Sentinel Lymph Node Biopsy in Breast Cancer: A Clinical Review and Update

Role of Progesterone Receptor Level in Predicting Axillary Lymph Node Metastasis in Clinical T1-T2N0 Luminal Type Breast Cancer

Background and Objectives: Axillary lymph node metastasis and the number of metastatic lymph nodes are important prognostic factors which are directly related to overall survival in women with breast cancer. Several factors have been identified to predict the likelihood of axillary lymph node metastasis in early-stage breast cancer. High PR expression is often more prevalent in the luminal A subgroup, which is associated with a better prognosis. The aim of this study was to determine the relationship between the percentage of PR expression and the likelihood of axillary metastasis in Her-2-negative, clinical T1-T2N0 luminal type breast cancer. Materials and Methods: A hundred and ninety-nine cases with luminal type, Her-2-negative, clinically and radiologically axilla-negative T1-T2 breast cancer who received radiotherapy were evaluated retrospectively. The pathological specimens were assessed by an experienced pathologist. Results: The statistical evaluation showed that tumor diameter greater than 2 cm, (p = 0.003), presence of lymphovascular invasion (p = 0.001), and PR expression level below 80% (p = 0.037) were identified as significant predictors of lymph node positivity in breast cancer patients. Conclusions: Percentage of progesterone receptor expression along with other molecular biological markers and clinicopathological parameters should be evaluated altogether when predicting axillary metastasis risk before surgery.

Utilization of lymph node elastography in the axillary staging of breast cancer

Background

The differential diagnosis of lymphadenopathy is an important determinant of prognosis in patients with breast cancer (BC). Invasive, fine needle aspiration (FNA) biopsy has been long considered as the gold standard for differentiating malignant lymph nodes (LN) from benign ones. Ultrasonography (USG) evaluation is a useful, rapid, and user-friendly imaging tool for LN assessment due to its high resolution. Compared to USG, ultrasound elastography is a relatively novel non-invasive method to differentiate benign and malignant lesions based on the stiffness heterogeneity of the tissue. The purpose of our study was to compare non-invasive imaging techniques, conventional USG, and strain elastography, to differentiate benign and malignant LNs lesions in a cohort of patients with early BC.

Methods

In total, 50 patients (48 women and 2 men) with histologically confirmed early BC were evaluated by conventional USG in B-mode followed by strain elastography (using parameters: pattern, strain ratio, hue histogram) for assessment of axillary LNs status. The surgical treatment included surgery of regional LNs (sentinel LN biopsy or axillary dissection), which served as the gold standard in statistical processing.

Results

The USG B-mode was found to have a sensitivity of 68.75% and a specificity of 61.54%. Among strain elastography parameters, the elastographic pattern showed the highest specificity (66.67%) while the sensitivity was 83.3%. The strain ratio showed 100% sensitivity and 55.6% specificity, followed by a hue histogram with a sensitivity of 72.2%, but specificity was only 25.9%.

Conclusion

Despite promising data, monitored parameters currently cannot reliably replace sentinel LN biopsy. However, the monitored parameters represent an appropriate additional tool that can be used to refine preoperative staging, better targeting of FNA biopsy, and more accurate assessment of LNs in follow-up patients within the dispensary.

IFNγ-dependent metabolic reprogramming restrains an immature, pro-metastatic lymphatic state in melanoma

Lymphatic vessels play a crucial role in activating anti-tumor immune surveillance but also contribute to metastasis and systemic tumor progression. Whether distinct lymphatic phenotypes exist that govern the switch between immunity and metastasis remains unclear. Here we reveal that cytotoxic immunity normalizes lymphatic function and uncouples immune and metastatic potential. We find that in mice and humans, intratumoral lymphatic vessel density negatively correlates with productive cytotoxic immune responses and identify IFNγ as an intrinsic inhibitor of lymphangiogenesis. Specific deletion of the Ifngr1 in lymphatic endothelial cells (LECs) greatly expanded the intratumoral lymphatic network and drove the emergence of a tip-like endothelial state, promoting lymph node metastasis but not dendritic cell migration. IFNγ inhibits oxidative phosphorylation, which is required for proliferation and acquisition of the pathologic transcriptional state. Our data indicate that IFNγ induces a phenotypic switch in tumor-associated lymphatic vessels to reinforce canonical immune surveillance and block metastasis.

Sentinel Node Biopsy in Post-neoadjuvant Chemotherapy Breast Cancer Patients Using Pre-chemotherapy Breast Tattooing

The role of sentinel lymph node biopsy (SLNB) in locally advanced breast cancer (LABC) post-neoadjuvant chemotherapy (NACT) is debatable. We conducted a novel pilot study in which pre-NACT tattooing of breast lumps in LABC patients resulted in black tattoos being deposited in the axillary node. We hypothesized that this black node was the sentinel node. The identification rate (IR) of the black node in our pilot study was 100%, and the false-negative rate (FNR) was 0%. This study aims to evaluate our hypothesis that the black node is the sentinel node in post-NACT LABC patients after pre-NACT breast tattooing. This is a cross-sectional study of prospectively collected data of women with LABC undergoing surgery after NACT. Patients underwent tattooing of breast primarily using black tattoo ink prior to NACT. Women who progressed on NACT were excluded. All patients underwent axillary dissection. Intraoperatively identified black nodes were sent separately for pathological evaluation. The accuracy of the black nodes was assessed using IR and FNR. Of the 214 patients, a complete clinical response was present in 36%. Black node IR was 88.8% and FNR was 17.4%. In pre-NACT cN0 and cN1 patients, IR was 100% and 96.6%, and FNR was 0% and 4.63%, respectively. SLNB using pre-NACT tattooing in LABC patients has a high IR and FNR. In the subset with low pre-NACT axillary burden (cN0 or cN1), SLNB by pre-NACT breast tattooing has a high IR and low FNR.

An Updated Review on the Early Detection and Drug Development Targeting Breast Cancer

Background:

Breast cancer is one of the most common types of cancer in women globally, which poses a significant public health threat on a global scale. Continuous updates of the recent development in terms of drug development and diagnosis are the key to decoding the complexity of the location-specific different forms of breast cancer. The aim of this review is to sifter out the current advances and status of drugs, treatments, therapies and technologies related to breast cancer.

Methodology:

The authors searched for a number of article sources, and all possible data was collected from different databases like MEDLINE, EMBASE, Pub Med, Web of Science and Google Scholar. to identify recent development in drug development and diagnosis.

Result:

After a detailed literature survey, it was found that in drug discovery, a number of new drug candidates for breast cancer have completed clinical trials; in the diagnosis of breast cancer, a number of new technologies like artificial intelligence (AI), smart bra, smart vest, clinical breast exam have developed. It was found that breast self-awareness has immense importance in the early detection of breast cancer, which is par with the accuracy of modern diagnostic tools.

Conclusion:

An effort has been made to present all the updated data related to recent drug development, like surveillance status of drugs in clinical trials, diagnosis and social stigma of people with breast cancer recovery. Recent technological advances have led to the development of many devices for the early detection of breast cancer, providing efficacy in line with the diagnostic tools that pave the way for early treatment using effective drug candidates.

Lymphatic vessels in the age of cancer immunotherapy

Lymphatic transport maintains homeostatic health and is necessary for immune surveillance, and yet lymphatic growth is often associated with solid tumour development and dissemination. Although tumour-associated lymphatic remodelling and growth were initially presumed to simply expand a passive route for regional metastasis, emerging research puts lymphatic vessels and their active transport at the interface of metastasis, tumour-associated inflammation and systemic immune surveillance. Here, we discuss active mechanisms through which lymphatic vessels shape their transport function to influence peripheral tissue immunity and the current understanding of how tumour-associated lymphatic vessels may both augment and disrupt antitumour immune surveillance. We end by looking forward to emerging areas of interest in the field of cancer immunotherapy in which lymphatic vessels and their transport function are likely key players: the formation of tertiary lymphoid structures, immune surveillance in the central nervous system, the microbiome, obesity and ageing. The lessons learnt support a working framework that defines the lymphatic system as a key determinant of both local and systemic inflammatory networks and thereby a crucial player in the response to cancer immunotherapy.

