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Prospective Evaluation of Radar-Localized Reflector-Directed Targeted Axillary Dissection in Node-Positive Breast Cancer Patients after Neoadjuvant Systemic Therapy. J Am Coll Surg 2022; 234:538-545. [PMID: 35290273 DOI: 10.1097/xcs.0000000000000098] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND This is a prospective, single-institution study to evaluate feasibility and accuracy of radar-localized reflector (RLR)-targeted axillary dissection (TAD) in node-positive breast cancer patients after neoadjuvant systemic therapy (NST). METHODS Patients with biopsy-proven T1-2, N1-3 disease were eligible. Before NST, a marker clip and/or RLR was placed into the positive node. After NST, RLR was inserted if not placed previously. All patients underwent RLR TAD followed by axillary lymph node dissection (ALND). Primary end points of the trial were feasibility of RLR TAD and false negative rate (FNR). RESULTS Between 2017 and 2021, 101 patients with N1-3 disease underwent NST. Five patients withdrew from the study, 1 was ineligible, and there were 9 technical failures, thus our final study cohort comprised 86 patients. RLR TAD was performed with probe guidance and confirmed with intraoperative specimen radiograph. After RLR TAD, ALND was performed. Median number of RLR TAD nodes removed was 2 (range 1-10), and the RLR TAD nodes remained positive in 56 patients. Median number of ALND nodes removed was 18 (range 4-46). Accounting for 9 technical failures, feasibility was 90%. All technical failures occurred with attempted placement of RLR after NST. Feasibility rate was 100% when RLR placement occurred at diagnosis. Of the evaluable 86 patients, RLR TAD accurately predicted axillary status in 83 patients, with FNR of 5.1%. CONCLUSION We demonstrate high accuracy of RLR TAD, especially when RLR is placed before NST. For patients who present with N1-3 disease, this is another step towards axillary surgery de-escalation strategies.
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Preoperative Prediction of Axillary Lymph Node Metastasis in Breast Cancer using Radiomics Features of DCE-MRI. Sci Rep 2019; 9:2240. [PMID: 30783148 PMCID: PMC6381163 DOI: 10.1038/s41598-019-38502-0] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Accepted: 12/31/2018] [Indexed: 02/06/2023] Open
Abstract
The accurate and noninvasive preoperative prediction of the state of the axillary lymph nodes is significant for breast cancer staging, therapy and the prognosis of patients. In this study, we analyzed the possibility of axillary lymph node metastasis directly based on Magnetic Resonance Imaging (MRI) of the breast in cancer patients. After mass segmentation and feature analysis, the SVM, KNN, and LDA three classifiers were used to distinguish the axillary lymph node state in 5-fold cross-validation. The results showed that the effect of the SVM classifier in predicting breast axillary lymph node metastasis was significantly higher than that of the KNN classifier and LDA classifier. The SVM classifier performed best, with the highest accuracy of 89.54%, and obtained an AUC of 0.8615 for identifying the lymph node status. Each feature was analyzed separately and the results showed that the effect of feature combination was obviously better than that of any individual feature on its own.
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Jonjic N, Mustac E, Dekanic A, Marijic B, Gaspar B, Kolic I, Coklo M, Sasso F. Predicting Sentinel Lymph Node Metastases in Infiltrating Breast Carcinoma With Vascular Invasion. Int J Surg Pathol 2016; 14:306-11. [PMID: 17041193 DOI: 10.1177/1066896906293054] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Sentinel lymph node and clinically negative axillary node status was compared with well-known clinicopathological characteristics such as tumor size, histologic and nuclear grade, lymphovascular invasion, steroid receptor, and HER-2 status in patients with breast cancer (pT1 and pT2). Positive sentinel lymph nodes were found in 29 of 100 patients: 19 with metastases detected by hematoxylin and eosin staining and 10 with micrometastases confirmed by immunohistochemistry with cytokeratin. Positive sentinel lymph nodes were present in larger carcinomas ( P < 0.03), more frequently in tumors with negative PR status ( P < 0.037) and evident lymphovascular invasion ( P < 0.002). Lymphovascular invasion was also associated with breast cancer of higher histologic ( P = 0.011) and nuclear grade ( P = 0.039). Tumor size and the presence of lymphovascular invasion were found to be significant predictors of pathologically positive sentinel lymph node in T1 and T2.
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Affiliation(s)
- Nives Jonjic
- Department of Pathology, School of Medicine, University of Rijeka, Croatia.
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Rapid diagnosis of lymph node metastasis in breast cancer using a new fluorescent method with γ-glutamyl hydroxymethyl rhodamine green. Sci Rep 2016; 6:27525. [PMID: 27277343 PMCID: PMC4899706 DOI: 10.1038/srep27525] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 05/19/2016] [Indexed: 12/26/2022] Open
Abstract
Sentinel lymph node biopsy is performed as a standard procedure in breast cancer surgery, and the development of quick and simple methods to detect metastatic lesions is in high demand. Here, we validated a new fluorescent method using γ-glutamyl hydroxymethyl rhodamine green to diagnose metastatic lymph nodes in breast cancer. One hundred and forty-nine lymph nodes from 38 breast cancer patients were evaluated in this study. Comparison of fluorescent and pathological images showed that this fluorescent method was successful for visualizing breast cancer cells in lymph nodes. This method had a sufficiently high sensitivity (97%), specificity (79%) and negative predictive value (99%) to render it useful for an intraoperative diagnosis of cancer. These preliminary findings suggest that this novel method is useful for distinguishing non-cancerous specimens from those in need of careful examination and could help save time and cost for surgeons and pathologists.
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Ensani F, Enayati L, Rajabiani A, Omranipour R, Alavi N, Mosahebi S. Improved detection of metastases by step sectioning and immuno-histochemical staining of axillary sentinel nodes in patients with breast carcinoma. Asian Pac J Cancer Prev 2015; 14:5731-4. [PMID: 24289570 DOI: 10.7314/apjcp.2013.14.10.5731] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The object of this study was to examine whether a new protocol including step-sectioning and immunohistochemistry (IHC) staining of axillary sentinel nodes (SN) would lead to detection of more metastases in patients with breast cancer. MATERIALS AND METHODS Sixty-nine tumor free sentinel lymph nodes were examined. Step frozen sectioning was performed on formalin fixed SN and stained both by hematoxylin and eosin (H and E) and cytokeratin markers using IHC. Any tumoral cell in IHC stained slides were considered as a positive result. Metastases up to 0.2 mm were considered as isolated tumor cells and 0.2 up to 2 mm as micrometastasis. RESULTS Mean age of the patients was 48.7±12.2 years. Step sectioning of the SN revealed 11 involved by metastasis which was statistically significant (p<0.001). Furthermore, 15 (21.7%) of the patients revealed positive results in IHC staining for pan-CK marker and this was also statistically significant (p=0.001). Ten patients had tumoral involvement in lymph nodes harvested from axillary dissection and 4 out of 15 lymph nodes with positive result for CK marker were isolated tumor cells. However, 4 of 10 patients with tumor positive lymph nodes in axillary dissection were negative for CK marker and in contrast 6 of the pan-CK positive SN were in patients with tumor-free axillary lymph nodes. CONCLUSIONS Both IHC and step sectioning improve the detection rate of metastases. Considering the similar power of these two methods, we recommend using either IHC staining or step sectioning for better evaluation of harvested SNs.
