Sentinel node biopsy for staging of small peripheral lung cancer

Is it possible to choose between limited lymph node sampling and systematic lymphadenectomy from the distribution of sentinel lymph nodes in patients with small lung cancer less than 2 cm in diameter? METHODS: Twenty-four patients with cN0M0 lung cancer less than 2 cm in diameter were enrolled. A radioisotope tracer (Tc-99 m tin colloid or phyphate) was injected in the vicinity of the tumor before surgery under computed tomography (CT) guidance. The radioactivity of each resected lymph node was measured separately with a hand-held gamma probe after complete tumor resection. Sentinel nodes were identified and the accuracy of sentinel node mapping was examined. RESULTS: Successful radionuclide migration occurred in 20 of the 24 patients (83.3%). There were 21 N0 patients and 3 N-positive patients. There was no false-negative case, so the sensitivity and the specificity was 100%. The lobar lymph nodes were identified as sentinel nodes more frequently than other lymph nodes. CONCLUSION: The sentinel node concept is valid in patients with small lung cancer less than 2 cm in diameter. We believe that, if sentinel nodes are identified, sentinel node mapping can allow the accurate intraoperative diagnosis of pathological N0 status in patients with small peripheral lung cancer.     

Sentinel Node Navigation Surgery is Acceptable for Clinical T1 and N0 Esophageal Cancer

Background

If the sentinel node (SN) concept is established for esophageal cancer, it will be possible to reduce safely the extent of lymphadenectomy. Our objective was to perform SN mapping in esophageal cancer to assess distribution of lymph node metastases with the goal to reduce the need for extensive lymphadenectomy.

Methods

A total of 134 patients who underwent esophagectomy with lymph node dissection were enrolled. The number of patients with clinical T1, T2, and T3 tumors was 60, 31, and 32, respectively. Eleven patients also received neoadjuvant chemoradiation therapy (CRT). ^99mTc-Tin colloid was injected endoscopically into the esophageal wall around the tumor 1 day before surgery. SNs were identified by using radioisotope (RI) uptake. RI uptake of all dissected lymph nodes was measured during and after surgery. Lymph node metastases, including micrometastases, were confirmed by hematoxylin eosin and immunohistochemical staining.

Results

Detection rates of SNs were 93.3% in cT1, 100% in cT2, 87.5% in cT3, and 45.5% in CRT patients. In the 120 cases where SNs were identified, lymph node metastases were found in 12 patients with cT1, 18 with cT2, 24 with cT3 tumors, and 3 with CRT. Accuracy rate of SN mapping was 98.2% in cT1, 80.6% in cT2, 60.7% in cT3, and 40% in CRT patients. Although one false-negative case had cT1 tumor, the lymph node metastasis was detected preoperatively.

Conclusions

SN mapping can be applied to patients with cT1 and cN0 esophageal cancer. SN concept might enable to perform less invasive surgery with reduction of lymphadenectomy.

     

Lymphatic mapping and sentinel lymphadenectomy for primary and metastatic pulmonary malignant neoplasms

