Abstract P1-01-22: Which cytologically proven node-positive breast cancer patients can avoid axillary lymph dissection after neaodjuvant chemotherapy?

BACKGROUND:

It is still controversial whether axillary lymph node dissection can be omitted after negative sentinel lymph node biopsy in breast cancer patients with clinically positive axilla at presentation treated with neoadjuvant chemotherapy (NAC). The aim of this study was to analyze whether SLN biopsy could be useful in these patients.

METHODS:

After NAC of 112 patients with cytology-proven axillary node metastasis at the time of diagnosis, SLNB using radioisotope and blue dye was performed including completion node dissection between 2008 and 2012. The results of SLNB and clinicopathological characteristics were analyzed for correlation with pathological axillary lymph node status.

RESULTS:

SLN was successfully identified in 107 (95.5%) patients. Tumor nonresponse and extensive residual nodal disease were found to be significantly associated with detection failure of sentinel nodes. Axillary status was predicted with 94% accuracy and a false negative rate of 8.7%. Axillary nodal status before NAC (cN2 versus cN12) was associated with higher false-negative rates (p = 0.02). Conversion to node-negative disease was achieved in 38 (35%) patients: 23% of patients with the luminal A subtype, 12% of patients with the luminal B, 39% of patients with the HER2-enriched, and 26% of patients with the triple-negative breast cancer subtype. The tripple negative and HER2-enriched breast cancer subtypes had a significantly better false negative rate and accuracy.

CONCLUSIONS:

SLNB was found to be technically feasible, but its routine use was not recommended for LABCs after NAC. However, acceptable performance was noted for tripple negative and HER2-enriched breast cancer patients presented with N1 axillary status in the beginning of NAC, and thus SLNB might be safely considered in these selected patients.

Citation Information: Cancer Res 2013;73(24 Suppl): Abstract nr P1-01-22.

Axillary sentinel node biopsy after neoadjuvant chemotherapy

INTRODUCTION

The role of sentinel lymph node biopsy (SLNB) in patients with locally advanced breast cancer (LABC) with potentially sterilized axillary lymph nodes after neoadjuvant chemotherapy (NAC) remains unclear.

PATIENTS AND METHODS

Between 2002 and 2008, SLNB with both blue-dye and radioisotope injection was performed in 77 patients with LABC whose cytopathologically confirmed positive axillary node(s) became clinically negative after NAC. Factors associated with SLN identification and false-negative rates, presence of non-sentinel lymph node (non-SLN) metastasis were analyzed retrospectively.

RESULTS

SLNB was successful in 92% of the patients. Axillary status was predicted with 90% accuracy and a false-negative rate of 13.7%. Patients with residual tumor size >2 cm had a decreased SLN identification rate (p=0.002). Axillary nodal status before NAC (N2 versus N1) was associated with higher false-negative rates (p=0.04). Positive non-SLN(s) were more frequent in patients with multifocal/multicentric tumors (versus unifocal; p=0.003) and positive lymphovascular invasion (versus negative; p=0.0001). SLN(s) positive patients with pathologic tumor size >2 cm (versus <or=2 cm; p=0.004), positive extra-sentinel lymph node extension (versus negative; p=0.002) were more likely to have metastatic non-SLN(s).

CONCLUSIONS

SLNB has a high identification rate and modest false-negative rate in LABC patients who became clinically axillary node negative after NAC. Residual tumor size and nodal status before NAC affect SLNB accuracy. Additional involvement of non-SLN(s) increases with the presence of multifocal/multicentric tumors, lymphovascular invasion, residual tumor size >2 cm, and extra-sentinel node extension.

Is the sentinel lymph node biopsy accurate for patients with initially clinically axilla-positive locally advanced breast cancer after neoadjuvant chemotherapy?

