Evaluation Of Sentinel Lymph Nodes Research Articles

Is the retropharyngeal lymph node the first echelon node for carcinoma tonsil? Prospective evaluation and literature review.

Tonsil cancer being predominantly treated by non-surgical means, there is a paucity of data on lymph nodal drainage pathways and histo-pathologically confirmed metastatic rates. This study assesses the retropharyngeal lymph node (RPLN) in N0 squamous cell carcinoma tonsil as a possible first echelon node and a site for occult metastasis. Prospective study involving treatment naïve N0 carcinoma tonsil treated by primary surgery and adjuvant treatment from June 2017 to March 2019. In-vivo lymph nodal drainage patterns were assessed by sentinel node mapping by preoperative SPECT-CT and intra-operative hand-held Gamma probe. All patients had a subsequent Level I-III/IV sampling neck dissection supplemented with RPLN dissection. Histological evaluation of sentinel nodes and RPLN involved step-serial sectioning and pan-cytokeratin immunohistochemistry. A comprehensive literature review was performed with keywords "retropharyngeal lymph node", "oropharynx", "tonsil", "squamous cell carcinoma" to determine the incidence of RPLN positivity in previously published series. Sentinel node was successfully identified by SPECT-CT in all 17 patients (ipsilateral level 2a-13/17, 2b-1/17, 3-1/17; bilateral 2a-1/17; isolated contralateral retropharyngeal node-1/17). 8/17 had occult neck metastasis. In no patient was an ipsilateral RPLN identified as the sentinel node. Histological sampling did not indicate metastatic tumor in the RPLN in any patient (0/17). A systematic literature review further confirmed that RPLN metastasis in oropharyngeal cancer is noted only in the presence of pN + disease at other neck levels, and isolated RPLN metastasis is extremely rare (1.2%). The ipsilateral RPLN is not identified either as the first echelon node or as a site of occult metastatic disease in N0 tonsil cancer. CTRI/2019/06/019551.

Improved detection of sentinel lymph node metastases allows reliable intraoperative identification of patients with extended axillary lymph node involvement in early breast cancer

BackgroundAn improved procedure that allows accurate detection of negative sentinel lymph node (SLN) and of SLN macrometastases during surgery would be highly desirable in order to protect patients from further surgery and to avoid unnecessary costs. We evaluated the accuracy of an intraoperative procedure that combines touch imprint cytology (TIC) and subsequent frozen section (FS) analysis. 2276 SLNs from 1072 patients with clinical node-negative early breast cancer were evaluated during surgery using TIC. Only cytologically-positive SLN were subsequently analysed with a single FS, preserving cytologically-negative SLN for the final postoperative histological diagnosis. Sensitivity, specificity and the accuracy of this approach were analysed by comparing the results from intra- and postoperative SLN and axillary node evaluation. This intraoperative method displayed 100% specificity for SLN metastases and was significantly more sensitive for prognostically relevant macrometastases (85%) than for micrometastases (10%). Sensitivity was highest for patients with two or more positive LNs (96%) than for those with only one (72%). 98% of the patients with final pN2a-pN3a were already identified during surgery. Patients who received primary axillary lymph node dissection had significantly more frequent metastases in further LNs (44.6%). Sensitivity was highest for patients with luminal-B, HER2+ and triple negative breast cancer and for any subtype if Ki-67 > 40%. TIC and subsequent FS of cytologically-positive SLNs is highly reliable for detection of SLN macrometastases, and allows accurate identification of patients with a high risk of extended axillary involvement during surgery, as well as accurate histological diagnosis of negative SLN.

Diagnostic Accuracy and Clinical Impact of Sentinel Lymph Node Sampling in Endometrial Cancer at High Risk of Recurrence: A Meta-Analysis.

