1
|
Survival in Cytologically Proven Node-Positive Breast Cancer Patients with Nodal Pathological Complete Response after Neoadjuvant Chemotherapy. Cancers (Basel) 2020; 12:cancers12092633. [PMID: 32942650 PMCID: PMC7564641 DOI: 10.3390/cancers12092633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Revised: 09/08/2020] [Accepted: 09/11/2020] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND It is unknown whether patients with cytologically proven axillary node-positive breast cancer who achieve axillary pathological complete response (pCR) after neoadjuvant chemotherapy (NAC) have comparable prognosis to patients with axillary pathological node-negative disease (pN-) without NAC. METHODS We retrospectively reviewed the data of patients with cytologically proven axillary node-positive disease who received NAC and those with axillary pN- without NAC for control between January 2007 and December 2012. We compared outcomes according to response in the axilla to NAC and between patients with axillary pCR and matched pairs with axillary pN- without NAC using propensity scores. RESULTS We included 596 patients with node-positive breast cancer who received NAC. The median follow-up period was 64 months. Patients with axillary pCR showed significantly better distant disease-free survival (DDFS) and overall survival (OS) than patients with residual axillary disease (both p < 0.01). There was no significant difference in DDFS and OS between patients with axillary pCR and matched pairs with axillary pN- without NAC. CONCLUSION Axillary pCR was associated with improved prognosis. Patients with axillary pCR and matched pairs with axillary pN- without NAC had comparable outcomes. This information will be useful when considering the intensity of follow-up and adjuvant therapy.
Collapse
|
2
|
Akita S, Yamaji Y, Takeuchi N, Wakai K, Azuma K, Nakagawa A, Fujimoto H, Sangai T, Nagashima T, Mitsukawa N, Ikehara Y. Detection of Nonpalpable Tiny Axillary Lymph Nodes Surrounded by Adipose Tissue Using a Near-Infrared Camera. Lymphat Res Biol 2020; 18:455-463. [PMID: 32048903 DOI: 10.1089/lrb.2019.0022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: It is not always possible to detect nonpalpable small lymph nodes (LNs) surrounded by adipose tissue under the wavelength of visible light. A newly developed near-infrared camera with InGaAs element was able to capture photographs using light at >1000-nm wavelength, at which the difference in absorbance between water and lipids is large. This study investigated the ability to detect nonvisible small LNs using light at 1300-nm wavelength. Methods and Results: Following retrieval of LNs through axillary LN dissection from 20 patients with breast cancer, residual specimens were simultaneously photographed using light at 970-, 1070-, 1200-, 1300-, 1450-, and 1600-nm wavelengths. A total of 45 specimens were observed pathologically at the selected portions in which the 1300-nm light was absorbed (high absorbance group [HA group], n = 25) and those in which the 970-nm light was absorbed instead (low absorbance group [LA group], n = 20). All specimens categorized in the HA group detected the LNs, whereas none of those categorized in the LA group detected an LN. The sensitivity and specificity in the identification of an LN were 1.0. The LNs detected using this camera were significantly smaller than those detected by surgeons (3.00 ± 2.93 mm vs. 5.90 ± 3.91 mm, p < 0.01). Discussion: The light at 1300-nm wavelength was absorbed by axillary LNs. This camera detected LNs that were undetectable by surgeons. This novel technology may be applied to lymphatic microsurgery and contribute to the development of a minimally invasive LN dissection method.