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Affiliation(s)
- Fereshteh Ensani
- Department of Pathology, Iran Cancer Institute, Emam Khomeini Hospital, Tehran University of Medical Sciences, Tehran, Iran E-mail :
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Abstract
Sentinel node biopsy has become well accepted as a minimally invasive means of accurately staging the axilla in breast cancer patients. Patients with metastases in the sentinel node(s) have traditionally proceeded to completion of axillary node dissection, whereas patients who are node negative can be spared the morbidity of this procedure. Recently, there has been some debate as to what constitutes node-positive disease and whether patients with metastasis in the sentinel node(s) require completion axillary dissection. This review addresses the controversies regarding the management of sentinel node-positive breast cancer patients.
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Affiliation(s)
- Anees B Chagpar
- Division of Surgical Oncology Director, JG Brown Cancer Center Multidisciplinary Breast Program, University of Louisville, 312 East Broadway, Suite #314, Louisville, KY 40202, USA.
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Chagpar AB, McMasters KM. Sentinel lymph node biopsy for breast cancer: from investigational procedure to standard practice. Expert Rev Anticancer Ther 2014; 4:903-12. [PMID: 15485323 DOI: 10.1586/14737140.4.5.903] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Sentinel lymph node biopsy, popularized in melanoma, has revolutionized the management of breast cancer. While the morbidity associated with axillary node dissection was once thought to be a requisite risk in order to appropriately stage the axilla, large validation studies have demonstrated that sentinel lymph node biopsy is a minimally invasive technique that can accurately predict nodal status. This technique has become an accepted practice in many centers, but there remain many controversies surrounding the technique itself, the pathologic evaluation of the sentinel node and the optimal management of patients with minimal nodal disease. The historic roots of this technique are discussed, along with the controversial issues surrounding the technique and the clinical trials that are currently ongoing.
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Affiliation(s)
- Anees B Chagpar
- Division of Surgical Oncology, University of Louisville, KY 40202, USA.
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Hirche C, Mohr Z, Kneif S, Murawa D, Hünerbein M. High rate of solitary sentinel node metastases identification by fluorescence-guided lymphatic imaging in breast cancer. J Surg Oncol 2011; 105:162-6. [PMID: 21882198 DOI: 10.1002/jso.22075] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 07/27/2011] [Indexed: 12/18/2022]
Abstract
BACKGROUND The lymph node status was shown to be an important prognostic factor for breast cancer, but controversial issues remain. There has been increased focus on optimizing the visualization of lymph nodes for an accurate and selective approach to axillary lymph nodes. Fluorescence-guided lymphatic imaging is a potential candidate for further research on remaining controversies. METHODS Forty-seven patients were subject to injection of indocyanine green for navigation to the SLN based on fluorescent dye retention detection. In two groups, patients either received intended axillary lymph node dissection (ALND) and sentinel lymph node biopsy (SLNB) for superstaging or isolated SLNB for minimal-invasive staging. The prospective study was designed to evaluate the technical feasibility with focus on solitary positive SLN. RESULTS Visualization of lymphatic vessels with bright fluorescence of the SLN was feasible in 46 of 47 patients. Eighteen of 19 nodal positive patients were correctly identified with a sensitivity of 94.7% in all patients after ALND. After immunohistochemistry, in 19 of 25 overall nodal positive patients (76%) the SLN was the only positive lymph node. CONCLUSION Fluorescence-guided imaging using fluorescence retention detection allows transcutaneous navigation with a high rate of solitary positive SLN identification as an alternative technique for further research.
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Affiliation(s)
- Christoph Hirche
- Department of Hand, Plastic, and Reconstructive Surgery, Trauma Center Ludwigshafen, Department of Plastic and Hand Surgery, University of Heidelberg, Heidelberg, Germany
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Clinical Significance of Minimal Sentinel Node Involvement and Management Options. Surg Oncol Clin N Am 2010; 19:493-505. [DOI: 10.1016/j.soc.2010.03.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
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ICG fluorescence-guided sentinel node biopsy for axillary nodal staging in breast cancer. Breast Cancer Res Treat 2010; 121:373-8. [PMID: 20140704 DOI: 10.1007/s10549-010-0760-z] [Citation(s) in RCA: 158] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Accepted: 01/19/2010] [Indexed: 01/20/2023]
Abstract
BACKGROUND Sentinel lymph node (SLN) biopsy is a selective approach to axillary staging of breast cancer with reduced morbidity. Current detection methods including radioisotope and blue dye show good results but some drawbacks are remaining. Indocyanine green (ICG) fluorescence detection was evaluated as a new method for SLN biopsy in breast cancer allowing both transcutaneous visualization of lymphatic vessels and intraoperative identification of SLN. METHODS Forty-three women with clinically node negative breast cancer received subareolar injection of ICG for fluorescence detection of SLN. All patients underwent either planned axillary lymph node dissection (ALND) with SLN biopsy or selective SLN biopsy to determine need for ALND. Clinical feasibility, detection rate, sensitivity, and axillary recurrence after isolated SLN biopsy were analyzed. RESULTS Overall ICG fluorescence imaging identified 2.0 SLN in average in 42 of 43 patients (detection rate: 97.7%). Metastatic involvement of the SLN was found in 17 of 18 nodal positive patients by conventional histopathology (sensitivity: 94.4%). Immunohistochemistry revealed isolated tumor cells in five further cases. There was only one false-negative case in 43 patients (5.6%). In 17 of 23 overall nodal positive patients, the SLN was the only positive lymph node. After a median follow-up of 4.7 years none of the patients presented with axillary recurrence. CONCLUSION ICG fluorescence imaging is a new method for SLN biopsy in breast cancer with acceptable sensitivity and specificity comparable to conventional methods. One advantage of this technique is that it allows transcutaneous visualization of lymphatic vessels and intraoperative lymph node detection without radioisotope.
