New safer management for breast cancer patients who need neoadjuvant therapy during SARS-COVID pandemic.

During the first hit of SARS-COVID pandemic, an important reorganization of Healthcare Services has been done, and new protocols and pathways to protect frail patients like oncological patients were designed. The second hit of pandemic had stressed these new pathways and suggests to health-workers some improvements for safer management of patents.We reported our experience in organizing the clinical pathway of neoadjuvant therapy candidate patients based on the execution of sentinel lympho-node biopsy and the placement of implantable venous access port in the same access to operating room before neoadjuvant chemotherapy suggesting a possible organizational model. In the period October-December 2020 we have included in this new type of path twelve patients and we have not registered any cases of COVID among the patients included. We think this new path, adopted amid the second hit, will be useful for all Breast Units that are facing the challenge of guaranteeing the highest standards of care in a historical moment where the health emergency occupies the efforts of health workers and the economic resources of health systems.

Controversies in Sentinel Lymph Node Biopsy for Gynecologic Malignancies.

OBJECTIVE: Sentinel lymph node (SLN) biopsy represents an evolution in the advancement of minimally invasive surgical techniques for gynecologic cancers. Prospective and retrospective studies have consistently shown its accuracy in the detection of lymph node metastases for endometrial and cervical cancers. However, consistent with any emerging surgical technique in the early phases of adoption, new questions have arisen regarding its application and impact. This paper served as a scoping review to identify the key controversies that have arisen in the field of SLN biopsy for endometrial and cervical cancers. DATA SOURCES: Several key controversies were identified, and PubMed, the Cochrane Library (cochranelibrary.com) advanced search function, and the National Comprehensive Cancer Network guidelines were searched for supporting evidence. These included search terms such as "the accuracy of SLN biopsy for high grade endometrial cancer or cervical cancers >2-cm," "cost effectiveness of SLN biopsy for gynecologic cancers," "clinical significance of low volume metastases in endometrial cancer," "morbidity of SLN biopsy for endometrial and cervical cancer," and "impact on cancer survival of SLN biopsy for endometrial and cervical cancer." METHODS OF STUDY SELECTION: Studies were selected for review if they included significant numbers of patients, were level I evidence, or were prospective trials. Where this level of evidence failed to exist, seminal observational series that were published in high-quality journals were included. TABULATION, INTEGRATION, AND RESULTS: Similar studies were listed and subcategorized and cross-compared, excluding those that included repeated analyses of the same patient populations. The relevant clinical trials or observational studies were clustered and reviewed for each chosen controversy. Adequate evidence supports the accuracy of SLN biopsy in the staging of high-grade endometrial cancer and cervical cancer, and it seems to be a cost-effective strategy for invasive endometrial cancer. Conclusive evidence was lacking with respect to the oncologic outcomes related to SLN biopsy, the impact on patient morbidity, and whether clinicians should treat isolated tumor cells in SLNs with adjuvant therapy. CONCLUSION: SLN biopsy is an accepted staging strategy for cervical and endometrial cancer surgery; however, controversies remain in how it can be applied with the most safety and efficacy. These ultimately need to be resolved with further clinical trials and observations of larger series of patients.

Should Sentinel Lymph Node Biopsy Be Performed for All T1b Melanomas in the New 8th Edition American Joint Committee on Cancer Staging System?

BACKGROUND: In the 8th edition of the American Joint Committee on Cancer melanoma staging system, the T1b category has been redefined based solely on thickness and ulceration. National Comprehensive Cancer Network guidelines recommend consideration of sentinel lymph node biopsy (SLNB) for all patients with T1b melanomas (0.8 to 1.0 mm thick). We hypothesized that the new staging system would lead to excessive use of SLNB in patients with non-ulcerated T1b melanomas with a low risk of positive sentinel lymph nodes. STUDY DESIGN: The National Cancer Database 2015 Melanoma Public Use File was used to select patients undergoing SLNB for thin T1 cutaneous melanoma from 2010 to 2015. Clinicopathologic risk factors for having a positive SLNB were evaluated. Univariable and multivariable logistic regression models and classification and regression tree analysis were performed to identify groups with high and low risk of positive SLNB. RESULTS: We selected patients undergoing SLNB without ulceration with thickness 0.75 to 1.04 mm, staged T1b in the new 8th edition American Joint Committee on Cancer by thickness criteria alone (6,894 patients). Independent risk factors for a positive sentinel lymph node were age 56 years or younger (odds ratio [OR] 1.74; 95% CI 1.38 to 2.17), thickness 1.0 vs 0.8 to 0.9 mm (OR 1.36; 95% CI 1.09 to 1.70), female sex (OR 1.36; 95% CI 1.09 to 1.69), and mitotic rate ≥1/mm2 (OR 2.01; 95% CI 1.54 to 2.64). Classification and regression tree analysis identified 2 groups based on age, mitotic rate, and thickness with a risk of positive SLNB <5%. These 2 groups made up 55% of T1b, nonulcerated melanoma patients who underwent SLNB. CONCLUSIONS: The new 8th edition American Joint Committee on Cancer melanoma staging system T1b category should not be used to determine use of SLNB in thin melanoma, as more than one half of T1b lesions without ulceration have a low risk of positive sentinel lymph nodes.

