Sentinel Lymph Node Biopsy Research Articles

Assessing para-aortic nodal status in high-grade endometrial cancer patients with negative pelvic sentinel lymph node biopsy.

To determine the accuracy of pelvic sentinel lymph node biopsy (SLN) in detecting positive para-aortic (PA) lymph nodes in high-grade uterine cancer, and to determine the recurrence rate in patients with high-grade uterine cancers who did not receive adjuvant chemotherapy based on negative pelvic SLNs. This was a retrospective cohort study of patients with newly diagnosed, high-grade endometrial cancer who underwent surgery, including pelvic SLNs with or without PA node dissection, at a tertiary care institution between 2015 and 2020. Baseline demographics, surgical management, pathology data, and outcomes were analyzed using descriptive statistics, and survival analysis. Postoperative histology of the 110 patients meeting inclusion criteria was 45.5% grade 3 endometrioid, 36.4% serous, 10.9% clear cell, and 7.3% carcinosarcoma. On final pathology, 63.7% were stage 1, and 23.6% were stage 3C with positive nodes. A total of 63 patients (57.3%) had a PA lymph node dissection (56 bilateral, 7 unilateral) in addition to the pelvic SLN. Among this group, 5.8% (95% confidence interval 1.2%-16.0%) had a positive PA node despite a negative pelvic SLN. Among those with a negative pelvic SLN and no adjuvant chemotherapy (n = 75), the rate of distant recurrence was 14.7%, and 3-year recurrence-free survival was 71.9%. The rate of isolated PA node metastasis in high-grade endometrial cancers despite a negative pelvic SLN may be significantly higher than the accepted rate of isolated PA node metastasis in low-grade endometrial cancer. This supports adjuvant treatment decisions continuing to incorporate primary tumor pathology and molecular classification.

Are Clinically Node-Negative Patients with a Positive Preoperative Axillary Lymph Node Biopsy Appropriate Candidates for Sentinel Lymph Node Biopsy?

Whether cN0 patients with image-detected nodal metastases are appropriate for sentinel lymph node biopsy (SLNB) or should proceed directly to axillary lymph node dissection (ALND) or neoadjuvant chemotherapy (NAC) is controversial. We sought to determine how often ALND is needed with upfront surgery and to identify factors associated with ≥ 3 positive SLNs after a positive preoperative lymph node (LN) biopsy. Patients with cT1-2N0 breast cancer and a positive LN biopsy treated from 2014 to 2022 were identified from a prospective database. Patients who received NAC were excluded. Clinicopathologic characteristics were compared between women with 1-2 positive SLNs and ≥ 3 positive SLNs. Of 90 eligible patients, 66 (73%) had 1-2 positive SLNs and 24 (27%) had ≥ 3 positive SLNs. The median patient age was 62 years, median tumor size was 2.2 cm, and 16 women (18%) received a mastectomy. There was no difference in body mass index, tumor size, histology, grade, multifocality, presence of lymphovascular invasion, and receptor status between groups. On multivariable analysis, having ≥ 3 positive SLNs was associated with > 1 abnormal LN on preoperative imaging (odds ratio [OR] 4.36, 95% confidence interval [CI] 1.47-14.0; p = 0.01), microscopic extracapsular extension in the SLNs (OR 3.83, 95% CI 1.25-13.7; p = 0.025), and a higher median number of SLNs removed (OR 1.42, 95% CI 1.10-1.88; p = 0.01). More than 70% of women with cT1-2 breast cancer with image-detected nodal metastases had < 3 positive SLNs and did not require ALND. To avoid multiple trips to the operating room, frozen section can be considered in women with multiple abnormal LNs on imaging.

Frozen Section Analysis of Sentinel Nodes in Patients With Oral Squamous Cell Carcinoma

