Successful Sentinel Lymph Node Biopsy Research Articles

Implementing Sentinel Lymph Node Biopsy Programs in Developing Countries: Challenges and Opportunities

Sentinel lymph node biopsy (SLNB) is the accepted standard of care in early-stage breast cancer and cutaneous melanoma. This technology is accurate for nodal staging and determining the prognosis of these patients. There are several randomized controlled trials confirming the accuracy of this technique and confirming its role in reducing morbidity and improving quality of life. It is also gaining increased acceptance in the management of other solid tumors. Despite the established benefits of SLNB as a minimally invasive approach for nodal staging, the procedure is still underutilized in many developing countries. The Human Health Division of the International Atomic Energy Agency (IAEA) convened advisory meetings with panels of multidisciplinary experts from different backgrounds with the remit to analyze the difficulties encountered by developing countries in establishing a successful SLNB program. The other remit of the panel was to recommend an effective program based on existing evidence that can be adapted and implemented in developing countries. The experience of some members of the panel in the training for this technique in Asia, Latin America, and Africa provided the insight required for the development of a comprehensive and structured program. The panel included recommendations on the technical aspects of the procedure, as well as a comprehensive training program, including theoretical teaching, practical training in surgical skills, laboratories, and hands-on proctored learning. Particular emphasis was placed on in-built quality assurance requirements to ensure that this powerful staging investigation is implemented with the highest possible standard in the management of cancer patients, with the lowest false negative rate. It is hoped that this article will be a useful resource for our colleagues planning to establish a SLNB program.

Factors associated with the misdiagnosis of sentinel lymph nodes using touch imprint cytology for early stage breast cancer

Accurate intraoperative diagnosis of sentinel node metastasis enables the surgeon to make an immediate decision to proceed to axillary lymph node dissection (ALND), thereby avoiding the economic and psychological costs of a second operation. The present study aimed to evaluate the clinical value of touch imprint cytology (TIC) and investigate the potential factors associated with misdiagnosis. A total of 366 patients with Tis-T2 breast carcinoma were included after undergoing successful sentinel lymph node biopsy (SLNB). TIC was routinely performed intraoperatively, and the results were compared with definitive histological assessments of serial sections (SS) with hematoxylin and eosin (H&E) staining. A total of 992 SLNs from 366 patients were used in the study. Based on the final histological diagnosis, the sensitivity, specificity and overall accuracy of TIC was 76.6, 98.8 and 92.3%, respectively, on a per patient basis, and 79.9, 98.9 and 96.1%, respectively, on a per node basis. TIC was significantly more sensitive for macrometastasis than micrometastasis (80.0 vs. 28.6%, P<0.01). Of 9 total 'false positives', 3 were due to micrometastasis which were not identified by serial section with H&E staining, 4 were actual false-positives which were due to interpretation error, and 2 were due to sampling error. The majority of the false-negatives (28 of 30 SLNs) were due to micrometastasis in the SLNs (sampling error). In conclusion, TIC is feasible for clinical use and is able to detect macrometastasis in the SLNs of early stage invasive breast cancer patients with an acceptable accuracy while its ability to detect micrometastasis is limited.

Abstract P1-01-20: Validation of MSKCC Nomogram in Predicting Sentinel Lymph Node Metastasis of a Chinese Breast Cancer Population

