Underwent Sentinel Lymph Node Biopsy Research Articles

Ganglio centinela positivo en melanoma: factores predictivos y resultados del vaciamiento ganglionar

Background: Sentinel lymph node (SLN) biopsy is the technique accepted to determine the prognosis of early cutaneous melanomas. The advantage of lymph node dissection (LND) when SLN biopsy is positive has recently been questioned. Objective: The aim of this study is to describe the percentages and factors associated with SLN and non-sentinel node (NSN) metastases in LNDs of SLN-positive patients. Material and methods: The clinical records and pathology reports of 139 patients undergoing surgery for cutaneous melanoma between January 2012 and December 2019 were retrospectively reviewed. Results: Ninety-six (69%) patients underwent SLN biopsy. Mean age was 61.7 ± 17.5 years (19-93) and 53 (55.2%) were men. The primary lesion was located in the extremities in 47 (49%) cases, in the trunk in 39 (40.6%), and in the head and neck in 10 (10.4%). Mean Breslow thickness was 5.01 mm (1.05-50 mm) and ulceration was found in 35 cases (36.4%). The SLN was identified in all the cases and was positive in 39 (40.6%). There was an association with thickness ≥ 3 mm (p = 0.000017) and ulceration (p = 0.0011). Those patients with positive SLN biopsy underwent LND of the territory involved: axillary in 23, inguinal in 10 and cervical in 6. Twenty-three (59%) presented NSLN metastases and were associated with thickness (p = 0.022) and ulceration (p = 0.019). Conclusion: There was a high percentage of positive NSLN in the population studied which was associated with thickness and ulceration. These characteristics and the difficulty to achieve strict follow-up are the reasons for completion LND in SLN-positive patients.

Sentinel lymph node biopsy in women over 70: Evaluation of rates of axillary staging and impact on adjuvant therapy in elderly women

BackgroundThe 2016 Society of Surgical Oncology Choosing Wisely guidelines recommended against routine sentinel lymph node biopsy in women ≥70 years old with favorable, early-stage breast cancer, as sentinel lymph node biopsy does not decrease recurrence or mortality in these patients. This study’s objective was to evaluate the use of sentinel lymph node biopsy and its effect on management in elderly patients. MethodsA retrospective analysis of female patients ≥70 years old with stage I–II, clinically node-negative, hormone-receptor positive, HER2-negative disease undergoing upfront breast cancer surgery between 2017 and 2019. Primary outcome was rate of sentinel lymph node biopsy. Secondary outcome was effect of sentinel lymph node biopsy on adjuvant therapy. ResultsIn total, 142 patients were included. Median age was 76 (interquartile range 73–81), and 71.8% underwent lumpectomy. On final pathology, 57.7% had invasive ductal carcinoma, and median tumor size was 15 mm (interquartile range 10–24.3). A total of 118 patients (83.1%) underwent sentinel lymph node biopsy; of these, 27 (22.9%) were positive for N1mi (7 patients) or N1a disease (20 patients). On multivariate regression analysis, patients undergoing sentinel lymph node biopsy were more likely to be younger (odds ratio 0.87, 95% confidence interval 0.78–0.95). The major risk factor for sentinel lymph node biopsy positivity was lymphovascular invasion (odds ratio 13.4, 95% confidence interval 4.57–40.1). Patients with sentinel lymph node biopsy positivity were more likely to receive local adjuvant radiation therapy (odds ratio 4.66, 95% confidence interval 1.49–16.8) and tended to receive more adjuvant regional radiation therapy (75.0% if sentinel lymph node biopsy positive compared with 15.3% if sentinel lymph node biopsy negative, P < .001). ConclusionDespite the 2016 Choosing Wisely guidelines, more than 80% of patients ≥70 years old underwent sentinel lymph node biopsy at our institution. If sentinel lymph node biopsy was positive, this is associated with over 4-fold higher rates of adjuvant radiation therapy.

Inguinofemoral sentinel lymph node biopsy by scar injection in vulvar cancer: an assessment of feasibility and long-term outcomes

BackgroundPerforming inguinofemoral sentinel lymph node biopsy for vulvar cancer following a previous vulvar excision, often referred to as ‘scar injection’, is debated.ObjectiveTo assess the feasibility of sentinel lymph node biopsy...

