Use Of Sentinel Lymph Node Biopsy Research Articles

Trends and efficacy of omitting axillary lymph node dissection in early-stage male breast cancer with limited nodal involvement: A population-based cohort study.

The effectiveness of sentinel lymph node biopsy (SLNB) versus axillary lymph node dissection (ALND) in managing early-stage male breast cancer (MBC) patients with T1-2 tumors and limited lymph node metastasis, all receiving radiotherapy, remains uncertain. This study examines trends and survival outcomes for SLNB and ALND in the United States. We conducted a retrospective analysis of the Surveillance, Epidemiology, and End Results (SEER) data from 2010 to 2020 for MBC patients with T1-2 tumors and 1-2 positive lymph nodes undergoing radiotherapy. Patients were classified by nodes removed (SLNB ≤5, ALND ≥10), comparing overall survival (OS) and breast cancer-specific survival (BCSS) between the groups before and after propensity score matching. Of 299 MBC patients analyzed, SLNB usage increased from 18.8% in 2010 to 61.0% in 2020. Multivariable logistic regression highlighted significant associations of SLNB use with diagnosis year, race, surgery type, positive lymph node count, and metastasis size. No significant differences in 5-year OS (77.98% SLNB vs. 85.85% ALND, p = 0.337) or BCSS (91.54% SLNB vs. 94.97% ALND, p = 0.214) were observed. Propensity score matching (96 patients per group) confirmed similar 5-year OS (83.9% for SLNB vs. 82.0% for ALND, p = 0.925) and BCSS (90.1% for SLNB vs. 96.9% for ALND, p = 0.167). SLNB and ALND provide comparable survival outcomes in early-stage MBC patients with limited lymph node metastasis undergoing radiotherapy. The increased utilization of SLNB supports its consideration to reduce surgical morbidity in selected MBC patients despite limited direct evidence.

Prospective Randomized Study on the Use of Sentinel Node Biopsy for High-risk Cutaneous Squamous Cell Carcinomas of the Head and Neck.

The use of sentinel lymph node biopsy (SLNB) for high-risk cutaneous squamous cell carcinoma (CSCC) is not yet clearly documented, especially for the head and neck area, due to its rich and cross-branching lymphatic system. We present the first prospective randomized study on the use of SLNB in high-risk CSCCs of the head and neck. Seventy-six patients with high-risk CSCCs of the head and neck were randomly divided into two groups: A (n = 38) and B (n = 38). In group A, SLNB was performed additionally to the excision of squamous cell carcinoma, whereas in group B, only excision of the lesion was performed. The patients were followed up for 5 years postoperatively, and local recurrences, regional metastases (regional lymph nodes), and mortality were documented. One patient of group A, who never attended any follow-up, was excluded. Both groups had similar characteristics regarding Breslow thickness, perineurial invasion, peripheral limits, differentiation, size, previous incomplete excision, age, sex, education, sun exposure, Fitzpatrick score, previous incomplete excision, previous skin cancer, and smoking. Two patients had a positive sentinel lymph node and were submitted to regional lymphadenectomy. We documented deaths (three in group A and two in group B; P = 0.674), local recurrence (seven in group A and six in group B; P = 0.768), and regional metastasis (zero in group A and two in group B; P = 0.159). There is no clear benefit on the use of SLNB in high-risk CSCCs of the head and neck regarding metastasis, mortality, or local recurrence control.

Impact of sentinel node use in lymphedema formation among gynecologic cancer patients.

The most common surgical procedure associated with lymphedema formation is the regional lymphadenectomy. One of the advantages of sentinel node biopsy is the reduction of the risk of lymphedema formation. The purpose of this review is to collect and analyze the most relevant and recent evidence of the use of sentinel node biopsy and its implication on the development of postoperative lymphedema in gynecological cancer. The current evidence of the use of sentinel node biopsy in cervical cancer to reduce lymphedema is heterogeneous and more data is needed to establish its role.Sentinel lymph node biopsy in endometrial cancer is a staging procedure with lower surgical complications, as well as lymphedema formation; while the results of prospective trials evaluating its impact on quality of life are still lacking.Sentinel lymph node biopsy in vulvar cancer minimizes the need for extensive dissection and reduces the incidence of complications associated with overharvesting of lymph nodes such as lymphedema without compromising oncological outcomes. The prevalence of lymphedema in gynecological cancer varies based on the surgical treatment or additional therapies applied. Over the past years, one of the most important surgical modifications to decrease lymphedema formation has been implementation of sentinel lymph node technique mainly in vulvar cancer patients.