Hospital-Based Study of Compliance with NCCN Guidelines and Predictive Factors of Sentinel Lymph Node Biopsy in the Setting of Thin Melanoma Using the National Cancer Database.

Thin melanoma is the most common form of melanoma in the United States. The National Comprehensive Cancer Network (NCCN) has guidelines for sentinel lymph node biopsy (SLNB) which recommend "discuss and consider" SLNB for invasion >0.75 mm and "discuss and offer" SLNB for invasion >0.75 mm with suspicious features. This study looked at compliance with NCCN guidelines and factors that are predictive of a positive SLNB. This is a retrospective study of patients diagnosed with thin melanoma 2012-2013 using the National Cancer Database. A total of 26,456 patients met study qualifications. Univariate analysis showed that 76 per cent of patients meeting criteria underwent SLNB. Patients recommended to "discuss and consider" received SLNB 53 per cent of the time and those not recommended for SLNB received SLNB 20 per cent of the time. On multivariate analysis, depth was not predictive for positive SLNB whereas mitoses and ulceration were. Other factors predictive of positive SLNB were nodular cell type, lymphovascular invasion, and Clark's level greater than or equal to IV. Patients with thin melanoma that meet NCCN guidelines for SLNB undergo this procedure in good compliance but those who do not meet criteria continue to receive SLNB. Positive predictive factors for positive SLNB include mitoses, ulceration, Clark's level, and primary site.

AHNS Series: Do you know your guidelines? Principles of surgery for head and neck cancer: A review of the National Comprehensive Cancer Network guidelines.

This article continues a series developed by the American Head and Neck Society's Education Committee entitled "Do you know your guidelines?" It is hoped that these features will increase awareness of and adherence to current best practices in head and neck cancer care. In this installment, the National Comprehensive Cancer Network (NCCN) guidelines for surgical therapy are reviewed. © 2016 Wiley Periodicals, Inc. Head Neck 39: 791-796, 2017.

Is sentinel lymph node biopsy the standard of care for cutaneous head and neck melanoma?

OBJECTIVES/HYPOTHESIS: Sentinel lymph node biopsy (SLNB) is considered one of the most important melanoma advancements to date. Since its inception in 1992, a plethora of data and associated controversies has emerged leading to the question: Is SLNB considered the standard of care for head and neck (HN) cutaneous melanoma? STUDY DESIGN: English literature (1990-2014) review. METHODS: The PubMed database search was conducted using key terms "melanoma" and "sentinel node." This review included both dedicated HN SLNB studies and larger prospective SLNB studies, in which HN patients were included among the cohort. Bibliography cross-referencing was conducted to ensure a comprehensive search. RESULTS: SLNB is safe and accurate in the HN region. Review of large prospective SLNB trials identified the pathologic status of the SLN as the most important prognostic factor for recurrence and survival. Early lymphadenectomy following a positive SLNB imparts a survival benefit. CONCLUSIONS: Our review of the current literature suggests that SLNB is the standard of care for selected cases of HN cutaneous melanoma. It is now incorporated into the American Joint Committee on Cancer staging system, the National Comprehensive Cancer Network practice guidelines, and numerous national and international consensus statements.

Irradiación de áreas ganglionares en pacientes sin linfadenectomía axilar / Axillary radiation in patients without axillary lymphadenectomy

La biopsia selectiva del ganglio centinela (BSGC) es actualmente una propuesta estándar para la estadificación de la axila en pacientes con cáncer de mama con una clara tendencia a minimizar la cirugía axilar incluso en presencia de ganglio centinela (GC) positivo. En caso de GC negativo la BSGC ha reemplazado a la linfadenectomía axilar (LA) demostrando equivalente supervivencia, mientras que los más sólidos consensos (American Society of Clinical Oncology) y, hasta fechas recientes, las guías de la National Comprehensive Cancer Network recomendaban completar la LA cuando se identifican metástasis en el GC. Esto da como resultado un excelente control locorregional y proporciona información que permite tomar decisiones sobre tratamientos adyuvantes tanto al oncólogo médico como al oncólogo radioterápico. No obstante, en los últimos tiempos múltiples estudios han debatido el valor terapéutico de la linfadenectomía quirúrgica, cobrando especial relevancia a raíz de la publicación del ensayo del American College of Surgeons Oncology Group (ACOSOG) Z0011, en el que se cuestiona el valor de esta actitud terapéutica y se propone únicamente una BSGC, omitiéndose la LA, en pacientes seleccionadas con uno o 2 GC positivos. La evidencia científica nos dice que la radioterapia puede jugar un papel fundamental en el control de la enfermedad axilar y, a fecha de hoy, no sabemos si la baja tasa de recidiva a este nivel, en los estudios mencionados, puede estar influida por la irradiación de la mama y axila inferior. Serían necesarios estudios con un diseño apropiado para contestar esta pregunta. En ausencia de más datos, nuestra propuesta es la irradiación axilar valorando individualmente los factores de riesgo de recidiva locorregional(AU)

