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Expression of Microphthalmia Transcription Factor in Sentinel Lymph Nodes of Patients with Melanoma  [PDF]
Minia Hellan, Michelle S. Gentile, Luay Ailabouni, George I. Salti
Journal of Cancer Therapy (JCT) , 2011, DOI: 10.4236/jct.2011.22035
Abstract: Background: Sentinel lymph node biopsy is widely used in the management of melanoma patients. Multiple markers are used to stain sentinel lymph node tissue including S100, HMB-45 and melan A with different success. We investigated, for the first time, the use of Microphthalmia transcription factor (Mitf) staining in a larger series of sentinel lymph nodes. Mitf is a transcription factor essential for the development and survival of melanocytes. It has been introduced recently as a sensitive and specific marker for melanomas. Methods: Thirty patients with cutaneous melanoma were included in our study: twenty patients underwent sentinel lymph node biopsy; ten patients underwent complete lymph node dissection for clinically positive disease. Results: Ten out of twenty sentinel lymph nodes were negative for tumor cells and showed no Mitf staining. Out of the ten positive sentinel lymph nodes, eight were also positive for Mitf. Only four out of the ten clinically positive lymph nodes stained for Mitf. Conclusions: We conclude that Mitf can be used as an additional marker for evaluating sentinel lymph nodes in patients with melanoma. In addition, our results imply that Mitf is involved in melanoma differentiation.
Interval Sentinel Lymph Nodes: An Unusual Localization in Patients with Cutaneous Melanoma  [PDF]
A. M. Manganoni,R. Farfaglia,E. Sereni,C. Farisoglio,C. Pizzocaro,D. Marocolo,F. Gavazzoni,L. Pavoni,P. Calzavara-Pinton
Dermatology Research and Practice , 2011, DOI: 10.1155/2011/506790
Abstract: Background. Recent studies have demonstrated that there exists a great variation in the lymphatic drainage in patients with malignant melanoma. Some patients have drainage to lymph nodes outside of conventional nodal basins. The lymph nodes that exist between a primary melanoma and its regional nodal basin are defined “interval nodes”. Interval node occurs in a small minority of patients with forearm melanoma. We report our experience of the Melanoma Unit of University Hospital Spedali Civili Brescia, Italy. Methods. Lymphatic mapping using cutaneous lymphoscintigraphy (LS) has become a standard preoperative diagnostic procedure to locate the sentinel lymph nodes (SLNs) in cutaneous melanoma. We used LS to identify sentinel lymph nodes biopsy (SLNB) in 480 patients. Results. From over 2100 patients affected by cutaneous melanoma, we identified 2 interval nodes in 480 patients with SLNB . The melanomas were both located in the left forearm. The interval nodes were also both located in the left arm. Conclusion. The combination of preoperative LS and intraoperative hand-held gamma detecting probe plays a remarkable role in identifying these uncommon lymph node locations. Knowledge of the unusual drainage patterns will help to ensure the accuracy and the completeness of sentinel nodes identification. 1. Introduction Recent studies have demonstrated that there exists a great variation in the lymphatic drainage among patients with malignant melanoma [1–11]. While most melanomas show lymphatic drainage to usual nodal basins (axillary, inguinal, and cervical regions), some patients also have drainage to lymph nodes outside these regions [5, 6, 9, 12]. Lymphatic nodes in the area between the primary melanoma and the regional basins are called “in-transit nodes”, “interval nodes”, or “interval sentinel lymph nodes”, and by definition are also SLNs [2–5, 9, 10]. We describe our experience at the Melanoma Unit of University Hospital Spedali Civili Brescia, Italy. 2. Materials and Methods A retrospective study was performed considering 480 patients selected from over 2100 Caucasian patients affected by cutaneous melanoma with SLNB. These patients were followed up by the Melanoma Unit of University Hospital Spedali Civili Brescia, Italy. All patients gave an informed consent to be entered into the database. They were staged with the use of American Joint Committee on Cancer (AJCC) staging classification [13–15]. The combination of preoperative LS and intraoperative hand-held gamma detecting probe allows detection of the SLNs in 99,0% of the patients with malignant
