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BACKGROUND: Prospective trials demonstrate that sentinel node (SN) biopsy after neoadjuvant chemotherapy (NACT) has a significant false negative rate (FNR) when only 1 or 2 SNs are removed. It is unknown whether this increased FNR correlates with an elevated risk of recurrence. METHODS: Tumor Registry data at an NCI-designated Comprehensive Cancer Center were reviewed from 2004-2018 for patients having a negative SN biopsy after NACT. RESULTS: Among 190 patients with histologically negative nodes after NACT having 1 (n=42), 2 (n=46), and ≥3 (n=102) SNs, axillary recurrences occurred in 7.14%, 0% and 1.96% (p=0.09), breast recurrences occurred in 2.38%, 6.52% and 0.98% (p=0.12), and distance recurrences occurred in 16.67%, 8.70%, 7.84% (p=0.27), respectively. Time to first recurrence did not differ by SN count (p=0.41). After adjustment for age, race, clinical stage and receptor status, there were no differences in the rates of axillary (p=0.26), breast (p=0.44), or distance recurrence (p=0.24) by numbers of SNs harvested. Median follow up was 46.8 months. CONCLUSIONS: Despite higher post-NACT FNRs reported in randomized trials for patients having

Background and objectives Omission of routine axillary staging and adjuvant radiation (XRT) in women ≥ 70 years old with early stage, hormone receptor-positive, clinically node-negative breast cancer has been endorsed based on several landmark studies. We sought to determine how much omission of axillary staging/XRT has been adopted. Methods Using the National Cancer Data Base, we selected malignant breast cancer cases in women ≥ 70 with ER + tumors, ≤2 cm with clinically negative lymph nodes who underwent breast conservation and had known XRT status in 2005-2015. The use of sentinel lymph node biopsy (SNB) and XRT status was summarized by year to determine trends over time. Results In total, 57 230/69 982 patients underwent SNB. Of the 12 752 patients in whom SNB was omitted, 6296 were treated at comprehensive community cancer programs. Regarding XRT, 33 891/70 114 received adjuvant XRT. There were no significant trends with regards to patients receiving SNB or those receiving XRT. Conclusion Since 2005, there has been no change in SNB or XRT for early stage ER + breast tumors. However, there was a difference in omission of SNB based on facility type and setting. Future monitoring is needed to determine if these trends persist following the recently released Choosing Wisely® recommendations.

Sentinel node biopsy has dramatically altered the treatment of breast cancer worldwide. The author's investigation into its use in breast cancer began nearly 30 years ago and evolved from simply identifying a node predictive of the axillary status to being a therapeutic procedure eliminating axillary dissection for selected node-negative and some node-positive women. This paper summarizes a personal experience with the evolution of this technique.

Secondary angiosarcoma of the breast following catheter-based brachytherapy after lumpectomy is rare. We describe a case of a patient with breast cancer treated with partial mastectomy and sentinel node biopsy followed by accelerated partial breast irradiation (APBI), who developed skin changes 6 years after completion of therapy. Punch biopsy confirmed the diagnosis of secondary angiosarcoma. This case is even more unique in that the location of the skin changes was remote to the lumpectomy site. There is a critical need to recognize secondary angiosarcoma presentation after APBI and determine the rate of occurrence compared with traditional external beam irradiation.

Background. Optimal neck lymphadenectomy in patients with papillary thyroid cancer (PTC) and microscopic lymph node metastasis needs to be defined in order to aid surgeons in their decision about the best way to proceed in these cases.Methods. Patients who underwent total thyroidectomy and lymphadenectomy at levels IIa to VI were divided into two groups: Group 1 (G1) with macroscopic metastasis detected before surgery and Group 2 (G2) with microscopic metastasis detected in sentinel node during surgery. Odds ratio (OR) was computed for age, sex, tumor size, multicentricity, capsular invasion, vascular/lymphatic permeation, and nodes with metastasis.Results. Primary tumor size was (G1 versus G2, respectively) 3.8 cm versus 1.98 cm (PConclusion. Selective lymphadenectomy at levels III, IV, and VI is optimal for PTC patients without preoperative evidence of lymph node disease, but who present with lymph node microscopic metastasis in an intraoperative assessment.

Preoperative or neo-adjuvant chemotherapy in the management of breast cancer is a treatment approach that has gained in popularity in recent years. However, it is unclear if the treatment paradigms often employed for patients treated with surgery first hold true for those treated with preoperative chemotherapy. The role of sentinel node biopsy and the data supporting its use is different for those with clinically negative and clinically positive nodes prior to chemotherapy. For clinically node-negative patients, sentinel node biopsy after neo-adjuvant chemotherapy may be appropriate. For those node-positive patients whose axillary disease resolves clinically, the false-negative rate of the sentinel node biopsy is high. However, there are measures that can reduce that rate. After surgery, the radiation oncologist is often faced with complicated decisions surrounding the optimal radiotherapy in this setting. Tailoring radiation plans based on chemotherapy response holds promise and is the subject of ongoing clinical trials. In the accompanying article, we review the current literature on both surgery and radiation in axillary management and describe the interplay between these two treatment modalities. This highlights the need for multidisciplinary management in making treatment decisions for patients treated in this manner.

