errarese F

Prognostic factors in breast cancer: the predictive value of the Nottingham Prognostic Index in patients with a long-term follow-up that were treated in a single institution

The Nottingham Prognostic Index (NPI) is an index, derived from a retrospective multivariate study, that is able to predict survival in patients with breast cancer. The index is based on tumour size, lymph node stage and histological grade and allows the stratification of patients into three different prognostic groups. The aim of this study was to verify, according to our experience with a long-term follow-up, the effect of some prognostic variables on survival and to establish the independent influence of each of them by means of a survival regression analysis. Then we applied the NPI to the same group of patients in order to assess the predictive power and reproducibility of the index. 402 patients treated from January 1979 to December 1987 were evaluated. In multivariate analysis (Cox proportional hazard model), only size, lymph node involvement and histological grade remained independent prognostic factors. The survival curves obtained after applying the NPI are similar to those for the factors with independent prognostic significance derived from our multivariate analysis. Our improved survival rates may be attributed to the administration of adjuvant therapies to a larger number of patients. The NPI allow us to accurately predict prognosis and we advocate its more common use.

Subareolar injection may be more accurate than other techniques for sentinel lymph node biopsy in breast cancer.

AbstractBackground: The aims of this study were to compare peritumoral injection of 99mTc-labeled albumin and subdermal injection of blue dye with subareolar (SA) injection of blue dye alone in terms of success of the sentinel lymph node identification rate, false negative (FN) rate, overall accuracy, and sensitivity of the two procedures. Methods: From January 1999 to October 2002, 155 patients with localized breast cancer were treated. Patients were subdivided into two groups. In patients in group 1 (n = 115; January 1999 to December 2001), lymphoscintigraphy together with injection of vital dye was performed. In patients in group 2 (n = 40; January 2002 to October 2002), SA injection of blue dye alone was performed. Results: In patients in group 1, the overall successful identification rate was 94.8%. The success rate of identifying a sentinel lymph node by a combination of the two techniques was 95%. With blue dye alone, the successful identification rate was 94.6% in patients in group 1 (subdermal) and 97.5% in group 2 (SA). The FN rate was 9% in group 1 and 0% in group 2. The overall accuracy of lymphatic mapping was 97% in group 1 and 100% in group 2. Sensitivity was 91% in group 1 and 100% in group 2. Conclusions: This study of dye-only injection into the SA plexus demonstrates a high sentinel node identification rate, absent FN rate, and rapid learning curve. On the basis of these findings, we propose that injections into the SA lymphatic plexus are the optimal way to perform dye-only lymphatic mapping of the breast.

Effect of the use of vital dye, lymphoscintigraphy, or a combination for axillary lymphatic mapping and sentinel node biopsy in breast cancer

Axillary dissection in patients with breast cancer is associated with significant morbidity. Because 85% of the patients with a cancer ≤1 cm have negative axillary nodal status, axillary dissection in these patients is only a staging procedure. A study of the sentinel lymph node (SLN) biopsy has been developed to determine axillary nodal status by means of a minimally invasive procedure. The aim of our study was to estimate the degree of reliability for identifying the SLN using a vital dye or lymphoscintigraphy, or a combination of the two. From January 1999 to May 2000 a series of 60 patients with breast cancer were evaluated for enrollment in the study. For the mapping procedure, lymphoscintigraphy in combination with injection of vital blue dye was performed in 24 patients, and vital dye alone was utilized in 36. Complete axillary dissection was performed in all patients after SLN biopsy. The mapping procedure was possible in 59 cases (98.3%). The SLNs were positive in 19 patients (32.2%) and negative in 40; in 38 of the 40 patients all axillary nodes were negative. There was concordance in 57 of 59 cases (96.6%). The false-negative rate was 5% (2/40). The overall sensitivity of the SLN biopsy was 90.4% (19/21), with a negative predictive value of 95% (38/40). Our results indicate that SLN biopsy guided by a gamma probe in combination with vital dye can identify a negative axilla with high accuracy. We conclude that the use of both techniques produces an optimal result, as they are complementanry.RésuméLa lymphadénectomie de l’aisselle pour cancer du sein est responsable d’une certaine morbidité. Puisque 85% des patients ayant un cancer <1 cm n’ont pas d’atteinte ganglionnaire axillaire, la lymphadénectomie chez ces patients ne sert qu’au staging. L’étude des ganglions satellites, basée sur la biopsie de ganglion sentinelle (GS), a été développée pour pouvoir déterminer l’état ganglionnaire axillaire par un procédé minimal-invasif. Le but de notre étude a été, pour optimiser les résultats, d’évaluer la fiabilité de l’identification du GS par l’utilisatiaon des colorations vitales ou la lymphoscintigraphie ou les deux. Entre janvier 1999 et mai 2000, 60 patientes porteuses de cancer du sein ont été incluses dans l’étude. La coloration vitale a été utilisée seule (n=36) ou en combinaison avec la lymphoscintigraphie (n=24). Chez toutes les patientes, une lymphadénectomie axillaire complète a été réalisée après biopsie du GS. Une cartographie a été obetnue avec succès dans 59 cas (98.3%). Les GS étaient positifs chez 19 patientes (32.2%), négatifs chez 40 patientes alors que chez 38 de ces patientes, tous les ganglions axillaires étaient indemnes. Il y a eu concordance donc dans 57/59 cas (96.6%). Le taux de faux négatifs a été de 5% (2/40). La sensibilité globale de la biopsie du GS a été de 90.4% (19/21), avec une valeur prédictive négative de 95% (38/40). Nos résultats indiquent que la biopsie du GS guidée par une sonde γ en combinaison avec une coloration vitale pourrait identifier avec une grande précision une aisselle négative et nous conclusons que l’utilisation des deux techniques produit un résultat optimal en raison de leur complémentarité.ResumenEl vaciamiento axilar en el cáncer de mama origina una importante morbilidad. Dado que el 85% de los pacientes cuyo cáncer de mama tiene un tama no igual o menor a 1 cm, presentan adenopatías axilares negativas, la disección de la axila sólo tiene por objeto verificar la estadificación del proceso neoplásico. El concepto de biopsia del ganglio centinela se ha desarrollado con objeto de averiguar la estadificación ganglionar, mediante una intervención mínimamente invasiva. El presente trabajo tiene por objeto averiguar el grado de fiabilidad, en la identificación del ganglio centinela (SLN), de los colorantes vitales, de la linfoescintigrafía, o, para optimizar los resultados, de la combinación de ambas técnicas. Desde enero de 1999 a mayo de 2000, se estudiaron con estos fines 60 pacientes con cáncer de mama. La cartografía en 24 enfermos se realizó mediante linfoescintigrafía combinada con la inyección de contraste vital azul; en 36 sólo se emploó la coloración vital. En todos los pacientes, tras la biopsia del ganglio centinela (SLN), se realizó un vaciamiento total de axila. La cartografía fue posible en 59 casos (98.3%). El SLN fue positivo en 19 (32.2%) de los pacientes; negativo en 40, de los que en 38, registramos adenopatías axilares negativas. Así pues, observamos una concordancia en 57/59 casos (96.6%). El porcentaje de falsos negativos fue del 5% (2/40). La sensibilidad global de la biopsia del SLN fue del 90.4% (19/21) con un valor pronóstico negativo del 95% (38/40). Nuestros resultados demuestran que la biopsia del SLN guidad por gammagrafía combinada con la utilización de colorantes vitales permite descartar la presencia de metástasis ganglionares axilaraes, alcanzándose resultados óptimos si se emplean conjuntamente ambas técnicas.