Yann Delpech

An axilla scoring system to predict non-sentinel lymph node status in breast cancer patients with sentinel lymph node involvement

Background. Axillary lymph node dissection (ALND) is the current standard of care for breast cancer patients with sentinel lymph node (SN) involvement. However, the SN is the only involved axillary node in a significant proportion of these patients. Here we examined factors predictive of non-SN involvement in patients with a metastatic SN, in order to develop a scoring system for predicting non-SN involvement.Materials and Methods. This study was based on a prospective database of 337 patients who underwent SN biopsy for breast cancer, of whom 81 (24) were SN-positive; we examined factors predictive of non SN involvement in the 71 of these 81 women who underwent complementary ALND. All clinical and histological criteria were recorded and analysed according to non-SN status, by using Chi-2 analysis, Student’s t-test, and multivariate logistic regression.Results. Univariate analysis showed a significant association between non-SN involvement and histological primary tumor size (p=0.0001), SN macrometastasis (p=0.01), the method used to detect SN metastasis (H&E versus immunohistochemistry) (p=0.03), the number of positive SNs (p=0.049), the proportion of involved SNs among all identified SNs (p=0.0001) and lymphovascular invasion (p=0.006). Histological primary tumor size (p=0.006), SN macrometastasis (p=0.02) and the proportion of involved SNs among all identified SNs (p=0.03) remained significantly associated with non-SN status in multivariate analysis. Based on the multivariate analysis, we developed an axilla scoring system (range 0–7) to predict the likelihood of non-SN metastasis in breast cancer patients with SN involvement.Conclusion. In patients with invasive breast cancer and a positive SN, histological primary tumor size, the size of SN metastases, and the proportion of involved SNs among all identified SNs were independently predictive of non-SN involvement.

Sentinel lymph node evaluation in endometrial cancer and the importance of micrometastases

The presence of lymph node (LN) metastases has a major impact on the prognosis of women with endometrial cancer and compromises recurrence-free time. LN assessment has become the standard of care in the surgical staging of patients and plays a crucial role in decision making. Sentinel lymph node (SLN) detection improves the accuracy of lymphatic drainage mapping compared to pelvic node dissection used alone. Serial sectioning of SLNs followed by immunohistochemical examination with conventional histology improves accuracy of micrometastatic identification. In this review, we found a high incidence of micrometastases in endometrial cancer, reaching 25% depending on the stage and the techniques used for the node examination. Current data are insufficient to evaluate the prognostic impact of the presence of micrometastases, but it seems that more accurate detection of lymphatic spread will allow better stratification of intermediate risk patients. Ultimately, this will assist in tailoring adjuvant treatment.

Clinical benefit from neoadjuvant chemotherapy in oestrogen receptor-positive invasive ductal and lobular carcinomas.

Background:The aim of this study was to compare clinical and pathological outcomes after neoadjuvant chemotherapy between oestrogen receptor (ER)-positive invasive pure lobular carcinoma (ILC) and invasive ductal carcinoma (IDC).Methods:This analysis included 1895 patients (n=177 ILC; n=1718 IDC), with stage I–III breast cancer, who received neoadjuvant chemotherapy. Clinical and pathological response rates, the frequency of positive surgical margins and rate of breast-conserving surgery were compared.Results:There was a trend for fewer good clinical responses in ILC compared with IDC. Tumour downstaging was significantly less frequent in ILC. Positive or close surgical resection margins were more frequent in ILC, and breast-conserving surgery was less common (P<0.001). These outcome differences remained significant in multivariate analysis, including tumour size, nodal status, age, grade and type of chemotherapy. Invasive pure lobular carcinoma was also associated with a significantly lower pathological complete response (pCR) rate in univariate analysis, but this was no longer significant after adjusting for tumour size and grade.Conclusion:Neoadjuvant chemotherapy results in lower rates of clinical benefit, including less downstaging, more positive margins and fewer breast-conserving surgeries in ER-positive ILC compared with ER-positive IDC. Pathological complete responses are rare in both groups, but do not significantly differ after adjusting for other variables.

Laparoscopic sentinel node biopsy in cervical cancer using a combined detection: 5-years experience.

