[The importance of the extracapsular extension of the sentinel node metastasis in the surgical treatment of breast cancer]. / Az orszemnyirokcsomó extracapsularis áttétének jelentosége az emlorák sebészi kezelésében.

Introduction: The introduction of sentinel node biopsy (SNB) has led to a significant decrease of axillary lymph node dissections (ALND). The importance of the extracapsular extension (ECE) in the sentinel lymph node (SN) remains unclear. Method: The data of 635 patients with T1-T2N0M0 invasive breast cancer who underwent SNB between 2014 and 2018 were retrospectively analysed. 25% of the SNB patients (158) had metastasis in the SNs. These patients were grouped based on the presence or absence of ECE. The main objective of our study was to analyse the occurrence of massive (>3) node metastasis in the case of ECE negative and ECE positive patients, where ALND was performed. Results: There were 91/158 patients (58%) in the ECE negative group and 67/158 patients (42%) in the ECE positive group. ALND was performed in 42% of the ECE negative and in 69% of the ECE positive patients. There were no significant differences in the mean age of the patients; size, histological type and grade of the tumours, presence of lymphovascular invasion and proportion of hormone and HER2 receptor positivities. In the ECE negative ALND group, pN1 involvement was 82%, pN2+pN3 involvement represented 18% of cases. In the ECE positive ALND group, pN1 involvement was 60%, pN2+pN3 involvement was found in 40% of cases. The presence of ECE was associated with greater axillary disease burden. These results show a significant difference (p = 0.038). Conclusions: ECE of the SN is an important predictor for non-sentinel lymph node involvement. These data suggest, when ECE is confirmed, it is a further factor to be considered in deciding about ALND.

The role of sentinel node biopsy in male breast cancer.

BACKGROUND: Sentinel lymph node biopsy (SLNB) is a standard procedure in women with breast cancer. The risk of morbidity related to axillary lymph node dissection (ALND) is similar for men and women with breast cancer and SLNB could minimize this risk. METHODS: Between January 2004 and August 2013, 25 men with primary breast cancer were operated on at the Bács-Kiskun County Teaching Hospital. These were reviewed retrospectively. SLNB was performed following lymphoscintigraphy with intraoperative gamma probe detection and blue dye mapping. RESULTS: SLNB was successful in all 16 male patients (100 %), in whom it was attempted. The SLNs were negative in 4 cases (25 %) and were involved in 12. Intraoperative imprint cytology was positive in 9 of the 12 involved cases (75 %) and resulted immediate completion ALND. In 7 patients, the intraoperative imprint cytology was negative, with 3 false-negative results that resulted in delayed completion ALND. After a median follow-up of 48 months, there was only one axillary recurrence after ALND and none in the SLNB group. CONCLUSIONS: SLNB is successful and accurate in male breast cancer patients too. Although compared to women a larger proportion of men have positive nodes, for men with negative nodes, ALND-related morbidity may be reduced by SLNB. We recommend SLNB in male patients with breast cancer and clinically negative axilla.

[Analysis of predictive tools for further axillary involvement in patients with sentinel-lymph-node-positive, small (< or =15 mm) invasive breast cancer]. / A hónalji nyirokcsomók további érintettségére vonatkozó modellek elemzése kisméretu (< / =15 mm) ôrszemnyirokcsomó-áttétes emlôrákokban.

Small breast cancers often require different treatment than larger ones. The frequency and predictability of further nodal involvement was evaluated in patients with positive sentinel lymph nodes and breast cancers < or =15 mm by means of 8 different predictive tools. Of 506 patients with such small tumors 138 with positive sentinel nodes underwent axillary dissection and 39 of these had non-sentinel node involvement too. The Stanford nomogram and the micrometastatic nomogram were the predictive tools identifying a small group of patients with low probability of further axillary involvement that might not require completion axillary lymph node dissection. Our data also suggest that the Tenon score can separate subsets of patients with a low and a higher risk of non-sentinel node metastasis. Predictive tools based on multivariate models can help in omitting completion axillary dissection in patients with low risk of non-sentinel lymph node metastasis based on their small tumor size.

Predicting non-sentinel lymph node status after positive sentinel biopsy in breast cancer: what model performs the best in a Czech population?