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Upender S, Mohan H, Handa U, Attri AK. Intraoperative evaluation of sentinel lymph nodes in breast carcinoma by imprint cytology, frozen section and rapid immunohistochemistry. Diagn Cytopathol 2009; 37:871-5. [DOI: 10.1002/dc.21120] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Laparoscopic sentinel node mapping using combined detection for endometrial cancer: a study of 33 cases—is it a promising technique? Am J Surg 2009; 197:1-7. [DOI: 10.1016/j.amjsurg.2007.10.021] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2007] [Revised: 10/22/2007] [Accepted: 10/22/2007] [Indexed: 11/22/2022]
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Unal B, Gur AS, Kayiran O, Johnson R, Ahrendt G, Bonaventura M, Soran A. Models for predicting non-sentinel lymph node positivity in sentinel node positive breast cancer: the importance of scoring system. Int J Clin Pract 2008; 62:1785-91. [PMID: 19143863 DOI: 10.1111/j.1742-1241.2008.01887.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
BACKGROUND Although delayed axillary lymph node dissection is the gold standard for evaluating axillary status after identification of a positive sentinel lymph node (SLN), between 40% and 70% of sentinel lymph node positive patients will have negative non-sentinel nodes and undergo a non-therapeutic axillary dissection. Accurate estimates of the likelihood of additional disease in the axilla can assist decision-making about further treatment. To predict non-SLN metastases in patients with a positive SLN biopsy, four different nomograms have been created. METHOD This paper reviews the scoring systems and nomograms reported in the literature and compares their predictive probability of non-SLN involvement in patients with SLN positive breast cancer. RESULT There are several published scoring systems that contain different parameters to estimate the rate of non-SLN metastases in SLN positive patients. We reviewed Memorial Sloan-Kettering Cancer Center (MSKCC), Tenon, Stanford and Cambridge nomograms published and used scoring systems including three to eight variables. We found that the MSKCC nomogram is the most validated model in the literature to predict non-SLN status accurately. The other three models have not yet been verified in outside institutions. CONCLUSION Despite having some limitations, the MSKCC nomogram is the most validated model in the literature. These models should be tested and verified in different programs and different patient groups before they are widely accepted.
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Affiliation(s)
- B Unal
- Department of Surgical Oncology, Magee-Womens Hospital of University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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Abstract
The tumor status of the axillary lymph nodes is the single most important predictor of survival for patients with primary breast cancer. Because of its essential role in staging, regional control, and perhaps survival, axillary lymph node dissection (ALND) has long been the standard of care for patients with operable breast cancer. During the past decade, the introduction and development of sentinel lymph node dissection (SLND) for primary breast cancer have allowed surgeons to determine the tumor status of the axilla without a standard level I and II ALND. Several well-designed studies have documented that SLND is an effective way of assessing axillary nodal status with minimal morbidity and high accuracy. We address the current status and future directions of SLND for primary breast cancer.
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Affiliation(s)
- Lori L Wilson
- Joyce Eisenberg Keefer Breast Center, John Wayne Cancer Institute at St. John's Health Center, 2200 Santa Monica Boulevard, Santa Monica, CA 90404, USA
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Delpech Y, Cortez A, Coutant C, Callard P, Uzan S, Darai E, Barranger E. The sentinel node concept in endometrial cancer: histopathologic validation by serial section and immunohistochemistry. Ann Oncol 2007; 18:1799-803. [PMID: 17709801 DOI: 10.1093/annonc/mdm334] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND The sentinel node (SN) is defined as the first node in the lymphatic system that drains a tumor site. If the SN is not metastatic, then all other nodes should also be disease-free. We used serial sections and immunohistochemical (IHC) staining to examine both SN and non-sentinel nodes (non-SNs). PATIENTS AND METHODS Twenty-three patients (median age 69 years) with early endometrial cancer underwent a laparoscopic SN procedure based on a combined detection method, followed by complete laparoscopic pelvic lymphadenectomy. If the SN was free of metastasis by both hematoxylin and eosin (H&E) and IHC staining, all non-SNs were also examined by the combined staining method. RESULTS SNs were identified in 19 patients (82.6%). A total of 47 SNs were removed (mean 2.5). Ten SNs (21.3%) from five patients (26.3%) were found to be metastatic at the final histologic assessment. In 14 patients, no metastatic SN involvement was detected by H&E and IHC staining. In these 14 patients, 120 non-SNs were examined by serial sectioning and IHC, and none were found to be metastatic. CONCLUSION The SN procedure appears to reliably predict the metastatic status of the regional lymphatic basin in patients with early endometrial cancer.
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Affiliation(s)
- Y Delpech
- Department of Gynecologic and Breast Cancers, Hôpital Tenon, Paris, France
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Tsujimoto M, Nakabayashi K, Yoshidome K, Kaneko T, Iwase T, Akiyama F, Kato Y, Tsuda H, Ueda S, Sato K, Tamaki Y, Noguchi S, Kataoka TR, Nakajima H, Komoike Y, Inaji H, Tsugawa K, Suzuki K, Nakamura S, Daitoh M, Otomo Y, Matsuura N. One-step nucleic acid amplification for intraoperative detection of lymph node metastasis in breast cancer patients. Clin Cancer Res 2007; 13:4807-16. [PMID: 17699859 DOI: 10.1158/1078-0432.ccr-06-2512] [Citation(s) in RCA: 319] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE Detection of sentinel lymph node (SLN) metastasis in breast cancer patients has conventionally been determined by intraoperative histopathologic examination of frozen sections followed by definitive postoperative examination of permanent sections. The purpose of this study is to develop a more efficient method for intraoperative detection of lymph node metastasis. EXPERIMENTAL DESIGN Cutoff values to distinguish macrometastasis, micrometastasis, and nonmetastasis were determined by measuring cytokeratin 19 (CK19) mRNA in histopathologically positive and negative lymph nodes using one-step nucleic acid amplification (OSNA). In an intraoperative clinical study involving six facilities, 325 lymph nodes (101 patients), including 81 SLNs, were divided into four blocks. Alternate blocks were used for the OSNA assay with CK19 mRNA, and the remaining blocks were used for H&E and CK19 immunohistochemistry-based three-level histopathologic examination. The results from the two methods were then compared. RESULTS We established CK19 mRNA cutoff values of 2.5 x 10(2) and 5 x 10(3) copies/muL. In the clinical study, an overall concordance rate between the OSNA assay and the three-level histopathology was 98.2%. Similar results were obtained with 81 SLNs. The OSNA assay discriminated macrometastasis from micrometastasis. No false positive was observed in the OSNA assay of 144 histopathologically negative lymph nodes from pN0 patients, indicating an extremely low false positive for the OSNA assay. CONCLUSION The OSNA assay of half of a lymph node provided results similar to those of three-level histopathology. Clinical results indicate that the OSNA assay provides a useful intraoperative detection method of lymph node metastasis in breast cancer patients.
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Ollila DW, Klauber-DeMore N, Tesche LJ, Kuzmiak CM, Pavic D, Goyal LK, Lian J, Chang S, Livasy CA, Sherron RF, Sartor CI. Feasibility of breast preserving therapy with single fraction in situ radiotherapy delivered intraoperatively. Ann Surg Oncol 2007; 14:660-9. [PMID: 17091330 DOI: 10.1245/s10434-006-9154-1] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND Accelerated partial breast irradiation (APBI) has gained widespread interest as a means of improving the convenience and availability of breast conserving radiotherapy. Intraoperative radiation therapy (IORT) is an APBI technique that delivers breast radiotherapy as a single dose at the time of partial mastectomy. We adapted the technique of Veronesi to deliver IORT prior to tumor excision to improve delivery to the region at risk and reduce the volume of normal tissue irradiated. METHODS Patients age >or=55 with ultrasonographically defined tumors <or=3 cm and invasive ductal carcinoma confirmed by core biopsy were eligible. Pre-operative ultrasound was performed at the time of needle localization and radiocolloid injection. IORT treatment planning was performed prior to surgery using ultrasound tumor definition, selecting cone size and electron energy to optimize dose distribution. In the operating room, the surgeon retracted the skin over the tumor, cone was placed and radiotherapy delivered. Standard partial mastectomy was then performed. RESULTS Twenty-three patients were enrolled in the study. Eighteen patients completed IORT with 10 patients having successful IORT no additional local therapy necessary. In five patients, the intraoperative radiation therapy served as the boost and in three patients unsuspected larger tumors or multicentric disease necessitated a mastectomy. The majority of patients had a good to excellent cosmetic result. CONCLUSIONS Single fraction in situ IORT prior to partial mastectomy is feasible for patients with small breast cancers in achieving a good to excellent cosmetic result. Based on this early preliminary data, we plan to expand our feasibility trial.
