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Torras I, Cebrecos I, Castillo H, Rodríguez L, Zaragoza-Ballester P, Sitges C, Loinaz I, Garcia M, Molla M, Vidal-Sicart S, Mension E. Surgical Management and Its Impact on Adjuvant Treatment in Recurrent Ipsilateral Breast Cancer: A Retrospective Cohort Study. J Clin Med 2024; 13:5142. [PMID: 39274355 PMCID: PMC11396610 DOI: 10.3390/jcm13175142] [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: 06/02/2024] [Revised: 08/28/2024] [Accepted: 08/29/2024] [Indexed: 09/16/2024] Open
Abstract
Background: Breast cancer (BC) recurrence, defined as the reappearance of cancer in the ipsilateral breast after primary treatment, poses significant challenges in clinical management. Despite advances in treatment, recurrence rates persist, ranging from 0.6 to 1.5% annually, reaching 10-15% at 20 years. This study aims to analyze the surgical and oncological characteristics of patients with BC recurrence. Methods: This retrospective study includes 56 patients diagnosed with recurrent BC between October 2018 and April 2022. Data were collected from a prospectively maintained surgical database. A descriptive analysis was performed on the initial BC, and the recurrence, including surgical complications, was classified using the Clavien-Dindo system. The success rates of selective sentinel lymph node (SLN) biopsies and aberrant drainages were assessed based on previous surgeries. Results: The cohort included 55 females and 1 male, with a median age of 65.3 years. The mean time to BC recurrence was 11.5 years. Among them, 26.8% underwent breast-conserving surgery, 41.1% had a mastectomy, 21.4% had a mastectomy with reconstruction, and 10.7% had an excision over a previous mastectomy. An SLN biopsy was performed in 78.6% of cases, with higher success rates in those without a previous axillary lymph node dissection (85.7% vs. 63.2%). Aberrant drainage was more frequent in patients with a previous ALND (44.4% vs. 20%). The median follow-up was 41.3 months, with 10.7% experiencing a second recurrence. Conclusions: Repeat breast-conserving surgery with re-irradiation for ipsilateral recurrence is feasible and does not significantly increase complications. SLN biopsy is valuable for restaging and tailoring adjuvant therapies, with ALND not being necessary if re-SLN biopsy shows no drainage. The management of aberrant drainage remains controversial.
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Affiliation(s)
- Ines Torras
- Department of Obstetrics and Gynecology and Neonatology, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
- Faculty of Medicine, University of Barcelona, 08007 Barcelona, Spain
| | - Isaac Cebrecos
- Department of Obstetrics and Gynecology and Neonatology, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
- Faculty of Medicine, University of Barcelona, 08007 Barcelona, Spain
| | - Helena Castillo
- Department of Obstetrics and Gynecology and Neonatology, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
| | - Laura Rodríguez
- Department of Nuclear Medicine, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
- Department of Nuclear Medicine, Central University Hospital of Asturias, 33011 Oviedo, Spain
| | - Pablo Zaragoza-Ballester
- Department of Nuclear Medicine, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
- Department of Nuclear Medicine, Hospital 12 de Octubre, 28041 Madrid, Spain
| | - Carla Sitges
- Department of Radiology, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
| | - Ignacio Loinaz
- Department of Obstetrics and Gynecology and Neonatology, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
| | - Marta Garcia
- Department of Obstetrics and Gynecology and Neonatology, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
| | - Meritxell Molla
- Faculty of Medicine, University of Barcelona, 08007 Barcelona, Spain
- Translational Genomics and Targeted Therapies in Solid Tumors Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), 08036 Barcelona, Spain
