Celia Chao

Complications associated with sentinel lymph node biopsy for melanoma

AbstractBackground: Sentinel lymph node (SLN) biopsy has become widely accepted as a method of staging the regional lymph nodes for patients with melanoma. Although it is often stated that SLN biopsy is a minimally invasive procedure associated with few complications, a paucity of data exists to specifically determine the morbidity associated with this procedure. This analysis was performed to evaluate the morbidity associated with SLN biopsy compared with completion lymph node dissection (CLND).n Methods: Patients were enrolled in the Sunbelt Melanoma Trial, a prospective multi-institutional study of SLN biopsy for melanoma. Patients underwent SLN biopsy and were prospectively followed up for the development of complications associated with this technique. Patients who had evidence of nodal metastasis in the SLN underwent CLND. Complications associated with SLN biopsy alone were compared with those associated with SLN biopsy plus CLND.n Results: A total of 2120 patients were evaluated, with a median follow-up of 16 months. Overall, 96 (4.6%) of 2120 patients developed major or minor complications associated with SLN biopsy, whereas 103 (23.2%) of 444 patients experienced complications associated with SLN biopsy plus CLND. There were no deaths associated with either procedure.n Conclusions: SLN biopsy alone is associated with significantly less morbidity compared with SLN biopsy plus CLND.

Defining the Optimal Surgeon Experience for Breast Cancer Sentinel Lymph Node Biopsy: A Model for Implementation of New Surgical Techniques

ObjectiveTo determine the optimal experience required to minimize the false-negative rate of sentinel lymph node (SLN) biopsy for breast cancer. Summary Background DataBefore abandoning routine axillary dissection in favor of SLN biopsy for breast cancer, each surgeon and institution must document acceptable SLN identification and false-negative rates. Although some studies have examined the impact of individual surgeon experience on the SLN identification rate, minimal data exist to determine the optimal experience required to minimize the more crucial false-negative rate. MethodsAnalysis was performed of a large prospective multiinstitutional study involving 226 surgeons. SLN biopsy was performed using blue dye, radioactive colloid, or both. SLN biopsy was performed with completion axillary LN dissection in all patients. The impact of surgeon experience on the SLN identification and false-negative rates was examined. Logistic regression analysis was performed to evaluate independent factors in addition to surgeon experience associated with these outcomes. ResultsA total of 2,148 patients were enrolled in the study. Improvement in the SLN identification and false-negative rates was found after 20 cases had been performed. Multivariate analysis revealed that patient age, nonpalpable tumors, and injection of blue dye alone for SLN biopsy were independently associated with decreased SLN identification rates, whereas upper outer quadrant tumor location was the only factor associated with an increased false-negative rate. ConclusionsSurgeons should perform at least 20 SLN cases with acceptable results before abandoning routine axillary dissection. This study provides a model for surgeon training and experience that may be applicable to the implementation of other new surgical technologies.

Sentinel lymph node biopsy for breast cancer: impact of the number of sentinel nodes removed on the false-negative rate

BACKGROUNDnNumerous studies have demonstrated that sentinel lymph node (SLN) biopsy can accurately determine axillary nodal status for breast cancer, but unacceptably high false negative rates have also been reported. Attention has been focused on factors associated with improved accuracy. We have previously shown that injection of blue dye in combination with radioactive colloid reduces the false negative rate compared with injection of blue dye alone. We hypothesized that this may be from the increased ability to identify multiple sentinel nodes. The purpose of this analysis was to determine whether removal of multiple SLNs results in a lower false negative rate.nnnSTUDY DESIGNnThe University of Louisville Breast Cancer Sentinel Lymph Node Study is a prospective multiinstitutional study. Patients with clinical stage T1-2, N0 breast cancer were eligible for enrollment. All patients underwent SLN biopsy using blue dye alone, radioactive colloid alone, or both agents in combination, followed by completion level I and II axillary dissection.nnnRESULTSnA total of 1,436 patients were enrolled in the study from August 1997 to February 2000. SLNs were identified in 1,287 patients (90%), with an overall false negative rate of 8.3%. A single SLN was removed in 537 patients. Multiple SLNs were removed in 750 patients. The false negative rates were 14.3% and 4.3% for patients with a single sentinel node versus multiple sentinel nodes removed, respectively (p = 0.0004, chi-square). Logistic regression analysis revealed that use of blue dye injection alone was the only factor independently associated with identification of a single SLN (p<0.0001), and patient age, tumor size, tumor location, surgeons previous experience, and type of operation were not significant.nnnCONCLUSIONSnThe ability to identify multiple sentinel nodes, when they exist, improves the diagnostic accuracy of SLN biopsy. Injection of radioactive colloid in combination with blue dye improves the ability to identify multiple sentinel nodes compared with the use of blue dye alone.