Collapse
Affiliation(s)
- Shinsuke Akita
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Yoshihisa Yamaji
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Nobuyoshi Takeuchi
- Department of Pathology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Ken Wakai
- Department of Pathology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Kazuhiko Azuma
- Department of Pathology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Ayako Nakagawa
- Department of Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Hiroshi Fujimoto
- Department of Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Takafumi Sangai
- Department of Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Takeshi Nagashima
- Department of Department of General Surgery, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Nobuyuki Mitsukawa
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan
| | - Yuzuru Ikehara
- Department of Pathology, Graduate School of Medicine, Chiba University, Chiba, Chiba, Japan.,Biotechnology Research Institute for Drug Discovery, National Institute of Advanced Industrial Science and Technology, Tsukuba, Japan
| |
Collapse
|
3
|
van Nijnatten TJA, Simons JM, Moossdorff M, de Munck L, Lobbes MBI, van der Pol CC, Koppert LB, Luiten EJT, Smidt ML. Prognosis of residual axillary disease after neoadjuvant chemotherapy in clinically node-positive breast cancer patients: isolated tumor cells and micrometastases carry a better prognosis than macrometastases. Breast Cancer Res Treat 2017; 163:159-166. [PMID: 28213782 PMCID: PMC5387009 DOI: 10.1007/s10549-017-4157-0] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2017] [Accepted: 02/13/2017] [Indexed: 11/12/2022]
Abstract
PURPOSE The aim of this study was to compare disease-free survival (DFS) and overall survival (OS) between clinically node-positive breast cancer patients, treated with neoadjuvant chemotherapy (NAC), with axillary pathologic complete response (ypN0), residual axillary isolated tumor cells or micrometastases (ypNitc/mi), and residual axillary macrometastases (ypN1-3). METHODS All patients diagnosed with clinically node-positive primary invasive breast cancer treated with NAC and subsequent axillary lymph node dissection between 2005 and 2008 were retrospectively analyzed. Data were obtained from the Netherlands Cancer Registry. Patients were stratified by final pathological axillary status: ypN0, ypNitc/mi, or ypN1-3. The main outcome measures DFS and OS were analyzed using Kaplan-Meier survival analysis. Uni- and multivariable cox regression analyses were used to determine independent predictors for DFS and OS. RESULTS A total of 1347 patients were included. Pathologic nodal status was ypN0 in 22.2%, ypNitc/mi in 3.8%, and ypN1-3 in 74.0% of patients. Overall, 5-year DFS was 57.8% and mean OS was 7.4 years. DFS and OS were comparable between ypN0 and ypNitc/mi (HR 1.38 (0.40-4.79, p = 0.613) and HR 0.92 (0.27-3.09, p = 0.889), respectively), but significantly different between ypN0 and ypN1-3 (HR 1.78 (1.06-3.00, p = 0.031) and HR 1.70 (1.07-2.71, p = 0.026), respectively). CONCLUSIONS Clinically node-positive patients, treated with NAC, with axillary nodal status ypN0 or ypNitc/mi carry similar prognosis regarding DFS and OS. Axillary nodal status ypN1-3 is associated with a less favorable prognosis. Future studies should consider ypN0 and ypNitc/mi as one entity.
Collapse
Affiliation(s)
- T J A van Nijnatten
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands.
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands.
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands.
| | - J M Simons
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - M Moossdorff
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - L de Munck
- Department of Research, Netherlands Comprehensive Cancer Organisation, Utrecht, The Netherlands
| | - M B I Lobbes
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - C C van der Pol
- Department of Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - L B Koppert
- Department of Surgical Oncology, Erasmus MC Cancer Institute, Rotterdam, The Netherlands
| | - E J T Luiten
- Department of Surgery, Amphia Hospital, Breda, The Netherlands
| | - M L Smidt
- Department of Surgery, Maastricht University Medical Center+, Maastricht, The Netherlands
- GROW - School for Oncology and Developmental Biology, Maastricht University Medical Center+, Maastricht, The Netherlands
| |
Collapse
|
4
|
Kishan AU, McCloskey SA. Postmastectomy radiation therapy after neoadjuvant chemotherapy: review and interpretation of available data. Ther Adv Med Oncol 2016; 8:85-97. [PMID: 26753007 DOI: 10.1177/1758834015617459] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Postmastectomy radiotherapy (PMRT) has been shown to decrease locoregional recurrence and improve overall survival in patients with tumors greater than 5 cm or positive nodes. Because neoadjuvant chemotherapy (NAC) can cause significant downstaging, the indications for PMRT in the setting of NAC remain controversial and thus careful consideration of clinical stage at presentation, pathologic response to NAC, and other clinical characteristics, such as grade and biomarker status is required. The current review synthesizes both prospective and retrospective data to provide evidence for recommending PMRT after NAC for patients presenting with cT3-4 disease, cN2-3 disease, and residual nodal disease, as well as rationale for omitting PMRT in patients with cT1-2N0-1 disease who achieve a pathologic complete response. Other scenarios, including nodal complete response in the presence of other risk factors, are also explored. The topics of pre-NAC clinical staging and pathologic axillary nodal staging are reviewed, and radiation portal design is briefly discussed.