Basal cell carcinomas of the areola-nipple complex: Case report and review of the literature

Basal cell carcinoma of the areola-nipple complex poses diagnostic and therapeutic challenges due to its rarity and unique anatomical location. This subtype of basal cell carcinoma necessitates meticulous management to address potential recurrence and metastasis. Surgical excision with clear margins remains the cornerstone treatment for basal cell carcinoma of the areola-nipple complex, while alternative modalities such as radiation therapy, Mohs surgery, and systemic therapies may be considered in specific cases. However, optimal management strategies remain contentious, with varying opinions on the necessity of aggressive surgical intervention to minimize recurrence and metastasis risks. Additionally, the absence of standardized diagnostic criteria and treatment guidelines complicates clinical decision-making. Herein, we present a rare case of basal cell carcinoma of the areola-nipple complex in a 47-year-old woman with a notable medical history of hypertension, type 2 diabetes, and untreated psychosis, alongside a family history of breast cancer in her aunt. The patient exhibited a non-regressing ulceration on the right areolar region of the breast, persisting for approximately 10 years and progressively extending over time. Following surgical excision, a favorable post-therapeutic course was observed during follow-up. This case underscores the diagnostic challenges and nuanced management considerations inherent in basal cell carcinoma of the areola-nipple complex, underscoring the imperative for tailored treatment approaches.

Comparison of Intraoperative Imprint Cytology versus Frozen Section for Sentinel Lymph Node Evaluation in Breast Cancer. A study along with Systematic Review and Meta-analysis of literature

BACKGROUND

Sentinel lymph node (SLN) is the first lymph node to drain the lymph from a particular region involved by cancer. The commonly performed intraoperative methods for SLN evaluation are touch imprint cytology (TIC) and frozen section (FS). The present study aimed to determine the sensitivity, specificity and accuracy of TIC and FS with histopathological diagnosis as gold standard.

MATERIALS AND METHODS

The nodes were bissected along their long axis and wet surface was imprinted on to clean glass slides followed by toluidine blue and rapid Papanicolaou staining. Subsequently the lymph node slices were cut at three levels using the cryostat machine and stained with Hematoxylin and eosin stain. The cytological and FS findings were compared and the specificity, sensitivity, accuracy, positive predictive value (PPV) and negative predictive value (NPV) of TIC and FS was evaluated taking histopathological diagnosis as gold standard. In addition, pooled sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy for touch imprint cytology and frozen section were assessed for the studies included in the meta-analysis.

RESULTS

The specificity, sensitivity, diagnostic accuracy, positive predictive value and negative predictive value of touch imprint cytology were 100%, 88.2%, 90%, 100% and 60% respectively. The specificity, sensitivity, diagnostic accuracy, PPV and NPV of frozen section were 100%, 94.1%, 95%, 100% and 75% respectively. The sensitivity of TIC and FS for detection of micrometastasis was 60% and 80% respectively. The pooled sensitivity and specificity for touch imprint cytology were 85.24% (95% CI, 83.46%-86.90%), and 98.99% (95% CI, 98.69%-99.23%) respectively. The pooled sensitivity and specificity for frozen section examination were 90.45% (95% CI, 85.15%-94.34%), and 100% (95% CI, 99.24%-100%) respectively.

CONCLUSION

Even though the sensitivity of FS was better than imprint cytology in detection of micrometastasis, TIC is a rapid inexpensive technique which can be utilized in remote areas in absence of cryostat machine. The sensitivity of the two techniques with respect to detection of macrometastasis was comparable. This meta-analysis highlights the accuracy of the touch imprint cytology and frozen section examination in the intra-operative detection of malignancy in breast cancer.

Advancements in Solid Lipid Nanoparticles and Nanostructured Lipid Carriers for Breast Cancer Therapy

Solid Lipid Nanocarriers (SLNs) offer a promising avenue for breast cancer treatment, a disease that accounts for 12.5% of global cancer cases. Despite strides in combined therapies (surgery, chemotherapy, radiation, and endocrine therapy), challenges like systemic toxicity, drug resistance, and adverse effects persist. The manuscript offers several novel contributions to the field of breast cancer treatment through the use of SLNs, and these are innovative drug delivery systems, multifunctionality, and biocompatibility, the potential to overcome drug resistance, integration with emerging therapies, focus on personalized medicine, ongoing and future research directions and potential for reduced side effects. SLNs present a novel strategy due to their unique physicochemical properties. They can encapsulate both hydrophilic and hydrophobic drugs, ensuring controlled release and targeted delivery, thus enhancing solubility and bioavailability and reducing side effects. The multifunctional nature of SLNs improves drug delivery while their biocompatibility supports their potential in cancer therapy. Challenges for pharmacists include maintaining stability, effective drug loading, and timed delivery. Combining SLNs with emerging therapies like gene and immunotherapy holds promise for more effective breast cancer treatments. SLNs represent a significant advancement, providing precise drug delivery and fewer side effects, with the potential for overcoming drug resistance. Ongoing research will refine SLNs for breast cancer therapy, targeting cells with minimal side effects and integrating with other treatments for comprehensive approaches. Advances in nanotechnology and personalized medicine will tailor SLNs to specific breast cancer subtypes, enhancing effectiveness. Clinical trials and new treatment developments are crucial for realizing SLNs' full potential in breast cancer care. In conclusion, SLNs offer a transformative approach to breast cancer treatment, addressing issues of drug delivery and side effects. Ongoing research aims to optimize SLNs for targeted therapy, potentially revolutionizing breast cancer care and providing hope for patients.

Factors Predictive of Positive Lymph Nodes for Breast Cancer

BACKGROUND

Axillary node status is an important prognostic factor in breast cancer. The primary aim was to evaluate tumor size and other characteristics relative to axillary disease.

MATERIALS AND METHODS

Single institution retrospective chart review of stage I-III breast cancer patients collected demographic and clinical/pathologic data from 1998-2019. Student's t-test, Chi-squared test (or Fisher exact test if applicable), and logistic regression models were used for testing the association of pN+ to predictive variables.

RESULTS

Of 728 patients (mean age 59 yrs) with mean follow up of 50 months, 86% were estrogen receptor +, 10% Her2+, 78% ER+HER2-negative, and 10% triple-negative. In total, 351/728 (48.2%) were pN+ and mean tumor size was larger in pN+ cases compared to pN- cases (mean = 27.7 mm versus 15.5 mm) (p < 0.001). By univariate analysis, pN+ was associated with lymphovascular invasion (LVI), higher grade, Her2, and histology (p < 0.005). Tumor-to-nipple distance was shorter in pN+ compared to pN- (45 mm v. 62 mm; p< 0.001). Age < 60, LVI, recurrence, mastectomy, larger tumor size, and shorter tumor-nipple distance were associated with 3+ positive nodes (p < 0.05).

CONCLUSIONS

Larger tumor size and shorter tumor-nipple distance were associated with higher lymph node positivity. Age less than 60, LVI, recurrence, mastectomy, larger tumor size, and shorter tumor-nipple distance were all associated with 3+ positive lymph nodes.

Evaluation of Dual Dye Technique for Sentinel Lymph Node Biopsy in Breast Cancer: Two-Arm Open-Label Parallel Design Non-Inferiority Randomized Controlled Trial

INTRODUCTION

Radioisotope and blue dye are standard agents for performing sentinel lymph node (SLN) biopsy in breast cancer. The paucity of nuclear medicine facility poses logistic challenge. This study evaluated performance of radioisotope & methylene blue (MB) with indocyanine green (ICG) and MB for SLNB.

PATIENTS AND METHODS

This randomized controlled trial was conducted from December 2019 to July 2022 comparing SLN identification proportions of radioisotope-blue dye [Group A] with dual dye (MB + ICG; Group B]. Secondary objective included time required and cost effectiveness of performing SLNB. Sample size of 70 (35 in each arm) was calculated. Upfront operable node negative early breast cancer was included in the study. Clinico-demographic data, number & type of SLN, time taken were noted. Cost analysis was done including the equipment, manpower & consumables. Chi-square/Fisher exact test was used to compare proportion between two groups. p value of less than 0.05 was considered to represent statistical significance.