Purpose. To assess the value of sentinel lymph node (SLN) sampling in high risk endometrial cancer according to the ESMO-ESGO-ESTRO classification. Methods. We performed a comprehensive search on PubMed for clinical trials evaluating SLN sampling in patients with high risk endometrial cancer: stage I endometrioid, grade 3, with at least 50% myometrial invasion, regardless of lymphovascular space invasion status; or stage II; or node-negative stage III endometrioid, no residual disease; or non-endometrioid (serous or clear cell or undifferentiated carcinoma, or carcinosarcoma). All patients underwent SLN sampling followed by pelvic with or without para-aortic lymphadenectomy. Results. We included 17 original studies concerning 1322 women. Mean detection rates were 89% for unilateral and 68% for bilateral. Pooled sensitivity was 88.5% (95%CI: 81.2–93.2%), negative predictive value was 96.0% (95%CI: 93.1–97.7%), and false negative rate was 11.5% (95%CI: 6.8; 18.8%). We noted heterogeneity in SLN techniques between studies, concerning the tracer and its detection, the injection site, the number of injections, and the surgical approach. Finally, we found a correlation between the number of patients included and the SLN sampling performances. Discussion. This meta-analysis estimated the SLN sampling performances in high risk endometrial cancer patients. Data from the literature show the feasibility, the safety, the limits, and the impact on surgical de-escalation of this technique. In conclusion, our study supports the hypothesis that SLN sampling could be a valuable technique to diagnose lymph node involvement for patients with high risk endometrial cancer in replacement of conventional lymphadenectomy. Consequently, randomized clinical trials are necessary to confirm this hypothesis.

Pre-operative Stereotactic Ablative Body Radiotherapy (SABR) for Early-Stage Breast Cancer: A Novel Approach to Accelerated Partial Breast Radiotherapy

To evaluate pathologic and radiologic responses to pre-operative stereotactic ablative body radiotherapy (SABR) in early-stage breast carcinoma as well as treatment-related toxicity and cosmesis outcomes. To test hypothesis that pre-operative SABR will produce at least 10% probability of pathologic complete response. This investigation was conducted as a phase-2 prospective single-institution trial. Study population included women over 50 years of age with low-risk breast cancer defined as requiring all the following: unifocal tumor less than 2cm in size, ER+, Her-2 non-amplified, clinically node-negative, and non-lobular histology. Eligible patients underwent pre-operative SABR to 28.5 Gy in 3 fractions of 9.5 Gy/fraction followed by breast conserving surgery and sentinel lymph node (SLN) evaluation 6-8 weeks later. Diagnostic MRI was registered to simulation CT in all patients to define target volumes. The GTV was expanded by 15mm for CTV and 3mm was added for PTV. All patients were simulated and treated in the prone position. Primary endpoint was pathologic response. Secondary endpoints included radiologic responses on MRI, toxicity and cosmesis. Twenty patients were enrolled and treated. No pathologic complete responses were observed. With median follow-up of 13.5 (4-24) months, no local recurrences have been observed. Four patients were incidentally node-positive following SLN evaluation, two micro-metastases and two macro-metastases, and underwent post-SABR whole-breast radiotherapy. In patients who only had SABR, 15% (3) and 5% (1) developed late grade 2 or 3 soft-tissue toxicity, respectively. Of the 4 node-positive cases who received both SABR and whole-breast radiotherapy, two developed Gr 3 late soft-tissue toxicity. Pre-operative SABR failed to achieve pathologic complete response at 6-8 weeks following treatment although was well tolerated and improved convenience for most patients. Significant risk remains even in this low-risk cohort for positive nodes; 20% in our series. The resultant addition of whole breast radiotherapy in these cases may increase risk of grade 3 late toxicity.

Retrospective Comparison of Frozen Section vs Touch Prep Intraoperative Evaluation of Sentinel Lymph Nodes in Breast Cancer

Journal of the American College of Surgeons 231(4):p e87, October 2020. | DOI: 10.1016/j.jamcollsurg.2020.08.219

Sentinel lymph node sampling is associated with better survival outcome in intermediate-high risk patients with endometrial cancer

Objective: The aim of this study was to assess the value of sentinel lymph node (SLN) sampling compared to lymphadenectomy (LND) for staging in patients with intermediate-high risk endometrial cancer, based on GOG99 characteristics.

