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Nijveldt JJ, Rajan KK, Boersma K, Noorda EM, van der Starre-Gaal J, Kate MV'VT, Roeloffzen EMA, Vendel BN, Beek MA, Francken AB. Implementation of the Targeted Axillary Dissection Procedure in Clinically Node-Positive Breast Cancer: A Retrospective Analysis. Ann Surg Oncol 2024; 31:4477-4486. [PMID: 38523225 DOI: 10.1245/s10434-024-15182-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Accepted: 03/03/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND The targeted axillary dissection (TAD) procedure is used in clinically positive lymph node (cN+) breast cancer to assess whether pathological complete response (pCR) is achieved after neoadjuvant systemic therapy (NST) to decide on de-escalation of axillary lymph node dissection (ALND). In this study, we review the implementation of the TAD procedure in a large regional breast cancer center. METHODS All TAD procedures between 2016 and 2022 were reviewed. The TAD procedure consists of marking pre-NST the largest suspected metastatic lymph node(s) using a radioactive I-125 seed. During surgery, the marked node was excised together with a sentinel node procedure. Axillary therapy (ALND, axillary radiotherapy, or nothing) recommendations were based on the amount of suspected positive axillary lymph nodes (ALNs < 4 or ≥ 4) pre-NST and if pCR was achieved after NST. RESULTS A total of 312 TAD procedures were successfully performed in 309 patients. In 134 (43%) cases, pCR of the TAD lymph nodes were achieved. Per treatment protocol, 43 cases (14%) did not receive any axillary treatment, 218 cases (70%) received adjuvant axillary radiotherapy, and 51 cases (16%) underwent an ALND. During a median follow-up of 2.8 years, 46 patients (14%) developed recurrence, of which 11 patients (3.5%) had axillary recurrence. CONCLUSIONS Introduction of the TAD procedure has resulted in a reduction of 84% of previously indicated ALNDs. Moreover, 18% of cases did not receive adjuvant axillary radiotherapy. These data show that implementation of de-escalation axillary treatment with the TAD procedure appeared to be successful.
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Affiliation(s)
- Joni J Nijveldt
- Department of Surgical Oncology, Isala Zwolle, Zwolle, The Netherlands
| | - Kiran K Rajan
- Department of Surgical Oncology, Isala Zwolle, Zwolle, The Netherlands.
| | - Karina Boersma
- Department of Surgical Oncology, Isala Zwolle, Zwolle, The Netherlands
| | - Eva M Noorda
- Department of Surgical Oncology, Isala Zwolle, Zwolle, The Netherlands
| | | | | | | | - Brian N Vendel
- Department of Nuclear Medicine, Isala Zwolle, Zwolle, The Netherlands
| | - Maarten A Beek
- Department of Surgical Oncology, Isala Zwolle, Zwolle, The Netherlands
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Schipper RJ, de Bruijn A, van der Sangen MJC, Bloemen JG, van den Hoven I, Schepers EEM, Vriens BEP, Boerman T, Rijkaart DC, van de Winkel LMH, Brouwer C, van Warmerdam LJC, Gielens MPM, van Bommel RMG, van Riet YE, Voogd AC, Nieuwenhuijzen GAP. Oncologic outcomes of de-escalating axillary treatment in clinically node-positive breast cancer patients treated with neoadjuvant systemic therapy - A two center cohort study. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108472. [PMID: 38870876 DOI: 10.1016/j.ejso.2024.108472] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2024] [Revised: 05/18/2024] [Accepted: 06/04/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND The aim of the present study was to report the 5-year axillary recurrence-free interval (aRFI) in clinically node-positive breast cancer patients treated according to a de-escalating axillary treatment protocol after neoadjuvant systemic therapy (NST). METHODS All patients diagnosed in two hospitals between October 2014 and March 2021 were identified retrospectively. Data on diagnostic workup, treatment and follow-up was collected. Adjuvant axillary treatment was considered based on the initial staging using 18F-FDG PET/CT and the results of axillary lymph node marking with a radioactive-iodine seed protocol or a targeted axillary dissection procedure. Follow-up was updated until 27th April 2024. Kaplan-Meier curves were calculated to report the 5-year aRFI with corresponding 95 % confident intervals (95%-CI). RESULTS A total of 199 patients were included. Axillary pathological complete response was reported in 66 (33.2 %). Based on the treatment protocol and initial clinical staging, no adjuvant axillary treatment was indicated in 30 patients (15 %), while 139 (70 %) received axillary radiotherapy without performance of an axillary lymph node dissection (ALND). The remaining 30 patients (15 %) underwent an ALND with additional locoregional radiotherapy. A median follow-up of 62 months (30-106) showed that 4 (2 %) patients experienced an axillary recurrence after 7, 8, 36 and 36 months, respectively. In all 4 patients, synchronous distant metastases were diagnosed. The estimated 5-year aRFI was 97.8 % (95%-CI 95.6-99.9 %) CONCLUSION: Although longer follow-up should be awaited before final conclusions can be drawn regarding the oncological safety of this approach, the implementation of a de-escalating axillary treatment protocol appears to be safe since the estimated 5-year aRFI is 97.8 %.
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Affiliation(s)
- Robert-Jan Schipper
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands; Department of Surgery, Anna Hospital, Geldrop, the Netherlands.
| | - Anne de Bruijn
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands
| | | | - Johanne G Bloemen
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands
| | | | | | - Birgit E P Vriens
- Department of Internal Medicine, Catharina Hospital Eindhoven, the Netherlands
| | - Thom Boerman
- Department of Pathology, Eurofins PAMM, Veldhoven, the Netherlands
| | - Dorien C Rijkaart
- Department of Radiotherapy, Catharina Hospital Eindhoven, the Netherlands
| | | | - Christel Brouwer
- Department of Nuclear Medicine, Catharina Hospital Eindhoven, the Netherlands
| | | | | | | | - Yvonne E van Riet
- Department of Surgery, Catharina Hospital Eindhoven, the Netherlands
| | - Adri C Voogd
- Department of Epidemiology, Maastricht University, Maastricht, the Netherlands; Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), Utrecht, the Netherlands
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Heidinger M, Weber WP. Axillary Surgery for Breast Cancer in 2024. Cancers (Basel) 2024; 16:1623. [PMID: 38730576 PMCID: PMC11083357 DOI: 10.3390/cancers16091623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/18/2024] [Accepted: 04/21/2024] [Indexed: 05/13/2024] Open
Abstract
Axillary surgery for patients with breast cancer (BC) in 2024 is becoming increasingly specific, moving away from the previous 'one size fits all' radical approach. The goal is to spare morbidity whilst maintaining oncologic safety. In the upfront surgery setting, a first landmark randomized controlled trial (RCT) on the omission of any surgical axillary staging in patients with unremarkable clinical examination and axillary ultrasound showed non-inferiority to sentinel lymph node (SLN) biopsy (SLNB). The study population consisted of 87.8% postmenopausal patients with estrogen receptor-positive, human epidermal growth factor receptor 2-negative BC. Patients with clinically node-negative breast cancer and up to two positive SLNs can safely be spared axillary dissection (ALND) even in the context of mastectomy or extranodal extension. In patients enrolled in the TAXIS trial, adjuvant systemic treatment was shown to be similar with or without ALND despite the loss of staging information. After neoadjuvant chemotherapy (NACT), targeted lymph node removal with or without SLNB showed a lower false-negative rate to determine nodal pathological complete response (pCR) compared to SLNB alone. However, oncologic outcomes do not appear to differ in patients with nodal pCR determined by either one of the two concepts, according to a recently published global, retrospective, real-world study. Real-world studies generally have a lower level of evidence than RCTs, but they are feasible quickly and with a large sample size. Another global real-world study provides evidence that even patients with residual isolated tumor cells can be safely spared from ALND. In general, few indications for ALND remain. Three randomized controlled trials are ongoing for patients with clinically node-positive BC in the upfront surgery setting and residual disease after NACT. Pending the results of these trials, ALND remains indicated in these patients.
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Affiliation(s)
- Martin Heidinger
- Breast Surgery, University Hospital Basel, 4031 Basel, Switzerland;
- Faculty of Medicine, University of Basel, 4001 Basel, Switzerland
| | - Walter P. Weber
- Breast Surgery, University Hospital Basel, 4031 Basel, Switzerland;
- Faculty of Medicine, University of Basel, 4001 Basel, Switzerland
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van Hemert A, van Loevezijn AA, Bosman A, Vlahu CA, Loo CE, Peeters MJTFDV, van Duijnhoven FH, van der Ploeg IMC. Breast surgery after neoadjuvant chemotherapy in patients with lobular carcinoma: surgical and oncologic outcome. Breast Cancer Res Treat 2024; 204:497-507. [PMID: 38189904 DOI: 10.1007/s10549-023-07192-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 11/19/2023] [Indexed: 01/09/2024]
Abstract
INTRODUCTION Breast cancer patients with invasive lobular carcinoma (ILC) have an increased risk of positive margins after surgery and often show little response to neoadjuvant chemotherapy (NAC). We aimed to investigate surgical outcomes in patients with ILC treated with NAC. METHODS In this retrospective cohort study, all breast cancer patients with ILC treated with NAC who underwent surgery at the Netherlands Cancer Institute from 2010 to 2019 were selected. Patients with mixed type ILC in pre-NAC biopsies were excluded if the lobular component was not confirmed in the surgical specimen. Main outcomes were tumor-positive margins and re-excision rate. Associations between baseline characteristics and tumor-positive margins were assessed, as were complications, locoregional recurrence rate (LRR), recurrence-free survival (RFS), and overall survival (OS). RESULTS We included 191 patients. After NAC, 107 (56%) patients had breast conserving surgery (BCS) and 84 (44%) patients underwent mastectomy. Tumor-positive margins were observed in 67 (35%) patients. Fifty five (51%) had BCS and 12 (14%) underwent mastectomy (p value < 0.001). Re-excision was performed in 35 (33%) patients with BCS and in 4 (5%) patients with mastectomy. Definitive surgery was mastectomy in 107 (56%) patients and BCS in 84 (44%) patients. Tumor-positive margins were associated with cT ≥ 3 status (OR 4.62, 95% CI 1.26-16.98, p value 0.021) in the BCS group. Five-year LRR (4.7%), RFS (81%), and OS (93%) were not affected by type of surgery after NAC. CONCLUSION Although 33% of ILC breast cancer patients undergoing BCS after NAC required re-excision for positive resection margins, it is considered safe given that five-year RFS remained excellent and LRR and OS did not differ by extent of surgery.
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Affiliation(s)
- Annemiek van Hemert
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Ariane A van Loevezijn
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Anne Bosman
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
- Department of Surgery, NoordWest Ziekenhuisgroep, Wilhelminalaan 12, 1815 JD, Alkmaar, The Netherlands
| | - Carmen A Vlahu
- Department of Pathology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Claudette E Loo
- Department of Radiology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | | | - Frederieke H van Duijnhoven
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Iris M C van der Ploeg
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.
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van Hemert AKE, van Duijnhoven FH, Vrancken Peeters MJTFD. This house believes that: MARI/TAD is better than sentinel node biopsy after PST for cN+ patients. Breast 2023; 71:89-95. [PMID: 37562108 PMCID: PMC10432821 DOI: 10.1016/j.breast.2023.06.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 06/03/2023] [Accepted: 06/28/2023] [Indexed: 08/12/2023] Open
Abstract
The increasing use and effectiveness of primary systemic treatment (PST) enables tailored locoregional treatment. About one third of clinically node positive (cN+) breast cancer patients achieve pathologic complete response (pCR) of the axilla, with higher rates observed in Human Epidermal growth factor Receptor (HER)2-positive or triple negative (TN) breast cancer subtypes. Tailoring axillary treatment for patients with axillary pCR is necessary, as they are unlikely to benefit from axillary lymph node dissection (ALND), but may suffer complications and long-term morbidity such as lymphedema and impaired shoulder motion. By combining pre-PST and post-PST axillary staging techniques, ALND can be omitted in most cN + patients with pCR. Different post-PST staging techniques (MARI/TAD/SN) show low or ultra-low false negative rates for detection of residual disease. More importantly, trials using the MARI (Marking Axillary lymph nodes with Radioactive Iodine seeds) procedure or sentinel lymph node biopsy (SLNB) as axillary staging technique post-PST have already shown the safety of tailoring axillary treatment in patients with an excellent response. Tailored axillary treatment using the MARI procedure in stage I-III breast cancer resulted in 80% reduction of ALND and excellent five-year axillary recurrence free interval (aRFI) of 97%. Similar oncologic outcomes were seen for post-SLNB in stage I-II patients. The MARI technique requires only one invasive procedure pre-NST and a median of one node is removed post-PST, whereas for the SLNB and TAD techniques two to four nodes are removed. A disadvantage of the MARI technique is its use of radioactive iodine, which is subject to extensive regulations.
