Intraoperative frozen section of subareolar tissue in nipple-sparing mastectomy: Towards a less is more approach.

BACKGROUND: Nipple preservation contributes to aesthetic outcome and quality of life in women undergoing Skin-Sparing Mastectomy (SSM) with immediate breast reconstruction for the treatment of breast cancer. Intraoperative Frozen Section (IFS) has been advocated to facilitate conversion from Nipple-Sparing Mastectomy (NSM) to SSM in cases with positive subareolar margins. This study investigated the application of IFS at our comprehensive cancer centre. METHODS: In this single-centre retrospective study, for all patients who underwent therapeutic NSM with IFS from 2000 to 2021 pathological reports, patient- and tumour characteristics were retrieved. RESULTS: In total 640 women were included in whom 662 intended NSMs with IFS had been performed. Sensitivity and specificity of frozen section compared with definitive histopathology were 75.2% and 98.5% respectively. In six women with a false positive result, the nipple had been removed. In 16 out of 32 women with a false negative result, the nipple was excised in a second procedure. In total 115 nipples were resected. In 40% of these nipples, no residual disease was detected. DISCUSSION: IFS is a moderately sensitive and highly specific diagnostic tool to detect positive subareolar margins. An alternative approach is to omit frozen section but take intraoperative biopsies of the sub areolar margin, which are postoperatively analysed with definitive formalin-fixed paraffin-embedded histopathology. This allows for shared decision making regarding nipple excision in cases where minimal disease is found in subareolar tissue or cases with an indication for post-mastectomy radiotherapy.

Breast surgery after neoadjuvant chemotherapy in patients with lobular carcinoma: surgical and oncologic outcome.

INTRODUCTION: Breast cancer patients with invasive lobular carcinoma (ILC) have an increased risk of positive margins after surgery and often show little response to neoadjuvant chemotherapy (NAC). We aimed to investigate surgical outcomes in patients with ILC treated with NAC. METHODS: In this retrospective cohort study, all breast cancer patients with ILC treated with NAC who underwent surgery at the Netherlands Cancer Institute from 2010 to 2019 were selected. Patients with mixed type ILC in pre-NAC biopsies were excluded if the lobular component was not confirmed in the surgical specimen. Main outcomes were tumor-positive margins and re-excision rate. Associations between baseline characteristics and tumor-positive margins were assessed, as were complications, locoregional recurrence rate (LRR), recurrence-free survival (RFS), and overall survival (OS). RESULTS: We included 191 patients. After NAC, 107 (56%) patients had breast conserving surgery (BCS) and 84 (44%) patients underwent mastectomy. Tumor-positive margins were observed in 67 (35%) patients. Fifty five (51%) had BCS and 12 (14%) underwent mastectomy (p value < 0.001). Re-excision was performed in 35 (33%) patients with BCS and in 4 (5%) patients with mastectomy. Definitive surgery was mastectomy in 107 (56%) patients and BCS in 84 (44%) patients. Tumor-positive margins were associated with cT ≥ 3 status (OR 4.62, 95% CI 1.26-16.98, p value 0.021) in the BCS group. Five-year LRR (4.7%), RFS (81%), and OS (93%) were not affected by type of surgery after NAC. CONCLUSION: Although 33% of ILC breast cancer patients undergoing BCS after NAC required re-excision for positive resection margins, it is considered safe given that five-year RFS remained excellent and LRR and OS did not differ by extent of surgery.

The Safe Use of 125I-Seeds as a Localization Technique in Breast Cancer during Pregnancy.

INTRODUCTION: Some aspects of the treatment protocol for breast cancer during pregnancy (PrBC) have not been thoroughly studied. This study provides clarity regarding the safety of the use of 125I-seeds as a localization technique for breast-conserving surgery in patients with PrBC. METHODS: To calculate the exposure to the fetus of one 125I-seed implanted in a breast tumor, we developed a model accounting for the decaying 125I-source, time to surgery, and the declining distance between the 125I-seed and the fetus. The primary outcome was the maximum cumulative fetal dose of radiation at consecutive gestational ages (GA). RESULTS: The cumulative fetal dose remains below 1 mSv if a single 125I-seed is implanted at a GA of 26 weeks. After a GA of 26 weeks, the fetal dose can be at a maximum of 11.6 mSv. If surgery takes place within two weeks of implantation from a GA of 26 weeks, and one week above a GA of 32 weeks, the dose remains below 1 mSv. CONCLUSION: The use of 125I-seeds is safe in PrBC. The maximum fetal exposure remains well below the threshold of 100 mSv, and therefore, does not lead to an increased risk of fetal tissue damage. Still, we propose keeping the fetal dose as low as possible, preferably below 1 mSv.