Abstract Background: The Memorial Sloan-Kettering Cancer Center (MSKCC) developed a nomogram to predict the presence of sentinel lymph node (SLN) metastasis in breast cancer patients. Our study was designed to validate the clinical value of the MSKCC nomogram in Chinese early-stage breast cancer population. Methods: Data were collected from 524 patients with successful SLN biopsy who were treated during 2005 March to 2009 October. Positive SLN metastasis was found in 154 patients. Touch imprint cytology (TIC) and serial section with H&amp;E staining were performed routinely on each sentinel node. Univariate analysis and logistic regressions tested whether a characteristic was correlated with the SLN positivity. MSKCC nomogram was used to estimate probability of SLN involvement and compared with actual probability after grouping into deciles. A ROC curve was drawn and predictive accuracy was assessed by calculating the area under the receiver-operating characteristic (ROC) curve. Results: It was shown that age, tumor size, histological grade and lymphovascular invasion was correlated with the probability of SLN metastasis by univariate analysis (P&amp;lt;0.05). By multivariate analysis, tumor size and lymphovascular invasion were identified as independent predictors of SLN metastasis. The odds ratio (OR) of the lymphovascular invasion was 9.462(95% CI 5.551-16.130)while OR of tumor size was 1.429(95% CI 1.142-1.788). The trend of actual probability in various decile groups was comparable to the predicted probability. Patients in the group with the least probability of a positive SLN predicted by the nomogram (≥10 decile) were all diagnosed with a negative SLN by serial section by H&amp;E staining. Three patients in our collective with extremely high probability (≥90) were all diagnosed as positive SLN by pathology. The area under the ROC curve was 0.757 as compared to 0.754 in the original population. Conclusion: As far as we know, this is the first study designed to evaluated the MSKCC nomogram in Chinese early breast cancer population. The MSKCC nomogram that predicts metastasis of breast cancer in the sentinel lymph node performed good in a Chinese breast cancer population. Though the nomogram cannot be an alternative of SLN biopsy, it could provide a clinical accessory in the preoperative discussion with patients, especially in the very high or very low risk of patients. The nomogram could be used in very low risk patients to safely avoid a SLN procedure, thereby reducing postoperative morbidity, whereas the rate could be as high as 7% in the literature. While for patients with very high risk estimated by the nomogram, axillary lymph node dissection could be recommended directly. The shortcoming of the nomogram is that clinical and pathological parameters include detail histological diagnosis of the primary tumor before the final decision for surgical procedure. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-01-20.

Abstract P1-01-29: Clinical and Histopathological Factors Affecting Failed Sentinel Node Localization in Axillary Staging for Breast Cancer

Abstract Background: Sentinel lymph node biopsy (SLNB) has become the standard of care in axillary staging of clinically node-negative breast cancer patients. We hypothesize that clinical parameters are associated with failure to identify an axillary sentinel lymph node. Methods: We performed a retrospective review of 164 consecutive breast cancer patients who underwent SLNB from March 2008 to January 2010. A superficial injection technique was used as advocated by the UK National Training Programme (NEW START). All patients had lymphoscintigrams. Delayed imaging was performed if initial lymphoscintigram was negative up to 22 hours post-injection. Patient/surgical data, histopathological data and tumour location data were recorded. A univariate and multivariate analysis was performed. Results: Mean time from radiocolloid injection to surgery was 785.10 minutes (SD 435.97). 9/164 patients failed to show nodes on delayed imaging. In 2/9 patients successful SLNB was carried out following subareolar blue dye injection and 5 minute massage. 6/9 patients showed no evidence of radioactivity or blue dye. These patients underwent a stage 2 axillary clearance. 5/6 had multiple node involvement. Age and nodal status were significant factors (P&amp;lt;0.05). For every unit increase in age there was a 9% (CI, 0.84 - 0.99) reduced chance of failed sentinel node localization. Patients with negative nodal status had a 90% (CI, 0.02 - 0.99) reduced risk of failed sentinel node localization than patients with nodal macrometastasis and extracapsular nodal invasion. Weight (p=0.063, CI 0.91 - 1.03), previous breast surgery (p=0.062, CI 0.006 - 1.136) and tumour location (p=0.402, CI 0.03 - 4.17) showed weak association but failed to reach statistical significance. Discussion: Our results suggest that aberrant lymphatic flow secondary to tumour burden increase the chance of failed axillary sentinel node localization. Review of lymphoscintigrams showed that in all failed localizations the radiocolloid persisted around the injection site, showing limited local diffusion only. Similar findings were observed for blue dye injection. We further hypothesize that technical factors at the time of the injection may also play a role. Citation Information: Cancer Res 2010;70(24 Suppl):Abstract nr P1-01-29.

