This house believes that: MARI/TAD is better than sentinel node biopsy after PST for cN+ patients

Different strategies in de-escalation of axillary surgery in node-positive breast cancer following neoadjuvant treatment: a systematic review and meta-analysis of long-term outcomes

PURPOSE

Different surgical options existed in the management of axilla among breast cancer patients who were initially node-positive and were converted node-negative after neoadjuvant systemic treatment (NST). De-escalation of axillary surgery was feasible, but previous studies focused on the false-negative rate (FNR) of respective procedures. The aim of this study is to evaluate the oncological outcomes of sentinel lymph-node biopsy (SLNB), MARI procedure, and targeted axillary dissection (TAD).

PATIENTS AND METHODS

PubMed, Embase, and the Cochrane library literature databases were searched systematically. Studies were eligible if they addressed the axillary recurrence rate of patients with nodal pathological complete response (pCR) and omission of axillary lymph-node dissection (ALND) after NST. Pooled analysis was performed using inverse variance methods for logit transformed proportions.

RESULTS

Eleven retrospective studies and three prospective studies involving 4268 patients with node-positive breast cancers were included. A total of 1650 patients achieved nodal pCR and avoided ALND, 1382 patients with SLNB only and 268 patients with MARI/TAD. The pooled estimate of axillary recurrence was 2.1% (95%CI 1.4-3.2%) for patients with negative SLNB and 1.5% (95% CI 0.5-4.1%) for patients with negative MARI/TAD. There was no significant benefit of ALND over SLNB in patients with nodal pCR after NST. Pooled estimates of 5-year DFS, DDFS, and OS of SLNB alone were 0.87 (95% CI 0.83-0.90], 0.90 (95% CI 0.88-0.92), and 0.92 (95% CI 0.88-0.94), respectively.

CONCLUSION

Breast cancer patients who are converted node-negative after NST have extremely low nodal recurrence rate, irrespective of the choice of axillary surgery. Omission of ALND is oncologically safe in patients who have nodal pCR after NST.

Predicting sentinel lymph node metastasis in breast cancer: a study based on the SEER database

BACKGROUND

Sentinel lymph node biopsy (SLNB), a standard surgical procedure for clinically axillary-negative breast cancer patients, significantly reduces complications compared with axillary lymph node dissection, but it is still a relatively invasive procedure with some complications, affecting patient's quality of life. To identify patients who might benefit from avoiding SLNB, this study aimed to develop a nomogram for predicting sentinel lymph node metastasis (SLNM) in breast cancer patients using the SEER database.

METHODS

We identified breast cancer patients whose 1-5 lymph nodes were examined in the SEER database as those who underwent SLNB. Patients were randomly assigned to the training and validation cohorts at a 3:1 ratio. Univariate and multivariate logistic regression were used to evaluate the relationships between SLNM and patients' clinicopathological characteristics. A nomogram was constructed, and its performance was validated via ROC curves, calibration curves, and decision curve analysis.

RESULTS

Age, race, primary site, T stage, M stage, histological grade, pathological type, estrogen receptor status, and progesterone receptor status are independent predictive factors for SLNM in patients with breast cancer. We successfully developed a predictive nomogram for sentinel lymph node status, with AUC values of 0.711 and 0.700 for the training and validation cohorts, respectively.

CONCLUSION

Our study successfully established an SLNM nomogram that provides richer predictive information. The model exhibits good clinical efficacy and serves as a reference value for populations potentially exempt from SLNB.

A systematic review and meta-analysis of risk factors influencing patient-reported arm symptoms post-breast cancer treatment: Accounting for radiotherapy impact

OBJECTIVES

To systematically review risk factors for patient-reported arm symptoms (AS) in breast cancer (BC), considering radiotherapy (RT) impact, using the EORTC QLQ-BR23 questionnaire (BR23).

METHODS

PubMed, Embase, Cochrane Library, MEDLINE, and Web of Science were searched using the keywords "breast neoplasms", "radiotherapy", and "BR23" up to March 5th, 2024.

INCLUSION CRITERIA

both univariate and multivariate analyses.