Intermediate-thickness melanoma: A population-based study of surgical quality metrics

BackgroundVariability in guideline compliance for melanoma lymph node surgery is partially attributable to controversy about patient selection. Prior data has indicated suboptimal practice of sentinel lymph node biopsy and undertreatment of clinically node-positive disease, predating Multicenter Selective Lymphadenectomy Trial II publication. To minimize bias, we studied compliance with lymph node surgery guidelines in T2/T3 (intermediate-thickness) melanoma patients, where the greatest agreement exists. MethodsT2/T3 and metastasis 0 melanoma cases were identified from 2004 to 2018 Surveillance, Epidemiology, and End Results data. Analysis used Cochran-Armitage test for trends, multivariable logistic regression, and Kaplan-Meier survival estimates. ResultsOf 66,319 eligible T2/T3 patients, 57,211 were clinically node negative; 2,191 were clinically node positive; 6,197 were clinical node unreported; and 19,044/66,319 (28.8%) had no lymph node surgery. Among clinically node-negative patients, 36,433 (63.7%) underwent sentinel lymph node biopsy and 31,026 (85.2%) were pathologically node negative; 1,499 clinically node-positive patients (68.4%) had a lymph node dissection. Lymph node dissection rates declined from 2004 to 2018, 79.8% to 32.0% for clinically node-negative/pathologically node-positive patients and 80.4% to 61.2% for clinically node-positive/pathologically node-positive patients (both P < .0001). For clinically node-negative patients, lymph node surgery compliance improved from 63.7% (2004) to 70.4% (2018) (P < .0001). Compliance correlated with younger age, male sex, tumor mitotic rate, and site (extremity > trunk/head/neck) in multivariable analysis and improved 5-year cancer-specific survival (90.0% vs 83.4%) (all P < .0001). ConclusionsDespite clear guidelines, one-third of intermediate-thickness melanoma patients in a recent cohort did not have recommended lymph node surgery. Lymph node status is a key determinant of the relative benefit of adjuvant systemic therapy and the need for active surveillance of pathologically node-positive/clinically node-negative patients. These data highlighted a clinical care gap. Efforts to improve guideline compliance are a logical strategy to improve cancer outcomes for intermediate-thickness melanoma patients.

A novel nomogram for decision-making assistance on exemption of axillary lymph node dissection in T1-2 breast cancer with only one sentinel lymph node metastasis.

BackgroundT1–2 breast cancer patients with only one sentinel lymph node (SLN) metastasis have an extremely low non-SLN (NSLN) metastatic rate and are favorable for axillary lymph node dissection (ALND) exemption. This study aimed to construct a nomogram-based preoperative prediction model of NSLN metastasis for such patients, thereby assisting in preoperatively selecting proper surgical procedures.MethodsA total of 729 T1–2 breast cancer patients with only one SLN metastasis undergoing sentinel lymph node biopsy and ALND were retrospectively selected from Harbin Medical University Cancer Hospital between January 2013 and December 2020, followed by random assignment into training (n=467) and validation cohorts (n=262). A nomogram-based prediction model for NSLN metastasis risk was constructed by incorporating the independent predictors of NSLN metastasis identified from multivariate logistic regression analysis in the training cohort. The performance of the nomogram was evaluated by the calibration curve and the receiver operating characteristic (ROC) curve. Finally, decision curve analysis (DCA) was used to determine the clinical utility of the nomogram.ResultsOverall, 160 (21.9%) patients had NSLN metastases. Multivariate analysis in the training cohort revealed that the number of negative SLNs (OR: 0.98), location of primary tumor (OR: 2.34), tumor size (OR: 3.15), and lymph-vascular invasion (OR: 1.61) were independent predictors of NSLN metastasis. The incorporation of four independent predictors into a nomogram-based preoperative estimation of NSLN metastasis demonstrated a satisfactory discriminative capacity, with a C-index and area under the ROC curve of 0.740 and 0.689 in the training and validation cohorts, respectively. The calibration curve showed good agreement between actual and predicted NSLN metastasis risks. Finally, DCA revealed the clinical utility of the nomogram.ConclusionThe nomogram showed a satisfactory discriminative capacity of NSLN metastasis risk in T1–2 breast cancer patients with only one SLN metastasis, and it could be used to preoperatively estimate NSLN metastasis risk, thereby facilitating in precise clinical decision-making on the selective exemption of ALND in such patients.

Transcutaneous sentinel lymph node detection in cutaneous melanoma with indocyanine green and near-infrared fluorescence: A diagnostic sensitivity study.

Sentinel lymph node (SLN) biopsy with preoperative radiocolloid-based lymphoscintigraphy and blue dye injection is considered the standard procedure for staging nodal metastases in early-stage cutaneous melanoma patients with clinically uninvolved lymph nodes. While this combination renders good accuracy in SLN detection, radiation exposure and the frequent allergic reactions to the blue dye are considered drawbacks of this technique. Indocyanine green (ICG) is a water-soluble fluorescent dye that can be identified through near-infrared fluorescence imaging (NIRFI). The aim of this prospective diagnostic sensitivity study was to assess the feasibility of ICG and NIRFI to identify SLNs in melanoma transcutaneously ("before skin incision") and to analyze the various factors influencing detection rate, in comparison to lymphoscintigraphy. This study included 93 patients undergoing SLN biopsy for cutaneous melanoma. The region and the number of the SLNs identified with lymphoscintigraphy and with ICG were recorded. Patients' characteristics, as well as tumor details were also recorded preoperatively. One hundred and ninety-four SLNs were identified through lymphoscintigraphy. The sensitivity of ICG for transcutaneous identification of the location of the SLNs was 96.1% overall, while the sensitivity rate for the number of SLNs was 79.4%. Gender and age did not seem to influence detection rate, but a body mass index >30 kg/m2 was associated with a lower identification rate of the number of SLNs (P = .045). Transcutaneous identification of SLNs through ICG and NIRFI technology is a feasible technique that could potentially replace in selected patients the standard SLN detection methodology in cutaneous melanoma.