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Affiliation(s)
- David W Ollila
- Department of Surgery, UNC Lineberger Comprehensive Cancer Center, The University of North Carolina at Chapel Hill, 3010 Old Clinic Building, CB #7213, Chapel Hill, NC 27599-7213, USA.
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Caudle AS, Brier SE, Calvo BF, Kim HJ, Meyers MO, Ollila DW. Experienced Radio-Guided Surgery Teams Can Successfully Perform Minimally Invasive Radio-Guided Parathyroidectomy without Intraoperative Parathyroid Hormone Assays. Am Surg 2006. [DOI: 10.1177/000313480607200905] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Minimally invasive parathyroidectomy is an accepted treatment option for primary hyperpara-thyroidism. The need for intraoperative parathyroid hormone assays (iPTH) to confirm adenoma removal remains controversial. We studied minimally invasive radio-guided parathyroidectomy (MIRP) performed using preoperative sestamibi localization studies, intraoperative gamma detection probe, and the selective use of frozen section pathology without the use of iPTH. This is a single institution review of patients with primary hyperparathyroidism treated with MIRP by surgeons experienced in radio-guided surgery between October 1, 1998 and July 15, 2005. Information was obtained by reviewing computer medical records as well as contacting primary care physicians. Factors evaluated included laboratory values, pathology results, and evidence of recurrence. One hundred forty patients were included with a median preoperative calcium level of 11.3 mg/dL (range, 9.6–17) and a PTH level of 147 pg/mL (range, 19–5042). The median postoperative calcium level was 9.3 mg/dL. All patients were initially eucalcemic postoperatively except for one who had normal parathyroid levels. However, five (4%) patients required re-exploration for various reasons. Of the failures, one was secondary to the development of secondary hyperparathyroidism, and therefore would not have benefited from iPTH, one had thyroid tissue removed at the first operation, and three developed evidence of a second adenoma. One of these three patients had a drop in PTH level from 1558 pg/mL preoperatively to 64 pg/mL on postoperative Day 1, indicating that iPTH would not have prevented this failure. Thus, only three (2.1%) patients could have potentially benefited from the use of iPTH. MIRP was successful in 96 per cent of patients using a combination of preoperative sestamibi scans, intraoperative localization with a gamma probe, and the selective use of frozen pathology. This correlates with reported success rates of 95 per cent to 100 per cent using iPTH. We conclude that minimally invasive parathyroidectomy can be successfully performed without using iPTH assays.
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Affiliation(s)
- Abigail S. Caudle
- Departments of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Sarah E. Brier
- School of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Benjamin F. Calvo
- Departments of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Hong Jin Kim
- Departments of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - Michael O. Meyers
- Departments of Surgery, University of North Carolina, Chapel Hill, North Carolina
| | - David W. Ollila
- Departments of Surgery, University of North Carolina, Chapel Hill, North Carolina
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Ollila DW, Caudle AS, Cance WG, Kim HJ, Cusack JC, Swasey JE, Calvo BF. Successful minimally invasive parathyroidectomy for primary hyperparathyroidism without using intraoperative parathyroid hormone assays. Am J Surg 2006; 191:52-6. [PMID: 16399106 DOI: 10.1016/j.amjsurg.2005.10.003] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2005] [Revised: 06/28/2005] [Indexed: 10/25/2022]
Abstract
BACKGROUND The need for intraoperative parathyroid hormone (iPTH) assays in minimally invasive parathyroidectomy (MIP) remains controversial. We report the results of MIP performed without the use of iPTH assays. METHODS This was a single-institution retrospective review of patients with primary hyperparathyroidism treated with MIP between October 1, 1998, and December 31, 2002. RESULTS Seventy-seven patients were studied. The mean preoperative calcium level was 11.4 mg/dL. All patients had a normal calcium level postoperatively (range, 7.4-10.2 mg/dL, mean, 9.1 mg/dL). Three patients (4%) required re-exploration for various reasons including the development of a second adenoma, secondary hyperparathyroidism, and discordant pathology. All 3 patients initially were eucalcemic. CONCLUSIONS Our success rate of 96% using a combination of preoperative sestamibi scans, intraoperative gamma probe localization, and selective frozen pathology is consistent with the published success rates using iPTH assays of 95% to 100%. We conclude that MIP can be performed successfully without using iPTH assays.
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Affiliation(s)
- David W Ollila
- Division of Surgical Oncology, University of North Carolina, 3010 Old Clinic Building, CB #7213, Chapel Hill, NC 27599, USA
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Seenu V, Pavan Kumar MN, Sharma U, Gupta SD, Mehta SN, Jagannathan NR. Potential of magnetic resonance spectroscopy to detect metastasis in axillary lymph nodes in breast cancer. Magn Reson Imaging 2005; 23:1005-10. [PMID: 16376185 DOI: 10.1016/j.mri.2005.10.004] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2005] [Revised: 10/18/2005] [Accepted: 10/18/2005] [Indexed: 10/25/2022]
Abstract
Focused pathological evaluation of axillary lymph nodes in breast cancer is gaining importance. Nuclear magnetic resonance (NMR) spectroscopy that assesses the whole of the specimen has the potential in evaluating micrometastases. The biochemical changes associated with breast cancer metastases in axillary nodes by in vitro NMR and its use in the detection of axillary metastases in a clinical setting in comparison with conventional histopathology is presented in this study. Eighty-eight lymph nodes obtained from 30 patients with breast cancer were investigated. Histopathology revealed metastases in 20 nodes from 11 patients, while in vitro NMR spectroscopy revealed metastases in 22 nodes. Out of these 22 nodes, 16 were the same, which showed metastases on histopathology, while 6 nodes have shown metastases only on in vitro magnetic resonance spectroscopy (MRS). These 6 nodes with suspicion of metastases on MRS were subjected to reevaluation with serial sectioning and immunohistochemistry, but no additional metastases were revealed. Forty metabolites could be identified from the MR spectrum of lymph nodes. The levels of the glycerophosphocholine-phosphocholine (GPC-PC), choline, lactate, alanine and uridine diphosphoglucose were elevated significantly in nodes with metastases. In addition, the intensity ratio of GPC-PC/threonine (Thr) was higher in nodes with metastases, and using this as marker, MRS detected the axillary metastases with a sensitivity, specificity and accuracy of 80%, 91% and 88%, respectively. Neoadjuvant chemotherapy (NACT) lowered the concentrations of GPC-PC and GPC-PC/Thr ratio. The accuracy of MRS in detecting metastases was 75% in patients who received NACT (n=9) as compared to 96% in those who did not (n=21). Our results demonstrate the potential of in vitro MRS in characterizing the metabolite profile of the axillary nodes with breast cancer metastases. It detected axillary metastases with reasonable accuracy and can be complementary to histopathological evaluation and immunohistochemistry.
