Ultrasound-guided Node Biopsy Research Articles

EP142 - "Unravelling the Enigma: Navigating the Diagnostic Dilemma of Abdominal Toxoplasmosis"

Abstract Introduction Abdominal toxoplasmosis, an infrequent yet medically significant manifestation of Toxoplasma infection, primarily caused by the protozoan parasite Toxoplasma gondii. Although toxoplasmosis can affect various organs, its occurrence in the abdominal region introduces unique diagnostic complexities, presenting symptoms such as abdominal pain, gastrointestinal disruptions, and systemic complications. Case Report In a notable case, a middle-aged patient presented with perplexing gastrointestinal symptoms, including nausea, vomiting, abdominal pain, and irregular bowel habits. With a history of anaemia and thrombocytopenia necessitating transfusions and yielding inconclusive bone marrow biopsies, the patient underwent OGD and colonoscopy with biopsies during initial management, revealing a hiatus hernia and diverticulosis that did not explain the symptoms. Despite being discharged pending biopsy results, subsequent normal findings failed to clarify. Upon readmission with persistent gastrointestinal complaints, a CTAP revealed two suspicious neoplastic focal areas of small bowel wall thickening and enlarged mesenteric lymph nodes. The MDT discussions ensued to rule out malignancy, leading to a follow-up PET scan suggesting nodal disease, raising concerns about lymphoma, small bowel adenocarcinoma, or carcinoid tumour and recommended an ultrasound-guided lymph node biopsy, 5 HIAA if asymptomatic, and diagnostic laparoscopy if symptomatic or obstructed. Subsequent core biopsy of a neck lymph node unveiled appearances consistent with toxoplasmosis, prompting treatment with anti-parasitic drugs. The patient awaits capsule endoscopy, and a follow-up CT scan displayed a reduction in bowel lesions and lymph nodes. Conclusion This case highlights the swift and precise identification of toxoplasmosis, resulting in an optimal patient outcome. The clinical manifestations of toxoplasmosis are diverse and lack distinct characteristics, making it challenging to definitively diagnose, particularly in immunocompetent individuals.

The ratio of lymph node eluate/serum cytokeratin 21-1 is a potential predictor of lymph node metastasis in lung adenocarcinoma.

Lymph node metastasis (LNM) plays an important role in prognosis of lung cancer, either in preoperative TNM staging or postoperative disease recurrence or progress. This study aimed to explore the diagnostic performances of biomarkers from lymph node eluate for LNM in lung adenocarcinoma (LUAD). A prospective analysis was conducted based on lymph node eluate specimens collected via ultrasound-guided lymph node biopsy from 48 LUAD patients with suspected LNM in the neck. According to cytopathological results, the patients were categorized into two groups: one with LNM and the other with non-LNM (NLNM). Carcinoembryonic antigen (CEA), cytokeratin 21-1 fragment (CYFRA21-1), neuron-specific enolase (NSE) and gastrin precursor releasing peptide (ProGRP) in lymph node eluate were detected by immunoassay analyzers, and tumor marker was simultaneously collected in serum of patients. The serum levels of CEA, CYFRA21-1, NSE, and the ratios of CYFRA21-1 and NSE in the lymph node eluate to serum were significantly higher in the LNM group, compared to NLNM group. The areas under curves (AUCs) for CEA, CYFRA21-1, NSE, and ratios of CYFRA21-1 and NSE were 0.79, 0.91, 0.85, 0.93, and 0.89, respectively. The ratio of CYFRA21-1 in lymph node eluate to serum (rCYFRA21-1) performed best in diagnosing, with a sensitivity of 92.3%, a specificity of 92.9%, and an AUC of 0.93. The rCYFRA21-1 to that in the serum might serve as a potential predictor for LNM in LUAD.

