Is the UICC pathological node status system useful? comparison with the Japanese Breast Cancer Society pathological node status system

BACKGROUND AND OBJECTIVES: The UICC and the Japanese Breast Cancer Society have different TNM classifications. There is a large discrepancy between the pathological node status in the UICC (UICC-NS) and JBCS (JBCS-NS) systems. We compared the UICC-NS with the JBCS-NS. METHODS: Reviewed were data on 1,684 invasive ductal carcinomas at the Cancer Institute Hospital from 1981 to 1986. Each case was categorized according to the UICC-NS and JBCS-NS, respectively. Overall survival 10 years after surgery (OS) by UICC-NS and JBCS-NS was calculated by the Kaplan-Meier method. RESULTS: OS with UICC-NS and number of case were, respectively, 87.8% and 968 for pN0, 83.9% and 93 for pN1a, 71.6% and 190 for pN1bi, 60.0% and 25 for pN2, 58.8% and 51 for pN1bii, 55.7% and 238 for pN1biii, 54.2% and 24 for pN1biv, 44.8% and 58 for pN3, and 20.6% and 34 for pM (LYM). Differences between pN1a and pN1bi and pN3 and pM (LYM) were significant (p < 0.05). In JBCS-NS, they were 87.8% and 968 for n0, 75.3% and 384 for n1 alpha, 51.3% and 152 for n1 beta, 46.6% and 141 for n2, 21.2% and 33 for n3, 0% and 2 for n4d and n4i, respectively. Differences between n0 and n1 alpha, n1 alpha and n1 beta, and n2 and n3 were significant (p < 0.05). CONCLUSIONS: With a large number of classification factors, UICC-NS was more complicated and hard to show significant difference in OS than JBCS-NS. But the latter also had redundant classifications. So, it is necessary to establish a new, simple, and easy-to-register node classification in future.     

What is the impact of sentinel node biopsy in the management of cancer?

Sentinel node biopsy (SNB) is a surgical/histopathological diagnostictool that is increasingly used but still being evaluated insurgical oncology. The concept of sentinel node biopsy (SNB) was first establishedin melanoma of the skin [1]. It is based on the observationthat from a given area of the skin, lymphatic spreading of melanomacells proceeds following sequential steps, in an orderly fashion.The first lymph node encountered by floating melanoma cellsis called the sentinel node (SN) and SN is specifically (95%)the site of micrometastases if they exist. In case of unpalpableregional lymph node (N0), the histological status of     

When is a completion axillary lymph node dissection necessary in the presence of a positive sentinel lymph node?

BackgroundThe management of the axilla in the presence of positive sentinel lymph node (SLN) remains controversial. Many centres forgo completion axillary lymph node dissection (cALND) in the presence of micrometastatic disease. The American College of Surgeons Oncology Group (ACOSOG) Z0011 trialists argue for extending this to macrometastasis. The aim of this study was to correlate tumour burden in SLNs with that in the residual lymph node basin to determine the likelihood of residual disease in patients with micro- and macrometastasis in the SLN.MethodsPatients who underwent cALND following a positive SLN were analysed for histopathological features of the primary tumour and burden of axillary disease.ResultsOf 155 patients, 115 (74%) had macrometastases and 40 (26%) micrometastases in the SLNs. Residual axillary disease was detected in 55/155 (35%) patients with macrometastases and 4/40 (10%) with micrometastases. Generally, with increasing size of metastasis in the SLN there was an increasing risk of further disease in residual lymph nodes. Logistic regression analysis showed increased odds ratios for further disease for all groups when compared with the <2 mm (micrometastasis) SLN group.ConclusionPatients may be advised to forgo cALND where the SLN contains isolated tumour cells or micrometastasis. Recommendations for proceeding to cALND can be based on the size of metastasis in the SLN, which relates to the risk of further disease in the residual axillary lymph nodes and subsequent regional recurrence.     

Does the introduction of sentinel node biopsy increase the number of node positive patients with early breast cancer? A population based study form the Danish Breast Cancer Cooperative Group

Background. The validation series of sentinel lymph node biopsy (SLNB) in the treatment of breast cancer have shown that 10-20% more lymph node metastases are detected. However, their impact has never been studied in populations where the method has been fully implemented. In a population-based setting, the objective of the current study was to estimate the increased risk of metastases after introduction of the sentinel lymph node biopsy technique. Methods. We identified all new breast cancer patients in three different counties in two time periods (1996-1997 and 2002-2003). The study cohort was comprised of 2 932 patients. The main outcome was the frequency of patients with metastases. The frequencies of patients with metastases were compared as well as adjusted (using a multivariate logistic regression) and unadjusted odds-ratio for detecting lymph node metastases. Results. In counties where sentinel lymph node biopsy was implemented, the frequency of patients with lymph node metastases increased significantly 7.3% (95% CI: 1.0-13.7%) and 13.3% (95% CI: 7.3-19.3%), respectively. In the county without sentinel lymph node biopsy, an insignificant increase of 6.9% (-0.1-13.9%) in the frequency of patients with metastases was seen. The adjusted odds- ratio for detecting lymph node metastases was 1.41 (1.07-1.87) and 1.70 (1.30-2.23) in the counties with SLNB. Conclusion. The frequency of patients with metastases increased significantly in counties where sentinel lymph node biopsy was implemented.     

