Search

Background Sentinel node biopsy in vulvar cancer is associated with much less morbidity than inguinofemoral node dissection. Our study focused on describing the morphology of superficial lymphatic drainage of the vulva and its relationship to regional nodes, which may facilitate orientation during surgery. Materials and methods In 24 female cadavers, injections of patent blue (at various localizations mediallyunilaterally and bilaterally) were used to visualize the lymphatic drainage of the vulva. After dissection of lymphatic vessels and nodes, their course was documented by photograph and then analyzed. Subsequently, a map of vulvar superficial lymphatics was created. Results The cutaneous and subcutaneous tissue of the vulva primarily drained to superficial inguinal nodes. There was no evidence of a solitary lymph node that drained the unilateral vulva. Each area of the vulva drained to its own lymph node, which was variably localized in the subcutaneous groin around the great saphenous vein. Anastomoses between individual inguinal superficial lymph nodes are likely. Right-left symmetry in the course of lymphatic collectors was not detected. Natural drainage of the medial and paramedial areas to contralateral inguinal nodes was also not detected. The drainage pattern to ipsilateral inguinal nodes was consistent in cadavers without evidence of vulvar disease and may be applicable in the early stages of vulvar cancer. Conclusions There was no evidence of a solitary node that drained the unilateral vulva. Each part of the vulva may drain to a corresponding lymph node in a different localization of the groin. The surgeon should take this variability into account.

The presence of lymph node metastasis is the most important prognostic factor in penile cancer (PeCa). Due to limited sensitivity of currently available imaging modalities, invasive staging approaches remain indispensable for adequate nodal staging. As an alternative to radical inguinal lymphadenectomy and with the aim to reduce morbidity, staging strategies such as modified lymphadenectomy and dynamic sentinel node biopsy (DSNB) have been introduced. Over the years, DSNB evolved into a safe and reliable staging technique when performed in high volume centers. Recent enhancements of the procedure such as Single-photon emission computed tomography/computed tomography (SPECT/CT) and the introduction of hybrid tracers have improved pre- and intraoperative sentinel node (SN) visualization. Other technologies such as superparamagnetic iron oxide nanoparticles could have a potential future role to further refine DSNB. Future efforts should be aimed at optimizing diagnostic accuracy whilst minimizing perioperative morbidity.

BACKGROUND: Postoperative radiotherapy (PORT) is currently recommended for the treatment of Merkel cell carcinoma. Nevertheless, deviations occur frequently due to the generally elderly and frail patient population. We aimed to evaluate the influence of PORT on survival in stage I-III MCC patients treated in the Netherlands.METHODS: Patients were included retrospectively between 2013 and 2018. Fine-Gray method was used for cumulative incidence of recurrence and MCC-related death, cox regression was performed for overall mortality. Analyses were performed in patients with clinical (sentinel node biopsy [SN] not performed) stage I/II (c-I/II-MCC), pathologic (SN negative) stage I/II (p-I/II-MCC) and stage III MCC (III-MCC), separately. Propensity score matching (PSM) was performed to assess confounding by indication.RESULTS: In total 182 patients were included, 35 had p-I/II-MCC, 69 had c-I/II-MCC and 78 had III-MCC. Median follow up time was 53.5 (IQR 33.4-67.4), 30.5 (13.0-43.6) and 29.3 (19.3-51.0) months, respectively. Multivariable analysis showed PORT to be associated with less recurrences and reduced overall mortality, but not with MCC-related mortality. In stage III-MCC, extracapsular extension (sub-distribution hazard [SDH] 4.09, p = 0.012) and PORT (SDH 0.45, p = 0.044) were associated with recurrence, and ≥ 4 positive lymph nodes (SDH 3.24, p = 0.024) were associated with MCC-related mortality.CONCLUSIONS: PORT was associated with less recurrences and reduced overall mortality in patients with stage I-III MCC, but not with MCC-related mortality. Trends in overall survival benefit are likely to be caused by selection bias suggesting further refinement of criteria for PORT is warranted, for instance by taking life expectancy into account.

The initial management of early-stage ovarian cancer consists of staging surgery including pelvic and para-aortic lymphadenectomy. The use of the sentinel lymph node (SLN) procedure in this setting may decrease the morbidity associated with this surgery. The objective of this review was to evaluate the feasibility of the SLN procedure in ovarian cancer diagnosed at an early stage by comparing the different techniques used and their accuracy. A systematic literature search was performed on PubMed and ClinicalTrials.gov for articles in English or French about the SLN technique in ovarian cancer. Ten studies were included in the analysis, with a total of 179 patients. The main tracers used were Technetium-99m, indocyanine green, and patent blue, and the most common site of injection was the proper ovarian and unfundibulopelvic ligaments. The overall detection rate was 87.7%. Of the small number of cases of lymph node metastasis reported, the SLN procedure had a sensitivity of 90.9% and a negative predictive value of 98.8%. The sentinel node procedure appears to be feasible and safe and could be reliable in determining the lymph node status of patients with early-stage ovarian cancer.

Contains fulltext : 249915.pdf (Publisher’s version ) (Open Access) OBJECTIVE: To evaluate the incidence of pulmonary metastases in the preoperative work-up of patients with primary vulvar squamous cell carcinoma (SCC). DESIGN: Retrospective cohort study. SETTING: Tertiary referral centre. POPULATION: Patients treated for primary vulvar SCC from 2000 to 2018. METHODS: The pre-operative chest imaging of 452 consecutively treated patients was documented with a minimal follow-up period of 2 years. MEAN OUTCOME MEASURES: Incidence of pulmonary metastases, frequency of chest imaging and subsequent coincidental findings. RESULTS: In total, 80.8% of patients underwent pre-operative chest imaging. Seven patients (1.9%), with a median tumour size of 80 mm, presented with pulmonary metastases. None of the patients with early stage disease and tumour size

The surgical management of breast cancer has been marked by a therapeutic de-escalation from radical surgery to breast conservation and from axillary curage to sentinel lymph node sampling. With regard to breast surgery, the de-escalation of treatment has been largely due to organized screening, which has made it possible to diagnose tumors of smaller volume or at an earlier stage. The indications for conservative surgery have been broadened by the addition of radiotherapy on one hand, and the introduction of adjuvant and neo-adjuvant treatments on the other hand. In an effort to de-escalate surgery, totally non-invasive techniques such as radiofrequency, HIFU (High Intensity Focused Ultrasound) or cryotherapy have been tested. Currently, three trials are underway to evaluate active surveillance, without surgery, in the management of certain low-risk ductal carcinomas in situ (DCIS). Regarding axillary procedures, the sentinel node technique has allowed axillary staging in patients with early breast cancer without clinical or radiological lymph node involvement. Currently, international recommendations (ASCO, NCCN) and the consensus of experts in St Gallen do not recommend additional curage in cases of macro or micrometastatic invasion of the sentinel lymph nodes if the criteria of ACOSOG Z0011 are met. The question now arises as to the relevance of a biopsy of suspected axillary nodes during the initial workup and the usefulness of the sentinel node technique in the case of a negative initial workup.

Reconstruction of the lower lip is complex. The Colmenero flap is an effective albeit rarely described method for the repair of medium- to large-sized defects of the lower lip.A retrospective review was carried out using data gathered from patients who had undergone Colmenero flap reconstruction of the lower lip at our centre between 2015 and 2020. We analysed demographic, histologic and anatomic variables as well as surgical results. This review assessed flap functionality based on proper mouth closure, absence of microstomia and oral competence.Thirteen Colmenero flaps were performed in 9 patients, with the flap being used bilaterally in four cases. All patients had squamous cell carcinoma of the lower lip. The mean length of the reconstructed defect was 4.1 cm (ranging between 3-7.5 cm). None of the flaps exhibited signs of necrosis. Five patients required minor surgical touch up during the second procedure: two for dehiscence, two for oral leakage and one for esthetic improvement. All patients had excellent functional and aesthetic final outcomes.The Colmenero flap is a good resource for medium- and large-sized lower lip reconstructions due to its reliability, limited complications, and good aesthetic and functional results.Ricostruzione del labbro inferiore mediante lembo di Colmenero dopo ampia chirurgia demolitiva: una opzione affidabile.La ricostruzione del labbro inferiore è complessa. Il lembo di Colmenero è un metodo efficace anche se raramente descritto per la riparazione di difetti medio-grandi del labbro inferiore.È stata effettuata una revisione retrospettiva utilizzando i dati raccolti da pazienti sottoposti a ricostruzione del labbro inferiore mediante lembo di Colmenero presso il nostro centro tra il 2015 e il 2020. Abbiamo analizzato le variabili demografiche, istologiche e anatomiche nonché i risultati chirurgici ottenuti. Questa revisione ha valutato la funzionalità del lembo in base alla corretta chiusura della bocca, all’assenza di microstomia e ripristino della competenza orale.Tredici lembi di Colmenero sono stati eseguiti in 9 pazienti, in quattro dei quali bilateramente. Tutti i pazienti erano affetti da carcinoma a cellule squamose del labbro inferiore. La lunghezza media del difetto ricostruito è risultata di 4,1 cm (compresa tra 3-7,5 cm). Nessuno dei lembi ha manifestato segni di necrosi. Cinque pazienti hanno richiesto piccoli ritocchi chirurgici mediante una seconda procedura: due per deiscenza, due per incontinenza orale e uno per miglioramento estetico. Tutti i pazienti hanno avuto ottimi risultati finali funzionali ed estetici.Il lembo Colmenero è una buona risorsa per ricostruzioni del labbro inferiore di medie e grandi dimensioni grazie alla sua affidabilità, alle modeste complicazioni e ai buoni risultati estetici e funzionali.