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Affiliation(s)
- Annemiek K E van Hemert
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066, CX, Amsterdam, the Netherlands
| | - Frederieke H van Duijnhoven
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066, CX, Amsterdam, the Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Plesmanlaan 121, 1066, CX, Amsterdam, the Netherlands; Department of Surgery, Amsterdam University Medical Center, Meibergdreef 9, 1105, AZ, Amsterdam, the Netherlands.
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6
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Žatecký J, Coufal O, Zapletal O, Kubala O, Kepičová M, Faridová A, Rauš K, Gatěk J, Kosáč P, Peteja M. Ideal marker for targeted axillary dissection (IMTAD): a prospective multicentre trial. World J Surg Oncol 2023; 21:252. [PMID: 37596658 PMCID: PMC10439625 DOI: 10.1186/s12957-023-03147-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Accepted: 08/15/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Targeted axillary dissection (TAD) is an established method for axillary staging in patients with breast cancer after neoadjuvant chemotherapy (NAC). TAD consists of sentinel lymph node biopsy and initially pathological lymph node excision, which must be marked by a reliable marker before NAC. METHODS The IMTAD study is a prospective multicentre trial comparing three localisation markers for lymph node localisation (clip + iodine seed, magnetic seed, carbon suspension) facilitating subsequent surgical excision in the form of TAD. The primary outcome was to prospectively compare the reliability, accuracy, and safety according to complication rate during marker implantation and detection and marker dislodgement. RESULTS One hundred eighty-nine patients were included in the study-in 135 patients clip + iodine seed was used, in 30 patients magnetic seed and in 24 patients carbon suspension. The complication rate during the marker implantation and detection were not statistically significant between individual markers (p = 0.263; p = 0.117). Marker dislodgement was reported in 4 patients with clip + iodine seed localisation (3.0%), dislodgement did not occur in other localisation methods (p = 0.999). The false-negativity of sentinel lymph node (SLN) was observed in 8 patients, the false-negativity of targeted lymph nodes (TLN) wasn´t observed at all, the false-negativity rate (FNR) from the subcohort of ypN + patients for SLN is 9.6% and for TLN 0.0%. CONCLUSION The IMTAD study indicated, that clip + iodine seed, magnetic seed and carbon suspension are statistically comparable in terms of complications during marker implantation and detection and marker dislodgement proving their safety, accuracy, and reliability in TAD. The study confirmed, that the FNR of the TLN was lower than the FNR of the SLN proving that the TLN is a better marker for axillary lymph node status after NAC. TRIAL REGISTRATION NCT04580251. Name of registry: Clinicaltrials.gov. Date of registration: 8.10.2020.
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Affiliation(s)
- Jan Žatecký
- Department of Surgical Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic.
- Department of Surgery, Silesian Hospital in Opava, Opava, Czech Republic.
- Faculty of Public Policies, The Institute of Paramedical Health Studies, Silesian University, Opava, Czech Republic.
| | - Oldřich Coufal
- Department of Surgical Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Surgical Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ondřej Zapletal
- Department of Surgical Oncology, Masaryk Memorial Cancer Institute, Brno, Czech Republic
- Department of Surgical Oncology, Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Otakar Kubala
- Department of Surgical Studies, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
- Department of Surgery, University Hospital Ostrava, Ostrava, Czech Republic
| | - Markéta Kepičová
- Department of Surgery, University Hospital Ostrava, Ostrava, Czech Republic
| | - Adéla Faridová
- Oncogynecology Centre, The Institute for the Care of Mother and Child, Prague, Czech Republic
| | - Karel Rauš
- Oncogynecology Centre, The Institute for the Care of Mother and Child, Prague, Czech Republic
| | - Jiří Gatěk
- Department of Surgery, EUC Clinic Zlín, Zlín, Czech Republic
- Tomáš Baťa University in Zlín, Zlín, Czech Republic
| | - Peter Kosáč
- Department of Surgery, EUC Clinic Zlín, Zlín, Czech Republic
| | - Matúš Peteja
- Department of Surgery, Silesian Hospital in Opava, Opava, Czech Republic
- Faculty of Public Policies, The Institute of Paramedical Health Studies, Silesian University, Opava, Czech Republic
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7
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Kuemmel S, Heil J, Bruzas S, Breit E, Schindowski D, Harrach H, Chiari O, Hellerhoff K, Bensmann E, Hanf V, Graßhoff ST, Deuschle P, Belke K, Polata S, Paepke S, Warm M, Meiler J, Schindlbeck C, Ruhwedel W, Beckmann U, Groh U, Dall P, Blohmer JU, Traut A, Reinisch M. Safety of Targeted Axillary Dissection After Neoadjuvant Therapy in Patients With Node-Positive Breast Cancer. JAMA Surg 2023; 158:807-815. [PMID: 37285140 PMCID: PMC10248815 DOI: 10.1001/jamasurg.2023.1772] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Accepted: 02/19/2023] [Indexed: 06/08/2023]
Abstract
Importance The increasing use of neoadjuvant systemic therapy (NST) has led to substantial pathological complete response rates in patients with initially node-positive, early breast cancer, thereby questioning the need for axillary lymph node dissection (ALND). Targeted axillary dissection (TAD) is feasible for axillary staging; however, data on oncological safety are scarce. Objective To assess 3-year clinical outcomes in patients with node-positive breast cancer who underwent TAD alone or TAD with ALND. Design, Setting, and Participants The SenTa study is a prospective registry study and was conducted between January 2017 and October 2018. The registry includes 50 study centers in Germany. Patients with clinically node-positive breast cancer underwent clipping of the most suspicious lymph node (LN) before NST. After NST, the marked LNs and sentinel LNs were excised (TAD) followed by ALND according to the clinician's choice. Patients who did not undergo TAD were excluded. Data analysis was performed in April 2022 after 43 months of follow-up. Exposure TAD alone vs TAD with ALND. Main Outcomes and Measures Three-year clinical outcomes were evaluated. Results Of 199 female patients, the median (IQR) age was 52 (45-60) years. A total of 182 patients (91.5%) had 1 to 3 suspicious LNs; 119 received TAD alone and 80 received TAD with ALND. Unadjusted invasive disease-free survival was 82.4% (95% CI, 71.5-89.4) in the TAD with ALND group and 91.2% (95% CI, 84.2-95.1) in the TAD alone group (P = .04); axillary recurrence rates were 1.4% (95% CI, 0-54.8) and 1.8% (95% CI, 0-36.4), respectively (P = .56). Adjusted multivariate Cox regression indicated that TAD alone was not associated with an increased risk of recurrence (hazard ratio [HR], 0.83; 95% CI, 0.34-2.05; P = .69) or death (HR, 1.07; 95% CI, 0.31-3.70; P = .91). Similar results were obtained for 152 patients with clinically node-negative breast cancer after NST (invasive disease-free survival: HR, 1.26; 95% CI, 0.27-5.87; P = .77; overall survival: HR, 0.81; 95% CI, 0.15-3.83; P = .74). Conclusions and Relevance These results suggest that TAD alone in patients with mostly good clinical response to NST and at least 3 TAD LNs may confer survival outcomes and recurrence rates similar to TAD with ALND.
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Affiliation(s)
- Sherko Kuemmel
- Interdisciplinary Breast Unit, Kliniken Essen-Mitte, Essen, Germany
- Department of Gynecology With Breast Center Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Joerg Heil
- Department of Obstetrics and Gynecology, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Simona Bruzas
- Interdisciplinary Breast Unit, Kliniken Essen-Mitte, Essen, Germany
| | - Elisabeth Breit
- Interdisciplinary Breast Unit, Kliniken Essen-Mitte, Essen, Germany
| | | | - Hakima Harrach
- Interdisciplinary Breast Unit, Kliniken Essen-Mitte, Essen, Germany
| | - Ouafaa Chiari
- Interdisciplinary Breast Unit, Kliniken Essen-Mitte, Essen, Germany
| | | | | | - Volker Hanf
- Breast Unit Klinikum Fürth, Frauenklinik Nathanstift, Fürth, Germany
| | | | - Petra Deuschle
- Breast Unit, Marienhaus Klinikum Hetzelstift Neustadt/Weinstraße, Neustadt, Germany
| | - Kerstin Belke
- Klinik für Gynäkologie und Geburtshilfe, Robert-Koch-Krankenhaus Apolda, Apolda, Germany
| | - Silke Polata
- Klinik für Innere Medizin/Onkologisches Zentrum, Evangelisches Waldkrankenhaus Spandau, Berlin, Germany
| | - Stefan Paepke
- Klinik und Poliklinik für Frauenheilkunde, Klinikum rechts der Isar, TU München, Munich, Germany
| | - Mathias Warm
- Brustzentrum Holweide, Kliniken der Stadt Köln, Cologne, Germany
| | | | | | - Wencke Ruhwedel
- Klinik für Frauenheilkunde und Geburtshilfe, Klinikum Gütersloh, Gütersloh, Germany
| | - Ulrike Beckmann
- Brustzentrum der Niels-Stensen-Kliniken, Franziskus-Hospital Harderberg, Georgsmarienhütte, Germany
| | - Ulrich Groh
- Klinik für Gynäkologie, Geburtshilfe und Senologie, Hochwaldkrankenhaus Bad Nauheim, Bad Nauheim, Germany
| | - Peter Dall
- Brustzentrum und Gynäkologisches Krebszentrum, Städtisches Klinikum Lüneburg, Lüneburg, Germany
| | - Jens-Uwe Blohmer
- Department of Gynecology With Breast Center Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Alexander Traut
- Department of Gynecology and Gynecologic Oncology, Kliniken Essen-Mitte, Essen, Germany
| | - Mattea Reinisch
- Interdisciplinary Breast Unit, Kliniken Essen-Mitte, Essen, Germany
- Department of Gynecology With Breast Center Charité—Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
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8
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Heidinger M, Knauer M, Tausch C, Weber WP. Tailored axillary surgery - A novel concept for clinically node positive breast cancer. Breast 2023; 69:281-289. [PMID: 36922305 PMCID: PMC10034500 DOI: 10.1016/j.breast.2023.03.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 02/25/2023] [Accepted: 03/07/2023] [Indexed: 03/11/2023] Open
Abstract
Axillary surgery in patients with breast cancer has been a history of de-escalation; however, surgery for clinically node-positive breast cancer remained at the dogmatic level of axillary lymph node dissection (ALND). In these patients, currently the only way to avoid ALND is neoadjuvant systemic treatment (NST) with nodal pathologic complete response (pCR) as diagnosed by selective lymph node removal. However, pCR rates are highly dependent on tumor biology, with luminal tumors being most present yet showing the lowest pCR rates. Therefore, the TAXIS trial is investigating whether in clinically node-positive patients, either with residual disease after NST or in the upfront surgical setting, ALND can be safely omitted. All patients undergo tailored axillary surgery (TAS), which includes removal of the biopsied and clipped node, the sentinel lymph nodes as well as all palpably suspicious nodes, turning a clinically positive axilla into a clinically negative. Feasibility of TAS was recently confirmed in the first pre-specified TAXIS substudy. TAS is followed by axillary radiotherapy to treat any remaining nodal disease. Disease-free survival is the primary endpoint of this non-inferiority trial, and morbidity as well as quality of life are the main secondary endpoints, with ALND being known for having a relevant negative impact on both. Currently, 663 of 1500 patients were randomized; accrual completion is projected for 2025. The TAXIS trial stands out in including clinically node-positive patients in both the neoadjuvant and upfront surgery setting, thereby investigating surgical de-escalation at the far-end of the risk spectrum of patients with breast cancer.
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Affiliation(s)
- Martin Heidinger
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland
| | - Michael Knauer
- Breast Center Eastern Switzerland, St. Gallen, Switzerland
| | | | - Walter P Weber
- Breast Center, University Hospital Basel, Basel, Switzerland; University of Basel, Basel, Switzerland.
