Sentinel lymph node biopsy is associated with improved survival compared to level I & II axillary lymph node dissection in node negative breast cancer patients

Objective

The few long-term follow-up data for sentinel lymph node (SLN) negative breast cancer patients demonstrate a 5-year disease-free survival of 96–98%. It remains to be elucidated whether the more accurate SLN staging defines a more selective node negative patient group and whether this is associated with better overall and disease-free survival compared with level I & II axillary lymph node dissection (ALND).

Methods

Three-hundred and fifty-five consecutive node negative patients with early stage breast cancer (pT1 and pT2 ≤ 3 cm, pN0/pN_SN0) were assessed from our prospective database. Patients underwent either ALND (n = 178) in 1990–1997 or SLN biopsy (n = 177) in 1998–2004. All SLN were examined by step sectioning, stained with H&E and immunohistochemistry. Lymph nodes from ALND specimens were examined by standard H&E only. Neither immunohistochemistry nor step sections were performed in the analysis of ALND specimen.

Results

The median follow-up was 49 months in the SLN and 133 months in the ALND group. Patients in the SLN group had a significantly better disease-free (p = 0.008) and overall survival (p = 0.034). After adjusting for other prognostic factors in Cox proportional hazard regression analysis, SLN procedure was an independent predictor for improved disease-free (HR: 0.28, 95% CI: 0.10–0.73, p = 0.009) and overall survival (HR: 0.34, 95% CI: 0.14–0.84, p = 0.019).

Conclusions

This is the first prospective analysis providing evidence that early stage breast cancer patients with a negative SLN have an improved disease-free and overall survival compared with node negative ALND patients. This is most likely due to a more accurate axillary staging in the SLN group.     

Prediction of rectal lymph node metastasis by pelvic computed tomography measurement

Aim

Rectal cancer staging represents a crucial step to select the best treatment for this tumour. Particularly after neo-adjuvant chemoradiotherapy (CRT), it may influence the surgical procedure (e.g. radical resection vs. local excision). The aim of this study was to determine the best lymph node size cut-off at computed tomography (CT) to predict nodal metastasis in rectal cancer patients with and without preoperative CRT.

Methods

A consecutive series of patients operated on for primary mid–low rectal adenocarcinoma, all staged with pelvic CT scan, were subdivided as follows: those who underwent surgery alone treatment without CRT (Group A) and those who underwent preoperative CRT (Group B). All CT scans were re-viewed by a single radiologist and, based on the lymph node size, findings were compared with pathologic lymph node status (pN). At each lymph node size cut-off value, the following were calculated: accuracy, sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV). The best cut-off value was defined as having an accuracy ≥70% with the highest NPV.

Results

The study population consisted of 162 patients: Group A (n = 52) and Group B (n = 110). Patients classified as pN-positive (n = 45) had a higher number of and larger sized lymph nodes by CT scan than patients classified as pN-negative (n = 117). The cut-off values with an accuracy ≥70% ranged between 7 and 11 mm in Group A and between 9 and 14 mm in Group B. The cut-off with the best NPV was 7 mm for Group A and 10 mm for Group B.

Conclusions

Acknowledging the limitations of the dimensional criterion, lymph node size cut-off values found in our study may be useful for planning rectal cancer treatment using CT scan.     

A mathematical prediction model incorporating molecular subtype for risk of non-sentinel lymph node metastasis in sentinel lymph node-positive breast cancer patients: a retrospective analysis and nomogram development

Background

Molecular subtype of breast cancer is associated with sentinel lymph node status. We sought to establish a mathematical prediction model that included breast cancer molecular subtype for risk of positive non-sentinel lymph nodes in breast cancer patients with sentinel lymph node metastasis and further validate the model in a separate validation cohort.

