Tumor-Positive Sentinel Node Biopsy of the Groin in Clinically Node-Negative Melanoma Patients: Superficial or Superficial and Deep Lymph Node Dissection?

Background The extent of a completion groin dissection in sentinel node–positive melanoma patients was guided by the location of the second-echelon nodes on the preoperative lymphoscintigram. The purposes of the current study were to investigate the pathological findings, the lymph node recurrences and (disease-free) survival associated with this approach. Methods Between June 1996 and April 2007, 42 patients underwent completion groin dissection after a tumor-positive sentinel node biopsy. Eighteen patients had femoro-inguinal second-echelon nodes on their lymphoscintigram and underwent a superficial lymph node dissection. Twenty-four patients had iliac-obturator second-echelon nodes found by scan and underwent a combined superficial and deep dissection. Results The median follow-up time was 61 months. One of the 18 patients who underwent a superficial groin dissection developed a deep (obturator) lymph node recurrence after 12 months. Revision of the lymphoscintigram showed that the images had been interpreted incorrectly and that the second-echelon node was located in the obturator area after all. A combined superficial and deep dissection revealed additional involved nodes in the deep lymph node compartment in 2 of the 24 patients. At 5 years, 77% of all patients were alive, and 56% were alive and free of disease. These figures were 76% and 53%, respectively, in the patients who underwent superficial dissection only, and 80% and 61%, respectively, in the patients who also underwent deep dissection. Conclusions This study suggests that a strategy to determine the extent of the groin dissection that is based on the location of the second-tier nodes may be valid.     

Is Sentinel Node Biopsy of the Internal Mammary Lymph Nodes Relevant in the Management of Breast Cancer?

The aim of this study was to review the outcomes of a series of breast cancer patients who underwent sentinel node biopsy inclusive of lymphoscintigraphy, and to assess the incidence of internal mammary node (IMN) metastatic positivity at exploration and whether these findings influenced treatment. Between April 2001 and December 2012, 581 breast cancer patients at Princess Alexandra Hospital underwent preoperative lymphoscintigraphy in the course of the performance of sentinel node biopsy. Analysis was performed of those patients who demonstrated radio‐isotope uptake to the IMN chain, and who had sentinel node biopsy of the IMN's and were found to have metastatic involvement. Assessment was made to determine whether the finding of IMN metastases changed the adjuvant systemic management of these patients, and to review complication rates. 95 of 581 (16.4%) patients with preoperative breast lymphoscintigraphy had lymphatic mapping to the IMN chain. 51 (54%) of these patients had IMN chain surgically explored and IMN nodes were found in 35 of these patients (success rate of 69%). Of these, three patients (3/35 = 8.6%) had metastatic involvement of the IMN sentinel node group. All three IMN positive patients received adjuvant breast radiotherapy, chemotherapy, and hormonal therapy. In four patients (7.8%) IMN surgical exploration was complicated by pneumothorax. Only a small proportion of breast cancer patients were found to have metastasic involvement of the IMN chain and which did not significantly change their adjuvant therapy management. These findings suggest that the benefits of exploration of the IMN chain in breast cancer patients are limited and may be outweighed by the risk of complications.     

Preceding Sentinel Node Biopsy in Early Breast Cancer: Does it Affect the Number of Axillary Lymph Nodes ?

In the staging of early breast cancer a positive sentinel node biopsy is followed by axillary dissection in order to assess the number of metastasised lymph nodes. Immediate axillary dissection has been abandoned in our centre. If necessary, an axillary dissection takes place about two weeks later, but the post surgical inflammatory reaction might hinder dissection and decrease the number of removed lymph nodes. In a retrospective study, the total number of lymph nodes removed by sentinel node biopsy followed later by axillary dissection (n = 53) was compared with the total number of lymph nodes removed by axillary dissection without previous sentinel node biopsy in combination with breast conserving therapy (n = 113), or following breast conserving therapy (n = 15), or in combination with mastectomy (n = 65). A total number of 12 (median) lymph nodes were removed by sentinel node biopsy followed later by axillary dissection. Only in the mastectomy + axillary dissection group were less lymph nodes (median of 9) removed (P = 0.009). Multiple regression showed the total number of axillary lymph nodes to be correlated with age (R = -0.21; P = 0.002) and with the number of lymph nodes with metastasis (R = 0.31; P < 0.0001). Age distribution showed that the mastectomy + axillary dissection group had the oldest patient population. The number of removed axillary lymph nodes is not decreased by preceding sentinel node biopsy, but depends on other factors.     