- Department of Radiation Oncology, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
| | - Sergi Vidal-Sicart
- Department of Nuclear Medicine, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
- Diagnosis and Therapy in Oncology Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), 08036 Barcelona, Spain
| | - Eduard Mension
- Department of Obstetrics and Gynecology and Neonatology, Hospital Clinic of Barcelona, 08036 Barcelona, Spain
- Faculty of Medicine, University of Barcelona, 08007 Barcelona, Spain
- Translational Genomics and Targeted Therapies in Solid Tumors Group, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), 08036 Barcelona, Spain
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Weber WP, Hanson SE, Wong DE, Heidinger M, Montagna G, Cafferty FH, Kirby AM, Coles CE. Personalizing Locoregional Therapy in Patients With Breast Cancer in 2024: Tailoring Axillary Surgery, Escalating Lymphatic Surgery, and Implementing Evidence-Based Hypofractionated Radiotherapy. Am Soc Clin Oncol Educ Book 2024; 44:e438776. [PMID: 38815195 DOI: 10.1200/edbk_438776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024]
Abstract
The management of axillary lymph nodes in breast cancer is continually evolving. Recent data now support omitting axillary lymph node dissection (ALND) in most patients with metastases in up to two sentinel lymph nodes (SLNs) during upfront surgery and those with residual isolated tumor cells after neoadjuvant chemotherapy (NACT). In the upfront surgery setting, ALND is still indicated, however, in patients with clinically node-positive breast cancer or more than two positive SLNs and, after NACT, in case of residual micrometastases and macrometastases. Omission of the sentinel lymph node biopsy (SLNB) can be considered in many postmenopausal patients with small luminal breast cancer, particularly when axillary ultrasound is negative. Several randomized controlled trials (RCTs) are currently aiming at eliminating the remaining indications for ALND and also establishing omission of SLNB in a broader patient population. The movement to deescalate axillary staging is in part because of the association between ALND and lymphedema, which is swelling of an extremity because of lymphatic damage and obstructed lymphatic drainage. To reduce the risk of developing this condition, patients undergoing ALND can undergo reverse mapping of the axilla and immediate reconstruction or bypass of the lymphatics from the involved extremity. Decongestion and compression are the foundation of conservative treatment for established lymphedema, while lymphovenous bypass and lymph node transfer are surgical procedures to address the physiologic dysfunction. Radiotherapy is an essential component of breast locoregional therapy: more than three decades of radiation research has optimized treatment according to patient's risk of local recurrence while substantially reducing the number of treatment visits. High-quality RCTs have shown the efficacy and safety of hypofractionation-more than 2Gy radiation dose per treatment (fraction)-significantly reducing the burden of radiotherapy treatment for many patients with breast cancer. In 2024, guidelines recommend no more than 15-16 fractions for whole-breast and nodal radiotherapy, with some recommending five fractions for whole-breast radiotherapy. In addition, simultaneous integrated boost (SIB) has been shown to be noninferior to sequential boost with regards to ipsilateral breast tumor recurrence with similar or reduced long-term side effects, also reducing overall treatment length. Further RCTs are underway investigating other indications for five fractions, including SIB and regional node irradiation, such that, in future, it may be possible for the majority of breast radiotherapy patients to be treated with a 1-week course. This manuscript serves to outline the latest updates on axillary surgical staging, lymphatic surgery, and evidence-based radiotherapy in the treatment of breast cancer.