Prognostic implication of sentinel lymph node biopsy in cutaneous head and neck melanoma

Current therapy for intermediate thickness melanoma involves wide local excision with sentinel lymph node biopsy (SLNB). SLNB provides important prognostic information and immediate regional lymphadenectomy for a positive sentinel lymph node (SLN) may improve survival and identifies patients who are candidates for adjuvant therapy and/or clinical trials. The head and neck site is unique because of its complex lymphatic drainage pattern to multiple nodal basins and because of the risk of site-specific morbidity associated with regional lymphadenectomy when compared to other body sites. The goal of this study is to report the results of SLNB for head and neck cutaneous melanoma in locating the sentinel node and to report on the prognostic implications of SLNB for this cohort of patients. A prospectively entered melanoma database was used to review consecutive patients with head and neck cutaneous melanoma undergoing SLNB at Memorial Sloan-Kettering Cancer Center between 1996 and 2007. The database, along with a retrospective chart review, was used to evaluate the success of SLNB at locating an SLN and the success rate of frozen section and permanent section analysis at diagnosing metastatic disease. Recurrence at all sites including the nodal basin and status at last follow-up was recorded. Characteristics of the patients' primary melanoma were included. Descriptive statistics along with univariate and multivariate survival analysis were performed. Between 1996 and 2007, 234 patients with a diagnosis of head and neck cutaneous melanoma underwent SLNB and had at least 1 month of follow-up. At least 1 SLN was identified in 218 of these patients (93%) by lymphoscintigraphy. In 16 patients, no SLN was found. These patients had a much shorter time to recurrence (4.75 months) than either the SLN-positive group (10.7 months) or the SLN-negative group (26.0 months). They had a disease-specific survival (DSS) in between the SLN-positive and SLN-negative group. Of the patients in whom an SLN was identified, 28 patients (12%) had at least 1 positive SLN. Of these, the SLNs of 14 patients (50%) were identified on frozen section; 14 (50%) could only be identified after further sectioning or immunohistochemical analysis postoperatively. Among 190 patients with a negative SLNB, 12 patients had recurrences in the nodal basin. This resulted in a sensitivity of 70%, a negative predictive value of 94%, and a false-negative rate of 30%. The 3-year disease-free survival for SLN-negative and SLN-positive patients was 84% (p < .031) and 58% (p < .102), respectively. The 3-year melanoma-specific survival was 98% (p < .012) and 75% (p < .201), respectively. The SLN status is an important predictor of survival. The technique, performed in the head and neck is complex and associated with a high false-negative rate.

SPECT/CT for Lymphatic Mapping of Sentinel Nodes in Early Squamous Cell Carcinoma of the Oral Cavity and Oropharynx

Adequate staging and treatment of the neck in squamous cell carcinoma of the oral cavity and oropharynx (OSCC) is of paramount importance. Elective neck dissection (END) of the clinical N0-neck is widely advocated as neck treatment. With regard to the prevalence of 20–40% of occult neck metastases found in the ND specimens, the majority of patients undergo surgery of the lymphatic drainage basin without therapeutic benefit. Sentinel node biopsy (SNB) has been shown to be a safe, reliable and accurate alternative treatment modality for selected patients. Using this technique, lymphatic mapping is crucial. Previous reports suggested a benefit of single photon emission computed tomography with CT (SPECT/CT) over dynamic planar lymphoscintigraphy (LS) alone. SPECT/CT allows the surgeon for better topographical orientation and delineation of sentinel lymph nodes (SLN's) against surrounding structures. Additionally, SPECT/CT has the potential to detect more SLN's which might harbour occult disease, than LS. SPECT/CT is recommended to be used routinely, although SPECT/CT is not indispensable for successful SNB.