Frozen section (FS) analysis of sentinel nodes offers potential on-table diagnosis and treatment for occult metastasis in oral squamous cell cancer. Systematic analysis of FS during sentinel node biopsy has not been illuminated in the literature. To systematically review pooled data from studies using FS analysis in evaluating sentinel nodes in patients with cT1-T2 N0 oral squamous cell cancer. An academic librarian led the search of CENTRAL, CINAHL, Cochrane Database of Systematic Reviews, Embase, and MEDLINE for studies published in English between January 2000 and January 2023. Two authors independently screened cohort studies, case series, and randomized clinical trials, in which FS analysis was used to evaluate sentinel nodes in patients with cT1-T2 N0 oral squamous cell cancer. Data were extracted by 2 reviewers. Reporting quality was estimated using the Diagnostic Precision Study Quality Assessment Tool. Data analysis was performed between April and July 2023, and the meta-analysis was completed using the bivariate random-effects model. The primary outcome was the pooled sensitivity of FS sentinel node analysis. Secondary outcomes included evaluation of the FS technique, rate of occult metastasis, false-negative rate, and survival. Seventeen articles with 878 patients met the eligibility criteria. Although protocols varied, confirmatory serial step sectioning was performed in all studies. Occult metastasis was found in 263 of 878 patients (30%), and FS analysis identified 173 cases (65.8%). Following serial sectioning, an additional 90 positive results were identified, leading to 47 patients undergoing staged completion neck dissection. The pooled sensitivity of FS was 0.71 (95% CI, 0.60-0.80), the diagnostic odds ratio was 110, and the false-negative rate was 34.2%. The Cochrane Q value was 15.62 (df = 16; P = .48) and τ2 = 0.36. In this systematic review and meta-analysis, evaluated studies showed various techniques, in which pooled sensitivity reached 0.71, providing a benchmark for comparison to other 1-stop approaches. Due to the high false-negative rate of approximately one-third of patients, intraoperative FS must always be supplemented by serial sectioning. On-table diagnosis remains a key objective for sentinel node biopsy, and FS detection may be improved by standardizing protocols.

Breast and axillary marking in the neoadjuvant setting: survey results from experts of the Brazilian society of mastology.

The precise location of the tumor site is essential for the success of surgical treatment. Neoadjuvant chemotherapy (NAC) is a challenge for preoperative tumor and node localization. Thus, the knowledge and attitudes of the affiliated members of the Brazilian Society of Mastology (SBM) regarding breast and axilla marking were evaluated and a consensus regarding management and treatment was reached. This was an online survey conducted between June and December 2022. All 1,742 active mastologists affiliated to the SBM were invited anonymously. The online form contained 28 objective questions, of which 22 were formulated on a Likert scale. These questions addressed relevant aspects related to breast and axilla marking in the neoadjuvant setting. Responses that reached 70% agreement were considered consensual. Statistical analysis was performed using the SPSS program version 26.0. Post hoc analysis was performed when appropriate and the significance level was set at p < 0.05. Polychoric regression analyses were conducted using `VGAM` package. In total, 468 mastologists answered the questionnaire (26.8%), with a predominance of professionals aged between 40-49 years (32.1%). Most professionals were board-certified (84,8%). The indication of tumor marking in the breast prior to NAC was consensual (96.4%) and the metal clip was the preferred method (69.7%). There was no consensus regarding the indication of pre-NAC histologically positive lymph node marking (49.8% disagree and 42.8% agree). However, there was consensus that the clinical and imaging evaluation was insufficient for staging the axilla as N1 (71.6%). The contraindication of breast and node marking in T4b tumors (71.2%) was consensual. There was consensus on the indication of sentinel lymph node biopsy (SLNB) for initially cN1 (92.3%) or cN2 (72.7%) tumors that became cN0 after NAC, with 67.5% opting for dual staining with technetium and patent blue. When <3 lymph nodes were retrieved 41.0% of mastologists performed axillary lymphadenectomy. Among the 28 questions, consensus was reached on only 11 (39.3%). The indication of pre-NAC breast marking is consensual among Brazilian mastologists, although axillary nodal marking is not. There is a great divergence of attitudes among Brazilian surgeons in relation to the many issues related to pre-NAC breast and axilla marking.

Primary breast lymphoma mimicking triple-negative breast cancer: a case report with clinical and pathological implications

