Sentinel lymph node biopsy for stage II endometrial cancer: Recent utilization and outcome in the United States.

OBJECTIVE: To examine trends and outcomes related to sentinel lymph node (SLN) biopsy for stage II endometrial cancer. METHODS: This is a retrospective observational cohort study querying the National Cancer Institute's Surveillance, Epidemiology, and End Results Program. The study population was 6,314 women with T2 endometrial cancer who underwent hysterectomy from 2010-2018. Exposure allocation was based on nodal evaluation type: lymphadenectomy (LND; n=4,915, 77.8%), SLN biopsy (n=340, 5.4%), or no surgical nodal evaluation (n=1,059, 16.8%). The main outcomes were (i) trends and characteristics related to nodal evaluation assessed by multinomial regression, and (ii) overall survival (OS) assessed by an inverse probability of treatment weighting propensity score analysis. A sensitivity analysis was performed to examine concurrent LND in women who underwent SLN biopsy. RESULTS: The utilization of SLN biopsy increased from 1.6% to 16.1%, while the number of LND decreased from 81.5% to 65.7% between 2010-2018 (P<0.05). In multivariable analysis, the utilization of SLN biopsy increased 45% annually (adjusted-odds ratio 1.45, 95% confidence interval [CI] 1.37-1.54, P<0.001). The frequency of SLN biopsy alone exceeded the frequency of SLN biopsy with concurrent LND in 2017 (6.8% versus 3.4%), followed by continued increase in SLN biopsy alone (11.2% versus 4.9%) in 2018. In the weighted model, the 3-year OS rate was 79.9% for the SLN biopsy group and 78.6% for the LND group (hazard ratio 0.98, 95%Cl 0.80-1.20, P=0.831). Similarly, the SLN biopsy alone without concurrent LND had comparable OS compared to the LND group (hazard ratio 0.90, 95%CI 0.59-1.36, P=0.615). CONCLUSION: Utilization of SLN biopsy in stage II endometrial cancer increased significantly over time, and SLN biopsy-incorporated nodal assessment was not associated with worsened short-term survival outcome.

Analysis of Surgical Trends for Axillary Lymph Node Management in Patients with Ductal Carcinoma In Situ Using the NSQIP Database: Are We Following National Guidelines?

BACKGROUND: For patients with ductal carcinoma in situ (DCIS), multiple national cancer organizations recommend that sentinel lymph node biopsy (SLNB) be offered when treated with mastectomy, but not when treated with breast-conserving surgery (BCS). This study analyzes national surgical trends of SLNB and axillary lymph node dissection (ALND) in DCIS patients undergoing breast surgery with the aim to quantify deviations from national guidelines. METHODS: A retrospective cohort analysis of the American College of Surgeons' National Surgical Quality Improvement Program (ACS NSQIP) database from 2005 to 2017 identified patients with DCIS. Patients were categorized by their primary method of breast surgery, i.e. mastectomy or BCS, then further categorized by their axillary lymph node (ALN) management, i.e. no intervention, SLNB, or ALND. Data analysis was conducted via linear regression and a non-parametric Mann-Kendall test to assess a temporal trend and Sen's slope. RESULTS: Overall, 43,448 patients with DCIS met the inclusion criteria: 20,504 underwent mastectomy and 22,944 underwent BCS. Analysis of DCIS patients from 2005 to 2017 revealed that ALND decreased and SLNB increased in every subgroup, regardless of surgical treatment modality. Evaluation in the mastectomy group increased overall: mastectomy alone increased from 57.1 to 65.8% (p < 0.01) and mastectomy with immediate reconstruction increased from 58.5 to 72.1% (p < 0.01). Increases also occurred in the total BCS population: partial mastectomy increased from 14.0 to 21.1% and oncoplastic surgery increased from 10.5 to 23.0% (both p < 0.01). CONCLUSIONS: Despite national guideline recommendations for the management of ALN surgery in DCIS patients, approximately 20-30% of cases continue to not follow these guidelines. This warrants further education for surgeons and patients.

Twenty-five years of change in the management of the axilla in breast cancer.