Quantitative Measurement of Melanoma Spread in Sentinel Lymph Nodes and Survival  [PDF]
Anja Ulmer ,Klaus Dietz,Isabelle Hodak,Bernhard Polzer,Sebastian Scheitler,Murat Yildiz,Zbigniew Czyz,Petra Lehnert,Tanja Fehm,Christian Hafner,Stefan Schanz,Martin R?cken,Claus Garbe,Helmut Breuninger,Gerhard Fierlbeck,Christoph A. Klein
PLOS Medicine , 2014, DOI: 10.1371/journal.pmed.1001604
Abstract: Background Sentinel lymph node spread is a crucial factor in melanoma outcome. We aimed to define the impact of minimal cancer spread and of increasing numbers of disseminated cancer cells on melanoma-specific survival. Methods and Findings We analyzed 1,834 sentinel nodes from 1,027 patients with ultrasound node-negative melanoma who underwent sentinel node biopsy between February 8, 2000, and June 19, 2008, by histopathology including immunohistochemistry and quantitative immunocytology. For immunocytology we recorded the number of disseminated cancer cells (DCCs) per million lymph node cells (DCC density [DCCD]) after disaggregation and immunostaining for the melanocytic marker gp100. None of the control lymph nodes from non-melanoma patients (n = 52) harbored gp100-positive cells. We analyzed gp100-positive cells from melanoma patients by comparative genomic hybridization and found, in 45 of 46 patients tested, gp100-positive cells displaying genomic alterations. At a median follow-up of 49 mo (range 3–123 mo), 138 patients (13.4%) had died from melanoma. Increased DCCD was associated with increased risk for death due to melanoma (univariable analysis; p<0.001; hazard ratio 1.81, 95% CI 1.61–2.01, for a 10-fold increase in DCCD + 1). Even patients with a positive DCCD ≤3 had an increased risk of dying from melanoma compared to patients with DCCD = 0 (p = 0.04; hazard ratio 1.63, 95% CI 1.02–2.58). Upon multivariable testing DCCD was a stronger predictor of death than histopathology. The final model included thickness, DCCD, and ulceration (all p<0.001) as the most relevant prognostic factors, was internally validated by bootstrapping, and provided superior survival prediction compared to the current American Joint Committee on Cancer staging categories. Conclusions Cancer cell dissemination to the sentinel node is a quantitative risk factor for melanoma death. A model based on the combined quantitative effects of DCCD, tumor thickness, and ulceration predicted outcome best, particularly at longer follow-up. If these results are validated in an independent study, establishing quantitative immunocytology in histopathological laboratories may be useful clinically. Please see later in the article for the Editors' Summary
Sentinel lymph nodes and breast carcinoma : Analysis of 70 cases by frozen section  [cached]
Al-Shibli Khalid,Mohammed Hiba,Mikalsen Kari
Annals of Saudi Medicine , 2005,
Abstract: BACKGROUND : The sentinal node biopsy (SNB) is a reliable method for determining the status of the regional lymph nodes in patients with breast cancer. SNB technology is evolving rapidly, but no standardization has yet been accomplished. The aim of this study is to discuss the accuracy of this procedure and the optimal method for identifying micrometastases. METHODS : We collected data from 70 women with primary invasive breast carcinoma who underwent SNB for breast cancer. We examined two frozen sections levels from each half of each lymph node, as well as a cytology imprint before arriving at the frozen section diagnosis. Immunohistochemistry with pancytokeratin (AE1/AE3) was done on the paraffin sections. For the association between the lymph node size and the possibility of metastases, Student′s t test was used and a P value of less than 0.05 was regarded as significant. RESULTS : The number of patients with metastases in SNB was 19, from which 15 cases were correctly diagnosed in frozen sections/imprints and four cases were false negative. The axillary toilet from all cases with SNB metastases smaller than 2 mm showed no additional positive nodes. Lymph node diameter showed a significant association with sentinel node status ( P < 0.0001). CONCLUSION : Frozen section examination of SNB from patients with breast carcinoma is both specific (100%) and sensitive (79%). Diagnosis of lobular carcinoma can be difficult, and may require immunohistochemistry with cytokeratin for diagnosis. Small metastases in a non-optimal frozen section may be difficult to discern. Cytology imprints add nothing to the diagnosis.