BackgroundPrimary breast lymphoma (PBL) is a rare type of extranodal lymphoma, the diagnostic process for which presents significant challenges owing to an overlap in clinical and pathological features with those observed in triple-negative breast cancer (TNBC). However, the current literature reveals a paucity of information regarding the ramifications of potential diagnostic errors, particularly in the context of emergent therapeutic strategies for TNBC. Thus, we present a unique report of a case of PBL.Case presentationA 76-year-old female with no past medical or family history presented to the hospital with the chief complaint of a mass in the right breast. Two masses were palpated in the right breast: one 56 mm mass (No. 1) located at 10 o'clock, and a 21 mm large, elastic, hard mass (No. 2) at 4 o'clock. Needle biopsy was performed only on the larger 56 mm mass (No. 1). The results showed invasive carcinoma that was negative for estrogen receptor, progesterone receptor, and human epidermal growth factor receptor-2. The preoperative diagnosis was right breast cancer (T3N0M0 Stage IIB) of the TNBC subtype. The patient refused the preoperative chemotherapy recommended by the treatment team; therefore, right breast mastectomy and sentinel lymph-node biopsy were performed instead. The histopathological diagnosis of the first mass was diffuse large B-cell lymphoma (DLBCL); that of the second mass (No. 2) was an invasive breast carcinoma of no special type. Postoperative treatment consisted of endocrine therapy (letrozole) for breast cancer, while the DLBCL was treated with chemotherapy and three courses of intrathecal chemotherapy. At the time of this report, the patient is still living, and neither tumor had recurred in the 2 years following surgery.ConclusionsOn rare occasions, PBL can preoperatively mimic TNBC. While this case did not lead to serious consequences, because surgery was eventually selected as the first therapy, clinicians should be aware that the diagnosis of PBL is challenging using only a core-needle biopsy and can often be misdiagnosed as TNBC.

Para-aortic lymph node recurrence in surgically treated early-stage cervical cancer without para-aortic lymph node surgical staging

ObjectiveThe standard treatment for early-stage cervical cancer includes radical hysterectomy with pelvic lymph node staging ± bilateral salpingo-oophorectomy. Para-aortic lymphadenectomy may be considered; however, its role remains controversial. The objective...

'Balancing Challenges and Personal Resources': A Qualitative Study of Women's Experiences of Arm Impairment After Axillary Surgery for Breast Cancer.

To explore how women previously treated for breast cancer experience living with arm impairment after axillary surgery. Descriptive qualitative study. The inductive starting point for the analysis was followed by a deductive approach as the categories were related to the components of the sense of coherence framework. Twenty-eight relapse-free Swedish-speaking females participated in six focus group discussions conducted between September and December 2022. All participants had undergone sentinel lymph node biopsy with or without completion axillary dissection4 years earlier. Data were analysed using qualitative content analysis. Three categories and an overall theme were identified. The categories 'Sense-making', 'Daily life' and 'Driving force' reflect actions to understand and prevent arm symptoms, adaptations made in daily life and the empowering resources adopted to meet challenges. The overall theme, 'Balancing challenges and personal resources', comprised a process that began at diagnosis and remained ongoing for some participants. Most participants considered their new life situations manageable. However, those with more pronounced arm impairment reported that they did not always receive adequate aid, and that their daily lives were negatively affected. Returning to everyday life after axillary surgery for breast cancer is associated with varying degrees of challenges. Individuals with persistent arm impairment find returning to normal life more challenging. Therefore, further improvements in person-centred care are of utmost importance. Members of the Swedish Breast Cancer Association were involved in the creation of the interview guide. This study emphasises the requirement for providing further individualised support to those living with more severe arm impairment after axillary surgery. This study was reported in accordance with the Standards for Reporting Qualitative Research.

8581 Unusual Case of Multifactorial Hyperthyroidism

Abstract Disclosure: D.D. Bagar: None. E. Meyers: None. M. Correia: None. Background: Nivolumab is an immune checkpoint inhibitor that is used to treat specific types of cancer, including melanoma, by increasing the ability of the immune system to detect cancer through activating cytotoxic T-cells. The side effects of immune checkpoint inhibitors are mainly through the overactivation of the immune system that can affect many organs with autoimmune diseases, including endocrine glands, which could be severe and irreversible, like hypothyroidism or immune thyroiditis. The uniqueness of this case is the presence of multifactorial causes of hyperthyroidism; in addition, it is one of the few cases of immune checkpoint inhibitor induced positive TSI thyroiditis.Clinical Case: An 82-year-old male with a known history of atrial fibrillation on amiodarone presented to his dermatologist with a left forearm lesion. A shave biopsy showed melanoma, and he underwent wide local excision with negative sentinel lymph node biopsy. However, he had significant melanoma in situ present within 5 mm of the margin and was deemed not a candidate for further excision. Tumor board recommended close surveillance. He then received two cycles of pembrolizumab for one year, followed by nivolumab. During his treatment course, he had CT scans with iodinated contrast every 8-12 weeks for the clinical trial. At his clinic visit, routine thyroid function tests were significant for hyperthyroidism with a TSH &amp;lt;0.01 and free T4 of 6.07 (0.8-1.8). He was asymptomatic except for unintentional weight loss. He denied using any biotin supplements. His labs also showed positive thyroid stimulating immunoglobulin (TSI) of 1.10 (&amp;lt;=0.54 IU/L). A thyroid US with doppler showed two nodules less than 1.1 cm and no increased vascularity. Amiodarone was discontinued, and prednisone and methimazole were started. His free T4 has since normalized and both prednisone and methimazole are being tapered down. Conclusion: This case is a multifactorial cause of hyperthyroidism. He had been using amiodarone for atrial fibrillation, had multiple imaging studies with iodinated contrast, and was on immune checkpoint inhibitor therapy with a positive TSI. The uniqueness of this case is not only that combined factors can affect thyroid function but also that he developed a positive TSI, which indicates either Graves’ disease or immune-induced thyroiditis by nivolumab, which has been reported only in a few cases. Presentation: 6/3/2024

