Ulkem Yararbas

Problematic aspects of sentinel lymph node biopsy and its relation to previous excisional biopsy in breast cancer.

Purpose: The aim of the study is to review problematic aspects of sentinel lymph node biopsy (SLNB) and to evaluate the influence of a previous excisional biopsy on these problems. Materials and Methods: A total of 345 patients were evaluated retrospectively, 156 of them had a previous biopsy. Tc-99m tin colloid was injected the day before surgery at 4 quadrants around the areola intradermally. Problems complicating SLNB are reviewed in 3 topics: visualization or gamma probe detection problems, dilated lymphatic channels, and misleading activity accumulation. Results: SLN detection rate and mean sentinel lymph node numbers were as follows in patients with and without biopsy, respectively: 95.5% versus 99.4% and 1.71 ± 0.97 versus 1.70 ± 0.92. Problems complicating the procedure occurred in 20 patients (5.8%). Among these 20 patients, 15 had a prior excisional biopsy, and incisions were located in the upper, outer and periareolar zones. Visualization or gamma probe detection problems occurred in 8 patients. Except for one with faint uptake in a sentinel node, all had a prior biopsy. Lymphatic channel dilatation complicated the procedure in 7 patients. Of these 7 patients, 4 had a previous biopsy. Misleading activity accumulations compromised SLNB in 5 patients, 4 of whom had a prior biopsy. Conclusion: Although SLNB is still applicable with a high success rate in cases with excisional biopsy, a review of problematic aspects of SLNB demonstrated a relation with the presence of a previous biopsy and its localization. The demonstration of nonvisualization preoperatively and the precise localization of atypically located activity accumulation may be helpful in the prevention of potential complications.

Sentinel lymph node biopsy in breast cancer: review on various methodological approaches.

AIMS AND BACKGROUND Sentinel lymph node biopsy has been accepted as a standard procedure for early stage breast cancer. In this retrospective analysis, the results obtained with different methodological approaches using radiocolloid with or without blue dye were examined. METHODS A total of 158 sentinel lymph node biopsies were performed in 152 patients. Group A (85 patients) underwent lymphatic mapping using a combination of periareolar intradermal radiocolloid and subareolar blue dye injections. Group B (73 patients) underwent only periareolar intradermal radiocolloid injection. One large tin colloid and two small radiocolloids (nanocolloid of serum albumin -NC- and colloidal rhenium sulphide -CS-) were used. RESULTS Successful lymphatic mapping was attained in 157 of 158 procedures (99.4%). Radiocolloids localized sentinel lymph nodes in 99.4% and blue dye in 75.3% of the cases. The number of sentinel lymph nodes removed was greater in nanocolloid and colloidal rhenium sulphide groups (P ≤0.05). Among 60 metastatic sentinel lymph nodes, frozen section analysis using hematoxylin and eosin staining failed to detect 1 macro- and 10 micrometastasis. Radiocolloid uptake was higher in sentinel lymph nodes accumulating blue dye (1643 ± 3216 counts/10 sec vs 526 ± 1284 counts/10 sec, P <0.001). Higher count rates were obtained by using larger sized colloids (median and interquartile range: tin colloid, 2050 and 4548; nanocolloid, 835 and 1799; colloidal rhenium sulphide, 996 and 2079; P = 0.01). Only 2 extra-axillary sentinel lymph nodes were visualized using periareolar intradermal injection modality. CONCLUSIONS Radiocolloids were more successful than blue dye in sentinel lymph node detection. More sentinel lymph nodes were harvested with small colloids, but different sized radiocolloids were similarly successful. Sentinel lymph nodes having higher radiocolloid uptake tended to accumulate blue dye more frequently. Sentinel lymph nodes manifested higher count rates when a larger colloid was used. Frozen section was very successful in detecting macrometastatic disease in sentinel lymph nodes, but the technique failed in most of the micrometastates.

Sentinel lymph node biopsy in breast cancer: predictors of axillary and non-sentinel lymph node involvement.