Purpose Development of new lymphatic tracers and advancement of hybrid tracers, such as Indocyanine Green (ICG)-Nanocoll, represent an exciting step in the future of sentinel lymph node biopsy (SLNB). These tracers aim to improve our ability to detect sentinel lymph nodes by enhancing their localisation. The aim of this study was to assess the performance of a novel dual tracer, double injection technique of ICG-“cold”-Nanocoll and radiolabeled Nanocoll, in SLNB for early stage oral cancer. Methods Double injection technique was performed firstly using 99mTc-Nancoll prior to sentinel node imaging followed by ICG-“cold”-Nanocoll injection in theatre. Analysis involved examination of number, labelling and location of nodes harvested, sentinel node status, survival analysis, false negative rate and complications associated with use of our technique. Results ICG “cold” Nanocoll results showed concordance of fluorescence and radioactivity detection in 74 nodes in 24 patients. Most importantly, all nodes found positive for metastasis (6 nodes) were discovered to be both “hot” and fluorescent; 74 nodes removed were both “hot” and fluorescent, 8 fluorescent only and 6 “hot” only. Conclusion Our results indicate that two sets of tracer injection given at two different time points will flow to the same sentinel nodes. This double labelling increased our confidence that the retrieved node with double labelling does represent a sentinel node.

PURPOSE The Groningen International Study on Sentinel nodes in Vulvar cancer (GROINSS-V)-II investigated whether inguinofemoral radiotherapy is a safe alternative to inguinofemoral lymphadenectomy (IFL) in vulvar cancer patients with a metastatic sentinel node (SN). METHODS GROINSS-V-II was a prospective multicenter phase-II single-arm treatment trial, including patients with early-stage vulvar cancer (diameter < 4 cm) without signs of lymph node involvement at imaging, who had primary surgical treatment (local excision with SN biopsy). Where the SN was involved (metastasis of any size), inguinofemoral radiotherapy was given (50 Gy). The primary end point was isolated groin recurrence rate at 24 months. Stopping rules were defined for the occurrence of groin recurrences. RESULTS From December 2005 until October 2016, 1,535 eligible patients were registered. The SN showed metastasis in 322 (21.0%) patients. In June 2010, with 91 SN-positive patients included, the stopping rule was activated because the isolated groin recurrence rate in this group went above our predefined threshold. Among 10 patients with an isolated groin recurrence, nine had SN metastases > 2 mm and/or extracapsular spread. The protocol was amended so that those with SN macrometastases (> 2 mm) underwent standard of care (IFL), whereas patients with SN micrometastases (≤ 2 mm) continued to receive inguinofemoral radiotherapy. Among 160 patients with SN micrometastases, 126 received inguinofemoral radiotherapy, with an ipsilateral isolated groin recurrence rate at 2 years of 1.6%. Among 162 patients with SN macrometastases, the isolated groin recurrence rate at 2 years was 22% in those who underwent radiotherapy, and 6.9% in those who underwent IFL ( P = .011). Treatment-related morbidity after radiotherapy was less frequent compared with IFL. CONCLUSION Inguinofemoral radiotherapy is a safe alternative for IFL in patients with SN micrometastases, with minimal morbidity. For patients with SN macrometastasis, radiotherapy with a total dose of 50 Gy resulted in more isolated groin recurrences compared with IFL.

BackgroundSentinel node biopsy is a surgical technique to explore lymph nodes for surgical staging of endometrial cancer, which has replaced full retroperitoneal lymph node dissection. However, the effectiveness of sentinel node biopsy, its value to patients, and potential harms compared with no-node dissection have never been shown in a randomized trial.Primary ObjectivesStage 1 will test recovery from surgery. Stage 2 will compare disease-free survival at 4.5 years between patients randomized to sentinel node biopsy versus no retroperitoneal node dissection.Study HypothesisThe primary hypothesis for stage 1 is that treatment with sentinel node biopsy will not cause detriment to patient outcomes (lymphedema, morbidity, loss of quality of life) and will not increase treatment-related morbidity or health services costs compared with patients treated without a retroperitoneal node dissection at 12 months after surgery. The primary hypothesis for stage 2 is that disease-free survival at 4.5 years after surgery in patients without retroperitoneal node dissection is not inferior to those receiving sentinel node biopsy.Trial DesignThis phase III, open-label, two-arm, multistage, randomized non-inferiority trial (ENDO-3) will determine the value of sentinel node biopsy for surgical management of endometrial cancer. Patients with endometrial cancer are randomized to receive: (1) laparoscopic/robotic hysterectomy, bilateral salpingo-oophorectomy with sentinel node biopsy or (2) laparoscopic/robotic hysterectomy, bilateral salpingo-oophorectomy without retroperitoneal node dissection. In stage 1, 444 patients will be enrolled to demonstrate feasibility and quality of life. If this is demonstrated, we will enroll another 316 patients in stage 2.Major Inclusion and Exclusion CriteriaInclusion criteria include women aged 18 years or older with histologically confirmed endometrial cancer; clinical stage 1, who meet the criteria for laparoscopic or robotic total hysterectomy and bilateral salpingo-oophorectomy. Patients with uterine mesenchymal tumors are excluded.Primary EndpointsThe endpoint for stage 1 is surgical recovery, with the proportion of patients returning to usual daily activities at 3 months post-surgery as measured with the EQ-5D. Stage 2 is disease-free survival at 4.5 years.Sample Size760 participants (both stages).Estimated Dates for Completing Accrual and Presenting ResultsStage 1 commenced in January 2021 and is planned to be completed in December 2024 when 444 participants have completed 12 months' follow-up. Stage 2 will enroll a further 316 participants for a total of 760 patients.Trial RegistrationNCT04073706.

Summay Introduction Squamous cell carcinoma of the ear (SCC-E) shows high rates of local recurrence (LR) and lymph node metastases (NM). SCC-E is the leading cause of death from nonmelanoma skin cancer. Objective To determine the LR and NM rates and survival after Mohs micrographic surgery (MMS). Patients and methods We treated 170 invasive SCC-E with MMS with a mean follow up of 48 months. Mean age was 76 years, 93.2% were male patients, mean size: 1.5 cm, and 61.8% of the tumours were well differentiated. Results We observed 5 LRs, 2 locoregional recurrences, and 16 NMs in 23 patients. LR and NM rates were 4.1% and 10.6%, respectively. Only 3/25 recurrences occurred after 2 years of follow up. We observed 1(0.6%) distant metastasis (DM) in a patient who also presented LR + NM. Six out of seven cases with LR and 8/18 with NM died of disease, regardless of aggressive surgical rescue with or without adjuvant radiotherapy. Five-year overall survival, disease-free survival, and disease-specific survival were 81%, 82.6%, and 89.7%, respectively. Conclusions Undeniably, the outcome in SCC-E is determined by locoregional control. DM are sporadic and rarely the cause of death. Systematic reviews and retrospective studies show a solid trend in favor of MMS vs surgical excision. The LR rate of this series (4.1%) is one of the lowest published to date with regard to SCC-E, and confirms this assertion. We observed 10.6% NMs according to other series that treated the whole spectrum of SCC-E. Almost 2/3 of patients with NMs die after therapeutic rescue. We believe that it is essential to identify prognostic factors to select patients for one of the following: close surveillance (ultrasonography) during the first 2 years after surgery, sentinel node biopsy, or elective treatment of the nodes (surgery or radiotherapy).