Abstract #5123

Background: Approximately one third of patients with locally advanced breast cancer (LABC) have no axillary metastatic lymph node(s) after neoadjuvant chemotherapy (NAC). Axillary dissection could be omitted in these patients if SLNB is negative. The aim of this study is to evaluate the accuracy of sentinel lymph node biopsy (SLNB) after NAC for LABC.&#x2028; Materials and Methods: Between January 1992 to May 2008, a total of 69 patients with clinical or radiological positive axilla (N1 or N2) in LABC were enrolled in this study. After NAC, all patients underwent SLNB followed by complete axillary lymph node dissection. SLNB was performed with either a combined detection using blue dye and radiocolloid or blue dye alone. All the sentinel lymph nodes were examined by multisection hematoxylin eosin staining and cytokeratin- immunohistochemistry, whereas the non-sentinel nodes were examined by routine histology.&#x2028; Results: Sentinel lymph nodes were successfully identified in 58 patients among 69 patients (85%). The median age was 46 (range 25 to 76). The clinical stages before chemotherapy were as follows: IIB:46%, IIIA: 22%, and IIIB: 32%, respectively. All of 58 patients had either clinically or radiologically suspicious node-positive disease based on ultrasound findings before neoadjuvant chemotherapy. Pathologic complete response were obtained in 5 patients (9%). The false negative rate was found to be 17.4 % (8/46), whereas the accuracy rate was 86.2% (50/58) among patients with succesful lymphatic mapping.&#x2028; Conclusion: The accuracy of the SLNB procedure seems to be not reliable in patients with locally advanced disease with a positive axilla before NAC therapy due to its high false negative rates. Therefore, complete axillary dissection is still required in patients with a positive-axilla before chemotherapy.

Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 5123.

The value of Tc-99m tetrofosmin in the imaging of pituitary adenomas

AIM

Magnetic resonance imaging (MRI) and computerized tomography (CT) are used in the diagnosis and follow-up of pituitary adenoma cases. Sometimes, these methods cannot display the post-operative residual tissue. It has been shown that some radionuclides were taken up by the pituitary adenomas. The aim of this study was to evaluate the uptake of the technetium-99m (Tc-99m) tetrofosmin (TF) in the pituitary adenoma and normal pituitary tissue and assess the ability of Tc-99m TF to predict tumor malignancy in pituitary gland.

METHODS

The patients with pituitary adenoma (7 invasive and 8 non-invasive) were compared with control group (no. 13). Single-photon emission computed tomography (SPECT) imaging of pituitary gland was performed in both groups. Tc-99m uptake indices were evaluated statistically with the use of Mann-Whitney U test.

RESULTS

The average tetrofosmin uptake index of pituitary adenoma is 2.44+/-1.54 for the patients and 1.69+/-0.71 for the control group. Any significant difference was not observed between the groups (p 0.3). The average index was calculated as 3.04+/-2.15 for invasive adenomas and 1.92+/-0.33 for the non-invasive group, and there was no significant difference between the two groups regarding uptake of the agent (p 0.53). Furthermore, it was determined that the invasive and non-invasive adenomas displayed an uptake of Tc-99m TF similar to normal pituitary tissue.

CONCLUSIONS

Since the pituitary adenoma and normal pituitary tissue gave similar results regarding Tc-99m TF uptake, it was concluded that this agent would not be useful in the diagnosis of pituitary adenoma.

Factors predicting the sentinel and non-sentinel lymph node metastases in breast cancer

The sentinel lymph node (SLN) is the only focus of axillary metastasis in a significant proportion of patients. In this single institutional study, clinicopathologic characteristics were investigated to determine the factors predicting the status of a SLN biopsy and the metastatic involvement of non-SLNs. Data were retrospectively reveiwed for 400 consecutive patients with clinical T1/T2 N0 breast cancer who underwent a SLN biopsy including axillary and/or internal mammary lymph nodes. The SLNs were evaluated by using the new AJCC staging criteria following multiple sectioning and immunohistochemical (IHC) analyses of nodes. The SLN contained metastases in 148 patients (38.5%) including 18 patients (12.2%) with micrometastases (<or=0.2 mm) and 130 patients (87.8%) with macrometastases (>0.2 cm). Five patients had isolated tumor cells detected by IHC (<or=0.2 mm, N(0i)). Patients with tumor size more than 2 cm (T1, 29.8% versus T2, 51.6%; OR=2.31, 95% CI, 1.50-3.56) and lymphovascular invasion (LVI-, 30.3% versus LVI+, 51.3%; OR=2.07, 95% CI, 1.34-3.19) were more likely to have positive SLNs in both univariate and multivariate analyses. Among patients with a positive SLN biopsy, those with T2 tumors (versus T1; 63.1% versus 36.9; OR=2.93, 95% CI, 1.43-6.04), macrometastases in SLNs (versus micrometastases; 88.9% versus 11.1%; OR=8.83; 95% CI, 1.82-42.87) and extracapsular node extension (versus without extracapsular node extension; 65.4% versus 34.6%; OR, 2.23; 95% CI, 1.05-4.72) were more likely to have non-SLN metastases in both univariate and multivarite analyses. These results indicate that clinicopathologic factors might be helpful to select patients who were less likely to have negative SLN or non-SLNs. However, additional factors are still needed to be identified to omit surgical axillary staging.