The Prognostic Value of Minimally Involved Melanoma Sentinel Lymph Nodes  [PDF]
Alend Saadi, Didier Roulin, Essia Saiji, Hanifa Bouzourene, Nicolas Demartines, Maurice Matter
Journal of Cancer Therapy (JCT) , 2013, DOI: 10.4236/jct.2013.410180
Abstract:

Background: Sentinel node (SLN) status is the most important prognostic factor for early-stage melanoma patients. It will influence follow-up and may change therapy. Positive SLNs present different degrees of involvement so that subgroups of patients may have minimal SLN invasion. The aim of this study was to evaluate survival in subgroups with minimally involved SLNs and to compare them to negative SLN patients. Method: SLN biopsy was performed in 499 consecutive clinically N0 patients between 1997 and 2008. Following updated recommendations from the Melanoma Group of the European Organization of Research and Treatment of Cancer, degrees of SLN involvement were fully reassessed for two anatomopathological parameters: tumour burden according to Rotterdam criteria (<0.1 mm, 0.1 - 1.0 mm, and >1.0 mm) and microanatomic location according to Dewar (subcapsular, combined subcapsular and parenchymal, parenchymal, multifocal, or extensive). Minimally involved SLNs were defined as those with tumor burden <0.1 mm and/or subcapsular metastasis location. Kaplan-Meier and multivariable logistic regression analyses were performed. Results: Out of 499 clinically N0 patients, positive SLNs were found in 123 patients (24.7 percent). With a median follow-up of 52 months (range: 9 - 146), five-year disease-free (DFS), disease-specific survival (DSS) and overall survival (OS) were 88.1, 93.9 and 89.9 percent for negative SLN patients, respectively. In minimally involved SLNs, there were 21 with tumour burden <0.1 mm, and 52 with subcapsular metastasis. Five-year DFS, DSS and OS in these sub-groups were 79.6, 86.6 and 86.6 percent, then 57.3, 69.8 and 67.8 percent respectively. DFS univariable analysis of these sub-groups compared to negative SLNs showed: (HR1.89, 95 percent CI 0.75 - 4.79; p 0.175) and (HR 3.92, 95 percent CI 2.29 - 6.71; p < 0.0001) respectively. Minimally involved sub-groups were not predictive for NSLN negativity. Conclusion: Rotterdam’s tumour burden stratification is an easy and useful prognostic factor of melanoma survival. There was a trend showing that patients with SLN tumour burden <0.1 mm have a lower survival compared to SLN negative patients. One might suggest that patients with minimally involved SLNs may not be managed similarly to negative SLN patients. Subcapsular metastasis subgroup according to the microanatomic location has statistically significant worst

Molecular Subtype Classification Is a Determinant of Non-Sentinel Lymph Node Metastasis in Breast Cancer Patients with Positive Sentinel Lymph Nodes  [PDF]
Wenbin Zhou, Zhongyuan He, Jialei Xue, Minghai Wang, Xiaoming Zha, Lijun Ling, Lin Chen, Shui Wang, Xiaoan Liu
PLOS ONE , 2012, DOI: 10.1371/journal.pone.0035881
Abstract: Background Previous studies suggested that the molecular subtypes were strongly associated with sentinel lymph node (SLN) status. The purpose of this study was to determine whether molecular subtype classification was associated with non-sentinel lymph nodes (NSLN) metastasis in patients with a positive SLN. Methodology and Principal Findings Between January 2001 and March 2011, a total of 130 patients with a positive SLN were recruited. All these patients underwent a complete axillary lymph node dissection. The univariate and multivariate analyses of NSLN metastasis were performed. In univariate and multivariate analyses, large tumor size, macrometastasis and high tumor grade were all significant risk factors of NSLN metastasis in patients with a positive SLN. In univariate analysis, luminal B subgroup showed higher rate of NSLN metastasis than other subgroup (P = 0.027). When other variables were adjusted in multivariate analysis, the molecular subtype classification was a determinant of NSLN metastasis. Relative to triple negative subgroup, both luminal A (P = 0.047) and luminal B (P = 0.010) subgroups showed a higher risk of NSLN metastasis. Otherwise, HER2 over-expression subgroup did not have a higher risk than triple negative subgroup (P = 0.183). The area under the curve (AUC) value was 0.8095 for the Cambridge model. When molecular subtype classification was added to the Cambridge model, the AUC value was 0.8475. Conclusions Except for other factors, molecular subtype classification was a determinant of NSLN metastasis in patients with a positive SLN. The predictive accuracy of mathematical models including molecular subtype should be determined in the future.