Ultrasound-guided lymph node biopsy sampling to study the immunopathogenesis of rheumatoid arthritis: a well-tolerated valuable research tool

BackgroundAnalyses of lymphoid organs are required to further elucidate the pathogenesis of inflammatory diseases like rheumatoid arthritis (RA). Yet, invasive tissue collection methods are scarcely applied, because they are often considered burdensome, although patients do not always consider invasive methods as a high burden. We aimed to investigate the perspectives of study participants undergoing ultrasound-guided inguinal lymph node (LN) needle biopsy sampling and determine the molecular and cellular quantity and quality of LN biopsies.MethodsTogether with patient research partners, questionnaires were developed to evaluate the motives, expectations, and experiences of participants undergoing a LN biopsy. Healthy controls and RA(-risk) patients were asked to complete these questionnaires before and after the procedure. RNA and lymphocyte yields from obtained LN biopsies were also calculated.ResultsWe included 50 individuals, of which 43 (86%) reported their pre- and post-procedure experiences. The median reported pain on a 5-point Likert scale (1 not to 5 very painful) was 1. Interestingly, almost all (n = 32; 74%) study participants would undergo a second procedure and more than half (n = 23; 54%) would encourage others to take part in the LN biopsy study. Motives for current and future participation were mostly altruistic. Inguinal hematoma occurred frequently, but no other significant or unexpected complications ensued. The LN biopsies yielded sufficient and high-quality RNA and lymphocyte numbers.ConclusionsUltrasound-guided inguinal LN biopsy sampling is well-tolerated, safe, and provides sufficient material for further molecular and cellular analyses. Our participants’ positive experiences endorse the application of this research tool to further elucidate the pathogenesis of RA and other inflammatory diseases.

Multifocal Mycobacterium kansasii osteomyelitis in a patient on ruxolitinib

• The presence of non-caseating granulomas on biopsy does not preclude mycobacterial infection, and should trigger careful investigation. • JAK inhibitors such as ruxolitinib increase the risk of mycobacterial infections, making specific investigations critical to diagnostic certainty. • M. Kansasii infection in bones and joints is rare, and is mainly found in immunosuppressed patients. • Biopsy and culture including specifically for mycobacteria should be initiated if there is any clinical suspicion. Mycobacterium kansasii spinal infection is rare. This is the first reported case in a patient taking ruxolitinib. A 69-year-old woman attended the emergency department with severe debilitating lumbar back pain and right sided flank pain. She had experienced persistent right lower chest wall pain following 4 weeks of coryzal symptoms but denied fever or weight loss. She was being treated with ruxolitinib for myelofibrosis. C reactive protein was 9 mg/L. CT and MRI showed bilateral hilar and mediastinal lymphadenopathy, and lytic lesions in the T10 vertebral body and left iliac bone. Noncaseating granuloma were found on endobronchial ultrasound guided lymph node biopsy and on biopsy of the iliac crest, with sarcoid considered a possible diagnosis. On two occasions the patient had pain so severe that she required hospitalisation. Pulsed intravenous corticosteroids was given with symptomatic improvement. Iliac bone biopsy grew Mycobacterium Kansasii at 6-week culture. The patient completed 12 months of treatment (12 months rifampicin and isoniazid, 6 months ethambutol), with resulotion of pain. We present a challenging case of mycobacterial osteomyelitis where there was initial diagnostic uncertainty. Sarcoidosis can involve multiple bony lesions but would not typically cause a spondylodiscitis. A recent pharmacovigilance report highlights that JAK inhibitors such as ruxolitinib increase the risk of mycobacterial infections, making specific investigations critical to diagnostic certainty.

1-25OH2D Mediated Hypercalcemia Secondary to DISR From Immune Checkpoint Inhibitors

