A predictive tool to estimate the risk of axillary metastases in breast cancer patients with negative axillary ultrasound

BACKGROUND

Sentinel node biopsy (SNB) is the "gold standard" in axillary staging in clinically node-negative breast cancer patients. However, axillary treatment is undergoing a paradigm shift and studies are being conducted on whether SNB may be omitted in low-risk patients. The purpose of this study was to evaluate the risk factors for axillary metastases in breast cancer patients with negative preoperative axillary ultrasound.

METHODS

A total of 1,395 consecutive patients with invasive breast cancer and SNB formed the original patient series. A univariate analysis was conducted to assess risk factors for axillary metastases. Binary logistic regression analysis was conducted to form a predictive model based on the risk factors. The predictive model was first validated internally in a patient series of 566 further patients and then externally in a patient series of 2,463 patients from four other centers. All statistical tests were two-sided.

RESULTS

A total of 426 of the 1,395 (30.5 %) patients in the original patient series had axillary lymph node metastases. Histological size (P < 0.001), multifocality (P < 0.001), lymphovascular invasion (P < 0.001), and palpability of the primary tumor (P < 0.001) were included in the predictive model. Internal validation of the model produced an area under the receiver operating characteristics curve (AUC) of 0.731 and external validation an AUC of 0.79.

CONCLUSIONS

We present a predictive model to assess the patient-specific probability of axillary lymph node metastases in patients with clinically node-negative breast cancer. The model performs well in internal and external validation. The model needs to be validated in each center before application to clinical use.

Selective ductectomy for the diagnosis and treatment of intraductal papillary lesions presenting with single duct discharge

Solitary ductal papilloma of the breast, although considered a benign disorder has a potential association with carcinomas. We studied and analyzed the role of selective ductectomy (SD) for the diagnosis and treatment of intraductal lesions presenting with single duct discharge and ductography suggestive of intraductal (papillary) lesions. During a ten-year-period, files of patients presenting with single (or rarely dual) duct discharge were retrospectively reviewed. The examinations included mammography, ductography and ultrasonography and cytology of the fluid discharged from the duct in all patients. Patients treated with SD were considered further and their histological diagnosis and treatment were analyzed. The series included 100 patients. In 6 cases malignancy was found in the specimen consisting of four in situ and two invasive ductal carcinomas. These 6 patients had a second operation and this was followed by adjuvant treatment. Nine further patients had atypical ductal hyperplasia in or around papillomas and one patient had lobular neoplasia around her papilloma. In the present series, the incidence of carcinoma associated with the clinical suspicion of papillary lesions was 6%, and further 10% had low grade neoplastic proliferations resulting in the diagnosis of atypical papillomas or atypical ductal hyperplasia or lobular neoplasia around the papilloma, indicating that single duct discharge may be a symptom a malignancy, and that ductal papillomas have malignant potential. For such a low risk and grade of malignancy simple follow-up could be one option, but in some cases SD could be applied to relieve the patients from symptoms and establish a diagnosis.

Blue nodes left behind after vital blue dye-guided axillary sentinel node biopsy in breast cancer patients

BACKGROUND

Vital dye-guided sentinel node biopsy is affordable in most hospitals, but may be of limited accuracy in identifying all sentinel nodes. Leaving sentinel nodes in the axilla may result in a false nodal staging of breast carcinomas.

METHODS

From a series of 112 successful sentinel lymph node biopsies with Patent Blue dye followed by axillary dissection, 10 cases were identified where 1-3 blue nodes were found in the axillary dissection specimens. These 10 cases were compared with those which had all blue nodes identified during surgery. Five of the 10 patients with missed blue nodes also underwent lymphoscintigraphy with 99m-Tc-labeled colloidal human albumin and all of their nodes were subjected to external gamma well counting postoperatively.

RESULTS

There were six false-negative sentinel lymph node biopsies overall, but none in patients with missed blue nodes. Patients with primarily unidentified blue nodes had more sentinel nodes and a higher rate of multiple sentinel nodes than the others.

CONCLUSION

Blue nodes missed during surgery may be either true sentinel nodes or second echelon nodes labeled by dye overflow. This type of error may occur in <8% of patients and may lead to false-negative sentinel node-based staging in an even smaller proportion of cases (none in this series).

