Is axillary lymph node dissection always necessary in breast cancer patients with a positive sentinel node?

Axillary lymph node dissection (ALND) is recommended for patients with breast cancer metastasis to a sentinel lymph node (SLN). However in 40-70% of cases, the SLN may be the only area of metastasis in the dissected axillary contents. In patients with a positive SLN, independently predictive factors for non-SLN metastasis include size of the primary tumor, the size of the SLN metastases, extracapsular extension, and the proportion of positive SLN's among all identified SLNs. Some authors have developed scores and nomograms to estimate a patient's risk for non-SLN metastases. These scores and nomograms should be applied prospectively to a large numper of SLN positive patients who thereafter undergo completion ALND. It is necessary to verify the predictive validity of these scores before we recommend the abandonment of ALND in patients with a very low likelihood of non-SLN metastasis. In this article we review the various predictive factors of non-SLN involvement and the scores or nomograms which have been developed to predict the likelihood of a positive ALND after a positive SLN biopsy.     

Is sentinel lymph node mapping relevant for colon cancer?: a feasibility study

BACKGROUND: Sentinel lymph node (sln) technique using blue injection is controversial for colon cancer. The aim of this study was to evaluate the feasibility and interest of sentinel node detection to identify the ultrastaging rate detecting occult nodal micrometastases missed on routine H&E examination. METHODS: During surgery blue dye was injected subserously around the tumor in 30 patients operated for a colon cancer. The first lymph nodes to turn blue were noted as sln. For each sln three examination levels were performed; if no tumor was detected by H&E examination, a cytokeratine immunohistochemistry study was performed. RESULTS: For each case, one or more sln were found (100%). The median number of lymph nodes examined and of sln found was, respectively, 23 (range 10-55) and 2 (1-4). There were 21 pN0 tumors, among which we found two cases (9%) with a micrometastasis and one case of isolated tumor cells detected, resulting in a 14% (3/21) ultrastaging for pTxN0. The sln was positive in five patients out of nine with a N+ disease. CONCLUSIONS: Sln detection was a successful technique when there was no evident lymph node involvement, no primary large lesion or no associated liver metastasis. Focused examination of the sln identified 10-20% of additional ultrastaging disease for staged pT1, 2, 3N0M0 tumor. This may have an important implication for follow-up and adjuvant treatment in future protocols.     

Is a completion axillary dissection indicated for micrometastases in the sentinel lymph node?

OBJECTIVE: The purpose of this study is to determine if a completion axillary dissection (CAD) is necessary when microscopic metastasis (<2 mm) is detected in the sentinel lymph node (SLN) of patients diagnosed with breast cancer. METHODS: A retrospective chart review was performed on 227 consecutive breast cancer patients who underwent SLN mapping (SLNM) between June 1998 and March 2001. These patients underwent intraoperative lymphatic mapping with peritumoral injections of blue dye alone or in combination with technetium-labeled sulfur colloid. The SLN was assessed by touch preparation or frozen section at the time of surgery, and later, by hematoxylin and eosin stain. Patients in whom the SLN showed evidence of metastatic disease on frozen section underwent immediate CAD. RESULTS: One patient was excluded because of inability to identify the SLN. Of the 226 patients in whom SLNM was successful, 67 (27%) had macrometastasis in the SLN, and a completion CAD was performed. Thirty-four of these 67 patients (51%) had additional disease in the axilla. A total of 15 patients (6.7%) was determined to have micrometastasis. In 11 patients, micrometastasis was identified and CAD was performed with no further evidence of disease. The 4 patients diagnosed with micrometastatic disease on permanent staining did not have further surgical intervention. The 15 patients identified with micrometastasis show no evidence of local recurrence to date, with a mean follow-up of 13.5 months (range 1 to 27). CONCLUSIONS: This study suggests that CAD may not be necessary for the subset of breast cancer patients with micrometastasis detected upon SLNM. A larger randomized prospective study with long-term follow up is necessary to confirm these data.     

