Myriam Benamor

Validation and Limitations of Use of a Breast Cancer Nomogram Predicting the Likelihood of Non–Sentinel Node Involvement After Positive Sentinel Node Biopsy

BackgroundAxillary lymph node dissection (ALND) for patients with positive sentinel lymph nodes (SLNs) is currently under discussion in the literature. The breast cancer nomogram (BCN), an online tool developed by the Memorial Sloan-Kettering Cancer Center (MSKCC), aims to predict the risk of positive non-SLN in SLN-positive patients. The purpose of this study was to test the accuracy of the nomogram on patients with macrometastatic and micrometastatic SLN-positive biopsy findings.MethodsPatient characteristics, tumor pathology, and positive SLN characteristics were collected on 588 consecutive patients who underwent completion ALND. The MSKCC BCN tool was used to calculate risk of metastases for all 588 cases that included a subgroup of the 213 patients with SLN micrometastases. The BCN was performed for positive SLN biopsy findings regardless of the method of metastasis detection. Evaluation of the BCN was performed by the area under the curve method.ResultsThe BCN applied to all 588 patients achieved an area under the receiver operating characteristic curve (ROC) of .724 (range, .677–.771) compared with .76 in the MSKCC study. When the tool was applied solely to micrometastases found by hematoxylin and eosin staining and metastases found by immunohistochemistry, the area under the ROC was .538 (range, .423–.653).ConclusionsThe MSKCC nomogram has been validated for all the patients having a metastatic SLN at the Institut Curie. However, this model was not reliably predictive for positive non–SLN in cases with micrometastic positive SLN.

18F-FDG PET/CT bone/bone marrow findings in Hodgkin’s lymphoma may circumvent the use of bone marrow trephine biopsy at diagnosis staging

PurposeAccurate staging of Hodgkin’s lymphoma (HL) is necessary in selecting appropriate treatment. Bone marrow trephine biopsy (BMB) is the standard procedure for depicting bone marrow involvement. BMB is invasive and explores a limited part of the bone marrow. 18F-FDG PET/CT is now widely used for assessing response to therapy in HL and a baseline study is obtained to improve accuracy. The aim of this retrospective analysis was to assess whether routine BMB remains necessary with concomitant 18F-FDG PET/CT.MethodsData from 83 patients (newly diagnosed HL) were reviewed. All patients had received contrast-enhanced CT, BMB and 18F-FDG PET/CT. Results of BMB were not available at the time of 18F-FDG PET/CT imaging.ResultsSeven patients had lymphomatous involvement on BMB. Four patients had bone involvement on conventional CT (two with negative BMB). All patients with bone marrow and/or bone lesions at conventional staging were also diagnosed on 18F-FDG PET/CT scan. PET/CT depicted FDG-avid bone/bone marrow foci in nine additional patients. Four of them had only one or two foci, while the other had multiple foci. However, the iliac crest, site of the BMB, was not involved on 18F-FDG PET/CT. Osteolytic/sclerotic lesions matching FDG-avid foci were visible on the CT part of PET/CT in three patients. MRI ordered in three other patients suggested bone marrow involvement. Interim and/or end-therapy 18F-FDG PET/CT documented response of FDG-avid bone/bone marrow foci to chemotherapy in every patient.Conclusion18F-FDG PET/CT highly improves sensitivity for diagnosis of bone/bone marrow lesions in HL compared to conventional staging.

Impact of internal mammary sentinel node imaging in breast cancer.

A 28-year-old woman underwent mammary lymphoscintigraphy for evaluation of the sentinel node status of a small infiltrating ductal carcinoma in the central, lower, and outer quadrant of the left breast confirmed by biopsy. The patient was scheduled for lumpectomy and sentinel node biopsy. Lymphoscintigraphy showed increased uptake at two sites of the peritumorally injected tracer (60 MBq; 1.6 mCi rhenium sulfur nanocolloid) in internal mammary nodes, two of which were located most proximal to the tumor and related to the tumor by two distinct lymphatic ducts. An axillary lymph node was also detected. At surgery, the gamma probe confirmed the location of all the hot spots, and four nodes were harvested: one axillary, two first internal mammary nodes in the third intercostal space, and one internal mammary node in the second intercostal space. Histologic analysis revealed that the axillary sentinel node was free of disease, but the two first intramuscular sentinel nodes were metastatic. The second-echelon internal mammary node above the sentinel nodes (second intercostal space) was free of disease. This case shows the benefit of imaging all the drainage pathways of a breast tumor and retrieving nonaxillary lymph nodes, which may be the only positive nodes. As a result of the findings, the patient’s prognosis may be altered and the subsequent therapeutic approach may be modified. Although exclusive involvement of the internal mammary chain is well established and relatively rare (occurring in approximately 5% of cases), it is important to remember that the axillary status of a breast tumor is not the only major prognostic factor.

Value of 18FDG PET scan in staging of ocular adnexal lymphomas: a large single-center experience

Abstract Fluorine 18 deoxyglucose positron emission tomography (18FDG PET) is widely used in staging of non-Hodgkins lymphomas (NHL), but very few studies have focused on its role in the initial staging of patients with ocular adnexal lymphoma (OAL). The aim of this study was therefore to evaluate the role of 18FDG PET in the diagnosis of ophthalmologic lymphoma. A retrospective review of all imaging records, including computed tomography (CT), magnetic resonance imaging (MRI), and FDG PET, was performed. Forty-one OAL patients were included in the study. A pathologic review according to the World Health Organization classification showed 32 low-grade lymphoma patients (78%), including 26 mucosa-associated lymphoid tissue lymphomas (63%). Ophthalmologic sites were intra-orbital + lacrimal gland in 24 patients (59%), conjunctival in 13 patients (32%), multiple in 4 cases, and bilateral in 6 patients. 18FDG PET was positive in orbital and conjunctival sites in 68 and 35% of cases, respectively. 18FDG PET positivity was correlated with pathologic sites detected by MRI in 22/30 patients (73%); 18FDG PET positivity was correlated with pathologic sites detected by CT in 25/34 patients (73%). This study shows that 18FDG PET has a lower sensitivity than MRI to detect ophthalmologic lymphoma, particularly in non-conjunctival sites.

