Surgery and sentinel lymph node biopsy

In patients with melanoma, surgery is pivotal not only for the primary tumor but also for regional and often distant metastases. The minimally invasive technique of sentinel node (SN) biopsy has become standard for detection of occult regional node metastasis in patients with intermediate-thickness primary melanoma; in these patients it has a central role in determining prognosis and a significant impact on survival when biopsy results are positive. Its role in thin melanoma remains under evaluation. The regional tumor-draining SN also is a useful model for studies of melanoma-induced immunosuppression. Although completion lymphadenectomy remains the standard of care for patients with SN metastasis, results of ongoing phase III trials will indicate whether SN biopsy without further lymph node surgery is adequate therapy for certain patients with minimal regional node disease.     

放射性纳米药物与前哨淋巴结活检

随着纳米科学与技术的兴起，纳米药物的研制及其在生物医药领域中的应用日益受到重视。放射性纳米药物主要应用于肿瘤核医学，作为放射导向手术中所使用的辅助手术工具——γ探针的导向试剂，进行前哨淋巴结活检。文章着重评述了前哨淋巴结的概念、活检方法以及用作导向试剂的放射性纳米药物。     

Techniques of sentinel lymph node biopsy

Axillary node status is the single most important prognostic factor for patients with primary breast carcinoma. During the last decade, one of the major advances in breast cancer has been the development of techniques that make axillary staging less morbid and more conservative. The sentinel lymph node (SLN) biopsy technique has received much attention as a possible alternative to axillary lymph node dissection (ALND). The SLN is defined as the first node in the regional lymphatic basin that receives drainage of the primary tumor. We will review the different techniques of lymphatic mapping for breast carcinoma, including radioactive and/or blue dye indicators, timing and site of injection, and preoperative lymphoscintigraphy. The SLN technique involves a multidisciplinary team. It is therefore important that each surgeon validate the technique in his or her own institution to ensure the successful and accurate assessment of the axilla. The SLN technique has modified the surgical management of breast cancer patients, although questions as to its safety have yet to be answered.     

Repeat operative sentinel lymph node biopsy

Because sentinel lymph node (SLN) biopsy continues to be used for staging in patients with breast cancer, physicians treating these patients will be faced with in-breast recurrences and new primary breast cancers in the treated breast. Repeat operative SLN biopsy might be feasible in this clinical scenario. This report describes the case of a patient with an ipsilateral different-site, recurrent, infiltrating ductal carcinoma 14 months after lumpectomy; negative SLN biopsy result; and radiation therapy, now with a positive SLN biopsy result.     

Predicting sentinel and residual lymph node basin disease after sentinel lymph node biopsy for melanoma

BACKGROUND: The selection of patients for sentinel lymph node biopsy (SNB) and selective lymphadenectomy for histologically positive sentinel lymph nodes (SLND) are areas of debate. The authors of the current study attempted to identify predictors of metastases to the sentinel and residual nonsentinel lymph nodes in patients with melanoma. METHODS: The Indiana University Interdisciplinary Melanoma Program computerized database was queried to identify all patients who underwent SNB for clinically localized cutaneous melanoma. Demographic, surgical, and histopathologic data were recorded. Univariate and multivariate logistic regression analyses were performed to identify associations with SNB and nonsentinel lymph node positivity. Classification tree and logistic procedures were performed to identify the ideal tumor thickness cutpoint at which to perform SNB. RESULTS: Two hundred seventy-five SNB procedures were performed to stage 348 regional lymph node basins for occult metastases from melanoma. Of the 275 melanomas, 54 (19.6%) had a positive SNB, as did 58 of 348 basins (16.7%). Classification and logistic regression analysis identified a Breslow depth of 1.25 mm to be the most significant cutpoint for SNB positivity (odds ratio 8. 8:1; P = 0.0001). By multivariate analyses, a Breslow thickness cutpoint >/= 1.25 mm (P = 0.0002), ulceration (P = 0.005), and high mitotic index (> 5 mitoses/high-power field; P = 0.04) were significant predictors of SNB results. SLND was performed in 53 SNB positive patients, 15 of whom (28.3%) had at least 1 additional positive lymph node. SLND positivity was noted across a wide range of primary tumor characteristics and was associated significantly with multiple positive SN, but not with any other variable. SNB result correlated significantly with disease free and overall survival. CONCLUSIONS: Patients with a Breslow tumor thickness >/= 1. 25 mm, ulceration, and high mitotic index are most likely to have positive SNB results. SLND is recommended for all patients after positive SNB because it is difficult to identify patients with residual lymph node disease.     

