Advantages of preoperative localization and surgical resection of metastatic axillary lymph nodes using magnetic seeds after neoadjuvant chemotherapy in breast cancer.

PURPOSE: To assess the safety and effectiveness of magnetic seeds in preoperative localization and surgical dissection of metastatic axillary lymph nodes (LN+) in breast cancer patients with axillary involvement, after neoadjuvant chemotherapy (NAC). In addition, to assess the impact of targeted axillary dissection (TAD) in reducing the rate of false negatives (FN) in sentinel lymph node biopsy (SLNB). MATERIALS AND METHODS: A cross-sectional prospective cohort study was conducted from April 2017 to September 2019, including breast cancer patients with axillary lymph node involvement treated with NAC. Prior to NAC, the LN+ were marked by ultrasound-guided clip insertion. After NAC, a magnetic seed (Magseed®) was inserted in the clip-marked lymph node (MLN). During surgery, the MLN was located and removed with the aid of a magnetic detection probe (Sentimag®) and the sentinel lymph node was removed. Axillary lymph node dissection (ALND) was used to determine the rate of FN for SLNB alone and the combination of SLNB and MLN dissection, called TAD. RESULTS: The study included 29 patients (mean age, 55; range, 30-78 years). Selective preoperative localization and surgical dissection were successful for all 30 MLNs (100%). The MLN corresponded to the SLN in 50% of cases. After ALND, there were 21.4% (3/14) FN with SLNB alone and 5.9% (1/17) with TAD. CONCLUSIONS: Following NAC, selective surgical removal of MLN by preoperative localization using magnetic seeds is a safe and effective procedure with a success rate of 100%. Adding TAD reduces the rate of FN associated with SLNB alone.

Pneumoendoscopic single port approach to breast cancer. How we do it?

Endoscopic procedures have not become the gold standard in breast surgery. In order to improve today's outcomes we have developed a pilot study in the Breast Pathology Unit of Hospital Germans Trias i Pujol. A surgical procedure was performed creating a pneumoendoscopic cavity by using a Single Incision Laparoscopic Surgery (Single port) approach with a follow up of four years. Four patients underwent pneumoendoscopic single-port breast surgery receiving skin-sparing quadrantectomy and axillary surgery requiring lymphadenectomy in all of them. All patients had immediate reconstruction with a Latisimus Dorsi flap. No perioperative complications appeared. Mean operative time was 290 min (range 240-315 min) and mean hospital stay was 3,2 days. Surgical margins of all cases were pathologically negative and all patients were disease free after four years of monitoring. All patients were satisfied with the cosmetic outcome in the immediate postoperative and during the follow up. Although all innovative techniques generate hesitation on their beginnings and are liable to improve, we believe that pneumoendoscopic single-port breast surgery can be suitable for breast cancer, offering better cosmetic outcomes with oncological safety.

Utilidad del SPECT-CT en la biopsia del ganglio centinela tras quimioterapia neoadyuvante en cáncer de mama y axila positiva / The usefulness of SPECT-CT in sentinel lymph nodes identification after neoadjuvant chemotherapy in patients with breast cancer and axillary involvement

Objetivo Valorar la utilidad de los estudios híbridos SPECT-CT en la biopsia del ganglio centinela (BGC) post quimioterapia neoadyuvante (QNA) en pacientes cN+. Método Estudio transversal de los resultados obtenidos en un grupo de 25 pacientes tratadas en la Unidad Funcional de Mama del HUGTIP desde marzo de 1918 a septiembre de 2020. La metodología específica para este estudio incluye: 1)ecografía axilar y colocación de marcador ecovisible en el ganglio afecto antes de iniciar la QNA; 2)tras QNA, colocación de marcador ferromagnético (Magseed®) en ganglio marcado previamente (GM); 3)valoración del estado axilar tras la QNA, que incluye estudio linfogammagráfico axilar con SPECT-CT; BGC y exéresis del ganglio marcado (GM) si es distinto al ganglio centinela (GC), y vaciado ganglionar axilar (VGA). Resultados La valoración de los SPECT-CT permitió verificar la coincidencia entre el GM y el GC en 14 casos (56%). En 3 casos no se encontró GC y en 8 casos el marcador magnético no estaba en un GC. La biopsia selectiva de los ganglios (GC y/o GM) fue negativa en 12 pacientes (2 con VGA positivo) y positiva en 13 (4 con VGA positivo). Conclusión El estudio SPECT-CT aportó información adicional sobre la localización y la concordancia del ganglio marcado y el ganglio centinela previa a la cirugía, mejorando la planificación de la misma. (AU)

