Sentinel Lymph Node Sampling Research Articles

Comparison of Sentinel Lymph Node Sampling with Positron Emission Tomography in the Evaluation of Axillary Lymph Node Involvement in Breast Cancer Patients

Objectives Axillary lymph node status is the most important prognostic factor in breast cancer patients.: This study was carried out to evaluate the diagnostic accuracy of FDG-PET/CT as a noninvasive technique and intraoperative frozen biopsy of sentinel lymphadenectomy (SLNB) in detecting axillary lymph node metastasis. Materials and Methods This study was carried out retrospectively on 44 patients diagnosed with breast cancer, who underwent preoperative FDGPET/ CT imaging and intraoperative SLNB, at the General Surgery Clinic of Istanbul Medeniyet University Göztepe Training and Research Hospital. The axilla was clinically negative in all patients. Preopative FDG-PET/CT imaging and intraoperative SLNB were performed. FDG-PET/CT results were compared with the histopathological results of SLNB and axillary lymph node dissection (ALND). Results According to the pathology results of axillary dissection, metastatic nodes were detected in 22 of 44 cases, and FDG-PET/ CT imaging gave false-negative results in 10. The number of false negative cases of SLNB was 3; Axillary involvement was detected as a result of pathology in one of them, while the others were evaluated as skip metastases. The sensitivity of SLNB and FDG-PET/CT imaging was measured as 86.3% and 54.5%. The specificity values were 95.4% and 100%. FDG-PET/CT imaging has low sensitivity; specificity and positive predictive value were at acceptable levels Conclusion: The sensitivity of FDG-PET/CT imaging is low in detecting axillary involvement, and SLNB is needed in those with negative axillary involvement in FDG-PET/ CT imaging. In our study, SLNB examination was superior to FDG-PET/CT imaging in detecting axillary nodal status. Bangladesh Journal of Medical Science Vol. 23 No. 04 October’24 Page : 1083-1094

Sentinel Lymph Node Assessment in Endometrial Cancer: A Review.

As the number of patients diagnosed with endometrial cancer rises, so does the number of patients who undergo surgical treatment, consisting of radical hysterectomy, bilateral salpingo-oophorectomy, and bilateral pelvic lymphadenectomy or lymph node sampling. The latter entail intra- and post-surgical complications, such as lymphedema and increased intra-operative bleeding, which often outweigh their benefits. Sentinel Lymph Node (SLN) sampling is now common practice in surgical management of breast cancer, as it provides important information about the disease without jeopardizing surgical radicality and patient outcomes. While this technique has also been shown to be feasible in patients with endometrial cancer, there is little consensus on several aspects, such as tracer injection volume and site, pathological ultrastaging, and result interpretation. The aim of this review is to analyze the current literature on SLN assessment in order to help standardize the procedure.

Encapsulated papillary carcinoma of the breast clinicopathological features and management: Could sentinel lymph node biopsy be exempted?

Papillary lesions in the breast pose diagnostic and therapeutic challenges. Encapsulated papillary carcinoma (EPC) is a rare breast cancer. However, evidence-based guidelines are limited. For this reason, there is no complete clarity in diagnosis and treatment management, and there are insufficient studies in the literature. This study aimed to examine the necessity of sentinel lymph node sampling in the management of EPC, in line with patients' clinicopathological data. We retrospectively screened patients with EPC in our clinic between January 2012 and March 2022. We recorded and statistically evaluated patients' demographic, clinical, radiological, pathological, and treatment management. Sixty-four patients with EPCs were identified. The final pathologic evaluation revealed that 19 patients (18.7%) had pure EPC, 27 patients (43.7%) had EPC with associated ductal carcinoma in situ and 18 patients (37.5%) had EPC associated with invasion. The mean age was 61 years, and two patients were male. Breast-conserving surgery was performed in 62 patients, and simple mastectomy was performed in two patients. Sentinel lymph node biopsy (SLNB) was positive in only one patient. Sixty-three patients with EPC were hormone receptor-positive, and one patient was triple-negative and was associated with invasion. None of the patients died, one had a local recurrence, and a mastectomy was performed. The overall prognosis and long-term survival of patients with EPC were excellent. Our study and the current literature indicate that routine SLNB is overtreatment because surgical excision with negative margins is sufficient in EPC cases and lymph node metastasis is rare, even with an invasive component.