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Affiliation(s)
- Walter Paul Weber
- Breast Clinic, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Summer E Hanson
- Plastic and Reconstructive Surgery, The University of Chicago Medicine and Biological Sciences Division, Chicago, IL
| | - Daniel E Wong
- Plastic and Reconstructive Surgery, The University of Chicago Medicine and Biological Sciences Division, Chicago, IL
| | - Martin Heidinger
- Breast Clinic, University Hospital Basel, Basel, Switzerland
- Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Giacomo Montagna
- Breast Service, Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY
| | - Fay H Cafferty
- Institute of Cancer Research Clinical Trials and Statistics Unit, London, United Kingdom
| | - Anna M Kirby
- Institute of Cancer Research and Royal Marsden NHS Foundation Trust, London, United Kingdom
| | - Charlotte E Coles
- Department of Oncology, University of Cambridge, Cambridge, United Kingdom
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Ge I, Erbes T, Juhasz-Böss I. Prognostic value and management of regional lymph nodes in locoregional breast cancer recurrence: a systematic review of the literature. Arch Gynecol Obstet 2022; 306:943-957. [PMID: 35122159 PMCID: PMC9470629 DOI: 10.1007/s00404-021-06352-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Accepted: 11/24/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Management of regional lymph nodes in breast cancer recurrence has been heterogeneous. To facilitate clinical practice, this review aims to give an overview on the prognosis, staging and operative management of (inapparent) regional lymph nodes. METHODS Current national and international guidelines are reviewed and a structured search of the literature between Jan 1, 1999 and Feb 1, 2021 on the repeat sentinel node biopsy (re-SNB) procedure was performed. RESULTS Positive regional lymph nodes in recurrent breast cancer indicate a poorer outcome with axillary recurrences being the most favorable tumor site among all nodal regions. Most preferred staging method is ultrasound ± guided biopsy. PET-CT, scintimammography, SPECT-CT may improve visualization of affected lymph nodes outside the axilla. Concerning operative management 30 articles on re-SNB were identified with a mean harvesting rate of 66.4%, aberrant drainage and aberrant metastasis in 1/3 of the cases. Total rate of metastasis is 17.9%. After previous axillary dissection (ALND) the re-SNB has a significantly lower harvesting rate and higher aberrant drainage and aberrant metastasis rate. The prognostic outcome after re-SNB has been favorable. CONCLUSION Nodal status in recurrent disease has prognostic value. The choice of operative management of clinically inapparent regional lymph nodes during local recurrence should be based on the previous nodal staging method. Patients with previous ALND should be spared a second systematic ALND. Re-SNB or no axillary surgery at all are possible alternatives. Lymphoscintigraphy may be performed to identify extraaxillary drainage. However, for definite recommendations randomized controlled studies are heavily needed.
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Affiliation(s)
- Isabell Ge
- Department of Obstetrics and Gynecology, Medical Center - University of Freiburg, Freiburg, Germany. .,Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Thalia Erbes
- Department of Obstetrics and Gynecology, Medical Center - University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Ingolf Juhasz-Böss
- Department of Obstetrics and Gynecology, Medical Center - University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Yoon CI, Ahn SG, Kim D, Choi JE, Bae SJ, Cha CH, Park S, Jeong J. Repeat Sentinel Lymph Node Biopsy for Ipsilateral Breast Tumor Recurrence After Breast Conserving Surgery With Sentinel Lymph Node Biopsy: Pooled Analysis Using Data From a Systematic Review and Two Institutions. Front Oncol 2020; 10:518568. [PMID: 33072563 PMCID: PMC7538804 DOI: 10.3389/fonc.2020.518568] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 08/18/2020] [Indexed: 01/30/2023] Open
Abstract
Introduction: Best surgical approach of axillary staging remains controversial in locally recurrent breast cancer. We evaluated the reliability of repeat sentinel lymph node biopsy (reSLNB) in patients with ipsilateral breast tumor recurrence (IBTR) after breast conserving surgery (BCS) with sentinel lymph node biopsy (SLNB) in terms of identification rate (IR) and false negative rate (FNR). To address the FNR, we identified patients who underwent sequential axillary lymph node dissection (ALND) after reSLNB. Methods: A systematic search of PubMed, EMBASE, and Cochrane Library were conducted to identify patient-level data from articles. We searched for data of patients who underwent BCS with SLNB for primary breast cancer and who underwent sequential ALND after reSLNB due to local recurrence. Patients data was also identified by the same criteria at two institutions. Results: In total, 197 peer-reviewed publications were obtained, of which 20 included patients who met the eligibility criteria. Data from 464 patients were collected. From the two institutions, 31 patients were identified. A total of 495 patients were pooled. The IR of reSLNB was 71.9% (356/495). To address the FNR of reSLNB, 171 patients who underwent ALND after reSLNB were identified. The FNR and accuracy of reSLNB were 9.4% (5/53) and 97.1% (165/170), respectively. Conclusion: Our pooled data analysis showed that the FNR of reSLNB is lower than 10%, indicating that this operation is a reliable axillary surgery in patients with IBTR after they underwent BCS.