Background: Drug induced sarcoid like reactions (DISR) have recently been described as a potential consequence of immune checkpoint inhibitor therapy. However, hypercalcemia associated with DISR has not been reported.Clinical Case: A 72 year old male presented with metastatic melanoma. He initiated therapy with Ipilimumab/Nivolumab (Ipi/Nivo). Three weeks after his first cycle he developed symptomatic hypercalcemia (calcium 14.4 mg/dL), and acute kidney injury (creatinine 3.45mg/dL), PTH 12 pg/mL, 25OHD 51, and PTHrp 0.5. He received IV fluids and IV bisphosphonates and calcium normalized to 9.1 mg/dL and creatinine 1.85 mg/dL. His Ipi/Nivo were stopped due to concern for neurotoxicity. He subsequently switched to Q3week Pembrolizumab (Pembro) and after 2 infusions, he again developed hypercalcemia (calcium 11.8 mg/dL). FDG PET demonstrated a complete radiographic response. Labs showed a 1,25OH2D of 103 pg/mL (reference range 19.9–79.3 pg/mL), PTH of 4 pg/mL and calcium of 11.4 mg/dL. He was treated with prednisone 20 mg QD. After 9 days on prednisone, 1,25OH2D was 26 pg/mL and calcium 9.4 mg/dL. He took prednisone for 3 weeks total. Repeat labs off prednisone for one week were 1,25OH2D of 38 pg/mL and calcium 9.1 mg/dL. He continued on Pembro. After being off steroids for 5 weeks, he developed body aches and swelling of the hands. 1,25OH2D increased to 100 pg/mL and calcium to 10 mg/dL. He restarted prednisone and stopped Pembro. Labs one month later showed a 1,25OH2D of 45 pg/dL while still on prednisone 10 mg qd and a normal calcium in the mid 9’s. Follow up FDG PET showed hypermetabolic bilateral hilar and mediastinal lymphadenopathy not seen on previous imaging. Ultrasound-guided lymph node biopsy revealed granulomatous lymphadenitis. He was diagnosed with DISR, secondary to immunotherapy with checkpoint inhibitors. He continues on prednisone 10 mg per day and calcium and 1,25OH2D levels have remained normal.Conclusion: This is the first case of 1,25OH2D mediated hypercalcemia as a consequence of DISR induced by immune checkpoint inhibitor therapy. Hypercalcemia in the setting of malignancy is more commonly due to humoral hypercalcemia of malignancy from PTHrp or bone metastasis, but DISR needs to be a consideration in persons with hypercalcemia on immune checkpoint inhibitor therapy, with elevated 1,25OH2D levels and low PTH and PTHrp levels.

A203 PAVING THE WAY TO THE DUODENUM: A CASE REPORT OF DUODENAL TUBERCULOSIS

Abstract Background Duodenal tuberculosis (DTB) is an uncommon manifestation of tuberculosis (TB), representing only 0.5% of all TB cases. The nonspecific features of its clinical presentation make diagnosis challenging, which can lead to delayed identification and even inappropriate treatments. Further, the location is also difficult to reach on conventional endoscopy and there are few studies on the use of balloon enteroscopy to diagnose DTB. Aims We report a case of DTB diagnosed using balloon enteroscopy that was successfully treated with symptom resolution. We also highlight uncommon features of DTB, including cobblestoning seen on endoscopy and villous blunting with duodenal lymphocytosis seen on histopathology. Methods Case report Results A 30-year-old previously healthy male returning from India 16 months prior presented to the emergency department with 1 month of abdominal distension, non-bloody diarrhea, and night-sweats. Examination was notable for fever and a distended abdomen. Computed-tomography showed thickening of the jejunum and ileum, with omental fat-stranding and intra-abdominal lymphadenopathy. As the lesion appeared out of reach for conventional endoscopy, balloon enteroscopy was performed, revealing an area of cobblestoning in the duodenum. Acid-fast bacilli (AFB) staining was negative. While TB culture was pending, a second balloon enteroscopy was performed, with AFB staining negative on repeat biopsy. Pathology showed villous blunting and increased intraepithelial lymphocytes but was negative for granulomas. As the diagnosis remained uncertain, endoscopic ultrasound-guided lymph node biopsy was performed and multiple lymph nodes were seen in the gastro-hepatic area. Lymph node biopsy AFB staining was also negative. 4 weeks later, pathology from the first balloon enteroscopy returned positive for TB. The remaining biopsy cultures were negative for TB. The patient was treated with standard of care treatment. At 2 and 4 months of follow-up, he reported complete resolution of symptoms. Conclusions The diagnosis of DTB is challenging due its non-specific presentation and rarity. Our case highlights the difficulty of diagnosis as endoscopic findings such as cobblestoning are highly uncommon. We provide support for the use of balloon enteroscopy as a novel method for diagnosis of DTB. With early identification, we were able to provide appropriate therapy and prevent propagation of the disease. Funding Agencies None

