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PubMed1986

[Breast conservation surgery with irradiation in breast cancer].

For the treatment of patients with early breast cancer, breast conservation surgery with irradiation is gaining world wide acceptance as opposed to more mutilating operations. In Japan, however, most surgeons and radiation oncologists are still unfamiliar with this technique. To achieve optimum functional and cosmetic results, understanding the philosophy and details of the technique is of primary importance. We propose a method of executing the procedures. Tumor excision with a tumor-free margin and breast irradiation with tangential fields are the essential part of the treatment. The entire breast should not receive more than 50 Gy. Limited axillary dissection is used for deciding the indications for chemotherapy, and it is necessary to obtain more than five nodes. Irradiation to the lymph nodes is optional.

Breast Neoplasms↗

PubMed2000

Standardized probe-directed sentinel node dissection in melanoma.

BACKGROUND: Radiopharmaceutical agents appear to improve the accuracy of sentinel node (SN) identification in patients with early-stage melanoma, but the optimal radiopharmaceutical agent and its timing from injection to surgery remain controversial. We undertook this investigation to examine the utility of 3 methods of intraoperative lymphatic mapping with radiopharmaceutical-directed sentinel lymphadenectomy (LM/SL). We suspected that concurrent injection of radiopharmaceutical and blue-dye would lead to the greatest success of SN identification. METHODS: The study was composed of 247 consecutive patients who had American Joint Committee on Cancer stage I or II melanoma. Before LM/SL, all patients underwent cutaneous lymphoscintigraphy by 1 of 3 techniques: technetium 99m (Tc 99m) human serum albumin (HSA) injected at least 24 hours before LM/SL (124 patients), Tc 99m filtered sulfur colloid (SC) injected no more than 4 hours before LM/SL (same-day SC, 95 patients), or Tc 99m SC injected at least 18 hours before LM/SL (prior-day SC, 28 patients). At the time of LM/SL, isosulfan blue dye was injected alone (SC groups) or with a second dose of HSA (HSA group). A hand-held gamma probe was used to determine the radioactive (hot) counts of blue-stained and nonstained nodes, and the in vivo and ex vivo node-to-background count ratios of the nodes were compared. RESULTS: Preoperative LS identified 299 drainage basins; LM/SL identified at least 1 SN in 119 (98%) of 121 basins using same-day SC, 142 (97%) of 146 basins using HSA, and 32 (100%) of 32 basins using prior-day SC. There was no difference (P = .62) in the accuracy rate between the 3 techniques. The total number of SNs was 463. Same-day SC yielded higher intraoperative node-to-background count ratios than did either of the other techniques (P < .0001). Same-day SC also had the greatest relative change in radioactivity between the blue sentinel node and the post-excision basin (P < .0001), and the highest rate of SNs that were both blue and hot (in vivo or ex vivo ratio > or = 2, P = .05). CONCLUSIONS: LS and LM/SL performed on the same day with a single injection of filtered Tc 99m SC serves as the most useful method for probe-directed LM/SL. This technique demonstrated the highest in vivo and ex vivo count ratios, fall-off of radioactivity between the excised nodes and post-excision basin, and concordance between blue dye and hot nodes. It should be recommended as the method of choice for probe-directed LM/SL.

Humans↗

PubMed2000

Identification of the sentinel node in patients with breast cancer.

Sentinel node analysis represents a significant advance in the diagnosis and treatment of invasive breast cancer. The traditional crude method of full axillary dissection for assessing the status of the axillary nodes can now be discarded in favor of the much more elegant and modern approach of minimally invasive sentinel node analysis and its attendant elimination of the morbidity of traditional axillary node dissection. The many impediments to and pitfalls in the technique of sentinel node analysis, however, must be recognized and overcome for the procedure to be reliable and consistently successful. The use of ultrasound and a smaller particle size can help overcome many of these pitfalls. Because ultrasound identification of the axillary sentinel node in patients with invasive breast cancer is possible, it may allow for percutaneous excision of these nodes in the future (Fig. 8). Combining percutaneous excision and ablation of the primary breast carcinoma with percutaneous excision of the sentinel node allows for the nonsurgical treatment of small breast cancers in the future. The modern breast radiologist should be at the forefront of these advances.

Axilla↗

PubMed1995

Non-tuberculous mycobacterial lymphadenopathy.

The surgical and antimicrobial treatment of non-tuberculous mycobacterial lymphadenopathy in 17 children was reviewed. Node excision was curative, but most nodes were still incised leaving discharging lesions. Standard antituberculous treatment was unhelpful, but a new macrolide/quinolone combination appeared to be effective in three cases.

