S. Schuman

Processing Sentinel Nodes in Breast Cancer When and How Many

OBJECTIVES To analyze a series of sentinel nodes (SNs) from patients with node-positive breast cancer to determine their diagnostic value, to delineate a working algorithm, and to assess the clinical value of our common practice DESIGN A prospectively collected database. SETTING Tertiary referral center. PATIENTS One hundred five patients with node-positive breast cancer who underwent SN biopsy. MAIN OUTCOME MEASURES The diagnostic value of SNs by analyzing the sensitivity of processing the hottest, 2 hottest, hot and blue, or hot, blue, and suspicious SNs. RESULTS Three hundred fifty-three axillary SNs were recorded in the database. An analysis of the 282 radioactive axillary nodes for which the 10-second count was recorded reveals that the most radioactive node was positive in 73 of 94 analyzable patients (77.7%). Consideration of the 2 most intense axillary nodes was sufficient to diagnose nodal disease in an additional 12 patients, representing a significant increase in sensitivity to 90.4% (P < .001). Examination of all other radioactive nodes did not diagnose any additional cases. On the basis of all 105 patients, consideration of nonradioactive blue axillary nodes did not add significant diagnostic value relative to testing only radioactive nodes: sensitivity of 86.7% vs 88.6% (P = .50), whereas consideration of all hot, blue, and suspicious nodes improved sensitivity to 96.2% (P = .002). CONCLUSIONS Processing of the 2 hottest nodes, along with suspicious but nonhot and nonblue nodes, is sufficient for initial axillary staging. Additional radioactive SNs should be processed only in the presence of nodal disease.

A Phase I Study using low-dose fractionated whole abdominal radiotherapy as a chemopotentiator to full-dose cisplatin for optimally debulked stage III/IV carcinoma of the endometrium

OBJECTIVE To evaluate the feasibility of combining low-dose fractionated whole abdominal radiation (LDF-WAR) with weekly full-dose cisplatin (FD-CDDP) for patients with stage III/IV endometrial carcinoma. METHODS Patients with optimally debulked stage III/IV carcinoma of the endometrium (without extra-abdominal disease) were eligible for the study. Postoperatively, patients received the institutional standard systemic chemotherapy and vaginal brachytherapy. Patients then underwent experimental six weekly cycles of FD-CDDP (40 mg/m², maximum 70 mg IV) followed by LDF-WAR 6-8 hours after initiation of chemotherapy. In a conservative design, 6 patients were accrued to two sequential cohorts of LDF-WAR, at 0.5 Gy/fraction [Fx] (total 3 Gy) and 0.75 Gy/Fx (total 4.5 Gy). Toxicities and laboratory studies were evaluated at each visit. RESULTS Twelve patients were enrolled from January 2005 to June 2009 with median follow-up of 13.5 months (range: 5-27 months). Seventy-five percent of enrolled patients had uterine papillary serous histology. Eleven patients at least partially completed therapy (range: 2-6 cycles of FD-CDDP/LDF-WAR) with one additional patient opting out at the higher dose level. Combination therapy overall was well tolerated. Three patients in each cohort experienced grade 3 acute hematologic events with one recorded grade 4 toxicity in the second cohort. Of patients receiving any of the experimental treatment, five have experienced recurrences. Three of these patients were in cohort one and received 0.5 Gy/Fx LDF-WAR. CONCLUSION Combination therapy with LDF-WAR as a novel chemopotentiator to FD-CDDP is a feasible adjuvant regimen in optimally debulked patients with stage III/IV endometrial carcinoma. Further investigation is warranted to determine treatment efficacy.

