Sentinel lymphadenectomy: an alternative to axillary lymphadenectomy in breast carcinoma

BACKGROUND: Axillary lymph node status is an important determinant of prognosis in breast cancer. However, lymphadenectomy does not benefit half of the patients in whom axillary nodes are free of disease. Sentinel lymph node biopsy is a new technique which allows accurate staging of breast carcinoma without performing total axillary dissection. We describe our experience with the introduction of sentinel lymphadenectomy. METHODS: Thirty-seven sentinel lymphadenectomies were performed in 35 patients referred to the Department of Obstetrics and Gynaecology of the University of Berne between December 1997 and June 1998. Mapping procedures were performed using a combination of vital blue dye with preoperative lymphscintigraphy with 99mTechnetium-labelled colloidal albumin and intraoperative use of a gamma probe. Complete axillary lymphadenectomy was then performed in 34 patients. RESULTS: One or more lymph nodes were identified in 33 of 37 procedures (89%). With the combination of both localisation techniques the sentinel nodes were identified in all (100%) of the last 19 patients. Sentinel and non-sentinel lymph nodes were always concordant. In this series the negative predictive value is 100% (95% confidence interval: 87.7%-100%). Metastases were found in the sentinel node in 11 of 30 patients (37%). From these 11 patients, 3 (27%) had micrometastases. CONCLUSIONS: Histopathologic examination of the sentinel lymph node accurately predicts the axillary lymph-node status. Patients with sentinel nodes free of metastases could avoid the unnecessary peri- and postoperative complications of complete axillary dissection. Further studies are needed to assess whether the improved diagnosis of micrometastases by sentinel lymphadenectomy influences the long-term prognosis of breast cancer.     

Occult breast cancer causing axillary metastasis

Orthodontic bands form retention areas which create favourable conditions for growth of lactobacilli. This study deals with the numbers and specific species of lactobacilli in the oral cavity of teenage orthodontic patients. High numbers of lactobacilli were obtained (log 6.398 +/- 0.761 cfu/ml) and the buffer capacity of saliva indicated a high caries risk amongst these individuals but the actual DMFT values were relatively low. Homofermentative lactobacilli predominated in both plaque and saliva and particularly L. salivarius and L. casei. These two lactobacilli species indicated that these patients are at a high caries risk. Several other homofermentative and heterofermentative lactobacilli were isolated which indicated the complexity of the oral lactobacilli community in saliva and plaque.     

A randomized study comparing retroperitoneal drainage with no drainage after lymphadenectomy in gynecologic malignancies

Drug-nutrient interactions affecting chromium were investigated in this study. Rats were injected with indomethacin to reduce endogenous prostaglandin synthesis and dosed with prostaglandin analogues or prostacyclin. Effects on absorption, tissue distribution and urinary excretion of 51Cr from 51CrCl3 were evaluated using a 2 x 4 factorial experimental design. Forty-eight adult male rats were food deprived for 12 h and then injected intraperitoneally with indomethacin (5 mg/kg body wt) or placebo. Thirty minutes later, rats were intubated and dosed with one of four treatments: a prostaglandin E1 analogue (misoprostol) at 50 microg/kg body wt; a prostaglandin E2 analogue (16,16-dimethylprostaglandin E2) at 7.5 microg/kg body wt; prostacyclin at 20 microg/kg body wt; or control (7.64 mmol/L Tween-80 suspended in 0.15 mol/L NaCl containing 0.48 mol/L ethanol). Immediately after intubation, rats were dosed with 3.7 mBq of 51CrCl3 by micropipette. Blood was collected from the tail at intervals after 51Cr dosing. Six hours after dosing, 51Cr rats were exsanguinated by cardiac puncture. Indomethacin, an inhibitor of prostaglandin synthesis, significantly increased (P < 0.05) 51Cr in blood at all time periods tested except at 15 min. In tissues, indomethacin significantly increased 51Cr retention. Urinary 51Cr excretion at 6 h was higher (P < 0.05) in indomethacin-pretreated rats than in control rats. Administration of indomethacin, which blocks prostaglandin synthesis, enhanced 51Cr absorption, whereas dosing with 16,16-dimethylprostaglandin E2 decreased 51Cr absorption.     