Several models have previously been proposed to predict the probability of non-sentinel lymph node (NSLN) metastases after a positive sentinel lymph node (SLN) biopsy in breast cancer. The aim of this study was to assess the accuracy of two previously published nomograms (MSKCC, Stanford) and to develop an alternative model with the best predictive accuracy in a Czech population. In the basic population of 330 SLN-positive patients from the Czech Republic, the accuracy of the MSKCC and the Stanford nomograms was tested by the area under the receiver operating characteristics curve (AUC). A new model (MOU nomogram) was proposed according to the results of multivariate analysis of relevant clinicopathologic variables. The new model was validated in an independent test population from Hungary (383 patients). In the basic population, six of 27 patients with isolated tumor cells (ITC) in the SLN harbored additional NSLN metastases. The AUCs of the MSKCC and Stanford nomograms were 0.68 and 0.66, respectively; for the MOU nomogram it reached 0.76. In the test population, the AUC of the MOU nomogram was similar to that of the basic population (0.74). The presence of only ITC in SLN does not preclude further nodal involvement. Additional variables are beneficial when considering the probability of NSLN metastases. In the basic population, the previously published nomograms (MSKCC and Stanford) showed only limited accuracy. The developed MOU nomogram proved more suitable for the basic population, such as for another independent population from a mid-European country.

[Sentinel lymph node biopsy for in situ carcinoma of the breast. Experience at the Bács-Kiskun County Hospital and review of the literature]. / Orszemnyirokcsomó-biopszia in situ emlorákban. A Bács-Kiskun Megyei Onkormányzat Kórházának tapasztalatai és irodalmi összefoglalás.

UNLABELLED: Sentinel node biopsy (SNB) is controversial for in situ breast cancers. We reviewed our experience with in situ and microinvasive carcinomas and surveyed the literature. METHODS: SNB was performed with intraparenchymal administration of vital dye alone or combined with radiocolloid. The SNs were assessed histologically with haematoxylin eosin staining and cytokeratin immunohistochemistry. RESULTS: Patients with in situ (36) or microinvasive (20) carcinomas underwent SNB: 59 axillary and 1 parasternal, and 39 axillary and 1 parasternal SNs were recovered, respectively. The SNs were positive in 4 patients and 1 patient, respectively: 1 micrometastasis and 3 isolated tumour cells, and 1 micrometastasis in the respective groups. No further axillary nodes were found positive after dissection. Further 21 invasive carcinomas (often with extensive intraductal component) had an in situ carcinoma diagnosis preoperatively: of 39 axillary and 3 parasternal SNs 10 patients had nodal involvement in 13 axillary SNs; 5 patients also had further lymph nodes involved after dissection. CONCLUSIONS: The definitive diagnosis of in situ carcinoma does not warrant SNB. This procedure should be considered if the tumour is to be removed by mastectomy, or if the diagnosis is preoperative and there are associated high-risk factors for the subsequent diagnosis of invasive cancer.

[Early clinical experience with postoperative monitoring of a patient after laparoscopic splenectomy combined with spleen autotransplantation. A case report]. / Minimálisan invazív módszerrel végzett, lép autotranszplantált beteg posztoperatív követésére alkalmazott képalkotó eljárásokkal nyert kezdeti tapasztalataink. Esetismertetés.

We performed splenectomy combined with spleen autotransplantation after blunt abdominal trauma by minimally invasive technique at the County Teaching Hospital in Kecskemét. In case of advanced post traumatic spleen injury, spleen autotransplantation (Furka's spleen chips) is a well-known method to try to avoid postsplenectomy syndrome. During the operation, when in situ preservation of the spleen is not possible, chips of spleen tissue are transplanted into the omentum. Function of the transplanted spleen tissue was monitored by scintigraphy. We describe two different types of spleen scintigraphy to check the viability of spleen chips.

Use and limitations of a nomogram predicting the likelihood of non-sentinel node involvement after a positive sentinel node biopsy in breast cancer patients.

After a positive sentinel lymph node (SLN) biopsy, some patients may be considered to have a very low risk of non-SLN involvement and could be candidates for axillary sparing. The aim of this study was to validate the nomogram created at the Memorial Sloan-Kettering Cancer Center (MSKCC) for the prediction of non-SLN involvement in an independent set of 140 patients with both positive SLNs and axillary dissection. The predicted proportions of positive non-SLNs were compared with the observed percentages of non-SLN metastasis. Although the SLN metastasis size and tumor size did influence the risk of non-SLN involvement, the correlation between the predicted and observed proportions was weaker for our patients (R: 0.84) than for the patients assessed at the MSKCC (R: 0.97). Differences were noted in the intraoperative assessment and in the final histology of the SLNs (imprints vs frozen sections and more detailed vs less detailed, respectively), and these could partly explain the lower level of the correlation. The nomogram could not be validated and was found to be of only limited use for the prediction of non-SLN involvement in patients operated on under similar, though not fully identical conditions. We therefore warn against the unvalidated use of this prediction tool.

Axillary sentinel node and tumour-related factors associated with non-sentinel node involvement in breast cancer.