Axillary lymph node dissection can be omitted in patients with limited clinically node-positive breast cancer: a National Cancer Database analysis.

De-escalation of axillary surgery in breast cancer has progressively taken place when appropriate. Data supporting surgical de-escalation in patients with clinically node-positive (cN+) disease remains scarce. Here, survival among patients with cN+ T1-2 tumours undergoing sentinel lymph node biopsy (SLNB) and regional nodal irradiation (RNI) was investigated and compared with that among patients undergoing axillary lymph node dissection (ALND) with or without RNI. The National Cancer Data Base was used to identify three groups of patients with cN+ tumours according to axillary management among those treated between 2010 and 2016: patients who underwent SLNB and RNI (cN+ SLNB/RNI group); those who had ALND and RNI (cN+ ALND/RNI group); and those who had ALND alone (cN+ ALND/no RNI group). Patients who underwent neoadjuvant chemotherapy, and those who had stage IV breast cancer or pN2-3 disease were excluded. A total of 12 560 patients met the inclusion criteria: 3030 in the cN+ SLNB/RNI, 5446 in the cN+ ALND/RNI, and 4084 in the cN+ ALND/no RNI group. The sizes of cN + SLNB/RNI and cN+ ALND/RNI groups increased over the study interval, whereas the cN+ ALND/no RNI group decreased in size (P < 0.001). There was a median of one positive node in the cN+ SLNB/RNI group and two nodes in the cN+ ALND/RNI and cN+ ALND/no RNI groups. The median number of nodes examined was three, 14, and 14, respectively (P < 0.001). Median follow-up was 57.9 (range 0.8-114) months. The overall survival rate was 97, 97, and 92 per cent respectively at two years, and 88, 86, and 78 per cent at five years (P < 0.001). Patients with limited cN+ T1-2 breast cancer undergoing upfront SLNB and RNI have favourable survival outcomes that are not inferior to those of patients undergoing ALND with or without RNI. Prospective studies are warranted to assess locoregional control and long-term outcomes.

34151 Association of type II diabetes mellitus with characteristics and outcomes for patients undergoing sentinel lymph node biopsy for cutaneous melanoma

Background: Limited data exist describing patients with type II diabetes mellitus (T2DM) who are diagnosed with clinically localized primary cutaneous melanoma and require sentinel lymph node (SLN) biopsy. Methods: Consecutive patients diagnosed with AJCC clinical Stage I-II melanoma who underwent wide excision and SLN biopsy at a single institution (2007-2016) were identified, and patients with and without T2DM at the time of melanoma diagnosis were compared using logistic regression analysis. Patients were further stratified by whether their T2DM was non-insulin dependent (NID-T2DM) or insulin dependent (ID-T2DM). Associations between factors and outcomes were analyzed using Cox proportional hazards regression analysis. Results: Of the 1128 patients evaluated, 111 (9.8%) had T2DM (n = 94 [84.7%] NID-T2DM; n = 17 [15.3%] ID-T2DM). On multivariable analysis controlling for patient and tumor factors, T2DM patients were more likely to be older (odds ratio [OR] 1.04, p 1.0 mm thick (OR 1.91, P = .019), and have microsatellitosis (OR 2.27, P = .029). Ten-year cumulative incidence of melanoma recurrence was significantly greater for those with ID-T2DM (64.4% ID-T2DM vs. 34.4% NID-T2DM vs. 21.8% no T2DM, P < .001). On multivariable analysis, ID-T2DM was independently associated with melanoma recurrence (hazard ratio [HR] 2.58, P = .015); this association was not seen with NID-T2DM (HR 0.82, P = .421). Conclusion: Patients with insulin-dependent type II diabetes mellitus appear to present with more advanced melanoma and are at increased risk for melanoma recurrence. Further study as to whether this reflects differences in tumor biology or host differences in immune response is warranted.

Beyond N Staging in Breast Cancer: Importance of MRI and Ultrasound-based Imaging.