Cutaneous melanoma during pregnancy: Management and real-world outcomes.

e21554 Background: Pregnancy associated melanoma (PAM) occurs in 1% of female patients with melanoma and affects 1 in 2200 pregnancies. Antepartum evaluation of melanoma must incorporate both maternal and fetal factors, and currently there is lack of standardization. Our study aimed to review the incidence of antepartum melanoma at our institution and highlight patterns in management and treatment during this high-risk scenario. Methods: After IRB approval, the Mayo Clinic electronic medical record was searched with key words “melanoma” and “pregnancy”. 25 patients with melanoma during pregnancy were identified from 1987-2023. 6 patients were excluded as skin changes noted during pregnancy were not formally diagnosed as melanoma until after delivery. Abstracted data included demographic information, disease characteristics, staging (per AJCC guidelines at time of diagnosis), and clinical outcomes. Survival data were calculated. Results: 19 patients were included. Diagnosis occurred at an average maternal age of 30 years (range 24-38 years) and a mean gestational age of 20 weeks (range 6-35 weeks). All patients had a term delivery. 4 patients underwent labor induction at 37 weeks for staging/treatment. 60% of patients had a delay in imaging or treatment attributed to pregnancy, including 1 patient who was upstaged with metastatic disease based on postpartum imaging. 82% of stage I-III patients underwent wide local excision during pregnancy; however, 35% of sentinel lymph node sampling was delayed until postpartum. 3 stage II/III patients received adjuvant therapy (interferon or sargramostim) after delivery. Adjuvant immunotherapy was discussed with 2 patients in the postpartum period but ultimately not given due to the time lapse between surgery and delivery. 1 patient with stage IV disease diagnosed at a gestational age of 20 weeks was evaluated with MRI PET scan then treated with vemurafenib monotherapy during pregnancy. Workup and outcomes were reviewed by stage (Table 1). 7 of 19 patients had subsequent pregnancies, and 1 had recurrence of melanoma during a second pregnancy (stage II followed by stage IV). Due to a low number of censoring events, median progression free survival and overall survival were not reached. Conclusions: Melanoma diagnosed during pregnancy can be safely and effectively staged with sentinel lymph node surgery, MRI imaging (PET-MRI vs standard), and CT imaging with shielding without a need for early induction of labor nor a delay in cancer care. Furthermore, we report a patient with stage IV disease treated with vemurafenib during and immunotherapy after pregnancy, indicating that treating stage IV PAM with systemic therapy is a consideration. [Table: see text]

EnBloc Resection of Sentinel Lymph Nodes with the Hysterectomy Specimen in Endometrial Cancer.

We demonstrate the surgical technique of removing the sentinel lymph nodes with its afferent lymphatic vessels attached to the hysterectomy specimen. Stepwise demonstration of the technique with narrated video footage. Sentinel lymph node sampling has been established as an acceptable staging method in endometrial cancer cases.1 Lymphatic anatomy has been described according to three consistent channels for endometrial cancer dissemination: (1) an upper paracervical pathway draining external or obturator lymph nodes; (2) a lower pathway draining internal iliac lymph nodes; and (3) the infundibulo-pelvic pathway with a course along the broad ligament.2 A study in patients with cervical cancer identified tumor cells in the afferent lymphatic vessels of the upper pathway, even when the corresponding sentinel node was negative (3/20 patients).3 This could be an important prognostic factor in patients with cervical cancer. Since the typical position of sentinel nodes is the same in both endometrial and cervical cancers, we aimed to assess the feasibility of removing 'enbloc' the sentinel node with its afferent lymphatic vessels, and the uterus.4 INTERVENTIONS: The Da Vinci Xi surgical system was used. Indocyanine green was injected cervically, the pelvic surgical spaces were developed, and the sentinel lymph nodes, along with the afferent lymphatic vessels, were identified using the Firefly infrared camera. The lymphovascular tissue was mobilized and separated from the uterine artery, which was skeletonized and ligated. Colpotomy was performed and the specimen was retrieved vaginally. Emerging evidence regarding diagnosis, characterization, and treatment of endometrial cancer has introduced a new era, based on minimally invasive techniques for staging through sentinel lymph node biopsy, molecular classification, and personalized treatment algorithms that include immune checkpoint inhibitors and targeted therapies.5 Lymph node staging is one of the most significant prognostic factors in endometrial cancer patients and is a guide for adjuvant treatment. Sentinel lymph node biopsy is not inferior to conventional lymphadenectomy and is in fact a better way of identifying low-volume cancer through the use of ultrastaging, as part of the sentinel node algorithm.6 The dissection technique described in this video could offer an improvement in the staging of endometrial cancer, ensuring that the true sentinel lymph node is identified and that potential cancer cells inside the afferent lymphatic vessels are also excised. Therefore, it could be utilized as a more accurate way of planning adjuvant treatment and consequently improving recurrence and survival; however more studies are needed to further evaluate the feasibility and sensitivity of identifying disease in the afferent lymphatic vessels. This novel surgical technique emphasizes the importance of anatomical knowledge and offers inspiration for studies with potential clinical benefit that should follow.

