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Godinho DM, Silva C, Baleia C, Felício JM, Castela T, Silva NA, Orvalho ML, Fernandes CA, Conceição RC. Modelling level I Axillary Lymph Nodes depth for Microwave Imaging. Phys Med 2022; 104:160-166. [PMID: 36463580 DOI: 10.1016/j.ejmp.2022.11.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 11/23/2022] [Accepted: 11/25/2022] [Indexed: 12/03/2022] Open
Abstract
PURPOSE Patient-specific information on the depth of Axillary Lymph Nodes (ALNs) is important for the development of new diagnostic imaging technologies, e.g. Microwave Imaging (MWI), aiming to assess the diagnosis of ALNs during breast cancer staging. Studies about ALNs depth have been presented for treatment planning, but they lack information on sample size and usability of the data to infer the depth of ALNs. The aim of this study was to create a mathematical model that can be used to predict a depth interval where level I ALNs are likely to be located. METHODS We extracted biometric features of 98 patients who underwent breast Magnetic Resonance Imaging (MRI) to train two types of regression models. We then tested different combination of features to predict ALNs depth and found the best predictor. The final prediction models were then implemented in an algorithm used for MWI and tested with anthropomorphic phantoms of the axillary region. RESULTS Body Mass Index (BMI) was the feature with best performance to predict ALNs depth with coefficient of determination (R2) ranging from 0.49 to 0.55 and Root Mean Squared Error (RMSE) ranging from 0.68 to 0.91 cm. The proposed model showed satisfactory results in microwave images of patients with different BMIs. CONCLUSIONS The presented results contribute to the development of reconstruction algorithms for new imaging technologies and to the assessment of ALNs in other medical applications.
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Affiliation(s)
- Daniela M Godinho
- Instituto de Biofísica e Engenharia Biomédica, Faculdade de Ciências, Universidade de Lisboa, 1749-016 Lisbon, Portugal.
| | - Carolina Silva
- Departamento de Física, Faculdade de Ciências, Universidade de Lisboa, 1749-016 Lisbon, Portugal
| | - Cláudia Baleia
- Departamento de Física, Faculdade de Ciências, Universidade de Lisboa, 1749-016 Lisbon, Portugal
| | - João M Felício
- Centro de Investigação Naval (CINAV), Escola Naval, 2810-001 Almada, Portugal; Instituto de Telecomunicações, Instituto Superior Técnico, Universidade de Lisboa, 1049-001 Lisbon, Portugal
| | - Tiago Castela
- Departamento de Radiologia, Hospital da Luz Lisboa, Luz Saúde, 1500-650 Lisbon, Portugal
| | - Nuno A Silva
- Hospital da Luz Learning Health, Luz Saúde, 1500-650 Lisbon, Portugal
| | - M Lurdes Orvalho
- Departamento de Radiologia, Hospital da Luz Lisboa, Luz Saúde, 1500-650 Lisbon, Portugal
| | - Carlos A Fernandes
- Instituto de Telecomunicações, Instituto Superior Técnico, Universidade de Lisboa, 1049-001 Lisbon, Portugal
| | - Raquel C Conceição
- Instituto de Biofísica e Engenharia Biomédica, Faculdade de Ciências, Universidade de Lisboa, 1749-016 Lisbon, Portugal
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Kaidar-Person O, Offersen BV, Boersma L, Meattini I, Dodwell D, Wyld L, Aznar M, Major T, Kuehn T, Strnad V, Palmu M, Hol S, Poortmans P. Tricks and tips for target volume definition and delineation in breast cancer: Lessons learned from ESTRO breast courses. Radiother Oncol 2021; 162:185-194. [PMID: 34302915 DOI: 10.1016/j.radonc.2021.07.015] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 07/10/2021] [Accepted: 07/12/2021] [Indexed: 10/20/2022]
Abstract
Delineation of target and 'organ at risk' volumes is a critical part of modern radiation therapy planning, the next essential step after deciding the indication, patient discussion and image acquisition. Adoption of volume-based treatment planning for non-metastatic breast cancer has increased greatly along with the use of improved planning techniques, essential for modern therapy. However, identifying the volumes on a planning CT is no easy task. The current paper is written by ESTRO's breast course faculty, providing tricks and tips for target volume definition and delineation for optimal postoperative breast cancer irradiation.
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Affiliation(s)
- Orit Kaidar-Person
- Sheba Medical Center, Ramat Gan, Israel; Sackler School of Medicine, Tel-Aviv University, Israel.
| | - Birgitte V Offersen
- Department of Experimental Clinical Oncology, Aarhus University Hospital, Denmark
| | - Liesbeth Boersma
- Department of Radiation Oncology (Maastro), GROW School for Oncology, Maastricht University Medical Centre+, The Netherlands
| | - Icro Meattini
- Department of Experimental and Clinical Biomedical Sciences "M. Serio", University of Florence & Radiation Oncology Unit - Oncology Department, Azienda Ospedaliero Universitaria Careggi, Florence, Italy
| | - David Dodwell
- Nuffield Department of Population Health, University of Oxford, UK
| | - Lynda Wyld
- Department of Oncology and Metabolism, University of Sheffield, UK
| | - Marianne Aznar
- Division of Cancer Sciences, Faculty of Biology, Medicine and Health, University of Manchester, UK
| | - Tibor Major
- Center of Radiotherapy, National Institute of Oncology, Budapest, Hungary & Department of Oncology, Semmelweis University, Budapest, Hungary
| | - Thorsten Kuehn
- Department of Gynaecology and Obstetrics, Interdisciplinary Breast Center, Klinikum Esslingen, Germany
| | - Vratislav Strnad
- Dept. of Radiation Oncology, University Hospital Erlangen, Erlangen, Germany
| | - Miika Palmu
- European SocieTy for Radiotherapy and Oncology, UK
| | - Sandra Hol
- Instituut Verbeeten, Tilburg, The Netherlands
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Breast Cancer Skip Metastases: Frequency, Associated Tumor Characteristics, and Role of Staging Nodal Ultrasound in Detection. AJR Am J Roentgenol 2021; 217:835-844. [PMID: 32997506 DOI: 10.2214/ajr.20.24371] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND. Staging nodal ultrasound (US) evaluates locations beyond those assessed during routine surgical dissection and has an increasing role in breast cancer management given the growing use of neoadjuvant systemic therapy before surgical staging. OBJECTIVE. The purpose of this study is to identify the patterns of nodal spread of breast cancer observed at staging nodal US and to determine the frequency of skip metastases and associated tumor characteristics. METHODS. This retrospective study included 1269 consecutive patients (31 with bilateral synchronous cancers) who had 1300 newly diagnosed, untreated, invasive breast cancers and underwent US examination of the ipsilateral regional nodal basins from January 2016 through March 2017. Cases with suspicious nodes on US underwent fine-needle aspiration (FNA) biopsy. Cases with benign results on FNA and no suspicious nodes on US underwent sentinel lymph node biopsy. Results of US with FNA were compared with final surgical pathology. Skip metastases were defined as spread across discontiguous nodal levels or distant metastases in the absence of ipsilateral nodal metastases. The incidence and patterns of spread of skip metastases were summarized; associations with tumor characteristics were tested using the Fisher exact test. RESULTS. A total of 591 metastatic cases (45.5%) were confirmed by needle biopsy or sentinel lymph node biopsy, comprising 463 nodal metastases (N+) confirmed by FNA, 121 nodal metastases (N+) confirmed by sentinel lymph node biopsy, and seven distant organ metastases without nodal metastases (N0M1) confirmed by CT-guided biopsy. US with FNA had sensitivity of 86.0%, specificity of 100.0%, PPV of 100.0%, NPV of 89.5%, and accuracy of 93.6%. There were 34 skip metastases, for an incidence of 2.6% (34/1300) (95% CI, 1.8-3.6%) among all invasive cancers and 7.2% (34/470) (95% CI, 5.1-9.9%) among metastatic cancers detected by US and FNA. Skip metastases occurred to axillary level III (n = 4), the supraclavicular nodal basin (n = 21), the contralateral axilla (n = 2), and distant organs (n = 7). Cancers with skip metastases, compared with those with nonskip metastases, had higher rates (p = .005) of lobular histology (23.5% vs 6.7%) and mixed ductal and lobular histology (11.8% vs 6.7%). Skip metastases were not associated with grade, T category, or molecular subtype (p > .05). CONCLUSION. Skip metastases to locations beyond standard surgical axillary dissection occur in 7.2% of metastatic breast cancers. CLINICAL IMPACT. Staging nodal US identifies skip metastases that otherwise would be undetected, helping to achieve more accurate staging and minimize undertreatment.
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Less Axillary Lymphadenectomy is More Beneficial: 27-Year Follow-up of Patients with Breast Cancer. INTERNATIONAL JOURNAL OF CANCER MANAGEMENT 2021. [DOI: 10.5812/ijcm.108538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Background: One of the most important alterations in breast cancer treatment is the change of view in axillary lymph node management. At the moment, sentinel lymph node biopsy (SLNB) is the standard care in axillary lymph node management. However, in patients with clinically positive lymph nodes or in patients, who have no willingness to receive radioactive drugs, axillary lymph node dissection (ALND) must be done. To the best of our knowledge, there is no overall survival (OS) benefit in ALND, especially at the early stage of breast cancer, during which this procedure is not justified. Objectives: Herein, we have reported the results of 27 years of experiments in limited axillary lymph node dissection (LALND) in comparison to ALND as well as the relationship among the number of removed lymph nodes, OS, and disease-free survival (DFS) at the early stage of breast cancer. Methods: OS and DFS for 588 cases, who were at the early stage of breast cancer and treated by LALND between 1984 and 2019, were compared with 1026 patients, who were treated by ALND during the same interval in this study. Notably, SLNB cases were excluded. Results: The results revealed no significant difference among the groups in terms of DFS (P = 0.268, 0.123, and 0.333). Also, there was no difference in terms of OS between the LALND group (1 - 4 nodes, 5 - 6 nodes, and 7 - 8 nodes) and ALND group (≥ 9 nodes) in patients without lymph node involvement (AHR less than 2). However, in the patients with axillary lymph node metastasis (N1, N2), similar results were obtained. Correspondingly, in this group, the best results were observed in those patients, whose 7 - 8 lymph nodes were removed. Conclusions: Regarding the results of the current study; it can be concluded that performing the LALND in the defined anatomic range and removing 7 - 8 lymph nodes instead of removing 10 lymph nodes are not inferior when it is not possible to do SLNB (there is no access to it) and/or being a contraindication to do it for evaluating the status of axillary lymph nodes in the patients at the early stage of breast cancer.