Comparison of Subdermal and Peritumoral Injection Techniques of Lymphoscintigraphy to Determine the Sentinel Lymph Node in Breast Cancer

PURPOSE

The purpose of this study was to evaluate 2 different injection techniques for lymphoscintigraphy to determine the axillary sentinel lymph node (SLN) in patients with breast cancer.

METHODS

Thirty-six patients with early breast cancer were studied prospectively. Both peritumoral (PT) and subdermal (SD) injections were performed on each patient with Tc-99m rhenium sulfide colloid. PT injections were done 1 to 8 days before surgery and SD injections were done on the day of operation. An intraoperative gamma probe was used to explore the axillary SLNs prior to tumor excision and axillary dissection. All surgical specimens were evaluated histopathologically.

RESULTS

In 19 of 36 patients, the same lymphatic drainage sites were observed with both techniques. Of these, 17 patients showed only axillary, 1 showed axillary and internal mammary (IM), and 1 showed axillary and subclavicular drainage sites. With PT injections 26 of 36 patients (72%), and with SD injections 33 of 36 patients (92%), showed axillary drainage and axillary SLNs. With PT injections 9 patients, and with SD injections only 2 patients, did not show any drainage site. During the operation with a gamma probe, axillary SLNs were excised in 35 patients (success rate, 97%). IM drainage was seen in 8 of 36 patients who underwent PT injections and in 3 of 36 with SD injections.

CONCLUSION

The success rate was found to be higher with the SD injection technique than with PT injections to visualize the axillary SLN. To increase the visualization of both axillary and IM SLNs, it may be useful to perform lymphoscintigraphy with SD and PT injections together.

Can preoperative lymphoscintigraphy be used as a guide in treatment planning of breast cancer?

PURPOSE

The purpose of this study was to map the lymphatic drainage patterns of breast cancer with lymphoscintigraphy to evaluate the variability of drainage and to determine whether lymphatic mapping can help to increase the certainty of breast cancer staging.

MATERIALS AND METHODS

Fifty women with breast cancer (mean age, 49 years) were included in the study. Lymphoscintigraphy was performed with 1 mCi Tc-99m rhenium sulfide colloid in a 2-ml volume injected into the four quadrants of the peritumoral area using a 25-gauge needle. Ten-minute dynamic images and 2-hour delayed static images were obtained in the anterior and lateral positions using a gamma camera with a high-resolution collimator. All patients had a modified radical mastectomy and axillary dissection. The results were evaluated with histopathologic findings of the axilla.

RESULTS

Six patients had excision biopsies before surgery. Of 13 patients with centrally located tumors, 84% had axillary lymphatic drainage, whereas 53% drained to internal mammary lymphatics. Of 23 patients with outer quadrant tumors, 4 showed no lymphatic drainage and all of them had metastatic tumor in the axillary lymph nodes. Axillary drainage was seen in 82% of patients and internal mammary lymphatic drainage in 23%. Of eight patients with inner quadrant tumors, one patient with no lymphatic drainage was found to have metastases in the axilla. In this group, 62% had axillary and 50% had internal mammary lymphatic drainage, and one patient had supraclavicular drainage.

