Axillary radiotherapy instead of axillary dissection: a randomized trial. Italian Oncological Senology Group

Axillary dissection versus axillary observation for low risk, clinically node-negative invasive breast cancer: a systematic review and meta-analysis

Purpose

1. To systematically analyse studies comparing survival outcomes between axillary lymph-node dissection (ALND) and axilla observation (Obs), in women with low-risk, clinically node-negative breast cancer. 2. To consider results in the context of current axillary surgery de-escalation trials and studies.

Methods

9 eligible studies were identified, 6 RCTs and 3 non-randomized studies (4236 women in total). Outcomes assessed: overall survival (OS) and disease-free survival (DFS). The logged (ln) hazard ratio (HR) was calculated and used as the statistic of interest. Data was grouped by follow-up.

Results

Meta-analyses found no significant difference in OS at 5, 10 and 25-years follow-up (5-year ln HR = 0.08, 95% CI − 0.09, 0.25, 10-year ln HR =  0.33, 95% CI − 0.07, 0.72, 25-year ln HR = 0.00, 95% CI − 0.18, 0.19). ALND caused improvement in DFS at 5-years follow-up (ln HR = 0.16, 95% CI 0.03, 0.29), this was not demonstrated at 10 and 25-years follow-up (10-year ln HR = 0.07, 95% CI − 0.09, 0.23, 25-year ln HR = − 0.03, 95% CI − 0.21, 0.16). Studies supporting ALND for DFS at 5-years follow-up had greater relative chemotherapy use in the ALND cohort.

Conclusion

ALND does not cause a significant improvement in OS in women with clinically node-negative breast cancer. ALND may improve DFS in the short term by tailoring a proportion of patients towards chemotherapy. Our evidence suggests that when the administration of systemic therapy is balanced between the two arms, axillary de-escalation studies will likely find no difference in OS or DFS.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12282-021-01273-6.

Treatment of the axila in breast cancer surgery: Systematic review of its impact on survival

Sentinel lymph node biopsy and ACOSOG-Z0011 criteria have modified axillary treatment in breast cancer surgery. We performed a systematic review of studies assessing the impact of axillary treatment on survival. The search showed 6891 potentially eligible items. Of them, 23 clinical trials and 12 meta-analyses published between 1980 and 2017 met the study criteria. The review revealed that axillary lymph node dissection (ALND) can be omitted in patients pN0 and pN1mic, without compromising survival. In patients pN1 it is proposed not to treat the axilla or replace ALND for axillary radiotherapy. The main limitations of this study are the inclusion of old tests that do not use therapeutic targets and lack of risk categorization of relapse. In conclusion, axillary treatment can be avoided in patients without metastatic involvement or micrometastases in the sentinel lymph node. However, there is no evidence to make a recommendation of axillary treatment in N1 patients, so individualized analysis of patient risk factors is needed.

Omission of axillary lymph node dissection for clinically node negative early-stage breast cancer patients

BACKGROUND

For clinically node negative (N0) breast cancer patients, sentinel node (SN) biopsy (SNB) is a standard technique and complete axillary lymph node dissection (ALND) remains the standard treatment when the SN is positive. However, the American College of Surgeons Oncology Group Z0011 trial and the International Breast Cancer Study Group 23-01 trial showed that SNB without ALND can offer excellent regional control and equal survival compared with ALND for limited macrometastatic and micrometastatic SN involvement, respectively. We retrospectively evaluated axillary control rates in clinically N0 patients who had no axillary surgical treatment.

METHODS

Data on 158 patients who underwent breast-conserving therapy without any axillary surgical procedure between 1994 and 2010 were extracted. The last follow-up was on May 2013, and the overall median follow-up period was 119.0 months.

RESULTS

Of all 158 patients, 10 (6.3 %) and 3 (1.9 %) developed locoregional and axillary recurrences, respectively. The 10-year locoregional and axillary recurrence rates were 5.8 and 2.1 %, respectively. The 5- and 10-year overall survival rates were 94.0 and 84.8 %, respectively. Cases with axillary recurrence tended to have common risk factors for recurrence.

CONCLUSION

Even if SNB and ALND were omitted, local and regional recurrence rates were very low among clinically N0 patients and were at the same levels shown in recent trials. This suggests that at least ALND might be safely avoided in clinically N0 patients without any obvious risk factors regardless of axillary nodal status after SNB.

[Selective biopsy of the sentinel lymph node in breast cancer: without axillary recurrences after a mean follow-up of 4.5 years]

OBJECTIVE

To analyze the rate of axillary recurrences (AR) in patients with early breast cancer who had not undergone an axillary node dissection (ALND) because of a negative sentinel lymph node biopsy (SLNB).

MATERIAL AND METHODS

The study includes 173 patients operated on for breast cancer and selective node biopsy. In 32 patients the SLNB was positive and undergone subsequent ALND. We followed up 141 patients with negative SLNB without LDN, with a median follow up of 55 months (range 74-36).