Sentinel Lymph Node Biopsy in Patients with Previous Ipsilateral Complete Axillary Lymph Node Dissection

Prior ipsilateral completion axillary lymph node dissection (CALND) may be considered a contraindication to performing a sentinel lymph node (SLN) mapping in a patient with recurrent breast carcinoma. However, reoperative SLN biopsy following axillary dissection would determine if alternative lymphatic drainage pathways exist. If nodes were found to contain metastatic disease, staging and locoregional control of the disease could be affected. An institutional breast cancer database and electronic health record (IRB No. 102554) prospectively accrued 6225 patients between 1994 and 2007. Under separate IRB approval (IRB No. 102552), this database was queried for patients with a prior history of CALND who received a SLN biopsy. Patients' demographic, clinical, and treatment variables were recorded. Of the 6225 patients, 45 (0.7%) were identified as having previously undergone breast-conservation surgery, CALND, and ipsilateral reoperative SLN mapping and biopsy. Of the 45 patients, 13 (29%) had a successful ipsilateral reoperative SLN mapping and biopsy. Nonaxillary drainage was identified in 5 patients with reoperative SLN biopsy. Reoperative SLN mapping and biopsy is feasible in the setting of local recurrence after previous CALND. This procedure performed for breast cancer recurrence provides important staging information while identifying extra-axillary drainage that could affect both staging and local control.

Histologic changes associated with false‐negative sentinel lymph nodes after preoperative chemotherapy in patients with confirmed lymph node‐positive breast cancer before treatment

A wide range of false-negative rates has been reported for sentinel lymph node (SLN) biopsy after preoperative chemotherapy. The purpose of this study was to determine whether histologic findings in negative SLNs after preoperative chemotherapy are helpful in assessing the accuracy of SLN biopsy in patients with confirmed lymph node-positive disease before treatment. Eighty-six patients with confirmed lymph node-positive disease at presentation underwent successful SLN biopsy and axillary dissection after preoperative chemotherapy at a single institution between 1994 and 2007. Available hematoxylin and eosin-stained sections from patients with negative SLNs were reviewed, and associations between histologic findings in the negative SLNs and SLN status (true negative vs false negative) were evaluated. Forty-seven (55%) patients had at least 1 positive SLN, and 39 (45%) patients had negative SLNs. The false-negative rate was 22%, and the negative predictive value was 67%. The negative SLNs from 17 of 34 patients with available slides had focal areas of fibrosis, some with associated foamy parenchymal histiocytes, fat necrosis, or calcification. These histologic findings occurred in 15 (65%) of 23 patients with true-negative SLNs and in only 2 (18%) of 11 patients with false-negative SLNs (P = .03, Fisher exact test, 2-tailed). The lack of these histologic changes had a sensitivity and specificity for identifying a false-negative SLN of 82% and 65%, respectively. Absence of treatment effect in SLNs after chemotherapy in patients with lymph node-positive disease at initial presentation has good sensitivity but low specificity for identifying a false-negative SLN.

Pre-operative lymphoscintigraphy before sentinel lymph node biopsy for breast cancer

Pre-operative lymphoscintigram for axillary sentinel lymph node biopsy (SLNB) may not be required for successful SLNB. The 117 consecutive patients who underwent SLNB had pre-operative lymphoscintigraphy. The operating surgeon was blinded to the results of the lymphoscintigram before SLNB. After SLNB was complete, the surgeon was unblinded to the results of the lymphoscintigram; re-exploration carried out if more nodes were predicted on the lymphoscintigram. 116 patients (99%) had successful SLNB before unblinding. In 85 patients (73%), operative findings corresponded with scintigraphic findings. In 26 patients (22%), the lymphoscintigram predicted more sentinel nodes than had been found; further nodes were identified and excised in only 4 patients (3%). None were positive for cancer. SLNB was successful in 99% of cases without pre-operative lymphoscintigraphy. Only 3% of patients had further nodes identified as a result of the lymphoscintigram. Pre-operative lymphoscintigraphy does not improve the ability to perform axillary SLNB during breast cancer surgery.