Sentinel node biopsy for breast cancer: Does the number of sentinel nodes removed have an impact on the accuracy of finding a positive node?

BACKGROUND AND OBJECTIVES: The number of sentinel lymph nodes (SLNs) removed during biopsy may have an impact on the accuracy of finding a positive SLN. This study investigated various factors to determine if they had any significant correlation with the number of SLNs found during biopsy. In patients with positive SLNs, the nodes were then analyzed to determine which SLN contained metastasis. METHODS: For 263 patients with breast cancer who successfully underwent SLN biopsy, parameters such as tumor size, histologic characteristics, differentiation, and receptor status, patient age, breast quadrant, type of surgery, mapping with blue dye only or with radiocolloid, and whether biopsy was performed before or after tumorectomy were prospectively collected. These factors were analyzed to determine whether they had any significant correlation to the number of removed lymph nodes. Positive SLNs were ranked in the order they were removed and examined for which node contained the metastasis. RESULTS: During biopsy, a mean of 1.8 (range, 1-5) SLNs were found. The SLNs were negative in 158 patients and positive in 105. The number of SLNs removed was comparable between node-negative and node-positive patients, and none of the parameters analyzed was significantly related to the number of SLNs removed. Of the 105 patients with a positive SLN, the first SLN independently predicted the pathologic status of the axilla in 96 patients (91.4%; 95% CI 86.1-96.8), and the first and second SLN independently predicted the status in 104 patients (99%; 95% CI 97.2-100). Only one of 105 patients had metastasis in the third SLN removed. CONCLUSION: The pathologic status of the axilla was independently determined by removal of the first or first and second SLN in 99% of patients; removal of more than three SLNs did not increase the accuracy of finding a positive node.     

What is a sentinel node? Re‐evaluating the 10% rule for sentinel lymph node biopsy in melanoma

INTRODUCTION: Many surgeons use the "10% rule" to define whether a lymph node is a sentinel node (SLN) when staging malignant melanoma. However, this increases the number of SLN removed and the time and cost of the procedure. We examined the impact of raising this threshold on the accuracy of the procedure. METHODS: We reviewed the records of 561 patients with melanoma (624 basins) who underwent SLN with technetium Tc99 labeled sulfur colloid using a definition of a SLN as 10% of that of the node with the highest counts per minute (CPM). RESULTS: Of the 624 basins, 154 (25%) were positive for metastases. An average of 1.9 nodes per basin were removed (range 1-6). Metastases were found in the hottest node in 137 cases (89% of positive basins, 97% of basins overall). Increasing the threshold above 10% decreased the number of nodes excised and the costs involved, but incrementally raised the number of false negative cases above baseline (a 4% increase for a "20% rule," 5% for a "30% rule," 6% for a "40% rule," and 7% for a "50% rule"). Taking only the hottest node would raise the false negative rate by 11%. CONCLUSIONS: Although using thresholds higher than 10% for the definition of a SLN will minimize the extent of surgery and decrease the costs associated with the procedure, it will compromise the accuracy of the procedure and is not recommended.     

Should the splenic hilar lymph node be dissected for the management of adenocarcinoma of the esophagogastric junction?

BackgroundSplenic hilar lymphadenectomy is not recommended for advanced proximal gastric cancer that does not invade the greater curvature according to the results of the previous studies. The efficacy of splenic hilar lymphadenectomy for type II and type III adenocarcinomas of the esophagogastric junction and easy spread to the greater curvature of the stomach remains unclear. This study aimed to investigate the efficacy of splenic hilar lymphadenectomy and identify the risk factors for metastasis to splenic hilar nodes.MethodsWe examined patients who underwent R0/1 gastrectomy for Siewert types II and III at a single high–volume center in Japan. We analyzed the metastatic incidence, therapeutic value index, and risk factors for splenic hilar lymph node metastasis.ResultsWe examined 126 patients (74, type II; 52, type III). Splenectomy was performed in 76 patients. Metastatic incidence and the therapeutic value index of splenic hilar lymph nodes in patients with type II and type III tumors were 4.5% and 0, and 21.9% and 9.4, respectively. In the patients who underwent splenectomy, we identified Siewert type III tumors (odds ratio: 6.93, 95% confidence interval: 1.24–38.8, p = 0.027) and tumor location other than the lesser curvature (odds ratio: 7.36, 95% confidence interval: 1.32–41.1, p = 0.023) to be independent risk factors. The metastatic incidence (46.2%) and therapeutic value index (15.4) were high in patients with both risk factors.ConclusionsSplenic hilar lymphadenectomy may contribute to the survival of patients with Siewert type III tumors, especially when the predominant location is not the lesser curvature.     