BACKGROUND: Mediastinal lymph node sampling understages a significant number of lung cancers, even when nodes are evaluated by immunohistochemical techniques. Intraoperative lymphatic mapping and sentinel lymphadenectomy allows focused pathologic evaluation of a few lymph nodes that accurately stage the entire basin. HYPOTHESIS: Lymphatic mapping and sentinel lymphadenectomy is a practical and accurate method of staging lymph nodes that drain primary and metastatic neoplasms of the lung. DESIGN AND SETTING: Retrospective review at a tertiary referral center. PATIENTS: Sixty-seven patients undergoing resection of lung tumors. MAIN OUTCOME MEASURES: Sentinel lymph node (SN) identification rate, number of SNs, nodal pathologic features, and survival. RESULTS: Twenty-eight patients had primary lung cancer and 39 had pulmonary metastases from melanoma (33 cases), squamous cell carcinoma (2 cases), colon cancer (2 cases), or other cancers (2 cases). Lymphatic mapping and sentinel lymphadenectomy was successful in all patients. The median number of lymph nodes identified by dye alone was 2 (range, 1-7); the median number identified by dye plus radiocolloid was 4 (range, 1-9). Most SNs (69%) were N1; 31% were N2. Lower lobe lesions drained to upper mediastinal nodes in 3 (13%) of 24 cases. Lymph node metastases were found in 11 patients with lung cancer (39%) and 8 patients with pulmonary metastases (21%). Ten (91%) of the 11 patients with lung cancer had SN involvement. In the 33 patients with metastatic melanoma, SN involvement significantly reduced the rate of 2-year survival (0% vs 48%). CONCLUSIONS: Lymphatic mapping and sentinel lymphadenectomy of intrapulmonary malignancies is technically challenging but feasible. Blue dye is most useful for in vivo identification of SNs; ex vivo radioactivity can confirm that excised nodes are SNs. Lymphatic mapping and sentinel lymphadenectomy can provide important prognostic information for patients with melanoma and lung metastases, and it may improve the staging of primary lung cancer.     

Risk factors for occult nodal metastasis in clinical T1N0 lung cancer: a negative impact on survival

BACKGROUND: The application of CT imaging has increased the identification of patients with clinical T1N0 (cT1N0) lung cancer. The optimal management strategy for these early stage lung cancers remains unclear. We analyzed the impact of occult nodal metastasis on cT1N0 lung cancer patients. METHODS: We studied patients with cT1N0 lung cancer enrolled in our database from January 1995 to December 2002. Preoperative staging was confirmed by review of CT and PET scan studies. Pathology specimens were reviewed. Multivariate analysis was performed to determine the risk of occult nodal involvement. Kaplan-Meier method was applied to analyze survival. RESULTS: Two hundred and ninety-seven patients with cT1N0 disease were identified. Fifty-eight percent of patients were pathological T1N0. Overall, 15% of patients had occult nodal metastasis. Logistic regression analysis demonstrated a three-fold increase in the risk of having pathologic stage II or stage III disease with every 1.0 cm increase in tumor size (odds ratio 3.2; 95% CI: 2.3-4.6). Multivariate analysis demonstrated tumor size to be a significant predictor of nodal metastasis (adjusted odds ratio 3.5; 95% CI: 2.4-5.1). Median survival was different between pathological stage I (96.3 months), stage II (41.4 months), and stage III (36.1 months) disease (p=0.002). CONCLUSION: Clinical T1N0 tumors are often understaged. The risk of occult nodal disease increases with tumor size, and this occult disease negatively impacts survival. Because of the limitations of clinical staging, we believe that lobectomy and lymph node analysis should be offered to cT1N0 lung cancer patients to provide accurate staging and to optimize multimodality adjuvant treatment of lung cancer.     

临床T1、T2 N0 M0乳腺癌腋窝淋巴结转移状况研究的意义

目的 探讨临床T1、T2、 N0、M0.乳腺癌腋窝淋巴结转移状况及临床意义.方法 结合原发肿瘤位置、年龄、病理等,分析了276例临床T1、T2 N0M0乳腺癌患者腋窝淋巴结转移情况及意义.结果 临床T1 N0M0.腋淋巴结转移率低于T2 N0M0乳腺癌患者(P=0.027),乳腺中央区与外下象限乳腺癌发生腋淋巴结转移明显高于其他部位肿瘤(P=0.004);乳腺外侧象限肿瘤腋窝下组淋巴结转移率高于其他部位肿瘤组(P=0.000);乳头中央区和内侧象限乳腺癌腋上组淋巴结转移高于乳腺外侧象限肿瘤(P=0.000).非特殊型癌发生淋巴结转移明显高于早期癌和其他类型(P-0.001).9例单纯癌6例发生2组以上腋淋巴结转移.90例发生腋淋巴结转移的病例中,>50岁者62例(68.9%)发生腋淋巴结转移,≤50岁者28例(31.1%)发生腋淋巴结转移(P=0·000).发现"跳跃式"转移病例2例(0.7%),均为临床T2 N0M0患者,肿瘤位于乳头中央区1例,外下象限者1例.其中浸润型导管癌1例,单纯癌1例.结论 研究临床T1、T2 N0M0乳腺癌腋窝转移淋巴结分布情况对开展SLNB及制定合理的治疗方案有一定指导价值.     