RESULTS

Seventy patients randomized to either group were similar in clinico-demographic and tumor characteristics. SLN identification rate (IR) was 91.43% in group A and 100% in group B. Overall IR of MB, radioisotope and ICG were 91.43%, 91.43% and 100%, respectively. Mean number of SLNs identified were 3 in group A and 4 in group B. Median time required for SLNB was 12 min and 14 min in either group, respectively. Cost of performing SLNB was higher in Group B.

CONCLUSION

SLNB using dual dye is non-inferior to radioisotope-blue dye in upfront operable early breast cancer. Trial registration number Clinical Trial registry India CTRI/2020/02/023503.

An adapted protocol for magnetic localisation of nonpalpable breast cancer lesions and sentinel lymph nodes using a magnetic seed and superparamagnetic iron oxide tracer

BACKGROUND

Localisation techniques for nonpalpable breast cancer lesions and sentinel lymph node biopsy (SLNB) are associated with several drawbacks. A complete magnetic technique using magnetic seeds and superparamagnetic iron oxide tracer could be an interesting alternative. This study describes a clear protocol and the results of a combined magnetic approach.

METHODS

From August 2021 to February 2022 40 patients undergoing breast conserving surgery with SLNB were eligible for inclusion. Localisation was performed under ultrasound or stereotactic guidance, 1 week before surgery. Subsequently, 1 ml of tracer was injected at least 4 cm away from the tumour. Technetium-99m (^99m Tc) was injected 1 day before surgery as control procedure. Outcomes were SLNB time, a number of nodes detected with magnetic tracer including comparison with ^99m Tc, a success rate of malignant lesion detection and pathological margin assessment.

RESULTS

In total, 40 procedures were performed on 39 patients. A median of one node was retrieved. Sentinel nodes were retrieved using MagTrace® with a 92.5% detection rate compared to ^99m Tc. Wide local excision under magnetic guidance was successful in 35 cases.

CONCLUSIONS

This paper describes a combined magnetic approach for breast-conserving surgery and SLNB. An adapted protocol is described and could be used for implementation.

Evaluating the Necessity for Routine Sentinel Lymph Node Biopsy in Postmenopausal Patients Being Treated for Clinically Node Negative Breast Cancer the Era of RxPONDER

INTRODUCTION

Traditionally, sentinel lymph node biopsy (SLNB) was performed to inform adjuvant chemotherapy prescription and prognosis in breast cancer. Following RxPONDER, the OncotypeDX Recurrence Score (RS) guides adjuvant chemotherapy prescription for all postmenopausal patients with estrogen receptor positive, human epidermal growth factor receptor-2 negative (ER+/HER2-) breast cancer with 0 to 3 positive lymph nodes (0-3 + LN).

AIMS

To establish the oncological safety of omitting SLNB in postmenopausal patients with ER+/HER2- breast cancer indicated to undergo SLNB and to evaluate the primary determinants of chemotherapy prescription for these patients.

PATIENTS AND METHODS

A retrospective cohort study was undertaken. Cox regression and Kaplan-Meier analyses were performed. Data analytics was performed using SPSS v26.0.

RESULTS

Five hundred and seventy five consecutive patients were included (mean age: 66.5 years, range: 45-96). The median follow-up was 97.2 months (range: 3.0-181.6). Of the 575 patients, just 12 patients had positive SLNB (SLNB+) (2.1%). Using Kaplan-Meier analyses, SLNB+ failed to impact recurrence (P = .766) or mortality (P = .310). However, using Cox regression analyses, SLNB+ independently predicted poorer disease-free survival (hazard ratio: 1.001, 95% confidence interval (95% CI): 1.000-1.001, P = .029). Logistic regression analysis identified RS as the sole predictor of chemotherapy prescription (odds ratio: 1.171, 95% CI: 1.097-1.250, P < .001).

CONCLUSION

Omitting SLNB may be safe and justifiable in postmenopausal patients with ER+/HER2- breast cancer with clinically negative axillae. Following RxPONDER, RS is the most important guide of chemotherapy use in these patients and SLNB may be less important than previously perceived. Prospective, randomized clinical trials are required to fully establish the oncological safety of omitting SLNB in this setting.

Is Sentinel Lymph Node Biopsy Necessary in Patients who Undergo Prophylactic Mastectomy?

BACKGROUND

Over the last decade, rates of risk-reducing prophylactic mastectomy (PM) have risen dramatically. A topic of debate regarding the procedure is whether to use sentinel lymph node biopsy (SLNB) at the time of PM and what factors might predict for such need. In order to assess the rate of identifying presence of occult invasive breast cancer in the PM specimen, we performed a retrospective review of the pathology findings from a single-surgeon case-series of PM.

METHODS

Patients undergoing PM between January 2013 and June 2019 at Orlando Health Cancer Institute were identified for a retrospective chart review. Demographic, clinical, and histopathological data from the surgical procedure were collected and analyzed for the incidence of occult invasive breast cancer in the PM specimen.

RESULTS

A total of 146 consecutive patients with PM were identified; 120 (82.2%) underwent contralateral PM (CPM) and 26 (17.8%) underwent bilateral PM (BPM). Final pathology of the 172 PM specimens identified 4 (3.3%) with lobular carcinoma in situ, 3 (2.5%) with atypical ductal hyperplasia, and 2 (1.7%) with atypical lobular hyperplasia and 2 (1.7%) with intraductal papilloma. No invasive malignancy was detected in any of the 172 PM specimens.

CONCLUSIONS

The absence of occult invasive carcinoma in 172 consecutive PM specimens suggests a limited clinical utility in routinely performing SLNB in this setting. This study also suggests that use of preoperative breast MRI imaging could offer a potential non-invasive tool to detect occult malignancy and select patients who can safely undergo omission of SLNB at the time of PM.

Phosphorylcholine-conjugated gold-molecular clusters improve signal for Lymph Node NIR-II fluorescence imaging in preclinical cancer models

Sentinel lymph node imaging and biopsy is important to clinical assessment of cancer metastasis, and novel non-radioactive lymphographic tracers have been actively pursued over the years. Here, we develop gold molecular clusters (Au₂₅) functionalized by phosphorylcholine (PC) ligands for NIR-II (1000–3000 nm) fluorescence imaging of draining lymph nodes in 4T1 murine breast cancer and CT26 colon cancer tumor mouse models. The Au-phosphorylcholine (Au-PC) probes exhibit ‘super-stealth’ behavior with little interactions with serum proteins, cells and tissues in vivo, which differs from the indocyanine green (ICG) dye. Subcutaneous injection of Au-PC allows lymph node mapping by NIR-II fluorescence imaging at an optimal time of ~ 0.5 − 1 hour postinjection followed by rapid renal clearance. Preclinical NIR-II fluorescence LN imaging with Au-PC affords high signal to background ratios and high safety and biocompatibility, promising for future clinical translation.

Fluorescent tracers facilitate the identification and subsequent collection of tumour draining lymph node biopsies, enabling important clinical assessment. Here, the authors present a molecular gold nanocluster NIR-II fluorescent imaging probe and demonstrate its utility to visualise draining lymph nodes in breast and colon cancer mouse models.

Is Routine Intraoperative Frozen Section Analysis of Sentinel Lymph Nodes Necessary in Every Early-Stage Breast Cancer?

Purpose

Clinical application of the ACOSOG Z0011 trial results allows clinically node-negative breast cancer patients who meet criteria to avoid axillary dissection even when 1–2 sentinel lymph nodes (SLNs) are positive for metastatic disease. Intraoperative frozen section (iFS) analyses of SLNs were thought to reduce re-operation rates despite variable reported sensitivity and possibility of a false negative result. This study evaluated the rate of re-operations prevented by SLN iFS in a tertiary care hospital in Bangkok, Thailand, over a 6-year time-frame.

Patients and Methods

From April 2016 to April 2022, 1284 sentinel lymph node biopsy (SLNB) procedures were performed. Of these, 214 cases were breast-conserving surgery in accordance with the ACOSOG criteria with concomitant usage of iFS. Clinicopathological features of these cases were collected and analyzed. Re-operation rates prevented by the additional intervention were reported.

Results

Only five additional operations were prevented with the usage of 214 iFS. The discordance rate between frozen and permanent sections in terms of presence of metastatic disease and number of total lymph nodes was around 15%. Tumor staging, node staging, Nottingham histologic grading and lymphovascular invasion are significant predictors of SLN metastasis.