8581 Unusual Case Of Multifactorial Hyperthyroidism

Abstract Disclosure: D.D. Bagar: None. E. Meyers: None. M. Correia: None. Background: Nivolumab is an immune checkpoint inhibitor that is used to treat specific types of cancer, including melanoma, by increasing the ability of the immune system to detect cancer through activating cytotoxic T-cells. The side effects of immune checkpoint inhibitors are mainly through the overactivation of the immune system that can affect many organs with autoimmune diseases, including endocrine glands, which could be severe and irreversible, like hypothyroidism or immune thyroiditis. The uniqueness of this case is the presence of multifactorial causes of hyperthyroidism; in addition, it is one of the few cases of immune checkpoint inhibitor induced positive TSI thyroiditis.Clinical Case: An 82-year-old male with a known history of atrial fibrillation on amiodarone presented to his dermatologist with a left forearm lesion. A shave biopsy showed melanoma, and he underwent wide local excision with negative sentinel lymph node biopsy. However, he had significant melanoma in situ present within 5 mm of the margin and was deemed not a candidate for further excision. Tumor board recommended close surveillance. He then received two cycles of pembrolizumab for one year, followed by nivolumab. During his treatment course, he had CT scans with iodinated contrast every 8-12 weeks for the clinical trial. At his clinic visit, routine thyroid function tests were significant for hyperthyroidism with a TSH &amp;lt;0.01 and free T4 of 6.07 (0.8-1.8). He was asymptomatic except for unintentional weight loss. He denied using any biotin supplements. His labs also showed positive thyroid stimulating immunoglobulin (TSI) of 1.10 (&amp;lt;=0.54 IU/L). A thyroid US with doppler showed two nodules less than 1.1 cm and no increased vascularity. Amiodarone was discontinued, and prednisone and methimazole were started. His free T4 has since normalized and both prednisone and methimazole are being tapered down. Conclusion: This case is a multifactorial cause of hyperthyroidism. He had been using amiodarone for atrial fibrillation, had multiple imaging studies with iodinated contrast, and was on immune checkpoint inhibitor therapy with a positive TSI. The uniqueness of this case is not only that combined factors can affect thyroid function but also that he developed a positive TSI, which indicates either Graves’ disease or immune-induced thyroiditis by nivolumab, which has been reported only in a few cases. Presentation: 6/3/2024

Evaluation and Surgical Management of Pediatric Cutaneous Melanoma and Atypical Spitz and Non-Spitz Melanocytic Tumors (Melanocytomas): A Report From Children's Oncology Group.

The purpose of this study was to develop recommendations for the diagnostic evaluation and surgical management of cutaneous melanoma (CM) and atypical Spitz tumors (AST) and non-Spitz melanocytic tumors (melanocytomas) in pediatric (age 0-10 years) and adolescent (age 11-18 years) patients. A Children's Oncology Group-led panel with external, multidisciplinary CM specialists convened to develop recommendations on the basis of available data and expertise. Thirty-three experts from multiple specialties (cutaneous/medical/surgical oncology, dermatology, and dermatopathology) established recommendations with supporting data from 87 peer-reviewed publications. (1) Excisional biopsies with 1-3 mm margins should be performed when feasible for clinically suspicious melanocytic neoplasms. (2) Definitive surgical treatment for CM, including wide local excision and sentinel lymph node biopsy (SLNB), should follow National Comprehensive Cancer Network Guidelines in the absence of data from pediatric-specific surgery trials and/or cohort studies. (3) Accurate classification of ASTs as benign or malignant is more likely with immunohistochemistry and next-generation sequencing. (4) It may not be possible to classify some ASTs as likely/definitively benign or malignant after clinicopathologic and/or molecular correlation, and these Spitz tumors of uncertain malignant potential should be excised with 5 mm margins. (5) ASTs favored to be benign should be excised with 1- to 3-mm margins if transected on biopsy. (6) Re-excision is not necessary if the AST does not extend to the biopsy margin(s) when complete/excisional biopsy was performed. (7) SLNB should not be performed for Spitz tumors unless a diagnosis of CM is favored on clinicopathologic evaluation. (8) Non-Spitz melanocytomas have a presumed increased risk for progression to CM and should be excised with 1- to 3-mm margins if transected on biopsy. (9) Re-excision of non-Spitz melanocytomas is not necessary if the lesion is completely excised on biopsy.

