Factores Predictivos de Compromiso Axilar en ocasión de Ganglio Centinela Positivo en Cáncer de Mama Temprano / Predictive Factors of Axillary Compromise on the Occasion of Positive Sentinel Lymph Node in Early Breast Cancer

Introducción: Se ha demostrado en diversos protocolos que, en gran proporción de casos con cáncer de mama en estadíos tempranos y ganglio centinela positivo, no se observa enfermedad metastásica en ganglios linfáticos no centinelas (GNC). A raíz de esto es que se han descripto diferentes factores predictores de metástasis axilar. Esto nos motivó a realizar el presente trabajo. Objetivo: Analizar diferentes factores anatomopatológicos y su influencia en el compromiso metastásico de los ganglios no centinela. Material y método: Se estudiaron casos de cáncer de mama estadíos tempranos (T1-T2) con ganglio centinela positivo y seguidas de vaciamiento axilar, operadas en IMGO entre febrero del año 2000 y diciembre de 2012. De la muestra total se identificaron dos grupos: GnC negativos y GnC positivos. Analizamos diferentes variables anatomopatológicas vinculadas a cada grupo y calculamos su grado de significancia. Finalmente, analizamos estas variables en una tabla de análisis multivariado. Resultados: De una muestra de 205 casos (20,8% del total de ganglios estudia- dos en ese período de tiempo), el 48.3% (n=99) presentaba metástasis solo en el GC. De todas las características anatomopatológicas de mal pronóstico analizadas encontramos que el tamaño tumoral 2, el subtipo lobulillar y la invasión linfovascular tuvieron correlación significativa con la cantidad de GnC comprometidos. En el análisis multivariado encontramos tres factores predictivos, la invasión linfovascular, el tamaño de la metástasis en el ganglio centinela y el número de ganglios centinelas comprometidos. Conclusiones: Los factores independientes de compromiso de ganglios no centinela (GNC) en nuestra serie fueron: la invasión linfovascular, el tamaño de la metástasis en el ganglio centinela y el número de ganglios centinelas comprometidos

Introduction: It has been shown in various protocols that pathologically negative nonsentinel lymph node (NSN) disease, is observed in the rest of the armpit in a large proportion of cases with early stage breast carcinoma and positive sentinel node. As a result of this, different pathological predictors of axillary metastasis have been described. This motivated us to carry out the present work. Objetive: To analyze different pathological factors and their influence on the metastatic involvement of nonsentinel nodes. Material and method: Early stage breast cancer cases (T1-T2) with positive sentinel node and axillary emptying, operated on in IMGO between February 2000 and December 2012, were studied. Two groups were identified from the total sample: negative GnC and positive GnC, and analyzed diffe- rent pathological variables associated with metastatic nonsentinel nodes, calculating their significance. Finally, we analyze these variables in a multivariate analysis table. Results: From a sample of 205 cases (20.8% of the total lymph nodes studied), 48.3% (n = 99) had metastasis only in the SN. Of all the anatomo-pathological characteristics analyzed, we found that tumor size two, lobular subtype, and lymphovascular invasion had a significant correlation with the amount of compromised non-sentinel node (NSN). In the multivariate analysis, we found three predictive factors: lymphovascular invasion, the size of the metastasis in the sentinel node and the number of positive sentinel nodes. Conclusions: The independent factors of nonsentinel node involvement (NSN) in our series are: lymphovascular invasion, the size of the sentinel node metastasis, and the number of sentinel nodes involved

Factores predictivos de alta carga residual ganglionar axilar post biopsia de ganglio centinela positiva / Predictive factors of high residual burden in axillary lymph node after positive sentinel node biopsy

El estado axilar es un factor pronóstico para los estadios tempranos de cáncer de mama. Existen factores que podrían predecir riesgo de mayor enfermedad axilar. El objetivo es determinar cuáles son los factores predictivos independientes de alta carga residual ganglionar axilar (4 o más GNC comprometidos) luego de la BGC positiva. Estudio analítico, observacional, cohorte retrospectiva de pacientes con tumores T1-2, axila clínicamente negativa, a las que se les realizó cirugía conservadora (CC) y BGC con resultado positivo (marco o micrometástasis) y se les realizó posterior linfadenectomía axilar (LA). Del total de 325 pacientes, 96 tuvieron resultado positivo para metástasis en el ganglio centinela (29,5%) y también se les realizó LA. Se dividió a la población seleccionada en dos grupos según el compromiso de los GNC: baja carga axilar 0-3 GNC positivos, y alta carga axilar 4 o más GNC positivos. Se observaron como factores que demostraron mayor riesgo para alta carga axilar ganglionar residual al grado histológico, ki-67 y la invasión extracapsular en el GC; pero solamente la invasión extracapsular en el GC demostró ser significativa en el análisis multivariado. Probablemente con un mayor número de pacientes otras variables pudieran haber resultado factores de riesgo independiente

Axillary status is a prognostic factor for early stages of breast cáncer. There are predictive factors that might indicate the risk of greater axilary disease. The aim is to determine which are the independent predictive factor sor a high residual axillary nodal burden (four or more non-sentinel lymph nodes involved) after a positive sentinel node biopsy. Retrospective cohort analytic observational study of patients with T1-2 tumors, negative axilla, who underwent breast conserving surgery and sentinel node biopsy with a positive result (macro ­ or micro-metastasis) and later underwent lymph node dissection. Out of the total 325 patients, 96 got a positive result for metástasis in the sentinel lymph node (29.5%) and also underwent lymph node dissection. The selected population was divided into two groups according to the involvement of NSLNs: low axillary burden: 0-3 NSLNs, and high axillary burden: 4 or more positive NSLNs. Among the factors found to have a higher risk of high residual axillary nodal burden were the histologic grade, Ki-67 and the extracapsular invasión of the SLN, but only the extracapsular invasión of the SLN was found to be significant in the multivariate analysis. It is likely that with a higher number of patients, other variables might have been independent risk factors