Preservation of pectoralis minor in axillary clearance for breast cancer

BACKGROUND: There has been a gradual shift away from radical surgery towards conservation treatment for breast cancer. The pectoralis minor muscle is increasingly preserved in women undergoing axillary clearance as part of either breast conservation or mastectomy. METHODS: A retrospective study was conducted to determine the axillary node count in 578 patients who underwent axillary clearance, 276 with removal of pectoralis minor and 302 who had the muscle preserved. RESULTS: The mean number of nodes excised in the group who had pectoralis minor excised was 25.5 (range 8-50) compared with 24.5 (range 9-68) in the preservation group. CONCLUSION: For the majority of patients with operable breast cancer, retention of the pectoralis minor muscle is not associated with understaging or undertreatment of the axilla.     

Role of axillary lymph node dissection after tumor downstaging with induction chemotherapy for locally advanced breast cancer

BACKGROUND: Induction chemotherapy has become the standard of care for patients with locally advanced breast cancer (LABC) and currently is being evaluated in prospective clinical trials in patients with earlier-stage disease. To better gauge the role of axillary lymph node dissection in patients with LABC this study was performed to assess initial axillary status on physical and ultrasound examination, axillary tumor downstaging following induction chemotherapy, and the accuracy of physical examination compared with axillary sonography in predicting which patients will have axillary lymph node metastases found on pathologic examination. METHODS: Between 1992 and 1996, 147 consecutive patients with LABC were registered in a prospective trial of induction chemotherapy using 5-fluorouracil, doxorubicin, and cyclophosphamide. Physical and ultrasound examinations of the axilla were performed at diagnosis and after induction chemotherapy. Segmental resection with axillary lymph node dissection or modified radical mastectomy was performed, followed by postoperative chemotherapy and irradiation of the breast or chest wall and regional lymphatics. RESULTS: Following induction chemotherapy, 43 (32%) of the 133 patients with clinically positive lymph nodes on initial examination had axillary tumor downstaging as assessed by physical and ultrasound examination. The sensitivity of axillary sonography in identifying axillary metastases was significantly higher than that of physical examination (62% vs. 45%, P=.012). The specificity of physical examination (84%) was higher than that of sonography (70%), but the difference did not reach statistical significance. Among the 55 patients in whom the findings of both physical and ultrasound examination of the axilla were negative following induction chemotherapy, 29 patients (53%) were found to have axillary lymph node metastases on pathologic examination of the axillary contents. However, 28 (97%) of these patients had either 1 to 3 positive lymph nodes or only micrometastases 2 to 5 mm in diameter. CONCLUSIONS: Preoperative clinical assessment of the axilla by physical examination combined with ultrasound examination is not completely accurate in predicting metastases in patients with LABC following tumor downstaging. However, patients with negative findings on both physical and ultrasound examinations of the axilla may be potential candidates for omission of axillary dissection if the axilla will be irradiated because minimal axillary disease remains. Patients who have positive findings on preoperative physical or ultrasound examinations should receive axillary dissection to ensure local control. A prospective randomized trial of axillary dissection versus axillary radiotherapy in patients with a clinically negative axilla following induction chemotherapy is currently underway.     

Percutaneous suction aspiration and drainage for pyogenic spondylitis

STUDY DESIGN: Retrospective evaluation of results in 23 cases of early-stage pyogenic spondylitis treated with percutaneous suction aspiration and drainage. OBJECTIVES: To evaluate the efficacy of percutaneous suction aspiration and drainage as a treatment method for early-stage pyogenic spondylitis. SUMMARY OF BACKGROUND DATA: Traditional surgical treatment for pyogenic spondylitis has the disadvantage of increased morbidity caused by the extensive exposure required in the presence of infection. Recently, a few case reports have described minimally invasive treatment for pyogenic spondylitis in which percutaneous suction aspiration was used. However, the efficacy of this new treatment has not yet been evaluated. METHODS: All charts, radiographs, and bacteriologic and histologic findings were reviewed. All 23 patients who received the new treatment were observed clinically and radiographically, to evaluate the efficacy of the treatment. RESULTS: To date, all patients have been observed for more than 2 years. Twenty (87%) of the 23 patients have shown good results according to the evaluation. The causative organism was identified using tissue culturing in 12 (52%) of the 23 patients. The causative organism was Staphylococcus aureus in 8, and Staphylococcus epidermidis, Candida albicans, Pseudomonas aeruginosa, and Propionibacterium acnes in 1 each. Back pain as the major symptom in these patients was relieved within an average of 9.4 days after the operation. However, the patient in whom the spondylitis was caused by Candida albicans has received this new treatment twice without success. CONCLUSIONS: Evaluation of percutaneous suction aspiration with drainage shows that it is an effective treatment for early-stage pyogenic spondylitis.     