Immunoglobulin A-dominant membranoproliferative glomerulonephritis-like pattern of injury as a possible paraneoplastic nephropathy in a breast cancer patient.

A middle-aged woman was found to have proteinuria during a health check-up. About sixteen months later, she was diagnosed with stage IIA invasive ductal carcinoma of the right breast. Her proteinuria progressed to nephrotic syndrome with significant hematuria. Hormone therapy was initiated for her estrogen and progesterone receptor-positive breast cancer. A kidney biopsy performed 47days after starting the therapy revealed an IgA-dominant membranoproliferative glomerulonephritis-like pattern of injury. Electron microscopy showed subendothelial-dominant electron-dense deposits (EDD), with small amounts of mesangial EDD and a single occurrence of subepithelial hump-like EDD, along with occasional mesangial interpositions. Similar pathology can be caused by IgA vasculitis with nephritis, IgA-dominant infection-associated glomerulonephritis, and liver disease-associated glomerulopathy, but all of these were ruled out. The deposited IgA was found to be galactose-deficient IgA1. Thus, IgA nephropathy with glomerular capillary IgA deposition was considered. She underwent a right partial mastectomy and sentinel lymph node biopsy in the right axilla 75days after starting hormone therapy, followed by adjuvant radiation. Proteinuria and hematuria tended to decrease after the treatment, and this trend continued even after corticosteroid therapy for glomerulonephritis, which was administered 156days after starting hormone therapy. Approximately 15months after starting hormone therapy, her proteinuria had reduced to around 1.0g/g of creatinine, and her hematuria was negative. IgA nephropathy with glomerular capillary IgA deposition is known to be resistant to corticosteroid therapy. The favorable clinical course of the rare glomerulopathy following breast cancer treatment suggested a diagnosis of paraneoplastic glomerulopathy secondary to breast cancer in our patient.

The impact of Substantial LYMphovascular space invasion on sentinel lymph nodes status and recurrence in Endometrial Cancer patients: SLYM-EC a multicenter retrospective study

IntroductionTo evaluate the prognostic impact of substantial lymph vascular space invasion (LVSI) on the sentinel lymph node involvement and recurrence rate of patients with apparent uterine-confined endometrial cancer. Materials and methodsWe enrolled consecutive patients with apparent confined endometrial cancer who underwent surgical staging with sentinel node mapping from 14 European reference centers. LVSI was analyzed semi-quantitatively, according to a 3-tiered scoring system classified as absent, focal, and substantial. ResultsAmong 2352 eligible patients, 1980 were included in the analysis. Upon final pathology 226 patients (11.4 %) had SLNs involvement. LVSI was diagnosed focal in 152 patients (7.7 %), whereas 357 patients (18.0 %) showed substantial LVSI. Focal or substantial LVSI rate were significantly higher in patients with positive SLNs when compared to patients without SLNs involvement (p < 0.0001). On overall patient-based analysis, the sensitivity, specificity, positive predictive value, and negative predictive value of LVSI for sentinel lymph node metastases were 73 %, 80 %, 32 %, and 96 %, respectively. The 3-year multivariate analysis of recurrence-free survival showed that only the presence of substantial LVSI, and grade 3 disease were associated with relapse. Neither positive sentinel lymph node, deep myometrial infiltration, nor age at surgery were statistically significant. ConclusionsIn patients having undergone sentinel node biopsy, positive LVSI demonstrated moderate sensitivity and reasonable specificity in detecting SLN involvement. LVSI positivity does not correlate with nodal involvement. The presence of substantial LVSI remains a strong independent risk factor for recurrence, indicating a role for potential hematogenous dissemination in patients with early-stage disease.

