Mária Rajtár

Comparison of vital dye-guided lymphatic mapping and dye plus gamma probe-guided sentinel node biopsy in breast cancer

The optimal technique for sentinel lymph node biopsy (SLNB) is still debated. SLNB with peritumoral injection of Patent blue dye was performed in 129 clinically T1-T2 and NO breast cancers in 127 patients (group A); it was later replaced by combined dye and radiocolloid-guided SLNB preceded by lymphoscintigraphy in 72 breast cancer patients (group B). This study compares these two methods. All patients underwent completion axillary dissection. Means of 1.4 and 1.3 SLNs were identified in groups A and B, respectively. The mean number of non-SLNs for the whole series was 14.9 (range 5–42). The first 53 cases of lymphatic mapping (dye only) comprised the institutional learning period during which the identification rate of at least 1 SLN in 30 consecutive attempts reached 90%. The identification rate for the subsequent 76 group A patients was 92%. The accuracy rate of SLNBs for overall axillary nodal status prediction and the false-negative rate for group A patients (after excluding the learning-phase cases) were 93% and 10%, respectively. All 72 group B cases had at least one SLN identified, and only one false-negative case occurred in this group (accuracy and false-negative rates of 99% and 3%, respectively). Both the dye-only and the combined SLNB methods are suitable for SLN identification, but the latter works better and results in higher accuracy, a higher negative predictive value, and a lower false-negative rate. It is therefore the method of choice.RésuméLa technique optimale pour identifier le ganglion sentinelle (GS) est toujours débattèe. On a injecté en péritumorale, dans le but d’une biopsie d’un GS, du bleu Patent chez 127 patientes porteuses de 129 tumeurs du sein, classées T1–T2 et NO cliniquement (Groupe A); cette méthode a été remplacée ultérieurement par l’utilisation de la combinaison de colorant et de biopsie de GS précédée d’une lymphoscintigraphie chez 72 patientes porteuses de cancer de sein (Groupe B). Cette étude compare les deux méthodes de biopsie du GS. Toutes les patientes ont eu une lymphadénectomie axillaire. On a identifié 1.4 et 1.3 GS en moyenne, respectivement, dans les groupes A et B. Le taux moyen pour toute la série a été de 14.9 (extrêmes 5–42). Les 53 premiers cas de cartographie lymphatique (colorant uniquement) ont été considérés comme la période d’apprentissage initial, pendant laquelle l’identification d’au moins un GS a atteint 90% parmi les 30 premiers essais consécutifs. Par la suite, le taux d’identification dans le groupe A a été de 92%. La précision de la biopsie des GS pour la prédiction d’atteinte ganglionnaire globale et le taux de faux négatifs pour le groupe A (après exclusion des cas de la courbe d’apprentissage) ont été, respectivement, de 93% et de 10%. On a identifié au moins un GS chez toutes les 72 patientes du groupe B, et seulement un faux négatif a été reconnu dans ce groupe, c’est-à-dire une précision et un taux de faux négatifs de, respectivement, 99% et 3%. L≐utilisation du colorant seul ou de l’ensemble colorant/lymphoscintigraphie est valable pour l’identification du GS, mais, pour cette dernière, l’efficacité et la précision sont meilleures, la valeur prédictive négative plus élevée et le taux de faux-négatifs plus bas. c’est donc la méthode de choix.ResumenTodavía existe controversia sobre cual es la mejor técnica para la realización de la biopsia del ganglio centinela (SLNB). La SLNB mediante la sola inyección peritumoral del contraste Patent azul se utilizó en 129 cánceres de mama en estadio T1–T2 N0, correspondientes a 127 pacientes (grupo A). Más tarde se sustituyó esta técnica por una SLNB guiada por la utilización conjunta del colorante vital y de radiocoloides, precedida por una linfoescintigrafía. Este método se empleó en 72 pacientes con cáncer de mama (grupo B). En todos los pacientes se realizó un vaciamiento completo de axila. Un promedio de 1.4 y 1.3 SLN se identificaron en el grupo A y en el B. Los primeros 53 casos de cartografía linfática (sólo con colorante vital) constituyen el periodo de aprendizaje durante el cual se identificó al menos 1 SLN en 30 pacientes consecutivos, por lo que el porcentaje de identificación alcanzó el 90%. El porcentaje de identificación en los 76 pacientes restantes del grupo A fue del 92%. La precisión de la SLNB para el pronóstico global del estadio ganglionar axilar y el porcentaje de falsos negativos en pacientes del grupo A (exclusión hecha de los casos utilizados durante el periodo de aprendizaje) fue respectivamente del 93% y 10%. En los 72 casos del grupo B se identificó, como mínimo, 1 SLN registrándose tan solo 1 falso negativo lo que implica una exactitud del 99% y un porcentaje de falsos negativos del 3%. Tanto el contraste vital solo como asociado a una escintografía son métodos apropiados para la SLNB y la identificación del ganglio centinela (SLN) pero la asociación de ambos métodos es mejor, pues proporciona una gran exactitud, mayores valores predictivos negativos, y menor porcentaje de falsos negativos. Por ello, constituye el método de elección.