Progress in local treatment of breast cancer: A narrative review / Evolução do tratamento local do câncer de mama: Revisão narrativa

Abstract The present paper reports on the local treatment of breast cancer from a historical perspective. A search for articles written in English was made in the Medline and EMBASE databases, and 40 papers were selected. Over the past 10 years, various randomized, controlled clinical trials on the local treatment of breast cancer indicated that patients with the samemolecular subtypemay receive different individualized surgical treatments aimed atoptimizing systemic adjuvant therapy. With a view to retaining the gainsmade in diseasefree and overall survival, surgical techniques have advanced from radical surgery to conservative mastectomies, thus reducing sequelae, while adjuvant and neoadjuvant therapies have contributed toward controlling the disease, both distant metastases and local recurrence. Current studies evaluate whether future breast cancer therapy may even succeed in eliminating surgery to the breast and axilla altogether.

Resumo Este artigo discute o tratamento local do câncer de mama a partir de uma perspectiva histórica. Uma busca de artigos publicados em inglês foi realizada nas bases de dados Medline e EMBASE, sendo selecionados 40 artigos. Nos últimos 10 anos, vários ensaios clínicos controlados e randomizados sobre o tratamento local do câncer de mama indicaram que pacientes com o mesmo subtipo molecular podem receber diferentes tratamentos cirúrgicos individualizados como objetivo de otimizar a terapia adjuvante sistêmica. Pretendendo reter os ganhos obtidos na sobrevida livre de doença e na sobrevida global, as técnicas cirúrgicas avançaram progressivamente da cirurgia radical para mastectomias conservadoras, reduzindo sequelas, enquanto as terapias adjuvantes e neoadjuvantes contribuíram para o controle da doença, tanto em relação às metástases distantes quanto à recorrência local. Estudos atuais avaliam se a terapia futura contra o câncer de mama poderá até mesmo eliminar a cirurgia da mama e da axila por completo.

Can Sentinel Lymph Node Biopsy Predict Various Levels of Echelon Nodes in Oral Cancers?

Abstract Introduction The efficacy of sentinel node biopsy in early stage oral cancer is well established. Its evolving role can be reinforced by further studies. Objective Analyzing the predictability of the levels of echelon nodes for various oral cavity tumor subsites on sentinel node biopsy. Methods A prospective study of 20 patients with stage I/II oral squamous cell carcinoma who underwent sentinel node biopsy-guided neck dissection between January 2017 and 2018 at our institute. The procedure included radiotracer injection, imaging (lymphoscintigraphy, single photon emission computed tomography-computed tomography), and gamma probe application. Sentinel node detection on imaging and gamma probe were compared. Results Out of 20 patients, 13 (65%) had carcinoma of the tongue, 6 (30%) had buccal mucosa carcinoma, and 1 (5%) had retromolar trigone carcinoma. Themean age of the patients was 52.3 years. A total of 13 (65%) patients were male, and 7 (35%) were female. The sentinel node identification rates with imaging and gamma probe were of 70% and 100% respectively. In tongue and retromolar trigone primaries, the most common first-echelon nodes in both modalities were levels IIA and IB respectively. For buccal mucosa primaries, first-echelon nodes were detected only with the gamma probe, which was level IB. On imaging, second-echelon nodes were detected only for tongue primaries, and had equivalent incidence of levels II, III, and IV. On the gamma probe, level IIA, followed by III, and IV for the tongue, and level IIA were the most common second-echelon nodes for the buccal mucosa. Third-echelon nodes were detected only with the gamma probe for tongue carcinoma at level IV. Conclusion The combined use of imaging and gamma probe provides the best results, with high identification rate and predictability of echelon levels.

An Observational Analytical Study Of Sentinel Node Mapping And Biopsy In Patients With Stage I And Iia Cervical Cancer

Aim: To reduce the morbidity associated with pelvic node dissection in early stage cervical cancer. Objectives: Ÿ Inject methylene blue dye at 3'0 clock and 9' 0 clock positions into the stroma of cervix and identify the sentinel node. Ÿ Frozen section analysis of the sentinel node and its correlation with the final histological findings Ÿ Subject the detected sentinel node, pelvic nodes to standard histopathological examination and detect correlation if any.

Localización radioguiada de lesiones no palpables y ganglio centinela en estadios iniciales de Cáncer de Mama (snoll). Primera experiencia en el Hospital Italiano de Buenos Aires / Radioguided non-palpable lesion localization and sentinel lymph node mapping (snoll) at early breast carcinoma. First experience at Hospital Italiano de Buenos Aires