Adjuvant chemotherapy (CT) significally reduces the rate of relapse in +pN (stage III) colon cancer (CC) and in some pN0 (stage II) with risk factors such as pT4, vascular invasion V1, perineural invasion Pn1, and complicated tumors. However, unexpectedly, 20%-30% of pN0 present a relapse in the follow-up, which may suggest that the lymph node involvement was not discovered in the conventional histological study (CS), and its finding with a superstudy (SS) could increase the number of patients who would benefit from neoadjuvant CT. It is not possible to perform this SS in every lymph node (LN) from the specimen, but it is possible in a small group of LN which are representative of the N status (definition of sentinel node SN). The aim of our work is to state the representativeness of the SN and to analyze de number of patients who are suprastaged after the SS of the SN.Prospective study of a series of patients who have undergone curative surgery for CC, to whom we perform selective biopsy of sentinel node (SBDN). Identification of SN was carried out with in vivo injection of the radiotracer, with ex vivo isolation of SN. Once the specimen is out, we take pictures of the surgical bed to rule out the presence of aberrant drainage routes, out of the routine oncological resection area. We performed the histological CS (Hematoxilin-Eosin stain (H-E) in conventional sections) in the rest of the LN from the mesocolon. In the SN we performed the CS and a SS with H-E in serial sections, immunohistochemistry (IHC) and molecular study with OSNA® (One Step Nucleic Acid Amplification). Diagnostic validity study od SBSN was carried out, defining the false negative (FN) as the negativity of the SN while other LN are positive (N+), as well as a valuation of the suprastaging due to the SS of the SN.We performed lymphatic map in 72 patients, finding the SN in 62 of them (87.3%). The 9 identification failures happened in the first 17 cases. We have not found aberrant drainage routes. A total of 1.164 LN were studied in the 62 patients (18.8 LN/patient), from which 145 are SN (2,34 SN/patient), having found 103 positive LN with the CS and 112 positive with the SS of SN (9+ LN more in 8 patients than detected with the CS). Positivity after CS in the SN group is 17.24% (25/145), while it is 8.53% in the rest (87/1.019) (P .001). With the CS, 50% of the patients (31/62) were pN+ (4 are N+ exclusively in the SN), and after the SS of the SN, only 1 of the 31 pN0 patients (3.2%) becomes pN1a, with a definitive 51.6% of N+ in the whole series (32 N+ in the 62 patients) (5 are N+ exclusively in the SN). Exclusively with the SS of the SN, FN rate ("-SN, +others", meaning patients who are N+ having -SN) is 54.8% (17/31). With the SS of the SN, 8 of the 62 patients (12.9%) increase their total number of +LN: apart from the patient who turns from pN0 to pN1a, suprastaging from IIA to IIIB (and therefore increasing the total number of pN+ to 32), 5 of the 17 FN in the CS turns into positive (2 change the pN subindex and one is suprastaged from IIIB to IIIC), decreasing FN to 37.5% (12/32 cases). Besides, 2 patients whose SN is already positive in the CS increase the number of +SN after the SS of the SN, therefore both changing their pN subindex and one of them suprastaging from IIIB to IIIC. In summary, 8 patients increase the total number of positive SN after the SS (8/62, 12.9%), 5 of them changing the pN subindex (5/62, 12.9%), even if only 3 of them get suprastaged (3/62, 4.8%), among them the one who turns from pN0 to pN1a.Technique is valid and reproducible, with a high detection rate even with a high learning curve. It globally increases the number of affected LN in 12.9% of patients, having prognostic implications in 4.8% (suprastaging rate). Only 3.2% of pN0 patients in the CS turn to be +pN after the SS of the SN, with its therapeutic implications (prescription of adjuvant CT), which could be relevant when extrapolated to a big number of patients. The high FN rate (37.5%) prevents us from accepting the representativeness of SN as the global N status, but it is not clinically relevant in CC, as its aim is not to avoid lymphadenectomy, which remains mandatory (opposite to breast cancer or melanoma in which SN detection decides upon whether to perform or not the lymphadenectomy), but to decide which patients would benefit from adjuvant CT.

OBJECTIVE To investigate factors predicting the risk of developing 90-day postoperative complications and lymphatic-specific morbidity in patients undergoing surgical staging for high-risk endometrial cancer. METHODS This is a multi-institutional retrospective cohort study. Patients affected by apparent early-stage high-risk endometrial cancer (endometrioid FIGO grade 3 with deep myometrial invasion and non-endometrioid endometrial cancer) undergoing surgical staging between 2007 and 2019. Complications were graded according to the Clavien-Dindo classification system. Martin criteria were applied to improve quality of complications reporting. RESULTS Charts of 279 patients were evaluated. Lymphadenectomy, sentinel node mapping (SNM), and SNM followed by back-up lymphadenectomy were performed in 83 (29.7%), 50 (17.9%), and 146 (52.4%) patients, respectively. The former group of patients included 13 patients who had lymphadenectomy after the failure of the SNM technique. Thirteen (4.6%) patients developed severe postoperative events (grade 3 or worse). At multivariate analysis, body mass index (OR: 1.08 (95%CI: 1.01, 1.17)) and open abdominal surgery (OR: 2.27 (95%CI: 1.02, 5.32)) were the two independent factors predictive of surgery-related morbidity. Seven severe lymphatic complications occurred. The adoption of laparoscopic approach (p��

Purpose Coregistered SPECT/CT can improve accuracy of sentinel node biopsy (SNB) for staging melanoma. This benefit has implications for pathology services and surgical practice with increased diagnostic and surgical workload. The purpose of this study was to investigate the effectiveness of SPECT/CT imaging. Methods SNB data were collected over a 10-year period. Preoperative SLN mapping was performed by using planar lymphoscintigraphy (LSG) for all patients (n = 1522) and after October 2015, patients underwent a second co-registered SPECT/CT scan (n = 559). The patients were stratified according to the imaging protocol. The number of nodes and nodal basins were assessed. The reasons for cancellation also were assessed. Results A total of 95% (1446/1522) of patients underwent a successful SNB procedure. Significantly more sentinel nodes were identified by the SPECT/CT protocol (3 vs. 2; p < 0.0001). More patients were cancelled in the SPECT/CT cohort (9.3% vs. 2.5%; p < 0.0001). Head & neck, lower limb, and AJCC IB primaries were significantly less likely to proceed to SNB. SPECT/CT identified significantly more positive SNBs (20.9% vs. 16.5%; p = 0.038). SPECT/CT imaging was associated with improved disease-free (hazard ratio [HR] = 0.74; 95% confidence interval [CI]: 0.54–1.0); p = 0.048) and disease-specific survival (HR = 0.48; 95% CI: 0.3–0.78; p = 0.003). Patients who did not proceed to SNB had a significantly increased nodal relapse rate (23.5% vs. 6.8%; HR = 3.4; 95% CI: 1.9–6.2; p < 0.0001) compared with those who underwent SNB. Conclusions This large cohort study confirms the increased accuracy of SPECT/CT for identifying SLN metastases, which would appear to have a significant therapeutic benefit, although an increased risk of cancellation of the SNB procedure on the day of surgery.

Aim Our study aims to investigate the safety and effectiveness of sentinel lymph node biopsy using indocyanine green (ICG) for the surgical staging of early-stage endometrial cancer in comparison to technetium-99 m use. Methods We conducted an observational retrospective study with patients diagnosed of endometrial cancer and FIGO stages I-II. All participants were injected technetium-99m the day prior to the surgery and underwent lymphoscintigraphy along with single-photon emission computed tomography. In addition, all patients were administered intraoperatively ICG injection to detect sentinel lymph node biopsy. The surgical staging was then completed according to the European Society for Medical Oncology preoperative risk category. Data obtained from the analysis of technetium-99m detection was compared to ICG detection. Results A total of 53 women with endometrial cancer were included in the study, 49 (92.5%) of them showed drainage preoperatively in the single-photon emission computed tomography and/or lymphoscintigraphy. The intraoperative bilateral detection rate for technetium-99 m was 26 (49.1%) patients compared to 40 (75.5%) patients with ICG (p = 0.013). We observed a 42.5% increase in the mean number of lymph nodes retrieved by ICG compared to technetium-99m (2.85 vs 2,0 nodes; p = 0.002). We intraoperatively identified 164 lymph nodes, 104 (63.4%) located in both obturator areas and external iliac vessels. Conclusion The use of ICG for the performance of sentinel node biopsy in patients with endometrial cancer seems safe and could be superior to technetium-99 m, since it offers a higher bilateral detection rate and nodal retrieval, resulting in the possibility to perform safely less full staging lymphadenectomies.