Sentinel lymph node (SLN) biopsy is now used worldwide. It has led to many changes in how we manage the axilla in patients with breast cancer. This review covers four areas of management of the axilla in breast cancer: assessing the clinically node-negative axilla, managing the clinically negative axilla found to be involved at SLN biopsy, management of the clinically positive axilla in the context of neo-adjuvant chemotherapy, and treatment of the diseased axilla when radical therapy is required. We suggest that the evidence supports an optimum number of 3 nodes to be removed for accurate SLN biopsy. Breast cancer departments that have not adopted Z0011 patient management cannot continue to avoid change. The evidence is clear: Not all patients with limited axillary nodal disease on sentinel node biopsy need axillary lymph node dissection. For patients who do need axillary treatment, axillary radiotherapy continues to be under-used. Patients undergoing neo-adjuvant chemotherapy can be safely assessed by post-therapy SLN biopsy, with retrieval of any previously biopsied involved nodes by targeted axillary dissection. There is much to support the trend to doing less in the axilla. We are obliged to act based on the available robust clinical trial data in a way that limits morbidity while at the same time does not increase the risk of disease recurrence.

Trends in Sentinel Lymph Node Biopsy Enactment for Cutaneous Melanoma.

BACKGROUND: Over recent years, sentinel lymph node biopsy (SLNB) recommendations in guidelines for cutaneous melanoma have changed considerably. We aimed to assess trends in enactment of SLNB to evaluate to what extent guidelines were adhered to, and to identify clinical and pathological determinants of (non-)adherence. METHODS: Clinicopathological data from the Dutch nationwide network and registry of histopathology and cytopathology were retrieved from patients diagnosed with primary cutaneous melanoma in The Netherlands between 2003 and 2014. SLNB enactment was analyzed per year. Multivariable regression models were developed to assess the determinants of SLNB enactment. RESULTS: A total of 51,510 primary cutaneous melanomas in 49,514 patients were diagnosed, of which 24,603 melanomas were eligible for SLNB as they were staged T1b or higher. In practice, only 9761 (39.7%) patients underwent SLNB, with an increasing trend from 39.1% in 2003 to 47.8% in 2014 (p < 0.001). A total of 759 (2.9%) of 26,426 patients without SLNB indication underwent SLNB anyway. Variables significantly associated with enactment of SLNB were male sex, younger age, and melanoma on sites other than the head and neck. CONCLUSIONS: Although there was an increasing trend in time in SLNB enactment, enactment of SLNB did not comply well with recommendations in (inter)national guidelines. Female sex, higher age, and melanoma located on the head and neck were associated with non-enactment of SLNB.

Uptake of sentinel lymph node procedures in women with vulvar cancer over time in a population based study.

OBJECTIVES: To evaluate trends in uptake of sentinel lymph node (SLN) procedures over time and associated factors in women with vulvar cancer. METHODS: A retrospective population-based cohort study identified women with invasive squamous cell carcinoma (SCC) of the vulva using health administrative data for the province of Ontario, Canada, between 2008 and 2016. Patients who underwent SLN procedures were compared to those who had groin node dissection (GND). Multivariable analysis was used to identify factors associated with SLN procedures. RESULTS: 1385 patients with SCC of the vulva were identified; 1079 had a surgical procedure. Only those with groin node assessment were included in the study cohort (n = 732, 68%). SLN procedures were done in 52%. When comparing SLN versus GND, the rate of SLNs was significantly different by year of diagnosis (P < 0.001), associated comorbidity (P < 0.001) and institution (P < 0.0001). The rates of SLNs by institution with gynecologic oncologist were variable and ranged from 32% to 79% among 9 centers. There were no differences in age, income quintile, and urban/rural residence. The proportion of SLN procedures increased from 30.1% (CI 18.9-45.6) in 2008 to 65.2% (CI 36.5-107.6) in 2016. On multivariate analysis, factors significantly associated with SLN procedures were more recent year of diagnosis (OR 7.9, CI 2.7-23.5) associated comorbidities (OR 2.7, CI 1.5-5.0) and institution (Site 5, OR 19.6 [CI 3.6-108.3] and Site 6, [OR 6, CI 1.1-33.4]). CONCLUSIONS: The proportion of SLN procedures in women with vulvar cancer has increased over time, but uptake is not uniform across institutions. Barriers to uptake should be explored.