Sentinel Lymph Node Biopsy for Melanoma: How Many Radioactive Nodes Should be Removed?

Background: Sentinel lymph node (SLN) biopsy has become a standard method of staging patients with cutaneous melanoma. Sentinel lymph node biopsy usually is performed by intradermal injection of a vital blue dye (isosulfan blue) plus radioactive colloid (technetium sulfur colloid) around the site of the tumor. Intraoperative gamma probe detection has been shown to improve the rate of SLN identification compared to the use of blue dye alone. However, multiple sentinel nodes often are detected using the gamma probe. It is not clear whether these additional lymph nodes represent true sentinel nodes, or second-echelon lymph nodes that have received radiocolloid particles that have passed through the true sentinel node. This analysis was performed to determine the frequency with which these less radioactive lymph nodes contain metastatic disease when the most radioactive, or hottest, node does not.Materials and Methods: In the Sunbelt Melanoma Trial, 1184 patients with cutaneous melanoma of Breslow thickness 1.0 mm or more had sentinel lymph nodes identified. Sentinel lymph node biopsy was performed by injection of technetium sulfur colloid plus isosulfan blue dye in 99% of cases. Intraoperative determination of the degree of radioactivity of sentinel nodes (ex vivo) was measured, as well as the degree of blue dye staining.Results:Sentinel nodes were identified in 1373 nodal basins in 1184 patients. A total of 288 of 1184 patients (24.3%) were found to have sentinel node metastases detected by histology or immunohistochemistry. Nodal metastases were detected in 306 nodal basins in these 288 patients. There were 175 nodal basins from 170 patients in which at least one positive sentinel node was found and more than one sentinel node was harvested. Blue dye staining was found in 86.3% of the histologically positive sentinel nodes and 66.4% of the negative sentinel nodes. In 40 of 306 positive nodal basins (13.1%), the most radioactive sentinel node was negative for tumor when another, less radioactive, sentinel node was positive for tumor. In 20 of 40 cases inding a positive sentinel node other than the hottest node.Conclusions: If only the most radioactive sentinel node in each basin had been removed, 13.1% of the nodal basins with positive sentinel nodes would have been missed. It is recommended that all blue lymph nodes and all nodes that measure 10% or higher of the ex vivo radioactive count of the hottest sentinel node should be harvested for optimal detection of nodal metastases.Preliminary findings presented at the annual meeting of the Society of Surgical Oncology, Orlando, Florida, March 4–7, 1999.     

Lobectomy and Prophylactic Central Neck Dissection for Papillary Thyroid Microcarcinoma: Do Involved Lymph Nodes Mandate Completion Thyroidectomy?

Background

The present study was designed to investigate the necessity of completion thyroidectomy for patients who underwent thyroid lobectomy for low-risk papillary thyroid microcarcinoma (PTMC) that was later pathologically diagnosed as central lymph node (CLN) metastasis.

Methods

Between 1986 and 2001, we assessed 551 patients who underwent thyroidectomy with prophylactic ipsilateral central compartment neck dissection, and 409 patients were followed-up completely. Thyroid lobectomy were performed in 281 and 128 patients, respectively. The patients were divided into two groups according to CLN metastasis. Clinicopathological profiles and follow-up details were investigated by retrospective chart review.

Results

The CLN-positive and -negative groups were comprised of 43 (15.2 %) and 238 patients (84.8 %), respectively. The mean ages of the two groups were not significantly different (p > 0.05). The mean tumor size of the CLN-positive group (6.8 mm) was significantly larger than that of the CLN-negative group (5.6 mm; p < 0.05). Microscopic capsular invasion was significantly higher in the CLN-positive group (51.2 vs. 23.9 %; p < 0.05). Overall, 21 patients (7.4 %, 21/281) experienced recurrence. Among these, 2 (4.7 %, 2/43) and 19 (8.0 %, 19/238) were in the CLN-positive and -negative groups, respectively. There was no significant correlation between CLN metastasis and tumor recurrence.