Laparoendoscopic single-site extraperitoneal aortic lymphadenectomy: First experience

OBJECTIVES To report the first clinical experience with laparoendoscopic single-site (LESS) extraperitoneal aortic lymphadenectomy. MATERIALS AND METHODS A 33-year-old woman with biopsy proven locally advanced squamous cell carcinoma of the cervix was taken to the operating room for surgical staging. Preoperative imaging did not detect any aortic lymph node metastases. Informed consent for LESS extraperitoneal aortic lymphadenectomy was obtained. A 2 cm transverse incision was made on the left side midway between the iliac crest and inferior costal margin along the middle axillary line. The preperitoneal space was created and the Triport(TM) inserted. Using the Deflectable-Tip EndoEye(TM) laparoscope and two straight instruments, the aortic lymphadenectomy was performed as defined by the disease-specific oncologic principles. RESULTS The procedure was completed in 125 minutes. There were no intraoperative or postoperative complications, and the blood loss was minimal (10 mL). The patient was discharged home on postoperative day number 1. LESS extraperitoneal aortic lymphadenectomy yielded 10 lymph nodes. Microscopic metastatic squamous cell carcinoma was detected in 1 out of the 10 lymph nodes. Her treatment plan was modified to extend the field of radiation to include the paraaortic lymphatic basins. CONCLUSIONS LESS extraperitoneal aortic lymphadenectomy is feasible and safe, and provides a comprehensive assessment of aortic lymph nodes as defined by the disease-specific oncologic principles.

Processing Sentinel Nodes: When and How Many?

Background: Processing multiple sentinel nodes (SN) is expensive and time consuming. The aim of this study was to analyze a series of SNs from node positive breast cancer patients in order to determine their diagnostic value and delineate a working algorithm. Materials and methods: A prospective database of 105 node positive breast cancer patients undergoing a SN biopsy was created. The SN biopsies were performed with Technetium sulfur colloid, blue dye (Isosulfan Blue or Patent Blue) or both. SN were defined as any blue, suspicious node or radioactive nodes up to 10% of the hottest node. Location of the nodes, criteria of SN definition (hot/blue/suspicious), ten second radioactive counts and pathologic status were recorded. A statistical analysis of the diagnostic value of those nodes was performed. Results: Three hundred and seventy five SNs were recorded in the database. The number of nodes per patient ranged from 1 to 15 with a median value of 3. Radioactivity was found in a total of 322 (86%) sentinel nodes and blue dye in a total of 105 (28%) nodes, with 92 (25%) nodes being both hot and blue. Fourty (11%) sentinel nodes were removed for suspicious appearance. One hundred fifty nine (42%) of the 375 sentinel nodes tested positive for disease. Among the 159 positive nodes, 139 (87%) were radioactive, 52 (33%) were blue, and 46 (29%) were both hot and blue. An analysis of the 322 radioactive nodes reveals that the most radioactive node was positive in 74/95 analyzable patients (77.9%). Consideration of the two most intense nodes was sufficient to diagnose nodal disease in an additional 15 patients, representing a significant increase in sensitivity to 93.7%, p Conclusions: Processing of the two hottest and the suspicious nodes is sufficient for the initial axillary staging. Additional SNs should be processed only in presence of nodal disease. Citation Information: Cancer Res 2009;69(24 Suppl):Abstract nr 1007.

Internal Mammary Nodes in Breast Cancer: A Review of the Literature and Practical Surgical Recommendations

Background : Involvement of internal mammary lymph nodes with metastatic disease in breast cancer upstages the patient and carries a poorer prognosis. It is the most important prognostic factor after axillary nodal status. Although 75% of the breast lymphatic drainage goes to the axillary lymph nodes, extra-axillary lymph node basins drain the remainder. Extra-axillary recurrences led to the evolution from Halsted’s radical mastectomy to Wangensteen’s “super-radical” and Urban’s “extended-radical” mastectomies, which remove the internal mammary and supra-clavicular lymph nodes in addition to axillary nodes. However, these surgeries failed to improve disease free survival and overall survival and the interest in pursuing extra-nodal metastasis faded away. With the development of the sentinel node techniques, interest in extra-axillary lymph node metastasis was renewed because of identification of drainage to these locations. Several reports from different institutions demonstrate this renewed interest as well as the feasibility of procedures leading to upstaging and changing of treatment plans when metastasis to internal mammary nodes is identified. In this review, the literature addressing internal mammary lymph nodes in breast cancer is examined. Methods : Systematic review of the literature from 1867 to 2015. Conclusion : The techniques and factors that affect the reliability and reproducibility of internal mammary sentinel node biopsy are discussed. In addition, we discuss whether the treatment of positive internal mammary nodes translates into a survival advantage. Finally, we propose a minimally invasive working algorithm to internal mammary lymph node evaluation.