The Z0011 trial has fundamentally changed axillary management in breast cancer patients. However, some important questions remain, like the role of extracapsular nodal extension (ENE) in positive sentinel nodes and the need for further axillary treatment. In this retrospective cohort study, we reviewed and analyzed data from 342 clinically node negative (cN0) breast cancer patients with a positive sentinel node and subsequent axillary lymph node dissection (ALND) from the BRENDA data base. The 104 (30.4%) ENE positive patients had a significantly higher proportion of ≥3 positive axillary lymph nodes (65.0%) compared to ENE negative patients with a positive sentinel node (21.4%). Likewise, ENE positive patients had significantly more often lymph node metastasis size >2 mm (96.2%) than ENE negative patients (72.7%). T1 status was observed significantly more often in ENE negative patients (53.2%) than in ENE positive patients (24.0%). While ENE was linked to worse overall survival in univariate analysis, this effect disappeared when adjusting for nodal status, age, and comorbidities in multivariate analysis. ENE of the sentinel node is an important predictor for nonsentinel lymph node involvement. We suggest that ENE influences survival only via a higher number of positive nodes - one of the most predictive parameters for survival outcome in breast cancer.

The aim of this study was to review the outcomes of a series of breast cancer patients who underwent sentinel node biopsy inclusive of lymphoscintigraphy, and to assess the incidence of internal mammary node (IMN) metastatic positivity at exploration and whether these findings influenced treatment. Between April 2001 and December 2012, 581 breast cancer patients at Princess Alexandra Hospital underwent preoperative lymphoscintigraphy in the course of the performance of sentinel node biopsy. Analysis was performed of those patients who demonstrated radio-isotope uptake to the IMN chain, and who had sentinel node biopsy of the IMN's and were found to have metastatic involvement. Assessment was made to determine whether the finding of IMN metastases changed the adjuvant systemic management of these patients, and to review complication rates. 95 of 581 (16.4%) patients with preoperative breast lymphoscintigraphy had lymphatic mapping to the IMN chain. 51 (54%) of these patients had IMN chain surgically explored and IMN nodes were found in 35 of these patients (success rate of 69%). Of these, three patients (3/35 = 8.6%) had metastatic involvement of the IMN sentinel node group. All three IMN positive patients received adjuvant breast radiotherapy, chemotherapy, and hormonal therapy. In four patients (7.8%) IMN surgical exploration was complicated by pneumothorax. Only a small proportion of breast cancer patients were found to have metastasic involvement of the IMN chain and which did not significantly change their adjuvant therapy management. These findings suggest that the benefits of exploration of the IMN chain in breast cancer patients are limited and may be outweighed by the risk of complications.

Background. Most institutions require a patient undergoing sentinel lymph node biopsy to go through nuclear medicine prior to surgery to be injected with radioisotope. This study describes the long-term results using intraoperative injection of radioisotope. Methods. Since late 2002, all patients undergoing a sentinel lymph node biopsy at the Yale-New Haven Breast Center underwent intraoperative injection of technetium-99m sulfur colloid. Endpoints included number of sentinel and nonsentinel lymph nodes obtained and number of positive sentinel and nonsentinel lymph nodes. Results. At least one sentinel lymph node was obtained in 2,333 out of 2,338 cases of sentinel node biopsy for an identification rate of 99.8%. The median number of sentinel nodes found was 2 and the mean was 2.33 (range: 1–15). There were 512 cases (21.9%) in which a sentinel node was positive for metastatic carcinoma. Of the patients with a positive sentinel lymph node who underwent axillary dissection, there were 242 cases (54.2%) with no additional positive nonsentinel lymph nodes. Advantages of intraoperative injection included increased comfort for the patient and simplification of scheduling. There were no radiation related complications. Conclusion. Intraoperative injection of technetium-99m sulfur colloid is convenient, effective, safe, and comfortable for the patient.

Background. We investigated the results of quality control study prior to phase III trial of sentinel lymph node navigation surgery (SNNS). Methods. Data were reviewed from 108 patients enrolled in the feasibility study of laparoscopic sentinel basin dissection (SBD) in gastric cancer. Seven steps contain tracer injection at submucosa (step 1) and at four sites (step 2) by intraoperative esophagogastroduodenoscopy (EGD), leakage of tracer (step 3), injection within 3 minutes (step 4), identification of at least one sentinel basin (SB) (step 5), evaluation of sentinel basin nodes (SBNs) by frozen biopsy (step 6), and identification of at least five SBNs at back table and frozen sections (step 7). Results. Failure in step 7 (n=23) was the most common followed by step 3 (n=15) and step 6 (n=13). We did not find any differences of clinicopathological factors between success and failure group in steps 1~6. In step 7, body mass index (BMI) was only the significant factor. The success rate was 97.1% in patients with BMI 2 and 80.3% in those with BMI ≥ 23 kg/m2 (P=0.028). Conclusions. Lower BMI group showed higher success rate in step 7. Surgeons doing SNNS should be cautious when evaluating sufficient number of SBN in obese patients.

