Lymphscintigraphies of the internal mammary ganglion chain: our experience

In this study we have evaluated 301 internal mammary lymphoscintigraphies. The results were compared with the histology of internal mammary lymphoscintigraphies, lymphatic chain and axillary lymph nodes, with the anatomo-pathological stage of the disease, with primary tumor site, and also with patients survival. The influence of breast surgery and radiotherapy on the internal breast is shown in the results of the said 301 internal breast lymphscannings. We understand LCMI as a procedure that helps to evaluate the disease stage, to plan therapeutics, to provide a prognosis factor.     

Sentinel lymph node identification in a primary ductal carcinoma arising in the vulva

Primary or metastatic breast-like carcinoma of the vulva is a rare event. Because of the similarity with breast ductal carcinoma, we think that the same principles used for treatment of orthotopic breast cancer can be applied, as well as the use of sentinel lymph node technique, which is widely accepted in the management of early-stage breast cancer. We report a 49-old-year postmenopausal woman who was referred to our institution after small biopsy of a 3.5- x 3-cm right vulvar tumor. Histopathologically, infiltration of the vulvar dermis by a ductal carcinoma of mammary gland type was reported. At operation, the sentinel node technique revealed two sentinel nodes in the right inguinal area. Although these nodes proved negative for malignancy, the patient underwent wide local excision of tumor and complete ipsilateral inguinofemoral lymphadenectomy. The remaining excised nodes were negative. Surgical specimen proved estrogen- and progesterone-positive receptors, the reason for which the patient received tamoxifen adjuvant therapy. This report represents the first case in the world literature of primary breast carcinoma arising in the vulva in which sentinel lymph node identification has been possible. Because of the rarity of this condition, the pathologic similarity of this tumor along with currently accepted guidelines for the management of breast cancer supports the possibility of local excision and sentinel lymph node identification as a possible alternative to inguinofemoral lymphadenectomy.     

Sentinel lymph node biopsy. Preferred method of axillary staging for breast cancer

Sentinel lymph node (SLN) biopsy has replaced routine axillary lymph node dissection (ALND) for most breast cancer patients with clinically normal lymph nodes. The morbidity (lymphedema, arm numbness) of SLN biopsy is significantly less than ALND. The use of alternative injection sites (skin or subareolar) yields high SLN identification rates and may shorten the learning curve associated with standard peritumoral injection. The dual-agent (radiocolloid plus blue dye) technique is recommended to decrease false-negative rates, especially when surgeons are just learning how to perform SLN biopsy. Regardless of the technique employed, SLN identification rates should be > 95% with a false-negative rate of < 5%. Using serial sectioning and immunohistochemistry, SLN micrometastases can be identified in 10% to 20% of node-negative patients. However, the clinical significance of micrometastases is not known. Axillary recurrence is rare for patients without SLN metastases who do not undergo further axillary surgery. Outside a clinical trial, ALND is recommended for most patients with SLN metastases, except for cases with SLN metastases < 0.2 mm detected by immunohistochemistry alone. The indications for SLN biopsy have expanded and include breast cancer patients with multifocal/multicentric disease and large tumors, and male breast cancer. Although minimally invasive internal mammary SLN biopsy is feasible, the usefulness of this procedure is not established.     

Recurrencias loco-regionales en pacientes con cáncer de mama invasivo que presentan 3 ganglios positivos o menos. ¿Está indicada la radioterapia?

Introduction

There is international consensus on the role of regional lymph node radiotherapy in patients with early stage breast cancer and four or more positive lymph nodes. However, the decision is less clear when fewer than four affected lymph nodes are affected. As our hospital does not systematically carry out adjuvant radiotherapy in regional lymph nodes in patients with three or fewer positive lymph nodes, we assessed locoregional recurrence in this group of patients during the first 5 years after treatment.

Material and Methods

We performed a retrospective study based on a 5-year follow-up after the end of treatment. Data were obtained from the patients’ clinical histories. Outcomes were compared with those reported by Overgaard et al in a subgroup of patients with three or fewer affected lymph nodes receiving radiotherapy in the regional lymph nodes.

Results

No locoregional recurrence was detected up to 5 years after treatment. No significant differences were found between our patients and those of Overgaard (p = 0.5412).

Conclusion

In view of the obtained results it does not seem necesary to treat with radiotherapy on lymph node chains to all early stage breast cancer patiens with three or fewer affected lymph nodes.     