Pilot Study for Sentinel Lymph Node Evaluation by Using Fluorescein Dye in Modified Inguinal Lymph Node Dissection in Patients of Carcinoma of the Penis

Singh, Harvinder MBBS, MS, MCh; Singh, Aditya MBBS; Kumar Pal, Ajay MBBS FACS; Kumar, Awanish MBBS, MS Author Information

Sentinel lymph node intraoperative analysis in endometrial cancer.

Surgical staging in endometrial cancer has evolved and sentinel lymph node (SLN) mapping has replaced a full pelvic and paraaortic lymphadenectomy in several cases. An intraoperative evaluation of SLN might identify patients who could benefit the most from a full lymphadenectomy. The aim of this study is to evaluate the clinical relevance of frozen section of SLN. A retrospective analysis in patients with endometrial cancer who underwent SLN mapping with intraoperative evaluation at frozen section between February 2016 and September 2019 was performed. In case of metastatic involvement, a full lymphadenectomy was performed. Fifty-eight patients met the inclusion criteria. Clinical-pathologic characteristics of the patients and surgical data were analyzed. Overall, bilateral and unilateral detection rates were 100% (58/58), 89.7% (52/58), and 10.3% (6/58), respectively. Eight patients had a stage IIIC disease at permanent section. Frozen section detected SLN metastases in four of eight patients. Of these, two were micrometastases and two were macrometastases. At frozen section of the SLNs, no macrometastases were misdiagnosed. Sensitivity, specificity, accuracy, positive predictive value and negative predictive value of frozen section in detecting metastases was 50%, 100%, 93%, 100% and 92.6%, respectively. The intraoperative evaluation of SLN in endometrial cancer accurately identifies patients with macrometastases. This is the cohort that might benefit the most of a full lymphadenectomy for a higher risk of additional lymph node metastases.

Sentinel lymph node mapping and intraoperative assessment in a prospective, international, multicentre, observational trial of patients with cervical cancer: The SENTIX trial

BackgroundSENTIX (ENGOT-CX2/CEEGOG-CX1) is an international, multicentre, prospective observational trial evaluating sentinel lymph node (SLN) biopsy without pelvic lymph node dissection in patients with early-stage cervical cancer. We report the final preplanned analysis of the secondary end-points: SLN mapping and outcomes of intraoperative SLN pathology. MethodsForty-seven sites (18 countries) with experience of SLN biopsy participated in SENTIX. We preregistered patients with stage IA1/lymphovascular space invasion-positive to IB2 (4 cm or smaller or 2 cm or smaller for fertility-sparing treatment) cervical cancer without suspicious lymph nodes on imaging before surgery. SLN frozen section assessment and pathological ultrastaging were mandatory. Patients were registered postoperatively if SLN were bilaterally detected in the pelvis, and frozen sections were negative. Trial registration: ClinicalTrials.gov (NCT02494063). ResultsWe analysed data for 395 preregistered patients. Bilateral detection was achieved in 91% (355/395), and it was unaffected by tumour size, tumour stage or body mass index, but it was lower in older patients, in patients who underwent open surgery, and in sites with fewer cases. No SLN were found outside the seven anatomical pelvic regions. Most SLN and positive SLN were localised below the common iliac artery bifurcation. Single positive SLN above the iliac bifurcation were found in 2% of cases. Frozen sections failed to detect 54% of positive lymph nodes (pN1), including 28% of cases with macrometastases and 90% with micrometastases. InterpretationSLN biopsy can achieve high bilateral SLN detection in patients with tumours of 4 cm or smaller. At experienced centres, all SLN were found in the pelvis, and most were located below the iliac vessel bifurcation. SLN frozen section assessment is an unreliable tool for intraoperative triage because it only detects about half of N1 cases.

Challenge for Diagnostic Assessment of Deep Learning Algorithm for Metastases Classification in Sentinel Lymph Nodes on Frozen Tissue Section Digital Slides in Women with Breast Cancer.