Methods

We reviewed the clinicopathologic data of breast cancer patients with sentinel lymph node metastasis who underwent axillary lymph node dissection between June 16, 2014 and November 16, 2017 at our hospital. Sentinel lymph node biopsy was performed and patients with pathologically proven sentinel lymph node metastasis underwent axillary lymph node dissection. Independent risks for non-sentinel lymph node metastasis were assessed in a training cohort by multivariate analysis and incorporated into a mathematical prediction model. The model was further validated in a separate validation cohort, and a nomogram was developed and evaluated for diagnostic performance in predicting the risk of non-sentinel lymph node metastasis. Moreover, we assessed the performance of five different models in predicting non-sentinel lymph node metastasis in training cohort.

Results

Totally, 495 cases were eligible for the study, including 291 patients in the training cohort and 204 in the validation cohort. Non-sentinel lymph node metastasis was observed in 33.3% (97/291) patients in the training cohort. The AUC of MSKCC, Tenon, MDA, Ljubljana, and Louisville models in training cohort were 0.7613, 0.7142, 0.7076, 0.7483, and 0.671, respectively. Multivariate regression analysis indicated that tumor size (OR?=?1.439; 95% CI 1.025–2.021; P?=?0.036), sentinel lymph node macro-metastasis versus micro-metastasis (OR?=?5.063; 95% CI 1.111–23.074; P?=?0.036), the number of positive sentinel lymph nodes (OR?=?2.583, 95% CI 1.714–3.892; P?<?0.001), and the number of negative sentinel lymph nodes (OR?=?0.686, 95% CI 0.575–0.817; P?<?0.001) were independent statistically significant predictors of non-sentinel lymph node metastasis. Furthermore, luminal B (OR?=?3.311, 95% CI 1.593–6.884; P?=?0.001) and HER2 overexpression (OR?=?4.308, 95% CI 1.097–16.912; P?=?0.036) were independent and statistically significant predictor of non-sentinel lymph node metastasis versus luminal A. A regression model based on the results of multivariate analysis was established to predict the risk of non-sentinel lymph node metastasis, which had an AUC of 0.8188. The model was validated in the validation cohort and showed excellent diagnostic performance.

Conclusions

The mathematical prediction model that incorporates five variables including breast cancer molecular subtype demonstrates excellent diagnostic performance in assessing the risk of non-sentinel lymph node metastasis in sentinel lymph node-positive patients. The prediction model could be of help surgeons in evaluating the risk of non-sentinel lymph node involvement for breast cancer patients; however, the model requires further validation in prospective studies.

     

Sentinel node biopsy in breast cancer has a greater node positivity rate than axillary node sample: Results from a retrospective analysis

Background

Sentinel node biopsy as a surgical method of axillary staging for early breast cancer has been widely accepted as an alternative to traditional four-node axillary node sampling, and is the recommended technique by the Association of Breast Surgery in the United Kingdom. In selected units axillary sampling has been compared with either radioisotope sentinel node or blue dye only techniques with comparable node positivity rates. There are no studies directly comparing combined method sentinel node biopsy (SNB) with conventional axillary (four) node sampling (ANS).

Methods

Data for all patients undergoing axillary staging by axillary node sample or sentinel node biopsy were collected, including those proceeding to axillary clearance as a second procedure, but excluding those undergoing axillary clearance as a first procedure.

Results

From January 2005 to January 2011, 641 axillary staging procedures were performed (SNB n = 231 (36.0%), ANS n = 410 (64.0%)). Baseline tumour characteristics were similar for the two groups except for a higher frequency of breast conservation in the SNB group (95.6 vs. 75.6%; p < 0.0001). The proportion of cases with positive nodes was higher in the SNB group (20.8 vs. 14.4%; p = 0.042). In patients who had presented with symptomatic disease, there was a significantly higher node positivity rate with SNB (30.9%) than with ANS (15.5%; p = 0.002), despite similar baseline characteristics in both groups.

Conclusion

Combined method sentinel node biopsy is more sensitive at detecting low volume axillary disease than traditional four-node sample.     

Lymphatic mapping in patients with primary or recurrent breast cancer following previous axillary surgery

Aims

To evaluate the feasibility of lymphatic mapping in breast cancer patients after previous axillary surgery and to identify parameters associated with mapping failure.