CONCLUSIONS

Lymphoscintigraphy indicates that drainage routes may vary, and thus it may play a guiding role in patients with breast cancer who need radiotherapy. In patients with internal mammary lymphatic drainage, the accuracy of radiotherapy planning may increase if internal mammary lymphoscintigraphy is added to the protocol. In patients with internal mammary drainage, obtaining an internal mammary lymphatic biopsy during surgery will also increase the accuracy of staging.

Episcleritis and scleritis: clinical features and treatment results

PURPOSE

To evaluate the clinical experience with episcleritis and scleritis at a tertiary care eye center.

METHODS

Retrospective chart review.

RESULTS

One hundred thirty-four patients with scleral inflammation were seen over a 12-year period. Thirty-seven patients had episcleritis, and 97 patients had scleritis. Ocular complications occurred in only 13.5% of patients with episcleritis but in 58.8% of patients with scleritis (P <.0001). No patient with episcleritis had a decrease in visual acuity, whereas 15.9% of patients with scleritis did. Only 16.7% of patients with episcleritis required more than topical corticosteroids for treatment, and these patients required oral nonsteroidal anti-inflammatory drugs. Conversely, 30.4% of patients with scleritis required nonsteroidal anti-inflammatory drugs, 31.9% oral prednisone, and 26.1% systemic immunosuppressive drugs (P <.0001). Necrotizing scleritis and posterior scleritis more often were associated with ocular complications, occurring in 91.7% and 85.7%, respectively, than were diffuse anterior scleritis and nodular anterior scleritis (P =.020). Patients with necrotizing scleritis and posterior scleritis were more likely to be treated with oral corticosteroids or immunosuppressive drugs (90% and 100%, respectively) than were patients with diffuse anterior scleritis and nodular anterior scleritis (56.4% and 21.4%, respectively, P =.002).

CONCLUSIONS

Scleritis is a severe ocular inflammation, often associated with ocular complications, and nearly always treated with systemic medications. Nearly 60% of these patients will need oral corticosteroids or immunosuppressive drugs to control the disease.

Lymphatic mapping for Merkel cell carcinoma

Merkel cell trabecular carcinoma of the skin has a prognosis poorer than expected for a small skin lesion. An early diagnosis and prompt treatment can contribute to improve survival in cases of this aggressive skin tumor. A wide local excision is indicated for localized disease. Elective lymph node dissection is controversial. The authors report a rare case of Merkel cell tumor treated with wide local excision and sentinel lymph node biopsy.

Scintigraphic varieties in Hashimoto's thyroiditis and comparison with ultrasonography

The scintigraphic findings in Hashimoto's thyroiditis are highly variable and can mimic any thyroid abnormality. In this study, we compared the scintigraphic findings with ultrasonography in 48 patients with Hashimoto's thyroiditis. Thyroid scintigrams revealed diffuse hyperplasia in 12 patients, multinodular goiter in 20 patients and a solitary nodule in 16 patients (toxic adenoma, n = 1; hypoactive nodule, n = 4; hyperactive nodule with no suppression, n = 3; normoactive nodule, n = 8). Ultrasonography revealed diffuse hyperplasia in 19 patients, multinodular goiter in 20 patients and a solitary nodule in 9 patients. The thyroid scan and ultrasonography revealed the same findings of diffuse hyperplasia in 12 patients and multinodular goiter in 20 patients. Of the 16 patients with a solitary nodule on scintigraphy, only 9 showed the same finding on ultrasonography, with the other 7 showing diffuse hyperplasia. The difference in nodularity between thyroid scanning (74.9%) and sonography (60.4%) has been attributed to pseudonodularity in Hashimoto's thyroiditis. In conclusion, our results confirmed that Hashimoto's thyroiditis can mimic any thyroid abnormality, including diffuse hyperplasia, nodular goiter and multinodular goiter on scintigraphy. Therefore, scintigraphy, ultrasonography and serum thyroid hormone estimation alone may not be helpful for the final diagnosis of Hashimoto's disease. To eliminate unnecessary surgical intervention, all patients should be evaluated by means of physical examination and thyroid autoantibodies, in addition to a thyroid scan, ultrasonography, serum thyroid hormones and fine-needle aspiration biopsy when necessary.