Targeted Removal of Axillary Lymph Nodes After Carbon Marking in Patients with Breast Cancer Treated with Primary Chemotherapy

In breast cancer patients who have received primary chemotherapy and then no longer have any suspicious lymph nodes clinically and/or on imaging, marking of initially suspicious axillary lymph nodes with targeted removal has recently been discussed and practised both in Germany and internationally as an alternative to complete axillary lymph node dissection. Tattooing of the suspicious lymph nodes with a highly purified carbon suspension is currently being investigated in clinical studies. Compared with other techniques, the advantages of this method are the high rate of intraoperative lymph node detection, avoidance of an immediately preoperative localisation procedure and the low costs. The practical aspects of lymph node tattooing and the current data regarding this method will be described.Key words: breast cancer, lymph nodes, carbon marking, primary chemotherapy, targeted axillary dissection, TAD     

Detection of axillary metastases in breast cancer patients using ultrasound and colour Doppler combined with fine needle aspiration cytology

The aims of this study were to evaluate the diagnostic value of ultrasonography and colour Doppler combined with fine needle aspiration (FNA) cytology for the detection of non-palpable axillary lymph node metastases in breast cancer patients. Forty patients with operable breast cancer (T1/T2), invasive carcinoma, not submitted to neo-adjuvant therapy, underwent axillary ultrasonography and colour Doppler preoperatively. FNA cytology was performed on axillary lymph nodes presenting ultrasonographic and/or Doppler suspicious features. A total of 542 lymph nodes were surgically removed from the 40 patients; 19 were metastatic lymph nodes. Ultrasound-guided FNA detected metastases in six out of 11 histologically node-positive patients. Sensitivity and specificity in this preliminary study was 55% and 100%, respectively. These are the preliminary results of a prospective study that has the purpose of reducing the sentinel node procedures in breast cancer patients with clinically negative axillae, but positive FNA cytology.     

Identification of the sentinel lymph node stained with blue dye in breast cancer patients

PURPOSE: This study aimed to evaluate the reproducibility of sentinel lymphadenectomy in breast cancer patients (T1N0M0 and T2N0M0) and its possibility of predicting the total axillary behavior. METHODS: A total of 25 patients were evaluated, all presenting palpable mammary nodes between 1.5 and 5 cm (T1 and T2), with clinically negative axillary lymph nodes (N0). After an incisional biopsy of the tumor and histopathological confirmation of invasive breast carcinoma, a study of the sentinel lymph node took place with a peritumoral injection of 4 ml of blue dye at 2.5%. After waiting for 15 to 20 minutes, a search for the blue stained lymphatic vase in the axillary fat was carried out, which would lead to the sentinel lymph node, stained or not. At that point, a mastectomy (20 patients) or a quadrantectomy (5 patients) was performed, both with axillary lymphadenectomy at grades 1, 2 and 3. The sentinel lymph nodes and the material from the axillary dissection were sent separately for an anatomicopathological test in paraffin. RESULTS: The lymph nodes were identified in 19 patients, which represented a 76% detection rate. There was a concordance between the sentinel lymphadenectomy and the standard axillary dissection in 68.4% of the patients. The false-positive and the false-negative rates observed were 10% and 55.5%, respectively. A higher detection rate was found in tumors larger than 2 cm and situated in external quadrants. CONCLUSIONS: Sentinel lymphadenectomy identified the sentinel lymph node in the majority of the patients in this study, although the high rate of false-negatives observed prevented an accurate staging.     

Detection of atypical site of "sentinel lymph nodes" by lymph drainage scintigraphy in patients with breast carcinoma

OBJECTIVE: Sentinel lymph node (SLN) localization in breast cancer allows biopsy of directly tumor drained lymph nodes. The objective was to study the association of tumor and SLN localization. PATIENTS AND METHODS: SLN was identified in 39 (81%) of 48 patients with histologically proven breast cancer, clinically and sonographically unsuspected axillary lymph nodes after peritumoral application of 40-50 Mbq 99mTc-Nanocolloid. Patients age, tumor size and localization, histology and localization of the SLN as well as removed axillary lymph nodes were analyzed. RESULTS: Axillary lymph node metastases were found in 11 (28%) of 39 patients. Involvement of the SLN was confirmed by intraoperative frozen sections (n = 9) and paraffin embedded histology (n = 1). One (9%) patient with a positive node revealed a false-negative SLN. In 24 patients with a tumor in the lateral hemisphere of the breast the SLN were identified in the ipsilateral axilla. In 6 (40%) of 15 patients with a central or medial localized tumor the SLN was observed infraclavicular (n = 3), parasternal (n = 2) or in the contralateral axilla (n = 1). In the latter one the SLN of the contralateral axilla showed metastases, whereas the simultaneous SLN and all removed lymph nodes of the ipsilateral axilla were not involved. More than one SLN were found in 12 (31%) of the 39 cases. CONCLUSION: A correlation between tumor localization and localization of the SLN is suggested, but the lymph drainage seems more variable in cases of medial tumor size. Using blue dye for map of extraaxillary SLN seems inappropriate. Currently the diagnostic and therapeutic impact of the detection of extraaxillary SLN is still unclear.     

