Feasibility and validation of the targeted axillary dissection technique in the axillary staging of breast cancer after neoadjuvant therapy: Definitive results.

AIM: to study the feasibility and value of "Targeted Axillary Dissection" (TAD) in cN1 breast cancer (BC) patients undergoing neoadjuvant chemotherapy (NACT), in order to avoid unnecessary axillary lymph node dissection (ALND). MATERIALS AND METHODS: Design: Prospective observational study. INCLUSION CRITERIA: Patients with histologically confirmed cN1 staging BC and treated with NACT between January 2016 and August 2019 who accomplished clinical response. METHOD: Fine-Needle Aspiration (FNA) positive axillary nodes were marked with a metallic clip prior to neoadjuvant treatment. All patients were summited to TAD and ALND. Analysis of data: We performed [1]: a feasibility analysis of clinical, radiological and pathological variables, as well as difficulties and complications of the TAD [2]; a diagnostic test study of the sentinel lymph node biopsy (SLNB), clipped lymph node biopsy (BCLIP) and their combination (TAD), using ALND as the Gold Standard. RESULTS: 60 patients were included. 43 patients (71.7%) had a complete clinical lymph node response to NACT. Neither limitations nor complications in clip placement were found. Intraoperative location of the clipped node was problematic in 7 cases (11.7%). The pathological complete response rate (pCR) was 30.5% (18 patients) and ypN0 staging rate was 38.3% (23 patients). Sensitivity values of each technique were: SLNB: 80.9% (95%CI: 61.8-100); BCLIP: 80.8% (95%CI: 63.7-97.8); TAD: 92.6% (95%CI: 80.9-100) with negative predictive values of: SLNB: 84.6% (95%CI: 68.8-100); BCLIP: 81.0% (95%CI: 63.7-97.8); TAD: 91.3% (95%CI: 77.6-100). CONCLUSION: TAD is feasible and valid to rule out axillary metastatic involvement in cN1 breast cancer patients who respond to NACT.

Development of a predictive score of axillary lymph node dissection based on targeted axillary dissection in patients with breast cancer diagnosis, affected lymph nodes, and neoadjuvant treatment.

AIM: To determine predictive factors of axillary lymph node dissection (ALND) results in breast cancer (BC) patients undergoing neoadjuvant chemotherapy (NACT), and subsequent staging using Targeted Axillary Dissection (TAD). MATERIAL AND METHOD: Case-control study between January 2016 and August 2019. Patients with BC, cN1 staging, marked with a metallic clip prior to NACT, and subsequently staged with TAD and ALND were included. They were divided into 2 groups: ALND patients with or without metastatic involvement (group 1 and group 2, respectively). We carried out a univariate analysis comparing clinical, radiological, surgical and pathological variables, and a logistic regression, (dependent variable: positive result of ALND; independent variables: number of suspicious lymph nodes in diagnostic ultrasound, positive hormone receptors, HER2 positive, complete clinical-radiological response to NACT, positive TAD, and biopsy of ≤2 nodes in TAD). A score for prediction of a metastatic ALND was proposed, with an internal validation study. RESULTS: 60 patients were included: Group 1: 33 (55.0%); Group 2: 27 (45.0%). Tumor size (Odds Ratio (OR) = 1.67; 95%CI 1.02-2.74), number of suspected nodes in ultrasound (OR = 2.20; 95%CI 1.01-4, 77), HER2 positive (OR 0.04; 95%CI 0.003-0.54), clinical-radiological response to NACT (OR = 0.07; 95%CI 0.01-0.75), and positive TAD (OR 15.48; 95%CI 1.68-142.78) were independent predictors of a positive result in ALND. We developed a "positive ALND predictive score", with good calibration (Hosmer-Lemeshow test: p = 0.65), and discrimination (AUC = 0.93; 95% CI 0, 87-0.99), with highest Youden index (0.7) at cut-off point of 17% risk of positive ALND (sensitivity = 100%; specificity = 70%). CONCLUSION: Tumor size, number of suspected nodes, positive HER2, response to NACT, and metastatic TAD are independent predictors of ALND. The predictive score for positive ALND would be a good indicator to safely omit ALND.