Methods

Lymphatic mapping using peritumoural injection of blue dye and a radiocolloid was attempted in 30 patients with primary (n = 7) or recurrent (n = 23) breast cancer and a history of previous axillary lymph node dissection or sentinel node biopsy.

Results

Lymphatic mapping identified a mean number of 1.6 (range 1–3) lymph nodes in 19 of 30 patients (identification rate 63%). The lymph nodes were removed from the ipsilateral axilla (n = 13), the internal mammary chain (n = 2), both the internal mammary nodes and the axilla (n = 2), the interpectoral space (n = 1) and the contralateral axilla (n = 1). Four of 19 patients revealed a positive lymph node. Fifteen of 19 patients had a negative lymph node. Axillary lymph node dissection was done in 13 of 15 patients but found no positive nodes (false negative rate = 0). A negative lymphoscintigram (p < 0.001) and a number of more than 10 lymph nodes removed at the time of initial surgery (p = 0.02) were significantly associated with a mapping failure.

Conclusion

Lymphatic mapping following prior axillary surgery was accurate but associated with a low identification rate. The lymphatic drainage pattern was unpredictable and the use of a radionuclide was necessary for a successful mapping procedure.     

Lymph node micrometastasis in node negative early gastric cancer

Aims

The clinical significance of lymph node micrometastasis for histologically node negative gastric cancer is not well documented. This study was to assess the incidence and to clarify the risk factors of lymph node micrometastasis in patients with node negative early gastric cancer (EGC).

Methods

We investigated the lymph node micrometastasis with using an anticytokeratin immunohistochemical stain in 90 patients with node negative EGC who underwent curative resection between 1991 and 2000.

Results

Among 3526 nodes from 90 patients, there were 17 cytokeratin immunohistochemical stain positive nodes from nine patients. The incidence of micrometastasis was higher in patients with lymphatic invasion (p = 0.012), venous invasion (p = 0.026) and larger tumor (p = 0.003). The independent risk factors for lymph node micrometastasis were lymphatic invasion (p = 0.004, RR = 22.915, 95% CI = 2.709 ∼ 193.828) and tumor size (p = 0.029, RR = 1.493, 95% CI = 1.042 ∼ 2.138). Although there were 10 deaths during the follow-up period of mean 67.6 months (1 month ∼ 147 months), there was no death from a cancer recurrence.

Conclusions

The incidence of lymph node micrometastasis in patients with node negative early gastric cancer was 10%, and the independent risk factors for micrometastasis were lymphatic invasion and tumor size.     

Patterns of lymph node spread and its influence on outcome in resectable parotid cancer

Aim

To assess the metastatic topography of intraparotideal and neck lymph nodes in parotid cancer and its influence on tumour recurrence and survival.

Methods

The lymph node spread of 142 patients with primary parotid carcinoma treated from 1986 to 2006 was analysed. Disease-free survival (DFS) and overall survival (OS) were calculated. The role of the metastatic pattern as prognostic factors were univariately and multivariately analysed.

Results

A lateral, total or radical parotidectomy was performed in 19, 80 and 43 patients, respectively. A radical/radical-modified or selective neck dissection was performed in 68 and 74 patients, respectively. Eighty-seven neck dissection specimens were negative (pN0). Twelve patients had intraparotideal and cervical lymph node involvement (pPar+/pN+). In 24 patients only intraparotideal metastases were detected (pPar+/pN0). 19 patients only had cervical nodal involvement (pPar−/pN+). Twenty-five patients had occult locoregional lymph metastases (cN0/pN+). The median follow-up was 24.4 months. The disease-free survival rate was 81% at 5 years, and 62% at 10 years. By univariate analysis, R+ (p = 0.001), pT (p = 0.019), lymphangiosis carcinomatosa (p = 0.019), pN+ (p = 0.042), and extracapsular spread (p = 0.046) were prognostic for disease-free survival. Multivariate analysis revealed R+ as independent risk factor (p = 0.046). In pN+ patients, involvement of parotid lymph nodes (p = 0.013), nodes in neck level I (p < 0.0001) and IV (p = 0.005) were univariate risk factors. Multivariate analysis showed lymph node metastases in level I as independent risk factor (p = 0.022).

