Utility Of Sentinel Lymph Node Biopsy Research Articles

Utilization and outcomes of sentinel lymph node biopsy in patients with early stage vulvar cancer

ObjectiveA retrospective cohort study comparing survival and perioperative outcomes of patients with early vulvar cancer who underwent sentinel lymph node biopsy versus standard lymphadenectomyMethodsPatients diagnosed between January 2012 and December...

Perioperative outcomes and disparities in utilization of sentinel lymph node biopsy in minimally invasive staging of endometrial cancer

ObjectiveTo assess the emergence of sentinel lymph node biopsy (SLNB) for disparities in utilization, and impacts on perioperative outcomes. MethodsRetrospective cohort study of the National Cancer Database, selecting for patients with T1NxM0 endometrial cancer undergoing minimally invasive surgical staging from 2012 to 2016. Disparities in SLNB utilization were described. Propensity matching was performed. Association of SLNB with perioperative outcomes was assessed with logistic regression. ResultsAmong 67,365 patients, 6356 (9.4%) underwent SLNB, increasing from 2.8% to 16.3% from 2012 to 2016. Disparities were identified within race (7.0% Black, 9.4% non-Black), ethnicity (8.3% Hispanic, 9.5% non-Hispanic), insurance (6.0% uninsured, 9.5% insured), county density (3.7% rural, 9.8% metro), and income (7.0% bottom-quartile, 11.8% top-quartile). Risk of conversion to open surgery was lower with SLNB alone (1.03%) or SLNB followed by LND (1.40%), versus upfront LND (2.80%). SLNB was associated with reduced risk of conversion to open surgery in Intention-To-Treat (SLNB+/-LND vs. upfront LND; ORITT = 0.53; 95%CI 0.39–0.72) and Per-Protocol (PP; SLNB alone vs. upfront LND or SLNB+LND; ORPP = 0.49; 95%CI 0.32–0.75) comparisons. SLNB was also associated with lower risk of length of stay >1 day (overall rate 6.3%; ORITT = 0.51; 95%CI 0.40–0.64; ORPP = 0.39; 95%CI 0.28–0.55), and unplanned readmission (overall rate 2.3%; ORPP = 0.52; 95%CI 0.33–0.81). There were no deaths within 90 days among 1370 SLNB alone cases, versus 2/1294 (0.15%) for SLNB+LND, and 123/28,828 (0.41%) for upfront LND. ConclusionWe identified significant disparities in the utilization of SLNB, as well as evidence that this less-invasive technique is associated with lower rates of certain perioperative complications. Equitable access to this emerging technique could lessen disparate outcomes.

Abstract P3-03-21: Usefulness of sentinel lymph node biopsy by indocyanine green fluorescence method for cN0 breast cancer patients

Abstract Background. Indocyanine green (ICG) fluorescence method (ICG-f) has been recently widely used in sentinel lymph node (SLN) detection. The advantages of ICG-f are no radiation exposure, no limitation to use in high-volume medical centers without radioactive facility, and to confirm lymph flow as a real-time image from outside the body. ICG-f identified an average of 2.3-3.4 SLNs and the detection rate was 99%, compared to 1.7-2 SLNs by RI methods. Long-term observation after SNB using ICG-f has not been reported, including arm lymphedema as the complication of this method.We evaluate the usefulness of SLN biopsy (SNB) for cN0 breast cancer patients from data of multicenter cohort study on long-term results after negative SNB by ICG-f. Methods. Eleven hundred and thirty-two women were enrolled who had histologically proved clinical stage T1-4, pN0, M0 primary invasive breast cancer with SNB using ICG-f (ICG alone or combination of RI/blue dye method) sparing axillary lymph node dissection from May 2007 to December 2015. This study is retrospective, multicenter cohort study conducted at 6 centers in Japan. Primary endpoint is axillary recurrence rate. We analyzed the correlation with the axillary recurrence and adjuvant systemic therapy, adjuvant radiotherapy, and the clinicopathological characteristics. Secondary endpoint is lymphedema. Results and Discussion. The median follow-up time was 41 (range 21-117) months, and axillary recurrence was found in 6 patients (0.53%). Five out of 6 patients were not received standard adjuvant systemic therapy or adjuvant radiation therapy after breast conserving surgerybecause of patient's preference or old age. Lymphedema was identified only 4 patients in 632 patients. It is reported that axillary recurrence after SNB was 0.3-1.65%, which was consistent with our result. Lymphedema was not frequent in patients received SNB using ICG-f, because SLNs are removed along with lymphatic ducts in the limited area of axillary adipose tissue. Conclusion.Axillary recurrence after negative SNB using ICG-f was comparable to RI or blue dye method. It might be important to perform appropriate adjuvant medication or radiation therapy for preventing axillary recurrence after SNB using ICG-f. Next, ICG-f after neoadjuvant chemotherapy is to be investigated, because itis reported that removing more than 2 SLNs were associated with a lower likelihood of false negative ratio in patients with clinically node-positive disease converted to clinically node-negative after chemotherapy, and ICG-f might overcome this issue. Citation Format: Maeshima Y, Takahara S, Yamauchi A, Yamagami K, Sugie T, Yamashiro H, Kato H, Torii M, Takada M, Torii M. Usefulness of sentinel lymph node biopsy by indocyanine green fluorescence method for cN0 breast cancer patients [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P3-03-21.