Is adjuvant radiotherapy necessary after positive lymph node dissection in head and neck melanomas?

Introduction: Postoperative radiotherapy (PR) has been recommended in patients with advanced head and neck melanomas to improve regional control. This study examined the incidence of cervical recurrence among patients who did not receive PR after surgical management of nodepositive head and neck melanomas. Methods: A computerized search of a database listing more than 10,000 patients with melanoma prospectively acquired between 1971 and 1998 identified 217 patients with pathologically positive nodes who had undergone regional lymph node dissection (RLND). Of these patients, 21 had received PR and 196 had not. Results: Median follow-up after RLND was 20 months for nonsurvivors and 32 months for survivors. The overall incidence of cervical recurrence was 14% (27/196). The 5-year cervical recurrence-free survival rate was 83%. Five-year cervical recurrence-free survival rates were 69% vs. 87% for patients with vs. without extranodal disease (P=.004), 96% vs. 81% for patients with nonpalpable vs. palpable nodes (P=.0761), and 82% vs. 91% for patients with one to three positive nodes vs. more than three positive nodes (P=.256). Multivariate analysis, which included the timing of nodal disease presentation and the effect of systemic adjuvant therapy, identified extranodal disease as the only independent predictor of cervical recurrence (P=.034). Cervical recurrence was significantly related to the subsequent occurrence of distant relapse. Conclusions: The low incidence of cervical recurrence after RLND in patients with node-positive head and neck melanomas does not justify the routine use of PR. The only subset of patients who may benefit from PR are those with extranodal disease. Presented at the 53rd Annual Meeting of the Society of Surgical Oncology, New Orleans, Louisiana, March 16–19, 2000.     

High body mass index predicts multiple prostate cancer lymph node metastases after radical prostatectomy and extended pelvic lymph node dissection

Our aim is to evaluate the association between body mass index(BMI)and preoperative total testosterone(TT)levels with the risk of single and multiple metastatic lymph node invasion(LNI)in prostate cancer patients undergoing radical prostatectomy and extended pelvic lymph node dissection.Preoperative BMI,basal levels of TT,and prostate-specific antigen(PSA)were evaluated in 361 consecutive patients undergoing radical prostatectomy with extended pelvic lymph node dissection between 2014 and 2017・Patients were grouped into either nonmetastatic,one,or more than one metastatic lymph node invasion groups.The association among clinical factors and LNI was evaluated.LNI was detected in 52(14.4%)patients:28(7.8%)cases had one metastatic node and 24(6.6%)had more than one metastatic node.In the overall study population,BMI correlated inversely with TT(r=-0.256;P<0.0001).In patients without metastases,BMI inversely correlated with TT(r=-0.282;P<0.0001).In patients with metastasis,this correlation was lost.In the overall study population,BMI(odds ratio[OR]=1.268;P=0.005)was the only in dependent clinical factor associated with the risk of multiple metastatic LNI compared to cases with one metastatic node.In the nonmetastatic group,TT was lower in patients with BMI>28 kg m^2(P<0.0001).In patients with any LNI,this association was lost(P=0.232).The median number of positive nodes was higher in patients with BMI>28 kg m^2(P-0.048).In our study,overweight and obese patients had a higher risk of harboring multiple prostate cancer lymph node metastases and lower TT levels when compared to patients with normal BMI.     

Is there a requirement for axillary lymph node dissection following identification of micro-metastasis or isolated tumour cells at sentinel node biopsy for breast cancer?