Clinical Relevance of Nonvisualized Sentinel Lymph Nodes in Unselected Breast Cancer Patients during Lymphoscintigraphy  [PDF]
Yung-Feng Lo,Swei Hsueh,Shih-Ya Ma,Shin-Cheh Chen
Chang Gung Medical Journal , 2005,
Abstract: Background: Sentinel lymph node (SLN) biopsy in breast cancer is an effective techniquewith a high degree of accuracy and low false-negative rate to replace axillarylymph node dissection (ALND). This study analyzed the major clinicopathologicalfactors associated with nonvisualized sentinel nodes during preoperativelymphoscintigraphy.Methods: Breast cancer patients who underwent preoperative lymphoscintigraphy andsentinel node biopsy between 2000 and 2003 were retrospectively reviewed.Sentinel node biopsy was performed with a two-day protocol. On day one, afiltered (45 m Millipore) technetium-99m sulfur colloid isotope with amean radioactive dose of 37 MBq (1 mCi) in a diluted volume of 1 ml wasinjected subdermally just above the primary breast tumor site. Serial dynamicimages were taken with a high-resolution collimator and a static imagewas acquired after the SLN was identified. No hot spot identified two hoursafter injection was classified as nonvisualization unless lymphatic drainagechannels were viewed by the lymphoscintigraphy and a prolonged two hourscan was obtained. Sentinel nodes were harvested on day two. The caseswith nonvisualized sentinel nodes were analyzed according to clinicalhistopathologic parameters to determine the clinical significance.Results: A total of two hundred thirty-two breast cancer patients were enrolled in thisstudy. Twenty-four of these cases presented with advanced breast cancerprior to neoadjuvant chemotherapy. The sentinel node was nonvisualized intwenty-seven of two hundred thrity-two cases (11.6%). Tumor size (p =0.025) and lymph node metastasis (p = 0.001) were two factors associatedwith nonvisualized sentinel node in univariate analysis. Multivariate logisticregression analysis showed that more than three nodes (p = 0.001) and morethan ten nodes (p = 0.001) metastasis were independent factors associatedwith nonvisualized sentinel node.Conclusions: Patients with more than three axillary nodes metastasis is an independentfactor associated with nonvisualized sentinel node during lymphoscintigraphy.
Evaluation of the Benefit of Routine Intraoperative Frozen Section Analysis of Sentinel Lymph Nodes in Breast Cancer  [PDF]
C. M. T. P. Francissen,R. F. D. van la Parra,A. H. Mulder,A. M. Bosch,W. K. de Roos
ISRN Oncology , 2013, DOI: 10.1155/2013/843793
Abstract: Aims. Intraoperative analysis of the sentinel lymph node (SLN) by frozen section (FS) allows for immediate axillary lymph node dissection (ALND) in case of metastatic disease in patients with breast cancer. The aim of this study is to evaluate the benefit of intraoperative FS, with regard to false negative rate (FNR) and influence on operation time. Materials and Methods. Intraoperative analysis of the SLN by FS was performed on 628 patients between January 2005 and October 2009. Patients were retrospectively studied. Results. FS accurately predicted axillary status in 525 patients (83.6%). There were 78 true positive findings (12.4%), of which there are 66 macrometastases (84.6%), 2 false positive findings (0.3%), and 101 false negative findings (16.1%), of which there are 65 micrometastases and isolated tumour cells (64.4%) resulting in an FNR of 56.4%. Additional operation time of a secondary ALND after wide local excision and SLNB is 17 minutes, in case of ablative surgery 35 minutes. The SLN was negative in 449 patients (71.5%), making their scheduled operation time unnecessary. Conclusions. FS was associated with a high false negative rate (FNR) in our population, and the use of telepathology caused an increase in this rate. Only 12.4% of the patients benefited from intraoperative FS, as secondary ALND could be avoided, so FS may be indicated for a selected group of patients. 1. Introduction Axillary lymph node status is still considered the most important prognostic factor in patients with breast cancer. With the ongoing improvement of breast cancer screening programs, more patients are diagnosed at an earlier stage, leading to less nodal involvement. Sentinel lymph node biopsy (SLNB) has been established as a reliable method to evaluate the lymph node status of the axilla, making standard axillary lymph node dissection (ALND) unnecessary. Compared to ALND, SLNB is associated with less morbidity. Intraoperative analysis of the sentinel node by frozen section (FS) allows for immediate ALND when a metastasis is found in the sentinel node, thus avoiding a second procedure. However, among the drawbacks of FS are (1) the possibility of false negative and false positive results and (2) increase in operation time, because extra time is scheduled in advance in case the FS turns out to be positive. The sensitivity of FS has been reported to range from 58% to 76%, depending on tumour characteristics (e.g., tumour size) and the method of pathological examination [1–6]. This study was designed to evaluate the benefit of FS in our hospital, with regard to the