For older patients with clinically lymph node-negative breast cancer who have estrogen receptor-positive tumors and are treated with tamoxifen, randomized trials comparing axillary lymph node dissection (ALND) versus no ALND show that the omission of ALND improves patient quality of life and has no adverse effects on mortality. These results have served to justify sentinel node biopsy (SNB) omission in selected older patients with breast cancer. More recently, clinical trials were launched to assess SNB omission in younger patients, with recurrence and survival as the primary outcomes of interest. Three important considerations serve as the basis for these ongoing trials. First, it is assumed that SNB omission will improve patient quality of life, although, to date, there is no level I evidence to support this assumption. Second, axillary surgery has never been shown to reduce breast cancer mortality, but it does reduce the risk of axillary recurrences, although adjuvant systemic therapy and radiotherapy also reduce these recurrence risks. Finally, nodal status is losing importance as a guide for adjuvant systemic therapy decision making because these decisions are now increasingly predicated on tumor biomarkers and gene profiling, but it is gaining importance for adjuvant radiotherapy decision making. Because quality-of-life considerations are the primary motivation for abandoning SNB, there is a need for randomized trials comparing SNB versus no SNB/no axillary surgery, with quality of life as the primary end point (level I evidence). Moreover, suitable alternatives to guide adjuvant radiotherapy decision making will require validation before SNB omission can be justified for patients of all ages who have clinically node-negative breast cancer. LAY SUMMARY: In this review article, the authors provide a brief historical overview of the role of axillary surgery in breast cancer management and discuss additional studies and ramifications that should be considered before abandoning the sentinel node biopsy (SNB) procedure. Specifically, there is a need for level I evidence demonstrating that omission of the SNB procedure will improve patient quality of life and a need to validate suitable alternatives to SNB as a guide for adjuvant radiotherapy decision making.

Management strategy for melanoma patients is constantly evolving. Ever since D.L. Morton described sentinel node biopsy, its place in melanoma management is being continuously studied and discussed. Metastasis through the lymphatic system is a complex cascade of processes. Plenty of factors can influence it: patient’s age, localization of the primary tumor, depth of invasion, etc. In this review, we consider clinical value and advisability of sentinel node biopsy, including the evolution of indications for it., Тактика ведения пациентов с меланомой постоянно развивается и претерпевает изменения. С тех пор как D.L. Morton описал биопсию сигнального лимфатического узла, ее роль до сегодняшнего дня изучается и обсуждается. Механизмы распространения меланомы лимфогенным путем представляют собой сложный каскад процессов, на который влияет много факторов, таких как возраст, локализация первичной опухоли, толщина термального компонента и тому подобных. В этом литературном обзоре мы рассмотрим клиническую ценность и целесообразность биопсии сигнального лимфатического узла, эволюцию показаний к этой процедуре., Тактика ведення пацієнтів з меланомою постійно розвивається та зазнає змін. З того часу як D.L. Morton описав біопсію сигнального лімфатичного вузла, її роль до сьогодні вивчається та обговорюється. Механізми поширення меланоми лімфогенним шляхом являють собою складний каскад процесів, на який впливає багато факторів, таких як вік, локалізація первинної пухлини, товщина термального компонента тощо. В літературному огляді ми розглянемо клінічну цінність та доцільність біопсії сигнального лімфатичного вузла, еволюцію показань до цієї процедури.

Summary Introduction Axillary sentinel node biopsy for melanoma is routinely performed under general anaesthesia. Emerging evidence has shown general anaesthetics are associated with increased mortality in the context of the COVID-19 pandemic. In the interest of patient safety, we have designed a series of bespoke axillary regional blocks enabling surgeons to remove nodes up to and including level III without the need for a general anaesthetic. The aim of this study was to assess the feasibility of performing axillary sentinel node biopsy under such blocks. Methods Approval was granted by the Joint Study Review Committee on behalf of the Research and Ethics Department. Ten consecutive patients having axillary sentinel node biopsy for melanoma were included in this prospective study. Patients completed a Quality of Recovery-15 (QoR15) questionnaire preoperatively and 24 h postoperatively. Discussion One patient had a positive sentinel node, the remining were negative. A significant reduction in time spent in hospital post-operatively (p = 0.0008) was observed. QoR15 patient reported outcome measures demonstrated high levels of satisfaction evidenced by lack of statistical difference between pre and post-operative scores (p = 0.0118). 80% of patients were happy to have a regional block and 90% were happy to attend hospital during the pandemic. Conclusion ASNB under regional block is safe, negates risks associated with performing GAs during the COVID-19 pandemic and facilitates quicker theatre turnover and discharge from hospital. Collaboration between anaesthetic and surgical teams has enabled this change in practice. There is a learning curve with both patient selection, education and development of technique.

Tailoring axillary surgery to disease burden has occurred for patients treated with breast-conserving surgery, but limited data exist for patients treated with mastectomy, thus most of these patients who are clinically node-negative but found to be pathologically node-positive are treated with axillary dissection. From 2295 clinically node-negative mastectomy patients treated at our institution 2008-2018, we studied 338 with 1-2 positive sentinel nodes. Patients with a positive sentinel node identified on intraoperative frozen section pathology had a higher nodal disease burden. 66 of 108 patients (61%) whose nodal disease was identified only on permanent section pathology were treated with sentinel node surgery without axillary dissection with no 5-year regional nodal recurrences. This approach permits tailoring axillary surgery in most clinically node-negative mastectomy patients whilst avoiding a second operation. Introduction : Controversy exists regarding optimal management of the axilla in clinically node-negative (cN0) mastectomy patients with 1-2 positive sentinel nodes (+SLNs). We evaluated the influence of frozen section pathology on axillary management and recurrence. Materials and Methods : We studied cN0 breast cancer patients treated 2008-2018 with mastectomy and SLN surgery with 1-2+SLNs. Patients with 1-2+SLNs identified on frozen section intraoperatively (FS+SLN) were compared to those with 1-2+SLNs not detected by frozen section (FS–SLN). Recurrence rates were estimated using the Kaplan-Meier method. Results : Of 2295 cN0 mastectomy patients, 338 had 1-2+SLNs: 108 (32%) FS-SLN and 230 (68%) FS+SLN. In FS+SLN cases, completion axillary dissection (cALND) was more frequent (97% versus 39%, p Conclusions : Mastectomy patients with 1-2 FS+SLNs have a higher nodal disease burden than FS-SLN patients. The majority of FS+SLN patients underwent cALND and 52% received PMRT with very low 5-year regional nodal recurrence rates. A substantial proportion of FS-SLN patients successfully avoided both cALND and PMRT. Frozen section pathology analysis can guide de-escalation of axillary management.

Background: Sentinel Lymph Node Biopsy is a technique developed to predict lymphatic involvement in patients with early endometrial cancer, decreasing the morbimortality associated with routine systematic lymphadenectomy and improving quality of life. Main Objective: To determine the detection rate and negative predictive value of the Sentinel Lymph Node Biopsy by Immunofluorescence in patients with early endometrial cancer. Methods: A descriptive observational study in patients with early endometrial cancer (FIGO stage I-II) for all histological types and grades, who underwent the Sentinel Lymph Node by immunofluorescence Technique, between June 2019 and March 2020 at the Fundación Jiménez Díaz University Hospital. We used indocyanine green powder for injection, with a concentration of 25 milligrams (mg). We proceeded to dissolve it in 10 cubic centimeters (cc) of distilled water to. After which, we injected 2 cc of the prepared solution into the cervix at the 3 and 9 o’clock positions at a depth of 1 centimeter. Results: Eighteen patients were included, analysing a total of 26 sentinel nodes: 24 pelvic and 2 paraortic; and a total of 273 lymph nodes (sentinel and non-sentinel nodes): 83 right pelvic, 86 left pelvic and 104 paraortic. All nodes were negative for metastasis. Global and bilateral detection rates were 77.78% and 50% respectively. The Negative Predictive Value and sensitivity were 100%. No significant difference in morbimortality was found between performing only Sentinel Lymph Node technique or systematic lymphadenectomy, but the association with quality of life was significant, with better results for those who only underwent the sentinel lymph node technique versus systematic lymphadenectomy (0% vs 77%). Conclusion: The global and bilateral detection rates of the Sentinel Lymph Node Technique by immunofluorescence were 77.78% and 50% respectively, obtaining a Negative Predictive Value and Sensitivity of 100%. Sentinel Node Biopsy is a valid technique to predict lymphatic affectation in early endometrial cancer, with lower morbimortality than systematic lymphadenectomy.