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Hu J, Xia X, Yang H, Yu Y. Dissection of Level III Axillary Lymph Nodes in Breast Cancer. Cancer Manag Res 2021; 13:2041-2046. [PMID: 33664591 PMCID: PMC7924124 DOI: 10.2147/cmar.s290345] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 01/31/2021] [Indexed: 11/23/2022] Open
Abstract
Axillary lymph node dissection is an indispensable step in modified radical mastectomy for breast cancer. It is the most reliable method and the golden standard to determine the status of axillary lymph nodes. It is also of great importance to evaluate the prognosis and develop treatment plans for breast cancer patients. Axillary lymph node dissection can be anatomically divided into levels I, II, and III. Level I and Level II axillary lymph dissection is the standard clinical treatment of axillary lymph nodes positive breast cancer, whereas level III axillary lymph node dissection has been controversial. Level III axillary lymph node metastasis is one of the important factors that can easily cause distant metastasis and recurrence. It is also an important index to estimate the prognosis of breast cancer patients. To facilitate the decision of whether or not to perform level III lymph node dissection, we reviewed the indications, complications, and surgical procedures of level III lymph node dissection.
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Affiliation(s)
- Jiejie Hu
- Breast Surgery Department, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Xianghou Xia
- Breast Surgery Department, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Hongjian Yang
- Breast Surgery Department, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou City, Zhejiang Province, People's Republic of China
| | - Yang Yu
- Breast Surgery Department, Cancer Hospital of the University of Chinese Academy of Sciences (Zhejiang Cancer Hospital), Institute of Cancer and Basic Medicine (IBMC), Chinese Academy of Sciences, Hangzhou City, Zhejiang Province, People's Republic of China
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Lee YW, Huang CS, Shih CC, Chang RF. Axillary lymph node metastasis status prediction of early-stage breast cancer using convolutional neural networks. Comput Biol Med 2020; 130:104206. [PMID: 33421823 DOI: 10.1016/j.compbiomed.2020.104206] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Revised: 12/28/2020] [Accepted: 12/28/2020] [Indexed: 11/25/2022]
Abstract
Deep learning (DL) algorithms have been proven to be very effective in a wide range of computer vision applications, such as segmentation, classification, and detection. DL models can automatically assess complex medical image scenes without human intervention and can be applied as a second reader to provide an additional opinion for the physician. To predict the axillary lymph node (ALN) metastatic status in patients with early-stage breast cancer, a deep learning-based computer-aided prediction system for ultrasound (US) images was proposed. A total of 153 women with breast tumor US images were involved in this study; there were 59 patients with metastasis and 94 patients without ALN metastasis. A deep learning-based computer-aided prediction (CAP) system using the tumor region and peritumoral tissue in ultrasound (US) images were employed to determine the ALN status in breast cancer. First, we adopted Mask R-CNN as our tumor detection and segmentation model to obtain the tumor localization and region. Second, the peritumoral tissue was extracted from the US image, which reflects metastatic progression. Third, we used the DL model to predict ALN metastasis. Finally, the simple linear iterative clustering (SLIC) superpixel segmentation method and the LIME explanation algorithm were employed to explain how the model makes decisions. The experimental results indicated that the DL model had the best prediction performance on tumor regions with 3 mm thick peritumoral tissue, and the accuracy, sensitivity, specificity, and AUC were 81.05% (124/153), 81.36% (48/59), 80.85% (76/94), and 0.8054, respectively. The results indicated that the proposed CAP system could help determine the ALN status in patients with early-stage breast cancer. The results reveal that the proposed CAP model, which combines primary tumor and peritumoral tissue, is an effective method to predict the ALN status in patients with early-stage breast cancer.
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Affiliation(s)
- Yan-Wei Lee
- Department of Computer Science and Information Engineering, National Taiwan University, Taipei, 10617, Taiwan
| | - Chiun-Sheng Huang
- Department of Surgery, College of Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, 100, Taiwan
| | - Chung-Chih Shih
- Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, 10617, Taiwan
| | - Ruey-Feng Chang
- Department of Computer Science and Information Engineering, National Taiwan University, Taipei, 10617, Taiwan; Graduate Institute of Biomedical Electronics and Bioinformatics, National Taiwan University, Taipei, 10617, Taiwan; Graduate Institute of Network and Multimedia, National Taiwan University, Taipei, 10617, Taiwan; MOST Joint Research Center for AI Technology and All Vista Healthcare, Taipei, 10617, Taiwan.
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7
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Joshi S, Noronha J, Hawaldar R, Kundgulwar G, Vanmali V, Parmar V, Nair N, Shet T, Badwe R. Merits of Level III Axillary Dissection in Node-Positive Breast Cancer: A Prospective, Single-Institution Study From India. J Glob Oncol 2020; 5:1-8. [PMID: 30811304 PMCID: PMC6426546 DOI: 10.1200/jgo.18.00165] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE A complete axillary lymph node (ALN) dissection is therapeutic in node-positive breast cancer. Presently, there is no international consensus regarding anatomic levels to be addressed in complete axillary dissection. We assessed the burden of disease in level III axilla. MATERIALS AND METHODS A prospectively maintained database was assessed for 1,591 consecutive patients with nonmetastatic breast cancer registered at Tata Memorial Center, Mumbai, between January 2009 and December 2014. RESULTS A median of four (zero to 20) level III ALNs were dissected and a median of two (one to 17) nodes were positive. A total of 27.3% (434 of 1,591) patients had level III ALN metastasis, and 4.7% of patients had positive interpectoral nodes. Some 53.2% of patients had level III metastases in the presence of four or more positive level I and II ALNs. A total of 9.4% of patients had level III involvement when one to three ALNs were positive in level I and II ( P < .001). Some 53.2% of patients had level III metastases in the presence of four or more positive level I and II ALNs. On logistic regression analysis, four or more positive ALNs in level I or II ( P < .001), inner/central quadrant tumor location ( P = .013), and perinodal extension ( P < .001) were associated with level III ALN involvement. At a median follow-up of 36 months, the disease-free survival was significantly worse for level III ALN metastases on univariate analysis ( P < .001). On multivariate Cox regression analysis, histologic grade ( P = .006), four or more positive ALNs ( P < .001), hormone receptor status ( P < .001), and tumor size ( P = .037) were independent prognostic factors for disease-free survival. CONCLUSION The axillary nodal burden is high in patients with breast cancer in developing countries like India. One of two women with four or more positive level I and II ALNs may have residual disease in level III if it is not cleared during surgery. Intraoperative interpectoral space clearance should be considered in the presence of either palpable interpectoral lymph nodes or multiple positive ALNs.
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Affiliation(s)
- Shalaka Joshi
- Tata Memorial Hospital Parel, Mumbai, Maharastra, India
| | - Jarin Noronha
- Tata Memorial Hospital Parel, Mumbai, Maharastra, India
| | | | | | | | - Vani Parmar
- Tata Memorial Hospital Parel, Mumbai, Maharastra, India
| | - Nita Nair
- Tata Memorial Hospital Parel, Mumbai, Maharastra, India
| | - Tanuja Shet
- Tata Memorial Hospital Parel, Mumbai, Maharastra, India
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Loganadane G, Truong PT, Taghian AG, Tešanović D, Jiang M, Geara F, Moran MS, Belkacemi Y. Comparison of Nodal Target Volume Definition in Breast Cancer Radiation Therapy According to RTOG Versus ESTRO Atlases: A Practical Review From the TransAtlantic Radiation Oncology Network (TRONE). Int J Radiat Oncol Biol Phys 2020; 107:437-448. [PMID: 32334035 DOI: 10.1016/j.ijrobp.2020.04.012] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2019] [Revised: 04/02/2020] [Accepted: 04/08/2020] [Indexed: 01/05/2023]
Abstract
Regional nodal irradiation has gained interest in recent years with the publication of several important randomized trials and the availability of more conformal techniques. Target volume delineation represents a critical step in the radiation planning process. Adequate coverage of the microscopic tumor spread to regional lymph nodes must be weighed against exposure of critical structures such as the heart and lungs. Among available guidelines for delineating the clinical target volume for the breast/chest wall and regional nodes, the Radiation Therapy Oncology Group and European Society for Radiotherapy and Oncology guidelines are the most widely used internationally. These guidelines have been formulated based on anatomic boundaries of areas historically covered in 2-dimensional field-based radiation therapy but have not been validated by patterns-of-failure studies. In recent years, an important body of data has emerged from mapping studies documenting patterns of local and regional recurrence. We aim to review, discuss, and compare contouring guidelines for breast cancer radiation therapy in the context of contemporary data on locoregional relapse to improve their implementation in modern practice.
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Affiliation(s)
- Gokoulakrichenane Loganadane
- Henri Mondor Breast Center and Department of Radiation Oncology, APHP; University of Paris-Est Creteil (UPEC) and INSERM Unit 955 - Team 21. Creteil, France
| | - Pauline T Truong
- Department of Radiation Oncology, British Columbia Cancer Agency and University of British Columbia, Vancouver, Canada
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital and Harvard Medical School, Boston, Massachusetts
| | - Dušanka Tešanović
- Medical Faculty of University of Novi Sad, Novi Sad and Oncology Institute of Vojvodina, Sremska Kamenica, Serbia
| | - Mawei Jiang
- University Hospital of Xinhua and Jiao Tong University, Shanghai, China
| | - Fady Geara
- Department of Radiation Oncology, American University of Beirut, Beirut, Lebanon
| | - Meena S Moran
- Department of Radiation Oncology, Yale University School of Medicine, Smilow Cancer Center, New Haven, Connecticut
| | - Yazid Belkacemi
- Henri Mondor Breast Center and Department of Radiation Oncology, APHP; University of Paris-Est Creteil (UPEC) and INSERM Unit 955 - Team 21. Creteil, France.