EXCLUSION CRITERIA

pregnancy, recurrence, distant metastasis BC, reirradiation, or lack of RT. The risk of bias of included papers was assessed using the Critical Appraisal Skills Program (CASP) checklist. Descriptive and meta-analyses were conducted using risk ratio (RR) or standardized mean difference (SMD) with 95 % confidence intervals (CI) as effect measures. A random-effects model was applied if I2 > 50 %.

RESULTS

Eighteen out of 734 studies were included, with sample sizes ranging from 172 to 2208. Commonly reported risk factors included axillary lymph node dissection (ALND), mastectomy, chemotherapy (CT), and RT (6, 5, 4, and 4 studies, respectively). In meta-analyses, ALND was a risk factor for arm pain (RR [95 % CI] = 1.75 [1.14; 2.71]), lymphedema (RR [95 % CI] = 5.41 [3.48; 8.39]), and overall AS (SMD [95 % CI] = 0.49 [0.14; 0.83]) compared to sentinel lymph node biopsy. RT was not a risk factor, but axillary RT significantly increased overall AS (SMD [95 % CI] = 0.55 [0.40; 0.70]) compared to no axillary RT.

CONCLUSION

ALND and mastectomy were the primary risk factors for patient-reported AS. Axillary RT was a significant risk factor, whereas general RT was not.

Wire-Free Targeted Axillary Dissection: A Pooled Analysis of 1300+ Cases Post-Neoadjuvant Systemic Therapy in Node-Positive Early Breast Cancer

Recent advances in neoadjuvant systemic therapy (NST) have significantly improved pathologic complete response rates in early breast cancer, challenging the role of axillary lymph node dissection in nose-positive patients. Targeted axillary dissection (TAD) integrates marked lymph node biopsy (MLNB) and tracer-guided sentinel lymph node biopsy (SLNB). The introduction of new wire-free localisation markers (LMs) has streamlined TAD and increased its adoption. The primary endpoints include the successful localisation and retrieval rates of LMs. The secondary endpoints include the pathological complete response (pCR), SLNB, and MLNB concordance, as well as false-negative rates. Seventeen studies encompassing 1358 TAD procedures in 1355 met the inclusion criteria. The localisation and retrieval rate of LMs were 97% and 99%. A concordance rate of 67% (95% CI: 64-70) between SLNB and MLNB was demonstrated. Notably, 49 days (range: 0-272) was the average LM deployment time to surgery. pCR was observed in 46% (95% CI: 43-49) of cases, with no significant procedure-related complications. Omitting MLNB or SLNB would have under-staged the axilla in 15.2% or 5.4% (p = 0.0001) of cases, respectively. MLNB inclusion in axillary staging post-NST for initially node-positive patients is crucial. The radiation-free Savi Scout, with its minimal MRI artefacts, is the preferred technology for TAD.

Assessing the Efficacy of Radioactive Iodine Seed Localisation in Targeted Axillary Dissection for Node-Positive Early Breast Cancer Patients Undergoing Neoadjuvant Systemic Therapy: A Systematic Review and Pooled Analysis

Targeted axillary dissection (TAD), employing marked lymph node biopsy (MLNB) alongside sentinel lymph node biopsy (SLNB), is increasingly recognised for its efficacy in reducing false negative rates (FNRs) in node-positive early breast cancer patients receiving neoadjuvant systemic therapy (NST). One such method, 125I radioactive seed localisation (RSL), involves implanting a seed into a biopsy-proven lymph node either pre- or post-NST. This systematic review and pooled analysis aimed to assess the performance of RSL in TAD among node-positive patients undergoing NST. Six studies, encompassing 574 TAD procedures, met the inclusion criteria. Results showed a 100% successful deployment rate, with a 97.6% successful localisation rate and a 99.8% retrieval rate. Additionally, there was a 60.0% concordance rate between SLNB and MLNB. The FNR of SLNB alone was significantly higher than it was for MLNB (18.8% versus 5.3%, respectively; p = 0.001). Pathological complete response (pCR) was observed in 44% of cases (248/564). On average, the interval from 125I seed deployment to surgery was 75.8 days (range: 0-272). These findings underscore the efficacy of RSL in TAD for node-positive patients undergoing NST, enabling precise axillary pCR identification and facilitating the safe omission of axillary lymph node dissection.