Introducción Actualmente, entre un 25 y un 35% de los cánceres de mama se diagnostican como lesiones no palpables. La detección de lesiones cada vez más pequeñas exige el desarrollo de nuevas técnicas prequirúrgicas de marcación y localización. Presentamos la experiencia del Hospital Italiano de Buenos Aires con la técnica de localización radioguiada de lesiones no palpables y ganglio centinela (snoll). Objetivos El objetivo de este trabajo es describir las características clínico-patológicas de las pacientes sometidas a dicha técnica y las ventajas, desventajas, complicaciones y resultados en términos de márgenes libres, tasa de retumorectomías, volumen tumoral resecado y tiempo quirúrgico. Material y método Se trata de un estudio observacional, retrospectivo. Se incluyeron todas las pacientes con carcinomas no palpables en quienes se llevó a cabo la técnica de snoll entre el 1 de agosto de 2016 y el 4 de mayo de 2017. Resultados Se incluyó un total de 25 pacientes, todas con diagnóstico previo de carcinoma de mama invasor a través de una punción histológica. Utilizando la técnica snoll, se logró identificar la lesión de mama en el 96% de las pacientes. En el 100% de las pacientes, los márgenes quirúrgicos estaban libres de lesión, por lo que no se realizaron retumorectomías. Se identificó el 100% de los ganglios centinelas, 76% mediante la técnica snoll y 24% mediante la inyección previa del colorante Azul Patente. Conclusiones La técnica snoll demostró ser una técnica sencilla, que mejora el confort de la paciente y que presenta resultados comparables con las técnicas tradicionales. Si bien se trata de una primera experiencia, son alentadores los resultados en términos de márgenes libres, tiempo quirúrgico y volumen resecados.

Introduction Currently, about 25 to 35% of all breast tumors are diagnosed at a nonpalpable stage. The increasing ability to detect small lesions consequently demands the development of novel technology for preoperative lesion identification and intraoperative localization. In this study, we present our initial experience using Sentinel Node Occult Lesion Localization (snoll) at the Hospital Italiano de Buenos Aires. Objectives The objective of this study is to describe clinical and pathological characteristics of patients who were submitted to snoll technique and the advantages and disadvantages, complications and results in terms of tumor-free margins, subsequent surgery rate, total specimen volume and surgical time. Materials and method This is a retrospective, observational study. We included all patients with non-palpable breast cancer who were submitted to surgery and snoll technique between August 1st, 2016 and March 14th, 2017. Results A total of 25 patients were included in this study. All patients had previous diagnosis of invasive breast cancer by core needle biopsy. The breast lesion was correctly identified in 96% of patients through snoll. Surgical margins were tumor-free in all patients. No patients required subsequent surgery. All sentinel nodes were correctly identified. In 76% of cases, snoll was sufficient and in 24% additional injection of patent blue was required. Conclusions In our experience, snoll has proven to be a simple technique that improves patient comfort and shows comparable results when compared to traditional identification methods. Although these are our initial results, we believe our findings to be promising in terms of adequacy of margins, surgical time and total specimen volume.

Ganglio centinela en cáncer de mama. Experiencia en nuestros primeros 100 casos / Sentinel Node in Breast Cancer. Our first 100 cases experience

Introducción Desde los trabajos presentados por Giuliano et al . en 1994 y sus posteriores validaciones, la biopsia del ganglio centinela se ha convertido en el standard de la evaluación axilar en estadios tempranos del cáncer de mama. Es de vital importancia respaldar esta técnica con altas tasas de identificación y de correlación anatomopatológica intraoperatoria/diferida. Objetivos 1) Determinar nuestra tasa de identificación usando solo azul patente. 2) Determinar la correlación entre el estudio intraoperatorio y diferido. 3) Determinar la tasa de recurrencia axilar. Material y método Se reclutaron 100 pacientes con cáncer de mama T1 T2 N0 o cdis extenso de alto grado diagnosticadas por punción con aguja fina (paf) o Core Biopsy. Se utilizó solo Azul Patente al 1%, inyección subareolar, masaje circular por 10 minutos, incisión axilar. Se reconoce como Ganglio Centinela al ganglio o a los ganglios teñidos de azul o con su linfático aferente con colorante. El estudio intraoperatorio se realizó por sección en fresco e impronta citológica. El diferido por coloración con Hematoxilina y Eosina. Las pacientes fueron seguidas por el cirujano actuante y/u oncología clínica. Resultados Se evaluaron 100 pacientes. Nuestra tasa de detección fue del 98%. Los falsos negativos intraoperatorios por impronta citológica fueron del 3%. Luego de un seguimiento promedio de 63,8 meses, no se detectaron recidivas axilares. El número total de Ganglios Centinela positivos fue del 26,5%. El promedio de Ganglios hallados fue de 1,2. Conclusiones La Biopsia de Ganglio Centinela usando Azul Patente como único método es una operación confiable, de bajo costo y al alcance de todo centro con interés de desarrollar dicha técnica.

Introduction Since Giuliano et al. publications in 1994 and forward validations, sentinel node biopsy (snp) has become the standard procedure for staging the axilla in early breast cancer. Therefore, it is of vital importance to back this technique up by a high rate of identification and high intraoperative/final pathology correlation. Objectives 1) To determine our identification rate by only using Patent Blue dye. 2) To determine the correlation between intraoperative and final pathology results. 3) To determine axillary recurrence. Materials and method A hundred patients have been recruited. Each was diagnosed with T1 T2 N0 Breast Cancer or extense high grade Ductal Carcinoma In situ (dcis) by fine needle aspiration (fna) and/or Core Biopsy. Patent Blue 1% was injected subareolary. In addition, circular massage was performed during 10 minutes and an axillary incision was made. The node or nodes dyed in blue or with coloured lymphatic afferent have been acknowledged as sentinel nodes. The node was analyzed intraoperatively by touch imprint citology. The final study was done with Hematoxilin Eosin coloration. Further follow up was in charge of the surgeon and/or clinical oncologist. Results A hundred patients were assesed. Our identification rate was 98%. The pathology intraoperative false negative rate was 3%. Afer an average of 63,8 months follow up, no axillary recurrence was detected. 26,5% of positive sentinel nodes was found. The average of sentinel nodes found was 1,2. Conclusions snb by using only patent blue dye is a low cost reliable technique, and available for every institution interested in its development.