Objective To evaluate the usefulness of SPECT-CT hybrid studies in the biopsy of sentinel lymph node (SLNB) after neoadjuvant chemotherapy (NAC) in patients with axillary metastatic disease (N+). Methods Cross-sectional study of 25 patients treated in the HUGTIP Breast Functional Unit from March 2018 to September 2020. All patients included in the study were submitted to: (1)axillary ultrasound (US) and US visible marker placement in the affected node before starting the NAC; (2)placement of a ferromagnetic marker in the previously marked lymph node (MLN) after NAC; (3)assessment of axillary status after NAC: it includes SPECT-CT lymphoscintigraphy; SLNB and excision of the MLN whether different from the sentinel lymph node (SLN); and axillary lymph node dissection (ALND). Results In 14 patients (56%) the MLN corresponded with the SLN. In 3 cases it was not possible identify the SLN and in 8 cases the MLN was not a SLN. The biopsy of MLN and SLN was negative for metastasis in 12 patients (2 of them had a positive ALND) and was positive for metastasis in 13 patients (4 of them had a positive ALND). Conclusion The SPECT-CT study provided additional information about the identification and the concordance of the MLN and the SLN improving the surgical planning. (AU)

Necesidad de vaciamiento axilar en el cáncer de mama. Rigor en los métodos predictivos / Need for axillary lymph node dissection in breast cancer. Rigour in predictive methods

Introduccción: El objetivo es describir la validez diagnóstica y la seguridad de los métodos empleados en nuestro entorno para obviar el vaciamiento axilar en el tratamiento quirúrgico primario de mama en estadio inicial tras determinación de macrometástasis en el ganglio centinela. Métodos: Estudio observacional retrospectivo multicéntrico aprobado por el Comité de Ética. Determinación de sensibilidad, especificidad, valor predictivo positivo y negativo de los métodos: OSNA (punto de corte a 15.000 copias de ARN), score Tenon 5 (punto de corte en 5), perfil de alto riesgo (si no cumple T1G2RH+ HER-), criterios ACOSOG Z-11 y resultado de ganglio secundario. Se incluyó a pacientes con cáncer de mama dirigidas a tratamiento quirúrgico primario; tamaño T1-T2 y axila clínica y radiológicamente negativa; con resultado de ganglio centinela positivo para macrometástasis. Resultados: Se incluyó a 279 pacientes con macrometástasis en el ganglio centinela, de los cuales resultaron 69 (24,4%) linfadenectomías positivas. Los resultados de sensibilidad, especificidad, valor predictivo positivo y negativo fueron: OSNA (100%, 17%, 32%, 100%); Tenon 5 (91%, 34%, 31%, 92%); alto riesgo (82%, 32%, 28%, 85%), ACOSOG Z-11 (30%, 97%, 75%, 84%); ganglio secundario (86%, 76%, 55%, 94%). Conclusiones: El método más seguro, score Tenon 5, solo evitaría un tercio de linfadenectomías negativas. Un perfil de riesgo no ofrecería suficiente seguridad. La propuesta del grupo ACOSOG Z-11 sería el método menos seguro. La cuantificación de la macrometástasis por método OSNA no conseguiría validez diagnóstica. El análisis del ganglio secundario, siendo el método menos aplicado, sería el más válido, con mejor sensibilidad y especificidad conjunta. En nuestra valoración, ninguno de los métodos estudiados resultaría suficientemente riguroso pues no obtendrían resultados óptimos para permitir obviar la linfadenectomía

Introduction: The aim of this study was to describe the diagnostic validity and safety of the most commonly used methods to avoid axillary lymph node dissection (ALND) in the primary surgical treatment of initial-stage breast cancer after determination of sentinel node macrometastases. Methods: This multicenter, retrospective observational study was approved by the ethics committee and assessed the sensitivity, specificity, positive and negative predictive value of the following methods: OSNA (cut-off point of 15,000 RNA copies), Tenon 5 score (cut-off point 5), HIGH risk profile (RH+ HER-), ACOSOG Z-11 criteria and second-tier sentinel node outcome. We included patients with breast cancer undergoing primary surgical treatment, with T1-T2 tumours, clinically and radiologically negative axillae, and sentinel node macrometastases. Results: We included 279 patients, of whom 69 (24.4%) had a positive ALND. The results of sensitivity, specificity, positive predictive value and negative predictive value were as follows: OSNA (100%, 17%, 32%, 100%); Tenon 5 (91%, 34%, 31%, 92%); HIGH (82%, 32%, 28%, 85%), ACOSOG Z-11 (30%, 97%, 75%, 84%); SECOND (86%, 76%, 59%, 94%). Conclusions: The most accurate method, the Tenon score, would only avoid one-third of negative lymphadenectomies. Relying on a risk profile would not provide enough safety. The proposal of the ACOSOG Z-11 group was the least safe method. Quantification of macrometastases by OSNA would not be a valid diagnostic method. Second-tier sentinel node analysis, the least applied method, seems the most accurate, with the best sensitivity and specificity.In our analysis, none of the methods would be sufficiently rigorous to safely allow avoidance of ALND