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Affiliation(s)
- Vuthaluru Seenu
- Department of Surgical Disciplines, All India Institute of Medical Sciences, New Delhi 110029, India
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21
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Ollila DW, Neuman HB, Sartor C, Carey LA, Klauber-Demore N. Lymphatic mapping and sentinel lymphadenectomy prior to neoadjuvant chemotherapy in patients with large breast cancers. Am J Surg 2005; 190:371-5. [PMID: 16105521 DOI: 10.1016/j.amjsurg.2005.01.044] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2004] [Revised: 01/10/2005] [Accepted: 01/10/2005] [Indexed: 01/09/2023]
Abstract
BACKGROUND Lymphatic mapping and sentinel lymphadenectomy (LM/SL) accurately evaluates the axilla in patients with small breast cancers. LM/SL in patients with large breast cancers is controversial. We examined the accuracy of LM/SL prior to neoadjuvant chemotherapy in patients with large (>3.5 cm) breast cancers. METHODS Patients with large breast cancers underwent LM/SL prior to neoadjuvant chemotherapy using 99m-technetium radiocolloid and isosulfan-blue dye technique. RESULTS Twenty-one patients with large (median 5.0 cm) breast cancers underwent LM/SL prior to neoadjuvant chemotherapy. Twelve patients had a tumor-free sentinel node (SN) and received doxorubicin-based chemotherapy; 9 patients had disease in the SN and received doxorubicin followed by a taxane. No patient progressed while receiving neoadjuvant chemotherapy, nor has there been an axillary recurrence (median 36 months). CONCLUSIONS LM/SL performed prior to neoadjuvant chemotherapy in patients with large breast cancers is an accurate method of axillary staging. Axillary staging prior to neoadjuvant chemotherapy may have prognostic and therapeutic implications.
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Affiliation(s)
- David W Ollila
- Division of Surgical Oncology, Department of Surgery, University of North Carolina, Chapel Hill, NC 27599, USA.
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22
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Abstract
Sentinel lymph node biopsy is an accurate method for the detection of axillary metastases in cases of breast carcinoma and is of value as a replacement for axillary dissection. There is variation, however, in the methods and protocols used for the histopathological evaluation of sentinel lymph nodes, standardisation of which will be required if results of sentinel lymph node analysis are to be used to stratify patients into prognostic groups. The significance of micrometastases, isolated tumour cells (ITCs) and the value of immunohistochemistry are also matters for further definition. In this Expert Opinion we present reviews from two authors, providing American and European perspectives on the approach to sentinel lymph node evaluation.
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Affiliation(s)
- G Cserni
- Bács-Kiskun County Teaching Hospital, Kecskemét, Hungary.
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23
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Marchiolé P, Buénerd A, Benchaib M, Nezhat K, Dargent D, Mathevet P. Clinical significance of lympho vascular space involvement and lymph node micrometastases in early-stage cervical cancer: A retrospective case-control surgico-pathological study. Gynecol Oncol 2005; 97:727-32. [PMID: 15943983 DOI: 10.1016/j.ygyno.2005.01.004] [Citation(s) in RCA: 105] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2004] [Revised: 12/21/2004] [Accepted: 01/04/2005] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Several studies have shown that lympho vascular space involvement (LVSI) and lymph node micrometastases (LNmM) may be risk factors for recurrence in early-stage cervical cancer with no apparent lymph node metastases. We performed a retrospective case-control study to reassess whether the presence of lymph node micrometastases and LVSI is predictive of subsequent recurrence following surgical resection of early-stage cervical cancer. METHODS In a series of 292 patients diagnosed with early cervical cancer and treated by the same surgical procedure (laparoscopic-vaginal radical hysterectomy) during the same time period, two paired series were selected. The first series consisted of 26 cases who recurred in a median time of 36.8 months and the second series were 26 cases matched for age, histological sub-type, surgico-pathological stage and maximal tumor diameter, who did not recur after a median follow-up of 122 months. Sections taken from the hysterectomy specimens were reassessed for LVSI. All the lymph node blocks which have initially been considered as uninvolved were submitted to serial sectioning. Immunohistochemical staining using anti-cytokeratins AE1 and AE3 was used for identifying LNmM. RESULTS LVSI was twice more frequent and LNmM ten-fold more frequent in the group of patients who recurred: 20/26 (77%) versus 9/26 (35%) and 11/26 (42%) versus 1/26 (4%) respectively. The relative risk of recurrence is 2.64 (1.67-5.49, P < 0.01) in the presence of LVSI and 2.44 (1.58-3.78, P < 0.01) in the presence of LNmM. All the patients with LNmM were LVSI positive. At bivariate analysis, the true LNmM (deposits more than 200 um in size) was the only independent risk factor. CONCLUSIONS LNmM is an important risk factor of tumor recurrence in patients with early cervical cancer with no apparent lymph node metastases. LNmM seems to occur only in LVSI positive tumors. These data may lead to improve management of early-stage cervical cancer to reduce the risk of recurrence in those cases.
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Affiliation(s)
- Pierangelo Marchiolé
- Department of Obstetrics and Gynecology, Hôpital Edouard Herriot, Lyon 69437, France
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24
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Chagpar A, Middleton LP, Sahin AA, Meric-Bernstam F, Kuerer HM, Feig BW, Ross MI, Ames FC, Singletary SE, Buchholz TA, Valero V, Hunt KK. Clinical outcome of patients with lymph node-negative breast carcinoma who have sentinel lymph node micrometastases detected by immunohistochemistry. Cancer 2005; 103:1581-6. [PMID: 15747375 DOI: 10.1002/cncr.20934] [Citation(s) in RCA: 91] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND The ideal pathologic assessment of sentinel lymph nodes (SLNs) in patients with breast carcinoma remains controversial. The authors evaluated how detailed assessment of SLNs using immunohistochemistry (IHC) and serial sectioning would affect treatment decisions and outcomes in patients with breast carcinoma who had negative SLNs on standard hematoxylin and eosin staining. METHODS The SLNs from patients who were treated between June 1998 and June, 1999 and who had negative lymph node status determined by hematoxylin and eosin staining (n = 84 patients) were evaluated further with serial sectioning and cytokeratin IHC. Patients were offered adjuvant therapy based on primary tumor factors. RESULTS The median patient age was 57 years, and the median tumor size was 1.2 cm. At a median follow-up of 40.2 months, 81 patients (96%) were alive with no evidence of disease, 1 patient was alive with disease, 1 patient had died of disease, and 1 patient had died of other causes. Fifteen patients (18%) had micrometastases identified on IHC. Of the total 84 patients, information regarding adjuvant therapy was not available for 5 patients. Of the remaining 79 patients, 10 patients (13%) were not offered adjuvant chemotherapy but had positive SLN status determined by IHC. SLN status based on IHC evaluation did not correlate with age (P = 0.077), tumor size (P = 0.717), grade (P = 0.148), estrogen receptor status (P = 1.000), or lymphovascular invasion (P = 0.274). Furthermore, IHC-detected positive SLN status did not correlate with distant metastasis (P = 0.372) or overall or distant metastasis-free survival (P = 0.543 and P = 0.540, respectively). CONCLUSIONS Although the finding of SLN micrometastases by IHC may change management in > 12% of patients, preliminary results suggested that such micrometastases do not affect outcomes significantly.