PurposeAssessing the status of metastasis in sentinel lymph nodes (SLNs) by pathologists is an essential task for the accurate staging of breast cancer. However, histopathological evaluation of SLNs by a pathologist is not easy and is a tedious and time-consuming task. The purpose of this study is to review a challenge competition (HeLP 2018) to develop automated solutions for the classification of metastases in hematoxylin and eosin–stained frozen tissue sections of SLNs in breast cancer patients.Materials and MethodsA total of 297 digital slides were obtained from frozen SLN sections, which include post–neoadjuvant cases (n = 144, 48.5%) in Asan Medical Center, South Korea. The slides were divided into training, development, and validation sets. All of the imaging datasets have been manually segmented by expert pathologists. A total of 10 participants were allowed to use the Kakao challenge platform for 6 weeks with two P40 GPUs. The algorithms were assessed in terms of the area under receiver operating characteristic curve (AUC).ResultsThe top three teams showed 0.986, 0.985, and 0.945 AUCs for the development set and 0.805, 0.776, and 0.765 AUCs for the validation set. Micrometastatic tumors, neoadjuvant systemic therapy, invasive lobular carcinoma, and histologic grade 3 were associated with lower diagnostic accuracy.ConclusionIn a challenge competition, accurate deep learning algorithms have been developed, which can be helpful in making frozen diagnosis of intraoperative SLN biopsy. Whether this approach has clinical utility will require evaluation in a clinical setting.

The value and practical utility of intraoperative touch imprint cytology of sentinel lymph node(s) in patients with breast cancer: A retrospective cytology-histology correlation study.

Objective:Intraoperative evaluation of sentinel lymph nodes (SLNs) for patients with breast cancer is widely performed with frozen section (FS), cytology, or a combination of both. Touch imprint cytology (TIC) reportedly has an equivalent sensitivity to FS. We studied its diagnostic utility to detect SLN metastases.Materials and Methods:Cases of 367 patients with breast cancer who underwent intraoperative valuation of SLNs (507 LNs) were evaluated. All FS and corresponding TIC slides of SLNs of each case were reviewed microscopically for the presence of metastases of any size. If present, the metastatic focus was measured on the FS.Results:Of these 507 SLNs, 82 LNs (16.2%) from 69 women were found to have metastases in the FS and consisted of 5 LNs of isolated tumor cells, 15 of micrometastasis, and 62 of macrometastasis. TIC identified metastases in 69 of these 82 SLNs (sensitivity: 84.1%, specificity: 100%, and accuracy: 97.4%). All macrometastases could be detected by TIC, whereas TIC identified approximately 50% of micrometastases and none of isolated tumor cells. The size detection limit of metastatic foci, defined as the smallest dimension of metastasis detected without false negatives, was 2 mm. The smallest metastatic focus identified was 0.8 mm.Conclusions:TIC of SLNs is of great use given its negative predictive value of 100% for identification of macrometastasis in our study. For intraoperative evaluation of SLNs, based on our data, a practical two-step approach is proposed: SLN evaluation should be initially performed by TIC and then proceed to FS histological analysis only when cytologically positive to determine the size of metastatic focus.

Two ultrastaging protocols for the detection of lymph node metastases in early-stage cervical and endometrial cancers

ObjectiveTo date, there is no universal consensus on which is the optimal ultrastaging protocol for sentinel lymph node (SLN) evaluation in gynecologic malignancies. To estimate the impact of different ultrastaging...

External validation of a prognostic model based on total tumor load of sentinel lymph node for early breast cancer patients

BackgroundA prognostic model based on the results of molecular analysis of sentinel lymph nodes (SLN) is needed to replace the information that staging the entire axilla provided. The aim of the study is to conduct an external validation of a previously developed model for the prediction of 5-year DFS in a group of breast cancer patients that had undergone SLN biopsy assessed by the One Step Nucleic Acid Amplification (OSNA) method.MethodsWe collected retrospective data of 889 patients with breast cancer, who had not received systemic treatment before surgery, and who underwent SLN biopsy and evaluation of all SLN by OSNA. The discrimination ability of the model was assessed by the area under the ROC curve (AUC ROC), and its calibration by comparing 5-years DFS Kaplan–Meier estimates in quartile groups of model predicted probabilities (MPP).ResultsThe AUC ROC ranged from 0.78 (at 2 years) to 0.73 (at 5 years) in the training set, and from 0.78 to 0.71, respectively, in the validation set. The MPP allowed to distinguish four groups of patients with heterogeneous DFS (log-rank test p < 0.0001). In the highest risk group, the HR were 6.04 [95% CI 2.70, 13.48] in the training set and 4.79 [2.310, 9.93] in the validation set.ConclusionsThe model for the prediction of 5-year DFS was successfully validated using the most stringent form of validation, in centers different from those involved in the development of the model. The external validation of the model confirms its utility for the prediction of 5-year DFS and the usefulness of the TTL value as a prognostic variable.