El problema de la estadificación axilar en el cáncer de mama tras quimioterapia neoadyuvante. Papel de la disección axilar dirigida y tipos de marcadores ganglionares / The problem of axillary staging in breast cancer after neoadjuvant chemotherapy. Role of targeted axillary dissection and types of lymph node markers

La disección axilar dirigida (DAD) consiste en una nueva técnica de estadificación axilar que combina la biopsia selectiva del ganglio centinela (BSGC) y la biopsia del ganglio marcado con clip (BCLIP) en la misma cirugía, para reestadificar a las pacientes con cáncer de mama con ganglios axilares positivos tratadas mediante quimioterapia neoadyuvante (QTNA). Para su realización, previo a la QTNA, se punciona el ganglio metastásico de manera ecoguiada y se deja un marcador en su interior, para biopsiarlo de manera dirigida en la cirugía posterior. Existen numerosos marcadores: desde clips de acero, titanio o ácido poliglicólico hasta semillas de radioyodo o ferromagnéticas, que difieren en su método de localización y recuperación (arpón, sonda de detección gamma, o sonda magnética). El objetivo de este trabajo es realizar una revisión sistemática del estado actual de la DAD, así como explicar las diferentes técnicas y tipos de marcaje axilar, con base en la evidencia disponible

Targeted axillary dissection (TAD) consists of a new axillary staging technique that combines sentinel lymph node biopsy (SLNB) and clipped lymph node biopsy (CLNB) in the same surgery, in order to re-stage patients with breast cancer and positive axillary lymph nodes undergoing neoadjuvant chemotherapy (NAQT). Prior to the NAQT, the affected lymph node is punctured and a solid marker is left inside echo-guided, in order to biopsy it in the subsequent surgery. There are numerous types of markers: metallic (steel, titanium or polyglycolic acid clips), radioiodine or ferromagnetic seeds, which differ in the method of location (wire, gamma-detection or magnetic probe). The aim of this study is to perform a systematic review about the current status of the TAD, as well as to explain the different techniques and types of axillary marking, based on the current available evidence

The problem of axillary staging in breast cancer after neoadjuvant chemotherapy. Role of targeted axillary dissection and types of lymph node markers. / El problema de la estadificación axilar en el cáncer de mama tras quimioterapia neoadyuvante. Papel de la disección axilar dirigida y tipos de marcadores ganglionares.

Targeted axillary dissection (TAD) consists of a new axillary staging technique that combines sentinel lymph node biopsy (SLNB) and clipped lymph node biopsy (CLNB) in the same surgery, in order to re-stage patients with breast cancer and positive axillary lymph nodes undergoing neoadjuvant chemotherapy (NAQT). Prior to the NAQT, the affected lymph node is punctured and a solid marker is left inside echo-guided, in order to biopsy it in the subsequent surgery. There are numerous types of markers: metallic (steel, titanium or polyglycolic acid clips), radioiodine or ferromagnetic seeds, which differ in the method of location (wire, gamma-detection or magnetic probe). The aim of this study is to perform a systematic review about the current status of the TAD, as well as to explain the different techniques and types of axillary marking, based on the current available evidence.

Validation of the targeted axillary dissection technique in the axillary staging of breast cancer after neoadjuvant therapy: Preliminary results.