Utility and pitfalls of sentinel node identification using indocyanine green during segmentectomy for cT1N0M0 non-small cell lung cancer

Purposes

Sentinel node identification using indocyanine green (ICG) is not only simpler, but also more cost-effective, than using radioisotope tracers. We herein examined the utility and pitfalls of sentinel node (SN) identification using ICG during segmentectomy in patients with cT1N0M0 non-small cell lung cancer (NSCLC).

Methods

ICG was injected around the tumor after thoracotomy, followed by segmentectomy and lymph node dissection, in 135 patients with cT1N0M0 NSCLC. The dissected nodes were examined using an ICG fluorescence imaging system.

Results

SNs could be identified in 113 patients (84 %). The mean number of SNs was 2.3 ± 1.3. The percentages of being an SN were 57 % for both stations #12 and #13, which was significantly higher than the 18 % for #10 and 22 % for #11 (p < 0.001). Fourteen patients had N1 or N2 disease. Of these, the SNs were true positive (i.e., SNs contained metastasis) in 11 patients (79 %) and false negative (i.e., SNs did not contain metastasis, while non-SNs contained metastasis) in three patients (21 %). Of the three patients with false-negative results, all non-SNs containing metastases were at station #12 or #13.

Conclusion

While ICG makes it simple to identify SNs during segmentectomy for cT1N0M0 NSCLC, stations #12 and #13 should be submitted for frozen sections along with the identified SNs to avoid missing true SNs.

     

Use of technetium-99m tin colloid for sentinel lymph node identification in non-small cell lung cancer

BACKGROUND: To test the reliability of sentinel lymph node identification in non-small cell lung cancer, sentinel nodes were localized with a radioactive colloid in patients undergoing surgery. METHODS: Forty-six patients with non-small cell lung cancer undergoing curative resection with mediastinal lymph node dissection were examined. The day before surgery, technetium-99m ((99m)Tc) tin colloid was injected into the peritumoral region. At operation, the radioactivity of the lymph nodes was counted with a handheld gamma counter before (in vivo) and after (ex vivo) dissection. Lymph nodes with an ex vivo radioactive count more than 10 times the background value were identified as sentinel nodes. The correlation between the in vivo and ex vivo results was examined. RESULTS: Lymphoscintigraphy revealed that it took longer than 6 hours for sufficient (99m)Tc tin colloid to reach the sentinel nodes. Sentinel nodes could be identified in 40 patients (87%). Patients whose sentinel nodes could not be identified had a significantly lower ratio of forced expiratory volume in 1 second to forced vital capacity than did those with identifiable sentinel nodes (P =.03). No false-negative sentinel nodes were detected in 14 patients with N1 or N2 disease (0%). In the hilar lymph node stations, the lobar lymph nodes were most frequently identified as sentinel nodes (as often as 85% of the time). Fourteen patients (35%) had sentinel nodes in the mediastinum, the distribution of which depended on the lobe. In vivo and ex vivo counting showed 88% concurrence for the identification of sentinel nodes in mediastinal lymph node stations. CONCLUSION: The identification of sentinel nodes with (99m)Tc tin colloid is a reliable method of establishing the first site of nodal metastasis in non- small cell lung cancer. Sentinel nodes could be hardly identified in patients with a low ratio of forced expiratory volume in 1 second to forced vital capacity because of such conditions as chronic obstructive pulmonary disease. In vivo identification of sentinel nodes in the mediastinum could be useful approach to guide mediastinal lymph node sampling or dissection.     