Use of indirect computed tomography lymphangiography to determine metastatic status of sentinel lymph nodes in dogs with a pre-operative diagnosis of melanoma or mast cell tumour.

Canine melanomas and mast cell tumours (MCTs) frequently metastasize to lymph nodes, worsening prognosis compared with dogs without metastasis. Sentinel lymph node (SLN) evaluation is more specific than evaluation of the lymph node closest to the tumour, which may not be the draining lymph node. Computed tomography lymphangiography (CTL) allows for SLN identification and one study of canine mammary tumours found that CTL was able to assist in determination of the metastatic status of inguinal SLNs prior to extirpation and histopathology. The objective of the present study was to evaluate CTL for use in determining metastasis to the SLN in dogs with a pre-operative diagnosis of melanoma or MCT in various locations by correlating CTL findings with histopathology. The hypothesis was that CTL would not be able to determine the metastatic status of lymph nodes, based on author experience. Dogs were prospectively enrolled and underwent CTL and subsequent SLN extirpation. Histopathology results for the primary tumour, SLN, and additional extirpated lymph nodes were recorded. Fifteen dogs were enrolled and 21 SLN were evaluated. The SLN enhancement pattern (heterogeneous, homogenous or peripheral) was not associated with metastasis, nor was the attenuation value at 1 minute, 5 minutes, or the change in attenuation value. No correlation was found between CTL findings and metastatic status of SLNs. Based on these results, CTL alone cannot be used to diagnose SLN metastasis. Extirpation of the SLN with histopathology is recommended to diagnose lymph node metastasis in dogs with melanoma and MCT.

Abstract OT3-01-02: Preservation of axillary lymph nodes compared to complete dissection in T1-T2 breast cancer patients presenting 1-2 metastatic sentinel lymph nodes: A multicenter randomized clinical trial. Sinodar One Study