BACKGROUND Sentinel lymph node biopsy is a standard method for the evaluation of axillary status in patients with T1-2N0M0 breast cancers. AIMS To determine the prognostic significance of primary tumour-related clinico-histopathological factors on axillary and non-sentinel lymph node involvement of patients who underwent sentinel lymph node biopsy. STUDY DESIGN Retrospective clinical study. METHODS In the present study, 157 sentinel lymph node biopsies were performed in 151 consecutive patients with early stage breast cancer between June 2008 and December 2011. RESULTS Successful lymphatic mapping was obtained in 157 of 158 procedures (99.4%). The incidence of larger tumour size (2.543±1.21 vs. 1.974±1.04), lymphatic vessel invasion (70.6% vs. 29.4%), blood vessel invasion (84.2% vs. 15.8%), and invasive lobular carcinoma subtype (72.7% vs. 27.3%) were statistically significantly higher in patients with positive SLNs. Logistic stepwise regression analysis disclosed tumour size (odds ratio: 1.51, p=0.0021) and lymphatic vessel invasion (odds ratio: 4.68, p=0.001) as significant primary tumour-related prognostic determinants of SLN metastasis. CONCLUSION A close relationship was identified between tumour size and lymphatic vessel invasion of the primary tumour and axillary lymph node involvement. However, the positive predictive value of these two independent variables is low and there is no compelling evidence to recommend their use in routine clinical practice.

A new and simple predictive formula for non-sentinel lymph node metastasis in breast cancer patients with positive sentinel lymph nodes, and validation of 3 different nomograms in Turkish breast cancer patients.

Background: Nomogram accuracies for predicting non-sentinel lymph node (SLN) involvement vary between different patient populations. Our aim is to put these nomograms to test on our patient population and determine our individual predictive parameters affecting SLN and non-SLN involvement. Patients and Methods: Data from 932 patients was analyzed. Nomogram values were calculated for each patient utilizing MSKCC, Tenon, and MHDF models. Moreover, using our own patient- and tumor-depended parameters, we established a unique predictivity formula for SLN and non-SLN involvement. Results: The calculated area under the curve (AUC) values for MSKCC, Tenon, and MHDF models were 0.727 (95% confidence interval (CI) 0.64–0.8), 0.665 (95% CI 0.59–0.73), and 0.696 (95% CI 0.59–0.79), respectively. Cerb-2 positivity (p = 0.004) and size of the metastasis in the lymph node (p = 0.006) were found to correlate with non-SLN involvement in our study group. The AUC value of the predictivity formula established using these parameters was 0.722 (95% CI 0.63–0.81). Conclusion: The most accurate nomogram for our patient group was the MSKCC nomogram. Our unique predictivity formula proved to be as equally effective and competent as the MSKCC nomogram. However, similar to other nomograms, our predictivity formula requires future validation studies.

The effect of radiocolloid preference on major parameters in sentinel lymph node biopsy practice in breast cancer

INTRODUCTION The possible effects of radiocolloid preference on sentinel lymph node biopsy (SLNB) were investigated. METHODS A total of 200 patients with T1-2N0M0 breast cancer were evaluated. The first 100 patients underwent SLNB using (99m)Tc tin colloid (TC) and the next 100 using (99m)Tc nanocolloid (NC). Radiocolloid was injected intradermally at four quadrants of the periareolar region the day before surgery. All patients underwent lymphoscintigraphy 1 h after injection. All nodes having fourfold activity of the background were harvested using gamma probe. RESULTS Sentinel lymph node (SLN) identification rate by gamma probe was 98% in each group. The number of SLNs identified by lymphoscintigraphy, gamma probe and pathological evaluation was 1.39 ± 0.7, 1.70 ± 1.0 and 2.23 ± 1.70 in the TC and 2.03 ± 0.94, 2.60 ± 1.36 and 3.05 ± 1.90 in the NC group, respectively (P<.05). Metastatic SLN was found in 24 (24.4%) of 98 patients in the TC group and 41 (41.8%) of 98 patients in the NC group (P=.04). None of the patients showed dispersion to internal mammarian lymph nodes. Lymphatic vessel visualization was observed in eight (8.1%) of 98 TC patients and in 47 (47.9%) of 98 NC patients (P=.000). SLNs were the only metastatic node(s) in 54.1% of TC and 73.1% of NC patients. CONCLUSION The periareolar intradermal injection technique gives a high detection rate in the localization of SLNs independently from the choice of the tracer. Mean SLN numbers and lymphatic vessel visualization frequency were significantly higher using a smaller albumin Tc-99m nanocolloid as compared to a stannous fluoride Tc-99m tin colloid. The results of our study support the idea that the influence of increased number of SLNs on positive SLN frequency is critical.