AIM: To study the feasibility and validity of ultrasound-guided pre-chemotherapy marking of metastatic axillary lymph nodes followed by targeted axillary dissection (TAD), in breast cancer patients undergoing neoadjuvant chemotherapy (NACT). MATERIAL AND METHOD: Prospective diagnostic test study conducted between January 2016 and March 2018. Patients with breast cancer and indication for NACT, cN1 or cN2 axillary staging, were included. A clip was placed in the affected lymph node prior to NACT. A sentinel lymph-node biopsy (SLNB) and a clipped lymph-node biopsy (BCLIP) were conducted, followed by axillary lymph node dissection (ALND). Location rate (LR) and negative predictive value (NPV) were evaluated, taking SLNB, BCLIP and their combination (TAD) as evaluated tests and metastatic involvement in the ALND specimen as the gold standard. RESULTS: Twenty-three patients were included in the study. Sentinel lymph node could only be detected in 19 cases (LR = 80.61%), whereas BCLIP was successful in 22 (LR = 95.65%). The sentinel lymph node coincided with the marked lymph node in 14 patients (60.9%). We found a NPV for the SLNB of 0.85 (95%CI: 0.61-1.0), whereas for TAD it was 1.00 (95%CI: 0.74-1.0). CONCLUSION: TAD is a feasible test for axillary restaging after NACT, with a higher success rate than SLNB.

Variables relacionadas con la diseminación metastásica axilar en el cáncer de mama con ganglio centinela positivo. Evaluación de modelos predictivos / Factors related to metastatic axillary disease in breast cancer patients with a positive sentinel lymph node. Evaluation of predictive models

Objetivos. Evaluar las variables relacionadas con la diseminación metastásica axilar e intentar validar los diferentes modelos predictivos creados hasta la fecha. Pacientes y método. Realizamos un estudio retrospectivo a lo largo de 10 años. Fueron incluidas todas las pacientes intervenidas de cáncer de mama en nuestro hospital con ganglio centinela positivo. Se recogieron 27 variables clínico/histológicas del tumor y se realizó un análisis uni/multivariante para valorar la relación con la presencia de metástasis en ganglios axilares no centinelas. Se aplicaron los modelos predictivos a nuestra población: MSKCC, Stanford, Tenon, Meretoja unicéntrico y Meretoja multicéntrico y se calculó para cada uno de ellos el área bajo la curva de característica operativa de receptor (ROC). Resultados. Las variables significativas con la diseminación metastásica axilar fueron el IMC, la macrometástasis en el ganglio centinela, la unifocalidad y la extensión extranodal. Ningún modelo predictivo pudo ser validado, pues todos presentan una capacidad discriminativa diagnóstica baja, con áreas bajo la curva menores de 0,7. Conclusiones. Los modelos predictivos de diseminación metastásica axilar en caso de ganglio centinela positivo por sí solos no permiten discriminar aquellas pacientes con afectación metastásica axilar en el ganglio no centinela (AU)

Objectives. To evaluate factors related to metastatic axillary disease and to validate and update the predictive models created to date for metastatic axillary disease. Patients and method. In this retrospective study, we included all patients with a positive sentinel lymph node biopsy who underwent breast cancer surgery in our hospital in the last 10 years. We obtained 27 clinical/histopathological variables for each patient and univariate and multivariate statistical analyses were performed to evaluate the relationship between these variables and the presence of metastases in non-sentinel axillary nodes. We applied the main published predictive models (MSKCC, Stanford, Tenon, Meretoja single-center and multicenter models) to our population. The area under the receiver operating characteristic curve was calculated for each of the models. Results. The variables significantly related to metastatic axillary disease were body mass index, macrometastases in the sentinel lymph node, single-focus, and extranodal spread. None of the predictive models was validated because all of them had low diagnostic discrimination, with areas below the curve lower than 0.7. Conclusions. Predictive models for metastatic axillary disease in patients with a positive sentinel lymph node have low diagnostic accuracy in identifying low risk patients (AU)

Neumomediastino asintomático tras extracción cordal / Asymptomatic Pneumomediastinum After Wisdom Tooth Extraction