Conclusion

iFS results in a very low prevention rate for follow-up ALND in patients with preoperative clinically negative axillary nodes and is associated with a non-negligible discordance rate with permanent sections. Our study suggests iFS may be avoided in most cases of early-stage clinically and radiographically node-negative breast cancer patients. Doing so may reduce surgical costs and total operative time without a significant impact on the overall quality of treatment and standard of care.

Overuse of Axillary Surgery in Patients with Ductal Carcinoma In Situ: Opportunity for De-escalation

BACKGROUND

Ductal carcinoma in situ (DCIS) is noninvasive breast cancer and therefore nodal staging is not routinely recommended. We evaluated the use of and factors associated with axillary surgery in DCIS in the National Cancer Database (NCDB).

METHODS

DCIS cases were identified from the NCDB 2012-2018. Use of axillary surgery was evaluated over time, and factors associated with axillary surgery were assessed for breast-conserving surgery (BCS) and mastectomy groups.

RESULTS

We identified 178,762 patients, median age of 60 years. Majority of DCIS (87%) was ER-positive, and 14% low, 43% intermediate, and 44% high grade. Median DCIS size was 1.1 cm. BCS was performed in 72%, whereas 28% had mastectomy. Overall axillary surgery was performed in 38% and was higher in patients undergoing mastectomy compared with patients undergoing BCS (88% vs. 19%, p < 0.001). At axillary surgery, the vast majority (92%) had 1-5 nodes examined, whereas 8% had >5 nodes examined. Over time, axillary surgery decreased in BCS patients (21% in 2012 to 17% in 2018, p < 0.001) but increased slightly in mastectomy patients (86% in 2012 to 90% in 2018, p < 0.001). On multivariable analysis, factors significantly associated with axillary surgery were younger patient age, larger tumor size, higher grade, and ER-negative status.

CONCLUSIONS

Factors associated with axillary surgery reflect higher risk disease for upstage to invasive cancer, indicating surgeon judgment. However, despite axillary surgery being overtreatment of DCIS, it is common in mastectomy and is performed for one in five patients undergoing BCS. This provides opportunity for improvement in breast cancer care delivery.

Budget impact analysis of HARMONIC FOCUS™+ Shears for mastectomy and breast-conserving surgery with axillary lymph node dissection compared with monopolar electrocautery from an Italian hospital perspective

Background

Mastectomy or breast conserving surgery, both with axillary lymph node dissection, are common treatments for early-stage breast cancer. Monopolar electrocautery is typically used for both procedures, despite evidence of improved clinical outcomes with HARMONIC FOCUS™+. This analysis evaluated the budget impact of adopting HARMONIC FOCUS™+ versus monopolar electrocautery for patients undergoing these procedures from an Italian hospital perspective.

Methods

Total costs for an annual caseload of 100 patients undergoing mastectomy or breast conserving surgery, with axillary lymph node dissection, with either the intervention or comparator were calculated. Italian clinical and cost input data were utilised. The analysis included costs for the device, operating room time, postoperative length of stay, treating seroma and managing postoperative chest wall drainage. Deterministic and probabilistic sensitivity analyses assessed uncertainty of model input values. Two scenario analyses investigated the impact of conservative estimates of postoperative length of stay reduction and daily hospital cost on the simulated cost difference.

Results

HARMONIC FOCUS™+ achieves annual savings of EUR 100,043 compared with monopolar electrocautery, derived from lower costs for operating room time, postoperative length of stay and seroma and postoperative chest wall drainage management, offsetting the incremental device cost increase (EUR 43,268). Cost savings are maintained in scenario analyses and across all variations in parameters in deterministic sensitivity analysis, with postoperative hospital stay costs being key drivers of budget impact. The mean (interquartile range) cost savings with HARMONIC FOCUS™+ versus monopolar electrocautery in probabilistic sensitivity analysis are EUR 101,637 (EUR 64,390–137,093) with a 98% probability of being cost saving.

Conclusions

The intervention demonstrates robust cost savings compared with monopolar electrocautery for mastectomy or breast conserving surgery, with axillary lymph node dissection, in an Italian hospital setting, and improved clinical and resource outcomes. These findings, with other clinical and cost analyses, support HARMONIC FOCUS™+ use in this setting.

Methylene Blue Near-Infrared Fluorescence Imaging in Breast Cancer Sentinel Node Biopsy

INTRODUCTION

Fluorescence-based navigation for breast cancer sentinel node biopsy is a novel method that uses indocyanine green as a fluorophore. However, methylene blue (MB) also has some fluorescent properties. This study is the first in a clinical series presenting the possible use of MB as a fluorescent dye for the identification of sentinel nodes in breast sentinel node biopsy.

MATERIAL AND METHODS

Forty-nine patients with breast cancer who underwent sentinel node biopsy procedures were enrolled in the study. All patients underwent standard simultaneous injection of nanocolloid and MB. We visualized and assessed the sentinel nodes and the lymphatic channels transcutaneously, with and without fluorescence, and calculated the signal-to-background ratio (SBR). We also analyzed the corresponding fluorescence intensity of various dilutions of MB.

RESULTS

In twenty-three patients (46.9%), the location of the sentinel node, or the end of the lymphatic path, was visible transcutaneously. The median SBR for transcutaneous sentinel node location was 1.69 (range 1.66-4.35). Lymphatic channels were visible under fluorescence in 14 patients (28.6%) prior to visualization by the naked eye, with an average SBR of 2.01 (range 1.14-5.6). The sentinel node was visible under fluorescence in 25 patients (51%). The median SBR for sentinel node visualization with MB fluorescence was 2.54 (range 1.34-6.86). Sentinel nodes were visualized faster under fluorescence during sentinel node preparation. Factors associated with the rate of visualization included diabetes (p = 0.001), neoadjuvant chemotherapy (p = 0.003), and multifocality (p = 0.004). The best fluorescence was obtained using 40 μM (0.0128 mg/mL) MB, but we also observed a clinically relevant dilution range between 20 μM (0.0064 mg/mL) and 100 μM (0.032 mg/mL).

CONCLUSIONS

For the first time, we propose the clinical usage of MB as a fluorophore for fluorescence-guided sentinel node biopsy in breast cancer patients. The quenching effect of the dye may be the reason for its poor detection rate. Our analysis of different concentrations of MB suggests a need for a detailed clinical analysis to highlight the practical usefulness of the dye.

Sentinel Lymph Node Biopsy in Breast Cancer Patients With Pathological Complete Response in the Axillary Lymph Node After Neoadjuvant Chemotherapy

Purpose

Sentinel lymph node biopsy (SLNB) alone following neoadjuvant chemotherapy (NAC) remains controversial in patients with breast cancer who are initially lymph node-positive. The present study aimed to evaluate the impact of SLNB and axillary lymph node dissection (ALND) on breast cancer recurrence and survival in patients who converted from lymph node-positive to pathological node-negative (ypN0) after NAC.

Methods

This single-center retrospective study included 223 patients who converted to axillary lymph node-negative status after NAC and underwent breast and axillary surgery between January 2006 and December 2015. This study compared the overall survival (OS), disease-free survival (DFS), ipsilateral axillary lymph node recurrence rates and incidence of postoperative complications, especially, arm lymphedema and shoulder stiffness between SLNB and ALND.

Results

This study included 223 patients with axillary pathological complete response (pCR) after NAC and surgery. The SLNB and ALND groups included 94 and 129 patients, respectively. The median follow-up time was 57 (range, 6–155) in the SLNB group and 99 (range 2–159) months in the ALND group. The corresponding 5-year OS and DFS rates were 96.3% and 94.2% (p = 0.392), and 89.2% and 86.4% (p = 0.671), respectively. Four patients (4.3%) in the SLNB group and nine (7.0%) in the ALND group developed locoregional recurrences. Ipsilateral axillary lymph node recurrence and distant metastasis were observed in one (1.1%) and three (2.3%) patients, and in 10 (10.6%) and 11 (8.5%) patients, respectively. Patients in the ALND group were more likely than their SLNB counterparts to experience complications, such as shoulder stiffness (9 [7.0%] vs. 4 [4.3%] patients, p = 0.57). The rate of lymphedema in the ALND group was three times that in the SLNB group (35 [27.1%] vs. 8 [8.5%] patients, p < 0.001).