Simple SummaryBreast cancer is the most frequent cancer affecting women and metastatic breast cancer is still the leading cause of death from all cancers in women, accounting for about 3.6% of all deaths in women. The N-stage represents the main prognostic factor affecting the rate of recurrence and the therapeutic management so that a correct staging of the axillary lymph node status is fundamental. Since clinical examination of the axillary cavity is associated with a high false negative rate, reaching values of 45%, the role of imaging becomes crucial to obtain an accurate assessment of loco-regional lymph nodes at the time of diagnosis. In this setting, Ultrasound and Magnetic Resonance Imaging (MRI) represent two important diagnostic tools. In particular, MRI represents an accurate and reproducible technique, which allows an accurate staging of the “N-stage”. The correct N-staging in breast cancer is crucial to tailor treatment and stratify the prognosis. N-staging is based on the number and the localization of suspicious regional nodes on physical examination and/or imaging. Since clinical examination of the axillary cavity is associated with a high false negative rate, imaging modalities play a central role. In the presence of a T1 or T2 tumor and 0–2 suspicious nodes, on imaging at the axillary level I or II, a patient should undergo sentinel lymph node biopsy (SLNB), whereas in the presence of three or more suspicious nodes at the axillary level I or II confirmed by biopsy, they should undergo axillary lymph node dissection (ALND) or neoadjuvant chemotherapy according to a multidisciplinary approach, as well as in the case of internal mammary, supraclavicular, or level III axillary involved lymph nodes. In this scenario, radiological assessment of lymph nodes at the time of diagnosis must be accurate. False positives may preclude a sentinel lymph node in an otherwise eligible woman; in contrast, false negatives may lead to an unnecessary SLNB and the need for a second surgical procedure. In this review, we aim to describe the anatomy of the axilla and breast regional lymph node, and their diagnostic features to discriminate between normal and pathological nodes at Ultrasound (US) and Magnetic Resonance Imaging (MRI). Moreover, the technical aspects, the advantage and limitations of MRI versus US, and the possible future perspectives are also analyzed, through the analysis of the recent literature.

CT Lymphography Using Lipiodol® for Sentinel Lymph Node Biopsy in Early-Stage Oral Cancer.

This study evaluated sentinel lymph node (SLN) identification with CT lymphography (CTL) following peritumoral administration of Lipiodol® relative to conventional 99mTc-nanocolloid lymphoscintigraphy (including SPECT/CT) in 10 early-stage oral cancer patients undergoing SLN biopsy. Patients first underwent early dynamic and static scintigraphy after peritumoral administration of 99mTc-nanocolloid. Subsequently, Lipiodol® was administered at the same injection sites, followed by fluoroscopy and CT acquisition. Finally, late scintigraphy and SPECT/CT were conducted, enabling the fusion of late CTL and SPECT imaging. The next day, designated SLNs were harvested, radiographically examined for Lipiodol® uptake and histopathologically assessed. Corresponding images of CT, 99mTc-nanocolloid lymphoscintigraphy and SPECT/late CTL fusion were evaluated. 99mTc-nanocolloid lymphoscintigraphy identified 21 SLNs, of which 7 were identified with CTL (33%). CTL identified no additional SLNs and failed to identify any SLNs in four patients (40%). Out of six histopathologically positive SLNs, two were identified by CTL (33%). Radiographic examination confirmed Lipiodol® uptake in seven harvested SLNs (24%), of which five were depicted by CTL. CTL using Lipiodol® reached a sensitivity of 50% and a negative predictive value (NPV) of 75% (median follow-up: 12.3 months). These results suggest that CTL using Lipiodol® is not a reliable technique for SLN mapping in early-stage oral cancer.

National Practice Patterns in the Management of the Regional Lymph Node Basin After Positive Sentinel Lymph Node Biopsy for Cutaneous Melanoma.

Immediate completion lymph node dissection (CLND) for patients with sentinel lymph node (SLN) metastasis from cutaneous melanoma has been replaced largely by ultrasound nodal surveillance since the publication of two landmark trials in 2016 and 2017. National practice patterns of CLND remain poorly characterized. Patients with a diagnosis of cutaneous melanoma in 2016 and 2018 without clinical nodal disease who underwent sentinel lymph node biopsy (SLNB) were identified from the National Cancer Database (NCDB). Characteristics associated with CLND were analyzed by uni- and multivariate logistic regression. Overall survival (OS) was estimated using Kaplan-Meier and Cox proportional hazards regression analyses. Of the 3517 patients included in the study, 1405 had disease diagnosed in 2016. The patients with cutaneous melanoma diagnosed in 2016 had a median age of 60 years and a tumor thickness of 2.3 mm compared to 62 years and 2.4 mm, respectively, for the patients with cutaneous melanoma diagnosed in 2018. According to the NCDB, 40 % (n = 559) of the patients underwent CLND in 2016 compared with 6 % (n = 132) in 2018. The factors associated with receipt of CLND in 2018 included younger age (odds ratio [OR], 0.97; 95 % confidence interval [CI], 0.95-0.99; p = 0.001), rural residence (OR, 3.96; 95 % CI, 1.50-10.49; p = 0.006), head/neck tumor location (OR, 1.88; 95 % CI, 1.10-3.23; p = 0.021), and more than one positive SLN (OR, 1.80; 95 % CI, 1.17-2.76; p = 0.007). The 5-year OS did not differ between the patients who received SLNB only and those who underwent CLND (hazard ratio [HR], 0.93; p = 0.54). The rates of CLND have decreased nationally. However, patients with head/neck primary tumors who live in rural locations are more likely to undergo CLND, highlighting populations for which treatment may be non-uniform with national practice patterns.

