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Kustić D. Size of Extranodal Extension in the Sentinel Lymph Node as a Predictor of Prognosis in Early-Stage Breast Cancer. Clin Breast Cancer 2024; 24:e560-e570. [PMID: 38871577 DOI: 10.1016/j.clbc.2024.05.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 05/08/2024] [Accepted: 05/10/2024] [Indexed: 06/15/2024]
Abstract
INTRODUCTION The presence of extranodal extension (ENE) in sentinel lymph nodes (SLNs) can predict non-SLN metastases in breast cancer (BC) patients; however, the prognostic relevance of its extent remains controversial. The purpose of this study was to examine the predictive role of ENE in SLNs measured by its widest dimension (WD), highest dimension (HD), and the WD/HD ratio for non-SLN involvement, overall, and disease-free survival (OS, DFS) in cT1-2N0 BC patients with positive SLNs. MATERIALS AND METHODS A total of 511 women with cT1-2N0 BC and positive SLNs undergoing axillary lymph node dissection were retrospectively enrolled. The associations of ENE's WD, HD, and WD/HD ratio with non-SLN metastases, 5-year OS, and DFS were established through a multivariable modeling approach. RESULTS SLNs were ENE-positive in 149 (29.16%) participants, and 133 (26.03%) had non-SLN metastases. During the median 60 (16-60)-month follow-up, 69 (13.50%) patients experienced recurrences, and 62 (12.13%) died. The numbers of SLNs, non-SLNs, and total axillary LNs involved differed between the ENE-negative and ENE-positive groups, as well as between the WD/HD ≤ 1.2 and WD/HD > 1.2 subgroups (all P-values were < .001). Multivariable analyses showed significant associations of the WD/HD ratio > 1.2 with non-SLN involvement, OS, and DFS (P-values were .003, < .001, and .005, respectively). DISCUSSION Despite no predictive value of ENE's WD and HD, the WD/HD ratio > 1.2 was an independent predictor of non-SLN involvement, mortality, and recurrence. ENE's WD/HD ratio could be a valuable indicator for cT1-2N0 BC individuals with positive SLNs for whom further axillary treatment may be beneficial.
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Affiliation(s)
- Domagoj Kustić
- Department of Nuclear Medicine, Clinical Hospital Center Rijeka, Rijeka, Croatia.
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Naoum GE, Oladeru O, Ababneh H, Shui A, Ly A, Taghian AG. Pathologic Exploration of the Axillary Soft Tissue Microenvironment and Its Impact on Axillary Management and Breast Cancer Outcomes. J Clin Oncol 2024; 42:157-169. [PMID: 37967296 DOI: 10.1200/jco.23.01009] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2023] [Revised: 08/22/2023] [Accepted: 09/07/2023] [Indexed: 11/17/2023] Open
Abstract
PURPOSE Axillary soft tissue (AXT) involvement with tumor cells extending beyond the positive lymph node (LN+) and extracapsular extension (ECE) has been overlooked in breast pathology specimen analysis. MATERIALS AND METHODS We analyzed 2,162 LN+ patients, dividing them into four groups on the basis of axillary pathology: (1) LN+ only, (2) LN+ and ECE only, (3) LN+ and AXT without ECE, and (4) LN+ with both AXT and ECE. The primary end points were 10-year locoregional failure (LRF), the 10-year axillary failure, and 10-year distant metastasis rates. Multivariable Cox models, accounting for clinical factors, were fitted using the entire cohort, and subgroups analyses were conducted. RESULTS The median follow-up was 9.4 years. The 10-year distant metastasis incidence was 42% for LN + AXT + ECE, 23% for both LN + AXT and LN + ECE only, and 13% for LN+ only. The 10-year axillary failure rates were 4.5% for LN + AXT + ECE, 4.6% for LN + AXT, 0.8% for LN + ECE only, and 1.6% for LN+ only. The 10-year LRF rates were 14% for LN + AXT + ECE, 10% for LN + AXT, 5.7% for LN + ECE only, and 6.2% for LN+ only. Multivariable analysis revealed that AXT was significantly associated with distant metastasis (hazard ratio [HR], 1.6; P < .001), locoregional failure (HR, 2.3; P < .001), and axillary failure (HR, 3.3; P = .003). Subgroup analyses showed that regional LN radiation (RLNR) improved locoregional tumor outcomes with AXT, ECE, or both (HR, 0.5; P = .03). Delivering ≤50 Gy to the axilla in the presence of AXT/ECE increased axillary failure (HR, 3.0; P = .04). Moreover, when delivering RLNR, axillary LN dissection could be de-escalated to sentinel node biopsy even in the presence of features such as AXT or ECE without significantly increasing any failure outcome: (HR, 1.0; P = .92) for LRF, (HR, 1.1; P = .94) axillary failure, and (HR, 0.4; P = .01) distant metastasis. CONCLUSION Routine reporting of axillary tissue involvement, beyond LNs and ECE, is crucial in predicting breast cancer outcomes. Ruling out the presence of AXT is imperative before any form of axillary de-escalation, especially RLNR omission.