IntroductionRecent decades have seen a significant shift towards conservative management of the axilla. Increasingly, immunohistochemical analysis of sentinel nodes leads to the detection of small tumour deposits, the significance of which remains uncertain. The aims of this study are to examine patients whose sentinel lymph nodes are positive for macro-metastasis, micro-metastasis or isolated tumour cells (ITCs) and to determine the rate of further nodal disease after axillary lymph node dissection (ALND).MethodsA retrospective analysis of all patients undergoing a sentinel lymph node biopsy (SLNB) between January 2007 and December 2010 in a tertiary referral breast unit was performed. Patients who underwent an axillary lymph node dissection for macro-metastasis, micro-metastasis or ITCs were identified. Demographics, histological data and the rate of further axillary disease were examined.ResultsIn total, 664 breast cancer patients attended the symptomatic breast unit during the study period, 360 of whom underwent a SLNB. Seventy patients had a SLNB positive for macro-metastasis. All of these patients underwent ALND. A positive SLNB with either micro-metastasis or ITCs was identified in 58 patients. Only 41 of the 58 patients went on to have an ALND, due primarily to variations in surgeons' preferences. Nineteen patients with micro-metastasis underwent an ALND. Four patients had further axillary disease (21%). Twenty-two patients had ITCs identified, of whom only one had further disease (4.5%). No statistically significant difference was found between the two groups in terms of tumour size, grade, lymphovascular invasion or oestrogen receptor status.ConclusionALND should be considered in patients with micro-metastasis at SLNB. It should rarely be employed in the setting of SLNB positive for ITCs.     

The risk factors for lymph node metastasis in early gastric cancer patients who underwent endoscopic resection: is the minimal lymph node dissection applicable?

Purpose

The purpose of this study was to identify risk factors associated with lymph node (LN) metastasis in early gastric cancer patients who underwent endoscopic resection (ER) and to evaluate the feasibility of minimal LN dissection in these patients.

Methods

From January 2001 to March 2011, patients who underwent gastrectomy with lymphadenectomy due to the potential risk of LN metastasis after ER were enrolled at National Cancer Center, Korea. The incidence, risk factors, and distribution of LN metastasis were evaluated.

Results

Of the 147 enrolled patients, the LN metastasis was identified in 12 patients (8.2 %). The incidence of LN metastasis was not significantly increased in patients with submucosal invasion, lymphovascular invasion, and mixed undifferentiated histology [odds ratio (OR), 5.55, 1.349, and 0.387; 95 % confidence interval (CI), 0.688–43.943, 0.405–4.494, and 0.081–1.84, respectively]. Tumor size more than 2 cm was significantly associated with LN metastasis (OR, 14.056; 95 % CI, 1.76–112.267). The incidence of LN metastasis gradually increased from 3.2 to 20 %, as number of risk factors increased (P = 0.019). LN metastasis was present primarily along the perigastric area in all except two patients (1.4 %) with skip metastasis to extragastric area.

Conclusions

Standard surgery with at least D1 + LN dissection must be recommended for patients who proved to have risk factors for LN metastasis after ER, because the potential of skip metastasis is not negligible. Nevertheless, the minimal LN dissection, such as sentinel basin dissection, might be applied cautiously in patients with small-sized tumors after ER.     

Can axillary lymph node dissection be omitted in patients with breast cancer and positive sentinel nodes?

Sentinel lymph node biopsy has evolved as the surgical procedure of choice for women with clinically negative axillae, as part of an effort to move toward the less invasive surgical management of breast cancer. Axillary lymph node dissection remains the standard of care for patients with a positive axillary node and was previously performed on all patients with breast cancer prior to the implementation of the sentinel lymph node biopsy. There is, however, controversy regarding whether or not all patients with a positive sentinel lymph node need to undergo completion axillary dissection for either prognostic or therapeutic purposes. This article reviews the literature related to this controversial and evolving topic.     

Is a limited lymph node dissection an adequate staging procedure for prostate cancer?