[Research progress of sentinel lymph node biopsy and regional dissection in melanoma].

Melanoma is a malignant tumor derived from the skin and mucous membrane, the epidemiological data showed that the incidence of melanoma elevated rapidly in the last decade. Early lymph node metastasis is a distinguishing characteristic of melanoma. The assessment of regional lymph nodes is a vital factor for melanoma staging and comprehensive therapeutic strategies. The sentinel lymph node biopsy (SLNB) plays an important role in this comprehensive diagnosis and treatment system. Completion lymph node dissection (CLND) with positive sentinel lymph node was accepted by traditional theories. But it has recently been questioned via the latest global clinical trial. CLND limited the benefit for melanoma specific survival. However, SLNB is the reliable procedure for staging and prognostic evaluation of melanoma patients with positive sentinel lymph node, and CLND can significantly improve the local control and decrease the regional recurrence according to the evidence-based medicine. The authors summary the recently correlational research of SLNB and CLND in melanoma in this review.

Trends in Sentinel Lymph Node Mapping and Adjuvant Therapy in Endometrial Carcinoma.

We analyzed 54,039 women with uterine cancer in the National Cancer Database from 2013 to 2014 including 38,453 (71.2%) who underwent lymphadenectomy, 1929 (3.6%) who underwent sentinel lymph node (SLN) mapping, and 13,657 (25.3%) who did not undergo nodal assessment. SLN mapping increased from 2.8% in 2013 to 4.3% in 2014 (P < 0.001). Patients treated in 2014 and those at community centers were more likely to undergo SLN biopsy, while women with advanced-stage disease, sarcomas, and grade 3 tumors were less likely to undergo SLN mapping (P < 0.05). There was no association between use of SLN biopsy and use of radiation (aRR = 0.92; 95% CI, 0.82-1.05).

Time trends in axilla management among early breast cancer patients: Persisting major variation in clinical practice across European centers.

Background We examined time trends in axilla management among patients with early breast cancer in European clinical settings. Material and methods EUROCANPlatform partners, including population-based and cancer center-specific registries, provided routinely available clinical cancer registry data for a comparative study of axillary management trends among patients with first non-metastatic breast cancer who were not selected for neoadjuvant therapy during the last decade. We used an additional short questionnaire to compare clinical care patterns in 2014. Results Patients treated in cancer centers were younger than population-based registry populations. Tumor size and lymph node status distributions varied little between settings or over time. In 2003, sentinel lymph node biopsy (SLNB) use varied between 26% and 81% for pT1 tumors, and between 2% and 68% for pT2 tumors. By 2010, SLNB use increased to 79-96% and 49-92% for pT1 and pT2 tumors, respectively. Axillary lymph node dissection (ALND) use for pT1 tumors decreased from between 75% and 27% in 2003 to 47% and 12% in 2010, and from between 90% and 55% to 79% and 19% for pT2 tumors, respectively. In 2014, important differences in axillary management existed for patients with micrometastases only, and for patients fulfilling the ACOSOG Z0011 criteria for omitting ALND. Conclusion This study demonstrates persisting differences in important aspects of axillary management throughout the recent decade. The results highlight the need for international comparative patterns of care studies in oncology, which may help to identify areas where further studies and consensus building may be necessary.

Current Trends and Emerging Future of Indocyanine Green Usage in Surgery and Oncology: An Update.

BACKGROUND: Indocyanine green (ICG) is a widely available dye of clinical importance that has been used for more than 50 years. Near-infrared (NIR) ICG fluorescence imaging has found a niche in cancer care since 2005, and was reviewed in 2011. There is a need for a comprehensive update and we aim to provide this through a review of the most recent literature. METHODS: A systematic review of the literature using PubMed, EMBASE, and MEDLINE databases of articles published from 2000 to June 2015 evaluated topics pertinent to NIR fluorescence imaging with ICG in the diagnosis and surgical treatment of cancer. Articles previously referenced in a 2011 review and a 2015 meta-analysis were excluded, while articles that referenced future directions and economics were included in this current review. RESULTS: Since 2011, the literature has grown exponentially, with significant advances at the molecular level. Significant findings from 89 select articles and 10 reviews, most of which were published between 2011 and 2015, are summarized. Preclinical studies are currently underway investigating tumor-specific fluorescence and targeted therapeutic delivery. The potential for ICG exists at every level of cancer care, from diagnosis to surveillance. CONCLUSION: The indications, applications, and potential for ICG have grown exponentially in the past decade; an updated review of the literature is overdue and we present the most comprehensive review to date.