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Affiliation(s)
- Anees Chagpar
- Department of Surgical Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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25
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Perez N, Vidal-Sicart S, Zanon G, Velasco M, Santamaria G, Palacin A, Campo E, Cardesa A, Fernandez PL. A Practical Approach to Intraoperative Evaluation of Sentinel Lymph Node Biopsy in Breast Carcinoma and Review of the Current Methods. Ann Surg Oncol 2005; 12:313-21. [PMID: 15827677 DOI: 10.1245/aso.2005.07.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2004] [Accepted: 11/29/2004] [Indexed: 11/18/2022]
Abstract
BACKGROUND Sentinel lymph node (SLN) biopsy is increasingly becoming an alternative method for assessing axillary status in breast carcinoma patients. Intraoperative SLN evaluation can potentially select patients for immediate axillary clearance and spare most of them a second surgical procedure. Nevertheless, no standard protocol for intraoperative SLN evaluation has been developed. The aims of this study were to establish the reliability of SLN intraoperative evaluation in breast carcinoma staging, to review the published methods currently used, and to propose a standard protocol. METHODS One hundred fifty-two SLNs were collected from 86 patients. Lymphoscintigraphy, blue dye, and gamma camera intraoperative controls were used for localization. Each SLN was sliced 2 mm thick and was intraoperatively evaluated by using the combination of frozen section and imprint cytology. The final examination included standard hematoxylin and eosin staining, and, in case of persistent negativity, further sectioning, including hematoxylin and eosin combined with immunohistochemistry (CAM5.2 cytokeratin), was performed. RESULTS The combination of frozen section and imprint cytology for intraoperative SLN evaluation yielded an intraoperative sensitivity of 78% and a specificity of 100%. All macrometastases (>2 mm) were detected during surgery, as were 2 micrometastases. Final examination detected seven more micrometastases, six of which consisted of isolated tumor cells. CONCLUSIONS We propose a fast, cost-effective, and accurate procedure for SLN evaluation that is useful for making intraoperative decisions, feasible for most institutions, and reliable because of its high sensitivity (100% for macrometastases) and specificity.
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Affiliation(s)
- Noelia Perez
- Department of Pathology, Hospital Clinic, C/Villarroel 170, 08036, Barcelona, Spain
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26
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Rao RS, Taylor J, Palmer J, Jennings WC. Breast Cancer Pseudometastasis in a Sentinel Lymph Node with Cytokeratin-Positive Debris. Breast J 2005; 11:134-7. [PMID: 15730460 DOI: 10.1111/j.1075-122x.2005.21680.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We report extensive pseudometastasis detected by immunohistochemical (IHC) staining within a sentinel lymph node. An 83-year-old woman underwent simple mastectomy and sentinel lymph node biopsy (SLNB) for infiltrating ductal carcinoma. Intraoperative frozen section of the SLNB specimen appeared histologically negative for metastasis. IHC staining for cytokeratin in permanent sections, however, showed what was reported as micrometastasis in the subcapsular sinus. Since these cells did not resemble the primary tumor cells morphologically, and had actually been called histiocytes in the frozen section, further IHC staining was done. The subcapsular cells were negative for epithelial membrane antigen (EMA) staining, but they were positive for CD68, a macrophage marker. Thus the cytokeratin-positive cells were not metastatic breast tumor cells, but rather were histiocytes with phagocytized cytokeratin debris. This case report illustrates that IHC staining for cytokeratin in SLNB specimens for breast cancer must be supported by morphologic assessment and further appropriate staining before it can become the basis for treatment decisions.
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Affiliation(s)
- Rohini S Rao
- Department of Surgery, University of Oklahoma College of Medicine, Tulsa, OK 74135-2512, USA
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27
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Cserni G. Surgical pathological staging of breast cancer by sentinel lymph node biopsy with special emphasis on the histological work-up of axillary sentinel lymph nodes. Breast Cancer 2005; 11:242-9; discussion 264-6. [PMID: 15550842 DOI: 10.1007/bf02984544] [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: 02/06/2023]
Abstract
Axillary nodal status assessed by traditional histological methods is a proven independent prognostic factor in breast cancer. Sentinel lymph node biopsy is a surgical pathologic staging procedure that not only allows the selective removal of the most likely sites of lymphogenic metastases, but also enables upstaging of breast carcinoma by detecting nodal involvement undetected by standard methods of nodal staging. This review highlights the upstaging potential of sentinel node biopsy. It also suggests that incomplete reporting of the pathological methods may make the comparisons of results from different studies difficult. The article also describes a few methods that have been claimed optimal but are probably not, and it formulates basic considerations for building up a histological protocol that can identify all metastases larger than 2 mm, which are of unquestionable prognostic relevance. These considerations are also useful for the detection of micrometastases. Issues of pathological reporting of sentinel nodal findings are also highlighted, with emphasis on the lack of standardization and on the differentiation of isolated tumor cells from micrometastases. Finally the stepwise building up of our current histology protocol and our experience gained since the introduction of sentinel node biopsy in 1997 is also briefly summarized.
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Affiliation(s)
- Gábor Cserni
- Department of Surgical Pathology, Nyiri ut 38., H-6000 Kecskemet, Hungary
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28
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Stitzenberg KB, Groben PA, Stern SL, Thomas NE, Hensing TA, Sansbury LB, Ollila DW. Indications for lymphatic mapping and sentinel lymphadenectomy in patients with thin melanoma (Breslow thickness < or =1.0 mm). Ann Surg Oncol 2004; 11:900-6. [PMID: 15383424 DOI: 10.1245/aso.2004.10.002] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Patients with thin (Breslow thickness < or =1.0 mm) melanoma have a good prognosis (5-year survival >90%). Consequently, the added benefit of lymphatic mapping and sentinel lymphadenectomy (LM/SL) in these patients is controversial. We hypothesize that LM/SL with a focused examination of the sentinel node (SN) will detect a significant number of SN metastases in patients with thin melanoma and that certain clinical or histopathologic factors may serve as predictors of SN tumor involvement. METHODS Over 6 years, 349 patients with melanoma underwent LM/SL and were prospectively entered into an institutional review board (IRB)-approved database. LM/SL was performed with a combined radiotracer and blue dye technique. SNs were serially sectioned, and each section was examined by a dermatopathologist at multiple levels with hematoxylin and eosin as well as immunohistochemical stains. RESULTS One hundred forty-six patients (42%) had a melanoma with Breslow thickness < or =1.0 mm; six (4%) of these 146 patients had a tumor-involved SN. On multivariate analysis, none of the clinical or histopathologic factors examined were significantly associated with SN tumor involvement in patients with thin melanoma. Completion lymphadenectomy was performed on all patients with a tumor-involved SN. None of the patients had non-SN tumor involvement. CONCLUSIONS The incidence of SN tumor involvement in patients with thin melanoma is considerable. Although we were unable to identify predictors of SN tumor involvement in patients with thin melanoma, efforts to identify predictors of SN tumor involvement should continue. Until better predictors are identified, we continue to advocate offering LM/SL to patients with thin melanomas who demonstrate clinical or histopathologic characteristics that have historically been associated with an increased risk of recurrence and mortality.