Axillary Management in Breast Cancer Patients: A Comprehensive Review of the Key Trials

Optimal regional management in breast cancer patients has yet to be established. In patients who are clinically node-negative, but sentinel lymph node biopsy (SLNB)-positive, the treatment paradigm has shifted toward the de-escalation of further axillary management. In patients with 2 or fewer positive sentinel nodes, the standard of practice has shifted away from complete axillary lymph node dissection (ALND) as a result of the ACOSOG Z0011 trial. The role of regional nodal irradiation (RNI) to the axilla, supraclavicular and internal mammary regions has also been investigated in the setting of positive SLNB in trials such as the MA20 and EORTC 22922. Having shown evidence of benefit in locoregional control, efforts are now focused on comparing ALND with RNI in patients with limited nodal disease. Results of early trials such as AMAROS suggest noninferiority of radiotherapy. In patients with node-positive or locally advanced disease, neoadjuvant chemotherapy (NAC) is often used to downsize or downstage the disease. The utility of SLNB after NAC has been investigated, with discordant results reported from a number of trials. Current trials in progress seek to validate the noninferiority of RNI compared with ALND in patients with limited nodal disease, or in some trials, the complete omission of further axillary management. There is a global paradigm shift toward de-escalation of axillary management on the basis of recent evidence suggesting lack of benefit from overaggressive treatment. In this review we aim to summarize the seminal trials addressing regional management in breast cancer to illustrate this fact.

Head and neck desmoplastic melanoma: Utility of sentinel node biopsy

PurposeThe utility of sentinel lymph node biopsy in desmoplastic melanoma has been questioned due to multiple reports of a low rate of occult nodal metastasis in this variant of melanoma. We describe a single institution experience with management of desmoplastic melanoma of the head and neck and discuss the utility of sentinel lymph node biopsy. Materials and methodsA retrospective review was performed of 49 patients with desmoplastic melanoma of the head and neck at a tertiary care center from 1994 to 2014. ResultsSentinel lymph node biopsy was performed in 15 patients. Only 1 (6.7%) of these patients was found to have a positive sentinel node. Of the 46 patients without evidence of neck disease at presentation, 3 (6.5%) were found to have occult nodal disease or developed neck recurrences. When looking at the entire cohort, there were a total of 16 recurrences in 14 patients (28.6%). The majority (85.7%) of recurrences were either local or distant metastasis with only 2 (14.3%) recurrences being in regional lymph node basins. The overall rates of local, regional, and distant recurrences were 14.2%, 4.1%, and 10.2% respectively. The mixed pathologic subtype was not associated with a higher rate of nodal metastasis. ConclusionsDesmoplastic melanoma has a low rate of occult nodal metastasis and a high propensity to recur locally or as a distant metastasis, regardless of regional node status. Our experience combined with the uncertain impact that sentinel node status has on survival raises the question of the utility of routine sentinel node biopsy in this specific variant of melanoma.

Utilization of Axillary Surgery for Patients With Ductal Carcinoma In Situ: A Report From the National Cancer Data Base.