RESULTS

The detection rate of SLN was of 99.42%. After a median follow-up of 4.5 years, there were no axillary recurrences. Two patients developed local recurrence, other two patients developed distant metastases and four patients developed a metachronous tumor. Four patients died, none of them because of breast cancer.

CONCLUSIONS

The results obtained support the SLNB as an accurate technique in the axillary stratification of patients with breast cancer, offering in the cases of negative SLNB a safe axillary control after 4.5 year follow-up.

Optimal treatment of the axilla after positive sentinel lymph node biopsy in early invasive breast cancer. Early results of the OTOASOR trial

Introduction: Sentinel lymph node biopsy alone has become an acceptable alternative to elective axillary lymph node dissection in patients with clinically node-negative early-stage breast cancer. Approximately 70 percent of the patients undergoing breast surgery develop side effects caused by the axillary lymph node dissection (axillary pain, shoulder stiffness, lymphedema and paresthesias). Aim: The current standard treatment is to perform completion axillary lymph node dissection in patients with positive sentinel lymph node biopsy. However, randomized clinical trials of axillary dissection versus axillary irradiation failed to show survival differences between the two types of axillary treatment. The National Institute of Oncology, Budapest conducted a single centre randomized clinical study. The OTOASOR (Optimal Treatment of the Axilla – Surgery or Radiotherapy) trial compares completion axillary lymph node dissection to axillary nodal irradiation in patients with sentinel lymph node-positive primary invasive breast cancer. Method: Patients with primary invasive breast cancer (clinically lymph node negative and less than or equal to 3 cm in size) were randomized before surgery for completion axillary lymph node dissection (arm A–standard treatment) or axillary nodal irradiation (arm B–investigational treatment). Sentinel lymph node biopsy was performed by the radio-guided method. The use of blue-dye was optional. Sentinel lymph nodes were investigated with serial sectioning at 0.5 mm levels by haematoxylin and eosin staining. In the investigational treatment arm patients received 50Gy axillary nodal irradiation instead of completion axillary lymph node dissection. Adjuvant treatment was recommended and patients were followed up according to the actual institutional guidelines. Results: Between August 2002 and June 2009, 2106 patients were randomized for completion axillary lymph node dissection (1054 patients) or axillary nodal irradiation (1052 patients). The two arms were well balanced according to the majority of main prognostic factors. Sentinel lymph node was identified in 2073 patients (98.4%) and was positive in 526 patients (25.4%). Fifty-two sentinel lymph node-positive patients were excluded from the study (protocol violation, patient’s preference). Out of the remaining 474 patients, 244 underwent completion axillary lymph node dissection and 230 received axillary nodal irradiation according to randomization. The mean length of follow-up to the first event and the mean total length of follow-up were 41.9 and 43.3 months, respectively, and there were no significant differences between the two arms. There was no significant difference in axillary recurrence between the two arms (0.82% in arm A and 1.3% in arm B). There was also no significant difference in terms of overall survival between the arms at the early stage follow-up. Conclusions: The authors conclude that after a mean follow-up of more than 40 months axillary nodal irradiation may control the disease in the axilla as effectively as completion axillary lymph node dissection and there was also no difference in terms of overall survival. Orv. Hetil., 154(49), 1934–1942.

Outcomes of clinically node-negative breast cancer without axillary dissection: can preserved axilla be safely treated with radiation after a positive sentinel node biopsy?

PURPOSE

We analyzed whether axillary nodal irradiation could control clinically node-negative disease, including those patients with a positive sentinel lymph node biopsy (SLNB), most of whom received regional nodal irradiation. We also evaluated toxicity profiles that resulted from nodal irradiation.

PATIENTS AND METHODS

From 1988 to 2011, 2107 patients with cT1-T2N0M0 breast cancer underwent breast conservation therapy in the absence of axillary dissection: nx group (n = 1548), without any axillary surgery; the sn(-) group (n = 518), with a negative SLNB; and sn(+) group (n = 104), with a positive SLNB.

RESULTS

The median follow-up times were 88, 56, and 55 months for the nx, sn(-), and sn(+) groups, respectively. The nx group had more risk factors than did the other 2 groups in terms of age, grade, or T stage. Ninety-eight percent of the sn(-)group received only tangent irradiation, and 100% and 83% of the sn(+) and nx group, respectively, received additional regional nodal irradiation. The 5-year cumulative incidences of axillary failure and regional nodal failure were 34, 3, and 0 (2.7%, 0.7%, and 0%; P = .02, log-rank test) and 57, 4, and 0 (4.4, 1%, and 0; P = .04), respectively. Overall survival rates in 5 years were 96.4%, 98.9%, and 97.6% (P = .03), respectively. Symptomatic but transient radiation pneumonitis developed in 31, 16, and 6 (2.0%, 3.1%, and 5.7%). Mild arm edema was observed in 1, 4, and 0 (0.06%, 0.8%, and 0%) in the nx, sn(-), sn(+) groups, respectively.