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Affiliation(s)
- George E Naoum
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Radiation Oncology, Northwestern University Memorial Hospital, Chicago, IL
| | - Oluwadamilola Oladeru
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
- Department of Radiation Oncology, Mayo Clinic, Jacksonville, FL
| | - Hazim Ababneh
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Amy Shui
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Amy Ly
- Department of Clinical Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Alphonse G Taghian
- Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Extranodal extension, an international survey on its evaluation and reporting in breast cancer patients. Pathol Res Pract 2022; 237:154070. [PMID: 36030639 DOI: 10.1016/j.prp.2022.154070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/08/2022] [Indexed: 11/20/2022]
Abstract
Lymph node metastasis is the most important prognostic factor for breast cancer patients. In addition to the number of nodes involved and the largest metastatic focus, extranodal extension (ENE) is also used to subclassify breast cancer patients into different risk groups. More recently, pathologists are required to report the size/extent of ENE per the new CAP guideline, as it seems to be associated with more axillary nodal burden and/or a worse prognosis. Although the definition of ENE is largely understood and agreed upon among pathologists around the world, evaluation and reporting for the size of ENE are not. To understand current practice, we conducted an international survey among pathologists who are interested in breast pathology. A total of 70 pathologists responded. The results showed that (1) 98% of the participants reported the presence or absence of ENE and 61% also reported the size of ENE in millimeter (mm). (2) There was no uniform method of measuring the size of ENE; 47% measured the largest dimension regardless of orientation, while 30% measured the largest perpendicular distance from the capsule. (3) The most common factors affecting the accuracy in diagnosis of ENE are the presence of lymphovascular invasion (LVI), lack of capsule integrity, and the presence of fatty hilar or fatty replacement of a lymph node. (4) 71% felt that the H&E stain is adequate to evaluate ENE, deeper levels and IHC analysis for vascular and cytokeratin markers can be helpful if needed. (5) 75% agreed that there is an urgent need to standardize the measurement and reporting for ENE. Our survey highlights the variation in ENE evaluation and the need for its standardization in breast cancer patients with axillary node metastasis.
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Nowikiewicz T, Szymankiewicz M, Drzewiecka M, Głowacka-Mrotek I, Tarkowska M, Nowikiewicz M, Zegarski W. Did the COVID-19 Pandemic Truly Adversely Affect Disease Progress and Therapeutic Options in Breast Cancer Patients? A Single-Centre Analysis. J Clin Med 2022; 11:1014. [PMID: 35207286 PMCID: PMC8879378 DOI: 10.3390/jcm11041014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/03/2022] [Accepted: 02/11/2022] [Indexed: 02/05/2023] Open
Abstract
PURPOSE The uncontrolled spread and transmission of SARS-CoV-2 infections has disrupted most areas of social and economic life all over the world. The most important changes concern problems related to the functioning of healthcare systems. The aim of this study was to evaluate clinical consequences associated with the COVID-19 pandemic for patients with newly diagnosed breast cancer, treated at our centre. METHODS The study participants were patients first time diagnosed with breast cancer, treated between January 2019 and March 2021, who were provided any type of cancer treatment at our centre. The study determined the grade of clinical and pathological progress of the disease and types of cancer treatment applied in patients. RESULTS In total, 2863 patients were included in the analysis. The number of hospitalized patients was 1228 (1123 treated surgically, 105 receiving conservative treatment) in 2019, 1318 (1206 and 112 patients, respectively) in 2020, and 317 (288 and 29 patients, respectively) in 2021. CONCLUSIONS Despite many hazards associated with the new epidemiological situation, we were able to maintain the continuous operation of our centre. We have achieved a measurable success, and even managed to increase the number of treated breast cancer patients.