Conclusion

As an alternative to ALND, SLNB has oncological safety in patients with axillary pathological complete response after NAC.

The Role of US in Depicting Axillary Metastasis in High-Risk Breast Cancer Patients

Purpose: The aim of this study is to evaluate the role of US in depicting axillary nodal disease in high-risk patients with and without pathogenic mutations. Methods: The retrospective study included consecutive high-risk breast cancer (BC) patients who underwent a multigene testing panel for hereditary cancers, pre-operative axillary US and breast/axillary surgery. The group was divided into patients with pathogenic mutations (PM group) and patients without PM. Statistical analyses were performed using GraphPad Prism by applying Chi-square and Fisher exact tests, with a reference p-value < 0.05 and a CI of 95%. Results: Out of 190 patients with BC, 96 (51%) were negative and 94 (49%) were positive for PM as follows: 28 (25.5%) BRCA1, 16 (17%) BRCA2, 15 (16%) CHECK2, 14 (14%) RAD Group, 7 (7%) PALB, 6 (6%) NBN, 3 (3%) TP53 and ATM and 2 (2%) BARD1. US was positive in 88 of the patients, 36 with PM and 52 without PM. US and surgery (≥N1 stage) were both positive in 31 (62%) of PM patients and 44 (88%) of patients without genetic changes. There were 19 (61%) false negative US examinations in the PM group and 6 (13%) in the group without genetic changes, respectively. If the US is positive, there is a 2.6 times greater risk of positive nodes in PM patients (p-value < 0.000, 95% CI = 4.2–37.9), and a 6.2 times greater risk of positive nodes in patients without genetic changes (p-value < 0.000, 95%CI = 8.4–37.4). In the PM group, US compared to surgery reached a sensitivity = 62, with PPV = 86 and NPV = 67. In the BRCA1/2 subgroup, there is 2.5 greater times risk of nodal disease if the US is positive (p-value = 0.001, 95%CI = 2.6–76). In patients without PM, US compared to surgery reached a sensitivity = 88, PPV = 84 and NPV = 86. Conclusion: US is more sensitive in depicting axillary nodal disease in high-risk patients without PM compared to PM patients. Furthermore, there are more false negative US examinations in PM patients, compared to surgery patients.

High-resolution three-dimensional imaging for precise staging in melanoma

INTRODUCTION

Many cancer guidelines include sentinel lymph node (SLN) staging to identify microscopic metastatic disease. Current SLN analysis of melanoma patients is effective but has the substantial drawback that only a small representative portion of the node is sampled, whereas most of the tissue is discarded. This might explain the high clinical false-negative rate of current SLN diagnosis in melanoma. Furthermore, the quantitative assessment of metastatic load and microanatomical localisation might yield prognosis with higher precision. Thus, methods to analyse entire SLNs with cellular resolution apart from tedious sequential physical sectioning are required.

PATIENTS AND METHODS

Eleven melanoma patients eligible to undergo SLN biopsy were included in this prospective study. SLNs were fixed, optically cleared, whole-mount stained and imaged using light sheet fluorescence microscopy (LSFM). Subsequently, compatible and unbiased gold standard histopathological assessment allowed regular patient staging. This enabled intrasample comparison of LSFM and histological findings. In addition, the development of an algorithm, RAYhance, enabled easy-to-handle display of LSFM data in a browsable histologic slide-like fashion.

RESULTS

We comprehensively quantify total tumour volume while simultaneously visualising cellular and anatomical hallmarks of the associated SLN architecture. In a first-in-human study of 21 SLN of melanoma patients, LSFM not only confirmed all metastases identified by routine histopathological assessment but also additionally revealed metastases not detected by routine histology alone. This already led to additional therapeutic options for one patient.

CONCLUSION

Our three-dimensional digital pathology approach can increase sensitivity and accuracy of SLN metastasis detection and potentially alleviate the need for conventional histopathological assessment in the future. GERMAN CLINICAL TRIALS REGISTER: (DRKS00015737).

Sentinel lymph node mapping with patent blue dye in patients with breast cancer: a retrospective single institution study

Background

Since the end of the last century, sentinel lymph node biopsy (SLNB) has replaced axillary lymph node dissection (ALND) as standard of care for axillary staging in early breast cancer in patients without any clinical sign of axillary lymph node infiltration. The worldwide most frequently used mapping method consists in the injection of radioactive technetium-99 isotope alone or in combination with blue dye. As a specific infrastructure and dedicated personnel are needed for the use of a radioactive tracer, the CHC in Liege (Belgium) decided to test the use of patent blue dye alone to detect sentinel lymph nodes in a large consecutive cohort of patients and compared the results with radioactive mapping methods and guidelines recommendations.

Methods

Patent blue dye was used in 456 consecutive patients with early breast cancer who underwent conservative breast cancer surgery or radical mastectomy between 1/1/2000 and 31/12/2007 in a community hospital (CHC Liège, Belgium). After SLNB, an ALND was performed in each patient.

Results

Sentinel lymph nodes were identified in 444 patients among the 456 patients evaluated by this mapping method during this time period, which represents a detection rate of 97.4%. Infiltrated lymph nodes were detected in 32.7% of patients (149/456) while in the 444 patients with sentinel lymph nodes identified and resected, 137 patients have at last one positive lymph node (30.9%). The false negative rate was 4.9% and the predictive negative value was 97.7% with the blue dye mapping method.

Conclusions

In addition of the simplicity of the method and the large economic advantage, SNLB using blue dye alone showed a quite acceptable performance in our retrospective analysis concerning its ability to find the SLN as well as its reliability to remove the good ones.

Diagnostic Performance of Indocyanine Green Plus Methylene Blue Versus Radioisotope Plus Methylene Blue Dye Method for Sentinel Lymph Node Biopsy in Node-Negative Early Breast Cancer

PURPOSE

Sentinel lymph node biopsy (SLNB) by dual-dye method (radioisotope plus blue) is the gold standard for axillary staging in patients with breast cancer, but in developing countries, logistic issues and financial constraint play a vital role. Recently, indocyanine green (ICG) has emerged as an alternative to radioisotope (technetium-99 [Tc-99]) for SLNB in breast cancer. This study compared the diagnostic performance of Tc-99 plus methylene blue (MB) dye versus ICG + MB dye SLNB.

METHODS

Two hundred seven patients with early breast cancer (T1-3N0) were included in the study from 2017 to 2019. SLNB was done either with Tc-99 + MB or with ICG + MB as per availability of radioisotope. SLN identification rate (IR), SLN positivity rate, and metastatic SLN counts were compared between the 2 groups.

RESULTS

IR was 199 (96%) of 207. IR was 95% in Tc-99 + MB compared with 97% with ICG + MB. The mean number of SLNs identified were 3.17 (standard deviation [SD], 1.84), with > 1 SLN identified in 87% patients by Tc-99 + MB. SLN was positive in 31.3% of patients with a metastatic SLN count of 0.37 (SD, 0.76). With ICG + MB, the number of SLNs was 2.73 (SD, 1.55), with > 1 SLN identified in 79% of patients. Twenty-eight percent of patients had positive SLNs, with a metastatic SLN count of 0.41 (SD, 0.77). A sharp decline in the availability of Tc-99 was observed, with 58% of patients in 2014 and only 12% of patients in 2018.

CONCLUSION

ICG is equivalent to Tc-99 for SLNB in early breast cancer and has a good potential to be adopted by surgeons in resource-constrained setups.

A panel of miRNAs as prognostic markers for African-American patients with triple negative breast cancer

BACKGROUND

To investigate the global expression profile of miRNAs, their impact on cellular signaling pathways, and their association with poor prognostic parameters in African-American (AA) patients with triple negative breast cancer (TNBC).

METHODS

Twenty-five samples of AA TNBC patients were profiled for global miRNA expression and stratified considering three clinical-pathological parameters: tumor size, lymph node (LN), and recurrence (REC) status. Differential miRNA expression analysis was performed for each parameter, and their discriminatory power was determined by Receiver Operating Characteristic (ROC) curve analysis. KMplotter was assessed to determine the association of the miRNAs with survival, and functional enrichment analysis to determine the main affected pathways and miRNA/mRNA target interactions.