BackgroundTo evaluate the feasibility after 5 years experience of a laparoscopic sentinel node (SN) procedure with combined radioisotopic and patent blue labeling in patients with cervical cancer.MethodsSixty-seven patients (median age 48.9 years) with cervical cancer underwent a laparoscopic SN procedure using an endoscopic gamma probe, after both radioactive and patent blue injections. After the procedure, all the patients underwent complete laparoscopic pelvic/para-aortic lymphadenectomy.ResultsAt least one SN was identified in 57 patients (85.1%). According to the Stage, the SN identification rate was 91.2% in early-stage cervical cancer and 78.5% in locally advanced cervical cancer. The mean number of SN was 2.3 per patient (range 1–5). A total of 129 SNs were removed. Lymph node metastasis involvement was identified in the 20 SNs (15.5%) from 14 patients (24.6%). Nine of the 14 patients had at least one macrometastases, three patients presented micrometastases in H&S, and two patients presented isolated single cells. Six patients presented a pelvic non-SN involvement including two patients whose SNs were uninvolved. The false-negative SNs rate was 12.5% (two patients out of 16). Both patients have locally advanced cervical cancer.ConclusionThis study confirms that laparoscopic SN detection with a combination of radiocolloid and patent blue is accurate in patients with early cervical cancer to assess pelvic lymph node status.

Hypoxia Imaging of Uterine Cervix Carcinoma With 18F-FETNIM PET/CT

Purpose Our aims were to assess the feasibility of imaging hypoxia in cervical carcinoma with 18F-fluoroerythronitroimidazole (18F-FETNIM) and to compare 18F-FETNIM uptake with metabolic uptake of 18F-FDG. Patients and Methods We included 16 patients with cervical carcinoma. After imaging with FDG, 18F-FETNIM PET/CT was performed and tumor-to-muscle (T/M) ratio uptake was assessed. 18F- FETNIM uptake was correlated to FDG uptake and osteopontin (OPN), a marker of hypoxia, and patients’ outcomes. Results All tumors were detected by 18F-FDG PET. 18F-FETNIM T/M ratios ranged from 1.3 to 5.4. There was no significant correlation between 18F-FETNIM and 18F-FDG uptake. High 18F-FETNIM uptake (T/M > 3.2) was associated with reduced progression-free survival (log-rank = 0.002) and overall survival (log-rank = 0.02). Osteopontin ranged from 39 to 662 &mgr;g/L (median, 102.5 &mgr;g/L). Patients with OPN greater than 144 &mgr;g/L had reduced progression-free survival compared with those with OPN less than 144 &mgr;g/L (log-rank = 0.03). We found no significant correlation between 18F-FETNIM uptake and OPN blood levels. Conclusions Our preliminary results showed that a high uptake of 18F-FETNIM was associated with a worse progression-free and overall survival.

Laparoscopic sentinel node mapping using combined detection for endometrial cancer: a study of 33 cases—is it a promising technique?

BACKGROUND To evaluate the feasibility of a laparoscopic sentinel node (SN) procedure based on combined method in patients with endometrial cancer. METHODS Thirty-three patients (median age 66.1 years) with endometrial cancer of apparent stage I or stage II underwent a laparoscopic SN procedure based on combined radiocolloid and patent blue injected pericervically. After the SN procedure, all the patients underwent laparoscopic bilateral pelvic lymphadenectomy. RESULTS SNs were identified in only 27 patients (81.8%). The mean number of SNs was 2.5 per patient (range 1-5). Only 18 patients (54.5%) had an identified bilateral SN. The most common site of the SNs was the medial external iliac region (67.6%). Fourteen SNs (19.7%) from 8 patients (24.2%) were found to be metastatic at the final histological assessment. No false-negative SN results were observed. CONCLUSIONS A SN procedure based on a combined detection and laparoscopic approach is feasible in patients with early endometrial cancer. However, because of a low rate of bilateral and global SN detections and problems of injection site using pericervical injection of radiocolloid and blue dye, alternative methods should be explored. Pericervical injections should be avoided.

