Prognostic impact of histological subtyping in triple-negative breast cancer.

The impact of special histological types (ST) in triple-negative breast cancer (TNBC) and its association with overall outcome has gained increasing relevance as survival has been linked to specific histological TNBC subtypes. We evaluated the clinicopathological and survival data of 598 patients with 613 TNBCs, including 464 TNBCs of no special type (NST) and 149 TNBCs ST (low-grade, n = 12, 8.1%; high-grade, n = 112, 75.2%; apocrine and androgen receptor-positive [APO AR], n = 25, 16.8%). Patients with low-grade TNBC ST and TNBC ST APO AR were significantly older (P < 0.001) and had a lower Ki67 index (P < 0.001) than those with TNBC NST. Patients with high-grade TNBC ST were significantly older (P = 0.006) and had poorer pathological responses to neoadjuvant chemotherapy (NAC) (P < 0.001) than those with TNBC NST. Significant survival differences were observed between low-grade TNBC ST, TNBC ST APO AR, high-grade TNBC ST, and TNBC NST in the entire study group (DFS, P = 0.002; DDFS, P = 0.001) and in the non-NAC subgroup (OS, P = 0.034; DFS, P = 0.001; DDFS, P < 0.001). Patients with low-grade TNBC ST had the best survival outcomes. Patients with high-grade TNBC ST showed significantly worse outcomes than those with TNBC NST (entire study group: OS, P = 0.049; DFS, P < 0.001; DDFS, P = 0.001; non-NAC subgroup: OS, P = 0.014; DFS, P < 0.001; DDFS, P < 0.001). We conclude that prognostic stratification of TNBC ST is ultimately important for optimizing the therapeutic management of patients with these rare tumor entities.

Oncoplastic breast consortium recommendations for mastectomy and whole breast reconstruction in the setting of post-mastectomy radiation therapy.

AIM: Demand for nipple- and skin- sparing mastectomy (NSM/SSM) with immediate breast reconstruction (BR) has increased at the same time as indications for post-mastectomy radiation therapy (PMRT) have broadened. The aim of the Oncoplastic Breast Consortium initiative was to address relevant questions arising with this clinically challenging scenario. METHODS: A large global panel of oncologic, oncoplastic and reconstructive breast surgeons, patient advocates and radiation oncologists developed recommendations for clinical practice in an iterative process based on the principles of Delphi methodology. RESULTS: The panel agreed that surgical technique for NSM/SSM should not be formally modified when PMRT is planned with preference for autologous over implant-based BR due to lower risk of long-term complications and support for immediate and delayed-immediate reconstructive approaches. Nevertheless, it was strongly believed that PMRT is not an absolute contraindication for implant-based or other types of BR, but no specific recommendations regarding implant positioning, use of mesh or timing were made due to absence of high-quality evidence. The panel endorsed use of patient-reported outcomes in clinical practice. It was acknowledged that the shape and size of reconstructed breasts can hinder radiotherapy planning and attention to details of PMRT techniques is important in determining aesthetic outcomes after immediate BR. CONCLUSIONS: The panel endorsed the need for prospective, ideally randomised phase III studies and for surgical and radiation oncology teams to work together for determination of optimal sequencing and techniques for PMRT for each patient in the context of BR.

Retrospective, Multicenter Analysis Comparing Conventional with Oncoplastic Breast Conserving Surgery: Oncological and Surgical Outcomes in Women with High-Risk Breast Cancer from the OPBC-01/iTOP2 Study.