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Quelles sont les meilleures méthodes d’imagerie actuelle pour statuer sur le stade N0 radiologique avant le traitement des cancers du sein ? IMAGERIE DE LA FEMME 2019. [DOI: 10.1016/j.femme.2019.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Delgado-Bocanegra RE, Millen EC, do Nascimento CM, Bruno KDA. Intraoperative imprint cytology versus histological diagnosis for the detection of sentinel lymph nodes in breast cancer treated with neoadjuvant chemotherapy. Clinics (Sao Paulo) 2018; 73:e363. [PMID: 30088537 PMCID: PMC6038057 DOI: 10.6061/clinics/2018/e363] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2017] [Accepted: 02/08/2018] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES To compare imprint cytology and paraffin section histology for sentinel lymph node detection in women with breast cancer treated with neoadjuvant chemotherapy. METHOD A cross-sectional study and report of the sentinel lymph node statuses of 64 patients with breast cancer who underwent intraoperative imprint cytology and neoadjuvant chemotherapy in a referral cancer institute in Rio de Janeiro, Brazil, between 2014 and 2016. RESULTS The mean age was 51 years. The most common histological type was invasive ductal carcinoma (93.75%), and the most common differentiation grade was 2 (62.5%). Overall, 153 lymph nodes were identified, with a mean of 2.39/case. Thirty-four lymph nodes tested positive for malignancy by imprint cytology, and 55 tested positive by histology. Of the 55 positive lymph nodes, 41 (74.5%) involved macrometastases, and 14 (25.5%) involved micrometastases. There were 21 false negatives with imprint cytology, namely, 7 for macrometastases and 14 for micrometastases, resulting in a rate of 17.6%. The sensitivity of imprint cytology was 61.8%, with a specificity and positive predictive value of 100%, a negative predictive value of 82.4% and an accuracy of 86.3%. The method presented null sensitivity for the identification of micrometastases. CONCLUSIONS The false-negative rate with imprint cytology was associated with the number of sentinel lymph nodes obtained. The rate found for complete response to neoadjuvant chemotherapy was comparable to the rates reported in the literature. The accuracy of imprint cytology was good, and its specificity was excellent for sentinel lymph node detection; however, the method was unable to detect lymph node micrometastases.
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De Cicco C, Cremonesi M, Chinol M, Bartolomei M, Pizzamiglio M, Leonardi L, Fiorenza M, Paganelli G. Optimization of Axillary Lymphoscintigraphy to Detect the Sentinel Node in Breast Cancer. TUMORI JOURNAL 2018; 83:539-41. [PMID: 9226014 DOI: 10.1177/030089169708300210] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Affiliation(s)
- C De Cicco
- Division of Nuclear Medicine, European Institute of Oncology, Milan, Italy
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Kim WG, Lee J. Axillary Skip Metastases and the False-Negative Rate of Sentinel Lymph Node Biopsy in Patients With Breast Cancer Are Related to Negative ALDH-1 Expression and Ki-67 Expression. Int J Surg Pathol 2017; 25:397-405. [DOI: 10.1177/1066896917690024] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Breast cancer stem cells (CSCs) have been hypothesized to be the driving force behind tumorigenesis and metastasis. In this study, we evaluated the relationships between CSC expressions in primary breast cancers and corresponding metastatic sentinel and nonsentinel lymph nodes (SLNs and NSLNs). The clinical implications of these relationships were also investigated. CSC expressions were evaluated in 167 breast cancer specimens and associated lymph node biopsies (when present). We used double immunohistochemistry of CD44/CD24 and single immunohistochemistry of ALDH-1 on paraffin-embedded breast tissue, SLN, and NSLN specimens. Seven cases had metastatic NSLNs without SLN involvement—so-called “skip metastasis.” Fifty cases of SLNs (29.9%) and 33 cases of NSLNs (25.7%) had metastases. In the breast cancers, metastatic SLNs, and NSLNs, the expression rates of CD44+/CD24− were 47.9%, 26.1%, and 34.6 %, respectively, while the expression rates of ALDH-1+ were 42.5%, 36.4%, and 33.3%, respectively. Significant relationships were not observed between CSC expressions in breast cancer and metastatic SLNs or NSLNs. The presence of skip metastasis correlated with negative ALDH-1 in breast cancer ( P = .04), as well as several clinicopathologic factors: age >50 years ( P = .004), negative lymphovascular tumor emboli ( P = .02), and high Ki-67 expression ( P = .04). Axillary lymph node metastasis showed no significant relationship with any CSC marker. However, CD44+/CD24− and ALDH-1 expressions of metastatic SLNs correlated with CSCs of primary breast cancers. In summary, skip metastasis correlated with negative expression of ALDH-1 in primary breast cancers, which could be promising as a means of assessing the risk of skip metastasis.
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Affiliation(s)
- Woo Gyeong Kim
- Department of Pathology, Inje University Haeundae Paik Hospital, Busan, Republic of Korea
| | - JungSun Lee
- Department of Surgery, Inje University Haeundae Paik Hospital, Busan, Republic of Korea
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Jinno H, Inokuchi M, Ito T, Kitamura K, Kutomi G, Sakai T, Kijima Y, Wada N, Ito Y, Mukai H. The Japanese Breast Cancer Society clinical practice guideline for surgical treatment of breast cancer, 2015 edition. Breast Cancer 2016; 23:367-77. [PMID: 26921084 DOI: 10.1007/s12282-016-0671-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 01/23/2016] [Indexed: 11/28/2022]
Affiliation(s)
- Hiromitsu Jinno
- Department of Surgery, Teikyo University School of Medicine, 2-11-1 Kaga, Itabashi, Tokyo, 1738606, Japan.
| | - Masafumi Inokuchi
- Department of Breast Oncology, Kanazawa University Hospital, Ishikawa, Japan
| | - Toshikazu Ito
- Department of Surgery, Rinku General Medical Center, Osaka, Japan
| | - Kaoru Kitamura
- Department of Breast Surgery, Nagumo Clinic Fukuoka, Fukuoka, Japan
| | - Goro Kutomi
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University Hospital Hokkaido, Sapporo, Japan
| | - Takehiko Sakai
- Breast Oncology Center, Cancer Institute Hospital of the Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Yuko Kijima
- Department of Digestive Surgery, Breast and Thyroid Surgery, Kagoshima University School of Medicine, Kagoshima, Japan
| | - Noriaki Wada
- Department of General and Breast Surgery, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
| | - Yoshinori Ito
- Department of Breast Medical Oncology, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Hirofumi Mukai
- Department of General and Breast Surgery, Tokyo Dental College Ichikawa General Hospital, Chiba, Japan
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Komoike Y, Inokuchi M, Itoh T, Kitamura K, Kutomi G, Sakai T, Jinno H, Wada N, Ohsumi S, Mukai H. Japan Breast Cancer Society clinical practice guideline for surgical treatment of breast cancer. Breast Cancer 2014; 22:37-48. [PMID: 25091115 DOI: 10.1007/s12282-014-0558-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 07/16/2014] [Indexed: 10/24/2022]
Affiliation(s)
- Yoshifumi Komoike
- Section of Breast and Endocrine Surgery, Department of Surgery, Kinki University Faculty of Medicine, 377-2 Onohigashi, Osakasayama, Osaka, 589-8511, Japan,
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Özdemir A, Mayir B, Demirbakan K, Oygür N. Efficacy of Methylene Blue in Sentinel Lymph Node Biopsy for Early Breast Cancer. THE JOURNAL OF BREAST HEALTH 2014; 10:88-91. [PMID: 28331650 DOI: 10.5152/tjbh.2014.1914] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 03/04/2014] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Sentinel lymph node biopsy is the recommended approach in the evaluation of axilla during breast cancer surgery. In this study, results of patients who underwent methylene blue sentinel lymph node biopsy were evaluated. MATERIALS AND METHODS The study included 32 female patients with T1 and T2 tumors. 5 ml of 1% methylene blue was injected into the peritumoral area or around the cavity. The axillary sentinel lymph node was found and removed, and then axillary dissection was performed. The sentinel lymph node and axillary dissection specimen were histopathologically examined and the results were compared. RESULTS The sentinel lymph node was found in 30 (94%) patients. Lymph node metastasis was not observed in 17 patients in both the sentinel lymph node and axilla. Two patients had metastasis in the axilla although this was not detected in sentinel lymph node. Eleven patients had metastasis both in the sentinel lymph node and in the axilla. The accuracy rate was 93%, and the false negativity rate was identified as 15%. CONCLUSION Sentinel lymph node biopsy by methylene blue is a method that can be applied with high accuracy. Methylene blue can be considered as an alternative to isosulphane blue in sentinel lymph node biopsy.
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Affiliation(s)
- Altan Özdemir
- Department of General Surgery, Bucak State Hospital, Burdur, Turkey
| | - Burhan Mayir
- Department of General Surgery, Antalya Education and Research Hospital, Antalya, Turkey
| | - Kenan Demirbakan
- Department of General Surgery, Gaziantep 25 Aralık State Hospital, Gaziantep, Turkey
| | - Nezihi Oygür
- Department of General Surgery, Akdeniz University Faculty of Medicine, Antalya, Turkey
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Ahmed A, Bhatnagar S, Rana SPS, Ahmad SM, Joshi S, Mishra S. Prevalence of Phantom Breast Pain and Sensation Among Postmastectomy Patients Suffering from Breast Cancer: A Prospective Study. Pain Pract 2013; 14:E17-28. [DOI: 10.1111/papr.12089] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2013] [Accepted: 04/22/2013] [Indexed: 11/29/2022]
Affiliation(s)
- Arif Ahmed
- Department of Anaesthesia, Pain and palliative Care; Dr. BRA Institute Rotary Cancer Hospital; All India Institute of Medical Sciences; New Delhi India
| | - Sushma Bhatnagar
- Department of Anaesthesia, Pain and palliative Care; Dr. BRA Institute Rotary Cancer Hospital; All India Institute of Medical Sciences; New Delhi India
| | - Shiv Pratap Singh Rana
- Department of Anaesthesia, Pain and palliative Care; Dr. BRA Institute Rotary Cancer Hospital; All India Institute of Medical Sciences; New Delhi India
| | - Syed Mehmood Ahmad
- Department of Anaesthesia, Pain and palliative Care; Dr. BRA Institute Rotary Cancer Hospital; All India Institute of Medical Sciences; New Delhi India
| | - Saurabh Joshi
- Department of Anaesthesia, Pain and palliative Care; Dr. BRA Institute Rotary Cancer Hospital; All India Institute of Medical Sciences; New Delhi India
| | - Seema Mishra
- Department of Anaesthesia, Pain and palliative Care; Dr. BRA Institute Rotary Cancer Hospital; All India Institute of Medical Sciences; New Delhi India
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Imagerie préopératoire de l’extension ganglionnaire initiale et locorégionale des cancers du sein. ONCOLOGIE 2013. [DOI: 10.1007/s10269-013-2290-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Affiliation(s)
- Kathryn T Chen
- Department of Surgical Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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Study on the skip metastasis of axillary lymph nodes in breast cancer and their relation with Gli1 expression. Tumour Biol 2012; 33:1943-50. [PMID: 22797820 DOI: 10.1007/s13277-012-0455-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2012] [Accepted: 07/02/2012] [Indexed: 10/28/2022] Open
Abstract
The skip metastasis (SM) of axillary lymph nodes (ALN) in breast cancer is an important phenomenon which is crucial to determine the correct choice of surgical resection. The mechanism of SM of ALN is unclear. Gli1 protein is a core epithelial-to-mesenchymal transition (EMT) regulatory factor that plays essential roles in both development and disease processes and has been associated with metastasis in carcinomas. The aim of this study was to investigate the clinicopathological characteristics of SM and evaluate the significance of Gli1 expression in breast cancer patients with metastasis of ALN. Clinicopathological data from 1,037 female breast cancer patients who underwent radical mastectomy were retrospectively reviewed. In this study, an SM was defined as level I absence but level II and/or level III involvement. The expression of Gli1 was evaluated by immunohistochemistry in 102 non-SM cases with positive nodes and 33 SM cases. In univariate analysis, we found that pN category, TNM stage, intrinsic subtypes and Gli1 expression was significant risk factor of SM. Further logistic regression analysis revealed that luminal A cases had a lower risk of SM relative to luminal B 1 (HER2 negative) cases. Further multivariate analysis revealed that Gli1 expression and numbers of positive lymph nodes were the independent factors which associated with SM. Collectively, Breast cancer with SM of ALN associated with the intrinsic subtype of the luminal B1. Gli1 expression related with the procession of breast cancer with SM, which can be used as a predictor of SM of ALN in breast cancer.