RESULTS

A panel of eight, 23 and 27 miRNAs were associated with tumor size, LN, and REC status, respectively. Combined ROC analysis of two (miR-2117, and miR-378c), seven (let-7f-5p, miR-1255b-5p, miR-1268b, miR-200c-3p, miR-520d, miR-527, and miR-518a-5p), and three (miR-1200, miR-1249-3p, and miR-1271-3p) miRNAs showed a robust discriminatory power based on tumor size (AUC = 0.917), LN (AUC = 0.945) and REC (AUC = 0.981) status, respectively. Enrichment pathway analysis revealed their involvement in proteoglycans and glycan and cancer-associated pathways. Eight miRNAs with deregulated expressions in patients with large tumor size, positive LN metastasis, and recurrence were significantly associated with lower survival rates. Finally, the construction of miRNA/mRNA networks based in experimentally validated mRNA targets, revealed nodes of critical cancer genes, such as AKT1, BCL2, CDKN1A, EZR and PTEN.

CONCLUSIONS

Altogether, our data indicate that miRNA deregulated expression is a relevant biological factor that can be associated with the poor prognosis in TNBC of AA patients, by conferring to their TNBC cells aggressive phenotypes that are reflected in the clinical characteristics evaluated in this study.

Convolutional Neural Network of Multiparametric MRI Accurately Detects Axillary Lymph Node Metastasis in Breast Cancer Patients With Pre Neoadjuvant Chemotherapy

BACKGROUND

Accurate assessment of the axillary lymph nodes (aLNs) in breast cancer patients is essential for prognosis and treatment planning. Current radiological staging of nodal metastasis has poor accuracy. This study aimed to investigate the machine learning convolutional neural networks (CNNs) on multiparametric MRI to detect nodal metastasis with 18FDG-PET as ground truths.

MATERIALS AND METHODS

Data were obtained via a retrospective search. Inclusion criteria were patients with bilateral breast MRI and 18FDG-PETand/or CT scans obtained before neoadjuvant chemotherapy. In total, 238 aLNs were obtained from 56 breast cancer patients with 18FDG-PET and/or CT and breast MRI data. Radiologists scored each node based on all MRI as diseased and non-diseased nodes. Five models were built using T1-W MRI, T2-W MRI, DCE MRI, T1-W + T2-W MRI, and DCE + T2-W MRI model. Performance was evaluated using receiver operating curve (ROC) analysis, including area under the curve (AUC).

RESULTS

All CNN models yielded similar performance with an accuracy ranging from 86.08% to 88.50% and AUC ranging from 0.804 to 0.882. The CNN model using T1-W MRI performed better than that using T2-W MRI in detecting nodal metastasis. CNN model using combined T1- and T2-W MRI performed the best compared to all other models (accuracy = 88.50%, AUC = 0.882), but similar in AUC to the DCE + T2-W MRI model (accuracy = 88.02%, AUC = 0.880). All CNN models performed better than radiologists in detecting nodal metastasis (accuracy = 65.8%).

CONCLUSION

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Automated and rapid detection of cancer in suspicious axillary lymph nodes in patients with breast cancer

Preoperative staging of suspicious axillary lymph nodes (ALNs) allows patients to be triaged to ALN dissection or to sentinel lymph node biopsy (SLNB). Ultrasound-guided fine needle aspiration (FNA) and cytology of ALN is moderately sensitive but its clinical utility relies heavily on the cytologist's experience. We proposed that the 5-h automated GeneXpert system-based prototype breast cancer detection assay (BCDA) that quantitatively measures DNA methylation in ten tumor-specific gene markers could provide a facile, accurate test for detecting cancer in FNA of enlarged lymph nodes. We validated the assay in ALN-FNA samples from a prospective study of patients (N = 230) undergoing SLNB. In a blinded analysis of 218 evaluable LN-FNAs from 108 malignant and 110 benign LNs by histology, BCDA displayed a sensitivity of 90.7% and specificity of 99.1%, achieving an area under the ROC curve, AUC of 0.958 (95% CI: 0.928-0.989; P < 0.0001). Next, we conducted a study of archival FNAs of ipsilateral palpable LNs (malignant, N = 72, benign, N = 53 by cytology) collected in the outpatient setting prior to neoadjuvant chemotherapy (NAC). Using the ROC-threshold determined in the prospective study, compared to cytology, BCDA achieved a sensitivity of 94.4% and a specificity of 92.5% with a ROC-AUC = 0.977 (95% CI: 0.953-1.000; P < 0.0001). Our study shows that the automated assay detects cancer in suspicious lymph nodes with a high level of accuracy within 5 h. This cancer detection assay, scalable for analysis to scores of LN FNAs, could assist in determining eligibility of patients to different treatment regimens.

Value of the Sentinel Node Procedure in Pediatric Extremity Rhabdomyosarcoma: A Systematic Review and Retrospective Cohort Study

Background

Our aim is to show whether the sentinel node procedure (SNP) is recommendable for pediatric patients with extremity rhabdomyosarcoma (RMS). Lymph node metastases are an important prognostic factor in pediatric patients with extremity RMS. Accurate nodal staging is necessary to treat the patient accordingly. An alternative to the current recommended lymph node sampling is the sentinel node procedure (SNP).

Methods

A systematic review was performed summarizing all published cases of SNP in addition to 13 cases from our hospital and 8 cases from two other hospitals that have not been published before.

Results

For all patients (n = 55), at least one SLN was identified, but the SNP technique used was not uniform. The SNP changed the nodal classification of eight patients (17.0%) and had a false-negative rate of 10.5%.

Conclusions

The SNP is recommendable for pediatric patients with extremity RMS. It can change lymph node status and can be used to sample patients in a more targeted way than nodal sampling alone. Therefore, we recommend use of the SNP in addition to clinical and radiological nodal assessment for pediatric patients with extremity RMS.

The impact of breast cancer surgery on functional status in older women - A systematic review of the literature

Primary endocrine therapy as treatment of breast cancer is only recommended in older women with limited life expectancy. However, many older women opt for endocrine therapy due to concerns regarding frailty and potential decline in function after surgery. A decline in functional status after surgery is documented in some cancer types, such as colorectal, however, the full impact of breast cancer surgery is less understood. A systematic review was performed to examine the evidence for impact of breast cancer surgery on functional status in older women. PubMed and Embase databases were searched. Studies were eligible if performed within the last 10 years; included patients over the age of 65 years undergoing breast cancer surgery; included stratification of results by age; measured functional status pre-operatively and at least six months following surgery. A total of 11 studies including 12 030 women were appraised. Two studies represented level-II and nine level-IV evidence. Overall, physical activity level was negatively impacted by breast cancer surgery and this was compounded by the extent of surgery. Evidence for impact of breast cancer surgery on quality of life, fatigue and cognition, was conflicting. The possibility of decline in functional status after breast cancer surgery should be discussed in all older women considering surgery. A structured exercise program may improve the negative effects of surgery on physical activity. Further work is required in the areas of quality of life, fatigability and cognition.

Comparing scraping cytology with touch imprint cytology and frozen section analysis in the intraoperative diagnosis of sentinel lymph node metastasis in breast cancer

BACKGROUND

Breast cancer is a common cancer in the female population. Sentinel lymph node (SLN) in breast cancer patients can be evaluated by different methods including intraoperative frozen section analysis (FSA), touch imprint cytology (TIC), and scraping cytology (SC). In this study, in addition to investigating TIC and FSA, we focused on SC to evaluate the diagnostic value of this almost new method.

MATERIALS AND METHODS

In this retrospective study, the quadrantectomy and sentinel lymph node resection of 150 specimens with mammography and core needle biopsy-confirmed breast cancer were examined. Of the 150 participants, 77 and 73 had negative and positive results for the permanent pathology of SLN metastasis, respectively. Intra-operative FSA, TIC, and SC for SLN were performed for the patients and all were confirmed by permanent pathology.

RESULTS

All the specimens were taken from females aged between 25 and 82 years. The sensitivity and specificity of TIC, FS, and SC were 73% and 50%, 92.6% and 50%, and 92.1% and 50%, respectively. Among the three techniques, TIC had the lowest positive and negative predictive values. However, FS had the highest positive predictive value whereas SC had the highest negative predictive value.