Collapse
Affiliation(s)
- Amar U Kishan
- Department of Radiation Oncology, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Susan A McCloskey
- Department of Radiation Oncology, 1223 16th Street, Santa Monica, CA 90404, USA
| |
Collapse
|
5
|
Gangi A, Choi M, Giuliano AE. Management of the Axilla After Neoadjuvant Therapy: Current Data and Controversies. CURRENT BREAST CANCER REPORTS 2014. [DOI: 10.1007/s12609-014-0167-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
|
6
|
Chen S, Liu Y, Huang L, Chen CM, Wu J, Shao ZM. Lymph Node Counts and Ratio in Axillary Dissections Following Neoadjuvant Chemotherapy for Breast Cancer: A Better Alternative to Traditional pN Staging. Ann Surg Oncol 2013; 21:42-50. [DOI: 10.1245/s10434-013-3245-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2013] [Indexed: 11/18/2022]
|
7
|
Chen S, Chen CM, Yu KD, Yang WT, Shao ZM. A prognostic model to predict outcome of patients failing to achieve pathological complete response after anthracycline-containing neoadjuvant chemotherapy for breast cancer. J Surg Oncol 2011; 105:577-85. [DOI: 10.1002/jso.22140] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2011] [Accepted: 10/19/2011] [Indexed: 12/16/2022]
|
8
|
Local-regional recurrence with and without radiation therapy after neoadjuvant chemotherapy and mastectomy for clinically staged T3N0 breast cancer. Int J Radiat Oncol Biol Phys 2011; 81:782-7. [PMID: 21885207 DOI: 10.1016/j.ijrobp.2010.06.027] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2009] [Revised: 06/07/2010] [Accepted: 06/17/2010] [Indexed: 02/03/2023]
Abstract
PURPOSE The purpose of this study was to determine local-regional recurrence (LRR) risk according to whether postmastectomy radiation therapy (PMRT) was used to treat breast cancer patients with clinical T3N0 disease who received neoadjuvant chemotherapy (NAC) and mastectomy. METHODS AND MATERIALS Clinicopathology data from 162 patients with clinical T3N0 breast cancer who received NAC and underwent mastectomy were retrospectively reviewed. A total of 119 patients received PMRT, and 43 patients did not. The median number of axillary lymph nodes (LNs) dissected was 15. Actuarial rates were calculated using the Kaplan-Meier method and compared using the log-rank test. RESULTS At a median follow-up of 75 months, 15 of 162 patients developed LRR. For all patients, the 5-year LRR rate was 9% (95% confidence interval [CI], 4%-14%). The 5-year LRR rate for those who received PMRT was 4% (95% CI, 1%-9%) vs. 24% (95% CI, 10%-39%) for those who did not receive PMRT (p <0.001). A significantly higher proportion of irradiated patients had pathology involved LNs and were ≤40 years old. Among patients who had pathology involved LNs, the LRR rate was lower in those who received PMRT (p <0.001). A similar trend was observed for those who did not have pathology involved LN disease. Among nonirradiated patients, the appearance of pathologic LN disease after NAC was the only clinicopathologic factor examined that significantly correlated with the risk of LRR. CONCLUSIONS Breast cancer patients with clinical T3N0 disease treated with NAC and mastectomy but without PMRT had a significant risk of LRR, even when there was no pathologic evidence of LN involvement present after NAC. PMRT was effective in reducing the LRR rate. We suggest PMRT should be considered for patients with clinical T3N0 disease.