Histologic confirmation of axillary nodal metastases preoperatively avoids a sentinel node biopsy and enables a one step surgical procedure. The aim of this study was to establish the local positive predictive value of axillary ultrasound (AUS) and guided needle core biopsy (NCB) in axillary staging of breast cancer, and to identify factors influencing yield. A prospective audit of 142 consecutive patients (screening and symptomatic) presenting from 1st December 2008-31st May 2009 with breast lesions categorized R4-R5, who underwent a preoperative AUS, and proceeded to surgery was undertaken. Ultrasound-guided NCB was performed on nodes radiologically classified R3-R5. Lymph node size, number, and morphological features were documented. Yield was correlated with tumor size, grade, and histologic type. AUS/NCB was correlated with post surgical pathologic findings to determine sensitivity, specificity, positive and negative predictive value of AUS and NCB. A total of 142 patients underwent surgery, of whom 52 (37%) had lymph node metastases on histology. All had a preoperative AUS, 51 (36%) had abnormal ultrasound findings. 46 (90%) underwent axillary node NCB of which 24 (52%) were positive. The smallest tumor size associated with positive nodes at surgery was 11.5 mm. The sensitivity of AUS was 65%. Specificity was 81%, with a positive predictive value (PPV) of 67% and negative predictive (NPV) value of 80%. Sensitivity of U/S-guided NCB was 75%, with a specificity of 100%, PPV 100% and NPV 64%. Sensitivity of AUS for lobular carcinoma was 36% versus 76% for all other histologies. Sensitivity of NCB for lobular cancer was 33% versus 79% for all other histologies. The most significant factor producing discordance between preoperative AUS and definitive histologic evidence of lymph node metastasis was tumor type. Accurate preoperative lymph node staging was prejudiced by lobular histology (p < 0.0019).

In this chapter, we try to debate two of the most several controversial points about melanoma: the role of the ultraviolet (UV) ray exposure and the position of the sentinel node biopsy in the dermatological daily activity. It has been demonstrated as a direct relationship between UV exposure and the risk of developing melanoma, but it is also true that a chronic continuous UV ray exposure can develop a protective action. Nodal evaluation is one of the most important prognostic indicators to be considered for the patient outcome. The aims for which sentinel node biopsy is so often adopted can be summarized in three points: a detailed nodal staging, a regional disease control, and a possible overall improved survival. At present, many authors do not think that it let the overall survival grow; therefore, they suggest its use only to stage regional lymph nodes and accurately identify patients who could benefit through an early complete regional lymphadenectomy.

Summary In 2006 Meiron Thomas, writing in the British Journal of Surgery, made the following statement about the value of sentinel lymph node biopsy (SLNB) as a staging procedure in cutaneous malignant melanoma (1): “Perhaps a more important concern for those hoping to gain reassurance from accurate nodal staging relates to positive SN(S) that are prognostically inaccurate, information that can be devastating for the patient, leading to unnecessary lymphadenectomy and possibly unnecessary adjuvant therapy”. In September 2011 Meyrick Ross and Gershenwald, writing in the Journal of Surgical Oncology, made the following statement about the management of patients with cutaneous malignant melanoma (2): “Sentinel node biopsy has become an important component of the initial management of many of these patients for accurate staging of regional lymph nodes, as well as enhanced regional disease control and improved survival in the patients with microscopically involved nodes.” These two extremes have polarized the debate about the proper management of patients with malignant melanoma and have lead to widespread confusion and dismay amongst practicing clinicians, GP’s and patient groups. In fact both statements are inaccurate, misleading and result from a false reading of the literature and in the case of Ross and Gershenwald a false interpretation of their own data (3). The following article explains why.

Axillary node status is a major prognostic factor in early-stage disease. Traditional staging needs levels I and II axillary lymph node dissection. Axillary involvement is found in 10%–30% of patients with T1 (<2 cm) tumours. Sentinel lymph node biopsy is a minimal invasive method of checking the potential nodal involvement. It is based on the assumption of an orderly progression of lymph node invasion by metastatic cells from tumour site. Thus, when sentinel node is free of metastases the remaining nodes are free, too (with a false negative rate lesser than 5%). Moreover, Randomized trials demonstrated a marked reduction of complications associated with the sentinel lymph node biopsy when compared with axillary lymph node dissection. Currently, the sentinel node biopsy procedure is recognized as the standard treatment for stages I and II. In these stages, this approach has a positive node rate similar to those observed after lymphadenectomy, a significant decrease in morbidity and similar nodal relapse rates at 5 years. In this review, the indications and contraindications of the sentinel node biopsy are summarized and the methodological aspects discussed. Finally, the new technologic and histologic developments allow to develop a more accurate and refinate technique that can achieve virtually the identification of 100% of sentinel nodes and reduce the false negative rate.

