Continuous innovation in precision radio-guided surgery

Since its origins, nuclear medicine has faced technological changes that led to modifying operating modes and adapting protocols. In the field of radioguided surgery, the incorporation of preoperative scintigraphic imaging and intraoperative detection with the gamma probe provided a definitive boost to sentinel lymph node biopsy to become a standard procedure for melanoma and breast cancer. The various technological innovations and consequent adaptation of protocols come together in the coexistence of the disruptive and the gradual. As obvious examples we have the introduction of SPECT/CT in the preoperative field and Drop-in probes in the intraoperative field. Other innovative aspects with possible application in radio-guided surgery are based on the application of artificial intelligence, navigation and telecare.

Abstract P2-14-21: NiToNo Study. Evaluation in terms of quality of life and upper extremity functionality after Targeted Axillary Dissection versus lymphadenectomy

Introduction: Targeted Axillary Dissection (TAD) is the combination of the sentinel lymph node biopsy (SLNB) and retrieval of the clipped node that was proved positive before neoadjuvant treatment (NAT). Previous studies have demonstrated that this approach has a low false-negative rate in patients with cN+ before NAT. Current guidelines recommend axillary radiotherapy in cN+ despite a complete pathological response reported after NAT.

Aim: To evaluate if TAD improves the quality of life and arm functionality compared to axillary lymph node dissection (ALND) in patients with cN+ before NAT.

Methods: Prospective observational study. The study started in 2017 and ended in 2021. We included patients with one to three suspected lymph nodes and at least one confirmed by fine-needle aspiration. Suspicious lymph nodes were clipped before NAT. After NAT if a complete radiological response was achieved by axillary ultrasound, TAD was performed. During surgery, we used ultrasound-guided marked lymph node dissection and dual tracer SLNB. Clipped and SLN were assessed with intraoperative frozen section H&E, standard H&E, and IHC with CKAE1/AE3. After surgery, the breast tumor board analyzes the pathological findings and the surgical performance. When ITC, micro-metastases, or macro-metastases were found in the nodes, or when surgical performance is considered suboptimal, we proceed to ALND. We assessed QoL with standard forms and upper extremity mobility and lymphedema by physical examination.

Results: We analyzed 44 women. Median age 53.9 years old. ALND was performed on 28 patients and TAD on 16 patients. Age and other confounding factors such as (BMI, type of surgery, and type of NAT) were similar in both groups. Median follow-up time: 24 months (5-60). No regional relapse in both groups. The axillary staging is shown in table 1. The surgical procedure and indications for ALND are shown in Table 2. Any patient with a Luminal-A-like profile had an axillary response to NAT and subsequent ALND was performed in all 4 patients. By contrast, patients with HER2 overexpression or triple negatives had better axillary responsiveness and 12/21 were stratified only with TAD. Two patients had a false positive finding on the post-NAT axillary ultrasound (one patient with LuminalB-Her2 positive tumor and one patient with HER2 positive not luminal) and ALND was performed, complete pathological response with only fibrosis was observed. Indications of ALND are shown in table 1. On the questionnaires, health status perception (84.9 TAD vs 65.77 ALND, p=0.02), QoL (83.33 TAD vs 64.29 ALND p=0.03), upped extremity symptoms (8.33% TAD vs 30.16% ALND, p< 0.01) and breast symptoms (14.06% TAD vs 31.25% ALND, p=0.03) are better on TAD than in ALND patients. On physical examination, 11 patients of the ALND group had some alteration in functionality (8 patients had limitation of abduction and 7 patients had lymphedema). By contrast, any alteration was found in the patients staged only with TAD.

Conclusions: Targeted axillary dissection reduces posttreatment symptomatology and allows a better quality of life with no axillary relapses though follow-up is short. Patients with Luminal-A-like cancer probably are not good candidates for TAD because of a lack of responsiveness and perhaps another approach must be considered.

Table 1: Axillary staging after NAT

Table 2: Surgical procedure and indications for lymphadennectomy

Citation Format: Laia Vila Homs, MAria Lourdes Carrillo-Guivernau, Catalina Sampol, Gabriel Matheu Capo, Pau CAMARASA, Catalina Serra, Monica Mariño, Angela Tarongí, Octavi Cordoba, Antonia Perelló. NiToNo Study. Evaluation in terms of quality of life and upper extremity functionality after Targeted Axillary Dissection versus lymphadenectomy [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr P2-14-21.

Sentinel lymph node biopsy procedure in squamous vulvar cancer. 10 years follow-up analysis

AIM

Application of sentinel lymph node biopsy (SLNB) procedure in early-stage vulvar cancer and analysis of results, recurrences and complications.

MATERIAL AND METHODS

40 patients with vulvar cancer and SLNB between 2008 and 2018 were retrospectively reviewed. During the surgical procedure the inguinofemoral lymph nodes were checked with a gamma probe to identify the sentinel nodes that were removed and referred for intraoperative pathological assessment. Subsequently, long-term patient follow-up was performed with analysis of complications, relapse and mortality.

RESULTS

40 patients (mean age: 72 years [47-86], the overall detection rate per patient was 95% and a total of 129 Sentinel Lymph Nodes (SLNs) were removed (3.22 SLN/patient). In 3 out of 25 patients with lateral tumour lesions drainage was bilateral and in 2 out of 15 with midline lesions drainage was unilateral. On lymphoscintigraphy, 16 out of 40 had bilateral drainage and 24 unilateral. A total of 119 SLN- and 10 SLN+ were obtained, in 8 out of 10 an inguinofemoral lymphadenectomy was performed. In the SLN- group, one case of lymphatic blockage and one false negative were included. In 12 out of 40 patients there were post-surgical complications, 4 of them lymphoedemas. In the median follow-up (40 months), 6 out of 10 with SLN+ (40% mortality) and 7 out of 30 SLN- (16% mortality) had recurrences.

CONCLUSIONS

SLNB in vulvar cancer is the technique of choice for correct staging and locoregional therapy. Correct clinical lymph node staging is important before surgery in order to avoid potential blockage drainages which could induce a false negative SLN.

[Axillary recurrences after sentinel lymph node biopsy in initial breast cancer]

OBJECTIVE

The aim of our study was to analyze the application of the Selective Sentinel Lymph Node Biopsy (SLNB) in early Breast Cancer of our population, through the analysis of axillary recurrences in patients with false negative sentinel node procedures without complete axillary lymphadenectomy, after a subsequent clinical follow-up.

MATERIAL AND METHODS

A total of 218 early Breast Cancer patients who underwent SLNB after being diagnosed of early breast cancer (T1-2N0) with complete axillary dissection only when the SLNB was positive in the histopathological analysis. In every case, a 2-day protocol was used to localize the sentinel node after injection of (⁹⁹m)Tc-Nanocolloid.

RESULTS

The mean subsequent clinical follow-up was 27 months. A total of 413 sentinel nodes were removed with a median of 1.89/p (range 1-5). Infiltration was detected in 33.9% of patients (59.45% macrometastasis, 22.97% micrometastasis and 17.5% Isolated Tumor Cells (ITC)) and negative for the other nodes excised after conventional lymphadenectomy in 60% of cases. In our population, there was only one case of false negative (FN) SLN due to massive lymphatic blockage, and an abnormal lymph node without uptake adjacent to the SLN was identified intraoperatively. No case of axillary recurrence was detected during an average follow-up of 27 months.

CONCLUSION

The absence of axillary recurrences in our population with negative SLNB without complete axillary dissection demonstrates the appropriate local control offered by this procedure in early Breast Cancer.