Conclusion

Total parotidectomy and radical-modified neck dissection is recommended as surgical treatment of parotid cancer and should be analysed in a prospective trial.     

Curative chemoradiotherapy for isolated retroperitoneal lymph node recurrence of colorectal cancer

Purpose

To investigate the efficacy of curative chemoradiotherapy for isolated retroperitoneal lymph node recurrence of colorectal cancer.

Materials and methods

Twenty-two colorectal cancer patients who received three-dimensional conformal radiotherapy (n = 20) or helical tomotherapy (n = 2) for isolated retroperitoneal lymph node recurrence were analyzed retrospectively. Radiation dose was 55.8 Gy in 31 fractions or 63 Gy in 35 fractions, and 60 Gy in 20 fractions by helical tomotherapy. All patients received concurrent chemotherapy and 16 (72.7%) received adjuvant chemotherapy.

Results

The treatment response was complete in 13 (59.1%), partial in 6 (27.3%), and stable in 3 (13.6%) patients. Median follow-up for 11 (50%) surviving patients was 32 months (range, 27-61). The 3- and 5-year overall survival rates were 64.7% and 36.4%, and median overall survival was 41 months. Recurrences developed in 15 (68.2%) patients; outside the retroperitoneum in 13. The 3- and 5-year recurrence-free survival rates were 34.1% and 25.6%, and median recurrence-free survival was 20 months. Response and adjuvant chemotherapy were significant prognostic factors for overall survival. Gastrointestinal toxicity ? Grade 3 was not observed.

Conclusions

Definitive chemoradiotherapy is an effective salvage treatment for isolated retroperitoneal lymph node recurrence of colorectal cancer without severe complications.     

Histopathological predictors of axillary lymph node metastases in patients with Breast Cancer

Background  A tumor 30 mm or less in diameter is a standard candidate for breast conserving surgery (BCS) in Japan. Axillary lymph node metastases (ALNM) is the most important prognostic factor for survival in patients with breast cancer, but the role of axillary node dissection has been controversial. Histopathological predictive factors of axillary lymph node involvement have not been established. The purpose of this study was to determine the association between the incidence of ALNM and histopathological factors by univariate and multivariate analysis. Methods  Sixty-five patients with noninvasive ductal carcinoma, and 993 patients with tumors 30 mm or less in diameter who underwent axillary dissection between 1988 and 1997 at our institute were reviewed. The association between ALNM and 13 histopathological factors (size, age, histological subtype, histological invasiveness, lymphatic invasion, vascular invasion, macroscopic classification, histological daughter mass, ductal spread, ER, PgR, p-53, and c-erbB-2) were analyzed by univariate and, when significant, by multivariate analysis. Results  Only one patient with noninvasive ductal carcinoma had ALNM, and 33.1% of 993 patients with a tumor 30 mm or less in size had ALNM. Multivariate analysis identified six factors as independent predictors for ALNM: lymphatic invasion, size, histological invasiveness, macroscopic classification, age and histological daughter mass. Conclusions  Axillary lymph node dissection can be omitted in patients with noninvasive ductal carcinoma. Histopathological features of tumors 30 mm or less in diameter can be used to estimate the risk of ALNM, and routine axillary node dissection might be spared in selected patients at minimal risk of ALNM, if the treatment decision is not influenced by lymph node status, such as in elderly patients.     