The role of pre-operative lymphoscintigraphy before sentinel lymph node biopsy (SLNB) for breast cancer

Introduction: Pre-operative lymphoscintigram for axillary SLNB requires on-site nuclear medicine facilities which are not available at district general hospitals and may not be required for successful SLNB.

Is There an Additional Value of SPECT/CT Over Planar Lymphoscintigraphy for Sentinel Node Mapping in Oral/Oropharyngeal Squamous Cell Carcinoma?

Lymphatic mapping for sentinel node biopsy (SNB) has been shown to be crucial for detection of sentinel lymph nodes (SLN). Previous reports suggested a benefit of single photon emission computed tomography with CT (SPECT/CT) over dynamic planar lymphoscintigraphy (LS) alone. The aim was to assess whether there is an additional value of SPECT/CT over LS alone for lymphatic mapping of SLNs in oral/oropharyngeal SCC. A consecutive cohort of 58 patients was evaluated using SNB with additional SPECT/CT to preoperative LS. In the entire cohort of 58 patients undergoing LS and SPECT/CT, hot spots could be revealed in all but 4 cases. The guidance of the handheld gamma probe was able to reveal 9 additional SLNs within 3 patients not detected by either modality. Lymphoscintigraphy showed full concordance with SPECT/CT in 81% of the cases. SPECT/CT was able to detect additional HS in 11 patients, in 1 case even with additional metastatic disease. The false negative rate for SNB was 6%, and the negative predictive value 98%. SPECT/CT has the potential to detect more SLNs, which might harbor occult disease, than LS alone. With regard to the excellent results achieved with LS and the intraoperative use of the gamma probe, SPECT/CT is not indispensable for successful SNB. Both imaging modalities have difficulties in detecting level I sentinel nodes close to the injection site.

Age-Related Lymphatic Dysfunction in Melanoma Patients

Age-related outcomes have become increasingly common in evaluating patients with melanoma. For instance, as age increases, sentinel node (SN) nonidentification increases and SN positivity decreases. Furthermore, advanced age is a risk factor for in-transit disease. We hypothesized that increasing age is accompanied by alterations in lymphatic function, possibly explaining these findings. Our center's melanoma database was queried to identify patients who underwent successful sentinel node biopsy after lymphoscintigraphy. Records of those treated between 2000 and 2005 were reviewed for age, sex, drainage basin, intraoperative radioactivity, and SN pathology. The 858 patients had a mean age of 55 years; 59% were men. Mean radioactivity in the hottest SN was 5232 counts per second; 179 patients (21%) had SN metastases. SN count rates were significantly and inversely related to age (P < .001 by Pearson correlation, analysis of variance, and chi(2) test). Mean counts per second were 6105, 5883, and 2720 for axillary, inguinal, and cervical basins, respectively (P < .01), and count rates in these basins were consistently lower with increasing age (neck and axilla, P < .001; groin, P = .060; Pearson correlation). Multivariate analysis confirmed an independent inverse association between age and count rates (P < .001), overall and within each primary tumor site. Lymphatic function, as assessed by radiocolloid transit to and uptake within the SN, declines with age. Altered lymphatic function in older patients may modify metastatic patterns; knowledge of this may help clarify findings of reduced nodal positivity and increased in-transit disease in this population.