CONCLUSION

In addition to FS and TIC as rapid, cost-effective, and reliable diagnostic methods in SLN metastasis, SC is an acceptable and highly sensitive method. A combination of these methods may provide a more favorable diagnostic value for SLN assessment in breast cancer patients.

Moving beyond the stage: how characteristics at diagnosis dictate treatment and treatment-related quality of life year losses for women with early stage invasive breast cancer

Background:Although evaluations of breast cancer screening programs frequently estimate quality-adjusted life-year (QALY) losses by stage, other breast cancer characteristics influence treatment and vary by mode of detection - i.e. whether the cancer is detected through screening (screen-detected), between screening rounds (interval-detected) or outside screening (community-detected). Here, we estimate the association between early-stage invasive breast cancer (ESIBC) characteristics and treatment-related QALY losses.Methods:Using clinicopathological and treatment information from 675 women managed for ESIBC, we estimated the average five-year treatment-related QALY loss by detection group. We then used regression analysis to estimate the extent to which known cancer characteristics and the detection mode, are associated with treatment and treatment-related QALY losses.Results:Community-detected cancers had the largest QALY loss (0.76 QALYs [95% CI 0.73;0.80]), followed by interval-detected cancers (0.75 QALYs [95% CI 0.68;0.82]) and screen-detected cancers (0.69 QALYs [95%CI 0.67;0.71]). Adverse prognostic factors more common in community-detected and interval-detected breast cancers (large tumours, lymph node involvement, high grade) were largely associated with QALY losses from mastectomies and chemotherapy. Receptor-positive subtypes, more common in screen-detected cancers, were associated with QALY losses related to endocrine therapy.Conclusions:The associations between ESIBC characteristics and treatment-related QALY losses should be considered when evaluating breast cancer screening and treatment strategies.

Early Physical Rehabilitation after Sentinel Lymph Node Biopsy in Breast Cancer: Is It Feasible and Safe?

The primary purpose of this research was to investigate the feasibility and safety of delivering an early supervised physical therapy intervention to women after sentinel lymph node biopsy (SLNB); furthermore, we aimed to provide explorative data on its effects. This was a single-site feasibility study. Pre- and post-evaluation was conducted from baseline to follow-up at 6 months. Primary outcomes were participant recruitment, participant retention, compliance with the intervention, and safety. Secondary outcomes were shoulder range of motion, handgrip strength, upper limb pain and disability, scar recovery, quality of life, and the incidence of axillary web syndrome (AWS) and/or lymphoedema. A total of 43 participants (mean age 55.37 years) completed the trial and the follow-up period. A total of 91% of women who met the inclusion criteria agreed to participate, and the adherence rate was 80%. No adverse events were reported. Incidence of AWS was 9.3%, and there was no incidence of lymphoedema at 6 months. Our results support that this intervention is feasible and safe. The results presented in this study also provide preliminary evidence for the use of a rehabilitation program as a supportive intervention after SLNB, but future research on effectiveness is needed.

New technologies in breast cancer sentinel lymph node biopsy; from the current gold standard to artificial intelligence

Sentinel lymph node biopsy is an important diagnostic procedure performed in early breast cancer patients with clinically negative axillary lymph nodes. Detection and examination of sentinel lymph nodes determine further therapy decisions, therefore a choice of optimal technique minimising the risk of false-negative results is of great importance. Currently, the gold standard is the dual technique comprising the blue dye and radiotracer, however, this method creates a logistical problem for many medical units. The intrinsic constraints of the existing methods led to the development of a very wide range of alternatives with varying clinical efficiency and feasibility. While each method presents with its own advantages and disadvantages, many techniques have improved enough to become a non-inferior alternative in the sentinel lymph node biopsy. Along with the improvement of the existing technologies, there are evolving trends such as multimodality of the techniques maximising the diagnostic outcome or an emerging use of artificial intelligence (AI) improving the workflow of the procedure. This literature review aims to give an overview of the current status of the standard techniques and emerging cutting-edge technologies in the sentinel lymph node biopsy.

Lymphatic targeting by albumin-hitchhiking: Applications and optimisation

The lymphatic system plays an integral role in the development and progression of a range of disease conditions, which has impelled medical researchers and clinicians to design, develop and utilize advanced lymphatic drug delivery systems. Following interstitial administration, most therapeutics and molecules are cleared from tissues via the draining blood capillaries. Macromolecules and delivery systems >20 kDa in size or 10-100 nm in diameter are, however, transported from the interstitium via draining lymphatic vessels as they are too large to cross the blood capillary endothelium. Lymphatic uptake of small molecules can be promoted by two general approaches: administration in association with synthetic macromolecular constructs, or through hitchhiking on endogenous cells or macromolecular carriers that are transported from tissues via the lymphatics. In this paper we review the latter approach where molecules are targeted to lymph by hitchhiking on endogenous albumin transport pathways after subcutaneous, intramuscular or intradermal injection. We describe the properties of the lymphatic system and albumin that are relevant to lymphatic targeting, the characteristics of drugs and delivery systems designed to hitchhike on albumin trafficking pathways and how to further optimise these properties, and finally the current applications and potential future directions for albumin-hitchhiking approaches to target the lymphatics.

Letter to the Editor: comment on 'Breast-conserving surgery with intraoperative radiotherapy in recurrent breast cancer: the patient's perspective' by Elfgen et al

This is a comment on the article by Elfgen et al. on the use of intraoperative radiotherapy in patients with ipsilateral breast cancer recurrence following breast conserving surgery. The achievement of acceptable breast preservation rates without compromising oncologic safety in breast cancer patients is very important. Therefore, we wish to highlight a significant issue regarding axillary surgery treatment plan of their study group.

ABC4 Consensus: First Latin American Meeting-Assessment, Comments, and Application of Its Recommendations

Breast cancer accounts for a high burden among all the neoplasms in Latin America, with more-advanced stages at presentation, which could result in high mortality rates. The 4th International Consensus Conference for Advanced Breast Cancer (ABC4) is focused on standardizing therapy for advanced breast cancer (ABC) and has held 5 meetings so far. ABC4 took place in Lisbon, Portugal, from November 2 to 4, 2017; however, the first Latin American ABC conference was held in Lima, Peru, from 18 to 19 May, 2018, chaired by Fatima Cardoso, MD, PhD. During these 2 days, the ABC4 consensus recommendations for advanced and locally advanced breast cancer were presented. Local treatment and systemic therapy were discussed with local experts, mainly focusing on anti-human epidermal growth factor receptor 2 therapy and newly approved drugs for hormone receptor-positive breast cancer, such as as CDK4/6, mammalian target of rapamycin, and poly (ADP-ribose) polymerase inhibitors for triple-negative breast cancer. The discussion focused additionally on access to drugs and ABC4 consensus recommendations as regards Latin American patients.

Can Low-cost Indo Cyanine Green Florescence Technique for Sentinel Lymph Node Biopsy Replace Dual Dye (Radio-colloid and Blue Dye) Technique in Early Breast Cancer: A Prospective Two-arm Comparative Study

BACKGROUND

The objective of this study was to assess the detection and accuracy of sentinel lymph node (SLN) biopsy (SLNB) using the low-cost indocyanine green (ICG) fluorescence method and to compare this method with the gold standard dual-dye method (radio-colloid + methylene blue dye [MB]).

MATERIALS AND METHODS

One hundred patients with node-negative early breast cancer assessed clinically and by ultrasound axilla underwent an SLNB procedure using technetium-99m radio-colloid, MB, and ICG. The detection rate of SLNs and positive SLNs and the number of SLNs were compared. The injection safety of ICG and MB was evaluated.

RESULTS

One hundred female patients with a median age of 52.3 years participated in the study. Sixty-eight percent had a body mass index < 25, 85% presented with a palpable lump, of which 59% were in the outer quadrant. SLNs were identified in all 100 cases. A total of 290 SLNs were removed (mean, 2.9; range, 1-6). The identification rate with dual dye was 94%, whereas with ICG alone, it was 96%. The SLNB sensitivity rate and false negative rate were 97.6% versus 93.2% and 3.1% versus 6.2% in the ICG and dual-dye combination, respectively. None of the patients had any local or systemic reaction with ICG; 3 patients with blue dye had tattooing and staining of skin.