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Affiliation(s)
- Tomasz Nowikiewicz
- Department of Surgical Oncology, Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, 85-067 Bydgoszcz, Poland;
- Department of Clinical Breast Cancer and Reconstructive Surgery, Oncology Centre-Prof. Franciszek Łukaszczyk Memorial Hospital, 85-796 Bydgoszcz, Poland;
| | - Maria Szymankiewicz
- Department of Microbiology, Oncology Centre-Prof. Franciszek Łukaszczyk Memorial Hospital, 85-796 Bydgoszcz, Poland;
| | - Marta Drzewiecka
- Department of Clinical Breast Cancer and Reconstructive Surgery, Oncology Centre-Prof. Franciszek Łukaszczyk Memorial Hospital, 85-796 Bydgoszcz, Poland;
| | - Iwona Głowacka-Mrotek
- Department of Rehabilitation, Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, 85-094 Bydgoszcz, Poland;
| | - Magdalena Tarkowska
- Department of Urology, Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, 85-094 Bydgoszcz, Poland;
| | - Magdalena Nowikiewicz
- Department of Hepatobiliary and General Surgery, A. Jurasz University Hospital, 85-094 Bydgoszcz, Poland;
| | - Wojciech Zegarski
- Department of Surgical Oncology, Nicolaus Copernicus University in Toruń, Collegium Medicum in Bydgoszcz, 85-067 Bydgoszcz, Poland;
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Nowikiewicz T, Kurylcio A, Głowacka-Mrotek I, Szymankiewicz M, Nowikiewicz M, Zegarski W. Clinical relevance of a degree of extracapsular extension in a sentinel lymph node in breast cancer patients: a single-centre study. Sci Rep 2021; 11:8982. [PMID: 33903665 PMCID: PMC8076211 DOI: 10.1038/s41598-021-88351-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 04/07/2021] [Indexed: 11/09/2022] Open
Abstract
In some breast cancer (BC) patients, an examination of lymph nodes dissected during sentinel lymph node biopsy (SLNB) demonstrates a presence of metastatic lesions and extracapsular extension (ECE) in a SLN. This study aimed to evaluate clinical relevance of ECE in BC patients. This is a retrospective analysis of 891 patients with cancer metastases to SLN, referred to supplementary axillary lymph node dissection (ALND), hospitalized between Jan 2007 and Dec 2017. Clinical and epidemiological data was evaluated. Long-term treatment outcomes were analysed. In 433 (48.6%) patients, cancer metastases were limited to the SLN (group I), in 61 (6.8%) patients the SLN capsule was exceeded focally (≤ 1 mm—group II). In 397 (44.6%) patients, a more extensive ECE was found (> 1 mm—group III). Metastases to non-sentinel lymph nodes (nSLNs) were diagnosed in 27.0% patients from group I, 44.3% patients from group II and in 49.6% patients from group III. No statistically significant differences were observed in long-term treatment outcomes for compared groups. The presence of ECE is accompanied by a higher stage of metastatic lesions in the lymphatic system. The differences in this respect were statistically significant, when compared to the group of ECE(−) patients. ECE, regardless of its extent, did not impact the long-term treatment results. ECE remains an indication for supplementary ALND and for other equivalent cancer treatment procedures, regardless of ECE size.
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Affiliation(s)
- Tomasz Nowikiewicz
- Department of Surgical Oncology, Nicolaus Copernicus University Ludwik Rydygier's Collegium Medicum, Prof I. Romanowskiej 2, 85-796, Bydgoszcz, Poland. .,Department of Clinical Breast Cancer and Reconstructive Surgery, Oncology Centre, Prof I. Romanowskiej 2, 85-796, Bydgoszcz, Poland.
