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Background Nodal surveillance (NS) has overtaken completion lymphadenectomy as the preferred management for sentinel node-positive (SLN+) melanoma, but requires frequent exams and nodal ultrasound (US). Social determinants of health (SDoH) may affect US adherence in real-world populations, and evaluation of these potential impacts is needed. Methods Adults with SLN+ melanoma diagnosed from July 2017 to December 2019 who received NS at nine cancer centers were identified retrospectively. Exposures included insurance status, travel distance, and Centers for Disease Control and Prevention (CDC) Social Vulnerability Index (SVI), a validated measure of area-level SDoH, indicated as 0 (low) to 1 (high) vulnerability. The primary outcome was US adherence (≥ 1 study per 6-month follow-up interval). The secondary outcomes were combined-modality adherence [US, computed tomography (CT), or positron emission tomography (PET)] and loss to follow-up (LTFU). Bivariate analyses and mixed-effects multivariable logistic regression were performed. Results Most of the 519 patients were male (57%), non-Hispanic white (94.4%), and insured privately (45.3%) or by Medicare (43.5%). The median travel distance was 63.3 miles (interquartile range [IQR], 31.2–111.0 miles), and the median SVI was 0.426 (IQR, 0.253–0.610). The surveillance adherence rates were 41.6% for US and 75.1% for combined modalities. No significant differences in US adherence were observed based on sociodemographic covariates in regression analysis. Medicaid (odds ratio [OR], 3.12; p  = 0.02) and uninsured (OR 4.48; p  = 0.01) patients had increased likelihood of LTFU. Conclusions Less than half of the patients in this multicenter cohort achieved US adherence, although the rates improved with combined modalities. Medicaid or non-insurance were social risk factors for LTFU. Optimizing surveillance practices for socially vulnerable groups will be crucial for the ongoing real-world implementation of NS.

Background With nodal surveillance increasingly used for sentinel lymph node-positive (SLN+) melanoma following the Second Multicenter Selective Lymphadenectomy Trial (MSLT-II), high-quality nodal ultrasonography (U/S) has become a critical need. Previous work has demonstrated low utilization of MSLT-II U/S criteria to define abnormal lymph nodes requiring intervention or biopsy. To address this gap, an evidence-based synoptic template was designed and implemented in this single-center study. Methods Sentinel lymph node-positive patients undergoing nodal surveillance at a tertiary cancer center from July 2017 to June 2023 were identified retrospectively. Ultrasound reporting language was analyzed for MSLT-II criteria reported and clinically actionable recommendations (e.g., normal, abnormal with recommendation for biopsy). Following a multidisciplinary design process, the synoptic template was implemented in January 2023. Postimplementation outcomes were evaluated by using U/S reports and provider surveys. Results A total of 337 U/S studies were performed on 94 SLN+ patients, with a median of 3 U/S per patient (range 1–12). Among 42 synoptic-eligible U/S performed postimplementation, 32 U/S (76.0%) were reported synoptically. Significant increases were seen in the number of MSLT-II criteria reported (Pre 0.5 ± 0.8 vs. Post 2.5 ± 1.0, p < 0.001), and clinically actionable recommendations for abnormal findings (Pre 64.0% vs. Post 93.0%, p = 0.04). Nearly all surgeon and radiologist survey respondents were “very” or “completely” satisfied with the clinical utility of the synoptic template (90.0%). Conclusions Following implementation of a synoptic template, U/S reports were significantly more likely to document MSLT-II criteria and provide an actionable recommendation, increasing usefulness to providers. Efforts to disseminate this synoptic template to other centers are ongoing.

Recent data have demonstrated no survival benefit to immediate completion lymph node dissection (CLND) for positive sentinel node (SN) disease in melanoma. It is important to identify parameters in positive SNs, which predict prognosis in melanoma patients. These might provide prognostic value in staging systems and risk models by guiding high-risk patients’ adjuvant therapy in clinical practice. In this retrospective study of university hospital melanoma database we analyzed tumor burden and prognosis in patients with positive SNs. Patients were stratified by the diameter of tumor deposit, distribution of metastatic focus in SN, ulceration and number of metastatic SNs. These were incorporated in Cox proportional hazard regression models. Predictive ability was assessed using Akaike information criterion and Harrell’s concordance index. A total of 110 patients had positive SN and 104 underwent CLND. Twenty-two (21%) patients had non-SN metastatic disease on CLND. The 5-year melanoma specific survival for CLND-negative patients was 5.00 years (IQR 3.23–5.00, range 0.72–5.00) compared to 3.69 (IQR 2.28–4.72, range 1.01–5.00) years in CLND-positive patients (HR 2.82 (95% CI 1.17–6.76, p = 0.020).The models incorporating distribution of metastatic focus and the largest tumor deposit in SN had highest predictive ability. According to Cox proportional hazard regression models, information criterions and c-index, the diameter of tumor deposit > 4 mm with multifocal location in SN despite of number of metastatic SN were the most important parameters. According to the diameter of tumor deposit and distribution of metastatic focus in SN, adequate stratification of positive SN patients was possible and risk classes for patients were identified.