Short-term and long-term outcomes of indocyanine green for sentinel lymph node biopsy in early-stage breast cancer

BackgroundIndocyanine green (ICG) is becoming a frequently used sentinel lymph node (SLN) tracer of breast cancer in China. However, there is still a lack of data on its safety. We reported the clinical outcome of ICG as a tracer of SLN over a median 67-month follow-up period to evaluate its feasibility in clinically node-negative patients with breast cancer.MethodsA total of 194 consecutive patients underwent sentinel lymph node biopsy (SLNB) with ICG, radioisotopes (RI) and methylene blue (MB), or with ICG and MB. The SLN mapping data by each tracer was recorded, and safety outcomes were analyzed through follow-up.ResultsWith the triad mapping (N = 44), the identification rate of SLN by ICG was 95.5%, slightly higher than that of MB (86.4%) and comparable with RI (95.5%) and combined methods (95.5%, 100%) (p = 0.068). Analysis of all candidates (N = 194) demonstrated that the identification rate of SLN by ICG or by ICG and MB was 99%, significantly higher than that by MB (92.8%) (p < 0.0001). No tracer-related allergic reaction and permanent skin staining of ICG were observed. Local disease progression was reported in 2 of the 194 patients at the ipsilateral axilla. After remedial axillary lymph node dissection, no disease progression was detected at follow-up.ConclusionsICG as an SLN tracer is more accurate than MB and comparable to the combined methods and has good clinical safety. ICG can be considered a useful supplement or suitable alternative to traditional tracers.

Feasibility of targeted axillary dissection for de-escalation of surgical treatment after neoadjuvant chemotherapy in breast cancer

BackgroundTargeted axillary dissection, which combines sentinel lymph node biopsy with removal of the proven involved node noted during the staging process, has been shown to improve axillary staging and decrease false negative rates after neoadjuvant chemotherapy in patients with breast cancer. Objective(s)The main goal of this study was to assess the ability to identify and remove the clipped node and the false negative rate of targeted axillary dissection. MethodsWe performed a prospective study among patients with biopsy-confirmed nodal metastases who received neoadjuvant chemotherapy. A clip was placed on the sample node prior systemic therapy. After neoadjuvant chemotherapy, all patients underwent sentinel lymph node biopsy (dual tracer), localization and excision of the clipped node and axillary lymph node dissection. The clipped node was preoperatively localized in all cases placing an iodine-125 seed guided by ultrasound. The pathology of the sentinel nodes and clipped node was compared with other nodes. ResultsA total of 455 patients with invasive breast cancer were studied. Of the 148 patients with NAC, 32 met the eligibility criteria and were enrolled in the study. Mean age at diagnosis was 52.3 years. Systematic lymphadenectomy was performed in all patients, with an average of 14.3 lymph nodes removed. Detection rate of the clipped node alone was 96.9%, and 100% for targeted axillary dissection. Ability of clipped node alone to predict nodal status showed a FNR of 10,5% while SLNB alone performed by dual tracer and targeted axillary dissection, showed FNRs of 5.3% and 5.0%, respectively. Sentinel lymph nodes matched clipped node in 23 patients (74.2%). Conclusion (s)In node positive breast cancer patients, targeted axillary dissection is a reliably approach for axillary staging after neoadjuvant chemotherapy. The preoperative location of the clipped node is mandatory to increase the detection rate and optimize the results of the technique.

Sentinel lymph node biopsy for stage II endometrial cancer: Utilization and outcomes in the United States (346)