INTRODUCTION: Recent data suggest that margins ≥2 mm after breast-conserving surgery may improve local control in invasive breast cancer (BC). By allowing large resection volumes, oncoplastic breast-conserving surgery (OBCII; Clough level II/Tübingen 5-6) may achieve better local control than conventional breast conserving surgery (BCS; Tübingen 1-2) or oncoplastic breast conservation with low resection volumes (OBCI; Clough level I/Tübingen 3-4). METHODS: Data from consecutive high-risk BC patients treated in 15 centers from the Oncoplastic Breast Consortium (OPBC) network, between January 2010 and December 2013, were retrospectively reviewed. RESULTS: A total of 3,177 women were included, 30% of whom were treated with OBC (OBCI n = 663; OBCII n = 297). The BCS/OBCI group had significantly smaller tumors and smaller resection margins compared with OBCII (pT1: 50% vs. 37%, p = 0.002; proportion with margin <1 mm: 17% vs. 6%, p < 0.001). There were significantly more re-excisions due to R1 ("ink on tumor") in the BCS/OBCI compared with the OBCII group (11% vs. 7%, p = 0.049). Univariate and multivariable regression analysis adjusted for tumor biology, tumor size, radiotherapy, and systemic treatment demonstrated no differences in local, regional, or distant recurrence-free or overall survival between the two groups. CONCLUSIONS: Large resection volumes in oncoplastic surgery increases the distance from cancer cells to the margin of the specimen and reduces reexcision rates significantly. With OBCII larger tumors are resected with similar local, regional and distant recurrence-free as well as overall survival rates as BCS/OBCI.

Residual Axillary Burden After Neoadjuvant Chemotherapy (NACT) in Early Breast Cancer in Patients with a priori Clinically Occult Nodal Metastases - a transSENTINA Analysis.

Background Among patients with breast cancer undergoing neoadjuvant chemotherapy (NACT), the association between pathological complete remission (pCR) in the breast and clinical/pathological parameters is well established, whereas the association between these parameters and residual axillary involvement after NACT remains unclear. Methods Patients with clinically occult nodal metastases (i.e. negative by clinical assessment but positive by SLNB prior to NACT, i.e. Arm B of the SENTINA trial) were included in the presented analysis. All patients received a second sentinel lymph node biopsy (SLNB) and axillary dissection after NACT. Univariate and multivariate analyses were carried out to evaluate the association between clinical/pathological parameters and axillary involvement after NACT. Results Arm B of the SENTINA study contained 360 patients, 318 of which were evaluable for this analysis. After NACT, 71/318 (22.3%) patients had involved SLNs or non-SLNs after NACT. Overall, 71/318 (22.3%) patients achieved a pCR in the breast. Associations of extranodal spread, lack of multifocality and pCR in the breast with residual axillary burden were statistically significant. In a descriptive analysis including all patients with clinically negative axilla before NACT in the SENTINA trial 1.2% of triple negative (TN) patients and 0.5% of HER/2 positive patients had residual axillary disease in case of a breast pCR. Conclusions Patients in the SENTINA trial with clinically negative axilla and involved SLNs still carried a significant risk of nodal metastases after NACT. However, the risk of residual axillary burden was particularly low in TN and HER/2 positive tumors in case of a breast pCR.

Correction: Residual Axillary Burden After Neoadjuvant Chemotherapy (NACT) in Early Breast Cancer in Patients with a priori Clinically Occult Nodal Metastases - a transSENTINA Analysis.

[This corrects the article DOI: 10.1055/a-1298-3453.].

Impact of Breast Surgery in Primary Metastasized Breast Cancer: Outcomes of the Prospective Randomized Phase III ABCSG-28 POSYTIVE Trial.

BACKGROUND: Conflicting evidence exists regarding the value of surgical resection of the primary in stage IV breast cancer patients. OBJECTIVE: The prospective randomized phase III ABCSG-28 POSYTIVE trial evaluated median survival comparing primary surgery followed by systemic therapy to primary systemic therapy in de novo stage IV breast cancer. METHODS: Between 2011 and 2015, 90 previously untreated stage IV breast cancer patients were randomly assigned to surgical resection of the primary tumor followed by systemic therapy (Arm A) or primary systemic therapy (Arm B) in Austria. Overall survival (OS) was defined as the primary study endpoint. RESULTS: The trial was stopped early due to poor recruitment. Ninety patients (45 arm A, 45 arm B) were included; median follow-up was 37.5 months. Patients in the surgery arm had more cT3 breast cancer (22.2% vs 6.7%) and more cN2 staging (15.6% vs 4.4%). Both groups were well balanced with respect to the type of first-line systemic treatment. Median survival in arm A was 34.6 months, versus 54.8 months in the nonsurgery arm [hazard ratio (HR) 0.691, 95% confidence interval (95% CI) 0.358-1.333; P = 0.267]; time to distant progression was 13.9 months in the surgery arm and 29.0 months in the nonsurgery arm (HR 0.598, 95% CI 0.343-1.043; P = 0.0668). CONCLUSION: The prospective phase III trial ABCSG-28 (POSYTIVE) could not demonstrate an OS benefit for surgical resection of the primary in breast cancer patients presenting with de novo stage IV disease.