Solitary metastasis to the left axillary lymph node after curative gastrectomy in gastric cancer

Regional lymph node metastasis in advanced gastric cancer is common, whereas axillary lymph node metastasis (ALNM) is rare. We experienced a patient with a solitary ALNM in gastric cancer. A 48-year-old woman underwent curative distal gastrectomy for advanced gastric cancer (P0H0T3N3M0CY0, stage IV). Twenty-one months after the surgery, she complained of an asymptomatic left axillary tumor. Mammography and computed tomography (CT) scans showed the presence of tumors in neither breast nor lung. Fine-needle aspiration of the axillary tumor demonstrated poorly differentiated adenocarcinoma cells, which coincided with the cells of the resected gastric carcinoma. We diagnosed ALNM from gastric cancer and operated on the patient with radical left axillary lymph node dissection. One year after the reoperation, she has had no recurrence. We conclude that gastric cancer can metastasize to unusual sites. A re-radical resection is recommended if curative resection is feasible. Received: March 6, 2002 / Accepted: April 23, 2002 Offprint request to: O. Kobayashi     

A nomogram for predicting individual survival of patients with gastric cancer who underwent radical surgery with extended lymph node dissection

Background

We developed and validated a nomogram for use at a high-volume center where radical surgery with extended lymph node dissection is the standard treatment for gastric cancer.

Methods

Overall, 1,614 patients were randomly divided into the test set (n = 805) and validation set (n = 809). The scoring system was calculated using a Cox proportional hazard regression model with the survival of gastric cancer as the predicted endpoint. The concordance index (c-index) was used as an accuracy measure, with bootstrapping to correct for optimistic bias. Calibration plots were constructed.

Results

Based on a Cox model, we developed a nomogram that predicts the probability of 3- and 5-year survival from the time of surgery. The bootstrap-corrected c-indices were 0.87 and 0.84 in the test and validation sets, respectively. Survival was well predicted in both sets. The predictions of our nomogram discriminated better than the AJCC staging system (test set: c-index, 0.87 vs. 0.77; P < 0.0001; validation set: c-index, 0.84 vs. 0.79; P < 0.001).

Conclusion

We developed and validated a nomogram that provided a significantly accurate prediction of postoperative survival in Korean patients with gastric cancer who underwent radical gastrectomy with extended lymph node dissection.     

Phosphorylated c-Jun NH2-terminal kinase is overexpressed in human papillary thyroid carcinomas and associates with lymph node metastasis

To evaluate the associations of phosphorylated c-Jun NH2-terminal kinase (p-JNK) expression with clinicopathological features in patients with papillary thyroid carcinoma, p-JNK expression were immunohistochemically measured in 121 thyroid samples. p-JNK was overexpressed in papillary thyroid carcinomas with respect to matched nontumorous tissues (P = 0.000), which was supported by western blot analysis. Increased p-JNK expression was significantly associated with the presence of lymph node metastases (P = 0.001) and advanced TNM stages (P = 0.02). Furthermore, p-JNK expression was positively correlated with osteopontin (OPN) expression (r = 0.58, P < 0.001). Activation of p-JNK may play a role in the carcinogenesis and lymph node metastasis of papillary thyroid carcinoma, and may be a molecular target for therapeutic intervention.     

Pattern of lymph node metastases and its implication in radiotherapeutic clinical target volume delineation of regional lymph node in patients with gastric carcinoma

Purpose

To study the pattern of lymph node metastases (LNM) of gastric carcinoma (GC) and clarify the clinical target volume delineation of regional lymph node (CTVn).

Methods and materials

The pattern of LNM of a total of 875 GC patients who had undergone gastrectomy and lymphadenectomy with more than 15 lymph nodes retrieved were retrospectively examined. The clinicopathologic factors related to LNM were analyzed using logistic regression analysis and linear regression.

Results

The rate of LNM in patients with upper GC was 75.3%, in middle ones 78.9%, in lower ones 64.9%, and 82.2% in patients with whole GCs. In terms of the ratio between metastatic and examined lymph nodes (N ratio) of GC patients, it was 35.8% in patients with upper tumors, 36.6% in middle ones, 27.6% in lower ones, and 51.0% in whole GCs. The maximum diameter and T stage of tumor emerged as statistically significant risk factors of the rate of LNM of GC (P < 0.001, 0.001, respectively; HR = 1.172, 2.132, respectively; 95% confidence interval: 1.083-1.268, 1.777-2.558, respectively). T stage (P < 0.001), the maximum diameter of tumor (P < 0.001), tumor differentiation (P = 0.018) and macroscopic types of tumor (P = 0.030) were significantly associated with N ratio. Our material showed an orderly spread to stations 1-16 clearly related to the position of the tumor (P < 0. 001), nevertheless, there was no statistical difference between different locations of tumor with regards of the rate of LNM (P = 0.614, HR = 0.945, 95% confidence interval: 0.759-1.177) as well as N ratio (P > 0.05).