Immunohistochemically detected micrometastases in peribronchial and mediastinal lymph nodes from patients with T1, N0, M0 pulmonary adenocarcinomas

The T1, N0, M0 subset of stage I lung adenocarcinoma is a tumor that has a 5-year disease-free survival rate of 66% to 85%. To date, there has not been a rigorous immunohistochemically detected lymph node micrometastasis study composed of patients with identical stage and type of tumors, and in which standard histologic features were incorporated into multivariate analyses. We immunohistochemically examined the peribronchial and mediastinal lymph nodes from 80 consecutively accrued patients with T1, N0, M0 adenocarcinomas and bronchioloalveolar carcinomas unselected for distant metastasis, and an additional 39 patients with similar stage and type neoplasms who were selected for their development of metastases to evaluate the prevalence of micrometastases, their association with distant metastases, and their relationship with other pathologic prognostic features. All slides were stained with keratin AE1/3. Micrometastases were confirmed with Ber-Ep4. Three immunohistochemically detected lymph node micrometastases were identified in three of 80 consecutively accrued patients (4%). These three positive stains constituted 0.5% of the 573 stains required to immunohistochemically screen all of the lymph node blocks from these patients. Among the 39 patients who were selected because they developed distant metastases, three immunohistochemically detected lymph node micrometastases from three patients were identified, which constituted 8% of patients in this group and 1% of the 280 stains required to screen all of these patients' lymph nodes. Small vessel invasion, maximum tumor dimension, and immunohistochemically detected lymph node micrometastases were independently associated with metastases on multivariate analysis. Among patients who developed metastases, there was no significant difference in the disease-free survival rate between those with and those without immunohistochemically detected lymph node micrometastases. Given the low sensitivity in terms of the number of immunohistochemical stains performed, and the prognostic significance of standard histologic features, the use of immunohistochemical screening lymph nodes from all patients with T1, N0, M0 adenocarcinomas is questionable.     

乳腺癌前哨淋巴结活检

目的 评价前哨淋巴结活检预测腋窝淋巴结有无肿瘤转移的准确性及其临床意义。方法 用^99m锝－硫胶体作为示踪剂,用γ探测仪导向,对70例临床分期为T1－2N0M0的乳腺癌患者进行前哨淋巴结活检,所有的患者均同时行腋窝淋巴结清扫,HE染色阴性的前哨淋巴结再切片,用CK8、CK19、KP－1行免疫组织化学染色。结果 70例患者中成功发现前哨淋巴结的有67例,发现率为95.7%（67／70）。前哨淋巴结的数量为1－5枚,平均每例1.6枚。非前哨淋巴结5－20枚,平均例12.3枚。67例前哨淋巴结活检成功的患者中,29例患者（43.3%）有腋窝淋巴结转移,其中前哨淋巴结有转移者24例（35.8%）,前哨淋巴结未发现转移而非前哨淋巴结有转移者5例（7.5%）。7例患者（10.4%）只有有淋巴结为阳性淋巴结,前哨淋巴结活检的准确性为100％。43例患者的65枚HE染色阴性一的前哨淋巴结,CK8及CK19免疫组织化学染色均为阴性。结论 前哨淋巴结检能较准确地预测腋窝淋巴结转移情况,对原发灶为T1的乳腺癌,前哨淋巴结活检的准确性为100％。同一层面切片行免疫组织化学染色并不能提高淋巴结微转移癌的发现率。     

Does the lobectomy plus lymph node dissection still remain a standard surgical procedure for patients with cT1N0M0 adenocarcinoma of the lung?