Collapse
|
9
|
Boughey JC, Donohue JH, Jakub JW, Lohse CM, Degnim AC. Number of lymph nodes identified at axillary dissection. Cancer 2010; 116:3322-9. [DOI: 10.1002/cncr.25207] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
|
10
|
Bélanger J, Soucy G, Sidéris L, Leblanc G, Drolet P, Mitchell A, Leclerc YE, Beaudet J, Dufresne MP, Dubé P. Neoadjuvant chemotherapy in invasive breast cancer results in a lower axillary lymph node count. J Am Coll Surg 2008; 206:704-8. [PMID: 18387477 DOI: 10.1016/j.jamcollsurg.2007.10.016] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2007] [Revised: 10/28/2007] [Accepted: 10/31/2007] [Indexed: 11/17/2022]
Abstract
BACKGROUND It is essential to have the highest level of confidence in axillary staging assessment. Many surgeons and pathologists believe that fewer lymph nodes are present in axillary dissection specimens of women treated by neoadjuvant chemotherapy. Consequently, the purpose of this study was to compare the lymph node counts of axillary dissection specimens from patients having received neoadjuvant chemotherapy with those of patients treated with primary operation. STUDY DESIGN A retrospective analysis of a prospective database from our institution identified 283 women with invasive breast cancer who underwent level I and II axillary lymph node dissections. Women from the neoadjuvant chemotherapy group (n=107) were compared with those from the primary surgery group (n=176). The total number of lymph nodes harvested was considered as a continuous variable, but also dichotomized into two categories (< 10 and >or=10). Its correlation with the different variables was analyzed. RESULTS The median number of lymph nodes retrieved in the neoadjuvant chemotherapy group was 10.0 (range 0 to 38) compared with 12.5 (range 0 to 30) in the control group (p=0.002). There were also significantly more patients with fewer than 10 lymph nodes recovered in the neoadjuvant group (45 versus 28%, p=0.007). Logistic regression showed that neoadjuvant chemotherapy was the only factor associated with retrieval of fewer than 10 lymph nodes. CONCLUSIONS This study suggests that administration of neoadjuvant chemotherapy to breast cancer patients results in a reduced number of lymph nodes retrieved in the axillary dissection specimens.
Collapse
Affiliation(s)
- Julie Bélanger
- Department of General Surgery, Maisonneuve-Rosemont Hospital, University of Montréal, Montréal, PQ, Canada
| | | | | | | | | | | | | | | | | | | |
Collapse
|
11
|
Shet T, Agrawal A, Chinoy R, Havaldar R, Parmar V, Badwe R. Changes in the tumor grade and biological markers in locally advanced breast cancer after chemotherapy--implications for a pathologist. Breast J 2007; 13:457-64. [PMID: 17760666 DOI: 10.1111/j.1524-4741.2007.00465.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
There is insurgence of literature evaluating prognostic and predictive factors in breast carcinomas treated with chemotherapy, with a parallel need to develop guidelines for the pathologist interpreting such excisions. Prechemotherapy gun biopsy and postchemotherapy excision specimens from 78 women with locally advanced breast cancer were analyzed for histological changes in the tumor, changes in the tumor grade, hormone receptors, cerb2, and bcl2 and their impact on disease-free survival (DFS). An unusually prominent granulomatous response to tumor was seen in three cases. The tumor grade changed in five patients, estrogen receptor (ER) expression was altered in 10 cases, progesterone receptor detection changed in 16 cases, cerb2 in one case and bcl2 in 16 cases. Fixation of the gun biopsy in Bouin's fluid and severe damage of nuclei after chemotherapy were the reasons for shift in the expression of hormone receptors. A low-grade tumor was associated with better response to chemotherapy. In the Kaplan-Meier analysis the ER expression and a low-grade tumor (grade I and II) significantly affected DFS. None of the factors evaluated impacted the overall survival of patients. To conclude there is a change in the tumor grade, bcl2, cerb2 and hormone receptors after chemotherapy. A pathologist interpreting specimens of breast cancer after chemotherapy must always record the postchemotherapy grade as it is an indicator of better response to chemotherapy and survival.
Collapse
Affiliation(s)
- Tanuja Shet
- Department of Pathology, Tata Memorial Hospital, Parel, Mumbai, India.
| | | | | | | | | | | |
Collapse
|
12
|
Shimizu C, Ando M, Kouno T, Katsumata N, Fujiwara Y. Current Trends and Controversies over Pre-operative Chemotherapy for Women with Operable Breast Cancer. Jpn J Clin Oncol 2007; 37:1-8. [PMID: 17202251 DOI: 10.1093/jjco/hyl122] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The multi-disciplinary approach, including surgery, chemotherapy, endocrine therapy and radiation therapy, has become the standard treatment for primary breast cancer patients. The indication of pre-operative chemotherapy has been extended to women with potentially operable breast cancer based on the results of large randomized studies and has become an attractive option that extends the chance of breast conservation. The clinical and pathological responses to pre-operative chemotherapy correlates with long-term outcome. The anthracycline-containing regimen is now considered the standard. Sequential administration of non-cross-resistant drugs, namely taxanes, improves local tumor response but its long-term benefit has been controversial. Prediction of response to pre-operative chemotherapy still remains a challenge. Identification of useful predictive markers and development of molecular-targeted drugs is the key to individualized therapy in the future.