The Evolution of Axillary Staging in Breast Cancer.

Breast cancer treatment has a long, fascinating history. Multimodality therapy utilizes surgery, systemic therapy and radiation. The role of surgical axillary staging in breast cancer continues to evolve. Secondary to randomized, controlled trials, sentinel lymph node biopsy is the standard for surgical staging in patients with a clinically negative axilla. Traditionally, when sentinel nodes revealed metastases, a complete axillary lymph node dissection was performed. Recently however, the value of complete axillary dissection is being challenged.

Evolution of sentinel lymph node biopsy in breast cancer, in and out of vogue?

Sentinel lymph node biopsy (SLNB) was introduced 2 decades ago and thereafter validated for routine surgical management of breast cancer, including cases treated with neoadjuvant chemotherapy. As the number of lymph nodes for staging has decreased, pathologists have scrutinized SLN with a combination of standard hematoxylin and eosin, levels, immunohistochemistry (IHC), and molecular methods. An epidemic of small-volume metastases thereby arose, leading to modifications in the American Joint Committee on Cancer staging to accommodate findings such as isolated tumor cells (ITC) and micrometastases. With the goal of determining the significance of these findings, retrospective followed by prospective trials were performed, showing mixed results. The ACOSOG Z10 and NSABP B-32 trials both independently showed that ITC and micrometastases were not significant and thus discouraged the use of levels and IHC for detecting them. However, the Surveillance Epidemiology and End Results database showed that patients with micrometastases had an overall decreased survival. In addition, the MIRROR (Micrometastases and ITC: Relevant and Robust or Rubbish?) trial, showed that patients with ITC and micrometastases treated with adjuvant therapy had lower hazard ratios compared with untreated patients. Subsequently, the ACOSOG Z0011 trial randomized patients with up to 2 positive SLN to axillary lymph node dissection (ALND) or not, all treated with radiation and chemotherapy, showing no difference in survival or recurrence rates between the 2 groups and causing a shift from ALND. As the rate of ALND has declined, the necessity of performing levels, IHC, frozen section, and molecular studies on SLN needs to be revisited.

Utilization of sentinel lymph node biopsy in patients with ductal carcinoma in situ undergoing mastectomy.

BACKGROUND: Current guidelines suggest consideration of sentinel lymph node biopsy (SLNB) for patients with ductal carcinoma in situ (DCIS) undergoing mastectomy. Our objective was to identify factors influencing the utilization of SLNB in this population. METHODS: We used the Surveillance Epidemiology and End Results database to identify all women with breast DCIS treated with mastectomy from 2000 to 2008. We excluded patients without histologic confirmation, those diagnosed at autopsy, those who had axillary lymph node dissections performed without a preceding SLNB, and those for whom the status of SLNB was unknown. We used multivariate logistic regression reporting odds ratios (OR) and 95% confidence intervals (CI) to evaluate the relationship of patient- and tumor-related factors to the likelihood of undergoing SLNB. RESULTS: Of 20,177 patients, 51% did not receive SLNB. Factors associated with a decreased likelihood of receiving a SLNB included advancing age (OR 0.66; 95% CI 0.62-0.71), Asian (OR 0.75; CI 0.68-0.83) or Hispanic (OR 0.84; 95% CI 0.74-0.96) race/ethnicity, and history of prior non-breast (OR 0.57; 95% CI 0.53-0.61). Factors associated with an increased likelihood of receiving a SLNB included treatment in the east (OR 1.28; 95% CI 1.17-1.4), intermediate (OR 1.25; 95% CI 1.11-1.41), high (OR 1.84; 95% CI 1.62-2.08) grade tumors, treatment after the year 2000, and DCIS size 2-5 cm (OR 1.54; 95% CI 1.42-1.68) and >5 cm (OR 2.43; 95% CI 2.16-2.75). CONCLUSIONS: SLNB is increasingly utilized in patients undergoing mastectomy for DCIS, but disparities in usage remain. Efforts at improving rates of SLNB in this population are warranted.