Prevalence of Lymphedema and Associated Risk Factors Following Multimodal Breast Cancer Treatment

Background: Breast cancer related Lymphedema (BCRL) in the respective arm is a common but serious negative sequel of breast cancer management. Risk factors include dissection of Axillary lymph nodes and irradiation of Regional lymph nodes. Nearly 20% of patients receiving treatment of breast cancer develop this complication and it has a negative impact on quality of life of the patient. Objective: Current study aims to equip the medical professionals with all the details needed for prevention, early detection, intervention and management of this hazardous late treatment related complication. Material and Methods: Total 350 breast cancer patients (with their consent) treated at Government Cancer Hospital, Indore in the Radiotherapy and Oncology Department, in period from January 2019till December 2021, with chest wall radiotherapy following subsequent hormonal therapy, as needed. Patients then analysed for occurrence of lymphedema. Subsequently, efforts were given for finding out the correlation between lymphedema and related treatment modality like adjuvant radiotherapy following definitive surgery with number of excised lymph nodes and number of involved lymph nodes, chemotherapy, hormonal therapy, subjective co-morbid condition (obesity, diabetes mellitus and high blood pressure). Results: Current study demonstrate a significant correlation of adjuvant radiotherapy, including progressive involvement of the lymph node stations, with radical or conservative breast surgery with lymph node dissection represents a statistically significant risk factor, with relative risk, RR=1.49 (95% CI=0.72–3.05), p<0.001. Subsequent increase in number of dissected lymph nodes shown a risk factor with statistical significance as relative risk for more than 25 removed lymph nodes, demonstrated significant risk of lymphedema than for 16-25 removed lymph nodes. Other analysed risk factors, which did not influence lymphedema development like, associated chemotherapy, hormonal therapy or presence of co-morbid illnesses. Conclusions: Arm lymphedema is a late sequel associated with carcinoma breast treatment using radiation or surgery, and quite capricious occurrence that can happen years after axillary clearance surgery. With the use of sentinel node sampling, could reduce the need of frank axillary clearance by showing either involvement of lymph node in axilla, so as to manage only by radiotherapy. That significantly reduces the risk of lymphedema from 16% with axillary clearance to 5% without dissection. Keywords: Lymphedema, Breast cancer, Risk factors, Axillary lymph node

Preoperative Role of Superb Microvascular Imaging and Shear-Wave Elastography for Prediction of Axillary Lymph Node Metastasis in Patients With Breast Cancer.

This study aims to evaluate the role of shearwave elastography (SWE) and superb microvascular imaging (SMI) for preoperative prediction of axillary lymph node metastasis (ALNM) in patients with breast cancer. In a cohort of 214 women with breast cancer, B-Mode ultrasonography (US), SMIvascular-index (SMIvi), and SWE (E-mean, E-ratio) values were recorded before tru-cut biopsy. Axillary fine-needle aspiration biopsy (FNAB) and sentinel lymph node sampling results were collected. Imaging findings and histopathological data were statistically compared. Receiver operating characteristic curve analysis was used to evaluate diagnostic performance. Reverse stepwise logistical regression analysis was conducted. Although ALNM was negative in 111 cases, it was positive in 103 patients. Axillary lymph node metastasis (+) group had larger size ( P < 0.001), higher vascularization (SMIvi: 8.0 ± 6.0 versus 5.0 ± 4.3, P < 0.001), and higher elasticity value (E-mean: 129 ± 31 kPa versus 117.3 ± 40 kPa, P = 0.014). Axillary lymph node metastasis was observed statistically more frequently in Her-2 positive cases ( P = 0.005). There was no significant difference between other B-mode US findings ( P > 0.05), SMI Adler ( P = 0.878), and E-ratio ( P = 0.212). The most appropriate cutoff value for the prediction of ALNM was 23.5 mm for size, 3.8 for SMIvi, and 138.5 kPa for E-mean. The most sensitive (77%) method was the SMIvi measurement, while the most specific (86%) finding was Her-2 positivity. The combined model (being Her-2 positive, >23.5 cm, and >3.8 SMIvi) increased the specificity (78%), PPV (71%), and accuracy (68%). Although the increased size is a previously studied parameter in predicting the risk of ALNM, Her-2 and data obtained by SWE, and SMI can be used to assist conventional US.