This study evaluated the use of axillary surgery (AS), including sentinel lymph node biopsy (SLNB), for patients with ductal carcinoma in situ (DCIS) and the factors associated with its use. To determine whether utilization of SLNB is appropriate, predictors of SLNB performance were compared with factors predictive of tumor upstaging. The National Cancer Data Base was utilized to identify patients with American Joint Committee on Cancer (AJCC) clinical stage 0 breast cancer treated from 2004 to 2013. DCIS with microinvasionwas excluded. Chi square tests and logistic regression were used to examine patient, tumor, and facility features associated with SLNB and tumor upstaging. Of the 218,945 total patients, 155,093 (70.8%) underwent lumpectomy, and 63,852 (29.2%) underwent mastectomy. SLNB was performed for 19.0% of lumpectomy patients and 63.5% of mastectomy patients. Multivariate analysis for 2012-2013 demonstrated that estrogen receptor (ER)-negative and grade 3 tumors were more likely to be treated with SLNB in both groups. Tumor size was significant only for the lumpectomy patients who underwent one operation. Further, 22.8% of lumpectomy patients and 18.7% of mastectomy patients who underwent AS were upstaged compared with 1.8% of lumpectomy and 3.6% of mastectomy patients who did not undergo AS. Tumor upstaging was predicted by ER-negative status (odds ratio [OR] 2.99; 95% confidence interval [CI] 2.76-3.24) but not by higher grade or larger tumor size. Use of SLNB for DCIS is high with mastectomy, and nearly one fifth of the lumpectomy patients underwent SLNB. However, the performance of AS was strongly associated with the likelihood of upstaging in both groups, suggesting that surgical judgment plays an important role in this decision.

Does duration to ipsilateral breast tumor recurrence affect the success of reoperative sentinel lymph node biopsy?

Abstract Background Five to ten percent of patients with prior breast cancer treated with breast conservation therapy (BCT) will develop ipsilateral breast tumor reoccurrence (IBTR), requiring reoperative sentinel lymph node biopsy (SNLB). IBTR patients may have a history of prior axillary surgery, which can be a SLNB or an axillary lymph node dissection (ALND). Materials & Methods A retrospective chart review was conducted on patients with IBTR who received care in the Department of Surgery at William Beaumont Hospital, Royal Oak and Troy, Michigan, from January 2007 to December 2009. Results Twenty-eight patients were identified and categorized as Prior ALND (>10 lymph nodes, n =14), Prior SLNB (≤10 lymph nodes, n =10) and an Unknown number of lymph nodes ( n =4). Among Prior ALND patients, reoperative SLNB success was increased in the ≥10 years group (25% vs. 50%, p =0.58). Similarly, among Prior SLNB patients, reoperative SLNB success was increased in the ≥10 years group (71% vs. 100%, p =1.0). Conclusion Increased duration to IBTR may be associated with success of reoperative SNLB in patients with IBTR with prior ALND or SNLB. Further study is required to better understand this relationship. Microabstract The relationship between timing of and success of reoperative sentinel lymph node biopsy (SLNB) has not been studied. We conducted an observational, retrospective analysis of 28 patients with ipsilateral breast tumor recurrence (IBTR). Our results may suggest a higher rate of reoperative SNLB success with increased (≥10 years) duration to IBTR among patients who initially underwent breast conserving therapy with initial axillary lymph node dissection or SNLB. Further research is required to characterize this potential relationship. Clinical practice points Specific mechanisms for the regeneration of lymphatic channels in patients with IBTR after original SLNB or ALND are currently being investigated. The time necessary to reestablish significant lymphatic networks is unknown, but likely impacts the success of reoperative SNLB in ITBR patients. Our results may suggest a higher rate of reoperative SNLB success with increased (≥10 years) duration to IBTR among patients who initially underwent BCT with original axillary lymph node dissection or SNLB. Although more advanced research is required to better understand the relationship between timing of and success of reoperative SLNB, the results of this study may suggest that the utility of SLNB may be greater with increased length to IBTR. As a result, clinicians should be somewhat skeptical of the success of SLNB in patients with immediate IBTR until further research can be conducted.

Risk Factors Associated with Sentinel Lymph Node Biopsy in Patients with a Preoperative Diagnosis of Ductal Carcinoma <i>In Situ</i>

Purpose: Sentinel lymph node (SLN) biopsy has become the gold standard for axillary staging of invasive breast cancer. However, some controversy has existed concerning the usefulness of SLN biopsy in ductal carcinoma in situ (DCIS). In this study, we tried to identify the usefulness of SLN biopsy in patients with an initial preoperative diagnosis of DCIS. Methods: A retrospective analysis was performed using single-center data of 415 patients with an initial diagnosis of DCIS between January 2003 and December 2013. Many features were correlated with upstaging and positive SLN biopsy using univariate analysis and multivariate analysis. Results: A total of 415 patients with a preoperative diagnosis of DCIS were enrolled in this study. Total 320 of 415 patients (77.1%) underwent axillary evaluation via SLN biopsy, axillary lymph node dissection, or additional axillary lymph node dissection, and 24 of 320 patients (7.5%) were diagnosed with axillary lymph node metastasis or micrometastases in the lymph nodes. Of 415, 296 patients (71.3%) underwent SLN biopsy and 16 patients (5.4%) had positive SLN biopsy. The rate of upstaging to invasive cancer was 4.1% (17 of 415 patients) on final pathology. Of the 17 patients who were upstaged to invasive carcinoma at final pathology, seven patients (41.2%) had a positive SLN biopsy. The statistically significant factors of upstaging were large tumor size (≥2 cm), histologic features of intermediate or high-grade tumor, and positive SLN biopsy. Conclusion: SLN biopsy should be considered in patients with high risk DCIS as a part of the primary surgical procedure. Keywords: Breast; Noninfiltrating intraductal carcinoma; Sentinel lymph node biopsy