CONCLUSIONS

Treatment without axillary dissection showed excellent outcomes with negligible toxicity for patients with clinically node negative, including those with a positive SLNB. Regional nodal irradiation after a positive SLNB is a reasonable alternative to axillary dissection.

Who should have or not have an axillary node dissection with breast cancer?

There have been dramatic changes in the approach to the axilla in women with breast cancer over the last 100 years, reflecting the evolution in our understanding of the underlying tumor biology, reduced disease burden because of early detection, and advances in all breast cancer treatment modalities. The approach to the axilla needs to be individualized, much like the extent of surgery for the primary tumor. Axillary dissection remains an important intervention for patients with more locally advanced disease. However, in patients with early-stage breast cancer, in whom regional recurrence is extremely low, the added benefit of an ALND has yet to be confirmed.

Prediction of non-sentinel lymph node status in breast cancer patients with sentinel lymph node metastases: evaluation of the tenon score

INTRODUCTION

Current guidelines recommend completion axillary lymph node dissection (cALND) in case of a sentinel lymph node (SLN) metastasis larger than 0.2 mm. However, in 50%-65% of these patients, the non-SLNs contain no further metastases and cALND provides no benefit. Several nomograms and scoring systems have been suggested to predict the risk of metastases in non-SLNs. We have evaluated the Tenon score.

PATIENTS AND METHODS

In a retrospective review of the Swedish Sentinel Node Multicentre Cohort Study, risk factors for additional metastases were analysed in 869 SLN-positive patients who underwent cALND, using uni- and multivariate logistic regression models. A receiver operating characteristic (ROC) curve was drawn on the basis of the sensitivity and specificity of the Tenon score, and the area under the curve (AUC) was calculated.

RESULTS

Non-SLN metastases were identified in 270/869 (31.1%) patients. Tumour size and grade, SLN status and ratio between number of positive SLNs and total number of SLNs were significantly associated with non-SLN status in multivariate analyses. The area under the curve for the Tenon score was 0.65 (95% CI 0.61-0.69). In 102 patients with a primary tumour <2 cm, Elston grade 1-2 and SLN metastases ≤2 mm, the risk of non SLN metastasis was less than 10%.

CONCLUSION

The Tenon score performed inadequately in our material and we could, based on tumour and SLN characteristics, only define a very small group of patients in which negative non-sentinel nodes could be predicted.

Is obesity an independent prognosis factor in woman breast cancer?

BACKGROUND

Breast cancer and obesity represent important public health issues in most western countries. A number of studies found a negative prognosis effect of obesity or excess of weight in woman breast cancer. However, to date, this issue remains controversial. The objectives of this study were to confirm the prognosis role of obesity on a large cohort of patients and to investigate a potential independent effect.

MATERIALS AND METHODS

We constituted a cohort of 14,709 patients who were recruited and treated at the Curie Institute (Paris) from 1981 to 1999. These patients were followed prospectively for a first unilateral invasive breast cancer without distant metastasis. Obesity was defined by a Body Mass Index (BMI) above 30 kg/m(2) according to the World Health Organization recommendations.

RESULTS

Obese patients (8%) presented more extended tumors at diagnosis time suggesting a delayed breast cancer diagnosis. However, obesity appeared as a negative prognosis factor for several events in respectively univariate and multivariate survival analysis: metastasis recurrence (HR = 1.32[1.19-1.48]; HR = 1.12[1.00-1.26]), disease free interval (1.20[1.08-1.32]; 1.10[0.99-1.22]), overall survival (1.43[1.28-1.60]; 1.12[0.99-1.25]) and second primary cancer outcome (1.57[1.19-2.07]; 1.43[1.09-1.89]). Even if obese patients presented more advanced tumors at diagnosis time, multivariate analysis showed that there was a relevant independent effect. Other BMI codings, distinguishing overweight patients or using BMI as a continuous variable, showed a consistent correlation between BMI's value and prognosis effect. Interaction analysis revealed a more important obesity effect in the presence of tumor estrogen receptors and among limited extent tumors.

CONCLUSIONS

This survey confirms the prognosis role of obesity on one of the largest cohort by investigating several prognosis events. While independent obesity effect linked to hormonal disorders appeared consistent as obesity's mechanism, we stress that obesity prognosis effect was also related to breast cancer presentation at diagnosis time.

The role of surgery in the management of older women with breast cancer

Standard treatment for early breast cancer usually involves multi-modality treatment with a combination of surgery and one or more adjuvant therapies. These may include chemotherapy, radiotherapy, endocrine therapy and Trastuzumab. The treatment schedule for an individual patient may be complex, prolonged and associated with significant morbidity. The benefits of such regimens are clear to see in the improving mortality statistics for this breast cancer. However, such protocols may not appropriate for all women. Older women (over 70 years) have increasing rates of co-morbidities, reduced life expectancy and generally have more favourable breast cancer disease biology. Competing causes of death mean that they are less likely to die of their breast cancer, stage for stage, than a younger woman. In addition, their tolerance to some of the therapies is reduced which increases treatment related morbidity and reduces the risk to benefit ratio. It may therefore be appropriate to modify treatment protocols in selected older women. This should be done in consultation with the multi-disciplinary team with input from specialists in Medicine for the Elderly. The views and wishes of the patient should be respected during these discussions. This article reviews these issues.