Collapse
Affiliation(s)
- Chikako Shimizu
- Division of Breast and Medical Oncology, National Cancer Center Hospital, Tokyo, Japan
| | | | | | | | | |
Collapse
|
13
|
van Rijk MC, Nieweg OE, Rutgers EJT, Oldenburg HSA, Olmos RV, Hoefnagel CA, Kroon BBR. Sentinel Node Biopsy Before Neoadjuvant Chemotherapy Spares Breast Cancer Patients Axillary Lymph Node Dissection. Ann Surg Oncol 2006; 13:475-9. [PMID: 16485148 DOI: 10.1245/aso.2006.07.025] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2005] [Accepted: 10/27/2005] [Indexed: 01/08/2023]
Abstract
BACKGROUND Neoadjuvant chemotherapy in breast cancer patients is a valuable method to determine the efficacy of chemotherapy and potentially downsize the primary tumor, which facilitates breast-conserving therapy. In 18 studies published about sentinel node biopsy after neoadjuvant chemotherapy, the sentinel node was identified in on average 89%, and the false-negative rate was on average 10%. Because of these mediocre results, no author dares to omit axillary clearance just yet. In our institute, sentinel lymph node biopsy is performed before neoadjuvant chemotherapy. The aim of this study was to evaluate our experience with this approach. METHODS Sentinel node biopsy was performed before neoadjuvant chemotherapy in 25 T2N0 patients by using lymphoscintigraphy, a gamma ray detection probe, and patent blue dye. Axillary lymph node dissection was performed after chemotherapy if the sentinel node contained metastases. RESULTS Ten patients had a tumor-positive axillary sentinel node, and one patient had an involved lateral intramammary node. Four patients had additional involved nodes in the completion lymph node dissection specimen. The other 14 patients (56%) had a tumor-negative sentinel node and did not undergo axillary lymph node dissection. No recurrences have been observed after a median follow-up of 18 months. CONCLUSIONS Fourteen (56%) of the 25 patients were spared axillary lymph node dissection when the sentinel node was found to be disease free. Performing sentinel node biopsy before neoadjuvant chemotherapy seems successful and reliable in patients with T2N0 breast cancer.
Collapse
Affiliation(s)
- Maartje C van Rijk
- Department of Surgery, The Netherlands Cancer Institute, Plesmanlaan 121, Amsterdam, CX, 1066, The Netherlands.
| | | | | | | | | | | | | |
Collapse
|
14
|
Kim R, Osaki A, Toge T. Current and future roles of neoadjuvant chemotherapy in operable breast cancer. Clin Breast Cancer 2005; 6:223-32; discussion 233-4. [PMID: 16137432 DOI: 10.3816/cbc.2005.n.024] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Neoadjuvant chemotherapy was initially used only as treatment for locally advanced breast cancer. However, because breast cancer is considered to be a systemic disease in which distant micrometastases are already present at the time of the initial diagnosis, primary systemic therapy may be beneficial in the eradication of these micrometastatic lesions. Despite the fact that no survival benefit of neoadjuvant chemotherapy over adjuvant chemotherapy has yet been demonstrated, the clinical indication for neoadjuvant chemotherapy is being extended not only to stage T3/4 tumors but also to some stage T1/2 operable breast cancers. The current clinical benefits of the use of neoadjuvant chemotherapy are that (1) the safety of neoadjuvant chemotherapy is comparable with that of adjuvant chemotherapy, (2) neoadjuvant chemotherapy increases the possibility of the use of breast-conserving surgery, and (3) pathologic complete response may be a predictive indicator of better survival. Importantly, the response to neoadjuvant chemotherapy in vivo could provide a useful prediction of prognosis and help define strategies for an individual patient's future treatment with alternative chemotherapy regimens or molecular-targeting agents. Furthermore, the discovery of predictive markers for tumor response to neoadjuvant chemotherapy through the analysis of complementary DNA microarrays and proteomics may also help facilitate individualized chemotherapy, particularly by improving survival in patients with breast cancer with a poor prognosis. Herein we review the current status and future role of neoadjuvant chemotherapy in operable breast cancer in terms of its survival benefit and the potential for the individualization of adjuvant therapy for these patients.