Intraoperative frozen section assessment of sentinel lymph nodes in the operative management of women with symptomatic breast cancer
Rohanna Ali, Ann M Hanly, Peter Naughton, Constantino F Castineira, Rob Landers, Ronan A Cahill, R Gordon Watson
World Journal of Surgical Oncology , 2008, DOI: 10.1186/1477-7819-6-69
Abstract: The accuracy of intraoperative frozen section (FS) of sentinel nodes was determined in 94 consecutive women undergoing surgery for clinically node negative, invasive breast cancer (37:T1 disease; 43:T2; 14:T3). Definitive evidence of lymphatic spread on FS indicated immediate level II axillary clearance while sentinel node "negativity" on intraoperative testing led to the operation being curtailed to allow formal H&E analysis of the remaining sentinel nodal tissue.Intraoperative FS correctly predicted axillary involvement in 23/30 patients with lymphatic metastases (76% sensitivity rate) permitting definitive surgery to be completed at the index operation in 87 women (93%) overall. All SN found involved on FS were confirmed as harbouring tumour cells on subsequent formal specimen examination (100% specificity and positive predictive value) with 16 patients having additional non-sentinel nodes found also to contain tumour. Negative Predictive Values were highest in women with T1 tumours (97%) and lessened with more local advancement of disease (T2 rates: 86%; T3: 75%). Of those with falsely negative FS, three had only micrometastatic disease.Intraoperative FS reliably evaluates the status of the sentinel node allowing most women complete their surgery in a single stage. Thus SN can be offered with increased confidence to those less likely to have negative axillae hence expanding the population of potential beneficiaries.Sentinel lymph node (SLN) biopsy is now established as an accurate, minimally invasive means of providing regional staging for primary breast cancer. As axillary clearance remains the standard of care for those with nodal spread[1], many centres however confine the use of SLN mapping to women with "early" or "small" breast cancer (i.e. T1 cancers in most instances)[2]. However, such a strategy deprives the benefits of minimally invasive lymphatic staging from those women who have disease that is locally advanced but still contained within the breast.
High Prevalence of Human Cytomegalovirus Proteins and Nucleic Acids in Primary Breast Cancer and Metastatic Sentinel Lymph Nodes  [PDF]
Chato Taher, Jana de Boniface, Abdul-Aleem Mohammad, Piotr Religa, Johan Hartman, Koon-Chu Yaiw, Jan Frisell, Afsar Rahbar, Cecilia S?derberg-Naucler
PLOS ONE , 2013, DOI: 10.1371/journal.pone.0056795
Abstract: Background Breast cancer is a leading cause of death among women worldwide. Increasing evidence implies that human cytomegalovirus (HCMV) infection is associated with several malignancies. We aimed to examine whether HCMV is present in breast cancer and sentinel lymph node (SLN) metastases. Materials and Methods Formalin-fixed paraffin-embedded tissue specimens from breast cancer and paired sentinel lymph node (SLN) samples were obtained from patients with (n = 35) and without SLN metastasis (n = 38). HCMV immediate early (IE) and late (LA) proteins were detected using a sensitive immunohistochemistry (IHC) technique and HCMV DNA by real-time PCR. Results HCMV IE and LA proteins were abundantly expressed in 100% of breast cancer specimens. In SLN specimens, 94% of samples with metastases (n = 34) were positive for HCMV IE and LA proteins, mostly confined to neoplastic cells while some inflammatory cells were HCMV positive in 60% of lymph nodes without metastases (n = 35). The presence of HCMV DNA was confirmed in 12/12 (100%) of breast cancer and 10/11 (91%) SLN specimens from the metastatic group, but was not detected in 5/5 HCMV-negative, SLN-negative specimens. There was no statistically significant association between HCMV infection grades and progesterone receptor, estrogen receptor alpha and Elston grade status. Conclusions The role of HCMV in the pathogenesis of breast cancer is unclear. As HCMV proteins were mainly confined to neoplastic cells in primary breast cancer and SLN samples, our observations raise the question whether HCMV contributes to the tumorigenesis of breast cancer and its metastases.
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