Role of lymphadenectomy in surgical treatment of solid tumors: an update on the clinical data

BACKGROUND

The role of lymphadenectomy as an adjunct of standard excision for treatment of cancer is highly debated and controversial. Standard practice for treatment of solid tumors is resection with regional lymphadenectomy. This surgical concept assumes that cancers grow and spread in an orderly manner, from primary cancer to regional lymph nodes and finally to vital organs. We reviewed randomized trials, published a description of lymphatic anatomy and physiology, and presented data that disputed the role of lymphadenectomy as standard practice. The present review updates the literature and reiterates the concept that lymphadenectomy does not increase survival in the surgical treatment of solid tumors.

METHODS

We reviewed the English-language literature (Medline) for prospective randomized trials and nonrandomized reports, as well as retrospective studies addressing the role of lymphadenectomy in cancers of the esophagus, lung, stomach, pancreas, breast, and skin (melanoma) reported between 2000 and 2006.

RESULTS

This extensive review demonstrates that there are few prospective randomized trials assessing patient survival with solid tumors that contrast resection with or without lymphadenectomy. However, there was at least one, and for some cancers more than one, prospective randomized trial for each organ site studied, and the data demonstrate no statistically significant difference in overall survival of patients treated with or without lymphadenectomy. Most nonrandomized and retrospective studies, with a few exceptions, support the conclusions of randomized trials; lymphadenectomy does not improve overall survival in solid tumors. Overall survival is primarily a function of the biological nature of the primary tumor, as evidenced by lymphovascular invasion, lymph node involvement, and other prognostic features.

CONCLUSIONS

This extensive literature review of recent reports indicates that lymphadenectomy does not improve overall survival. Lymph node resection should be conceived in terms of staging, prognosis, and regional control only.

Regional lymph node metastases; a singular manifestation of the process of clinical metastases in cancer: contemporary animal research and clinical reports suggest unifying concepts

Research results from laboratory animals and human clinical reports provide insight into cancer cell disseminations and elaborate the complex metastatic cascade of cells into both regional lymph nodes and other distant organs. Critical appraisal of clinical trials indicates that lymph node metastases are themselves non-lethal, but indicate prognosis, confirming laboratory conclusions. Distant vital organ metastases can be resected with long term survival in highly selective situations, demonstrating metastatic specificity in oligometastatic disease. Appreciating lymphatic system embryology, anatomy, and physiology is necessary for understanding lymph node metastases. The primary lymphatic system function was to return interstitial fluid to the circulation. Later evolutionary insertion of lymphocyte collections in lymph nodes interrupting lymph flow completed a system of analyzing external antigens to enable adaptive immunologic responses. Human cancers seldom elicit major immunological responses; they are not generally "foreign" enough. Therefore, lymphatic metastases have little meaning in evolutionary terms. Organ specificity of both lymphatic and distant metastases occurs as metastatic cells lie dormant, but grow selectively only in liver, lung, bone, or lymph nodes. These organ specific metastatic cells have little ability to produce different organ site clinical metastases. Thus, laboratory findings and clinical correlations emphasize that surgical lymph node removal should be de-emphasized or omitted. More physiological approaches to the highly manipulable multi-step processes of clinical metastases arising from host microenvironments will eventually prevail.

Regional lymph node metastases, a singular manifestation of the process of clinical metastases in cancer: contemporary animal research and clinical reports suggest unifying concepts

The multistep complex metastatic cascade in cancer has been extensively studied in recent years. In addition, the concept of metastatic organ specificity has been elaborated. Histological studies in clinical situations have become far more sophisticated, enabling the frequent discovery of minor collections of cells in bone marrow and lymph nodes. Pertinent clinical evidence of the selective nodal metastatic pattern exists in differentiated thyroid cancer in younger, low-risk patients, yet none of the published risk group definitions indicate that lymph node metastases have a relationship to thyroid cancer survival. This unique clinical situation with very frequent nodal metastases but excellent survival is replicated in carcinoid cancers of the gastrointestinal tract. The lymph node metastatic frequency without distant organ metastases in these two human cancers help cement the understanding gained from laboratory and animal research regarding metastatic specificity and hopefully will help place the role of lymph node metastases generally and their surgical removal on a more scientifically and logically based understanding. More broadly, the elaboration of the frequency of metastatic cell dissemination to distant organs as well as lymph nodes, and comprehension of the metastatic cascade with metastatic specificity may reorient our understanding of the evolution from metastatic cells to clinical metastatic disease. Additionally, these concepts reemphasize that lymph node metastases are indicators, not governors, of distant metastases and survival, and add the assumption that metastatic tumor cells and tumor cell clusters, and perhaps even micrometastases in other organs, are themselves only indicators and not governors of distant metastases and survival in human cancers since they represent dormant metastases prior to their host microenvironmental changes that, on rare occasions, lead to angiogenesis and clinical metastases. Thus, the future may allow us to abandon some aspects of our surgical or systemic attack on clinical cancer metastases, such as lymph node removal or use of toxic chemotherapy, but open the door to more physiological and hopefully less traumatic approaches to the highly manipulable multistep genetic and physiological process of metastatic development. The future biological models of clinical cancer behavior will have to incorporate aspects of understanding the intricate metastatic cascade, and particularly the host microenvironmental factors that permit or prevent progressive growth of dormant cells or cell clusters to clinical metastases.