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9
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de Mooij CM, Samiei S, Mitea C, Lobbes MBI, Kooreman LFS, Heuts EM, Beets-Tan RGH, van Nijnatten TJA, Smidt ML. Axillary lymph node response to neoadjuvant systemic therapy with dedicated axillary hybrid 18F-FDG PET/MRI in clinically node-positive breast cancer patients: a pilot study. Clin Radiol 2022; 77:e732-e740. [PMID: 35850866 DOI: 10.1016/j.crad.2022.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Revised: 06/07/2022] [Accepted: 06/20/2022] [Indexed: 11/26/2022]
Abstract
AIM To investigate the diagnostic performance of dedicated axillary hybrid 18F-2-[18F]-fluoro-2-deoxy-d-glucose (FDG) positron emission tomography (PET)/magnetic resonance imaging (MRI) in detecting axillary pathological complete response (pCR) following neoadjuvant systemic therapy (NST) in clinically node-positive breast cancer patients. MATERIALS AND METHODS Ten prospectively included clinically node-positive breast cancer patients underwent dedicated axillary hybrid 18F-FDG PET/MRI after completing NST followed by axillary surgery. PET images were reviewed by a nuclear medicine physician and coronal T1-weighted and T2-weighted MRI images by a radiologist. All axillary lymph nodes visible on PET/MRI were matched with those removed during axillary surgery. Diagnostic performance parameters were calculated based on patient-by-patient and node-by-node validation with histopathology of the axillary surgical specimen as the reference standard. RESULTS Six patients achieved axillary pCR at final histopathology. A total of 84 surgically harvested axillary lymph nodes were matched with axillary lymph nodes depicted on PET/MRI. Histopathological examination of the matched axillary lymph nodes resulted in 10 lymph nodes with residual axillary disease of which eight contained macrometastases and two micrometastases. The patient-by-patient analysis yielded a sensitivity, specificity, positive predictive value, and negative predictive value of 25%, 100%, 100%, and 67%, respectively. The diagnostic performance parameters of the node-by-node analysis were 0%, 96%, 0%, and 88%, respectively. Excluding micrometastases from the node-by-node analysis increased the negative predictive value to 90%. CONCLUSION This pilot study suggests that the negative predictive value and sensitivity of dedicated axillary 18F-FDG PET/MRI are insufficiently accurate to detect axillary pCR or exclude residual axillary disease following NST in clinically node-positive breast cancer patients.
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Affiliation(s)
- C M de Mooij
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands; GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands.
| | - S Samiei
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands; GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - C Mitea
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - M B I Lobbes
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Department of Medical Imaging, Zuyderland Medical Center, Sittard-Geleen, the Netherlands
| | - L F S Kooreman
- GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Department of Pathology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - E M Heuts
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - R G H Beets-Tan
- GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands; Department of Radiology, Antoni van Leeuwenhoek/Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - T J A van Nijnatten
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, the Netherlands; GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
| | - M L Smidt
- Department of Surgery, Maastricht University Medical Center+, Maastricht, the Netherlands; GROW - School for Oncology and Reproduction, Maastricht University, Maastricht, the Netherlands
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10
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Song YX, Xu Z, Liang MX, Liu Z, Hou JC, Chen X, Xu D, Fei YJ, Tang JH. Diagnostic accuracy of de-escalated surgical procedure in axilla for node-positive breast cancer patients treated with neoadjuvant systemic therapy: A systematic review and meta-analysis. Cancer Med 2022; 11:4085-4103. [PMID: 35502768 DOI: 10.1002/cam4.4769] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 03/19/2022] [Accepted: 04/10/2022] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND More initial clinical node-positive breast cancer patients achieve axillary pathological complete response (ax-pCR) after neoadjuvant systemic therapy (NST). Restaging axillary status and performing de-escalated surgical procedures to replace routine axillary lymph nodes dissection (ALND) is urgently needed. Targeted axillary lymph node biopsy (TLNB) is a novel de-escalated surgical strategy marking metastatic axillary nodes before NST and targeted dissection and biopsy intraoperatively to tailor individual axillary management. METHODS This study provided a systematic review and meta-analysis to evaluate the feasibility and diagnosis accuracy of TLNB. Prospective and retrospective clinical trials on TLNB were searched from Pubmed, Embase, and Cochrane. Identification rate (IFR), false-negative rate (FNR), negative predictive value (NPV), and rate of ax-pCR were the outcomes of this meta-analysis. RESULTS One thousand nine hundred and twenty patients attempted TLNB, with an overall IFR of 93.5% (95% confidence interval [CI] 90.1%-96.2%). IFR of three nodal marking methods, namely iodine seeds, clips, and carbon dye, was 95.6% (95% CI 91.2%-98.7%), 91.7% (95% CI 87.3%-95.4%), and 97.1% (95% CI 89.1%-100.0%), respectively. Of them, 847 patients received ALND, with an overall FNR of 5.5% (95% CI 3.3%-8.0%), and NPV ranged from 90.1% to 96.1%. Regression analysis showed that the overlap of targeted and sentinel biopsied nodes might associate with IFRs and FNRs. CONCLUSION TLNB is a novel, less invasive surgical approach to distinguish initial node-positive breast cancer that achieves negative axillary conversion after NST. It yields an excellent IFR with a low FNR and a high NPV. A combination of preoperative imaging, intraoperative TLNB with SLNB, and postoperative nodal radiotherapy might affect the future treatment paradigm of primary breast cancer with nodal metastases.
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Affiliation(s)
- Yu-Xin Song
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zheng Xu
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Ming-Xing Liang
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Zhen Liu
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jun-Chen Hou
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Xiu Chen
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Di Xu
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Yin-Jiao Fei
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jin-Hai Tang
- The Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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11
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van Loevezijn AA, van der Noordaa MEM, Stokkel MPM, van Werkhoven ED, Groen EJ, Loo CE, Elkhuizen PHM, Sonke GS, Russell NS, van Duijnhoven FH, Vrancken Peeters MJTFD. Three-year follow-up of de-escalated axillary treatment after neoadjuvant systemic therapy in clinically node-positive breast cancer: the MARI-protocol. Breast Cancer Res Treat 2022; 193:37-48. [PMID: 35239072 PMCID: PMC8993719 DOI: 10.1007/s10549-022-06545-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/13/2022] [Indexed: 12/29/2022]
Abstract
Purpose In clinically node-positive (cN+) breast cancer patients, evidence supporting response-guided treatment after neoadjuvant systemic therapy (NST) instead of axillary lymph node dissection (ALND) is increasing, but follow-up results are lacking. We assessed three-year axillary recurrence-free interval (aRFI) in cN+ patients with response-adjusted axillary treatment according to the ‘Marking Axillary lymph nodes with Radioactive Iodine seeds’ (MARI)-protocol. Methods We retrospectively assessed all stage II–III cytologically proven cN+ breast cancer patients who underwent the MARI-protocol between July 2014 and November 2018. Pre-NST axillary staging with FDG-PET/CT (less- or more than four suspicious axillary nodes; cALN < 4 or cALN ≥ 4) and post-NST pathological axillary response measured in the pre-NST largest tumor-positive axillary lymph node marked with an iodine seed (MARI-node; ypMARI-neg or ypMARI-pos) determined axillary treatment: no further treatment (cALN < 4, ypMARI-neg), axillary radiotherapy (ART) (cALN < 4, ypMARI-pos and cALN ≥ 4, ypMARI-neg) or ALND plus ART (cALN ≥ 4, ypMARI-pos). Results Of 272 women included, the MARI-node was tumor-negative in 56 (32%) of 174 cALN < 4 patients and 43 (44%) of 98 cALN ≥ 4 patients. According to protocol, 56 (21%) patients received no further axillary treatment, 161 (59%) received ART and 55 (20%) received ALND plus ART. Median follow-up was 3.0 years (IQR 1.9–4.1). Five patients (one no further treatment, four ART) had axillary metastases. Three-year aRFI was 98% (95% CI 96–100). The overall recurrence risk remained highest for patients with ALND (HR 4.36; 95% CI 0.95–20.04, p = 0.059). Conclusions De-escalation of axillary treatment according to the MARI-protocol prevented ALND in 80% of cN+ patients with an excellent three-year aRFI of 98%.
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Affiliation(s)
- Ariane A van Loevezijn
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
- Department of Surgery, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marieke E M van der Noordaa
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - Marcel P M Stokkel
- Department of Nuclear Medicine, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - Erik D van Werkhoven
- Department of Biometrics, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - Emma J Groen
- Department of Pathology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - Claudette E Loo
- Department of Radiology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - Paula H M Elkhuizen
- Department of Radiation Oncology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - Gabe S Sonke
- Department of Medical Oncology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - Nicola S Russell
- Department of Radiation Oncology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - Frederieke H van Duijnhoven
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Amsterdam, The Netherlands.
- Department of Surgery, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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12
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Sentinel node detection in breast cancer. Nucl Med Mol Imaging 2022. [DOI: 10.1016/b978-0-12-822960-6.00016-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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13
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van Loevezijn AA, Stokkel MPM, Donswijk ML, van Werkhoven ED, van der Noordaa MEM, van Duijnhoven FH, Vrancken Peeters MJTFD. [ 18F]FDG-PET/CT in prone compared to supine position for optimal axillary staging and treatment in clinically node-positive breast cancer patients with neoadjuvant systemic therapy. EJNMMI Res 2021; 11:78. [PMID: 34417932 PMCID: PMC8380204 DOI: 10.1186/s13550-021-00824-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Accepted: 08/11/2021] [Indexed: 11/10/2022] Open
Abstract
PURPOSE Axillary staging before neoadjuvant systemic therapy in clinically node-positive breast cancer patients with tailored axillary treatment according to the Marking Axillary lymph nodes with radioactive iodine seeds (MARI)-protocol, a protocol developed at the Netherlands Cancer Institute, is performed with [18F] fluorodeoxyglucose (FDG) positron emission tomography and computed tomography (PET/CT). We aimed to assess the value of FDG-PET/CT in prone compared to standard supine position for axillary staging. METHODS We selected patients with FDG-PET/CT in supine and prone position who underwent the MARI-protocol. One hour after administration of 3.5 MBq/kg, [18F]FDG-PET was performed with a low-dose prone position CT-thorax followed by a supine whole-body scan. Scans were separately reviewed by two nuclear medicine physicians and categorized by number of FDG-positive axillary lymph nodes (ALNs; cALN<4 or cALN≥4). Main outcome was axillary up- or downstaging. RESULTS Of 153 patients included, 24 (16%) patients were up- or downstaged at evaluation of prone images: One observer upstaged 14 patients, downstaged 3 patients and reported a higher number of ALNs (3.6 vs. 3.2, p < 0.001), while staging (4 up- and 5 downstaged) and number of ALNs (2.8 vs. 2.8) did not differ for the other. Observers agreed on up- or downstaging in only 1 (1%) patient. Irrespective of supine or prone position scanning, observers agreed on axillary staging in 124 (81%) patients and disagreed in 5 (3%). Interobserver agreement was lower with prone assessments (86%, K = 0.67) than supine (92%, K = 0.80). CONCLUSIONS Axillary staging with FDG-PET/CT in prone compared to supine position did not result in concordant up- or downstaging. Therefore, FDG-PET/CT in supine position only can be considered sufficient for axillary staging.