Using ultrasound and palpation for predicting axillary lymph node status following neoadjuvant chemotherapy - Results from the multi-center SENTINA trial.

BACKGROUND: With the growing importance of neoadjuvant systemic therapy (NST) the assessment of post neoadjuvant axillary status is of increasing importance especially in patients who presented initially with suspicious nodes (cN1). This study aims to investigate the predictive value of palpation and axillary ultrasound of formerly cN1 patients following NST. PATIENTS AND METHODS: The SENTINA trial (SENTinel NeoAdjuvant) is a 4-arm prospective multicenter study designed to evaluate the role of sentinel node biopsy (SLNB) in the context of neoadjuvant systemic treatment (NST) of breast cancer patients. RESULTS: 1240 patients from 103 institutions entered the trial. 715 (arm C n = 592; arm D n = 123) patients, who presented initially cN1 underwent clinical evaluation of lymph node status following NST. Palpation alone demonstrated a sensitivity of 8.3%, specifity of 94.8% and a negative predictive value (NPV) of 46.6%. Ultrasound alone revealed a sensitivity of 23.9%, specificity 91.7%, and a NPV of 50.3%.The investigators combined classification (palpation and ultrasound) resulted in a sensitivity of 24.4%, specificity 91.4%, and a NPV of 50.3%. Investigators classified the axilla nodes as being unsuspicious (cN0) following NST in 592/715 patients; of them 298 (50.3%) were pN0, 151 (25.5%) had 1-2 histologically involved nodes and 143 (24.2%) had >2 histologically involved nodes. CONCLUSION: The diagnostic accuracy of ultrasound and palpation following NST is unacceptably low and additional tools for evaluation of the axillary lymph node status following NST are urgently needed.

Sentinel-lymph-node biopsy in patients with breast cancer before and after neoadjuvant chemotherapy (SENTINA): a prospective, multicentre cohort study.

BACKGROUND: The optimum timing of sentinel-lymph-node biopsy for breast cancer patients treated with neoadjuvant chemotherapy is uncertain. The SENTINA (SENTinel NeoAdjuvant) study was designed to evaluate a specific algorithm for timing of a standardised sentinel-lymph-node biopsy procedure in patients who undergo neoadjuvant chemotherapy. METHODS: SENTINA is a four-arm, prospective, multicentre cohort study undertaken at 103 institutions in Germany and Austria. Women with breast cancer who were scheduled for neoadjuvant chemotherapy were enrolled into the study. Patients with clinically node-negative disease (cN0) underwent sentinel-lymph-node biopsy before neoadjuvant chemotherapy (arm A). If the sentinel node was positive (pN1), a second sentinel-lymph-node biopsy procedure was done after neoadjuvant chemotherapy (arm B). Women with clinically node-positive disease (cN+) received neoadjuvant chemotherapy. Those who converted to clinically node-negative disease after chemotherapy (ycN0; arm C) were treated with sentinel-lymph-node biopsy and axillary dissection. Only patients whose clinical nodal status remained positive (ycN1) underwent axillary dissection without sentinel-lymph-node biopsy (arm D). The primary endpoint was accuracy (false-negative rate) of sentinel-lymph-node biopsy after neoadjuvant chemotherapy for patients who converted from cN1 to ycN0 disease during neoadjuvant chemotherapy (arm C). Secondary endpoints included comparison of the detection rate of sentinel-lymph-node biopsy before and after neoadjuvant chemotherapy, and also the false-negative rate and detection rate of sentinel-lymph-node biopsy after removal of the sentinel lymph node. Analyses were done according to treatment received (per protocol). FINDINGS: Of 1737 patients who received treatment, 1022 women underwent sentinel-lymph-node biopsy before neoadjuvant chemotherapy (arms A and B), with a detection rate of 99.1% (95% CI 98.3-99.6; 1013 of 1022). In patients who converted after neoadjuvant chemotherapy from cN+ to ycN0 (arm C), the detection rate was 80.1% (95% CI 76.6-83.2; 474 of 592) and false-negative rate was 14.2% (95% CI 9.9-19.4; 32 of 226). The false-negative rate was 24.3% (17 of 70) for women who had one node removed and 18.5% (10 of 54) for those who had two sentinel nodes removed (arm C). In patients who had a second sentinel-lymph-node biopsy procedure after neoadjuvant chemotherapy (arm B), the detection rate was 60.8% (95% CI 55.6-65.9; 219 of 360) and the false-negative rate was 51.6% (95% CI 38.7-64.2; 33 of 64). INTERPRETATION: Sentinel-lymph-node biopsy is a reliable diagnostic method before neoadjuvant chemotherapy. After systemic treatment or early sentinel-lymph-node biopsy, the procedure has a lower detection rate and a higher false-negative rate compared with sentinel-lymph-node biopsy done before neoadjuvant chemotherapy. These limitations should be considered if biopsy is planned after neoadjuvant chemotherapy. FUNDING: Brustkrebs Deutschland, German Society for Senology, German Breast Group.