UTILITY OF ENDOBRONCHIAL ULTRASOUND-GUIDED LYMPH NODE BIOPSY IN RADIOGRAPHIC STAGE 1 LUNG CANCER

TYPE: Abstract Publication TOPIC: Procedures PURPOSE: Current guidelines recommend using endobronchial ultrasound guided lymph node biopsy (EBUS) in staging non-small cell lung cancer (NSCLC) with evidence of lymphatic metastasis, in primary tumor located centrally, and in tumors > 3cm in size. In patients with radiographic stage 1 (RS1) there are no recommendations on EBUS, yet it is still widely performed. We aim to show that in radiographic stage 1 NSCLC, surveillance of all mediastinal and hilar nodes is not necessary. METHODS: A retrospective study identifying patients that underwent an EBUS from January 2005 to May 2019 in adult patients who underwent both a CT and PET/CT that showed a RS1 lung nodule prior to an EBUS. All included patients had proven NSCLC from the identified nodule. RESULTS: 188 patients were included with demographic data displayed in Table 1. Of those, 13 (6.9%; 95% CI, 4.1%-11.5%) had a positive lymph node with 6 (3.2%; 95% CI, 1.5%-6.8%) were N1 nodes and 7 (3.7%; 95% CI, 1.8%-7.5%) were N2 nodes. Multivariate analysis with the significant variables in univariate anaylsis showed that only the amount of smoking was significant to upstaging lymph nodes (p=0.04). CONCLUSIONS: This study supports the use of EBUS for staging RS1 lung cancer, but with limited lymph node surveillance showing no positive N3 nodes in our cohort which shows sampling of N3 nodes is not indicated in RS1 tumors. CLINICAL IMPLICATIONS: EBUS is stil extremely valuable, but this study supports less lymph node sampling in specific patients. DISCLOSURE: No significant relationships. KEYWORDS: lung cancer, EBUS, Staging

Performance of endobronchial-ultrasound guided miniforceps biopsy of targeted mediastinal and hilar lesions.

Performance of endobronchial-ultrasound guided miniforceps biopsy of targeted mediastinal and hilar lesions.

Different outcome in node-positive breast cancer patients found by axillary ultrasound or sentinel node procedure

BackgroundThe Z0011 trial initiated a paradigm shift in the axillary treatment of breast cancer patients with a positive sentinel lymph node biopsy (SLNB), disregarding patients with a positive ultrasound-guided lymph node biopsy (UGLNB). We examined whether relevant differences exist between these patients to determine if the conclusions of the ACOSOG Z0011 trial are applicable to UGLNB-positive patients.MethodsPatients diagnosed with invasive breast cancer in the Netherlands between January 2008 and December 2014 were selected from the Netherlands Cancer Registry.ResultsA total of 11,820 cases were included: 9149 cases in the SLNB group and 2671 in the UGLNB group. Multivariate analyses showed that UGLNB-positive patients were older (p < 0.001), more likely to have a poorly differentiated tumor (p < 0.001), had a negative hormone receptor status (p < 0.001), and more often had extensive nodal involvement (p < 0.001). However, they were less likely to undergo adjuvant radiation (p = 0.004) or systemic therapy (p < 0.001). Even after adjusting for these factors, UGLNB-positive patients had a worse overall survival (HR = 1.38; 95% CI 1.23–1.56) than SLNB-positive patients.ConclusionThis nationwide retrospective study shows that young patients found positive by UGLNB have less favorable disease characteristics and a worse prognosis compared to patients with a positive SLNB. Selection by ultrasound plays an important role when axillary treatment strategies are considered. Hence, the conclusions of the Z0011 trial cannot unconditionally be applied to patients with a positive UGLNB.

Abstract P2-01-04: Use of axillary ultrasound impacts outcome of node positive breast cancer patients