Conclusions

The pattern of LNM in GC is mainly correlated with the maximum diameter of tumor, T stage, macroscopic types and histologic differentiation. Rate of LNM and N ratio can be recommended as applicable parameters for lymph nodes involvement of GC. These factors should be considered comprehensively to design the CTVn for radiotherapy (RT) of GC. Selective regional irradiation including the correlated lymphatic drainage regions should be performed as well.     

The prognostic significance of extracapsular lymph node involvement in node positive patients with colonic cancer

Aims

In colonic cancer the prognostic significance of extracapsular lymph node involvement (LNI) is not established and is therefore the objective of this study.

Methods

Between January 1994 and May 2005, all patients who underwent resection for primary colonic cancer with lymph node metastasis were reviewed. All resected lymph nodes were re-examined to assess extracapsular LNI. In uni- and multivariate analysis disease-free survival (DFS) was correlated with various clinicopathologic factors.

Results

One hundred and eleven patients were included. In 58 patients extracapsular LNI was identified. Univariate analysis revealed that pN-stage (5-year DFS pN1 vs. pN2: 65% vs. 14%, p < 0.001), extracapsular LNI (5-year DFS intracapsular LNI vs. extracapsular LNI: 69% vs. 41%, p = 0.003), and lymph node ratio (5-year DFS <0.176 vs. ≥0.176: 67% vs. 42%, p = 0.023) were significant prognostic indicators. Among these variables pN-stage (hazard ratio 3.5, 95% confidence interval [CI]: 1.72–7.42) and extracapsular LNI (hazard ratio 1.98, 95% CI: 1.00–3.91) were independent prognostic factors. Among patients without extracapsular LNI, those receiving adjuvant chemotherapy had a significantly better survival (p = 0.010). In contrast, chemotherapy did not improve DFS in patients with extracapsular LNI.

Conclusion

Together with pN2 stage, extracapsular LNI reflects a particularly aggressive behaviour and has significant prognostic potential.     

Intramammary lymph node metastasis predicts poorer survival in breast cancer patients

Involvement of an intramammary lymph node with metastatic breast cancer is an uncommon clinical or radiological presentation. Previously reported series of patients are small in number and the clinical advice is unclear.We identified 100 patients on our pathology database with intramammary lymph nodes in association with a primary breast cancer. Ten were identified pre-operatively on breast imaging and 90 were first discovered on pathological assessment of excised breast tissue. Twenty one contained metastasis. Factors that predicted for intramammary node metastasis were increasing age (p = 0.017), lymphovascular invasion (p = 0.002) and grade of tumour (p = 0.012). The presence of metastasis within the intramammary lymph node was associated with a poorer disease free survival (p = 0.007) and reduced overall survival (p = 0.035). Sixty seven percent of patients with intramammary node metastasis had further axillary metastases. One patient had an intramammary node metastasis but uninvolved axillary sentinel node. She presented 19 months later with an axillary nodal recurrence.The presence of intramammary lymph node metastasis is associated with poorer outcome in breast cancer patients. Pre-operative detection of intramammary lymph node metastasis is helpful to guide breast and axillary surgeries. Intramammary lymph node metastasis predicts strongly for axillary metastatic disease and axillary node clearance is recommended.     