Abstract PO2-23-06: Clinical study of stained region lymph node biopsy (SrLNB) in axillary surgery after neoadjuvant systemic therapy in patients with axillary lymph node positive breast cancer

Abstract Background The probability of axillary lymph node converting from positive to negative after neoadjuvant systemic therapy (NST) for breast cancer patients is approximately 40%. A variety of axillary lymph node biopsy surgeries based on sentinel lymph node biopsy (SLNB) can help to omit axillary lymph node dissection (ALND). The common disadvantages, however, are mainly the restrictions, such as the need for strict regulation of the use of radiotracers, the high number of retrieved lymph nodes required, and the need to purchase ancillary equipment. The more restrictions there are, the more they limit the spread and availability of the technique and, more importantly, reduce the number of patients who will benefit. In fact, for patients with metastatic lymph nodes, the sentinel lymph nodes must be included in the lymph nodes that have metastasized. If these metastatic lymph nodes can be accurately marked and precisely retrieved after NST, it is possible to assess whether the axillary lymph nodes are converted from positive to negative without the need for SLNB. Materials and methods Breast cancer patients with pathologically confirmed axillary lymph node metastases who were receiving NST were recruited for this study. Before NST, carbon nanoparticles suspension injections were injected into the cortex of the pathologically confirmed metastatic lymph node to stain the region where the metastatic lymph node was located. The lymph nodes in the stained region were retrieved by stained region lymph node biopsy (SrLNB) during the axillary surgery, followed by ALND, without the use of SLNB. Finally, the identification rate and false-negative rate (FNR) of SrLNB were statistically analyzed according to pathology data. Results A total of 159 patients were successfully enrolled in this study between September 24, 2020 and December 2, 2022, with an axillary pCR rate of 40.9% (65/159). The identification rate of SrLNB was 100% (159/159), with an overall FNR of 5.3% (5/94). Subgroup analysis revealed that in the subgroups of 1, 2, 3 and ≥4 SrLN, the FNR was 0%, 0%, 0% and 8.9% (5/56), respectively, whereas in the cN1, cN2 and cN3 subgroups the FNR was 7.7% (3/39), 2.6% (1/38) and 5.9% (1/17), respectively. The FNR indexes were within the safety threshold of 10% in all subgroups. Conclusion SrLNB has a high identification rate and a low FNR and is useful for screening patients with positive to negative axillary lymph nodes for omitting ALND. srLNB requires only the use of an affordable and radiation-free carbon nanoparticles suspension injection for marking, making the whole technique simpler and easier to disseminate. The data from this study also suggest that SLNB may not be mandatory for axillary biopsy in patients with positive axillary lymph nodes undergoing NST. Table 1. General characteristics of enrolled patients. Table 2. Analysis of factors affecting axillary pCR rates. Table 3. Analysis for the FNR of SrLNB. Citation Format: Jue Wang, Rui Chen, Cuiying Li, Hailing Zha, Qiannan Zhu, Lifeng Huang, Xiaoming Zha. Clinical study of stained region lymph node biopsy (SrLNB) in axillary surgery after neoadjuvant systemic therapy in patients with axillary lymph node positive breast cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO2-23-06.

Abstract PO4-23-02: Blue Dye-Only for Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy in Patients with Initially Node-positive Breast Cancer