Collapse
Affiliation(s)
- Ryungsa Kim
- Department of Surgical Oncology, Research Institute for Radiation Biology and Medicine, Hiroshima University, Japan.
| | | | | |
Collapse
|
15
|
Soni NK, Spillane AJ. EXPERIENCE OF SENTINEL NODE BIOPSY ALONE IN EARLY BREAST CANCER WITHOUT FURTHER AXILLARY DISSECTION IN PATIENTS WITH NEGATIVE SENTINEL NODE. ANZ J Surg 2005; 75:292-9. [PMID: 15932439 DOI: 10.1111/j.1445-2197.2005.03376.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
AIMS The aims of surgical therapy of breast cancer are loco-regional tumour control and staging. Axillary staging is still considered the single most important prognostic indicator in breast cancer. Surgical removal of axillary nodes remains the standard way to assess their involvement in most centres. The morbidity associated with axillary dissection (AD) is well recognized. In recent years sentinel node biopsy (SNB) has evolved. Multiple studies suggest it has the same accuracy as AD in axillary staging and less morbidity in early breast cancer (EBC). SNB has become the standard of practice in EBC in many parts of the world. In Australia, the preference has been to wait for the results of the Sentinel Node versus Axillary Clearance (SNAC) trial as well as other international trials before accepting SNB as a standard of care. The experience of a single surgeon with SNB alone in EBC without further completion axillary dissection (CAD) in negative sentinel node (SLN) is described in the present paper. METHODS An audit was done of the senior author's prospective data from the Royal Australasian College of Surgeons database. Other information was added retrospectively from case notes. RESULTS Between December 2000 and December 2003, 154 EBC cases (153 patients) underwent SNB alone. An average of four SLN was removed. Of these cases, 31.8% had positive SLNs (excluding 2.6% cases that had isolated tumour cells), of these, 93.9% had metastases (39.1% micro- and 60.9% macro-metastases) in axillary-SLN (ASLN) and almost all of these had CAD. ASLNs were the only positive nodes in 73.9%. Extra-ASLN retrieved in 68.8% of 34% demonstrated on lymphoscintigraphy. Of these, 12.1% were positive (6.1% micro- and macro-metastases each), all internal mammary. Mean follow up was 22.1 months. There was one local-regional-systemic and one systemic recurrence over this time. CONCLUSION SNB has a valid role in staging of the axilla particularly in low-risk patients. After adequate self audit, SNB offers a minimal morbidity and reliable method of axillary staging. Patients choosing SNB alone must understand that the long-term results of the randomized controlled trial are still pending for level I evidence of long-term efficacy.
Collapse
Affiliation(s)
- Naresh K Soni
- Sydney Breast Cancer Institute, Sydney Cancer Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | | |
Collapse
|
16
|
Schrenk P, Hochreiner G, Fridrik M, Wayand W. Sentinel node biopsy performed before preoperative chemotherapy for axillary lymph node staging in breast cancer. Breast J 2003; 9:282-7. [PMID: 12846861 DOI: 10.1046/j.1524-4741.2003.09406.x] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Sentinel node (SN) biopsy in breast cancer patients following preoperative chemotherapy is associated with a decreased identification rate and an increased false-negative rate when compared to SN biopsy performed in untreated patients. We performed SN biopsy in 21 breast cancer patients scheduled for preoperative chemotherapy using either vital blue dye alone (n = 11) or in combination with a radiocolloid (n = 10). Following a mean of four cycles of preoperative chemotherapy, surgery to the breast and complete axillary lymph node dissection was performed irrespective of the SN status. A mean of 1.9 SNs were identified in all 21 patients, 12 were SN negative and 9 were SN positive. Preoperative chemotherapy decreased mean tumor size from 40.2 to 17.7 mm and breast conservation was possible in 14 of 21 patients (67%). All SN-negative patients and three of nine SN-positive patients had negative lymph nodes in the axillary specimen, whereas six of nine patients with a positive SN revealed lymph node metastases following preoperative chemotherapy. SN biopsy performed before preoperative chemotherapy found a 100% identification rate with no false-negative results. Following preoperative chemotherapy, SN-negative patients may forego a complete axillary dissection.