Synopsis We report the utility of office-based, nonimaged guided fine needle aspiration of palpable axillary lymph nodes in breast cancer patients. We examine the sensitivity and specificity of this procedure, and examine factors associated with a positive fine needle aspiration biopsy result. Abstract: Although the utility of ultrasound-guided fine needle aspiration biopsy (FNA) of axillary lymph nodes is well established, there is little data on nonimage guided office-based FNA of palpable axillary lymphadenopathy. We investigated the sensitivity and specificity of nonimage-guided FNA of axillary lymphadenopathy in patients presenting with breast cancer, and report factors associated with a positive FNA result. Retrospective study of 94 patients who underwent office-based FNA of palpable axillary lymph nodes between 2004 and 2008 was conducted. Cytology results were compared with pathology after axillary sentinel node or lymph node dissection. Nonimage-guided axillary FNA was 86% sensitive and 100% specific. On univariate analysis, patients with positive FNA cytology had larger breast tumors (p = 0.007), more pathologic positive lymph nodes (p

National Comprehensive Cancer Network (NCCN) guidelines for female breast cancer treatment and surveillance are well established, but similar guidelines on male breast cancers are less recognized. As an NCCN institution, our objective was to examine practice patterns and follow-up for male breast cancer compared to established guidelines for female patients. After Institutional Review Board approval, a prospective breast database from 1990 to 2009 was queried for male patients. Medical records were examined for clinico-pathological factors and follow-up. The 5-year survival rates with 95% confidence intervals were estimated using Kaplan-Meier method and Greenwood formula. Of the 19,084 patients in the database, 73 (0.4%) were male patients; 62 had complete data. One patient had bilateral synchronous breast cancer. The median age was 68.8 years (range 29-85 years). The mean/median invasive tumor size was 2.2/1.6 cm (range 0.0-10.0 cm). All cases had mastectomy (29 with axillary node dissection, 23 with sentinel lymph node biopsy only, 11 with sentinel node biopsy followed by completion axillary dissection). Lymph node involvement occurred in 25/63 (39.7%). Based on NCCN guidelines, chemotherapy, hormonal therapy, and radiation are indicated in 34 cases, 62 cases, and 14 cases, respectively. Only 20/34 (59%) received chemotherapy, 51/62 (82%) received hormonal therapy, and 10/14 (71%) received post-mastectomy radiation. Median follow-up was 26.2 months (range: 1.6-230.9 months). The 5-year survival estimates for node positive and negative diseases were 68.5% and 87.5%, respectively (p = 0.3). Despite the rarity of male breast cancer, treatment options based on current female breast tumors produce comparable results to female breast cancer. Increased awareness and a national registry for patients could help improve outcomes and tailor treatment recommendations to the male variant.

Several studies have put to question and evaluated the indication and prognosis of sentinel lymph node biopsy (SNLB) as sole treatment in human breast cancer. We reviewed 1588 patients who underwent axillary surgery. In 239 patients, axillary lymph node dissection (ALND) was performed following positive fine needle aspiration cytology (FNAC), and, in 299 cases, ALND was executed after positive SNLB. The most dramatic result from our data is that patients with either micrometastasis of the sentinel lymph node (SLN) or only metastatic SLN have, respectively, an 84.5% and a 75.0% chance of having no other nodal involvement. We believe a more refined patient selection is neccessary when considering ALND. Where the primary tumor is larger than 5 cm, where radio or adjuvant therapies are not indicated, in cases of FNAC+ nodes, and in cases presenting more than one metastatic sentinel node, we prefer to carry out ALND. Having thus said, however, our data suggests that it is wise not to perform ALND in almost all cases presenting positive SLNs.

The purpose of this study was to compare short-term versus long-term axillary drainage in women treated for lymph node positive breast cancer. A comparative cohort study on differences between short-term or long-term axillary drainage was performed. Primary outcome measures were seroma formation demanding aspiration and wound related complications. Secondary outcome measures were type of operation (modified radical mastectomy (MRM) or wide local excision with axillary lymph node dissection (ALND) or completing ALND after positive sentinel node), length of hospital stay, and visits to the emergency department and outpatient clinic. The short-term drainage group consisted of 37 patients, and the long-term drainage group of 40 patients. Short-term drainage was associated with a shorter hospital stay (1.7 versus 2.6 days, p = 0.01), but more visits to the emergency department (0.3 versus 0.1, p = 0.04) and outpatient clinic (3.6 versus 2.8, p = 0.03). Overall incidence of seroma formation was 40% and more frequently in the short-term drainage group (p = 0.01). The highest incidence of seroma and largest aspirated volumes were found in patients with short-term drainage and MRM. No difference in incidence of wound infection was found between both groups, and overall incidence of wound infection was 32%. Seroma formation itself was associated with a higher risk of wound infection (OR 4.39 95% CI 1.6-12.1). Short-term axillary drainage does not lead to an increase in wound-related problems, but is associated with a higher incidence of seroma. This seems especially the case in patients who underwent MRM. Therefore, we propose a differentiated policy: patients treated with MRM should be offered long-term axillary drainage, whereas patients treated with breast conserving therapy and ALND or completing ALND after a positive sentinel node should be offered short-term axillary drainage.