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Affiliation(s)
- Ariane A van Loevezijn
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands.,Department of Surgery, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Marcel P M Stokkel
- Department of Nuclear Medicine, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Maarten L Donswijk
- Department of Nuclear Medicine, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Erik D van Werkhoven
- Department of Biometrics, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Marieke E M van der Noordaa
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Frederieke H van Duijnhoven
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni Van Leeuwenhoek, Plesmanlaan 121, 1066 CX, Amsterdam, The Netherlands. .,Department of Surgery, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
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14
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de Wild SR, Simons JM, Vrancken Peeters MJTFD, Smidt ML, Koppert LB. MINImal vs. MAXimal Invasive Axillary Staging and Treatment After Neoadjuvant Systemic Therapy in Node Positive Breast Cancer: Protocol of a Dutch Multicenter Registry Study (MINIMAX). Clin Breast Cancer 2021; 22:e59-e64. [PMID: 34446364 DOI: 10.1016/j.clbc.2021.07.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 07/21/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Node positive breast cancer (cN+) patients with an axillary pathologic complete response after neoadjuvant systemic therapy (NST) are not expected to benefit from axillary lymph node dissection (ALND). Therefore, less invasive axillary staging procedures have been introduced to establish response-guided treatment. However, evidence is lacking with regard to their oncologic safety and impact on quality of life (QoL). We hypothesize that if response-guided treatment is given, less invasive staging procedures are non-inferior to standard ALND in terms of oncologic safety, and superior to standard ALND in terms of QoL. PATIENTS AND METHODS MINIMAX is a Dutch multicenter registry study that includes patients with cN1-3M0 unilateral invasive breast cancer, who receive NST, followed by axillary staging and treatment according to local protocols. In a retrospective registry of ±4000 patients, the primary endpoint is oncologic safety at 5 and 10 years (disease-free, breast-cancer-specific and overall survival, and axillary recurrence rate). In a prospective multicenter registry, the primary endpoints are QoL at 1 and 5 years, and we aim to verify the 5-year oncologic safety. With an estimated 5-year disease-free survival of 72.5% and anticipated loss to follow-up of 10%, a sample size of 549 is needed to have 80% power to detect non-inferiority (with a 10% margin) of less invasive staging procedures. CONCLUSION In cN+ patients treated with NST, less invasive axillary staging procedures are already implemented globally. Evidence is needed to support the assumed oncologic safety and superior QoL of such procedures. This study will contribute to evidence-based guidelines.
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Affiliation(s)
- Sabine R de Wild
- Department of Surgical Oncology, Maastricht University Medical Center+, Maastricht, the Netherlands; GROW School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands.
| | - Janine M Simons
- Department of Surgical Oncology, Maastricht University Medical Center+, Maastricht, the Netherlands; GROW School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | | | - Marjolein L Smidt
- Department of Surgical Oncology, Maastricht University Medical Center+, Maastricht, the Netherlands; GROW School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, the Netherlands
| | - Linetta B Koppert
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, the Netherlands
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15
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Līcīte B, Irmejs A, Maksimenko J, Loža P, Trofimovičs G, Miklaševičs E, Nazarovs J, Romanovska M, Deičmane J, Irmejs R, Purkalne G, Gardovskis J. Ultrasound guided needle biopsy of axilla to evaluate nodal metastasis after preoperative systemic therapy in cohort of 106 breast cancers enriched with BRCA1/2 pathogenic variant carriers. Hered Cancer Clin Pract 2021; 19:30. [PMID: 34233740 PMCID: PMC8262039 DOI: 10.1186/s13053-021-00187-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 06/18/2021] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Aim of the study is to evaluate the role of ultrasound guided fine needle aspiration cytology (FNAC) in the restaging of node positive breast cancer after preoperative systemic therapy (PST). METHODS From January 2016 - October 2020 106 node positive stage IIA-IIIC breast cancer cases undergoing PST were included in the study. 18 (17 %) were carriers of pathogenic variant in BRCA1/2. After PST restaging of axilla was performed with ultrasound and FNAC of the marked and/or the most suspicious axillary node. In 72/106 cases axilla conserving surgery and in 34/106 cases axillary lymph node dissection (ALND) was performed. RESULTS False Positive Rate (FPR) of FNAC after PST in whole cohort and BRCA1/2 positive subgroup is 8 and 0 % and False Negative Rate (FNR) - 43 and 18 % respectively. Overall Sensitivity - 55 %, specificity- 93 %, accuracy 70 %. CONCLUSION FNAC after PST has low FPR and is useful to predict residual axillary disease and to streamline surgical decision making regarding ALND both in BRCA1/2 positive and negative subgroups. FNR is high in overall cohort and FNAC alone are not able to predict ypCR and omission of further axillary surgery. However, FNAC performance in BRCA1/2 positive subgroup is more promising and further research with larger number of cases is necessary to confirm the results.
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Affiliation(s)
- Baiba Līcīte
- Department of Surgery, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia.
- Department of Surgery, (Affiliated Partner of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS)), Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia.
| | - Arvīds Irmejs
- Department of Surgery, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Department of Surgery, (Affiliated Partner of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS)), Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Institute of Oncology, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Jeļena Maksimenko
- Department of Surgery, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Department of Surgery, (Affiliated Partner of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS)), Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Institute of Oncology, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Pēteris Loža
- Department of Surgery, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Department of Surgery, (Affiliated Partner of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS)), Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Genādijs Trofimovičs
- Department of Surgery, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Department of Surgery, (Affiliated Partner of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS)), Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Edvīns Miklaševičs
- Institute of Oncology, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Jurijs Nazarovs
- Department of Pathology, Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Māra Romanovska
- Department of Pathology, Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Justīne Deičmane
- Department of Radiology, Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Reinis Irmejs
- St John's College, University of Cambridge, Cambridge, England
| | - Gunta Purkalne
- Department of Surgery, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Department of Oncology, Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
| | - Jānis Gardovskis
- Department of Surgery, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Department of Surgery, (Affiliated Partner of the European Reference Network on Genetic Tumour Risk Syndromes (ERN GENTURIS)), Pauls Stradiņš Clinical University Hospital, Pilsoņu iela 13, LV-1002, Riga, Latvia
- Institute of Oncology, Riga Stradiņš University, Pilsoņu iela 13, LV-1002, Riga, Latvia
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16
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van der Noordaa MEM, van Duijnhoven FH, Cuijpers FNE, van Werkhoven E, Wiersma TG, Elkhuizen PHM, Winter-Warnars G, Dezentje V, Sonke GS, Groen EJ, Stokkel M, Vrancken Peeters MTFD. Toward omitting sentinel lymph node biopsy after neoadjuvant chemotherapy in patients with clinically node-negative breast cancer. Br J Surg 2021; 108:667-674. [PMID: 34157085 DOI: 10.1002/bjs.12026] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/20/2020] [Accepted: 08/03/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND The nodal positivity rate after neoadjuvant chemotherapy (ypN+) in patients with clinically node-negative (cN0) breast cancer is low, especially in those with a pathological complete response of the breast. The aim of this study was to identify characteristics known before surgery that are associated with achieving ypN0 in patients with cN0 disease. These characteristics could be used to select patients in whom sentinel lymph node biopsy may be omitted after neoadjuvant chemotherapy. METHODS This cohort study included patients with cT1-3 cN0 breast cancer treated with neoadjuvant chemotherapy followed by breast surgery and sentinel node biopsy between 2013 and 2018. cN0 was defined by the absence of suspicious nodes on ultrasound imaging and PET/CT, or absence of tumour cells at fine-needle aspiration. Univariable and multivariable logistic regression analyses were performed to determine predictors of ypN0. RESULTS Overall, 259 of 303 patients (85.5 per cent) achieved ypN0, with high rates among those with a radiological complete response (rCR) on breast MRI (95·5 per cent). Some 82 per cent of patients with hormone receptor-positive disease, 98 per cent of those with triple-negative breast cancer (TNBC) and all patients with human epidermal growth factor receptor 2 (HER2)-positive disease who had a rCR achieved ypN0. Multivariable regression analysis showed that HER2-positive (odds ratio (OR) 5·77, 95 per cent c.i. 1·91 to 23·13) and TNBC subtype (OR 11·65, 2·86 to 106·89) were associated with ypN0 status. In addition, there was a trend toward ypN0 in patients with a breast rCR (OR 2·39, 0·95 to 6·77). CONCLUSION The probability of nodal positivity after neoadjuvant chemotherapy was less than 3 per cent in patients with TNBC or HER2-positive disease who achieved a breast rCR on MRI. These patients could be included in trials investigating the omission of sentinel node biopsy after neoadjuvant chemotherapy.
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Affiliation(s)
- M E M van der Noordaa
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - F H van Duijnhoven
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - F N E Cuijpers
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - E van Werkhoven
- Department of Biometrics, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - T G Wiersma
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - P H M Elkhuizen
- Department of Radiation Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - G Winter-Warnars
- Department of Radiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - V Dezentje
- Department of Medical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - G S Sonke
- Department of Medical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - E J Groen
- Department of Pathology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - M Stokkel
- Department of Nuclear Medicine, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
| | - M T F D Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, the Netherlands
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17
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Dickhoff LR, Vrancken Peeters MJ, Bosman PA, Alderliesten T. Therapeutic applications of radioactive sources: from image-guided brachytherapy to radio-guided surgical resection. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF... 2021; 65:190-201. [PMID: 34105339 DOI: 10.23736/s1824-4785.21.03370-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
It is well known nowadays that radioactivity can destroy the living cells it interacts with. It is therefore unsurprising that radioactive sources, such as iodine-125, were historically developed for treatment purposes within radiation oncology with the goal of damaging malignant cells. However, since then, new techniques have been invented that make creative use of the same radioactivity properties of these sources for medical applications. Here, we review two distinct kinds of therapeutic uses of radioactive sources with applications to prostate, cervical, and breast cancer: brachytherapy and radioactive seed localization. In brachytherapy (BT), the radioactive sources are used for internal radiation treatment. Current approaches make use of real-time image guidance, for instance by means of magnetic resonance imaging, ultrasound, computed tomography, and sometimes positron emission tomography, depending on clinical availability and cancer type. Such image-guided BT for prostate and cervical cancer presents a promising alternative and/or addition to external beam radiation treatments or surgical resections. Radioactive sources can also be used for radio-guided tumor localization during surgery, for which the example of iodine-125 seed use in breast cancer is given. Radioactive seed localization (RSL) is increasingly popular as an alternative tumor localization technique during breast cancer surgery. Advantages of applying RSL include added flexibility in the clinical scheduling logistics, an increase in tumor localization accuracy, and higher patient satisfaction; safety measures do however have to be employed. We exemplify the implementation of RSL in a clinic through experiences at the Netherlands Cancer Institute.
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Affiliation(s)
- Leah R Dickhoff
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands -
| | - Marie-Jeanne Vrancken Peeters
- Department of Surgical Oncology, Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.,Department of Surgery, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Peter A Bosman
- Life Sciences and Health group, Centrum Wiskunde & Informatica, Amsterdam, The Netherlands
| | - Tanja Alderliesten
- Department of Radiation Oncology, Leiden University Medical Center, Leiden, The Netherlands
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18
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van der Noordaa MEM, Ioan I, Rutgers EJ, van Werkhoven E, Loo CE, Voorthuis R, Wesseling J, van Urk J, Wiersma T, Dezentje V, Vrancken Peeters MJTFD, van Duijnhoven FH. Breast-Conserving Therapy in Patients with cT3 Breast Cancer with Good Response to Neoadjuvant Systemic Therapy Results in Excellent Local Control: A Comprehensive Cancer Center Experience. Ann Surg Oncol 2021; 28:7383-7394. [PMID: 33978889 DOI: 10.1245/s10434-021-09865-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 03/02/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND Many cT3 breast cancer patients are treated with mastectomy, regardless of response to neoadjuvant systemic therapy (NST). We evaluated local control of cT3 patients undergoing breast-conserving therapy (BCT) based on magnetic resonance imaging (MRI) evaluation post-NST. In addition, we analyzed predictive characteristics for positive margins after breast-conserving surgery (BCS). METHODS All cT3 breast cancer patients who underwent BCS after NST between 2002 and 2015 at the Netherlands Cancer Institute were included. Local recurrence-free interval (LRFI) was estimated using the Kaplan-Meier method, and predictors for positive margins were analyzed using univariable analysis and multivariable logistic regression. RESULTS Of 114 patients undergoing BCS post-NST, 75 had negative margins, 16 had focally positive margins, and 23 had positive margins. Of those with (focally) positive margins, 12 underwent radiotherapy, 6 underwent re-excision, and 21 underwent mastectomy. Finally, 93/114 patients were treated with BCT (82%), with an LRFI of 95.9% (95% confidence interval [CI] 91.5-100%) after a median follow-up of 7 years. Predictors for positive margins in univariable analysis were hormone receptor-positive/human epidermal growth factor receptor 2-negative (HR+/HER2-) subtype, lobular carcinoma, and non-mass enhancement (NME) on pre-NST MRI. MRI response was not correlated to positive margins. In multivariable regression, the odds of positive margins were decreased in patients with HER2-positive (HER2+; odds ratio [OR] 0.27, 95% CI 0.10-0.73; p = 0.01) and TN tumors (OR 0.17, 95% CI 0.03-0.82; p = 0.028). A trend toward positive margins was observed in patients with NME (OR 2.38, 95% CI 0.98-5.77; p = 0.055). CONCLUSION BCT could be performed in 82% of cT3 patients in whom BCT appeared feasible on post-NST MRI. Local control in these patients was excellent. In those patients with HR+/HER2- tumors, NME on MRI, or invasive lobular carcinoma, the risk of positive margins should be considered preoperatively.