Objectives: Controversies still exists regarding treatment for cT1N0M0 adenocarcinoma of the lung. The following topics need to be answered: 1) Should all patients undergo lobectomy plus lymph node dissection? and 2) Is there poor-prognostic subgroup that may need adjuvant therapy? Methods: Between 1990 and 1999,141 patients with cT1N0M0 adenocarcinoma of the lung underwent lobectomy plus lymph node dissection. Fifteen clinicopathological characteristics of the entire population were investigated with regard to survival. Forty-seven samples, which were possible to reexamine among 68 patients with small adenocarcinoma 2 cm or less in greatest dimension, were assessed according to Noguchi’s classification. Results: Nine of fifteen clinicopathological variables were significant in indicating poor prognostic factors in univariate analysis: gender, differentiation, p-T status, p-N status, pm, lymphatic invasion, vascular invasion, pleural invasion, and serum carcinoembryonic antigen (CEA) level. The p-N status and high serum CEA level were independent predictive variables in multivariate analysis. A five-year survival rate for patients with Noguchi’s type A and B was 100%. However, six (8.8%) of 68 patients with small adenocarcinoma had lymph node involvement and four patients (5.9%) had pulmonary metastasis. Conclusions: It is inappropriate and inadequate to omit lobectomy or lymph node dissection only on the basis of tumor size. Therefore, it seems reasonable to conclude that lobectomy plus lymph node dissection still remains as a standard surgical procedure to treat cT1N0M0 adenocarcinoma of the lung. We must continue to search for new deciding factors in order to choose candidates for limited operation among patients with cT1N0M0 adenocarcinoma of the lung. Read at the Fifty-sixth Annual Meeting of the Japanese Association for Thoracic Surgery, Symposium, Tokyo, November 19–21, 2003.     

Detection of occult metastasis in squamous cell carcinoma of the penis using a dynamic sentinel node procedure

PURPOSE: We evaluated the so-called dynamic sentinel node procedure in patients with penile cancer. This new staging technique consists of excisional biopsy of the first lymph node onto which a tumor drains the so-called sentinel node, based on individual mapping of lymphatic drainage. MATERIALS AND METHODS: From 1994 to 1998, 55 consecutive patients with stage T2 or greater bilateral or unilateral node negative squamous cell carcinoma of the penis were prospectively entered in this study. Tumor stage was T2N0 in 42, T2N1 in 4 and T3N0 in 9 cases. To locate the sentinel node each patient underwent lymphoscintigraphy with 99mtechnetium nanocolloid injected intradermally around the tumor. The following day the sentinel node was identified intraoperatively using patent blue dye injected intradermally around the tumor and a gamma detection probe. Regional lymph node dissection was restricted to patients with a tumor positive sentinel node only. RESULTS: Scintigraphy revealed 125 sentinel nodes in 107 inguinal regions, including no sentinel node in 2 patients, 1 or more unilateral nodes in 10 and bilateral drainage in 43. At surgery 108 sentinel nodes were removed. In 8 patients with 2 or more sentinel nodes on lymphoscintigraphy only 1 was noted intraoperatively and in 9 an additional sentinel node was removed, which was not identified by scintigraphy. All nodes were identified with the gamma detection probe. In 1 patient a wound abscess developed. Regional lymph node dissection was performed in 11 patients with sentinel node metastasis. Median followup was 22 months (range 4.1 to 61). In 1 patient lymph node metastasis was noted at followup despite prior excision of a tumor-free sentinel node. CONCLUSIONS: The dynamic sentinel node procedure is a promising staging technique to detect early metastatic dissemination of penile cancer based on individual mapping of lymphatic drainage, and enables identification of patients with clinically node negative disease requiring regional lymph node dissection.     

Segmentectomy for c-T1N0M0 non-small cell lung cancer

While the use of segmentectomy to treat lung cancer remains controversial, it has recently gained status as a radical surgery for cT1aN0M0 non-small cell lung cancer. I herein review the literature regarding segmentectomy and present my data to discuss the following issues: the prognosis after segmentectomy; local recurrence; the area required for lymph node dissection at the hilum and mediastinum; the technique used to cut the intersegmental plane; the selection of the lymph nodes for frozen sections; the postoperative pulmonary function; the role of completion lobectomy after radical segmentectomy for cT1N0M0/pN1-2; expectations and concerns regarding the randomized controlled trial JCOG0802; and the future of segmentectomy.     