Lymphoscintigraphy and sentinel lymph node biopsy, in cutaneous melanoma staging and treatment decisions.

Sentinel lymph node biopsy (SLNB) is a widely accepted method in the management of clinically localized cutaneous melanomas. The aim of this study was to report the results on patients scheduled for preoperative lymphoscintigraphy and SLNB for staging and further treatment planning. Two hundred and one patients (115 male and 86 female, median age 57 years, range 9-81) with cutaneous melanoma having undergone SLB at Military Medical Academy between November 2010 and October 2014, were recruited for retrospective study. Dual labeling method (Tc-99m Nanocolloid (blue dye) was used. In order to delineate the relation between patients' tumors and scintigraphic characteristics with positive SLN findings, we examined all variables by univariate logistic regression with odd ratios representing the size effect. The overall identification rate of SLN was 98.5%. One or more positive SLN were seen in 47 (23.4%) of the patients. Drainage to one regional basin was noticed in 176 (88%) and multiple drainage regions, up to three, was noticed in 24 patients (12%). Transit lymph nodes were detected in 20 patients (10%). The characteristics that were assotiated significatly with sentinel lymph node metastases were Breslow thickness, nodular melanoma histological subtype and acral localization. Besides the well established primary tumor thickness being a predictor of SLN malignancy, we observed: acral body site location and nodular melanoma histological subtype to be significant independent factors in increasing the risk for regional metastases. Our results suport the clinical usefulness of SLNB within a multidisciplinary approach (dermatooncology, plastic/head and neck surgery, pathology, nuclear medicine), as a reliable method in staging and for treatment planning in melanoma patients.

The utility of sentinel lymph node biopsy in patients with ductal carcinoma in situ suspicious for microinvasion on core biopsy.

When microinvasion cannot be ruled out on core needle biopsy (CNB) in the setting of ductal carcinoma in situ (DCIS), the surgeon must decide whether to perform a sentinel lymph node biopsy (SLNB) at the time of surgery. Up to 10 % of patients with T1mi have nodal disease, but the utility of SLNB in DCIS suspicious for microinvasion (Smic) is unclear. The University of Chicago pathology database was queried for a diagnosis of Smic or definite microinvasion (Mic) on CNB from 2000 to 2014. We analyzed histology, imaging, core needle size, and the use of myoepithelial immunohistochemistry (IHC) markers. We identified 103 women, 72 with Smic and 31 with Mic on CNB. After surgery, 32 % of Smic patients had infiltrating ductal carcinoma (IDC). Seventy-two percent of Smic patients underwent SLNB, with 67 % performed at the initial surgery. SLNB was positive in 6 % and 10 % of Smic and Mic patients, respectively (p = 0.66). Excluding N1mic, the incidence of macrometastatic nodal disease was 1.9 % for Smic patients and 3.3 % for Mic patients (p = 1.00). For Smic patients, IDC was associated with a larger lesion size and smaller CNB needle. In the setting of Smic, grade, necrosis, or presence of a mass did not increase the risk of IDC. In patients with Smic on CNB, the incidence of macrometastatic nodal disease after SLNB is rare. Surgeons may consider omitting SLNB until IDC is definitively confirmed, especially in patients with Smic apart from other high-risk features.