Differences in axillary ultrasound protocols among prospective de-escalating axillary surgical staging trials in clinically node negative early breast cancer patients

BackgroundSurgical axillary staging of the axilla is a topic of debate regarding the potential of de-escalation in clinically node negative (cN0) early breast cancer patients treated with breast-conserving therapy. Axillary ultrasound is important to determine clinical nodal status. The aim of the current narrative review is to provide an overview of prospective trials on de-escalating axillary surgical staging in cN0 early breast cancer patients, with an emphasis on axillary ultrasound protocols. MethodsThis narrative review provides an overview of the prospective de-escalating axillary surgical staging trials, in terms of comparing sentinel lymph node biopsy (SLNB) versus complete omission of SLNB, in cT1/2N0 patients treated with breast-conserving therapy. Information from each trial was collected, including reported axillary ultrasound protocols (including cortical thickness cut-off value) and axillary ultrasound-guided biopsy technique (fine-needle aspiration or core-needle biopsy). ResultsThere is one recently published prospective trial and three ongoing prospective trials within the topic of this narrative review. Number of included patients in these trials ranges from 1405 to 5505 patients. The included trials differed whether or not to include patients with suspicious axillary ultrasound findings and a negative ultrasound-guided biopsy. Cortical thickness cut-off value ranged from 2.3 mm to 3.0 mm. Different ultrasound-guided biopsy techniques were performed among the included trials. ConclusionProspective de-escalating axillary surgical staging trials in clinically node negative early breast cancer patients treated with breast-conserving therapy do report differences in terms of axillary ultrasound protocols and ultrasound-guided biopsy techniques. Axillary ultrasound protocols do require uniformity in order to improve extrapolation of these trial results.

Trends and efficacy of omitting axillary lymph node dissection in early-stage male breast cancer with limited nodal involvement: A population-based cohort study.

The effectiveness of sentinel lymph node biopsy (SLNB) versus axillary lymph node dissection (ALND) in managing early-stage male breast cancer (MBC) patients with T1-2 tumors and limited lymph node metastasis, all receiving radiotherapy, remains uncertain. This study examines trends and survival outcomes for SLNB and ALND in the United States. We conducted a retrospective analysis of the Surveillance, Epidemiology, and End Results (SEER) data from 2010 to 2020 for MBC patients with T1-2 tumors and 1-2 positive lymph nodes undergoing radiotherapy. Patients were classified by nodes removed (SLNB ≤5, ALND ≥10), comparing overall survival (OS) and breast cancer-specific survival (BCSS) between the groups before and after propensity score matching. Of 299 MBC patients analyzed, SLNB usage increased from 18.8% in 2010 to 61.0% in 2020. Multivariable logistic regression highlighted significant associations of SLNB use with diagnosis year, race, surgery type, positive lymph node count, and metastasis size. No significant differences in 5-year OS (77.98% SLNB vs. 85.85% ALND, p = 0.337) or BCSS (91.54% SLNB vs. 94.97% ALND, p = 0.214) were observed. Propensity score matching (96 patients per group) confirmed similar 5-year OS (83.9% for SLNB vs. 82.0% for ALND, p = 0.925) and BCSS (90.1% for SLNB vs. 96.9% for ALND, p = 0.167). SLNB and ALND provide comparable survival outcomes in early-stage MBC patients with limited lymph node metastasis undergoing radiotherapy. The increased utilization of SLNB supports its consideration to reduce surgical morbidity in selected MBC patients despite limited direct evidence.

Surgical treatments for older breast cancer patients: A systematic review and meta-analysis of real-world evidence

BackgroundOlder patients with breast cancer are often underrepresented in clinical trials, leading to a lack of evidence-based guidelines for surgical treatment in this cohort. Consequently, synthesizing real-world data is crucial for determining the optimal surgical management of geriatric patients with breast cancer. MethodsA comprehensive search was conducted of the PubMed, Embase, and Cochrane Library databases. The review included clinical studies evaluating treatments in patients aged ≥65 years with breast cancer. Comparisons were made between primary surgical treatment and endocrine therapy alone, breast-conserving surgery without radiotherapy versus mastectomy, sentinel lymph node biopsy versus omission of sentinel lymph node biopsy, and surgery plus axillary lymph node dissection versus omission of axillary lymph node dissection. ResultsA total of 44 studies were analyzed. Surgery significantly increased overall survival, breast cancer–specific survival, and recurrence-free survival compared with endocrine therapy alone. Pooled estimates revealed that mastectomy yielded significantly better prognoses than breast-conserving surgery without radiotherapy in terms of both overall survival and breast cancer–specific survival. Omitting sentinel lymph node biopsy and axillary lymph node dissection did not significantly reduce overall survival. ConclusionsFor older patients with breast cancer, primary surgical treatment significantly enhances survival and regional control compared with endocrine therapy alone without compromising quality of life. Frail patients with nonmetastatic breast cancer who are unwilling to undergo radiotherapy benefit from mastectomy, with no notable psychosocial decline compared with breast-conserving surgery alone. Sentinel lymph node biopsy omission does not increase recurrence rates or mortality, and avoiding axillary lymph node dissection may be viable for node-positive older patients due to its comparable survival outcomes.