Abstract Introduction Sentinel lymph node (SLN) staging is currently used to avoid complete axillary lymph node dissection (ALND) in breast cancer (BC) patients with negative SLNs without jeopardizing survival or regional control. International guidelines keep recommending ALND in the presence of positive (+) SLNs. However SLN is the only site of axillary metastasis (MTS) in many cases (60%). Retrospective studies have also shown a low risk of locoregional relapse in patients with SLNs+ not receiving ALND.This latter finding was recently confirmed in a randomized trial comparing SLN biopsy (SLNB) alone with SLNB followed by ALND in patients with 1-2 SLNs+. However the observation of both similar relapse rate and survival in the 2 arms and the conclusion of a non-inferiority of SLNB compared to ALND require cautiousness because of some study limitations: premature enrollment cessation due to death rate lower than expected, short follow-up (6 years), small tumor size (≤2cm in 70% of cases), frequent presence of only microMTS in SLN (40%), prevalent use of “whole breast” adjuvant radiotherapy (&amp;gt;90%) which irradiates the breast but also the I° axillary level, thereby contributing to the low rate of regional relapse in the SLNB arm due to lymph node sterilization. Consequently further randomized trials with more precise selection criteria based on homogeneous clinico-pathological features and with longer follow-up are needed to confirm that performing only SLNB does not affect survival or relapse risk in patients with 1-2 SLNs+. Materials and Methods Primary and secondary aims of the present 2-arm randomized trial are to assess whether ALND omission in BC patients with 1-2 SLNs+ is associated with worse survival and/or increased rate of regional/distant relapse, respectively, thus evaluating whether SLNB is or is not inferior to ALND. Patients receive either conservative surgery or mastectomy and radiotherapy. They all undergo intraoperative SLNB and SLN evaluation, and are randomly assigned to either further dissection of level I-II axillary lymph nodes (standard ALND arm) or absence of any axillary surgery (experimental SLNB arm). According to International Guidelines post-surgery treatments. Eligibility criteria are: age 40-75 years; primary invasive T1-T2 tumor; axillary nodes clinically N0; no more than 2 SLNs presenting macroMTS at intraoperative or definitive histological evaluation; no distant MTS; no neoadjuvant therapy; no previous invasive BC, signed informed consent. Exclusion criteria are: in situ, inflammatory, contralateral BC; presence of only microMTS in the SLN+; pregnancy or breast feeding; comorbidity impeding adjuvant therapy. Follow-up controls foresee: clinical examination every 6 months for 5 years and yearly thereafter; annual mammography and breast echography; annual axillary echography for patients in the SLNB arm; additional laboratory and instrumental surveys in case of suspected onset of distant MTS. The primary endpoint is overall survival (OS). Secondary endpoints are disease-free survival (DFS) referring to distant MTS and to locoregional (ipsilateral breast or axillary, internal mammary or sopraclaveolar lymph nodes) disease recurrence. All analyses are performed both on all patients according to the Intention-To-Treat principle and excluding those patients who did not receive the axillary treatment randomly assigned. Citation Format: Corrado Tinterri, Emilia Marrazzo, Federico Frusone, Wolfgang Gatzemeier, Erika Barbieri, Andrea Sagona, Alberto Bottini, Valentina Errico, Alberto Testori, Giuseppe Canavese. Preservation of axillary lymph nodes compared to complete dissection in T1-T2 breast cancer patients presenting 1-2 metastatic sentinel lymph nodes: A multicenter randomized clinical trial. Sinodar One Study [abstract]. In: Proceedings of the 2019 San Antonio Breast Cancer Symposium; 2019 Dec 10-14; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2020;80(4 Suppl):Abstract nr OT3-01-02.

Role of gamma probe-assisted intraoperative sentinel lymph node evaluation in predicting axillary breast cancer metastasis after neoadjuvant chemotherapy.

Intraoperative sentinel lymph node biopsy is a universally accepted technique to identify patients who are candidates for axillary lymph node dissection during breast cancer surgery. However, there is controversy over its use in patients who underwent preoperative neoadjuvant chemotherapy. This study aimed to examine the diagnostic value of gamma probe-assisted intraoperative sentinel lymph node examination with frozen section in breast cancer patients who had undergone preoperative neoadjuvant chemotherapy. This retrospective study included 94 tumors diagnosed with stage IIA, IIB or IIIA invasive breast cancer with locoregional lymph node metastasis who underwent surgical treatment after neoadjuvant chemotherapy. Intraoperatively, axillary sentinel lymph node sampling was done using radioactive colloid and gamma probe and materials were examined with frozen section method. Patients with positive sentinel nodes underwent axillary resection. Histopathological examination of all surgical samples was done postoperatively. In 87 of 94 tumors (92.6%), a sentinel lymph node could be identified using the method. The sensitivity, specificity and accuracy of the method for predicting axillary macro metastasis were 85.7, 86.5 and 86.2%, respectively, with 5.7% false negative rate. Sentinel lymph node identification using preoperative scintigraphy and intraoperative use of gamma probe seems to be a feasible and efficient method in terms of differentiating patients that require axillary lymph node dissection during breast cancer surgery, even when they have received neoadjuvant chemotherapy. Further large prospective studies allowing subgroup analyses are warranted.

Characteristics of Melanoma in Panama: National Cancer Institute Experience from 2012 to 2017.

Background: According to statistics from the Panama National Cancer Registry, an increase in the incidence rate of melanoma has been seen, reaching twice as much in only two years, being 1.2/100 000 hab. in 2014 to 2.3/100 000 hab. in 2016, for both sexes. The prognosis of patients with melanoma is variable and closely related to the stage at the time of diagnosis. The base of treatment consists of surgery with negative margins and sentinel lymph node evaluation if there is no clinical lymphatic disease. When melanoma has metastasized, the 5 year OS will be only 15-20%. Over the last decade the systemic treatment of melanoma has advanced with giant steps thanks to the targeted therapy and immunotherapy. This therapies only have been available in our country in the last couple of years. Panama has a population of 4.09 millions, with multiple racial backgrounds thanks to the immigration attracted by the Panama Canal construction over a century ago. To this date there aren’t published studies about the characteristics, treatment and evolution of the melanoma patients in Panama.