Sentinel node involvement in T0-T1 breast cancers]

STUDY AIM: Determination of axillary lymph node status is crucial in diagnosis of early breast cancer. However thanks to an early diagnosis, an increasing number of axillary lymph node dissections are free of disease. This raises questions about the need for this procedure. The study aim was to report an experience with lymphadenectomy and sentinel node mapping in patients with T0-T1 carcinoma of the breast. METHODS: Between November 1997 and December 1999, 84 consecutive women (T0-T1 N0 according to the 1987 UICC classification) with recently diagnosed breast cancer, were included in this study for identification of the sentinel lymph node (SLN). The SLN was removed and submitted for histological examination. All patients underwent axillary dissection; nodes from levels I and II (Berg's classification) were excised and submitted to histological examination. RESULTS: The average tumor diameter was 12.7 mm (range, 3 to 25 mm). The lymphatic mapping technique was obtained after injection of the isotope into the breast around the tumor in 53/84 patients: the sentinel lymph node was the only positive node in 10 patients and it was positive in 5 patients with other axillary nodes. In 15/84 patients, an intradermal injection of blue dye was used; two sentinel nodes were positive and one falsely negative. In 16/84 patients, an interdermal injection of blue dye was used to make up for. In this study, the sentinel node was positive in three patients and falsely negative in one patient. The discrepancy was due to an important involvement of an axillary area excluded from the lymphatic channels. 22/84 patients (26%) had a metastatic spread to the axillary nodes. 30/84 patients had also an isotopic captation in another lymph node group (internal mammary). CONCLUSION: This study confirms that lymphatic mapping is technically possible in the patients with T0-T1 breast cancer and that the histological characteristics of the sentinel node probably reflect the histological characteristics of the rest of the axillary lymph nodes, but do not provide any information about the other lymph node sites.     

Treatment of Clinical T2N0M0 Esophageal Cancer

Background

Management of clinical T2N0M0 (cT2N0M0) esophageal cancer remains controversial. We reviewed our institutional experience over 21 years (1990–2011) to determine clinical staging accuracy, optimal treatment approaches, and factors predictive of survival in this patient population.

Methods

Patients with cT2N0M0 esophageal cancer determined by endoscopic ultrasound (EUS) were identified through a prospectively collected database. Demographics, perioperative data, and outcomes were examined. Cox regression model and Kaplan–Meier plots were used for statistical survival analysis.

Results

A total of 731 patients underwent esophagectomy, of whom 68 cT2N0M0 patients (9 %) were identified. Fifty-seven patients (84 %) had adenocarcinoma. Thirty-three patients (48.5 %) were treated with neoadjuvant chemoradiation followed by surgery, and 35 underwent surgical resection alone. All resections except one included a transthoracic approach with two-field lymph node dissection. Thirty-day operative mortality was 2.9 %. Only 3 patients (8.5 %) who underwent surgery alone had T2N0M0 disease identified by pathology: the disease of 15 (42.8 %) was found to be overstaged and 17 (48.5 %) understaged after surgery. Understaging was more common in poorly differentiated tumors (p = 0.03). Nine patients (27.2 %) had complete pathologic response after chemoradiotherapy. Absence of lymph node metastases (pN0) was significantly more frequent in the neoadjuvant group (29 of 33 vs. 21 of 35, p = 0.01). Median follow-up was 44.2 months. Overall 5-year survival was 50.8 %. On multivariate analysis, adenocarcinoma (p = 0.001) and pN0 after resection (p = 0.01) were significant predictors of survival.