Recurrence after sentinel lymph node biopsy with or without axillary lymph node dissection in patients with breast cancer

BACKGROUND

A regional nodal recurrence is a major concern after a sentinel lymph node biopsy (SLNB) alone in patients with breast cancer. In this study we investigated patterns and risk factors of regional nodal recurrence after SLNB alone.

PATIENTS AND METHODS

Between January 1999 and March 2005, a series of 1,704 consecutive breast cancer cases in 1,670 patients (34 bilateral breast cancer cases) with clinically negative nodes or suspicious nodes for metastasis who underwent SLNB at a single institute (Saitama Cancer Center) were studied. All 1,704 cases were classified based upon presence or absence of a metastatic lymph node, treated with or without axillary lymph node dissection (ALND). The site of first recurrence was classified as local, regional node, or distant. The regional node recurrences were subclassified as axillary, interpectoral, infraclavicular, supraclavicular, or parasternal.

RESULTS

After a median follow-up period of 34 months (range, 2-83 months), first recurrence occurred in local sites in 32 (1.9%) cases, regional nodes in 26 (1.5%) cases, and distant sites in 61 (3.6%) cases. In 1,062 cases with negative nodes treated without ALND and 459 cases with positive nodes treated with ALND, 11 (1.0%) and 15 (3.3%) recurred in regional nodes, respectively, and 4 (0.4%) and 2 (0.6%) recurred in axillary nodes, respectively. Of 822 cases of invasive breast cancer with negative nodes treated with SLNB alone, 10 (1.4%) recurred in regional nodes, and 4 (0.5%) recurred in axillary nodes. In the 10 patients with regional nodal failure, all of the tumors were negative for estrogen receptor (ER) and/or progesterone receptor (PR) and were nuclear grade (NG) 3.

CONCLUSIONS

The axillary recurrence rate was low in patients treated with SLNB alone. Omitting ALND is concluded to be safe after adequate SLNB. Risk factors for regional nodal failure after SLNB alone are negative hormone receptor status and high NG.

Locoregional therapy of breast cancer: maximizing control, minimizing morbidity

The goal of locoregional therapy in breast cancer has remained unchanged for a century: the eradication of all malignant cells from the breast and draining lymph nodes, hopefully prior to them having spread to distant organs. However, how we accomplish this goal has changed dramatically over this time period and our success in achieving this goal has been greatly enhanced by improvements in breast imaging and systemic therapies. The therapeutic importance of surgery and radiation has been underestimated in recent years and is thought to have minimal impact on long-term outcome. More recent data have reputed this contention and the relationship between local control and survival in breast cancer is becoming increasingly apparent. This article will review the importance of attaining optimum local control with minimum morbidity and examine where the future of locoregional therapy of breast cancer may lie.

Clinical patterns of metastasis

In human solid cancer, lymph node status is the most important indicator for clinical outcome. Recent developments in the sentinel lymph node concept and technology have resulted in a more precise way of examining micrometastasis in the sentinel lymph node and the role of lymphovascular system in the facilitation of cancer metastasis. Different patterns of metastasis are described with respect to different types of solid cancer. Expect perhaps for papillary carcinoma and sarcoma, the overwhelming evidence is that solid cancer progresses in an orderly progression from the primary site to the regional lymph node or the sentinel lymph node in the majority of cases with subsequent dissemination to the systemic sites. The basic mechanisms of cancer metastasis through the lymphovascular system form the basis of rational therapy against cancer. Beyond the clinical patterns of metastasis, it is imperative to understand the biology of metastasis and to characterize patterns of metastasis perhaps due to heterogeneous clones based on their molecular signatures.

The impact of the number of excised axillary nodes and of the percentage of involved nodes on regional nodal failure in patients treated by breast-conserving surgery with or without regional irradiation

PURPOSE

After breast-conserving surgery, recommendations for regional nodal radiotherapy are usually based on the number of positive nodes. This number is dependent on the number of nodes removed during the axillary dissection. This study examines whether the percentage of positive nodes may help to select patients for regional radiotherapy.

METHODS AND MATERIALS

A retrospective study was conducted on 1,372 T1-T2 node-positive breast cancer patients treated at L'Hôtel-Dieu de Québec Hospital between 1972 and 1997.