Good Prediction of the Likelihood for Sentinel Lymph Node Metastasis by Using the MSKCC Nomogram in a German Breast Cancer Population

The sentinel lymph node (SLN) procedure could be omitted in cases of accurate prediction of very high or very low probability of SLN metastasis in early breast cancer patients. We evaluated a breast cancer nomogram, an online tool provided by the Memorial Sloan-Kettering Cancer Center (MSKCC), that predicts the likelihood of a positive lymph node. Data from 545 patients with successful SLN biopsy were collected, including 118 patients with a positive sentinel lymph node. Histopathological assessment of the SLN included hematoxylin and eosin staining and/or immunohistochemistry. Predictive accuracy was assessed by calculating the area under the receiver-operator characteristic (ROC) curve. In our collective tumor size, histology, lymphovascular infiltration, multifocality, Her-2-neu positivity, and nuclear grade correlated with the probability of SLN metastasis. The ROC of the validated nomogram in our breast cancer population revealed a value of 0.78 compared with 0.75 in the original publication. The MSKCC nomogram is a useful tool in our population of breast cancer patients. However, variations in the pathological assessment of the SLN between breast cancer centers worldwide might be an impediment to widespread application of the nomogram.

First Three Sentinel Lymph Nodes Accurately Stage the Axilla in Breast Cancer

Sentinel lymph node (SLN) biopsy is the preferred method of assessing lymph nodes in breast cancer. Recent literature suggests increasing morbidity with increased number of SLN removed. However, controversy exists regarding the number of SLN that should be removed. A retrospective review of patients undergoing SLN biopsy for breast cancer from 2003 to 2005 was performed. Data analyzed included the number of SLNs, nodes per specimen, and pathology. The order of SLN removal was documented and the first positive lymph node noted. Three hundred fifty-three patients underwent successful SLN biopsy. On average, only one surgical SLN was identified. However, the average number of pathologically identified SLN was 1.3. Nodal disease was identified in 79 patients (22.4%). The first SLN was positive in 70 of those patients (88.6%). Six additional patients were diagnosed by the second SLN (76 of 79 [96.2%]), and all 79 patients were identified within the first three nodes. All patients with nodal disease were identified within three SLNs. These data support the concept that surgeons do not need to remove all identifiable sentinel nodes. Moreover, surgeons could consider limiting the number of excised SLNs to three.

Factors associated with detection failure and false‐negative sentinel node biopsy findings in gastric cancer: Results of prospective single center trials

The factors associated with successful sentinel node biopsy (SNB) are limited in gastric cancer despite a wide range of sensitivities reported. This study was performed to identify the factors associated with detection failure and SNB false-negativity in gastric cancer. SNB was performed on 156 gastric cancer patients from May 2002 to April 2007 at the Korean National Cancer Center during three consecutive prospective trials. Indications for SNB were determined preoperatively in cT1-2N0 patients. Dissected SNs and non-SNs after D2 lymphadenectomy were pathologically evaluated for metastasis. Clinical, pathological, and technical factors were analyzed for detection failure and false-negativity. SNs were detected in 147 patients (94.2%) and the median number of SNs detected per patient was 3 (1-12). Twenty-five of 37 with nodal metastasis were diagnosed by SNB (sensitivity, 67.6%). Surgeon's inexperience (<or=30 procedures) and a male patient gender were significantly associated with detection failure (P = 0.014 and 0.031, respectively). A small number of SNs (<or= 3) was found to be significantly associated with false-negativity (P = 0.027). SNB requires experience for successful detection and should be performed cautiously in male patients. Harvesting of more than three SNs is warranted to reduce false-negatives when diagnosing nodal metastasis.

Optimal Detection of Sentinel Lymph Node Metastases by Intraoperative Radioactive Threshold and Molecular Analysis in Patients with Melanoma