Clinicopathologic Features and Surgical Management in Vulvovaginal Melanoma – A Retrospective Single Center Study

Background and AimsVulvovaginal melanoma is a rare malignancy characterized with poor prognosis. The aim of this study was to review vulvovaginal melanoma patients treated in Helsinki University Hospital. Objective was to evaluate the clinicopathologic features, treatment and factors affecting outcome. MethodsSingle-center retrospective review on patients treated between 2001 and 2021 was conducted. Data were collected from medical records. Clinicopathologic features, treatment, survival, and prognostic factors were analyzed. ResultsA total of 21 patients were included in the analysis. Localization was vulvar in 86% (n=18) and vaginal in 14% (n=3). Median age at diagnosis was 80 years. Initial treatment included surgery in 18 patients (86%); wide local excision in 19%, radical excision in 62%, and pelvic exenteration in 4.8%. Negative margins were achieved in 83% (n=15). Eleven (52%) patients underwent inguinal treatment: sentinel lymph node biopsy in 33%, direct lymphadenectomy in 14%, and both in 4.8%. Nine patients experienced melanoma recurrence. Recurrences were locoregional (n=1), distant (n=4), and both locoregional and distant (n=4). Median disease-free survival was 18.9M and median overall survival (OS) was 36.5M. 5-year relative OS was 20%. Melanoma was cause of death for seven patients (33%). Vaginal localization tended to worsen prognosis. Nodal status was the only melanoma characteristic significantly associated with survival. Surgical radicality did not affect survival. ConclusionsVulvovaginal melanoma is associated with an extremely poor survival and high rates of recurrence, primarily involving distant metastasis. In local control, wide local excision seems to be viable alternative to more radical surgery. Nodal status is a key prognostic factor emphasizing the importance of further research into the applicability of sentinel lymph node biopsy for vulvovaginal melanoma.

Advancements in Managing Pure Ductal Carcinoma In Situ: An 18-Year Artificial Intelligence-Aided Analysis of 998 Patients

IntroductionThe integration of artificial intelligence (AI) in oncological diseases has opened new avenues for early cancer detection, accurate risk assessments, and personalized treatment protocols. The objective of our study was to describe the shift in the treatment indications and prognosis of ductal carcinoma in situ (DCIS) in a prospective cohort of 998 patients managed over 18 years at a single University Hospital in France. MethodsThis analysis included all patients managed for DCIS at the University Hospitals of Strasbourg between January 14, 2002, and December 18, 2019, from the prospective SENOMETRY cohort, which initially included 9599 patients with both in situ and invasive breast cancer. Data were analyzed using Onconum, an AI-based natural language processing tool, to extract structured information from medical records. ResultsThe incidence of DCIS remained stable at 65 new cases per year. The mean age at diagnosis increased from 55 years in 2002 to 61 years in 2019. There was a significant rise in high-grade DCIS (DIN3) cases from 25% to 35%. The re-excision rate decreased from 57% in 2002 to 18% in 2019. Most DCIS cases were managed with breast-conserving surgeries (682), while total mastectomies accounted for 385 cases. Sentinel lymph node biopsy was performed in 39% of cases, primarily in high-grade and multifocal DCIS. Specific mortality was 0%, with a recurrence rate of 2.2%, predominantly invasive and occurring earlier in high-grade DCIS. Discussion: Over 18 years, there has been a notable shift in the clinicopathological characteristics of DCIS, with an increase in patient age at diagnosis and higher histopathological grades. Therapeutic management evolved significantly, with reduced surgical margins and fewer adjuvant treatments, while maintaining low and stable recurrence rates. AI significantly enhanced data extraction and analysis efficiency, contributing to better clinical decision-making. ConclusionThe study confirms the possibility of therapeutic de-escalation in DCIS, supported by AI-driven data analysis, allowing individualized treatment approaches and leading to optimized patient outcomes.