Antitubercular Agents↗

PubMed2002

Internal mammary node lymphoscintigraphy and biopsy in breast cancer.

BACKGROUND: In patients with breast cancer, sentinel nodes (SNs) are detected outside the axilla in 1-2% of cases after superficial injection of radiocolloid in the breast. We investigated whether deep injection of tracer visualized internal mammary chain lymph (IMC) nodes more often, and assessed the impact of IMC status on disease staging. METHODS: A total of 400 patients were enrolled in this trial. The study group included 200 patients with T1-T2 N0 breast cancer in an inner quadrant. Radio tracer was injected superficially in 100 (group A), and deeply under the tumor in the others (group B). If an IMC took up tracer in group B patients it was biopsied. An additional 200 patients with outer quadrant lesions were also studied lymphoscintigraphically following superficial (100 patients) or deep (100 patients) injection, but IMC nodes were not biopsied as this would have required an additional surgical excision. RESULTS: An SN was visualized in the IMC in 65.6% of inner quadrant patients after deep injection and in 2.1% after superficial injection. In outer quadrant patients, deep injection visualized an SN in the IMC in 10% of cases. The IMC SN was located mainly in the 2nd and 3rd intercostal spaces. Radioguided IMC biopsy was performed in 62 patients. Node removal proved simple and risks insignificant. Stage migration occurred in 8% of cases. CONCLUSIONS: Deep injection allows SN localization in the IMC in 65% of inner quadrant breast lesions. Biopsy of the axillary plus IMC resulted in stage migration in 8% of patients. It is unclear whether this additional information can lead to better survival.

Adult↗

PubMed1999

Sentinel lymphadenectomy for breast cancer: experience with 180 consecutive patients: efficacy of filtered technetium 99m sulphur colloid with overnight migration time.

BACKGROUND: Axillary node status remains the most important prognostic indicator of survival in breast cancer patients. Only 25% to 35% of patients having standard level I/II axillary dissection have involved nodes, yet all accept the potential for morbidity after the operation. This study was conducted to assess whether status of the sentinel node(s) was an accurate predictor of the presence of metastatic disease in axillary or internal mammary nodes. STUDY DESIGN: In 180 patients, technetium 99m sulphur colloid was injected in a 4-quadrant peritumoral distribution. During the first phase of the study, 72 patients had sentinel node excision followed by a level I/II axillary dissection. During the second phase of the study, 108 patients had sentinel node excision and only those with positive nodes had completion axillary dissection. Nodes were examined after formalin fixation by taking 10 sections at 20-microm intervals and staining with hematoxylin-eosin. RESULTS: Sentinel nodes were found in 162 (90%) of 180 patients. The mean number of sentinel nodes examined was 3.1. Of the 162 patients with successful lymphatic mapping, positive sentinel nodes were found in 44 (27%). In 23 (66%) of 35 patients with positive sentinel nodes who had a completion level I/II axillary dissection, the sentinel nodes were the only positive nodes. The concurrent negative predictive value was 4% in the first 72 patients who had completion axillary dissection after sentinel node excision, and 2% for the entire series. With evolution of technique, identification of sentinel nodes with radiolabeled colloid was successful in 97% of the last 100 patients. CONCLUSIONS: Because the concurrent negative predictive value was low, sentinel node excision appeared to accurately identify node status, potentially avoiding the need for standard level I/II axillary dissection in sentinel node-negative patients.

Axilla↗

PubMed1997

Intraoperative lymphatic mapping for early-stage melanoma of the head and neck.

BACKGROUND: We previously reported dye-directed intraoperative lymphatic mapping and selective sentinel lymphadenectomy for primary cutaneous melanomas draining to the neck lymph nodes. In this study we determined whether combining the dye with a radiopharmaceutical agent would enhance our rate of sentinel node detection. METHODS: One hundred seventeen patients with primary cutaneous melanomas of the upper chest and head and neck underwent preoperative cutaneous lymphoscintigraphy to confirm lymphatic drainage to neck nodes, followed by intraoperative lymphatic mapping and sentinel lymphadenectomy. In 94 cases, isosulfan blue dye was injected at the primary site; in the remaining 23 cases, a 1:3 mixture of radiopharmaceutical and dye was injected, and a hand-held probe was used to determine the radioactive counts. RESULTS: Preoperative cutaneous lymphoscintigraphy identified 129 drainage basins; 12 patients (10%) had dual-basin drainage. During intraoperative lymphatic mapping and sentinel lymphadenectomy, 183 sentinel nodes were identified and excised from 120 basins (1.5 nodes/basin). The blue dye alone identified sentinel nodes in 93 of 101 basins (92%). The probe identified sentinel nodes in 28 of 28 basins, only one of which failed to reveal blue-staining sentinel nodes; thus, the probe plus dye identified sentinel nodes in 27 of 28 basins (96%). Histopathologic analysis revealed metastasis in sentinel nodes from 11 patients (12%) who underwent sentinel lymphadenectomy with blue dye alone and in 3 patients (13%) who underwent sentinel lymphadenectomy with dye plus probe. There were no same-basin recurrences over a mean follow-up of 46 months (range 1 to 125). CONCLUSIONS: Selective sentinel lymphadenectomy is a highly accurate method of staging the regional nodes in patients with primary tumors of the head and neck. Although we initially demonstrated the utility of this technique with blue dye alone, our results now suggest that the combination of dye and radiopharmaceutical may be a more sensitive method to detect sentinel nodes.