The role of sentinel lymph node biopsy for melanoma

Regional lymph nodes are a common site of melanoma metastases, and the presence or absence of melanoma in regional lymph nodes is the single most important prognostic factor for predicting survival. Furthermore, identification of metastatic melanoma in lymph nodes and excision of these nodes may enhance survival in a subgroup of patients whose melanoma has metastasized only to their regional lymph nodes and not to distant sites. Sentinel lymph node (SLN) biopsy was developed as a low morbidity technique to stage the lymphatic basin without the potential morbidity of lymphedema and nerve injury. The presence or absence of metastatic melanoma in the SLN accurately predicts the presence or absence of metastatic melanoma in that lymph node basin. When performed by experienced centers, the false-negative rate of SLN biopsy is very low. As such, the nodal basin that contains a negative SLN will usually be free of microscopic disease. Since occult micrometastatic disease affects only 12% to 15% of patients with melanoma, selective SLN dissection allows up to 85% of patients with melanoma to be spared a formal lymph node dissection, thus avoiding the complications usually associated with that procedure. While standard pathologic evaluation of lymph nodes may miss metastatic melanoma cells, more sensitive techniques are developing which may identify micrometastases more accurately. The clinical significance of these micrometastases remains unknown and is the subject of active investigations.     

Groin lymph node detection and sentinel lymph node biopsy in vulvar cancer

ObjectiveTo identify suitable diagnostic tools and evaluate the efficacy of sentinel lymph node (SLN) biopsy for inguinal lymph node metastasis in vulvar cancer.MethodsData from 41 patients with vulvar cancer were evaluated retrospectively, including magnetic resonance imaging (MRI) measurements, SLN biopsy status, groin lymph node metastasis, and prognosis.ResultsSLN biopsy was conducted in 12 patients who had stage I to III disease. Groin lymphadenectomy was omitted in five of the nine patients with negative SLNs. All SLN-negative patients who did not undergo groin lymphadenectomy showed no evidence of disease after treatment. On MRI, the long and short diameters of the inguinal node were significantly longer in metastasis-positive cases, compared with negative cases, in 25 patients whose nodes were evaluated pathologically (long diameter, 12.8 mm vs. 8.8 mm, p=0.025; short diameter, 9.2 mm vs. 6.7 mm, p=0.041). The threshold of >10.0 mm for the long axis gave a sensitivity, specificity, positive predictive value, and negative predictive value of 87.5%, 70.6%, 58.3%, and 92.3%, respectively, using a binary classification test. Decision tree analysis revealed a sensitivity, specificity, and accuracy of 87.5%, 70.6%, and 76.0%, respectively, with the threshold of >10.0 mm for the long axis on MRI. The criteria of >10.0 mm for the long axis on MRI predicted an advanced stage and poorer prognosis using a validation set of 15 cases (p=0.028).ConclusionMinimally invasive surgery after preoperative evaluation on MRI and SLN biopsy is a feasible strategy for patients with vulvar cancer.     

Axillary recurrence after sentinel lymph node biopsy.

Sentinel lymph node biopsy (SLNB) without further axillary dissection in patients with sentinel node-negative breast carcinoma appears to be a safe procedure to ensure locoregional control. During a median follow-up of 35 months the false-negative rate was 1% in our study population of 185 patients. BACKGROUND: The objective of this prospective study is to provide data on follow-up of patients with primary operable breast carcinoma staged with SLNB without axillary lymph node dissection (ALND) if the sentinel lymph nodes (SLNs) were tumour-negative. METHODS: One hundred and eighty-five patients were enrolled. Preoperative dynamic and static lymphoscintigraphy were performed; both a vital blue dye and a gamma detection probe were used intraoperatively. Patients with tumour-positive SLNs received completion ALND or if no SLNs could be identified. All patients were monitored according to regional follow-up protocols. RESULTS: The SLNs were identified in 179 out of the 185 patients. In 73 patients the SLNs were tumour-positive and in 106 patients tumour-negative. The median follow-up was 35 months (range 17-59). In one SLN-negative patient an axillary recurrence occurred 26 months after the SLNB (false-negative rate: 1%). CONCLUSIONS: SLNB without ALND appears to be a safe procedure to ensure locoregional control in SLN-negative breast carcinoma, if carried out by an experienced team.     