Are there changes in characteristics and therapy of young patients with early-onset breast cancer in Germany over the last decade?

PURPOSE: The objective of the study is to investigate recent changes in patient characteristics and treatment procedures of young breast cancer patients over the last 10 years in Germany. METHODS: The study describes the data of 518 patients who were treated adjuvantly between 2008 and 2011 and participated in a resident mother-child program for rehabilitation (cohort II). The data includes TNM-categories, biology of tumor and therapies. This population is compared to a cohort of 535 patients, who were treated between 2002 and 2006 (cohort I). Characteristics and treatment of cohort II are compared with a normally age distributed cohort. RESULTS: 51.5 % of the patients in cohort II were diagnosed with tumor category pT1, 36.9 % pT2, 4.4 % pT3 and 1.2 % pT4. 3.3 % had merely DCIS. 58.1 % of the patients were pN0, 28.4 % pN1 and 13.5 % had a more intense manifestation of lymph nodes. 45.8 % of the tumors showed a grading classified as G3, 69.3 % were estrogen and progesterone hormone receptor positive and 21.8 % Her2 positive. 24.5 % of the examined patients showed a triple negative carcinoma. 66.2 % of the patients with pT1 or pT2 underwent breast-conserving surgery. Overall 19.2 % of the women received mastectomy only and 17.4 % received mastectomy with subsequent reconstruction. 98.6 % of the patients received axillary surgery, 87.6 % chemotherapy. Overall, 21.0 % of the patients received their chemotherapy in connection with clinical studies. 88.0 % of the patients with hormone receptor positive tumors received endocrine therapy, 25.5 % of them with GnRH-analogs. In comparison with cohort I the tumors in cohort II were detected with a higher proportion of negative lymph nodes (48.8 %/58.1 %, p = 0.008) and G1 grading (4.9/5.6 %, p = 0.001). On the other hand the percentage of triple negative tumors increased from 21.0 % to 24.5 % (p = 0.018). Operative therapy has adjusted to a more moderate way. Breast-conserving therapy with pT1 and pT2 increases from 57.3 % to 66.2 % (p = 0.006), sentinel lymph node biopsy only from 24.5 % to 47.5 % (p[Symbol: see text]0.001) over the years. The percentages of chemotherapy, radiation, endocrine therapy and antibody therapy with positive receptor have stayed stable over the last decade. Comparing cohort II with a normally age distributed group (DMP II 2007-2009) the young patients have still a much lower portion of negative lymph nodes (58.1 %/67.9 %) and positive hormone receptor status (69.3 %/85.1 %). The percentage of a high grading G3 is 45.8 % in cohort II versus 24.7 % in DMP II. The portion of breast-conserving therapy with pT1 is with 68.9 versus 82.2 % still comparatively low. Young patients received more axillary surgery (98.6 %/81.5 %) but less endocrine therapy with hormone receptor positive tumors (93.3 %/94.7 %). CONCLUSION: Young breast cancer patients in Germany can still be regarded as a special group. Although tumors are now more often detected before reaching the lymph nodes than 10 years ago, an even bigger percentage is triple negative. Operative treatment has improved to a less aggressive way. Still operative and medical treatments have to be chosen after very careful evaluation.

Trends in Sentinel Lymph Node Biopsies in Patients With Inflammatory Breast Cancer in the US.