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Dobi E, Bazan F, Dufresne A, Demarchi M, Villanueva C, Chaigneau L, Montcuquet P, Ivanaj A, Sautière JL, Maisonnette-Escot Y, Cals L, Algros MP, Woronoff AS, Pivot X. Is extracapsular tumour spread a prognostic factor in patients with early breast cancer? Int J Clin Oncol 2012; 18:607-13. [PMID: 22763660 DOI: 10.1007/s10147-012-0439-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2012] [Accepted: 06/07/2012] [Indexed: 11/29/2022]
Abstract
BACKGROUND This study searched for extra capsular tumour spread (ECS) as a prognostic factor for recurrence in terms of Disease Free Survival (DFS) and Overall Survival (OS). PATIENTS AND METHODS For this study, from a retrospective database of the Doubs cancer registry, 823 eligible women with node positive breast cancer treated from February 1984 to November 2000 were identified. The following factors were evaluated: ECS, numbers of involved nodes, histological tumour grade, tumour size, status of estrogen and progesterone receptors, and age of patient. A Cox proportional hazards method was used to search for significant factors related to OS and DFS length. RESULTS In the multivariate analysis, factors related to DFS length were found to be: tumour grade (aHR 0.76, 95 % CI 0.61-0.96, p = 0.02), ECS status (aHR 0.7, 95 % CI 0.49-0.96, p = 0.03), progesterone (PgR) status (aHR 0.63, 95 % CI 0.44-0.85 p = 0.008), number of nodes involved (aHR 0.75, 95 % CI 0.56-1, p = 0.05). The multivariate analysis for OS found as significant factors: tumour grade (aHR 0.76, 95 % CI 0.61-0.95; p = 0.02) and PgR status (aHR 0.8, 95 % CI 0.56-0.99, p = 0.02). CONCLUSIONS This study might suggest taking into account ECS status in the adjuvant decision-making process.
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Affiliation(s)
- Erion Dobi
- Department of Medical Oncology, University Hospital of Besancon, Besançon, France.
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Sun J, Yin J, Ning L, Liu J, Liu H, Gu L, Fu L. Clinicopathological characteristics of breast cancers with axillary skip metastases. J INVEST SURG 2012; 25:33-6. [PMID: 22272635 DOI: 10.3109/08941939.2011.598605] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
OBJECTIVE The presence of discontinuous or "skip" metastases in breast cancer is crucial for determining the optimal therapeutic choice. In this study, we compared the clinicopathological characteristics and prognosis of patients with or without skip metastases (SMs). METHODS We retrospectively analyzed the records of 1,502 breast cancer patients who underwent radical mastectomy and a separate group of 118 patients who had sentinel lymph node biopsies (SLNB). The median follow-up time was 10 years. RESULTS Axillary lymph nodes (ALN) were involved in 814/1502 patients, and SMs was found in 119 patients (14.6%). Age, tumor size, location, clinical stage, and the proportion of interpectoral lymph node (IPN) metastases were similar in patients with or without SMs (p > .05). In stage I and II disease, the event-free survival rate of patients with SMs was significantly lower than patients without (p < .05); there was no significant difference in stage III patients (p > .05). The Cox multivariate analysis showed that the tumor size, number of lymphatic metastases, lymph node involvement, and SMs were important prognostic factors. The false-negative rate of SLNB was 12.0% (3/25). CONCLUSION Axillary lymphatic SM is difficult to predict, but their presence can predict a poorer prognosis for stage I and II patients. SM could occur in SLNB-negative patients.
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Affiliation(s)
- Jingyan Sun
- Department of Breast Oncology, Key Laboratory of Cancer Prevention and Therapy, Tianjin Medical University Cancer Institute and Hospital, Hexi District, Tianjin, China
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Kim JY, Ryu MR, Choi BO, Park WC, Oh SJ, Won JM, Chung SM. The prognostic significance of the lymph node ratio in axillary lymph node positive breast cancer. J Breast Cancer 2011; 14:204-12. [PMID: 22031802 PMCID: PMC3200516 DOI: 10.4048/jbc.2011.14.3.204] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2011] [Accepted: 08/05/2011] [Indexed: 02/06/2023] Open
Abstract
PURPOSE This study evaluated the prognostic impact of the lymph node ratio (LNR; i.e., the ratio of positive to dissected lymph nodes) on recurrence and survival in breast cancer patients with positive axillary lymph nodes (LNs). METHODS The study cohort was comprised of 330 breast cancer patients with positive axillary nodes who received postoperative radiotherapy between 1987 and 2004. Ten-year Kaplan-Meier locoregional failure, distant metastasis, disease-free survival (DFS) and disease-specific survival (DSS) rates were compared using Kaplan-Meier curves. The prognostic significance of the LNR was evaluated by multivariate analysis. RESULTS Median follow-up was 7.5 years. By minimum p-value approach, 0.25 and 0.55 were the cutoff values of LNR at which most significant difference in DFS and DSS was observed. The DFS and DSS rates correlated significantly with tumor size, pN classification, LNR, histologic grade, lymphovascular invasion, the status of estrogen receptor and progesterone receptor. The LNR based classification yielded a statistically larger separation of the DFS curves than pN classification. In multivariate analysis, histologic grade and pN classification were significant prognostic factors for DFS and DSS. However, when the LNR was included as a covariate in the model, the LNR was highly significant (p<0.0001), and pN classification was not statistically significant (p>0.05). CONCLUSION The LNR predicts recurrence and survival more accurately than pN classification in our study. The pN classification and LNR should be considered together in risk estimates for axillary LNs positive breast cancer patients.
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Affiliation(s)
- Ji-Yoon Kim
- Department of Radiation Oncology, The Catholic University of Korea College of Medicine, Seoul, Korea
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Khafagy M, Mostafa A, Fakhr I. Distribution of axillary lymph node metastases in different levels and groups in breast cancer, a pathological study. J Egypt Natl Canc Inst 2011; 23:25-30. [DOI: 10.1016/j.jnci.2011.07.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2010] [Accepted: 02/18/2011] [Indexed: 12/01/2022] Open
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Mainiero MB. Regional Lymph Node Staging in Breast Cancer: The Increasing Role of Imaging and Ultrasound-Guided Axillary Lymph Node Fine Needle Aspiration. Radiol Clin North Am 2010; 48:989-97. [DOI: 10.1016/j.rcl.2010.06.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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26
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Diagnostic value of diffusion-weighted magnetic resonance imaging (DWI) compared to FDG PET/CT for whole-body breast cancer staging. Eur J Nucl Med Mol Imaging 2010; 37:1077-86. [DOI: 10.1007/s00259-010-1399-z] [Citation(s) in RCA: 114] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2009] [Accepted: 01/24/2010] [Indexed: 12/26/2022]
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The value of level III clearance in patients with axillary and sentinel node positive breast cancer. Ann Surg 2009; 249:834-9. [PMID: 19387317 DOI: 10.1097/sla.0b013e3181a40821] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The value of level III axillary clearance is contentious, with great variance worldwide in the extent and levels of clearance performed. OBJECTIVE To determine rates of level III positivity in patients undergoing level I-III axillary clearance, and identify which patients are at highest risk of involved level III nodes. METHODS From a database of 2850 patients derived from symptomatic and population-based screening service, 1179 patients who underwent level I-III clearance between the years 1999-2007 were identified. The pathology, surgical details, and prior sentinel nodes biopsies of patients were recorded. RESULTS Eleven hundred seventy nine patients had level I-III axillary clearance. Of the patients, 63% (n = 747) were node positive. Of patients with node positive disease, 23% (n = 168) were level II positive and 19% (n = 141) were level III positive. Two hundred fifty patients had positive sentinel node biopsies prior to axillary clearance. Of these, 12% (n = 30) and 9% (n = 22) were level II and level III positive, respectively. On multivariate analysis, factors predictive of level III involvement in patients with node positive disease were tumor size (P < 0.001, OR = 1.36; 95% CI: 1.2-1.5), invasive lobular disease (P < 0.001, OR = 3.6; 95% CI: 1.9-6.95), extranodal extension (P < 0.001, OR = 0.27; 95% CI: 0.18-0.4), and lymphovascular invasion (P = 0.04, OR = 0.58; 95% CI: 0.35-1). Lobular invasive disease (P = 0.049, OR = 4.1; 95% CI: 1-16.8), extranodal spread (P = 0.003, OR = 0.18; 95% CI: 0.06-0.57), and having more than one positive sentinel node (P = 0.009, OR = 4.9; 95% CI: 1.5-16.1) were predictive of level III involvement in patients with sentinel node positive disease. CONCLUSION Level III clearance has a selective but definite role to play in patients who have node positive breast carcinoma. Pathological characteristics of the primary tumor are of particular use in identifying those who are at various risk of level III nodal involvement.