Surgical Management Modifications Following Systematic Additional Shaving of Cavity Margins in Breast-Conservation Treatment

BackgroundPositive wide local excision margins are the most important risk factor of local breast-carcinoma recurrence. Shaving additional margins could lower the need for re-excisions when wide local excision margins are positive and cavity margins are negative.Materials and MethodsThis retrospective study, from January 2007 to December 2008, included 99 women with breast carcinomas who underwent wide local excision with 4 additional, systematically shaved, surgical cavity margins. All therapeutic decisions concerning post-wide local excision treatment were made by consensus during multidisciplinary meetings.ResultsThis systematic cavity-shaving strategy avoided 25 re-excisions (25.3%), and 6 patients required new surgery because of carcinoma found in the additional cavity-shaving margins, despite negative wide local excision margins. No preoperative factor predictive of positive cavity margins was identified.ConclusionsSystematic shaving of additional cavity margins changed the surgical management after breast-conservation treatment.

Management of lymph nodes in endometrioid uterine cancer.

Purpose of review Hysterectomy with bilateral salpingo-oophorectomy is the standard surgery for endometrial cancer. However, the indication and extent of surgical lymph node staging continues to be controversial if the carcinoma is confined to the uterus, even in the eyes of the experts. The survival benefit of this invasive staging technique has not been clearly demonstrated in this setting. Recent findings We have focused our review on lymph node disease in patients with early endometrial cancer. We report on the important issues surrounding lymphadenectomy in endometrial cancer and the results of a recent large randomized trial that do not indicate a benefit of surgical staging. Other issues, including complications and the benefits of combining laparoscopy with lymphadenectomy, will also be discussed. Summary Pelvic and para-aortic lymphadenectomies are not appropriate for low-risk patients with endometrioid uterine cancer. The risk–benefit balance for these patients seems rather in favor of not performing surgical staging. On the contrary, high-risk patients would seem to benefit from complete pelvic and para-aortic lymph node staging with adjuvant treatments tailored to the results of lymphadenectomy.

Clinical nomogram to predict bone-only metastasis in patients with early breast carcinoma

Background:Bone is one of the most common sites of distant metastasis in breast cancer. The purpose of this study was to combine selected clinical and pathologic variables to develop a nomogram that can predict the likelihood of bone-only metastasis (BOM) as the first site of recurrence in patients with early breast cancer.Methods:Medical records of patients with non-metastatic breast cancer were retrospectively collected. On the basis of the analysis of patient and tumour characteristics using the Cox proportional hazards regression model, a nomogram to predict BOM was constructed for a 4175-patient-training cohort. The nomogram was validated in an independent cohort of 579 patients.Results:Among 4175 patients with non-metastatic breast cancer, 314 developed subsequent BOM. Age, T classification, lymph node status, lymphovascular space invasion, and hormone receptor status were significantly and independently associated with subsequent BOM. The nomogram had a concordance index of 0.69 in the training set and 0.73 in the validation set.Conclusions:We have developed a clinical nomogram to predict subsequent BOM in patients with non-metastatic breast cancer. Selection of a patient population at high risk for BOM could facilitate research of more specific staging approaches or the selective use of bone-targeted therapy.

Stadification ganglionnaire des cancers du col utérin avancé

Lymph node staging in patients with locally advanced cervical cancer is the most important prognostic factor and also leads to adjuvant treatment choice. Because of the lymphadenectomy associated morbidity and delay in the beginning of adjuvant therapy, noninvasive approaches were developed during the last decennia. Recently, positron emission tomography employing a glucose analogue (FDG-PET) has been shown to be more sensitive and more specific than magnetic resonance imaging or than computed tomography usually used in diagnosis of pelvic and para-aortic lymph node metastases. Even if recent studies have reported promising results, surgical pelvic and para-aortic staging remains actually the most accurate procedure for evaluating lymph node metastases. This procedure should be accomplished by transperitoneal or extraperitoneal laparoscopy, with the benefits of minimal morbidity, shorter length of hospital stay and no significant increase of complications comparing to laparotomy approach. Laparoscopy also allows an early start of adjuvant treatment, this delay constituting an important prognostic factor for patients with locally advanced cancer. However, the survival benefit of lymph node dissection is still controversial and should be proved in randomised studies.