Conclusions

EUS was inaccurate in staging cT2N0M0 esophageal cancer in this study. Poorly differentiated tumors were more frequently understaged. Adenocarcinoma and absence of lymph node metastases (pN0) were independently predictive of long-term survival. pN0 status was significantly more common in patients undergoing neoadjuvant therapy, but long-term survival was not affected by neoadjuvant therapy. A strategy of neoadjuvant therapy followed by resection may be optimal in this group, especially in patients with disease likely to be understaged.     

Radioisotope lymph node mapping in nonsmall cell lung cancer: can it be applicable for sentinel node biopsy?

BACKGROUND: Previous studies on intrathoracic lymph node mapping have focused on the validity of a sentinel node concept, but not on the usefulness for sentinel node biopsy. METHODS: The subjects were 15 patients clinically diagnosed with N0 nonsmall cell lung cancer. Technetium-99m tin colloid was injected into the peritumoral area 1 day preoperatively and a time course of tracer migration was monitored by scintigraphy. A hand-held gamma probe counter was used to count the intrathoracic lymph node stations. Resected nodes were also counted to assess the accuracy of the intrathoracic counting. RESULTS: Serial scintigraphies showed that the tracer migrated through airways and the appearance resembled hot nodes. On intrathoracic counting, 50% of the nodal stations appeared positive; however, only 23% of these apparently positive nodal stations were ultimately shown to be truly radioactive. The true positive and true negative rates of detecting intrathoracic hot nodes were 100% and 56%, respectively. Because the counts of the nodal stations could include the counts from the hot primary tumor ("shine-through") or airway radioactivity, legitimate hot nodes were identified after dissecting all the apparently positive nodal stations. Two of the 9 patients in whom hot nodes were identified had nodal metastatic disease and actually had tumor cells within the hot nodes. The only complication related to the preoperative injection of technetium-99m was a minor pneumothorax. CONCLUSIONS: Although radioisotope intrathoracic lymph node mapping is safe, it appears to be unsuitable for sentinel node biopsy because shine-through and the airway-migrated radioactive tracer complicated the intrathoracic counting. Only serial scintigraphy could distinguish hot nodes from airway migration.     

Pathologic N0 status in pulmonary adenocarcinoma is predictable by combining serum carcinoembryonic antigen level and computed tomographic findings

OBJECTIVES: It is not clear whether lymphadenectomy has therapeutic benefit in non-small cell lung cancer management. To avoid unnecessary lymphadenectomy, we attempted to identify clinical or radiologic predictors of pathologic N0 disease in patients with peripheral adenocarcinoma. METHODS: From August 1992 through April 1997, 269 consecutive patients with peripheral adenocarcinoma who underwent major lung resection and systematic lymph node dissection were enrolled in this study. We reviewed their contrast-enhancement computed tomographic scans and recorded the maximum dimension of tumors both on pulmonary (pDmax) and on mediastinal (mDmax) window setting images, the largest dimension perpendicular to the maximum axis on both pulmonary (pDperp) and mediastinal (mDperp) window setting images, and the size of all detectable hilar-mediastinal lymph nodes. We defined a new radiologic parameter, tumor shadow disappearance rate (TDR), which is calculated with the following formula: TDR = 1 - (mDmax x mDperp)/(pDmax x pDperp). RESULTS: In multivariable analysis a lower serum carcinoembryonic antigen level and a higher tumor shadow disappearance rate were significant predictors of pathologic N0 disease. Lymph node size on computed tomographic scanning was not a significant predictor. Among 59 patients with a normal preoperative carcinoembryonic antigen level and a tumor shadow disappearance rate of 0.8 or more, 58 (98%) patients had pathologic N0 disease, and the other patient had pathologic N1 disease. CONCLUSIONS: Mediastinal lymph node involvement was not found in patients with a normal preoperative serum carcinoembryonic antigen level and a tumor shadow disappearance rate 0.8 or more. The patients who meet these criteria may be successfully managed with major lung resection without systematic mediastinal lymphadenectomy.     