| | - Andrzej Kurylcio
- Department of Surgical Oncology, Medical University, Lublin, Poland
| | - Iwona Głowacka-Mrotek
- Department of Rehabilitation, Nicolaus Copernicus University Ludwik Rydygier's Collegium Medicum, M. Sklodowskiej-Curie 9, 85-001, Bydgoszcz, Poland
| | - Maria Szymankiewicz
- Department of Microbiology, Oncology Centre, Prof I. Romanowskiej 2, 85-796, Bydgoszcz, Poland
| | - Magdalena Nowikiewicz
- Department of Hepatobiliary and General Surgery, A. Jurasz University Hospital, M. Sklodowskiej-Curie 9, 85-001, Bydgoszcz, Poland
| | - Wojciech Zegarski
- Department of Surgical Oncology, Nicolaus Copernicus University Ludwik Rydygier's Collegium Medicum, Prof I. Romanowskiej 2, 85-796, Bydgoszcz, Poland
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Invernizzi M, Corti C, Lopez G, Michelotti A, Despini L, Gambini D, Lorenzini D, Guerini-Rocco E, Maggi S, Noale M, Fusco N. Lymphovascular invasion and extranodal tumour extension are risk indicators of breast cancer related lymphoedema: an observational retrospective study with long-term follow-up. BMC Cancer 2018; 18:935. [PMID: 30268112 PMCID: PMC6162920 DOI: 10.1186/s12885-018-4851-2] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2018] [Accepted: 09/24/2018] [Indexed: 12/21/2022] Open
Abstract
Background Breast cancer related lymphoedema (BCRL) occurs in a substantial proportion of breast cancer survivors and is a major contributor to patients’ disability. Regrettably, there are no validated predictive biomarkers, diagnostic tools, and strong evidence-supported therapeutic strategies for BCRL. Here, we provide an integrative characterization of a large series of women with node-positive breast cancers and identify new bona fide predictors of BCRL occurrence. Methods Three hundred thirty-two cases of surgically-treated node-positive breast cancers were retrospectively collected (2–10.2 years of follow-up). Among them, 62 patients developed BCRL. To identify demographic and clinicopathologic features related to BCRL, Fisher’s exact test or Chi-squared test were carried out for categorical variables; the Wilcoxon rank-sum was employed for continuous variables. Factors associated with BCRL occurrence were assessed using a Cox proportional hazards regression model. Results En-bloc dissection of the axillary lymph nodes but not the type of breast surgery impacted on BCRL development. Most of BCRL patients had a Luminal A-like neoplasm. The median number of lymph nodes involved by metastatic deposits was significantly higher in BCRL compared to the control group (p = 0.04). Both peritumoral lymphovascular invasion (LVI) and extranodal extension (ENE) of the metastasis had a negative impact on BCRL-free survival (p = 0.01). Specifically, patients with LVI and left side localization harboured 4-fold higher risk of developing BCRL, while right axillary nodes metastases with ENE increased the probability of BCRL compared to ENE-negative patients. Conclusions Assessment of LVI and ENE should be integrated with clinical and surgical data to improve BCRL risk stratification. Electronic supplementary material The online version of this article (10.1186/s12885-018-4851-2) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marco Invernizzi
- Physical and Rehabilitative Medicine, Department of Health Sciences, University of Eastern Piedmont "A. Avogadro", Viale Piazza D'Armi 1, 28100, Novara, Italy
| | - Chiara Corti
- Division of Pathology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.,School of Medicine, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy
| | - Gianluca Lopez
- Division of Pathology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Anna Michelotti
- Division of Pathology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.,School of Medicine, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy.,Division of Medical Oncology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Luca Despini
- Division of Breast Surgery, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Donatella Gambini
- Division of Medical Oncology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy
| | - Daniele Lorenzini
- Division of Pathology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy.,School of Pathology, University of Milan, Via Festa del Perdono 7, 20122, Milan, Italy
| | - Elena Guerini-Rocco
- Department of Pathology, European Institute of Oncology, Via Giuseppe Ripamonti 435, 20141, Milan, Italy.,Department of Oncology and Hemato-oncology, University of Milan, Via Commenda 10, 20122, Milan, Italy
| | - Stefania Maggi
- National Research Council (CNR), Neuroscience Institute Aging Branch, Via Giustiniani 2, 35128, Padua, Italy
| | - Marianna Noale
- National Research Council (CNR), Neuroscience Institute Aging Branch, Via Giustiniani 2, 35128, Padua, Italy
| | - Nicola Fusco
- Division of Pathology, Fondazione IRCCS Ca' Granda, Ospedale Maggiore Policlinico, Via Francesco Sforza 35, 20122, Milan, Italy. .,Department of Biomedical, Surgical and Dental Sciences, University of Milan, Via Commenda 10, 20122, Milan, Italy.