Ganglio Centinela en Cáncer de Mama: Experiencia de 11 años del Instituto Privado de Mastología, Ginecología y Obstetricia (imago) de la Provincia de Salta, Argentina / Sentinel node in breast cancer. 11 years experience at Instituto Privado de Mastología, Ginecología y Obstetricia (imago) of Provincia de Salta, Argentina

Introducción El desarrollo de la técnica de la Biopsia del Ganglio Centinela (bgc) descripta por Giuliano1,2 se convirtió en el procedimiento de elección para estadificar la axila en el cáncer de mama, ya que permite seleccionar un subgrupo de pacientes en las que la linfadenectomia axilar no aporta beneficio adicional alguno. Objetivos El objetivo de este trabajo fue comunicar nuestra experiencia de 11 años en la identificación del Ganglio Centinela. Material y método Desde enero de 2004 a enero de 2015, 223 pacientes con carcinoma mamario y ganglios axilares clínicamente negativos se sometieron a bgc. Resultados En 146 pacientes el gc fue negativo, 15 fueron a vaciamiento axilar por formar parte del periodo de curva de aprendizaje y en 131 pacientes no se llevó a cabo más tratamiento axilar. En 74 casos (33,18%), se hallaron uno o más gc positivos, y se realizó disección axilar total. Conclusiones Nuestra experiencia con 223 pacientes de cáncer de mama inicial a las que se les realizó bgc indica que en tumores pequeños (hasta 4 cm), con ganglios axilares clínicamente negativos, la bgc es el procedimiento de elección para determinar estadio ganglionar.

Introduction The sentinel node biopsy technique development (snb), described by Giuliano, became the procedure of choice for staging the axilla in breast cancer. This technique allows selection of a subset of patients in which axillary lymphadenectomy does not provide any additional benefit. Objectives The aim of this study is to report our 11 years experience in sentinel node identification. Materials and method From January 2004 to January 2015, we studied 223 breast carcinoma patients with clinically negative axillary nodes who underwent snb. Results We found that the centinel node was negative in 146 patients. 15 of those patients went to an axillary lymphadenectomy as part of the learning curve period. Finally, 131 patients did not carried out further axillary treatment. We found one or more positive sentinel nodes in 74 cases (33.18%) and, as a result of this, total axillary dissection was performed. Conclusions Our experience with 223 patients who had early breast cancer, in which we conducted snb, indicates that small tumors (up to 4 cm), with clinically negative axillary nodes, the sentinel node biopsy is the procedure of choice to determine nodal stage.

Evaluación de la técnica de Biopsia de Ganglio Centinela Axilar a través de la incisión mamaria en la cirugía conservadora / Evaluation of Sentinel Lymph Node Axilar Biopsy through the mammary incision in conservative surgery

Introducción El abordaje del ganglio centinela por incisión mamaria única permite acceder al ganglio evitando la realización de incisión axilar, lo que disminuiría el linfedema, el dolor y las disestesias y mejoraría el resultado estético. Objetivos Describir el abordaje quirúrgico del ganglio centinela a través de la incisión mamaria utilizada para la tumorectomía del carcinoma mamario. Material y método Entre septiembre de 2013 y agosto de 2015, se evaluaron 83 pacientes consecutivas con axila clínicamente negativa, que fueron sometidas a cirugía conservadora más biopsia de ganglio centinela, un grupo mediante abordaje clásico (incisión axilar) y otro por la incisión mamaria. Se estudió: edad; tamaño tumoral y ubicación; tipo histológico; técnica de identificación del ganglio centinela; número de ganglios resecados; ganglios centinelas positivos; y complicaciones perioperatorias. Resultados La detección del ganglio centinela por una única incisión se logró en todas las pacientes (100% de éxito). La realización de una única incisión presentó menores complicaciones en comparación con las pacientes a las que se les realizó diferentes incisiones; además, se encontraron mejores resultados estéticos. Conclusiones El abordaje del ganglio centinela mediante la misma incisión de la cirugía mamaria conservadora presenta una excelente tasa de detección, ofreciendo menos complicaciones y mejores resultados estéticos.

Introduction The sentinel node approach through a single breast incision allows its detection avoiding axillary incision, which could reduce complications and improve aesthetic result. Objectives The aim of this work was to describe the surgical approach of sentinel node via the single incision used for conservative surgery for breast carcinoma. Materials and method Patients (n=83) with clinically negative axilla, who went through conservative surgery and axillary sentinel node biopsy using classical approach (axillary incision) and single breast incision, in early-stage breast cancer, were studied. Clinical, anatomical and pathological variables and perioperative complications were considered. Results Our results showed that the method of detection of sentinel node by a single breast incision was successful in 100 % of the cases. The performance of a single incision presented minor complications compared to patients who underwent different incisions; also better aesthetic results were also found. Conclusions The surgical approach of the sentinel node through the single incision of breast conserving surgery presents an excellent detection rate, fewer complications and better aesthetic results.

