Rosemary Giuliano

Sentinel Node Biopsy in Ductal Carcinoma In Situ Patients

Background: Sentinel lymph node (SLN) mapping is an effective and accurate method of evaluating the regional lymph nodes in breast cancer patients. The SLN is the first node that receives lymphatic drainage from the primary tumor. Patients with micrometastatic disease, previously undetected by routine hematoxylin and eosin (H&E) stains, are now being detected with the new technology of SLN biopsy, followed by a more detailed examination of the SLN that includes serial sectioning and cytokeratin immunohistochemical (CK IHC) staining of the nodes.Methods: At Moffitt Cancer Center, 87 patients with newly diagnosed pure ductal carcinoma in situ (DCIS) lesions were evaluated by using CK IHC staining of the SLN. Patients with any focus of microinvasive disease, detected on diagnostic breast biopsy by routine H&E, were excluded from this study. DCIS patients, with biopsy-proven in situ tumor by routine H&E stains, underwent intraoperative lymphatic mapping, using a combination of vital blue dye and technetium-labeled sulfur colloid. The excised SLNs were examined grossly, by imprint cytology, by standard H&E histology, and by IHC stains for CK. All SLNs that had only CK-positive cells were subsequently confirmed malignant by a more detailed histological examination of the nodes.Results: CK IHC staining was performed on 177 SLNs in 87 DCIS breast cancer patients. Five of the 87 DCIS patients (6%) had positive SLNs. Three of these patients were only CK positive and two were both H&E and CK positive. Therefore, routine H&E staining missed microinvasive disease in three of five DCIS patients with positive SLNs. In addition, DCIS patients with occult micrometastatic disease to the SLN underwent a complete axillary lymph node dissection, and the SLNs were the only nodes found to have metastatic disease. Of interest, four of the five nodepositive patients had comedo carcinoma associated with the DCIS lesion, and one patient had a large 9.5-cm low grade cribriform and micropapillary type of DCIS.Conclusions: This study confirms that lymphatic mapping in breast cancer patients with DCIS lesions is a technically feasible and a highly accurate method of staging patients with undetected micrometastatic disease to the regional lymphatic basin. This procedure can be performed with minimal morbidity, because only one or two SLNs, which are at highest risk for containing metastatic disease, are removed. This allows the pathologist to examine the one or two lymph nodes with greater detail by using serial sectioning and CK IHC staining of the SLNs. Because most patients with DCIS lesions detected by routine H&E stains do not have regional lymph node metastases, these patients can safely avoid the complications associated with a complete axillary lymph node dissection and systemic chemotherapy. However, DCIS patients with occult micrometastases of the regional lymphatic basin can be staged with higher accuracy and treated in a more selective fashion.

Clinical patterns of metastasis.

In human solid cancer, lymph node status is the most important indicator for clinical outcome. Recent developments in the sentinel lymph node concept and technology have resulted in a more precise way of examining micrometastasis in the sentinel lymph node and the role of lymphovascular system in the facilitation of cancer metastasis.Different patens of metastasis are described with respect to different types of solid cancer. Expect perhaps for papillary carcinoma and sarcoma, the overwhelming evidence is that solid cancer progresses in an orderly progression from the primary site to the regional lymph node or the sentinel lymph node in the majority of cases with subsequent dissemination to the systemic sites. The basic mechanisms of cancer metastasis through the lymphovascular system form the basis of rational therapy against cancer. Beyond the clinical patterns of metastasis, it is imperative to understand the biology of metastasis and to characterize patterns of metastasis perhaps due to heterogeneous clones based on their molecular signatures.

Radioguidance for nonpalpable primary lesions and sentinel lymph node(s).

BACKGROUND Radioguided surgery can also be used for the simultaneous guidance to a nonpalpable primary tumor and sentinel lymph nodes. METHODS Retrospective review of a prospective database. The surgeon used a gamma probe for guidance to an iodine-125 labeled titanium seed at the primary lesion and technetium-99 labeled sulfur colloid at the sentinel lymph node. RESULTS Forty-three patients with nonpalpable breast carcinoma underwent dual isotope radioguided surgery. The radioactive seed and primary lesion were retrieved in the first excision in all 44 patients (100%). Eleven patients (25%) had pathologically involved margins. Sentinel lymph node mapping was successful in 42 patients (98%). A mean of 2.4 sentinel nodes were excised and metastatic carcinoma was present in four patients (10%). CONCLUSIONS Dual isotopes can be effectively used in breast cancer patients for simultaneous radioguidance to both a nonpalpable primary lesion and sentinel lymph node and allows for improved logistics.

Sentinel Node Biopsy in Breast Cancer: An Overview.

Abstract: The most powerful predictor of survival in breast cancer is the presence or absence of lymph node metastases. Lymphatic mapping and sentinel node biopsy is a new technique that provides more accurate nodal staging compared to routine histology for women with breast cancer without the morbidity of a complete lymph node dissection. Sentinel lymph node biopsy is a more conservative approach to the axilla that requires close collaboration between the surgical team, nuclear medicine, and pathology. National trials are investigating the clinical relevance of the upstaging that occurs with a more intense examination of the sentinel node. Since complaints due to the axillary node dissection are a common occurrence after definitive breast cancer surgery, if the side effects of the level I and II node dissection can be avoided, particularly in the node‐negative population, a major advance in treating this disease will be made.