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Affiliation(s)
| | - Ileana Ioan
- Department of Radiology, Policlinico San Donato, Milan, Italy
| | - Emiel J Rutgers
- Department of Surgical Oncology, NKI-AVL, Amsterdam, The Netherlands.,Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Claudette E Loo
- Department of Radiology, NKI-AVL, Amsterdam, The Netherlands
| | - Rosie Voorthuis
- Department of Surgical Oncology, NKI-AVL, Amsterdam, The Netherlands
| | - Jelle Wesseling
- Department of Pathology, NKI-AvL and Leiden University Medical Center, Amsterdam, The Netherlands
| | - Japke van Urk
- Department of Radiology, NKI-AVL, Amsterdam, The Netherlands
| | - Terry Wiersma
- Department of Radiation Oncology, NKI-AVL, Amsterdam, The Netherlands
| | - Vincent Dezentje
- Department of Medical Oncology, NKI-AVL, Amsterdam, The Netherlands
| | - Marie-Jeanne T F D Vrancken Peeters
- Department of Surgical Oncology, NKI-AVL, Amsterdam, The Netherlands.,Department of Surgery, University of Amsterdam, Amsterdam, The Netherlands
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19
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De Luca A, Frusone F, Buzzacchino F, Amabile MI, Taffurelli M, Del Mastro L, Rutgers EJT, Sacchini V, Caruso F, Minelli M, Fortunato L. First Surgical National Consensus Conference of the Italian Breast Surgeons association (ANISC) on breast cancer management in neoadjuvant setting: Results and summary. Eur J Surg Oncol 2021; 47:1913-1919. [PMID: 33972142 DOI: 10.1016/j.ejso.2021.04.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 04/22/2021] [Accepted: 04/27/2021] [Indexed: 12/31/2022] Open
Abstract
RATIONALE On October 15th, 2020, the first Surgical National Consensus Conference on neoadjuvant chemotherapy (NACT) was promoted by the Italian Association of Breast Surgeons (ANISC). METHOD The Consensus Conference was entirely held online due to anti-Covid-19 restrictions and after an introductory four lectures held by national and international experts in the field, a total of nine questions were presented and a digital "real-time" voting system was obtained. A consensus was reached if 75% or more of all panelists agreed on a given question. RESULTS A total of 202 physicians, from 76 different Italian Breast Centers homogeneously distributed throughout the Italian country, participated to the Conference. Most participants were surgeons (75%). Consensus was reached for seven out of the nine considered topics, including management of margins and lymph nodes at surgery, and there was good correspondence between the 32 "Expert Panelists" and the "Participants" to the Conference. Consensus was not achieved regarding the indications to NACT for high-grade luminal-like breast tumors, and the need to perform an axillary lymph node dissection in case of micrometastases in the sentinel lymph node after NACT. CONCLUSIONS NACT is a topic of major interest among surgeons, and there is need to develop shared guidelines. While a Consensus was obtained for most issues presented at this Conference, controversies still exist regarding indications to NACT in luminal B-like tumors and management of lymph node micrometastases. There is need for clinical studies and analysis of large databases to improve our knowledge on this subject.
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Affiliation(s)
- Alessandro De Luca
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | - Federico Frusone
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy
| | | | - Maria Ida Amabile
- Department of Surgical Sciences, Sapienza University of Rome, Rome, Italy.
| | - Mario Taffurelli
- IRCCS Policlinico di Sant'Orsola, University of Bologna, Bologna, Italy
| | - Lucia Del Mastro
- IRCCS Ospedale Policlinico San Martino, Breast Unit, and Department of Internal Medicine and Medical Specialties (DIMI), Genova, Italy
| | - Emiel J T Rutgers
- Department of Surgery, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Virgilio Sacchini
- Breast Service, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, 10065, USA
| | - Francesco Caruso
- Department of Oncological Surgery, Humanitas Catanese Center of Oncology, Catania, Italy
| | - Mauro Minelli
- Division of Medical Oncology, San Giovanni-Addolorata Hospital, Rome, Italy
| | - Lucio Fortunato
- Breast Centre, San Giovanni-Addolorata Hospital, Rome, Italy.
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20
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Selakovic V, Ranisavljevic M, Lukic D, Djuric M. 21 YEARS AFTER INTRODUCING SENTINEL LYMPH NODE BIOPSY IN CLINICAL PRAXIS AT THE ONCOLOGY INSTITUTE OF VOJVODINA. SANAMED 2021. [DOI: 10.24125/sanamed.v16i1.471] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
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21
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Banys-Paluchowski M, Gasparri ML, de Boniface J, Gentilini O, Stickeler E, Hartmann S, Thill M, Rubio IT, Di Micco R, Bonci EA, Niinikoski L, Kontos M, Karadeniz Cakmak G, Hauptmann M, Peintinger F, Pinto D, Matrai Z, Murawa D, Kadayaprath G, Dostalek L, Nina H, Krivorotko P, Classe JM, Schlichting E, Appelgren M, Paluchowski P, Solbach C, Blohmer JU, Kühn T. Surgical Management of the Axilla in Clinically Node-Positive Breast Cancer Patients Converting to Clinical Node Negativity through Neoadjuvant Chemotherapy: Current Status, Knowledge Gaps, and Rationale for the EUBREAST-03 AXSANA Study. Cancers (Basel) 2021; 13:1565. [PMID: 33805367 PMCID: PMC8037995 DOI: 10.3390/cancers13071565] [Citation(s) in RCA: 67] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 03/15/2021] [Accepted: 03/22/2021] [Indexed: 12/13/2022] Open
Abstract
In the last two decades, surgical methods for axillary staging in breast cancer patients have become less extensive, and full axillary lymph node dissection (ALND) is confined to selected patients. In initially node-positive patients undergoing neoadjuvant chemotherapy, however, the optimal management remains unclear. Current guidelines vary widely, endorsing different strategies. We performed a literature review on axillary staging strategies and their place in international recommendations. This overview defines knowledge gaps associated with specific procedures, summarizes currently ongoing clinical trials that address these unsolved issues, and provides the rationale for further research. While some guidelines have already implemented surgical de-escalation, replacing ALND with, e.g., sentinel lymph node biopsy (SLNB) or targeted axillary dissection (TAD) in cN+ patients converting to clinical node negativity, others recommend ALND. Numerous techniques are in use for tagging lymph node metastasis, but many questions regarding the marking technique, i.e., the optimal time for marker placement and the number of marked nodes, remain unanswered. The optimal number of SLNs to be excised also remains a matter of debate. Data on oncological safety and quality of life following different staging procedures are lacking. These results provide the rationale for the multinational prospective cohort study AXSANA initiated by EUBREAST, which started enrollment in June 2020 and aims at recruiting 3000 patients in 20 countries (NCT04373655; Funded by AGO-B, Claudia von Schilling Foundation for Breast Cancer Research, AWOgyn, EndoMag, Mammotome, and MeritMedical).
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Affiliation(s)
- Maggie Banys-Paluchowski
- Department of Obstetrics and Gynecology, Campus Lübeck, University Hospital of Schleswig Holstein, 23538 Lübeck, Germany
- Medical Faculty, Heinrich-Heine-University Düsseldorf, 40225 Düsseldorf, Germany
| | - Maria Luisa Gasparri
- Department of Gynecology and Obstetrics, Ente Ospedaliero Cantonale, Ospedale Regionale di Lugano, 6900 Lugano, Switzerland;
- Faculty of Biomedicine, University of the Italian Switzerland (USI), 6900 Lugano, Switzerland
| | - Jana de Boniface
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 77 Stockholm, Sweden; (J.d.B.); (M.A.)
- Department of Surgery, Capio St. Göran’s Hospital, 112 19 Stockholm, Sweden
| | - Oreste Gentilini
- Breast Surgery Unit, San Raffaele Hospital Milan, 20132 Milano MI, Italy; (O.G.); (R.D.M.)
| | - Elmar Stickeler
- Department of Gynecology and Obstetrics, University Hospital Aachen, 52074 Aachen, Germany;
| | - Steffi Hartmann
- Department of Gynecology and Obstetrics, University Hospital Rostock, 18059 Rostock, Germany;
| | - Marc Thill
- Department of Gynecology and Gynecological Oncology, AGAPLESION Markus Krankenhaus, 60431 Frankfurt am Main, Germany;
| | - Isabel T. Rubio
- Breast Surgical Unit, Clínica Universidad de Navarra, 28027 Madrid, Spain;
| | - Rosa Di Micco
- Breast Surgery Unit, San Raffaele Hospital Milan, 20132 Milano MI, Italy; (O.G.); (R.D.M.)
| | - Eduard-Alexandru Bonci
- Department of Surgical Oncology, “Prof. Dr. Ion Chiricuță” Institute of Oncology, 400015 Cluj-Napoca, Romania;
- 11th Department of Oncological Surgery and Gynecological Oncology, “Iuliu Hațieganu” University of Medicine and Pharmacy, 400012 Cluj-Napoca, Romania
| | - Laura Niinikoski
- Breast Surgery Unit, Comprehensive Cancer Center, Helsinki University Hospital, University of Helsinki, 00280 Helsinki, Finland;
| | - Michalis Kontos
- 1st Department of Surgery, Laiko Hospital, National and Kapodistrian University of Athens, 115 27 Athens, Greece;
| | - Guldeniz Karadeniz Cakmak
- Breast and Endocrine Unit, General Surgery Department, Zonguldak BEUN The School of Medicine, Kozlu/Zonguldak 67600, Turkey;
| | - Michael Hauptmann
- Brandenburg Medical School Theodor Fontane, 16816 Neuruppin, Germany;
| | | | - David Pinto
- Champalimaud Clinical Center, Breast Unit, Champalimaud Foundation, 1400-038 Lisboa, Portugal;
| | - Zoltan Matrai
- Department of Breast and Sarcoma Surgery, National Institute of Oncology, 1122 Budapest, Hungary;
| | - Dawid Murawa
- Collegium Medicum, University of Zielona Góra, 65-046 Zielona Góra, Poland;
| | - Geeta Kadayaprath
- Breast Surgical Oncology and Oncoplastic Surgery, Max Institute of Cancer Care, Max Healthcare Delhi, Delhi 110092, India;
| | - Lukas Dostalek
- Gynecologic Oncology Center, Department of Obstetrics and Gynecology, First Faculty of Medicine, Charles University, General University Hospital, 128 00 Prague, Czech Republic;
| | - Helidon Nina
- Oncology Hospital, University Hospital Center “Nene Tereza”, 1000 Tirana, Albania;
| | - Petr Krivorotko
- Petrov Research Institute of Oncology, 197758 Saint-Petersburg, Russia;
| | - Jean-Marc Classe
- Department of surgical oncology, Institut de cancerologie de l’Ouest Nantes, 44800 Saint Herblain, France;
| | - Ellen Schlichting
- Department for Breast and Endocrine Surgery, Oslo University Hospital, 0188 Oslo, Norway;
| | - Matilda Appelgren
- Department of Molecular Medicine and Surgery, Karolinska Institutet, 171 77 Stockholm, Sweden; (J.d.B.); (M.A.)