Diagnostic value of ultrasound and color Doppler in identifying axillary lymph node metastases in patients with breast cancer

PURPOSE: The aim of this study was to evaluate the diagnostic ability of ultrasound and color Doppler in axillary lymph node metastases of patients with breast cancer. MATERIAL AND METHODS: A prospective study including 55 patients with primitive, invasive, node negative breast cancer who underwent preoperative axillary ultrasound and color Doppler. Doppler and morphologic ultrasound criteria were applied to the identification of axillary lymph node metastases. RESULTS: The imagery study of all 55 patients identified a total of 141 nodes; 44 were considered to be positive according to established criteria. The histological examination of the axillary dissection revealed a total of 989 nodes; 77 out of 989 presented metastases; all invaded nodes belonged to 21 patients. The previous imagiologic study was positive for axillary lymph node metastases in 15 out of these 21 patients. A sensitivity of 71.4%, a specificity of 71.4%, a negative predictive value of 80.6% and a positive predictive value of 60.0% were achieved. CONCLUSION: The imagery study of the axillary region through ultrasound and color Doppler might be useful in assessing axillary lymph node metastases in patients with breast cancer.     

Sentinel lymph node biopsy in breast cancer: state of the art

Axillary lymph node excision of level I and II with at least 10 lymph nodes is the operative gold standard for invasive breast cancer. Axillary lymph node excision is a diagnostic procedure for histopathologic tumor classification, for assessment of prognosis, local tumor control and adjuvant therapy decision. The sentinel node biopsy is a minimal-invasive procedure to determine the axillary lymph node status by excision of one or more sentinel nodes. This procedure is being increasingly implemented in breast cancer surgery. The classical axillary lymph node excision can be replaced by sentinel node biopsy if sentinel nodes are free of invasion in the intraoperative as well as in the final histopathological report. Sentinel node biopsy can become an operative routine procedure only in a quality-controlled environment.     

Axillary lymphadenectomy for intraductal carcinoma of the breast.

During a ten year period, 175 axillary lymph node dissections were done as part of the treatment for intraductal carcinoma of the breast; 98 patients were treated with modified radical mastectomy and 77 were treated by mammary preservation, consisting of excision of the lesion, axillary dissection and radiation therapy. One of 175 axillary node dissections yielded positive nodes. Axillary dissection for intraductal carcinoma of the breast is unlikely to yield involved nodes and is not indicated for use in most instances. It should be reserved for lesions demonstrating microinvasion.     

Sentinel lymph node biopsy. The possibilities for axial staging in early breast cancer and the results in 187 patients

The authors studied the sentinel lymph node (SLN) identification rate and its accuracy in predicting axillary staging (N- or N+) in patients with early breast cancer. One hundred eighty seven mapping procedures were performed using a vital dye (Patent blue V, Drimaren Brilliant blue or Mitoxantrone) injected at the primary tumour site. The overall rate of identification of SLN was 81.3% (in 152 of 187 patients). The pathological status of the sentinel nodes was compared with that of the remaining axillary nodes. The accuracy of the sentinel biopsy was 89.5% (in 42 of 47 axillary positive patients). In 15 cases with lymph metastases, the SLN was the only site of disease. This experience indicates the sentinel lymphadenectomy should diminish staging morbidity and could improve surgical management of the axilla in women with early breast cancer.     

Interest of preoperative lymphoscintigraphy on sentinel lymph node identification in patients with breast cancer

Sentinel lymph node biopsy is nowadays an accepted method of staging breast cancer patients. In case of an injection of radioactive colloid, preoperative lymphoscintigraphy is recommended to establish a lymphatic mapping and to predict the number of sentinel lymph nodes identified during surgery. Preoperative lymphoscintigraphy does not decrease the false-negative rate. However, positive preoperative lymphoscintigraphy significantly improves the identification rate of intraoperative sentinel nodes comparing with negative preoperative lymphoscintigraphy. Detecting extra-axillary sentinel lymph nodes, because of its minimal therapeutic consequences, does not appear to be an indication for preoperative lymphoscintigraphy. Given logistics and cost required, preoperative lymphoscintigraphy should be only performed for patients with a high risk of intraoperative failed localization. In case of negative preoperative lymphoscintigraphy, sentinel lymph node biopsy must be tried because sentinel nodes are still identified in the majority of these patients. Another possibility, with important cost and logistic, should consist in performing a later lymphoscintigraphy on the day after radioactive injection to ameliorate sentinel lymph nodes identification.     