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Sentinel lymph node detection and evidence of axillary lymphatic integrity after transaxillary breast augmentation: a prospective study using lymphoscintography. Aesthetic Plast Surg 2008; 32:879-88. [PMID: 18661171 DOI: 10.1007/s00266-008-9212-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2008] [Accepted: 06/19/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND The transaxillary breast augmentation (TBA) technique has gained popularity because of several advantages. However, the impact of the procedure on breast lymphatic drainage and sentinel node (SN) detection remains controversial. The objective of this study was to evaluate the lymphatic patterns and SN detection rates after TBA by using lymphoscintigraphy (LSG). METHODS Twenty patients (40 breasts) who underwent TBA were evaluated by LSG immediately after periareolar injections of phytate-99 mTc at three time points: before TBA (Pre-LSG) and approximately 30 days (Recent-Post-LSG) and 6 months after TBA (Late-Post-LSG). Statistical analysis considered p \ 0.05 significant, or p \ 0.017 when Bonferroni correction was applied. RESULTS All breasts drained primarily to the axillary SN. The binomial test did not show statistical differences in lymphatic drainage patterns between Pre-LSG and Recent-Post-LSG (p = 1), Pre-LSG and Late-Post-LSG (p = 0.625), and Recent-Post-LSG and Late-Post-LSG (p = 0.625). The average number of hot SN was 1.28 in Pre-LSG, 1.10 in Recent-Post-LSG, and 1.23 in Late-Post-LSG, without significant differences (p = 0.202). The average time of the first SN appearance was not significantly different (p = 0.186). Analysis of SN uptake percentage showed a significant difference between Pre-LSG and Recent-Post-LSG (p = 0.009), with a reduction of drainage magnitude in Recent-Post-LSG. CONCLUSION The preservation of axillary lymphatic drainage after TBA allowed for SN detection in all studied breasts. It seems that the applied surgical technique played an important role in axillary lymphatic integrity.
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Gruber G, Cole BF, Castiglione-Gertsch M, Holmberg SB, Lindtner J, Golouh R, Collins J, Crivellari D, Thürlimann B, Simoncini E, Fey MF, Gelber RD, Coates AS, Price KN, Goldhirsch A, Viale G, Gusterson BA. Extracapsular tumor spread and the risk of local, axillary and supraclavicular recurrence in node-positive, premenopausal patients with breast cancer. Ann Oncol 2008; 19:1393-1401. [PMID: 18385202 DOI: 10.1093/annonc/mdn123] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Extracapsular tumor spread (ECS) has been identified as a possible risk factor for breast cancer recurrence, but controversy exists regarding its role in decision making for regional radiotherapy. This study evaluates ECS as a predictor of local, axillary, and supraclavicular recurrence. PATIENTS AND METHODS International Breast Cancer Study Group Trial VI accrued 1475 eligible pre- and perimenopausal women with node-positive breast cancer who were randomly assigned to receive three to nine courses of classical combination chemotherapy with cyclophosphamide, methotrexate, and fluorouracil. ECS status was determined retrospectively in 933 patients based on review of pathology reports. Cumulative incidence and hazard ratios (HRs) were estimated using methods for competing risks analysis. Adjustment factors included treatment group and baseline patient and tumor characteristics. The median follow-up was 14 years. RESULTS In univariable analysis, ECS was significantly associated with supraclavicular recurrence (HR = 1.96; 95% confidence interval 1.23-3.13; P = 0.005). HRs for local and axillary recurrence were 1.38 (P = 0.06) and 1.81 (P = 0.11), respectively. Following adjustment for number of lymph node metastases and other baseline prognostic factors, ECS was not significantly associated with any of the three recurrence types studied. CONCLUSIONS Our results indicate that the decision for additional regional radiotherapy should not be based solely on the presence of ECS.
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Affiliation(s)
- G Gruber
- Institut für Radiotherapie, Klinik Hirslanden and Swiss Group for Clinical Cancer Research (SAKK), Zurich, Switzerland.
| | - B F Cole
- International Breast Cancer Study Group Statistical Center, Boston, MA and Department of Mathematics and Statistics, University of Vermont, Burlington, USA
| | - M Castiglione-Gertsch
- International Breast Cancer Study Group (IBCSG) Coordinating Center, Bern, Switzerland
| | - S B Holmberg
- Department of Surgery, Sahlgrenska University Hospital, Göteborg, Sweden
| | - J Lindtner
- The Institute of Oncology, Ljubljana, Slovenia
| | - R Golouh
- The Institute of Oncology, Ljubljana, Slovenia
| | - J Collins
- Department of Surgery, The Royal Melbourne Hospital, Melbourne, Australia
| | | | - B Thürlimann
- Senology Center of Eastern Switzerland, Kantonsspital and SAKK, St Gallen, Switzerland
| | - E Simoncini
- Oncologia Medica-Spedali Civili, Brescia, Italy
| | - M F Fey
- Department of Medical Oncology, Inselspital and SAKK, Bern, Switzerland
| | - R D Gelber
- IBCSG Statistical Center, Dana-Farber Cancer Institute, Frontier Science and Technology Research Foundation, Harvard School of Public Health, Boston, MA, USA
| | - A S Coates
- International Breast Cancer Study Group, Bern, Switzerland and University of Sydney, Sydney, Australia
| | - K N Price
- IBCSG Statistical Center, Frontier Science and Technology Research Foundation, Boston, MA, USA
| | - A Goldhirsch
- Oncology Institute of Southern Switzerland, Lugano, Switzerland and European Institute of Oncology, Milan, Italy
| | - G Viale
- Division of Pathology and Laboratory Medicine, European Institute of Oncology and University of Milan, Milan, Italy
| | - B A Gusterson
- Division of Cancer Sciences and Molecular Pathology, Faculty of Medicine, Glasgow University, Glasgow, UK
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Pathological Examination of Sentinel Lymph Nodes: Work-Up – Interpretation – Clinical Implications. Breast Care (Basel) 2007. [DOI: 10.1159/000101043] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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Keskek M, Balas S, Gokoz A, Sayek I. Re-evaluation of axillary skip metastases in the era of sentinel lymph node biopsy in breast cancer. Surg Today 2006; 36:1047-52. [PMID: 17123131 DOI: 10.1007/s00595-006-3322-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2006] [Accepted: 06/09/2006] [Indexed: 02/06/2023]
Abstract
PURPOSE To investigate whether skip axillary metastases are really skip metastases or a continuation of level I micrometastases in invasive breast cancer, and to determine whether there are any factors predisposing to skip metastases. METHODS We reviewed 568 consecutive patients with breast cancer who underwent complete axillary lymph node dissections (ALND) between January 1998 and December 2004. For patients with skip axillary lymph node metastases, resectioning and immunohistochemical staining of the remaining part of paraffin blocks from level I lymph nodes were done to determine whether there were any micrometastases in this group of lymph nodes. RESULTS Skip axillary metastases were found in 27 (10%) of 268 patients with axillary lymph node metastases. Re-evaluation of the level I lymph nodes, both with thin sectioning and immunohistochemical staining, in the patients with axillary skip metastases revealed no micrometastases. No significant correlation was found between the demographic and histopathological variables of the patients with skip metastases and those with regular axillary metastases. CONCLUSIONS These results suggest that skip axillary metastases are actual skip metastases, not a continuation of undetected level I micrometastases. Moreover, none of the clinical and histopathological measures of primary tumors are predictors of the presence of skip metastases.
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Affiliation(s)
- Mehmet Keskek
- Fifth Department of Surgery, Ankara Numune Training and Research Hospital, Ankara, Turkey
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Kodama H, Nio Y, Iguchi C, Kan N. Ten-year follow-up results of a randomised controlled study comparing level-I vs level-III axillary lymph node dissection for primary breast cancer. Br J Cancer 2006; 95:811-6. [PMID: 17016485 PMCID: PMC2360550 DOI: 10.1038/sj.bjc.6603364] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Abstract
The most appropriate level of axillary dissection for breast cancer remains unclear. The present randomised study compared the treatment results of level-I vs level-III dissection in T1/2/3 and N0/1a/1b (1987 UICC classification) breast cancer without distant metastasis. Between 1995 and 1997, 522 patients were enrolled, and 514 were eligible. They were stratified into breast-conserving surgery or mastectomy, and then further stratified into level-III dissection (group-A, n=258) or level-I dissection (group-B, n=256). All patients were given oral 5-fluorouracil at 200 mg day-1 and tamoxifen at 20 mg day-1, daily for 2 years. Group-A resulted in a significantly longer operation time (77.0 vs 60.5 min, P<0.0001) and significantly larger blood loss (62.1 vs 48.1 ml, P<0.0001) than group-B, but in no significant differences in the frequencies of arm oedema and shoulder disturbance. Group-A resulted in a significantly larger number of dissected nodes than group-B (18.7 vs 14.8, P<0.0001), but in no differences in the number of involved nodes (1.54 vs 1.44). There were no significant differences in the 10-year overall and disease-free survival rates: 89.6 and 76.6% for group-A vs 87.8 and 74.1% for group-B, respectively. In conclusion, level-III dissection resulted in a longer operation time and greater blood loss than level-I, but did not improve the survival rate. Level-III dissection is not a recommended surgery for T1-3/N0-1b breast cancer.
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Affiliation(s)
- H Kodama
- Kodama Breast Clinic, Kitano-kamihakubai-cho-35, Kita-ku, Kyoto, Japan.