Desmoplastic neurotropic melanoma in a patient with trigeminal neuralgia: FDG PET/CT and MRI.

A 51-year-old man presented with a hard subcutaneous nodule adhering to the underlying bone structures of the left eyelid in 2004. Histopathology showed a desmoplastic neurotropic melanoma (DNM) with perineural invasion. Patient presented with a first recurrence in October 2005, which was treated by surgery. In August 2006 he presented with trigeminal neuralgia of the left face in the area innervated by the first and second branches of the trigeminal nerve. A PET scan clearly shows the tumoral hypermetabolism of the subcutaneous recurrence of the neurotropic melanoma with invasion of the second or maxillary branch that follows the nerve up to the trigeminal ganglion, which was detected despite the physiological high uptake in the temporal lobe. MRI confirms the invasion and a second PET and MRI 6 months later done to evaluate resectability showed progressive disease. DNM is a rare subtype of spindle cell melanoma. It corresponds to dermal proliferation of desmoplastic cells of neural differentiation. Unlike other melanomas, however, survival for DNM may be better compared with other forms of melanoma. This rare case report presents PET imaging involving cranial nerve invasion by this uncommon melanoma subtype.

Réseaux lymphatiques de la glande mammaire : l’identification du ganglion sentinelle revue à la lumière des anciens anatomistes

Lymphatic drainage of the mammary gland. Sentinel node biopsy revisited at the light of historical anatomical works Sentinel node biopsy for breast cancer was described in 1994 and is part of the daily treatment of small operable breast cancers. Colorimetric and/or isotopic technique allows identification of breast lymphatic network and its drainage towards the axilla. Periareolar or peri-tumoral injection of the Isotope or patent blue were demonstrated as injecting the same axillary node or group of nodes. The anatomy of the breast lymphatic drainage was described in the 19th century and before Sappey’s description one can say that the aesthetical and lactation diseases were the main concerns about the breast. Even though Queen Anne d’Autriche was treated with red iron for her T IV, the treatment of breast cancer remained poorly described until the end of the 19th century. Screening programs allow the discovery of smaller and smaller cancers in which the classical axillary dissection is no more useful. Identification of breast lymphatic drainage rediscovered the ancients’ anatomical works with lymphotropic dye and isotopes which can be used in vivo. The re-discovery of the anatomy by these authors is very valuable and very useful for our patients

Do isolated cells (pN0i+) in the sentinel lymph node change the post-operative management in breast cancer?.

Abstract #206 Background: immunohistochemical (IHC) analysis of the sentinel lymph node (SLN) allows detection of occult metastases not routinely diagnosed by conventional techniques. There is, however, no consensus concerning the post-operative management of those patients with IHC-positive (pN0i+) nodes: should one re-operate, change the medical treatment or alter the irradiation fields?
 Patients and methods: 2692 patients with early invasive breast cancer underwent conservative treatment with SLN biopsy between 2000 and 2006. SLN were evaluated with frozen section followed by serial-section HES and IHC if HES showed no tumour cells. Lymph node staging followed the accepted pTNM classification: pN0, pN0i+ (≤ 0.2mm, IHC+), pNmi (0.2-2mm) and pN1a (> 2mm). In 1506 patients with T1pN0 tumours : 143 were pN0i+, that is 10%. We compared the post-operative management of pN0 patients, who had no completion axillary dissection (CAD), to those pN0i+ who did. All positive SLNs underwent CAD according to our institutional protocol.
 Results: 15 of 143 (10.5%) pN0i+ patients showed metastases in their CAD; a single node in 10 cases, 2-3 in 4 and > 3 in one patient. Univariate analysis showed chemo- and hormono-therapy to be more frequently administered in pN0i+ (24.5% vs. 77.6%) compared to pN0 (9.1% vs. 55.8%) patients; p Citation Information: Cancer Res 2009;69(2 Suppl):Abstract nr 206.

Le ganglion sentinelle en routine dans les cancers du sein. Expérience de l’Institut Curie (Routine sentinel node detection in breast cancer. Experience of the Institutt Curie)

Depuis janvier 2000, la technique du ganglion sentinelle (GS) est devenue une activite de routine a l’Institut Curie, pratiquee par une equipe multidisciplinaire comprenant des chirurgiens, des medecins nucleaires, des radiologues et pathologistes entraines. Sur une periode de trois ans, 738 patientes consecutives ont beneficie de cette technique dans le cadre d’un traitement conservateur d’un cancer du sein de petite taille. Nos recommandations specifiques pour la procedure du GS etait la pratique systematique des diagnostics pre-operatoires par cytoponction ou biopsie, le choix d’un site d’injection des traceurs toujours peritumoral, un prelevement chirurgical premier du GS en vue d’un examen extemporane par coupe congele et enfin l’application de criteres precis pour de cider d’une re-intervention chirurgicale. Cet article est une evaluation des pratiques d’un centre specialise et permet de degager les points forts et les points faibles de la procedure.