| | - Peter Paluchowski
- Department of Gynecology and Obstetrics, Regio Klinikum Pinneberg, 25421 Pinneberg, Germany;
| | - Christine Solbach
- Breast Center, Department of Gynecology and Obstetrics, University of Frankfurt, 60590 Frankfurt am Main, Germany;
| | - Jens-Uwe Blohmer
- Department of Gynecology and Breast Cancer Center, Charite Berlin, 10117 Berlin, Germany;
| | - Thorsten Kühn
- Department of Gynecology and Obstetrics, Klinikum Esslingen, 73730 Esslingen, Germany;
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The Evolving Role of Marked Lymph Node Biopsy (MLNB) and Targeted Axillary Dissection (TAD) after Neoadjuvant Chemotherapy (NACT) for Node-Positive Breast Cancer: Systematic Review and Pooled Analysis. Cancers (Basel) 2021; 13:cancers13071539. [PMID: 33810544 PMCID: PMC8037051 DOI: 10.3390/cancers13071539] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 01/15/2023] Open
Abstract
Simple Summary The 5-year survival rate for patients with breast cancer, in whom disease has spread to local lymph nodes, is 85%. However, many live with the complications of surgery to remove the lymph nodes in the armpit thus impacting their quality of life. In recent years, new approaches have been developed to minimise surgery and reduce complications. The aim of this systematic review was to assess the feasibility and accuracy of two minimally invasive surgical procedures, Marked Lymph Node Biopsy and Targeted Axillary Dissection as an alternative to complete removal of the axillary lymph nodes after upfront chemotherapy in patients in whom cancer spread to the regional lymph nodes. Our findings confirm that these procedures can safely replace more radical surgery in women who have responded well to upfront drug treatment. Therefore, although further research to determine long-term outcomes is required, this review concludes that it is reasonable to offer such patients the option of less invasive surgery thus avoiding over treatment and enhancing quality of life. Abstract Targeted axillary dissection (TAD) is a new axillary staging technique that consists of the surgical removal of biopsy-proven positive axillary nodes, which are marked (marked lymph node biopsy (MLNB)) prior to neoadjuvant chemotherapy (NACT) in addition to the sentinel lymph node biopsy (SLNB). In a meta-analysis of more than 3000 patients, we previously reported a false-negative rate (FNR) of 13% using the SLNB alone in this setting. The aim of this systematic review and pooled analysis is to determine the FNR of MLNB alone and TAD (MLNB plus SLNB) compared with the gold standard of complete axillary lymph node dissection (cALND). The PubMed, Cochrane and Google Scholar databases were searched using MeSH-relevant terms and free words. A total of 9 studies of 366 patients that met the inclusion criteria evaluating the FNR of MLNB alone were included in the pooled analysis, yielding a pooled FNR of 6.28% (95% CI: 3.98–9.43). In 13 studies spanning 521 patients, the addition of SLNB to MLNB (TAD) was associated with a FNR of 5.18% (95% CI: 3.41–7.54), which was not significantly different from that of MLNB alone (p = 0.48). Data regarding the oncological safety of this approach were lacking. In a separate analysis of all published studies reporting successful identification and surgical retrieval of the MLN, we calculated a pooled success rate of 90.0% (95% CI: 85.1–95.1). The present pooled analysis demonstrates that the FNR associated with MLNB alone or combined with SLNB is acceptably low and both approaches are highly accurate in staging the axilla in patients with node-positive breast cancer after NACT. The SLNB adds minimal new information and therefore can be safely omitted from TAD. Further research to confirm the oncological safety of this de-escalation approach of axillary surgery is required. MLNB alone and TAD are associated with acceptably low FNRs and represent valid alternatives to cALND in patients with node-positive breast cancer after excellent response to NACT.
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23
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Rietbergen DD, VAN Oosterom MN, Kleinjan GH, Brouwer OR, Valdes-Olmos RA, VAN Leeuwen FW, Buckle T. Interventional nuclear medicine: a focus on radioguided intervention and surgery. THE QUARTERLY JOURNAL OF NUCLEAR MEDICINE AND MOLECULAR IMAGING : OFFICIAL PUBLICATION OF THE ITALIAN ASSOCIATION OF NUCLEAR MEDICINE (AIMN) [AND] THE INTERNATIONAL ASSOCIATION OF RADIOPHARMACOLOGY (IAR), [AND] SECTION OF THE SOCIETY OF RADIOPHARMACEUTICAL CHEMISTRY AND BIOLOGY 2021; 65:4-19. [PMID: 33494584 DOI: 10.23736/s1824-4785.21.03286-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
Within interventional nuclear medicine (iNM) a prominent role is allocated for the sub-discipline of radioguided surgery. Unique for this discipline is the fact that an increasing number of clinical indications (e.g. lymphatic mapping, local tumor demarcation and/or tumor receptor targeted applications) have been adopted into routine care. The clinical integration is further strengthened by technical innovations in chemistry and engineering that enhance the translational potential of radioguided procedures in iNM. Together, these features not only ensure ongoing expansion of iNM but also warrant a lasting clinical impact for the sub-discipline of radioguided surgery.
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Affiliation(s)
- Daphne D Rietbergen
- Section of Nuclear Medicine, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands.,Department of Radiology, Interventional Molecular Imaging Laboratory, Leiden University Medical Center, Leiden, the Netherlands
| | - Matthias N VAN Oosterom
- Department of Radiology, Interventional Molecular Imaging Laboratory, Leiden University Medical Center, Leiden, the Netherlands.,Department of Urology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Gijs H Kleinjan
- Department of Urology, Leiden University Medical Center, Leiden, the Netherlands
| | - Oscar R Brouwer
- Department of Radiology, Interventional Molecular Imaging Laboratory, Leiden University Medical Center, Leiden, the Netherlands.,Department of Urology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Renato A Valdes-Olmos
- Section of Nuclear Medicine, Department of Radiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Fijs W VAN Leeuwen
- Department of Radiology, Interventional Molecular Imaging Laboratory, Leiden University Medical Center, Leiden, the Netherlands.,Department of Urology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
| | - Tessa Buckle
- Department of Radiology, Interventional Molecular Imaging Laboratory, Leiden University Medical Center, Leiden, the Netherlands - .,Department of Urology, Netherlands Cancer Institute, Antoni van Leeuwenhoek Hospital, Amsterdam, the Netherlands
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Targeted Axillary Dissection for Patients Who Convert to Clinically Node Negative After Neoadjuvant Chemotherapy for Node-Positive Breast Cancer. CURRENT BREAST CANCER REPORTS 2020. [DOI: 10.1007/s12609-020-00375-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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25
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Sentinel Node Imaging and Radioguided Surgery in the Era of SPECT/CT and PET/CT: Toward New Interventional Nuclear Medicine Strategies. Clin Nucl Med 2020; 45:771-777. [PMID: 32701805 DOI: 10.1097/rlu.0000000000003206] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
We review recent technological advances and new clinical indications for sentinel node (SN) and radioguided surgery in order to delineate future tendencies of interventional nuclear medicine in this field. A literature research was performed in PubMed to select relevant articles to be used as key references for analysis of the current approaches and tendencies in SN and radioguided surgery, as well as the evolving contribution of nuclear medicine intervention techniques to the various clinical applications. For classic indications such as melanoma and breast cancer, the incorporation of the SN approach based on the combined use of existing and new preoperative and intraoperative technologies in high-risk patient categories is becoming an emerging area of clinical indication. For SN biopsy staging in other malignancies with more complex lymphatic drainage, the incorporation of sophisticated tools is most helpful. The consecutive use of PET/CT and the SN procedure is increasing as a potential combined approach for the management of specific areas such as the axilla and the pelvis in patients at high risk of regional dissemination. Also, for the management of locoregional metastasis and oligometastatic disease, interventional nuclear medicine techniques are becoming valuable alternatives. The extended experience with SN biopsy is leading to technological advances facilitating the incorporation of this procedure to stage other malignancies with complex lymphatic drainage. New nuclear medicine-based approaches, incorporating SPECT/CT and PET/CT to guide resection of SNs and occult metastases, have recently been gaining ground.
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26
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Predictive factors of lymph node metastasis and effectiveness of intraoperative examination of sentinel lymph node in breast carcinoma: A retrospective Belgian study. Ann Diagn Pathol 2020; 49:151607. [PMID: 32949894 DOI: 10.1016/j.anndiagpath.2020.151607] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 08/17/2020] [Accepted: 08/17/2020] [Indexed: 11/22/2022]
Abstract
Recently, several trials demonstrated the safety of omitting axillary lymph node dissection in clinically N0 patients with positive sentinel nodes in select subgroups. However, this fact is still troublesome to clarify to surgeons and clinicians, as they used to perform intraoperative examination of the sentinel node and axillary dissection for many years. Hence, we decided to review our practice. This is to firstly highlight the predictive factors of node metastasis and secondly, to evaluate the effectiveness of intraoperative examination of the sentinel node. There were 406 total procedures. The rate of positive lymph nodes in the final diagnosis was 27%. Factors associated with metastasis were age, tumour size, TNM classification, tumour grade, vascular invasion, molecular classification and KI-67 index. The rate of reoperation was 6.2% in cases with final positive nodes, however, the complementary ALND was justified in only 2.7%. Forty-nine percent of SLN were examined during surgery (IOESLN), whereby the false negative rate was 11.8%. Sixty-three intraoperative examinations were necessary to prevent a second operation on a patient. We recommend changing the clinical management of the axilla, resulting in fewer ALNDs in selected cN0, SLN-positive patients. In keeping with recent large clinical trial (ACOSOG Z0011, AMAROS and OTOASOR) data, our results support that intraoperative exam in selected cN0, SLN-positive Belgian patients is no longer effective.
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27
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van Zeeland M, Westhoff P, Wauters C, Bult P, Werner A, Laurens N, Strobbe L, Meijer H. Omission of axillary lymph node dissection after neoadjuvant chemotherapy for clinically node-positive breast cancer: How can we select patients? Breast J 2020; 26:1869-1870. [PMID: 32524674 PMCID: PMC7586789 DOI: 10.1111/tbj.13930] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Revised: 05/19/2020] [Accepted: 05/20/2020] [Indexed: 11/30/2022]
Affiliation(s)
| | - Paulien Westhoff
- Department of Radiotherapy, Radboudumc, Nijmegen, The Netherlands
| | - Carla Wauters
- Department of Pathology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Peter Bult
- Department of Pathology, Radboudumc, Nijmegen, The Netherlands
| | - Annelies Werner
- Department of Surgical Oncology, Radboudumc, Nijmegen, The Netherlands
| | - Nicole Laurens
- Department of Medical Oncology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Luc Strobbe
- Department of Surgical Oncology, Canisius Wilhelmina Hospital, Nijmegen, The Netherlands
| | - Hanneke Meijer
- Department of Radiotherapy, Radboudumc, Nijmegen, The Netherlands
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28
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Combined positive axillary lymph node marking with iodine-125 seeds and sentinel lymph node biopsy in breast cancer patients treated with neoadjuvant chemotherapy. Rev Esp Med Nucl Imagen Mol 2020. [DOI: 10.1016/j.remnie.2019.12.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Banys-Paluchowski M, Gruber IV, Hartkopf A, Paluchowski P, Krawczyk N, Marx M, Brucker S, Hahn M. Axillary ultrasound for prediction of response to neoadjuvant therapy in the context of surgical strategies to axillary dissection in primary breast cancer: a systematic review of the current literature. Arch Gynecol Obstet 2020; 301:341-353. [PMID: 31897672 DOI: 10.1007/s00404-019-05428-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 12/17/2019] [Indexed: 02/07/2023]
Abstract
PURPOSE Data on the optimal treatment strategy for patients undergoing neoadjuvant therapy (NAT) who initially presented with metastatic nodes and convert to node-negative disease (cN+ → ycN0) are limited. Since NAT leads to axillary downstaging in 20-60% of patients, the question arises whether these patients might be offered less-invasive procedures than axillary dissection, such as sentinel node biopsy or targeted removal of lymph nodes marked before therapy. METHODS We performed a systematic review of clinical studies on the use of axillary ultrasound for prediction of response to NAT and ultrasound-guided marking of metastatic nodes for targeted axillary dissection. RESULTS The sensitivity of ultrasound for prediction of residual node metastasis was higher than that of clinical examination and MRI/PET in most studies; specificity ranged in large trials from 37 to 92%. The diagnostic performance of ultrasound after NAT seems to be associated with tumor subtype: the positive predictive value was highest in luminal, the negative in triple-negative tumors. Several trials evaluated the usefulness of ultrasound for targeted axillary dissection. Before NAT, nodes were most commonly marked using ultrasound-guided clip placement, followed by ultrasound-guided placement of a radioactive seed. After chemotherapy, the clip was detected on ultrasound in 72-83% of patients; a comparison of sonographic visibility of different clips is lacking. Detection rate after radioactive seed placement was ca. 97%. CONCLUSION In conclusion, ultrasound improves prediction of axillary response to treatment in comparison to physical examination and serves as a reliable guiding tool for marking of target lymph nodes before the start of treatment. High quality and standardization of the examination is crucial for selection of patients for less-invasive surgery.