Demonstration of the sentinel lymph node in axillary dissection for breast cancer

OBJECTIVES: The sentinel node is defined as the first-line axillary lymphatic drainage node in breast cancer. If the sentinel node can be identified, during axillary dissection for breast cancer, resection could be limited reducing subsequent morbidity. However, before modifying the standard dissection procedure, it is important to prove that the sentinel node is representative of the metastatic status of other axillary nodes. PATIENTS AND METHODS: Between March and December 1996, 86 patients (mean age 58 years, range 32-82) underwent amputation (n = 20), tumorectomy with dissection (n = 56) or tumorectomy followed by secondary dissection (n = 10) for breast cancer. Ten ml of diluted patent blue was injected either into the peripheral portion of the tumor or the tumorectomy cavity. Node dissection was performed 10 to 20 minutes after injection. The blue sentinel node was identified prior to standard dissection. RESULTS: A mean 12 nodes were removed (range 4-21). Seventy-nine sentinel nodes were identified (91%) and in 7 cases (8%) a sentinel node could not be identified. In 7 other cases the sentinel node was a false negative, i.e. non malignant despite metastases in other dissected nodes. In all the other cases, the status of the sentinel node predicted the status of the other nodes, i.e. a non-metastatic sentinel node associated with other metastatic nodes. Finally, in 7 cases, the sentinel node was the only invaded node among the nodes dissected. During the last 3 months of the study, the sentinel node was identified in 100% of the cases and was representative of the overall dissection. CONCLUSION: Identifying the sentinel node is an alternative to standard axillary node dissection procedures. The method requires a training period and identification can be improved with radioimmunologic guidance. Patient selection within the framework of a rigorous multidisciplinary protocol is indispensable. A nationwide study is currently being conducted to validate these preliminary results.     

Lung cancer after radiation therapy for breast cancer

BACKGROUND: Radiation, including radiation therapy (RT) for a variety of conditions, is known to be a lung carcinogen. METHODS: Data from the Surveillance, Epidemiology, and End Results program of the National Cancer Institute for 1973-1986 were utilized to investigate whether RT for breast cancer affects the risk of subsequent lung cancer. The relative risk was calculated by comparing the incidence rate in patients with irradiated breast cancer with that in those with nonirradiated breast cancer. RESULTS: It was found that the risk of lung cancer overall was increased in women who underwent irradiation compared with those who were not irradiated 10 years after the initial breast cancer diagnosis with a relative risk of 2.0 (95% confidence interval, 1.0-4.3). In addition, the risk of lung cancer was in the ipsilateral lung compared with the contralateral lung for irradiated women. This increase was observed after 10 years for lung cancer overall and for the three major histologic subgroups (small cell, squamous cell, and adenocarcinoma). Specific information on RT doses and treatment plans and cigarette smoking were not available. CONCLUSIONS: It was concluded that RT for breast cancer may increase the risk of lung cancer after a latency period of 10 years.     

Is axillary dissection always indicated in invasive breast cancer?

In light of the changing trends in the diagnosis and management of invasive breast cancer, the practice of routine axillary dissection should be reevaluated. A growing number of patients with breast cancer are diagnosed as having small tumors with an associated low risk of lymph node metastases. The pathologic features of the primary tumor are increasingly being used as a prognostic guide for recommendations about adjuvant systemic therapy, and there are recent reports suggesting a superior prognostic value for tumor cells detected in bone marrow, as compared to axillary lymph node metastases. Consequently, axillary lymph node status is no longer the single prognostic guide for recommendations about adjuvant systemic therapy. For treatment of the axilla, there is evidence that, in clinical N0 patients, radiation therapy to the axilla is an effective alternative to axillary dissection. Finally, there are cost and morbidity considerations for patients undergoing axillary dissection in whom the indications of the procedure are equivocal. In the management of invasive breast cancer, a selective policy toward axillary lymph node dissection should be considered. This review discusses the nonsurgical management of the axilla; ie, radiation therapy to the axilla and observation of the axilla as an alternative to axillary dissection.     