Abstract Importance: Randomized trials evaluated the false negative rate (FNR) of sentinel lymph node biopsy (SLNB) in initially node-positive (cN1/2) breast cancer (BC) patients who downstaged after neoadjuvant chemotherapy (NAC): the studies were negative, as they found FNR above 10%. However, the FNR was adequate when the lymph node was marked with a clip before NAC or at least 3 lymph nodes were removed. SLNB using a combination of blue dye and a radiotracer (Technetium-99) was encouraged to facilitate identification and maximize SLNB results in this scenario. However, radiotracer is unavailable in many services around the world, particularly in low- and middle-income countries (LMIC), but the feasibility and the recurrence rates of SNLB with the use of blue dye-only, in previous cN1/2 patients, are unknown. Objective: The aim of this study was to evaluate the feasibility, proportion of patients undergoing SLNB without axillary dissection (AD) and mean number of resected sentinel nodes (SN), and recurrence rates (axillary recurrence [AR], ipsilateral breast recurrence [IBR], new contralateral primary, disease-free survival [DFS] and overall survival [OS]) of SNLB with the use of blue dye-only in initially node-positive BC (cN1/2). Design, Setting, and Participants: From 2013 to 2023, a cohort of patients undergoing NAC was evaluated at a public institution in Brazil (Hospital Geral de Fortaleza - HGF). Radiotracer and clips were not available. Patients with prior cN1/2 were identified and evaluated. AD was not recommended in cases of negative histopathological results for lymph node metastases after SLNB using blue dye-only. Inflammatory, cN0 and cN3 BC patients were excluded. Results: Among 119 cN1/2 BC patients treated with NAC, 100 (84%) cases underwent SLNB with blue dye-only and 70 (59%) had SLNB alone. The median of SN were 3.1 and 55 (78%) cases had 3 or more SN. No events related to blue dye occurred. The median age of these 70 patients was 49 (25-84) years, and most cases were T2 (n=40/57.1%), followed by T3 (n=18/25.7%), T4 (n=6/8.6%) and T1 (n=6/8.6%), while N1 predominated in axillary status (n=64/91.4%). Regarding breast cancer subtype, there were 19 (27.1%) hormone receptor-positive/HER2-negative, 16 (22.9%) hormone receptor-negative/HER2-positive, 21 (30%) hormone receptor-positive/HER2-positive and 14 (20%) triple-negative cases. 55 (79%) patients received regimens containing anthracyclines and taxanes. Anti-HER2 therapy was used in all cases, but pertuzumab associated with trastuzumab were available in only 8 patients (8/37). Breast-conserving surgery was performed in 40 (57%) cases while total mastectomy in 30 (43%). Patients with hormone-positive BC received endocrine therapy. Adjuvant radiotherapy was made in all cases, except one who underwent mastectomy. After 36 months of median follow-up, no axillary recurrences were observed. One patient had a new primary in the contralateral breast. Three patients had distant disease and two died. Conclusions: This cohort found that the use of SLNB with blue dye-only in Initially cN1/2 BC patients who achieved complete response after NAC is feasible, with very low axillary recurrence rates, like previous reports in the literature that used a combination of tracers. These data reinforce the need for further studies in this scenario, as it maintains the possibility of avoiding AD in places with difficult access to oncological treatment, especially in LMIC. Figure 1 - Flowchart cN: Clinical node stage; BC: Breast cancer; NAC: Neoadjuvant chemotherapy; SNLB: Sentinel lymph node biopsy; AD: Axillary dissection; SN: Sentinel node Table 1 - Demographic Characteristics Citation Format: Francisco Pimentel Cavalcante, Felipe Zerwes, Alessandra Souza, Patricia Ziegelmann, Ryane Alcantara, Amanda Cardoso, Andre Mattar, Eduardo Millen, Antonio Frasson. Blue Dye-Only for Sentinel Lymph Node Biopsy After Neoadjuvant Chemotherapy in Patients with Initially Node-positive Breast Cancer [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO4-23-02.

The Role of Sentinel Lymph Node Biopsy in the Management of Merkel Cell Carcinoma: A Systematic Review and Meta-analysis.

Merkel cell carcinoma (MCC) is a rare cutaneous malignancy with high metastatic potential. Sentinel lymph node biopsy (SLNB) is used to assess locoregional spread, facilitate staging, and inform prognosis. Positive nodal status is associated with higher recurrence rates and reduced overall survival. A systematic search was conducted. Eligible articles included patients diagnosed with MCC, who would be candidates for or who had SLNB. The Covidence tool was used for screening and data extraction, including additional treatments, disease-free survival, overall survival, and recurrence. Methodological quality was assessed using the Newcastle-Ottowa Scale criteria. SLNB was associated with increased likelihood of completion lymphadenectomy (223 versus 41), regional radiotherapy (2167 versus 808), and systemic chemotherapy (138 versus 31). Overall survival for patients undergoing SLNB was 81% at 2 years, 75% at 3 years, and 72% at 5 years (odds ratio: 0.79). Hazard ratio for positive SLNB versus negative was 3.36 (P < 0.001). Five-year disease recurrence was 23.3% in patients undergoing SLNB. Lymph node metastases are associated with reduced overall survival and increased recurrence of MCC. Determining nodal status early can inform prognosis, facilitate staging, and determine need for adjuvant treatment. Adjuvant treatments are associated with reduced mortality and improved overall survival; SLNB is an important influencer of their use. Early prophylactic intervention should be considered in MCC in both positive and negative nodal status to improve overall outcomes. Widespread use of SLNB will allow more accurate assessment of the role of nodal status on adjuvant treatment and long-term outcomes.

