Validation of the S classification of sentinel lymph node and microanatomic location of sentinel lymph node metastases to predict additional lymph node involvement and overall survival in breast cancer patients.

BACKGROUND: Most patients with a positive sentinel lymph node (SN) have no further metastases in the axillary lymph nodes and may therefore not benefit from axillary lymph node dissection. In patients with melanoma, evaluation of the centripetal depth of tumor invasion in the SN, also known as the S classification of SN, and microanatomic localization of SN metastases were shown to predict non-SN involvement. This phenomenon has been less extensively studied in breast cancer. We sought to validate the S classification and microanatomic location of SN metastases in breast cancer patients with regard to their predictive value for non-SN involvement and overall survival (OS). METHODS: A total of 236 patients with positive SN followed by axillary lymph node dissection were reevaluated according to the S classification and the microanatomic location of SN (subcapsular, parenchymal, combined subcapsular and parenchymal, multifocal, extensive) metastases to predict the likelihood of non-SN metastases and OS. RESULTS: S classification and the microanatomic location of SN metastases were significantly correlated with non-SN status (P < 0.001). Especially patients with a maximum depth of invasion ≤0.3 mm (stage I according to the S classification) and those with SN metastases only in subcapsular location had a low probability of further non-SN metastases (7.8 and 6.1%) and a good prognosis for OS. CONCLUSIONS: S classification and microanatomic location of SN metastases predicts the likelihood of non-SN involvement. Especially patients with subcapsular or S stage I metastases have a low probability of non-SN metastases and a good prognosis for OS.

S-classification of sentinel lymph node predicts axillary nonsentinel lymph node status in patients with breast cancer.

BACKGROUND: One-half of breast cancer patients with positive sentinel lymph node (SN) have no further metastases in the axillary lymph node basin. The aim of the present study was to identify patients with positive SN who are unlikely to have further metastases in the axillary lymph node basin, using a new classification of SN, namely the S-classification. METHODS: Specimens of positive SN were subjected to a pathological review according to the previously published S-classification. S-stages of positive SN were correlated with the status of further metastases in the axillary lymph node basin after axillary lymph node dissection (ALND). RESULTS: Of 117 patients who underwent sentinel lymph node biopsy, 36 (30.8%) had a positive SN and were subjected to level I and II ALND. The occurrence of positive nonsentinel nodes was significantly related to the S-stage of SN. No patient with stage SI had additional metastases in the nonsentinel lymph nodes, while 14.3% of patients with SII stage disease and 60.9% of patients with SIII disease had other non-SN that were metastatic. CONCLUSION: S-stages of positive SN are highly predictive for axillary nonsentinel node status. Especially patients with SI sentinel node metastases appear to be at low risk for further nonsentinel node metastases.

Value of micromorphometric criteria of sentinel lymph node metastases in predicting further nonsentinel lymph node metastases in patients with melanoma.

Patients with metastases in the sentinel node (SN) are advised to undergo complete lymph node dissection, although the majority of them will have no further metastatic disease. Some of these patients undergo unnecessary surgery. In this study, we tried to predict the likelihood of further non-SN metastases on the basis of earlier published micromorphometric classifications of SN metastases. Metastases in the SN were re-evaluated on the basis of the microanatomic location of the lesions according to the Dewar's criteria, the S-classification of SN, and tumor burden in accordance with the Rotterdam criteria. The results of these classifications were correlated with the presence of further non-SN metastases. Specimens of 124 positive-SN basins and subsequent complete lymph node dissection were investigated. Further metastases in non-SNs were found in 30 lymph node basins (24.2%). All of the above-mentioned classification systems were significantly correlated with non-SN tumor status. Especially, in patients with SN metastases in subcapsular location, a maximum depth of invasion of less than 0.3 mm (stage I according to the S-classification) or metastases of less than 0.1 mm in diameter had a very low probability of further non-SN metastases (0-5%). The validity of earlier published classifications of SN metastases-based on the micromorphometric criteria in predicting non-SN status was confirmed. Especially, in patients with subcapsular metastases, SI stage metastases or metastases of less than 0.1 mm had a very low risk of further non-SN metastases.

Lupus anticoagulant in patients with chronic venous insufficiency.

Chronic venous insufficiency is a widespread disease that can often lead to venous leg ulcers. Recent studies report that certain clotting abnormalities, such as anticardiolipin antibodies, are associated with leg ulcers. Although lupus anticoagulant belongs to the antiphospholipid antibodies, its presence in patients with chronic venous insufficiency has not been reported previously. The purpose of our study was to determine the presence of lupus anticoagulant in chronic venous insufficiency patients at a stage with no leg ulcers, and to follow the clinical outcome. In 37 patients with chronic venous insufficiency and in 54 control patients, lupus anticoagulant was evaluated using the Viper Venom Russell's Diluted Test. Lupus anticoagulant was found significantly more often (p < 0.001) in patients with chronic venous insufficiency than in controls. After 4 years, patients with chronic venous insufficiency with lupus anticoagulant were found to develop a venous leg ulceration more frequently compared to those without (p = 0.01), suggesting that lupus anticoagulant may play an important role in the pathogenesis of chronic venous insufficiency.

Proximal extent of pelvic vein thrombosis and its association with pulmonary embolism.

OBJECTIVE: Conventional methods such as duplex ultrasound scanning do not provide accurate information about proximal extension of pelvic vein thrombosis. We evaluated proximal extent of thrombus toward pelvic veins with magnetic resonance imaging in patients with suspected deep vein thrombosis (DVT) proximal to the inguinal ligament on the basis of duplex ultrasound scans. In addition, frequency of pulmonary embolism (PE) and early (4 weeks) clinical outcome were evaluated. METHODS: Two hundred twelve patients with acute symptomatic DVT proximal to the inguinal ligament, diagnosed at duplex ultrasound scanning, were enrolled in this prospective study. All patients underwent magnetic resonance imaging of the abdominal and pelvic veins, as well as lung scintigraphy to detect the presence of pulmonary embolism. RESULTS: In 24 of 212 patients (11%), thrombus was restricted to the femoral vein. The thrombus extended into iliac veins in 142 patients (67%) and into the inferior vena cava in 46 patients (22%). The frequency of PE was not associated with the most proximal extension of thrombus (P =.61). No patients died as a consequence of thromboembolic events. CONCLUSIONS: Extension of DVT into the inferior vena cava occurs relatively frequently. In our patients this finding was not associated with higher risk for PE compared with DVT of the femoral or iliac veins.