Identification of sentinel and axillary node involvement in breast cancer

Axillary node dissection for breast cancer is important for staging and prognosis. "Sentinel nodes" are the first nodes into which primary cancer drains. Identification, removal and pathological examination of those nodes indicates whether completion of axillary lymphadenectomy is required. The sentinel nodes are identified using a vital dye injected at the primary tumor site. With this technique we were able to identify sentinel nodes in 46 of 48 (95%) women examined. An average of 2.7 +/- 1.2 nodes were identified as sentinel nodes. In 81% of cases there was a correlation between involvement of sentinel nodes and of other axillary nodes as well. In 10% of patients sentinel nodes were involved with tumor while other axillary nodes were negative. The major problem in routine application of this is relationship in surgical decisions is reliable real time pathological identification of lymph node involvement by tumor.     

Peroperative radiologic findings of axillary lymph nodes in breast cancer

The series consists of 49 operable breast cancers, prospectively registered over a five month period. The removed axillary fat was peroperatively radiologically examined by trained radiologist, and the result was reported to the surgeon. Afterwards it was sent to the pathologist for a thorough histopathological examination. Peroperative radiographic examination showed that 30.6% of the resected axillary fat contained less than ten lymph nodes. Subsequent pathological examination found that only 8.2% actually contained less than ten lymph nodes. We conclude that peroperative radiological examination of removed axillary fat is not a reliable method to assess the number of lymph nodes removed during the surgical procedure. In our hands, a careful anatomical dissection removing all axillary fatty tissue and lymphatics including level I and II seems to be the method of choice.     

Lung function after recovery from empyema treated by closed chest tube drainage

In 32 patients 8 years after recovery from unilateral empyema treated by chest tube drainage the pulmonary function was studied. The most frequently occurring abnormalities were diminished dynamic lung compliance, diffusion capacity and perfusion evaluated by scintigraphy. Restrictive patterns were observed only in 2 patients. The greatest abnormalities were observed in patients with extensive empyema, in patients with delay in drainage and with residual radiological changes after recovery.     

Lymphoscintigraphy and radioguided biopsy of the sentinel axillary node in breast cancer

Lymphoscintigraphy associated with radioguided biopsy of the sentinel node (SN) is well established in clinical practice for melanoma. In breast cancer, the SN concept is similarly valid, and lymphoscintigraphy is a useful method for localizing the axillary SN. The aim of this study was to optimize the lymphoscintigraphy technique in association with a gamma ray detecting probe (GDP) for identifying and removing the SN in breast cancer patients. METHODS: Two-hundred fifty patients with operable breast tumor underwent lymphoscintigraphy before surgery. Three different size ranges of 99mTc-labeled colloid particles (<50, <80 and 200-1000 nm) were used, with either subdermal (above tumor) or peritumoral injection. Early and late scintigraphic images were obtained in anterior and oblique projections, and the skin projection of the detected SN was marked. Sentinel nodes were identified and removed with the aid of the GDP during breast surgery; they were tagged separately. Complete axillary dissection followed. In 40 patients, a blue dye was also administered in addition to subdermal radiolabeled colloid to compare blue dye mapping with lymphoscintigraphy localization. RESULTS: Lymphoscintigraphy successfully revealed lymphatic drainage in 245 of 250 patients (98%). The axillary SN was identified in 240 patients (96%). SN biopsy correctly predicted axillary node status in 234 of 240 patients (97.5%). Lymphoscintigraphy and GDP detected the SN most easily and consistently when 200-1000 nm colloid was administered subdermally in an injection volume of 0.4 ml. Blue dye mapping was successful in 30 of 40 patients (75%). In 26 of these patients, the dye and lymphoscintigraphy identified the same node; in 4 cases different nodes were identified. None of these four patients had axillary disease. CONCLUSION: Lymphoscintigraphy is a simple procedure that is well tolerated by patients. Sentinel node identification is more reliable when large-size radiolabeled colloids are injected in a relatively small injection volume (0.4 ml). Use of a GDP greatly facilitates precise pinpointing and rapid removal of the SN.