Validation of a nomogram to predict the risk of nonsentinel lymph node metastases in breast cancer patients with a positive sentinel node biopsy: validation of the MSKCC breast nomogram.

BACKGROUND: Completion axillary lymph node dissection (ALND) remains the standard of care for patients with disease-positive sentinel lymph nodes (SLN). However, approximately two-thirds will have no additional disease-positive nodes. To identify the patient's individual risk for non-SLN metastases, the Memorial Sloan-Kettering Cancer Center (MSKCC) developed a nomogram. METHODS: The records of 182 breast cancer patients who underwent SLN and ALND were selected. Serial hematoxylin and eosin (HE) analysis and immunohistochemistry were routinely performed on each sentinel node. For application of the nomogram, the detection method was assigned in two ways: for all metastases visible by serial HE, the method of detection was scored as "serial HE" (method 1), independent of the tumor size, and by a combination of size and staining method (method 2); so macrometastasis were scored as detected by routine HE, micrometastasis by serial HE, and isolated tumor cells by immunohistochemistry. A receiver operating characteristic curve (ROC) was drawn, and the area under the curve was calculated to assess the discriminative power of the nomogram. RESULTS: The area under the ROC was .71 (range, .64-.79) according to method 1 and .75 (range, .67-.88) according to method 2. CONCLUSIONS: Because the variable "method of detection" in the MSKCC nomogram is a surrogate for SLN metastasis size, the size category of the SLN metastasis can be used in applying the nomogram to patients in whom the SLN histologic analysis is performed by a much different procedure than that used to develop the MSKCC nomogram. This results in an improved predictive accuracy.

The value of sentinel lymph node biopsy in ductal carcinoma in situ (DCIS) and DCIS with microinvasion of the breast.

AIM: Ductal carcinoma in situ (DCIS) refers to the preinvasive stage of breast carcinoma and should not give axillary metastases. Its diagnosis, however, is subject to sampling errors. The role of sentinel lymph node biopsy (SLNB) in management of DCIS or DCISM (with microinvasion) remains unclear. The purpose of this study was to review our experience with SLNB in DCIS and DCISM. METHODS: A review of 51 patients with a diagnosis of DCIS (n=45) or DCISM (n=6), who underwent SLNB and a definitive breast operation between January 1999 and December 2006, was performed. RESULTS: In 10 patients (19.6%) definitive histology revealed an invasive carcinoma. SLN (micro)metastases were detected in 5 out of 51 patients, of whom 2 had a preoperative diagnosis of grade III DCIS and 3 of DCISM. Three patients (75%) had micrometastases (< 2 mm) only. In 2 patients, histopathology demonstrated a macrometastasis (> 2 mm). All 5 patients underwent axillary dissection. No additional positive axillary lymph nodes were found. CONCLUSIONS: In case of a preoperative diagnosis of grade III DCIS or a grade II DCIS with comedo necrosis and DCIS with microinvasion, an SLNB procedure has to be considered because in almost 20% of the patients an invasive carcinoma is found after surgery. In this case the SLNB procedure becomes less reliable after a lumpectomy or ablation has been performed. SLN (micro)metastases were detected in nearly 10% of the patients. The prognostic significance of individual tumour cells remains unclear.

[A fatal infection due to avian influenza-A (H7N7) virus and adjustment of the preventive measures]. / Een fatale infectie door aviair influenza-A (H7N7)-virus en aanpassing van het preventiebeleid.

In February 2003, the highly pathogenic avian influenza-A virus, subtype H7N7, was the causative agent of a large outbreak of fowl plague in the Netherlands. Two days after visiting a poultry farm that was infected by fowl plague, a 57-year-old male veterinarian developed malaise, headache and fever. After 8 days he was admitted to hospital with signs of pneumonia. Five days later, his condition deteriorated alarmingly. Despite extensive pharmacotherapy he died 4 days later of acute pneumonia. Influenza-A virus, subtype H7N7, was identified by means of reverse transcriptase/PCR in broncho-alveolar washings that had been obtained earlier; routine virus culture yielded the isolate A/Nederland/219/03, which differs by 14 amino-acid substitutions from the first isolate in a chicken (A/kip/Nederland/1/03). Partly as a result of this case, the preventive measures were then adjusted; people who came into contact with infected poultry were given increased possibilities for vaccination and the administration of oseltamivir.

[Persistent infiltrative pulmonary disease]. / Persisterende infiltratieve longafwijkingen.

Two patients, a woman aged 63 and a man aged 64 years, were admitted with pulmonary complaints and persistent infiltrative lung abnormalities as revealed in chest X-rays. Routine diagnostic analysis did not lead to a diagnosis. However, a pathological examination of biopsies acquired by means of video-assisted thoracoscopic surgery (VATS), revealed bronchiolitis obliterans organising pneumonia (BOOP). In the first patient the BOOP manifested itself as a rapidly progressive disease with fever, pulmonary complaints and X-ray abnormalities. There was no response to standard antibiotic treatment. The other patient had suffered from rheumatoid arthritis for a considerable time and gradually developed BOOP. Both patients recovered following adequate therapy with high doses of oral corticosteroids. BOOP is a pathological-anatomical entity. It is a nonspecific excessive repair response to a variety of stimuli, such as infection, drugs, collagen vascular diseases, inflammatory disorders, transplantation, intoxication and irradiation. BOOP can also occur idiopathically. A high-resolution CT-scan is useful in distinguishing BOOP from interstitial pulmonary fibrosis and other interstitial lung diseases. An open lung biopsy is necessary for the diagnosis BOOP and is best performed by means of VATS. The treatment of BOOP consists of administering high doses of corticosteroids (prednisone 1 mg/kg/day) and if treated adequately, the prognosis is fairly good. Due to the extensive variety in aetiology, the specific diagnostic procedures and the good response to necessary treatment, BOOP should be considered in the differential diagnosis of patients with persistent infiltrative lung disease.

[Objective re-evaluation procedures in cases of possible diagnostic error]. / Naar een objectieve herbeoordelingsprocedure bij een mogelijke diagnostische dwaling.

Auxiliary diagnostic specialists such as clinical pathologists or radiodiagnosticians may be held liable by injured patients for erroneous diagnoses. Nearly always there will be a reconstruction of the situation in which the alleged misstake was made, and relevant facts will be tested against both professional and legal rules. The Court or one of the parties involved frequently ask an expert for re-evaluation of microscopic preparations, X-rays, etc. This objectivating evaluation requires a procedure that does justice to the original diagnostic situation and therefore should not be made by one single expert familiar with the chain of events. The results of the re-evaluation should be interpreted meticulously and their relative importance established by the Court.