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Pejavar S, Wilson LD, Haffty BG. Regional nodal recurrence in breast cancer patients treated with conservative surgery and radiation therapy (BCS+RT). Int J Radiat Oncol Biol Phys 2006; 66:1320-7. [PMID: 17049182 DOI: 10.1016/j.ijrobp.2006.07.1379] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2006] [Revised: 07/22/2006] [Accepted: 07/25/2006] [Indexed: 10/24/2022]
Abstract
PURPOSE To review regional nodal (RN) management and identify predictors of RN relapse in patients treated with breast conserving surgery and radiation therapy (BCS+RT). METHODS AND MATERIALS Patients with Stage I and II breast cancer (N = 1920) underwent BCS+RT from 1973 to 2003. Patients undergoing RN were treated with a median dose of 46 Gy. Patients undergoing axillary dissection (AXD, N = 1330) were treated to the breast alone if node-negative (N = 984), and to the breast and supraclavicular fossa if node-positive (N = 346). Patients who did not undergo AXD (N = 590) were treated with RT to the supraclavicular fossa and axilla. Sentinel node biopsy (SNB) was performed on 126 patients. SN-negative patients (N = 110) were treated with tangents only. There were 16 SN-positive patients who did not undergo complete AXD and were treated with RT. RESULTS As of September 2005, there have been 36 RN relapses for an actuarial nodal control rate (NCR) of 98% at 10 years. There was no difference in NCR between those undergoing AXD (NCR = 97.4%) and those receiving RT without AXD (NCR = 97.9%). In multivariate analysis, young age, non-Caucasian race, and pathologic nodal status correlated with increased risk of nodal relapse. Of the 126 patients undergoing SNB, there was only 1 nodal recurrence. None of the 16 SN-positive patients treated with RT without AXD had nodal failure. CONCLUSIONS In patients undergoing BCS+RT, both regional nodal irradiation and AXD (including SNB) resulted in equally high rates of regional nodal control. Nodal RT may also be an effective treatment for SN-positive patients.
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Affiliation(s)
- Sunanda Pejavar
- Department of Therapeutic Radiology, Yale University School of Medicine, New Haven, CT, USA
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Omoto K, Hozumi Y, Omoto Y, Taniguchi N, Itoh K, Fujii Y, Mizunuma H, Nagai H. Sentinel node detection in breast cancer using contrast-enhanced sonography with 25% albumin--Initial clinical experience. JOURNAL OF CLINICAL ULTRASOUND : JCU 2006; 34:317-26. [PMID: 16869006 DOI: 10.1002/jcu.20241] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Abstract
PURPOSE To determine the clinical usefulness of a sentinel lymph node (SLN) identification technique using contrast-enhanced sonography (CEUS) with 25% albumin. METHODS The subjects were 23 women with breast cancer. Each was injected subcutaneously with 5 ml of 25% albumin solution as a negative contrast agent directly superficial to the breast tumor. The area was massaged, and the inferior axillary hairline was examined continuously using gray-scale sonography with a 7.5- or 10-MHz transducer. Any contrast-enhanced lymph node was considered a CEUS-detected SLN, was differentiated from other level I and II nodes, and was resected and pathologically assessed. RESULTS In all 23 patients, 1 or 2 CEUS-detected SLNs (mean, 1.3 SLNs) were identified. Their sizes ranged from 5 mm to 25 mm (mean, 11.3 mm), and their depths (from the skin surface) ranged from 5mm to 20 mm (mean, 12.6 mm). Pathologic examination revealed a metastasis in 5 of the 23 patients, all in CEUS-detected SLNs. CONCLUSION In a clinical study using CEUS with 25% albumin, contrast-enhanced nodes were identified in all subjects. The pathologic findings suggested that any metastatic nodes observed were SLNs, indicating that this technique may represent a new modality for SLN identification.
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Affiliation(s)
- Kiyoka Omoto
- Department of Clinical Laboratory Medicine, Jichi Medical University, Yakushiji 3311-1, Shimotsuke-city , Tochigi-pref, 329-0498, Japan
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Bowers K, Liu Y, Ghesani N, Kim SH. A level III sentinel lymph node in breast cancer. World J Surg Oncol 2006; 4:31. [PMID: 16759381 PMCID: PMC1557507 DOI: 10.1186/1477-7819-4-31] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2006] [Accepted: 06/07/2006] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND For accurate nodal staging, all blue and radioactive lymph nodes should be sampled during the sentinel lymph node biopsy for breast cancer. We report a case of anomalous drainage in which one of the sentinel lymph nodes was unexpectedly found in the level III axillary space. CASE PRESENTATION A 40-year-old female underwent mastectomy for extensive high-grade ductal carcinoma in-situ (DCIS) with micro-invasion. The index lesion was located in the right upper inner quadrant. Lymphoscintigraphy was performed on the morning of surgery. Two sentinel lymph nodes were identified. At operation, 5 mls of isosulfan blue dye was injected at the same site of the radio-colloid injection. The first sentinel lymph node was found at level I and was blue and radioactive. The second sentinel node was detected in an unexpected anomalous location at level III, medial to the pectoralis minor. Both sentinel nodes were negative. CONCLUSION Sentinel node staging can lead to unexpected patterns of lymphatic drainage. For accurate staging, it is important to survey all potential sites of nodal metastasis either with preoperative lymphoscintigraphy and/or rigorous examination of regional nodal basins with the intra-operative gamma probe.
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Affiliation(s)
- Kim Bowers
- Department of Surgery, New Jersey Medical School, University of Medicine and Dentistry, Newark, New Jersey, USA
| | - Yiyan Liu
- Department of Radiology, New Jersey Medical School, University of Medicine and Dentistry, Newark, New Jersey, USA
| | - Nasrin Ghesani
- Department of Radiology, New Jersey Medical School, University of Medicine and Dentistry, Newark, New Jersey, USA
| | - Steve H Kim
- Department of Surgery, New Jersey Medical School, University of Medicine and Dentistry, Newark, New Jersey, USA
- Department of Surgery, Medical Science Building, G-512, 185 South Orange Ave, Newark, NJ 07103, USA
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Gruber G, Bonetti M, Nasi ML, Price KN, Castiglione-Gertsch M, Rudenstam CM, Holmberg SB, Lindtner J, Golouh R, Collins J, Crivellari D, Carbone A, Thürlimann B, Simoncini E, Fey MF, Gelber RD, Coates AS, Goldhirsch A. Prognostic value of extracapsular tumor spread for locoregional control in premenopausal patients with node-positive breast cancer treated with classical cyclophosphamide, methotrexate, and fluorouracil: long-term observations from International Breast Cancer Study Group Trial VI. J Clin Oncol 2005; 23:7089-97. [PMID: 16192592 DOI: 10.1200/jco.2005.08.123] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE We sought to determine retrospectively whether extracapsular spread (ECS) might identify a subgroup that could benefit from radiotherapy after mastectomy, especially patients with 1 to 3 positive lymph nodes (LN1-3+). PATIENTS AND METHODS We randomized 1,475 premenopausal women with node-positive breast cancer to three, six, or nine courses of "classical" CMF (cyclophosphamide, methotrexate, and fluorouracil). After a review of all pathology forms, 933 patients (63%) had information on the presence or absence of ECS. ECS was present in 49.5%. The median follow-up was 10 years. RESULTS In univariate analyses, ECS was associated with worse disease-free survival (DFS) and overall survival (OS). In multivariate analyses adjusting for tumor size, vessel invasion, surgery type, and age group, ECS remained significant (DFS: hazard ratio, 1.61; 95% CI, 1.34 to 1.93; P < .0001; OS: 1.67; 95% CI, 1.34 to 2.08; P < .0001). However, ECS was not significant when the number of positive nodes was added. The locoregional failure rate +/- distant failure (LRF +/- distant failure) within 10 years was estimated at 19% (+/- 2%) without ECS, versus 27% (+/- 2%) with ECS. The difference was statistically significant in univariate analyses, but not after adjusting for the number of positive nodes. No independent effect of ECS on DFS, OS, or LRF could be confirmed within the subgroup of 382 patients with LN1-3+ treated with mastectomy without radiotherapy. CONCLUSION Our results do not support an independent prognostic value of ECS, nor its use as an indication for irradiation in premenopausal patients with LN1-3+ treated with classical CMF. However, we could not examine whether extensive ECS is of prognostic importance.
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Affiliation(s)
- Günther Gruber
- Department of Radiation Oncology, and the Institute of Medical Oncology, Inselspital, Switzerland.
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Soni NK, Spillane AJ. EXPERIENCE OF SENTINEL NODE BIOPSY ALONE IN EARLY BREAST CANCER WITHOUT FURTHER AXILLARY DISSECTION IN PATIENTS WITH NEGATIVE SENTINEL NODE. ANZ J Surg 2005; 75:292-9. [PMID: 15932439 DOI: 10.1111/j.1445-2197.2005.03376.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIMS The aims of surgical therapy of breast cancer are loco-regional tumour control and staging. Axillary staging is still considered the single most important prognostic indicator in breast cancer. Surgical removal of axillary nodes remains the standard way to assess their involvement in most centres. The morbidity associated with axillary dissection (AD) is well recognized. In recent years sentinel node biopsy (SNB) has evolved. Multiple studies suggest it has the same accuracy as AD in axillary staging and less morbidity in early breast cancer (EBC). SNB has become the standard of practice in EBC in many parts of the world. In Australia, the preference has been to wait for the results of the Sentinel Node versus Axillary Clearance (SNAC) trial as well as other international trials before accepting SNB as a standard of care. The experience of a single surgeon with SNB alone in EBC without further completion axillary dissection (CAD) in negative sentinel node (SLN) is described in the present paper. METHODS An audit was done of the senior author's prospective data from the Royal Australasian College of Surgeons database. Other information was added retrospectively from case notes. RESULTS Between December 2000 and December 2003, 154 EBC cases (153 patients) underwent SNB alone. An average of four SLN was removed. Of these cases, 31.8% had positive SLNs (excluding 2.6% cases that had isolated tumour cells), of these, 93.9% had metastases (39.1% micro- and 60.9% macro-metastases) in axillary-SLN (ASLN) and almost all of these had CAD. ASLNs were the only positive nodes in 73.9%. Extra-ASLN retrieved in 68.8% of 34% demonstrated on lymphoscintigraphy. Of these, 12.1% were positive (6.1% micro- and macro-metastases each), all internal mammary. Mean follow up was 22.1 months. There was one local-regional-systemic and one systemic recurrence over this time. CONCLUSION SNB has a valid role in staging of the axilla particularly in low-risk patients. After adequate self audit, SNB offers a minimal morbidity and reliable method of axillary staging. Patients choosing SNB alone must understand that the long-term results of the randomized controlled trial are still pending for level I evidence of long-term efficacy.