Incidence of PSMA PET thyroid incidentaloma depends on analysis method and tracer.

OBJECTIVE: To investigate the incidences of prostate-specific membrane antigen (PSMA) thyroid incidentaloma (PTI) using different methods to define PTI, to compare the incidence of PTI among different PSMA PET tracers, and to evaluate the clinical consequences of PTI. METHODS: PSMA PET/CT scans in consecutive patients with primary prostate cancer were analyzed for the presence of PTI using a structured visual (SV) analysis reporting any elevated thyroidal uptake; a semi-quantitative (SQ) analysis using a SUVmax thyroid/bloodpool (t/b) ratio ≥ 2.0 as cutoff; and an analysis of PTI incidence in the clinical reports (RV analysis). RESULTS: A total of 502 patients were included. The incidence of PTIs was 22% in the SV analysis, 7% in the SQ analysis, and 2% in the RV analysis. PTI incidences differed significantly from 29 to 64% (SQ, resp. SV analysis) for [18F]PSMA-1007, 7 to 23% for [68Ga]PSMA-11, 2 to 8% for [18F]DCFPyL, and to 0% for [18F]PSMA-JK-7. The majority of PTI in the SV and SQ analyses consisted of diffuse (72-83%) and/or only slightly elevated thyroidal uptake (70%). Inter-observer agreement in the SV analysis was substantial (kappa = 0.76-0.78). During follow-up (median 16.8 months), there were no thyroid-related adverse events except in three patients. CONCLUSIONS: The incidence of PTI varies greatly among different PSMA PET tracers and is strongly dependent on the analysis method applied. PTI may safely be restricted to focal thyroidal uptake with a SUVmax t/b ratio ≥ 2.0. The clinical pursuit of a PTI must be weighed up to the expected outcome of the underlying disease. KEY POINTS: • Thyroid incidentalomas (PTIs) are recognized in PSMA PET/CT. • Incidence of PTI varies greatly among PET tracers and analysis methods. • Incidence of thyroid-related adverse events in PTI cases is low.

The co-occurrence of both breast- and differentiated thyroid cancer: incidence, association and clinical implications for daily practice.

BACKGROUND: Breast cancer (BC) and differentiated thyroid cancer (TC) are two common cancer types with the highest incidence in women. BC and TC can develop synchronous or metachronous and the occurrence of both is higher than expected by chance. This study aimed to examine the association between BC and TC in the Netherlands. METHODS: This is a retrospective cohort study during the period of 1989-2020 retrieved from the Netherlands Cancer Registry (NCR). Patients diagnosed with BC-TC and BC alone as control group and TC-BC and TC alone as control group were included. The primary outcome was the standardized incidence ratio (SIR) of BC-TC and TC-BC. Secondary outcomes included data on the demographics, type of malignancy, treatment and overall survival (OS). RESULTS: The incidence of TC among 318.002 women with BC (BC-TC) was 0.1% (423 patients) (SIR = 1.86 (95% CI: 1.40-2.32)) and the incidence of BC among 12,370 patients with TC (TC-BC) was 2.9% (355 patients) (SIR = 1.46 (95% CI: 1.09-1.83)). BC-TC patients were younger compared to the BC alone group at BC diagnosis (55 vs 60 years, p < 0.001). The age-adjusted odds ratio to develop TC was not significantly increased for patients who received chemotherapy and radiotherapy. Most TC cases were synchronous tumors after BC diagnosis (19%) with a TNM stage 1. Only 6% of the BC tumors after TC occurred synchronous with a TNM stage 1 in most cases. The OS of all groups was the most favorable in patients with both BC and TC compared to BC- and TC alone. CONCLUSION AND RELEVANCE: The SIR of TC after BC diagnosis and BC after TC diagnosis was higher than predicted based on the rates of the general population. TC and BC as second primary tumors were diagnosed in an early stage and did not affect overall survival. Therefore, Dutch women who have been treated for BC or TC require no special surveillance for their thyroid- and breast gland.