Sentinel node detection in cervical cancer

BACKGROUND: For superficial tumors such as melanoma, breast, and vulvar cancer, sentinel node detection prevents unnecessary extensive lymph node dissections. Sentinel node detection has not yet proved feasible in tumors, such as cervical cancer, that drain to deep pelvic lymph nodes. TECHNIQUE: We injected technetium-99m colloidal albumin around the tumor allowing preoperative lymphscintigraphy and intraoperative gamma probe detection of sentinel nodes. For visual detection, blue dye was injected at the start of surgery. EXPERIENCE: In six of 10 eligible women who had Wertheim-Meigs operations for cervical cancer stage Ib, one or more sentinel nodes could be detected by scintigraphy. Intraoperative gamma probe detection was successful in eight of ten women, whereas visual detection found sentinel nodes in only four. They were found as far as the common iliac level. One woman had positive lymph nodes, of which one was a sentinel node. CONCLUSION: Identification of sentinel nodes using radionuclide is possible in women with cervical cancer and potentially identifies women in whom lymph node dissection can be avoided.     

Endoscopic axillary lymph node excision--results of a pilot study

OBJECTIVE: Assessment of axillary nodal status with reduced shoulder-arm-morbidity remains a major challenge for primary surgery of breast cancer patients. In a pilot study endoscopic axillary lymph node dissection was evaluated. MATERIAL AND METHODS: In 30 breast cancer patients axillary lymphadenectomy was performed after liposuction using an endoscopic approach. During a learning phase of 15 cases an open revision was routinely carried out. Later complete endoscopic lymph node dissection was performed. The exposition of anatomical landmarks, the number of resected lymph nodes, postoperative lymphorrhea, histopathological signs of traumatisation were assessed as well as intra and postoperative complications. RESULTS: In any case we found excellent exposure of anatomical landmarks. Following a learning curve of 15 cases the average number of resected lymph nodes was equal to the average number of lymph nodes resected with conventional techniques (18.2 vs. 18.4, median 17 vs 18). Minimal intraoperative complications were observed. Postoperative lymphorrhea and seroma rate were not remarkably reduced in comparison with open procedures. CONCLUSIONS: Our study demonstrates, that endoscopic lymph node dissection may be performed with a low complication rate and with identical accuracy as achieved by open techniques.     

Sentinel lymph node biopsy in breast cancer: feasibility study and initial experiments

OBJECTIVE: To evaluate and accredit the sentinel lymph node biopsy in the surgical treatment of breast cancer in our institute. PATIENTS AND METHODS: From February to September 2001 at Tenon Hospital, 64 patients with breast cancer and clinically negative node underwent sentinel lymph node biopsy followed immediately by standard axillary dissection. Both blue dye and radioisotope were used in the majority of patients (70.4%) to identify the sentinel node. These sentinel nodes were evaluated by hematoxylin and eosin, immunohistochemistry and multiple sections. RESULTS: The mean tumor diameter was 17.2 mm (range, 7 to 40 mm). The sentinel node was identified in 97% of the cases (62/64). Of the 62 patients, 24 were histologically positive (38.7%). The sentinel node was falsely negative in one patient (4%). In patients with tumors less than 20 mm, the identification and false negative rates were 97.8% and 0%, respectively. CONCLUSIONS: Our study confirms the validity of the sentinel lymph node. This procedure identifies in a reliable way the sentinel node in most cases. The histological characteristics of the sentinel node reflect those of the rest of the axillary lymph nodes. This procedure appears more accurate for patients with tumors less than 20 mm. This procedure will become the method of choice for axillary staging in small-sized breast cancer. This minimally invasive procedure represents a major step in the field of breast cancer treatment.     