Factores predictivos histológicos e inmunohistoquimícos de metástasis en ganglio no centinela en pacientes con cáncer de mama y ganglio centinela positivo / Histological and histochemical predicting factors of increased risk of metastatic compromise of non sentinel nodes, in patients with positive sentinel node biopsy

Introducción La biopsia del ganglio centinela (bgc) permite estadificar la axila en pacientes con cáncer de mama (cm) y axila clínicamente negativa. Mediante este procedimiento, se evita la linfadenectomía axilar en una proporción de pacientes. Sin embargo, frente a la positividad del ganglio centinela, una vez completada la linfadenectomía, un subgrupo de pacientes no tienen enfermedad residual en el resto de los ganglios axilares, definidos como ganglios no centinela. Objetivo Analizar los factores de predicción histológicos e inmunohistoquímicos de compromiso en ganglios no centinelas (gnc) en aquellas pacientes con bgc positiva seguida de linfadenectomía axilar, operadas por el Servicio de Patología Mamaria del Hospital Fernández en el período que transcurre entre enero de 1998 y marzo de 2016. Material y método Se realizaron 712 bgc entre los meses de enero de 1998 y marzo de 2016, en el Servicio de Patología Mamaria del Hospital Fernández. Del total, 140 resultaron positivas. Se analizó retrospectivamente la vinculación entre diversas características y la existencia de enfermedad axilar en gnc en 119 casos. Resultados Cuando la bgc resultó positiva, se encontró enfermedad en gnc en el 53,8% de los casos. El análisis univariable demostró correlación estadísticamente significativa entre presencia de metástasis en gnc y la presencia de 2 o más gc positivos, el tamaño tumoral mayor a 2 cm, el compromiso por macrometástasis del gc, la presencia del receptor her2 en el tumor y el alto grado mitótico y el compromiso de la cápsula ganglionar. Conclusiones Los factores independientes de compromiso de gnc son los siguientes: el alto grado mitótico, la presencia del receptor her2, la existencia de 2 o más gc positivos, el compromiso de la cápsula ganglionar.

Introduction The sentinel node biopsy can stage breast cancer patients with negative axillary lymph node examination. Using this procedure it is possible to avoid axillary lymph node dissection in some patients. However, when sentinel node biopsy results positive, once achieved the axillary node dissection, some patients do not have residual disease in the non sentinel nodes. Objective To study histological and histochemical predicting factors of increased risk of metastatic compromise of non sentinel nodes, in patients with positive sentinel node biopsy and subsequent axillary lymph node dissection, treated in the Breast Disease Division of Hospital Fernandez between January 1998 and March 2016. Materials and method Between January 1998 and March 2016, 712 patients underwent to node sentinel biopsy in the Breast Disease Division of Hospital Fernández. This study assessed, in a retrospective way, the association between the histological and histochemical predicting factors and non sentinel node disease in 119 cases. Results When sentinel node biopsy was positive, there was non sentinel lymph node metastasis in 53,8% of cases. The following variables were found to be potentially associated with non-sentinel node metastases in the univariated analysis: number of positive sentinel lymph node, size of the tumor, size of the metastasis in the sentinel lymph node, presence of her2 receptor in the tumor, high mitotic rate and extracapsular perinodal spread. Conclusions Independent factors for involvement of non sentinel nodes are: the high mitotic rate, the presence of her2 receptor in the tumor, the number of positive sentinel lymph nodes and the extracapsular perinodal spread.

Resultados falsos negativos transoperatorios en los ganglios centinelas de cáncer de mama, asociación con las características histológicas del tumor en el Departamento de Patología del Hospital México / Intraoperative false negative results in sentinel nodes of breast cancer, association with the histological characteristics of the tumor in the Department of Pathology of Hospital México

Resumen:El carcinoma de mama representó el tumor en mujeres más frecuente en Costa Rica para el año 2013. La disección axilar en el cáncer de mama es una de las causas de mayor comorbilidad en las pacientes. La realización de un ganglio centinela para determinar si es necesario la disección axilar, ha resultado de gran ayuda, reduciendo las comorbilidades en las pacientes con cáncer de mama. La experiencia del cirujano en la realización de procedimiento y del patólogo, han reducido los falsos negativos en los ganglios centinelas por congelación hasta en un 4.5%.En este estudio se analizaron los ganglios centinelas por congelación que contaban con biopsia definitiva y se determinó que los falsos negativos para nuestro hospital eran del 1.2%, además en estos casos, se determinó la media de tipo histológico, el grado histológico y el tamaño del cáncer de mama. En conclusión, se determinó que una de las casusas principales asociadas a los falsos negativos es la presencia de tejido adiposo en el ganglio centinela.

AbstractBreast carcinoma represented de most frequent tumor in Costa Rica during 2013. The axillary dissection in pacients with breast cancer is one of the causes of the most frecuent comorbidity. Studying sentinel ganglion to decide if it is necesary to make an axillary dissection has become very useful in reducing comorbidity in pacients with breast cancer. The surgeon´s and de pathologist´s work experience with this procedure has reduced false positive results in the sentinel ganglion´s biopsies by frezzing method in 4,5%. During the current report the sentinel ganglions by freezing method that had a definite biopsy were studied and we arrived to the conclusion that for our hospital falsepositives were less than 1,2%. As well in this cases it was determined the histologic type, the histologic grade and the size of the breast cancer. In conclusion it was determined that one of the most frecuent causes associated with false positives is the presence of adipose tissue in the sentinel ganglion.

Idade precoce do câncer de mama e suas implicações / Early age of breast cancer and implications

Este estudo teve como objetivo comparar os resultados de um grupo de mulheres com câncer de mama em idade inferior a 40 anos a outro grupo fora desta faixa etária.É um estudo analítico prospectivo com arquivo de dados desde Fevereiro de 2001, tendo limite final em Junho de 2014, tendo 629 casos de Neoplasia Maligna de Mama.O fator de exposição foi a idade ao diagnóstico, dividindo a amostra em 2 grupos: idade inferior a 40 anos e idade igual a superior a 40 anos.Os dados coletados foram: nome, idade, procedência, ferramenta principal de diagnóstico, tipo tumoral, grau tumoral, tamanho tumoral, estadiamento patológico, tipo de tratamento, linfonodo sentinela, sobrevida em 5 e 10 anos.Inclusão no estudo foi presença de dados e informação até 2013 de controle no serviço, tendo 40 casos em Grupo 1 e 408 , Grupo 2.Não existiu diferença significativa na taxa de ocorrência de diagnóstico precoce, ferramenta principal de diagnóstico em cada estadiamento, tamanho tumoral médio, presença de Receptor Hormonal de Estrogênio positivo, presença de superexpressão da Mutação C-erb 2, modalidade de tratamento e sobrevida entre os Grupos.A História familiar negativa foi predominante em todos os Grupos.O estudo demonstra um papel importante da Mamografia em mulheres com idade inferior a 40 anos. O resultado pode ser decorrente de nosso protocolo de Mamografia de base após 35 anos.

