New article from Giuliano: occult mets in sentinel nodes

This is the researcher who did the study that showed that 1-2 + sentinel nodes did not require full ALND for survival benefit.

Here, he did special stains of sentinel nodes to find tiny mets and also did bone marrow aspirates (ouch) and found only the positive bone marrow aspirates corresponded to risk of recurrence.

I really think he's working hard to define the role of lymph node sampling

http://jama.ama-assn.org/content/306/4/385.abstract?sid=39a9ce41-01db-4076-89b5-0e949016805b

Original Contribution
JAMA. 2011;306(4):385-393. doi: 10.1001/jama.2011.1034
Association of Occult Metastases in Sentinel Lymph Nodes and Bone Marrow With Survival Among Women With Early-Stage Invasive Breast Cancer

Armando E. Giuliano, MD;
Debra Hawes, MD;
Karla V. Ballman, PhD;
Pat W. Whitworth, MD;
Peter W. Blumencranz, MD;
Douglas S. Reintgen, MD;
Monica Morrow, MD;
A. Marilyn Leitch, MD;
Kelly K. Hunt, MD;
Linda M. McCall, MS;
Andrea Abati, MD;
Richard Cote, MD

[+] Author Affiliations

Author Affiliations: Division of Surgical Oncology, John Wayne Cancer Institute at Saint John's Health Center, Santa Monica, California (Dr Giuliano); Department of Pathology, University of Southern California Norris Comprehensive Cancer Center, Los Angeles (Dr Hawes); Division of Biomedical Statistics and Informatics, Mayo Clinic, Rochester, Minnesota (Dr Ballman); Nashville Breast Center, Nashville, Tennessee (Dr Whitworth); Morton Plant Hospital, Clearwater, Florida (Dr Blumencranz); Lakeland Regional Cancer Center, Lakeland, Florida (Dr Reintgen); Memorial Sloan-Kettering Cancer Center, New York, New York (Dr Morrow); University of Texas Southwestern Medical Center, Dallas (Dr Leitch); Department of Surgical Oncology, the University of Texas M. D. Anderson Cancer Center, Houston (Dr Hunt); American College of Surgeons Oncology Group, Durham, North Carolina (Ms McCall); Cytopathology Section, Laboratory of Pathology, National Cancer Institute, Bethesda, Maryland (Dr Abati); and Department of Pathology, University of Miami Miller School of Medicine, Miami, Florida (Dr Cote). Dr Giuliano is now with Cedars-Sinai Medical Center, Los Angeles, California, and Dr Abati is now with Dermpath Diagnostics, Port Chester, New York.

Abstract

Context Immunochemical staining of sentinel lymph nodes (SLNs) and bone marrow identifies breast cancer metastases not seen with routine pathological or clinical examination.

Objective To determine the association between survival and metastases detected by immunochemical staining of SLNs and bone marrow specimens from patients with early-stage breast cancer.

Design, Setting, and Patients From May 1999 to May 2003, 126 sites in the American College of Surgeons Oncology Group Z0010 trial enrolled women with clinical T1 to T2N0M0 invasive breast carcinoma in a prospective observational study.

Interventions All 5210 patients underwent breast-conserving surgery and SLN dissection. Bone marrow aspiration at the time of operation was initially optional and subsequently mandatory (March 2001). Sentinel lymph node specimens (hematoxylin-eosin negative) and bone marrow specimens were sent to a central laboratory for immunochemical staining; treating clinicians were blinded to results.

Main Outcome Measures Overall survival (primary end point) and disease-free survival (a secondary end point).

Results Of 5119 SLN specimens (98.3%), 3904 (76.3%) were tumor-negative by hematoxylin-eosin staining. Of 3326 SLN specimens examined by immunohistochemistry, 349 (10.5%) were positive for tumor. Of 3413 bone marrow specimens examined by immunocytochemistry, 104 (3.0%) were positive for tumors. At a median follow-up of 6.3 years (through April 2010), 435 patients had died and 376 had disease recurrence. Immunohistochemical evidence of SLN metastases was not significantly associated with overall survival (5-year rates: 95.7%; 95% confidence interval [CI], 95.0%-96.5% for immunohistochemical negative and 95.1%; 95% CI, 92.7%-97.5% for immunohistochemical positive disease; P = .64; unadjusted hazard ratio [HR], 0.90; 95% CI, 0.59-1.39; P = .64). Bone marrow metastases were associated with decreased overall survival (unadjusted HR for mortality, 1.94; 95% CI, 1.02-3.67; P = .04), but neither immunohistochemical evidence of tumor in SLNs (adjusted HR, 0.88; 95% CI, 0.45-1.71; P = .70) nor immunocytochemical evidence of tumor in bone marrow (adjusted HR, 1.83; 95% CI, 0.79-4.26; P = .15) was statistically significant on multivariable analysis.

Conclusion Among women receiving breast-conserving therapy and SLN dissection, immunohistochemical evidence of SLN metastasis was not associated with overall survival over a median of 6.3 years, whereas occult bone marrow metastasis, although rare, was associated with decreased survival.

Trial Registration clinicaltrials.gov Identifier: NCT00003854