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Extra-nodal extension is a significant prognostic factor in lymph node positive breast cancer. PLoS One 2017; 12:e0171853. [PMID: 28199370 PMCID: PMC5310784 DOI: 10.1371/journal.pone.0171853] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Accepted: 01/26/2017] [Indexed: 11/28/2022] Open
Abstract
Presence of lymph node (LN) metastasis is a strong prognostic factor in breast cancer, whereas the importance of extra-nodal extension and other nodal tumor features have not yet been fully recognized. Here, we examined microscopic features of lymph node metastases and their prognostic value in a population-based cohort of node positive breast cancer (n = 218), as part of the prospective Norwegian Breast Cancer Screening Program NBCSP (1996–2009). Sections were reviewed for the largest metastatic tumor diameter (TD-MET), nodal afferent and efferent vascular invasion (AVI and EVI), extra-nodal extension (ENE), number of ENE foci, as well as circumferential (CD-ENE) and perpendicular (PD-ENE) diameter of extra-nodal growth. Number of positive lymph nodes, EVI, and PD-ENE were significantly increased with larger primary tumor (PT) diameter. Univariate survival analysis showed that several features of nodal metastases were associated with disease-free (DFS) or breast cancer specific survival (BCSS). Multivariate analysis demonstrated an independent prognostic value of PD-ENE (with 3 mm as cut-off value) in predicting DFS and BCSS, along with number of positive nodes and histologic grade of the primary tumor (for DFS: P = 0.01, P = 0.02, P = 0.01, respectively; for BCSS: P = 0.02, P = 0.008, P = 0.02, respectively). To conclude, the extent of ENE by its perpendicular diameter was independently prognostic and should be considered in line with nodal tumor burden in treatment decisions of node positive breast cancer.
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Swaminathan S, Reintgen M, Kerivan L, Reintgen E, Smith J, Reintgen D. Extracapsular Extension in the Sentinel Lymph Node: Guidelines for Therapy. Clin Breast Cancer 2016; 16:e65-8. [DOI: 10.1016/j.clbc.2016.02.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2015] [Accepted: 02/03/2016] [Indexed: 01/23/2023]
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Bishop JA, Sun J, Ajkay N, Sanders MAG. Decline in Frozen Section Diagnosis for Axillary Sentinel Lymph Nodes as a Result of the American College of Surgeons Oncology Group Z0011 Trial. Arch Pathol Lab Med 2015; 140:830-5. [PMID: 26716950 DOI: 10.5858/arpa.2015-0296-oa] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
CONTEXT -Results of the American College of Surgeons Oncology Group Z0011 trial showed that patients with early-stage breast cancer and limited sentinel node metastasis treated with breast conservation and systemic therapy did not benefit from axillary lymph node dissection. Subsequently, most pathology departments have likely seen a decrease in frozen section diagnosis of sentinel lymph nodes. OBJECTIVE -To determine the effect of the Z0011 trial on pathology practice and to examine the utility of intraoperative sentinel lymph node evaluation for this subset of patients. DESIGN -Pathology reports from cases of primary breast cancer that met Z0011 clinical criteria and were initially treated with lumpectomy and sentinel lymph node biopsy from 2009 to 2015 were collected. Clinicopathologic data were recorded. RESULTS -Sentinel lymph node biopsies sent for frozen section diagnosis occurred in 22 of 22 cases (100%) in 2009 and 15 of 22 cases (68%) in 2010 during the pre-Z0011 years, and in 3 of 151 cases (2%) collected in 2011 through 2015, considered to be post-Z0011 years. Of the 151 post-Z0011 cases, 28 (19%) had sentinel lymph nodes with metastasis, and 147 (97%) were spared axillary lymph node dissection. CONCLUSIONS -Following Z0011, intraoperative sentinel lymph node evaluation has significantly decreased at our institution. Prior to surgery, all patients had clinically node-negative disease. After sentinel lymph node evaluation, 97% (147 of 151) of the patients were spared axillary lymph node dissection. Therefore, routine frozen section diagnosis for sentinel lymph node biopsies can be avoided in these patients.
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Affiliation(s)
| | | | | | - Mary Ann G Sanders
- From the Department of Pathology & Laboratory Medicine (Drs Sanders, Bishop, and Sun) and the Department of Surgery (Dr Ajkay), University of Louisville Hospital, Louisville, Kentucky. Dr Sun is now with the Department of Pathology, SUNY, University of Buffalo at Buffalo, New York
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