Retrospective analysis of PSMA PET/CT thyroid incidental uptake in adults: incidence, diagnosis, and treatment/outcome in a tertiary cancer referral center and University Medical Center.

PURPOSE: A prostate-specific membrane antigen (PSMA) thyroid incidentaloma (PTI) is an unexpected, PSMA-avid thyroid lesion, newly detected during the investigation of an unrelated condition using PSMA PET/CT. The aim of this study is to examine the incidence and clinical significance of PTI and the associated management strategies since the implementation of the PSMA PET/CT scan. METHODS: This study involves a retrospective cohort study of 61 PTI cases depicted on PSMA PET/CT scans performed between January 2016 and July 2021, almost exclusively for (re)staging prostate cancer. The medical records of the included cases were retrospectively reviewed and data of the PSMA PET/CT scans, primary malignancy, thyroid diagnostics, treatment, and follow-up were collected. RESULTS: PTI was reported in 1.1% of the patients who underwent oncologic PSMA PET/CT scans included in this study. Two PTI cases had a histologically proven thyroid cancer: one a benign thyroid lesion and one a metastasis of a renal cell carcinoma. In none of the cases in whom any form of further thyroid workup was withheld, the PTI became clinically relevant during follow-up (median 1.8 years (1.1-3.3)). Six patients (10%) died due to their primary cancer. CONCLUSION: The incidence of thyroid incidentalomas on PSMA PET/CT was low (1.1%) in this large, two-center experience. Less than half of the PTI cases were analyzed and the risk of malignancy, despite being low, was not negligible. The clinical outcome was good using a standard diagnostic workup for PTI, while the prognosis of the patient was determined by the primary malignancy. The consideration to analyze and treat PTI cases should be part of the shared decision-making in cancer patients.

Retrospective Analyses of 18FDG-PET/CT Thyroid Incidentaloma in Adults: Incidence, Treatment, and Outcome in a Tertiary Cancer Referral Center.

Background: A thyroid incidentaloma (TI) is an unexpected, asymptomatic thyroid lesion discovered during the investigation of an unrelated condition. The aim of the present study is to examine the incidence of 18Fluorodeoxyglucose (FDG)-positron emission tomography (PET) TI, the associated management strategies and the outcomes in a tertiary cancer referral center. Methods: This study involves a retrospective cohort study of 1003 patients with TI found on 18FDG-PET/CT scans performed between January 2010 and January 2020 for a nonthyroidal malignancy. The Kaplan-Meier method was used for survival analyses in patients concerning an underlying malignancy, with a prevalence of 5% or higher in this cohort. Logistic- and cox regression analyses were performed to analyze predictors of thyroid malignancy and mortality. A propensity score weighted method was used to control for baseline differences between the intervention (additional TI diagnostics) and control (no TI diagnostics) group. Results: FDG-positive TI occurred in 1.9% (1003/52,693) of the oncologic 18FDG-PET/CT scans performed in our center. Thyroid surgery was performed in 47 patients (6%) and a thyroid malignancy was detected in 31 of them, which is 66% of those who had an operation and 4% of all patients. During the follow-up (median 6 years), 334 deaths (42%) related to different types of cancer (38%) or other causes (4%) were observed. One patient died from medullary thyroid cancer. In multivariate analysis adjusted for age, gender and the type- and stage of nonthyroidal malignancy, were independent predictors of survival (P < .05). Conclusions: The incidence of TI in this tertiary cancer referral center was comparable to current literature. Further thyroid workup was performed in less than half of the patients, and only a minority of patients underwent thyroid surgery. Since only one patient died from thyroid cancer, the strategy to withhold from thyroid diagnostics and treatment seems valid for most TI. Active thyroid treatment might benefit a subgroup of patients in whom the primary nonthyroidal malignancy is successfully treated or presumably stable. A wait-and-see policy with ultrasound follow-up could be an alternative strategy. These considerations should be part of the shared decision making in cancer patients with a TI.

The Effect of Radioactive Iodine Therapy on Ovarian Function and Fertility in Female Thyroid Cancer Patients: A Systematic Review and Meta-Analysis.