Concurrent finding of Breast cancer and axillary Lymph nodes in Receptor Positive Patients

Background and Objectives: The most frequent site of disease involvement in breast cancer that has progressed from the initial lesion is the axillary lymph nodes (ALN). There are still no reliable ways to anticipate ALN status prior to surgery, despite sentinel node biopsy being a reliable means of managing ALN. Materials and Methods: This was a retrospective study of female patients with invasive breast cancer at Tertiary care hospital between January 2020 and January 2023. The clinical data and tumor character­istics for all invasive breast cancers (425) had been collected in breast cancer database. This study was approved by the institu­tional review board and ethics committee. Breast cancer patients who had undergone surgery were identified. The exclusion criteria were: 1) ductal carcinoma in situ; 2) neoadjuvant therapy; 3) bilateral invasive breast cancer; and 4) patients without breast-conserving surgery with ALND or sentinel lymph node sampling or modified radical mastectomy. SVM was used for analysis. Results: Of these, 242 patients had positive ALNM. The mean tumor size was 24.4 mm (SD=1.5); 38% of the patients had T1 tumors (＜20 mm), followed by 52% with T2 tumors and 10% with T3 tumors. The histology grade was predominantly grade II (57%), with 28% grade III and 15% grade I tumors. Lymph vascular invasion was found in 200 patients (47%). The ER/PR/HER2 profile showed 270 patients (63.5%) had luminal A type tumors, followed by 16.5% with triple-negative tumors, 13.1% with luminal B type tumors, and 6.9% with HER2-positive tumors. A higher AUC value indicated a better diagnostic perfor­mance. The AUC value of this study was 0.754 by SVM. Conclusion: It is possible to forecast ALN status using a model that is just dependent on clinically common pathologic data derived from the source tumor. This could support the surgeon's decision-making for ALN management and breast cancer counseling.

Explaining risks and benefits of loco-regional treatments to patients.

Treatment for early-stage breast cancer is complex, requiring multidisciplinary care with a multitude of treatment options available for each patient. Coupled with the rising importance of shared decision-making, patient-physician conversations are progressively more complicated. These conversations require frank disclosure of risks and benefits of the different treatment modalities in a way that is individualized for each patient and simple to understand. In most patients, breast conserving therapy with radiation should be presented as the gold-standard local treatment given similar long-term and improved quality of life outcomes. De-escalation is currently at the forefront of research in loco-regional treatments, and further investigations are required to best determine the optimal patient populations for reduced sentinel lymph node sampling, omission of sentinel lymph node biopsy altogether and omission of radiation treatment. For future trials, better endpoints need to be established considering patient-centered outcomes as well as recurrence.

Sentinel lymph node sampling versus full lymphadenectomy in endometrial cancer: a SEER database analysis

ObjectiveTo assess the long term outcomes and prognosis of sentinel lymph node sampling compared with full lymph node dissection in endometrial cancer patients.MethodsWe used the Surveillance, Epidemiology, and End Results...

Rolul ganglionului-santinelă în tratamentul actual al cancerului de endometru

Introduction. Endometrial cancer is the most prevailing gynecological malignancy in developed countries, with an incidence rising annually. For years, systematic lymphadenectomy had been the preferred method for staging purposes, but a less aggressive approach, with no negative impact on the oncologic outcomes, is the current trend in endometrial cancer management. In this review, we aim to evaluate the role of sentinel lymph node (SLN) mapping as an eligible alternative to complete pelvic lymphadenectomy in the surgical staging process, as well as its influence on the adjuvant treatment options. Materials and method. We analyzed the leading international guidelines regarding sentinel lymph node mapping in endometrial cancer, published between 2018 and 2023, as well as several studies that met the inclusion criteria, from the PubMed database, to outline the recommended surgical techniques, the algorithm, the accuracy, and the advantages of the SLN sampling procedure compared to pelvic lymphadenectomy. Results. Most international guidelines conclude that SLN sampling is the desirable alternative to systematic lymphadenectomy. However, it is agreed that, in case of failed SLN mapping, the radical option consisting in complete pelvic lymphadenectomy is recommended. As far as high-risk patients are concerned, most of the reviewed studies and guidelines encourage the use of SLN mapping in the treatment of endometrial cancer. Our findings revealed high sensitivity and detection rates of SLN mapping, influenced especially by the type of tracer used, indocyanine green having the best outcomes. Conclusions. Considering the high sensitivity and the low morbidity rates of the procedure, SLN mapping is soon to become a gold standard practice for the surgical staging process of endometrial cancer in many gynecologic oncology centers. Thus, SLN mapping represents a viable alternative to complete pelvic lymphadenectomy, acknowledging the principles of minimally invasive surgery and personalized medicine, without compromising the oncologic outcomes.