RESULTS

Among the patients who did not receive regional radiotherapy, the percentage of involved nodes was significantly associated with axillary failure. Ten-year axillary control rates were 97% and 91% when the percentage of involved nodes was <50% and > or =50%, respectively (p = 0.007). In addition, regional radiotherapy is always significantly associated with a decrease in overall regional failure (axillary and/or supraclavicular), regardless of the percentage of involved nodes. However, regional radiotherapy reduced the axillary failure rate (2% vs. 9%, p = 0.007) only when more than a specific percentage of nodes was involved (> or =40% if N1-3 and > or =50% if N>3 nodes).

CONCLUSIONS

The percentage of involved nodes should be taken into consideration in selecting patients for regional radiotherapy. Irradiation of the axilla should be reserved for patients with a specific ratio: >40% involved nodes if N1-3 and > or =50% involved nodes if N>3 nodes.

Pathologic examination of the axillary sentinel lymph nodes in patients with early-stage breast carcinoma: current and resolving controversies on the basis of the European Institute of Oncology experience

Several controversial aspects of sentinel lymph node biopsy (SLNB) for patients with early-stage, node-negative breast carcinoma have been dealt with and resolved in the past decade since its introduction. Unfortunately, however, there is still no consensus on how best to examine sentinel lymph nodes (SLN) histologically. As a consequence, the protocols for SLN examination are remarkably variable in different institutions, leading to a very poor reproducibility of the data stemming from investigations on series of patients whose SLNs have been evaluated according to diverse protocols. Patient outcomes, however, can be optimised only by standardization of the whole procedure of SLNB, with particular reference to the histopathologic scrutiny. Lack of a standardized histopathologic protocol likely derives also from the uncertainties about the clinical implications of minimal lymph node involvement (isolated tumour cells and micrometastases) with regard both to the risk of additional metastases to non-sentinel lymph nodes of the same basin and to the prognostic value for patients' survival. This review aims at highlighting some of the controversial issues of the histopathologic examination of the SLNs, including the number of sections and cutting intervals, the use of immunohistochemistry and the role of molecular biology assays.

Histopathology of primary breast cancer 2005

Major efforts have been recently devoted to a better definition of intraductal proliferative lesions with atypia. The new WHO classification of tumors of the breast highlights the morphological features of flat epithelial atypia (DIN 1A) and atypical duct hyperplasia (DIN 1B). Flat epithelial atypia now encompasses lesions previously designated as clinging carcinoma (monomorphous type) and atypical columnar changes. Atypical ductal hyperplasia (ADH) is characterized by the same cytological changes as low-grade DCIS, involving a very small portion of the ductal tree. Minimal lymph node involvement includes true micrometastases (from 0.2 to 2 mm in size) and isolated tumor cells (ITC). ITC have been defined as individual tumor cells or small clusters of cells, not more than 0.2 mm in size, that do not typically show evidence of metastatic activity or penetration of vascular or lymphatic sinus walls. The biological and clinical implications of ITC remain to be elucidated.

A randomized trial comparing axillary dissection to no axillary dissection in older patients with T1N0 breast cancer: results after 5 years of follow-up

SUMMARY BACKGROUND DATA

Axillary dissection, an invasive procedure that may adversely affect quality of life, used to obtain prognostic information in breast cancer, is being supplanted by sentinel node biopsy. In older women with early breast cancer and no palpable axillary nodes, it may be safe to give no axillary treatment. We addressed this issue in a randomized trial comparing axillary dissection with no axillary dissection in older patients with T1N0 breast cancer.

METHODS

From 1996 to 2000, 219 women, 65 to 80 years of age, with early breast cancer and clinically negative axillary nodes were randomized to conservative breast surgery with or without axillary dissection. Tamoxifen was prescribed to all patients for 5 years. The primary endpoints were axillary events in the no axillary dissection arm, comparison of overall mortality (by log rank test), breast cancer mortality, and breast events (by Gray test).

RESULTS

Considering a follow-up of 60 months, there were no significant differences in overall or breast cancer mortality, or crude cumulative incidence of breast events, between the 2 groups. Only 2 patients in the no axillary dissection arm (8 and 40 months after surgery) developed overt axillary involvement during follow-up.

CONCLUSIONS

Older patients with T1N0 breast cancer can be treated by conservative breast surgery and no axillary dissection without adversely affecting breast cancer mortality or overall survival. The very low cumulative incidence of axillary events suggests that even sentinel node biopsy is unnecessary in these patients. Axillary dissection should be reserved for the small proportion of patients who later develop overt axillary disease.

Development of axillary surgery in breast cancer

Axillary surgery is a critical part of the treatment of breast carcinoma: its importance is related to the staging of disease, prescription of adjuvant therapy and prognosis. For years, complete axillary dissection has remained the standard approach to breast cancer lymphatic staging; its value is still high, but the development of sentinel-node biopsy has significantly changed the indication of the procedure. We discuss the evolution of axillary surgery in breast cancer.