Collapse
Affiliation(s)
- Peter Schrenk
- Second Department of Surgery-Ludwig Boltzmann Institute, Allgemein Offentliches Krankenhaus, Linz, Austria.
| | | | | | | |
Collapse
|
17
|
Bland KI. Utilization of sentinel lymph node mapping to determine pathologic outcomes for patients receiving neoadjuvant chemotherapy for locally advanced breast cancer. Ann Surg Oncol 2002; 9:217-9. [PMID: 11923125 DOI: 10.1007/bf02573056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
|
18
|
Stearns V, Ewing CA, Slack R, Penannen MF, Hayes DF, Tsangaris TN. Sentinel lymphadenectomy after neoadjuvant chemotherapy for breast cancer may reliably represent the axilla except for inflammatory breast cancer. Ann Surg Oncol 2002; 9:235-42. [PMID: 11923129 DOI: 10.1007/bf02573060] [Citation(s) in RCA: 211] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND After neoadjuvant chemotherapy, women with locally advanced breast cancer (LABC) undergo a modified radical mastectomy or lumpectomy with axillary lymph node dissection (ALND) and radiotherapy. Sentinel lymphadenectomy (SL) is accepted for axillary evaluation in early breast cancer. We assessed the feasibility and predictive value of SL after neoadjuvant chemotherapy. METHODS Eligible women received neoadjuvant therapy for LABC and were scheduled to undergo a definitive surgical procedure. Vital blue dye SL was attempted followed by level I and II axillary dissection. RESULTS SL was successful in 29 of 34 patients (detection rate, 85%). Thirteen patients (45%) had positive nodes, and eight (28%) had negative nodes on both SL and ALND. In five patients (17%), the sentinel node was the only positive node identified. Overall, there was a 90% concordance between SL and ALND. The false-negative rate and negative predictive value were 14% and 73%, respectively. Among the subgroup without inflammatory cancer, the detection and concordance rates were 89% and 96%, respectively. The false-negative rate was 6%, and the negative predictive value was 88%. CONCLUSIONS SL after neoadjuvant chemotherapy may reliably predict axillary staging except in inflammatory breast cancer. Further studies are required to assess the utility of SL as the only mode of axillary evaluation in these women.
Collapse
Affiliation(s)
- Vered Stearns
- Breast Cancer Program, Department of Oncology, Lombardi Cancer Center, Georgetown University School of Medicine, Washington, DC, USA.
| | | | | | | | | | | |
Collapse
|
19
|
|
20
|
Abstract
Sentinel lymph node biopsy (SLNB) is an emerging surgical technique to improve lymph node staging for breast cancer. Despite the rapid development of this technique, there remain aspects of SLNB that need to be further defined to provide a standardized approach. Variables, including patient selection, technical details for the performance of SLNB, extent of pathologic evaluation of the sentinel lymph node, and the impact of micrometastases, are areas of controversy. This paper reviews the controversies and discusses available data as well as personal experience and opinion.
Collapse
MESH Headings
- Aged
- Axilla
- Bibliometrics
- Breast Neoplasms/drug therapy
- Breast Neoplasms/pathology
- Breast Neoplasms/surgery
- Carcinoma, Ductal, Breast/diagnostic imaging
- Carcinoma, Ductal, Breast/drug therapy
- Carcinoma, Ductal, Breast/pathology
- Carcinoma, Ductal, Breast/secondary
- Carcinoma, Ductal, Breast/surgery
- Carcinoma, Intraductal, Noninfiltrating/pathology
- Chemotherapy, Adjuvant
- Coloring Agents
- Contraindications
- Female
- Humans
- Lymph Node Excision/adverse effects
- Lymphatic Metastasis/diagnosis
- Lymphatic Metastasis/diagnostic imaging
- Lymphatic Metastasis/pathology
- Lymphedema/etiology
- Lymphedema/prevention & control
- Mastectomy
- Middle Aged
- Neoplasm Staging
- Patient Care Team
- Radionuclide Imaging
- Radiopharmaceuticals
- Rosaniline Dyes
- Sentinel Lymph Node Biopsy/methods
- Sentinel Lymph Node Biopsy/statistics & numerical data
Collapse
Affiliation(s)
- R J Bold
- Department of Surgery, Division of Surgical Oncology, University of California, Davis Cancer Center, 4501 X Street, Sacramento, CA 95817, USA.