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Affiliation(s)
- Karyn B Stitzenberg
- Division of Surgical Oncology, Department of Surgery, 3010 Old Clinic Building, CB#7213, University of North Carolina, Chapel Hill, NC 27599-7213, USA
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29
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Kelley MC, Hansen N, McMasters KM. Lymphatic mapping and sentinel lymphadenectomy for breast cancer. Am J Surg 2004; 188:49-61. [PMID: 15219485 DOI: 10.1016/j.amjsurg.2003.10.028] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Lymphatic mapping and sentinel lymphadenectomy has become an important tool for axillary lymph node staging in women with early-stage breast cancer. This review examines data regarding the staging accuracy, indications and technical aspects of the procedure, and clinical trials investigating the technique. Multiple studies now confirm that sentinel lymphadenectomy accurately stages the axilla and is associated with less morbidity than axillary dissection. Blue dye, radiocolloid, or both can be used to identify the sentinel node, and several injection techniques may be used successfully. Many patient factors previously thought to affect accuracy of the procedure have now been shown to be of limited significance. The indications for the procedure are expanding, and the histopathologic evaluation of the sentinel node and the role of lymphoscintigraphy have been clarified. Clinical trials are now underway that will determine the prognostic significance of micrometastases and the therapeutic benefit of axillary dissection in women with and without sentinel node metastases. Incorporation of sentinel lymphadenectomy into routine clinical practice will maintain accurate axillary staging with lower morbidity and improved quality of life for women with early-stage breast cancer.
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Affiliation(s)
- Mark C Kelley
- Vanderbilt University Medical Center, Nashville, TN, USA
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Barranger E, Cortez A, Grahek D, Callard P, Uzan S, Darai E. Laparoscopic sentinel node procedure using a combination of patent blue and radiocolloid in women with endometrial cancer. Ann Surg Oncol 2004; 11:344-9. [PMID: 14993032 DOI: 10.1245/aso.2004.07.005] [Citation(s) in RCA: 60] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND We assessed the feasibility of a laparoscopic sentinel node (SN) procedure based on the combined use of radiocolloid and patent blue labeling in patients with endometrial cancer. METHODS Seventeen patients (median age, 69 years) with endometrial cancer of stage I (16 patients) or stage II (1 patient) underwent a laparoscopic SN procedure based on combined radiocolloid and patent blue injected pericervically. After the SN procedure, all patients underwent complete laparoscopic pelvic lymphadenectomy and either laparoscopically assisted vaginal hysterectomy (16 patients) or laparoscopic radical hysterectomy (1 patient). RESULTS SNs (mean number per patient, 2.6; range, 1-4) were identified in 16 (94.1%) of the 17 patients. Macrometastases were detected in three SNs from two patients by hematoxylin and eosin staining. In three other patients, immunohistochemical analysis identified six micrometastatic SNs and one SN containing isolated tumor cells. No false-negative SN results were observed. CONCLUSIONS An SN procedure based on a combination of radiocolloid and patent blue is feasible in patients with early endometrial cancer. Combined use of laparoscopy and this SN procedure permits minimally invasive management of endometrial cancer.
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Affiliation(s)
- Emmanuel Barranger
- Department of Gynecologic and Breast Cancers, Hôpital Tenon, Assistance Publique des Hôpitaux de Paris, Paris, France.
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Marchiolè P, Buénerd A, Scoazec JY, Dargent D, Mathevet P. Sentinel lymph node biopsy is not accurate in predicting lymph node status for patients with cervical carcinoma. Cancer 2004; 100:2154-9. [PMID: 15139058 DOI: 10.1002/cncr.20212] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND The authors evaluated the accuracy of sentinel lymph node biopsy in predicting lymph node status for patients with early cervical carcinoma. In particular, the authors set out to determine the false-negative rate associated with sentinel lymph node biopsy in this setting. METHODS Twenty-nine consecutive patients with early cervical carcinoma who were treated with pelvic laparoscopic lymphadenectomy and radical surgery underwent sentinel lymph node biopsy following lymphatic mapping with patent blue dye. All sentinel and nonsentinel lymph nodes were evaluated for micrometastases via multilevel sectioning followed by immunohistochemical staining. RESULTS At least one sentinel lymph node was identified for each patient. On routine pathologic evaluation, 3 patients (10%) were found to have positive lymph nodes. Among the remaining 26 patients, multilevel sectioning in conjunction with immunohistochemical analysis identified 5 patients (19%) who had micrometastases in the pelvic lymph nodes. Two of these five patients had micrometastases in a sentinel lymph node; however, the more notable finding was that the other three patients had micrometastases in nonsentinel pelvic lymph nodes despite having negative findings on sentinel lymph node biopsy. Thus, the negative predictive value of sentinel lymph node biopsy in the current study was 87.5%. CONCLUSIONS Multilevel sectioning followed by cytokeratin immunohistochemistry may identify additional patients who have lymph node micrometastases; in the current study, this technique identified cases in which micrometastases were present in nonsentinel lymph nodes even when sentinel lymph nodes were found to be negative for disease on biopsy. This high false-negative rate associated with sentinel lymph node biopsy, raises questions regarding the validity of the sentinel lymph node concept in cervical carcinoma.
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Cserni G. A model for determining the optimum histology of sentinel lymph nodes in breast cancer. J Clin Pathol 2004; 57:467-71. [PMID: 15113852 PMCID: PMC1770292 DOI: 10.1136/jcp.2003.014308] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
AIMS To create and use a geometrical model for sentinel lymph node (SLN) histopathology in breast cancer. METHODS The model involves a spherical metastasis randomly situated in an SLN. Two extreme situations are taken as the starting points. In one of these, the metastasis is seen in its largest dimension, whereas in the other it is only just visible, approximating 0 mm in size. Intermediate positions are analysed, with different metastasis sizes and different distances between the levels assessed by histology. RESULTS The findings suggest that sections taken 1 mm apart afford a reasonable means of identifying almost all metastases measuring > 2 mm (referred to as macrometastases here). For nearly all micrometastases to be identified correctly according to the current TNM definitions (that is, metastases > 0.2 mm), a step sectioning protocol with levels of 250 microm or 200 microm would be adequate. CONCLUSIONS SLNs are the most likely sites of nodal metastasis. Macrometastases are of recognised prognostic relevance so that all should be identified, preferably correctly as macrometastases; an assessment of levels 1 mm apart appears satisfactory and sufficient for this aim. SLNs also offer an ideal method for the study of the significance of micrometastases; for this, step sections separated by 200 or 250 microm are a good choice.