Abstract Background The Z0011 trial initiated a paradigm shift in the treatment of axillary node positive breast cancer patients. Treatment strategy, however, starts with the information gathered by the diagnostic axillary work up. This can either be done by sentinel lymph node biopsy (SLNB) or ultrasound guided lymph node biopsy (UGLNB). We examined whether there are relevant clinical and prognostic differences between patients found node positive by these two diagnostic selection processes. Methods Patients diagnosed with invasive breast cancer in the Netherlands between January 2000 and December 2013 were studied. Patients with no clinically palpable lymphadenopathy (cN0) and node-positive disease after an axillary lymph node dissection (ALND) were included. Patients with stage IV breast cancer, with clinical stage T3-T4 breast tumor according to the TNM-classification, those treated within the neo-adjuvant setting, patients with palpable axillary nodes (cN≥1) and patients who did not undergo an ALND were excluded. Results A total of 14,730 patients fulfilled the inclusion criteria, of whom 9,448 were included in the SLNB group and 5,282 in the UGLNB group. Patients in the UGLNB group were older at diagnosis (p&amp;lt;0.001), had larger tumors (p&amp;lt;0.001), a higher tumor grade (p=0.001), and were more likely to have a negative hormonal receptor status (p&amp;lt;0.001) and to undergo a mastectomy (p&amp;lt;0.001). Patients in the UGLNB group were also more likely to have ≥3 positive axillary lymph nodes (p&amp;lt;0.001) and, after adjustment for these differences, had a worseoverall survival (HR=1.64; 95% CI=1.53-1.75) compared to the node-positive patients in the SLNB group. Conclusion Our multicenter study shows that patients with a positive UGLNB have less favorable disease characteristics and a worse prognosis compared to patients with a positive SLNB. The diagnostic selection process plays an important role when axillary treatment strategies are considered. Therefore, we conclude that the conclusions of the Z0011 trial cannot (yet) be applied to patients with a positive UGLNB. Citation Format: Verheuvel NC, Voogd AC, Tjan-Heijnen VCG, Roumen RMH. Use of axillary ultrasound impacts outcome of node positive breast cancer patients [abstract]. In: Proceedings of the 2016 San Antonio Breast Cancer Symposium; 2016 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2017;77(4 Suppl):Abstract nr P2-01-04.

Potential impact of application of Z0011 derived criteria to omit axillary lymph node dissection in node positive breast cancer patients

BackgroundThe ACOSOG Z0011 trial, a randomized controlled trial among patients with sentinel node positive breast cancer treated with breast conserving therapy, concluded that axillary lymph node dissection (ALND) can be omitted in these patients. However, questions were raised on the general applicability if the results of the Z0011 trial. Therefore, the aim of this study was to assess the practice changing effect of the Z0011 trial by quantifying the proportion of all node positive breast cancer patients who meet the inclusion criteria which are based on the Z0011 trial, thus in whom an ALND could be omitted. MethodsA multicenter population based study including patients with clinical T1–2N0–1M0 invasive non-metastatic breast cancer, a positive sentinel node or ultrasound guided lymph node biopsy, treated with breast conserving therapy and adjuvant systemic therapy between January 2007 and December 2012. ResultsA total of 11,031 patients had invasive breast cancer including 3051 cases treated with breast conserving therapy and adjuvant systemic therapy. Subsequently, 916 cases with a positive nodal status underwent an ALND of whom 558 cases (60.9%), representing 5.1% of the total breast cancer population, would potentially have fulfilled the Z0011 criteria. ConclusionApplication of Z0011 based criteria is practice changing in nearly 61% of all node positive patients, which could result in omission of the ALND in a substantial number of patients in the future. Further research has to be performed on the applicability of these conclusions to other categories of breast cancer patients.

Predictors for extensive nodal involvement in breast cancer patients with axillary lymph node metastases

PurposeVarious prediction models have been developed to predict the risk of having no additional axillary metastases in patients with a positive sentinel lymph node biopsy (SLNB), thereby disregarding patients with a positive ultrasound-guided lymph node biopsy (UGLNB). However, in the post-Z0011 trial era it is important to identify all patients with extensive nodal involvement for whom axillary treatment might still be beneficial. Therefore, the aim of this study is to identify factors predicting extensive nodal involvement (≥3 positive nodes) in the axilla, with the emphasis on the method of axillary staging: node positivity by UGLNB versus SLNB. MethodsAll patients diagnosed with invasive breast cancer between January 2006 and December 2011 at the Máxima Medical Center were included. Univariate and multivariate logistic regression analyses were performed. ResultsWe included 302 cases, representing 301 node positive patients, of whom 177 cases had 1 or 2 positive lymph nodes and 125 cases had ≥3 positive lymph nodes. Multivariate analyses showed that a positive UGLNB (OR = 5.10; 95%CI = 2.78–9.36), lymphovascular invasion (OR = 3.60; 95%CI = 1.79–7.23) and a larger tumor size (OR = 1.03 per mm increase; 95%CI = 1.00–1.06) were significantly associated with extensive nodal involvement in patients with invasive breast cancer. ConclusionThis study shows that a positive axilla, determined by UGLNB, is the most important factor for predicting further extensive nodal involvement. Hence, the role of axillary staging by ultrasound should be redefined since it might play an important role in selecting patients who may still benefit from axillary treatment.