Sentinel node mapping performed before preoperative chemotherapy may avoid axillary dissection in breast cancer patients with negative or micrometastatic sentinel nodes.

BACKGROUND: Sentinel node (SN) biopsy after preoperative chemotherapy (PC) in breast cancer patients is associated with a lower identification rate (IR) and an increased false-negative rate (FNR) compared with SN biopsy in untreated patients. Our aims were to examine the feasibility of SN mapping before PC and the possibility to assess the lymph node status after chemotherapy through a follow-up lymphatic mapping. METHODS: SN biopsy was performed in 45 clinically node-negative breast cancer patients before PC. A follow-up lymphatic mapping was done after completion of chemotherapy and irrespective of the lymph node status was followed by axillary lymph node dissection (ALND). RESULTS: SN mapping before chemotherapy identified a mean of 2.3 SNs in all patients (IR 100%). Nineteen patients revealed a negative SN; 26 patients had a positive SN (micrometastasis found in 6/26 patients). After PC follow-up lymphatic mapping was successful in 29 of 45 patients (IR 64%). IR for follow-up mapping was 80% for patients with a negative or micrometastatic SN before chemotherapy compared with 45% for patients with macrometastatic SNs (P = .027, Fisher exact test). None of the patients with a negative or micrometastatic SN before chemotherapy revealed positive lymph nodes after PC (P = .031, McNemar test) and the FNR for follow-up lymphatic mapping in these patients was 0%. Contrary to that, 15 of 20 patients with a macrometastasis before PC had positive nodes after chemotherapy, and the FNR of follow-up mapping in these patients was 50%. CONCLUSIONS: Patients with a negative SN before PC may forego complete ALND after PC, whereas this may not be valid for patients with macrometastatic SNs. Follow-up lymphatic mapping in patients with positive nodal status before chemotherapy is associated with a low IR and a high FNR.

Central quadrantectomy with resection of the nipple-areola complex compared with mastectomy in patients with retroareolar breast cancer.

Appropriate surgery in women with retroareolar breast cancer should allow resection of the cancer with wide free margins and an acceptable cosmetic result. The aim of this study was to compare breast conservation surgery (BCS) to mastectomy for treatment of retroareolar breast cancer. In a prospective nonrandomized study, 69 women with retroareolar breast cancers underwent either central quadrantectomy (n=33) with complete removal of the nipple-areola complex or mastectomy (n=36). Two of 33 (6%) patients scheduled for BCS had a secondary mastectomy and immediate reconstruction due to involved margins. After a median follow-up of 42 month (range 17-99 months) in the BCS group and 43 months (range 16-118 months) in the mastectomy group local and regional recurrences as well as systemic disease were comparable between both groups. The postoperative cosmetic result after BCS as evaluated by the patients was rated as excellent in 80% and good in 20% with no poor result. BCS followed by radiation therapy is a feasible alternative to mastectomy in patients with retroareolar breast cancer.

Oncoplastic techniques allow breast-conserving treatment in centrally located breast cancers.