Adjuvant radiotherapy in the management of porocarcinoma with lymphatic micrometastasis

Background. Porocarcinoma is a rare skin tumor originating from dermal sweat glands. Surgical procedures are the first choice of treatment, but the role of adjuvant therapies, such as chemotherapy and radiotherapy (RT), is not clear. In this case report and review of the literature, we aimed to present a patient who underwent adjuvant RT for the diagnosis of porocarcinoma with lymphatic micrometastasis and a review of the current literature. Case summary. A 61-year-old male was admitted to the dermatology department for a nodular lesion on the left knee skin. An excisional biopsy was performed, and the pathology result was reported as porocarcinoma. The closest surgical margin of the tumor was 0.2 cm. In the inguinal sentinel lymph node sampling, two of the three removed lymph nodes had micrometastases. Then, adjuvant RT was applied to the left inguinofemoral lymphatics and primary tumor bed. No recurrence was observed in the patient with a follow-up period of 24 months. No acute or late toxicity was observed including lymphedema, subcutaneous fibrosis, or stiffness of the knee joint. Conclusions. Although adjuvant RT is not a routinely recommended treatment, it can be applied to increase local and regional control in patients with high-risk factors for recurrence or with lymph node metastases. There is a great need for clinical studies clarifying the role of RT, but for now, all patients should undergo multidisciplinary evaluation when a decision on adjuvant therapies is made.

Contrast-enhanced and indirect computed tomography lymphangiography accurately identifies the cervical lymphocenter at risk for metastasis in pet dogs with spontaneously occurring oral neoplasia.

For dogs with oral tumors, cervical lymph node (LN) metastasis alters treatment and prognosis. It is therefore prudent to make an accurate determination of the clinical presence (cN+ neck) or absence (cN0 neck) of metastasis prior to treatment. Currently, surgical LN extirpation with histopathology is the gold standard for a diagnosis of metastasis. Yet, recommendations to perform elective neck dissection (END) for staging are rare due to morbidity. Sentinel lymph node (SLN) mapping with indirect computed tomography lymphangiography (ICTL) followed by targeted biopsy (SLNB) is an alternative option to END. In this prospective study, SLN mapping followed by bilateral END of all mandibular LNs (MLNs) and medial retropharyngeal LNs (MRLNs) was performed in 39 dogs with spontaneously occurring oral neoplasia. A SLN was identified by ICTL in 38 (97%) dogs. Lymphatic drainage patterns were variable although most often the SLN was identified as a single ipsilateral MLN. In the 13 dogs (33%) with histopathologically confirmed LN metastasis, ICTL correctly identified the draining lymphocentrum in all (100%). Metastasis was confined to the SLN in 11 dogs (85%); 2 dogs (15%) had metastasis beyond the SLN ipsilaterally. Contrast enhanced CT features had good accuracy in predicting metastasis, with short axis measurements less than 10.5 mm most predictive. ICTL imaging features alone were unable to predict metastasis. Cytologic or histopathologic SLN sampling is recommended prior to treatment to inform clinical decision-making. This is the largest study to show potential clinical utility of minimally invasive ICTL for cervical LN evaluation in canine oral tumors.

Abstract P1-14-01: Incidence, Clinicopathological Features and Treatment Outcomes Of Young Breast Cancer Patients: A Cohort Analysis From a High-Volume Tertiary Cancer Center in The United Arab Emirates

Abstract Introduction: Breast cancer (BC) in women age 40 or younger represents approximately 7% of all BC cases. Studies have reported that BC in younger women is more likely to have adverse tumor characteristics and outcomes when compared to elder women. Despite the fact that BC in the Middle East seems to occur at a younger age, data on tumor characteristics in these patients are scarce, especially in the United Arab Emirates. Objective: This study was conducted to investigate the incidence, clinicopathological characteristics, treatment modalities, and outcomes of young BC patients at a major cancer center in the UAE, Tawam Hospital. This will provide a better insight in local features and enables comparison of UAE data with other parts of the world. Method: Data of 911 BC patients age ≤ 40 years treated at Tawam Hospital between 2000 and 2020 were analyzed. Information was obtained from the prospective Tawam Hospital Cancer Registry database and analyzed using (Python 3.9.7). Result: A total of 911 patients were included in this study. Median follow up time 34 months (0.3 - 1404). Patients ≤ 40 years of age comprised 24% (911/3782) of all BC cases diagnosed between 2000-2020. The clinical and pathological characteristics of these patients are provided in table 1. Of the total population, 625 (68.6%) patients were diagnosed based on palpable breast mass. 67 (7.3%) had pregnancy-related BC, and 346 (38%) had hereditary genetics testing conducted. Of those, 38 (11%) had pathogenic mutation (13 BRCA1, 16 BRCA2, 4 TP53, 2 PalbB2, 1 ATM, 1 APC, 1 NBN) and 59 (17%) had mutations with variants of unknown significance. Of patients with early-stage disease (N=764), 14 (2%) had excisional biopsy, 314 (41%) had a lumpectomy and 474 (62%) had a mastectomy, 257 (34%) had sentinel lymph node sampling, 439 (57%) had axillary lymph node dissection, 621(81%) had adjuvant radiation therapy, 727 (95%) had adjuvant/neoadjuvant systemic chemotherapy +/- anti-HER2/neu therapy. Of those who received neoadjuvant systemic therapy (N=341/727), 123 (36%) achieved pathologic complete remission. Of those with HR+ status early BC (N=487/764), 455 (93%) received adjuvant hormonal therapy (180 (40%) ovarian suppression, 391 (86%) tamoxifen, 39 (8.5%) aromatase inhibitor). Of all early BC patients, 180 (24%) developed recurrent disease (initial site: 45 (25%) locoregional recurrence, 83 (46%) visceral metastases, 66 (37%) bone metastases, 22 (12%) brain metastases, and 1 other sites). Kaplan Meier with log rank analysis and cox-proportional hazard models to be presented in the meeting. Conclusion: The findings of this study are in accordance with previous studies on young BC patients. On initial presentation, patients had higher-grade tumors, a significant proportion with HER2/neu positive disease, larger tumor size, and nodal involvement. This study will help clinicians, researchers, and decision-makers better understand the unmet needs for young breast cancer patients in the UAE. Table 1: Clinical and Pathological Characteristics of young BC patient ≤ 40 (N=911) Citation Format: Aydah Al-Awadhi, Mohammed Hourani, Mawada Hussein, Fatima Alkindi, Lina Wahba, Abla AlAgha, Alaa Shoqeir, Ali Yousif, Mouza AlShebli, Diaeddine Trad, Asif Masih, Fathi Azribi, Ernest J. Luiten, Humaid Al-Shamsi, Khaled Toffaha. Incidence, Clinicopathological Features and Treatment Outcomes Of Young Breast Cancer Patients: A Cohort Analysis From a High-Volume Tertiary Cancer Center in The United Arab Emirates [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P1-14-01.