Favourable prognostic role of regression of primary melanoma in AJCC stage I-II patients

The prognostic significance of regression in primary melanoma has been debated over the past few years. Once it was considered to be a negative prognostic factor, as it may have prevented proper melanoma thickness measurement, therefore affecting the staging of the tumours. For this reason, it was considered to be an indication for sentinel lymph node biopsy (SLNB) in melanoma < 1 mm. To ascertain the utility of SLNB in thin melanoma and to clarify the role of regression in disease-free survival (DFS) and overall survival (OS) in our series. We analysed data collected from 1693 consecutive patients with AJCC (American Joint Committee on Cancer) stage I-II melanoma. Globally, SLNB was performed in 656 out of 1693 patients. Regression was present in 349 patients and 223 of them were characterized by thin lesions. SLNB was performed in 104 cases of thin melanoma with regression. The majority of regional lymph node metastases were observed in patients who did not undergo SLNB (89 out of 132). Among the remaining 43 'false negative' patients only three showed regression in the primary. Using the Cox multivariate model, histological regression maintained a significant protective role [hazard ratio (HR) 0·62, P = 0·012 for DFS; HR 0·43, P = 0·008 for OS] when corrected for the principal histopathological and clinical features, despite SLNB. We confirmed that regression alone should not be a reason to perform SLNB in thin melanoma and, on the contrary, it can be considered a favourable prognostic factor in patients with AJCC stage I-II melanoma.

Significance of core needle biopsies with ductal carcinoma in situ suspicious for microinvasive carcinoma.

86 Background: Sentinel lymph node biopsy (SLNB) is not routinely recommended for women diagnosed with ductal carcinoma in situ (DCIS); however, when the pathologist cannot rule out microinvasion on core biopsy (CB), the surgeon must decide whether to perform a SLNB at the time of surgical excision. Up to 10% of patients with T1mi are found to have breast cancer cells in the axillary lymph nodes, but less than 2% contain macrometastasis making the utility of SLNB in this setting unclear. Methods: The University of Chicago pathology database was queried for patients whose CB showed DCIS suspicious for microinvasion (Smic) or definite microinvasion (Mic) from 2000 to 2012. We analyzed histology, imaging, nodal status, core needle size, and the use of myoepithelial immunohistochemistry (IHC) markers to identify microinvasion. Results: We identified 60 women with Smic and 19 women with Mic on CB. In the Smic group, 33% had infiltrating ductal carcinoma (IDC) in the surgical specimen (35, 30, 30, 1 and 0% for T1mi, T1a, T1b, T1c, and T2 respectively compared to 58, 21, 0, 10.5 and 10.5% in the Mic group). A SLNB was performed at the initial surgery in 38/60 (63%) of Smic and in all Mic biopsies; they were positive in 3/42 (7%) and 2/19 (11%) respectively (p=0.64). When N1mic was excluded, the incidence of macroscopic nodal disease was 1/42 (2.4%) and 1/19 (5.3%) p=0.53. Of those with Smic, we observed a higher proportion of IDC associated with a lesion size ≥ 14 mm on imaging (75% versus 15% for &lt; 14 mm, p&lt;0.02); smaller CB needle size (69% with 11, 12 and 14 gauge versus 0% with 9 gauge, p&lt;0.01); and the use of IHC on the CB to identify microinvasion (58% versus 22% without IHC, p&lt;0.01). There was no association to IDC with respect to grade, necrosis, mass on imaging, or biopsy guidance. Conclusions: The incidence of clinically positive nodal disease in patients with Smic on CB is extremely low. However, those with tumors ≥ 14 mm, the use of smaller gauge CB needles, and Smic based on myoepithelial IHC may be at higher risk for IDC. Of the Smic group with DCIS after excision, none harbored nodal disease; therefore, the use of SLNB only after a definitive diagnosis of IDC may prevent overtreatment.

Sentinel Lymph Node Biopsy in pediatric soft tissue sarcoma patients: Utility and concordance with imaging

BackgroundThe purpose of this study was to report our experience with sentinel lymph node biopsy (SLNB) for pediatric soft tissue sarcomas to add to the limited literature about its feasibility, utility, and concordance with pre-operative imaging, including CT and 18F-FDG PET (PET) scanning. MethodsMedical records of patients with a sarcoma who underwent SLNB as part of their treatment for a soft tissue sarcoma at our institution from 2000 to 2011 were identified and reviewed. ResultsEight patients underwent SLNB for soft tissue sarcoma during the study period. Two patients had positive SLNBs; both of these patients had rhabdomyosarcoma. Three patients with pathologically enlarged lymph nodes on CT scan underwent PET functional imaging prior to SLNB. The PET suggested the presence of nodal disease in all three patients; however, only one of these patients had a positive SLNB. ConclusionsOur series confirms that SLNB is feasible in pediatric sarcoma patients. Small numbers preclude definitive conclusions regarding the utility of SLNB compared with PET, however our data suggest functional imaging alone may not be sufficient to definitively determine lymph node status in these patients. Surgical lymph node sampling may still need to be performed to accurately identify nodal status in pediatric patients with soft tissue sarcoma.