Axillary lymph node metastasis in lung cancer

Study objectives Axillary lymph node metastasis (ALNM) from lung cancer is rare. Its prognosis and effective treatments remain unknown. To evaluate clinicopatholgical characteristics of such lung cancer patients, we performed a retrospective study of them, who had ALNM at the time of initial presentation or developed ALNM in their clinical courses. Methods We reviewed the medical records and pathological reports of all patients at our division who had a diagnosis of primary lung cancer from January 1985 through August 2007. Results Ten (0.75%) of 1,340 patients had ALNM. In eight of them, ALNM was detected at the time of initial diagnosis, and two patients developed ALNM in their clinical courses. Lymphatic metastasis to mediastinum was evident in all patients. Supraclavicular and cervical lymph nodes were involved in five and three patients, respectively. One patient had direct chest wall invasion from the lung. Three patients had distant metastases other than axillary or cervical lymph nodes. Four patients received systemic chemotherapy, and another four patients received palliative chest irradiation or supportive care because of their poor performance status. Median survival time of 8 patients who were diagnosed as having ALNMs at initial presentation was 7 months. Conclusions The most likely mechanism for axillary node involvement is intercostal lymphatics via spread from mediastinal lymph node metastasis. Routine palpation of the axillae is recommended if chest wall invasion, mediastinal and/or supraclavicular lymph nodes are found either at initial presentation or at follow-up of patients.     

Axillary sentinel node biopsy after neoadjuvant chemotherapy

Introduction

The role of sentinel lymph node biopsy (SLNB) in patients with locally advanced breast cancer (LABC) with potentially sterilized axillary lymph nodes after neoadjuvant chemotherapy (NAC) remains unclear.

Patients and methods

Between 2002 and 2008, SLNB with both blue-dye and radioisotope injection was performed in 77 patients with LABC whose cytopathologically confirmed positive axillary node(s) became clinically negative after NAC. Factors associated with SLN identification and false-negative rates, presence of non-sentinel lymph node (non-SLN) metastasis were analyzed retrospectively.

Results

SLNB was successful in 92% of the patients. Axillary status was predicted with 90% accuracy and a false-negative rate of 13.7%. Patients with residual tumor size >2 cm had a decreased SLN identification rate (p = 0.002). Axillary nodal status before NAC (N2 versus N1) was associated with higher false-negative rates (p = 0.04). Positive non-SLN(s) were more frequent in patients with multifocal/multicentric tumors (versus unifocal; p = 0.003) and positive lymphovascular invasion (versus negative; p = 0.0001). SLN(s) positive patients with pathologic tumor size >2 cm (versus ≤2 cm; p = 0.004), positive extra-sentinel lymph node extension (versus negative; p = 0.002) were more likely to have metastatic non-SLN(s).

Conclusions

SLNB has a high identification rate and modest false-negative rate in LABC patients who became clinically axillary node negative after NAC. Residual tumor size and nodal status before NAC affect SLNB accuracy. Additional involvement of non-SLN(s) increases with the presence of multifocal/multicentric tumors, lymphovascular invasion, residual tumor size >2 cm, and extra-sentinel node extension.     

The value of sentinel lymph node biopsy in ductal carcinoma in situ (DCIS) and DCIS with microinvasion of the breast

Aim

Ductal carcinoma in situ (DCIS) refers to the preinvasive stage of breast carcinoma and should not give axillary metastases. Its diagnosis, however, is subject to sampling errors. The role of sentinel lymph node biopsy (SLNB) in management of DCIS or DCISM (with microinvasion) remains unclear. The purpose of this study was to review our experience with SLNB in DCIS and DCISM.

Methods

A review of 51 patients with a diagnosis of DCIS (n = 45) or DCISM (n = 6), who underwent SLNB and a definitive breast operation between January 1999 and December 2006, was performed.

Results

In 10 patients (19.6%) definitive histology revealed an invasive carcinoma. SLN (micro)metastases were detected in 5 out of 51 patients, of whom 2 had a preoperative diagnosis of grade III DCIS and 3 of DCISM. Three patients (75%) had micrometastases (<2 mm) only. In 2 patients, histopathology demonstrated a macrometastasis (>2 mm). All 5 patients underwent axillary dissection. No additional positive axillary lymph nodes were found.