A study of recurrence, complication and survival rates in patients with early stage vulval cancer undergoing sentinel lymph node sampling: a single-centre experience.

Groin sentinel lymph node (SLN) identification and removal has become a standard of care for women with clinical early stage vulval cancer. There is evidence to support safe detection of the SLN with minimal morbidity. The purpose of this study is to report our experience of managing patients focusing on patient selection, adverse events, quality assurance of the procedure and any benefits and/or disadvantages to patients. This was a retrospective study of patients with clinical early stage vulval cancer in a cancer centre over 5years. Notes and hospital data were reviewed including admissions to emergency departments. Statistical software was used for the statistical analysis and the Kaplan Meier survival curve was generated to present survival rates. 61 cases were analysed. A total of 156 nodes have been removed and positive nodes were identified in 14 cases. In total, 9 women (14.75%) had disease recurrence within 5years from primary surgery. Overall, 4 patients (6.5%) developed groin recurrence. In 3 of these patients there was isolated groin recurrence (4.9%). The median length of admission was 3days and 6 cases were managed as day cases. Since the closure of the GROINNS-2 trial we have continued the procedure of SLN identification for women with clinical early stage vulval cancer. We have shown high level of adherence to our protocol and survival and complication rates comparable to other studies on the same field. There were a few patients managed as day-case which was of benefit to the patients.

Same-day dismissal for endometrial cancer robotic surgery: feasibility factors.

The aim of this study was to investigate the factors in feasibility and safety of same-day dismissal (SDD) of endometrial cancer patients undergoing robotic hysterectomy and staging. A single-institution retrospective chart review of endometrial cancer patients who underwent robotic hysterectomy and staging between 2012 and 2021 was performed. Patient demographics, medical and surgical history, intra- and postoperative events were examined as possible factors related to non-SDD. These factors were analyzed using univariate (chi-square test) and multivariate logistic regression analysis. Of the 292 patients, 117 (40%) had SDD, and 175 (60%) had non-SDD. The SDD rate increased from 13.8% to 88% over the 10-year study period. The factors significantly associated with non-SDD (p < 0.05) were surgery in the first 5years after the introduction of the SDD and ERAS protocols (2012-2016), age > 75years, and comorbidities such as cardiovascular diseases, anemia (Hb < 11g/dl), and anticoagulant therapy. Extensive adhesiolysis, the performance of complete pelvic and/or aortic lymphadenectomy, operating time > 180min, and PACU discharge after 2:00 p.m. were significant factors for non-SDD. Sentinel lymph node sampling was significantly associated with SDD (OR 0.050; CI 0.273-0.934, p = 0.029). We reported no significant difference in the number, setting and timing of any unscheduled postoperative contacts, complications, and readmissions between SDD and non-SDD groups. SDD after robotic hysterectomy and staging for endometrial cancer is feasible and safe. There are patient and surgery factors for the failure of SDD. The sentinel lymph node sampling was significantly associated with achieving SDD. Trial registration: Institutional Review Board approved the study protocol (#: 1764-05).