Introduction: Thyroid cancer is one of the most common carcinomas diagnosed in adolescents and young adults, with a rapidly rising incidence for the past three decades. Surgery is the standard treatment for patients with differentiated thyroid carcinoma (DTC), and when indicated, followed by radioactive iodine (RAI) treatment. The aim of this study was to evaluate the possible effects of RAI therapy on ovarian function and fertility in women. Methods: The PubMed, Embase, and Web of Science databases were systematically searched up to January 2020. In addition, a meta-analyses were performed for anti-Mullerian hormone (AMH) levels after RAI, comparison of AMH levels prior and 1 year after RAI, and pregnancy rates in patient with thyroid cancer receiving RAI compared with patients with thyroid cancer who did not receive RAI. Results: A total of 36 studies were eligible for full-text screening and 22 studies were included. The majority of the studies had a retrospective design. Menstrual irregularities were present in the first year after RAI in 12% and up to 31% of the patients. Approximately 8-16% of the patients experienced amenorrhea in the first year after RAI. Women who received RAI treatment (median dose 3700 MBq [range 1110-40,700 MBq]); had menopause at a slightly younger age compared with women who did not receive RAI treatment, 49.5 and 51 years, respectively (p < 0.001). Pooled AMH of the seven studies reporting AMH concentrations after RAI was 1.79 ng/mL. Of these, four studies reported AMH concentrations prior and 1 year after RAI. The mean difference was 1.50 ng/mL, which was significant. Finally, meta-analysis showed that patients undergoing RAI were not at a decreased risk of becoming pregnant. Conclusions: Most of the studies indicate that RAI therapy for DTC is not associated with a long-term decrease in pregnancy rates although meta-analyses show a significant decrease in AMH levels after RAI therapy. Prospective studies are needed to confirm these results. We recommend counseling patients about the possible effects of 131I and incorporate today's knowledge in multidisciplinary counseling.

Internal Mammary Chain Sentinel Nodes in Early-Stage Breast Cancer Patients: Toward Selective Removal.

BACKGROUND: Removal of internal mammary chain sentinel nodes (IMCSNs) affects prognosis and treatment of breast cancer, and internal mammary chain radiotherapy (IMCRT) can improve survival for selected patients. This study aimed to determine the effect of IMCSN biopsy on recurrence-free survival (RFS) and overall survival (OS) and to identify predictive factors for IMCSN and distant metastasis. METHODS: Patients with IMCSNs were selected from a prospective database for the period 1999-2007. Lymphoscintigraphy was performed after intratumoral technetium-99 m injection, and all sentinel nodes were removed. Both RFS and OS were calculated for subgroups with tumor-positive, tumor-negative, or non-removed IMCSNs. Predictive factors were identified for tumor-positive IMCSNs and distant metastasis by regression analysis. RESULTS: For 287 (85%) of 336 patients, IMCSN biopsy was performed, and metastasis was detected in 38 patients (13%). The patients with tumor-positive IMCSNs had poorer OS than the patients with no IMCSN metastasis or non-removed IMCSNs (p = 0.002). These patients also had worse RFS due to distant metastasis (p = 0.002). Axillary metastasis was predictive for tumor-positive IMCSNs (positive predictive value, 38.5%). The predictive factors for distant metastasis were tumor-positive IMCSNs (hazard ratio [HR], 2.5), non-removed IMCSNs (HR, 2.3), tumor diameter greater than 1.5 cm (HR, 3.5), and age older than 65 years (HR, 3.1; reference, < 50 years). CONCLUSIONS: Patients with IMCSNs have worse survival due to distant metastasis. The clinically relevant predictive factor for distant metastasis is tumor larger than 1.5 cm. According to the authors' current protocol, IMCSN biopsy is performed for patients younger than 70 years who have a tumor larger than 1.5 cm, with the cardiotoxicity of the adjuvant IMCRT weighed against the survival benefit.

Blue dye can be safely omitted in most sentinel node procedures for melanoma.