Intraoperative evaluation of sentinel lymph node in the era of acosog z0011

Introduction: Intraoperative evaluation of sentinel lymph node was routinely conducted to assess the presence or absence of metastasis and decide, during the same surgical procedure, whether to perform an axillary dissection, which would avoid a second surgical procedure. However, with the current recommendations for conservative axillary treatment, the role of the intraoperative assessment is questionable. Results of the American College of Surgeons Oncology Group Z0011 (ACOSOG Z0011) randomized trial allow skipping the axillary lymph node dissection in patients with two positive axillary sentinel lymph nodes treated with conservative surgery, which would also allow not performing the intraoperative evaluation of sentinel lymph node because the result would not change the surgical approach. However, the rate of axillary re-excision was not described for cases of ACOSOG Z0011 exclusion criteria after definite anatomopathological results. Objectives: To assess the rate of axillary retreatment in patients submitted to conservative breast surgery in the era of ACOSOG Z0011. Method: This is a retrospective cohort study of patients who had invasive breast carcinoma up to 5 cm, clinically negative axilla, and underwent conservative breast surgery and sentinel lymph node dissection from February 2008 to December 2018. Results: We evaluated 415 patients – 318 (76.7%) with negative sentinel lymph node, and 97 (23.3%) with positive. Among positive cases, 56 (57.8%) were treated with sentinel lymph node biopsy, and 41 (42.2%) were submitted to axillary lymph node dissection. Intraoperative evaluation occurred in 90.2% of cases prior to the publication of ACOSOG Z0011, decreasing to 30.8% after publication (p&lt;0.00001). The rate of surgical re-excision due to ACOSOG Z0011 exclusion criteria was only 3.7%. The main causes were the presence of metastasis in three or more axillary lymph nodes or capsular extravasation. Conclusions: Intraoperative evaluation of sentinel lymph node substantially decreased in patients with early-stage breast carcinoma treated with conservative surgery and sentinel lymph node biopsy after implementing the axillary treatment proposed in the ACOSOG Z0011 guidelines, and the rate of axillary surgical retreatment due to exclusion criteria was minimal.

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

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

Intraoperative imprint cytology of sentinel lymph nodes in breast cancer patients: Comparation with frozen section

Background/Aim. Sentinel lymph node (SLN) biopsy has been established as the standard of care for axillary staging in patients with invasive breast carcinoma and clinically negative lymph nodes. Intraoperative assessment of sentinel lymph nodes might be done by frozen section (FS), touch imprint cytology (TIC) and one step nucleic acid amplification. The aim of this study was to review our institution's results with SLN biopsy using TIC and FS technique as intraoperative diagnostic tool for breast cancer patients. Methods. SLNs from 101 patients were examined intraoperatively by frozen hematoxylin-eosin (H&amp;E) stain and by touch imprint cytology. Results of TIC were compared with FS and permanent histology sections. Results. The total number of dissected SLNs was 163 with a mean of 1.6 (1?4) per patient. The permanent H&amp;E identified 19 (19%) patients with a sentinel lymph node metastasis and 82 (81%) patients with tumor-free sentinel nodes. The sensitivity/ specificity rates were 73.7%/99.3%, respectively for TIC and 84.2%/100%, respectively for FS. Relevant positive/ negative predictive values were 93.3%/96.6%, respectively for TIC and 100%/97.9%, respectively for FS. Conclusion. Our experience with TIC and FS for the intraoperative evaluation of SLNs is similar to the findings from previously reported studies. We detected the high specificity for both methods, but TIC technique appeared to be less sensitive than FS in detecting SLN metastases in breast cancer patients. TIC could be recommended as reasonable alternative to frozen section due to its simplicity and low cost.