A Review of Contemporary Guidelines and Evidence for Wide Local Excision in Primary Cutaneous Melanoma Management.

Surgical wide local excision (WLE) remains the current standard of care for primary cutaneous melanoma. WLE is an elective procedure that aims to achieve locoregional disease control with minimal functional and cosmetic impairment. Despite several prospective randomised trials, the optimal extent of excision margin remains controversial, and this is reflected in the persistent lack of consensus in guidelines globally. Furthermore, there is now the added difficulty of interpreting existing trial data in the context of the evolving role of surgery in the management of melanoma, with our increased understanding of clinicopathologic and genomic prognostic markers leading to the often routine use of sentinel node biopsy (SNB) as a staging procedure, in addition to the development of adjuvant systemic therapies for high-risk disease. An ongoing trial, MelMarT-II, has been designed with the aim of achieving a definitive answer to guide this fundamental surgical decision.

Sentinel lymph node biopsy in patients with breast cancer. Experience in implementing at the regional level. Priority issues

Background. Despite the fact that sentinel lymph node biopsy (SLNB) in breast cancer patients has become a routine diagnostic procedure, it is still of great interest to researchers, since the priority issues of choosing methodology, equipment, technology, and stages of use are still being discussed. Although all obstacles to this technique implementation into routine clinical practice have been eliminated, SLNB in locally advanced breast cancer is still rarely used. We describe the experience of implementing SLNB in Nizhny Novgorod Regional Clinical Oncology Dispensary. We also discuss organizational, tactical, and practical approaches aimed to minimize the number of errors in technical terms, as well as to choose a multidisciplinary approach to the development of regulations for the examination and treatment of patients with locally advanced breast cancer.Aim. To assess the efficacy of SLNB implementation for patients with locally advanced breast cancer at the regional level.Materials and methods. This study included 500 patients with invasive (T1–2) breast cancer with clinically negative sentinel lymph nodes of all immunohistochemical subtypes that had undergone SLNB and histological examination. Sentinel lymph nodes were visualized using the radioisotope colloid 99mTc-Nanotop. We present the implementation algorithm for this procedure into routine clinical practice and evaluate short-term results.Results. A total of 500 patients have undergone SLNB. The first 30 cases were considered pilot cases, where all patients positive for sentinel lymph nodes additionally underwent standard axillary lymph node dissection. We observed a 100 % concordance of histological results. Then the surgery was routinely performed for all patients from this category. The assessment of short-term surgical outcomes demonstrated significant improvement of the postoperative period, reduced frequency of postoperative complications (persistent seroma of the axillary area to 2.85 %), reduced length of hospital stay (by 52.7 %) and improved functional and aesthetic results in the majority (&gt;62 %) of patients.Conclusion. Our algorithm of SLNB use in patients with breast cancer in routine clinical practice at the regional level allows for rapid method implementation, reduced length of hospital stay, better functional and aesthetic results, and lower incidence of persistent seroma of the axillary area.

Strict versus Liberal Use of Sentinel Node Biopsy in Breast Cancer Surgery: Any Clinical Outcome Differences? A 20-Year Clinical Experience

Introduction: As applied to early breast cancer (BC) patients, sentinel node biopsy (SNB) has undergone major changes over the years, especially concerning the widening of indication criteria or skipping systematic axillary lymph node dissection (ALND) after a positive SN. We aimed to ascertain whether a strict versus a more liberal use of SNB resulted in different clinical outcomes in our clinical experience. Methods: We studied consecutive BC patients undergoing SNB between January 1, 2000, and March 31, 2020. There were 1,587 patients and 1,634 SNB procedures. Cases were divided into two study groups: the “strict” SNB group (unifocal tumors up to 35 mm in which ALND was always performed for a positive SN, amounting to 1,183 SNBs), and the “liberal” SNB group (extended tumor size up to selected T3 cases, as well as multifocal or bilateral disease, and patients with previous contralateral BC, not always followed by ALND after a positive SN, amounting to 451 SNBs). Patients were closely followed up to the end of the study. Results: Clinico-pathological variables were strikingly different between study groups, with the liberal group showing a higher risk profile. Cox regression analysis for disease recurrence did not show significant differences in axillary, lymph node, or locoregional recurrence rates or distant relapse. There were no differences in survival between groups. Conclusion: It seems reasonable to adopt the liberal SNB approach, as the goal of surgical management in early BC patients must be attaining optimal locoregional disease control, no matter the differences in distant metastatic spread rates across different BC risk profiles.