Predicting non-sentinel lymph node status after positive sentinel biopsy in breast cancer: What model performs the best in a Czech population?

Several models have previously been proposed to predict the probability of non-sentinel lymph node (NSLN) metastases after a positive sentinel lymph node (SLN) biopsy in breast cancer. The aim of this study was to assess the accuracy of two previously published nomograms (MSKCC, Stanford) and to develop an alternative model with the best predictive accuracy in a Czech population. In the basic population of 330 SLN-positive patients from the Czech Republic, the accuracy of the MSKCC and the Stanford nomograms was tested by the area under the receiver operating characteristics curve (AUC). A new model (MOU nomogram) was proposed according to the results of multivariate analysis of relevant clinicopathologic variables. The new model was validated in an independent test population from Hungary (383 patients). In the basic population, six of 27 patients with isolated tumor cells (ITC) in the SLN harbored additional NSLN metastases. The AUCs of the MSKCC and Stanford nomograms were 0.68 and 0.66, respectively; for the MOU nomogram it reached 0.76. In the test population, the AUC of the MOU nomogram was similar to that of the basic population (0.74). The presence of only ITC in SLN does not preclude further nodal involvement. Additional variables are beneficial when considering the probability of NSLN metastases. In the basic population, the previously published nomograms (MSKCC and Stanford) showed only limited accuracy. The developed MOU nomogram proved more suitable for the basic population, such as for another independent population from a mid-European country.

Analysis of predictive tools for further axillary involvement in patients with sentinel lymph node positive small (≤15 mm) invasive breast cancer

Small breast cancers often require different treatment than larger ones. The frequency and predictability of further nodal involvement was evaluated in patients with positive sentinel lymph nodes and breast cancers < or =15 mm by means of 8 different predictive tools. Of 506 patients with such small tumors 138 with positive sentinel nodes underwent axillary dissection and 39 of these had non-sentinel node involvement too. The Stanford nomogram and the micrometastatic nomogram were the predictive tools identifying a small group of patients with low probability of further axillary involvement that might not require completion axillary lymph node dissection. Our data also suggest that the Tenon score can separate subsets of patients with a low and a higher risk of non-sentinel node metastasis. Predictive tools based on multivariate models can help in omitting completion axillary dissection in patients with low risk of non-sentinel lymph node metastasis based on their small tumor size.

Leukocyte labeling with 99mTc-HMPAO. The role of the in vitro stability of HMPAO on the labeling efficacy and image quality

Abstract 99m Tc-HMPAO was prepared by incubating for different times (range of 7–90 min) and was then used for in vitro leukocyte labeling. The effects of the variation of incubation time and cell concentration in the labeling suspension on the yield of the lipophilic complex, the labeling efficacy and the image quality were determined. The yield of lipophilic complex decreased with an increase of incubation time ( r = −0.5335). A weak correlation was observed between the incubation time and the labeling efficacy ( r = −0.2275) and between the lipophilic complex yield and the labeling efficacy ( r = −0.1960). The cell concentration in the labeling suspension appeared to be the most important factor affecting the labeling efficacy ( r = −0.4996). Variation of incubation time did not exert a change in quality of the images. The 99m Tc-HMPAO kit containing a stabilizing agent can be used for multiple leukocyte labeling after incubation for 7–90 min.