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Affiliation(s)
| | - Ines Verena Gruber
- Department for Women's Health, University of Tübingen, Tübingen, Germany
| | - Andreas Hartkopf
- Department for Women's Health, University of Tübingen, Tübingen, Germany
| | - Peter Paluchowski
- Department of Gynecology and Obstetrics, Regio Klinikum Pinneberg, Pinneberg, Germany
| | - Natalia Krawczyk
- Department of Obstetrics and Gynecology, University of Düsseldorf, Düsseldorf, Germany
| | - Mario Marx
- Department for Women's Health, University of Tübingen, Tübingen, Germany.,Department of Plastic, Reconstructive and Breast Surgery, Elblandklinikum Radebeul, Radebeul, Germany
| | - Sara Brucker
- Department for Women's Health, University of Tübingen, Tübingen, Germany
| | - Markus Hahn
- Department for Women's Health, University of Tübingen, Tübingen, Germany
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Diagnostic Accuracy of Different Surgical Procedures for Axillary Staging After Neoadjuvant Systemic Therapy in Node-positive Breast Cancer: A Systematic Review and Meta-analysis. Ann Surg 2019; 269:432-442. [PMID: 30312200 PMCID: PMC6369968 DOI: 10.1097/sla.0000000000003075] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Objective: The aim of this study was to perform a systematic review and meta-analysis to assess the accuracy of different surgical axillary staging procedures compared with ALND. Summary of Background Data: Optimal axillary staging after neoadjuvant systemic therapy (NST) in node-positive breast cancer is an area of controversy. Several less invasive procedures, such as sentinel lymph node biopsy (SLNB), marking axillary lymph node with radioactive iodine seed (MARI), and targeted axillary dissection (a combination of SLNB and a MARI-like procedure), have been proposed to replace the conventional axillary lymph node dissection (ALND) with its concomitant morbidity. Methods: PubMed and Embase were searched for studies comparing less invasive surgical axillary staging procedures to ALND to identify axillary burden after NST in patients with pathologically confirmed node-positive breast cancer (cN+). A meta-analysis was performed to compare identification rate (IFR), false-negative rate (FNR), and negative predictive value (NPV). Results: Of 1132 records, 20 unique studies with 2217 patients were included in quantitative analysis: 17 studies on SLNB, 1 study on MARI, and 2 studies on a combination procedure. Overall axillary pathologic complete response rate was 37%. For SLNB, pooled rates of IFR and FNR were 89% and 17%. NPV ranged from 57% to 86%. For MARI, IFR was 97%, FNR 7%, and NPV 83%. For the combination procedure, IFR was 100%, FNR ranged from 2% to 4%, and NPV from 92% to 97%. Conclusion: Axillary staging by a combination procedure consisting of SLNB with excision of a pre-NST marked positive lymph node appears to be most accurate for axillary staging after NST. More evidence from prospective multicenter trials is needed to confirm this.
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Custodio Rebollo Aguirre A, Sánchez Sánchez R, González Jiménez AD, Culiañez Casas M, Mendoza Arnau I, Rashki M, Rudolphi Solero T, Martínez Meca S. Combined procedure of marking axillary positive node with iodine-125 seed and sentinel lymph node biopsy in breast cancer patients treated with neoadjuvant chemotherapy. Rev Esp Med Nucl Imagen Mol 2019; 39:75-83. [PMID: 31759957 DOI: 10.1016/j.remn.2019.09.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2019] [Revised: 09/06/2019] [Accepted: 09/09/2019] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To present our initial experience in the combined procedure of intraoperative detection of axillary positive node marked with 125I seed (ML) and sentinel node biopsy (SLN) after neoadjuvant chemotherapy (NACT), in breast cancer patients. MATERIAL AND METHODS Prospective study, January 2017 - March 2019, 16 breast cancer patients T1-3N1. TNM stage: IIA: 3, IIB: 10, IIIA: 3. Histological type ductal invasive: 14. Molecular subtype: luminal A: 3, luminal B: 9, HER2: 3, basal like: 1. The ML was marked 227±36 days before neoadjuvant chemotherapy (n: 10), or 1-6 days before surgery, on previously identified node by ultrasound visibility marker, hydrogel (n: 3) or three dimensional-3D (n: 3). Axillary lymphadenectomy was undertaken in 10 patients. RESULTS ML and SLN were identified in the surgery in 93.7% (15/16) of the cases, in 33.3% (5/15) ML was not among SLN, and in only one patient (1/5) was there a discrepancy between the result of ML and SLN (macrometastases vs. negative 0/2). Median number of lymph nodes SLN: 2.2±0.9 (range 1-3) and AD: 13.5±5.2 (range 7-23). In all cases, histopathological analysis of ML, 125I seed and/or marker within, correctly predicted axillary status after neoadjuvant chemotherapy. In all patients the 125I radioactive seed was recovered. CONCLUSIONS Placing of 125I seeds is a feasible technique for intraoperative location of axillary positive node combined with SLN. The histopathological result of ML allows the axillary status to be determined after neoadjuvant chemotherapy.
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Affiliation(s)
| | - R Sánchez Sánchez
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, España
| | - A D González Jiménez
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, España
| | - M Culiañez Casas
- Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, España
| | - I Mendoza Arnau
- Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, España
| | - M Rashki
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, España
| | - T Rudolphi Solero
- Servicio de Medicina Nuclear, Hospital Universitario Virgen de las Nieves, Granada, España
| | - S Martínez Meca
- Servicio de Radiodiagnóstico, Hospital Universitario Virgen de las Nieves, Granada, España
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Hellingman D, Donswijk ML, Winter-Warnars GAO, de Koekkoek-Doll P, Pinas M, Budde-van Namen Y, Westerga J, Vrancken Peeters MJTFD, Kimmings N, Stokkel MPM. Feasibility of radioguided occult lesion localization of clip-marked lymph nodes for tailored axillary treatment in breast cancer patients treated with neoadjuvant systemic therapy. EJNMMI Res 2019; 9:94. [PMID: 31650284 PMCID: PMC6811805 DOI: 10.1186/s13550-019-0560-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 09/05/2019] [Indexed: 11/10/2022] Open
Abstract
Background Selective removal of initially tumor-positive axillary lymph nodes in breast cancer patients who underwent neoadjuvant systemic treatment (NST) improves the accuracy of nodal staging and provides the opportunity for more tailored axillary treatment. This study evaluated whether radioguided occult lesion localization (ROLL) of clip-marked lymph nodes is feasible in clinical practice. Methods Prior to NST, a clip marker was placed inside a proven tumor-positive lymph node in all breast cancer patients (cTis-4N1-3 M0). After NST, technetium-99m-labeled macroaggregated albumin was injected in the clip-marked lymph nodes. The next day, these ROLL-marked nodes were selectively removed at surgery to evaluate the pathological response of the axilla. Results Thirty-seven patients (38 axillae) underwent clip insertion. After NST, the clip was visible by ultrasound in 36 procedures (95%). In the other two patients, the ROLL-node injection was performed in a sonographically suspicious unclipped node (1), and near the clip under computed tomography guidance (1). Initial surgery successfully identified the ROLL-marked node with clip in 33 procedures (87%). Removed specimens in the other five procedures contained only the sonographically suspicious tumor-positive unclipped node (1), a node with signs of complete response but no clip (2), a clip without node (1), and tissue without node nor clip, and a second successful ROLL-node procedure was performed (1). Overall, 10 ROLL-marked nodes had no residual disease. Conclusions This study demonstrates that the ROLL procedure to identify clip-marked lymph nodes is feasible. This facilitates selective removal at surgery and may tailor axillary treatment in patients treated with NST.
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Affiliation(s)
- Daan Hellingman
- Department of Nuclear Medicine, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Postbus 90203, 1006, BE, Amsterdam, The Netherlands
| | - Maarten L Donswijk
- Department of Nuclear Medicine, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Postbus 90203, 1006, BE, Amsterdam, The Netherlands
| | - Gonneke A O Winter-Warnars
- Department of Radiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Postbus 90203, 1006, BE, Amsterdam, The Netherlands
| | - Petra de Koekkoek-Doll
- Department of Radiology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Postbus 90203, 1006, BE, Amsterdam, The Netherlands
| | - Marilyn Pinas
- Department of Radiology, Slotervaart hospital, Postbus 90440, 1006, BK, Amsterdam, The Netherlands.,Department of Radiology, Haaglanden Medical Center, Postbus 432, 2501, CK, The Hague, The Netherlands
| | - Yvonne Budde-van Namen
- Department of Radiology, Slotervaart hospital, Postbus 90440, 1006, BK, Amsterdam, The Netherlands
| | - Johan Westerga
- Department of Pathology, Slotervaart hospital, Postbus 90440, 1006, BK, Amsterdam, The Netherlands
| | | | - Nikola Kimmings
- Department of Surgical Oncology, Slotervaart hospital, Postbus 90440, 1006, BK, Amsterdam, The Netherlands.,Department of Surgical Oncology, Alexander Monro hospital, Postbus 181, 3720, AD, Bilthoven, The Netherlands
| | - Marcel P M Stokkel
- Department of Nuclear Medicine, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Postbus 90203, 1006, BE, Amsterdam, The Netherlands.
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Simons JM, van Pelt MLMA, Marinelli AWKS, Straver ME, Zeillemaker AM, Pereira Arias-Bouda LM, van Nijnatten TJA, Koppert LB, Hunt KK, Smidt ML, Luiten EJT, van der Pol CC. Excision of both pretreatment marked positive nodes and sentinel nodes improves axillary staging after neoadjuvant systemic therapy in breast cancer. Br J Surg 2019; 106:1632-1639. [PMID: 31593294 PMCID: PMC6856822 DOI: 10.1002/bjs.11320] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 03/10/2019] [Accepted: 06/23/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND Marking the axilla with radioactive iodine seed and sentinel lymph node (SLN) biopsy have been proposed for axillary staging after neoadjuvant systemic therapy in clinically node-positive breast cancer. This study evaluated the identification rate and detection of residual disease with combined excision of pretreatment-positive marked lymph nodes (MLNs) together with SLNs. METHODS This was a multicentre retrospective analysis of patients with clinically node-positive breast cancer undergoing neoadjuvant systemic therapy and the combination procedure (with or without axillary lymph node dissection). The identification rate and detection of axillary residual disease were calculated for the combination procedure, and for MLNs and SLNs separately. RESULTS At least one MLN and/or SLN(s) were identified by the combination procedure in 138 of 139 patients (identification rate 99·3 per cent). The identification rate was 92·8 per cent for MLNs alone and 87·8 per cent for SLNs alone. In 88 of 139 patients (63·3 per cent) residual axillary disease was detected by the combination procedure. Residual disease was shown only in the MLN in 20 of 88 patients (23 per cent) and only in the SLN in ten of 88 (11 per cent), whereas both the MLN and SLN contained residual disease in the remainder (58 of 88, 66 per cent). CONCLUSION Excision of the pretreatment-positive MLN together with SLNs after neoadjuvant systemic therapy in patients with clinically node-positive disease resulted in a higher identification rate and improved detection of residual axillary disease.