No disponible

El análisis molecular intraoperatorio (one-step nucleic acid amplification) del ganglio centinela como alternativa al estudio histopatológico diferido en el cáncer de mama: análisis coste-beneficio / One-step nucleic acid amplification (OSNA) assay for sentinel lymph node metastases as an alternative to conventional postoperative histology in breast cancer: A cost-benefit analysis

Introducción: El análisis molecular intraoperatorio del ganglio centinela con el método one-step nucleic acid amplification (OSNA) es una técnica ya validada para la detección de metástasis ganglionares en el cáncer de mama. Los autores comparan el coste económico de este nuevo método frente al estudio histopatológico convencional diferido. Metodología Estudio retrospectivo de análisis coste-beneficio que incluyó a pacientes con cáncer de mama operable y axila clínica y ecográficamente negativa que fueron intervenidas desde el 15 de octubre de 2008 hasta el 15 de diciembre de 2009. El análisis del ganglio centinela se realizó en el Grupo 1 (45 pacientes) mediante estudio histopatológico convencional diferido, mientras que en el Grupo 2 (35 pacientes) se realizó según el método OSNA. Se analizaron las siguientes variables: edad, tamaño tumoral, tipo histológico, número de ganglios centinela, resultado de la biopsia, tiempo quirúrgico, días de hospitalización, complicaciones postoperatorias, ganglios positivos en caso de linfadenectomía axilar, coste por paciente, coste por hospitalización y coste por intervención. Resultados El tiempo quirúrgico de la primera intervención en el Grupo 1 fue significativamente menor, pero el tiempo total fue mayor en el Grupo 1. La estancia media fue mayor en el Grupo 1 (p<0,001). El coste medio de la estancia hospitalaria fue mayor en el Grupo 1 frente al Grupo 2 (p<0,001), con una diferencia de medias de 199,69 €. El coste medio de la intervención fue mayor en el Grupo 1(p<0,001), con una diferencia de medias de 157,49 €. El (..) (AU)

Introduction: Intraoperative molecular analysis for sentinel lymph node (SLN) metastasesusing the OSNA (one-step nucleic acid amplification) method has been already validated in breast cancer. The authors compared the cost of OSNA versus the conventional postoperative histopathologic evaluation in patients with breast cancer. Methodology: Patients with operable breast cancer and clinically and sonographic negative evaluation of the axilla, and who subsequently were operated on between the 15th of October 2008 and the 15th of December 2009 were included in this retrospective cost-benefit analysis. The SLN was assessed by conventional postoperative histological evaluation in Group 1 (45 patients), and by OSNA in Group 2 (35 patients). The following variables were analysed: age, tumour size, histological type, number of SLNs, biopsy result, duration of surgery, days in hospital, postoperative complications, positive lymph nodes in the case of axillary lymphadectomy, cost per patient, hospitalisation cost, and cost per operation. Results: The duration of surgery of the first operation in Group 1 was significantly shorter, but the total time was also higher in this group. The mean hospital stay was longer in Group1 (P < .001). The mean cost of the hospital stay was higher in Group 1 compared to Group 2(P < .001), with a mean difference of 199.69 s. The mean cost of the surgery was higher in Group 1 (P < .001), with a mean difference of 157.49 s. The mean cost per SLN analysis was significantly higher in Group 1, with a mean difference of 162.5 s. The cost per patient was significantly higher in Group 1 (P < .005). A mean saving of 439.67 s per patient was achieved by using the OSNA method. Conclusion: Intraoperative molecular analysis for SLN metastases using the OSNA method reduces the number of admission days, duration of surgery, and achieves a saving of439.67 s per patient (AU)

[One-step nucleic acid amplification (OSNA) assay for sentinel lymph node metastases as an alternative to conventional postoperative histology in breast cancer: A cost-benefit analysis]. / El análisis molecular intraoperatorio (one-step nucleic acid amplification) del ganglio centinela como alternativa al estudio histopatológico diferido en el cáncer de mama: análisis coste-beneficio.