Background: Endoscopic treatments for gastric cancers have still been progressing even after the great success of endoscopic submucosal dissection (ESD). Summary: In further advancements of ESD, safe and less-invasive procedures are challenged by managing postoperative bleeding, one of the major adverse events in ESD. Covering the mucosal defect after removal of lesions appears reasonable and effective for preventing delayed bleeding from the post-ESD ulcers. Shielding with biodegradable sheets is attempted on clinical trials, which show equivocal results. Although suturing of the mucosal rims is technically challenging, pilot studies demonstrate favorable outcomes for avoiding post-ESD bleeding even in cases at high risk. In cases after noncurative resection of ESD, the selection of patients who truly require additional gastrectomy with lymph node dissection is important to provide necessary surgery. Risk stratification of lymph node metastases and surgery has been developed, which offers tailor-made management to each patient considering the risks and benefits. In surgery, function-preserving gastrectomy to minimize the resection area in both lymphadenectomy and the primary site is clinically introduced. The sentinel node navigation surgery is promising to realize the minimally invasive gastrectomy, and it should strongly fit ESD as well as laparoscopic endoscopic cooperative surgery or endoscopic full-thickness resection, although nonexposure approaches are desirable. Key Message: Development for less-invasive managements on gastric cancer will be continued in step with the advancement of endoscopic treatments.

Introduction It has been reported that the survival of patients having sentinel node (SN) biopsy for melanoma the day after lymphoscintigraphy using Tc99m-nanocolloid is worse than that of patients having lymphoscintigraphy and SN biopsy on the same day [1,2]. A possible explanation suggested is that overnight migration of the tracer from SNs to 2nd-tier nodes occurs, causing failure to remove true SNs. Materials and methods The possibility of overnight tracer migration leading to errors in SN-identification was investigated in 12 patients scheduled for lymphoscintigraphy the day before surgery by repeating SPECT-CT imaging the next morning, before their SN biopsy. The aim was to check whether onward migration of colloid from previously-identified SNs had occurred. Results No significant migration of Tc99m-nanocolloid occurred overnight in any patient. All nodes reported to be SNs on day 1 imaging were also present and regarded as SNs on day 2 images. No new foci were visualised on day 2, but some that had been identified on day 1 were not seen on day 2. Conclusions Since migration of nanocolloid overnight did not occur, this cannot explain the reported survival disadvantage for patients undergoing SN biopsy the day after lymphoscintigraphy. A likely alternative possibility is that inadequate doses of radioisotope were used for next-day procedures, causing the mistaken removal of 2nd-tier nodes instead of true SNs more frequently. Further research is required to explain the reported reduction in survival of patients having next-day SN biopsy procedures, since the possibility has important clinical implications.

Introduction and objectives To evaluate the migration of 99mTc-tilmanocept from the injection site (IS) as well as the uptake in sentinel nodes (SNs) and non-SNs for lymphatic mapping in patients with breast cancer and melanoma, scheduled for SN biopsy after interstitial tracer administration. Materials and methods For 29 primary tumours in 28 patients (mean age: 62y, range: 45–81y) scheduled for SN biopsy planar images were acquired 10 and 120 min after administration of 74 MBq 99mTc-tilmanocept, in order to evaluate lymphatic drainage as well as uptake ratios between injection site (IS), SN and non-SN. SPECT-CT was performed immediately after delayed planar images to enable anatomical lymph node localization. Results SNs were visualized in all patients (100%) with drainage to 34 basins. Uptake in non-SNs was perceived in 16 basins (47%). Number of SNs was concordant between early and delayed images in all basins excepting five (86%). In 24 patients tracer migrated to one lymph node basin (LNB), in three to 2 and in one to 4. When IS was included (N = 29) on image, IS/SN ratio could be measured per LNB. The IS/SN ratio at 2 h compared to 15 min decreased with an average of 66% (range: 15–96%). SN/non-SN 2 h ratio in LNBs with visible non-SNs averaged 6.6 (range: 2.3–15.6). In 9 patients with two SNs SN1/SN2 ratio averaged 1.9 on delayed images. At histopathology, SNs were found to be tumour positive in 7 basins (20%). Conclusion 99mTc-tilmanocept appears to meet the requirements for improved SN imaging in breast cancer and melanoma on the basis of early and persistent SN visualization frequently accompanied by no or markedly less non-SN uptake. This is associated to rapid migration from the injection site together with increasing SN uptake and retention as expressed by decreasing IS/SN and persistently high SN/non-SN ratios. Further head-to-head comparison of 99mTc-tilmanocept with standard SN radiotracers in larger series of patients is necessary.

European journal of cancer 154, 227-234 (2021). doi:10.1016/j.ejca.2021.05.026, Published by Elsevier, Amsterdam [u.a.]

Mammary Paget’s disease is a rare malignancy. Mastectomy or breast-conserving surgery has been considered as the standard treatment, while there have been few reports of neoadjuvant chemotherapy (NAC). A 53-year-old woman with erythema and skin ulceration of the left breast was admitted to our institution. Breast examinations revealed left invasive ductal carcinoma (cT1bN0M0, cStage I), and a punch biopsy of the left mammary erythema indicated Paget’s disease (cTisN0M0, cStage0). The patient received NAC because of multiple lesions. Consequently, the breast tumor clinically disappeared, and the erythema improved. These outcomes made it easier to perform surgery (left mastectomy and sentinel node biopsy). Histopathological examination revealed no residual cancer cells in either the mammary gland or breast skin, and no metastasis was found in the sentinel lymph node. Therefore, NAC may be a useful treatment for mammary Paget’s disease.

INTRODUCTION: Adjuvant therapy trials required completion lymph node dissection (CLND) for sentinel lymph node (SLN)-positive melanoma prior to systemic treatment, but nodal surveillance without CLND is now common. For patients receiving adjuvant therapy without CLND, patterns of recurrence are unknown and the value of regional nodal ultrasound alongside cross-sectional imaging is not well-defined. METHODS: In a retrospective cohort of SLN-positive melanoma patients managed with nodal surveillance from June 2014-June 2019, we evaluated the association between adjuvant treatment and location of first recurrence (loco-regional, nodal, distant, or multi-site) using chi-squared tests. We compared methods of recurrence detection and cost by surveillance intensity using chi-squared and Dunn’s tests. RESULTS: Among 177 nodal surveillance patients, 66 (37%) received adjuvant therapy. Median follow-up was 24 months, during which 48 patients (27%) recurred. Adjuvant treatment did not alter patterns of initial recurrence (p=0.76). Adjuvant therapy recipients more often had both nodal ultrasound and cross-sectional imaging surveillance (p

PURPOSE: We evaluated the oncologic efficacy of early inguinal lymph-node dissection, observation or dynamic sentinel node biopsy followed by delayed or selective inguinal lymph-node dissection in cN0 patients with penile squamous cell carcinoma. MATERIALS AND METHODS: Between 1980 and 2017 (inclusive), 296 evaluable consecutive cN0 penile squamous cell carcinoma patients underwent early inguinal lymph-node dissection (16), observation (114) or dynamic sentinel node biopsy (166). Median followup was 50 months. Tumor stage, grade, lympho-vascular invasion and age were considered. Kaplan-Meier plots illustrated 5-year inguinal relapse-free and cancer specific survival rates. Multivariable Cox regression models tested the treatment effect. Analyses were repeated after inverse probability of treatment weighting adjustment. RESULTS: The 5-year inguinal relapse-free survival and cancer specific survival rates following early, observation and dynamic sentinel node biopsy inguinal lymph-node dissection were 100%, 87%, 89%, and 84%, 81%, 85%, respectively. The 5-year crude inguinal relapse-free survival and cancer specific survival rates were 90% and 93% in low-risk patients undergoing observation. Clavien grade 3 complications were 0.6 vs 12.5% in the dynamic sentinel node biopsy and early inguinal lymph-node dissection group, respectively. After inverse probability after treatment weighting adjustment, 5-year inguinal relapse and cancer specific survival were 90% vs 73% and 90% vs 77% following dynamic sentinel node biopsy and observation, respectively. At multivariable Cox regression model, patients undergoing dynamic sentinel node biopsy had significantly lower inguinal relapse (HR 0.4, 95% CI 0.2-0.85, p 0.02) and cancer specific mortality (HR 0.29, 95% CI 0.11-0.77; p=0.01) compared to those under observation. The low number of patients undergoing early inguinal lymph-node dissection made a reliable comparison with this group impractical. CONCLUSIONS: Selective inguinal lymph-node dissection following dynamic sentinel node biopsy significantly improved inguinal relapse and cancer specific mortality when compared with observation, providing evidence of efficacy of dynamic sentinel node biopsy in clinical stage N0 squamous cell carcinoma of the penis.