The role of sentinel lymph node biopsy in patients with ductal carcinoma in situ or with locally advanced breast cancer receiving neoadjuvant chemotherapy

BACKGROUND A significant number of patients who are initially diagnosed with pure DCIS will harbor missed or occult invasive disease at their definitive surgery. To provide more accurate staging information and to avoid a second operation, some investigators believe that SLN mapping should be performed in DCIS patients. The role of SLN biopsy after neoadjuvant chemotherapy in patients with advanced breast cancer is controversial. METHODS A review of the literature was performed to determine the role of SLN biopsy in patients with DCIS or advanced breast cancer receiving neoadjuvant chemotherapy. The success rate of SLN biopsy after neoadjuvant chemotherapy was investigated as well as the percentage of positive SLNs in patients with DCIS. RESULTS Two consecutive studies revealed metastatic disease to the regional lymph nodes in up to 13% of DCIS patients. In addition, 10% of DCIS patients were upstaged to infiltrating ductal carcinoma at their definitive therapy. The ability of the SLN to predict the status of the remaining non-SLNs after neoadjuvant chemotherapy is unknown. False-negative rates range from 0% to 33%. The success rate for SLN identification for the combined series varies from 84% to 97%. CONCLUSIONS SLN biopsy is a minimally invasive technique that can be used to evaluate the regional nodal status of DCIS patients. Performing a SLN biopsy during the initial surgical procedure may avoid a second operation in some DCIS patients who are diagnosed with invasive disease at their definitive operation. The success rate of sentinel node identification does not seem to be altered after neoadjuvant therapy. However, the ability of the SLN to predict the pathologic status of the adjacent non-SLNs remains unknown. Therefore, until further prospective randomized trials are conducted, it cannot be assumed that all the regional nodes have the same biologic response to chemotherapy as the SLN.

Lymphatic mapping in breast cancer

The most accurate predictor of survival in breast cancer is the presence or absence of lymph node metastases. Lymphatic mapping with sentinel node biopsy is a new technique that provides more accurate nodal staging compared with routine histology for women with breast cancer, but without the morbidity of a complete lymph node dissection. Sentinel lymph node (SLN) biopsy is a more conservative approach to the axilla that requires close collaboration from the surgical team, nuclear medicine, and pathology. National trials are investigating the clinical relevance of the upstaging that occurs with a more intense examination of the SLN. As is the case with breast preservation as a viable alternative to mastectomy for the definitive treatment of the primary node, selective lymphadenectomy has the ability to decrease morbidity without compromising patient care.

The staging of malignant melanoma and the florida melanoma trial

Lymphatic mapping and sentinel lymph node (SLN) biopsy have changed the standard of care for patients with malignant melanoma, by providing a less morbid procedure to obtain the nodal staging information that is critical for therapeutic decisions. Detailed examination of the SLN identifies patients who have an increased risk for recurrence and death. Patients whose melanoma is upstaged with very sensitive assays based on reverse transcriptase polymerase chain reaction technology are better targeted for clinical trials or surgical or adjuvant therapies. In the future, melanoma may be “ultrastaged” by examining the SLNs, peripheral blood, and bone marrow. This may improve identification of patients who are surgically cured of their disease and therefore can be spared the side effects of more radical surgery or the toxicities of adjuvant therapy. The lymphatic mapping procedure is the most accurate way to determine the tumor status of the regional lymph nodes.

Lymphatic Mapping: A Technique Providing Accurate Staging for Breast Cancer.

ConclusionLymphatic mapping and selective lymphade-nectomy is an accurate method for staging breast cancer patients, providing a conservative approach to the surgical management and more information from a detailed examination. The histology of the SLN is reflective of the remaining axillary lymph nodes, particularly when the SLN is negative. The procedure can be accomplished as an outpatient procedure when there is negative nodal staging. Similar to breast preservation as a viable alternative to mastectomy in the management of breast cancer patients, the ability to decrease morbidity without compromising patient care is the greatest advantage.

The changing face of malignant melanoma

There is currently an epidemic of malignant melanoma occurring in the United States. At the same time there has been a heightened awareness for early detection of melanoma in the professional ranks as well as in the lay population. A database review was performed to investigate the changing patterns of melanoma presentation during a 2 decade time period in the State of Florida.

Breast Preservation in Women With Giant Juvenile Fibroadenoma

Introduction Fibroadenomas are defined as benign breast lesions, usually formed during menarche (15-25 years of age), that can exist as a solitary mass or multiple masses in the breasts of women. In develpment, as lobular structures are added to the breast’s ductal system, yperplastic lobules are often present. Although lobules are associted with normal growth, analysis of the cellular components link yperplastic lesions to fibroadenomas. Fibroadenomas that measure 5 cm are commonly classified as giant fibroadenomas. When these nlarged masses are found in young female patients, they are often alled juvenile fibroadenomas. The lesions are rare, accounting for nly 0.5% of the total diagnosed fibroadenomas, and can grow to arge sizes and cause prominent asymmetry of the breasts. Other structural changes include both stretching of the areola complex and distortion of the dermal tissue. Clinicians are confronted with treatment decisions on whether to manage these rare cases by way of continued routine examinations or to surgically remove the fibroadenomas. Cosmesis and lactation preservation are the main concerns in this population because malignancy is rare in this age group. Malignancy is of lesser concern with giant fibroadenomas due to their more cellular and less lobular his-