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Affiliation(s)
- Chang Ik Yoon
- Division of Breast Surgery, Department of Surgery, College of Medicine, Seoul St Mary's Hospital, The Catholic University of Seoul, Seoul, South Korea
| | - Sung Gwe Ahn
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Dooreh Kim
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Jung Eun Choi
- Department of Surgery, College of Medicine, Yeungnam University, Daegu, South Korea
| | - Soong June Bae
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Chi Hwan Cha
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Soeun Park
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Joon Jeong
- Department of Surgery, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
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Sato A, Sakai T, Iwase T, Kano F, Kimura K, Ogiya A, Koizumi M, Tanabe M, Horii R, Akiyama F, Ueno T, Ohno S. Altered lymphatic drainage patterns in re-operative sentinel lymph node biopsy for ipsilateral breast tumor recurrence. Radiat Oncol 2019; 14:159. [PMID: 31477153 PMCID: PMC6720389 DOI: 10.1186/s13014-019-1367-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/22/2019] [Indexed: 01/21/2023] Open
Abstract
Background This study aimed to evaluate the impact of previous local treatment on lymphatic drainage patterns in ipsilateral breast tumor recurrence (IBTR) based on our data on re-operative sentinel lymph node biopsy (re-SLNB) for IBTR. Methods Between April 2005 and December 2016, re-SLNB using lymphoscintigraphy with Tc-99 m phytate was performed in 136 patients with cN0 IBTR. Patients were categorized into two groups: the AX group included 55 patients with previous axillary lymph node dissection; the non-AX group included 69 patients with previous SLNB and 12 patients with no axillary surgery. The whole breast irradiation (RT) after initial surgery had performed in 17 patients in the AX group and 27 patients in the non-AX group. Results Lymphatic drainage was visualized in 80% of the AX group and 95% of the non-AX group (P < 0.01). The visualization rate of lymphatic drainage was associated with the number of removed lymph nodes in prior surgery. In the non-AX group, lymphatic drainage was visualized in 96% of patients without RT and 93% with RT. Lymphatic drainage was observed at the ipsilateral axilla in 98% of patients without RT and in 64% with RT (P < 0.0001). Aberrant drainage was significantly more common in patients with RT than without RT (60% vs. 19%, P < 0.001); it was observed mostly to the contralateral axilla (52% vs. 2%, P < 0.0001). In the AX group, patients with previous RT showed decreased lymphatic drainage to the ipsilateral axilla compared to those without RT (29% vs. 63%, P < 0.05) and increased aberrant drainage to the contralateral axilla (64% vs. 5%, P < 0.0001). Conclusion Lymphatic drainage patterns altered in re-SLNB in patients with IBTR and previous ALND and RT were associated with alterations in lymphatic drainage patterns.
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Affiliation(s)
- Ayaka Sato
- Department of Breast Surgical Oncology, Breast Oncology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto, Tokyo, 135-8550, Japan.,Department of Breast and Endocrine Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Takehiko Sakai
- Department of Breast Surgical Oncology, Breast Oncology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto, Tokyo, 135-8550, Japan
| | - Takuji Iwase
- Department of Breast Surgical Oncology, Breast Oncology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto, Tokyo, 135-8550, Japan
| | - Fumiko Kano
- Department of Breast Surgical Oncology, Breast Oncology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto, Tokyo, 135-8550, Japan
| | - Kiyomi Kimura
- Department of Breast Surgical Oncology, Breast Oncology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto, Tokyo, 135-8550, Japan.,Division of Gene regulation, Institute of Advanced Medical Research, Keio University School of Medicine, 35 Shinanomachi, Shinjuku-ku, Tokyo, 160-8582, Japan
| | - Akiko Ogiya
- Department of Breast Surgical Oncology, Breast Oncology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto, Tokyo, 135-8550, Japan
| | - Mitsuru Koizumi
- Department of Nuclear Medicine, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto, Tokyo, 135-8550, Japan
| | - Masahiko Tanabe
- Department of Breast and Endocrine Surgery, The University of Tokyo Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo, 113-8655, Japan
| | - Rie Horii
- Department of Pathology, Clinicopathology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto, Tokyo, 135-8550, Japan.,Division of Pathology, Clinicopathology Center, The Cancer Institute of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto, Tokyo, 135-8550, Japan
| | - Futoshi Akiyama
- Division of Pathology, Clinicopathology Center, The Cancer Institute of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto, Tokyo, 135-8550, Japan
| | - Takayuki Ueno
- Department of Breast Surgical Oncology, Breast Oncology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto, Tokyo, 135-8550, Japan.