Prognostic value of the lymph node ratio in stage Ⅲ colorectal cancer

The nodal stage of colorectal cancer is based on the number of positive nodes.It is inevitably affected by the number of removed lymph nodes,but lymph node ratio can be unaffected.We investigated the value of lymph node ratio in stage Ⅲ colorectal cancer in this study.The clinicopathologic factors and follow-up data of 145 cases of stage Ⅲ colorectal cancer between January 1998 and December 2008 were analyzed retrospectively.The Pearson and Spearman correlation analyses were used to determine the correlation coefficient,the Kaplan-Meier method was used to analyze survival,and the Cox proportional hazard regression model was used for multivariate analysis in forward stepwise regression.We found that lymph node ratio was not correlated with the number of removed lymph nodes(r =-0.154,P = 0.065),but it was positively correlated with the number of positive lymph nodes(r = 0.739,P 0.001) and N stage(r = 0.695,P 0.001).Kaplan-Meier survival analysis revealed that tumor configuration,intestinal obstruction,serum carcinoembryonic antigen(CEA) concentration,T stage,N stage,and lymph node ratio were associated with disease-free survival of patients with stage Ⅲ colorectal cancer(P 0.05).Multivariate analysis showed that serum CEA concentration,T stage,and lymph node ratio were prognostic factors for disease-free survival(P 0.05),whereas N stage failed to achieve significance(P = 0.664).We confirmed that lymph node ratio was a prognostic factor in stage Ⅲ colorectal cancer and had a better prognostic value than did N stage.     

Will we need lymph node dissection at all in the future?

Traditionally in the treatment of primary breast cancer, axillary lymph node dissection (ALND) plays an important role. However, a substantial and increasing percentage of patients appear to have no nodal involvement and have been subjected to ALND unnecessarily. The first reason to perform an ALND is axillary nodal staging. After reviewing the literature, it can be concluded that in clinically node-negative patients an adequately conducted lymphatic mapping by sentinel node procedure is equal to ALND for this purpose. The second reason to perform an ALND is to establish the extent of nodal involvement, which might have an impact on adjuvant treatment recommendations. However, there is no evidence available that patients with extensive nodal involvement (= 4 positive nodes) benefit more from adjuvant systemic treatment (either standard or high dose) in terms of reduction of odds of recurrence and mortality compared to patients with limited nodal involvement and optimally administered so-called standard adjuvant treatment. The third reason to perform an ALND is to ensure axillary tumor control. Reviewing the different treatment options, it can be concluded that in clinically node-negative patients axillary control after axillary radiotherapy appears to be similar to axillary control after ALND. In clinically overt axillary involvement, ALND (with or without adjuvant radiotherapy) may result in an improved regional control. In the near future, ALND will not be the standard of care but will be reserved for those patients with proven axillary lymph node involvement. In microscopic disease, radiotherapy may be an alternative with equal control and less morbidity.     

Can we avoid axillary dissection in the micrometastatic sentinel node in breast cancer?

There is considerable interest in foregoing axillary dissection (AD) when the sentinel node (SN) is positive in early breast cancer, particularly when involvement is minimal (micrometastases or isolated tumor cells). To address this issue we analyzed outcomes in patients with a single micrometastatic SN who did not receive AD. We selected 377 consecutive patients treated at the European Institute of Oncology between 1999 and 2007 for invasive breast cancer. Classical and competing risks survival analyses were performed to estimate prognostic factors for axillary recurrence, first events and overall survival. Median age was 53?years (range 26?C80); median follow-up was 5?years (range 1?C9). Most (91.8%) patients received conservative surgery; 209 (55.4%) had only one SN (range 1?C8). Five-year overall survival was 97.3%. There were 10 local events, 2 simultaneous local and axillary events, 6 axillary recurrences and 12 distant events. The cumulative incidence of axillary recurrence was 1.6% (95% CI 0.7?C3.3). By multivariable analysis, tumor size and grade were significantly associated with axillary recurrence. The high five-year survival and low cumulative incidence of axillary recurrence in this cohort provide justification for the increasingly common practice of foregoing AD in women with minimal SN involvement, and suggest in particular that AD can safely be avoided in women with small, low-grade tumors. Nevertheless, a subset of patients might be at high risk of developing overt axillary disease and efforts should be made to identify such patients by ancillary analyses of the results of ongoing or recently published clinical trials.     