Introduction Axillary status remains an important prognostic indicator in breast cancer. Certain patients with a positive sentinel node (SLNB) may not benefit from axillary clearance (AC). Uncertainty remains if this approach could be applied to patients diagnosed with axillary metastases on ultrasound-guided fine needle aspiration cytology (USFNAC). The aim of this study was to compare nodal burden in patients with positive USFNAC and a positive SLNB. Methods A retrospective study was performed involving all BC patients between 2007 and 2014 who had either pre-operative USFNAC or a SLNB. Patient/tumour characteristics and nodal burden were examined in all patients proceeding to AC. Results 974 patients were eligible for analysis. 439 patients (45 %) had positive USFNAC and 535 (55 %) had a positive SLNB. USFNAC-positive patients were more likely to undergo mastectomy (Chi-square test; p  < 0.001), have extra-nodal extension ( p  < 0.001), be oestrogen receptor negative ( p  < 0.001) and be HER2 positive ( p  < 0.001). The median total number of lymph nodes (LNs) excised during AC was higher in the USFNAC group (Mann–Whitney test; 23 vs. 21; p  < 0.001). The median total number of involved LNs was 3 (range 1–47) in FNAC-positive patients versus 1 (range 1–37) in SLNB-positive patients ( p  < 0.001). The median number of involved LNs in level 1 was 3 in FNAC-positive patients versus 1 in SLNB-positive patients ( p  < 0.001). Within the SLN-positive group, 49 % of the patients had only one involved LN, 28 % had two nodes involved and 23 % had ≥3. In comparison, within the FNAC-positive group only 13 % of the patients had one involved LN, 12 % had two nodes involved and 74 % had ≥3. Conclusion Patients with positive USFNAC have more aggressive clinico-pathological characteristics and higher nodal burden compared to SLNB-positive patients. Currently, the authors advocate that patients not receiving neoadjuvant chemotherapy, with a positive USFNAC, should proceed directly to an axillary ALND.

Background The incidence of adenocarcinoma of the esophagogastric junction (AEG) is increasing, but the surgical strategy for AEG remains controversial. We hypothesized that sentinel node (SN) mapping for AEG could be validated to avoid unnecessary lymphadenectomy and permit minimally invasive surgery. We examined the feasibility of SN mapping for AEG. Methods We enrolled 15 patients with preoperatively diagnosed cT1 N0 M0 primary AEG (Siewert type I, N  = 3; Siewert type II, N  = 12) lesions measuring <4 cm in diameter. The dual tracer method employing radioactive colloid and blue dye was used to detect SNs. The distribution of SNs was compared with that of metastatic lymph nodes in 52 patients who were surgically treated without SN mapping. Results SNs were successfully identified in all the patients. Two patients with lymph node metastasis had positive SNs identified via an intraoperative pathological examination, and the diagnostic sensitivity and accuracy based on the SN status were both 100 %. For Siewert type II AEG, the SNs were not detected in the lower mediastinum by intraoperative gamma probing. Thus, all surgical procedures were performed via a transhiatal approach. No patient without SN metastasis experienced cancer recurrence during a 38-month median follow-up. The distribution of SNs was similar to that of lymph node metastasis in the patients who were surgically treated without SN mapping. Conclusions We achieved 100 % SN detection. Our results suggested that SN mapping is feasible for AEG and highly sensitive and accurate in diagnosing lymph node metastasis. SN mapping may clarify the necessity of mediastinal lymph node dissection and individualize minimally invasive surgery.

Background We have developed a new nomogram to predict the probability of a patient with 1–2 metastatic sentinel lymph nodes (SLNs) to present further axillary disease. Methods Data were collected from 480 patients who were diagnosed with 1–2 positive lymph nodes and thus underwent axillary lymph node dissection between March 2005 and June 2011. Clinical and pathological features of the patients were assessed with multivariable logistic regression. The Shanghai Cancer Center Non-SLN nomogram (SCC-NSLN) was created from the logistic regression model. This new model was subsequently applied to 481 patients from July 2011 to December 2013. The predictive accuracy of the SCC-NSLN nomogram was measured by calculating the area under the receiver operating characteristic curve (AUC). Results Based on the results of the univariate analysis, the variables that were significantly associated with the incidence of non-SLN metastasis in an SLN-positive patient included lymphovascular invasion, neural invasion, the number of positive SLNs, the number of negative SLNs, and the size of SLN metastasis ( P  < 0.05). Using multivariate analysis, lymphovascular invasion, the number of positive SLNs, the number of negative SLNs, and the size of SLN metastasis were identified as independent predictors of non-SLN metastasis. The SCC-NSLN nomogram was then developed using these four variables. The new model was accurate and discriminating on both the modeling and validation groups (AUC: 0.7788 vs 0.7953). The false-negative rates of the SCC-NSLN nomogram were 3.54 and 9.29 % for the predicted probability cut-off points of 10 and 15 % when applied to patients who have 1–2 positive SLNs. Conclusion The SCC-NSLN nomogram could serve as an acceptable clinical tool in clinical discussions with patients. The omission of ALND might be possible if the probability of non-SLN involvement is <10 and <15 % in accordance with the acceptable risk determined by medical staff and patients.