BACKGROUND: Operative techniques for oncoplastic reconstruction combine oncologic extirpation of the tumor with immediate reconstruction of breast shape and symmetry. These techniques are increasingly being used for breast-conservation therapy of centrally located breast carcinomas. The goal of this study was to provide an overview of the various surgical options for oncoplastic treatment of central breast carcinomas. METHODS: From September of 1998 through January of 2005, 31 women (median age, 61 years) were treated for 32 centrally located breast carcinomas by breast-conserving therapy. There were 27 invasive tumors (median size, 13.5 mm), and five patients had ductal carcinoma in situ (median size, 39.6 mm). One patient received chemotherapy preoperatively for tumor reduction. A total of 11 patients had a positive lymph-node status, and 21 patients had a free sentinel node. RESULTS: The various surgical techniques included a central lumpectomy with direct closure (n = 6), central lumpectomy with inverted T-closure (n = 2), a circumareolar, Benelli-type closure (n = 2), a modified Grisotti-flap closure (n = 9), and a mammaplasty-type closure with an inferiorly based pedicle (n = 13). In 27 patients, a contralateral procedure was undertaken (bilateral carcinoma or symmetrizing mammaplasty). Two patients required a secondary mastectomy because of ductal carcinoma in situ with positive surgical margins in the final histology. They were treated by immediate reconstruction with an implant and a pedicled myocutaneous latissimus dorsi flap, respectively. In a median follow-up of 33.8 months, there were no local recurrences in the remaining breast or axilla, but two patients developed distant metastases. CONCLUSIONS: Breast carcinoma of small size that occurs in a central location can be safely treated oncologically by breast conservation therapy. The use of various oncoplastic techniques yields very satisfactory aesthetic results.

A nonrandomized follow-up comparison between standard axillary node dissection and sentinel node biopsy in breast cancer.

INTRODUCTION: In many countries sentinel node biopsy (SNB) has become the standard of care in breast cancer based on a large number of observational studies but without results from prospective randomized trials. The goal of our study was to evaluate the oncological safety of the SNB in breast cancer in a multicenter, nonrandomized setting with comparable groups. PATIENTS AND METHODS: Between 1996/05 and 2004/11, 2942 patients from 14 departments in Austria with unicentric, unilateral, invasive disease without neoadjuvant therapy were collected in a database. The recommendations of the Austrian Sentinel Node Study Group were to complete a training period (phase I) with 50 cases of SNB followed by axillary lymph node dissection (ALND) to prove a detection rate of > or = 90% and a false-negative rate of < or = 5%. In the executing period (phase II), SNB was followed by ALND only if the sentinel node (SN) contained metastases. We compared the results on disease-free survival, local recurrence rates, distant recurrence rates and overall survival of both groups. Cases from phases I and II generated groups I (n=671) and 2 (n=2271 cases), respectively. RESULTS: Overall mean follow-up time: 34.41 months. CONCLUSION: SNB followed by ALND only in cases with metastases in the SN is a safe procedure and at least equal to ALND in all cases.

Multicentric breast cancer: a new indication for sentinel node biopsy--a multi-institutional validation study.

PURPOSE: Multicentric breast cancer has been considered to be a contraindication for sentinel node (SN) biopsy (SNB). In this prospective multi-institutional trial, SNB-feasibility and accuracy was evaluated in 142 patients with multicentric cancer from the Austrian Sentinel Node Study Group (ASNSG) and compared with data from 3,216 patients with unicentric cancer. PATIENTS AND METHODS: Between 1996 and 2004, 3,730 patients underwent SNB at 15 ASNSG-affiliated hospitals. Patient data were entered in a multicenter database. One hundred forty-two patients presented with multicentric invasive breast cancer and underwent SNB. RESULTS: Intraoperatively, a mean number of 1.67 SNs were excised (identification-rate, 91.5%). The incidence of SN metastases was 60.8% (79 of 130). This was confirmed by axillary lymph node dissection (ALND) in 125 patients. Of patients with positive SNs, 60.8% (48 of 79) showed involvement of nonsentinel nodes (NSNs), as did three patients with negative SNs (false-negative rate, 4.0). Sensitivity, negative predictive value, and overall accuracy were 96.0%, 93.3%, and 97.3%, respectively. Ninety-one percent of the patients underwent mastectomy, and 9% were treated with breast conserving surgery. None of the patients have shown axillary recurrence so far (mean follow-up, 28.8 months). Compared with 3,216 patients with unicentric cancer, there was a significantly higher rate of SN metastases as well as in NSNs, whereas there was no difference in detection and false-negative rates. CONCLUSION: Multicentric breast cancer is a new indication for SNB without routine ALND in controlled trials. Given adequate quality control and an interdisciplinary teamwork of surgical, nuclear medicine, and pathology units, SNB is both feasible and accurate in this disease entity.