Multidrug-Resistant Tuberculous Mediastinal Lymphadenitis, with an Esophagomediastinal Fistula, Mimicking an Esophageal Submucosal Tumor.

Mediastinal tuberculous lymphadenitis rarely mimics esophageal submucosal tumor, particularly in the case of multidrug-resistant tuberculosis (MDR-TB). Herein, we report the case of a 61-year-old woman who visited a local hospital complaining of odynophagia. An initial esophagogastroduodenoscopy revealed an esophageal submucosal tumor, and subsequent chest computed tomography showed subcarinal lymphadenopathy with an esophagomediastinal fistula. The patient was then referred to Samsung Medical Center, and a second esophagogastroduodenoscopy showed deep central ulceration, as well as a suspicious fistula in the esophageal submucosal tumor-like lesion. A biopsy examination of the ulcerative lesion confirmed focal inflammation only. Next, an endobronchial, ultrasound-guided lymph node biopsy was performed, and TB was confirmed. The patient initially began a course of isoniazid, rifampicin, ethambutol, and pyrazinamide. However, after a drug sensitivity test, she was diagnosed with MDR-TB, and second-line anti-TB medications were prescribed. She recovered well subsequently.

Evaluation of axillary involvement by ultrasound-guided lymph node biopsy: A prospective study

ObjectivesThe primary aim of this prospective study was to evaluate the accuracy of pre-operative ultrasound (US) alone and associated with a fine needle aspiration cytology (FNAC) or a core needle biopsy (CNB) in the diagnosis of axillary node involvement in patient with breast cancer. The secondary study objective was to determine if this US±FNAC or CNB can lead to the adequate axillary surgery in cN0 and cN1 patient. MethodsA total of 121 consecutive women with stage cT1 to cT2, cN0/cN1, invasive breast cancer were prospectively identified at our institution between February 2, 2013 and August 30, 2013. The sensitivity, specificity, VPP, NPV were calculated, with confidence intervals, using the definitive histological result of the sentinel node biopsy (SLNB) or axillary lymph node dissection (ALND) as the baseline. ResultsTwenty-seven CNB and 2 FNAC were performed. For the whole series, the sensitivity and the specificity of US alone were 48.7% [36–59%] and 89% [83–94%]. For US±FNAC or CNB, the sensitivity and the specificity were 35.9% [26–38%] and 98.8% [94–100%]. Seven women with cN1 clinical examination had SLNB, which permit to decrease the number of ALND of 16.3%. It would have avoided unnecessary SLNB, prompting immediate ALND in 9 patients with cN0 axillae, which means a reduction of SLNB of 8.6%. US±FNAC or CNB lead to the adequate surgery in 72.7% of cases. ConclusionUS±CNB or FNAC is also a relatively efficient and safe test and should be considered routinely. It allowed triaging patients to the well axillary surgery (SLNB or ALND).

Abstract P2-01-09: Application of the Z0011 criteria on Dutch breast cancer patients

Abstract Background The American College of Surgeons Oncology Group reported a randomized controlled trial (Z0011-trial) among women with T1-2N0M0 breast cancer treated with breast conserving therapy. It showed that axillary lymph node dissection may be redundant in selected sentinel node positive patients. Though, it raises questions as to the general applicability of these results. Therefore, this study aims to examine the practice changing effect and the clinical relevance of the criteria described in the Z0011 trial, when applied to a Dutch population of patients diagnosed with invasive breast cancer. Methods This is a multicenter study including patients with T1-2N0-1M0 invasive breast cancer treated in either of the 10 different hospitals affiliated with the Dutch National Cancer Registry region South in the period between January 2007 and December 2012. All patients underwent a clinical examination, a mammography and sonographic examination of the breast and the ipsilateral axilla. Chi-square analyses or a Fisher’s exact test were used to assess differences in patient and tumor characteristics the Z0011 population and the Dutch cohort. A p-value of ≤0.05 was considered statistically significant. Results A total of 11,031 patients had invasive breast cancer, of whom 5368 patients were treated with breast conserving therapy. In 6.8% axillary status was determined by the ultrasound guided lymph node biopsy and in 93.1% axillary metastases were found trough the sentinel node procedure after a negative or inconclusive ultrasound. When applying the Z0011 criteria to our study population of node positive patients, 5.7% of all breast cancer patients, equalling 11.8% of patients receiving breast conserving therapy, met the Z0011 criteria. Conclusion These results suggest that when applying the Z0011 criteria to all node positive patients, including patients with a positive sentinel node and patients with a positive ultrasound guided lymph node biopsy, only in 5.7% of all invasive breast cancer patients could be spared an ALND and its morbidity. This is a small practice changing effect. Nevertheless, it is worthwhile to consider implementing the findings of Z0011 trial in daily clinical practice. Citation Format: Nicole C Verheuvel, Vivianne CG Tjan-Heijnen, Adri C Voogd, Rudi MH Roumen. Application of the Z0011 criteria on Dutch breast cancer patients [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P2-01-09.