Clinical lymph node staging in colorectal cancer; a flip of the coin?

Background

This study aims to provide insight in the quality of current daily practice in clinical lymph node staging in colorectal cancer (CRC) in the Netherlands.

Is the sentinel lymph node pathology protocol in breast cancer patients associated with the risk of regional recurrence?

Background

Internationally, there is no consensus on the pathology protocol to be used to examine the sentinel lymph node (SN) in breast cancer patients. Previously, we reported that ultra-staging led to more axillary lymph node dissections (ALND). The question was, whether ultra-staging is effective in reducing the risk of regional relapse.

Methods

From January 2002 to July 2003, 541 patients from 4 hospitals were prospectively registered when they underwent a SN biopsy. In hospitals A, B, and C, 3 levels of the SN were examined pathologically, whereas in hospital D at least 7 additional levels were examined. Patients with a positive SN, including isolated tumor cells, underwent an ALND. This analysis focuses on the 341 patients with a negative SN. Primary endpoint was 5-year regional recurrence rate.

Results

In hospital D 34% of the patients had a negative SN as compared to 71% in hospitals A, B, and C combined (p < 0.001). At 5 years follow-up, 9 (2.6%) patients had developed a regional lymph node relapse. In hospital D none of the patients had a regional recurrence, as compared to 9 (2.9%) cases of recurrence in hospitals A, B, and C.

Conclusion

The less intensified SN pathology protocol appeared to be associated with a slightly increased risk of regional recurrence. The absolute risk was still less than 3%, and does not seem to justify the intensified SN pathology protocol of hospital D.     

Diagnostic excision of the Rosenmüller's node. Screening for occult metastases before elective regional lymph node dissection in patients with lower limb melanoma?

Elective radical groin dissection was performed on 297 consecutive patients with high-risk melanoma of the leg, Anderson Stages I, IIA, IIIA. By separate histologic examination of the so-called "Rosenmüller's node," the other inguinal, and the external iliac lymph nodes, the diagnostic excision of the Rosenmüller's node was tested as a suitable mode of screening for metastases before a planned elective regional lymph node dissection. Eighty patients (27%) presented with what was histologically determined to be occult groin metastases. Rosenmüller's node was involved in 30 of these cases; in the remaining 50, however, it was not affected; that is, 63% of the cases were false-negative. Thus, the involvement of Rosenmüller's node is not representative of metastases in the other ilioinguinal lymph nodes, but is rather a matter of chance. In women with superficial spreading melanoma the rate of occult lymph node metastases was significantly lower than that in men with melanomas of the other type. Iliac lymph node involvement was observed in 18 patients (22%) depending on clinical stage and depth of invasion of the primary tumor.     

Does sentinel node biopsy improve the management of endometrial cancer? Data from 43 patients

OBJECTIVES: To map sentinel lymph nodes (SLNs) detected by intracervical injection in patients with endometrial cancer and to determine the prevalence of node micrometastases. METHODS: Radionuclide and blue dye injections were used for SLN detection in 43 patients with clinical stage I endometrial cancer. Lymphoscintigraphy was done before surgery. Intraoperatively, the pelvic and para-aortic territories were examined for blue and/or radioactive nodes. Pelvic lymphadenectomy was performed with or without para-aortic lymphadenectomy. SLNs stained with hematoxylin-eosin-saffron were examined and, when negative, evaluated using step sectioning and immunohistochemistry. RESULTS: Feasibility was 100%. No adverse effects occurred. SLNs were identified in 30 patients (69.8%), usually in an interiliac location (28/30 patients, 93.3%). SLNs were found only in the common iliac chain in 1 (3%) patient and in both the common iliac chain and promontory area in another (3%). No patients had para-aortic SLNs or SLNs confined to the promontory. Node metastases were identified in eight patients and were confined to SLNs in six. In 2 (2/30, 6%) patients, SLNs contained micrometastases. No false-negatives occurred. CONCLUSIONS: Intracervical injection of radionuclide and blue dye chiefly revealed pelvic SLNs. The prevalence of micrometastases was within the expected range. Comparisons with peritumoral injection are needed.     

Complications of sentinel lymph node biopsy for melanoma – A systematic review of the literature

Purpose

The complications reported after sentinel lymph node biopsy (SLNB) for melanoma is highly variable in the worldwide literature; the overall complication rate varies between 1.8% and 29.9%. With heterogeneous reporting of morbidity data, no ‘average’ complication rates of this procedure have been reported. This systematic review aims to determine the complications rates associated with SLNB.