Symmetrization reduction mammaplasty combined with sentinel node biopsy in patients operated for contralateral breast cancer.

BACKGROUND AND OBJECTIVES: Occult invasive cancer found in reduction mammaplasty specimen in the contralateral breast in breast cancer patients requires axillary lymph node dissection (ALND) to assess the lymph node status. Routine Sentinel node (SN) biopsy in these patients may avoid secondary ALND when an occult cancer is found and the SN is negative in the permanent histological examination. METHODS: One hundred sixty-nine breast cancer patients underwent contralateral reduction mammaplasty for symmetrization and with SN biopsy of the non-cancer breast. SN mapping was done using a vital blue dye alone (n = 136) or in combination with a radiocolloid (n = 33). RESULTS: A mean number of 1.4 SNs (range 1-3 SNs) was identified in 158 of 169 patients (identification rate 93.5%). One of 158 patients revealed a positive SN but no tumor was found in the reduction mammaplasty/mastectomy specimen, whereas the SN was negative in 157 patients. Histological examination of the 169 reduction mammaplasty specimen revealed 5 occult invasive cancers and 4 patients with high grade DCIS but due to a negative SN biopsy the patients were spared a secondary ALND. CONCLUSION: The small number of patients with occult contralateral cancers may not warrant routine SN mapping in patients scheduled for contralateral reduction mammaplasty.

The use of sentinel node biopsy in breast cancer patients undergoing skin sparing mastectomy and immediate autologous reconstruction.

BACKGROUND: Intraoperative frozen section examination of the sentinel node in breast cancer patients is associated with a high number of incorrect negative results with the sentinel node becoming positive in the permanent examination and necessitating a secondary axillary lymph node dissection. A reoperation of the axilla following skin-sparing mastectomy and immediate autologous tissue reconstruction may compromise the vascular pedicle of the flap and should be avoided. METHODS: Eighty breast cancer patients underwent skin-sparing mastectomy with immediate autologous reconstruction and sentinel node biopsy followed by axillary lymph node dissection irrespective of the result of the frozen section of the sentinel node. The goal of the study was to identify a subgroup of patients with incorrect negative sentinel node(s) in the frozen section who may forego a secondary axillary lymph node dissection due to a low risk of positive nonsentinel nodes. RESULTS: Frozen section examination of the sentinel node was negative in 58 patients and positive in 22 patients. Permanent histologic examination revealed tumor in 13 of 58 (22.4 percent) sentinel node(s) found negative in the frozen section. None of these 13 patients showed positive nodes in the axillary specimen, whereas nine of 22 patients with their metastases in the sentinel node found through intraoperative frozen section examination had additional positive nonsentinel node(s) (p = 0.001). CONCLUSIONS: Patients with incorrect negative sentinel node(s) found in the frozen section examination had a significantly decreased risk for additional positive nonsentinel node(s) compared with patients with sentinel node metastases found in the frozen section. However, to avoid a secondary axillary lymph node dissection, the authors suggest performing sentinel node biopsy before mastectomy under local anesthesia to have the permanent result of the sentinel node available before a planned reconstruction.

Sentinel node biopsy performed before preoperative chemotherapy for axillary lymph node staging in breast cancer.

Sentinel node (SN) biopsy in breast cancer patients following preoperative chemotherapy is associated with a decreased identification rate and an increased false-negative rate when compared to SN biopsy performed in untreated patients. We performed SN biopsy in 21 breast cancer patients scheduled for preoperative chemotherapy using either vital blue dye alone (n = 11) or in combination with a radiocolloid (n = 10). Following a mean of four cycles of preoperative chemotherapy, surgery to the breast and complete axillary lymph node dissection was performed irrespective of the SN status. A mean of 1.9 SNs were identified in all 21 patients, 12 were SN negative and 9 were SN positive. Preoperative chemotherapy decreased mean tumor size from 40.2 to 17.7 mm and breast conservation was possible in 14 of 21 patients (67%). All SN-negative patients and three of nine SN-positive patients had negative lymph nodes in the axillary specimen, whereas six of nine patients with a positive SN revealed lymph node metastases following preoperative chemotherapy. SN biopsy performed before preoperative chemotherapy found a 100% identification rate with no false-negative results. Following preoperative chemotherapy, SN-negative patients may forego a complete axillary dissection.