Sentinel node (SN) mapping based on the SN concept has been applied to early gastric cancer. However, it is still controversial whether or not the oncological safety is ensured in case pathological stage was advanced in these patients. The aim of this study was to investigate the validity of SN mapping in patients with clinically early staged gastric cancer diagnosed with pT2/deeper tumors. We retrospectively analyzed 40 patients with a diagnosis of cT1N0 or cT2N0 single-lesion gastric cancer who were shown to have pT2 or deeper tumors after gastrectomy with SN mapping. We adopted a dual-tracer method using a radioactive colloid and blue dye to detect SNs. The diagnostic accuracy and distribution of SNs at each tumor site were analyzed. Of the 40 patients, 24 (60%) were postoperatively diagnosed as pT2, and 16 (40%) as pT3 or T4. SNs were detected in all patients. The false negative rate was 9% (1/11), and in that patient, the non-SN metastasis was observed within the SN basin. Diagnostic accuracy was 98% (39/40). Overall distribution of SNs was similar to that for patients with early gastric cancer. No significant differences in overall and recurrence-free survival were observed between the patients who underwent standard gastrectomy and those who underwent function-preserving gastrectomy, based on the results of SN mapping. Our results confirmed validity of SN mapping for patients with clinically early staged gastric cancer diagnosed with pT2/deeper tumors after gastrectomy. Closed surveillance without additional surgical treatment is an option for these patients.

OBJECTIVES This study was conducted to verify the optimal extent of lymph node dissection or sampling during lung cancer surgery based on the sentinel node (SN) map created by computed tomography (CT) lymphography. METHODS From April 2010 to January 2015, patients with clinical stage I non-small-cell lung cancer, who were candidates for lobectomy or segmentectomy with standard hilar and mediastinal lymph node dissection, and in whom bronchus reached the tumour, were enrolled. An ultrathin bronchoscope was inserted to the target bronchus under the guidance of virtual bronchoscopic navigation images. CT images of the chest were obtained 30 s after 2.5 ml of iopamidol was injected. SNs were identified when the maximum CT attenuation value of the lymph nodes on postcontrast CT images increased by 30 Hounsfield units or more compared with the precontrast images. Patients underwent lobectomy with standard lymph node dissection. RESULTS SNs were identified in 36 (87.8%) of the 41 patients. The average number of SNs was 1.6 (range, 1–4). There was 1 false negative case; therefore, the accuracy of SN identification was 97.2% (35/36). In 5 (13.9%) of 36 patients, SNs were outside the lobe-specific lymph node station range (#11i from right S1, #7 from right S1, #4R from right S8, #12u from right S8, #7 and #12l from left S1 + 2). CONCLUSIONS CT lymphography demonstrated the diversity of lymphatic spreading patterns and there were cases in which lymph flows are found outside the lymph node dissection range.

Malignant melanoma (MM) is a highly aggressive neoplasm with a growing worldwide incidence. It is not uncommon that the disease is already metastatic at the time of the first diagnosis. Regional lymph nodes and skin are the first and most common metastatic sites, followed by distant visceral sites (lungs, liver, and central nervous system) and bone. In this clinical setting, fine-needle aspiration (FNA) often represents the first diagnostic approach. FNA is a useful tool to obtain a rapid and accurate diagnosis, in conjunction with ancillary techniques and molecular analysis, as recommended by recent guidelines. The aim of this review was to describe the cytomorphology, immunocytochemical tools, and molecular tools used for the diagnosis of MM metastases on FNA.

Sentinel node biopsy (SNB) is a safe and effective way to examine an N0 neck in early-stage oral cavity cancer (OCC). In this study, we evaluated the variables of SNB detection, surgery, and outcome.Ninety-two patients with N0 OCC examined with SNB were included. Number and brightness of nodes detected on preoperative imaging and during surgery were analyzed and compared with histological findings. Patients with recurrent disease were evaluated separately and the effect of smoking and alcohol consumption was analyzed.Eighteen patients had at least malignant cells in the sentinel lymph node (SLN); 18 patients had recurrent disease and nine patients died from the cancer. The negative predictive value of SNB was 95%. Six patients did not have metastases in the node with the strongest signal, but metastases were found in an SLN with a weaker signal. Smoking and alcohol consumption did not affect disease-specific or overall survival.SNB has been confirmed to be safe and effective in early stage N0 OCC. However, it is important to carefully harvest up to four hottest SLNs that emit a signal. Treatment of patients with only isolated tumor cells (ITC) in the SLN appears to be necessary.

Background Obtaining a sentinel lymph node biopsy (SLNB) specimen is a standard staging procedure in the management of cutaneous melanoma. However, there is no consensus on the safe time interval between the primary melanoma biopsy procedure and the SLNB procedure. Objective We evaluated the association between time from biopsy to SLNB and patients’ outcomes for melanoma. Methods We performed this systematic review and meta-analysis based on the recommendations of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results Six retrospective studies were included. Nine thousand seven hundred five patients were identified, of which 4383 underwent a SNLB procedure at a time interval defined as early and 4574 at an interval defined as late. A combined hazard ratio of 1.25 (95% confidence interval [CI] 0.92-1.68) was determined, and there was high heterogeneity (I2 = 83%; P = .002) of the SLNB time interval on melanoma-specific survival. The combined HR for disease-free survival was 1.05 (95% CI 0.95-1.15), with low heterogeneity (I2 = 9%; P = .36). Regarding overall survival, a combined HR of 1.25 (95% CI 0.92-1.70) was found, with low heterogeneity (I2 = 37%; P = .2). Limitations There is heterogeneity between some studies. Conclusion There are no significant differences in patient outcome between a short interval versus a long interval between the primary biopsy procedure and obtaining a SNLB specimen.

Purpose: Sentinel lymph node biopsy (SLNB) using both a radioactive isotope (RI) and blue dye is considered highly effective; however, there were limitations with the use of both agents in some hospitals, and blue dye has been shown to have some adverse effects. Additionally, preoperative prediction of sentinel lymph node (SLN) status using the maximum standardized uptake value (SUVmax) on positron emission tomography-computed tomography (PET-CT) can help avoid unnecessary axillary dissection or SLNB. Thus, we evaluated the efficacy and oncologic safety of SLNB using an RI alone in terms of long-term outcomes and determined the association between SLN metastasis and SUVmax of the primary tumor.Methods: This retrospective study was conducted at Konyang University Hospital between March 2011 and May 2018. Overall, 142 patients with breast cancer who underwent SLNB using an RI alone were enrolled. Data on identification and false-negative rates were collected. The SUVmax of primary tumors on PET-CT were analyzed for their association with SLN metastasis.Results: The identification and false-negative rates were 98.6% and 0%, respectively. There was no axillary local recurrence in patients with negative SLN findings. The correlation between the SUVmax of the primary tumor and SLN status was significant (r=0.249, P=0.005); the cutoff value for negative SLN metastasis was

BACKGROUND Sentinel lymph node (SLN) biopsy is an accurate staging modality in early oral squamous cell carcinoma (OSCC), but its accuracy relies on labor-intensive histopathology protocols. We sought to determine whether serial step sections with immunohistochemistry (SSSIHC) at narrow intervals of the entire SLN are required to accurately exclude metastasis. METHODS Consecutive SLN biopsies over a 13-year period were retrospectively evaluated. If the index section was negative for carcinoma, the entire SLN was subjected to SSSIHC at 150 μm intervals. The first section level and total number of section levels to contain carcinoma were recorded. RESULTS One hundred and eighteen SLN+ from 90 patients were included. SSSIHC upstaged the nodal status in 19.5% of patients. Metastasis was identified in 16.7% and 10.2% beyond section levels 4 and 6, respectively. Among SLNs requiring SSSIHC, 47.5% contained carcinoma in a single section level. CONCLUSION SSSIHC of the entire SLN at 150 μm intervals are required to identify occult metastasis in OSCC.