Sentinel node biopsy is a widely used staging procedure in melanoma. It is usually performed using the triple technique: lymphatic mapping after injection of a radiopharmaceutical, blue dye injection, and the use of a gamma probe. Blue dye offers visual confirmation of the location of the sentinel lymph node (SN). There are some disadvantages such as blurring of the surgical field, skin coloring, and possible anaphylactic reactions. We aimed to answer the question whether patent blue is truly necessary for correct intraoperative identification of the SN. One day preoperatively, lymphoscintigraphy (with or without single-photon emission computed tomography with integrated computed tomography) is performed and the location of the SN is marked on the skin. Perioperatively, patent blue is injected around the tumor. A handheld gamma-ray detection probe is used to determine the location of the incision and detect the SN during the operation. SNs are pursued in all regions indicated by imaging. In only six of the 681 patients (0.9%) a blue, not radioactive, sentinel node was removed. In one of them (0.15%), this was the only node excised. None of these lymph nodes harbored metastases. This study suggests that blue dye has no additional value in finding the sentinel node and is of low significance in detecting metastases. Therefore, blue dye can be safely omitted from the standardized triple technique. It may be useful in selected cases according to the surgeon's discretion.

Five-year follow-up of 16 melanoma patients with a Starz I-involved sentinel node in whom completion lymph node dissection was omitted.

The aim of the study was to determine the incidence of lymph node recurrence in 16 melanoma patients with a minimal metastasis (Starz level I) in a sentinel node in whom a completion lymph node dissection was omitted. A secondary aim was to examine whether other melanoma-related recurrences developed. Sixteen melanoma patients with an SI-involved sentinel node, who did not undergo completion lymph node dissection, were followed for a median of 66 months. Lymph node recurrences did not occur. One of the 16 patients developed a local recurrence and another developed satellite metastases. None of the 16 patients with an SI-positive sentinel node developed a nodal recurrence, which suggests that the risk of refraining from node dissection in such patients is small. This option could be considered and discussed with the patient in terms of the risk of nonsentinel node involvement and the unsolved problem of unknown overall survival advantage.

Prognosis in patients with sentinel node-positive melanoma is accurately defined by the combined Rotterdam tumor load and Dewar topography criteria.

PURPOSE: Prognosis in patients with sentinel node (SN)-positive melanoma correlates with several characteristics of the metastases in the SN such as size and site. These factors reflect biologic behavior and may separate out patients who may or may not need additional locoregional and/or systemic therapy. PATIENTS AND METHODS: Between 1993 and 2008, 1,080 patients (509 women and 571 men) were diagnosed with tumor burden in the SN in nine European Organisation for Research and Treatment of Cancer (EORTC) melanoma group centers. In total, 1,009 patients (93%) underwent completion lymph node dissection (CLND). Median Breslow thickness was 3.00 mm. The median follow-up time was 37 months. Tumor load and tumor site were reclassified in all nodes by the Rotterdam criteria for size and in 88% by the Dewar criteria for topography. RESULTS: Patients with submicrometastases (< 0.1 mm in diameter) were shown to have an estimated 5-year overall survival rate of 91% and a low nonsentinel node (NSN) positivity rate of 9%. This is comparable to the rate in SN-negative patients. The strongest predictive parameter for NSN positivity and prognostic parameter for survival was the Rotterdam-Dewar Combined (RDC) criteria. Patients with submicrometastases that were present in the subcapsular area only, had an NSN positivity rate of 2% and an estimated 5- and 10-year melanoma-specific survival (MSS) of 95%. CONCLUSION: Patients with metastases < 0.1 mm, especially when present in the subcapsular area only, may be overtreated by a routine CLND and have an MSS that is indistinguishable from that of SN-negative patients. Thus the RDC criteria provide a rational basis for decision making in the absence of conclusions provided by randomized controlled trials.

SPECT/CT for sentinel lymph node mapping in head and neck melanoma.

BACKGROUND: The additional value of single photon emission computed tomography with CT (SPECT/CT) for detection and localization of sentinel nodes in patients with a melanoma of the head and neck was determined. METHODS: Thirty-eight patients received conventional lymphoscintigraphy followed by hybrid SPECT/CT. The number of sentinel nodes visualized and anatomic information provided were analyzed. Changes in surgical approach due to additional information from the SPECT/CT were evaluated in 20 patients. RESULTS: SPECT/CT visualized a mean of 2.6 sentinel nodes per patient (range, 1-6). SPECT/CT depicted an additional sentinel node in 16% of the patients and clearly showed the anatomic location of the hot nodes in all patients. The surgical approach was adjusted on the basis of SPECT/CT images in 11 patients (55%). CONCLUSION: SPECT/CT visualizes more sentinel nodes than conventional images and shows their anatomic location. SPECT/CT is recommended in patients with a melanoma in the head or neck.