| | | | | |
Collapse
|
21
|
Abstract
The current attractiveness of neoadjuvant chemotherapy lies in its ability to downstage both the primary tumor and the axilla, making many patients good candidates for breast-conserving surgical techniques. This has been an important achievement in a patient group whose tumors are often considered inoperable. Attention has more recently turned to the use of neoadjuvant chemotherapy in patients with operable tumors. In patients with resectable stage II and III breast tumors, neoadjuvant chemotherapy has been demonstrated to provide effective downstaging of the primary tumor, and subsequent breast-conserving surgery results in excellent local control. In addition, neoadjuvant chemotherapy has been shown to downstage axillary lymph nodes from positive to negative in a significant number of cases. This raises the question of whether patients who have clinically negative axillae after neoadjuvant chemotherapy need to risk the morbidity associated with axillary lymph node dissection. Axillary irradiation may provide adequate regional control in patients who are clinically node negative. In addition, sentinel lymph node dissection has been shown to provide accurate assessment of the axilla in patients who have received neoadjuvant chemotherapy. An important ramification of the concept of neoadjuvant chemotherapy is that surgery that takes place after the completion of systemic therapy can become minimally invasive, accomplished in an outpatient setting without the need for an operating room suite.
Collapse
Affiliation(s)
- S E Singletary
- Department of Surgical Oncology, University of Texas M.D. Anderson Cancer Center, 1515 Holcombe Blvd., Box 444, Houston, TX 77030, USA.
| |
Collapse
|
22
|
Onaitis MW, Noone RB, Hartwig M, Hurwitz H, Morse M, Jowell P, McGrath K, Lee C, Anscher MS, Clary B, Mantyh C, Pappas TN, Ludwig K, Seigler HF, Tyler DS. Neoadjuvant chemoradiation for rectal cancer: analysis of clinical outcomes from a 13-year institutional experience. Ann Surg 2001; 233:778-85. [PMID: 11371736 PMCID: PMC1421320 DOI: 10.1097/00000658-200106000-00007] [Citation(s) in RCA: 117] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To examine clinical outcomes in patients receiving neoadjuvant chemoradiation for locally advanced rectal adenocarcinoma. SUMMARY BACKGROUND DATA Preoperative radiation therapy, either alone or in combination with 5-fluorouracil-based chemotherapy, has proven both safe and effective in the treatment of rectal cancer. However, data are lacking regarding which subgroups of patients benefit from the therapy in terms of decreased local recurrence and increased survival rates. METHODS A retrospective chart review was performed on 141 consecutive patients who received neoadjuvant chemoradiation (5-fluorouracil +/- cisplatin and 4,500-5,040 cGy) for biopsy-proven locally advanced adenocarcinoma of the rectum. Surgery was performed 4 to 8 weeks after completion of chemoradiation. Standard statistical methods were used to analyze recurrence and survival. RESULTS Median follow-up was 27 months, and mean age was 59 years (range 28-81). Mean tumor distance from the anal verge was 6 cm (range 1-15). Of those staged before surgery with endorectal ultrasound or magnetic resonance imaging, 57% of stage II patients and 82% of stage III patients were downstaged. The chemotherapeutic regimens were well tolerated, and resections were performed on 140 patients. The percentage of sphincter-sparing procedures increased from 20% before 1996 to 76% after 1996. On pathologic analysis, 24% of specimens were T0. However, postoperative pathologic T stage had no effect on either recurrence or survival. Positive lymph node status predicted increased local recurrence and decreased survival. CONCLUSIONS Neoadjuvant chemoradiation is safe, effective, and well tolerated. Postoperative lymph node status is the only independent predictor of recurrence and survival.
Collapse
Affiliation(s)
- M W Onaitis
- Department of Surgery, Duke University Medical Center, Durham, North Carolina 27710, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|