Abstract P6-08-45: Predictive characteristics for extensive nodal involvement in patients with axillary lymph node metastases

Abstract Background Staging of axillary lymph nodes in invasive breast cancer is an important prognostic indicator. Various prediction models have been developed to predict the risk of not having additional axillary metastases in patients with a positive sentinel node, thereby disregarding patients with a positive ultrasound. However, it is important to identify all patients with extensive nodal involvement, defined as 3 or more positive axillary lymph nodes, in whom an axillary lymph node dissection cannot be omitted. Aim This study aims to identify factors predicting extensive nodal involvement in the axilla, with the emphasis on the method of axillary staging; ultrasound guided lymph node biopsy versus sentinel node procedure. Methods All patients diagnosed with invasive breast cancer in the period between January 2006 and December 2011 at the breast center of the Máxima Medical Center were studied. Univariate and multivariate regression analyses were performed. Variables with a p-value of ≤0.10 in univariate analyses were entered in the multivariate model where a p-value of ≤0.05 was considered statistically significant. Results We included 307 cases, representing 306 node positive patients, of whom 178 cases had 1 or 2 positive lymph nodes and 129 cases had 3 or more positive lymph nodes. Multivariate analyses showed that factors as a positive axillary ultrasound (OR=4.513; 95%CI=2.30-8.86), palpability of axillary lymph nodes (OR=2.143; 95%CI=1.04-4.42) and lymphovascular invasion (OR=3.622; 95%CI=1.63-7.81) are significantly associated with extensive nodal involvement in patients with invasive breast cancer. Conclusion This study has identified clinically important factors predicting extensive nodal involvement in patients with a positive lymph node biopsy by either a sentinel lymph node procedure or an ultrasound guided lymph node biopsy. Hence, the role of axillary staging by ultrasound should be redefined since it might play an important role in selecting patients with extensive nodal involvement who, in our opinion, may still benefit from axillary treatment. Citation Format: Nicole C Verheuvel, Ingrid Van den Hoven, Hendrik WA Ooms, Vivianne CG Tjan-Heijnen, Rudi MH Roumen, Adri C Voogd. Predictive characteristics for extensive nodal involvement in patients with axillary lymph node metastases [abstract]. In: Proceedings of the Thirty-Seventh Annual CTRC-AACR San Antonio Breast Cancer Symposium: 2014 Dec 9-13; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2015;75(9 Suppl):Abstract nr P6-08-45.

A rare manifestation of neuro-ophthalmic sarcoidosis: A case report

PurposeAnterior uveitis is the most common ocular manifestation of sarcoidosis. Ocular involvement affects approximately 30–60% of patients with systemic sarcoidosis; however, optic disc edema is a rare event. We report a patient who presented with a rare case of sarcoidosis with neuro-ophthalmic manifestations. Case reportA 22-year-old man was referred to our clinic with the primary complaint of a visual field defect over the temporal side of his right eye of 2 months duration. He did not have a history of systemic disease. At the first ophthalmic examination, the visual acuity, intraocular pressure, and slit lamp examination were normal. The fundus examination revealed bilateral optic disc edema. He was initially suspected of having a choroidal lesion between the disc and fovea of the right eye. To evaluate the possible lesion, the patient underwent brain magnetic resonance imaging (MRI), chest radiography, and chest computed tomography (CT). There were no abnormalities on the brain MRI, but the chest radiographs and CT images revealed bilateral mediastinal and hilar lymphadenomegaly. Histopathologic evaluation of an ultrasound-guided lymph node biopsy confirmed the diagnosis of sarcoidosis. ConclusionNeuro-ophthalmic manifestations of sarcoidosis are rare but may be the only presenting sign of an otherwise occult disease. A high clinical suspicion for sarcoidosis and its inclusion as a differential diagnosis are key to establishing the diagnosis and proper treatment.