Surgical Management of the Axilla in HR+/HER2- Breast Cancer in the Z1071 Era: A Propensity Score-Matched Analysis of the National Cancer Database.

Axillary management varies between sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) for patients with clinical N1 (cN1), hormone receptor-positive (HR+), humanepidermal growth factor receptor 2 (HER2)/neu-negative (HER2-), infiltrative ductal carcinoma (IDC) who achieve a complete clinical response (cCR) to neoadjuvant systemic therapy (NAST). This study sought to evaluate clinical practice patterns and survival outcomes of SLNB versus ALND in this patient subset. Patients with cN1, HR+/HER2-, unilateral IDC demonstrating a cCR to NAST were identified from the 2012-2017 National Cancer Database (NCDB) and stratified based on final axillary surgery management (SLNB vs ALND). After propensity score-matching, overall survival (OS) was compared using a Kaplan-Meier analysis, and significant OS predictors were identified using Cox regression. Of the 1676 patients selected for this study, 593 (35.4%) underwent SLNB and 1083 (64.6%) underwent ALND. Use of SLNB increased by 28 % between 2012 and 2017. Among a total of 584 matched patients, 461 matched ypN0 patients, and 108 matched ypN+ patients, mean OS did not differ between SLNB and ALND (all patients [92.1 ± 0.8 vs 90.2 ± 1.0 months; p = 0.157], ypN0 patients [92.4 ± 0.8 vs 89.9 ± 0.9months; p = 0.105], ypN+ patients [83.5 ± 2.3 vs 91.7 ± 2.7 months; p ± 0.963). Cox regression identified age, Charlson score, clinical T stage, and pathologic nodal status as significant predictors of OS. The final surgical management strategy used for cN1, HR+/HER2- IDC patients who achieved a cCR to NAST did not have a significant impact on survival outcomes in this analysis. Potential opportunities for de-escalation of axillary management among this patient subset exist, and validation studies are needed.

Micrometastases in the sentinel node after neoadjuvant therapy. Is axillary dissection still required?

The present review intends to discuss the controversies and strengths in clinically node-positive patients with axillary nodal status ypNi+/mi after neoadjuvant chemotherapy. Over the past 20 years, a de-escalation approach toward axillary surgery has been observed in patients with breast cancer. The worldwide use of sentinel node biopsy in the upfront setting and after primary systemic therapy substantially reduced surgical complications or late sequelae and eventually improving quality of life of patients. However, the role of axillary dissection is still unclear in patients with low residual disease post-chemotherapy, namely those with micrometastases in the sentinel node, and its prognostic role is still not very clear. The aim of the present narrative review is to report the available evidence on this topic, discussing the pros and cons of performing axillary lymph node dissection in the infrequent finding of micrometastases in the sentinel node after neoadjuvant chemotherapy. We will also describe the ongoing prospective studies which are expected to shed light and guide future decisions.

Use of sentinel lymph node biopsy in elderly patients with breast cancer – 10-year experience from a Swiss university hospital

BackgroundThe Choosing Wisely initiative recommended the omission of routine sentinel lymph node biopsy (SLNB) in patients ≥ 70 years of age, with clinically node-negative, early stage, hormone receptor (HR) positive and human epidermal growth factor receptor 2 (Her2) negative breast cancer in August 2016. Here, we assess the adherence to this recommendation in a Swiss university hospital.MethodsWe conducted a retrospective single center cohort study from a prospectively maintained database. Patients ≥ 18 years of age with node-negative breast cancer were treated between 05/2011 and 03/2022. The primary outcome was the percentage of patients in the Choosing Wisely target group who underwent SLNB before and after the initiative went live. Statistical significance was tested using chi-squared test for categorical and Wilcoxon rank-sum tests for continuous variables.ResultsIn total, 586 patients met the inclusion criteria with a median follow-up of 2.7 years. Of these, 163 were ≥ 70 years of age and 79 were eligible for treatment according to the Choosing Wisely recommendations. There was a trend toward a higher rate of SLNB (92.7% vs. 75.0%, p = 0.07) after the Choosing Wisely recommendations were published. In patients ≥ 70 years with invasive disease, fewer received adjuvant radiotherapy after omission of SLNB (6.2% vs. 64.0%, p < 0.001), without differences concerning adjuvant systemic therapy. Both short-term and long-term complication rates after SLNB were low, without differences between elderly patients and those < 70 years.ConclusionsChoosing Wisely recommendations did not result in a decreased use of SLNB in the elderly at a Swiss university hospital.

