Can interpectoral nodes be sentinel nodes?

BACKGROUND: This study was designed to determine if interpectoral nodes could be sentinel nodes for some breast cancers. METHODS: Thirty-five consecutive breast cancer patients undergoing axillary node dissection had a dissection of the interpectoral nodes. These were sent to pathology as a separate specimen. RESULTS: Three patients were identified with isolated interpectoral nodal metastasis. CONCLUSION: In upper quadrants or deep breast cancers the interpectoral nodes may be the earliest site of nodal metastasis. This may lead to false negative results in some sentinel node biopsies.     

Surgical management of the axilla: do intramammary nodes matter?

Background

The therapeutic significance of intramammary lymph nodes is uncertain. The purpose of this study was to identify the appropriate surgical management of the axilla in intramammary node-positive patients undergoing sentinel lymph node (SLN) biopsy.

Methods

A retrospective review of consecutive patients staged between September 1996 and December 2004 was performed. Intramammary node identification and pathologic findings were compared with the status of axilla.

Results

Among 7,140 patients, intramammary nodes were identified in 151 (2%). Positive intramammary nodes were identified in 36 patients (24%). Axillary disease was identified in 61% of intramammary node-positive patients. No additional axillary disease was identified when axillary lymph node dissection was performed in intramammary node-positive patients with negative axillary SLN biopsy results.

Conclusions

The results suggest that completion axillary lymph node dissection may be based on the status of axillary SLN biopsies in clinically node negative patients when intramammary lymph node metastases are identified in the breast specimens.     

Should internal mammary nodes be sampled in the sentinel lymph node era?

Background Controversy exists regarding internal mammary lymph nodes (IMNs) in the staging and treatment of breast cancer. Sentinel lymph node identification with radiocolloid can map drainage to IMNs and directed biopsy can be performed with minimal morbidity. Furthermore, recent studies suggest that IMN drainage of breast tumors may be underestimated. To gain further insight into the prognostic value of IMNs, we reviewed the outcome of patients in whom the IMN status was routinely assessed. Methods A retrospective review of 286 patients with breast cancer who underwent IMN dissection between 1956 and 1987 was conducted. Results Median follow-up is 186 months, age was 52 years (range, 21–85 years), tumor size was 2.5 cm, and number of IMNs removed was 5 (range, 1–22); 44% received chemotherapy, 16% endocrine therapy, and 5% radiotherapy. Presence of IMN metastases correlated with primary tumor size (P<.0001) and number of positive axillary nodes (P<.0001) but did not correlate with primary tumor location or age. Overall, the 20-year disease-free survival is significantly worse for the 25% of patients with IMN metastases (P<.0001). In patients with positive axillary nodes and tumors smaller than 2 cm, there was a significantly worse survival (P<.0001) in the patients with IMN metastases. This difference in survival was not seen in women with tumors larger than 2 cm. Conclusions Patients with IMN metastases, regardless of axillary node status, have a highly significant decrease in 20-year disease-free survival. Treatment strategies based on knowledge of sentinel IMN status may lead to improvement in survival, especially for patients with small tumors. At present, sentinel IMN biopsies should be performed in a clinical trial setting. Presented at the 52nd Annual Meeting of the Society of Surgical Oncology, Orlando, Florida, March 4–7, 1999.     

Are 3 sentinel nodes sufficient?

HYPOTHESIS: It has recently been proposed that only 3 sentinel lymph nodes (SLNs) are required for an adequate SLN biopsy. Others have advocated removing all nodes that are blue, hot, at the end of a blue lymphatic channel, or palpably suspicious or that have radioactive counts of 10% or greater of the most radioactive SLN. Our objective was to determine the false-negative rate (FNR) associated with limiting SLN biopsy to 3 nodes. DESIGN: Multicenter prospective study. SETTING: Both academic and private practice. PATIENTS: A total of 4131 patients underwent SLN biopsy followed by completion axillary node dissection. MAIN OUTCOME MEASURE: The FNR associated with 3-node SLN biopsy. RESULTS: Of the 4131 patients in this study, an SLN was identified in 3882 (94.0%). The median number of SLNs identified was 2; more than 3 SLNs were removed in 738 patients (17.9%). Of the patients in whom a SLN was identified, 1358 (35.0%) were node positive. The overall FNR in this study was 7.7%. In 89.7% of node-positive patients, a positive SLN was found in the first 3 SLNs removed. If SLN biopsy had been limited to the first 3 nodes, the FNR would be 10.3% (P = .005 compared with removing >3 SLNs). The FNR increased with the strategy of limiting SLN biopsy to fewer SLNs (P<.001). CONCLUSION: Removing only 3 SLNs cannot be recommended, because it is associated with a substantially increased FNR.     

The number of lymph nodes in colon cancer specimens: what do the numbers really mean?