INTRODUCTION: Intraoperative molecular analysis for sentinel lymph node (SLN) metastases using the OSNA (one-step nucleic acid amplification) method has been already validated in breast cancer. The authors compared the cost of OSNA versus the conventional postoperative histopathologic evaluation in patients with breast cancer. METHODOLOGY: Patients with operable breast cancer and clinically and sonographic negative evaluation of the axilla, and who subsequently were operated on between the 15th of October 2008 and the 15th of December 2009 were included in this retrospective cost-benefit analysis. The SLN was assessed by conventional postoperative histological evaluation in Group 1 (45 patients), and by OSNA in Group 2 (35 patients). The following variables were analysed: age, tumour size, histological type, number of SLNs, biopsy result, duration of surgery, days in hospital, postoperative complications, positive lymph nodes in the case of axillary lymphadectomy, cost per patient, hospitalisation cost, and cost per operation. RESULTS: The duration of surgery of the first operation in Group 1 was significantly shorter, but the total time was also higher in this group. The mean hospital stay was longer in Group 1 (P<.001). The mean cost of the hospital stay was higher in Group 1 compared to Group 2 (P<.001), with a mean difference of 199.69 €. The mean cost of the surgery was higher in Group 1 (P<.001), with a mean difference of 157.49 €. The mean cost per SLN analysis was significantly higher in Group 1, with a mean difference of 162.5 €. The cost per patient was significantly higher in Group 1 (P<.005). A mean saving of 439.67 € per patient was achieved by using the OSNA method. CONCLUSION: Intraoperative molecular analysis for SLN metastases using the OSNA method reduces the number of admission days, duration of surgery, and achieves a saving of 439.67 € per patient.

[Gastrointestinal stromal tumors. Diagnosis, prognosis and current surgical treatment. Follow-up of 18 treated patients]. / Tumores gástricos estromales. Diagnóstico, pronóstico y tratamiento quirúrgico actual. Seguimiento de 18 pacientes tratados.

INTRODUCTION: Gastrointestinal stromal tumors (GIST) are the most frequent mesenchymal tumors of the digestive tract and their growth is directed through the signaling of the KIT or PDFGRA genes. The objective of the present study was to describe a series of cases of GIST tumors located in the stomach. PATIENTS AND METHODS: We performed a retrospective, descriptive study of 18 patients diagnosed with gastric GIST and treated by means of gastric resection between July 1996 and June 2004. There were 12 women and six men, with a mean age of 63 years (range 33-84). In all patients, diagnosis was performed with immunohistochemical markers, such as CD34 and CD117. Investigations included endoscopy, abdominal ultrasonography, abdominal computerized axial tomography and fine-needle aspiration biopsy. RESULTS: The main symptoms were digestive hemorrhage with severe anemia in 10 patients and abdominal pain in seven. In two patients, the tumors were incidental findings during laparotomy. Four patients underwent emergency surgery and the remainder underwent elective surgery. In all patients, gastric resection of variable extension was performed, according to tumoral location. Multicentric tumors were found in two patients. All patients were CD117- and CD34-positive. There were few postoperative complications. One patient died from acute myocardial infarction (5.6%). The mean follow-up was 47.5 months (range, 12-106). One patent died due to spread of a pancreatic neoplasm and the remaining patients are alive and without tumoral recurrence (94.1%). CONCLUSIONS: Initial symptoms consist of upper gastrointestinal hemorrhage and abdominal pain. Gastroscopy and imaging techniques lead to a suspected diagnosis, which can be confirmed by immunohistochemical studies, in which the "gold standard" is positivity for CD117; CD34 (+), vimentin (+), actin (-) and protein S-100 (-) are also used. Treatment consists of tumoral resection with negative margins.