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Affiliation(s)
- Naresh K Soni
- Sydney Breast Cancer Institute, Sydney Cancer Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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Wheatley D, Adwani A, Ebbs S, Hanson J, Ross G, Sharma AK, Wells P, Yarnold J. Matching supraclavicular fields to the extent of axillary surgery in women prescribed radiotherapy for early stage carcinoma of the breast. Clin Oncol (R Coll Radiol) 2005; 17:32-8. [PMID: 15714927 DOI: 10.1016/j.clon.2004.09.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
AIMS To determine (1) if the lower border of a standard anterior radiotherapy field to the supraclavicular fossa matches the upper limit of level II/III axillary dissection; and (2) whether standard lung blocks in patients prescribed axillary radiotherapy shield target axillary tissue in women with breast cancer. MATERIALS AND METHODS Between 1999 and 2001, 30 women with breast cancer undergoing level II/III axillary dissection had titanium clips placed to define the upper and medial limits of surgery. At radiotherapy planning, a supraclavicular fossa field similar to that described in the UK START trial protocol was simulated, with head twist applied to position the inferior field border (50% isodose) 1 cm below and parallel to the lower border of the clavicle. The field position was recorded on X-ray film. The location of the most superior axillary clip was measured in relation to this inferior field border on the X-ray film. The location of the most medial clip was measured in relation to the lung/chest wall interface. RESULTS The median distance between the most superior clip and the inferior border of the supraclavicular field was 3.6 cm (0.8-6.9 cm), representing significant underlap in all cases. In addition, five out of 30 (17%) patients had surgical clips over 2.0 cm medial to the lung/chest wall interface, suggesting that medial lymph nodes in an undissected axilla would be shielded by standard lung blocks in patients prescribed axillary radiotherapy. CONCLUSION Current standard radiation fields to the supraclavicular fossa, as applied in this study, leave apical axillary lymph nodes untreated in a high proportion of patients. Standard lung shielding, as applied in this study to patients simulated for axillary radiotherapy, protect medial axillary lymph nodes in a few patients. A change in practice is recommended.
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Affiliation(s)
- D Wheatley
- Department of Radiotherapy, The Royal Marsden Hospital, Sutton, Surrey, UK
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Jeruss JS, Winchester DJ, Sener SF, Brinkmann EM, Bilimoria MM, Barrera E, Alwawi E, Nickolov A, Schermerhorn GM, Winchester DJ. Axillary recurrence after sentinel node biopsy. Ann Surg Oncol 2004; 12:34-40. [PMID: 15827776 DOI: 10.1007/s10434-004-1164-2] [Citation(s) in RCA: 129] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2004] [Accepted: 09/20/2004] [Indexed: 11/27/2022]
Abstract
BACKGROUND Sentinel node biopsy (SNB) has evolved as the standard of care in the surgical staging of breast cancer. This technique is accurate for surgical staging of axillary nodal disease. We hypothesized that axillary recurrence after SNB is rare and that SNB may provide regional control in patients with microscopic nodal involvement. METHODS With institutional review board approval, SNB was performed with peritumoral injection of 99mTc-labeled sulfur colloid. From 1996 to 2003, 1167 patients were entered into a prospective cancer database after surgical therapy; 916 patients consented to long-term follow-up. Fifty-two patients (5.7%) did not map successfully and were excluded, leading to a study population of 864 patients. The median follow-up was 27.4 months (range, 1-98 months). RESULTS The median number of sentinel nodes harvested was 2, and 633 (73%) patients had negative sentinel nodes. Thirty (4.7%) of those sentinel node-negative patients underwent completion axillary dissection, whereas 592 (94%) patients were followed up with observation. A total of 231 (27%) had positive sentinel nodes: 158 (68%) of these patients underwent completion axillary dissection, and 73 (32%) were managed with observation alone. Two (.32%) patients who were sentinel node negative had an axillary recurrence; one of these patients had undergone completion axillary dissection. No patient in the observed sentinel node-positive group had an axillary recurrence (odds ratio, .37; P = .725). CONCLUSIONS On the basis of a median follow-up of 27.4 months, axillary recurrence after SNB is extraordinarily rare regardless of nodal involvement, thus indicating that this technique provides an accurate measure of axillary disease and may impart regional control for patients with node-positive disease.
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Affiliation(s)
- Jacqueline Sara Jeruss
- Feinberg School of Medicine, Northwestern University, 303 E. Chicago Avenue, Chicago, Illinois 60611, USA
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Abstract
Since the 1960s, bone scanning has played a major role in the management of breast cancer. In the last decade, however, the role of radionuclide molecular imaging has expanded significantly in the clinical management of breast cancer because of fluorodeoxyglucose positron emission tomography, mammoscintigraphy, and sentinel lymph node techniques. Molecular imaging also is instrumental in drug development,gene therapy, and in basic science research of breast cancer. This article provides a comprehensive review of the role of molecular imaging of breast cancer in clinical practice and reports on the current state of research in this field.
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Affiliation(s)
- David M Schuster
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology, Emory University Hospital, 1364 Clifton Road, NE, Atlanta, GA 30322, USA.
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Arnaud S, Houvenaeghel G, Moutardier V, Butarelli M, Martino M, Tallet A, Braud AC, Jacquemier J, Julian-Reynier C, Brenot-Rossi I. Patients' and surgeons' perspectives on axillary surgery for breast cancer. Eur J Surg Oncol 2004; 30:735-43. [PMID: 15296987 DOI: 10.1016/j.ejso.2004.05.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2004] [Indexed: 11/28/2022] Open
Abstract
AIMS The objectives of this study were to compare the postoperative morbidity of Sentinel lymph node biopsy (SLNB) and axillary lymph node dissection (ALND) and to compare the views of surgeons and patients regarding postoperative morbidity. METHODS A prospective and comparative study was initiated to evaluate, 1 year after surgery, morbidity and sequelae after SLNB in 231 patients. Group I (n=141) underwent SLNB without ALND, group II (n=90) underwent SLNB followed by ALND when SLN where involved. Morbidity analysis was performed, respectively, by surgeons and patients. RESULTS One hundred and eighty-five patients (80.5%) completed the questionnaire including 113 with SLNB alone, and 72 with ALND. One year after surgery, SLNB produced less morbidity than ALND for symptoms and function. There were significantly different assessments between surgeons and patients for pain, arm mobility and sensitiveness. CONCLUSIONS One-year postoperative morbidity after SLNB is significantly lower than after ALND but views of surgeons and patients appears to be significantly different. Additional data are required to assess late consequences of axillary surgery.
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Affiliation(s)
- S Arnaud
- INSERM U379, 13273 Marseille 9, France
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Schaapveld M, Otter R, de Vries EGE, Fidler V, Grond JAK, van der Graaf WTA, de Vogel PL, Willemse PHB. Variability in axillary lymph node dissection for breast cancer. J Surg Oncol 2004; 87:4-12. [PMID: 15221913 DOI: 10.1002/jso.20061] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
BACKGROUND The axillary nodal status may influence the prognosis and the choice of adjuvant treatment of individual breast cancer patients. The variation in number of reported axillary lymph nodes and its effect on the axillary nodal stage were studied and the implications are discussed. METHODS Between 1994 and 1997, a total of 4,806 axillary dissections for invasive breast cancers in 4,715 patients were performed in hospitals in the North-Netherlands. The factors associated with the number of reported nodes and the relation of this number with the nodal status and the number of positive nodes were studied. RESULTS The number of reported nodes varied significantly between pathology laboratories, the median number of nodes ranged from 9 to 15, respectively. The individual hospitals explained even more variability in the number of nodes than pathology laboratories (range in median number 8-15, P < 0.0001). The number of reported nodes increased gradually during the study period. A decreasing trend was observed with older patient age. A higher number of reported nodes was associated with a markedly increased chance of finding tumor positive nodes, especially more than three nodes. The frequency of node positivity increased from 28% if less than six nodes to 54% if >/=20 nodes were examined, the percentage of tumors with >/=4 positive nodes increased from 4 to 31%. Multivariate analysis confirmed these results. CONCLUSIONS This population-based study showed a large variation in the number of reported lymph nodes between hospitals. A more extensive surgical dissection or histopathological examination of the specimen generally resulted in a higher number of positive nodes. Although the impact of misclassification on adjuvant treatment will have varied, the impact with regard to adjuvant regional radiotherapy may have been considerable.
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Affiliation(s)
- Michael Schaapveld
- Comprehensive Cancer Center North-Netherlands (CCCN), Groningen, The Netherlands.
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Silberman AW, McVay C, Cohen JS, Altura JF, Brackert S, Sarna GP, Palmer D, Ko A, Memsic L. Comparative morbidity of axillary lymph node dissection and the sentinel lymph node technique: implications for patients with breast cancer. Ann Surg 2004; 240:1-6. [PMID: 15213610 PMCID: PMC1356366 DOI: 10.1097/01.sla.0000129358.80798.62] [Citation(s) in RCA: 63] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To assess our long-term complications from complete axillary lymph node dissection (AXLND) in patients with breast cancer. SUMMARY BACKGROUND DATA Complete AXLND as part of the surgical therapy for breast cancer has come under increased scrutiny due the use of the sentinel lymph node (SLN) biopsy technique to assess the status of the axillary nodes. As the enthusiasm for the SLN technique has increased, our impression has been that the perceived complication rate from AXLND has increased dramatically while the negative aspects of the SLN technique have been underemphasized. METHODS Female patients seen in routine follow-up over a 1-year period were eligible for our retrospective study of the long-term complications from AXLND if they were a minimum of 1 year out from all primary therapy; ie, surgery, radiation, and/or chemotherapy. All patients had previously undergone either a modified radical mastectomy (MRM) or a segmental mastectomy with axillary dissection and postoperative radiation (SegAx/XRT). All patients had a Level I-III dissection. Objective measurements, including upper and lower arm circumferences and body mass index (BMI), were obtained, and a subjective evaluation from the patients was conducted. RESULTS Ninety-four patients were eligible for our study; 44 had undergone MRM, and 50 had undergone SegAx/XRT. The average number of nodes removed was 25.6 (standard deviation, 8). Thirty-three percent of the patients had positive nodal disease, 95% of the patients had an upper arm circumference within 2 cm of the unaffected side, and 93.3% had a lower arm circumference within 2 cm of the unaffected side. Subjectively, 90.4% of the patients had either no or minimal arm swelling, and 96.8% of the patients had "good" or "excellent" overall arm function. The most common long-term symptom was numbness involving the upper, inner aspect of the affected arm (25.5%). CONCLUSIONS Our data indicate that a complete AXLND can be performed with minimal long-term morbidity. The lower the morbidity of AXLND, the less acceptable are the unique complications of the SLN technique.