Prophylactic Mastectomy in Patients at High Risk: Is There a Role for Sentinel Lymph Node Biopsy?

IntroductionProphylactic mastectomy (PM) rates in the United States are rising due to determination of increased Gail risk, moderate-high risk lesions, a strong family history, and gene mutation carriers. The role of sentinel lymph node biopsy (SLNB) in PM remains controversial. This report sought to examine clinical utility of SLNB in PM. MethodsA total of 292 patients underwent bilateral or contralateral PM (1999-2011). SLNB was performed on the PM side in 195 (66.7%) patients with standard techniques. Clinicopathologic data were analyzed for the incidence of occult cancer in prophylactic breast and/or axilla. Univariate analysis was used to determine factors that predict SLN positivity. ResultsThe median patient age was 49 years (range, 19-79 years). Contralateral invasive breast cancer (64.7%) was the most common indication for PM. A total of 209 (71.5%) invasive breast cancer and 49 (16.7%) in situ cancers (n = 38 ductal carcinoma in situ, n = 10 lobular carcinoma in situ) were identified on the therapeutic mastectomy side, with a median tumor size of 1.5 cm. 58.6% were estrogen receptor positive and 4.7% were multicentric. Three (1%) ductal carcinoma in situ, 4 (1.3%) lobular carcinoma in situ, and 5 (1.7%) atypical ductal, and 1 (0.3%) lobular hyperplasia were identified in PM breast. No invasive breast cancer or positive SLN was identified in PM breast and/or axilla. ConclusionAlthough a minimally invasive procedure, the utility of SLNB in patients with absent or contralateral early disease is limited. Advanced T stage, multicentricity, or receptor status on the therapeutic side or a finding of in situ or atypical hyperplasia in prophylactic breast specimen yielded no positive SLN. Routine SLNB in pure bilateral PM can safely be omitted, which reduces axillary morbidity and operative time and/or cost. Selective use of SLNB for contralateral recurrent and/or locally advanced cancers warrants further investigation.

A Positive Sentinel Lymph Node in Periocular Invasive Squamous Cell Carcinoma

The aim of this article was to describe positive sentinel lymph node biopsy (SLNB) findings in patients with periocular invasive squamous cell carcinoma (SCC). This was a retrospective chart review of 5 patients with invasive SCC of the periocular region who underwent SLNB and were found to have regional metastasis. All patients had large (2.0-4.3 cm) primary tumors with poor differentiation on pathology. In all 5 patients, SLNB was positive in the absence of other signs or evidence of regional or systemic metastasis. While tumor cells may drain to the preauricular or the submandibular basin, the preauricular lymph node was identified as the sentinel lymph node on lymphoscintigraphy in all 5 patients. With a positive sentinel lymph node, the results of SLNB changed the clinical staging and influenced subsequent treatment recommendations for each patient. We identified no complications related to SLNB including facial nerve damage, lymphedema, or allergic reaction to radioactive tracing material. In this series of patients with periocular invasive SCC, SLNB was well tolerated and uncovered regional metastasis in patients with no clinical signs of metastasis otherwise. The SLNB findings influenced subsequent oncologic management recommendations. The usefulness of SLNB for poorly differentiated SCC remains uncertain. Further research is necessary to establish the role of SLNB in periocular SCC.

Abstract S2-3: Disparities in the utilization of axillary sentinel lymph node biopsy among black and white patients with node-negative breast cancer from 2002–2007.