Sentinel lymph node biopsy for head and neck melanomas.

Background: Sentinel lymph node (SLN) biopsy for head and neck (H&&N) melanomas may be more technically challenging compared with other locations because of complex lymphatic drainage patterns. This analysis was performed to compare the results of SLN biopsy for H&&N, truncal, and extremity melanomas.Methods: The Sunbelt Melanoma Trial includes patients aged 18 to 70 with melanomas ≥1.0 mm thick. Statistical comparison was performed by χ2 or analysis of variance test.Results: A total of 2610 patients were evaluated with a median follow-up of 18 months. The mean number of SLN per nodal basin was 2.8, 2.7, and 2.1 for H&&N, truncal, and extremity melanomas, respectively. Median Clark level, Breslow thickness, and percentage of ulceration were similar between the groups. Peri-parotid SLN was identified in 25% of cases; there were no facial nerve injuries. SLN biopsy for H&&N melanoma had higher false-negative rates at 1.5% (vs. 0.5% for trunk or extremity) but less histologically positive SLN at 15% (vs. 23.4%, and 19.5%; P &< .001) compared with truncal and extremity melanoma. Blue dye was visualized less frequently in SLN of H&&N melanoma patients compared with those with trunk or extremity melanomas.Conclusions: Preoperative lymphoscintigraphy and meticulous intraoperative search for blue/radioactive nodes may improve results in H&&N melanomas.

Patterns of early recurrence after sentinel lymph node biopsy for melanoma

BACKGROUNDnPatterns of early recurrence after sentinel lymph node (SLN) biopsy for melanoma was determined from the Sunbelt Melanoma Trial, which includes patients with Breslow thickness > or =1.0 mm and nonpalpable regional lymph nodes.nnnMETHODSnSLN were evaluated by routine histology and S-100 protein stain. Overall, there were 1,183 patients with a median follow-up of 16 months.nnnRESULTSnSLN were positive in 233 of 1,183 patients (20%). The recurrence rate was greater among patients with histologically positive SLN than those with negative SLN (15.5% versus 6.0%, respectively, P <0.05). Patients with positive SLN were more likely to have distant metastases (as opposed to locoregional recurrence) than those with negative SLN (67% versus 46%, respectively, P <0.05). By multivariate analysis, SLN status, Breslow thickness, Clark level, and ulceration were significant independent factors associated with early recurrence. Of patients with negative SLN, 14 of 950 (1.5%) experienced metastatic disease in lymph node basins which were staged as negative for tumor by SLN biopsy initially.nnnCONCLUSIONSnEarly regional lymph node recurrence was very uncommon after positive SLN biopsy and completion lymphadenectomy. Patients with positive SLN are more likely than those with negative SLN to develop both local/in-transit recurrence and distant metastases within a short follow-up period.

Utility of intraoperative frozen section analysis of sentinel lymph nodes in breast cancer.

BACKGROUNDnIntraoperative frozen section pathologic analysis of sentinel lymph node (SLN) may guide immediate (single-stage) completion axillary dissection for patients with nodal metastases.nnnMETHODSnThe results of 203 consecutive patients undergoing SLN biopsy who had intraoperative pathology consultation between January 1998 and September 2000 were reviewed. SLN were analyzed by standard frozen section procedures. Final pathologic analysis included hematoxylin and eosin (H&E) staining of serial sections at 2-mm intervals.nnnRESULTSnFrozen section analysis correctly identified a positive or negative result in 185 of 203 cases (overall accuracy 91%). In 17 of 53 cases, the SLNs were negative for tumor by frozen section, but positive on permanent section analysis (sensitivity 68%). The mean size of the nodal metastases was 6.2 mm and 1.5 mm in patients found to have true positive and false negative results, respectively (P <0.003). A single false positive SLN is reported.nnnCONCLUSIONSnTwo thirds of the patients were spared the need for reoperative axillary lymphadenectomy.