Dynamic sentinel lymph node biopsy in penile cancer

Wilms tumor (WT) is the most common primary malignant renal tumor of childhood, accounting for 6% of all pediatric tumors, and represents one of the great success stories in pediatric cancer therapy. The paradigm for the treatment of a child with WT has evolved from a primary goal of survival alone to a risk-based approach. Unfortunately, despite 35 years of clinical trials by cooperative groups, bilateral WT (BWT) patients have not been formally studied. The most recent survival, rated for patients treated on National WT Study-5 with BWT, was 61–80.8% with favorable histology and 43.8% for a child with anaplastic or unfavorable histology. This article reviews outcomes and surgical considerations in the treatment of patients with synchronous BWT and proposes possible future directions in the treatment.     

核素示踪乳腺癌前哨淋巴结活检的准确性与可行性

目的:探讨核素示踪乳腺癌前哨淋巴结(SLN)活检的准确性和可行性。方法:1999年4月-2001年10月期间,应用原发肿瘤周围皮下注射放射性核素示踪技术(99mTC-标记硫化锑胶体或99mTC-标记硫胶体),对79例早期乳腺癌患者进行前哨淋巴结活检(SLND),随后,行包括腋窝淋巴结清扫(ALND)在内的根治性手术。分析评估两种核素淋巴示踪和SLND的准确性及其影响因素。结果:75例行术前淋巴闪烁照相,淋巴结显像67例(89.33%,67/75);术中应用γ探测仪成功证实SLNs 68例,成功率为86.08%(68/79),SLN预测腋窝淋巴结状态的准确性为95.59%(65/68),假阴性率为3/36(8.33%);前28例患者有9例不能证实SLN,3例假阴性;而后51例只有2例不能证实SLN,没有假阴性。两者差异有显著性(P<0.05)。结论:本研究结果表明,99mTC-标记硫胶体作为示踪剂,手术当天(术前4-6小时)乳腺肿瘤上方皮下注药进行SLND,可以准确预测早期乳腺癌腋窝淋巴结状态。     

Axillary recurrence after negative sentinel lymph node biopsy

Background Sentinel lymph node biopsy (SLNB) has almost totally replaced axillary lymph node dissection as the first-line axillary procedure for node-negative breast cancer. SLNB has a false-negative rate of 0–22%, and regional nodal recurrence is a major concern after SLNB. In this study, we assessed axillary recurrence and risk factors in breast cancer patients 40 months after negative SLNB. Methods Of 940 patients with node-negative breast cancer who underwent SLNB between December 2003 and January 2006 at Asan Medical Center, 720 were negative on SLNB, as determined using 99-m TC radiocolloid and subareolar injection technique. Of the 720 patients negative on SLNB, 174 underwent further axillary dissection, 253 underwent node sampling, and 293 received SLNB only. Results A mean of 2.1 SLNs was removed per patient. At a median follow-up of 40 months (range 24–49 months), recurrence in the axilla was observed in three patients, all of whom had undergone SLNB only; two of these patients also had recurrences in internal mammary lymph nodes. Tumors in all three patients were hormone-receptor negative, and two were c-erbb2 negative. Conclusion The axillary recurrence rate was low in patients negative on SLNB. Negative hormone-receptor status and high nuclear grade may be risk factors for regional nodal failure after SLNB.     

Axillary lymph node management in breast cancer with positive sentinel lymph node biopsy

The surgical treatment of localized breast cancer has become progressively less aggressive over the years. The management of the axillary lymph nodes has been modified by the introduction of sentinel lymph node biopsy. Axillary dissection can be avoided in patients with sentinel lymph node negative biopsies. Based on randomized trials data, it has been proposed that no lymph node dissection should be carried out even in certain patients with sentinel lymph node positive biopsies. This commentary discusses the basis of such recommendations and cautions against a general omission of lymph node dissection in breast cancer patients with positive sentinel lymph node biopsies. Instead, an individualized approach based on axillary tumor burden and biology of the cancer should be considered.