Conclusions

Postoperative recurrence was lower in the CLN-positive group, and there was no significant correlation between CLN metastasis and tumor recurrence. Our results suggest that it is not necessary to perform completion thyroidectomy for PTMC patients who have undergone thyroid lobectomy and who have been pathologically diagnosed with CLN metastasis.     

Does the Method of Biopsy Affect the Incidence of Sentinel Lymph Node Metastases?

More detailed examination of the sentinel lymph node (SLN) in breast cancer has raised concerns about the clinical significance of micrometastases, specifically isolated tumor cells detected only through immunohistochemical (IHC) staining. It has been suggested that these cells do not carry the same biologic implications as true metastatic foci and may represent artifact. A retrospective institutional review board-approved review was conducted on clinically node-negative breast cancer patients who underwent SLN biopsy (SLNB) between 1997 and 2003. Retrospective analysis of tumor characteristics and the method of the initial diagnostic biopsy were correlated with the presence and nature of metastatic disease in the SLN. Of 537 SLNBs, 123 (23%) were hematoxylin-eosin (H&E) positive. SLN positivity strongly correlated with tumor size (p<0.001) and tumor grade (p=0.025), but not with the method of biopsy (needle versus excisional biopsy). Prior to July 2002, we routinely evaluated H&E-negative SLNs with IHC (n=381). Of the 291 H&E-negative patients, 26 had IHC-only detected micrometastases (9%). The likelihood of detecting IHC-only metastases did not correlate with tumor size or grade, but was significantly higher in patients undergoing excisional biopsy than core needle biopsy. While the method of biopsy has no demonstrable effect on the likelihood of finding metastases in the SLN by routine serial sectioning and H&E staining, it may significantly impact the likelihood of finding micrometastases by IHC. IHC should not be used routinely in the evaluation of the SLN and caution should be used when basing treatment decisions (completion axillary lymph node dissection or adjuvant therapy) on IHC-only detected micrometastases.     

Definition of T3/4 and Regional Lymph Nodes in Gallbladder Cancer: Which Is More Valid, the UICC or the Japanese Staging System?

Background

The Union for International Cancer Control (UICC) and Japanese Society of Biliary Surgery (JSBS) staging systems differ in their staging of gallbladder cancer: they define hepatic invasion with or without invasion of another organ as T3 and either T3 or T4, respectively, and posterosuperior pancreatic lymph node (PSPLN) metastases as M1 and N2, respectively.

Methods

We retrospectively evaluated the survival of 224 patients who had undergone macroscopically curative resection for gallbladder cancer and assessed the influence of the differences between the two staging systems on survival.

Results

JSBS staging stratified the survival curves better for stages III or IV. Fifty-seven patients were classified as UICC-T3 but JSBS-T4. These patients had better survival than did 43 patients with UICC-T4/JSBS-T4 and comparable survival to 17 patients with UICC-T3/JSBS-T3. UICC stage IIIB is composed of two subgroups: U-T2N1 (18 patients) and U-T3N1 (21 patients). Their 5-year survivals were 85 and 41?%, respectively (P?=?0.01). The latter was comparable to that of 28 T3N0 patients (35?%, P?=?0.93). The survival of the UICC-M1 patients with disease restricted to PSPLNs was significantly better than that of those with involvement beyond PSPLNs (5-year survival 35 vs. 17?%; P?=?0.04).

Conclusions

Although UICC staging more accurately defines the T category, JSBS staging better stratifies the prognosis of patients with gallbladder cancer, mainly because UICC stage IIIB includes T1/2N1M0, which is associated with significantly better survival than T3N0M0. It would be appropriate to classify PSPLNs as regional lymph nodes.     

The Prognostic Effect of the Number of Histologically Examined Axillary Lymph Nodes in Breast Cancer: Stage Migration or Age Association?