Low-Dose Radioiodine Therapy in Well-Differentiated Thyroid Carcinoma

Thyroid carcinomas are usually diagnosed in small sizes and accepted as low-risk disease without disease-related mortality. However, there has been still controversy regarding the optimal management of differentiated thyroid carcinoma both in surgical technique and the use of radioactive iodine ablation. Moreover, there is also uncertainty about what activity should be administered for ablative purposes. In the current case, after completing almost 7 years of clinical follow-up without evidence of disease recurrence, low-dose radioactive ablation in thyroid cancer patients is discussed under the relevant literature.

Pediatric PTC with Diffuse Lung Metastases: Pulmonary Function Testing and Steroid Therapy Prior to RAI

Thyroid carcinoma is an uncommon malignancy in children, and metastatic involvement at initial presentation is much more common than adults. The clinical course of the disease is favorable; however, management is challenging due to differences in biologic behavior of the tumor and potential side effects of I-131 in the long-term follow-up. The current pediatric case highlights the possible pulmonary fibrosis after radioiodine treatment and indicates the importance of dose optimization particularly in children with diffuse lung metastases.

Papillary Thyroid Carcinoma and Microcarcinoma

Papillary thyroid carcinoma (PTC) is the most common thyroid cancer subtype and constitutes 80% of all thyroid malignancies. PTC lesions that are 1 cm or less in size are defined as “papillary thyroid microcarcinoma” (PTMC). The incidence of occult PTC cases detected on autopsy series is very high, ranging from 10 to 35%. With the increased use of diagnostic imaging modalities, the detection rate of thyroid cancer is increasing worldwide. Both PTC and PTMC have good prognosis. Due to indolent nature of the disease, especially in PTMC cases, both the extent of the initial surgery and the need for RAI treatment remain controversial.

Medullary Thyroid Carcinoma

Medullary thyroid carcinoma is a part of “multiple endocrine neoplasia” syndromes in 25% of the cases. Surgery is the primary curative treatment modality in the management of medullary thyroid carcinoma. Detection of the presence and the extent of the metastatic disease is important for the appropriate therapy planning. The contribution of two nuclear medicine procedures 18F-FDG PET/CT’ and 68Ga-DOTATATE PET/CT to the management of medullary thyroid carcinoma is presented in this section.

A Case of a Papillary Thyroid Cancer with Gross Residual Disease After Surgery

Locally advanced disease accounts for 5–15% of the differentiated thyroid cancer (DTC) patients. Although surgical excision of the entire primary lesion is aimed for the optimum disease management, incomplete resections may occur especially in patients having invasions to recurrent laryngeal nerve, respiratory tract, esophagus, or major vessels. Radioactive iodine (RAI) treatment is the primary adjuvant therapy modality in high-risk DTC cases. In cases with RAI-resistant disease, external beam radiotherapy (EBRT) may be an alternative. However, its role is debated due to the lack of prospective data and also conflicting results in retrospective studies. Since EBRT may have some severe side effects, the consequences of uncontrolled disease and the potential complications of EBRT should be considered comparatively.