Current and future approaches in the surgical management of T3b/T4 primary and locoregionally advanced melanoma.

Currently accepted principles of surgical management-margin width, use of sentinel node biopsy, performance of radical node dissections for node-positive cases-and some aspects of postoperative management (use of radiation for desmoplastic melanoma primaries and for clinically node-positive disease) will change in the future with the potential widespread adoption of adjuvant and neoadjuvant therapies.

Changes in healthcare costs and survival in the era of immunotherapy and targeted systemic therapy for melanoma.

ObjectivesMelanoma treatment has evolved over the past decade with the adoption of adjuvant and palliative immunotherapies and targeted therapies and changes in use of sentinel node biopsy. The impact on real-world healthcare costs and outcomes is uncertain. Here we examine changes in healthcare costs and survival using administrative data.&#x0D; ApproachUsing data from the universal healthcare system in Ontario, Canada, we examine a propensity-matched, retrospective cohort of patients aged 20+ years with Stage I-IV invasive cutaneous melanoma from 2018-2019 compared with those from 2007-2012. The primary outcomes were public payer’s mean healthcare per-person costs, and overall survival (OS). Costs were estimated with an established case-mix and claim-based costing algorithm for Ontario, in which person-level costs are allocated for the various healthcare utilizations over time. Standardized mean differences were used to compare costs, and the log-rank test and Cox regression were used to compare survival among stage-stratified, propensity-score matched cohorts.&#x0D; ResultsWe identified 1,138 patients with melanoma from 2018-2019 and 7,654 from 2007-2012. After stage stratification and propensity-matching (N=1,101 per cohort), sentinel lymph node biopsy (62.3% vs. 43.4%) and systemic therapy use (27.3% vs. 12.5%) were more frequent in 2018-2019 compared to 2007-2012. 2018-2019 patients had greater mean healthcare (including systemic therapy) costs compared to 2007-2012 with Stage II ($27,835 vs. $21,179), III ($90,508 vs. $46,242) and IV disease ($118,398 vs. $46,500). There was a seven-to-twelve-fold increase in mean systemic therapy costs for treated patients with Stage III ($68,207 vs. $9,832) and IV disease ($80,905 vs. $6,883). OS was greater in 2018-2019 versus 2007-2012 (2-year OS: 87.8% [95% Confidence Interval {CI}: 85.8-89.6%] vs. 83.7% [95% CI: 81.3-85.7%]; Hazard Ratio {HR}: 0.72 [95% CI: 0.59-0.89]; p&lt;0.05).&#x0D; ConclusionThese real-world data highlight trade-offs with adoption of new effective systemic therapies for melanoma, with a greater economic burden to the healthcare system but an associated improvement in survival. Such evolving paradigm changes may prompt dynamic evaluations of healthcare resources and policies to ensure cancer care is sustainable.

External validation study of endometrial cancer preoperative risk stratification model (ENDORISK).

IntroductionAmong industrialized countries, endometrial cancer is a common malignancy with generally an excellent outcome. To personalize medicine, we ideally compile as much information as possible concerning patient prognosis prior to effecting an appropriate treatment decision. Endometrial cancer preoperative risk stratification (ENDORISK) is a machine learning–based computational Bayesian networks model that predicts lymph node metastasis and 5-year disease-specific survival potential with percentual probability. Our objective included validating ENDORISK effectiveness in our patient cohort, assessing its application in the current use of sentinel node biopsy, and verifying its accuracy in advanced stages.MethodsThe ENDORISK model was evaluated with a retrospective cohort of 425 patients from the University Hospital Brno, Czech Republic. Two hundred ninety-nine patients were involved in our disease-specific survival analysis; 226 cases with known lymph node status were available for lymph node metastasis analysis. Patients were included undergoing either pelvic lymph node dissection (N = 84) or sentinel node biopsy (N =70) to explore the accuracy of both staging procedures.ResultsThe area under the curve was 0.84 (95% confidence interval [CI], 0.77–0.9) for lymph node metastasis analysis and 0.86 (95% CI, 0.79–0.93) for 5-year disease-specific survival evaluation, indicating quite positive concordance between prediction and reality. Calibration plots to visualize results demonstrated an outstanding predictive value for low-risk cancers (grades 1–2), whereas outcomes were underestimated among high-risk patients (grade 3), especially in disease-specific survival. This phenomenon was even more obvious when patients were subclassified according to FIGO clinical stages.ConclusionsOur data confirmed ENDORISK model’s laudable predictive ability, particularly among patients with a low risk of lymph node metastasis and expected favorable survival. For high-risk and/or advanced stages, the ENDORISK network needs to be additionally trained/improved.