Abstract Background: Disparities exist in many aspects of standard breast cancer treatment in certain patient populations. In the mid-1990s, axillary sentinel lymph node biopsy (SLNB) was introduced as an alternative to axillary lymph node dissection (ALND) for staging clinically node-negative breast cancer. During the early 2000s, the validity of SLNB was being determined and its technique was being disseminated throughout the surgical community. By the mid to late-2000s, SLNB had been shown to provide accurate axillary staging with lower complications and no difference in survival compared to ALND in node-negative patients. SLNB has now replaced ALND as the accepted method for staging early breast cancer. The purpose of this study is to examine differences in the utilization of SLNB in pathologic node-negative invasive black breast cancer patients compared to white patients as SLNB became standard axillary staging and whether this difference impacted patient complications. Methods: Using the population-based Surveillance, Epidemiology, and End Results (SEER)-Medicare data, cases of incident, non-metastatic, pathologic node-negative breast cancer in women age≥66 were identified. Patients were considered to have undergone SLNB if specified by SEER records or if a billing claim for axillary lymphatic mapping was identified. Unadjusted associations of SLNB with race were evaluated using the chi-square test. The Cochran-Armitage test evaluated trends over time. Multivariate logistic regression tested whether race was associated with the use of SLNB after adjustment for clinicopathologic factors. Five-year cumulative incidence of lymphedema assessed via ICD-9 diagnosis codes was measured using the Kaplan-Meier method. Adjusted proportional hazards regression evaluated assiciations of race and ALND with lymphedema risk. Results: Of 31,274 women identified, 1,767 (5.7%) were Black, 27,856 (89%) were White and 1,651 (5.3%) were of other/unknown race. SLNB was performed in 74% of white patients compared to 62% of black patients (P&amp;lt;0.001). Although use of SLNB increased by year for both black and white patients (P&amp;lt;0.001), a fixed disparity in the use of SLNB persisted through 2007. In adjusted analysis, black patients were 33% less likely than white patients to undergo SLNB (relative risk = 0.74, 95% CI 0.67-0.81; P&amp;lt;0.001). Five-year cumulative incidence of lymphedema was 11.4% in patients undergoing ALND vs. 6.3% in patients undergoing SLNB (adjusted HR 1.92, 95% CI 1.75-2.10; P&amp;lt;0.001). Overall, black race was also associated with a higher risk of lymphedema (adjusted HR 1.40; 95% CI 1.20-1.63; P&amp;lt;0.001). However, among patients undergoing SLNB, whites and blacks had similar risks of lymphedema (6.2% and 7.7%, respectively; P=0.08). Conclusion: Even with the increased use of SLNB and its acceptance as standard axillary staging for node-negative breast cancer patients, disparities persist in its underutilization in appropriate black patients compared to white patients by as much as 26%. This racial disparity in SLNB use translated to a higher risk of lymphedema for black patients. Improving surgeon practices, the multidisciplinary team approach, and patient education are important in optimizing the beneficial impact of SLNB and reducing complications from unnecessary ALNDs in all patients with early stage breast cancer. Future research is needed to delineate mechanisms underlying this persistent disparity and to identify strategies to mitigate it. Citation Information: Cancer Res 2012;72(24 Suppl):Abstract nr S2-3.

Sentinel lymph node biopsy in melanoma: Our 8-year clinical experience in a single French institute (2002–2009)

BackgroundSince the introduction of sentinel lymph node biopsy (SLNB), its use as a standard of care for patients with clinically node-negative cutaneous melanoma remains controversial. We wished to evaluate our experience of SLNB for melanoma.MethodsA single center observational cohort of 203 melanoma patients with a primary cutaneous melanoma (tumour thickness > 1 mm) and without clinical evidence of metastasis was investigated from 2002 to 2009. Head and neck melanoma were excluded. SLN was identified following preoperative lymphoscintigraphy and intraoperative gamma probe interrogation.ResultsThe SLN identification rate was 97%. The SLN was tumor positive in 44 patients (22%). Positive SLN was significantly associated with primary tumor thickness and microscopic ulceration. The median follow-up was 39.5 (5–97) months. Disease progression was significantly more frequent in SLN positive patients (32% vs 13%, p = 0.002). Five-year DFS and OS of the entire cohort were 79.6% and 84.6%, respectively, with a statistical significant difference between SLN positive (58.7% and 69.7%) and SLN negative (85% and 90.3%) patients (p = 0.0006 and p = 0.0096 respectively). Postoperative complications after SLNB were observed in 12% of patients.ConclusionOur data confirm previous studies and support the clinical usefulness of SLNB as a reliable and accurate staging method in patients with cutaneous melanoma. However, the benefit of additional CLND in patients with positive SLN remains to be demonstrated.

Utilization of Sentinel Lymph Node Biopsy in Patients with Ductal Carcinoma In Situ Undergoing Mastectomy