The sentinel node biopsy after previous breast surgery: preliminary results on 543 patients treated at the European Institute of Oncology

BACKGROUND

Sentinel lymph node biopsy (SLNB) is an accurate alternative to complete axillary lymph node dissection (ALND) in clinically node-negative breast cancer patients. A previous breast biopsy has been considered a relative contraindication to SLNB. We examined the accuracy of SLNB by following the axillary relapses after the procedure in patients who had undergone a breast biopsy before SLNB.

PATIENTS AND METHODS

Up to December 2003, 4351 patients with the diagnosis of invasive breast cancer underwent SLNB at the European Institute of Oncology. Already, 543 of these patients had undergone a breast biopsy; from June 1997 to January 2004, these patients received SLNB by lymphoscintigraphy performed on the biopsy area. We followed these patients with a clinical assessment every 6 months and instrumental examinations every year, particularly focusing on the research of axillary relapse of disease.

RESULTS

In 70.4% of cases, the sentinel node was negative, and only three cases underwent further axillary dissection. The sentinel node was identified in 99% of cases and this was the only positive node in 61.5% of cases with positive axillary nodes. The median follow-up was 2 years; 4 nodal recurrences were observed: 3 axillary lymph node relapses and 1 loco-regional.

CONCLUSIONS

SLNB accuracy after a previous breast biopsy is comparable with the results obtained in validation studies. SLNB after a previous breast biopsy can be considered a standard procedure. Lymphoscintigraphy identifies the sentinel node in 99% of patients.

Breast cancer

Breast cancer remains a public-health issue on a global scale. We report new information about the disease from the past 5 years. Early age at first birth, increasing parity, and tamoxifen use are related to long-term lifetime reduction in breast-cancer risk. Ductal carcinomas in situ has been suggested to be renamed ductal intraepithelial neoplasia to emphasise its non-life-threatening nature. An alternative approach, the progenitor/stem cell theory, predicts that only some tumour cells cause cancer progression and that these should be targeted by treatment. Mammography and ultrasonography are still the most effective for women with non-dense and dense breast tissues, respectively. Additionally, MRI, lymphatic mapping, the nipple-sparing mastectomy, partial breast irradiation, neoadjuvant systemic therapy, and adjuvant treatments are promising for subgroups of breast-cancer patients. Although tamoxifen can be offered for endocrine-responsive disease, aromatase inhibitors are increasingly used. Assessment of potential molecular targets is now important in primary diagnosis. Tyrosine-kinase inhibitors and other drugs with anti-angiogenesis properties are currently undergoing preclinical investigations.

Avoiding axillary dissection in breast cancer surgery: a randomized trial to assess the role of axillary radiotherapy

BACKGROUND

The need to dissect axillary nodes in patients with early breast cancer and clinically negative axilla remains controversial. The aim of the study was to assess the role of axillary radiotherapy (RT) in reducing axillary metastases in patients with early breast cancer who did not receive axillary dissection.

PATIENTS AND METHODS

From 1995 to 1998, 435 patients over 45 years old with breast cancer up to 1.2 cm and no palpable axillary nodes were randomized 214 to breast conservation without axillary treatment and 221 to breast conservation plus axillary RT.

RESULTS

After a median follow-up of 63 months, overt axillary metastases were fewer than expected: three cases in the no axillary treatment group (1.5%) and one in the RT group (0.5%). Expected cases were 43 in the no axillary treatment group and 10 in the RT group. Rates of distant metastases and local failures were low, and 5-year disease free survival was 96.0% (95% confidence interval, 94.1%-97.9%) without significant differences between the two arms.

CONCLUSIONS

This study suggests that occult axillary metastases might never become clinically overt and axillary dissection might be avoided in patients with small carcinomas and a clinically negative axilla. Axillary RT seems to protect the patients from axillary recurrence almost completely.

Sentinel node biopsy in breast cancer: early results in 953 patients with negative sentinel node biopsy and no axillary dissection

Sentinel node biopsy in patients with breast carcinoma accurately predicts the axillary nodal status. However, in some 6% of patients with negative sentinel nodes the remaining axillary nodes harbour metastases. Our purpose was to observe a large number of patients who did not undergo an axillary dissection after a negative sentinel node biopsy for the appearance of overt axillary metastases. 953 patients treated from 1996 to 2000, with negative sentinel nodes not submitted to axillary dissection, were followed-up to 7 years, with a median follow-up of 38 months. Fifty-five unfavourable events occurred among the 953 patients, 37 (4%) related to the primary breast carcinoma. Three cases of overt axillary metastases were found: they received total axillary dissection and are presently alive and well. The 5 year overall survival rate of the whole series was 98%. Patients with negative sentinel node biopsies not submitted to axillary dissection show during follow-up a rate of overt axillary metastases that is lower than that expected.

Treatment of breast carcinoma in patients with clinically negative axillary lymph nodes using radiotherapy versus axillary dissection

BACKGROUND

The role of axillary lymph node dissection (AxD) for patients with breast carcinoma who have clinically negative lymph nodes (cN0) and undergo breast-conserving therapy has been controversial. If patients do not undergo AxD, then it is uncertain whether specific lymph node irradiation should be given. The authors compared the results obtained from patients w ho underwent AxD with the results from patients who received axillary irradiation (AxR) using one of two radiotherapy techniques.