A 55-year-old woman underwent radical mastectomy and axillary node dissection because of an invasive ductal carcinoma with neuroendocrine features. Histologically, all 22 sampled lymph nodes had widespread cystic inclusions lined by a regular, serous-type epithelium positive for cytokeratin-7, WT-1, CA125, and estrogen receptors. Papillary projections were found in the lumen of some cysts. The lesions were consistent with florid, papillary endosalpingiosis (FPE), a hitherto unreported condition in a supradiaphragmatic location. Metastases from papillary carcinomas of ovary, breast, or thyroid were excluded considering the lesion's immunophenotype (negative for mammaglobin and TTF-1) and the absence of both atypical features and a concurrent abdominal serous tumor. In only one node, lesions co-existed with a metastasis of breast carcinoma. Supradiaphragmatic FPE represents a pitfall in the differential diagnosis of metastases, especially in sentinel nodes, since it may increase their size and reveal an unusual ultrasonographic image. Clinicopathologic findings and a focused immunohistochemical study led to the correct diagnosis of this benign lesion.

n Abstract: Over the past years, experience has been increasing with lymphatic mapping and sentinel node biopsy (SNB) after preoperative chemotherapy for breast cancer, with a wide range of results reported in the literature and final conclusions on the diagnostic value and clinical consequences of this sequential approach still missing. Between 1999 and 2002, the Austrian Breast and Colorectal Cancer Study Group (ABCSG) conducted a prospective randomized multicenter trial comparing three versus six preoperative cycles of epirubicin ⁄docetaxel + granulocyte colony-stimulating factor for operable breast cancer. Of the 292 patients recruited to the trial overall, 111 were enrolled in a prospective subprotocol for performing LM and SNB in addition to obligatory axillary lymph node dissection (ALND) after PC. SNB after PC identified at least one sentinel node in 100 of 111 patients (identification rate 90%). In six cases, a false-negative SN was identified, resulting in a false-negative rate of 13% (6 of 47). We only found little correlation between patients and tumor characteristics and the identification rate or false-negative rate. Lymphatic mapping and SNB after primary chemotherapy failed to predict histologic infiltration of the sentinel node with sufficient sensitivity. The routine use of SNB after primary chemotherapy should therefore be discouraged. n

GSCHWANTLER-KAULICH D., RIEGLER-KEIL M., RUECKLINGER E., SINGER C.F., SEIFERT M. & KUBISTA E. (2011) European Journal of Cancer Care20, 627–631 Factors influencing the identification rate of the sentinel node in breast cancer Sentinel node biopsy is a widely accepted alternative to primary axillary lymph node dissection for ipsilateral nodal assessment in breast cancer. We have performed a retrospective chart review in 713 consecutive patients with primary, operable breast cancer who underwent sentinel node biopsy in order to identify factors that determine the sentinel node identification rate. Chi-squared test, univariate and multivariate analyses were used to evaluate the influence of different factors on the sentinel identification rate. Among the factors investigated, tumour size was correlated with sentinel lymph nodes detection rates (multiple logistic regression, P= 0.002). In addition, the patient's age showed to be a significant influencing factor (multiple logistic regression, P= 0.006). Body mass index and grade only exhibited a significant correlation with the identification rate in the univariate (P= 0.041, P= 0.025), but not in the multivariate analysis (P= not significant). All associations were found to be independent of the site of injection. Interestingly, surgeons with intermediate expertise (11–20 prior dissections) had the highest detection rates (P= 0.004). We conclude that sentinel identification rates are higher in larger tumours and in younger patients, independent of the injection site. Surgical experience in sentinel node dissection is not linearly correlated with higher identification rates.

Sentinel lymph node biopsy (SLNB) is a safe and accurate minimally invasive method for detecting axillary lymph node (ALN) involvement in the clinically negative axilla thereby reducing morbidity in patients who avoid unnecessary axillary lymph node dissection (ALND). Although current guidelines recommend completion ALND when macro- and micrometastatic diseases are identified by SLNB, the benefit of this surgical intervention is under debate. Additionally, the management of the axilla in the presence of isolated tumour cells (ITCs) in SLNB is questioned. Particularly controversial is the prognostic significance of minimal SLNB metastasis in relation to local recurrence and overall survival. Preliminary results of the recently published Z0011 trial suggest similar outcomes after SNB or ALND when the SN is positive, but this finding has to be interpreted with caution.

The timing of sentinel node biopsy in the setting of neo-adjuvant chemotherapy for breast cancer is controversial. Sentinel node biopsy performed after neo-adjuvant chemotherapy may save patients with a nodal response the morbidity of an axillary lymph node dissection. A retrospective review of prospectively collected data compared sentinel node biopsies performed after patients had received neo-adjuvant chemotherapy with patients who had not received neo-adjuvant chemotherapy. Demographic factors, tumor characteristics, and the results of the sentinel node biopsies and completion lymph node dissections (when applicable) were compared. A total of 231 axillary procedures (224 patients) were evaluated. The patients who received neo-adjuvant chemotherapy (NEO; N = 52) were younger, had higher grade tumors, were more likely to have a mastectomy, and were more likely to have ER-negative and HER-2/neu positive tumors than the patients who did not receive neo-adjuvant chemotherapy (NON; N = 179). The mean clinical tumor size in the neo-adjuvant group was 4.5 cm (±1.8) prior to chemotherapy; the post-chemotherapy pathologic size was 1.4 cm (±1.3). A sentinel node was identified in all cases. There were no significant differences between the groups in the mean number of sentinel nodes removed (NEO = 3.3; NON = 3.1; p = 0.545), the percentage of positive axillae (NEO = 24%; NON = 21%; p = 0.776) or the mean number of positive sentinel nodes (NEO = 1.3; NON = 1.5; p = 0.627). There was no difference in the percentage of completion lymph node dissections with additional positive nodes (NEO = 20%; NON = 35%; p = 0.462); there was a difference in the number of nodes removed in the completion lymph node dissections (mean NEO = 12.0; NON = 16.4; p = 0.047). Sentinel node biopsy performed after neo-adjuvant chemotherapy appears to be an oncologically sound procedure and may save some patients the morbidity of a complete lymph node dissection.