Resting Tl-201 scintigraphy in the evaluation of myocardial sarcoidosis

In patients with sarcoidosis, myocardial involvement is common and may be fatal. With extensive disease, the primary manifestations may include conduction abnormalities and arrhythmias, which may lead to sudden death. Myocardial perfusion scintigraphy may be the most accurate method to assess extent of myocardial involvement and response to therapy.

Laser photocoagulation for persistent central serous retinopathy: results of long-term follow-up

PURPOSE

The authors evaluated the effect of laser photocoagulation for persistent central serous retinopathy (CSR).

METHODS

The authors evaluated 45 eyes of 38 patients who had been offered laser photocoagulation for CSR that did not resolve after 4 months of observation. Sixteen eyes of 14 patients who did not accept laser photocoagulation were followed as the control group. The remaining 29 eyes of 24 patients comprised the study group. Argon green laser photocoagulation was performed on 9 eyes, dye-yellow laser photocoagulation was performed on 12 eyes, and dye-orange laser photocoagulation was performed on 8 eyes. Mean follow-up was 4.8 years (range, 1-7 years).

RESULTS

In the group that received laser treatment, duration of the serous detachment was shorter (P < 0.0001) and final best-corrected visual acuity (BCVA) was better (P = 0.006) than those of the control group. Although none of the eyes in the laser photocoagulation group had a recurrence, seven eyes in the control group had one or more recurrences during the mean follow-up period of 4.8 years (P = 0.0003). Although the duration of the serous detachment was shorter in the dye-yellow laser photocoagulation subgroup than in the argon green laser treatment subgroup (P = 0.01), there were no other differences between the laser photocoagulation subgroups with respect to the duration of the serous detachments or the final BCVA.

CONCLUSION

Direct laser photocoagulation of the leakage site(s) for CSR that persists for 4 months is safe and effective to shorten the duration of the serous detachment, to improve final BCVA, and to decrease the incidence of recurrence.

Early stage melanoma: lymphoscintigraphy, reproducibility of sentinel node detection, and effectiveness of the intraoperative gamma probe

PURPOSE

To assess the influence of lymphoscintigraphic and intraoperative gamma probe findings on the surgical management of melanoma and to test reproducibility of lymphoscintigraphic findings.

MATERIALS AND METHODS

After lymphoscintigraphic identification of the sentinel node, intraoperative gamma probe localization and sentinel lymph node excision were performed in 25 patients. To assess reproducibility, 13 patients underwent lymphoscintigraphy twice within 2-17 days. A modified preparation of technetium-99m sulfur colloid with smaller particles than routinely obtained was injected intradermally around the lesion. Dynamic flow images were obtained at 10 seconds per frame followed by a series of static images obtained every 5 minutes for 30 minutes.

RESULTS

A sentinel node was identified in all patients. In eight patients, multiple drainage pathways were seen and surgical management was changed. In 11 of the 13 who underwent lymphoscintigraphy twice, sentinel node identification was reproducible.

CONCLUSION

Lymphoscintigraphy is reproducible in detection of the sentinel node and with the surgical probe helps effectively guide surgical management.

False-positive I-131 images mimicking thyroid cancer metastasis. The nose ring sign

This case report describes an I-131 whole-body scan with false-positive uptake at the site of a nose ring in a patient with follicular thyroid cancer.

Tc-99m nanocolloid and Tc-99m MDP three-phase bone imaging in osteomyelitis and septic arthritis. A comparative study

The aim of this study was to compare Tc-99m nanocolloid scintigraphy with Tc-99m MDP bone imaging in the diagnosis of osteomyelitis and septic arthritis. Overall, 31 Tc-99m MDP bone scans and 39 Tc-99m nanocolloid studies were performed in 34 patients (15 female, 19 male; mean age, 14.88 years +/- 19.00 years) who were suspected of osteomyelitis and/or septic arthritis. The final diagnoses were established by needle aspiration, cultures, radiography, clinical course, and, in some patients, with CT, ultrasonography, and biopsy. The sensitivity, specificity, and accuracy were 100%, 75%, and 92%, respectively for both Tc-99m MDP and Tc-99m nanocolloid scans in detecting osteomyelitis. For septic arthritis, Tc-99m MDP bone imaging showed 100%, 85%, and 94%, and Tc-99m nanocolloid scans showed 90%, 59%, and 76%, sensitivity, specificity, and accuracy, respectively. These results show that, although both scans are in good agreement for osteomyelitis, for septic arthritis nanocolloid is not specific enough to recommend it to be a complementary method to MDP bone scans.