PURPOSE: Generally lymph node dissection is only considered a staging procedure for prostate cancer. Therefore, the need for meticulous lymph node dissection is often questioned and only sampling is suggested. We performed a prospective study to identify the pattern of lymph node metastasis in prostate cancer and determine how extensive lymph node dissection must be not to under stage cases. MATERIALS AND METHODS: All patients with clinically organ confined prostate cancer, no prior hormonal treatment, negative preoperative staging computerized tomography and bone scan, who underwent radical prostatectomy between 1989 and 1999, were evaluated prospectively as to the number and location of lymph node metastasis. A meticulous lymph node dissection was performed along the external iliac vein, obturator nerve and internal iliac (hypogastric) vessels. Nodes from each location and side were submitted separately for histological evaluation. RESULTS: In 365 patients with a median serum prostate specific antigen of 11.9 ng./ml. (range 0.4 to 172) the median number of nodes removed was 21 (range 6 to 50). Lymph nodes were positive in 88 (24%) patients and the median number of positive nodes was 2 (range 1 to 19). Internal iliac lymph nodes were positive in 51 (58%) of the 88 patients, including 34 with additional positive lymph nodes along the external iliac vein and/or obturator nerve. Internal iliac lymph nodes alone were positive in 17 (19%) of 88 patients. CONCLUSIONS: There were significant numbers of lymph node metastases at all 3 different areas of lymphadenectomy. Positive lymph nodes were found along the internal iliac artery in more than half (58%) of the patients and exclusively in 19%. Therefore, we consider lymph node dissection along the internal iliac (hypogastric) vessels essential for representative staging. Without this dissection a fifth of node positive cases would have been under staged and diseased nodes would have remained in more than half of the cases.     

Systemic treatment after sentinel lymph node biopsy in breast cancer: who, what, and why?

SLNB, although subject to numerous technical problems, has nonetheless shown great promise in predicting the status of the remaining axillary lymph nodes. The growing use of SLNB has presented the opportunity of using immunohistochemical and molecular markers to detect occult micrometastases. These micrometastases may be important for more accurate staging and prediction of patient outcomes. Current standards for the use of systemic therapy recommend multidrug chemotherapy for all but the most favorable disease (T1a/b, NO). The detection of micrometastases by SLNB in this low-risk group may change treatment recommendations to include systemic therapy. Because of the significant frequency of false-negative results in SLNB, which will depend upon the surgeon's experience, caution is urged in determining when ALND can be safely eliminated in patients with a negative SLNB.     

Transurethral and suprapubic mesh resection after Prolift® bladder perforation: a case report

Bladder perforation is a complication which can occur after a Prolift® procedure and may enhance vesicovaginal fistula formation. Different methods of management of bladder perforation caused by mesh procedures are described in the literature, and most authors advise complete excision of the mesh. In the case described in this article, we propose a combined transurethral and suprapubical approach as the optimal method for maximal tape removal, being both minimally invasive and less damaging to the vesical wall. A suprapubical catheter can be removed shortly after surgery to enable optimal tissue healing of the vesical mucosa.     

Is completion lymphadenectomy after a positive sentinel lymph node biopsy for cutaneous melanoma always necessary?

HYPOTHESIS: Completion lymph node dissection (CLND) has usually been recommended after metastatic disease is identified in the sentinel lymph node (SLN) biopsy to eradicate further metastases in nonsentinel nodes. We hypothesized that patients with negative lymph nodes included in the initial SLN specimen have low risk of metastases in the residual draining basin and may not require CLND. DESIGN: Chart review. SETTING: University-affiliated tertiary care referral center. PATIENTS: Between January 1, 1997, and May 31, 2003, 506 consecutive patients underwent SLN biopsy for staging of primary cutaneous melanoma. INTERVENTION: The SLN biopsy identified 87 patients (17.2%) with metastatic melanoma, of whom 80 underwent CLND. RESULTS: In 28 patients, all SLNs were found to contain metastatic melanoma. Seven (25%) of these patients had additional metastases identified in the CLND specimen. In 52 patients, 1 or more SLNs did not contain metastatic melanoma. Five (10%) of these patients had additional metastases in the CLND specimen (P =.02). CONCLUSIONS: Although no evidence of metastatic melanoma was found on CLND in most patients in whom negative nodes had been removed with positive SLNs at the initial biopsy, 10% of these patients did have further metastases. This subgroup of patients (positive SLNs and negative nodes in the SLN biopsy specimen) is at significantly lower risk for further metastasis, but CLND cannot be safely omitted even for these patients.