Coloring Agents↗

PubMed1998

Intraoperative localization of the sentinel node in breast cancer: technical aspects of lymphoscintigraphic methods.

Axillary lymph node dissection is an important part of the surgical treatment of breast cancer as a staging procedure. Recent progressive advances in early detection have led to the treatment of small primary carcinomas; thus, a great number of axillary dissections show completely negative lymph nodes. The sentinel node (SN) concept, developed for melanoma patients, seems to be similarly valid in breast cancer and has the potential to change the standard surgical approach in these patients. To verify the accuracy of lymphoscintigraphic method associated with radioguided biopsy of the sentinel node in a large series of patients, we studied 382 patients with operable breast cancer. Lymphoscintigraphy (LS) was performed the day before surgery; three different-sized ranges of 99mTechnetium-labeled colloid particles were injected either by subdermal or peritumoral administration. Planar scans were registered in anterior and oblique projections, and a cutaneous marker was placed over the skin corresponding to the SN as visualized. SNs were localized and removed during surgery, using a gamma-detecting probe (GDP); total axillary dissection was then performed. In 54 patients, blue dye was also administrated in the tumor bed immediately after excision of the primary. LS identified at least one SN in 377 of 382 cases (98.7%). Axillary SN was localized in 371 cases (97.1%). The overall concordance between SN status and other axillary nodes was 96.8% (359 of 371). Localization of the SN was easier when large-size particles of colloidal albumin were injected in a volume of 0.4 ml. GDP successfully localized SN in 54/54 cases (100%), while blue dye identified SN in 37/54 patients (68.5%). In 33 of 37 cases (89%) the dye and LS identified the same node. LS and GDP-guided surgery provide accurate identification and removal of the SN, particularly when large-size radiolabeled colloids are injected in a small volume.

Axilla↗

PubMed2000

How many lymph nodes are enough during sentinel lymphadenectomy for primary melanoma?

BACKGROUND: Sentinel lymph node (SLN) biopsy has been shown to reliably identify nodal metastases and the subsequent need for further surgical and adjuvant therapy in patients with cutaneous melanoma. Although SLN identification rates have improved with the addition of radioactive colloid to the blue dye technique, it remains unclear how many lymph nodes should be removed to accurately determine the histologic status of the nodal basin. The objective of this study was to determine the optimal extent of SLN biopsy in these patients. METHODS: The records of 633 consecutive patients with melanoma (765 nodal basins) whose primary treatment included SLN biopsy with the use of a combination of blue dye and technetium Tc 99 labeled sulfur colloid were reviewed. SLN biopsy consisted of the removal of all of the blue-stained nodes and all nodes with radiotracer uptake activity of at least twice background. RESULTS: SLN biopsy was successful in 765 of 772 basins (99%). A mean of 1.9 SLNs (median, 2 SLNs) per basin were excised. At least 3 SLNs were removed in 176 basins (23%). The overall histologic status of a basin was always established by the first or second SLN harvested (ie, in no patient was the third or subsequent SLN positive when 1 of the first 2 was not). Of the 124 basins containing lymphatic metastases, the SLN that contained the maximal radiotracer uptake (hottest) and/or stained blue was pathologically positive in 118 basins (95%). In only 6 of the 124 positive basins (5%) was the sole evidence of occult nodal metastases identified in an SLN that was neither blue-stained nor the hottest. All but 1 of these SLNs had counts that were at least 66% of the hottest node in the basin. CONCLUSIONS: With a combined modality approach to SLN biopsy, removal of more than 2 SLNs did not provide information that upstaged any patient with primary melanoma. Removal of additional nonblue SLN(s) that contained radioactive counts of at least twice background but lower than two thirds of the SLNs with maximal radiotracer uptake affected patient management in less than 0.2% of all cases. These findings may be helpful in minimizing the extent of surgery and perhaps in reducing the costs and resource use associated with operating room time and pathologic examination.