Objectives: To examine trends and outcomes related to sentinel lymph node (SLN) biopsy for stage II endometrial cancer. Methods: This is a retrospective observational cohort study querying the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program. The study population was 6,314 women with T2 endometrial cancer who underwent hysterectomy from 2010-2018. Exposure allocation was based on nodal evaluation type: lym- phadenectomy (LND; n=4,915, 77.8%), SLN biopsy (n=340, 5.4%), or no surgical nodal evaluation (n=1,059, 16.8%). The main outcomes were (i) trends and characteristics related to nodal evaluation assessed by multinomial regression and (ii) overall survival assessed by an inverse probability of treatment weighting propensity score analysis. A sensitivity analysis was performed to examine concurrent LND in women who underwent SLN biopsy. Results: The utilization of SLN biopsy increased from 1.6% to 16.1%, while the number of LND decreased from 81.5% to 65.7% between 2010 and 2018 (both, p<0.05). In multivariable analysis, the utilization of SLN biopsy increased 45% annually (adjusted-odds ratio: 1.45, 95% CI: 1.37-1.54, p<0.001). The frequency of SLN biopsy alone exceeded the frequency of SLN biopsy with concurrent LND in 2017 (6.8% vs 3.4%), followed by a continued increase in SLN biopsy alone (11.2% vs 4.9%) in 2018. In the weighted model, the 3-year overall survival rate was 79.9% for the SLN biopsy group and 78.6% for the LND group (HR: 0.98, 95% Cl: 0.80-1.20, p=0.831). Similarly, the SLN biopsy alone without a concurrent performance of LND had comparable overall survival compared to the LND group (HR: 0.90, 95% CI: 0.59-1.36, p=0.615). Conclusions: Utilization of SLN biopsy in stage II endometrial cancer increased significantly over time, and SLN biopsy-incorporated nodal assessment was not associated with worsened short-term survival. Objectives: To examine trends and outcomes related to sentinel lymph node (SLN) biopsy for stage II endometrial cancer. Methods: This is a retrospective observational cohort study querying the National Cancer Institute’s Surveillance, Epidemiology, and End Results Program. The study population was 6,314 women with T2 endometrial cancer who underwent hysterectomy from 2010-2018. Exposure allocation was based on nodal evaluation type: lym- phadenectomy (LND; n=4,915, 77.8%), SLN biopsy (n=340, 5.4%), or no surgical nodal evaluation (n=1,059, 16.8%). The main outcomes were (i) trends and characteristics related to nodal evaluation assessed by multinomial regression and (ii) overall survival assessed by an inverse probability of treatment weighting propensity score analysis. A sensitivity analysis was performed to examine concurrent LND in women who underwent SLN biopsy. Results: The utilization of SLN biopsy increased from 1.6% to 16.1%, while the number of LND decreased from 81.5% to 65.7% between 2010 and 2018 (both, p<0.05). In multivariable analysis, the utilization of SLN biopsy increased 45% annually (adjusted-odds ratio: 1.45, 95% CI: 1.37-1.54, p<0.001). The frequency of SLN biopsy alone exceeded the frequency of SLN biopsy with concurrent LND in 2017 (6.8% vs 3.4%), followed by a continued increase in SLN biopsy alone (11.2% vs 4.9%) in 2018. In the weighted model, the 3-year overall survival rate was 79.9% for the SLN biopsy group and 78.6% for the LND group (HR: 0.98, 95% Cl: 0.80-1.20, p=0.831). Similarly, the SLN biopsy alone without a concurrent performance of LND had comparable overall survival compared to the LND group (HR: 0.90, 95% CI: 0.59-1.36, p=0.615). Conclusions: Utilization of SLN biopsy in stage II endometrial cancer increased significantly over time, and SLN biopsy-incorporated nodal assessment was not associated with worsened short-term survival.

Atypical Spitz tumours: an epidemiological, clinical and dermoscopic multicentre study with 16 years of follow-up.

Atypical Spitz tumours (ASTs) are regarded as an intermediate category distinguished from prototypical Spitz naevus by presenting one or more atypical features and often by an uncertain malignant potential. Clinical and dermoscopic features may play a relevant role in the diagnostic approach. To evaluate the clinical and dermoscopic features of ASTs, and their evolution over time. This was a descriptive, multicentre study of the clinical and dermoscopic characteristics of ASTs. Data on clinical and dermoscopic characteristics, histopathology, local extension, therapy and follow-up, lymph node staging, complete lymph node dissection, and outcome were collected from the databases of four Italian Dermatology Units for the period 2004-2021. The study population consisted of 99 patients (62 female, 37 male) with a histologically confirmed diagnosis of AST, including age at presentation ranged from 2 to 70 years (mean 28.1 years, median 24 years). Of the 99 patients, 29 (29.3%) underwent sentinel lymph node biopsy, which showed evidence of micrometastases in three cases (10.3%); all three patients underwent complete lymph node dissection with no evidence of further metastasis. Considering the whole study population, the clinical outcome was excellent, as all of the patients have no evidence of recurrence or distant metastasis. The follow-up period ranged from 6 to 216 months (mean 81.6 months, median 78 months). In addition, we collected data on the clinical and dermoscopic features of 26 lesions. The most frequent dermoscopic pattern observed was the multicomponent pattern (34.6%), followed by homogeneous (26.9%) and nonspecific (23.2%). In 66.7% of amelanotic ASTs, we observed glomerular (coiled) vessels uniformly distributed within the entire lesion, without asymmetry. The results of our study with a long follow-up show no recurrence or distant metastases, confirming the good clinical outcome, even in the case of sentinel lymph node positivity. From a diagnostic point of view, our series identified a typical dermoscopic picture for amelanotic ASTs, with a glomerular vascular pattern throughout the lesion in the absence of other dermoscopic parameters, making the correct diagnosis possible.