Value of axillary sentinel nodal status in breast cancer

Axillary clearance in node-negative breast cancer patients is performed only for staging and prognostic purposes. The sentinel node concept may provide an alternative conservative approach for these patients. This paper reports on the learning experience with lymphatic mapping involving the use of patent blue dye for the identification of sentinel lymph nodes (SLNs), followed by axillary dissection. The histopathology of the SLNs included serial sectioning and immunostaining for cytokeratin and epithelial membrane antigen, the remaining nodes being processed as usual. Of the 70 mapping procedures, 58 were successful; the surgical performance revealed a well defined learning period. The mean diameter of the successfully mapped tumors was 2.4 cm (ranging from in situ carcinoma to 4.8-cm invasive cancer). The mean numbers of SLNs and non-SLNs were 1.3 (range 1-3) and 19 (range 7-42), respectively. There were 36 SLN-positive cases, 21 of which had metastases only to these nodes. There were 19 node-negative cases, and 3 SLNs were falsely negative. Possible causes of the errors during lymphatic mapping are analyzed in the light of experiences published to date. SLN biopsy seems a good approach to enhancing the selectivity of axillary lymphadenectomy, but the limitations of the procedure must be evaluated and carefully considered.

[Chylothorax after blunt chest trauma]

An unusually lately discovered and successfully treated case with right sided chylothorax after blunt chest trauma is presented. Pathogenesis of chylothorax, diagnostic and treatment modalities are summarised.

[The role of the histopathological analysis of sentinel lymph nodes in breast cancer. Preliminary findings]

Axillary lymph node status is the single most powerful prognostic marker for breast cancer. Histopathological assessment of lymph nodes has become the gold standard, although conventional histological work-up may miss 10-20% of node-positive cases, potentially resulting in undertreatment and poorer survival of these patients. Identification and detailed histological assessment of sentinel lymph nodes may improve the error rate of conventional methods. We performed the first 30 lymphatic mappings using patent blue vital staining at our department of Surgery in the second semester of 1997. The success rate of identifying 1 or 2 sentinel nodes was 73.3% (22 cases). Axillary dissection and either breast conserving surgery of mastectomy were performed on all patients. Sentinel lymph nodes were serially sectioned and also investigated by immunohistochemistry using primary antibodies to cytokeratin and epithelial membrane antigen. This correctly predicted the qualitative axillary nodal status gained from all the nodes in 21 cases (95.5%). The only false negative sentinel node was associated with a micrometastatis in a non-sentinel lymph node. From the predictive cases 10 (47.6%) had positive nodes, and half of these had metastases only in the sentinel node. To our knowledge, we are the first in Hungary to report preliminary results from a lymphatic mapping study for breast cancer. It seems evident that assessment of sentinel lymph nodes increases the sensitivity of the less reliable conventional histopathological work-up, and this provides a more accurate staging when performed in conjunction with axillary dissection. On the other hand negativity of the sentinel lymph node may question the need for the clearance procedure.

[Spontaneous pneumoperitoneum localized in the left posterior pararenal space in acute pancreatitis]

The authors have analysed the 220 native, erect and supine abdominal X-ray views of 65 males and 45 females with the acute pancreatitis. The localized spontaneous pneumoretroperitoneum inside the left posterior pararenal space was observed in 3.8% of patients (4 cases). The extraperitoneal gas paralleled laterally and inferiorly the margins of kidney and medially the lateral margin of the iliopsoas muscle. Superiorly the gas collection overlay the suprarenal area and outlined the medial crus of the diaphragm, occasionally. The plain-film roentgenogram depended on the quantity of the extraperitoneal gas and of the perirenal fat, besides the subdiaphragmatic adhesions. The pathognostic pneumoretroperitoneum evolved within the initial stage of acute pancreatitis. Afterwards the extraperitoneal gas was hidden by the intraluminal gas bubbles and fluid levels of the dilated small and large bowels.

[Enzyme inductive effect of zixoryn (3-trifluoromethyl-alpha-ethyl-benzhydrol) in neonatal jaundice]

Zixoryn, (3-trifluoromethyl-alfa-aethyl-benzhydrole) is a new product of the Hungarian Chemical Works of Gedeon Richter Ltd. It induces the mixed function oxydase enzyme system of the endoplasmic reticulum of the liver and has no other pharmacological effects. We have studied the effect of Zixoryn on early hyperbilirubin-aemia. 42 neonates were studied, 21 of them were randomly assigned to be treated and the others served as control group Zixoryn treatment consisted of drops containing 10 mg Zixoryn per ml in a single 20 mg/kg body weight dose through a gastric tube. Results are summarized in Fig. 2. It shows the mean se bi levels during the first six days of life. It is remarkable that the decline of se bi level was much faster in the treated than in the control group. On the third day the difference between the two groups was significant. We may conclude that after Zixoryn administration the se bi level of otherwise healthy newborns decreased significantly faster than that of untreated neonates. No side-effects what so ever were observed. The administration is easy, a single oral dose has a satisfactory effect.