Importance: The standard of care for inflammatory breast cancer (IBC) is neoadjuvant chemotherapy, total mastectomy with axillary lymph node dissection (ALND), and postmastectomy radiation therapy. Existing studies suggest that sentinel lymph node biopsy (SLNB) may not be reliable in IBC. The use and frequency of SLNB in women with IBC is not well characterized. Objective: To determine the frequency and temporal trend of SLNB in patients with IBC. Design, Setting, and Participants: This retrospective cohort study used the National Cancer Database, a nationwide hospital-based cancer registry, and included women who were diagnosed with nonmetastatic IBC and underwent axillary surgery from 2012 to 2017. Data were analyzed from January 2021 to May 2021. Exposures: Any SLNB, including SLNB alone and SLNB followed by ALND, and ALND alone. Main Outcomes and Measures: Scatterplot fit with a linear regression model were used to evaluate the yearly increase of any SLNB use. Multivariable logistic regression models to evaluate the association of study variables with the outcome of any SLNB. Results: This study included a total of 1096 women (mean [SD] age, 56.1 [12.9] years) who were 18 years or older with nonmetastatic IBC diagnosed between 2012 and 2017. Of the 186 of 1096 women (17%) who received any SLNB, 137 (73.7%) were White individuals; and of the 910 of 1096 women (83%) who received an ALND only, 676 (74.3%) were White individuals. Among women undergoing any SLNB, 119 of 186 (64%) did not undergo a completion ALND. There was a statistically significant increasing trend in the use of SLNB from 2012 to 2017 (22 of 205 patients [11%] vs 32 of 148 patients [22%]; P = .004). In multivariable analysis, the use of SLNB was associated with diagnosis year (2017 vs 2012; odds ratio [OR], 2.26; 95% CI, 1.26-4.20), clinical nodal status (cN3 vs 0; OR, 0.39; 95% CI, 0.22-0.67), and receipt of reconstructive surgery (OR, 1.80; 95% CI, 1.09-2.96). Conclusions and Relevance: The findings of this cohort study suggest that there is frequent and increasing use of SLNB in patients with IBC that is not evidence-based or supported by current treatment guidelines.

Current trends and emerging future of indocyanine green usage in surgery and oncology: a literature review.

Ever since Kitai first performed fluorescent navigation of sentinel lymph nodes (SLNs) using indocyanine green (ICG) dye with a charge-couple device and light emitting diodes, the intraoperative use of near infrared fluorescence has served a critical role in increasing our understanding in various fields of surgical oncology. Here the authors review the emerging role of the ICG fluorophore in the development of our comprehension of the lymphatic system and its use in SLN mapping and biopsy in various cancers. In addition, they introduce the novel role of ICG-guided video angiography as a new intraoperative method of assessing microvascular circulation. The authors attempt to discuss the promising potential in addition to assessing several challenges and limitations in the context of specific surgical procedures and ICG as a whole. PubMed and Medline literature databases were searched for ICG use in clinical surgical settings. Despite ICG's significant impact in various fields of surgical oncology, ICG is still in its nascent stages, and more in-depth studies need to be carried out to fully evaluate its potential and limitations.

[Surgical de-escalation in gynecologic oncology]. / Désescalade chirurgicale en oncologie gynécologique.

The evolution of knowledge in gynecologic oncology is leading to surgical de-escalation in several areas, particularly in lymph node staging. Sentinel lymph node biopsy that was initially used in low and intermediate risk endometrial cancer, has now been extended to high-intermediate and high-risk endometrial cancer. Sentinel lymph node biopsy plays also an important role in the nodal staging of early-stage cervical cancer. The radicality of hysterectomies in patients with early cervical cancer is under debate. Similarly, surgical staging with para-aortic lymphadenectomy in locally advanced cervical cancer should be performed only for few cases. Systematic pelvic and para-aortic lymphadenectomy in patients with advanced ovarian cancers is not recommended anymore.

Axillary surgery for breast cancer: past, present, and future.

In breast cancer surgery, there has been a major shift toward less invasive local treatment. Although axillary lymph node dissection (ALND) was an integral part of surgical treatment for breast cancer, sentinel lymph node (SLN) biopsy was developed as an accurate method for axillary staging. ALND can be avoided not only in patients with negative SLNs but also in those with one or two positive SLNs receiving breast and/or axillary radiation. On the other hand, ALND has remained the standard treatment for patients with clinically positive nodes. However, axillary reverse mapping (ARM) was developed to map and preserve arm lymphatic drainage during ALND and/or SLN biopsy. This procedure allowed reduction of the rate of arm lymphedema without increasing axillary recurrence, although patients receive postoperative chemotherapy and high-risk patients undergo axillary radiation. Standard ALND may not be necessary even for patients with clinically positive nodes who receive axillary radiation and systemic therapy. Thus, the extent of axillary surgery in breast cancer has been decreased with increased use of systemic and radiation therapy.