Laparoscopic Sentinel Node Navigation Surgery for Gastric Cancer

Short-term surgical results of gastric cancer improve with use of a laparoscopic approach compared to those after conventional laparotomy, particularly in patients with early gastric cancer (EGC). However, due to gastric resection and lymph node dissection, poor long-term quality of life (QOL) after gastric cancer surgery is equivalent between the approaches. Thus, gastric resection and lymph node dissection should be minimized to avoid injury to innervating nerves and the sphincter, to maintain gastric function, preserve gastric volume, and improve long-term QOL. Such a procedure should not impair the oncological outcome by removing the primary tumor and metastasis to lymph nodes. After analysis of the many single center feasibility studies, sentinel node biopsy (SNB) is useful for this purpose but sensitivity varies and is unsatisfactory. A large multicenter Japanese feasibility study showed promising results after clinical application of SNB in patients with EGC. Based on those results, a multicenter prospective randomized phase III trial of laparoscopic SNB conducted by the Korean surgical study group, the SENORITA (SEntinel Node ORIented Tailored Approach), is now ongoing. Prior to this phase III trial, a quality control study of participating institutions was completed in an effort to standardize and overcome the SNB learning curve. Laparoscopic SNB with gastric volume and function-preserving surgery to improve the long-term QOL without impairing the oncological outcome may be a surgical option after this trial in the subgroup of patients with EGC.

A critical assessment on the role of sentinel node mapping in endometrial cancer / 부인종양

Endometrial cancer is the most common gynecologic malignancy in the developed countries. Although the high incidence of this occurrence no consensus, about the role of retroperitoneal staging, still exists. Growing evidence support the safety and efficacy of sentinel lymph node mapping. This technique is emerging as a new standard for endometrial cancer staging procedures. In the present paper, we discuss the role of sentinel lymph node mapping in endometrial cancer, highlighting the most controversies features.

Fator prognóstico da idade no câncer de mama / Prognosis of age factor in breast cancer

Este estudo teve como objetivo comparar os resultados de um grupo de mulheres com câncer de mama em idade inferior a 40 anos a outro grupo fora dessa faixa etária. É um estudo observacional retrospectivo de cohorte com coleta de dados em sistema de prontuário eletrônico de 575 casos no período de fevereiro de 2001 até julho de 2013. O fator de exposição foi a idade ao diagnóstico, dividindo a amostra em 2 grupos: idade inferior a 40 anos e idade igual a superior a 40 anos. Os dados coletados foram: nome, idade, procedência, tipo tumoral, grau tumoral, tamanho tumoral, estadiamento patológico, tipo de tratamento, linfonodo sentinela, sobrevida em 5 e 10 anos. Inclusão no estudo foi permitida ao caso com todos os dados acima citados. Foram excluídas as pacientes com carcinoma ductal in situ ? Estádio 0 e Estadiamento 4 no momento do diagnóstico. Adotando os critérios de inclusão e exclusão, a amostra de estudo foi constituída por 331 mulheres, disposta em 2 grupos: Grupo 1 com 30 casos (idade inferior a 40 anos) e Grupo 2 com 301 casos (idade de 40 anos ou mais). O estudo concluiu existir um perfil diferente da enfermidade em mulheres com menos de 40 anos com significância para p<0,05 em Estadiamento avançado e tendo menor sobrevida global em 5 anos após pareamento por estadiamento. Não atingiu significância em tamanho tumoral, grau, tipo histológico, tipo de tratamento, resultado do linfonodo sentinela e sobrevida de 10 anos possivelmente pelo número de casos.

This study was like objective compare the results of a group of women with breast cancer at the age under 40 years to another group outside this age range. It is an observational retrospective cohort with data collection in electronic medical record system of 575 cases in the period from February 2001 to July 2013. The exposure factor was age at diagnosis, dividing the sample into two groups: those aged up to 40 years and the age above 40 years. The data were collected: name, age, origin, tumor type, tumor grade, tumor size, pathological stage, type of treatment, sentinel node, survival at 5 and 10 years. Inclusion in the study was allowed to the case with all the data mentioned above. We excluded patients with ductal carcinoma in situ ? Stage 0 and Stage 4, being treated randomly staging upon survival analysis. Adopting the criteria of inclusion and exclusion, the study sample consisted of 331 women, arranged in two groups: Group 1 with 30 cases (aged under 40 years) and Group 2 included 301 patients (age 40 or older). The study shows a different profile of the disease in women under 40 with significance set at p <0.05 in Staging and having shorter survival after pairing Staging in 5 years. Did not reach significance in tumor size, grade, histology, type of treatment, results of sentinel lymph node and possibly survival of 10 years the number of cases.