Biopsy↗

PubMed1995

Surgical management of melanoma.

The incidence of melanoma is rising more rapidly than any other malignancy. More conservative margins of excision have been established and the role of elective node dissection awaits determination by prospective randomized trials. Lymphoscintigraphy has clarified lymphatic drainage from watershed areas. Lymphatic mapping and sentinel node biopsy may lead to acceptance of selective lymphadenectomy, and also allows for more sensitive staging. Further advances in outcome require the development of effective systemic adjuvant therapies. Until such time, surgery continues to play a pivotal role in all stages.

Biopsy↗

PubMed2006

[Melanoma].

The definition of the TNM classification and staging system of malignant melanoma have been fundamentally revised. Moreover, several clinical guidelines for the management of this neoplasm were recently proposed. Advances in surgical procedures are excision of primary lesions with narrow margin and introduction of sentinel node biopsy, which contribute to maintain the good quality of life of patients. The significance of high-dose interferon-alpha as adjuvant therapy is still controversial. No effective chemotherapy or biotherapy has been established to date, however, interesting new findings were recently reported in the fields of immunotherapy and molecular targeting therapy.

Combined Modality Therapy↗

PubMed1998

What's new in the treatment of cutaneous melanoma?

As surveyors of the skin, it is important for dermatologists to be aware of recent developments in the management of melanoma. Revised recommendations for surgical margins will be reviewed as will the use of Mohs micrographic surgery for the excision of melanoma, in particular lentigo maligna. An explanation of the technique of sentinel node biopsy is followed by a discussion of the results of recent clinical trials. Adjuvant immunotherapy in the form of vaccines and high-dose alpha-interferon is outlined as is the concept of biochemotherapy for more advanced disease.

Antineoplastic Combined Chemotherapy Protocols↗

PubMed1983

Considerations of cost and effectiveness in the choice of mastectomy.

Operable breast cancer may be managed equally well by a number of different regimens of mastectomy and/or radiotherapy. This paper examines the financial and morbidity costs, together with the node sampling efficacy, of three commonly employed techniques: simple mastectomy; total mastectomy with node biopsy or limited node excision; and modified radical mastectomy. Adjuvant radiotherapy (and/or chemotherapy) can only be applied rationally if node sampling is effective. Simple mastectomy cannot achieve this. Total mastectomy, providing that a node sample is obtained, is effective, and is probably the cheapest option. Total axillary clearance runs the risk of increased morbidity (and financial cost), while not necessarily guaranteeing more effective node sampling. Much of the cost and morbidity of mastectomy may be reduced by a limited but rational radiation policy.

Breast Neoplasms↗

PubMed1990

Results of conservative surgery and radiation therapy for breast cancer.

For stage I or II breast cancer, conservative surgery and radiation therapy are as effective as modified radical or radical mastectomy. In most cases, cosmetic considerations and the availability of therapy are the primary concerns. The extent of a surgical resection less than a mastectomy has not been a subject of a randomized trial and is controversial. It appears that removal of a quadrant of the breast for small lesions is safe but excessive. Using histologic findings in the biopsy as a guide, it may be possible to limit the breast resection to gross tumor removal for most patients while using wider resections for patients with an extensive intraductal component or for invasive lobular carcinoma. It also appears that excluding patients from breast conservation on the basis of positive margins on the first attempt at tumor excision may be unnecessarily restrictive. Although patients with an extensive intraductal component or invasive lobular carcinoma should have negative margins, it appears that a patient with predominantly invasive ductal carcinoma can be treated without re-excision if all gross tumor has been resected and there is no reason to suspect extensive microscopic disease. Patients with indeterminate margins should have a re-excision. Axillary dissection provides prognostic information and prevents progression of the disease within the axilla. Axillary dissections limited to level I will accurately identify a substantial number of patients who have pathologically positive but clinically negative nodes. When combined with radiation therapy to the axilla, a level I dissection results in a limited number of patients with progressive axillary disease. Patients with pathologically positive axillas and patients at particularly high risk for systemic disease because of the extent of axillary node involvement can be identified by dissections of levels I and II. Radiation therapy can be avoided safely in patients who have pathologically negative axillas by level I and II dissection. There appears to be no advantage to routine dissection of level III lymph nodes. Lymphedema of the arm and breast increases with more extensive dissections and with radiation therapy.