Previous plastic surgery procedures such as breast augmentation or reduction mammoplasty can potentially alter the lymphatic drainage of the breast. The purpose of this study is to determine the success rates of sentinel node lymphatic mapping in patients with previous plastic surgical procedures of the breast. A total of 83 patients with a history of plastic surgery of the breast that underwent subsequent sentinel node mapping between 1996 and 2008 were retrospectively analyzed. Eight-three patients that underwent a total of 108 sentinel node biopsies. Hundred cases (93%) previously underwent breast augmentation and eight cases (7%) previously underwent reduction mammoplasty. The mean time between the previous plastic surgical procedures and the sentinel node biopsy was 10.3 years (range: 2 months-32 years). Indications for the mapping procedure were invasive cancer (n = 64), ductal carcinoma in situ (n = 17), and prophylactic mastectomy (n = 27). The identification rate of the sentinel node was 95.3% (103/108). The success rate based on type of procedure was 96% (96/100) for augmentation and 87.5% (7/8) for reduction mammoplasty. With a mean follow-up of 3.4 years, there has been only one local axillary recurrence that occurred at the time of an ipsilateral breast recurrence following lumpectomy. Lymphatic mapping can be successfully performed in patients who have previously undergone plastic surgery operations.

Sentinel node (SN) micrometastases are an indication to proceed to axillary clearance. The aim of this study is to determine the extent and level of axillary clearance required for patients with SN micrometastases. All patients with SN micrometastases which were followed by axillary clearances from 1999 to 2007 were identified. Slides were reviewed by a histopathologist to detail characteristics of SN micrometastases including size and site. The SN micrometastases and primary tumor characteristics were correlated with the presence and level of non-SN micrometastases. Fifty patients who had micrometastases followed by axillary clearances were identified. Of those 18% (n = 9) had non-SN metastases. Seven patients had metastases to level I, one patient had metastases to level I and III and one patient had non-SN metastases to level III only. No patient had metastases to level II. Patients with non-SN metastases had very limited number of non-SNs involved (maximum 2 non-SNs). No variable, including site of the micrometastasis, was predictive of non-SN metastases. In patients with SN micrometastases, a limited level I axillary clearance can be justified in view of the low number of additional nodes involved and in particular, the low (4%) rate of spread to level II/III nodes.

Axillary lymph node status is an important factor in determining the prognosis and treatment in patients with invasive breast cancer. The introduction of the sentinel lymph node biopsy technique in the axilla has significantly reduced the number of patients requiring an axillary clearance procedure. However, a proportion of patients will be found to have axillary metastases after a sentinel node biopsy and will then require a second axillary surgical procedure. A retrospective audit of 653 consecutive patients presenting with invasive breast cancer showed a preoperative diagnosis rate of axillary disease of 23% using axillary ultrasound and fine-needle aspiration (FNA) together. We performed 232 axillary FNAs to diagnose 150 positive axillae. This avoided the need for a second operation in 150 women. The negative predictive value for axillary metastases using this technique was 79%. Overall accuracy was 84%.

Identification and prediction of breast cancer patients with metastases isolated to the sentinel lymph node(s) would potentially allow avoidance of axillary dissection and its complications. In this study, we evaluate the performance of two recently published models (Alkhatib et al. and Chagpar et al.) that attempt to predict patients who have isolated sentinel lymph node metastases. Both of these models reported a 5% rate of positive nonsentinel nodes in their respective lowest risk category. From 1997 to 2004, 465 breast cancer patients had a positive sentinel node and underwent axillary lymph node dissection at Mayo Clinic. To evaluate the Alkhatib model, patients were assigned to the following groups: group 1: 1 positive sentinel node and > or =1 negative sentinel node(s); group 2: >1 positive sentinel node and > or =1 negative sentinel node(s); group 3: 1 positive sentinel node and no negative sentinel node(s); group 4: >1 positive sentinel node and no negative sentinel node(s). To evaluate the Chagpar model, patients were assigned a score based on the sum of three factors: tumor size (T1a = 1, T1b or T1c = 2, T2 = 3, and T3 = 4 points), number of positive sentinel nodes (>1 positive sentinel node = 1 point), and ratio of positive/total sentinel nodes (>50% positive = 1 point). The chi-square test was used to compare our results to those of the original studies. For the Alkhatib model, we found that 30% (p < 0.0001) of Group 1 patients had nonsentinel node metastases. Using the Chagpar model, the percentage of patients with a cumulative score of 1 with a nonsentinel node metastasis was 17% (p = 0.19). In our cohort, neither model accurately predicted which patients have a < or = 5% chance of having nonsentinel metastases. These models are not adequate to identify patients in whom axillary dissection can be omitted.