Linfadenectomia laparoscópica em cadela com neoplasia mamária / Laparoscopic lymphadenectomy in a bitch with breast cancer

A linfadenectomia laparoscópica é realizada de forma rotineira na medicina, contudo é pouco utilizada na veterinária. Neste relato, um canino fêmea apresentando tumores na cadeia mamária esquerda (M4 e M5), foi submetido à aplicação intradérmica do azul de metileno estéril, ao redor do maior tumor (M5), buscando-se demarcação dos vasos linfáticos e linfonodos regionais. Após 15 minutos, iniciou-se a linfadenectomia abdominal videolaparoscópica na região inguinal esquerda, seguida da ovário-histerectomia (OVH) lapararoscópica com três portais. Realizou-se ainda mastectomia total unilateral esquerda. Pela histologia, obtiveram-se dois linfonodos abdominais livres de células tumorais. A paciente não apresentou recidiva em 60 dias.

The laparoscopic lymphadenectomy is routinely performed in medicine, but not in veterinary medicine. This report describes a case of female canine with tumors in the left mammary chain (M4 and M5), which was subjected to intra-dermal application of sterile methylene blue, around the largest tumor (M5) which tried to demarcate the lymphatic vessels and regional lymph nodes. After 15 minutes, laparoscopic lymphadenectomy involving the abdominal in the left pelvic region started, followed by laparoscopic ovariohysterctomy (OVH) using three portals access. It was also performed an unilateral left total mastectomy. For histology, two abdominal lymph nodes were free of tumor cells. The patient had no recurrence in 60 days.

Current Status and Future Perspectives on Minimally Invasive Esophagectomy

Esophageal cancer has one of the highest malignant potentials of any type of tumor. The 3-field lymph node dissection is the standard procedure in Japan for surgically curable esophageal cancer in the middle or upper thoracic esophagus. Minimally invasive esophagectomy is being increasingly performed in many countries, and several studies report its feasibility and curability; further, the magnifying effect of the thoracoscope is another distinct advantage. However, few studies have reported that minimally invasive esophagectomy is more beneficial than open esophagectomy. A recent meta-analysis revealed that minimally invasive esophagectomy reduces blood loss, respiratory complications, the total morbidity rate, and hospitalization duration. A randomized study reported that the pulmonary infection rate, pain score, intraoperative blood loss, hospitalization duration, and postoperative 6-week quality of life were significantly better with the minimally invasive procedure than with other procedures. In the future, sentinel lymph node mapping might play a significant role by obtaining individualized information to customize the surgical procedure for individual patients' specific needs.

Ganglio centineaa en melanoma de cara: abordaje inicaal / Sentinel ganglion in melanoma of the face: an initial approach

A pesar de las campañas preventivas no se ha logrado disminuir la incidencia de las neoplasias cutáneas, probablemente por las alteraciones de la capa de ozono, con el consecuente aumento de la radiación ultravioleta, por eso en países del trópico se presentan lesiones como el melanoma de piel, que es considerado como una de las lesiones tumorales más agresivas. La cara y el cuello son zonas del cuerpo con una alta exposición solar, reflejándose en un mayor número de casos de este sombrío tumor. El mayor factor pronóstico en contra de los pacientes que padecen esta enfermedad es la presencia de metástasis ganglionares, por eso el grupo tratante debe esclarecer si están presentes, debido a esto hace varias décadas se realizan disecciones de cuello profilácticas, pero en la mayoría de los casos los ganglios extirpados son negativos. Una posible solución para evitar esto, es la extracción del o de los primeros ganglios que drenan el sitio del tumor primario (Ganglio Centinela). En el área de cabeza y cuello usualmente están presentes varios a la vez, lo que dificulta tomar la decisión de cuál extirpar. En nuestro grupo hemos iniciado la estandarización de esta técnica, y como abordaje inicial se realizó el primer caso de una paciente con melanoma de la cara a quien se practicó resección local amplia del tumor y extracción de los centinelas marcados por linfogammagrafía y a la vez disección de los relevos ganglionares positivos para drenaje demostrados por este estudio de medicina nuclear.

In spite of preventative campaigns having been mounted, it still has not been possible to reduce cutaneous neoplasia incidence, probably due to alterations in the ozone layer. This has led to a consequent increase in ultraviolet radiation and thus lesions occurring in tropical countries such as skin cancer (melanoma), considered as being one of the most aggressive tumour lesions. The face and neck are the body areas having the highest exposure to the sun, being reflected in a greater number of such tumour cases. The presence of ganglion metastasis is the greatest negative prognostic factor for patients suffering from this disease; the treating group must thus clarify whether this is present as prophylactic neck dissections were made several decades ago, but the ganglions so removed were negative in most cases. Extracting the first ganglions draining the primary tumour site (sentinel ganglion) represents a possible solution for avoiding this. Several of them are usually present at the same time in the head and neck area, thereby hampering taking a decision as to which should be removed. Our group has begun to standardise such technique; an initial approach has involved the first case of a patient with melanoma of the face who underwent wide local resection of the tumour and extraction of the sentinel ganglions. These were dyed and lymphogammagraphy was used, at the same time as dissection of positive ganglion relief for drainage, as demonstrated by this nuclear medicine study.