Introduction. A skin-sparing or nipple-sparing mastectomy is a surgical treatment that is increasingly used in the treatment of patients with breast cancer. More often women themselves decide or even ask to undergo this type of surgery. In our paper, we present the issue of combined treatment of 62 patients after nipple-sparing or skin-sparing mastectomy with a positive sentinel lymph node. Realisation of this type of surgery has further consequences in adjuvant treatment policies. Material and methods. The group of 62 previously untreated women with positive sentinel lymph nodes took part in this analysis. The individual plan of treatment was established for every patient by the multidisciplinary team according to the rules of the breast cancer unit. All patients were treated in the Holycross Cancer Centre in Kielce (in 2015–2018). Results. The early results show that proper qualification and realisation of oncological treatment is safe and effective. Severe complications appeared rarely. Conclusions. Skin-sparing or nipple-sparing mastectomy is a method of surgical treatment that is increasingly used in the treatment of patients with breast cancer. It should be remembered that the qualification for this type of procedure should be careful, and adjuvant treatment should be rationally planned. Our experience shows that it is an effective and safe method.

Sentinel lymph node (SLN) biopsy should be performed with the technical expertise required to correctly identify the sentinel node, in the context of understanding both the likelihood of positivity in a given patient and the prognostic significance of a positive or negative result. National Comprehensive Cancer Network guidelines recommend SLN biopsy for all cutaneous melanoma patients with primary tumor thickness greater than 1 mm and in select patients with thickness between 0.8 and 1 mm, yet admit a lack of consistent clarity in its utility for prognosis and therapeutic value in tumors

Background The Affordable Care Act's Medicaid expansion is associated with earlier diagnosis and improved care among lower socioeconomic status populations with cancer, but its impact on melanoma is undefined. Objective To determine the association of Medicaid expansion with stage of diagnosis and use of sentinel lymph node biopsy in nonelderly adult patients with newly diagnosed clinically localized melanoma. Methods Quasi-experimental, difference-in-differences retrospective cohort analysis using data from the National Cancer Database from 2010 to 2017. Patients from expansion versus nonexpansion states and diagnosed before (2010-2013) versus after (2014-2017) expansion were identified. Results Of 83,322 patients, 46.6% were female, and the median age was 55 years (interquartile range, 49-60). After risk adjustment, Medicaid expansion was associated with a decrease in the diagnosis of T1b stage or higher melanoma (odds ratio [OR], 0.93; 95% confidence interval [CI], 0.88-0.98; P = .011) and decrease in uninsured status (OR, 0.61; 95% CI, 0.52-0.72; P Limitations Retrospective study using a national database. Conclusion In this study of patients with clinically localized melanoma, Medicaid expansion was associated with a decrease in the diagnosis of later T-stage tumors.

Sentinel lymph node (SN) tumor burden is becoming increasingly important and is likely to be included in future N classifications in melanoma. Our aim was to investigate the prognostic significance of melanoma infiltration of various anatomically defined lymph node substructures. This retrospective cohort study included 1250 consecutive patients with SN biopsy. The pathology protocol required description of metastatic infiltration of each of the following lymph node substructures: intracapsular lymph vessels, subcapsular and transverse sinuses, cortex, paracortex, medulla, and capsule. Within the SN with the highest tumor burden, the SN invasion level (SNIL) was defined as follows: SNIL 1 = melanoma cells confined to intracapsular lymph vessels, subcapsular or transverse sinuses; SNIL 2 = melanoma infiltrating the cortex or paracortex; SNIL 3 = melanoma infiltrating the medulla or capsule. We classified 338 SN-positive patients according to the non-metric SNIL. Using Kaplan–Meier estimates and Cox models, recurrence-free survival (RFS), melanoma-specific survival (MSS) and nodal basin recurrence rates were analyzed. The median follow-up time was 75 months. The SNIL divided the SN-positive population into three groups with significantly different RFS, MSS, and nodal basin recurrence probabilities. The MSS of patients with SNIL 1 was virtually identical to that of SN-negative patients, whereas outgrowth of the metastasis from the parenchyma into the fibrous capsule or the medulla of the lymph node indicated a very poor prognosis. Thus, the SNIL may help to better assess the benefit-risk ratio of adjuvant therapies in patients with different SN metastasis patterns.

Background A 31-gene genetic expression profile (31-GEP; Class 1 = low risk, Class 2 = high risk) developed to predict outcome in cutaneous melanoma (CM) has been validated by retrospective, industry-sponsored, or small series. Methods Tumor features, sentinel node biopsy (SNB) results, and outcomes were extracted from a prospective database of 383 C M patients who underwent SNB and had a 31-GEP run on their primary tumor. Groups were compared by uni- and multi-variable analysis. Relapse-free and distant metastasis-free survival (RFS, DMFS) were estimated by Kaplan-Meier method. Results Breslow thickness, T stage, and SNB positivity were significantly higher in Class 2 patients. Recurrence rates were higher for Class 2 vs Class 1 patients and highest in patients who were Class 2 and SNB positive. GEP class was predictive of RFS and DMFS and independently predicted relapse in AJCC “low risk” (stages IA-IIA) patients. Conclusions 31-GEP adds prognostic information in CM patents undergoing SNB.

Background Targeted axillary dissection (TAD), the combination of sentinel lymph node biopsy (SLNB) and targeted lymph node biopsy (TLNB), can reduce the false negative rates of sentinel node biopsy alone dramatically in breast cancer patients, who received neoadjuvant chemotherapy (NAC). However methods for TAD are still under investigation. Methods Magseed®, a non-radioactive magnetic marker was used to mark the biopsied positive TLN after NAC. The SLNB with the standard technetium-based method and the selective TLNB with Magseed® localization were performed in 40 patients. The TLNs were identified with the Sentimag® probe and excised in all patients. Specimen x-ray was performed to confirm the Magseed® within the prior to NAC biopsied and clipped lymph node. Results The TLN identification rate was 100% (40/40), the SLN identification rate was 82.5% (33/40), the concordance rate between the TLN and the SLN was 65% (26/40). Complications according Magseed® deployment or identification could not be observed. Conclusion Magseed® is a reliable and feasible marker for the identification of TLNs after NAC., Highlights • TLNB is an accurate method for the identification of marked lymph nodes after NAC. • Selective excision of TLNs is feasible. • Magseed® allows a non-radioactive, wireless marking of TLNs.

Background Our aim is to show whether the sentinel node procedure (SNP) is recommendable for pediatric patients with extremity rhabdomyosarcoma (RMS). Lymph node metastases are an important prognostic factor in pediatric patients with extremity RMS. Accurate nodal staging is necessary to treat the patient accordingly. An alternative to the current recommended lymph node sampling is the sentinel node procedure (SNP). Methods A systematic review was performed summarizing all published cases of SNP in addition to 13 cases from our hospital and 8 cases from two other hospitals that have not been published before. Results For all patients (n = 55), at least one SLN was identified, but the SNP technique used was not uniform. The SNP changed the nodal classification of eight patients (17.0%) and had a false-negative rate of 10.5%. Conclusions The SNP is recommendable for pediatric patients with extremity RMS. It can change lymph node status and can be used to sample patients in a more targeted way than nodal sampling alone. Therefore, we recommend use of the SNP in addition to clinical and radiological nodal assessment for pediatric patients with extremity RMS.

Several authors have studied the potential of sentinel lymph node (SLN) tumor burden as prognostic factor but the microscopic classifications used in different study groups were variable. We examined the prognostic role of tumor burden in SLN on melanoma specific-survival and competing causes of death. We also analysed clinical and histological factors as predictors of disease relapses and additional non sentinel lymph node (NSLN) metastases. We included all patients with cutaneous melanoma that underwent SLN biopsy between 2002 and 2012 at Complejo Hospitalario de Navarra (Spain). The study end-points were death due to melanoma, melanoma relapse and involvement of NSLN. We used Fine-Gray test for competing risk analysis. A logistic regression model was performed to predict the risk of involvement of NSLN. Between 2002 and 2012, there were 348 patients who underwent SLN biopsy in our centre (308 were eligible for the study). 26.9% patients positive SLN. 88 patients died during the follow-up period and 66 (75%) died from melanoma. The 5-year cumulative incidence of melanoma death was 15.33% (95 % CI 15.25-15.42). The cumulative probability of death from melanoma was associated with gender, histological subtype, Breslow thickness, mitotic rate, ulceration and SLN tumor burden. In multivariable analysis, Breslow thickness and SLN tumor burden remained as independent prognostic factors. SLN tumor burden appears to be an important prognostic factor. It is very important reporting these characteristics in pathological reports. More prospective studies would be necessary to analyze these variables and to be able to make recommendations in management of melanoma patients.

