Center: 0.659; area under the curveMelanoma Institute Australia: 0.717, P = .027). Both models were poor predictors of sentinel lymph node positivity in young patients (age ≤30 years; area under the curveMemorial Sloan Kettering Cancer Center: 0.456; area under the curveMelanoma Institute Australia: 0.589, P = .283). ConclusionThe current study suggests that the 2 risk stratification tools differ in their abilities to predict sentinel lymph node positivity in specific populations: Memorial Sloan Kettering Cancer Center tool is a better predictor for older patients, whereas Melanoma Institute Australia tool is more accurate in patients with a higher mitotic index. Both nomograms performed poorly in predicting sentinel lymph node positivity in young patients.

The Use of Sentinel Lymph Node Biopsy in Patients Undergoing Mastectomy for DCIS

BackgroundCurrent guidelines do not recommend routine sentinel node biopsy (SLNB) for ductal carcinoma in situ (DCIS), except in the setting of mastectomy or microinvasive disease. This study aimed to evaluate national SLNB utilization in women undergoing upfront mastectomy for DCIS, identify predictors of SLNB utilization, and determine the percentage with a positive SLNB. MethodsA retrospective cohort analysis was performed using the NCDB of women with clinical DCIS who underwent upfront mastectomy between 2012 and 2017. Demographic and clinicopathologic variables were compared between patients who underwent SLNB and those who did not. Multivariate logistic regression models were used to identify factors associated with SLNB utilization and positive SLNB. ResultsAbout 38,973 patients met inclusion criteria: 34,231 (88%) underwent SLNB and 4742 (12%) had no surgical axillary staging. Most patients were age 50-69 (51%), non-Hispanic White (71%), with private insurance (66%). On multivariate analysis, older patients were less likely to receive SLNB (P < .01), while patients with higher grade DCIS were more likely to undergo SLNB (P < .01). In those who underwent SLNB (n = 34,231), only 1,149 (3.4%) had nodal involvement. Non-Hispanic Black patients had increased odds of a positive SLNB (P < .01), while those with estrogen receptor positive disease were less likely to be node positive (OR 0.68, P < .001). ConclusionsWhile 88% of patients had a SLNB, only 3.4% were found to be node positive. Given this low rate, it is reasonable to consider SLNB omission in select patients with low grade, hormone receptor positive DCIS undergoing upfront mastectomy.

Does Sentinel Lymph Node Biopsy Influence Subsequent Management Decisions in Women With Breast Cancer ≥ 70 Years Old?

BackgroundThere have been ongoing attempts to de-escalate surgical intervention in older breast cancer patients in recent years. However, there remains ongoing hesitancy amongst surgeons to de-implement axillary staging in this cohort. The supporting argument for performing a sentinel lymph node biopsy (SLNB) is that it may guide subsequent management. MethodsA retrospective review was performed of 356 SLNBs, in 342 women ≥ 70 years of age with invasive breast cancer, between 2014 and 2022 in a single institution. Data were collected on patient and tumor characteristics and subsequent management for all patients and for patients with ER+/HER2-, early-stage disease. ResultsPositive SLNB significantly increased likelihood of receiving adjuvant chemotherapy (CTh) in patients aged 70-75 in all clinical subtypes (OR 4.0, 95% CI, 1.6-10; P = .0035). Positive SLNB did not significantly increase likelihood of receiving adjuvant CTh in patients aged 75-80, however, an Oncotype Dx score of ≥ 26 did (OR 34.50, 95% CI, 3.00-455.2; P = .0103). Positive SLNB was significantly associated with receiving adjuvant radiotherapy (RTh) in all patients aged 70-75 (OR 4.5, 95% CI, 2.0-11; P = .0004) and 75-80 (OR 9.7, 95% CI, 2.7-46; P = .0015). In patients aged ≥ 80 years, positive SLNB did not have a significant influence on subsequent treatments. ConclusionIn this study, SLNB did not significantly influence subsequent management decisions in patients over 80 and should rarely be performed in this cohort. However, SLNB still had a role in patients aged 70-80 and should be used selectively in this cohort.