CONCLUSION

ICG fluorescence imaging permits real time visualization of lymphatics and provides an additional dimension to SLN biopsy that is safe and effective. These results confirm high sensitivity for fluorescence localization with comparable performance to the gold standard. ICG can reliably replace dual dye and be employed as a sole tracer for SLNB in early breast cancer.

Preoperative Axillary Ultrasound versus Sentinel Lymph Node Biopsy in Patients with Early Breast Cancer

Background and objectives: With improved diagnostic means of early breast cancer, the percentage of cases with metastasis in axillary lymph nodes has decreased from 50–75% to 15–30%. Lymphadenectomy and sentinel lymph node biopsy are not treatment procedures, as they aim at axillary nodal staging in breast cancer. Being surgical interventions, they can lead to various complications. Therefore, recently much attention has been paid to the identification of non-invasive methods for axillary nodal staging. In many countries, ultrasound is a first-line method to evaluate axillary lymph node status. The aim of this study was to evaluate the prognostic value of ultrasound in detecting intact axillary lymph nodes and to assess the accuracy of ultrasound in detecting a heavy nodal disease burden. The additional objective was to evaluate patients’ and tumor characteristics leading to false-negative results. Materials and Methods: A total of 227 women with newly diagnosed pT1 breast cancer were included to this prospective study conducted at the Breast Surgery Unit, Clinic of Surgery, Hospital of Lithuanian University of Health Sciences Kauno Klinikos, between May 1, 2016, and May 31, 2018. All patients underwent preoperative axillary ultrasound examination. Ultrasound data were compared with the results of histological examination. The accuracy and true-negative rate of ultrasound were calculated. The reasons of false-negative results were analyzed. Results: Of the 189 patients who had normally appearing axillary lymph nodes on preoperative ultrasound (PAUS-negative), 173 (91.5%) patients were also confirmed to have intact axillary lymph nodes (node-negative) by histological examination after surgery. The accuracy and the negative predictive value of ultrasound examination were 84.1% and 91.5%, respectively. In ≥3 node-positive cases, the accuracy and the negative predictive value increased to 88.7% and 98.3%, respectively. In total, false-negative results were found in 8.5% of the cases (n = 16); in the PAUS-negative group, false-negative results were recorded only in 1.6% of the cases (n = 3). The results of PAUS and pathological examination differed significantly between patients without and with lymphovascular invasion (LV0 vs. LV1, p < 0.001) as well as those showing no human epidermal growth factor receptor 2 (HER2) expression and patients with weakly or strongly expressed HER2 (HER2(0) vs. HER2(1), p = 0.024). Paired comparisons revealed that the true-negative rate was significantly different between the LV0 and LV1 groups (91% vs. 66.7%, p < 0.05), and the false-negative rate was statistically significant different between the HER2(0) and HER2(1) groups (10.5% vs. 1.2%, p < 0.05). Evaluation of other characteristics showed both the groups to be homogenous. Conclusions: Negative axillary ultrasound excluded axillary metastatic disease in 91.5% of the patients. PAUS had an accuracy of 88.7% in detecting a heavy nodal disease burden. With the absence of lymphovascular invasion (LV0), we can rely on PAUS examination that axillary lymph nodes are intact (PAUS-negative), and this patients’ group could avoid sentinel lymph node biopsy. Patients without HER2 expression are at a greater likelihood of false-negative results; therefore, the findings of ultrasound that axillary lymph nodes are intact (PAUS-negative results) should be interpreted with caution.

The Risk of Para-Aortic Lymph Node Metastases in Apparent Early Stage Ovarian Cancer

Background and objectives: To identify the risk factors for para-aortic lymph node metastases in cases with presumed early stage ovarian cancer. Materials and methods: Between 2014 and 2019, 48 patients with apparent early stage ovarian cancer were submitted to surgery. In all cases, pelvic and para-aortic lymph node dissection was performed for staging purposes. Results: Among the 48 cases we identified nine cases with positive pelvic lymph nodes and 11 cases with positive para-aortic lymph nodes. The positivity of the retrieved lymph nodes was significantly correlated with the histopathological subtype represented by serous histology (p = 0.02), as well as with the degree of differentiation (p = 0.004). Conclusion: Patients with serous ovarian carcinomas in association with a poorer degree of differentiation are at risk of associated lymph node metastases even in presumed early stages of the disease. Therefore, lymph node dissection should be performed in such cases in order to provide adequate staging and tailoring of further treatment.

Development of a novel murine model of lymphatic metastasis

Current laboratory models of lymphatic metastasis generally require either genetically modified animals or are technically challenging. Herein, we have developed a robust protocol for the induction of intralymphatic metastasis in wild-type mice with reproducible outcomes. To determine an optimal injection quantity and timeline for tumorigenesis, C57Bl/6 mice were injected directly into the mesenteric lymph duct (MLD) with varying numbers of syngeneic murine colon cancer cells (MC38) or gastric cancer cells (YTN16) expressing GFP/luciferase and monitored over 2-4 weeks. Tumor growth was tracked via whole-animal in vivo bioluminescence imaging (IVIS). Our data indicate that the injection of tumor cells into the MLD is a viable model for lymphatic metastasis as necropsies revealed large tumor burdens and metastasis in regional lymph nodes. This protocol enables a closer study of the role of lymphatics in cancer metastasis and opens a window for the development of novel approaches for treatment of metastatic diseases.

Learning curve for sentinel lymph node mapping in gynecologic malignancies

BACKGROUND AND OBJECTIVES

Only a few studies have reported the learning curve for sentinel lymph node (SLN) detection in gynecologic malignancies. We investigated the learning curve for SLN detection during robot-assisted laparoscopic surgery for endometrial and cervical carcinomas.

METHODS

This retrospective analysis included patients with stage IA to IIA1 cervical cancer or stage I to III endometrial cancer who underwent SLN mapping using indocyanine green during robot-assisted laparoscopic surgery performed by a single surgeon. Learning curves were analyzed in consecutive cases using SLN detection rates and the cumulative sum (CUSUM) method.

RESULTS

SLN mapping was achieved in 81.25% (65/80), 77.50% (62/80), and 66.25% (53/80) of the cases involving the right, left, and simultaneous bilateral pelvic areas, respectively. Learning curve analysis based on the cumulative detection rate showed initial fluctuations followed by stabilization; the time required for proficiency was discordant among the LN regions. However, the CUSUM method showed proficient mapping of the right, left, and bilateral SLNs after 27 to 28 cases.

CONCLUSION

At least 27 cases were required for SLN mapping proficiency in gynecologic cancer; the learning period could influence the surgical quality. Further studies are warranted to confirm the impact of this learning curve on disease outcomes.

Papillary breast cancer: A retrospective single-centre clinical study

Papillary carcinoma (PC) of the breast is a rare malignancy that accounts for 0.5%-1% of breast cancers. PC remains an understudied cancer, and we still require further information on its behaviour, staging and management. In particular, a significant proportion of PC cases still undergo sentinel lymph node biopsy without clear empirical justification. In the present study, we provide a valuable cohort of 44 PC patients and examine the clinicopathological features and outcome of loco-regional staging. Our results provide important insights into the behaviour of PC and suggest SLNB may be spared in this condition. Crucially, we show only one histologically confirmed PC case had evidence of nodal metastasis. In addition, up to 5 years postsurgery, no patient in our cohort died from their cancer. Together, our results support further work in the utility of SLNB in PC and highlight the favourable prognosis of this tumour. We propose SLNB should not be routinely indicated for patients with PC treated with breast conservation, and future studies should aim to incorporate prospective data to help inform optimal management of PC.

Engineered fluidic systems to understand lymphatic cancer metastasis

The majority of all cancers metastasize initially through the lymphatic system. Despite this, the mechanisms of lymphogenous metastasis remain poorly understood and understudied compared to hematogenous metastasis. Over the past few decades, microfluidic devices have been used to model pathophysiological processes and drug interactions in numerous contexts. These devices carry many advantages over traditional 2D in vitro systems, allowing for better replication of in vivo microenvironments. This review highlights prominent fluidic devices used to model the stages of cancer metastasis via the lymphatic system, specifically within lymphangiogenesis, vessel permeability, tumor cell chemotaxis, transendothelial migration, lymphatic circulation, and micrometastases within the lymph nodes. In addition, we present perspectives for the future roles that microfluidics might play within these settings and beyond.