Aim Stage‐specific survival for colon cancer is improved when more lymph nodes are identified in the surgical specimen. This association is typically attributed to staging effect, but may instead be a surrogate for tumour biology. Method We retrospectively studied a cohort of 48 consecutively treated patients with Stage II colon cancer who underwent complete resection between January 2000 and December 2002. Archived H&E slides were reviewed for lymphocytic infiltration at the leading edge, presence and degree of sinus histiocytosis in the largest node and the presence of lymph node hyperplasia. Results The mean number of lymph nodes identified was 14.1 ± 9.4. T stage was strongly associated with the number of nodes identified (P = 0.01) and the presence of a significant degree of sinus histiocytosis approached statistical significance (P = 0.077). No statistically significant relationship existed between number of lymph nodes in a specimen and tumour location (P = 0.44), grade (P = 0.56) or lymphovascular invasion (P = 0.64). Conclusions T stage is highly associated with the number of nodes found in a colon cancer specimen; a significant degree of sinus histiocytosis may also be predictive. Finding more nodes may be a surrogate for tumour or host‐related factors that impact prognosis.     

Does a laparoscopic approach affect the number of lymph nodes harvested during curative surgery for colorectal cancer?

Background  

This study aimed to assess the number of lymph nodes (LNs) harvested after laparoscopic and open colorectal cancer resections.     

Radiotherapy to the conserved breast, chest wall, and regional nodes: is there a standard?

BACKGROUND: The role of radiotherapy in the treatment of breast cancer has changed considerable during the last two decades. It has now become the standard part of the breast-conserving procedure, as well as in patients who underwent mastectomy with T3+tumor and/or 4 or more positive lymphnodes in axilla. METHODS: Improvements are seen in the postmastectomy radiotherapy area by delivering better treatment techniques herewith avoiding treatment of the heart and lungs in order to optimize the improvement of local control and the significant improvement in survival. Indications exist that the largest impact of postmastectomy radiotherapy on survival is mostly seen in patients with minimal tumorload, i.e. small tumors and/or 1 or 2 positive lymphnodes. RESULTS: In several clinical trials, it was shown that the relapse rate in the ipsilateral breast is reduced with a HR of 4 if whole breast irradiation is given after tumorectomy. The update of the Oxford meta-analysis demonstrated that this improvement in local control has also led to an improved survival in these patients. More information is recently gained on the required radiation dose in breast-conserving therapy. Especially patients less than 50 years of age have to be treated with a high radiation dose, 50 + 16 Gy boost, while a dose of 50 Gy in 5 weeks seems sufficient for patients older than 50 years, who have a microscopically complete excision. Further optimization of the radiotherapy technique is found in imaged guided approaches and intensity modulated radiotherapy. Combining these efforts allows for a more precise delivery of the radiation dose to a limited volume, so that the side effects like fibrosis will be reduced. CONCLUSIONS: Partial breast irradiation, instead of whole breast irradiation, is now being tested in a few randomized trials. Although this approach may be useful in certain patients groups, it still cannot be accepted as standard treatment, as no proper selection criteria exist and no long-term follow-up data have been presented.     

Have the American College of Surgeons Oncology Group Z0011 trial results influenced the number of lymph nodes removed during sentinel lymph node dissection?

Background

The American College of Surgeons Oncology Group Z0011 trial results have the potential to bias the number of sentinel lymph nodes (SLNs) surgeons remove and axillary lymph node dissections (ALNDs) performed.

Methods

A single-institution prospectively collected database was queried for T1 to T2 clinically node-negative breast cancer patients.

Results

A total of 923 patients underwent breast conserving therapy with SLN biopsy. The mean number of SLNs retrieved before the trial's presentation (June 2010) was 2.7 compared with 2.6 after (P = .19). The mean number of SLNs retrieved before the trial's publication (February 2011) was 2.7 compared with 2.5 after (P = .10). Overall, the rate of completion ALND in patients with SLN macrometastases decreased from after presentation (84% to 63%; P < .01) and publication (83% to 62%; P < .01).

Conclusions

There was no difference in the number of SLNs harvested after either the Z0011 trial presentation or publication; however, surgeons should be aware of the potential for bias. The trial appears to influence practice management with fewer completion ALNDs performed after its release.     

Epitrochlear sentinel lymph nodes in melanoma: interval or independent?

Most primary melanomas on the distal upper extremity metastasize to a sentinel lymph node (SLN) in the axillary basin, but occasionally a primary melanoma will drain to the epitrochlear basin. The relationship between tumor-draining axillary and epitrochlear SLNs is unclear. We hypothesize that the epitrochlear SLN functions in an interval manner with the axillary lymph node basin. We queried our melanoma database to identify patients who underwent SLN biopsy for a distal upper-extremity melanoma. Patient demographics, tumor characteristics, patterns of nodal drainage, and incidence of SLN metastasis were analyzed. Of 255 patients identified, 38 (14.9%) had an epitrochlear SLN. Mean Breslow thickness was 2.26 mm. All patients with epitrochlear drainage had concurrent axillary drainage and underwent axillary and epitrochlear SLN biopsies. Of these 38 patients, two (5.2%) had epitrochlear and axillary SLN metastasis, four (10.5%) had epitrochlear metastasis only, four (10.5%) had axillary metastasis only, and the remaining 28 (73.7%) had tumor-free SLNs. The invariable association of epitrochlear and axillary drainage in this study suggests that epitrochlear nodes function in an interval role with the axillary lymph node basin. Therefore we recommend that all patients with a positive epitrochlear SLN undergo completion axillary dissection.     