Resumen Conclusiones: Los diferentes estudios han demostrado que la técnica de SentiMag para la detección del ganglio centinela en el cáncer de mama no es inferior a las técnicas convencionales, aportando ventajas y grandes expectativas que permiten que esta técnica sea asequible para cualquier centro que no disponga de servicios de medicina nuclear, como suceden en los hospitales comarcales.

The clinical importance of metastatic spread of cancer has been recognized for centuries, and melanoma has loomed large in historical descriptions of metastases, as well as the numerous mechanistic theories espoused. The "fatal black tumor" described by Hippocrates in 5000 BC that was later termed "melanose" by Rene Laennec in 1804 was recognized to have the propensity to metastasize by William Norris in 1820. And while the prognosis of melanoma was uniformly acknowledged to be dire, Samuel Cooper described surgical removal as having the potential to improve prognosis. Subsequent to this, in 1898 Herbert Snow was the first to recognize the potential clinical benefit of removing clinically normal lymph nodes at the time of initial cancer surgery. In describing "anticipatory gland excision," he noted that "it is essential to remove, whenever possible, those lymph glands which first receive the infective protoplasm, and bar its entrance into the blood, before they have undergone increase in bulk". This revolutionary concept marked the beginning of a debate that rages today: are regional lymph nodes the first stop for metastases ("incubator" hypothesis) or does their involvement serve as an indicator of aggressive disease with inherent metastatic potential ("marker" hypothesis). Is there a better way to improve prediction of disease outcome? This article attempts to address some of the resultant questions that were the subject of the session "Novel Frontiers in the Diagnosis of Cancer" at the 8th International Congress on Cancer Metastases, held in San Francisco, CA in October 2019. Some of these questions addressed include the significance of sentinel node metastasis in melanoma, and the optimal method for their pathologic analysis. The finding of circulating tumor cells in the blood may potentially supplant surgical techniques for detection of metastatic disease, and we are beginning to perfect techniques for their detection, understand how to apply the findings clinically, and develop clinical followup treatment algorithms based on these results. Finally, we will discuss the revolutionary field of machine learning and its applications in cancer diagnosis. Computer-based learning algorithms have the potential to improve efficiency and diagnostic accuracy of pathology, and can be used to develop novel predictors of prognosis, but significant challenges remain. This review will thus encompass latest concepts in the detection of cancer metastasis via the lymphatic system, the circulatory system, and the role of computers in enhancing our knowledge in this field.

Based on the results of international multicenter randomized trials, completion lymph node dissection for patients with sentinel lymph node-positive melanoma is no longer routinely recommended. However, clinicians should take into consideration racial and medical resource differences when applying this evidence to clinical practice in Japan. To evaluate the clinical validity of the observation policy of omitting completion lymph node dissection, we retrospectively surveyed patients with sentinel lymph node-positive melanoma between 2002 and 2020 at Niigata Cancer Center Hospital. A total of 59 patients were categorized into the observation group (n = 19) and completion lymph node dissection group (n = 40). Newly developed anticancer agents, including targeted therapy and immunotherapy, were more commonly used in the observation group than in the completion lymph node dissection group as either adjuvant therapy (31.6% vs. 5.0%) or post-recurrence therapy (100% vs. 34.8%). The median overall survival in the observation group (not reached) was significantly longer than that in the completion lymph node dissection group (95.0 months; p = 0.02), which was mainly attributed to the difference in post-recurrence overall survival. There was no significant difference in recurrence-free survival between the two groups (p = 0.63). Although the use of new anticancer agents leads to bias, this study demonstrates that observation without prompt completion lymph node dissection provides a favorable overall survival without increasing the risk of recurrence compared with completion lymph node dissection. The observation policy for patients with sentinel lymph node-positive melanoma patients is considered to be clinically valid in real-world medical practice.

Background Melanoma is a leading cause of morbidity and mortality in Australia and New Zealand. New Zealand has the highest melanoma incidence in the world alongside Australia at 54 per 100 000 persons. The aim of this study is to conduct a retrospective quality audit of sentinel lymph nodal biopsy (SLNB) practices from 2007 to 2019 of a high-volume melanoma surgeon. Primary outcome was false negative rate (FNR). Secondary outcomes were sentinel node (SN) identification and removal rate, and complication rates. Methods A database was maintained, containing n = 553 consecutive SLNB's for cutaneous melanoma from 31 August 2007 to 31 August 2019. Patient characteristics and details of the primary lesion, sentinel lymph node biopsy, recurrence and complications were recorded. Results SN's were successfully identified in 444 (99.6%) out of 446 patients with an FNR of 9.1%. Positive SN's were identified in 70 (12.7%) SLNB's. Complications occurred in 76 out of 553 (13.7%) SLNB's. A review of internationally published literature reveals an SN identification rate of 94.4-99.5% with an FNR of 4.0-37.5%. SLNB is the best staging tool for melanoma and gives potential access to adjuvant systemic treatment if >1 mm deposits are found. It is a day-stay procedure with a low-complication rate. Conclusion SLNB is a safe and reliable procedure utilized for cutaneous melanoma. We propose our data should be used alongside international SN series to establish Quality Performance Indicators to improve melanoma management.

Sentinel lymph node biopsy (SLNB) is standard of care for clinically negative operable breast cancer. However, the best technique for intra-operative assessment of SLN still remains a matter of research. Accuracy of frozen section (FS), which is widely used for detecting metastasis in SLN varies from 79 to 89% with false negative rate being 5.5 to 43%. This study was hence done to evaluate if combined intraoperative FS and imprint cytology (IC) evaluation improves accuracy and reduces false negative rate for SLN evaluation in breast cancer. In this prospective cohort study, patients with operable breast cancer with negative axillary lymph node status (N0) were included. SLNB was done using combination technique with a radionuclide tracer and blue dye. Smears were prepared from SLNs for imprint cytology evaluation and excised SLNs were then sent for frozen section. Diagnostic indices of frozen section, imprint cytology, and combined technique were assessed in terms of sensitivity, specificity, positive predictive value, negative predictive value, likelihood ratios, false negative rate, and overall accuracy with 95% confidence intervals taking final histopathology as “gold standard.” Eighty-one cases of SLNB in which both FS and IC reports were available were included for analysis. Sensitivity (93.8%; CI 69.8–99.8%), specificity (100%; CI 89.3–100%), positive predictive value (100%; CI 66.3–100%), negative predictive value (98.4%; CI 91.6–100%), false negative rate (6.25%), and overall diagnostic accuracy (98.7%) of combined evaluation were superior as compared to either of the techniques. Combination of frozen section and imprint cytology has better diagnostic accuracy and reduced false negative rate as compared to either of them alone.

To investigate the impact of a preoperative CT on surgical decision making in primary vulvar squamous cell carcinoma (VSCC) and the accuracy of detecting inguinal lymph node metastases (LNM). Secondly to assess prevalence and consequences of incidental findings and comorbidity using a CT.This population-based study comprised of surgically treated patients with primary VSCC, at a regional tertiary center, using the Swedish Quality Registry for Gynecological Cancer for identification, and medical records were reviewed. Results from the preoperative CT was compared with the histological analysis from the lymphadenectomy in the total cohort and between tumor size4 cm versus ≥4 cm.In total 134 women had undergone CT before sentinel node (SN) biopsy (n = 83) or inguinofemoral lymphadenectomy (IFL) (n = 51). Fiftyone patients (38%) had groin LNM. Accuracy of CT in detecting groin LNM was 76%; sensitivity 43% and specificity 96%. Positive (PPV) and negative predictive values (NPV) were 88% and 73% respectively. In tumors4 cm (n = 87), sensitivity, specificity, PPV and NPV were 17%, 95%, 57% and 75% and in tumors ≥4 cm (n = 47) 67%, 100%, 100% and 69% respectively. CT altered surgical method from SN biopsy to IFL in only two cases. Incidental findings led to extra follow-up resulting in a benign diagnosis in 22 patients and major important findings in five patients.In primary VSCC, a preoperative abdominal-inguinal CT is of limited value for surgical decision making. In tumors4 cm, it may be omitted due to low diagnostic accuracy and disturbing incidental findings.