Summary Background: The aim of the study was to identify the informational needs of patients with melanoma on disease status and prognosis, and to ascertain their views on the utility of positron emission tomography (PET) and sentinel node biopsy (SNB). Patients and methods: Patients attending the weekly melanoma outpatient clinic at St Thomas’ Hospital London UK between February and August 2007 participated in this cross-sectional survey. Views of 106 melanoma patients were elicited using a face-to face semi-structured questionnaire. Results: The majority of participants wanted to know everything about their disease (88%). Prognostic information (> 85%) and information on palliative care input (97%) were highly valued. More than 50% expected the doctor to impart this information without negotiation. Nearly 70% of the responders who had previously had a PET scan felt they should decide if and when the scans should be performed. Fifty three percentage had undergone the SNB because the doctor had suggested it. Conclusions: Patients with melanoma want detailed and prompt information about their disease including prognosis. Regular PET scans provide reassurance. The role of SNB is not clear to all patients.

Mondor’s disease is an uncommon complication of breast and axillary surgery. Although self-limiting, the subcutaneous cords may be both painful and functionally limiting for the patient. Numerous pharmacologic approaches have been tried, but without widespread success, and we wished to evaluate the non-invasive technique of manual axial distraction in such patients. Thirty consecutive patients with axillary Mondor’s disease following surgery were treated solely with this technique by the senior author (RJS) over a 24-month period. Mean age was 45 years (range 32–72) with 27 having undergone formal axillary dissection and three sentinel node biopsy. 25 (83.3%) were successfully treated with a single procedure, three (10%) with two and two (6.7%) with three procedures. we present the initial results of the novel technique of manual axial distraction that has been found to be efficacious and without adverse effect. It provides a rapid and definitive cure in postoperative Mondor’s disease.

Summary Background: Although delayed axillary lymph node dissection is the gold standard for evaluating axillary status after identification of a positive sentinel lymph node (SLN), between 40% and 70% of sentinel lymph node positive patients will have negative non-sentinel nodes and undergo a non-therapeutic axillary dissection. Accurate estimates of the likelihood of additional disease in the axilla can assist decision-making about further treatment. To predict non-SLN metastases in patients with a positive SLN biopsy, four different nomograms have been created. Method: This paper reviews the scoring systems and nomograms reported in the literature and compares their predictive probability of non-SLN involvement in patients with SLN positive breast cancer. Result: There are several published scoring systems that contain different parameters to estimate the rate of non-SLN metastases in SLN positive patients. We reviewed Memorial Sloan-Kettering Cancer Center (MSKCC), Tenon, Stanford and Cambridge nomograms published and used scoring systems including three to eight variables. We found that the MSKCC nomogram is the most validated model in the literature to predict non-SLN status accurately. The other three models have not yet been verified in outside institutions. Conclusion: Despite having some limitations, the MSKCC nomogram is the most validated model in the literature. These models should be tested and verified in different programs and different patient groups before they are widely accepted.

Ductal carcinoma in situ with microinvasion (DCISM) is a distinct clinicopathologic entity. Its true metastatic potential has been unclear, due in part to historical differences in the definition of microinvasion. The role of routine axillary staging for DCISM is controversial, given the reportedly low incidence of axillary metastases. We describe our institutional experience with DCISM, and define the role of axillary staging. A retrospective analysis was made of patients with DCISM. Forty-four patients underwent axillary staging (24 axillary lymph node dissection [ALND], 22 sentinel node biopsy [SNB]). Macrometastatic disease was present in three patients (7%), and two patients had isolated tumor cells (itc) in the sentinel node. Patients with axillary metastases tended to be younger. Comedonecrosis, nuclear grade, multifocal microinvasion or presentation as a clinical mass was not associated with a higher rate of axillary metastases. In this series, 7% of patients had macrometastatic disease, and two patients (5%) had itc only. Axillary staging is indicated, and SNB is appropriate for the identification of axillary metastatic disease.

Patients with neurofibromatosis type I and breast cancer represent a subset of people who may be considered at high risk for secondary cancers after conventional whole breast radiation therapy and breast conservation surgery. A case of a 49-year-old woman with neurofibromatosis type I is presented. She was diagnosed with a 1.1-cm right breast infiltrating ductal carcinoma. Clinical, diagnostic imaging, and pathologic features are discussed. Her initial treatment plan of breast conserving therapy was thwarted when her sentinel node biopsy was positive for micrometastatic disease in 1/14 lymph nodes. She elected to have a bilateral simple mastectomy. This case addresses the rare dilemma of offering breast conservation therapy as a viable option for patients with neurofibromatosis type I. Current data on radiation-induced secondary cancers such as sarcoma after treatment for breast and other cancers are reviewed.