Sentinel lymph-node biopsy qualification in breast cancer

Lymphatic drainage from the breast is principally to the ipsilateral axilla. In patients with breast cancer the status of the nodes in the axilla is an important prognostic factor and can be used to determine local and systemic treatment. Clinical assessment of the node status is unreliable and imaging techniques, though promising, are at present not practical. The standard policy for management of the axilla is axillary clearance (either level II or III), which is justified by the fact that in both stages the armpit is treated. In those node-negative cases, however, it is an unnecessary operation and is linked to some morbidity. Various methods to obtain nodes for histologic evaluation in an attempt to stage the axilla have been tried. A pectoral node biopsy, where a single node is taken from the axillary tail, has been proven to be unreliable. A triple-node biopsy (pectoral, apical, internal mammary) provides excellent prognostic data but is difficult to perform in patients treated by breast conservation. Four-node sampling has been assessed in Edinburgh in two randomized trials comparing node sampling to level III axillary clearance. The four-node sampling technique was shown to be reliable for staging the axilla, and in node-negative cases no further treatment is required. Detailed morbidity has been evaluated in patients who underwent axillary dissection, and node sampling plus radiation and node sampling without radiation demonstrated that those with node sampling had the least morbidity. Those with radiation have reduced movement around the shoulder joint, and the axillary dissection group have increased swelling of the upper limb and slightly reduced abduction. Sentinel node biopsy is presently being evaluated in several centers by randomized studies. Several large series have shown the method to be accurate (98%) when the sentinel node is identified (about 90% of cases). Sentinel node biopsy should routinely enter the field of axilla surgery and thus patients without clinically recognized disease avoid overtreatment when the sentinel node is free of cancer.     

Mammakarzinom

The removal of axillary lymph nodes has been an important component of primary breast cancer surgery for more than a century. The clinical objective of lymph node surgery has, however, changed with the understanding of the biological behaviour of the disease and the modification of treatment strategies. Axillary lymph node dissection (ALD) was primarily regarded as a therapeutic procedure to remove all reachable tumour cells. ALD then changed to become a diagnostic tool when breast cancer was identified as a systemic disease and the lymph node status became the most important prognostic factor to determine systemic treatment decisions. For node-positive patients ALD remained the treatment of choice in order to ensure regional control. During the last decade the diagnostic role of ALD to identify node-positive patients was replaced by sentinel lymph node biopsy (SLNB), a targeted procedure that is associated with less morbidity compared to ALD. Recently the benefit of ALD has been questioned even for SLN-positive patients. However, ALD is still an important diagnostic tool for the cohort of node-positive patients. Women with pN2/3 disease derive benefit from a more intensive local and systemic treatment. Furthermore the data from a meta-analysis and a randomized trial indicate that patients with positive SLNs require regional treatment. Omission of SLNB requires new tools to define patients who derive a benefit from an intensified local and systemic treatment. Since local treatment is effective in node-positive patients, this treatment (radiotherapy vs surgery) must be clearly defined.     

Aktuelle Ver?nderungen der S3-Leitlinie Mammakarzinom

The amendments of the S3 guidelines from 2012 in the field of breast cancer surgery are based on data from published clinical studies, systematic reviews of international literature and international guidelines, such as NZGG 2009, SIGN 2005 and NICE 2009. The main changes are: the margins of tumor-free tissue around breast cancer after breast conserving surgery followed by radiotherapy of the whole breast are 1?mm for invasive cancer and surrounding ductal carcinoma in situ (DCIS) and 2?mm for purely DCIS. For selected patients (not more than two sentinel lymph nodes with metastases, no clinical and radiological signs of suspect lymph nodes, breast conserving surgery followed by irradiation of the whole breast) axillary lymph node extirpation in cases of positive sentinel lymph nodes (pN1sn) can be avoided. An extra irradiation of the axilla in cases of positive sentinel nodes and no consecutive axillary lymphonodectomy should be avoided.     

Interest of selective lymphadenectomy in patients with vulvar cancer

Vulvar cancer represents approximately 4% of all gynecologic malignancies and the most important prognosis factor in this cancer is the status of the regional lymph nodes. The radical inguinal lymphadenectomy, associated or not with radiotherapy, is accompanied by high morbidity, which can affect 50% of the patients. The sentinel node detection appears now to be feasible in patients with vulvar carcinoma, in order to reduce the morbidity of inguinal lymphadenectomy. But contrary to breast cancer, the learning curve is not easy to obtain because of the low number of cases. That is why we have described the procedure of selective lymphadenectomy. The aim of this technique is to remove the blue and/or marked inguinal lymph node and any other palpable lymph node, without a real radical inguinal lymphadenectomy. Thus, since November 2003, 4 procedures have been performed in total. With the lymphoscintigraphy, we identified 17 marked lymph node and we finally obtained 28 lymph nodes after surgery, with only one metastatic lymph node. There was no complication after our procedure. Selective lymphadenectomy appears to be a new procedure which may reduce the morbidity of usual inguinal lymphadenectomy.