The aim of this study was to optimize a protocol for radioguided biopsy of the sentinel lymph node (SLN) in patients with melanoma. The protocol was based on a combination of ex vivo counting of the nodes detected intraoperatively and analysis of the harvested nodes by hematoxylin and eosin staining plus immunohistochemistry (conventional histopathology [PATH]) and by molecular biology (reverse-transcriptase polymerase chain reaction [RT-PCR]). A total of 124 patients with primary clinical stage I-II (according to the American Joint Committee on Cancer) cutaneous melanoma underwent successful radioguided SLN biopsy. SLNs harvested for analysis included any additional nodes whose ex vivo counting rate exceeded 20% of the hottest node. All removed SLNs were examined by conventional PATH and with RT-PCR analysis for the expression of messenger RNA for tyrosinase and the melanoma antigens recognized by T cells. Complete lymph node dissection (CLND) was performed only in the case of SLN metastasis detected by PATH. Different combinations of the intraoperative parameters (only the hottest node and all nodes harvested) and of analysis (PATH and RT-PCR) were tested as predictors of clinical outcome on the basis of long-term follow-up (12-81 mo; median, 55 mo). A total of 197 SLNs were harvested, 41 of which harbored metastasis as detected by RT-PCR analysis; PATH detected metastasis in only 24 of 41 metastatic SLNs. In 5 of 41 instances, metastasis was not in the hottest SLN. The main factor determining correct classification of the SLN status was RT-PCR, which significantly improved detection of metastasis, even if applied only to the hottest node (P < 0.0001 vs. PATH analysis of either the hottest SLN or all nodes above the 20% threshold). Metastatic disease recurred locally in 5 patients who had not undergone CLND; RT-PCR analysis showed metastasis in 4 of these patients. The false-negative rate of SLN biopsy progressively decreased when applying PATH only to the hottest node (32.1%), additional RT-PCR to the hottest node (21.4%), PATH to all nodes (17.9%), and RT-PCR to all nodes (3.6%, P = 0.015 vs. PATH analysis of only the hottest SLN). On the basis of long-term follow-up (the gold standard for final clinical outcome of SLN biopsy), both 20% threshold and RT-PCR analysis should be applied for optimal detection of nodal metastases in patients with melanoma.

Regional Recurrence After Negative Sentinel Lymph Node Biopsy for Melanoma

Sentinel lymph node (SLN) biopsy has shown great utility in the management of melanoma. An analysis of regional recurrence in previously mapped negative SLN basins as the first site of relapse is performed. A retrospective query of a prospective melanoma database from 1994 to 2006 identified 1287 patients who underwent successful SLN biopsy. One thousand sixty patients (82.4%) were SLN negative and 227 (17.6%) patients SLN positive. Clinical variables were examined for the impact on regional recurrence by multivariate analysis. Mean follow-up was 44.3 months (range 3-155 months). Thirty-five patients (3.3%) presented with false-negative (FN) SLN biopsy. Pathologic review of the SLNs harvested from these basins found 7 (20.0%) samples positive for metastatic melanoma. Multivariate analysis found head and neck site [hazard ratio 3.67; 95% confidence interval (CI), 1.77-7.60, P < 0.001] and tumor thickness (hazard ratio 1.16; 95% CI, 1.04-1.30, P = 0.01) to be predictive of FN SLN biopsy. The 5-year melanoma specific survival calculated from the date of the SLN biopsy was 57.6% (95%CI, 35.7-41.9) in the FN group, which was not statistically different than the SLN positive group 60.0% (95% CI, 29.6-40.1; P = 0.14). Head and neck tumor site and tumor thickness are predictors of a FN SLN biopsy. Mechanisms other than pathologic SLN sampling error may contribute to the failure of the SLN biopsy in some patients. Patients with regional recurrence after negative SLN biopsy have a similar 5-year survival compared with patients with positive SLNs.

A systematic review of tests for lymph node status in primary endometrial cancer.