The effect of prior breast biopsy method and concurrent definitive breast procedure on success and accuracy of sentinel lymph node biopsy

BackgroundIt has been suggested that sentinel lymph node (SLN) biopsy for breast cancer may be less accurate after excisional biopsy of the primary tumor compared with core needle biopsy. Furthermore, some have suggested an improved ability to identify the SLN when total mastectomy is performed compared with lumpectomy. This analysis was performed to determine the impact of the type of breast biopsy (needle vs. excisional) or definitive surgical procedure (lumpectomy vs. mastectomy) on the accuracy of SLN biopsy.MethodsThe University of Louisville Breast Cancer Sentinel Lymph Node Study is a prospective multi-institutional study. Patients with clinical stage T1–2, N0 breast cancer were eligible. All patients underwent SLN biopsy and completion level I/II axillary dissection. Statistical comparison was performed by χ2 analysis.ResultsA total of 2206 patients were enrolled in the study. There were no statistically significant differences in SLN identification rate or false-negative rate between patients undergoing excisional versus needle biopsy. The SLN identification and false-negative rates also were not statistically different between patients who had total mastectomy compared with those who had a lumpectomy.ConclusionsExcisional biopsy does not significantly affect the accuracy of SLN biopsy, nor does the type of definitive surgical procedure.

Adjuvant Chemotherapy for Breast Cancer: How Presentation of Recurrence Risk Influences Decision-Making

PURPOSEnThe purpose of this study was to examine the impact of four methods of communicating survival benefits on chemotherapy decisions. We hypothesized that the four methods of communicating mathematically equivalent risk information would lead to different chemotherapy decisions.nnnMETHODSnEach participant received two hypothetical scenarios regarding their mother (a postmenopausal woman with an invasive, lymph node-negative, hormone receptor-positive breast cancer) and was asked to decide whether they would encourage their mother to take chemotherapy in addition to surgery and tamoxifen. In the part 1, participants received one of four methods of describing the chemotherapy survival benefit: (1) relative risk reduction, (2) absolute risk reduction, (3) absolute survival benefit, or (4) number needed to treat. In part 2, each participant received all four methods. Following each decision, participants were asked to rate their confidence and confusion regarding their decision.nnnRESULTSnParticipants included 203 preclinical medical students. In part 1, participants who received relative risk reduction information were significantly more likely to endorse chemotherapy. In part 2, there were no treatment decision differences when participants received all four methods of communicating survival benefits of chemotherapy. However, receiving all four methods led to significantly higher ratings of confusion. In deciding on endorsing chemotherapy, participants understood the information best when presented with data in the absolute survival benefit format.nnnCONCLUSIONnThese results support the hypothesis that the method used to present information about chemotherapy influences treatment decisions. Absolute survival benefit is the most easily understood method of conveying the information regarding benefit of treatment.

Radiofrequency ablation for unresectable hepatic tumors.

Abstract Background: Radiofrequency ablation (RFA) is a relatively new treatment for unresectable hepatic tumors. The purpose of this analysis was to examine the frequency of complications and local recurrence associated with RFA. Methods: Patients who underwent RFA of hepatic tumors with curative intent were included in this study. At laparotomy, RFA was performed using intraoperative ultrasound guidance. Computed tomography scans were obtained in the immediate postoperative period and every 3 to 6 months thereafter. Results: Forty patients underwent RFA for 122 hepatic tumors. Thirty-one patients had metastatic lesions from colorectal cancer; 9 had other liver tumors. Complications occurred in 8 patients. With 9.5 months median follow-up, 6 patients had local recurrence of their ablated tumors. Conclusions: Our initial experience shows that RFA can effectively eradicate unresectable hepatic tumors. The rate and severity of complications appear acceptable. However, further study is necessary to assess long-term recurrence rates and effect on overall survival.

The use of cytokeratin staining in sentinel lymph node biopsy for breast cancer

BACKGROUNDnControversy exists regarding the routine use of cytokeratin immunohistochemistry (IHC) in the histopathologic examination of breast cancer sentinel lymph nodes (SLN) because the clinical significance of micrometastases detected by IHC is unclear. This analysis was performed to determine the frequency of IHC-detected micrometastases.nnnMETHODSnAll patients underwent SLN biopsy, followed by completion axillary dissection. This analysis included patients who had SLN evaluated by IHC. SLN were examined by hematoxylin and eosin (H&E) stain at 2-mm intervals, with IHC in 2 sections. The axillary dissection specimen was evaluated by routine H&E staining.nnnRESULTSnIHC was performed in SLNs from 973 patients. Of the 869 patients with negative nodes by H&E, 58 (6.7%) were upstaged by IHC. In 6 of 58 patients (10.3%) who had IHC-only positive SLN, nodal metastases were found in the axillary dissection specimen.nnnCONCLUSIONSnIHC resulted in upstaging of 6.7% of patients who had negative SLN on H&E staining. These patients had a 10.3% risk of residual axillary nodal metastases. However, the clinical significance of IHC-only positive SLN requires further study.