Objective The objective was to analyze the frequency and factors influencing necrotic complication in female patients undergoing nipple‐ and areola‐sparing mastectomy. Summary and background data Nipple‐ and areola‐sparing mastectomy has recently been shown to yield satisfactory results in a carefully selected group of breast cancer patients. The technique includes extensive undermining of the nipple–areola complex, which may result in an increased rate of necrotic complications. We report our early experience with necrotic changes after nipple‐ and areola‐sparing mastectomy. Methods The medical records of 38 patients undergoing nipple‐ and areola‐sparing mastectomy were analyzed retrospectively. Results Mean age of the patient was 44.5 years (range 26–65). Necrotic complications occurred in 15.8% of patients and included: skin flap necrosis (1 case), partial nipple–areola complex necrosis (2 cases), and complete nipple–areola complex necrosis (3 cases). Two cases of capsular contraction were also recorded. Statistical analysis showed age below 45 years to be associated with a lower risk of necrotic complications (OR 4.51, P < 0.05). Conclusions The nipple‐ and areola‐sparing mastectomy, although resulting in a relatively high frequency of necrotic complications, is a valuable surgical option for patients with small, peripheral tumors and for women undergoing prophylactic mastectomy. The procedure seems to be safer for women under 45 years of age.

Complete lymph node dissection (CLND) following a positive sentinel lymph node biopsy (SLNB) has been the standard treatment for years. However, there is increasing evidence that CLND could be omitted. Approximately 80% of patients with a positive sentinel node biopsy do not have additional nodal involvement; in these contexts, the SLNB could be diagnostic and therapeutic. However, in this group of patients, the therapeutic effect of CLND is unclear. A systematic search was performed in EMBASE and MEDLINE (PubMed), for studies published between January 1, 2014 and December 31, 2019. Studies were included when they compared immediate CLND and observation after a positive sentinel node. The outcomes of interest were: Overall Survival (OS), melanoma-specific survival (MSS), and disease-free survival (DFS). Eleven studies met the inclusion criteria. Two randomized clinical trials reported no differences in OS or MSS when complete lymph dissection was compared with observation alone. An increase in regional relapse was observed in the CLND group, and in one randomized controlled trial (RCT) the rate of disease-free survival was superior in those patients. Most populations in both RCTs had low sentinel lymph node biopsy (SLNB) metastatic deposits, and head and neck melanomas were not included or underrepresented. When CNLD was omitted, an active surveillance protocol was carried out. The evidence supports that CLND in SLNB positive patients does not confer a survival benefit. Sentinel tumor burden, localization of primary tumor, and feasibility of active surveillance should be taken into account in treatment decisions.

Over the years, the management of early breast cancer has evolved by leaps and bounds, as has the concept of axillary staging and armpit surgical management. Five randomised studies exist that evaluate the possibility of omitting regional locus surgical axillary treatment in patients with early breast cancer and positive sentinel lymph nodes without it having an impact on the prognosis of the disease in selected cases. A review of the literature on the management of the axilla in early breast cancer is presented.

Background Historically, completion axillary lymph node dissection (cALND) is recommended in sentinel lymph node (SLN)-positive patients. However, the high rate of negative non-sentinel nodes (NSNs) in cALND and the reported low axillary recurrence rates have led to a more conservative approach. A risk score was developed to identify a patient’s individual risk for NSN metastases. Methods Data of 182 SLN-positive patients who underwent cALND were used for risk score development. The risk score, consisting of pathological tumor size (≤20/>20 mm), lymphovascular invasion (no/yes), extracapsular extension (no/yes), size of metastases (≤2/>2 mm), and number of positive SLNs (1/>1), was subsequently validated on an external population ( n  = 180). Results The area under the receiver operating characteristic curve was 0.78 (95 % CI 0.71–0.85) in the original population and 0.78 (95 % CI 0.70–0.85) in the validation population. Based on the predicted risk for positive NSNs, three groups were defined: low risk (≤20 %), intermediate risk (21–50 %), and high risk (>50 %). In total, 88 patients met the Z0011 inclusion criteria and none of them had a high predicted risk. Of the 199 non-Z0011 patients, 67 (33.7 %) had low risk, 96 (48.2 %) had intermediate risk, and 36 (18.1 %) had high risk. Conclusion A simple risk score, integrating just five clinicopathological variables, was developed that may assist in individual decision making regarding ALND in SLN-positive patients outside of the Z0011 trial.