BackgroundThe lymph node status of a patient is a key determinate in staging, prognosis and adjuvant treatment of endometrial cancer. Despite this, the potential additional morbidity associated with lymphadenectomy makes its role controversial. This study systematically reviews the accuracy literature on sentinel node biopsy; ultra sound scanning, magnetic resonance imaging (MRI) and computer tomography (CT) for determining lymph node status in endometrial cancer.MethodsRelevant articles were identified form MEDLINE (1966–2006), EMBASE (1980–2006), MEDION, the Cochrane library, hand searching of reference lists from primary articles and reviews, conference abstracts and contact with experts in the field. The review included 18 relevant primary studies (693 women). Data was extracted for study characteristics and quality. Bivariate random-effect model meta-analysis was used to estimate diagnostic accuracy of the various index tests.ResultsMRI (pooled positive LR 26.7, 95% CI 10.6 – 67.6 and negative LR 0.29 95% CI 0.17 – 0.49) and successful sentinel node biopsy (pooled positive LR 18.9 95% CI 6.7 – 53.2 and negative LR 0.22, 95% CI 0.1 – 0.48) were the most accurate tests. CT was not as accurate a test (pooled positive LR 3.8, 95% CI 2.0 – 7.3 and negative LR of 0.62, 95% CI 0.45 – 0.86. There was only one study that reported the use of ultrasound scanning.ConclusionMRI and sentinel node biopsy have shown similar diagnostic accuracy in confirming lymph node status among women with primary endometrial cancer than CT scanning, although the comparisons made are indirect and hence subject to bias. MRI should be used in preference, in light of the ASTEC trial, because of its non invasive nature.

Intraoperative identification of suspicious palpable lymph nodes as an integral part of sentinel node biopsy in patients with breast cancer

Despite the sensitivity and accuracy of sentinel lymph node biopsy (SLNB), the number of false negative (FN) results is still relatively high, which has prompted much investigation. We studied the effectiveness of the biopsy of suspicious palpable lymph nodes (LNs) in reducing the number of FN results. We reviewed the medical records of 865 breast cancer patients who underwent successful SLNB at a single institution. After excising the blue-stained or radioactive nodes, all suspicious palpable LNs that were not either blue-stained or radioactive were also excised. Sampling of a suspicious palpable LN was done in 342 (39.5%) of the 865 patients. The average number of suspicious palpable nodes was 1.9. The suspicious nodes harbored metastasis in 19 of the 342 patients. Both blue-stained and radioactive metastatic SLNs were found in 8 patients, whereas the palpable nodes were the only ones involved in the other 11. LN involvement was identified solely by biopsy of a suspicious palpable LN in 11 (6.5%) of 170 patients with SLN metastasis (6.5%). Biopsy of a suspicious palpable LN should be done as part of SLNB to reduce the number of FN results of SLNs in breast cancer patients.

Presence of bone marrow micrometastasis predicts metastatic pattern and disease-free interval in breast cancer patients – results from the Collaborative Group Bone Marrow Micrometastasis

The aim of the present study was to investigate the association between non sentinel lymph node metastasis (NSLNM) and clinicopathological factors, particularly in the case of sentinel lymph node (SLN) metastasis in one or two, in clinically node negative patients with breast cancer.Between 10/2010 and 10/2014, 350 sentinel lymph node biopsy (SLNB) were performed in patients with histologically proven primary breast cancer in our clinic. The data collection includes the following characteristics: age, pathological tumor size, histological type, histological grade, lymphovascular invasion (LVI), number of positive SLN, size of the SLN metastasis (macrometastasis, micrometastasis, isolated tumor cells), multifocality (MF), extracapsuler invasion (ECI) of the SLN, the estrogen receptor (ER) status, the progesterone receptor (PR) status and the Her 2 receptor status, Ki 67 reseptor status. Data were collected retrospectively and then analyzed.A successful SLN biopsy were performed in 345 (98.5%) cases. SLN metastases were detected in 110 (31.8%) cases. These patients then underwent axillary dissection; among these patients, 101 (91.8%) had only one to two positive SLNs. Of the 101 patients with positive SLN biopsies, 32 (31.6%) had metastases in the NSLNs. Univariate and multivariate analysis showed that lymphovascular invasion, extracapsular invasion (ECI), Her-2 receptor positive, and Ki-67 > 14% were related to NSLNM (p<.0.05).The predicting factors of NSLNM were LVI, ECI, Ki-67 level, Her-2 reseptor positive and but should be further validated in our institutions, different institutions and different patient groups prospectively.