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Affiliation(s)
- Allan W Silberman
- Divisions of Surgical Oncology, Cedars-Sinai Medical Center, Los Angeles, California, USA.
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Posther KE, Wilke LG, Giuliano AE. Sentinel lymph node dissection and the current status of American trials on breast lymphatic mapping. Semin Oncol 2004; 31:426-36. [PMID: 15190501 DOI: 10.1053/j.seminoncol.2004.03.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
The current national sentinel lymph node (SLN) clinical trials for breast carcinoma address the prognostic and therapeutic utility of SLN dissection (SLND) in women with early-stage, clinically node-negative breast cancer. Following completion of these studies, overall survival, disease-free survival, morbidity, and quality of life of patients will be compared. Surgeon participation is crucial to the ongoing success of clinical trials in the field of breast cancer surgery.
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Affiliation(s)
- Katherine E Posther
- Department of Surgery, Duke University Medical Center, Durham, NC 27710, USA
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Hinrichs CS, Watroba NL, Rezaishiraz H, Giese W, Hurd T, Fassl KA, Edge SB. Lymphedema Secondary to Postmastectomy Radiation: Incidence and Risk Factors. Ann Surg Oncol 2004; 11:573-80. [PMID: 15172932 DOI: 10.1245/aso.2004.04.017] [Citation(s) in RCA: 108] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Postmastectomy radiotherapy (PMRT) has proven benefits for certain patients with breast cancer; however, one of its complications is lymphedema. This study examines the incidence of and risk factors associated with lymphedema secondary to PMRT. METHODS The charts of patients treated with mastectomy at Roswell Park Cancer Institute between January 1, 1995, and April 20, 2001, who received PMRT were reviewed. Univariate analysis of patient, disease, and treatment variables was conducted. Multivariate analysis was performed on variables found to be significant in univariate analysis. RESULTS One hundred five patients received PMRT. The incidence of lymphedema was 27%. Patient age, body mass index, disease stage, positive lymph nodes, nodes resected, postoperative infection, duration of drainage, chemotherapy, and hormonal therapy were not associated with lymphedema. Total dose (P =.032), posterior axillary boost (P =.047), overlap technique (P =.037), radiotherapy before 1999 (P =.028), and radiotherapy at Roswell Park Cancer Institute (P =.028) were significantly associated with lymphedema. Increased lymphedema was noted with supraclavicular, internal mammary, mastectomy scar boost, and chest wall tangential photon beam radiation, but the associations were not statistically significant. CONCLUSIONS The high incidence and debilitating effects of lymphedema must be weighed against the benefits of PMRT. Efforts to prevent lymphedema should be emphasized.
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Affiliation(s)
- Christian S Hinrichs
- Roswell Park Cancer Institute, Department of Surgical Oncology, Elm and Carlton Streets, Buffalo, NY 14263, USA
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Mariani G, Erba P, Villa G, Gipponi M, Manca G, Boni G, Buffoni F, Castagnola F, Paganelli G, Strauss HW. Lymphoscintigraphic and intraoperative detection of the sentinel lymph node in breast cancer patients: the nuclear medicine perspective. J Surg Oncol 2004; 85:112-22. [PMID: 14991882 DOI: 10.1002/jso.20023] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
The concept of sentinel lymph node biopsy in breast cancer surgery relates to the fact that the tumor drains in a logical way via the lymphatic system, from the first to upper levels. Therefore, (1) the first lymph node met (the sentinel node) will most likely be the first one affected by metastasis, and (2) a negative sentinel node makes it highly unlikely that other nodes are affected. Sentinel lymph node biopsy would represent a significant advantage as a mini-invasive procedure, considering that, after operation, about 70% of patients are found to be free from metastatic disease, yet axillary node dissection can lead to significant morbidity. Although the pattern of lymphatic drainage from a breast cancer can be very variable, the mammary gland and the overlying skin can be considered as a biologic unit in which lymphatics tend to follow the vasculature. Considering that tumor lymphatics are disorganized and relatively ineffective, subdermal, and peritumoral injection of small aliquots of radiotracer is preferred to intratumoral administration. (99m)Tc-labeled colloids with most of the particles in the 100-200 nm size range would be ideal for radioguided sentinel node biopsy in breast cancer. Lymphoscintigraphy is an essential part of radioguided sentinel lymph node biopsy, as images are used to direct the surgeon to the site of the node. The sentinel lymph node should have a significantly higher count than background. After removal of the sentinel node, the axilla must be re-examined to ensure all radioactive sites are identified and removed for analysis. The success rate of radioguidance in localizing the sentinel lymph node in breast cancer surgery is about 94-97% in Institutions where a high number of procedures are performed, approaching 99% when combined with the vital blue dye technique. At present, there is no definite evidence that a negative sentinel lymph node biopsy is invariably correlated with a negative axillary status, except perhaps for T(1a-b) breast cancers, with size < or =1 cm. Randomized clinical trials should elucidate the impact of avoiding axillary node dissection in patients with a negative sentinel lymph node on the long-term clinical outcome of patients.
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Affiliation(s)
- Giuliano Mariani
- Regional Center of Nuclear Medicine, University of Pisa Medical School, Pisa, Italy.
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Rutgers EJT. Sentinel node procedure in breast carcinoma: a valid tool to omit unnecessary axillary treatment or even more? Eur J Cancer 2004; 40:182-6. [PMID: 14728931 DOI: 10.1016/j.ejca.2003.09.025] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Affiliation(s)
- E J T Rutgers
- Department of Surgery, The Netherlands Cancer Institute/Antoni van Leeuwenhoek Ziekenhuis, Plesmanlaan 121, 1066 CX Amsterdam, The Netherlands.
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Kuru B, Camlibel M, Dinc S, Gulcelik MA, Alagol H. Prognostic significance of axillary node and infraclavicular lymph node status after mastectomy. Eur J Surg Oncol 2004; 29:839-44. [PMID: 14624774 DOI: 10.1016/j.ejso.2003.08.003] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
AIMS The American Joint Committee on Cancer staging system for breast carcinomas has been revised. According to this revised staging system, metastasis to infraclavicular lymph nodes and number of positive axillary nodes have prognostic significance and a new stage, stage IIIC, has been introduced. The aim of this study is to investigate the association of positive axillary nodes by level and number with survival and stage migration between the old and the new stages in a large series of mastectomy patients. METHODS Data from 1277 consecutive breast cancer patients treated by mastectomy were studied, retrospectively. Prognostic value of number of positive axillary nodes and entirely invasion of apex axillary nodes were analysed. Survival curves were generated by Kaplan-Meier method, and multivariate analysis was performed by Cox proportional hazard model. RESULTS Five-year survival rates for metastasis to axillary level III and for stage IIIC breast cancer were 35.4 and 38.2%, respectively. Metastases to apex axillary nodes, 4-9 and 10 or more positive lymph nodes were found to be adverse and independent prognostic factors for survival in lymph node positive patients. CONCLUSION Invasion of infraclavicular nodes and 4-9 and > or =10 positive axillary lymph nodes were independent predictors for survival in node positive breast carcinomas in this series. Patients with the new stage IIIC had the worst survival among breast cancer patients.
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Affiliation(s)
- B Kuru
- Department of General Surgery, Ankara Oncology Education and Research Hospital, Ankara, Turkey.
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Kennedy RJ, Kollias J, Gill PG, Bochner M, Coventry BJ, Farshid G. Removal of two sentinel nodes accurately stages the axilla in breast cancer. Br J Surg 2003; 90:1349-53. [PMID: 14598413 DOI: 10.1002/bjs.4298] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Abstract
Background
Assessment of lymph node status in breast cancer is still necessary for staging. Sentinel lymph node biopsy (SNB) may provide accurate staging with less morbidity than axillary clearance. The aim of this study was to assess the effect of the number of sentinel nodes removed on the false-negative rate.
Methods
Data were collected prospectively from 395 women undergoing SNB for breast cancer, between June 1995 and December 2001. All nodes that were hot and/or blue were removed and analysed.
Results
During this interval 136 patients who had SNB were lymph node positive. The median number of sentinel nodes removed was two (range one to five). The overall false-negative rate of SNB in these women was 7·1 per cent. If only one sentinel node had been removed, the false-negative rate would have been 16·5 per cent. The removal of more than two nodes had no effect on axillary staging in all but two women.
Conclusion
In early breast cancer, when there were multiple sentinel nodes, removal of two sentinel nodes significantly reduced the false-negative rate compared with removal of one node. Removing more than two sentinel nodes did not significantly reduce the false-negative rate further.
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Affiliation(s)
- R J Kennedy
- Breast, Endocrine and Surgical Oncology Unit and Department of Surgery, University of Adelaide, Royal Adelaide Hospital, Adelaide, South Australia, Australia.
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Nährig JM, Richter T, Kuhn W, Avril N, Flatau B, Kowolik J, Höfler H, Werner M. Intraoperative examination of sentinel lymph nodes by ultrarapid immunohistochemistry. Breast J 2003; 9:277-81. [PMID: 12846860 DOI: 10.1046/j.1524-4741.2003.09405.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
The recently developed method of ultrarapid immunohistochemistry (IHC) was applied to the intraoperative examination of sentinel lymph nodes (SLNs) in breast cancer patients. In a prospective study of 50 patients with invasive breast carcinomas, a total of 60 SLNs were studied. Among them, 33 SLNs from 30 patients were studied intraoperatively using a direct immunoperoxidase method with anticytokeratin antibody clone MNF116. This technique has a turnaround time of less than 20 minutes. Ultrarapid IHC revealed 15 positive SLNs compared to 14 positive SLNs using hematoxylin and eosin (H and E) frozen sections. The one SLN missed in H and E frozen sections presented with cytokeratin-positive isolated tumor cells in the lymph node sinus. After paraffin embedding, H and E-stained serial step sections of the SLN specimens detected another two patients with isolated tumor cells. We also examined the remaining axillary lymph nodes (ALNs) by H and E-stained serial step paraffin sections. From 17 of the 30 patients with positive SLNs, 6 patients also had metastatic involvement of the ALNs of level I or II. Thus ultrarapid IHC was a very sensitive and rapid technique for the intraoperative detection of metastatic involvement of SLNs in breast cancer patients. This technique may be a useful complementary tool for the intraoperative study of SLNs, particularly in tumors that are a diagnostic challenge, such as lobular carcinoma.
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Affiliation(s)
- Jörg M Nährig
- Institute of Pathology, Technical University of Munich, Munich, Germany.
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