Lymphatic drainage patterns from the treated breast.

INTRODUCTION: Lymphatic drainage patterns from the breast have been described in the past. Drainage may change after treatment of a breast or axilla, and this may have implications for lymphatic mapping. The aim of this study was to determine the lymphatic drainage patterns in breast cancer patients with a previously treated ipsilateral breast. METHODS: Between January 1999 and November 2008, 115 sentinel node procedures were performed in breast cancer patients who had undergone treatment of the ipsilateral breast in the past. Lymphatic drainage patterns were analyzed based on preoperative lymphoscintigraphy and sentinel lymph node biopsy. Patients were divided into subgroups according to their previous treatment. RESULTS: Sentinel nodes were found in 84% of the patients: in 81 patients (70%) in the axilla, 43 patients (37%) had drainage to more than one site, and in 18 patients (16%) no drainage was detected. The percentage of drainage outside the axilla was higher than in a series of untreated breast cancer patients from our institution (51% versus 33%, P = 0.01). The 16% nonidentification rate was also higher than the 3.1% in patients without previous treatment (P = 0.003). Four patients (3.5%) had lymphatic drainage to the contralateral axilla. Twelve patients (10%) had involved sentinel nodes; these were harvested from the contralateral axilla in two of them. No lymph node recurrences were observed during a median follow-up time of 39 months. CONCLUSION: Lymphatic mapping yields a lymph node in 84% of breast cancer patients who have undergone previous treatment of the breast. Nonidentification and extra-axillary nodes are more frequently encountered than in patients without treatment of the breast in the past. The finding of involved nodes suggests that sentinel node biopsy improves staging. Long-term follow-up will determine the sensitivity of the procedure in this specific situation.

SPECT/CT for preoperative sentinel node localization.

The value of SPECT/CT for detection and localization of sentinel nodes is reviewed. SPECT/CT depicts extra sentinel nodes and identifies non-nodal tracer accumulation. SPECT/CT is indicated in patients with complex lymphatic drainage as often present in patients with head, neck and scapular melanoma, breast cancer patients with extra-axillary sentinel nodes and patients with tumors draining to pelvic nodes. SPECT/CT also clarifies the drainage pattern of inconclusive conventional images (non-visualization or unclear location of the nodes).

Reevaluation of the locoregional recurrence rate in melanoma patients with a positive sentinel node compared to patients with palpable nodal involvement.

BACKGROUND: The main aims of this study were to evaluate the occurrence of the various forms of locoregional recurrence in sentinel node-positive melanoma patients, to determine whether the different definitions that are being used to describe in-transit metastases influence this rate, and to identify factors associated with locoregional recurrence. A comparison was made with the rate of locoregional recurrence in patients who underwent lymph node dissection for palpable metastases. METHODS: Between December 1993 and December 2008, a total of 141 patients underwent completion lymph node dissection because of a tumor-positive sentinel node. In the same period, 178 patients underwent a regional lymph node dissection for palpable nodal metastases. RESULTS: In the sentinel node-positive patients, the local recurrence rate was 5%, the rate of satellite metastasis was 2%, and for in-transit metastasis, it was 15%. In patients with palpable nodal involvement, these values were 3%, 2%, and 14%, respectively. There was no statistically significant difference in locoregional recurrence-free rates between these two groups of node-positive patients (P = .172). Breslow thickness was the only predictive factor for locoregional recurrence (P = .015). CONCLUSIONS: The rate of locoregional metastases in patients with a tumor-positive sentinel node and patients with palpable nodal involvement is similar. The present study refutes the suggestion that a positive sentinel node indicates a predisposition for developing in-transit metastases.

Evaluation of lymphatic drainage patterns to the groin and implications for the extent of groin dissection in melanoma patients.