| | - Shinji Ohno
- Department of Breast Surgical Oncology, Breast Oncology Center, The Cancer Institute Hospital of Japanese Foundation for Cancer Research, 3-8-31, Ariake, Koto, Tokyo, 135-8550, Japan
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Poodt IGM, Vugts G, Maaskant-Braat AJG, Schipper RJ, Voogd AC, Nieuwenhuijzen GAP. Risk of Regional Recurrence After Negative Repeat Sentinel Lymph Node Biopsy in Patients with Ipsilateral Breast Tumor Recurrence. Ann Surg Oncol 2018; 25:1312-1321. [PMID: 29497910 PMCID: PMC5891565 DOI: 10.1245/s10434-018-6384-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Indexed: 01/17/2023]
Abstract
Background Repeat sentinel lymph node biopsy (rSLNB) has increasingly been used in patients with ipsilateral breast tumor recurrence (IBTR). The safety in terms of regional disease control after this procedure remains unclear. This study evaluates occurrence of regional recurrence as first event in patients with IBTR and negative rSLNB, treated without additional lymph node dissection. Patients and Methods Data were obtained from the Sentinel Node and Recurrent Breast Cancer (SNARB) study. In 201 patients, tumor-negative rSLNB was obtained without performing additional lymph node dissections. Results With median follow-up of 4.7 (range 0.9–12.7) years, regional recurrence occurred after median time of 3.0 (range 0.4–6.7) years in 4.5% (N = 9) of patients as first event after IBTR and rSLNB. In four of these nine patients, the site of recurrence was in concordance with the anatomical location of rSLNB. Two of the nine recurrences were reported in the ipsilateral axilla, resulting in an ipsilateral axillary regional recurrence rate of 1.0%. In the other seven patients, regional recurrence occurred in aberrant basins. Univariable analysis showed that triple-negative IBTR and lower amount of radioactive-labeled tracer (99mtechnetium) used during rSLNB were associated with developing regional recurrence as first event after negative rSLNB (P < 0.05). Conclusions The risk of developing regional recurrence after negative rSLNB is low. The low relapse rate supports the safety of rSLNB as primary nodal staging tool in IBTR. The time has come for clinical guidelines to adopt rSLNB as axillary staging tool in patients with IBTR. Electronic supplementary material The online version of this article (10.1245/s10434-018-6384-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ingrid G M Poodt
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands.
| | - Guusje Vugts
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | | | - Robert-Jan Schipper
- Department of Surgery, Catharina Hospital Eindhoven, Eindhoven, The Netherlands
| | - Adri C Voogd
- Department of Epidemiology, Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Research, Netherlands Comprehensive Cancer Organisation (IKNL), Utrecht, The Netherlands.,GROW-School for Oncology and Developmental Biology, Maastricht University Medical Center, Maastricht, The Netherlands
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Poodt IGM, Vugts G, Schipper RJ, Nieuwenhuijzen GAP. Repeat Sentinel Lymph Node Biopsy for Ipsilateral Breast Tumor Recurrence: A Systematic Review of the Results and Impact on Prognosis. Ann Surg Oncol 2018; 25:1329-1339. [DOI: 10.1245/s10434-018-6358-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Indexed: 11/18/2022]
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