Axillary lymph node dissection in patients with ductal carcinoma in situ (DCIS) of the breast is not warranted because DCIS has no metastatic potential. However, the risk of microinvasive carcinoma (MIC) exists in large DCIS treated by mastectomy. The aim of this series is to evaluate the incidence of lymph node metastases in DCIS and DCIS-MIC. We analyzed retrospectively patients treated in six French cancer centers for pure DCIS or DCIS-MIC. Surgical procedures were lumpectomy or mastectomy associated with an axillary sentinel node (SN) procedure. We included 161 patients suffering from pure DCIS (116/161, 72%) or DCIS-MIC (45/161, 28%). Mean age was 56 years (32-78). We observed underestimation between core biopsy and histological result in 43/142 cases (30%). These data show an association between lesion size, solid subtype, high-grade DCIS, and underestimation. Forty-eight breast conservative procedures were performed and 113 mastectomies (70%). SN procedure was performed using blue dye, technetium, or both. In our series, we selected patients with a high risk of occult invasive carcinoma: high grade (55%), mean size (27 mm), and mastectomy (112). Six SN were found positive (3.7%). In the five patients treated with complete axillary dissection, the SN was the only positive node. SN in DCIS is an interesting procedure but not necessary for all patients. We need to focus on the subgroup with or a high risk of occult MIC: extensive calcifications or palpable mass, DCIS diagnosed by core biopsy and underestimation, multifocality, high grade, large tumor size, MIC, and mastectomy.

The ability to predict axillary lymph node involvement in breast cancer patients in the preoperative setting is invaluable. This study provides a simple set of formulae to enable clinicians to make informed decisions in the management of screen-detected breast cancer. The tumor pathology reports were obtained of all 4,585 women identified between 1996 and 1999 in New South Wales (NSW) with T1 or T2 breast cancer by the statewide co-ordinated breast screening service (BreastScreen NSW). Equations predicting node positivity were calculated by linear regression analysis and, from published sentinel node false-negative rates, the probability of retrieval of a false-negative axillary lymph node by sentinel node biopsy was calculated for tumors of different size and grade. Node involvement was identified in 1,089 (23.8%) of women. A linear relationship for tumor size, grade, and nodal involvement was predicted by: frequency (%) = 1.5 x tumor size (mm) + 2 (or 6 or 10) for grade I (or II or III) tumors. Assuming a 7.5% false-negative rate, the probability of retrieving a false-negative sentinel node ranged from 0.8% for a patient with a 5 mm, grade I carcinoma to 6.0% for a 50 mm, grade III tumor. These simple formulae are easy to use in a clinical setting. The reference table enables breast surgeons to inform a patient about the absolute probability of false-negative sentinel biopsy rates for patients with screen-detected carcinomas when size can be estimated from preoperative imaging and when tumor grade is often available from preoperative core biopsy. Patients with large, T2 breast tumors may be best treated with axillary dissection rather than sentinel node biopsy alone due to the risk of under-staging the woman's disease and also the high probability of finding a positive sentinel node.

Core needle biopsy (CNB) is used to sample both mammographically and ultrasound detected breast lesions. A diagnosis of ductal carcinoma in situ (DCIS) by CNB does not ensure the absence of invasive cancer upon surgical excision and as a result an upstaged patient may need to undergo additional surgery for axillary nodal evaluation. This study evaluates the accuracy of CNB in excluding invasive disease and the preoperative features that predict upstaging of DCIS to invasive breast cancer. Two hundred fifty-four patients over an 8-year period from 1994 to 2002 with a diagnosis of DCIS alone by CNB were retrospectively reviewed. Underestimation of invasive cancer by CNB was determined. Radiographic, pathologic, and surgical features of the cohort were compared using univariate and multivariate analysis. The mean age was 55 years (range 27-84) and mean follow-up was 25 months with one patient unavailable for follow-up. There were a total of six patient deaths, all of which were not disease-specific. A total of 21 out of 254 patients (8%) with DCIS by CNB were upstaged to invasive cancer following surgical excision. There was a significant inverse relationship between the number of core biopsies and the incidence of upstaging (p0.006) in that patients with fewer core samples were more likely to be upstaged at surgical pathology. No relationship was noted between the size of the core samples and the likelihood of upstaging (p0.4). Of 21 patients with invasion, all but two had comedonecrosis by CNB. Comedonecrosis by CNB significantly increased the likelihood of upstaging (p0.001). Of the 21 patients who were upstaged, 12 required subsequent surgery for nodal evaluation while nine had sentinel node biopsy at initial operation. Finally, upstaged patients were significantly more likely to have a positive margin (p0.008). Ductal carcinoma in situ with comedonecrosis on CNB can help to predict the possibility of invasion. Increasing the number of core biopsies reduced the likelihood of sampling error.

Sentinel lymph nodes (SLNs) are the most likely site of regional metastasis. Their step sectioning and cytokeratin immunohistochemistry (IHC) result in the upstaging of breast cancer. The heterogeneity of histologic methods is partially responsible for differences in nodal upstaging of the disease in different reports. Intraoperative assessment might be done by both frozen sections and imprint cytology; both methods have advantages and disadvantages. Several guidelines relating to the histopathology of sentinel nodes, including the recent European Working Group for Breast Screening Pathology guidelines, are briefly summarized. These latter advocate multilevel assessment of grossly or intraoperatively negative sentinel nodes with levels separated by a maximum of 1 mm and allow IHC in their assessment, although this latter method is not mandatory. Both methods of intraoperative evaluation are allowable. There are also minimum requirements for the reports on sentinel node histology. For example, the reports should include the extent of nodal involvement, the method used for their identification, and preferably the method used for investigating the sentinel nodes, even if the results are negative. These guidelines are intended to form the basis for national guidelines in European countries.