Conclusions

In case of a preoperative diagnosis of grade III DCIS or a grade II DCIS with comedo necrosis and DCIS with microinvasion, an SLNB procedure has to be considered because in almost 20% of the patients an invasive carcinoma is found after surgery. In this case the SLNB procedure becomes less reliable after a lumpectomy or ablation has been performed. SLN (micro)metastases were detected in nearly 10% of the patients. The prognostic significance of individual tumour cells remains unclear.     

A differential intra-operative molecular biological test for the detection of sentinel lymph node metastases in breast carcinoma. An extended experience from the first UK centre routinely offering the service in clinical practice

Introduction

One-Step Nucleic acid Amplification (OSNA) is a molecular biological assay of cytokeratin-19 (a breast epithelial marker) mRNA. It can be employed intra-operatively for detection of lymph node metastases in breast carcinoma. Patients with positive sentinel nodes may proceed to axillary lymph node dissection (ALND) level I or higher dependent upon the OSNA quantitative result, during the same surgical procedure, avoiding a second operation and eliminating the technical difficulties possibly associated with delayed ALND.

Aims

Our Breast Unit was the first in the UK to implement this novel technique in routine practice. This study reviews our first 44-month data following introduction of OSNA “live” on whole sentinel nodes following an extensive validation study (Snook et al.).⁹

Methods

Data was collected prospectively from the period of introduction 01/12/2008 to 30/08/2012. All patients eligible for sentinel node biopsy were offered OSNA and operations were performed by five consultant breast surgeons. On detection of macro-metastasis a level II/III and for a micro-metastasis a level I ALND was performed.

Results

A total of 859 patients (1709 sentinel lymph nodes) were analysed. All except one were females. The majority underwent wide local excision (73.4%, n = 631) or mastectomy 25% (n = 215) and 1.6% (13) underwent SLN biopsy alone. IDC was seen in 79% (n = 680) of the patients and 53.5% (n = 460) had grade II tumours. One-third (30.8%, n = 265) had positive sentinel nodes and had further axillary surgery at the time of SLN biopsy. Of these, 47% (n = 125/265) had macro-metastases, 38% (n = 101/265) had micro-metastases and 14.7% (n = 39/265) had “positive but inhibited” results. Positive non-sentinel lymph nodes (NSLN) were seen in 35% (44/125) of those with macro-metastases; 17.8% (18/101) of the patients with micro-metastases and 10.2% (4/39) of the “positive but inhibited” group.

Conclusion

In our series over a third of our patients had positive lymph nodes detected with OSNA allowing them to proceed directly to axillary surgery at the same operation. This technique eliminates the need for a second operation in sentinel lymph node positive patients and avoids the anxiety waiting for histological results.     

Improving lymph node detection in colon cancer in community hospitals and their pathology department in southern Netherlands

Aim

The aim was to investigate whether a set of measures directed at increasing lymph node (LN) detection among colon cancer patients led to clinically relevant changes in LN detection rate.

Methods

Data of all patients with curative colon cancer (pT_any N_any M0) diagnosed in 1999–2007 whose resection specimens were evaluated by the Institute for Pathology and Medical Microbiology in Eindhoven (n = 1501) were included. Feedback to specialists, increased fixation time, and ex-vivo injection of the specimen with Patent blue V dye were used to increase LN detection rate. Trends in the proportion of patients with insufficient LNs examined were investigated; moreover, the Patent blue-stained patients (n = 86) were compared with a group of unstained patients (n = 84). Based on the decrease in the proportion of high-risk node-negative patients, a calculation of chemotherapy-related costs saved was made.

Results

The proportion of patients with <12 LNs examined decreased from 87% in 1999 to 48% in 2007 (p_trend < 0.0001). In the stained group this was 37%, versus 56% for the unstained group (p = 0.010). In 1999, 79% of stage II patients were high-risk compared to 55% in 2007, which translates to a saving of almost 1,000,000 euro based on 92 stage II patients diagnosed in 2007.

Conclusion

A diverse set of measures increased the number of examined lymph nodes among patients with colon cancer. Large savings can be made due to the reduced proportion of high-risk node-negative patients who would otherwise have received adjuvant chemotherapy.