Implementation of Choosing Wisely guidelines: Omission of lymph node surgery

ObjectivesIn 2016, the Choosing Wisely campaign published guidelines recommending omission of sentinel lymph node biopsy in clinically node-negative women ≥70 years with early-stage (cT1-2), hormone receptor-positive, and human epidermal growth factor receptor 2–negative breast cancers. This study aimed to evaluate the implementation of this guideline. MethodsThe National Cancer Database was queried from 2017 to 2020. All patients who met criteria for lymph node surgery omission were included and compared with those who underwent lymph node surgery. ResultsOf 138,648 patients who met criteria for lymph node surgery omission, 26,070 (21.0%) had lymph node surgery omission and 109,482 (79.0%) underwent lymph node surgery. Those who had lymph node surgery omission were older (median 79 [75–84] vs 75 [72–79] years, P < .01) and had increased comorbidities (28.3% with Charlson/Deyo score ≥3 had lymph node surgery omission vs 20.2% with score 0, P < .01). Academic/research institutions most frequently practiced lymph node surgery omission (25.8% vs 16.5% community cancer programs, 19.3% comprehensive community cancer programs, and 20.6% integrated network cancer programs, P < .01). A greater percentage of lymph node surgery omission was noted with ductal carcinoma (21.4% vs 17.6% lobular and 19.4% mixed, P < .01) and lower-grade tumors (21.7% of grade 1 vs 19.4% of grade 2 and 17.8% of grade 3, P < .01). Throughout the period studied, the overall rate of lymph node surgery omission increased from 17.7% in 2017 to 23.1% in 2020 (P < .01). ConclusionDespite the evidence-based Choosing Wisely guideline recommending lymph node surgery omission in selected patients with breast cancer, more than 75% of patients meeting criteria were still being subjected to lymph node surgery as of 2020. Future work is warranted to determine factors affecting implementation of the Choosing Wisely guideline.

Accelerated Partial Breast Irradiation for Early-Stage Invasive Lobular Carcinoma

Purpose: Invasive lobular carcinoma (ILC) represents 10-15% of invasive breast cancers with limited representation among trials of accelerated partial breast irradiation (APBI). Contemporary guidelines advise against treating ILC with APBI given a paucity of supportive evidence. Here, we evaluated oncologic outcomes among patients with ILC treated with APBI. Methods: Patients treated from 2010 –2022 with APBI following breast conserving surgery for ILC (or mixed ILC with other histologies) were ascertained from a prospectively-maintained institutional database. All patients received external beam APBI to 40Gy in 10 daily fractions. Outcomes of interest included local recurrence (LR) and overall survival (OS). Results: Of 1248 patients who underwent APBI at our center, the study cohort comprised 132 (11%) who had ILC, either exclusively or mixed with another histology (median age 63). Median tumor size was 1.1cm (IQR: 0.8, 1.5), nearly all had estrogen receptor positive disease (99%) and received endocrine therapy (91%), and most underwent sentinel node biopsy (89%) with the remainder having no axillary surgery. At 530 person-years and a median follow-up of 39 months, two LRs were observed yielding a 48-month cumulative incidence of LR of 3.0% (95% CI 0.56 –9.5%). Both events arose in patients with mixed lobular histology (none arose in patients with pure ILC). Two unrelated deaths were also observed yielding a 48-month overall survival of 98% (95% CI: 95% - 100%) Conclusion: Among patients with ILC who received APBI following BCS, we observed a 4-year LR rate of 3%. No regional or distant recurrences were observed, and overall survival was excellent. The safety of APBI for ILC will require confirmation among larger trials with longer follow-up, although the excellent outcomes observed here are consistent with those seen for invasive ductal carcinomas among contemporary trials of APBI.

ASO Author Reflections: Time to Explore Minimally Invasive Axillary Nodal Staging After Neo-Adjuvant Chemotherapy in Inflammatory Breast Cancer.

In inflammatory breast cancer (IBC), obstructed lymphatics present a barrier to sentinel node biopsy. In theory this challenge could be overcome by clipping the clinically positive node at presentation and surgically retrieving it after neoadjuvant chemotherapy (NAC). If the clipped node accurately reflects the axillary status, then deescalation of axillary nodal dissection could be a possibility in IBC with complete pathological nodal response post-NAC.