Fluorine 18-tagged fluorodeoxyglucose positron emission tomographic scanning to predict lymph node metastasis, invasiveness, or both, in clinical T1 N0 M0 lung adenocarcinoma

OBJECTIVE: We sought to predict lymph node metastasis and tumor invasiveness in clinical T1 N0 M0 lung adenocarcinomas, and we measured fluorodeoxyglucose uptake on positron emission tomography. METHODS: Fluorodeoxyglucose positron emission tomography was performed on 44 patients with adenocarcinomas of 1 to 3 cm in size clinically staged as T1 N0 M0 before major lung resection with lymph node dissection. Fluorodeoxyglucose uptake was evaluated by using the contrast ratio between the tumor and contralateral healthy lung tissue. Lymphatic and vascular invasion within tumors, pleural involvement, and grade of histologic differentiation were examined. RESULTS: The pathologic tumor stage was T1 N0 M0 in 36 patients, and a more advanced stage was found in 8 patients. Although all 22 adenocarcinomas with a contrast ratio of less than 0.5 in fluorodeoxyglucose uptake were pathologic T1 N0 M0 tumors, 8 (36%) of 22 with a contrast ratio of 0.5 or greater were of a more advanced stage than T1 N0 M0, with the difference being significant (P =.002). Adenocarcinomas with a contrast ratio of less than 0.5 showed less lymphatic and vascular invasion and less pleural involvement than those with a contrast ratio of 0.5 or greater (P =.006, P =.004, and P =.02, respectively). The grade of histologic differentiation was well differentiated in 19 of 22 adenocarcinomas with a contrast ratio of less than 0.5 (86%), which was a greater frequency than the 4 (18%) of 22 adenocarcinomas with a contrast ratio of 0.5 or greater (P <.001). CONCLUSION: Clinical T1 N0 M0 lung adenocarcinomas with a contrast ratio of less than 0.5 usually did not have lymph node metastasis, had less tumor involvement of vessels or pleura, and were more frequently well differentiated than those with a contrast ratio of 0.5 or greater. Limited lung resection could be indicated, lymph node dissection or mediastinoscopy could be reduced, or both in this type of adenocarcinoma.     

Sentinel lymph node biopsy after neo-adjuvant chemotherapy in breast cancer

The timing of sentinel node biopsy in the setting of neo-adjuvant chemotherapy for breast cancer is controversial. Sentinel node biopsy performed after neo-adjuvant chemotherapy may save patients with a nodal response the morbidity of an axillary lymph node dissection. A retrospective review of prospectively collected data compared sentinel node biopsies performed after patients had received neo-adjuvant chemotherapy with patients who had not received neo-adjuvant chemotherapy. Demographic factors, tumor characteristics, and the results of the sentinel node biopsies and completion lymph node dissections (when applicable) were compared. A total of 231 axillary procedures (224 patients) were evaluated. The patients who received neo-adjuvant chemotherapy (NEO; N=52) were younger, had higher grade tumors, were more likely to have a mastectomy, and were more likely to have ER-negative and HER-2/neu positive tumors than the patients who did not receive neo-adjuvant chemotherapy (NON; N=179). The mean clinical tumor size in the neo-adjuvant group was 4.5cm (±1.8) prior to chemotherapy; the post-chemotherapy pathologic size was 1.4cm (±1.3). A sentinel node was identified in all cases. There were no significant differences between the groups in the mean number of sentinel nodes removed (NEO=3.3; NON=3.1; p=0.545), the percentage of positive axillae (NEO=24%; NON=21%; p=0.776) or the mean number of positive sentinel nodes (NEO=1.3; NON=1.5; p=0.627). There was no difference in the percentage of completion lymph node dissections with additional positive nodes (NEO=20%; NON=35%; p=0.462); there was a difference in the number of nodes removed in the completion lymph node dissections (mean NEO=12.0; NON=16.4; p=0.047). Sentinel node biopsy performed after neo-adjuvant chemotherapy appears to be an oncologically sound procedure and may save some patients the morbidity of a complete lymph node dissection.