Recurrence Risk Stratification for Women with FIGO Stage I Uterine Endometrioid Carcinoma Who Underwent Surgical Lymph Node Evaluation

<h3>Purpose/Objective(s)</h3> To estimate the recurrence risk based on the number of prognostic factors in women with FIGO stage I uterine endometrioid carcinoma (EC) in a large cohort of patients who underwent surgical staging including surgical lymph node evaluation (SLNE) and were managed with no adjuvant therapy. <h3>Materials/Methods</h3> We queried our in-house prospectively maintained uterine cancer database for patients with FIGO stage I EC underwent surgical staging including SLNE between 1/1990-12/2020. Patients with synchronous ovarian and breast cancer diagnosis were excluded as well as those who received adjuvant therapy of any form. Patient's demographics and pathologic variables were analyzed. We used multivariate analysis (MVA) with Stepwise Model Selection to determine risk factors for 5-year recurrence-free survival (RFS). Study population was then stratified based on the number of risk factors identified (0, 1 or 2). The resultant groups were compared for RFS, disease-specific survival (DSS) and overall survival (OS) using log-rank test and Kaplan-Meier curves. Additionally, independent predictors of DSS and overall OS were estimated. <h3>Results</h3> 706 patients were identified who met our inclusion criteria with a median age of 60 years (range, 30-93) and a median follow-up of 120 months. All patients had at least pelvic SLNE with a median number of examined lymph node (LN) of 8 (range, 1-66): 66 patients (11%) had a sentinel LN sampling and 43% had paraaortic SLNE. 639 patients (91%) were stage IA and lymphovascular space invasion (LVSI) was detected in 6% (n=41). Recurrence was diagnosed in 44 patients (6%). Independent predictors of 5-year RFS include age ≥ 60 years (<i>p</i>=0.038), grade 2 vs. 1 (<i>p</i>=0.003), and grade 3 vs 1 (<i>p</i><0.001). 5-year RFS for group-0 (age < 60 years and grade 1) was 98% vs. 92% for group-1 (either: age ≥ 60 years or grade 2/3) vs 84% for group-2 (both: age ≥ 60 years and grade 2/3), respectively (<i>p</i><0.001). 5- year DSS for the three groups was (100% vs 98% vs 95%, <i>p</i>=0.012) and 5-year OS was (98% vs 90% vs 81%, <i>p</i><0.001), respectively. On MVA, stage IB vs IA was deterministic for DSS (<i>p</i>=0.02); whereas age ≥ 60 years (p<0.001) and grade 3 vs grade 1 (<i>p</i>=0.004) were predictors for worse OS. <h3>Conclusion</h3> In patients with stage I endometrioid carcinoma who had surgical staging including SLNE and no adjuvant therapy, only age ≥ 60 years and high tumor grade were independent predictors of cancer recurrence and hence can be used to quantify individualized recurrence risk. Surprisingly, LVSI was not an independent prognostic factor in this study cohort with SLNE.

Is the Platelet-Lymphocyte Ratıo a Useful Tool for Predicting Sentinel Lymph Node Metastasıs in Breast Cancer Patients Receiving Neoadjuvant Therapy?

Aim: Breast cancer is one of the cancers with the highest morbidity and mortality in women. Surgical excision of axillary lymph nodes facilitates staging and provides regional control in those with axillary metastases. Although SLNB is routinely performed in the management of patients with cN0 disease who underwent primary surgery, it is controversial when to perform SLNB in patients receiving neoadjuvant chemotherapy. In our study, we evaluated the success of the platelet/lymphocyte ratio before and after neoadjuvant therapy in predicting sentinel lymph node metastases in breast cancer patients receiving neoadjuvant therapy.&#x0D; &#x0D; Materials-Methods: Patients who received neoadjuvant chemotherapy for locally advanced breast cancer in our clinic were evaluated. Among these patients, patients with histopathologically proven axilla metastases but no pathological lymph nodes in clinical examination and imaging methods after neoadjuvant therapy were evaluated.&#x0D; &#x0D; Results: An average of 3.81 lymph node excisions were performed for sentinel lymph node sampling. We studied the PLR cut-off value with Roc-curve analysis. We found the cut-off value of 138.88 with a standard error of 0.061 (p=0.001). Patients with high PLR are more likely to have sentinel lymph node metastases than patients with low PLR (OR= 1.013, 95%Cl: 1.005-1.021, p=0.002). We also found a significant positive correlation between PLR and the number of metastatic sentinel lymph nodes (p=0.005). Each unit increase in PLR can cause an increase of 0.004 units in the number of metastatic sentinel lymph nodes.&#x0D; Conclusion: In patients receiving neoadjuvant chemotherapy, PLR plays an important role in predicting sentinel lymph node metastasis as a practical, simple, and inexpensive hematological indicator and may facilitate the selection of an appropriate treatment plan before surgery.&#x0D; Keywords: Sentinel lymph node, Breast cancer, inflammatory parameters