Axilla↗

PubMedDate not supplied

Nontuberculous mycobacterial adenitis in children: diagnostic and therapeutic management.

We reviewed a series of 45 patients affected by nontuberculous mycobacterial adenitis of the neck observed in the Ear, Nose, and Throat Institute of S. Orsola-Malpighi Hospital-Bologna over a 20-year period between 1981 and 2001. The mean age was 5.5 years. Patients were tested by using the differential Mantoux test, which was the principal diagnostic tool in the case of atypical mycobacterial infections. Forty-two patients were surgically treated by total excision of infected nodes, whereas parotidectomy with sparing of facial nerve was performed in those 3 cases with intraparotid nodes involvement. In all cases, the histopathological diagnosis was tubercular granulomatous lymphadenitis. The culture growth of nontuberculous mycobacteria was positive in 13 cases with a marked prevalence of the avium-intracellular germs. The disease was eradicated in all patients. The diagnostic and therapeutic management of nontuberculous mycobacterial adenitis is discussed in this retrospective study.

Anti-Bacterial Agents↗

PubMedDate not supplied

Importance of the footpad lesion in the mouse response to local inoculation of Mycobacterium marinum.

The importance of the footpad lesion was studied in CBA mice inoculated in the hind footpad with viable or heat-killed Mycobacterium marinum Popliteal or popliteal and inguinal lymphadenectomy was followed by modest enhancement of the process only when node excision was carried out 6 days after inoculation of a small number of viable organisms. Following inoculation in the footpad of a large number of heat-killed organisms, only 10% of the inoculum was recovered from the site of inoculation, only 0.1% from the popliteal node and even less from the inguinal node and spleen. Despite the small proportion of inoculated M. marinum remaining in the footpad, amputation of the inoculated foot as early as 4 days after inoculation abrogated the protective effects of the inoculation, whereas amputation performed 7 days after inoculation was without effect.

Amputation, Surgical↗

PubMed2004

Interpectoral nodes as the initial site of recurrence in breast cancer.

HYPOTHESIS: Interpectoral nodes can be the initial site of recurrent breast cancer. DESIGN: Retrospective review. SETTING: Comprehensive breast center, located in a university-based tertiary care center. PATIENTS: All patients undergoing operations for breast cancer at our breast center from 1995 to 2002 were reviewed. MAIN OUTCOME MEASURES: Patients with interpectoral node recurrence as the initial site of recurrent breast cancer were identified. RESULTS: During the 8-year period, 4097 patients underwent surgical management for breast cancer. During this time, 4 patients (0.1%) had recurrence at the interpectoral nodes. Three of the 4 patients were node-negative at the original operation. All lesions were mammographically occult. Preoperative needle biopsy was effective in the confirmation of malignancy. All 4 underwent excision without complications. CONCLUSIONS: Recurrence at the interpectoral nodes can be the initial site of surgical failure. These nodes may represent the site of primary drainage in a percentage of patients. The sentinel node identification technique, therefore, should diminish the number of patients affected by recurrence at this site. In patients with a palpable mass in the infraclavicular location, however, a high index of suspicion should be maintained. Workup should include additional breast imaging and needle biopsy prior to operation.

Adult↗

PubMed2007

Sentinel node in head and neck cancer: use of size criterion to upstage the no neck in head and neck squamous cell carcinoma.

BACKGROUND: Anatomical imaging tools demonstrate poor sensitivity in head and neck squamous cell carcinoma (HNSCC) patients with clinically node-negative necks (cN0). This study evaluates nodal size as a staging criterion for detection of cervical metastases, utilizing sentinel node biopsy (SNB) and additional pathology (step-serial sectioning, SSS; and immunohistochemistry, IHC). METHODS: Sixty-five patients with clinically N0 disease underwent SNB, with a mean of 2.4 nodes excised per patient. Nodes were fixed in formalin, bisected, and measured in 3 axes before hematoxylin-eosin staining. Negative nodes were subjected to SSS and IHC. SNB-positive patients underwent modified radical neck dissection. RESULTS: Maximum diameter was larger in levels II and III (13.1 and 13.2 mm) when compared with level I (10.5 mm; p = .004, p = .018), while minimum diameter was constant. Positive nodes were larger than negative nodes (p = .007), but nodes found positive by SSS/IHC were not significantly larger than negative nodes for either measurement (p = .433). Sensitivity and specificity were poor for all measurements. CONCLUSIONS: Nodal size is an inaccurate predictor of nodal metastases and should not be regarded as an accurate means of staging the clinically N0 neck.

Carcinoma, Squamous Cell↗