Background The number of pathologically examined axillary nodes has been associated with breast cancer survival, and examination of ≥10 nodes has been advocated for reliable axillary staging. The considerable variation observed in axillary staging prompted this population-based study, which evaluated the prognostic effect of a variable number of pathologically examined nodes. Methods In total, 5314 consecutive breast cancer patients who underwent mastectomy or breast-conserving surgery and axillary dissection between 1994 and 1999 were included. The prognostic effect of the examined number of nodes was assessed with crude and relative survival analysis. Results A median number of 12 (range, 1–43) nodes were histologically examined, and 59% of the patients had no nodal tumor involvement. The number of examined nodes decreased with age (P < .001) and increased with tumor size (P < .001). Stratified for the number of tumor-positive nodes, overall survival seemed to be worse for patients with <10 compared with patients with ≥10 examined nodes (P < .001), whereas the relative survival did not differ. After adjusting for age, tumor size, number of positive nodes, and detection by screening in a multivariate analysis, the number of examined nodes was not associated with relative survival. Conclusions This study shows that the association between the number of pathologically examined axillary nodes and overall survival in node-negative and node-positive patients results from stage migration. The absence of an association between the number of examined nodes and relative survival further indicates that the association between the number of examined nodes and crude survival is confounded by age.     

Isolated Tumor Cells in Sentinel Lymph Nodes of Invasive Breast Cancer: Cell Displacement or Metastasis?

The goal of this study was to determine whether the presence of isolated tumoral cells (ITCs) in sentinel lymph nodes (SLNs) after core needle biopsy (CNB) is related to the time interval between CNB and surgery and to histopathologic features of invasive breast cancer. Data from 633 consecutive patients with no micrometastasis or metastasis on both frozen sections and definitive pathologic examination of SLNs were retrieved from a prospective data base. No association was found between ITCs and the time interval between CNB and SLNB. The association was significant with tumor size, the tumor lymphovascular invasion (LVI) and the histologic type of the tumor. This study adds supplementary data to the association between tumoral LVI and ITCs in SLNs, The time interval between CNB procedure and SLNB was not related to affect presence of ITCs, which might not suggest the iatrogenic origin of these cells.     

Should Postmastectomy Radiotherapy to the Chest Wall and Regional Lymph Nodes Be Standard for Patients with 1–3 Positive Lymph Nodes?

The indication for adjuvant postmastectomy radiotherapy (PMRT) in breast cancer patients with small tumors and 1-3 macrometastases in the axilla remains a controversial issue, despite the recommendation that PMRT should be applied in these patients in the most recent overview by the Early Breast Cancer Trialists' Collaborative Group. In this report, we discuss the available data on the benefit from PMRT in patients diagnosed with N1 breast cancer. Based on this, we recommend adjuvant PMRT to the chest wall and regional lymph nodes in patients diagnosed with early node-positive breast cancer.     

How Does the Number of Resected Lymph Nodes Influence TNM Staging and Prognosis for Esophageal Carcinoma?

Background  

It is proposed by International Union Against Cancer (UICC) and American Joint Committee on Cancer (AJCC) that at least 6 lymph nodes (LN) should be removed during resection of esophageal cancer for an accurate N classification. However, large series evidence is needed. The aim of this study is to assess the impact of total number of removed LNs during esophagectomy on UICC-TNM staging and long-term survival.     

Does Previous Head and Neck Irradiation Increase the Chance of Multigland Disease in Patients with Hyperparathyroidism?

Background  

Exposure to therapeutic radiation, whether used to treat lymphoma, breast cancer, or benign conditions, such as acne, is thought to cause an increased risk for thyroid and/or parathyroid neoplasia. We therefore investigated whether patients with a history of head/neck irradiation and hyperparathyroidism (HPT) had a higher incidence of multigland disease.     

Renal Biopsy in the Elderly and Very Elderly: Useful or Not?

Longer life expectancy has led to a growing epidemic of kidney disease in the elderly (aged ≥ 65 years) and very elderly (aged ≥ 80 years). While much of the rising burden of kidney disease in these age-groups can be attributed to age-associated decline and a high prevalence of comorbidities such as hypertension and diabetes mellitus, a significant proportion of kidney disease is due to potentially reversible causes of injury in the glomerular, tubulointerstitial, and vascular compartments. A renal biopsy is crucial not only to diagnose such potentially reversible lesions but also to provide prognostic information and guide therapeutic decisions. In this review, we survey the literature on renal biopsy in the elderly and very elderly, focusing on the utility and safety of this procedure. We report the most common histopathologic findings in these age-groups and demonstrate that many of these lesions are associated with diseases that respond to appropriate therapies, regardless of age. We conclude that, in a variety of commonly encountered clinical situations, a renal biopsy is crucial for appropriate management of elderly and very elderly patients with kidney disease.