Sentinel lymph node biopsy compared with systematic lymphadenectomy in patients with uterine carcinosarcoma (536)

<b>Objectives:</b> To assess survival among patients with newly diagnosed uterine carcinosarcoma undergoing sentinel lymph node biopsy (SLN) alone and those undergoing systematic lymphadenectomy (LND). <b>Methods:</b> We identified all patients with newly diagnosed uterine carcinosarcoma who underwent primary surgical management at our institution from January 1996 to December 2019. Patients with gross extrauterine disease of any type were excluded. The SLN cohort underwent SLN biopsy alone, with bilateral SLNs identified. The systematic LND cohort did not undergo SLN biopsy. Progression-free survival (PFS) and overall survival (OS) were defined from the date of surgery to the event. Appropriate statistical testing was performed. <b>Results:</b> We identified 99 SLN and 100 LND patients. Median age and BMI were not different between the groups. Minimally invasive surgery was the approach in 56 (56.6%) SLN (56.6%) and 47 (47%) LND patients (p=0.2). There was no significant difference between cohorts with respect to the degree of myoinvasion (<50%, >50%), presence of lymphovascular space invasion (LVSI), stage, or positive washings. The median total node count was four (range: 1-13) for SLN and 19 (range: 2-50) for LN (p<0.001). Nodal metastasis was noted in 26 (26%) SLN and 21 (21%) LND (p=0.4). Postoperative therapy was given to 91 (92%) SLN and 87 (87%) LND (p=0.3). The type of postoperative therapy administered was as follows: none in eight (8%) SLN and 14 (14%) LND; chemotherapy with or without radiation (RT) in 86 (87%) SLN and 71 (71%) LND; RT alone in five (5%) SLN and 15 (15%) LND (p=0.02). Median follow-up was 51.3 months (range: 0.9-211.1) for the SLN cohort compared with 40.8 months (range: 0.5-269.1) for the LND cohort (p=0.3). The 4-year PFS was 62.4% (SE 5.3%) for SLN and 47.7% (SE 5.5%) for LND (p=0.07). The 4-year OS was 72.4% (SE 4.9%) for SLN and 62.2% (SE 4.2%) for LND (p=0.2). There was no difference in PFS or OS when adjusted for the type of postoperative therapy (chemotherapy with or without RT vs none/RT). An isolated nodal recurrence occurred in two (2%) SLN and four (4%) LND patients (p=0.2). <b>Conclusions:</b> There is no difference in PFS or OS among patients who have uterine carcinosarcoma and undergo SLN biopsy versus systematic LND. SLN biopsy adequately detects the presence of nodal metastasis in these patients. SLN biopsy alone does not compromise oncologic outcomes, and systematic LND is unnecessary in the setting of successful bilateral SLN mapping.

Incorporation of sentinel lymph node biopsy in cervical cancer surgery: Recent U.S. population trends (342)

<b>Objectives:</b> The utility of sentinel lymph node (SLN) biopsy in the surgical treatment of women with early cervical cancer is currently under active investigation. This study examined the trends, characteristics, and outcomes of SLN biopsy for cervical cancer surgery. <b>Methods:</b> This retrospective observational study queried the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. The study population included women with invasive cervical cancer (squamous cell carcinoma, adenocarcinoma, and adenosquamous carcinoma) who underwent both hysterectomy and lymphadenectomy for non-metastatic T1 disease from 2003-2018. The exposure allocation was per lymph node evaluation type (SLN biopsy or lymphadenectomy). The main outcome measures were <i>(i)</i> trend of utilization and patient characteristics related to SLN biopsy assessed with multivariable analysis and <i>(ii)</i> overall survival associated with SLN biopsy assessed with propensity score inverse probability of treatment weighting. Sensitivity cohorts included uterine-preserving conservative surgeries. <b>Results:</b> A total of 12,966 women met the inclusion criteria. Of those, 430 (3.3%) women underwent SLN biopsy. The utilization of SLN biopsy increased significantly from 0.8% to 15.2% during the study period (p<0.001). This association remained independent in multivariable analysis: 2011-2014 versus 2003-2010 with an adjusted odds ratio of 4.87, 95% CI: 3.29-7.23, and 2015-2018 versus 2003-2010 with an adjusted odds ratio of 20.6, 95% CI: 14.6-29.2. In a propensity score weighted model, women who had SLN biopsy had similar overall survival compared to those without SLN biopsy (3-year rates, 94.8% vs 94.2%, HR: 0.95, 95% CI: 0.64-1.41, p=0.799). The increase in SLN biopsy was also observed in uterine-preserving surgeries (3.5% to 9.6% for trachelectomy, p=0.043; and 2.5% to 19.5% in cervical excision, p<0.001). <b>Conclusions:</b> The landscape of surgical nodal evaluation is shifting from lymphadenectomy to SLN biopsy in cervical cancer surgery. Survival effects of SLN biopsy-incorporated surgical treatment in early cervical cancer merit further evaluation. Fig. 1

Association of type II diabetes mellitus with characteristics and outcomes for patients undergoing sentinel lymph node biopsy for cutaneous melanoma.