The role of ultrasound-guided lymph node biopsy in axillary staging of invasive breast cancer in the post-ACOSOG Z0011 trial era.

Axillary status in invasive breast cancer, established by sentinel lymph node biopsy (SLNB) or ultrasound-guided lymph node biopsy, is an important prognostic indicator. The ACOSOG Z0011 trial showed that axillary dissection may be redundant in selected sentinel node-positive patients, raising questions on the applicability of these conclusions on ultrasound positive patients. The purpose of this study was to evaluate potential differences in patient and tumor characteristics and survival between axillary node positive patients after ultrasound (US group) or sentinel lymph node procedure (SN group). Patients diagnosed with invasive breast cancer at the Máxima Medical Center between January 2006 and December 2011 were studied. In total, 302 node-positive cases were included: 139 and 163 cases in the US and SN groups, respectively. Patients in the US group were older at diagnosis (p<0.001), more often had palpable nodes (p<0.001), mastectomy (p<0.001), larger tumors (p<0.001), higher tumor grade (p=0.001), lymphovascular invasion (p=0.035), a positive Her2Neu (p=0.006), and a negative hormonal receptor status (p=0.003). Also, they were more likely to have more lymph nodes with macrometastases (p<0.001), extranodal extension (p<0.001), and involvement of level-III-lymph node (p<0.001). Finally, they showed a worse disease-free survival [hazard ratio (HR)=2.71; 95% confidence interval (CI)=1.49-4.92] and overall survival (HR=2.67; 95% CI=1.48-4.84) than the SN group. These results suggest that ultrasound-positive patients have less favorable disease characteristics and a worse prognosis than SN-positive patients. Therefore, we conclude that omitting an ALND is as yet only applicable, as concluded in the Z0011, in patients with a positive SLNB.

Extrapulmonary Tuberculosis (TB) Diagnosed With the Aid of Endoscopic Ultrasound–Guided Lymph Node Biopsy

BackgroundTuberculosis (TB) is the most common opportunistic infection in persons living with human immunodeficiency virus (HIV) worldwide. In the United States, the incidence of TB in 2009 was 4.1 per 100 000, with 10% of the patients coinfected with HIV. An estimated 10 to 15 million people in the

Endobronchial ultrasound-guided lymph node biopsy with transbronchial needle forceps: a pilot study

One limitation of endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is the size of the available needles, frequently yielding only cells for cytological examination. The aim of this pilot study was to evaluate the efficacy and safety of newly developed needle forceps to obtain tissue for the histological diagnosis of enlarged mediastinal lymph nodes. Patients with enlarged, positron emission tomography (PET)-positive lymph nodes were included. The transbronchial needle forceps (TBNF), a sampling instrument combining the characteristics of a needle (bevelled tip for penetrating through the bronchial wall) with forceps (two serrated jaws for grasping tissue) was used through the working channel of the EBUS-TBNA scope. Efficacy and safety was assessed. 50 patients (36 males and 14 females; mean age 51 yrs) with enlarged or PET-positive lymph nodes were included in this pilot study. In 48 (96%) patients penetration of the bronchial wall was possible and in 45 patients tissue for histological diagnosis was obtained. In three patients TBNF provided inadequate material. For patients in whom the material was adequate for a histological examination, a specific diagnosis was established in 43 (86%) out of 50 patients (nonsmall cell lung cancer: n=24; small cell lung cancer: n=7; sarcoidosis: n=4; Hodgkin's lymphoma: n=4; tuberculosis: n=2; and non-Hodgkin's lymphoma: n=2).No clinically significant procedure-related complications were encountered. This study demonstrated that EBUS-TBNF is a safe procedure and provides diagnostic histological specimens of mediastinal lymph nodes.