INTRODUCTION: Early conventional lymphoscintigrams can distinguish sentinel nodes from second-tier nodes and the new SPECT/CT technology shows their precise anatomical location. The purpose of the study was to analyze lymphatic drainage patterns to the groin using these techniques and to determine the implications for a potential groin dissection. METHODS: Fifty-five groins in 50 patients were analyzed using lymphoscintigrams and SPECT/CT. The superficial groin was divided in five Daseler-zones, and the pelvic region in three zones. RESULTS: A total of 106 sentinel nodes were depicted: 10% in the superior lateral, 13% superior medial, 42% inferior medial, 26% central, and 8% in the external iliac zone. The second-tier nodes were mostly visualized in the external iliac zone (54%). No drainage at all was seen to the inferior lateral zone. In lower trunk melanoma, 81% of the sentinel nodes were in the superior and central zones, and no second-tier nodes were observed in the inferior zones. Twelve sentinel nodes were involved: ten in the inferior medial and two in the central zone. CONCLUSIONS: Most (involved) sentinel nodes were found in the inferior medial and central zones. The high frequency of pelvic second-tier nodes indicates the need for a deep completion groin dissection in the majority of patients with positive sentinel nodes. In none of the patients, lymphatic drainage was seen to the inferior lateral zone, which suggests that this area need not be included in a completion dissection. In patients with lower trunk melanoma, the inferior medial zone may not need to be removed either.

Comparison of three micromorphometric pathology classifications of melanoma metastases in the sentinel node.

OBJECTIVE: The purposes of this study were to determine which classification best predicts additional lymph node disease and survival, and to suggest a threshold below which a completion dissection may be omitted. SUMMARY BACKGROUND DATA: Three micromorphometric parameters of melanoma sentinel node metastases were compared: invasion depth from the capsule (Starz-classification), maximum diameter (Rotterdam-criteria), and location within the node (Dewar-classification). METHODS: The pathology slides of 116 patients with tumor-positive sentinel nodes were reviewed. The follow-up data were obtained from the prospectively kept database. The median follow-up duration was 53 months. RESULTS: Metastases with an invasion depth under 0.3 mm or diameter less than 0.1 mm were not associated with additional involved nodes. Four percent of the patients with metastases with an invasion depth of 0.3 to 1.0 mm had other involved nodes and 3% of the patients with metastases with a diameter of 0.1 to 1.0 mm. Other nodes were involved in 3% of subcapsular metastases, 9% of both subcapsular and parenchymal metastases, and 33% in case of multifocal or extensive disease. The smallest tumor invasion depth and diameter associated with additional involved nodes was 0.4 mm. Only 5-year overall survival in the 3 successive invasion depth categories were statistically significant: 92%, 83%, and 68%. Five-year overall survival was 81% in patients with one involved sentinel node and 60% if there were more. CONCLUSIONS: Invasion depth and diameter of the metastasis correlate best with the presence of additional nodal disease. Invasion depth best predicts overall survival. It seems justified to refrain from completion dissection in patients with a sentinel node tumor invasion depth up to 0.4 mm.

Lymphatic drainage patterns in breast cancer patients who previously underwent mantle field radiation.

BACKGROUND: Lymphatic drainage may change after radiation of a breast or its regional lymph node basins, and this may have implications for lymphatic mapping afterward. The aim of this study was to determine the lymphatic drainage patterns in breast cancer patients who had undergone mantle field radiation for Hodgkin's lymphoma in the past. METHODS: Between January 1999 and November 2008, 22 breast cancer patients underwent a sentinel node procedure after previous mantle field radiation. Lymphatic drainage patterns were analyzed based on lymphoscintigraphy and sentinel node biopsy. The results were compared with the drainage patterns in patients without previous treatment from an earlier study. RESULTS: Sentinel nodes were found in the axilla in 19 patients (86%) and 9 patients (41%) also had drainage toward extra-axillary regions. Sentinel nodes were more often found outside the axilla compared to the patients in our earlier study (33%, P = 0.04), and the nonidentification rate was also higher (14% vs. 3%, P = 0.01). Sentinel nodes were involved in 5 patients (23%). These were harvested from the internal mammary chain in two of them. No lymph node recurrences were observed during a median follow-up time of 49 months. CONCLUSION: Lymphatic mapping is feasible and yields a lymph node in 86% of the breast cancer patients after previous mantle field radiotherapy for Hodgkin's lymphoma. Nonvisualization and extra-axillary nodes are more frequently encountered than in patients without a history of mantle field radiation. The finding of involved nodes suggests that sentinel node biopsy improves staging. Long-term follow-up will determine the sensitivity of the procedure in this specific situation.