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Affiliation(s)
- G Cserni
- Department of Pathology, Bács-Kiskun County Teaching Hospital, Hungary.
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Holck S, Galatius H, Engel U, Wagner F, Hoffmann J. False-negative frozen section of sentinel lymph node biopsy for breast cancer. Breast 2004; 13:42-8. [PMID: 14759715 DOI: 10.1016/s0960-9776(03)00124-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2003] [Accepted: 05/12/2003] [Indexed: 10/26/2022] Open
Abstract
A prospective study is presented of frozen section examinations (FS) performed in parallel with 265 consecutive sentinel lymph node procedures (SLNP) over a 20-month period. The final pathological study included immunohistochemistry (IHC) for keratin if the haematoxylin-eosin (HE)-stained section was tumour free. FS correctly identified node-positive or node-negative axillae in 235 cases. In 28 SLNPs the final examination gave a positive result not detected in the FS, resulting in reoperation. In 21 of these false-negative (FN) cases micrometastases (MIM) were present. There were no false-positive cases, but in two cases of lobular carcinoma the findings in the FS were equivocal, the final reports recording metastases in one but not in the other. Lobular carcinoma and other less common subtypes of carcinoma were overrepresented, ductal carcinoma not otherwise specified (NOS) being less likely to affect the FN findings.
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Affiliation(s)
- S Holck
- Department of Pathology, Hilleroed Hospital, Hilleroed 3400, Denmark.
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Roberts CA, Beitsch PD, Litz CE, Hilton DS, Ewing GE, Clifford E, Taylor W, Hapke MR, Babaian A, Khalid I, Hall JD, Lindberg G, Molberg K, Saboorian H. Interpretive disparity among pathologists in breast sentinel lymph node evaluation. Am J Surg 2003; 186:324-9. [PMID: 14553843 DOI: 10.1016/s0002-9610(03)00268-x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Immunohistochemical staining on breast sentinel lymph nodes (SLN) is controversial. METHODS Twenty-five SLN cases were reviewed by 10 pathologists (three academic, seven private) including 5 negative by both hematoxylin and eosin (H&E) and immunohistochemistry, 11 micrometastases (<2 mm) negative by H&E but positive by immunohistochemistry, and 8 micrometastases and 1 macrometastasis (>2 mm) positive for both H&E and immunohistochemistry. Answers included "positive," "negative," and "indeterminate" for each slide. RESULTS The mean number of incorrect responses was 6.6 for immunohistochemistry and 5 for H&E. Twelve percent of cases were correct by all 10 pathologists; 80% of positive IHC cases had at least one pathologist score it incorrectly. As tumor cells decrease in number, incorrect responses increase. When tumor cells numbered less than 10, more than 30% of pathologists answered incorrectly. CONCLUSIONS As tumor cells decrease in number pathologists' ability to recognize them decreases. We propose adding "indeterminate" to "positive" and "negative" when tumor cells number less than 10.
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Affiliation(s)
- Cory A Roberts
- Department of Pathology, St Paul University Hospital and University of Texas Southwestern Medical Center, Dallas, TX, USA.
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35
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Stitzenberg KB, Meyer AA, Stern SL, Cance WG, Calvo BF, Klauber-DeMore N, Kim HJ, Sansbury L, Ollila DW. Extracapsular extension of the sentinel lymph node metastasis: a predictor of nonsentinel node tumor burden. Ann Surg 2003; 237:607-12; discussion 612-3. [PMID: 12724626 PMCID: PMC1514520 DOI: 10.1097/01.sla.0000064361.12265.9a] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To identify predictors of nonsentinel node (NSN) tumor involvement in patients with a tumor-involved sentinel node (SN). SUMMARY BACKGROUND DATA For many breast cancer patients who undergo intraoperative lymphatic mapping and sentinel lymphadenectomy (LM/SL), the SN is the only tumor-involved axillary node. Associations between NSN tumor involvement and several clinical and histopathologic factors have been identified. The authors hypothesize that extracapsular extension (ECE) of the SN metastasis is highly predictive of NSN tumor involvement. METHODS Between May 1998 and December 2001, 260 patients (263 cases) with clinical T1 or T2 (<5.0 cm) breast cancer underwent LM/SL at the University of North Carolina, using a combined blue dye and technetium sulfur colloid technique. In all cases with a tumor-involved SN, axillary lymph node dissection (ALND) was recommended. Statistical analysis, with Pearson chi-square tests, Fisher exact test, and multiple logistic regression, was performed. RESULTS The SN contained tumor in 74 (28.1%) cases. ALND was performed in 70 of the 74 cases. ECE of the SN metastasis was present in 18 (25.7%) of the 70 cases. Patients with ECE of the SN metastasis were more likely to have NSN tumor involvement and had a greater total number of tumor-involved nodes than patients without ECE of the SN metastasis. Increasing size of the SN metastasis and increasing size of the primary tumor, examined as continuous variables, were associated with an increased likelihood of NSN tumor involvement on univariate analysis. However, only ECE of the SN metastasis was associated with NSN tumor involvement on multivariate analysis. CONCLUSIONS ECE of the SN metastasis is a strong predictor of NSN tumor involvement. All patients with ECE of the SN metastasis should undergo mandatory completion ALND.
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Affiliation(s)
- Karyn B Stitzenberg
- Department of Surgery, University of North Carolina, 3010 Old Clinic Building, Chapel Hill, NC 27599, USA
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Jani AB, Basu A, Heimann R, Hellman S. Sentinel lymph node versus axillary lymph node dissection for early-stage breast carcinoma: a comparison using a utility-adjusted number needed to treat analysis. Cancer 2003; 97:359-66. [PMID: 12518360 DOI: 10.1002/cncr.11081] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND The current study was performed to compare the value of sentinel lymph node dissection (SND) and axillary lymph node dissection (AND) in improving the utility-adjusted survival for early-stage breast carcinoma patients. METHODS A number needed to treat (NNT) analysis was used to compare SND with AND. In the NNT equation, 1/(S(SND) - S(AND)), S is the 5-year utility-adjusted survival. A literature review was performed to estimate 1) the prevalence of axillary lymph node disease for early-stage breast carcinoma, 2) the sensitivity and specificity of SND and AND, 3) the 5-year overall survival as a function of axillary lymph node involvement, 4) the risk of arm lymphedema as a function of the intervention performed, and 5) the utility correction (Uc; impairment of quality of life) for arm lymphedema. RESULTS The NNT method of analysis favored SND over nearly the entire range of parameters with a sign change to a negative value occurring only as Uc becomes very close to unity. This suggests the superiority of the SND approach. Only when there is minimal loss of utility does AND become favored and then only minimally. CONCLUSIONS Compared with AND, SND improves the utility-adjusted survival in patients with early-stage breast carcinoma. This finding is quite robust and was found to remain constant over a range of values for utility and lymph node prevalence.
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Affiliation(s)
- Ashesh B Jani
- Department of Radiation and Cellular Oncology, The University of Chicago, Chicago, Illinois 60637, USA
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