Does the greater number of lymph nodes removed during standard lymph node dissection predict better patient survival following radical cystectomy?

Purpose

To determine whether the number of lymph nodes (LNs) removed during radical cystectomy (RC) and pelvic LN dissection (LND) is associated with patient survival.

Methods

Data on 450 patients who underwent RC and standard bilateral pelvic LND for urothelial bladder cancer without receiving neoadjuvant chemotherapy were reviewed. The extent of LND included common iliac artery bifurcation proximally, genitofemoral nerve laterally and the pelvic floor caudally. The impact of the number of LNs removed, analyzed as both continuous and categorical variables, on cancer-specific survival (CSS) and recurrence-free survival (RFS) was analyzed.

Results

The median number of LNs removed was 18 (mean 19.6, range 10?C94). Of total 450 patients, 129 (28.7%) had node-positive (N?+) disease. For entire patients, the number of LNs removed was not associated with CSS and RFS in the analysis with continuous variable (P?=?0.715; P?=?0.442, respectively), quartiles (P?=?0.924; P?=?0.676, respectively), or <18 versus ??18 LNs removed (5-year CSS rates: 67.0% vs. 69.4%, P?=?0.679; 5-year RFS rates?=?59.4% vs. 60.6%, P?=?0.725, respectively). Similarly, the number of LNs removed was not associated with CSS and RFS in both N0 and N?+?patients, and in each T stage. Multivariate analyses showed that T stage and lymphovascular invasion were significant predictors for survival in N0 patients, whereas adjuvant chemotherapy and LN density were predictors for survival in N?+?patients.

Conclusions

If meticulous LND was performed based on standardized LND template during RC, the number of LNs removed was not associated with patient survival.     

What next? Managing lymph nodes in men with penile cancer

The management of patients with squamous cell carcinoma of the penis is often daunting given its rarity and subsequent lack of high-level evidence to support our decision-making. This culminates in the complex surgical issues involving the management of the regional lymph nodes, which is of critical importance to both quantity and quality of life for these patients. This review aims to highlight the decisive issues surrounding the management of the pelvic and inguinal lymph nodes in the setting of squamous cell carcinoma of the penis, and to spotlight recently published information that adds credence to accepted management strategies of both the clinically positive and negative groin after successful management of the primary lesion.Penile cancer remains an uncommon and potentially complex urological diagnosis in our practice in Canada. Although management of the primary lesion in itself is often problematic, any discussion or consideration of prognosis in patients with squamous cell carcinoma of the penis must also involve delineation of the presence and extent of metastatic disease to regional lymph nodes. Success in the management of penile cancer relies on the timely and appropriate management of the inguinal and pelvic lymph nodes.^1–3 This review aims to highlight the issues surrounding the management of the inguinal and pelvic lymph nodes in the setting of squamous cell carcinoma of the penis and to spotlight recently published information that adds credence to accepted management strategies or that approaches nodal disease in a novel or previously unexplored manner.In this review we will first focus on the management of the clinically positive groin, including lymph node dissection technique, as well as the management of pelvic lymph nodes and the role of chemotherapy in the neoadjuvant, adjuvant or palliative setting. Consideration will also be given to the management of the contralateral groin in unilaterally clinically positive disease. Many of the concepts presented are critical in describing and appreciating the often more complex clinical scenario of the patient with a clinically negative examination after successful management of the primary penile cancer. In highlighting the clinically negative groin, we discuss risk stratification based on the pathological characteristics of the primary lesion and the role of sentinel node biopsy and other methods of identifying occult metastasis.     

Additional prognostic value of the 70-gene signature (MammaPrint®) among breast cancer patients with 4–9 positive lymph nodes

BackgroundThe 70 gene-signature (MammaPrint^®) is a prognostic profile of distant recurrence and survival of primary breast cancer (BC). BC patients with 4–9 positive nodes (LN 4–9) are considered clinically at high-risk. Herein we examined MammaPrint^® added prognostic value in this group.Patients and methodsMammaPrint^® profiles were generated from frozen tumours of patients operated from primary BC. Samples were classified as genomic Low Risk (GLR) or genomic High Risk (GHR).ResultsAmong the 173 samples, 70 (40%) were classified as GLR and 103 (60%) as GHR. Tumours in the GHR group were significantly more often ductal carcinomas (93%), grade 3 (60%), oestrogen and progesterone-negative, Her2 positive (25%). In the GLR category, the 5-year overall survival was 97% vs. 76% for in the GHR group (p < 0.01); Distant Metastasis Free Survival (DMFS) at 5 years was 87% for GLR patients and 63% for GHR patients (p < 0.01). In the Luminal A subgroup, the genomic profile was the only independent risk factor for DM and BC specific death.ConclusionIn the Luminal A subgroup, MammaPrint^® is an independent prognostic marker in BC patients with LN 4–9 and may be integrated in a selection strategy of patients candidate for more aggressive therapeutic approaches.