Tumores gástricos estromales. Diagnóstico, pronóstico y tratamiento quirúrgico actual. Seguimiento de 18 pacientes tratados / Gastrointestinal stromal tumors. Diagnosis, prognosis and current surgical treatment.Follow-up of 18 treated patients

Introducción. Los tumores gastrointestinales estromales (GIST) son los tumores de origen mesenquimal más frecuentes del tracto digestivo y su crecimiento está dirigido a través de la señalización de los genes KIT o PDFGRA. El objetivo del presente estudio es describir una serie de casos de tumores GIST localizados en el estómago. Pacientes y método. Estudio retrospectivo y descriptivo de 18 pacientes con GIST gástricos diagnosticados y tratados mediante resección gástrica entre julio de 1996 y junio de 2004, de los que 12 eran mujeres y 6 varones con una edad media de 63 años (rango, 33-84 años). En todos los casos, el diagnóstico se ha realizado con marcadores inmunohistoquímicos, como CD34 y CD117. Los estudios incluyeron endoscopia, ecografía abdominal, tomografía computarizada y punción-aspiración con aguja fina. Resultados. La clínica predominante fue hemorragia digestiva alta con anemia grave en 10 casos y dolor abdominal en 7. En 2 pacientes resultaron ser hallazgo casual en una laparotomía. Se intervino de urgencia 4 pacientes y electivamente el resto, realizándose siempre resección gástrica extensión de variable según la localización. Se apreció multicentricidad en 2 casos. Todos los casos fueron CD117 y CD34 positivos. Las complicaciones postoperatorias fueron bajas y 1 paciente falleció por infarto agudo de miocardio (5,6%). El seguimiento medio ha sido 47,5 meses (rango, 12-106) y se ha producido el fallecimiento de 1 paciente por una neoplasia avanzada de páncreas, mientras que el resto permanece vivo y sin recidiva (94,1%). Conclusiones. Los datos clínicos iniciales son la hemorragia digestiva alta y el dolor abdominal. La endoscopia y las técnicas de imagen hacen presumir el diagnóstico, que se confirma con estudios de inmunohistoquímica cuyo patrón de referencia es la positividad para CD117, utilizándose además CD34 (+), vimentina (+), actina (­) y proteína S-100 (­). El tratamiento implica la resección del tumor con bordes sanos (AU)

Introduction. Gastrointestinal stromal tumors (GIST) are the most frequent mesenchymal tumors of the digestive tract and their growth is directed through the signaling of the KIT or PDFGRA genes. The objective of the present study was to describe a series of cases of GIST tumors located in the stomach. Patients and methods. We performed a retrospective, descriptive study of 18 patients diagnosed with gastric GIST and treated by means of gastric resection between July 1996 and June 2004. There were 12 women and six men, with a mean age of 63 years (range 33-84). In all patients, diagnosis was performed with immunohistochemical markers, such as CD34 and CD117. Investigations included endoscopy, abdominal ultrasonography, abdominal computerized axial tomography and fine-needle aspiration biopsy. Results. The main symptoms were digestive hemorrhage with severe anemia in 10 patients and abdominal pain in seven. In two patients, the tumors were incidental findings during laparotomy. Four patients underwent emergency surgery and the remainder underwent elective surgery. In all patients, gastric resection of variable extension was performed, according to tumoral location. Multicentric tumors were found in two patients. All patients were CD117- and CD34-positive. There were few postoperative complications. One patient died from acute myocardial infarction (5.6%). The mean follow-up was 47.5 months (range, 12-106). One patent died due to spread of a pancreatic neoplasm and the remaining patients are alive and without tumoral recurrence (94.1%). Conclusions. Initial symptoms consist of upper gastrointestinal hemorrhage and abdominal pain. Gastroscopy and imaging techniques lead to a suspected diagnosis, which can be confirmed by immunohistochemical studies, in which the "gold standard" is positivity for CD117; CD34 (+), vimentin (+), actin (­) and protein S-100 (­) are also used. Treatment consists of tumoral resection with negative margins (AU)