Transilluminated powered phlebectomy: advantages and disadvantages of a new technique.

BACKGROUND: Transilluminated powered phlebectomy is a new procedure for minimal invasive varicose vein surgery. OBJECTIVE: To evaluate this technique for its benefit and the technique-related risks and complications. METHODS: Thirty patients were prospectively operated with this new technique by the same surgeon (11 of them bilaterally [41 legs in all]). According to the sonography, sapheno-femoral-junction ligation and stripping of the long saphenous vein were done if necessary. The phlebectomy of the side branches was done with the new system (Trivex System/Smith and Nephew). The postoperative follow-up was at 10 days and 6 weeks. RESULTS: There was no intraoperative complication. The mean operation time per leg was 40 minutes. Twenty-five patients had an uneventful postoperative course. Twenty two have been very satisfied with the cosmetically result. Two patients required reoperation because of postoperative hematoma. One patient developed a seroma, which could be managed via puncture. One patient developed persistent brown scar. The overall morbidity was 12.2%. CONCLUSION: Using transilluminated powered phlebectomy, multiple and large incisions could be reduced. A perfect cosmetic outcome might be reached if the surgeon is aware of technique-related complications. To evaluate the real value of this technique, further randomized trials are necessary.

Prospective trial comparing bilateral and unilateral varicose vein surgery.

BACKGROUND: This study compared bilateral and unilateral varicose vein surgery in primary varicosis of the long or short saphenous vein with respect to blood loss. PATIENTS AND METHODS: The prospective trial assessed postoperative pain, analgesic consumption, blood loss, return to physical activity and work, cosmetic result, complications, hospitalization, patient satisfaction, and hospital cost in 73 consecutive patients undergoing unilateral ( n=40) or bilateral ( n=33) varicose vein surgery. RESULTS: There were no statistically significant differences between the two groups in postoperative pain, postoperative analgesic consumption immediately postoperatively and after 8 h, median postoperative stay, return to work and physical activity, or cosmetic result. All patients but one were either satisfied or very satisfied 6 weeks postoperatively. CONCLUSIONS: Patients undergoing a bilateral stripping operation did not differ from those undergoing unilateral operation. Therefore we recommend bilateral operation when indicated.

Sentinel node biopsy for breast cancer: does the number of sentinel nodes removed have an impact on the accuracy of finding a positive node?

BACKGROUND AND OBJECTIVES: The number of sentinel lymph nodes (SLNs) removed during biopsy may have an impact on the accuracy of finding a positive SLN. This study investigated various factors to determine if they had any significant correlation with the number of SLNs found during biopsy. In patients with positive SLNs, the nodes were then analyzed to determine which SLN contained metastasis. METHODS: For 263 patients with breast cancer who successfully underwent SLN biopsy, parameters such as tumor size, histologic characteristics, differentiation, and receptor status, patient age, breast quadrant, type of surgery, mapping with blue dye only or with radiocolloid, and whether biopsy was performed before or after tumorectomy were prospectively collected. These factors were analyzed to determine whether they had any significant correlation to the number of removed lymph nodes. Positive SLNs were ranked in the order they were removed and examined for which node contained the metastasis. RESULTS: During biopsy, a mean of 1.8 (range, 1-5) SLNs were found. The SLNs were negative in 158 patients and positive in 105. The number of SLNs removed was comparable between node-negative and node-positive patients, and none of the parameters analyzed was significantly related to the number of SLNs removed. Of the 105 patients with a positive SLN, the first SLN independently predicted the pathologic status of the axilla in 96 patients (91.4%; 95% CI 86.1-96.8), and the first and second SLN independently predicted the status in 104 patients (99%; 95% CI 97.2-100). Only one of 105 patients had metastasis in the third SLN removed. CONCLUSION: The pathologic status of the axilla was independently determined by removal of the first or first and second SLN in 99% of patients; removal of more than three SLNs did not increase the accuracy of finding a positive node.