Paradigm shift from lymphadenectomy to sentinel lymph node biopsy in vulvar cancer surgery (364)

<b>Objectives:</b> To examine trends, characteristics, and outcomes related to nodal assessment for vulvar cancer surgery in the United States. <b>Methods:</b> This is a retrospective observational cohort study querying the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. The study population was 5,604 women with T1b or T2-smaller (<4cm) squamous cell carcinoma of the vulva who underwent primary vulvectomy from 2003-2018. Exposure allocation was based on nodal evaluation type, including lymphadenectomy (LND; <i>n</i>=3,319, 59.2%), sentinel lymph node (SLN) biopsy (<i>n</i>=751, 13.4%), or no surgical nodal evaluation (<i>n</i>=1,534, 27.4%). The main outcomes were <i>1)</i> trends and characteristics related to SLN biopsy assessed by the multinomial regression model, and <i>2)</i> vulvar cancer-specific survival assessed by comparing risk analysis and propensity score weighting. The sensitivity analysis included evaluation of the external cohort with T1a disease (<i>n</i>=1,291). Fig. 1 <b>Results:</b> The utilization of SLN biopsy increased from 5.7% to 23.3% in 2006-2018, while the proportion of LND decreased from 64.1% to 48.8% in 2010-2018 (p<0.05) (top panel). These associations remained independent in multivariable analysis: SLN biopsy use in 2015-2018 versus 2003-2006, with an adjusted-odds ratio of 3.57 (95% CI: 2.54-5.01, p<0.001), and LND use in 2015-2018 versus 2003-2006, with an adjusted-odds ratio of 0.79 (95% CI: 0.63-0.97, p=0.027). In a propensity score weighted model, 5-year cumulative rate for vulvar cancer-specific mortality was 15.2% (interquartile range: 12.1-18.9) for the SLN biopsy group and 16.9% (interquartile range 15.6-18.3) for the LND group (subdistribution-HR [sHR]: 0.90, 95% CI: 0.76-1.06, p=0.217) (bottom panel). Similar association was also observed in T1b disease (sHR: 0.88, 95% CI: 0.70-1.09, p=0.236), T2-smaller (<4cm) disease (sHR: 0.82, 95% CI: 0.50-1.33. p=0.419), and N0 cases (sHR: 0.93, 95% CI: 0.70-1.22, p=0.594). Increasing performance of SLN biopsy was also observed in T1a disease from 1.3% to 7.3% during the study period (p<0.001). <b>Conclusions:</b> The landscape of surgical nodal evaluation is shifting from lymphadenectomy to SLN biopsy in vulvar cancer surgery. This study suggests that an SLN biopsy-incorporated treatment approach is not associated with worse survival compared to LND.

Microinvasive breast cancer and the role of sentinel lymph node biopsy

Whether sentinel lymph node biopsy (SLNB) should be performed in patients with microinvasive breast cancer (MIBC) has been a matter of debate over the last decade. MIBC has a favorable prognosis and while metastasis to the axilla is rare, it can impact treatment recommendations. In this study we evaluated clinical and histological features in both MIBC and background DCIS including ER, PR, and HER-2, number of foci of MIBC, the extent of the DCIS, nuclear grade, presence of comedo necrosis, as well as surgical procedures, adjuvant treatment and follow up to identify variables which predict disease free survival (DFS), as well as the factors which influence clinical decision making. Our study included 72 MIBC patients with a mean patient follow-up time of 55 months. Three patients with MIBC had recurrence, and two deceased, leaving five patients in total with poor long-term outcomes and a DFS rate of 93.1%. Performing mastectomy, high nuclear grade, and negativity for ER and HER-2 were found to be associated with the use of SLNB, although none of these variables were found to be associated with DFS. One positive lymph node case was discovered following SLNB in our study. This suggests the use of SLNB may provide diagnostic information to some patients, although these are the anomalies. When comparing patients who had undergone SLNB to those which had not there was no difference in DFS. Certainly, the use of SLNB in MIBC is quite the conundrum. It is important to acknowledge that surgical complications have been reported, and traditional metrics used for risk assessment in invasive breast cancer may not hold true in the setting of microinvasion.