BACKGROUND: After completion of axillary dissection, many breast cancer patients with axillary sentinel nodal involvement are found to have regional disease limited to the sentinel nodes. These patients are exposed to the morbidity of axillary clearance without any expected therapeutic benefit. METHODS: Sentinel node biopsy was performed either with Patent blue dye or with a combined dye, radiocolloid and gamma-probe-guided method involving peritumoral tracer administration. For a series of 150 consecutive patients with involved axillary sentinel nodes and axillary dissection, factors associated with non-sentinel nodal involvement were analysed in a multivariate analysis based on logistic regression with the use of fractional polynomials. RESULTS: The following variables were found to be potentially associated with non-sentinel node metastases: tumour size, sentinel node metastasis size, number of examined sentinel nodes, percentage of involved sentinel nodes (the latter two were found to be significant only when in combination), and extracapsular perinodal spread. CONCLUSIONS: Isolated tumour cells and micrometastases in axillary sentinel nodes carry a low risk of non-sentinel node metastasis. The risk of metastasis to further echelon nodes is higher with macrometastases, especially if there is extracapsular growth and the proportion of involved sentinel nodes is high.

Comparison of vital dye-guided lymphatic mapping and dye plus gamma probe-guided sentinel node biopsy in breast cancer.

The optimal technique for sentinel lymph node biopsy (SLNB) is still debated. SLNB with peritumoral injection of Patent blue dye was performed in 129 clinically T1-T2 and N0 breast cancers in 127 patients (group A); it was later replaced by combined dye and radiocolloid-guided SLNB preceded by lymphoscintigraphy in 72 breast cancer patients (group B). This study compares these two methods. All patients underwent completion axillary dissection. Means of 1.4 and 1.3 SLNs were identified in groups A and B, respectively. The mean number of non-SLNs for the whole series was 14.9 (range 5-42). The first 53 cases of lymphatic mapping (dye only) comprised the institutional learning period during which the identification rate of at least 1 SLN in 30 consecutive attempts reached 90%. The identification rate for the subsequent 76 group A patients was 92%. The accuracy rate of SLNBs for overall axillary nodal status prediction and the false-negative rate for group A patients (after excluding the learning-phase cases) were 93% and 10%, respectively. All 72 group B cases had at least one SLN identified, and only one false-negative case occurred in this group (accuracy and false-negative rates of 99% and 3%, respectively). Both the dye-only and the combined SLNB methods are suitable for SLN identification, but the latter works better and results in higher accuracy, a higher negative predictive value, and a lower false-negative rate. It is therefore the method of choice.

[Sentinel node biopsy for breast cancer patients at the Bács-Kiskun County Teaching Hospital]. / Emlórákos betegek axillaris órszem nyirokcsomó biopsiájának gyakorlata a Bács-Kiskun Megyei Onkormányzat Kórházában.

INTRODUCTION: The optimal technique of sentinel node biopsy (SNB) is still debated. AIMS: To compare two methods of SNB, describe the learning phase, the validation of the methods and the first results after implementing SNB as standard of care in selected breast cancer patients. PATIENTS AND METHODS: SNB with peritumoral or intratumoral injection of Patent blue dye only was performed in 129 clinically T1-T2 and N0 breast cancers in 127 patients (Group A); it was later replaced by combined dye and radiocolloid-guided SNB preceded by lymphoscintigraphy in 72 breast cancer patients (Group B). All patients underwent completion axillary dissection. Group C, to date, comprises 50 patients, in whom axillary dissection was performed on the basis of the SNB. Intraoperative imprint cytology was performed, and whenever positive, the axillary dissection was completed in the same step, whereas in cases of negative cytology findings but positive final histology, the dissection was done as a second operation. Histopathological assessment of SNs involved step sectioning and immunohistochemistry. RESULTS: Means of 1.4 and 1.3 SNs were identified in Groups A and B, respectively. The mean number of non-SNs for the whole series was 14.7 (range 5-42). The first 53 cases of lymphatic mapping with patent blue dye comprised the institutional learning period, during which the identification rate of at least 1 SN in 30 consecutive attempts reached 90%. The identification rate for the subsequent 76 Group A patients was 92%. The accuracy of SNB for overall axillary nodal status prediction and the false-negative rate for Group A patients (after exclusion of the learning-phase cases) were 93% and 10%, respectively. All 72 Group B cases had at least 1 SN identified, and only 1 false-negative case occurred in this group, i.e. the accuracy and false-negative rate were 99% and 3%, respectively. The identification rate in Group C was 98%; axillary dissection could be avoided in 25 patients, it was performed at the same time as the SNB in 15 and as a second operation in 10. Till now, no axillary recurrence was detected in Group C patients, although the follow-up period is short for the moment. CONCLUSIONS: The dye only and the radioguided SNB methods are complementary, their combination improves the performance, and can be the basis of performing axillary dissection on the basis of SNB results. After the technique of SNB has been validated in a given institution, it can become standard of care in a well selected group of patients, but requires a close follow up.