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Affiliation(s)
- J M Simons
- Department of Surgical Oncology, Erasmus Medical Centre Rotterdam, Rotterdam, the Netherlands.,Department of Surgical Oncology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands
| | - M L M A van Pelt
- Department of Surgical Oncology, Haaglanden Medical Centre, The Hague, the Netherlands
| | - A W K S Marinelli
- Department of Surgical Oncology, Haaglanden Medical Centre, The Hague, the Netherlands
| | - M E Straver
- Department of Surgical Oncology, Haaglanden Medical Centre, The Hague, the Netherlands
| | - A M Zeillemaker
- Department of Surgical Oncology, Alrijne Hospital, Leiderdorp, the Netherlands
| | - L M Pereira Arias-Bouda
- Department of Nuclear Medicine, Alrijne Hospital, Leiderdorp, the Netherlands.,Section of Nuclear Medicine, Department of Radiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - T J A van Nijnatten
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - L B Koppert
- Department of Surgical Oncology, Erasmus Medical Centre Rotterdam, Rotterdam, the Netherlands
| | - K K Hunt
- Department of Breast Surgical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - M L Smidt
- Department of Surgical Oncology, Maastricht University Medical Centre+, Maastricht, the Netherlands.,GROW - School for Oncology and Developmental Biology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - E J T Luiten
- Department of Surgical Oncology, Amphia Hospital, Breda, the Netherlands
| | - C C van der Pol
- Department of Surgical Oncology, University Medical Centre Utrecht, Utrecht University, Utrecht, the Netherlands.,Department of Surgical Oncology, Alrijne Hospital, Leiderdorp, the Netherlands
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Gera R, Kasem A, Mokbel K. Can Complete Axillary Node Dissection Be Safely Omitted in Patients with Early Breast Cancer When the Sentinel Node Biopsy Is Positive for Malignancy? An Update for Clinical Practice. In Vivo 2019; 32:1301-1307. [PMID: 30348682 DOI: 10.21873/invivo.11380] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2018] [Revised: 09/16/2018] [Accepted: 09/19/2018] [Indexed: 02/07/2023]
Abstract
The sentinel lymph node biopsy (SLNB) has become the new standard-of-care for patients with clinically node-negative invasive breast cancer. The focused examination of fewer lymph nodes in addition to improvements in histopathological and molecular analysis have increased the rate at which micrometastases and isolated tumor cells are identified. We reviewed the literature and summarized the evidence regarding the need for complete axillary lymph node dissection (ALND) following the finding of a positive sentinel node biopsy through the identification of the most important outcomes and evaluation of quality of evidence. The article focuses on the safe omission of complete ALND when the axillary lymph nodes contain macrometastases and provides an overview of the topic primarily based on level 1 evidence derived from randomized clinical trials with a critical appraisal of the ACOSOG Z0011 trial.
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Affiliation(s)
- Ritika Gera
- The London Breast Institute, Princess Grace Hospital, London, U.K
| | - Abdul Kasem
- The London Breast Institute, Princess Grace Hospital, London, U.K
| | - Kefah Mokbel
- The London Breast Institute, Princess Grace Hospital, London, U.K.
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35
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van der Noordaa MEM, Vrancken Peeters MJTFD. ASO Author Reflections: Reducing Axillary Lymph Node Dissections in Node-Positive Breast Cancer Patients. Ann Surg Oncol 2018; 25:677-678. [PMID: 30474766 DOI: 10.1245/s10434-018-6975-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Indexed: 01/18/2023]
Affiliation(s)
- Marieke E M van der Noordaa
- Department of Surgical Oncology, Netherlands Cancer Institute-Antoni van Leeuwenhoek, Amsterdam, The Netherlands
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36
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Spronk PER, Volders JH, van den Tol P, Smorenburg CH, Vrancken Peeters MJTFD. Breast conserving therapy after neoadjuvant chemotherapy; data from the Dutch Breast Cancer Audit. Eur J Surg Oncol 2018; 45:110-117. [PMID: 30348601 DOI: 10.1016/j.ejso.2018.09.027] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2018] [Revised: 08/30/2018] [Accepted: 09/05/2018] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION NAC has led to an increase in breast conserving surgery (BCS) worldwide. This study aims to analyse trends in the use of neoadjuvant chemotherapy (NAC) and the impact on surgical outcomes. METHODS We reviewed all records of cT1-4N0-3M0 breast cancer patients diagnosed between July 2011 and June 2016 who have been registered in the Dutch National Breast Cancer Audit (NBCA) (N = 57.177). The surgical outcomes of 'BCS after NAC' were compared with 'primary BCS', using a multivariable logistic regression model. RESULTS Between 2011 and 2016, the use of NAC increased from 9% to 18% and 'BCS after NAC' (N = 4170) increased from 43% to 57%. We observed an involved invasive margin rate (IMR) of 6,7% and a re-excision rate of 6,6%. As compared to 'primary BCS', the IMR of 'BCS after NAC' is higher for cT1 (12,3% versus 8,3%; p < 0.005), equal for cT2 (14% versus 14%; p = 0.046) and lower for cT3 breast cancer (28,3% versus 31%; p < 0.005). Prognostic factors associated with IMR for both 'primary BCS' as for 'BCS after NAC' are: lobular invasive breast cancer and a hormone receptor positive receptor status (all p < 0,005). CONCLUSION The use of NAC and the incidence of 'BCS after NAC' increased exponentially in time for all stages of invasive breast cancer in the Netherlands. This nationwide data confirms that 'BCS after NAC' compared to 'primary BCS' leads to equal surgical outcomes for cT2 and improved surgical outcomes for cT3 breast cancer. These promising results encourage current developments towards de-escalation of surgical treatment.
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Affiliation(s)
- Pauline E R Spronk
- Department of Surgery, Leiden University Medical Centre, Leiden, the Netherlands; Department of Research, Dutch Institute for Clinical Auditing (DICA), Leiden, the Netherlands.
| | - José H Volders
- Department of Surgery, VU University Medical Centre, Amsterdam, the Netherlands
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37
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van der Noordaa MEM, van Duijnhoven FH, Straver ME, Groen EJ, Stokkel M, Loo CE, Elkhuizen PHM, Russell NS, Vrancken Peeters MTFD. Major Reduction in Axillary Lymph Node Dissections After Neoadjuvant Systemic Therapy for Node-Positive Breast Cancer by combining PET/CT and the MARI Procedure. Ann Surg Oncol 2018; 25:1512-1520. [DOI: 10.1245/s10434-018-6404-y] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Indexed: 12/12/2022]
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38
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Taback B, Jadeja P, Ha R. Enhanced Axillary Evaluation Using Reflector-Guided Sentinel Lymph Node Biopsy: A Prospective Feasibility Study and Comparison With Conventional Lymphatic Mapping Techniques. Clin Breast Cancer 2018; 18:e869-e874. [PMID: 29544701 DOI: 10.1016/j.clbc.2018.02.001] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2018] [Revised: 02/04/2018] [Accepted: 02/05/2018] [Indexed: 11/24/2022]
Abstract
BACKGROUND Recently there are efforts to use sentinel lymph node biopsy (SLNB) techniques after neoadjuvant chemotherapy (NAC) to minimize axillary surgery. However, studies have shown higher false negative rates in this scenario, which might result in inaccurate assessment of treatment response and patient prognosis as well as leaving residual disease behind. In this study, we describe the use of reflector-guided excision of the percutaneously biopsied node (PBN) as an aid to conventional SLNB and its predictor of the axillary status after NAC. PATIENTS AND METHODS This was a single-institution analysis of patients who underwent axillary fiducial-reflector placement and subsequent SLNB compared with conventional SLNB. RESULTS Nineteen patients in the reflector group were matched with 19 patients who underwent conventional SLNB (conventional group). The PBN was identified in the SLNB in 19 patients (100%) in the reflector group and in 9 patients (47.3%) in the conventional group (P = .002). In the remaining 10 patients in the conventional group, the PBN was identified in the axillary lymph node dissection specimen in 4 patients (21%) and not identified in 6 patients (31.7%). Among the 38 patients, traditional mapping failed to identify the PBN in 13 patients (34.2%). The PBN was negative in 10 patients (36%) and positive in 18 patients (64%); no additional positive nodes were identified among patients with a negative PBN, correctly reflecting the status of the axilla in 100% of cases. CONCLUSION Mapping failure after NAC might compromise SLNB. Reflector-guided excision of the PBN is not only facile and feasible, but more accurately reflects the status of the axilla after NAC.
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Affiliation(s)
- Bret Taback
- Department of Breast Surgery, Columbia University Medical Center, New York, NY.
| | - Priya Jadeja
- Department of Breast Surgery, Columbia University Medical Center, New York, NY
| | - Richard Ha
- Department of Breast Imaging, Columbia University Medical Center, New York, NY
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39
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Kuerer HM, Vrancken Peeters MJTFD, Rea DW, Basik M, De Los Santos J, Heil J. Nonoperative Management for Invasive Breast Cancer After Neoadjuvant Systemic Therapy: Conceptual Basis and Fundamental International Feasibility Clinical Trials. Ann Surg Oncol 2017; 24:2855-2862. [PMID: 28766204 DOI: 10.1245/s10434-017-5926-z] [Citation(s) in RCA: 50] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Indexed: 02/01/2023]
Abstract
With current advances in neoadjuvant systemic therapy (NST) and improved breast imaging, the potential of nonoperative therapy for invasive breast cancer has emerged as a viable option when utilizing meticulous image-guided percutaneous biopsy to document pathologic complete response. Feasibility clinical trials utilizing this approach are being performed by teams of investigators from single and multicenter/cooperative groups around the world. Imaging alone after NST lacks sufficient sensitivity and specificity in predicting pCR and therefore cannot be utilized for clinical selection of patients for omission of surgery. Imaging with adequate sampling after NST of the residual lesions (or around the remaining clip if a complete radiologic response occurs) appears to be essential in selecting patients with pCR to lower the false-negative rates based on initial reported feasibility studies to identify pCR without surgery that range from 5 to 49%. In this manuscript, recently completed, ongoing, and planned clinical feasibility trials and a new omission of surgery trial are described. Drastic rethinking of all diagnostic and therapeutic management strategies that are ordinarily utilized for patients who receive standard breast cancer surgery is required. A roadmap of essential questions and issues that will have to be resolved as the field of nonoperative breast cancer management advances is described in detail.
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Affiliation(s)
- Henry M Kuerer
- Division of Surgery, Department of Breast Surgical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA.
| | | | - Daniel W Rea
- Cancer Research UK Clinical Trials Unit (CRCTU), Institute of Cancer and Genomic Sciences, University of Birmingham, Birmingham, UK
| | - Mark Basik
- Department of Surgery and Oncology, McGill University, Montreal, QC, Canada.,Department of Oncology and Surgery, Lady Davis Institute for Medical Research, Montreal, QC, Canada
| | - Jennifer De Los Santos
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Joerg Heil
- Department of Gynecology, University Breast Unit, Heidelberg, Germany
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40
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van der Noordaa MEM, Vrancken Peeters MTFD, Rutgers EJT. The intraoperative assessment of sentinel nodes - Standards and controversies. Breast 2017; 34 Suppl 1:S64-S69. [PMID: 28673534 DOI: 10.1016/j.breast.2017.06.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Intraoperative assessment of sentinel lymph nodes (SLNs) has the advantage of allowing breast cancer patients with tumor-positive SLNs to avoid a second surgery by immediately proceeding to axillary lymph node dissection (ALND). However, there are several reasons why the use of intraoperative assessment should be questioned. Whereas ALND was traditionally advised for all breast cancer patients with tumor-positive lymph nodes for axillary staging and locoregional control, more recent studies have demonstrated safety of omitting ALND in a substantial number of patients. In addition, there are concerns about the accuracy of intraoperative assessment methods including frozen section analysis, touch preparation cytology and one-step nucleic acid amplification. Moreover, intraoperative assessment of SLNs denies patients the opportunity to contribute to their treatment planning. In our opinion, intraoperative assessment of axillary lymph nodes should be reserved for patients who still have a strict indication for ALND. Patients with clinical node negative disease (cN0) and one or two positive SLNs can be safely treated with breast conserving surgery and radiotherapy. There has been more controversy for cN0 patients who are treated with mastectomy since radiotherapy is not routinely administered in these patients. However, there is increasing evidence that ALND may be omitted in patients undergoing mastectomy who have a low tumor-burden in their SLNs. Therefore, we defend the position that in cN0 patients undergoing mastectomy, SLNB should be performed and full pathologic evaluation of the SLN should be awaited. In cN0 patients undergoing neoadjuvant systemic therapy (NST) intraoperative assessment of SLNs can be omitted since ALND will not provide therapeutic benefit. It is being hypothesized that patients with limited axillary disease prior to NST who remain node-positive after NST could be treated safely with axillary radiotherapy instead of ALND. In these patients, omitting intraoperative assessment might be a reasonable option. In patients with extensive nodal disease prior to NST intraoperative assessment of axillary lymph nodes should be performed.
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Affiliation(s)
- M E M van der Noordaa
- Department of Surgical Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - M T F D Vrancken Peeters
- Department of Surgical Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands
| | - E J T Rutgers
- Department of Surgical Oncology, The Netherlands Cancer Institute - Antoni van Leeuwenhoek, Amsterdam, The Netherlands.
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