Current guidelines suggest consideration of sentinel lymph node biopsy (SLNB) for patients with ductal carcinoma in situ (DCIS) undergoing mastectomy. Our objective was to identify factors influencing the utilization of SLNB in this population. We used the Surveillance Epidemiology and End Results database to identify all women with breast DCIS treated with mastectomy from 2000 to 2008. We excluded patients without histologic confirmation, those diagnosed at autopsy, those who had axillary lymph node dissections performed without a preceding SLNB, and those for whom the status of SLNB was unknown. We used multivariate logistic regression reporting odds ratios (OR) and 95% confidence intervals (CI) to evaluate the relationship of patient- and tumor-related factors to the likelihood of undergoing SLNB. Of 20,177 patients, 51% did not receive SLNB. Factors associated with a decreased likelihood of receiving a SLNB included advancing age (OR 0.66; 95% CI 0.62-0.71), Asian (OR 0.75; CI 0.68-0.83) or Hispanic (OR 0.84; 95% CI 0.74-0.96) race/ethnicity, and history of prior non-breast (OR 0.57; 95% CI 0.53-0.61). Factors associated with an increased likelihood of receiving a SLNB included treatment in the east (OR 1.28; 95% CI 1.17-1.4), intermediate (OR 1.25; 95% CI 1.11-1.41), high (OR 1.84; 95% CI 1.62-2.08) grade tumors, treatment after the year 2000, and DCIS size 2-5 cm (OR 1.54; 95% CI 1.42-1.68) and >5 cm (OR 2.43; 95% CI 2.16-2.75). SLNB is increasingly utilized in patients undergoing mastectomy for DCIS, but disparities in usage remain. Efforts at improving rates of SLNB in this population are warranted.

Rural and urban disparities in the evolution of sentinel lymph node utilization in breast cancer.

71 Background: Sentinel lymph node biopsy (SLNB) has become the preferred method for axillary nodal staging. We examined SLNB utilization in urban versus rural settings as this procedure was adopted. We hypothesized that SLNB rates in urban centers quickly increased prior to 2000, while the technology shift and acceptance of SLNB was slower in rural centers. Methods: The SEER registry was used to identify patients with invasive ductal or lobular breast cancer from 1998-2008. Exclusion criteria included evidence of distant metastatic disease, T4 tumors, no curative-intent operation performed, or incomplete staging data. Residential setting was divided into three groups based on population density: rural, intermediate population, and urban. Results: The overall rate of SLNB increased with time (9.5% in 1998 to 72.7% in 2008). The adoption of SLNB was slower in rural settings than in urban populations (p&lt;0.001). By 2003, only urban areas were utilizing SLNB in over 50% of cases. When stratified by population density, there was a significant difference in SLNB rates according to type of surgery performed (lumpectomy vs mastectomy) as well as by T-stage, with lower T-stage positively correlating with the likelihood of SLNB usage in all categories. Overall, there was a two-year lag in the adoption of between the increases in SLNB utilization rates in these groups. Conclusions: Since 1998, the use of SLNB for breast cancer has slowly increased throughout the United States. Though widely accepted as the preferred staging method, the overall rate of SLNB remained near 50% and was lower in rural locations in 2004. By 2008, the SLNB rate for T1-T2 had increased to over 50% in all population categories. There was an overall 2-year lag in adoption of SLNB in less populated areas. While this may represent a more conservative approach as noted by the higher utilization in small tumors, the difference may be attributable to a shortage of experienced surgeons, lack of training, or lack of technological support at smaller institutions. The provision of continued training in emerging technologies for rural surgeons, such as SLNB, should remain a priority in continuing surgical education.

Selective approach to radionuclide-guided sentinel lymph node biopsy in high-risk ductal carcinoma in situ of the breast

Ductal carcinoma in situ (DCIS) currently represents approximately 15-25% of all breast cancers detected. Although inherently a noninvasive disease, occult invasive disease can be found at definitive histology. The role of sentinel lymph node (SLN) biopsy in DCIS is still unclear. The aim of this study was to evaluate the clinical usefulness of SLN biopsy and the incidence of SLN metastases in selected patients with high-risk DCIS, who are at highest risk for being upstaged to invasive carcinoma. Twenty-three high-risk patients with DCIS proven on core biopsy (mean age, 50 years; median age, 48 years; age range, 37-78 years) were included in the study. SLN scintigraphy was performed 2-4 h before surgery by injecting Tc-99m-labeled nanocolloid intradermally in the periareolar region. The first lymph node to appear on the scan was labeled as SLN and was marked on the skin by using a γ probe. The lymph node was explored in the axilla using a γ probe. The SLN was identified in all patients (100% success rate). Of 23 cases of DCIS on core biopsy, seven patients (30%) were shown to have invasive ductal carcinoma on final histological specimen. Among these seven patients, three had minimal invasive carcinoma (<1 cm) and none of these patients had positive SLN for metastases. Among 23 cases, only one patient with (4%) SLN was positive for metastasis despite histopathological diagnosis of pure DCIS. Although the study population is small, our findings suggest that patients with high-risk DCIS have an increased risk of invasive disease, as approximately one-third of these patients had invasive component at the time of definitive operative procedure. Furthermore, the study also suggests that SLNB appears to be reliable in identifying axillary lymph nodes status of these patients.