El ganglio centinela en el cáncer de mama precoz / Sentinel node in early breast cancer

Presentar nuestra experiencia en utilización del ganglio centinela en cáncer de mama precoz. Entre mayo 1998 y julio 1999 realizamos la identificación del ganglio centinela utilizando azul de isosulfán en 40 pacientes con carcinoma mamario, todos ganglios clínicamente negativos. El ganglio centinela fue determinado en 28 casos (70%), siendo positivo en 8 (36,4%). Desde agosto1999 - abril 2011, realizamos determinación del ganglio centinela mediante técnica combinada Linfazurín® 1% y/oazul patente 3% + 99m Tc (1 500 mCi 12 horas antes de la intervención 733/726 pacientes, todos axila clínicamente negativa. 5 falsos negativos (22,7%).Últimos 15 casos porcentaje de detección subió 73,3% falsos negativos solo 9,1%. La identificación fue posible solo con azul en 702/733 (95,67%) y solo con 99mTc en720 (98,22%) y en 728/733 (99,32%) al combinarlos. En cinco (0,68%) no fue posible localizar el ganglio centinela por ninguno de los dos métodos. Axila fue positiva en 175/733 casos (23,87%), siendo el centinela el único ganglio positivo en 84 (48%), micro-metástasis 42/175 casos (24%). 10 falsos negativos en 175 axilas positivas (5,71%). Sensibilidad del procedimiento combinado es 92,3% con especificidad 100%. Valor predictivo positivo 100% negativo 97,05%. Factores pronósticos más importantes para ganglio positivo fueron grado nuclear, invasión linfovascular. La combinación de azul con 99m Tc es idónea con alta sensibilidad y especificidad del procedimiento

Present our experience in utilization of sentinel lymph node in early breast cancer. We realized identification of sentinel lymph node utilized isosulfan blue in 40 patients with breast cancer, all of them with nodes clinical negative between May of 1998 to July1999. The sentinel lymph node was determinate in 28 cases (70%) it was positive 8 (36.4%). Until August 1999 - April 2011 realized the sentinel lymph node determination with combined technique Linfazurin 1% blue patent 3% + 99mTc(1500 mCi 12 hours before intervention. 733/726 patients with clinical negative axillaries. 5 negative false (22.7%). Last 15 cases percentile of detection was increased 73.3% negative false only 9.1%. Identification were possible only with blue 702/733 cases (95.67%) only with 99m Tc in 720 (98.22%) in 728/733 when combined both. Five (0.68%) was not possible localization of sentinel forany of two methods. The axils were positive 175/733 cases (23.87%) only positive node was the sentinel in 84 (48%), micro metastases 42/175 s (24%). 10 negative falser 175 positives axillaries (5.71%). The sensitive of combined procedure was 92.3% with specificity 100%. Predictive positive value was 100% negative 97.05%. Prognostic factors more important positive nodule were nuclear grade, and lymphatic vascular invasion. The combination of blue with 99m Tc is a procedure with high sensitive and specificity

Ganglio centinela para estadios tempranos en cáncer de cuello uterino

Objetivo: Determinar la factibilidad y seguridad del ganglio centinela (GC) con el uso combinado del mapeo linfático con Tc 99 y la inyección de colorante azul (patent blue) en pacientes con cáncer de cérvix temprano sometidas a histerectomía radical con linfadenectomía pélvica bilateral. Diseño: Estudio prospectivo. Institución: Instituto Nacional de Enfermedades Neoplásicas, Lima, Perú. Participantes: Pacientes con cáncer temprano de cuello uterino. Intervenciones: Entre diciembre de 2003 y diciembre de 2006, 66 pacientes con cáncer temprano de cuello estadios IA2 (n=2), IB1 (n=63) y IIA (n=1) fueron sometidas a detección del ganglio linfático centinela con linfoscintigrafía el día previo a la operación y mapeo linfático intraoperatorio con colorante azul y sonda detectora de radiación gama. El tratamiento quirúrgico se completó con la realización de la histerectomía radical y linfadenectomía pélvica bilateral, por laparotomía. Principales medidas de resultados: Detección de ganglios centinelas. Resultados: En las 66 pacientes estudiadas se detectó 136 ganglios centinelas, con un promedio de 2,06 por paciente. Se utilizó el método combinado (Tc 99 y patent blue). La localización más frecuente fue la región obturatriz con un 69,9% (n=95). Se halló metástasis en los ganglios pélvicos en 11 pacientes, que fueron correctamente localizadas en el ganglio centinela con una sensibilidad de 100%. Cuando el ganglio centinela fue negativo, no se encontró metástasis en los ganglios no centinela (VPN 100%). Conclusiones: La identificación del ganglio centinela con tecnecio-99 combinado con la inyección de colorante azul es factible y mostró un valor predictivo negativo de 100%.

Objective: To determine sentinel node (SN) detection feasibility and safety by using lymphatic mapping with 99m Tc Dextrán and injection of blue dye (patent blue) in patients with early cervical cancer undergoing radical hysterectomy with bilateral pelvic lymphadenectomy. Design: Prospective study. Setting: Instituto Nacional de Enfermedades Neoplasicas, Lima, Peru. Participants: Patients with early cervical cancer. Interventions: Between December 2003 and December 2006, 66 patients with early cervical cancer stages IA2 (n = 2), IB1 (n = 63) and IIA (n = 1) underwent sentinel lymph node detection with lymphoscintigraphy the day before operation and intraoperative lymphatic mapping with blue dye and gamma radiation detection probe. Surgical treatment was completed with radical hysterectomy and bilateral pelvic lymphadenectomy by laparotomy. Main outcome measures: Sentinel node detection. Results: One hundred and thirty-six sentinel nodes were detected in all 66 patients, average 2.06 per patient, by using the combined method 99m Tc dextrán and patent blue. Most common location was the obturator region in 69.9% of cases (n = 95). Pelvic lymph node metastases were found by the sentinel node in 11 patients (sensitivity of 100%). In negative sentinel node cases (55 patients) no metastases were encountered (negative predictive value, NPV = 100%). Conclusions: Sentinel node identification using 99m technetium Dextrán and blue dye injection is feasible and had a negative predictive value of 100%.