Comparison of renal perfusion indices in captopril scintigraphy

Perfusion indices used in renal scintigraphy were adapted to captopril-enhanced renal scintigraphy in order to determine if these parameters have any value in differentiating patients with renovascular hypertension (RVH) from normal subjects. Regions of interest (ROIs) were chosen over the aorta and kidneys, and time-activity curves generated. The ratio of integrated aortic counts to renal counts, from the time of injection to arterial peak, was calculated. The difference in the value of this index between captopril and basal scintigraphies was -17 +/- 12 and -16 +/- 13 for the right and left kidneys, respectively, in the group of patients with essential hypertension, whereas in the patients with renovascular hypertension, these values were 24 in the stenotic and 14 in the non-stenotic kidney. This parameter is useful for separating patients with RVH from normal subjects.

The role of quantitative 99Tcm-glucoheptonate scintigraphy in the evaluation of acute uveitis in patients with Behçet's disease

The purpose of this study was to evaluate the role of quantitative 99Tcm-glucoheptonate (99Tcm-GH) scintigraphy in the assessment of patients with Behçet's disease who suffered from ocular inflammation (uveitis). The study consisted of 13 patients with uveitis and five control subjects. There were a total of 25 eyes with chronic uveitis. Of these 25 eyes, 10 were in a state of remission, and the other 15 were in an acute phase of the illness. The study was performed by administering 370 MBq (10 mCi) 99Tcm-GH intravenously. Planar images were acquired 6 h later. Eye/scalp indices were quantified by drawing regions of interest (ROIs) around each eye and normalizing the mean counts per pixel by the mean counts in the scalp. The mean eye/scalp indices were 1.87 +/- 0.19 in controls and 1.98 +/- 0.19 in the affected eyes that were in remission (P = 0.23, nonsignificant). However, during the acute phase of the illness, the mean eye/scalp index was 2.18 +/- 0.28. The difference between controls and the eyes that were in the acute phase of the illness was significant (one way analysis of variance, P = 0.007). The mean value of the index for affected eyes in remission was not significantly different to that for eyes in the acute phase (P = 0.068, nonsignificant). These preliminary findings suggest that, despite previously published reports in animals with experimentally induced uveitis, 99Tcm-GH scintigraphy may not be a very sensitive method for evaluating human ocular inflammations.

Scintigraphic evaluation of the effectiveness of intranasal calcitonin therapy in Sudeck's atrophy

The aim of this study was to evaluate the efficacy of intranasal salmon calcitonin compared to a nonsteroidal anti-inflammatory drug (NSAID) in patients with Sudeck's atrophy by means of quantitative three-phase bone scanning. Included in the study were 14 patients with Sudeck's atrophy whose diagnoses were confirmed by clinical and radiological examinations. Seven patients were treated with intranasal salmon calcitonin (100 IU twice daily) and 1 g elementary calcium daily for 5 weeks. The other group of seven patients was treated with 75 mg indomethacin daily for 5 weeks. The effectiveness of both treatments was analysed by comparing quantitative three-phase bone scans which were performed before and after the treatment. Bone-to-soft tissue ratios were calculated from static (delayed) images and scintigraphic evaluations were done both visually and quantitatively. Patients who received the calcitonin/calcium regimen showed reduced bone/soft tissue indices after therapy whereas patients who received indomethacin showed no change or showed increased indices. In conclusion, the results show that intranasal salmon calcitonin and calcium treatment is more effective than NSAIDs in patients with Sudeck's atrophy.