Sentinel lymph node biopsy (SLNB) is currently a standard approach for staging of the axilla in patients with breast cancer, with a clear tendency to minimize surgery even in the presence of a positive axillary sentinel lymph node (SLN). The strongest consensus (American Society of Clinical Oncology) and, until recently, the National Comprehensive Cancer Network guidelines used to recommend complete axillary lymphadenectomy when metastases were identified in the SLN. However, SLNB has replaced axillary lymphadenectomy in SLN-negative patients and has demonstrated equivalent survival. This approach results in excellent locoregional control and provides information that allows both the medical oncologist and the radiation oncologist to take decisions about adjuvant treatments. Many recent studies, however, have debated the therapeutic value of surgical lymphadenectomy. This debate has become particularly important after the publication of the trial of the American College of Surgeons Oncology Group (ACOSOG) Z0011, which questions the value of this therapeutic approach and proposes SLNB alone, without lymphadenectomy, in selected patients with one or 2 positive SLN. The scientific evidence indicates that radiotherapy may play a major role in the control of axillary disease and, to date, it is not known whether the low recurrence rate in the axilla reported in the above-mentioned studies may have been influenced by radiation of the breast and lower axilla. To answer this question, new and appropriately designed trials are needed. In the absence of more data, we propose the use of axillary radiation, but with assessment of the risk factors for locoregional recurrence in each patient(AU)

[Sentinel lymph node biopsy under local anaesthesia: how to avoid the disadvantages of intraoperative examination?]. / Le prélèvement du ganglion sentinelle sous anesthésie locale ou comment s'affranchir des limites de l'analyse histologique peropératoire.

The sentinel lymph node procedure has become the standard in the surgical management of localised breast cancer. However, it is submitted to the uncertainties of intraoperative examination. Indeed, intraoperative examination has three major disadvantages: the type of histological method (frozen section versus imprint cytology), the size of sentinel node metastasis (macro- versus micrometastases) and the time requested for this technique. All of these limits are responsible for secondary re-interventions to complete axillary lymph node dissection. Few medical teams have described a new surgical strategy to avoid these limits. They proposed the detection of the sentinel lymph node under local anaesthesia and to wait for the definitive histological analysis before carrying out lumpectomy and axillary lymphadenectomy if necessary under general anaesthesia. We realized a review of the literature on this new procedure to evaluate its feasibility and to assess the technical aspects.

[Clinical practice guideline: 2005 update of recommendations for the management of patients with cutaneous melanoma without distant metastases (summary report)]. / Recommandations pour la pratique clinique: mise à jour 2005 des recommandations pour la prise en charge des patients adultes atteints d'un mélanome cutané sans métastase à distance (rapport abrégé).

CONTEXT: The National French federation of comprehensive cancer centres (FNCLCC) and the French society of dermatology (SFD) initiated together the update of clinical practice guideline for the management of patients with cutaneous melanoma in collaboration with the French national cancer institute and with specialists from French public universities, general hospitals and private clinics. This work is based on the methodology developed in the "Standards, Options and Recommendations" (SOR) project. OBJECTIVES: To update SOR guidelines for the management of patients with cutaneous melanoma previously validated in 1998 and French melanoma consensus conference published by SFD and ANAES in 1995. METHODS: The methodology is based on a literature review and critical appraisal by a multidisciplinary group of experts who define the CPGs according to the definitions of the Standards, Options and Recommendations project. Once the guidelines have been developed, they are reviewed by independent reviewers. RESULTS: This article is a summary version of the updated clinical practice guidelines with algorithms. The main questions addressed by the expert group in this update concerned (1) The new AJCC-UICC classification (2) Excision margins (3) Sentinel node biopsy (4) Adjuvant treatments (5) Initial staging and follow up of operated patients.

Controversial topics in breast lymphatic mapping.

As a result of increased accuracy of staging and decreased patient morbidity, lymphatic mapping and sentinel lymph node (SLN) biopsy for breast cancer has enjoyed a rapid acceptance into clinical practice. Despite the use of lymphatic mapping techniques to obtain nodal staging information, many controversies remain. We have attempted to highlight the major controversies in this report.