METHODS

Patients with T1-T2cN0 breast carcinoma were treated from 1983 to 2002 with either AxD (80 patients) or AxR (1134 patients received tangential-field [2-field] irradiation, and 303 patients received 3-field irradiation). The median follow-up was 161 months for the AxD group and 66 months for the AxR group (55 months for patients who received tangential-field irradiation, and 122 months for patients who received 3-field irradiation).

RESULTS

One patient in the AxD group and 35 patients in the AxR group had axillary recurrences. The 10-year cumulative axillary recurrence rates were 1.3% and 4.6% for the AxD group and the AxR group, respectively (P = 0.21). For patients with T1 tumors, the 10-year overall survival rates for the two groups were 94.7% and 92.7%, respectively (P = 0.34); and, for patients with T2 tumors, the 10-year overall survival rates were 92.5% and 89.1%, respectively (P = 0.34). In the AxR group, the 5-year axillary recurrence rates were 2.5% for patients who received tangential-field irradiation and 1.7% for patients who received 3-field irradiation (P = 0.18), and the 5-year regional recurrence rates for the two groups were 4.8% and 2.4%, respectively (P = 0.048). On multivariate analysis, positive lymphovascular invasion, outer tumor location, and larger tumor size were significant risk factors for regional failure.

CONCLUSIONS

For patients with cN0 breast carcinoma, AxD and AxR yielded the same overall survival rates. Most patients can be treated safely with tangential-field irradiation alone. Patients who are at increased risk of regional failure may benefit from three-field irradiation.

Less aggressive surgery and radiotherapy is the way forward

PURPOSE OF REVIEW

Conserving the breast is one of the main objectives in treating patients affected by carcinoma. This objective should be compatible with good local control to keep the risk of local failures low. The progressive reduction of the extension of surgery in the breast and in the axilla is now accompanied by a reduction of the radiation field. This article provides an update on conservative therapy for breast cancer.

RECENT FINDINGS

After the development of quadrantectomy, the effectiveness of sentinel node biopsy was demonstrated in the axillary staging of breast carcinoma. The situation took another step forward with partial breast irradiation. The highest incidence of local relapse after breast-conserving surgery is observed in the same area as the primary tumor. This factor provides the rationale for reducing the radiation field to a limited area of the breast primarily affected by carcinoma.

SUMMARY

The Milan I trial on breast conservative surgery provided definitive confirmation of the equivalence of quadrantectomy, followed by radiotherapy, to mastectomy in terms of local control of disease. The randomized trial on sentinel node biopsy demonstrated the effectiveness of this procedure in axillary staging of breast carcinoma. Radiotherapy is currently under investigation in terms of limiting the radiation field to the affected quadrant of the breast by means of various techniques.

Radiation therapy as an adjuvant treatment after sentinel lymph node surgery for breast cancer

Radiation therapy is an effective treatment of micrometastatic disease involving lymph nodes. Correspondingly, radiation may be an important adjuvant treatment for selected patients who undergo sentinel lymph node surgery. The specific cohorts for whom radiation maybe of benefit include those at risk for a false-negative surgery, patients with a positive sentinel lymph node who elect to forgo an axillary dissection, and patients with drainage to the internal mammary lymph nodes. For these patients, radiation treatment fields must be specifically designed to include the appropriate nodal regions within the target treatment volumes.

Patterns of recurrence after sentinel lymph node biopsy for breast cancer

BACKGROUND

Sentinel lymph node biopsy (SLNB) is gaining acceptance as an alternative to axillary lymph node dissection. The purpose of this study was to determine the frequency and pattern of disease recurrence after SLNB.

METHODS

Two-hundred twenty-two consecutive patients undergoing SLNB from April 6, 1998, to October 27, 1999, and who were >or=24 months out from their procedure were identified from a prospectively maintained database. Retrospective chart review and data analysis were performed to identify variables predictive of recurrence.

RESULTS

The median patient follow-up was 32 months (range, 24-43 months). A total of 159 patients (72%) were sentinel lymph node (SLN) negative and had no further axillary treatment. Five of these patients (3.1%) developed a recurrence (one local and four distant), with no isolated regional (axillary) recurrences. Sixty-three patients (28%) were SLN positive and underwent a subsequent axillary lymph node dissection. Six of these patients (9.5%) developed a recurrence (three local, one regional, and two distant). Pathologic tumor size (P <.001), lymphovascular invasion (P =.018), and a positive SLN (P =.048) were all statistically significantly associated with disease recurrence.

CONCLUSIONS

With a minimum follow-up of 24 months, patients with a negative SLN and no subsequent axillary treatment demonstrate a low frequency of disease recurrence. This supports the use of SLNB as the sole axillary staging procedure in SLN-negative patients.