Population-based assessment of sentinel lymph node biopsy in the management of cutaneous melanoma

Background:Sentinel lymph node biopsy (SLNB) for melanoma plays a central role in determining prognosis and guiding treatment and surveillance strategies. Despite widely published guidelines for SLNB, variation exists in its use. We aimed to determine the frequency of and predictive factors for SLNB in patients with clinically node-negative melanoma in British Columbia.Methods:A retrospective review was performed of patients with clinically node-negative melanoma diagnosed between January 2015 and December 2017. Patients included had a Breslow depth greater than 0.75 mm or a Breslow depth less than or equal to 0.75 mm with ulceration, or a mitotic rate greater than or equal to 1/mm2. SLNB was considered to be indicated for clinical stages IB to IIC (American Joint Committee on Cancer’s AJCC Cancer Staging Manual, seventh edition).Results:A total of 759 patients were included. SLNB was performed in 54.8% (363/662) of patients when indicated. SLNB was more likely to be performed for tumours with a Breslow depth greater than 1.0 mm or a mitotic rate greater than or equal to 1/mm2. SLNB was less likely to be performed in patients older than 75 years and with a nonextremity tumour location. Compliance with SLNB guidelines decreased distant recurrence but did not significantly affect regional recurrence, nor did it have a significant impact on overall survival among patients aged 75 years and younger.Conclusion:SLNB is being underutilized in British Columbia. These results are concerning and highly relevant given the rapidly evolving field of adjuvant systemic therapy for high-risk patients and the increased proportion of patients who should be considered for SLNB on the basis of the eighth edition of the AJCC Cancer Staging Manual and current guidelines. Efforts should be made to increase the use of SLNB in appropriate patients.

Sentinel lymph node biopsy in early oral cancers: are we ready for it yet? Results from a survey among Indian surgeons treating oral cancers

Emerging evidence has shown that sentinel node biopsy (SNB) is an oncologically safe option in patients with early oral cancer compared with elective neck dissection (END). However, its use on a routine basis could be associated with many challenges. This online survey was conducted among the Indian surgeons treating patients with oral cancer to understand and comprehend the incidence and patterns of usage of SNB in their practice, their approach toward the use of SNB, and the possible challenges they face or perceive in its routine use in patients with early oral cancer. We received 352 responses with a response rate of 47.63%. Most of the respondents (82.6%) were managing N-zero necks with END, only 15.1% (n=53) respondents practiced SNB currently. Most respondents believed that SNB offered the advantage of better shoulder function compared with END (76.4% [n=269]). The deterrents considered for routine use of SNB in early oral cancer were additional costs (71.9% [n=253]), the unavailability of necessary expertise and infrastructure (87.2% [n=307]), SLNB being a more time-consuming treatment (58.8% [n=207]), a higher false negative rate (74.1% [n=261]), and the possible need of a second surgery (82.4% [n=290]). Though SNB presently could be considered as an alternative treatment option, there seem to be various issues that need to be addressed before it can be adopted as a standard of care across centers.

Surgeons' preferences for using sentinel lymph node biopsy in patients with ductal carcinoma in situ.

BackgroundThere is a large variation between Dutch hospitals in the use of Sentinel Lymph Node Biopsy (SLNB) in patients with a biopsy diagnosis of Ductal Carcinoma in Situ. The aim of our study was to investigate whether this variation might be explained by preferences of surgeons, organisational factors or the influence of patients preferences.MethodsA cross-sectional web survey was conducted among 260 Dutch oncological/breast surgeons. Preferences of surgeons and the influence of the patients’ preferences were determined by means of best-worst scaling (BWS) of profile case scenarios and by ranking risk factors. The survey also explored organisational questions, the reported use of diagnostic techniques and influences on the decision.ResultsThe BWS scenarios were completed by 57 surgeons. The most important reasons for performing SLNB were a suspected invasive component and DCIS grade 3. In the ranking, these were also the first and second most important factor, followed by the size of the lesion and a mass on mammogram. In 58% to 70% of the scenarios, the surgeons would not change their decisions on the use of SLNB if the patient’s chose differed. No organisational factor was significantly associated with the reported use of SLNB.ConclusionThe inter-hospital variation in the use of SLNB could not be attributed to organisational factors or surgeons’ preferences for risk factors. The risk factors that most surgeons reported as reasons for performing SLNB are consistent with the factors described in the Dutch treatment guideline for the use of SLNB.