Surgical and oncological outcomes of sentinel lymph node sampling in elderly patients with intermediate to high-risk endometrial carcinoma (547)

<b>Objectives:</b> To evaluate the surgical and oncological outcomes of elderly patients with intermediate to high-risk endometrial cancer (EC) undergoing staging with sentinel lymph node (SLN) sampling and pelvic lymphadenectomy (LND). <b>Methods:</b> A retrospective study was conducted among all elderly (>65-year-old) patients diagnosed with EC between 2007 and 2017 and treated in a single center in Montreal, Canada. We compared the surgical and oncological outcomes of three cohorts undergoing surgical staging in non-overlapping eras: 1) LND, 2) LND and SLN, 3) SLN. Two-year progression-free survival (PFS), overall survival (OS), and disease-specific survival (DSS) were analyzed using life tables, Kaplan-Meier survival curves, and log-rank tests. Odds ratios (OR) and hazard ratios (HR) and their respective 95% confidence intervals (95% CI) were calculated using multivariable logistic regression and Cox proportional hazard models. <b>Results:</b> The study included 278 consecutive patients with a median age of 73 (65-91) years; 84 underwent LND, 120 underwent SLN with LND, and 74 had SLN alone. The SLN group had significantly more grade 2/3 disease (89.2% vs 72.5% and 70.2% in the SLN with LND and the LND groups, respectively, p=0.008) and a trend towards a higher rate of positive nodes (23% vs 14.2% and 14.3% in the SLN with LND and the LND groups, respectively, p=0.22). The SLN group had a shorter total operative time with a median duration of 199 minutes (range: 75-393) compared to 231 (range: 125-403) and 229 (range: 151-440) minutes in the SLN with LND and LND cohorts, respectively (p<0.001), as well as lower, estimated blood loss with a median loss of 20ml (5-150) versus 25ml (5-800) and 40ml (5-400) in the SLN with LND and LND cohorts, respectively (p=0.002). The 2-year OS and PFS were not significantly different between the three groups (p=0.45, p=0.51, respectively). On multivariable analysis after adjusting for age, ASA score, stage, grade, and LVSI, adding SLN was associated with better OS (HR: 0.2, 95% CI: 0.1-0.6, p=0.006), and PFS (HR: 0.5, 95% CI: 0.1-1.0, p=0.05). <b>Conclusions:</b> SLN based surgical staging is feasible and associated with better surgical and oncological outcomes in elderly patients with intermediate and high-risk EC.

Is lymph node assessment warranted in patients with endometrial intraepithelial neoplasia on an endometrial biopsy? (322)

<b>Objectives:</b> Endometrial intraepithelial neoplasia (EIN) on endometrial biopsy is associated with a significant risk of concurrent endometrial cancer (EC) at the time of hysterectomy. This study aimed to identify clinical and pathological factors that may improve our ability to predict underlying high-grade cancer. We also sought to evaluate the justifiability and the accuracy of the sentinel lymph node (SLN) sampling as a staging procedure in this set of patients. <b>Methods:</b> A retrospective cohort study of women undergoing hysterectomy, bilateral salpingo-oophorectomy (BSO), and lymph nodes assessment for EIN on endometrial biopsy was conducted from December 2007 and August 2021. Associations between grade 2-3 carcinoma and other variables were calculated using univariable linear and multivariate regression models; covariates included age, BMI, ASA score, preoperative CA-125, and time between diagnosis and surgery. <b>Results:</b> Of the 3557 charts reviewed, 160 patients were eligible and included. Sixty patients (37.5%) were ultimately diagnosed with carcinoma. Among patients diagnosed with cancer, one patient (1.7%) was diagnosed with FIGO stage II, one patient with IIIA, and two (3.3%) were found to have positive pelvic lymph nodes (stage IIIC1). Twenty percent of the patients had FIGO grade 2-3 disease and deep myometrial invasion was present in 16.7% of the cancer samples. Total 155 patients underwent SLN with bilateral and unilateral detection rates of 93.2% and 72.9%, respectively. None of the preoperative clinical factors were found to be significantly associated with concurrent grade 2-3 endometrial cancer. <b>Conclusions:</b> Although preoperative EIN presages low-risk disease, a considerable proportion of patients are found to have high-grade disease on final pathology, which would require either re-staging surgery or adjuvant radiotherapy, which could be avoided by proper staging. Also, given its decreased perioperative morbidity, high negative predictive value, and short procedure time, assessment by SLN might still be valuable in patients with EIN on endometrial biopsy.