Type II diabetes mellitus (T2DM) can lead to an immunosuppressed state, but whether T2DM is associated with worse outcomes for patients with melanoma has not been well studied. Consecutive patients diagnosed with clinical stage I-II cutaneous melanoma who underwent sentinel lymph node biopsy at a single institution (2007-2016) were identified. Melanoma characteristics and recurrence/survival outcomes were compared between patients with and without T2DM at the time of melanoma diagnosis. Of 1128 patients evaluated, 111 (9.8%) had T2DM (n = 94 [84.7%] non-insulin dependent [NID-T2DM]; n = 17 [15.3%] insulin dependent [ID-T2DM]). T2DM patients were more likely to be older (odds ratio [OR] 1.04, p < 0.001), male (OR 2.15, p = 0.003), have tumors >1.0 mm (OR 1.88, p = 0.023), and have microsatellitosis (OR 2.29, p = 0.030). Five-year cumulative incidence of melanoma recurrence was significantly higher for patients with ID-T2DM (46.7% ID-T2DM vs. 25.7% NID-T2DM vs. 17.1% no T2DM, p < 0.001), and on multivariable analysis, ID-T2DM was independently associated with melanoma recurrence (hazard ratio 2.57, p = 0.015). No difference in 5-year disease-specific survival was observed between groups. ID-T2DM appears to be associated with more advanced melanoma and increased risk for melanoma recurrence. Further study as to whether this reflects differences in tumor biology or host factors is warranted.

Sentinel Node Mapping in Early Breast Cancer: A Randomized Comparison of Fluorescein Guided All India Institute of Medical Sciences, Anurag's Technique with Technetium-99 m Sulfur Colloid Plus Methylene Blue.

Evaluation of fluorescein along with blue dye as an affordable tracer for sentinel node biopsy in comparison with technetium + methylene blue. A randomized trial was conducted with the following objectives: (1) to demonstrate that the identification of sentinel lymph node by fluorescein + methylene blue is not inferior to the identification by Tc-99 m sulfur colloid + methylene blue and (2) to evaluate the cost-effectiveness of sentinel node biopsy by above two tracers. One-thirty patients above age 18 years presenting with early breast cancer T1, T2, N0 breast carcinoma were randomized to undergo sentinel node biopsy by either fluorescein + methylene blue or Tc-99 m sulfur colloid + methylene blue. The sentinel lymph nodes were identified in 89% in Fluorescein + methylene blue group and 90.9% with Tc-99 m sulfur colloid + methylene blue group. The trial demonstrated noninferiority of fluorescein + methylene blue as compared to isotope + methylene blue with effect size = 1; 95% confidence interval- 9.54 to + 11.54. The fluorescein + methylene blue was more cost-effective than isotope guided sentinel node biopsy. Fluorescein-guided sentinel node biopsy is noninferior and more cost-effective than isotope-guided sentinel node biopsy.

Impact of the ACOSOG Z0011 trial on surgical practice in Asian patients: trends in axillary surgery for breast cancer from a Korean Breast Cancer Registry analysis

BackgroundSince the publication of the Z0011 trial, practice-changing clinical guidelines for breast surgery have been developed. Although recent studies confirmed the feasibility of the Z0011 strategy in Asian populations, there has been no study on the trends of axillary surgery in Asian cohort. This study aimed to investigate the time trend of axillary surgery for breast cancer from a Korean Breast Cancer Registry to understand the impact of the Z0011 trial in Asian patients.MethodsWe collected prospectively constructed data from the nationwide Korean Breast Cancer Registry (KBCR). We identified patients who underwent sentinel node biopsy followed by breast-conserving surgery from 2011 to 2018 and were found to have pathological stage T1-2N1-3M0 disease. Regression analyses were performed to compare the downward trend of axillary lymph node dissection (ALND) in Korean cohort with that previously reported in a Dutch cohort.ResultsFrom KBCR data, 7478 patients met the inclusion criteria. The proportion of ALND significantly decreased from 2011 (76.6%) to 2018 (47.5%). Multivariate analysis revealed that earlier years at diagnosis, larger tumor size, and lymphatic invasion were associated with a higher odds ratio of performing ALND. Compared to the Dutch cohort, the downward trend of ALND in Korea was significantly more gradual (annual percent change: 37.2 vs. 5.8%, p < 0.001).ConclusionsThis study demonstrated a downward trend of ALND in Korean patients with breast cancer. However, the rate of decrease was significantly slower than that in the Dutch cohort.